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Diabetes, foot disease expert wins international award from ACE
Andrew J.M. Boulton, MD, DSc (Hon.), FACP, FICP, FRCP, professor of medicine at the University of Manchester, U.K., has been awarded the International Endocrinology Award by the American College of Endocrinology.
The award is presented to an endocrinologist living outside of the U.S. who is delivering outstanding care and affecting change in their field and was conferred during the American Association of Clinical Endocrinologist Annual Scientific & Clinical Congress in Austin, Texas.
Boulton is an expert on diabetes and foot disease. Endocrine Today spoke with him about his career and his activities outside of work.
What was the defining moment that led you to your field?
Boulton: As a junior doctor working in Sheffield, England, in the late 1970s I first became aware of the multiple late complications that plagued many of our patients with diabetes. I was seeing patients with the same condition, diabetic neuropathy, presenting in very different scenarios that took me to research in the area of neuropathy and the diabetic foot. I remember seeing two patients with the same deficit (marked sensory loss): one was plagued by neuropathic pain and could not sleep at night and was experiencing marked side effects from the neuropathic pain medication he had been prescribed. The other had no pain whatsoever but was walking on a large plantar foot ulcer. It was seeing these contrasts that stimulated me to enter research in this particular area, which I have now been doing for almost 40 years. Today, I am often asked by residents and fellows, “How could this patient be so stupid as to walk on a large wound under their foot?” I always point out to them that it is not the patient that is stupid, but it is the doctors who fail to understand what it is to have lost the “gift of pain” that protects us from repetitive injuries.
What area of your field most interests you right now and why?
Boulton: There is no doubt that much progress has been made in our understanding of diabetic neuropathy over the last few decades. However, the true etiopathogenesis of the rare but serious condition known as “Charcot neuroarthropathy” remains enigmatic. This condition afflicts patients with advanced diabetic neuropathy but the reason why some patients with advanced neuropathy develop Charcot neuroarthropathy, and others with even more advanced neuropathy do not, remains puzzling. My group and others have looked at the RANKL/osteoprotegerin signaling system and believe that abnormalities here might be important to the genesis of the condition. I do hope that in the near future, our understanding of the pathways that result in this condition may help us develop targeted therapies that might prevent its development, and in that way save many legs.
What are some of the most exciting advances that you have been a part of?
Boulton: Working as a young assistant professor in the Diabetes Unit at the University of Miami in 1983-1984, together with colleagues in diabetes and dermatology, we were able to answer some of the puzzling questions that surrounded the pathogenesis and treatment of a rare skin condition known as necrobiosis lipoidica diabeticorum. We were able to describe using skin biopsies, that the necrobiotic inflammatory tissue destroys superficial nerves and, therefore, skin lesions on the lower limb of predominantly type 1 diabetic patients and are likely to be necrobiosis if there is loss of sensation in the lesion. This now may be the diagnosis of this rare condition. We also demonstrated that the most active areas of inflammation are not in the lesion itself but in the peri-lesional skin. Thus, if intra- lesional steroids are used in the management of acute necrobiosis, it is probably best to inject around the edge of the lesion rather than into the lesion itself. Second, in the area of painful neuropathy, in the early 1980s we reported that stabilization of glycemic control using continuous subcutaneous insulin infusion might help reduce neuropathic pain. Twenty years later we were able to confirm the importance of blood glucose flux continuous glucose monitoring and confirm that those with painful neuropathy have much more unstable 24 hour blood glucose profiles than those with painless neuropathy.
What advice would you offer to a student going into diabetes research today?
Boulton: To a medical student who wishes to pursue a clinical career and be active in clinical research, I would emphasize the importance of clinical observation, an art which seems to be dying in the 21st century. In my career, it has been interactions with patients, clinical observation and listening to histories that informed much of my research output in the last 35 years. Examples of clinical interactions that led to research ideas are outlined in my answers to the previous questions.
What are your hobbies/interests outside of work?
Boulton: I am a “campanologist”! This is English church bell ringing, which I have been involved with since a teenager. There are 5,000 or so churches in the U.K. with bells that ring in this fashion, which require quite a lot of effort as the bells swing through 360° and requires one ringer per bell! There are now more than 60 peels of English ringing bells in the U.S. and whilst in Miami as a professor in the Diabetes Research Institute from 2002-2004, I was able to train a number of local interested people in the art of church bell ringing at Miami Cathedral, which is one of those towers. Whereas within a 10-mile radius of my home in the U.K. there are probably 20 to 30 churches with ringing bells, the nearest peel of bells to Miami is either in Charleston, South Carolina, or Atlanta. Thus teaching ringers in Miami on my own was challenging but rewarding. A couple of months ago I was speaking at the DFCon meeting in Houston, where there are three peels of English ringing bells and after my 11-hour flight from the U.K. I went straight to join a ringing practice that evening! I also enjoy classical music, having previous been an oboist and have a keen interest in railways, which are still widely used as a form of transport in the U.K.