Common Associated Risk Factor Research Articles

Chronic Postoperative Opioid Use: A Systematic Review.

There are a number of studies in the literature that describe the prevalence, causes, and factors associated with chronic postoperative opioid use, but there is a lack of synthesis of the literature to guide clinicians in optimally managing postoperative pain while avoiding opioid dependence. Thus, the goal of this study was to perform a systematic review of the literature to investigate the prevalence of chronic postoperative opioid use and the associated risk factors. A systematic search was performed using Ovid Medline and Embase according to PRISMA guidelines. Data were collected on the following outcomes of interest: prevalence of opioid use at 3, 6, and 12months postoperatively, and risk factors associated with chronic postoperative opioid use. Forty-three articles were included in the final analysis. The mean prevalence of chronic postoperative opioid use in all populations at 3, 6, and 12months postoperatively was 30.5%, 25.6%, and 25.2%, respectively. The prevalence of patients who developed chronic opioid use at 3, 6, and 12months postoperatively was 10.4%, 8.5%, and 9.8%, respectively. Forty of the articles analyzed risk factors associated with chronic postoperative opioid use. The most common associated risk factor identified was preoperative opioid use with 27 articles demonstrating a significant association with chronic postoperative opioid use. The current opioid crisis is in part secondary to the prevalence of chronic opioid use following surgery. This study identified associated risk factors with chronic postoperative opioid use, which may help identify patients at risk for developing chronic postoperative opioid use.

Thrombotic Events with NovoSeven® RT in Approved Indications Are Rare (0.2%) and Associated with Older Age (>= 65 y), Cardiovascular Disease, and Concomitant Use of aPCCs

Introduction: Recombinant activated factor VII (NovoSeven®RT, Novo Nordisk A/S) is approved for treatment of bleeding and perioperative management in congenital hemophilia with inhibitors (CHwI), acquired hemophilia (AH), congenital factor VII (FVII) deficiency, and Glanzmann thrombasthenia (GT) with refractoriness to platelets. Serious thrombotic events (TEs) have been reported in clinical trials and postmarketing surveillance; however, the incidence of this risk (rate of thrombosis) is considered to be low within labeled indications. While many general risk factors are noted in the prescribing information (PI), the association of reported TEs with certain risk factors noted in the PI has not been established.Methods: A retrospective safety assessment of clinical trials and registries, used to support licensure and postmarketing surveillance, was performed from which the rate of thrombosis could be calculated in the 4 indicated disorders. Further, all postmarketing TE case reports in the Novo Nordisk safety database (including from registries, spontaneous reports, and the literature) were assessed to identify any of the risk factors listed in the PI and the temporal relationship to NovoSeven®RT use (defined as within 48 h given 2- to 3- hour half-life).Results: In clinical trials and registries used to support licensure and in postmarketing surveillance, overall rate of thrombosis was 0.17% of 12,288 bleeding and surgical episodes. There were 21 TEs identified (12 CHwI, 5 AH, 3 FVII deficiency, 1 GT). The specific risk by indication (Table 1) was 0.11% for CHwI (11,121 episodes), 0.19% for GT (518 episodes), 0.82% for FVII deficiency (367 episodes) and 1.77% for AH (282 episodes). Analysis of all postmarketing databases (Table 2) revealed 213 TEs (88 CHwI, 61 AH, 53 FVII deficiency, 11 GT). The majority were reported spontaneously (141), with fewer reported in the literature (47) or solicited in registries or investigator-sponsored studies (25). Of 213 TE cases, temporal relationship was assessed as plausible in 188 (88%) if NovoSeven®RT use was reported within 48 hours prior to TE or timing unknown; timing was more than 48 hours in 25 (12%) of cases. Overall, the most common associated risk factor was “elderly,” defined in the PI as age ≥65 years (29%), and was particularly common in patients with AH and TE (67%). Another common factor was concomitant use of activated prothrombin complex concentrates (aPCC), identified in 18% of all TEs and 34% of TEs in CHwI. Broadly defined cardiovascular disease (including arrhythmias) was noted in 18% of all TEs (36% AH, 15% FVII deficiency, 9% CHwI) and was much more common than specific note of atherosclerotic disease (2%). Other risk factors listed in the PI were uncommon and, in some cases, never identified in TE reports (eg, postoperative immobilization, sepsis, liver disease, disseminated intravascular coagulation, neonates, pregnancy, postpartum hemorrhage, crush injury).Conclusions: Data show that the rate of TEs within licensed indications is low (0.17%), as was originally described in the US PI from 1999-2009. It has remained stable over time during postapproval surveillance in multiple US and global registries, with active surveillance for safety information across the 4 approved indications. In postmarketing safety report assessments of patients with CHwI receiving concomitant treatment with aPCCs, older patients, particularly those with AH who are receiving other hemostatic agents, and patients with a history of cardiac and vascular disease may have an increased risk of developing TE. [Display omitted] DisclosuresRajpurkar:HEMA biologics: Honoraria; Bristol Myers Squibb: Research Funding; Shire: Honoraria; Pfizer: Honoraria, Research Funding; Novonordisk: Honoraria. Croteau:CSL-Behring: Consultancy; Catalyst Biosciences: Consultancy; Genetech: Consultancy, Research Funding; Novo Nordisk: Consultancy; Octapharma: Consultancy, Honoraria, Research Funding; Pfizer: Research Funding; Spark Therapeutics: Research Funding; Tremeau Pharmaceuticals: Consultancy; Bioveritiv: Consultancy; Biomarin: Consultancy; Bayer: Consultancy; Baxalta/Shire: Consultancy, Research Funding. Boggio:Novo Nordisk: Honoraria. Cooper:Novo Nordisk: Employment.

Notification and counselling of hepatitis positive blood donors, their immediate emotional response, contact-testing and their follow-up: Study from a tertiary care hospital!

IntroductionPost-donation counselling informs donors of unusual test results. Timely notification and counselling regarding their Transfusion Transmitted Infection (TTI) status is necessary for early clinical intervention in the donor and reducing risk of transmission. We share our experience with respect to Hepatitis B (HBV) and Hepatitis C (HCV) positive donors who were counselled and followed-up for clinical outcome. Materials and methodsIt was prospective 2-year study in TTI positive blood donors. Confirmed positive HBV/ HCV donors were notified to attend the donor-clinic or to visit local hepatologist for further management. At donor clinic, donor’s immediate emotional response was observed; donors were offered contact-testing, associated risk factors were noted, counselled, referred to hepatologist, treated and followed-up for clinical outcome. ResultsOf 481 donors (0.91%) confirmed positives, 351 were contacted telephonically; 280 promised to attend donor clinic and 71 were referred to their local hepatologist. 145 donors attended the donor clinic, eventually. Most common immediate emotional response noted were ‘feeling of fear’ (55.2%) and ‘disbelief’ (35.2%). Most common associated risk factor was history of medical treatment/ injections without knowledge of sterilisation. Five donors availed contact testing and four (spouses in all four cases) came out positive. Of 98 donors contacted post-counselling; 89 went to hepatologist. No medication was advised to seven donors (low viral load), 59 donors completed treatment course and 23 donors were undergoing treatment at time of follow-up. Nine donors opted for alternative treatment or “no treatment”. ConclusionDonor-clinic proved beneficial to substantial number of donors and their families.

Analysis of risk factors associated with unilateral hearing loss in children who initially passed newborn hearing screening

ObjectiveTo analyze 2007 Joint Committee on Infant Hearing (JCIH) risk factors in children with confirmed unilateral hearing loss (UHL) who initially passed newborn hearing screening. MethodsRetrospective record review of 16,108 infants who passed newborn hearing screening but had one or more JCIH risk factors prompting subsequent follow-up through the universal newborn hearing screening (UNHS) program in Virginia from 2010 to 2012. The study was reviewed and qualified as exempt by the Virginia Commonwealth University Institutional Review Board (IRB) and the Virginia Department of Health. ResultsOver the 2-year study period, 14896 (4.9% of total births) children passed UNHS but had the presence of one or more JCIH risk factor. Ultimately, we identified 121 babies from this group with confirmed hearing loss (0.7%), with 48 babies (0.2%) showing UHL. The most common risk factors associated with the development of confirmed UHL after passing the initial screen were neonatal indicators, craniofacial anomalies, family history, and stigmata of syndrome associated with hearing loss. ConclusionNeonatal indicators and craniofacial anomalies were the categories most often found in children with confirmed unilateral hearing loss who initially passed their newborn hearing screen. While neonatal indicators were also the most common associated risk factor in all hearing loss, craniofacial abnormalities are relatively more common in children with UHL who initially passed newborn hearing screening. Further studies assessing the etiology underlying the hearing loss and risk factor associations are warranted.

Prematurity as an Obstetric Complication and Its Awareness in Saudi Population

Background: Prematurity is a major obstetric complication that affects infants’ growth and development, and is also a big cause of infant mortality across the world. Prematurity is associated with certain risk factors, such as age extremes, mother’s diet and health, multiple pregnancies, maternal infections, maternal smoking, inadequate follow-up, and insufficient management of maternal chronic diseases. Aim: In this study we aim to study knowledge and attitude of pregnant women toward the prematurity causes and complication. Methodology: We conducted a cross-sectional study, of 2470 women who presented in king Abdulaziz University, Jeddah, Saudi Arabia from April 2017 to December Conclusion: We noted that although most mothers were aware of the positive impact on their health by regular follow-up visits to physician, many of them were not largely informed of the common associated risk factors. Better prenatal counselling can help create better awareness.

Erectile dysfunction therapy in countries where implant is economically not feasible.

Erectile dysfunction (ED), a frequent complaint in the primary care setting, is strongly associated with obesity, cigarette smoking and other common cardiovascular risk factors like hypertension, diabetes mellitus (DM), lipid disorders and the metabolic syndrome. The prevalence of these cardiovascular disorders is rising at staggering rates in most Latin American countries. ED is a symptom that mainly affects economically productive men (40–70 years of age) potentially causing major psychosocial repercussions and reduced quality of life. The management of ED in these developing countries is increasingly challenging due to poor patient education and non-adherence to the medical treatment of theses concomitant comorbidities. The financial implications of commonly prescribed medications and surgical procedures limit their use to a minority of patients. For this reason, the clinician must adopt a holistic approach in the management of this disease focusing on preventive measures based on patient education and non-surgical interventions. This review summarizes common associated risk factors of ED and outlines non-pharmacological interventions for the management of this disease.

Paediatric infectious keratitis: a case series of 107 children presenting to a tertiary referral centre

Background/aimsCorneal ulcers can result in severe visual impairment in children. The recent trends of paediatric microbial ulcerative keratitis in the USA are unknown. The purpose of this study is to...

CORONARY ARTERY DISEASE

Background: Development of heart failure is always secondary to presenceof risk factors like diabetes mellitus, hypertension, age, smoking and underlying coronaryartery disease. Objective: The objective of this study was to find the frequency of risk factorsand coronary artery involvement in patients of heart failure after myocardial infarction. StudyDesign: A non-randomized cross sectional study. Setting: Gulab Devi Chest Hospital. Period:Six months. Methods: 100 patients was done. Using non probability (purposive) samplingtechnique; all patients with ages between 20 to 80 years, irrespective of gender, diagnosedwith heart failure (with ejection fraction ≤ 40%) secondary to STEMI were included in thestudy. Patients that were not having heart failure secondary to STEMI and those that hadn’ttheir coronary angiography done were excluded from the study. The data were analyzed usingSPSS Version 20. Descriptive statistics was used to see analyze the data. Results: Mean ageof patients was 52.61±10.2years. There was an overall male predominance (81%). Commonrisk factors that we observed were smoking (65%), hypertension (62%), diabetes (58%) andpositive family history (38%). In this study 51% patients had triple vessels disease, 15% patientshad double vessels disease and 34% patients had single vessel disease. Most common lesionwas of LAD following LCX, RCA and LMS. Conclusion: Our study conclude that coronaryartery disease is the main causative factor for the development of heart failure in patients ofmyocardial infarction and even a single vessel disease can lead to heart failure with severesystolic dysfunction. Most common associated risk factor was smoking, hypertension being thesecond most common following diabetes and positive family history.

Frequency of Congenital Anomalies in Newborns and Its Relation to Maternal Health in a Tertiary Care Hospital in Peshawar, Pakistan

Background: Congenital anomalies are a major cause of perinatal and neonatal deaths, both in low- and high-income countries. They are relatively common worldwide, affecting 3% to 5% of live births. Methods: A cross-sectional study was conducted from January 2014 to June 2014 at the Khyber teaching hospital in Peshawar. Specific patient information was obtained from patient records at the beginning of the study. Those individuals found to have at least one birth defect were approached and their attendants (mothers) were interviewed. Information regarding various risk factors was collected. Descriptive analyses were carried out. Results: Out of 1062 deliveries, 2.9% (31) of newborns had various congenital anomalies.b Hydrocephalus (22.6%), anencephaly (12.9%), and spina bifida (9.7%) were major anomalies. The maternal age ranged from 18 years to 46 years (mean: 30 ± 8). Most of the anomalies (35.5%) were present in the 26-30 years age group. Out of 31 babies, 6.4% had multiple anomalies. The preponderance of various congenital anomalies was seen in parity 1 (35.4%); parities 2 to 4 had lower incidences (35.4%). The consanguinity rate was 67.7%; only 32.3% of patients were using folic acid. History of passive smoking was positive in 16.1% of cases. Conclusion: Anencephaly and hydrocephalus were the most prominent anomaly detected; early prenatal diagnosis may be helpful in decreasing mortality by offering early termination. Low intake of folic acid and a high consanguinity rate were the most common associated risk factors for congenital anomalies. These risk factors may be reduced by creating awareness regarding the avoidance of consanguineous marriage and promoting the use of folic acid during pregnancy.

Risk Factors and Saphenofemoral Junction in Varicose Veins

Introduction: Varicose veins (VVs) are dilated, tortuous, subcutaneous veins. It is common condition causing substantial morbidity. Prevalence of VVs ranges between 5% and 30% in the adult population. Surgery is one of the common modality of its treatment. A complete knowledge about anatomical variation at saphenofemoral junction (SFJ) and variations in tributaries of great saphenous vein (GSV) is important while dealing with such patients effectively. It will help in reducing chances of recurrences and complications. Methods: A prospective non-randomized study of fifty patients was carried out in our hospital between May 2014 and May 2015. Diagnosis was established by clinical examination and supplemented with venous duplex ultrasound study. Patients were subjected to trendelenburg's operation, stripping of GSV with hook phlebectomy of affected perforators. Results: A total of fifty patients were studied in this study, in which tobacco chewing was the most common associated risk factor with primary VVs, and it was observed in 46% of patients. Amongst them, twenty patients were obese with body mass index of more than 25 kg/m2 . Location of SFJ was a mean of 2.24 ± 0.55 cm inferior and 3.77 ± 0.61 cm lateral to the pubic tubercle on duplex ultrasound and 2.35 ± 0.42 cm inferior and 3.73 ± 0.58 cm lateral intraoperatively, both of which had nonsignificant P value. The number of tributaries varied from 2 to 6 at the first 5 cm from SFJ. There were two and six tributaries in one patient each whereas three tributaries were observed in 42% patients. The most frequent consistent branch was a superficial inferior epigastric vein, seen in 98% of patients. The least frequent branch was posterior accessory saphenous vein, seen only in 2% of patients. The external pudendal artery was crossing SFJ anteriorly in 38% and posteriorly in 56%, and it was not identified in remaining 4% patients. Conclusion: Our study showed the nonsignificant difference in Duplex ultrasound and intraoperative finding of SFJ location with respect to pubic tubercle; hence, one can plan a precise incision with the help of duplex ultrasound marking preoperatively. One must look for all tributaries for ligation which will prevent recurrence of varicose vein as variation in numbers and location of tributaries was remarkable in our study.

ANALYSIS OF PRESENTING COMPLAINT, RISK FACTORS AND MANAGEMENT PROTOCOL IN PATIENTS WITH UTERINE CANCERS

Endometrial cancers represent over 96% of the uterine cancer and are the most common gynecological carcinoma in developed countries.
 Purpose: To ascertain the presenting features, identify the risk factors and analysis of treatment method opted in endometrial carcinomas.
 Materials and Methods: Observational study of 84 patients with proven endometrial cancers, who reported during 2010 to 2011 in Mayo and services hospital Lahore. Performa included demographic variables along with presenting complaints, risk factors and management data. Data was analyzed by SPSS version 16 and results compiled.
 Results: The mean age was 58.5 years, mean parity 2.5 with mean age at marriage at 25. Major presenting complaint was irregular vaginal bleeding (33.3%). Most common associated risk factor observed was irregular exogenous hormone intake 26.19%. Total 91.66% cases underwent surgery while 8.33% were in late inoperable stage.
 Conclusion: Patients with irregular vaginal bleeding specifically in postmenopausal period should be thoroughly evaluated for endometrial carcinoma even in the absence of any associated risk factor.

Apports du bilan étiologique des occlusions de l’artère centrale de la rétine et de ses branches et conséquences thérapeutiques

Retinal artery occlusions (RAO) are severe conditions threatening vision, affecting the subsequent mortality of these patients.We retrospectively reviewed the work-up performed in all patients diagnosed with retinal artery occlusions evaluated in two university hospitals in France (Tours and Angers).A total of 131 patients (131 eyes) with RAO were included, with a mean age of 69.5years and male predominance (64 %). Central retinal artery occlusion (CRAO) resulted in poor initial visual acuity (90 % less than count fingers), whereas those with branch retinal artery occlusion (BRAO) had better visual acuity (63.6 % better than 20/40). Systemic arterial hypertension (HTN) was the most common associated risk factor. Carotid stenosis was found in 50 % of cases, leading to endarterectomy in nine patients (6.9 %), while an underlying cardiac cause was implicated in 14 % of cases. Giant cell arteritis was diagnosed in five patients (3.8 %).Work-up of RAO may detect treatable cardiovascular and systemic conditions, allowing prevention of further ocular recurrence or stroke.Etiologic work-up of retinal arterial occlusion can diagnose potentially treatable underlying systemic conditions, such as giant cell arteritis, cardiac conditions and extracranial cerebrovascular disease. Giant cell arteritis has to be ruled out at the acute phase, while the role and timing of semi-urgent testing (supra-aortic Doppler echography, echocardiography, electrocardiography, lab work-up) or delayed testing (transesophageal echocardiography, brain imaging) have yet to be determined.

Ischemic Optic Neuropathy Following Surgical Fixation of Multiple Ipsilateral Upper-Extremity Fractures: A Case Report.

Postoperative vision loss is a rare but devastating surgical complication. Ischemic optic neuropathy (ION) is one such form of vision loss, most commonly recognized with prone positioning in spinal surgery. It is also documented as a complication of multiple surgical specialties, including general orthopaedics1, otolaryngology2, obstetrics and gynecology3, cardiothoracic surgery4,5, and general trauma surgery6. ION is an acute ischemic disorder that causes blindness, with reported postoperative incidence ranging from 0.013% to 1.3%5,7-9. Blood flow to the optic nerve is autoregulated and is dependent on ocular perfusion pressure (OPP). OPP can decrease to a level beyond which autoregulation mechanisms can compensate10, leading to ischemic injury. The most common associated risk factors for this complication are often encountered in orthopaedic trauma, namely length of surgery11 and intraoperative arterial hypotension6,8. To our knowledge, ION has not previously been reported in the orthopaedic trauma literature. We present the case of a fifty-year-old man who developed ION after internal fixation of ipsilateral fractures of the proximal part of the humerus and olecranon. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A fifty-year-old healthy man sustained an eight-foot fall from a ladder, landing directly on the right elbow. He was hemodynamically stable with isolated closed injuries to the right upper extremity; there were no neurovascular deficits. The general surgery trauma team evaluated the patient, and no additional injuries were found. Radiographs and computed tomography (CT) of the right shoulder showed a comminuted fracture of the proximal part of the humerus, described as an Orthopaedic Trauma Association (OTA) classification type 11-B1.212, as well as a Neer two-part fracture involving the …

Necrotising soft tissue infection-risk factors for mortality.

Necrotising Soft Tissue Infection is a rapidly progressing fatal disorder, the prognosis of which depends on early diagnosis and management. In this study, our objective was to assess the factors contributing to mortality due to NSTI. A retrospective review of the records of all patients with NSTI involving fascia, skin or muscle between January 2007 and December 2011, was performed. The atiology, predisposing factors, risk factors, causative microbiological organisms and the clinical outcomes associated with mortality were studied. Statistical Data: Descriptive statistics comprising of proportion(%) presented. Chi-square test was employed to assess the statistical significance in the distribution of various known risk factors between the survivors and non-survivors. A 'p' value less than 0.05 was considered significant. Sixty patients records were reviewed. Fifty-one patients (85%) were males and nine (15%) were females. Mean age was 46.57 years (+/- 20.60) ranging from 15-83 years. All the patients were treated by debridement & wide spectrum antibiotics. Mono-microbial atiology being found in 27 patients (63.3%) and polymicrobial culture was isolated in 13 patients (36.7%), with E-coli and staphylococci being the most common organisms to be isolated. In most patients, multiple debridements were done. The overall mortality rate was estimated to be 25%. Age, aatiology, diabetes mellitus, hypoalbuminemia, alcohol, site of infection, bacteriology etc. were the risk factors associated with mortality, that were evaluated. Diabetes mellitus was the most common associated risk factor found in 32 patients (53.3%), though not statistically significant. Increasing age (>50 years, p value = 0.016), raised Serum Creatinine (>1.2mg/dl, p-value = 0.023) and delayed surgical intervention(>24 hours p value= 0.006) were the risk factors associated with Mortality in NSTI that were statistically significant. Despite the use of appropriate antibiotic treatment, aggressive debridement & resuscitation, NSTI still leads to a high mortality & morbidity. In this series, there is high mortality associated with increasing age, raised serum creatinine and delayed surgical intervention. The mortality rate (25%) is comparable with other studies.

Prevalence and Pattern of Dyslipidemia in Omani Patients Undergoing Coronary Artery Bypass Surgery

Synopsis: Dyslipidemia is one of the most significant risk factors for rapid atherosclerotic attrition of saphenous vein grafts. Recent studies have shown an increased prevalence of dyslipidemia in the general population in Oman. However, no data are available in regard to the prevalence of dyslipidemia in patients undergoing coronary artery bypass graft surgery (CABG). Purpose: The purpose of this study is to evaluate the prevalence and the pattern of dyslipidemia in Omani patients undergoing coronary artery bypass graft surgery. Methods: In this cross-sectional study, 104 consecutive patients undergoing elective CABG between March 2008 and October 2009 were included and data on lipid profile and major cardiovascular risk factors were reviewed. Results: Mean age of the patients is 57.6 years (range 31–87), of which 72% are males. 63% of patients have body mass index ≥25.0 kg/m2. The most common associated risk factors of coronary artery disease found in these patients are dyslipidemia (84%), hypertension (81%), and diabetes mellitus (54%). The most common pattern of dyslipidemia observed is low HDL-C (<0.9 mmol/L) in 51% of the patients, followed by high triglyceride (>1.7 mmol/L) in 34%, high total cholesterol (>5.2 mmol/L) in 29% and high LDL-C (>4.1 mmol/L) in 20% of patients. 89% of dyslipidemic patients were on simvastatin on admission and of those 49% only achieved an LDL-C target less than 2.6 mmol/L. Conclusions: The present study shows a high prevalence of diabetes, hypertension, and dyslipidemia in the Omani population undergoing CABG. The most common pattern of dyslipidemia is low HDL-C. A small percentage of the study group had achieved therapeutic LDL-C targets, which put them at continuous risk of rapid atherosclerotic attrition of coronary bypass grafts.

RISK FACTORS ASSOCIATED WITH NEONATAL HYPOGLYCEMIA

Objectives: Recurrent episodes of neonatal hypoglycemia are strongly associated with long termphysical and neuro-developmental deficits. (1) Moreover in neonates hypoglycemia can be overlooked as it may havenonspecific symptoms only. (2) This study was therefore carried out to analyse the risk factors associated with neonatalhypoglycemia and to evaluate the risk factors which have predictive value in its diagnosis. .Design: Based case controlstudy. Period: Six months from January 2005 to June 2005. Setting CMH Pano Aqil. Material and Methods: 385newborns were studied. Newborns of both civilians as well as military personnel were included in the study. 11newborns were excluded. Out of remaining 347 patients 101 were found to be hypoglycemia. Five risk factors (low birthweight, Birth Asphyxia, Neonatal sepsis, Meconeum aspiration syndrome delayed feeding ) strongly and independentlypredicated the risk of hypoglycemia. Results: The most common associated risk factor was low birth weight (47.47%)followed by delayed feeding (46.29%). Blood sampling for glucose estimation was done at birth / admission at 6 hours,12 hours, 24 hours and 48 hours. Test was initially performed by glucometer, the reading which were confirmed bylaboratory testing in border line case. Conclusions: In neonates with associated risk factors it is cost affective to carryout blood glucose levels at the time of birth and follow up readings taken as indicated by clinical progress later on.

Fungal Keratitis at the New York Eye and Ear Infirmary

This study was designed to review the clinical experience at our institution with fungal keratitis during a 16-year period. A review of the clinical and microbiology records of the New York Eye and Infirmary identified 61cases of fungal keratitis in 57 patients between January 1, 1987 and June 1, 2003. The medical records of all patients were retrospectively reviewed to better delineate patient demographics, risk factors, etiologic organisms, treatment, and outcomes. A total of 5083 positive corneal cultures were recorded'from January 1, 1987 to June 1, 2003. Sixty-one eyes in 57 patients (37 women) were positive for fungus (1.2%). Three'patients had bilateral simultaneous infections. Candida albicans accounted for 29 of 61 cases (48%). Human immunodeficiency virus (HIV) seropositivity (15 eyes), chronic ocular surface disease (14 eyes), and trauma (7 eyes) were the most commonly associated risk factors. Our experience with fungal keratitis in the northeastern United States appears to be different than those reported from other areas of the United States. Serologic positivity for HIV and chronic ocular surface disease were the most common associated risk factors followed by trauma, herpes simplex keratitis, and contact lens use. Candida species predominated, whereas filamentous fungi were uncommon.

Diabesity

Weight reduction has been shown to improve glycemic control and cardiovascular risk factors associated with insulin resistance in obese individuals with type 2 diabetes mellitus. Therapeutic options for these patients include promoting weight loss (non-pharmacologic and pharmacologic treatment) and improving glycemic control, as well as treating common associated risk factors such as arterial hypertension and dyslipidemias. This article provides an overview of anti-obesity drugs used in the treatment of obese individuals with type 2 diabetes. The most widely investigated drugs, sibutramine and orlistat, result in modest, clinically worthwhile weight loss, with demonstrable improvements in many co-morbidities, among them, type 2 diabetes. Clinical trials with these anti-obesity medications in cohorts of obese diabetic patients have been reviewed as well as cathecolaminergic agents (diethylpropion [amfepramone], fenproporex, mazindol, ephedrine-caffeine combination), serotoninergic drugs (fenfluramine, dexfenfluramine, fluoxetine), and other drugs that have some action on weight loss (the antidiabetic agent metformin, anti-epileptic agents topiramate and zonisamide, and the antidepressive bupropion [amfebutamone]). These trials show variable benefits in terms of effects on glucose profiles.

Fatal Pulmonary Embolism and Cancer - a Post Mortem Study.

Introduction: During the period of 1965–1990 and 1991–2000, two separate analyses were carried out at King's College Hospital, London, taking a retrospective review of all autopsy reports during this time. The initial aims of these reviews were to determine the number of deaths from autopsy-confirmed fatal pulmonary embolism (FPE) in hospitalised patients, and the clinical characteristics of these patients.Methodology: Cases for inclusion were identified and data derived from manually examining copies of post-mortem reports. The data form recorded the patient gender, age, race, height, weight and surgical status. In addition, evidence of DVT, myocardial infarction (MI), stroke, chronic obstructive pulmonary disease (COPD), cardiac failure, infection or cancer was recorded from the autopsy report. Cases of fatal PE were classified as occurring in either surgical (if death occurred within 8 weeks of surgery), or non-surgical patients. The outcome of fatal pulmonary embolism was recorded as the cause of death only when the post-mortem stated that embolism was the main or contributing cause of death and identified emboli present either in the main pulmonary trunk or in the proximal right or left pulmonary arteries formed from the bifurcation of the main trunk. Emboli found in the distal pulmonary arteries after further division of the right and left pulmonary arteries were not included. Emboli derived from bone marrow, fat, tumour, or amniotic fluid were also excluded from the analysis. Ethical approval for the study was obtained from the local research ethics committee. The identity of deceased patients was protected by the use of code numbers on the data forms.Results: Over the 35 year period there were 45,575 hospital deaths and 16,862 (37%) post-mortems. FPE was recorded as cause of death in 1,040 (6.2%) adult patients. Of these 85% (n=885) were in non-surgical patients, and 15% (n=155) in post-operative patients. Of the fatal pulmonary emboli, 347 of 1040 (33%) had either cancer (active malignancy) or a past history of cancer. Of this cancer group, 93% (n= 323) had an active malignancy, with 7% (n= 24) giving a past history of cancer. Cancer sites were gastro-intestinal in 34% (n= 119), lung 24% (n= 82), urological 10% (n= 33), gynaecological 8% (n= 29) and breast 8% (n= 28), 5% haematological (n= 17) endocrine 5% (n= 16), and dermatological 1% (n= 3). The majority of active cancers were found within the peritoneal cavity (60%, n= 194). Infection was the additional risk factor that was most prevalent in all those with FPE occurring in 32% (n=334), 76.3% (n=808) had one or more additional risk factors.Conclusions: Most fatal pulmonary emboli occur in non-surgical patients, cancer is a very common association (33%). Active cancer is seen in 93% of all FPE deaths associated with cancer. Intra-peritoneal cavity tumours are the commonest type to be associated with FPE. Infection is a common associated risk factor.

Current management strategies for coexisting diabetes mellitus and obesity.

Besides genetic predisposition, obesity is the most important risk factor for the development of diabetes mellitus. Weight reduction has been shown to markedly improve blood glucose control and vascular risk factors associated with insulin resistance in obese individuals with type 2 diabetes. Therapeutic strategies for the obese diabetic patient include: (i) promoting weight loss, through lifestyle modifications (low-calorie diet and exercise) and antiobesity drugs (orlistat, sibutramine, etc.); (ii) improving blood glucose control, through agents decreasing insulin resistance (metformin or thiazolidinediones, e.g. pioglitazone and rosiglitazone) or insulin needs (alpha-glucosidase inhibitors, e.g. acarbose) in preference to agents stimulating defective insulin secretion (sulphonylureas, meglitinide analogues); and (iii) treating common associated risk factors, such as arterial hypertension and dyslipidaemias, to improve cardiovascular prognosis. Whenever insulin is required by the obese diabetic patient after failure to respond to oral drugs, it should be preferably prescribed in combination with an oral agent, more particularly metformin or acarbose, or possibly a thiazolidinedione. When morbid obesity is present, both restoring a good glycaemic control and correcting associated risk factors can only be obtained through a marked and sustained weight loss. This objective justifies more aggressive weight reduction programmes, including very-low-calorie diets and bariatric surgery, but only within a multidisciplinary approach and long-term strategy.