Diabetic Renal Disease Research Articles

Symptoms at NSTEMI presentation - do they predict the outcome?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The most common clinical presentation of non-ST-segment elevation myocardial infarction (NSTEMI) is angina pectoris. However, some groups of patients such as elderly, women and patients with diabetes or chronic renal disease,may have atypical symptoms, like isolated dyspnea or syncope. Aim The aim of this study was to identify the outcomes of NSTEMI patients with different types of presenting symptoms and to verify if these presentations were independent predictors of the studied outcomes. Methods We studied patients >18 year-old admitted with NSTEMI between October 2010 and September 2019. Data was collected from a national multicentric registry. From an initial pool of 13739 patients, a total of 4726 were included (the main exclusion criterion was lack of follow-up registry). The patients were divided into 3 groups according to the main presentation symptom: group 1 – chest pain; group 2 – dyspnea/fatigue; group 3 – syncope. The primary endpoint was 1-year death from any cause. Results The most common presentation sympton was chest pain (91.3%; n=4313), followed by dyspnea/fatigue (7%; n=332) and syncope (1.7%; n=81). Seventy-one percent (n=3352) of patients were male and 29.1% (n=1374) female. Mean age was 68±13 years. Patients presenting with dyspnea/fatigue were older (75±11 vs 68±13 [group 1] vs 74±13 [group 3], p<0.001), more commonly women (41.9% vs 29.1% [group 1] vs 37% [group 3], p<0.001), with hypertension (89.5% vs 74.8% [group 1] vs 75% [group 3], p<0.001), diabetes mellitus (54.6% vs 33.7% [group 1] vs 38.3% [group 3], p<0.001), chronic kidney disease (18.1% vs 6.8% [group 1] vs 11.5% [group 3], p<0.001, and chronic obstructive pulmonary disease [COPD] (15.5% vs 5.9% [group 1] vs 10.3% [group 3], p<0.001). They also had worse Killip class at admission (KK> 1 80% vs 9.9% [group 1] vs 23.5% [group 3], p<0.001). One-year survival rate was lowest patients presenting with dyspnea/fatigue (75.7% vs 93.5% [group 1] vs 92.1 [group 3], p<0.001) and 1-year free from cardiovascular rehospitalization was also lowest in this group (75.6% vs 85% [group 1] vs 83.3% [group 3], p<0.001). However, after multivariate analysis, the different presenting symptoms were not significant independent predictors of the primary endpoint; identified independent predictors included age (HR 3.37, 95% CI 2.111 to 3.815, p<0.001), COPD (HR 2.508, 95% CI 1.584 to 3.969, p<0.001), LVEF < 50% (HR 2.350, 95% CI 1.642 to 3.365, p<0.001), and major bleeding (HR 4.66, 95% CI 2.118 to 10.254, p<0.001). Conclusion This study reveals that patients with dyspnea/fatigue at presentation have an overall worse prognosis than those who present with chest pain or syncope. The former patients were more commonly women, older and had more comorbidities; also, they presented with worse Killip class. However, symptoms themselves were not independent predictors of 1-year mortality.

Investigating the influence of the gut microbiome on diabetic renal disease

BackgroundGut microbiota have been implicated in a large array of pathophysiological processes including obesity and diabetes. In this study, we utilized a diabetic renal disease model with or without oral antibiotic treatment to investigate how gut microbiota alter diabetic renal disease.MethodsGut microbiota biomass was depleted using a modified antibiotic treatment protocol with a mixture of 1g/L ampicillin, 1g/L neomycin, and 0.5 g/L vancomycin (modified from Rakoff‐Nahoum et al. 2004). C57BL/6J male and female mice (6‐week‐old) were randomly assigned to four different groups (n=8 per sex per group): control diet (CD), high‐fat diet (HFD), CD + antibiotics, HFD + antibiotics. The mice were treated with different diets and/or with antibiotics in drinking water for nine weeks. We measured body weight (BW), non‐fasting glucose, insulin, and glomerular filtration rate (GFR). In addition, we performed a glucose tolerance test (GTT), insulin tolerance test (ITT), and blood analysis. Finally, we did H&E staining of the kidney, and analyzed urine Na+.Results1) BW was significantly increased by HFD (vs CD) in both males and females regardless of antibiotic treatment. 2) Non‐fasting glucose showed no difference among these four groups in males and females. 3) Fasting glucose was dramatically elevated by HFD in males but not females (vs CD). For the GTT, both the peak glucose level and area under curve (AUC) were significantly increased in HFD vs CD, regardless of antibiotic treatment or sex. 4) For the ITT, HFD promoted insulin resistance as measured by changes in the AUC in both males and females. For males on a CD, antibiotics improved insulin responsiveness. 5) GFR was increased by HFD vs CD in both males and females, consistent with a HFD‐induced hyperfiltration, as we published previously with this same model (Halperin Kuhns, AJP Renal 2018). Intriguingly, GFR in females was also enhanced by antibiotic treatment on both the CD and HFD (week 9: CD, F: 182±12.7; HFD, F: 290±19.9, p<0.0001; CD + antibiotics, F: 282±12.6; HFD + antibiotics, F: 373±20.1; p=0.0005 CD vs. CD+antibiotics; p=0.01 HF vs. HF+antibiotics). Similarly, GFR in males also increased with antibiotic treatment in CD, but, not HFD (week 9: CD, M: 191±10.0; HFD, M: 385±19.3, p<0.0001; CD + antibiotics, M: 263±10.5; HFD + antibiotics, M: 390±32.7; p=0.04 CD vs. CD+antibiotics; p>0.99 HF vs. HF+antibiotics). Preliminary data using germ‐free (GF) mice, which do not have microbiota, show that GFR was also increased in GF males and females (vs. conventional mice with gut microbes).ConclusionIn this study, depletion of the gut microbiota via antibiotics increased GFR in both males and females on CD. Interestingly, on a HFD, GFR increased with antibiotics in females but not males. These data suggest that gut microbial signals may directly influence renal function; we are now working to confirm these findings and to explore the underlying mechanisms.

Morganella morganii, an Emerging Cause of Bloodstream Infections.

ABSTRACTAlthough recent reports of extensively antibiotic-resistant strains have highlighted the importance of Morganella morganii as an emerging pathogen, the epidemiology of serious infections due to this organism is not well defined. The objective of this study was to determine the incidence, determinants, and outcomes of Morganella morganii bloodstream infections (BSIs). Retrospective, population-based surveillance for Morganella morganii BSIs was conducted in Queensland, Australia, in 2000 to 2019; 709 cases were identified, for an annual incidence of 9.2 cases per million population. Most cases were of community onset, with 280 (39.5%) community-associated cases and 226 (31.9%) health care-associated cases. Morganella morganii BSIs were rare in children and young adults, and the incidence increased markedly with advancing age. The most common foci of infection were skin and soft tissue (131 cases [18.5%]), genitourinary (97 cases [13.7%]), and intraabdominal (90 cases [12.7%]). Most patients (580 cases [81.8%]) had at least one comorbid medical illness, with diabetes mellitus (250 cases [35.3%]), renal disease (208 cases [29.3%]), and congestive heart failure (167 cases [23.6%]) being most prevalent. Resistance to one or more of quinolones, co-trimoxazole, aminoglycosides, or carbapenems was observed in 67 cases (9.5%), and this did not change significantly over the study. The 30-day all-cause case fatality rate was 21.2%, and increasing age, nonfocal infection, heart failure, dementia, and cancer were independently associated with increased risk of death. Morganella morganii BSIs are increasing in our population, and elderly male subjects and individuals with comorbidities are at highest risk. Although antibiotic resistance is not a major contributor to the current burden in Queensland, ongoing surveillance is warranted.IMPORTANCE Recent reports of extensively antibiotic-resistant strains have highlighted the importance of Morganella morganii as an emerging pathogen. Despite its present and evolving importance as an agent of human disease, there is a limited body of literature detailing the epidemiology of serious infections due to Morganella morganii. Therefore, the objectives of this study were to examine the incidence and determinants of Morganella morganii BSIs and to examine risk factors for death in a large Australian population in 2000 to 2019.

Outcomes of axillofemoral and aortofemoral bypass for intermittent claudication may be similar

Despite almost 40 years of experience with axillofemoral grafts, there remains an absence of clear guidelines for their use, especially in treating intermittent claudication (IC). This motivated Levin et al1Levin S.R. Farber A. King E.G. Beck A.W. Osborne N.H. DeMartino R.R. et al.Outcomes of axillofemoral bypass for intermittent claudication.J Vasc Surg. 2021; 75: 1687-1694Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar to examine the Vascular Quality Initiative (VQI) database to evaluate the appropriateness of axillofemoral bypass for IC. Although apparently their aim was not to compare axillofemoral bypass data with aortofemoral bypass grafts, much of their paper is devoted to such a comparison. On the basis of this evaluation, they first conclude that axillofemoral bypass is associated with significant perioperative morbidity, mortality, and long-term complications, and second, serious consideration should be given before its use for IC. Critical review posits that their second conclusion is correct and admirable, but the first may not be entirely accurate. In assessing an operative technique that involves a bypass graft, all preoperative, intraoperative, and postoperative variables and outcomes need to be considered to determine its efficacy and clinical benefit. Although the VQI is a formidable database, concerning axillofemoral bypass many confounding factors were not recorded. These include the status of the donor subclavian/axillary artery, the use of heparin surfaced grafts, postoperative surveillance protocols, and interventions to maintain patency of the donor artery. Indeed, recent papers2Samson R.H. Showalter D.P. Lepore M.R. Nair D.G. Dorsay D.A. Morales R.E. Improved patency after axillofemoral bypass for aortoiliac occlusive disease.J Vasc Surg. 2018; 68: 1430-1437Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,3Hardouin S. Cheng T.W. Farber A. Kalish J.A. Jones D.W. Malas M.B. et al.Axillarybifemoral and axillary-unifemoral artery grafts have similar perioperative outcomes and patency.J Vasc Surg. 2020; 71: 862-868Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar have demonstrated excellent patency rates when heparin-bonded axillofemoral polytetrafluoroethylene grafts had been used or with axillary arteries that were proven normal or endovascularly treated to be, or remain, an acceptable donor vessel. Further, it is critical that if axillofemoral grafts are compared with the "gold standard" aortofemoral procedures, variables must be equivalent. In this report, patients undergoing axillofemoral grafts were more often older, female, had noncommercial insurance, ambulated with assistance, had a previous inflow bypass, ipsilateral leg bypass, peripheral endovascular intervention, and major amputation. Further, they were more often hypertensive, more likely to have coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, anemia, and end-stage renal disease (P < .05 for all). Despite these significant risk factors, axillofemoral bypass was accompanied by a shorter length of stay, fewer pulmonary and renal complications, and, assuming these results, possibly lower cost. Further, despite these morbidities, they did not suffer more postoperative medical complications or operative mortality. Extensive comorbidities may also explain the difference in survivors’ amputation rate (5.2% vs 2%) and graft occlusion (7% vs 3.6%). However, the latter difference may also result from failure to use the more current heparin-bonded polytetrafluoroethylene or dual antiplatelet and statin therapy. Further, researchers must be leery of combined end points where one of its constituents significantly outweighs the others. For example, the authors reveal that 1-year ipsilateral reintervention/amputation/death was more likely with axillofemoral grafts, yet it is notable that occlusion/death and amputation/death were similar between cohorts. What then is the takeaway? First, appropriately surgeons who enter data into the VQI are more likely to use axillofemoral bypass grafts for high-risk patients. Second, even aortofemoral bypass grafts have significant morbidity and mortality. Therefore, the authors’ conclusion is correct that serious consideration should be given before axillofemoral bypass for IC. However, this conservative approach applies equally to aortofemoral bypass procedures. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Outcomes of axillofemoral bypass for intermittent claudicationJournal of Vascular SurgeryVol. 75Issue 5PreviewAlthough endovascular therapy is often the first-line option for medically refractory intermittent claudication (IC) caused by aortofemoral disease, suprainguinal bypass is often performed. Although this will often be aortofemoral bypass (AoFB), axillofemoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC. Full-Text PDF

Vascular Complications After Simultaneous Pancreas and Kidney Transplantation: A Case Report

A 51-year-old patient with type I diabetes and end-stage renal disease was qualified for a simultaneous kidney and pancreas transplant. The procedure was performed in a typical manner: arterial anastomosis to the right common iliac artery, the graft's portal vein with inferior vena cava, and side-to-side duodenal intestinal anastomosis. The kidney was implanted retroperitoneally. Six months after the transplant, the patient reported pain in the right lower abdomen, and imaging examinations revealed arterial anastomosis. Reconstruction of the right common iliac artery was performed with a Gore-Tex prosthesis and the pancreatic artery reanastomosed to the right external iliac artery. After the surgery, the function of the transplanted pancreas deteriorated, the level of C-peptide was decreased, and the patient required low doses of insulin. After another 8 months, the imaging studies revealed an aneurysm located in the bifurcation of the aorta up to the anastomosis of the pancreatic graft artery with the iliac artery. The patient was qualified for the implantation of an endovascular of 2 prosthesis, which improved the graft's function. After another 2 months, the presence of an aneurysm at the endovascular prosthesis was found again. The patient was requalified for endovascular prosthesis implantation. Currently, there is no aneurysm but the function of the pancreas graft is impaired, though the kidney graft function is good. Patients after simultaneous kidney and pancreas transplant are a group of patients with an increased risk of vascular complications. Treatment should take place in a multidisciplinary center.

Need for resuming sports and physical activity for children and adolescents following COVID-19 infection.

IntroductionA decline in sports activities among children and adolescents was noted during the stay-at-home restrictions imposed by COVID-19. With the easing of restrictions, physical activities are being resumed.Evidence acquisitionA data search was conducted to identify the role of parents in resuming sporting activities, the risks and benefits of doing so, the physical examination to be conducted prior to physical activity, the existence of guidelines/protocols for return to sports and physical activity, the role of comorbidities in influencing the restart of the same.Evidence synthesisParents should consult the child’s physician prior to allowing he/she to resume physical exercise. In preparation for this, a careful physical examination should be performed. Children with COVID-19, even if asymptomatic, should not resume any physical activity until at least 10 days after testing positive. Those with moderate or severe COVID-19 should be referred for cardiological evaluation. The level of activity should be resumed gradually, as per the GRTP protocol. Athletes with a positive COVID-19 test in the presence of concomitant medical conditions (diabetes, cardiovascular or respiratory or renal disease) should undergo medical evaluation prior to adhering to a GRTP. Those with complicated COVID19 infection or long Covid may need additional investigations.ConclusionsWhile there is no doubt that it will bring multiple benefits in terms of general health, returning to play sport should be gradual and preceded by an accurate physical examination in those young subjects previously affected by the coronavirus disease, especially when their heart and/or lungs and/or kidneys were affected.

COVID-19 associated pulmonary mucormycosis: A systematic review of published cases with review of literature.

Background:There is sharp rise in cases of Coronavirus disease 2019 (COVID-19)-associated mucormycosis worldwide and specially during second wave of COVID-19 pandemic. This systemic review was conducted to characterize pulmonary mucormycosis associated with COVID-19 infection.Materials and Methods:A systematic literature search was conducted in the electronic database of PubMed and Google Scholar from 1st January 2020 to June 5, 2021 using keywords. Details of all the cases that reported pulmonary mucormycosis in people with COVID-19 so far, were retrieved and analyzed.Result:Total 9 articles of pulmonary mucormycosis with COVID-19 infection were reported in the database of PubMed and Google Scholar. Only one case till date was reported from India, others are from USA (n-3), Italy (n-2), France (n-1), UK (n-1), and Arizona (n-1). Pooled data from this study showed mucormycosis was predominantly seen in males (8 male, 1 female). The most common comorbidities associated were diabetes (n-3), hematological malignancy, (n-2) and end-stage renal disease (n-2), while 2 cases did not show any associated comorbidity. All the cases were having severe COVID-19 infection and 7 out of 9 patients were in ICU and on mechanical ventilation at the time of diagnosis. None of the cases associated with rhino-orbital-cerebral mucormycosis (ROCM) except 1 patient with sinus involvement. Mortality was found in 7 out of 9 patients.Conclusion:There is a need to keep a high index of suspicion in patients with severe COVID-19 infections, diabetic, and received treatment in ICU with ventilator support for early diagnosis and treatment. Although Mucor is less common than Aspergillus infection, it is associated with higher mortality.

The relationship between B-cell lymphoma 2, interleukin-1β, interleukin-17, and interleukin-33 and the development of diabetic nephropathy

Diabetic nephropathy (DN) is among the main complications of diabetes mellitus and has been a major factor of renal failure. This study was designed to address the association between beta-cell lymphoma-2 (Bcl-2), interleukin (IL)-1β, IL-17, and IL-33 and the development of DN. In this study, 20 healthy volunteers and 100 patients were enrolled. According to their biochemical markers, the patients were categorized into five groups: diabetic, chronic renal disease, diabetic chronic renal disease, end-stage renal disease, and diabetic end-stage renal disease. Our results showed a noticeable elevation in IL-1β and IL-17 levels and a reduction in IL-33 and Bcl-2 levels in all investigated groups compared with those in the healthy group. Positive correlations were found between IL-1β and fasting blood sugar and between creatinine levels and IL-17, HbA1c%, and sodium levels. However, negative correlations were found between IL-33 and urea and sodium concentrations and between Bcl-2 and HbA1c% and creatinine levels. The present data revealed a marked relationship between Bcl-2, IL-1β, IL-17, and IL-33 levels and the onset and progression of DN. Understanding the molecular pathways of these processes could be translated into the development of therapeutic strategies.

JCL Roundtable. Obesity, Diabetes, and Liver Disease in Relation to Cardiovascular Risk

Metabolic risk for cardiovascular and other systems includes much more than just LDL cholesterol. This JCL Roundtable brings together 3 experts to address new opportunities to reduce the risks posed by obesity, diabetes, and fatty liver disease. Successful nutritional approaches to weight loss are diverse and need to be matched with individual preferences. Topiramate plus extended-release phentermine has been shown to promote meaningful weight loss in randomized trials, but the patented drug combination is expensive. Clinical experience suggests that generic topiramate and phentermine may also be effective. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) have shown favorable tolerability and efficacy for cardiovascular disease in randomized trials, an achievement without precedent among earlier diabetes medications. These 2 drug classes differ in their effects. GLP-1 RAs decrease atherosclerotic cardiovascular events and also decrease hemoglobin A1c, body weight, blood pressure, and possibly diabetic renal disease. SGLT2 inhibitors are effective in reducing heart failure events even among nondiabetic patients. They also decrease progression of diabetic renal disease. The presence of nonalcoholic fatty liver disease signifies risk for atherosclerotic cardiovascular disease as well as cirrhosis and serious hepatic decompensation, including hepatocellular carcinoma. The key to identifying cirrhosis risk is to assess pre-emptively liver fibrosis, which can be predicted initially with blood test risk scores (e.g., FIB-4 index) and more definitively by transient elastography and other imaging techniques and/or liver biopsy. Some medications approved for the treatment of type 2 diabetes may reduce liver fat (SGLT2 inhibitors, insulin) or even reverse steatohepatitis in paired liver biopsy studies (GLP-1 RAs or pioglitazone) Overall the field of preventive metabolic medicine is expanding. Clinical lipidologists should become familiar with recent advances.

TDAG51-Deficiency Podocytes are Protected from High-Glucose-Induced Damage Through Nrf2 Activation via the AKT-GSK-3β Pathway.

T cell death-associated gene 51 (TDAG51) has been implicated in the development of various pathological conditions. However, whether TDAG51 plays a role in diabetic renal disease remains unknown. The current work investigated the possible function of TDAG51 in diabetic renal disease using high-glucose (HG)-stimulated podocytes in vitro. The elevation of TDAG51 was observed in podocytes in response to HG exposure and the glomeruli of diabetic mice. The siRNAs targeting TDAG51 were applied to deplete TDAG51 in HG-stimulated podocytes. Crucially, TDAG51 deficiency was sufficient to decrease the apoptosis, oxidative stress, and inflammation caused by HG. Mechanically, the inhibition of TDAG51 was capable of enhancing the activation of nuclear factor E2-related factor 2 (Nrf2) associated with the upregulation of AKT-glycogen synthase kinase-3β (GSK-3β) pathway. The reduction of AKT abolished the activation of Nrf2 elicited by TDAG51 deficiency. Additionally, the reduction of Nrf2 diminished the anti-HG injury effect elicited by TDAG51 deficiency. Overall, these data demonstrate that TDAG51 deficiency defends against HG-induced podocyte damage through Nrf2 activation by regulating AKT-GSK-3β pathway. This study suggests that TDAG1 may have a potential role in diabetic renal disease by affecting HG-induced podocyte damage.

Systematic review and meta-analysis: the effect and safety of peritoneal dialysis in patients with end-stage diabetic kidney disease.

At present, peritoneal dialysis (PD) is widely used in the clinical treatment of patients with end-stage renal disease (ESRD), and comparison of the efficacy of PD and hemodialysis (HD) in the treatment of diabetic kidney disease (DKD) has been reported in a few clinical studies. In this study, "dialysis", "peritoneal dialysis", "renal replacement therapy", "end-stage renal disease", "diabetic renal disease", and "efficacy and safety" were used as search terms in Chinese and English databases. According to RevMan 5.3 and Stata 13 software provided by the Cochrane Collaboration, a meta-analysis was performed. Four randomized controlled trials were included in this study, and 3 trials described the randomization method, 3 described allocation concealment in detail, and 2 used the blinding method. Compared with the HD treatment in the control group, the PD treatment in the experimental group can significantly reduce the hemoglobin of patients with end-stage DKD [Mean difference (MD) =-0.13, 95% confidence interval (CI): -0.21 to -0.04; P=0.003<0.05] and Albumin level (MD = -0.10, 95% CI: -0.16 to -0.04; P=0.002<0.05). Compared with the control group, the PD treatment in the experimental group significantly increased the serum creatinine and blood urea nitrogen levels in patients with end-stage DKD, but there was no significant difference in the effects of PD and HD treatment on serum creatinine levels (MD =-0.30, 95% CI: -0.77 to 0.16; P=0.20>0.05), (MD =1.93, 95% CI: -2.65 to 6.51; P=-0.41>0.05). In addition, PD treatment in the experimental group significantly increased the probability of malignant tumors in patients with end-stage DKD [odds ratio (OR) =1.86, 95% CI: 1.64 to 2.10; P<0.00001], and the difference was significant. This study used meta-analysis to confirm that PD can significantly improve the renal function of patients with end-stage DKD, but it can also increase the probability of protein loss and complications.

POS-214 SHOULD WE BIOPSY TYPE II DIABETES MELLITUS?

Background: Type 2 diabetes mellitus (DM2) patients may have diabetic (DN) or non-diabetic renal disease (NDRD) and a histological diagnosis is needed. There is no clear consensus on when to biopsy, but a predictive model was recently published (1).

Perioperative Outcomes Among Major Endovascular Stent Grafts For The Treatment Of Abdominal Aortic Aneurysm

<h3>INTRODUCTION</h3> There are currently six endovascular stent grafts approved by the Food and Drug Administration for the endovascular repair (EVAR) of infra-renal abdominal aortic aneurysms (AAA). There is minimal data comparing the outcomes between devices. <h3>METHODS</h3> The National Surgical Quality Improvement Program (NSQIP) targeted database was queried for patients undergoing EVAR between 2011-2019. Devices used in at least 10% of patients were included (Cook Zenith, Gore Excluder, and Medtronic Endurant). Patient demographics, procedure details, 30-day EVAR specific complications and mortality were compared between devices. Multivariable logistic regression models were used to predict outcomes while adjusting for baseline differences between device cohorts. <h3>RESULTS</h3> 13,416 patients were included. Most patients underwent repair with a Gore Excluder (5,997; 44.7%). There was no difference in the rates of diabetes, hypertension, or end-stage renal disease between cohorts. Unadjusted outcomes are shown in Table 1. The rate of postoperative acute limb ischemia (ALI) was higher in overall patients who underwent repair with a Medtronic Endurant, as well as in subgroup analysis of patients with ruptured AAA. Patients who underwent repair with a Medtronic Endurant were more likely than those who underwent repair with a Gore Excluder (OR=2.06; 95%CI=1.49-2.86) or with a Cook Zenith device (OR=1.56; 95%CI=1.06-2.28), to have postoperative ALI. No differences between devices were associated with death, MACE, ischemic colitis, conversion to open or postoperative dialysis. <h3>CONCLUSION</h3> Overall, safety is similar among major endovascular stent grafts for EVAR, except for a higher rate of ALI following repairs with the Medtronic Endurant. Since with this study we cannot determine if the higher incidence of ALI relates to graft design, patient anatomy, or operative technique, future studies should be aimed to further evaluate this finding.Image, table 1Image, table 1

The Use of Sustained Release Intravitreal Steroid Implants in Non-Infectious Uveitis Affecting the Posterior Segment of the Eye.

The treatment of non-infectious uveitis affecting the posterior segment of the eye has been revolutionized by the development of sustained-release corticosteroid implants over the past decade. Their use is now supported by healthcare systems that have licensed and commissioned them on the basis of the high-quality randomised controlled trials that formed part of their development and which have informed clinicians as to their benefits and risks. In particular, they have provided an alternative mode of treatment for patients who do not wish to be systemically immunosuppressed, or in whom such immunosuppression is less desirable, such as those with unilateral disease or those with concurrent illnesses such as diabetes mellitus, renal disease or osteoporosis that are negatively impacted by systemic corticosteroids or other immunosuppressive agents. In this article, we review the evidence for the use of the major licensed corticosteroid implants and assess the advantages and disadvantages of each.

Masked hypertension and neonatal outcome in high-risk pregnancies.

We previously showed that masked hypertension is a frequent finding in high-risk pregnancies and a strong predictor of preeclampsia/eclampsia. However, neonatal consequences of masked hypertension have not been deeply analyzed. Consequently, the aim of this study was to determine if masked hypertension is a risk factor for poor neonatal outcome. We evaluated a cohort of 588 high-risk pregnant women (29 ± 7 years old with 27 ± 6 weeks of gestation at blood pressure evaluation); 22.1%, 8.5%, 2.9%, and 2.6% had history of hypertension, diabetes, collagen diseases and chronic renal disease, respectively. According to the data of office and ambulatory blood pressures monitoring, women was classified as normotension (61.7%), white-coat hypertension (5.4%), masked hypertension (21.6%) and sustained hypertension (11.2%) respectively. Compared to normotension, all neonatal outcomes were worst in women with masked hypertension; neonates had lower mean birth weight (2577 (842) vs. 3079 (688) g, P < 0.001), higher prevalence of very low (12.1% vs 2.0%, P = .002) and extremely low birth weight (4.3% vs 0%, P < 0.001), and low one-minute APGAR score (7.8% vs 1.8%, P < 0.001). Furthermore, 14.2% needed admission to neonatal intensive care unit (NICE) (P = 0.001). Compared with normotension the risk for poor the combined neonatal outcome (admission to NICE plus still born) was significantly higher in masked hypertension (adjusted OR 2.58 95% CI 1.23-5.40) but not in white-coat hypertension (adjusted OR 0.41 95% CI 0.05-3.12). In conclusion, in high-risk pregnancies, masked hypertension was a strong and independent predictor for poor neonatal outcomes.

Renal biopsy in diabetic patients: Histopathological and clinical correlations

Introduction: Diabetes is the leading cause of chronic kidney disease and end-stage kidney disease worldwide. A kidney biopsy in a diabetic patient must be considered when non-diabetic renal disease is suspected, such as in the presence of a rapid decline in renal function or severe unexplained proteinuria. However, the timing and criteria of a biopsy remain controversial in these patients. We aimed to identify clinical and histological markers that could help differentiate diabetic and non-diabetic renal disease and decide if this invasive approach is needed or not. Subjects and Methods: We reviewed 30 years of biopsies from diabetic patients performed at a tertiary hospital. We collected patient demographic data, biopsy indications, histological findings, and clinical and analytical data both at the moment of the biopsy and extensive followup. Based on kidney biopsy findings, patients were categorized as isolated diabetic nephropathy, non-diabetic kidney disease, or non-diabetic kidney disease superimposed on diabetic nephropathy (diabetic kidney disease). Results and Discussion: We enrolled 92 patients, mostly with type 2 diabetes, with a mean age of 62.9 ± 13.2 years. Nearly half of them had isolated diabetic nephropathy (53.3%), and 15.2% had diabetic nephropathy superimposed on non-diabetic kidney disease, comprising a total of 63 patients (68.5%) with diabetic kidney disease. Twenty-nine patients (31.5%) were considered to have non-diabetic kidney disease. These last patients were significantly less likely to need insulin therapy (p=0.002), had more frequently an acute deterioration of renal function (p=0.01), lower albumin levels (p=0.03), and a higher prevalence of microhematuria (p=0.001). We found the latter to be an independent predictor of non-diabetic kidney disease. Further, patients with the primary diagnosis of diabetic nephropathy had higher survival than those who had nondiabetic kidney disease, contradicting published data. Conclusions: The criteria for performing a biopsy in diabetic patients still lack consensus, although the priority to identify non-diabetic kidney disease prevails. We believe the non-diabetic kidney disease predictors we describe may prove helpful for determining the need for a histological assessment in diabetic patients.

Acute Presentation of Upper Limb Ischemia Requiring Amputation: A Case Report

Peripheral Artery Disease (PAD) of the upper extremities is common. It is most often asymptomatic but may cause exertional pains, ischemic pains, gangrene or ulceration. The risk factors for PAD are smoking, obesity, hypertension, diabetes, hypercholesterolemia and end stage renal disease. Here the authors reported a case of 45-year-old male patient, presenting with severe aching type of pain associated with paraesthesia and numbness and blue, cold and gangrenous right forearm which was amputated below the elbow. After amputation, the condition advanced and led to weakness of the right upper arm with bone necrosis and surrounding skin was hyperaemic and oedematous with differential warmth, therefore the patient undergone amputation of the right upper arm and was managed postoperatively with antibiotics and the wound was closed with non absorbable sutures and was on oral anticoagulant therapy and after complete recovery, patient was discharged. On follow-up, removal of sutures was done and patient was referred for physiotherapy for muscle strengthening and prosthesis fitment.

Association between Influenza vaccination and severity of lung involvement at CT images of the patients with COVID-19 infection: an Iranian retrospective case-control study.

Background:Despite advances in preventive measures, COVID -19 spread and mortality is continuing due to delay in timely diagnosis. This problem is partly dependent on variations in disease characteristics, distribution of risk factors particularly comorbidities and demographic characteristics of patients. This study aimed to determine the clinical presentation and associated factors of mortality in patients hospitalized with COVID -19 infection.Methods:Patients were divided into survivor and deceased groups, and clinical and laboratory findings and factors associated with mortality between the two groups were compared by calculating odds ratio (OR) with 95% confidence interval (95% CI).Results:A total of 257 patients (female 45.1%) with a mean age of 59.8+15.7 years and a mean hospital stay of 4.89+3.57 days were studied. Diabetes, hypertension, cardiovascular disease and chronic renal disease (CRD) were found in 29.6%, 37.5%, 16.3% and 3.5% of all patients, respectively. Forty-one (16%) patients died. Factors such as age >50 years, coexisting CRD, serum creatinine > 2 mg/dl; SPO2 <70% lymphocytes < 20% during hospitalization were independently associated with mortality. The adjusted ORs (95% CI) were 10.08 (1.39-73); 4.51(1.15-17.61); 6 (1.14-31.5); 16.8(2.93-96.7); and 4.9(1.31-18.1), respectively. Most of the expected effective drugs were not associated with lower mortality.Conclusion:These results indicate a high in-hospital mortality rate in COVID -19 patients. Some mortality factors occurring during hospitalization were reversible and could be prevented by timely diagnosis and appropriate treatment.

Current prescription status of antihypertensive drugs in Chinese patients with hypertension: analysis by type of comorbidities

ABSTRACT In 2020, the National Center for Cardiovascular Diseases with National Committee on Hypertension Management in Primary Health Care in China issued revised national clinical practice guidelines on the management of hypertension in primary health care based on the 2018 Chinese guidelines for the management of hypertension. To evaluate adherence to the guidelines, this retrospective study assessed the real-world status of antihypertensive drug prescribing for Chinese patients with hypertension, classified by comorbidity: coronary heart disease, diabetes mellitus, heart failure, stroke, and renal disease. About 1088212 hypertensive patients who received their first prescription for antihypertensive therapy between January 2021 to June 2021, were obtained from a database of Hangzhou Kang Sheng Health Consulting CO., Ltd. Calcium channel blockers (CCBs) and angiotensin II receptor blockers (ARBs) were the most common drugs prescribed for each comorbidity subgroup. Whereas diabetes mellitus or renal disease is a compelling indication for use of renin–angiotensin system inhibitors, CCBs were often administered in these subgroups. The treatment pattern for patients with coronary heart disease was closely similar to that for the overall patient population. Beta-blockers (BBs) were prescribed more frequently for patients with heart failure than for those with other comorbidities. Although antihypertensive drug prescription varied by comorbidity, pharmacological decisions were largely made under Chinese recommendations while physicians could select antihypertensive drugs based on the patients’ comorbidities. However, educational initiatives are still necessary to inspire clinicians to better familiarize themselves with the guidelines and manage hypertension comorbid diseases.

Pinch grafting: An alternative skin grafting technique

Pinch grafts are a useful and cost-effective technique as an adjunctive consideration for closure of sub-acute or chronic lower extremity wounds. In our institution, we have used this technique on numerous patients with appropriately prepared wounds amenable to skin grafting. Pertinent factors include patients with adequate arterial flow, absence of infection, metabolic stability of diabetes mellitus, cardiac disease, renal disease and acceptable nutrition. The procedure adds minimal morbidity, allows for primary closure of the donor site, and can be done in an outpatient setting under local anesthesia. This technique is efficient, economical, and useful on a wide variety of wounds with good results.