High Risk Of Future Complications Research Articles

P1514PERIPHERIAL VASCULAR DISEASE IN DIABETIC PATIENTS ON HEMODIALYSIS - RISK OF HOSPITALIZATION AND MORTALITY IN A LARGE EUROPEAN COHORT

Abstract Background and Aims Patients with diabetes mellitus on hemodialysis (HD) are at increased risk of development and progression of vascular calcification, atherosclerosis and peripheral vascular disease (PVD). Presence of PVD constitute a major risk factor for the development of cardiovascular events, such as myocardial infarction, stroke, hospitalization or cardiovascular death. The presence of PVD is also associated with a reduced quality of life and disability. A significant proportion of patients with PVD are asymptomatic with no or few classical symptoms and early detection to prevent progressive disease is therefore very important. Both the ACC/AHA and KDIGO guidelines recommend screening of individuals who are at risk. Method We analyzed the frequency of foot complications following implementation of a standardized foot examination in 345 prevalent diabetic hemodialysis patients in 12 DaVita centers; 8 in Poland (n=177 patients) and 4 in Portugal (n=168 patients). The protocol includes: history of ulcers, amputation and examination of the pedal pulses (a dorsalis pedis and a tibialis posterior). Foot complications were classified according to Wagner (grade 0-5). PVD was classified by clinical pulse measurement (normal vs weak or missing). We analyzed associations between foot complications and peripheral pulses with risk of hospitalization and mortality using Cox proportional hazard models. Results The mean age in all diabetic HD patients (58% men) was 70.4 (14 SD) yrs. Charlson comorbidity index (CCI) was 8.8 (2.4), Kt/V 1.8 (0.4), s-albumin 39 (4) g/L, Hb 11.1 (1.3) g/dL. A normal pulse in both a dorsalis pedis and both a tibialis posterior was found in 18% and 10% of patients. All other patients had weak or absent pulses. The Wagner classification score was 0 in 79% of patients, 1-3 in 16 % patients and 4-5 in 5 %. All-cause mortality was 31% during the 2 year follow up and 71% of patients had at least one hospital stay In patients hospitalized during follow up, a dors ped was normal/abnormal in 12% and 88% respectively (p<0.05); a tib post was normal/abnormal in 8% and 92%, respectively (p<0.05). There were no associations between Wagner score 0-5 and hospitalization or mortality. In unadjusted Cox models presence of weak or absent pulses in a dorsalis pedis was significantly associated with all-cause mortality RR 2.1 (CI 1.1-4.3; p<0.05). In adjusted analyses including age, sex, Hb, albumin, Kt/V, vascular access, phosphorus, PTH and CCI, only albumin was associated with mortality (RR 0.89, CI 0.84-0.94; p<0.001) and risk of hospitalization (RR 0.92, CI 0.89-0.96; p<0.001). Conclusion Diabetic patients on HD have a high prevalence of PVD that warrant close clinical attention. Documentation of peripheral foot pulses for early detection of PVD is simple and suitable to identify patients at high risk of future complications and mortality. This standardized protocol could be the basis of a program to improve overall health outcomes in this vulnerable group of patients.

Development of a transition program for adolescents with congenital heart disease.

Thanks to advances in care, most children with congenital heart disease nowadays survive into adulthood. The majority of patients remain at high risk for future complications. Hence, life-long follow-up is mandatory. Care needs of patients evolve, especially when reaching adulthood. A structured transition period to adult care is advocated. Currently, a fully detailed and structured transition program is not available for patients with congenital heart disease. The aim is to describe the development and design of a multicomponent transition program for adolescents with congenital heart disease, called "Transition with a heart." Transition with a heart was developed based on the Dutch program "On your own feet," starting at the age of 12 years and continuing after transfer. The most vital core components include a general and individualized flowchart, adolescent-centered communication, a joined transfer consultation, and an appointed transition coordinator. Adolescents are gradually informed about their condition and potential late consequences in adult life and stimulated to take medical care in their own hands.Conclusion: Transition with a heart is a practical, multicomponent, comprehensive transition program developed to cover the essential aspects of transitional care for adolescents with congenital heart disease (i.e., continuity of care, disease knowledge, and self-management skills). Interventions were selected from the highest sources of scientific evidence currently available.Clinical trial registration: Not applicableWhat is Known:• Transition towards adult life and health care is a complex process, requiring careful patients' guidance. Various task forces have described the need and potential benefits of transition programs in young people with chronic conditions. Details about the practical development and content of such programs in congenital heart disease are, however, currently lacking.What is New:• This method paper presents the development and design of a person-centered multicomponent transition program for adolescents with congenital heart disease comprising interventional components covering the most important aspects of transitional care: promoting autonomy, disease knowledge, and continuity of care.

STUDY ON THE ASSOCIATION OF OBESITY INDICES WITH INFLAMMATORY MARKERS IN PRE-DIABETES AND DIABETES

Objective: In this study, the main objective was to evaluate the association of markers of obesity with the inflammatory markers in pre-diabetes and diabetes.
 Methods: This study recruited 300 participants (100 control group, 100 pre-diabetic group, and 100 diabetic group). The anthropometric variables such as body mass index (BMI), waist-hip ratio (WHR), and waist circumference (WC), and biochemical variables such as fasting blood glucose, glycated hemoglobin, uric acid, C-reactive protein (CRP), fibrinogen, interleukin-6 (IL-6), and adiponectin were analyzed in each participant by standard methods.
 Results: The present study documented significantly high values of BMI and WHR in patient (pre-diabetic and diabetic) groups compared to the control group. Similarly, the level of adiponectin decreased and that of uric acid, CRP, fibrinogen, and IL-6 increased significantly. Both BMI and WC were correlated significantly with inflammatory mediators in diabetic patients. The correlation with adiponectin was negative. In the pre-diabetic group, a significant correlation was observed only between WHR, adiponectin, and uric acid.
 Conclusion: This study supports the fact that obesity-induced systemic inflammation of low grade is significantly associated with pre-diabetes and diabetes, thereby keeping these individuals at high risk of future complications especially cardiovascular diseases.

What is the Likelihood That Tumor Endoprostheses Will Experience a Second Complication After First Revision in Patients With Primary Malignant Bone Tumors And What Are Potential Risk Factors?

Endoprosthetic reconstruction of massive bone defects has become the reconstruction method of choice after limb-sparing resection of primary malignant tumors of the long bones. Given the improved survival rates of patients with extremity bone sarcomas, an increasing number of patients survive but have prosthetic complications over time. Several studies have reported on the outcome of first endoprosthetic complications. However, no comprehensive data, to our knowledge, are available on the likelihood of an additional complication and the associated risk factors, despite the impact of this issue on the affected patients. (1) What are the types and timing of complications and the implant survivorship free from revision after the first complication? (2) Does survivorship free from repeat revision for a second complication differ by anatomic sites? (3) Is the type of first complication associated with the risk or the type of a second complication? (4) Are patient-, tumor-, and treatment-related factors associated with a higher likelihood of repeat revision? Between 1993 and 2015, 817 patients underwent megaprosthetic reconstruction after resection of a tumor in the long bones with a single design of a megaprosthetic system. No other prosthetic system was used during the study period. Of those, 75% (616 of 817) had a bone sarcoma. Seventeen patients (3%) had a follow-up of less than 6 months, 4.5% (27 of 599) died with the implant intact before 6 months and 43% (260 of 599 patients) underwent revision. Forty-three percent of patients (260 of 599) experienced a first prosthetic complication during the follow-up period. Ten percent of patients (26 of 260) underwent amputation after the first complication and were excluded from further analysis. Second complications were classified using the classification of Henderson et al. to categorize surgical results. Briefly, this system categorizes complications as wound dehiscence (Type 1); aseptic loosening (Type 2); implant fractures or breakage and periprosthetic fracture (Type 3); infection (Type 4); and tumor progression (Type 5). Implant survival curves were calculated with the Kaplan-Meier method and compared using the log-rank test. Hazard ratios (HR) were estimated with their respective 95% CIs in multivariate Cox regression models. A second complication occurred in 49% of patients (115 of 234) after a median of 17 months (interquartile range [IQR] 5 to 48) after the surgery for the first complication. The time to complication did not differ between the first (median 16 months; IQR 5 to 57) and second complication (median 17 months; IQR 5 to 48; p = 0.976). The implant survivorship free from revision surgery for a second complication was 69% (95% CI 63 to 76) at 2 years and 46% (95% CI 38 to 53) at 5 years. The most common mode of second complication was infection 39% (45 of 115), followed by structural complications with 35% (40 of 115). Total bone and total knee reconstructions had a reduced survivorship free from revision surgery for a second complication at 5 years (HR 2.072 [95% CI 1.066 to 3.856]; p = 0.031) compared with single joint replacements. With the numbers we had, we could not show a difference between the survivorship free of revision for a second complication based on the type of the first complication (HR 0.74 [95% CI 0.215 to 2.546]; p = 0.535). We did not detect an association between total reconstruction length, patient BMI, and patient age and survivorship free from revision for a second complication. Patients had a higher risk of second complications after postoperative radiotherapy (HR 1.849 [95% CI 1.092 to 3.132]; p = 0.022) but not after preoperative radiotherapy (HR 1.174 [95% CI 0.505 to 2.728]; p = 0.709). Patients with diabetes at the time of initial surgery had a reduced survivorship free from revision for a second complication (HR 4.868 [95% CI 1.497 to 15.823]; p = 0.009). Patients who undergo revision to treat a first megaprosthetic complication must be counseled regarding the high risk of future complications. With second complications occurring relatively soon after the first revision, regular orthopaedic follow-up visits are advised. Preoperative rather than postoperative radiotherapy should be performed when possible. Future studies should evaluate the effectiveness of different approaches in treating complications considering implant survivorship free of revision for a second complication. Level III, therapeutic study.

Osteoporosis intervention following distal forearm fractures: a missed opportunity?

Fractures are a manifestation of osteoporosis, but therapeutic interventions to reduce the risk of recurrent fractures are not widespread. To identify predictors of osteoporosis treatment in postmenopausal women following distal forearm fracture. This population-based retrospective cohort study included all postmenopausal women, 45 years or older, residing in Olmsted County, Minnesota, who sustained a distal forearm fracture due to minimal trauma (a fall from standing height or under) in 1993 to 1997. Complete medical records were reviewed for each subject and Cox proportional hazards regression was used to evaluate the relationship of baseline demographic and clinical characteristics to therapeutic interventions for osteoporosis within 12 months following the fracture. A total of 343 women with a mean age of 70.5 years had a minimal trauma distal forearm fracture. Within 12 months, 83% had seen a nonorthopedic physician. Of these, 17% had a pharmacologic osteoporosis intervention and the 12-month actuarially estimated cumulative incidence of any intervention was 18% (95% confidence interval [CI], 14%-22%). In a multivariate analysis, treatment was more likely to be offered to those with a prior diagnosis of osteoporosis (relative risk [RR], 2.08; 95% CI, 1.21-3.58), previous distal forearm fracture (RR, 2.38; 95% CI, 1.30-4.34), or history of cigarette smoking (RR, 1.86; 95% CI, 1.11-3.12). Effective osteoporosis interventions are underutilized among postmenopausal women who experience an osteoporotic fracture. Further work is needed to overcome barriers to optimal osteoporosis management in these women who are at high risk for future complications of osteoporosis.