Higher Rates Of Diabetes Mellitus Research Articles

66 Comparison of Patient Demographics, Disposition, and Outcomes Using a Chief-Complaint-Based Denominator versus Administrative Claims-Based Denominator for Emergency Department Patients With Chest Pain

International Classification of Diseases (ICD) codes are used by many quality measures to identify cohorts of patients with disease positive states. Because emergency department (ED) patients are evaluated and managed in real-time according to their chief complaint, we hypothesize that quality measures utilizing a chief complaint-based denominator may be a more accurately reflect care delivered in the ED. In this study, we sought to compare patient demographics, disposition, and outcomes using 2 unique yet overlapping denominators using medical record data from a large health care network. Using electronic medical record data between 1/1/2017 - 4/13/2018 from 16 different emergency departments in Western Pennsylvania, we included all patients ≥ 18 years old, afebrile (temp ≤ 38°C), for whom an ECG and troponin were ordered in the ED. We excluded any patient not evaluated in an in-network outpatient office within 365 days before the index ED visit in order to allow reliable estimation of patient comorbidities in our patient cohort. We then identified ED patients with chest pain using 2 different methods. In our chief complaint cohort, patients were selected using a text string matching algorithm. In our ICD cohort, patients were selected using a predefined set of ICD-10 diagnostic codes for chest pain which matched the denominator of a quality measure currently used by the Emergency Quality Network (E-QUAL). Patient outcomes, including 30-day rates of acute myocardial infarction and mortality were determined from subsequent medical records, including office visits, and the national death index. We compared patient demographics, ED disposition, and outcomes between our 2 patient cohorts using a Pearson’s Chi-square test with alpha error rate of 0.05. Of 78,619 patients meeting our initial inclusion and exclusion criteria, 22,092 patients were identified using the chief-complaint algorithm while 21,800 patients were identified using the ICD coding method. Although there was no difference in overall admission rates between the chief complaint cohort and the ICD cohort, more patients in the ICD cohort were admitted to observation status (46.7 versus 41.4, p<0.001). In terms of 30-day outcomes, there was a higher rate of acute myocardial infarction and mortality in the chief complaint cohort relative to the ICD cohort (AMI: 2.0 versus 1.1, p<0.001; mortality: 0.8 versus 0.7, p=0.027). Similarly, there was a higher rate of diabetes mellitus and underlying coronary artery disease in the chief complaint cohort relative to the ICD cohort (diabetes: 20.6 versus 19.6, p=0.008; coronary artery disease: 18.7 versus 16.9, p<0.001). In comparison to a chief-complaint-based denominator, an ICD-based denominator may select for a lower risk ED population with a lower incidence of short-term morbidity and mortality.

Disparities in Cardiovascular Risk Factors in Northern Plains American Indians Undergoing Coronary Artery Bypass Grafting.

Objectives: Heart disease is the leading cause of death in American Indians (AIs). For AI patients with severe coronary artery disease requiring coronary artery bypass graft (CABG) surgery, little data exist. The purpose of this study was to evaluate short-term outcomes of Northern Plains AI undergoing CABG and identify variations in patient presentation.Methods: All patients undergoing isolated CABG between June 2012 and June 2017 were studied. Seventy-four AI and 1236 non-American Indian (non-AI) patients were identified. Risk factors, preoperative characteristics, cardiac status, procedural information, and outcomes were collected. Univariate analysis comparing short-term clinical outcomes between AI and non-AI populations was performed. Multivariable logistic regression models were constructed and outcome differences assessed. Unadjusted Kaplan–Meier survival estimates were produced using 5-year survival data.Results: AI patients presented with increased risk factors, including higher rates of diabetes mellitus (AI 63.5% vs. non-AI 38.7% p=< 0.001) and smoking/tobacco use (AI 60.8% vs. non-AI 20.0% p=> 0.001). Seventy-nine percent of AI patients resided on or near federal reservations and presented from rural locations. Internal mammary artery (IMA) graft use in both groups was high (AI 95.9% vs. non-AI 94.9% p=0.904), and multiarterial grafting with left internal mammary artery and radial artery use was common in both groups (AI 67.6% vs. non-AI 69.6% p=0.814). No significant differences in unadjusted 30-day mortality or short-term outcomes were detected. Adjusted Kaplan–Meier survival curves were similar between race groups up through 5 years after CABG (p-value=0.38).Conclusion: AIs presented with significantly more risk factors for cardiovascular disease compared with the general population, with especially high rates of insulin-dependent diabetes and active tobacco use. Despite this, outcomes were similar between groups. In propensity-matched groups, AIs were at decreased risk for prolonged length of stay and combined morbidity/mortality. In contrast to previous reports, AI racial identity did not adversely affect survival up to 5 years after CABG.

Factors associated with lumbar spinal stenosis in a large-scale, population-based cohort: The Wakayama Spine Study.

ObjectivePatients with lumbar spinal stenosis (LSS) who have radiographically similar degrees of stenosis may not necessarily exhibit equivalent symptoms. As part of a cross-sectional study, we examined factors associated with symptomatic LSS (sLSS) in the general population of Japan.MethodsWe evaluated 968 participants (men, 319; women, 649) between 2008 and 2010. Orthopedic surgery specialists diagnosed sLSS using interview results, medical examinations, and imaging findings. LSS was radiographically graded using a 4-level scale. Additionally, we examined basic anthropometry, smoking habits, alcohol consumption, ankle-brachial index values (ABI), and glycosylated hemoglobin (HbA1c) levels. We grouped patients with moderate and severe radiographic LSS, and compared the indicated factors on the basis of the presence/absence of sLSS. Data were evaluated using multiple logistic regression analyses.ResultsRadiographically, 451 participants had moderate and 288 severe stenosis. Clinically, 92 participants were diagnosed with sLSS, including 36 with moderate and 52 with severe stenosis. In the moderate stenosis group, participants with sLSS had significantly higher rates of diabetes mellitus (DM) and lower ABIs than did non-LSS participants. Although sLSS participants tended to be older (p = 0.19), there were no significant differences in the sex distribution, body mass index values, or in the percentages of participants who were drinkers/smokers. In the severe stenosis group, there were no differences in any of the evaluated factors. Multiple logistic regression showed that DM (odds ratio [OR], 3.92; 95% confidence interval [CI], 1.52–9.34]) and low ABI (1 SD = 0.09; OR, 1.36; 95% CI, 1.04–1.81) were significantly associated with LSS in the moderate stenosis group.ConclusionsDM and low ABIs are significantly associated with sLSS in patients with moderate radiographic stenosis. Neither factor is associated with sLSS in patients with severe stenosis. Notably, the effects of intrinsic factors on symptomology may be masked when anatomic stenosis is severe.

Cost of Diabetes in Saudi Arabia

Background: The Kingdom of Saudi Arabia (KSA) has made tremendous improvements in its health system in a short period of time due to extensive investments from oil revenues. In 2015, the Saudi Ministry of Health (MOH) housed 250,000 personnel, including 31,516 physicians and 75,978 nurses, and operated 249 hospitals with 34,000 beds. It is responsible for 60% of healthcare services, with the remaining 40% managed by a number of semi-public organizations and the private sector .The MOH is in charge of health promotion, disease prevention, and treatment. Health care services are provided for free throughout the country. In recent years and with improvements in infrastructure and health services, an increasing burden of non-communicable diseases is emerging. We recently reported high rates of diabetes mellitus.

The Health of America's Aging Prison Population.

Older incarcerated individuals comprise the fastest growing demographic in the US prison system. Unhealthy lifestyles among incarcerated individuals and inadequate health care lead to earlier onset and more rapid progression of many chronic conditions that are prevalent among community-living older adults. There are limited peer-reviewed epidemiologic data in this area; however, there is growing interest in identifying strategies for housing aging incarcerated individuals, delivering appropriate health care in prisons, and coordinating after-release health care. In this systematic review, we summarize the epidemiologic evidence of the health challenges facing the aging US prison population. Our comprehensive literature search focused on health outcomes, including diseases, comorbid conditions, mental health, cognition, and mobility. From 12,486 articles identified from the literature search, we reviewed 21 studies published between 2007 and 2017. All the studies were observational and cross-sectional, and most (n = 17) were based on regional samples. Sample sizes varied widely, ranging from 25 to 14,499 incarcerated people (median, 258). In general, compared with their younger counterparts, older incarcerated individuals reported high rates of diabetes mellitus, cardiovascular conditions, and liver disease. Mental health problems were common, especially anxiety, fear of desire for death or suicide, and depression. Activities of daily living were challenging for up to one-fifth of the population. We found no empirical data on cognition among older incarcerated individuals. The findings of this review reveal few empirical data in this area and highlight the need for new data to drive policy and practice patterns that address critical health issues related to the aging prison population.

High serum leptin levels are associated with central arterial stiffness in geriatric patients on hemodialysis.

Objective:Central arterial stiffness predicts cardiovascular (CV) mortality in hemodialysis (HD) patients. The aging process transforms lipid distribution and thus alters adipokine secretion. The harmful effects of leptin on CV events may change in the elderly. The purpose of this study was to investigate the relationship between leptin and central arterial stiffness markers through carotid–femoral pulse wave velocity (cfPWV) in geriatric HD patients.Materials and Methods:Patients over 65 years old on chronic HD were recruited. Blood samples were collected, and the cfPWV was measured with the SphygmoCor system. The patients with cfPWV values >10 m/s were defined as the high arterial stiffness group.Results:In total, 30 (51.7%) of the 58 geriatric patients on chronic HD in this study were in the high arterial stiffness group. The high arterial stiffness group had higher rates of diabetes mellitus (P = 0.019), hypertension (P = 0.019), and higher systolic blood pressure (P = 0.018), pulse pressure (P = 0.019), body mass index (P = 0.018), serum leptin levels (P = 0.008), and hemoglobin levels (P = 0.040) than those in the low arterial stiffness group. Multivariable forward stepwise linear regression analysis showed logarithmically transformed leptin (log-leptin, β =0.408, adjusted R2 change = 0.164; P = 0.001) and diabetes (β =0.312, adjusted R2 change = 0.085; P = 0.009) were associated with cfPWV values in geriatric HD patients. Moreover, an increased serum leptin level (odds ratio: 1.053; 95% confidence interval: 1.007–1.100; P = 0.023) was an independent factor for central arterial stiffness among geriatric HD patients after multivariate logistic regression analysis.Conclusion:In this study, a higher serum leptin level was correlated with central arterial stiffness in geriatric HD patients.

Incidence and risk factors of groin lymphocele formation after venoarterial extracorporeal membrane oxygenation in cardiogenic shock patients

ObjectiveVenous-arterial extracorporeal membrane oxygenation (VA-ECMO) is a well-established therapy for refractory cardiopulmonary failure. Femoral cannulation offers a quick and effective means of providing circulatory support but is not without complication. Inflammation or lymphatic disruption at the site of cannulation can cause the formation of lymphoceles, leading to the patient's discomfort and possibly necessitating intervention. The purpose of this study was to evaluate the incidence of in-hospital lymphocele formation in VA-ECMO patients and to identify predictors for their development. MethodsWe conducted a single-center retrospective review of 192 patients who underwent femoral VA-ECMO insertion and subsequent decannulation from March 2007 to August 2016 for cardiogenic shock. Baseline demographics, risk factors, and cannulation strategies were examined. Groin lymphocele formation was assessed as the primary outcome. ResultsMedian age was 58 years (interquartile range, 48-67 years) with a median duration of support of 4 days (interquartile range, 2-6 days). Lymphocele formation was identified in 31 patients (16%). Patients who developed lymphoceles were more likely to have post-heart transplantation primary graft dysfunction (PGD) as an indication for ECMO support compared with those who did not (54.2% vs 8%; P < .001). ECMO duration was similar between groups, but lymphocele patients were more likely to have undergone femoral cutdown procedures (68% vs 42%; P = .010). Compared with those PGD patients who did not develop lymphoceles, PGD lymphocele patients had higher rates of diabetes mellitus preoperatively (62% vs 8%; P = .006). Thirteen (42%) patients required surgical incision and drainage, and 4 of these patients (31%) required repeated surgical intervention. ConclusionsLymphocele formation is relatively common after femoral VA-ECMO. There was a significantly higher incidence of lymphocele formation in diabetic patients requiring support for PGD after heart transplantation.

Liver transplantation recipients with nonalcoholic steatohepatitis have lower risk hepatocellular carcinoma.

Liver transplantation (LT) is a well-established treatment for hepatocellular carcinoma (HCC) in carefully selected patients. Risk factors for tumors with poor prognostic features on explant have not been well described in a national cohort. We performed a retrospective cohort study of adult LT recipients with HCC transplanted from April 8, 2012 (when explant pathology in United Network for Organ Sharing [UNOS] became available) until September 30, 2014. We evaluated the association between listing diagnosis and other demographic factors with tumor features on explant using logistic regression. High-risk tumor features included the following: > 3 tumors, largest tumor > 5 cm, presence of vascular invasion, presence of metastases, and poor differentiation of tumor. In total, 3733 LT recipients with HCC who had complete explant data in UNOS were included. The median age was 60 years; 78% were male; and 68% were white. Of the primary non-HCC listing diagnoses, 2608 (70%) had hepatitis C virus (HCV); 271 (7%) had nonalcoholic steatohepatitis (NASH); 246 (7%) had alcoholic cirrhosis; and 189 (5%) had hepatitis B virus. Also, 1140 (31%) had evidence of ≥ 1 high-risk explant feature(s). The presence of ≥ 1 high-risk explant feature(s) was associated with HCC recurrence after transplant (odds ratio [OR], 5.00; P < 0.001). Compared with HCV-associated HCC transplant recipients, individuals with NASH had lower likelihood of high-risk explant features (OR, 0.71; P = 0.02) after adjusting for covariables. Women were more likely to have high-risk explant features (OR, 1.23; P = 0.04). Diabetes mellitus (DM) was not associated with high-risk explant features. In conclusion, LT recipients with NASH-associated HCC had fewer high-risk tumor features on explant compared with HCV-associated HCC, despite having higher rates of DM and other potential risk factors for the development of HCC. Women had a higher likelihood of high-risk tumor features. Further study is warranted whether these differences are due to disease-specific or sex-specific influences on tumor biology or due to selection criteria for transplant. Liver Transplantation 23 1015-1022 2017 AASLD.

Diabetes and pre-diabetes in tuberculosis patients in western Kenya using point-of-care glycated haemoglobin.

Setting: The tuberculosis (TB) clinics of five health facilities in western Kenya. Objective: To assess the prevalence and associated determinants of diabetes mellitus (DM) and pre-diabetes hyperglycaemia among adult TB patients using point-of-care DCA Vantage glycated haemoglobin (HbA1c) devices. Design: This was a cross-sectional study. Results: Of 454 patients, 272 (60%) were males, the median age was 34 years, 175 (39%) were co-infected with the human immunodeficiency virus (HIV), and the median duration of anti-tuberculosis treatment was 8 weeks; 180 (40%) patients reported at least one classical symptom suggestive of DM. The prevalence of DM (HbA1c ⩾6.5%) was 5.1% (95%CI 3.2-7.5), while that of pre-diabetes (HbA1c 5.7-6.4%) was 37.5% (95%CI 33.1-42.2). The number needed to screen (NNS) was 19.6 for DM and 2.7 for pre-diabetes. Combined, 42.6% (95%CI 38.0-47.3) of the patients had either pre-diabetes or DM (NNS 2.3). Seven of the 23 patients with DM knew their prior DM status. Higher rates of DM were associated with age ⩾40 years and a family history of DM, but not obesity, type of TB, HIV status or suggestive symptoms. Conclusions: High rates of pre-diabetes and DM were found in adult TB patients. This study supports the need for routine screening of all patients with TB for DM in Kenya.

Free Tissue Transfers for Head and Neck Reconstruction in Patients with End-Stage Renal Disease on Dialysis: Analysis of Outcomes Using the Taiwan National Health Insurance Research Database.

Background Patients diagnosed with end-stage renal disease (ESRD) are increasing at around 5% annually. Some of these patients will require free tissue transfers to reconstruct their body after trauma or cancer resection. Comorbidities can increase the level of complexity during reconstruction. Aim Our goal is to describe the outcomes of ESRD patients under dialysis who underwent free tissue transfer for head and neck reconstruction. Methods Two cohorts were analyzed: ESRD group on dialysis and a non-ESRD control group after free tissue transfer for head and neck reconstruction. Postoperative complications and mortality were recorded. For coexisting comorbidities, we determine the presence of diabetes mellitus (DM) and peripheral vascular disease (PVD). Results In this study, 85 cases with ESRD on dialysis and 841 controls were analyzed. Most patients were aged ≤ 65 years (82.5%) and nearly 92.9% of them were men. Types of head and neck cancer were neoplasm of other and unspecified parts of the mouth followed by neoplasm of tongue, the gingiva, hypopharynx, and floor of mouth. Patients with ESRD tended to have higher rates of DM and PVD (p &lt; 0.001) and were significantly associated with an increased risk of stroke and increased risk of 30-day mortality. However, there was no significant difference regarding flap failure among groups. Conclusion Despite greater preoperative risk factors, patients with renal failure on hemodialysis do not appear to have a higher rate of free flap failure following head and neck reconstruction. However, other complications can be minimized by optimizing patient's medical condition to succeed with this reconstructive effort.

Abstract P058: Hostility Attitudes &amp; Prevalent or Future Diabetes Among Black Adults: The Jackson Heart Study

Background: Hostility and diabetes mellitus (DM) share common determinants such as obesity, tobacco use and physical inactivity. Thus, we investigated their unstudied relationship at baseline and at 10 yrs after among Black adults in the Jackson Heart Study (JHS), a group with high rates of DM. Hypothesis: Hostility and its subdomains (hostile affect, aggressiveness, and cynicism) correlate with DM at baseline or at 10 yrs after. Methods: From the JHS cohort (n=5301), we studied 3,434 Blacks who completed the Cook-Medley Hostility Scale. Hostility was measured in 3 subdomains: hostile affect, cynicism and aggressiveness; higher scores correlated with higher hostility levels. Participants were stratified into quartiles based on the hostility scale. Frequency of DM at baseline or at 10 yrs after was compared amongst quartiles and tested for trend. Using multivariate logistic regression, we studied the cross-sectional relationship between quartiles of levels of hostility and the combined outcome of presence of diabetes at present or at 10 yrs after, adjusting for known confounders of DM. Subanalyses were conducted at each hostility domain level. Results: Our population was 35% men with a mean age of 54.3 (SD 12.6) yrs. Quartiles were associated with age, BMI, smoking, hA1c, caloric intake, hs-CRP, and alcohol intake (all p&lt;0.05). Overall hostility quartiles and its subscales correlated with DM at baseline but only the subdomains of hostile affect and cynicism correlated with DM at 10 yrs. When prevalent or DM at 10 yrs were assessed as a combined risk, individuals in the last quartile of the hostile affect subdomain was associated with a higher DM risk versus first quartile (Table). Similar link was not found in other subdomains. Conclusions: Hostility attitude was associated with DM risk factors and prevalent DM. Only 2/3 of the hostility subdomains correlated with DM at 10 yrs after. Individuals from the last quartile of hostile affect subdomain was related to a higher risk of prevalent or DM at 10 yrs when compared to the first quartile.

Factors associated with corneal epithelial defects after pars plana vitrectomy

To investigate the risk factors associated with corneal epithelial defects (CED) and delayed healing (exceeding 1week) following pars plana vitrectomy (PPV). This retrospective study enrolled patients who underwent PPV at a single center in Taiwan between 2011 and 2012. Medical records were reviewed, including demographic, underlying disease, surgical indication, operation parameters, and existence of CED. These data were statistically analyzed. All patients were evaluated during follow-ups at day 1 and week 1 after PPV. Patients with persistent CED 1week after PPV were diagnosed with delayed healing. A total of 255 patients were included in the study, consisting of 139 men and 116 women, with a mean age of 56.9years. PPV was performed under the indications of rhegmatogenous retinal detachment (RRD), diabetic retinopathy, or vitreoretinal interface disease. Out of 255 eyes, 59 developed CED 1day after surgery (23.1%), and CED was associated with younger age, diabetes mellitus (DM), RRD, longer duration of surgery, and silicon oil use during surgery. Among them, seven patients (11.9%) demonstrated delayed healing, which was associated with a higher rate of DM (p=0.085), compared to patients who healed within 1week. Patients with RRD, longer duration of surgery, and DM may be at risk of developing CED after PPV. In addition, patients with DM demonstrated a higher incidence of delayed corneal healing.

The Prevalence and Outcome of pre-DM/DM in an Urban HIV Primary Care Clinic

Background Diabetes mellitus (DM) is an important cause of mortality and morbidity in the US. There are limited data on DM prevalence among HIV infected patients (HIV+ patients). A recent study found that DM prevalence was higher among HIV+ patients (10.3%) vs. the general US population (8.3%), and was higher regardless of age, sex, and obesity status. We report on the prevalence of pre-DM/DM in our HIV clinic and outcomes.Methods Cross-sectional study by retrospective medical record review of patients ≥ 18 years who received HIV primary care at the Peter Krueger Clinic (PKC) at Mount Sinai Beth Israel, NY during October 2015–September 2016. The endocrine clinic is located outside PKC. Data collected include prevalence of pre-DM (Hgb A1C 5.7–6.4) and DM, demographics and HIV disease characteristics. Inadequate glycemic control was defined as Hgb A1C ≥ 7.0 in ≥ 50% of measures during study.ResultsThere were 1137 HIV+ patients during the study period. The population was mostly Black or Hispanic; mean age was 52.6 ± 11.2 years; 70% were male. Pre-DM prevalence was 301/1137 (26.5%) and DM prevalence was 176/1137 (15.5%). In univariate analysis, patients with DM were more likely to be older, female, Hispanic, HCV co-infected, had higher BMI, longer duration of HIV infection, and family history of DM (all p values < 0.05). Almost 40% of those with DM were also HCV co-infected. Of the 176 with DM, 91 (52%) had inadequate glycemic control. Only insulin use and referral to endocrinology were associated with poor control (P <0.05).Conclusion Rates of DM in our HIV clinic were almost twice the rate reported in the adult US population (8.3%) and 25% had pre DM. Traditional risk factors such as older age, family history, and higher BMI were more frequent in our population. The poorer outcomes in those referred to endocrine probably reflect difficult to manage advanced DM that prompted endocrine referral. The high rates of DM and pre DM supports the DHHS recommendation for screening and consideration of co-location of endocrine services to promote appropriate glycemic controlDisclosures All authors: No reported disclosures.

Microsurgical reconstruction for post—traumatic defects of lower leg in the elderly: A comparative study

Lower leg microsurgical reconstruction in the elderly is challenging, especially for post - traumatic defects. The present study aimed to evaluate the risk factors, management and outcome of free tissue transfer in patients older than 65 years of post-traumatic defects. Retrospective chart review was performed for all patients older than 18 years undergoing free tissue transfer for post-traumatic lower leg reconstruction from April 2000 to November 2014. A comparative study was designed to identify risk factors and outcome. In total, 197 patients (ages 18-64) and 44 patients (ages ≥65, average 71.7±6.3) were included and allocated into cohort 1 and 2, respectively. Cohort 2 had a higher rate of diabetes mellitus and/or peripheral artery disease (46.6%, P<0.01). There was no significant difference in major flap complications, donor site complications and amputation rates (P>0.05). A higher rate of intensive care unit (ICU) admission was observed in cohort 2 (37.8%, P<0.01). Comparable limb salvage rates were recorded (97.1% and 95.6%, P=0.59) with an average follow-up of 25.9±30.1months in cohort 1 and 23.7±16.6months in cohort 2. Post-traumatic microsurgical free tissue transfer to the lower leg can be performed safely in patients older than 65 years with high success rate and manageable complications.

Intra-Osseous Arthrodesis Techniques in the Foot and Ankle

Category: Ankle Arthritis Introduction/Purpose: Arthrodesis is considered the standard operative treatment for end-stage arthritis in the foot and ankle. The long-term effects of implant choices for fusions are largely unexplored in the literature. Many companies advertise implants as being "lower profile" and "less painful." The purpose of this study was to perform a clinical and radiographic review to determine outcomes, specifically rates of symptomatic hardware, using four major arthrodesis techniques in joints in the foot and ankle. Methods: A retrospective study was conducted including one-hundred and twenty-three patients (a total of 197 joints) who underwent arthrodesis of the ankle, or joints in the midfoot or hindfoot. A total of 197 joints underwent arthrodesis in this patient group. Four groups were created based on fixation methods; standard screw fixation, plate and screw fixation, screw-in- post fixation(so-called "intra-osseous" fixation), and a group using a combination of fixation methods. Through chart review and radiographic analysis, outcomes including fusion rate, pain at specific follow-up intervals(6-weeks, 3-months, 6-months, and 1-year), and symptomatic hardware requiring hardware removal were compared across groups. Results: No differences were found in fusion rates between the four groups. Non-union rates, hardware loosening, infection, and wound breakdown rates were all comparable across the cohort. Rates of reported pain at 6-weeks and 3-months were similar for all groups but the "plate and screw fixation" group reported significantly more pain at 6 months(p=0.035) and 1 year(p=0.022) than the other three groups and, subsequently, rates of symptomatic hardware requiring removal were significantly higher in this group as well. The patient population had higher rates of diabetes mellitus, human-immunodeficiency virus (HIV) and hepatitis C virus (HCV) than reported in recent studies of comparable design. Conclusion: In this high risk patient population, implant choice in arthrodesis of the midfoot, hidfoot or ankle has a significant effect on patient-reported pain during follow-up. In this cohort, the group fused with intra-osseous fixation methods did not demonstrate superiority with regards to rates of patient-reported post-operative pain related to hardware. Clinicians should expect significantly increased rates of symptomatic hardware when using plate fixation in fusions of the ankle, midfoot and hindfoot.

Bipolar disorder and diabetes mellitus: evidence for disease-modifying effects and treatment implications.

BackgroundBipolar disorder refers to a group of chronic psychiatric disorders of mood and energy levels. While dramatic psychiatric symptoms dominate the acute phase of the diseases, the chronic course is often determined by an increasing burden of co-occurring medical conditions. High rates of diabetes mellitus in patients with bipolar disorder are particularly striking, yet unexplained. Treatment and lifestyle factors could play a significant role, and some studies also suggest shared pathophysiology and risk factors.ObjectiveIn this systematic literature review, we explored data around the relationship between bipolar disorder and diabetes mellitus in recently published population-based cohort studies with special focus on the elderly.MethodsA systematic search in the PubMed database for the combined terms “bipolar disorder” AND “elderly” AND “diabetes” in papers published between January 2009 and December 2015 revealed 117 publications; 7 studies were large cohort studies, and therefore, were included in our review.ResultsWe found that age- and gender- adjusted risk for diabetes mellitus was increased in patients with bipolar disorder and vice versa (odds ratio range between 1.7 and 3.2).DiscussionOur results in large population-based cohort studies are consistent with the results of smaller studies and chart reviews. Even though it is likely that heterogeneous risk factors may play a role in diabetes mellitus and in bipolar disorder, growing evidence from cell culture experiments and animal studies suggests shared disease mechanisms. Furthermore, disease-modifying effects of bipolar disorder and diabetes mellitus on each other appear to be substantial, impacting both treatment response and outcomes.ConclusionsThe risk of diabetes mellitus in patients with bipolar disorder is increased. Our findings add to the growing literature on this topic. Increasing evidence for shared disease mechanisms suggests new disease models that could explain the results of our study. A better understanding of the complex relationship between bipolar disorder and diabetes mellitus could lead to novel therapeutic approaches and improved outcomes.

Influence of body mass index on postoperative outcomes after laparoscopic liver resection

Aims: Despite the increasing prevalence of obesity, the impact of body weight on postoperative outcomes of laparoscopic liver resection (LLR) still remains poorly evaluated. The present study aimed to explore the impact of body mass index (BMI) on perioperative outcomes in patients undergoing LLR. Methods: All patients undergoing LLR from January 2008 to December 2013 were retrospectively reviewed. BMI was subdivided in normal weight (<24.9 kg/m2), overweight (25.0–29.9 kg/m2) and obese (≥30.0 kg/m2). These 3 groups were compared in terms of demographic data, intraoperative factors, and postoperative outcomes. Logistic regression was used to determine odd ratios with 95% confidence intervals and evaluate BMI as an independent risk factor for morbidity. Results: Among 228 selected patients, 83 (36.4%) patients were overweight and 32 (14.0%) were obese. Despite higher rates of diabetes mellitus, hypertension and ischemic heart disease with an increase of BMI, no significant difference in operative time, blood loss and conversion rate was observed in the 3 groups. There were no significant differences in postoperative mortality rate between the groups (0.9% vs. 1.2% vs. 0%). The rate of overall complications (31.0% vs. 31.3% vs. 40.6%) and major complications (14.2% vs. 9.6% vs. 18.8%) did not differ in the three groups. Major hepatectomy (HR: 6.810, CI; 1.437–32.267, p = 0.016) and operative time >180 min (HR: 2.639, CI; 1.179–5.908, p = 0.018) were independently associated with postoperative complications. Conclusions: The present study demonstrated that BMI does not negatively affect the postoperative short-term outcomes. Therefore, obesity and overweight should not be a contraindication for LLR.

West Nile Virus Retinopathy and Associations with Long Term Neurological and Neurocognitive Sequelae

West Nile virus (WNV) has emerged as an important vector-borne pathogen in North America, with more than 3 million estimated to have been infected. Retinopathy from WNV infection has been previously reported in acute cases, though those prior reports did not evaluate the risk of retinopathy based on clinical severity of neurologic disease. The purpose of this cross-sectional study was to perform comprehensive ophthalmological and neurological examinations on 111 patients with a history of West Nile virus infection and describe the ocular manifestations. Out of 111 patients, 27 (24%) had evidence for West Nile virus associated retinopathy (WNVR); this observation was higher (49%) in those patients who initially presented with encephalitis. Individuals with WNVR had more frequent involvement of the macula and peripheral involvement compared to those patients without WNVR (p<0.05). WNVR was also associated with a greater likelihood of abnormal reflexes on neurological exam, poorer learning, greater dependence in activities of daily living, and lower quality of life (p<0.05). WNVR was seen more frequently in elderly patients (age > 60 years), and was associated with higher rates of diabetes mellitus and a history of encephalitis (p<0.05). A multivariable logistic regression revealed that only a history of encephalitis was independently associated with WNVR [Adjusted Odds Ratio = 4.9 (1.8–13.2); p = 0.001]. Our study found that WNVR occurs in one fourth of patients with a history of WNV infection and is more frequently observed in those with apparent severe neurological sequelae (e.g., encephalitis). The clinical relevance of WNVR was supported by its associations with dependence in activities of daily living and lower quality of life. This unique evaluation of WNV patients included fundoscopic examinations and their associations with neurologic impairment. Our findings can be used during ophthalmological consultation for the evaluation, treatment and rehabilitation phases of care for WNV patients.

Women in Control: Pioneering Diabetes Self-Management Medical Group Visits in the Virtual World

Background:The current state of diabetes self-management (DSM) education and support for diabetic patients is inadequate, especially for minority women who experience disproportionately high rates of diabetes mellitus (DM) in the US. While DSM education and support enables individuals with diabetes to make positive lifestyle choices and achieve clinical goals, this type of support is difficult to deliver in medical practice settings. Virtual reality can assist DM patients and their clinical teams by providing effective educational tools in an engaging, learner-centered environment that fosters self-efficacy and skill proficiency.Methods:Our prior research demonstrated that virtual worlds are suitable for supporting DSM education. Building upon this success, we are now investigating whether DSM virtual world medical group visits lead to similarly effective health and educational outcomes compared to face-to-face medical group visits. Currently in year one of a five year randomized controlled trial, we aim to compare the effectiveness of a virtual world DSM medical group visit format versus a face-to-face DSM medical group visit format to increase physical activity and improve glucose control (HbA1c) among Black/African American and Hispanic women with uncontrolled DM. We will also conduct a qualitative study of participant engagement with the virtual world platform to characterize learners’ interactions with the technology and assess its correlation with DSM behaviors and diabetes control.Discussion:Novel methods to promote diabetes self-management are critically needed, and the use of virtual world technology to conduct medical group visits offers a unique approach to such issue. If successful, our intervention will increase access to culturally-sensitive diabetes care and improve patient engagement in online DSM learning, leading to higher uptake of DSM behaviors and better diabetes control. Importantly, the program can be easily expanded to other chronic disease areas and scaled for widespread use.

High Rates of Diabetes Mellitus, Pre-diabetes and Obesity Among Somali Immigrants and Refugees in Minnesota: A Retrospective Chart Review.

We examined the prevalence of cardiovascular risk factors among Somali refugees at a midwestern hospital in the U.S. This was a retrospective cohort study of 1007 adult Somali patients and an age and frequency-matched cohort of non-Somali patients actively empanelled to a large, academic primary care practice network in the Midwest United States between January 1, 2011 and December 31, 2012. Cardiovascular risk factors were obtained by chart review and compared between the two cohorts using a Chi squared test. Median age was 35years (Q1, Q3; 27, 50). The prevalence of diabetes was significantly higher among Somali versus non-Somali patients (12.1 vs 5.3%; p=0.0001), as was prediabetes (21.3 vs 17.2%; p<0.02) and obesity (34.6 vs 32.1%; p=0.047). After adjusting for age, sex, body mass index, education and employment, among the Somali patients, the odds ratio (95% confidence interval) for diabetes was 2.78 (1.76-4.40) and 1.57 (1.16-2.13) for pre-diabetes. There was a significantly higher prevalence of diabetes, pre-diabetes and obesity among Somali patients compared with non-Somali patients. Further research into the specific causes of these disparities and development of targeted effective and sustainable interventions to address them is needed.