Morbidity In Patients Research Articles

Nursing Interventions for Preventing Hospital-Acquired Infections

Hospital-acquired infections (HAIs) are a significant contributor to patient morbidity, mortality, and healthcare costs. With an increasing emphasis on patient safety and infection control, nursing interventions play a vital role in reducing the incidence of HAIs. This systematic review and meta-analysis evaluated the effectiveness of nursing-led interventions in preventing HAIs, focusing on four primary strategies: hand hygiene, aseptic technique, environmental cleaning, and patient education. A total of 52 peer-reviewed studies, including over 50,000 patient cases across various healthcare settings, were analyzed. The meta-analysis revealed that hand hygiene adherence led to a 35% reduction in HAIs, with an odds ratio (OR) of 0.65 (95% CI: 0.54–0.79). Structured training in aseptic techniques for invasive procedures correlated with a 40% reduction in catheter-associated infections (OR: 0.60, 95% CI: 0.50–0.75), while enhanced environmental cleaning protocols decreased HAI rates by 30% (OR: 0.70, 95% CI: 0.55–0.89). Patient education showed a 15% reduction in HAIs, although results were less statistically significant. These findings highlight the essential role of nursing interventions in infection control and underscore the need for continuous training, compliance monitoring, and institutional support. Future research should explore integrated infection prevention programs and technological innovations to improve adherence and expand patient education initiatives. Overall, nursing interventions remain crucial to achieving lower HAI rates and enhancing patient safety.

The Outcomes of Adenovirus Infection in Kidney Transplant Recipients.

Adenovirus (ADV) infection can lead to significant morbidity and mortality in immunocompromised patients, particularly in those with hematopoietic stem cells or solid organ transplants. The incidence of ADV infection in kidney transplant (KT) is not well-defined as ADV is often asymptomatic and not routinely checked. This retrospective case-series study included KT and simultaneous pancreas-KT (SPKT) recipients from January 1, 2008, to January 31, 2024, across three Mayo Clinic sites (Arizona, Florida, and Minnesota) with symptomatic adenovirus polymerase chain reaction cases. The primary outcomes were allograft function at various intervals post-ADV infection, allograft, and patient survival. We report one of the largest multi-site case series regarding outcomes of ADV in KT with 17 patients. The median time to ADV infection was 30 weeks (5-74). Five patients (29%) developed disseminated infection. Nine patients (53%) of the entire cohort experienced graft loss within a median of 35 (4-168) weeks, with four (44%) of graft loss attributed to ADV. Nine patients (53%) developed rejections post-ADV infection with a median of 4 (2-8) weeks after resolution. One patient died from acute hypoxic respiratory failure from ADV infection. ADV should be considered in KT/SPKT patients with renal dysfunction, hematuria, and with or without fever. Despite the low mortality rate, there is a significant risk of graft loss and rejection after ADV infection. It is crucial to screen for ADV and develop intervention strategies for treatment. Further multicenter studies are needed to better define, stage, and manage ADV infection.

Comparative Study of Staphylococcus aureus Biofilm Formation among Clinical Isolates and Nasal Colonisers

Staphylococcus aureus (S. aureus) a noted versatile facultative commensal with pathogenic potential. This facultatively anaerobic cocci lives a commensal lifestyle in about a quarter of the world’s population awaiting a breach in the immune barrier to establish as a debilitating pathogen. This bacterium produces biofilms which acts as adhesive molecule enhancing the bacterial virulence and gives it an ability to withstand antibiotics, thereby causing tremendous burden on the healthcare community in terms of patient mortality and morbidity. This study assesses the biofilm producing ability among clinical isolates of staphylococci in comparison to colonizing staphylococci isolated from anterior nares of healthcare personnel. The present cross-sectional observational study was conducted in a tertiary care hospital in Mysore, India. In this study, 50 pathogenic isolates of S. aureus were assessed for phenotypic biofilm production. Additionally, 100 healthcare personnel were screened for nasal colonisation with S. aureus and the colonizing isolates were also screened for phenotypic biofilm formation. Phenotypic biofilm formation was evident among 22% of the pathogenic isolates. 23% of clinical S. aureus isolates demonstrated methicillin resistance (MRSA). There was no significant association of MRSA status with biofilm production (p > 0.05). Out of the 100 healthcare professionals screened for nasal carriage of S. aureus, 30% were colonized with S. aureus. Biofilm production among colonizing S. aureus isolates was found to be 26.6%. Methicillin resistance was a whopping 40% among the colonising strains. MRSA carriage was found to be highest among those healthcare personnel who had worked for an average of 20-30 years in the hospital environment. The Present study showed no significant association of biofilm production with the pathogenic potential of the S. aureus isolates (p > 0.05). Additionally, there was no significant association of methicillin resistance with the pathogenicity of the isolate. In conclusion, the interplay of virulence genes, biofilm forming ability, drug resistance of the isolate in coordination with the host immune status dictate the fate of the colonising as well as clinical isolates of S. aureus.

Reconstruction of large post-traumatic segmental femoral defects using vascularised bone flaps: a retrospective case series.

Large femoral defects after trauma, femoral non-unions, fractures complicated by osteomyelitis or defects after bone tumour resection present high burden and increased morbidity for patient and are challenging for reconstructive surgeons. Defects larger than 6 cm and smaller defects after failed spongioplasty are suitable for reconstruction using a free, eventually a pedicled vascularised bone flap. The free fibular flap is preferred but an iliac crest free flap or a pedicled medial femoral condyle flap can be also used. These vascularised flaps are ideal for bridging defects of long bones and can be also used as osteocutaneous or osteomuscular flaps for coverage of soft tissue defect if present. The patients and their families were informed that data will be submitted for publication and they gave their written informed consent prior to the submission. The study was approved by the institutional ethic committee. We analysed a group of eight patients with large diaphyseal or distal metaphyseal femoral defects. A free fibular flap was used in six patients, a pedicled medial ipsilateral femoral condyle flap was used in two patients and a defect in one patient was reconstructed using an iliac crest free flap. All flaps healed completely in all patients and no fracture of the flap was detected during the study period. In one patient, a locking plate broke and was replaced by a compression plate. At the last check-up all patients were able to step on the reconstructed limb with full weight. Although our study comprises a heterogeneous group of cases, they all have been successfully treated by a similar technique, adapted in each case specifically to the needs of the patient. A major limitation parameter of reconstruction by a free vascularised flap is the size of bone defect needed to be reconstructed. In case of a bone defect longer than 6cm and a concomitant soft tissue disruption, a vascularised double-barrel fibula is the preferred. Large femoral defects can be successfully reconstructed with good long-term results using suitable free or pedicled vascularised bone flaps, especially preferring the free fibular flap.

The Hidden Threat of Antimicrobial Resistance: A Case Study from A Private Hospital in Jordan

Antibiotic resistance is considered a widespread problem with global health implications, leading to increased patient morbidity and impacting the selection of effective antibiotics, consequently influencing patient recovery. This study aimed to assess antibiogram resistance patterns of bacterial records at the Islamic Hospital in Jordan using a retrospective study during the period 2020-2022. A total of 9369 samples obtained from different patients were cultured. Data were processed and analyzed with SPSS v.23.0. The results showed that 2841 (30.3%) samples were positive for bacterial infections. Microbial profiles of positive samples indicated the highest proportion for Escherichia coli, 39%, followed by Klebsiella pneumoniae 12% were the most frequent Gram-negative bacterial isolates, whereas Staphylococcus aureus 13% and Streptococcus pneumoniae 4% were the most common Gram-positive bacterial isolates. Interestingly, multidrug-resistant bacteria comprised 61.7% of the isolates. The percentage of multi-drug resistance in isolates of Staphylococcus aureus, Escherichia coli, and Klebsiella pneumoniae was 68.7%, 73.1%, and 72%, respectively. Escherichia coli was most resistant to ampicillin (89%) and most sensitive to imipenem (100%). Klebsiella pneumoniae showed a 100% sensitivity to meropenem but 49% resistance to ceftriaxone. Pseudomonas aeruginosa was the most sensitive to amikacin and colistin (86% and 100%, respectively). Staphylococcus aureus isolates have resistance rates of 78% for ciprofloxacin, 35.6% for clindamycin and an overall resistance rate of 68.7%. These findings indicate multiple resistance for isolated bacteria. Therefore, antimicrobial resistance should be monitored continuously, and patients should be treated based on anti-microbial susceptibility tests.

Preventive effects of nitric oxide donors in contrast-induced nephropathy in patients undergoing coronary artery angiography: an updated systematic review and meta-analysis of 13 randomized controlled trials.

Contrast-induced nephropathy (CIN) is associated with increased mortality and morbidity in patients undergoing coronary angiography (CAG) and percutaneous coronary intervention (PCI). We aimed to assess the latest evidence on the preventive effects of nitric oxide (NO) donors in CIN patients undergoing CAG/PCI. We conducted a comprehensive systematic review and meta-analysis of RCTs from PubMed, Web of Science, Scopus, Embase, and Cochrane searches until May 5th, 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using (R version 4.3). Our analysis included 13 RCTs encompassing 3,550 patients. NO donors were significantly associated with a decreased incidence of CIN compared to placebo either as an oral administration (RR: 0.33 with 95% CI [0.26, 0.42], P < 0.01) or IV infusions (RR: 0.56 with 95% CI [0.40, 0.78], P < 0.01). Moreover, NO donors were significantly associated with decreased serum creatinine levels compared to placebo either as an oral administration (MD: - 0.07 with 95% CI [- 0.10, - 0.04], P < 0.01) or IV infusions (MD: - 0.07 with 95% CI [- 0.09, - 0.04], P < 0.01). In terms of safety, NO donors were significantly associated with a decreased incidence of major adverse cardiac events (MACE) compared to placebo as an oral administration (RR: 0.64 with 95% CI [0.45, 0.89], P < 0.01). However, there was no significant difference between NO donors as IV infusions and placebo in MACE (RR: 0.68 with 95% CI [0.38, 1.21], P = 0.18). Finally, NO donors were significantly associated with a decreased incidence of all-cause mortality compared to placebo as an oral administration (RR: 0.58 with 95% CI [0.36, 0.94], P = 0.03). Nevertheless, there was no statistically significant difference in all-cause mortality between IV infusions of NO donors and placebo (RR: 1.84 with 95% CI [0.40, 8.52], P = 0.44). NO donors as adjunct therapy are associated with reduced incidence of CIN and decreased serum creatinine levels, either as an oral or IV administration. They were also associated with reduced incidence of MACE, all-cause mortality, and recurrent myocardial infarction as an oral administration, which makes this simple, low-cost intervention an important therapeutic option in patients undergoing CAG/PCI.

Delineating the psychiatric morbidity spectrum in congenital adrenal hyperplasia: a population-based registry study.

Clinical studies of psychiatric morbidity in patients with congenital adrenal hyperplasia (CAH) imply impaired mental health. To delineate psychiatric morbidity in a national CAH cohort by using complete data on psychiatric diagnoses from all Danish hospitals between 1977-2018 and on all psychiatric medication prescribed between 1995-2018. A registry-based cohort study. A public uniform healthcare system. Four-hundred-forty-eight patients (females: n=215) with CAH, hereof 410 with 21-hydroxylase deficiency (21-OHD) (females: n=255) and 44,527 age- and sex-matched general population controls. Diagnoses were analyzed by negative binomial regression yielding incidence rate ratios (IRR). Medication were analyzed by Cox regression yielding hazard ratios (HR). 21-OHD was associated with an increased risk of any psychiatric diagnosis; females: IRR=2.32 (confidence interval (CI) (1.48-3.64), males: IRR=2.74 (CI 1.31-5.71) as well as of medication related to psychiatric disorders; females: HR=1.74 (CI 1.42-2.13), males: HR=1.74 (CI1.30-2.33). Both females and males with 21-OHD had a significantly increased risk of alcohol use, stress- and adjustment disorders, and of suicidal behavior. For patients with more rare forms of CAH (n=24), the risk of any psychiatric diagnosis was significantly increased for males, IRR=12.85 (CI 1.78-92.87), but not for females, IRR=0.54 (CI 0.10-3.00). The risk of being prescribed psychiatric medication was not increased for neither females, HR=1.05 (CI 0.39-2.84), or males, HR=0.72 (CI 0.10-5.13), with rare forms of CAH. 21-OHD is associated with a significantly increased psychiatric morbidity. This study underlines a need for awareness of mental health in patients with 21-OHD.

Modern Endoscopic Approaches to Video-Assisted Sentinel Lymph Node Biopsy and Axillary Lymph Node Dissection: A Review

This article aims to analyze modern endoscopic techniques of sentinel lymph node biopsy and axillary lymph node dissection in breast cancer surgery.Owing to more accurate diagnosis and minimized patient morbidity and risks, endoscopic techniques have significantly expanded capabilities of breast cancer surgery.We review the main endoscopic techniques of sentinel lymph node biopsy and axillary lymph node dissection, analyze their efficacy and safety, and compare their benefits with those of conventional open techniques.The article discusses results of recent studies regarding diagnostic accuracy and complication rates. Furthermore, we discuss the impact of endoscopic axillary lymph node dissection on the prognosis and quality of life in patients with breast cancer.

Tropical Primary Pyomyositis of The Right Calf Muscle: A Rare and Unexpected Complication of Jump Squat Exercise

Diagnosing pyomyositis in its initial or invasive stages can pose a challenge due to its vague initial symptoms, which may mimic other conditions such as muscle strain, localized myositis, hematoma, deep vein thrombosis, cellulitis, or thrombophlebitis. A high index of suspicion for possible pyomyositis necessitates confirmation through radiographic imaging. A delayed diagnosis directly correlates with the time taken to commence treatment, thereby increasing the risk of patient morbidity and mortality. We present a case of a diabetic male who experienced bilateral calf muscle pain and right calf swelling after participating in jumping squat exercises, eventually developing right calf myositis and abscesses over a two-week period, which were initially overlooked by several general practitioners. This case underscores the crucial role of radiographic imaging in confirming the diagnosis, whether in the Emergency Department or any primary care setting. Prompt diagnosis and intervention, as demonstrated here, are imperative for minimizing the risks associated with this potentially severe disease. Knowledge of this condition and its diagnostic methods is highly advantageous for emergency physicians, primary care providers, and family physicians.

HPB SO45 - Level 1 evidence comparing aggressive versus non-aggressive intravenous fluid therapy in acute pancreatitis

Abstract Background Fluid balance in the management of acute pancreatitis (AP) is challenging and has been described as a “double-edged sword” whereby adequate fluids are required to counteract systemic hypovolaemia whilst excessive fluids may exacerbate systemic oedema. Given that data generated from randomised studies are conflicting, the optimal rate and type of fluid resuscitation for AP are yet to be determined. We aimed to perform a comprehensive meta-analysis of all existing randomized controlled trials (RCTs) to evaluate comparative outcomes of aggressive versus non-aggressive intravenous fluid (IVF) therapy in patients with AP. Method A systematic search of electronic data sources and bibliographic reference lists were conducted. All RCTs reporting outcomes of aggressive versus non-aggressive IVF therapy in AP were included and their risk of bias were assessed. Effect sizes were determined for overall mortality, systemic inflammatory response syndrome (SIRS), sepsis, respiratory failure, pancreatic necrosis, severe pancreatitis, clinical improvement, AKI, and length of stay using random-effects modelling. Trial sequential analysis was conducted to determine risk of types 1 or 2 errors. Results Ten RCTs enrolling 993 patients with AP who received aggressive (n = 475) or non-aggressive (n = 518) IVF therapy were included. Aggressive IVF therapy was associated with significantly higher rate of sepsis (OR:2.68, P=0.0005) and longer length of stay (MD:0.94, P&amp;lt;0.00001). There was no statistically significant difference in mortality (RD:0.02, P=0.31), SIRS (OR:0.93, P=0.89), respiratory failure (OR:2.81, P=0.07), pancreatic necrosis (OR:1.98, P = 0.06), clinical improvement (OR:1.12, P=0.83), severe pancreatitis (OR:1.31, P=0.38) or AKI (OR:1.06, P=0.91). Subgroup analysis demonstrated higher morbidity and mortality with aggressive fluids in severe AP. Trial sequential analysis detected risk of type 2 error. Conclusion Aggressive IVF therapy may be associated with higher morbidity in patients with acute pancreatitis compared with the non-aggressive approach, particularly in patients with more severe disease. It may also prolong length of hospital stay. The available evidence is subject to type 2 error indicating the need for adequately powered RCTs.

HPB SO29 - Outcomes of Percutaneous Image-Guided and Laparoscopic Cholecystostomies in High-Risk Patients With Acute Calculus Cholecystitis: A Five-Year District General Hospital Experience

Abstract Background Acute cholecystitis (AC), inflammation of the gall bladder, is one of the most common emergency surgical presentations. In the UK, approximately 15% of the population is estimated to have gallstones, and approximately 20% of them can develop AC. Laparoscopic cholecystectomy (LC) is considered the definitive management of AC. However, cholecystectomy carries a very high risk of morbidity and mortality in high-risk frail patients with multiple comorbidities who are deemed unfit for surgery. Percutaneous cholecystostomy (PC), both image-guided and laparoscopic, is generally acknowledged as an interim treatment measure before definitive management, which is the LC. Method This retrospective study from the Royal Albert Edward Infirmary in Wigan, UK, analyzed medical records of patients who underwent percutaneous cholecystostomy (PC) between January 2017 and December 2022. Excluded were patients with prior hepato-pancreato-biliary malignancy, those who had open cholecystostomy, or those with abdominal ascites. Data collected included age, gender, American Society of Anaesthesiologists (ASA) grades, procedure success rates (temporary or definitive), hospital stay duration, 30-day and 1-year mortality rates, timing of the procedure, and long-term complications, particularly those related to cholecystostomy tube dislodgment or blockage. Results In this study, 27 patients who underwent percutaneous cholecystostomy (PC) were divided into two groups: Group A (10 patients) had laparoscopic cholecystostomies, and Group B (17 patients) had ultrasound-guided cholecystostomies. The mean ages were 66.7 for Group A and 75.1 for Group B. Most patients were in ASA groups III (14) and IV (10). About 74% had procedures during the day, 26% at night. The mean hospital stay was 13.5 days. Around 55% had elective laparoscopic cholecystectomy (LC) as definitive management. Two patients died within 30 days, and eight within a year. About 40% experienced tube dislodgment or blockage complications. Conclusion This study concludes that PC, using both laparoscopic and US-guided techniques, can serve as an interim as well as a definitive measure, particularly in patients who are at high risk for anesthesia and the procedure itself and have multiple comorbidities.

EGS SO35 - Emergency laparotomies in the elderly: A patient perspective

Abstract Background Emergency laparotomy is known to convey worse morbidity and mortality for elderly patients. Despite a growing elderly population, there is a limited understanding of the patient experience in emergency laparotomy. This study aims to assess patient satisfaction following emergency laparotomy. Method Patients were identified from the National Emergency Laparotomy Audit (NELA) database, who were aged 80 and above, and underwent surgery between: January 2020 and August 2023 at Torbay Hospital. Of the patients who survived to discharge, a telephone-based interview was undertaken in January 2024. Exclusion criteria included: confusion, severe illness and relook laparotomy. Data was collected on functional status and satisfaction with the procedure. Patients were also asked what they wished they known prior to the operation. Post-operative outcomes were assessed in a separate study. Results 132 cases were undertaken in this period. 72 cases met inclusion criteria. We achieved a 54% response rate. 59% of respondents were living independently post operatively and had no functional decline. 92% of respondents were happy to have had the operation and if given the opportunity again would still have had the procedure. Patients were overall very happy with the information offered prior to the procedure, 8% felt they had no alternative option. One patient was not satisfied with the follow up received. Conclusion Although emergency laparotomy in the elderly is high risk, our data demonstrate excellent patient satisfaction. This study provides a better understanding of what is important to patients; this should be considered in the consent process and communication.

The Donnan equilibrium is still valid in high-volume HDF.

Clinical studies have shown that hemodiafiltration reduces morbidity and mortality of dialysis patients compared to hemodialysis alone. This is attributed to its superior middle molecule clearance compared to standard hemodialysis. However, doubts arose as to whether a high convective flux through the dialyzer membrane has an influence on the equilibrium concentration of small ions, especially that of sodium. Due to the presence of negatively charged impermeable proteins on the blood side, the Gibbs-Donnan effect leads to an asymmetric distribution of membrane permeable ions on both sides of the membrane. In thermodynamic equilibrium, the concentrations of those ions can easily be calculated. However, the convective fluid flow leads to deviations from thermodynamic equilibrium. In this article, the effect of a convective flow on the ion distribution across a semipermeable membrane is analyzed in a theoretical model. Starting from the extended Nernst-Planck equation, including diffusive, convective, and electrostatic effects, a set of differential equations is derived. An approximate solution for flow speeds up to 0.1 ms-1 as well as a numerical solution are given. The results show that in any practical dialysis setting the convective flow has negligible influence on the electrolyte concentrations.

HPB SO12 - Comparison of outcomes between stapled closure and sutured closure of pancreatic stump following robotic distal pancreatectomy

Abstract Background Postoperative pancreatic fistulas (POPFs) are associated with high patient mortality and morbidity. There are multiple approaches in managing pancreatic stumps following distal pancreatectomy. We compared the outcomes between sutured closure and stapled closure following robotic distal pancreatectomy and splenectomy, and the associated cost difference between the two techniques. Method We retrospectively analysed consecutive robotic distal pancreatectomy and splenectomy cases between October 2022 and January 2024 in a single United Kingdom tertiary hospital. Stapled closure was the initial standard approach. Sutured closure utilising 3/0 Prolene was regularly performed from July 2023. The study cohort was divided into these two groups and outcomes were compared. Primary outcome was POPF rates and secondary outcomes included postoperative length of stay (LOS), 30-day readmission rates and postoperative complications graded by Clavien-Dindo classification (CDC). Equipment costs for the respective procedures were obtained from hospital procurement team. Results 36 patients were reviewed; 14 (38.9%) were stapled and 22 (61.1%) were sutured. Patient characteristics including mean age, gender and ASA grade were similar in both groups. 23/36 (63.9%) patients had confirmed malignancy on postoperative histopathology – similar distribution in both groups. 6/14 (42.9%) in the stapled group vs 4/22 (18.2%) in the sutured group developed POPF Grade B (p=0.14). LOS, 30-day readmission and CDC complication rates were similar in both groups. Median costs were £2236.40 and £1541.86 in the stapled and sutured groups respectively. Conclusion Sutured closure of pancreatic stump yielded similar outcomes to stapled closure following robotic distal pancreatectomy, associated with a significant cost saving in favour of sutured closure.

BN O02 - Introducing the Cholecystectomy Urgency Index (CUI) – A novel way to visualise and optimise the waiting list for laparoscopic cholecystectomy at a large district general hospital

Abstract Background Gallstone disease effects approximately 10-15% of the adult population, and laparoscopic cholecystectomy is one of the most common surgical procedures in the UK, with over 60,000 performed each year. Delays to surgery from diagnosis has been found to increase patient morbidity and readmission rate. Waiting lists in the UK have been struck with a significant backlog from the COVID-19 pandemic, and navigating this ever-expanding patient population to determine priority for booking cases is complex. We propose a new system to prioritise and visualise this cohort of patients in real time – the Cholecystectomy Urgency Index. Method At one large district general hospital, we had a waiting list of 148 patients for laparoscopic cholecystectomy. We identified the individual underlying pathology and established the waiting time since diagnosis to allocation of operative date. We used excel to formulate a pairwise scatter plot of the waiting list patients based upon the time waiting. We were able then to colour code them based on pathology (biliary colic/cholecystitis/cholangitis/pancreatitis/obstructive jaundice). We were then able to link this directly to our scheduling to create a live, visual representation of our waiting list, by both days waited and causative pathology. Results We found our median wait times for patients varied based on pathology: Biliary Colic = 185 days, Cholecystitis = 57 days, Pancreatitis, Cholangitis and Obstructive Jaundice (OJ) = 65 days. We found that the pairwise scatter plot provided a rapidly accessible, easily identifiable visual representation of our patient cohort by both days waited and diagnosis. This allows relevant staff, surgeons and schedulers to plan elective cases according to both urgency and time waited. Long waiters are easily identified as outliers on the graph and can therefore be flagged for last minute cancellation slots. Conclusion By using this system, we can optimise our waiting lists, improve productivity and patient outcomes. We propose a system to enable this further when booking patients: to give them a colour coded CUI number of 1-3. 1 being biliary colic, 2 – cholecystitis, 3 – pancreatitis/cholangitis/OJ. This will be directly linked to our scatter graph and in doing so, provides us with a readily available, live snapshot in time of the current wait list. This system allows for both clinical urgency prioritisation and easy visualisation of patient cohorts, thus catalysing the elimination of long waiters by means of clear identification.

Emerging technologies for the management of diabetic foot ulceration: a review

Diabetic foot ulcers (DFUs) and infections are common complications that frequently result in reduced quality of life and even morbidity for patients with diabetes. This paper highlights significant findings in DFU treatments and emerging advanced technologies for monitoring ulceration in patients with diabetes. The management of DFUs requires a multidisciplinary approach that involves patient education. It is well-established that poor glycemic control significantly contributes to diabetic foot ulcer complications, presenting global challenges in quality of life, economics, and resource allocation, affecting approximately half a billion people and potentially leading to lower limb amputation or mortality. Therefore, effective DFU management necessitates a multidisciplinary approach that includes patient education. However, current clinical guidelines for DFU treatment are not performing effectively, resulting in unnecessary increases in financial and emotional burden on patients. Researchers have experimented with advanced technologies and methods, including traditional approaches, to address complications related to DFU healing. This paper also presents the evolution of patents in the field of DFU medication and advanced diagnostic methods, showcasing relevant innovations that may benefit a wide range of researchers.

Abstract 4146306: Rural Urban Disparities in Inpatient Outcomes of Chronic Limb-Threatening Ischemia in the United States

Background: Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease characterized by chronic ischemic rest pain, non-healing wounds, or gangrene in one or both legs. With prevalence rates of 1-2% in the United States (increasing with age, with over 20% of adults over 70 diagnosed with CLTI) and 1-year mortality rates approaching 20-25%, CLTI is a critical public health issue due to its significant impact on patient morbidity, mortality, and healthcare resources. Aims: To understand if disparities exist between rural and urban inpatient outcomes for patients with CTLI. Methods: A retrospective analysis of the National Inpatient Sample database from 2016 to 2021 was conducted to identify patients admitted with CLTI according to ICD-10 codes. Patients were stratified by rural and urban status, followed by propensity-matched analysis to compare inpatient outcomes between these groups. Results: A total of 2,667,279 patients with CLTI, with 445255 (16.7%) categorized as rural status and the remaining 83.3% categorized as urban status, were included in this study. Patients belonging to rural status had an increased odds of in-hospital mortality (aOR)=1.35; 95% CI 1.26-1.45; p&lt;0.001), in-patient sudden cardiac arrest (aOR=1.27; 95% CI=1.13-1.43; p&lt;0.001), cerebrovascular accidents (aOR=1.31; 95% CI=1.19-1.45; p&lt;0.001), venous thromboembolism (aOR=1.18; 95% CI=1.09-1.27; p&lt;0.001), surgical site infection (aOR=1.25; 95% CI=1.16-1.35; p&lt;0.001), requirement for vasopressors (aOR=2.02; 95% CI=1.76-2.32; p&lt;0.001), invasive (aOR=1.18; 95% CI=1.10-1.26; p&lt;0.001) and non-invasive (aOR=1.37; 95% CI=1.25-1.50; p&lt;0.001) mechanical ventilation, hemodialysis (aOR=1.11; 95% CI=1.06-1.15; p&lt;0.001), major amputation (aOR=1.38; 95% CI=1.32-1.43; p&lt;0.001), surgical revascularization (aOR=1.53; 95% CI=1.46-1.60; p&lt;0.001), endovascular revascularization (aOR=1.53; 95% CI=1.46-1.60; p&lt;0.001), and blood transfusion (aOR=0.92; 95% CI=0.88-0.97; p=0.001). No difference was observed in the odds of acute myocardial infarction (aOR=1.06; 95% CI=0.99-1.14; p=0.082) and risk of acute kidney injury (aOR=0.99; 95% CI=0.96-1.02; p=0.485). Conclusions: Disparities in CLTI outcomes are evident, with patients from rural areas experiencing worse outcomes than their urban counterparts. Future research should focus on understanding the underlying causes of these disparities and developing targeted interventions to bridge the gap between rural and urban health care outcomes.

Abstract 4138724: Artificial-Intelligence Based Tracking of Atrial Fibrillation Waves that Exit Pulmonary Veins Predicts Response to Ablation

Background: Pulmonary vein isolation (PVI) has been shown to reduce morbidity and mortality in patients with atrial fibrillation (AF). However, a major challenge is identify which patients will or will not respond. Hypothesis: We hypothesized that patients in whom AF activity predominantly exits the pulmonary veins (PV), identified using a novel artificial-intelligence (AI) wave tracking approach, will respond to ablation compared to patients in whom activity predominantly enters the PVs. Methods: We examined 26,640 electrograms in N=37 patients at AF ablation (age 66.3 ± 8.6 years, 13.5% females, 59.5% non-paroxysmal AF). Patients had AF recordings with multipolar catheters. We analyzed AF in 3X3 electrode grids, representing 1-3 cm 2 areas that approximate minimum tissue wavelength, near and remote from PVs. For each grid, we determined if AF waves exited PVs (i.e. active PVs) or entered PVs using AI-algorithms to assign electrode activations and grid vectors. We compared the numbers of waves that exited versus entered PVs relative to ablation success, defined using ambulatory ECGs over 1 year. Results: Spatial grids in Fig A show AF waves exiting the left superior PV in a 60 year old man with persistent AF whose PVI was successful. Fig B shows AF waves entering the PVs in a 70 year old woman whose subsequent PVI was unsuccessful. Examining 720 grids per patient (48 four second grids over 1 minute), AF waves varied considerably. Fig. C shows that more AF waves exited the PVs in patients with PVI success than in patients with PVI failure (p=0.03). Conversely, more AF waves headed towards the PVs in patients with PVI failure than with PVI success (p=0.04). Conclusions: In this study, AI-based wave identification enabled the identification of AF patients in whom PVI was more or less successful. The approach to determine active versus passive PVs could be extended to other metrics, including non-invasive tools.

Abstract 4115541: Association of Glucagon-like Peptide 1 Receptor Agonist Use with Incident Atrial Fibrillation

Background: Glucagon-like peptide 1 receptor agonists (GLP-1RAs) have shown efficacy for reducing cardiovascular morbidity and mortality in patients with diabetes mellitus (DM), but conflicting evidence exists regarding their impact on cardiac arrhythmias. Whereas some studies suggested a possible association between GLP-1RA use and arrhythmogenesis, other studies suggested decreased association with atrial fibrillation (AF). Overall, large-scale real-world data evaluating risk of AF in association with GLP-1RAs are lacking. Objective: To compare risk of incident AF after initiation of GLP1-RA vs Dipeptidyl peptidase-4 inhibitors (DPP4i), as active comparators, in patients with DM. Methods: This retrospective propensity score-matched cohort study was conducted within the Veterans Health Administration from fiscal years 2006 to 2021. The study included U.S. veterans aged 35 years or older who initiated either GLP1-RA or DPP4i prescriptions. The primary outcome assessed was a composite outcome of atrial fibrillation (AF), defined as a diagnosis of AF/flutter based on administrative codes or undergoing an AF procedure. Results: Out of 116,235 GLP1-RA users and 217,668 DPP4i users, we propensity score-matched 80,948 pairs, on 88 characteristics, including demographics, comorbidities, vital signs, cardiovascular risk score, healthcare utilization, DM control, laboratory investigation, and medications. Composite outcome of AF was similar in GLP-1RA group (4.1%) and DPP4i group (4.3%); odds ratio (OR) 0.96, 95% confidence interval (CI) 0.92-1.01. Secondary analyses stratified by medication use duration showed no significant differences in composite AF risk (P&gt;0.05). Notably, individuals achieving weight loss of 2%, 5%, or 10% of baseline body weight had significantly lower AF incidence, whereas no significant differences were observed in those with no weight loss or weight gain (OR 0.99, 95% CI 0.91-1.07). Conclusions: Use of GLP1-RA in patients with DM was not associated with a decreased risk of AF when compared with the use of DPP4i. In the subgroup analysis, significantly lower AF risk was seen in the GLP-1 RA group who achieved weight loss vs. DPP4i and this highlights weight loss as a potential modifier of cardiovascular outcomes in DM.

DIABETES MELLITUS E SUAS IMPLICAÇÕES RENAIS: UMA REVISÃO BIBLIOGRÁFICA FOCADA NA NEFROPATIA DIABÉTICA E INSUFICIÊNCIA RENAL CRÔNICA

The article explores the renal complications of diabetes mellitus (DM), focusing on diabetic nephropathy (DN) and chronic renal failure (CRF). DN, considered one of the main causes of CRF in the world, results in high rates of morbidity and mortality in diabetic patients. The article addresses the pathophysiology of these diseases, highlighting how chronic hyperglycemia in DM leads to a series of structural and functional changes in the kidneys. Mechanisms such as advanced protein glycation, oxidative stress, activation of inflammatory cytokines, and endothelial dysfunction are central to the progression of DN. In addition to pathophysiology, the article extensively discusses treatments available to slow the progression of DN and prevent CKD. Strict control of glycemic levels, through medication and lifestyle changes, is essential. Furthermore, the use of drugs such as ACE inhibitors and angiotensin II receptor blockers has shown beneficial effects on renal protection. Other emerging treatments include SGLT2 and GLP-1 inhibitors, which demonstrate efficacy in both glycemic control and preservation of renal function. The article concludes that prevention and adequate management of these complications are fundamental to improving patients' quality of life and reducing rates of progression to CKD.