Topical application of the bee hive protectant propolis is well tolerated and improves human diabetic foot ulcer healing in a prospective feasibility study

AimsPropolis is a naturally occurring anti-inflammatory bee derived protectant resin. We have previously reported that topically applied propolis reduces inflammation and improves cutaneous ulcer healing in diabetic rodents. The aim of this study was to determine if propolis shows efficacy in a pilot study of human diabetic foot ulcer (DFU) healing and if it is well tolerated.MaterialsSerial consenting subjects (n = 24) with DFU ≥ 4 week's duration had topical propolis applied at each clinic review for 6 weeks. Post-debridement wound fluid was analyzed for viable bacterial count and pro-inflammatory MMP-9 activity. Ulcer healing data were compared with a matched control cohort of n = 84 with comparable DFU treated recently at the same center.ResultsUlcer area was reduced by a mean 41% in the propolis group compared with 16% in the control group at week 1 (P < 0.001), and by 63 vs. 44% at week 3, respectively (P < 0.05). In addition, 10 vs. 2% (P < 0.001), then 19 vs. 12% (P < 0.05) of propolis treated vs. control ulcers had fully healed by weeks 3 and 7, respectively. Post-debridement wound fluid active MMP-9 was significantly reduced, by 18.1 vs. 2.8% week 3 from baseline in propolis treated ulcers vs. controls (P < 0.001), as were bacterial counts (P < 0.001). No adverse effects from propolis were reported.ConclusionsTopical propolis is a well-tolerated therapy for wound healing and this pilot in human DFU indicates for the first time that it may enhance wound closure in this setting when applied weekly. A multi-site randomized controlled of topical propolis now appears to be warranted in diabetic foot ulcers.     

Five-year mortality in patients with diabetic foot ulcer during 2009–2010 was lower than expected

AimMortality rates are decreasing in patients with diabetes. However, as this observation also concerns patients with diabetic foot ulcer (DFU), additional data are needed. For this reason, our study evaluated the 5-year mortality rate in patients with DFU during 2009–2010 and identified risk factors associated with mortality.MethodsConsecutive patients who attended a clinic for new DFU during 2009–2010 were followed until healing and at 1 year. Data on mortality were collected at year 5. Multivariate Cox proportional-hazards model was used to identify mortality risk factors.ResultsA total of 347 patients were included: mean age was 65 ± 12 years, diabetes duration was 16 [10; 27] years; 13% were on dialysis; and 7% had an organ transplant. At 5 years, 49 patients (14%) were considered lost to follow-up. Total mortality rate at 5 years was 35%, and 16% in patients with neuropathy. On multivariate analyses, mortality was positively associated with: age [hazard ratio (HR): 1.05 (1.03–1.07), P < 0.0001]; duration of diabetes [HR: 1.02 (1.001–1.03], P = 0.03]; PEDIS perfusion grade 2 vs. 1 [HR: 2.35 (1.28–4.29), P = 0.006)]; PEDIS perfusion grade 3 vs. 1 [HR: 3.14 (1.58–6.24), P = 0.001); and ulcer duration at year 1 [HR 2.09 (1.35–3.22), P = 0.0009].ConclusionMortality rates were not as high as expected despite the large number of comorbidities, suggesting that progress has been made in the health management of these patients. In particular, patients with neuropathic foot ulcer had a survival rate of 84% at 5 years.     

Assessment of risk factors in diabetic foot ulceration and their impact on the outcome of the disease

AimsThe current study aims to identify risk factors for diabetic foot ulcer and their impact on the outcome of the disease.MethodsThree hundred diabetic patients were enrolled in the study. One hundred eighty subjects with diabetic foot ulcer and 120 diabetic controls without foot lesions. All expected risk factors were studied in all patients and after a follow up period, patients with diabetic foot ulcer were classified into group A (patients with healed ulcers) and group B (patients with persistent ulcer or ended by amputation). The risk factors were reanalyzed in both groups to find out their impact on the outcome of the disease.ResultsThe following variables were significant factors for foot ulceration: Male gender (P = 0.009), previous foot ulcer (P = 0.003), peripheral vascular disease (P = 0.004), and peripheral neuropathy (P = 0.006). Also lack of frequent foot self-examination was independently related to foot ulcer risk. The outcome was related to longer diabetes duration (P = 0.004), poor glycaemic control (P = 0.006) and anaemia (P = 0.003) and presence of infection (P < 0.001).ConclusionsPeripheral vascular disease and peripheral neuropathy together with lack of foot self-examination, poor glycaemic control and anaemia are main significant risk factors for diabetic foot ulceration.     

Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD)

AimsThe objective was to describe the prevalence of diabetes-related foot complications in a managed care population and to identify the demographic and biological risk factors.MethodsWe assessed the period prevalence of foot complications on 6992 patients using ICD-9 diagnosis codes from health plan administrative data. Demographic and biological variables were ascertained from surveys and medical record reviews. We defined four mutually exclusive groups: any Charcot foot, DFU with debridement, amputation ± DFU and debridement, and no foot conditions.ResultsOverall, 55 (0.8%) patients had Charcot foot, 205 (2.9%) had DFU with debridement, and 101 (1.4%) had a lower-extremity amputation. There were 6631 patients with no prevalent foot conditions. Racial/ethnic minorities were less likely to have Charcot foot (OR = 0.21; 95% CI: 0.10, 0.46) or DFU (OR = 0.61; 95% CI: 0.44, 0.84) compared to non-Hispanic Whites, but there were no racial/ethnic differences in amputation. Histories of micro- or macrovascular disease were associated with a two- to four-fold increase in the odds of foot complications.ConclusionIn managed care patients with uniform access to health care, we found a relatively high prevalence of foot complications, but attenuation of the racial/ethnic differences of rates reported in the literature.     

Disección coronaria espontánea en España: un estudio sobre bases administrativas realizado a partir del Conjunto Mínimo Básico de Datos español

Introduction and objectivesSpontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI). We sought to compare the results on in-hospital mortality and 30-day readmission rates among patients with AMI-SCAD vs AMI due to other causes (AMI-non-SCAD).MethodsRisk-standardized in-hospital mortality (rIMR) and risk-standardized 30-day readmission ratios (rRAR) were calculated using the minimum dataset of the Spanish National Health System (2016-2019).ResultsA total of 806 episodes of AMI-SCAD were compared with 119 425 episodes of AMI–non-SCAD. Patients with AMI-SCAD were younger and more frequently female than those with AMI–non-SCAD. Crude in-hospital mortality was lower (3% vs 7.6%; P < .001) and rIMR higher (7.6 ± 1.7% vs 7.4 ± 1.7%; P = .019) in AMI-SCAD. However, after propensity score adjustment (806 pairs), the mortality rate was similar in the 2 groups (AdjOR, 1.15; 95%CI, 0.61-2,2; P = .653). Crude 30-day readmission rates were also similar in the 2 groups (4.6% vs 5%, P = .67) whereas rRAR were lower (4.7 ± 1% vs 4.8% ± 1%; P = .015) in patients with AMI-SCAD. Again, after propensity score adjustment (715 pairs) readmission rates were similar in the 2 groups (AdjOR, 1.14; 95%CI, 0.67–1.98; P = .603).ConclusionsIn-hospital mortality and readmission rates are similar in patients with AMI-SCAD and AMI–non-SCAD when adjusted for the differences in baseline characteristics. These findings underscore the need to optimize the management, treatment, and clinical follow-up of patients with SCAD.     

Anemia in diabetic patients at an internal medicine ward: Clinical correlates and prognostic significance

BackgroundCharacteristics and prognostic significance of anemia in hospitalized diabetic patients are unknown.MethodsWe studied 3145 unselected patients admitted to two Internal Medicine Departments, 872 (27.7%) of whom were diabetic. Forty diabetic patients died during the first hospitalization period. Out of the remaining 832 patients, 334 (40.2%) were anemic and evaluated for survival. In 87 diabetic patients, the cause of anemia was evident on admission, whereas the other 247 had to be further investigated for etiology of anemia.ResultsCompared to non-anemic diabetic patients, the diabetic anemic patients were older (mean age 71.4 vs. 64.4 years, P < .001) and predominantly females (52.4% vs. 44.4%, P < .02). Of the 247 evaluated patients, 38% were deficient in iron, 12% in vitamin B₁₂ and/or folate, 54% had anemia of chronic disease, 47% suffered from heart failure, 39% had renal dysfunction and 22% were complex nursing care patients and/or had diabetic foot. On median follow-up of 19.2 months, mortality rate was higher in anemic compared to non-anemic diabetic patients (17.3% vs. 4%, P < .001), the main cause of death being infection. Male sex (P = .03), albuminuria (P = .01) and heart failure (P = .06) were associated with shorter survival, male sex being the most significant (OR 2.02, 95% CI 1.04 ? 4.00).ConclusionFrequency of anemia was increased in diabetic patients admitted to the Internal Medicine Departments, compared to the studies performed on ambulatory patient populations. Anemia was multifactorial and associated with higher mortality, predominantly from infections. Males with albuminuria and heart failure were at higher risk of death.     

Effect of foot-ankle flexibility and resistance exercise in the secondary prevention of plantar foot diabetic ulcer

AimsThe study aimed to evaluate the effects of foot-ankle flexibility and resistance exercises on the recurrence rate of plantar foot diabetic ulcers, HbA1c levels, diabetic neuropathy examination (DNE) scores, ankle brachial index (ABI), and walking speed within 12 and 24 weeks.MethodsWe conducted a double-blind randomized clinical trial. Fifty patients with recently healed plantar foot diabetic ulcers were randomized to an intervention group that performed foot-ankle flexibility and resistance exercise three times a week in their home (n = 25) or a control group (n = 25). Both groups were given foot care education. Outcomes were assessed at plantar foot diabetic ulcer recurrence or at 12 and 24 weeks whichever came first. Outcome measures included plantar foot diabetic ulcer recurrence, changes of HbA1c levels, DNE scores, ankle brachial index ABI, and walking speed.ResultsThere were significant difference between groups in ulcer recurrence at either 12 weeks (intervention 8%, control 68%, RR 0.288; 95% CI 0.156–0.534, P = 0.000) within 12 weeks.or 24 weeks (intervention 16%, control 72%, RR 0.222; 95% CI 0.088–0.564, P = 0.000).). There were significant differences in the DNE score delta (P = 0.000) and walking speed delta (P = 0.000), but there were no significant differences in the HbA1c delta and ABI delta between groups at either 12 or 24 weeks.ConclusionsFoot-ankle flexibility and resistance exercises can reduce the recurrence of plantar foot diabetic ulcer incidence and improve diabetic neuropathy and walking speed.Clinical trial number: NCT04624516     

Resultados clínicos tempranos tras el implante percutáneo de válvula aórtica por acceso transaxilar comparado con el acceso transfemoral. Datos del registro español de TAVI

Introduction and objectivesTransaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access.MethodsWe analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics.ResultsA total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n = 113 TXA group and n = 3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P = .95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P = .001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P = .003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P = .03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P = .039 and OR, 2.3; 95%CI, 1.2-4.5; P = .01, respectively).ConclusionsCompared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA.     

Efficacy of shock wave therapy on chronic diabetic foot ulcer: A single-blinded randomized controlled clinical trial

ObjectiveThis study was conducted to evaluate the efficacy of extracorporeal shock wave therapy (ESWT) on the healing rate, wound surface area and wound bed preparation in chronic diabetic foot ulcers (DFU).MethodsThirty eight patients with 45 chronic DFU were randomly assigned into; the ESWT-group (19 patients/24 ulcers) and the control-group (19 patients/21 ulcers). Blinded therapist measured wound surface area (WSA), the percentage of reduction in the WSA, rate of healing and wound bed preparation at baseline, after the end of the interventions (W8), and at 20-week follow-up (W20). The ESWT group received shock wave therapy twice per week for a total of eight treatments. Each ulcer was received ESWT at a frequency of 100 pulse/cm², and energy flux density of 0.11 mJ/cm². All patients received standardized wound care consisting of debridement, blood-glucose control agents, and footwear modification for pressure reduction.ResultsThe overall clinical results showed completely healed ulcers in 33.3% and 54% in ESWT-groups and 14.28% and 28.5% in the control group after intervention (W8), and at follow-up (W20) respectively. The average healing time was significantly lower (64.5 ± 8.06 days vs 81.17 ± 4.35 days, p < 0.05) in the ESWT-group compared with the control group.ConclusionESWT-treated ulcers had a significant reduction in wound size and median time required for ulcer healing, with no adverse reactions. So, the ESWT is advocated as an adjunctive therapy in chronic diabetic wound.     

HEPACONTROL. A program that reduces early readmissions,mortality at 60 days,and healthcare costs in decompensated cirrhosis

Background & aimsDecompensated cirrhosis patients have an elevated incidence of early readmission, mortality and economic burden. The aims of HEPACONTROL were to reduce early readmission and to evaluate its impact on mortality and emergency department visits.Patients and methodsQuasi-experimental study with control group which compared two cohorts of patients discharged after being admitted for cirrhosis-related complications. A prospective cohort (n = 80), who followed the HEPACONTROL program, which began with a follow-up examination seven days after discharge at the Hepatology Unit Day Hospital and a retrospective cohort of patients (n = 112), who had been given a standard follow-up. Outcome variables that were compared between both groups were early readmission rates, the number of emergency department visits post-discharge, financial costs and mortality.ResultsThe rate of early readmission was lower in the group with HEPACONTROL (11.3% vs 29.5%; P = .003). Also, the mean number of visits to the emergency department post-discharge (1.10 ± 1.64 vs 1.71 ± 2.36; P = .035), mortality at 60 days (3.8% vs 14.3%; P = .016), and the cost of early readmission were all lower compared with the group with standard follow-up (P = .029).ConclusionsHEPACONTROL decreases the incidence of early readmission the rate of emergency department visits and mortality at 60 days in patients with decompensated cirrhosis, and it is cost-effective.     

Supervivencia a largo plazo de una población española con cardiopatía isquémica estable: el registro CICCOR

Introduction and objectivesData are lacking on the long-term prognosis of stable ischemic heart disease (SIHD). Our aim was to analyze long-term survival in patients with SIHD and to identify predictors of mortality.MethodsA total of 1268 outpatients with SIHD were recruited in this single-center prospective cohort study from January 2000 to February 2004. Cardiovascular and all-cause death during follow-up were registered. All-cause and cardiovascular mortality rates were compared with those in the Spanish population adjusted by age, sex, and year. Predictors of these events were investigated.ResultsThe mean age was 68 ± 10 years and 73% of the patients were male. After a follow-up lasting up to 17 years (median 11 years), 629 (50%) patients died. Independent predictors of all-cause mortality were age (HR, 1.08; 95%CI, 1.07-1.11; P < .001), diabetes (HR, 1.36; 95%CI, 1.14-1.63; P < .001), resting heart rate (HR, 1.01; 95%CI, 1.00-1.02; P < .001), atrial fibrillation (HR, 1.61; 95%CI, 1.22-2.14; P = .001), electrocardiographic changes (HR, 1.23; 95%CI, 1.02-1.49; P = .02) and active smoking (HR, 1.85; 95%CI, 1.31-2.80; P = .001). All-cause mortality and cardiovascular mortality rates were significantly higher in the sample than in the general Spanish population (47.81/1000 patients/y vs 36.29/1000 patients/y (standardized mortality rate, 1.31; 95%CI, 1.21-1.41) and 15.25/1000 patients/y vs 6.94/1000 patients/y (standardized mortality rate, 2.19; 95%CI, 1.88-2.50, respectively).ConclusionsThe mortality rate was higher in this sample of patients with SIHD than in the general population. Several clinical variables can identify patients at higher risk of death during follow-up.Full English text available from:www.revespcardiol.org/en     

Diabetes-related foot ulcers and associated factors: Results from the Nord-Trøndelag Health Survey (HUNT3) (2006–2008)

AimTo determine the proportion of people with diabetes reporting a history of foot ulcer and investigate associated factors and healing time in the Nord-Trøndelag Health Survey (HUNT3), Norway.MethodsIn 2006–2008, all inhabitants in Nord-Trøndelag County aged ≥ 20 years were invited to take part in this population-based study; 54% (n = 50,807) attended. In participants reporting to have diabetes we examined the relationships between foot ulcers requiring more than 3 weeks to heal (DFU) and sociodemographic, lifestyle and clinical variables using logistic regression analysis.ResultsAmong participants with diabetes, 7.4% (95% confidence interval (CI) 6.2%–8.6%) reported a DFU. The median healing time was 6.0 weeks. In the final model, factors associated with a DFU were age ≥ 75 years (odds ratio (OR) 2.3, 95% CI 1.4–3.7), male sex (OR 2.0, 95% CI 1.3–3.1), waist circumference ≥ 102 cm (men) or 88 cm (women) (OR 1.95, 95% CI 1.2–3.2), insulin use (OR 2.1, 95% CI 1.3–3.4) and any macrovascular complication (OR 1.8, 95% CI 1.1–2.8).ConclusionsThe proportion of people with diabetes reporting a DFU was 7.4%, associated factors were age ≥ 75 years, male sex, waist circumference ≥ 102 cm (men) or 88 cm (women), insulin use and any macrovascular complication. The median healing time was 6 weeks.     

The diabetic foot infections: Biofilms and antimicrobial resistance

AimTo study the difference in antimicrobial resistance profile among biofilm producing and non-producing microorganisms isolated from diabetic foot ulcer in a tertiary care hospital in North India.MethodologyWe performed a prospective study on 162 DFU in patients treated in a multidisciplinary based diabetes and endocrinology center of JNMCH, AMU, Aligarh, India during the period of December 2008–March 2011. Detailed history and physical examination was carried out for every subject. Patient's profile, grade of DFU, co-morbidities and complications, laboratory data and final outcome were collected. Standard methods of sample collection and identification of microorganism were adopted. Risk factors for biofilm producing infections were determined by univariate analysis with 95% of CI. P value <0.05 were considered as significant.ResultsThe overall biofilm producing infection rate among DFU was 67.9%. On univariate analysis, significant risk factors for biofilm producing infection were male sex [P = 0.015, OR 2.35, RR 1.71], duration of diabetes [P < 0.006, OR 4.0, RR 2.7], duration of ulcer >1 month [P < 0.02, OR 2.26, RR 1.72], size of ulcer >4 cm² [P < 0.05, OR 2.03, RR 1.54], Grade II ulcer [P < 0.06, OR 1.87, RR 1.63], necrotic ulcer [P < 0.002, OR 5.79, RR 3.59], previous antibiotic use [P < 0.007, OR 4.24, RR 2.74], subcutaneous infection [P < 0.06, OR 1.87, RR 1.63], HbA1c >7% [P < 0.04, OR 3.19, RR1.87] and polymicrobial infection [P < 0.001, OR 6.64, RR 3.21] were significant risk factors.ConclusionsTreating the DFU by shifting from the planktonic model of microbiology to the biofilm model was recommended. With this new scientific approaches along with coordination of clinical and laboratory efforts, education, and research, it is possible to imagine overcoming much of biofilm disease.     

The independent contribution of diabetic foot ulcer on lower extremity amputation and mortality risk

AimsTo estimate 3-year risk for diabetic foot ulcer (DFU), lower extremity amputation (LEA) and death; determine predictive variables and assess derived models accuracy.Material and MethodsRetrospective cohort study including all subjects with diabetes enrolled in our diabetic foot outpatient clinic from beginning 2002 until middle 2010. Data were collected from clinical records.Results644 subjects with mean age of 65.1 (± 11.2) and diabetes duration of 16.1 (± 10.8) years. Cumulative incidence was 26.6% for DFU, 5.8% for LEA and 14.0% for death. In multivariate analysis, physical impairment, peripheral arterial disease complication history, complication count and previous DFU were associated with DFU; complication count, foot pulses and previous DFU with LEA and age, complication count and previous DFU with death. Predictive models’ areas under the ROC curves ranged from 0.80 to 0.83. A simplified model including previous DFU and complication count presented high accuracy. Previous DFU was associated with all outcomes, even when adjusted for complication count, in addition to more complex models.ConclusionsDFU seems more than a marker of complication status, having independent impact on LEA and mortality risk. Proposed models may be applicable in healthcare settings to identify patients at higher risk of DFU, LEA and death.     

Cambios en el tratamiento y disminución de la mortalidad del síndrome aórtico agudo. Lecciones del Registro Español del Síndrome Aórtico Agudo (RESA)

Introduction and objectivesThe Spanish Registry of Acute Aortic Syndrome (RESA) was launched in 2005 to identify the characteristics of acute aortic syndrome (AAS) in Spain. The aim of this study was to analyze the differences in management and mortality in the 3 RESA iterations.MethodsWe analyzed data from patients with AAS prospectively included by 24 to 30 tertiary centers during the 3 iterations of the registry: RESA I (2005-2006), RESA-II (2012-2013), and RESA III (2018-2019).ResultsAAS was diagnosed in 1902 patients (74% men; age, 60.7 ± 12.5 years): 1329 (69.9%) type A and 573 (30.1%) type B. Comparison of the 3 periods revealed that the use of computed tomography increased as the first diagnostic technique (77.1%, 77.9%, and 84.2%, respectively; P = .001). In type A, surgical management increased (79.6%, 78.7%, and 84.5%; P = .045) and overall mortality decreased (41.2%, 34.5%, and 31.2%; P = .002), due to a reduction in surgical mortality (33.4%, 25.1%, and 23.9%; P = .003). In type B, endovascular treatment increased (22.8%, 32.8%, and 38.7%; P = .006), while medical and surgical treatment decreased. Overall type B mortality also decreased (21.6%, 16.1%, and 12.0%; P = .005) in line with a reduction in mortality with medical (16.8%, 13.8%, and 8.8%, P = .030) and endovascular (27.0%, 18.0%, and 9.2%; P = .009) treatments.ConclusionsThe iterations of RESA show a decrease in mortality from type A AAS, coinciding with an increase in surgical treatment and a reduction in surgical mortality. In type B, the use of endovascular treatment was associated with improved survival, allowing better management in patients with complications.     

Brecha de sexo en la miocardiopatía hipertrófica

Introduction and objectivesKey sex differences have been explored in multiple cardiac conditions. However, sex impact in hypertrophic cardiomyopathy outcome is unclear. We aimed to characterize sex impact in overall and cardiovascular (CV) mortality in a nationwide hypertrophic cardiomyopathy registry.MethodsWe analyzed 1042 adult patients, 429 (41%) women, from a national registry of hypertrophic cardiomyopathy, with mean age at diagnosis 53 ± 16 years and a mean follow-up of 65 ± 75 months. At baseline, women were older (56 ± 16 vs 51 ± 15 years; P < .001), more symptomatic (56.4%, vs 51.7%; P < .001) and had more heart failure (42.0% vs 24.2%. P < .001), diastolic dysfunction (75.2% vs 64.1% P = .001), moderate/severe mitral regurgitation (33.4% vs 21.7%; P = .003), and higher B-type natriuretic peptide levels (920 [366-2412] mg/dL vs 487 [170-1087] mg/dL; P < .001). Women underwent fewer stress tests and cardiac magnetic resonance.ResultsKaplan-Meier survival curves showed higher overall (8.4% vs 5.0%; P = .026) and CV mortality (5.5% vs 2.2%; P = .004) in women. Cox proportional hazard regression showed that female sex was an independent predictor of overall (HR, 2.05; 95%CI, 1.11–3.78; P = .021) and CV mortality (HR, 3.16; 95%CI, 1.25–7.99; P = .015). Women had more heart failure-related death (2.6% vs 0.8%, P = .024). Despite similar sudden cardiac death (SCD) risk, women received fewer implantable cardioverter-defibrillators (10.9% vs 15.6%; P = .032) and, in patients without cardioverter-defibrillators, SCD occurred more commonly in women (1.8% vs 0.4%; P = .031).ConclusionsIn this nationwide registry, female sex was an independent predictor of overall and CV-related death, with more heart failure-related death. Despite similar SCD risk, women were undertreated with implantable cardioverter-defibrillators. These data highlight the need for an improved clinical approach in women with HCM.     

In-hospital mortality and length of stay in patients with diabetes having foot disease

ObjectiveWe aimed to determine whether in-patient mortality and length of stay were greater in diabetes patients with foot disease compared to those without foot disease.MethodsRetrospective data analysis of admissions over four years (2007–2010) to University Hospital Birmingham. Based on discharge diagnostic codes we grouped admissions into those 1) with amputation, 2) with foot disease and 3) without foot disease. Inpatient mortality and length of stay were compared between the three groups, adjusting for confounders.ResultsWe identified 25,118 admissions with diabetes of which 1149 admissions (4.6%) had foot disease and another 195 (0.8%) had a code for lower limb amputation. When compared to those without foot disease the adjusted odds ratio for inpatient mortality was 1.31 (95% CI 1.04–1.65 P = 0.02) in the foot disease group, and 1.02 (95% CI 0.56–1.85 P = 0.95) in the amputation group; and the adjusted relative ratio for length of stay was 2.01 (95 CI 1.86–2.16 P < 0.001) in the foot disease group and 3.08 (95% CI 2.60–3.65 P < 0.001) in the amputation group.ConclusionFoot disease in hospitalised patients with diabetes is associated with increased length of stay and inpatient mortality. Our study adds to evidence on excess mortality associated with diabetic foot disease and to evidence on excess mortality observed in people with diabetes admitted to hospitals.     

Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study

BackgroundPulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions.MethodsThirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed.ResultsMild pulmonary congestion caused a 26.1% decline in DM (R² = .261; P = .004) and 20% reduction in walking time (R² = .200; P = .01), indicating decreases of 2.23 mm and 1.54 min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P = .002), walking (P = .034) and active time (P = .002), and number of steps taken (P = .01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P = .037) and lungs (P = .02), attenuation of exploratory behavior (P = .01) and significant decrease in traveled distance (P = .034). Thoracic ultrasonography of CKD mice showed presence of B-lines.ConclusionThe mild pulmonary congestion reduced DM and walking time in subjects undergoing HD. Individuals were less active on dialysis days. Furthermore, the experimental model implies that the presence of pulmonary congestion and inflammation may play a decisive role in the low physical and exploratory performance of CKD mice.