Costs of deep foot infections in patients with diabetes mellitus

OBJECTIVE: To calculate costs for the management of deep foot infections and to identify the most important factors related to treatment costs. DESIGN: Costs for in-hospital care, surgery, investigations, antibacterials, visits to the foot-care team, orthopaedic appliances and topical treatment were calculated retrospectively from diagnosis until healing or death. Multiple regression analysis was used to identify factors that independently affect costs. SETTING: A multidisciplinary foot-care team. PATIENTS: 220 prospectively followed patients with diabetes mellitus and deep foot infections who were referred to the team from 1986 to 1995. MAIN OUTCOME MEASURES AND RESULTS: Total cost for healing without amputation was Swedish kronor (SEK)136,600 per patient, while the corresponding cost for healing with minor amputation was SEK260,000 and with major amputation was SEK234,500. All costs were quoted in SEK at 1997 price levels (1 Pound sterling and $US1 equalled approximately SEK12.50 and SEK7.64, respectively). The cost of antibacterials was 4% of total costs. The cost of topical treatment was 51% of total costs and related to wound healing time. Number of weeks between diagnosis of deep foot infection and healing, and number of surgical procedures were variables that explained 95% of costs in the multiple regression analysis. It was not possible to find any parameters present at diagnosis that could contribute to an explanation of total treatment costs. CONCLUSIONS: Topical treatment accounted for the largest proportion of total costs and the most important cost driving factors were wound healing duration and repeated surgery. Costs of antibacterials should not be used as an argument in the choice between early amputation and conservative treatment.     

Management of bacterial urinary tract infections in adult patients with diabetes mellitus

Urinary tract infections (UTIs) are more common and tend to have a more complicated course in patients with diabetes mellitus than in the general population. The mechanisms that potentially contribute to the increased prevalence of both asymptomatic and symptomatic bacteriuria in these patients are defects in the local urinary cytokine secretions and an increased adherence of the microorganisms to the uroepithelial cells. The need for treatment of asymptomatic bacteriuria remains controversial. No evidence is available on the optimal treatment of acute cystitis and pyelonephritis in patients with diabetes. Because of the frequent (asymptomatic) upper tract involvement and the possible serious complications, many experts recommend a 7- to 14-day oral antibacterial regimen for bacterial cystitis in these patients, with an antibacterial agent that achieves high concentrations both in the urine and in urinary tract tissues. The recommended treatment of acute pyelonephritis does not differ from that in patients without diabetes. Clinical trials specifically dealing with the treatment of UTIs in patients with diabetes, comparing the optimal duration and choice of antibacterial agent, are needed. In addition, new approaches to preventive strategies must prove their value in this specific patient group.     

艾滋病患者常见机会性真菌感染的防治

艾滋病患者由于存在免疫缺陷而成为侵袭性真菌感染的高危人群,尽管高效抗反转录病毒联合治疗(HAART)在临床广泛使用,但机会性真菌感染仍是我国艾滋病患者常见的机会性感染和死亡原因,我国艾滋病患者常见的机会性真菌感染包括:口腔及食道念珠菌病、肺孢菌肺炎、隐球菌脑膜炎、曲霉病以及马尔尼菲青霉病等.机会性真菌感染的发生与艾滋病患者的细胞免疫状态有关,通过HAART提高患者CD4+T淋巴细胞计数以及针对高危人群采取预防性使用抗真菌药物是降低艾滋病患者机会性真菌感染的主要措施,但预防性用药有增加真菌耐药性产生的可能.对于艾滋病患者机会性真菌感染,在尽早使用敏感抗真菌药物的同时,适时给予抗HIV治疗有助于病情的恢复.对于临床治愈的患者,应根据患者细胞免疫状态,决定是否给予维持治疗以防止病情复发.新型高效广谱抗真菌药物不断出现,为艾滋病患者机会性真菌感染的防治提供了新的选择,但这些药物在艾滋病患者中的疗效和安全性有待进一步观察和研究.     

Pathogenesis and management of bacterial urinary tract infections in adult patients with diabetes mellitus

Urinary tract infections (UTIs) are more common and tend to have a more complicated course in patients with diabetes mellitus (DM). The mechanisms, which potentially contribute to the increased prevalence of both asymptomatic and symptomatic bacteriuriai in these patients are defects in the local urinary cytokine secretions and an increased adherence of the microorganisms to the uroepithelial cells. The need for treatment of asymptomatic bacteriuria remains controversial. No evidence is available on the optimal treatment of acute cystitis and pyelonephritis in patients with DM. Because of the frequent (asymptomatic) upper tract involvement and the possible serious complications, many experts recommend a 7-14-day oral antimicrobial regimen for bacterial cystitis in these patients, with an antimicrobial agent that achieves high levels both in the urine and in urinary tract tissues. Current data suggest that shorter regimens will lead to failure also in uncomplicated UTI in women. The recommended treatment of acute pyelonephritis does not differ from that in nondiabetic patients. Clinical trials specifically dealing with the treatment of UTIs in diabetic patients, comparing the optimal duration and choice of antimicrobial agent, are needed. Besides that, new approaches to preventive strategies must prove their value in this specific patient group.     

糖尿病相关皮肤病变

由于血糖长期慢性升高而导致的各种急慢性并发症是糖尿病患者寿命缩短、生活质量下降的重要原因。糖尿病引起的皮肤病变虽不像心、脑、肾、眼病那样直接危害生命，但也给患者带来很多痛苦，如处理不好也会导致严重后果。     

Urinary tract infections in patients with diabetes mellitus: epidemiology, pathogenesis and treatment

Patients with diabetes mellitus (DM) have a higher prevalence of asymptomatic bacteriuria (ASB) and incidence of urinary tract infections (UTIs) compared with patients without DM. They also more often have bacteraemia, with the urinary tract as the most common focus for these infections, as well as a higher mortality outside the hospital compared with patients without DM. It appears that the increased prevalence of ASB in diabetic women is not the result of a difference in causative bacteria, as the same virulence factors and resistance to antimicrobials were found in Escherichia coli isolated from the urine of diabetic women with ASB compared with non-diabetic controls. Bacterial growth in vitro is increased after the addition of glucose, however glucosuria is not a risk factor for ASB or for the development of UTIs in vivo. No differences in granulocyte function tests were demonstrated among diabetic women with ASB, non-bacteriuric women and healthy control subjects, but women with both ASB and DM had lower urinary cytokine and leukocyte concentrations than women with ASB without DM. Finally, it was found that E. coli expressing type 1 fimbriae adhere better to uroepithelial cells of women with DM compared with those isolated from women without DM. There are no randomised trials that answer the question as to the optimal duration of treatment for UTIs in diabetic patients. It has been recommended to consider these patients as having a complicated UTI and therefore to treat them for a period of 7-14 days.     

重症监护病房患者真菌感染临床分析

目的：对重症监护病房患者真菌感染情况进行临床分析。方法：对本院2009年2月～2010年2月重症监护病房发生真菌感染的33例患者,分别为血、尿、痰、局部引流物及中心穿刺针顶端真菌培养和药物敏感性试验阳性者。结果：本组33例真菌感染患者中,白色假丝酵母菌的感染率最高（36.4%）,其次是热带假丝酵母菌（21.2%）,感染部位以呼吸道为主,其次是泌尿道和穿刺针顶端。提示感染与侵入性操作和光谱抗生素的应用有关。克柔假丝酵母菌、光滑假丝酵母菌和热带假丝酵母菌对氟康唑的耐药性较高,分别为42.7%、37.5%、8.2%,所有菌株对二性霉素B和制霉菌素的敏感性均较好。结论：重症监护病房应合理使用抗生素,提高侵入性操作无菌化,从而降低真菌感染,提高治疗效果。     

Antiplatelet therapy in patients with diabetes mellitus

Platelets are key players in arterial thrombosis, and oral antiplatelet therapy is a cornerstone in the treatment and prevention of cardiovascular events. However, although currently approved antiplatelet drugs have proved successful in reducing cardiovascular events, platelet-dependent thrombosis remains an important cause of morbidity and mortality in patients with coronary artery disease. It is well-known that patients with diabetes mellitus (DM) have an increased risk of cardiovascular events and, therefore, understanding the mechanism of action and safety profile of antiplatelet drugs in this high-risk population is of particular interest. There is considerable inter-individual variation in the efficacy of established antiplatelet drugs, and high on-treatment platelet reactivity is associated with an increased risk of cardiovascular events, thus prompting the search for novel drugs against platelet-dependent thrombosis. New antiplatelet treatment strategies include drugs with more efficient and reversible platelet inhibition. This review discusses selective inhibitors of the platelet cyclooxygenase enzyme, thienopyridine and non-thienopyridine inhibitors of the platelet adenosine diphosphate receptor, phosphodiesterase inhibitors, and protease-activated receptor antagonists. An overview of currently available antiplatelet drugs is provided, focusing on benefits and limitations in patients with DM. Furthermore, the rationale for new oral antiplatelet drugs under development is discussed with particular focus on the potential role of these drugs to improve cardiovascular outcomes in patients with DM.     

Common drug-drug interactions in antifungal treatments for superficial fungal infections

Introduction: Antifungal agents can be co-administered alongside several other medications for a variety of reasons such as the presence of comorbidities. Pharmacodynamic interactions such as synergistic and antagonistic interactions could be the result of co-administered medications. Pharmacokinetic interactions could also transpire through the inhibition of metabolizing enzymes and drug transport systems, altering the absorption, metabolism and excretion of co-administered medications. Both pharmacodynamic and pharmacokinetic interactions can result in hospitalization due to serious adverse effects associated with antifungal agents, lower therapeutic doses required to achieve desired antifungal activity, and prevent antifungal resistance.

Areas covered: The objective of this review is to summarize pharmacodynamic and pharmacokinetic interactions associated with common antifungal agents used to treat superficial fungal infections. Pharmacodynamic and pharmacokinetic interactions that impact the therapeutic effects of antifungal agents and drugs that are influenced by the presence of antifungal agents was the context to which these antifungal agents were addressed.

Expert opinion: The potential for drug-drug interactions is minimal for topical antifungals as opposed to oral antifungals as they have minimal exposure to other co-administered medications. Developing non-lipophilic antifungals that have unique metabolizing pathways and are topical applied are suggested properties that could help limit drug-drug interactions associated with future treatments.     

Serum fructosamine in patients with diabetes mellitus

Serum fructosamine was compared with other measures of blood glucose control in 11 non-diabetic volunteers, 14 type 1 and 14 type 2 diabetic patients. Estimates of mean plasma glucose concentrations for the 28 diabetic patients were made by nine physicians, based on their interpretation of historical data, home capillary blood glucose profiles, fasting and random plasma glucose and plasma lipid levels. Significant differences between estimated and measured mean glucose levels were apparent with a tendency for physicians to underestimate mean blood glucose in the hyperglycaemic range (glucose greater than 11 mmol/l). Fructosamine results on the same patients correlated linearly both with mean plasma glucose concentrations (r = 0.86, p less than 0.001) and with glycosylated haemoglobin (HbA1c) levels (r = 0.93, p less than 0.001) and correctly classified diabetes control in most patients. Despite marked fluctuations of plasma glucose concentration, serum fructosamine levels measured at different times of the day did not alter significantly. We conclude that a random serum sample analysed for fructosamine provides a simple and reliable means to measure the efficacy of therapy and often provides information superior to clinical assessment of diabetic control.     

创伤患者合并糖尿病的临床特点及围手术期的处理

目的明确合并糖尿病的创伤患者外科围手术期血糖控制的安全方法。方法对50例并存糖尿病的创伤患者的围手术期诊断与治疗进行回顾性分析。结果糖尿病以2型多见,多见于年长者。5例因病情不典型而漏诊。1例死于严重的脑外伤。结论静脉应用普通胰岛素是围手术期糖尿病患者血糖控制的安全有效的方法。     

特殊人群侵袭性真菌感染的药物选择

及时合理使用有效的抗真菌药物是改善侵袭性真菌感染患者预后的关键,临床医生应根据患者不同病理生理状态选择合适的抗真菌治疗方案,并注意其他药物与抗真菌药物之间的相互作用.本文针对老年、儿童和妊娠妇女,以及艾滋病和肝肾功能不全患者等几类特殊人群,综述侵袭性真菌感染治疗的药物选择.     

Pharmacotherapy of hypertension in patients with diabetes mellitus

The co-existence of hypertension and diabetes dramatically and synergistically increases the risk of microvascular and macrovascular complications. Overwhelming evidence supports aggressive treatment of hypertension in diabetic patients. However, only a small percentage of diabetic hypertensive patients reach their treatment goal of blood pressure (BP) < 130/80 mmHg. Tight BP control is not only cost-effective but also more rewarding than glycaemic control. The optimal goal of BP control in diabetics should be 130/80 mmHg. In subjects with diabetes and renal insufficiency, the BP should be lowered to 125/75 mmHg to delay the progression of renal failure. The choice of an antihypertensive agent should be based on proven effects on morbidity and mortality rather than on surrogate parameters such as lipid or glucose. Limited data suggests that an angiotensin converting enzyme inhibitor (ACEI) is the agent of choice, especially in those with proteinuria or renal insufficiency. beta-blockers (betaBs) can be the first-line agent in diabetics with coronary heart disease, while thiazide diuretics (TD) and calcium-channel blockers (CCBs) are the second-line drugs. Angiotensin II-receptor blockers (ARBs) may be proven to be as effective as ACEIs in diabetics with hypertension. alpha-adrenergic antagonists (AAAs) should be avoided. Most hypertensive patients require more than one agent to control their BP. There is no evidence to support one combination regimen over others; nevertheless, a combination of an ACEI with a TD or a betaB may be the most cost-effective regimens compared to other combinations.     

Invasive fungal infections in patients with cancer in the Intensive Care Unit

Invasive fungal infections (IFIs) have emerged as a major cause of morbidity and mortality amongst critically ill patients. Cancer patients admitted to the Intensive Care Unit (ICU) have multiple risk factors for IFIs. The vast majority of IFIs in the ICU are due to Candida spp. The incidence of invasive candidiasis (IC) has increased over recent decades, especially in the ICU. A shift in the distribution of Candida spp. from Candida albicans to non-albicans Candida spp. has been observed both in ICUs and oncology units in the last two decades. Timely diagnosis of IC remains a challenge despite the introduction of new microbiology techniques. Delayed initiation of antifungal therapy is associated with increased mortality. Therefore, prediction rules have been developed and validated prospectively in order to identify those ICU patients at high risk for IC and likely to benefit from early treatment. These rules, however, have not been validated in cancer patients. Similarly, major clinical studies on the efficacy of newer antifungals typically do not include cancer patients. Despite the introduction of more potent and less toxic antifungals, mortality from IFIs amongst cancer patients remains high. In recent years, aspergillosis and mucormycosis have also emerged as significant causes of morbidity and mortality amongst ICU patients with haematological cancer.     

老年患者泌尿系真菌感染的临床分析

目的 了解老年患者泌尿系真菌感染的菌群分布情况及其耐药性特点,以指导临床合理使用抗真菌药物。方法 对本院老年医学科2016年1月—2019年4月临床泌尿系感染老年患者分离出的真菌菌株进行回顾性分析。结果 总共分离出278株真菌,其中以白念珠菌为主,占52.2%,其次是热带念珠菌,占23.7%,光滑念珠菌11.5%,克柔念珠菌6.1%,近平滑念珠菌3.2%及其他念珠菌(葡萄牙念珠菌、季也蒙念珠菌)3.3%,分离出的真菌菌株对伊曲康唑、氟康唑的耐药率相对较高,对伊曲康唑的耐药率分别为18.6%、15.1%、21.9%、35.3%、11.1%和0,对氟康唑的耐药率分别为8.9%、7.6%、25.0%、100%、0和0,分离的菌株对两性霉素B和5-氟胞嘧啶均敏感,对伏立康唑的平均耐药率为5.0%。结论     

老年患者泌尿系真菌感染的临床分析

目的 了解老年患者泌尿系真菌感染的菌群分布情况及其耐药性特点,以指导临床合理使用抗真菌药物。方法 对本院老年医学科2016年1月—2019年4月临床泌尿系感染老年患者分离出的真菌菌株进行回顾性分析。结果 总共分离出278株真菌,其中以白念珠菌为主,占52.2%,其次是热带念珠菌,占23.7%,光滑念珠菌11.5%,克柔念珠菌6.1%,近平滑念珠菌3.2%及其他念珠菌(葡萄牙念珠菌、季也蒙念珠菌)3.3%,分离出的真菌菌株对伊曲康唑、氟康唑的耐药率相对较高,对伊曲康唑的耐药率分别为18.6%、15.1%、21.9%、35.3%、11.1%和0,对氟康唑的耐药率分别为8.9%、7.6%、25.0%、100%、0和0,分离的菌株对两性霉素B和5-氟胞嘧啶均敏感,对伏立康唑的平均耐药率为5.0%。结论 本院老年医学科泌尿系真菌感染以白念珠菌、热带念珠菌为主,且检出的真菌对伊曲康唑、氟康唑、伏立康唑已出现不同程度的耐药性,因此,加强监测各种真菌的耐药情况对临床合理使用抗真菌药物显得尤为重要。     

Urinary tract infection in patients with diabetes mellitus

Urinary tract infections (UTI) are very often encountered in patients with diabetes mellitus. They may present themselves as asymptomatic bacteriuria, but may also lead to more serious infecitons. In most cases the kidney is involved, although signs and symptoms of renal infection may not be present. Asymptomatic bacteriuria is more prevalent in women, but no men, with diabetes mellitus compared to controls. Studies yield conflicting results, probably due to selection bias, about associated risk factors. The pathogens cultured are those seen in all complicated urinary tract infections. The suggested mechanisms of an increased susceptibility to UTI are (a) decreased antibacterial activity due to the 'sweet urine', (b) defects in neutrophil function and (c) increased adherence to uroephithelial cells. The latter is the most likely. UTI in diabetics should be treated as complicated UTI with agents reaching high tissue levels for 10-14 days.     

Pulmonary function in patients with diabetes mellitus.

The present study was carried out to assess the lung functions in oral medicated and insulin administered patients with normal controls. 20 subjects were selected as the study group for oral medication (Group I), 20 subjects were selected as the study group for insulin treatment (Group II) and 40 subjects were selected as normal controls. Age group of Group I and Group II were 51.25 +/- 6.28 and 50.8 +/- 6.56 respectively and controls were age and height matched. Seventeen patients of Group I were undergoing treatment for the last 10-20 years and 20 patients in Group II were undergoing treatment for the last 30 years. Only male subjects were selected for the study. Lung function test were carried out with Spirometer (Vitallograph Compact II). A significant reduction in forced expiratory volume/forced vital capacity (FEV1/FVC%) was observed in oral pills used subjects and insulin administered subjects as compared to controls. Significant decrease in forced expiratory flow rate (FEF25-75%) in group I subjects was also observed as compared to controls. Forced mid flow time (FMFT) showed a significant increase in group II in comparison to controls. These changes clearly show the expiratory flow rates are reduced both in orally medicated and insulin administered patients. Increase in FMFT in group I may be due to the reduced respiratory ability to carry out the FVC test along with the side effects of oral medication for diabetes mellitus.