Diabetes and burns: retrospective cohort study

Burn injuries are often associated with multisystemic complications, even in otherwise healthy individuals. It is therefore intuitive that for the diabetic patient, the underlying pathophysiologic alterations in vascular supply, peripheral neuropathy, and immune function could have a profoundly devastating impact on patient outcome. The effects of diabetes on morbidity and mortality of the burn-injured patient have not been examined in great detail. The purpose of this retrospective study was to compare clinical outcomes between diabetic and nondiabetic burn patients. We reviewed the charts of 181 diabetic (DM) and 190 nondiabetic (nDM) patients admitted with burns between January 1996 and May 2000, matched by sex and date of admission. Burn cause and size, time to presentation, clinical course, and outcomes were evaluated. Because age was a factor, the analysis was done by three age groups: younger than 18 years, 18 to 65 years, and older than 65 years. Of patients 18 to 65 years, 51% (98/191) were diabetic, whereas 84% (81/96) of those older than 65 and only 4% (3/85) of patients younger than 18 were diabetic. Because of the disproportion in numbers of diabetics compared with nondiabetics in the younger than 18 and older than 65 years-old groups, these patients will not be discussed. Diabetics were more likely to incur scald injury from tub or shower water rather than hot fluid spills (33% DM vs 15% nDM; P < or = 0.01), and have a delayed presentation (45 vs 23%; P = 0.00001). There was no difference in total burn size in all groups. Diabetics in the 18 to 65 years group had a higher rate of full-thickness burns (51 vs 31%; P = 0.025), skin grafts (50 vs 28%; P = 0.01) and burn-related procedures (57 vs 32%; P = 0.001), infections (65 vs 51%; P = 0.05), and longer lengths of stay (23 vs 12 days; P = 0.0001). Although there was no statistically significant difference in incidence of specific infections, the rates of cellulitis, wound infection, urinary tract infection, line infection, and osteomyelitis, were consistently higher in the diabetic population. Partial graft slough was 6% in diabetics 18 to 65 years with a 3% regraft rate, whereas nondiabetics had a 1% regraft rate. Comparing diabetics with controlled vs uncontrolled glucose levels, diabetics with uncontrolled glucose had higher rates of infection (72 vs 55%; P < or = 0.025), all burn-related procedures (68 vs 45%; P < or = 0.025), and longer ICU stays (24 vs 10 days; P = 0.048). Mortality rate was 2% for diabetics and for nondiabetics. In summary, presence of diabetes in the burn patient was associated with a worse outcome. A predilection for burn injuries in the diabetic was noted in the older adult population. Deeper burns, delayed presentation, higher rates of infection, graft failure and operations, and longer lengths of stay translate into an increased cost to society both economically and in lives. This data would suggest a need for better burn education for diabetics and health care professionals, recognizing the elderly population as a "high-risk" group. We believe that targeted prevention measures and treatment strategies, emphasizing earlier and more aggressive intervention for this population, may have a favorable effect on morbidity and mortality.     

Effect of diabetes on long-term mortality following contemporary percutaneous coronary intervention: analysis of 4,284 cases

OBJECTIVE: Diabetic patients are known to have reduced long-term survival following percutaneous transluminal coronary angioplasty compared with nondiabetic patients. However, it is unknown whether this survival disadvantage has persisted in the era of contemporary percutaneous coronary intervention (PCI) techniques, which include the widespread use of stents and the availability of platelet glycoprotein (GP) IIb/IIIa inhibitors. RESEARCH DESIGN AND METHODS: Three hospitals in New York City contributed prospectively defined data on 4,284 patients undergoing PCI. The primary end point was all-cause mortality following hospital discharge for PCI. RESULTS: Hypertension, renal insufficiency, and renal failure requiring dialysis were all more common in diabetic patients, whereas active smoking was less frequent. Congestive heart failure on admission was more common in diabetic than nondiabetic patients (7.7 vs. 4.0%, P < 0.001). Stents were placed in 78% of nondiabetic patients and 75% of diabetic patients (P = 0.045). Platelet GP IIb/IIIa antagonists were administered to 23% of nondiabetic and 24% of diabetic patients (P = NS). At a mean follow-up of 3 years, mortality was 8% among nondiabetic patients and 13% for diabetic patients (P < 0.001). After adjustment for differences in baseline characteristics between nondiabetic and diabetic patients, diabetes remained a significant independent hazard for late mortality (hazard ratio 1.462, 95% CI 1.169-1.828; P = 0.001). CONCLUSIONS: Following contemporary PCI, diabetic patients continue to have worse survival than nondiabetic patients.     

Bacteremia in adult diabetic patients

OBJECTIVE: To compare the microbiology, sources, complications, and outcome of bacteremia in diabetic and nondiabetic patients. RESEARCH DESIGN AND METHODS: A prospective study was conducted of all episodes of bacteremia in hospitalized diabetic and nondiabetic patients. The study consisted of patients greater than or equal to 18 yr of age with bacteremia detected within a 19-mo interval. RESULTS: We compared 124 episodes of bacteremia in 119 diabetic patients to 508 episodes in 480 nondiabetic patients. Diabetic patients were older than nondiabetic patients (median age 74 vs. 68 yr, P = 0.0001). In patients with an indwelling urinary catheter and bacteremic urinary tract infection, the percentage of Klebsiella in diabetic patients was 60% (6 of 10) and in nondiabetic patients was 17% (4 of 23, P = 0.04). In patients without an obvious source of bacteremia, the percentage of staphylococcal isolates in diabetic patients was 29% (10 of 35) and in nondiabetic patients was 14% (24 of 176, P = 0.04). Staphylococci were a common cause of bacteremic infections of the extremities in diabetic patients (12 of 19, 63%) and nondiabetic patients (20 of 50, 40%). Septic shock was the only complication that was more common in diabetic patients. The mortality in diabetic and nondiabetic patients was 28 and 29%, respectively. CONCLUSIONS: Our results represent elderly patients with non-insulin-dependent diabetes mellitus. In this group, empirical treatment for suspected bacteremic urinary tract infection in patients with a urinary catheter should include coverage for Klebsiella. Empiric treatment for suspected bacteremia of unknown origin or caused by infection of the extremities should include an antistaphylococcal drug. The prognosis of bacteremia in diabetic and nondiabetic patients was similar.     

Prevalence and mortality of acute myocardial infarction in patients with diabetes

The purpose of this study was to investigate if insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) predispose to the development of acute myocardial infarction (AMI) and modify the prognosis. The study includes 832 AMI patients consecutively hospitalized over a 3-yr period. The prevalence of diabetes mellitus among the AMI patients was 9.7% and is significantly higher than in an age-matched population, where it is 6.1% (P less than 0.001). The prevalence of diabetes was higher for women than for men (14.9% versus 7.6%). The risk of AMI was found to be twice as high among IDDM than among nondiabetic patients (P less than 0.001). Men with NIDDM were not found to have a significantly higher risk of AMI (P greater than 0.1), but the risk of AMI in women with NIDDM was approximately doubled (P less than 0.01). During the first month following AMI the mortality rate for nondiabetic patients was 20.2% compared with 42.0% for diabetic patients (P less than 0.001). Insulin treatment in NIDDM was associated with a reduced mortality rate compared with treatment with oral agents (P less than 0.05). The mortality rate was significantly higher in patients with poor metabolic control compared with patients in good control, whether before AMI or at the time of hospitalization. Diabetic patients had a higher risk of developing cardiogenic shock and conduction disorders than nondiabetic patients. We conclude that diabetes mellitus disposes to AMI and that the mortality rate of AMI is significantly increased among diabetic patients. Poor metabolic regulation of the diabetes may aggravate the prognosis for AMI.     

Bacteremia in diabetic patients: comparison of incidence and mortality with nondiabetic patients

We determined the incidence of bacteremia and associated mortality in diabetic and nondiabetic patients in the four major hospitals of one metropolitan area over the 5-yr period 1977-1981. Mortality rates, based on episodes of bacteremia, were similar in diabetic and nondiabetic patients in most instances. Diabetic patients experienced lower mortality rates from Enterobacteriaceae bacteremia compared with nondiabetic patients; this finding was explained by a greater tendency for diabetic patients to have Escherichia coli bacteremia due to community-acquired urinary tract infection. However, the incidence of bacteremia due to all microorganisms was increased twofold in diabetic patients and the incidence of Enterobacteriaceae bacteremia was increased threefold. Because of their increased incidence of bacteremia, diabetic patients in this population were nearly twice as likely to die as a result of bacteremia compared with nondiabetic patients. Thus, the frequent occurrence of bacteremia among patients with diabetes mellitus represents a significant problem.     

Impact of diabetes mellitus on other cardiovascular risk factors in patients with stenosis of the internal carotid artery

AIM: To examine cardiovascular risk factors, clinical features and their impact on the results of carotid endarterectomy in diabetic patients with stenosis of the internal carotid artery. MATERIAL AND METHODS: We analysed data on 100 diabetic and 607 nondiabetic patients who underwent carotid endarterectomy in Vilnius University Emergency hospital from 1995 through 2005. RESULTS: Diabetic patients with carotid artery stenosis were younger (p < 0.05), they smoked less often (p < 0.001) and were more often obese (p < 0.001) than nondiabetic patients. 93% of diabetic patients had arterial hypertension or hypercholesterolemia or even more cardiovascular risk factors. Diabetic were more likely to have nonspecific symptoms and severe bilateral carotid stenosis (p < 0.01). Perioperative stroke and mortality rate was 12% for diabetic and 3.4% for nondiabetic patients (p < 0.001), but no perioperative myocardial infarction was identified in diabetic patients. Four clinical factors increased the odds of complications: age 75 > (odds ratio--OR 2.2; 95% confidence interval--CI 1-4.9), smoking (OR 2.7, 95% CI 1.8-4.2), obesity (OR 6.1; 95% CI 3.9-9.5) and severe bilateral carotid stenosis (OR 2.1; 95% CI 1.3-3.6). CONCLUSION: Diabetes mellitus in patients with severe carotid artery stenosis changes conventional risk factors, clinical picture of the disease and increases the risk of carotid endarterectomy.     

Microbiologic features and outcome of pneumonia in transplanted patients

We prospectively evaluated lower respiratory tract infections in solid organ transplantation (SOT) patients to determine the microbiologic diagnosis and clinical outcomes. We diagnosed 83 cases of pneumonia, 38 of which were community acquired and 45 were nosocomial. Those with bilateral infiltrates or absence of improvement after 3 days of treatment underwent fiberoptic bronchoscopy. Bacterial pneumonia was the most frequent diagnosis and mixed infection predominated in the nosocomial group (11/45 nosocomial versus 1/38 community). Fiberoptic bronchoscopy with bronchoalveolar lavage had higher diagnostic yield in nosocomial pneumonia (77% versus 47%). Mortality differences between the 2 groups were 58% nosocomial versus 8% community-acquired infections (P < 0.001). SOT patients with nosocomial pneumonia, or those who needed mechanical ventilation, had a high mortality rate and benefits from the fiberoptic diagnostic techniques.     

Intensification of therapeutic approaches reduces mortality in diabetic patients with acute myocardial infarction: the Munich registry

OBJECTIVE: The myocardial infarction (MI) registry of the Academic Schwabing Hospital, Munich, investigates the hospital course of diabetic and nondiabetic patients with acute MI. The aim of this study was to improve quality care management and to compare hospital mortality and therapeutic approaches (i.e., PTCA, stenting, GPIIb/IIIa receptor antagonists, glucose-insulin infusion). RESEARCH DESIGN AND METHODS: Data of diabetic patients and nondiabetic patients were analyzed. All diabetic and nondiabetic subjects who were admitted in 1999 and 2001 were included: 1999, 126 (38%) diabetic and 204 (62%) nondiabetic patients; 2001, 91 (31%) diabetic and 205 (59%) nondiabetic patients. RESULTS: In 1999, coronary angiography (P < 0.01), percutaneous transluminal coronary angioplasty (PTCA) (P < 0.001), and stenting (P < 0.001) were performed less frequently in diabetic than in nondiabetic patients. During this period, total hospital mortality (29 vs. 16%, P < 0.01) and mortality within 24 h after admission (14 vs. 5%, P = 0.01) were higher in diabetic than in nondiabetic patients. In 2001, frequencies of coronary angiography, PTCA, and stenting were increased in diabetic patients (P < 0.001 vs. 1999), and the interventions were comparable with those performed in nondiabetic patients. Furthermore, glucose-insulin infusion was administered in 46% of diabetic subjects. In 2001, total hospital mortality decreased to 17% in diabetic subjects (P = 0.028 vs. 1999) and mortality within 24 h after admission declined to 4% (P = 0.027 vs. 1999). Logistic regression analysis revealed that an increase in the number of therapeutic approaches (also when adjusted for clinical variables) is associated with a reduction in mortality of diabetic patients with acute MI (adjusted odds ratio 0.14, P < 0.0001). CONCLUSIONS: Intensification of multiple advanced therapeutic strategies in diabetic patients with acute MI enables a substantial reduction in hospital mortality. The enforcement leads to rates of hospital mortality that are comparable to those of nondiabetic patients.     

Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome

OBJECTIVE: The aim of this study was to quantify the distribution of peripheral arterial disease in the diabetic and nondiabetic population attending for angiography and to compare severity and outcome between both groups of patients. RESEARCH DESIGN AND METHODS: Randomly selected lower-extremity angiograms were examined according to the Bollinger system. Patient demographics and medical history were recorded and case notes were examined to determine which patients later underwent a revascularization procedure or amputation and which patients had died. RESULTS: A total of 136 arteriograms obtained between 1992 and 1996 were analyzed. The age (mean +/- SD) of the patients was 64.7 +/- 10.8 years. Diabetic patients (43%) and nondiabetic patients were of similar age (63.9 +/- 10.4 vs. 65.3 +/- 11.1 years, P = 0.43), with a similar history of smoking (81.0 vs. 76.9%, P = 0.26), ischemic heart disease (41.4 vs. 37.2%, P = 0.54), and hypercholesterolemia (24.4 vs. 30.8%, P = 0.48). However, there were a greater proportion of hypertensive patients in the diabetic group (63.8 vs. 39.7%, P = 0.006). Diabetic patients had greater severity of arterial disease in the profunda femoris and all arterial segments below the knee (P = 0.02). A greater number of amputations occurred in the diabetic group: diabetic patients were five times more likely to have an amputation (41.4 vs. 11.5%, odds ratio [OR] 5.4, P < 0.0001). Mortality was higher in the diabetic group (51.7 vs. 25.6%, OR 3.1, P = 0.002), and diabetic patients who died were younger at presentation than nondiabetic patients (64.7 +/- 11.4 vs. 71.1 +/- 8.7 years, P = 0.04). CONCLUSIONS: In patients with peripheral arterial disease, diabetic patients have worse arterial disease and a poorer outcome than nondiabetic patients.     

Clinical Characteristics of Diabetic vs Nondiabetic Patients Who "Rule-in" for Acute Myocardial Infarction

OBJECTIVE: To compare the clinical characteristics of diabetic vs nondiabetic patients who present to the ED with acute myocardial infarction (AMI). METHODS: This was a prospective, observational study at a suburban, university hospital ED of patients presenting to the ED during study hours between December 1993 and October 1996 with typical and atypical symptoms consistent with cardiac ischemia. Diabetic and nondiabetic patients with AMI were compared. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Final discharge diagnosis of AMI was assigned by WHO criteria. Continuous variables were analyzed by t-tests. Clinical variables were analyzed by chi-square tests. All tests were two-tailed with alpha preset at 0.05. RESULTS: There were 216 patients with AMI during the study period; 51 of these patients (24%) were diabetic. For diabetic vs nondiabetic patients with AMI, there was no significant difference in age (64.0 +/- 13 vs 60.0 +/- 14 years, p = 0.13), female gender (37% vs 26%, p = 0.13), and time to presentation from symptom onset (192 +/- 238 vs 251 +/- 456 minutes, p = 0.41). Hypertension was the only cardiac risk factor significantly more prevalent in diabetic vs nondiabetic patients with AMI (77% vs 50%, OR = 1.54, 95% CI = 1.24 to 1.91, p = 0.001), though elevated cholesterol (48% vs 33%, OR = 1.47, 95% CI = 1.02 to 2.12, p = 0.06) tended to be more prevalent in the diabetic group. There was no statistically significant difference between the two groups in terms of the frequency of chest pain (OR = 1.04, 95% CI = 0.95 to 1.14, p = 0.30), associated symptoms, and diagnostic ECGs (OR = 1.16, 95% CI = 0.76 to 1.79, p = 0.53). CONCLUSION: Diabetic patients with AMI may have similar symptoms upon presentation as do nondiabetic patients with AMI. Of the cardiac risk factors, hypertension is more prevalent in diabetic vs nondiabetic patients with AMI.     

Elevated remnant-like particle cholesterol and triglyceride levels in diabetic men and women in the Framingham Offspring Study

OBJECTIVE: Remnants of triglyceride-rich lipoproteins are thought to be atherogenic. A new antibody-based assay allows for the isolation of remnant-like particles (RLPs) from plasma or serum, and the subsequent measurement of RLP cholesterol (RLPC) and triglycerides (RLPTGs). We hypothesized that diabetic patients would have higher remnant levels than nondiabetic patients. DESIGN AND METHODS: We compared RLPC and RLPTG levels of diabetic subjects (68 women, 121 men) participating in the Framingham Heart Study with those of nondiabetic subjects (1,499 women, 1,357 men). RESULTS: Mean RLPC values for diabetic women were 106% higher than those for nondiabetic women (0.367 +/- 0.546 mmol/l [14.2 +/- 21.1 mg/dl] vs. 0.179 +/- 0.109 mmol/l [6.9 +/- 4.2 mg/dl]; P < 0.0001), and RLPTG values for diabetic women were 385% higher than those for nondiabetic women (1.089 +/- 2.775 mmol/l [93.1 +/- 245.6 mg/dl] vs. 0.217 +/- 0.235 mmol/l [19.2 +/- 20.8 mg/dl]; P < 0.0001). Similar but less striking differences were observed in diabetic men, who had mean RLPC values 28% higher than those seen in nondiabetic men (0.285 +/- 0.261 mmol/l [11.0 +/- 10.1 mg/dl] vs. 0.223 +/- 0.163 mmol/l [8.6 +/- 6.3 mg/dl]; P < 0.001) and mean RLPTG values 70% higher than those seen in nondiabetic men (0.606 +/- 1.019 mmol/l [53.6 +/- 90.2 mg/dl] vs. 0.357 +/- 0.546 mmol/l [31.6 +/- 48.3 mg/dl]; P < 0.001). Moreover, diabetic men and women had significantly higher total triglycerides and lower HDL cholesterol levels than nondiabetic subjects. CONCLUSIONS: The data indicate that RLP particles are elevated in diabetic subjects. To achieve optimal reduction of risk for cardiovascular disease, treatment of elevated RLP values, along with the control of LDL cholesterol levels, should be considered.     

Coronary heart disease incidence in NIDDM patients in the Helsinki Heart Study.

OBJECTIVE--To determine coronary heart disease (CHD) incidence among dyslipidemic subjects with non-insulin-dependent diabetes mellitus (NIDDM) and to assess the effect of lipid-modifying treatment on serum and lipoprotein lipids and the CHD incidence in these patients. RESEARCH DESIGN AND METHODS--Of the 4081 men participating in the Helsinki Heart Study, a coronary primary prevention trial with gemfibrozil in middle-aged men with high non-high-density lipoprotein (HDL) cholesterol (greater than 5.2 mM; 200 mg/dL), 135 had NIDDM at entry. The incidence of definite myocardial infarction and cardiac death and changes in serum and lipoprotein lipids were determined during the 5-yr trial in the NIDDM patients and compared with those observed in nondiabetic trial participants. RESULTS--Compared with nondiabetic subjects, NIDDM patients had lower HDL cholesterol (P less than 0.001), higher triglyceride concentration (P less than 0.0001), and greater body mass index (P less than 0.001), there were more hypertensive patients (P less than 0.001) among them. The incidence of myocardial infarction and cardiac death was significantly higher among diabetic than nondiabetic participants (7.4 vs. 3.3%, respectively, P less than 0.02). CHD incidence in the gemfibrozil-treated diabetic men (n = 59) was 3.4% compared with 10.5% in the placebo group (NS). In multivariate analysis, diabetes (P less than 0.05), age (P less than 0.0001), smoking (P less than 0.0001), low HDL cholesterol (P less than 0.05), and high low-density lipoprotein cholesterol (P less than 0.005) were independently related to CHD incidence. Gemfibrozil-induced serum and lipoprotein lipid changes in diabetic patients were similar to those observed in nondiabetic subjects. CONCLUSIONS--Compared with similarly dyslipidemic nondiabetic subjects, patients with NIDDM are at markedly increased risk of CHD. This elevated risk can be somewhat reduced by gemfibrozil.     

Epidemiology of pediatric burn injuries in southern Turkey

The aim of this study was to identify the epidemiological features of pediatric burn injuries in southern part of Turkey. In this retrospective study, 137 hospitalized pediatric patients (85 men and 52 women) who were admitted to our burn unit during a period of 3 years were analyzed. Pediatric patients were categorized into three groups: the infants and toddlers (0-2 years), early childhood (3-6 years), and late childhood (7-15 years). Epidemiological data included age, sex, location, the cause and type, and place of burn. In the first two groups, scalding (95.1% and 86.7%, respectively) was the predominant cause of burn whereas in late childhood electric burns (51.4%) were a more common occurrence. No differences were found between the groups with respect to mean TBSA and full-thickness burns. A total of 15 (10.1%) patients died during the study period. A total of 74.4% of burn injuries occurred at home, and almost all were preventable, with 16 % of the burns occurring in the autumn; however, 42% occurred in the summer. These findings will be used as a basis for developing targeted preventive programs to protect children from burns. We also consider it is necessary to educate children and their parents about the prevention of burn injuries.     

Acanthocytes in the urine: useful tool to differentiate diabetic nephropathy from glomerulonephritis?

OBJECTIVE: The presence of hematuria has been suggested to indicate nondiabetic nephropathy in diabetic patients with proteinuria. However, hematuria is frequently found in patients with biopsy-proven diabetic glomerulosclerosis without nondiabetic nephropathy. Urine microscopy allows discrimination of glomerular hematuria, which is defined as acanthocyturia (urinary excretion of acanthocytes, which are dysmorphic erythrocytes with vesicle-like protrusions), from nonglomerular hematuria. We hypothesized that acanthocyturia is an uncommon finding in diabetic nephropathy, which suggests the presence of a nondiabetic nephropathy in diabetic patients with proteinuria. RESEARCH DESIGN AND METHODS: Urine samples of patients with the clinical diagnosis of diabetic nephropathy (n = 68), of patients with biopsy-proven glomerulonephritis (n = 43), and of age-matched healthy control subjects (n = 20) were examined by phase-contrast microscopy for the presence of hematuria (>/=8 erythrocytes/ micro l) and acanthocyturia. Acanthocyturia of >/=5% (5 acanthocytes among 100 excreted erythrocytes) was classified as glomerular hematuria; acanthocyturia of 2-4% was classified as suspected glomerular hematuria. RESULTS: Hematuria was found in 62% of patients with the clinical diagnosis of diabetic nephropathy, in 84% of patients with glomerulonephritis, and in 20% of the healthy control subjects upon a single urine examination. In contrast, glomerular hematuria occurred in 4% of patients with diabetic nephropathy and in 40% of patients with glomerulonephritis (P < 0.001). CONCLUSIONS: In contrast to hematuria, acanthocyturia is uncommon in patients with the clinical diagnosis of diabetic nephropathy. In diabetic patients with proteinuria, the finding of acanthocyturia points to nondiabetic glomerulopathies, and renal biopsy should be considered.     

In-vitro activity of cefepime and other broad-spectrum antimicrobials against several groups of gram-negative bacilli and Staphylococcus aureus

The in vitro activity of cefepime was compared with that of amikacin, ceftazidime, imipenem, ciprofloxacin, and piperacillin-tazobactam by using the E-test against five groups of carefully selected organisms: Klebsiella pneumoniae (68 isololates), Pseudomonas aeruginosa (62), methicillin-susceptible Staphylococcus aureus (MSSA) (60), and two groups of Enterobacteriaceae (60 and 62 isolates, respectively). The bacteria were subdivided according to whether the infection was nosocomial or community-acquired, applying accepted and predefined criteria. These isolates were obtained from patients admitted to our medical center throughout 1998. We retrospectively compared antimicrobial susceptibilities of the study sample with those of the +/- 3000 bacterial strains isolated from blood stream infections since 1990: the study sample appeared to represent adequately the clinical databank. Presence of extended-spectrum beta-lactamase (ESBL) was determined in all groups of Enterobacteriaceae with the ESBL screening E-test strip. Of the 252 Gram-negative bacilli tested, 242 (96%) were susceptible to cefepime, whereas only 168 (67%) were susceptible to ceftazidime, 211 (84%) to amikacin, and 220 (87%) to piperacillin-tazobactam (p < 0.001). Imipenem was slightly superior to cefepime with only seven isolates resistant (3%), six of which were P. aeruginosa. Cefepime was more active against Enterobacteriaceae than ceftazidime (93% vs. 72%, p < 0.001). This superiority was most evident against nosocomial strains of K. pneumoniae, against which cefepime was > three times more active than ceftazidime. The high level of resistance seen in nosocomial isolates of K. pneumoniae is consistent with high rates of ESBL production (69%, compared with 15-26% in other Enterobacteriaceae). The MIC90 of cefepime to methicillin-sensitive S. aureus was 1.5 micrograms/mL, whereas that of ceftazidime was 4 micrograms/mL; the susceptibility rate of both was 100%. In conclusion, cefepime possesses in vitro potencies against MSSA and current clinical strains of Gram-negative bacilli, many of which harbor resistance to other antimicrobial agents. Hence, it seems very suitable for empiric coverage of serious nosocomial infections.     

Hand skin blood flow in diabetic patients with autonomic neuropathy and microangiopathy.

OBJECTIVE: To determine whether changes in hand skin blood flow in diabetic men could be demonstrated with liquid crystal contact thermography and to assess the relative effects of autonomic neuropathy and microangiopathy on these changes. RESEARCH DESIGN AND METHODS: Thirty-four diabetic and 12 age-matched nondiabetic men comprised the study. The diabetic men were categorized according to standard cardiovascular autonomic function tests and the presence or absence of background or proliferative retinopathy and/or proteinuria. Bilateral hand thermograms were measured at rest and after immersion of the right hand in ice-cold water. RESULTS: Diabetic men with definite or severe autonomic neuropathy (n = 13) had a high frequency of anisothermal baseline thermograms (77 vs. 25% in nondiabetic subjects, P less than 0.05). After ice-cold water immersion, right-hand recovery was abnormally slow (514 +/- 157 arbitrary U, area under the curve) compared with nondiabetic men (685 +/- 135 arbitrary U, P less than 0.01). Diabetic men with proliferative retinopathy (n = 8) all had definite or severe autonomic neuropathy and showed the same abnormalities. Diabetic men with nor or early autonomic changes showed normal thermographic patterns. CONCLUSIONS: These results are consistent with increased palmar arteriovenous shunt blood flow or capillary closure in the hands of diabetic patients with definite or severe autonomic neuropathy. They indicate that thermoregulatory reflex changes in hand skin blood flow are controlled by the autonomic nervous system. It is possible, however, that diabetic microangiopathy, associated with the presence of proliferative retinopathy, also independently affects hand skin blood flow.     

Effect of graft bed on long-term functional results of extremity skin grafts

The purpose of the current study was to determine whether the long-term functional results of extremity burns grafted on fat were different from those grafted on fascia. Twelve patients (mean burn size, 38% TBSA) who had fascial excision of the majority of one or more extremities were examined a minimum of one year postinjury. Range of motion, motor strength, and sensation of the fascially excised extremities were measured. Twelve comparable patients with extremity burns (mean burn size, 35% TBSA) who had grafts placed on fat were used as positive controls. Patients whose burns were excised to fat had better joint mobility (P = 0.001) and sensory function (P = 0.001) than did patients whose burns were excised to fascia. Both groups had comparable muscle strength. These results indicate that patients with full-thickness burns of the extremities who have grafts placed on fat have significantly better long-term extremity function than do patients who have their skin grafts placed on fascia.     

The relationship between brain volume and walking outcomes in older adults with and without diabetic peripheral neuropathy

OBJECTIVE Diabetic peripheral neuropathy (DPN) alters walking. Yet, the compensatory role of central locomotor circuits remains unclear. We hypothesized that walking outcomes would be more closely related to regional gray matter volumes in older adults with DPN as compared with nonneuropathic diabetic patients and nondiabetic control subjects. RESEARCH DESIGN AND METHODS Clinically important outcomes of walking (i.e., speed, stride duration variability, and double support time) were measured in 29 patients with DPN (type 2 diabetes with foot-sole somatosensory impairment), 68 diabetic (DM) patients (type 2 diabetes with intact foot-sole sensation), and 89 control subjects. Global and regional gray matter volumes were calculated from 3 Tesla magnetic resonance imaging. RESULTS DPN subjects walked more slowly (P = 0.005) with greater stride duration variability (P < 0.001) and longer double support (P < 0.001) as compared with DM and control subjects. Diabetes was associated with less cerebellar gray matter volume (P < 0.001), but global gray matter volume was similar between groups. DPN subjects with lower gray matter volume globally (P < 0.004) and regionally (i.e., cerebellum, right-hemisphere dorsolateral prefrontal cortex, basal ganglia, P < 0.005) walked more slowly with greater stride duration variability and/or longer double support. Each relationship was stronger in DPN than DM subjects. In control subjects, brain volumes did not relate to walking patterns. CONCLUSIONS Strong relationships between brain volumes and walking outcomes were observed in the DPN group and to a lesser extent the DM group, but not in control subjects. Individuals with DPN may be more dependent upon supraspinal elements of the motor control system to regulate several walking outcomes linked to poor health in elderly adults.