Increased prevalence of infectious endocarditis in patients with type II diabetes mellitus

BACKGROUND: Patients with diabetes mellitus (DM) are at increased risk of infection. However, there are controversial reports about DM association with infectious endocarditis (IE). We evaluated the occurrence of IE in DM patients compared to a matched control. METHOD: Treatment files of inpatients' admission that contained discharge diagnosis (ICD-9 codes) from Veterans Health Administration hospitals were used for this study. ICD-9 codes for DM (n=293,124) and a control group with ICD-9 codes for hypertension without DM (n=552,623) were utilized for comparison. The prevalence of IE was studied using ICD-9 codes for IE. Multivariate analysis was performed adjusting for chronic and acute renal failure and aortic and mitral valve disease. Continuous variables were analyzed by unpaired t tests. Binary variables were analyzed using the chi-square test and Fisher's Exact Tests. RESULTS: IE was present in 1340 (0.5%) DM patients versus 1412 (0.3%) patients from the control group (relative increase of 40%). Using multivariate analysis adjusting for renal failure and valvular abnormalities, DM remained independently associated with IE (odds ratio=1.9; 95% confidence interval=1.8-2.1; P<.0001). CONCLUSION: Patients with type II DM have significantly higher prevalence of IE independent of renal failure or valvular abnormalities consistent with increased vulnerability of DM patients for infections.     

Increased prevalence of ventricular fibrillation in patients with type 2 diabetes mellitus

Diabetes mellitus (DM) is an independent risk for cardiovascular disease. Furthermore, patients with DM have increased risk for ventricular arrhythmia that is thought to be secondary to coronary artery disease (CAD) or congestive heart failure (CHF). We hypothesized that DM may cause ventricular arrhythmias independent of CAD or CHF. Using a large database, we evaluated the occurrence of ventricular fibrillation in patients with DM adjusting for CAD and CHF. We used patient treatment files (PTF), documents of inpatients' admissions containing discharge diagnoses (ICD-9 codes) from all Veterans Health Administration Hospitals. The patients were stratified in two groups: ICD-9 code for DM (293 124) and a control group with ICD-code for hypertension (HTN) but no DM (552 623). ICD-9 codes for ventricular fibrillation were used for this study. We performed uni- and multivariant analysis adjusting for comorbid conditions. Ventricular fibrillation was present in 563 (0.2%) vs 781 (0.1%) in the control group. Using multivariate analysis, DM remained independently associated with ventricular fibrillation (odds ratio: 1.7; confidence interval: 1.5–1.9; P < 0.000). Patients with DM have significantly higher prevalence of ventricular fibrillation independent of CAD or CHF, which in part may explain the higher risk of sudden death in patients with DM.     

Defining the contribution of renal dysfunction to outcome after traumatic injury

Renal failure is frequently considered an ominous development after injury, but its impact on outcome is poorly understood. Renal dysfunction or failure can be defined in many ways, such as elevated serum creatinine or the need for dialysis. The best method to characterize renal dysfunction however, is not known. To determine which definition of renal dysfunction correlates best with outcome, we retrospectively analyzed all injured patients from 1994 to 2000 who had an Injury Severity Score > or =14 and a hospital length of stay >2 days for the development of renal impairment. One hundred sixty-seven patients (4%) developed a serum creatinine > or =2.0 mg/dL and 49 patients required dialysis. Patients with renal dysfunction were older, suffered from more comorbid medical problems, were more seriously injured, and were more likely to have been in shock. A serum creatinine > or =2.0 mg/dL, the maximum creatinine level, and need for dialysis, were highly correlated with death, and the total number of dialysis treatments was not. All measures of renal dysfunction correlated relatively poorly with length of stay. These data demonstrate that the simple measure of serum creatinine > or =2.0 mg/dL is associated with a significantly increased likelihood of death in injured patients and is a stronger predictor than other common indicators of renal impairment.     

Diabetic foot infection

Foot infections are common in patients with diabetes and are associated with high morbidity and risk of lower extremity amputation. Diabetic foot infections are classified as mild, moderate, or severe. Gram-positive bacteria, such as Staphylococcus aureus and beta-hemolytic streptococci, are the most common pathogens in previously untreated mild and moderate infection. Severe, chronic, or previously treated infections are often polymicrobial. The diagnosis of diabetic foot infection is based on the clinical signs and symptoms of local inflammation. Infected wounds should be cultured after debridement. Tissue specimens obtained by scraping the base of the ulcer with a scalpel or by wound or bone biopsy are strongly preferred to wound swabs. Imaging studies are indicated for suspected deep soft tissue purulent collections or osteomyelitis. Optimal management requires aggressive surgical debridement and wound management, effective antibiotic therapy, and correction of metabolic abnormalities (mainly hyperglycemia and arterial insufficiency). Treatment with antibiotics is not required for noninfected ulcers. Mild soft tissue infection can be treated effectively with oral antibiotics, including dicloxacillin, cephalexin, and clindamycin. Severe soft tissue infection can be initially treated intravenously with ciprofloxacin plus clindamycin; piperacillin/tazobactam; or imipenem/cilastatin. The risk of methicillin-resistant S. aureus infection should be considered when choosing a regimen. Antibiotic treatment should last from one to four weeks for soft tissue infection and six to 12 weeks for osteomyelitis and should be followed by culture-guided definitive therapy.     

Does dopamine still have a leading role in advanced Parkinson's disease after subthalamic stimulation?

The role of endogenous dopamine in severe Parkinson's disease is often underestimated. We report on a case of acute general motor worsening induced by the ingestion of fluphenazine in a parkinsonian patient successfully treated with STN DBS. Other etiologies were ruled out. Clinical improvement was gradual and fully reversible 4 days after discontinuation of the antidopaminergic drug. We suggest that residual striatal and extrastriatal dopaminergic pathways still play a paramount role in mediating central neurotrasmissions that may take part in STN DBS's mechanism of action.     

Trends in the utilization of endoscopic retrograde cholangiopancreatography (ERCP) in the United States

OBJECTIVES: To evaluate nationwide trends in the utilization of endoscopic retrograde cholangiopancreatography (ERCP) in relation to the advent of noninvasive methods of visualizing the biliary and pancreatic tree. METHODS: Retrospective cohort study. The Nationwide Inpatient Sample (NIS) database was used to calculate the age-adjusted rate for ERCPs performed from 1988 to 2002. The State Ambulatory Surgery Database (SASD) was used to evaluate trends in outpatient ERCPs from 1997 to 2003. Linear Poisson multivariate regression model was used to control for variations in age, gender, and ethnicity among the overall patient population. RESULTS: The NIS database contained 402,343 patients who had an ERCP performed from 1988 to 2002. The mean age for these patients was 60.21 +/- 19.56 yr old. From 1988 to 1996; the age-adjusted rate for ERCPs increased by nearly threefold, from 25.66 per 100,000 in 1988 to 74.95 in 1996. The rate of 74.95 in 1996 declined to a rate of 59.70 by the year 2002. The rates of diagnostic ERCPs in men and women were 26.76 and 31.58 per 100,000 in 1988-1990, respectively. This rate then increased to 35.66 and 43.18 per 100,000 in 1994-1996, which then declined to 29.01 and 29.06 in 2000-2002. The age-adjusted rate for therapeutic ERCPs in men and women was 13.74 and 15.61 per 100,000 in 1988-1990, respectively, which continued to increase throughout the time span to 38.76 and 43.75 in 2000-2002. The SASD revealed a continual decline in outpatient ERCPs from 25.45 per 100,000 in 1997 down to 16.17 per 100,000 in the year 2003. CONCLUSION: The utilization of ERCP dramatically increased from 1988 to 1996; however, since the advent of noninvasive diagnostic techniques such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), there has been a steady decline in the utilization of diagnostic ERCPs from 1996 to 2002.     

18FDG] PET-CT-based intensity-modulated radiotherapy treatment planning of head and neck cancer

PURPOSE: To define the best threshold for tumor volume delineation of the (18) fluoro-2-deoxy-glucose positron emission tomography ((18)FDG-PET) signal for radiotherapy treatment planning of intensity-modulated radiotherapy (IMRT) in head and neck cancer. METHODS AND MATERIALS: In 25 patients with head-and-neck cancer, CT-based gross tumor volume (GTV(CT)) was delineated. After PET-CT image fusion, window level (L) was adapted to best fit the GTV(CT), and GTV(PET) was delineated. Tumor maximum (S) and background uptake (B) were measured, and the threshold of the background-subtracted tumor maximum uptake (THR) was used for PET signal segmentation. Gross tumor volumes were expanded to planning target volumes (PTVs) and analyzed. RESULTS: The mean value of S was 40 kBq/mL, S/B ratio was 16, and THR was 26%. The THR correlated with S (r = -0.752), but no correlation between THR and the S/B ratio was seen (r = -0.382). In 77% of cases, S was >30 kBq/mL, and in 23% it was 30% +/- 1.6% kBq/mL and 40% in tumors with S 相似文献   

Evaluation of a 15-year experience with splenic injuries in a state trauma system

BACKGROUND: The management of splenic injuries has evolved with a greater emphasis on nonoperative management. Although several institutions have demonstrated that nonoperative management of splenic injuries can be performed with an increasing degree of success, the impact of this treatment shift on outcome for all patients with splenic injuries remains unknown. We hypothesized that outcomes for patients with splenic injuries have improved as the paradigm for splenic injury treatment has shifted. METHODS: Consecutive patients from 1987 to 2001 with splenic injuries who were entered into a state trauma registry were reviewed. Demographic variables, injury characteristics, and outcome data were collected. RESULTS: The number of patients who were diagnosed with splenic injuries increased from 1987 through 2001, despite a stable number of institutions submitting data to the registry. The number of minor injuries and severe splenic injuries remained stable, and the number of moderately severe injuries significantly increased over time. Overall mortality rate improved but primarily reflected the decreased mortality rates of moderately severe injuries; the mortality rate for severe splenic injuries was unchanged. CONCLUSION: Trauma centers are seeing increasing numbers of splenic injuries that are less severe in magnitude, although the number of the most severe splenic injuries is stable. The increased proportion of patients with less severe splenic injuries who are being admitted to trauma centers is a significant factor in the increased use and success rate of nonoperative management.