Background Pretibial lacerations are common injuries that have a significant yet underestimated association with morbidity and mortality. Although they may occur in any age group, they are commonly ...followed by an often relatively minor trauma in elderly and frail patients. The six-month mortality among such patients may be more than double the age group average. Currently, 5.2 in 1000 patients per year present to the emergency departments in UK hospitals due to pretibial lacerations. The associated acute admissions have a high financial cost. Despite the significant disease burden, there is a paucity of evidence on the optimal management of such injuries. This study aimed to describe the typical demographic and injury factors of individuals presenting to two district general hospitals, as well as their subsequent management and referral. Methodology Relevant patients were identified through NHS coding searches. Subsequently, it was found that 99 patients presented to an NHS trust with pretibial lacerations throughout 2020. A retrospective manual evaluation of clinical documentation was performed to identify the details of the patients' injury, management, referral, and demographics. Results The patients had a mean age of 55.4 (SD 28.3), and 56.6% were female. The most commonly presenting mechanism of injury was direct blunt trauma. The majority of cases were solely managed and discharged directly by the emergency department (74.8%). Of the 99 patients, 25 (25.3%) were referred to specialist services, 12 (12.1%) were managed conservatively, and 13 (13.1%) underwent operative intervention. The mean length of stay for those referred was 5.9 days, and the mean for the same was greater for those managed conservatively compared to those managed operatively (9.0 vs. 2.6 days). Among patients discharged by the emergency department, the most common method of wound closure was steristrips (n = 40; 54.1%), followed by conservative management with dressings (n = 22; 29.7%), sutures (n = 10, 13.5%) and glue (n = 5; 6.8%). Conclusions Overall, this study showed that the majority of patients presenting with pretibial lacerations have minor wounds that can be effectively managed in the emergency department. However, those with considerably more injuries should be provided an early referral to specialist services, where they would ideally receive early surgery and comprehensive follow-up.
BACKGROUNDAnastomotic leaks (AL) and gastric conduit necrosis (CN) are serious complications following oesophagectomy. Some studies have suggested that vascular calcification may be associated with ...an increased AL rate, but this has not been validated in a United Kingdom population. AIMTo investigate whether vascular calcification identified on the pre-operative computed tomography (CT) scan is predictive of AL or CN. METHODSRoutine pre-operative CT scans of 414 patients who underwent oesophagectomy for malignancy with oesophagogastric anastomosis at the Queen Elizabeth Hospital Birmingham between 2006 and 2018 were retrospectively analysed. Calcification of the proximal aorta, distal aorta, coeliac trunk and branches of the coeliac trunk was scored by two reviewers. The relationship between these calcification scores and occurrence of AL and CN was then analysed. The Esophagectomy Complications Consensus Group definition of AL and CN was used. RESULTSComplication data were available in n = 411 patients, of whom 16.7% developed either AL (15.8%) or CN (3.4%). Rates of AL were significantly higher in female patients, at 23.0%, compared to 13.9% in males (P = 0.047). CN was significantly more common in females, (8.0% vs 2.2%, P = 0.014), patients with diabetes (10.6% vs 2.5%, P = 0.014), a history of smoking (10.3% vs 2.3%, P = 0.008), and a higher American Society of Anaesthesiologists grade (P = 0.024). Out of the 14 conduit necroses, only 4 occurred without a concomitant AL. No statistically significant association was found between calcification of any of the vessels studied and either of these outcomes. Multivariable analyses were then performed to identify whether a combination of the calcification scores could be identified that would be significantly predictive of any of the outcomes. However, the stepwise approach did not select any factors for inclusion in the final models. The analysis was repeated for composite outcomes of those patients with either AL or CN (n = 69, 16.7%) and for those with both AL and CN (n = 10, 2.4%) and again, no significant associations were detected. In the subset of patients that developed these outcomes, no significant associations were detected between calcification and the severity of the complication. CONCLUSIONCalcification scoring was not significantly associated with Anastomotic Leak or CN in our study, therefore should not be used to identify patients who are high risk for these complications.
Bisphosphonate therapy is the mainstay of pharmacological intervention in young people with skeletal fragility. The evidence of its use in a variety of conditions remains limited despite over three ...decades of clinical experience. On behalf of the Australasian Paediatric Endocrine Group, this evidence‐based consensus guideline presents recommendations and discusses the graded evidence (using the GRADE system) for these recommendations. Primary bone fragility disorders such as osteogenesis imperfecta are considered separately from osteoporosis secondary to other clinical conditions (such as cerebral palsy, Duchenne muscular dystrophy). The use of bisphosphonates in non‐fragility conditions, such as fibrous dysplasia, avascular necrosis, bone cysts and hypercalcaemia, is also discussed. While these guidelines provide an evidence‐based approach where possible, further research is required in all clinical applications in order to strengthen the recommendations made.
Open-Source Automated Insulin Delivery in Type 1 Diabetes Burnside, Mercedes J.; Lewis, Dana M.; Crocket, Hamish R. ...
New England journal of medicine/The New England journal of medicine,
09/2022, Letnik:
387, Številka:
10
Journal Article
Recenzirano
Odprti dostop
In this randomized trial, an open-source automated insulin delivery system controlled glucose time-in-range values significantly better than sensor-augmented insulin-pump therapy.
To assess long-term efficacy and safety of open-source automated insulin delivery (AID) in children and adults (7-70 years) with type 1 diabetes.
Both arms of a 24-week randomized controlled trial ...comparing open-source AID (OpenAPS algorithm within a modified version of AndroidAPS, preproduction DANA-i™ insulin pump, Dexcom G6 continuous glucose monitor) with sensor-augmented pump therapy (SAPT), entered a 24-week continuation phase where the SAPT arm (termed SAPT-AID) crossed over to join the open-source AID arm (termed AID-AID). Most participants (69/94) used a preproduction YpsoPump
insulin pump during the continuation phase. Analyses incorporated all 52 weeks of data, and combined between-group and within-subject differences to calculate an overall "treatment effect" of AID versus SAPT.
Mean time in range (TIR; 3.9-10 mmol/L 70-180 mg/dL) was 12.2% higher with AID than SAPT (95% confidence interval CI 10.4 to 14.1;
< 0.001). TIR was 56.9% (95% CI 54.2 to 59.6) with SAPT and 69.1% (95% CI 67.1 to 71.1) with AID. The treatment effect did not differ by age (
= 0.39) or insulin pump type (
= 0.37). HbA1c was 5.1 mmol/mol lower 0.5% with AID (95% CI -6.6 to -3.6;
< 0.001). There were no episodes of diabetic ketoacidosis or severe hypoglycemia with either treatment over the 48 weeks. Six participants (all in SAPT-AID) withdrew: three with hardware issues, two preferred SAPT, and one with infusion-site skin irritation.
Further evaluation of the community derived automated insulin delivery (CREATE) trial to 48 weeks confirms that open-source AID is efficacious and safe with different insulin pumps, and demonstrates sustained glycemic improvements without additional safety concerns.
Dystrophin gene mutations cause 2 common muscular dystrophies, Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD). Both are frequently associated with dilated cardiomyopathy (DCM) ...and premature death. We hypothesized that early diagnosis and treatment of DCM in DMD/BMD patients would lead to ventricular remodeling and that specific dystrophin gene mutations would predict cardiac involvement.
Sixty-nine boys with DMD (n=62) and BMD (n=7) (mean age, 12.9 and 13.7 years, respectively) were referred to our Cardiovascular Genetics Clinic for evaluation, including echocardiography and DNA analysis. Follow-up evaluations were scheduled yearly until the first abnormal echocardiogram indicative of DCM and quarterly thereafter. After the first abnormal echocardiogram, angiotensin-converting enzyme inhibitor or beta-blocker therapy was started. beta-Blockers were added if echocardiography showed no ventricular remodeling in angiotensin-converting enzyme inhibitor-treated patients after 3 months. DCM was diagnosed in 31 subjects (DMD, 27/62, 44%; BMD, 4/7, 57%) (mean age at onset, 15.4+/-2.8 years; range, 10.4 to 21.2 years). All 31 subjects were begun on pharmacological therapy after diagnosis. On follow-up (n=29), 2 subjects (both DMD) showed stable DCM, 8 subjects (all DMD) showed improvement, and 19 subjects (16 DMD; 3 BMD) showed normalization of left ventricular size and function (total improvement, 27/29 93%). DNA analysis in 47 cases (68%) revealed a significant association between DCM and exon 12 and 14 to 17 mutations, possible protection against DCM by exon 51 to 52 mutations, and a trend toward significant association between onset of DCM and exon 31 to 42 mutations. Statistical significance was based on nominal probability values.
Early diagnosis and treatment of DCM may lead to ventricular remodeling in DMD/BMD patients. Specific dystrophin gene mutations appear to be predictive of cardiac involvement, while other mutations may protect against or inhibit development of DCM. Further studies evaluating the impact of early intervention strategies on left ventricular geometry and function in muscular dystrophy patients seem warranted.
The adoption of ACT as the first line treatment for uncomplicated malaria in Nigeria has concentrated attention on the role of testing in appropriate malaria treatment. There are calls at both ...national and global level for malaria treatment to be based on test result, but it is still unclear how testing can be incorporated into treatment-seeking and practices of health providers. This study explored community members and health providers' perceptions and experiences with malaria tests in south east Nigeria.
The study was conducted in urban and rural areas of Enugu state in south-eastern Nigeria. A total of 18 focus group discussions with 179 community members including sub-groups of primary caregivers, adult men and adult women aged 15 years and above. Twenty-six (26) In-depth interviews were held with public and private health providers involved in prescribing medicines at public and private health facilities in the study area.
Both providers and community members were familiar with malaria tests and identified malaria tests as an important step to distinguish malaria from other illnesses with similar symptoms and as a means of delivering appropriate treatment. However, the logic of test-directed treatment was undermined by cost of test and a lack of testing facilities but above all concerns over the reliability of negative test results, with community members and providers observing inconsistencies between results and symptoms, and providers attributing inaccurate results to incompetencies of technicians. Recognition of malaria symptoms was deemed most important in determining the use of antimalarial drugs rather than the result of a malaria test.
The results highlight important areas of intervention to promote appropriate malaria treatment. If tests are to play a role in patient management, demand and supply side interventions are needed to change people's attitude towards malaria test results.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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