Considering the importance of early diagnosis of diabetic foot ulcers and its complications, this study aimed to evaluate the accuracy of erythrocyte sedimentation rate (ESR), C - reactive protein ...(CRP), and pro-calcitonin (PCT) in predicting the ulcer class, osteomyelitis, and peripheral arterial disease (PAD).
This cross-sectional study was performed on 200 consecutive patients suffering from diabetic foot ulcer who were referred to Infectious Disease Ward. The levels of PCT, ESR, and CRP were measured for all patients and the screening performance characteristics of each marker in predicting the ulcer class, osteomyelitis, and PAD was calculated.
The levels of PCT, ESR and CRP were significantly higher in patients with class IV foot ulcer compared to those with class III ulcers (p<0.001). Patients with evidence of osteomyelitis had significantly higher level of PCT, ESR and CRP. The best cutoff points of PCT, ESR and CRP in predicting osteomyelitis were 0.35 ng/ml (86.1% sensitivity, 45.3% specificity), 56.5 mm/hours (95.8% sensitivity, and 50.0% specificity) and 44 mg/ml (90.3% sensitivity, 57.0% specificity), respectively. The presence of PAD was significantly associated with increased levels of the three biomarkers. The best cutoff values for PCT, ESR and CRP in predicting PAD were 0.45 (70.8% sensitivity, 71.7% specificity), 61.5 (83.3% sensitivity, 52.0% specificity) and 49 (83.3% sensitivity, 63.8% specificity), respectively.
Based on the findings of the present study, although the accuracy of PCT, ESR, and CRP in predicting the severity of diabetic foot ulcers was fair, increase in the three parameters can predict the occurrence of osteomyelitis and PAD following diabetic food development with good accuracy and acceptable sensitivity.
The goal of this study was to see whether there was a link between the monocyte/high-density lipoprotein cholesterol ratio (MHR) and carotid intima-media thickness (CIMT) in people with type 2 ...diabetes.
Duplex ultrasonography parameters and demographic, physical, and paraclinical assessments were recorded. Using the t-test, the MHR and CIMT were compared between the two groups. Regression models were also constructed.
A total of 118 diabetics and 126 non-diabetics were included in the cross-sectional research. According to the stated diabetes duration, the observed age difference of 7 years might be considered. The MHR and CIMT were not substantially different between the two groups. In the DM and non-DM groups, the Spearman correlations between MHR and CIMT were 0.32 and - 0.08, respectively (p-values = 0.001 and 0.379). Thus, regression models (stratified for DM/non-DM and male/female) revealed that the MHR is a significant predictor of CIMT, but only in the case of male DM individuals, when crudely adjusted for confounders.
In diabetes mellitus, the current investigation found a direct link between MHR and CIMT. In addition, in male diabetic subjects, MHR was demonstrated to be a predictor of CIMT.
Key Clinical Message
There may be a connection between pemphigus vulgaris and nephrotic syndrome, as evidenced by the occurrence of focal segmental glomerulosclerosis in our pemphigus vulgaris ...patient and reviewing relevant literature. Therefore, if a patient with pemphigus vulgaris presents with bilateral lower extremity edema or proteinuria detected during urinalysis, it could indicate involvement of the kidneys.
Pemphigus vulgaris is a type of autoimmune blistering disease characterized by the presence of IgG autoantibodies against desmogleins 3 and 1. It is important to evaluate potential autoimmune associations in patients with pemphigus vulgaris so that appropriate laboratory and physical examinations can be performed to monitor for any increased risk of other autoimmune disorders. This case report describes a 55‐year‐old woman who presented with oral and axillary erosions, which were diagnosed as pemphigus vulgaris based on skin histopathology and immunofluorescence. During follow‐up, the patient was found to have proteinuria, which led to referral to a nephrologist. The patient was diagnosed with nephrotic syndrome and minimal change disease after a biopsy. Despite treatment, the patient's proteinuria persisted and serum creatinine levels increased, leading to a second biopsy which confirmed the diagnosis of focal segmental glomerulosclerosis. This study reports on the first case of pemphigus vulgaris with focal segmental glomerulosclerosis and reviews the literature on the co‐occurrence of acquired immunobullous diseases and nephrotic syndrome of any kind.
Normal glomerulus with a delicate basement membrane.
Background: Lupus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE). Activation of complement system which leads to the production of C4 and its ultimate product, C4d, ...plays an important role in the pathogenesis of LN. Objectives: Although serum C4d levels correlate with disease activity, there is almost no study on the correlation between tissue deposition of C4d and classes of LN. Patients and Methods: Seventy-two patients with a diagnosis of SLE who met ≥ 4 criteria of American Rheumatism Association (ARA) were enrolled in this study. Blood levels of anti-nuclear antigens (ANA), anti-double stranded DNA (Anti-dsDNA), C3, C4 and antiphospholipid antibodies were measured. Renal tissue obtained by biopsy was examined regarding diffuse granular deposition of C4d along the glomerular capillary loops and classes of LN according to the World Health Organization (WHO) classification. Results: LN class IV was the most prevalent and LN class I had the least prevalence. There was no correlation between positive C4d staining and classes of LN (P>0.05), but a significant correlation between positive Anti-dsDNA and C4d positive LN was found (P=0.05). Likewise no correlation was detected between the low levels of complements and classes of LN or C4d positivity. Conclusions: The presence of C4d indicates activation of classical complement pathway in LN. C4d deposition in glomerular capillaries of LN does not indicate the present disease activity but may be a useful marker to predict the prognosis of LN. Anti-dsDNA is a valuable test for disease activity and is correlated with C4d positive staining.
Non-albuminuric diabetic kidney disease (NA-DKD) is characterized by progressive loss of kidney function with an annual loss of estimated glomerular filtration rate (eGFR) more than 3 mL/ min/ 1.73m2 ...per year. NA-DKD is also associated with the late manifestation of diabetic kidney disease, characterized by reduced eGFR (< 60 mL/min/ 1.73m2), in the absence of albuminuria (urine albumin-to-creatinine ratio UACR less than 30 mg/g. The typical glomerular changes seen in diabetic nephropathy are less frequently observed in normoalbuminuric patients, while they predominantly show mesangial expansion and tubulointerstitial and vascular changes. The prevalence of NA-DKD has been increasing during the past decade, with a wide range of prevalence in different studies. It seems that patients with NA-DKD are more likely to be female and have better metabolic profile including a lower Hb A1c, lower triglyceride, lower cholesterol, lower BMI and systolic blood pressure, and lower rate of retinopathy. Compared to patients with albuminuria, those with NA-DKD show a lower risk for progression to end-stage kidney disease (ESKD), or rapid decline in eGFR. They also have increased risks of death and hospitalization for heart failure compared with non-DKD diabetic patients, but a lower risk in comparison with albuminuric DKD, regardless of GFR. There is no effective treatment for this phenotype of the disease, but limited data support the use of SGLT2 inhibitors to slow chronic kidney disease progression along with appropriate metabolic risk factor control. More clinical research and pathologic studies are needed for a better understanding of the phenotype, prevention, and treatment methods of the disease. DOI: 10.52547/ijkd.7966.
Strongyloides stercoralis (SS) is a unique nematode with an auto infective cycle, so that it completes its life cycle within the human host and can live there for many years. In immunocompromised ...patients, infection can cause Strongyloides hyperinfection syndrome (S.H.S) that is associated with serious morbidity and mortality. As various infections are one of the leading causes of membranoproliferative glomerulonephritis (MPGN), we should consider subclinical strongyloidiasis as a possible underlying disease, especially in endemic areas. Here we describe a case of strongyloidiasis following immunosuppressive therapy for MPGN, the diagnosis of which was made, only a few hours before death, by stomach biopsy.
Background: Caspofungin is prescribed for the systemic treatment of fungal infections and its correct prescription pattern is an issue of importance. Hence in this study Caspofungin utilization and ...the frequency rate of medication errors were investigated at a training hospital in a developing country.
Methods: This cross-sectional study enrolled 43 consecutive patients receiving Caspofungin in Firoozgar Hospital, Tehran, Iran from March to September 2017.
Results: The prescription frequency was higher in Intensive Care Unit by a rate of 58.1%. Infectious disease specialists were responsible for Caspofungin prescription only in 11 cases (25.5%). The cause of Caspofungin prescription was unknown in 18.6% of cases; but empiric treatment for febrile neutropenia and ICU patients with Candida Score > 2.5 were the most known causes. The drug administration in 11 cases (25.6%) occurred in less than one hour. The indication of treatment was incorrect in 12 out of 43 cases (28%). On the first day of the treatment a dose of both 70 mg and 50 mg was prescribed, which was higher than the appropriate dose and also it was lower than the optimal dose in five cases (83.7%). The mean treatment duration was 10.88 ± 5.35 days ranging from 2 to 24 days. The duration of treatment was correct in 20 cases (46.5%) and incorrect for 23 patients (53.5%).
Conclusion: In comparison with the Sanford and IDSA Guidelines there are multiple discordances in our setting, such as inappropriate duration, continuation, and indications. Hence these should be announced to the physicians for taking further caution in the aforementioned cases, and it is advisable to consult with infectious diseases specialists for the administration of anti-fungal drugs.
J Pharm Care 2019; 7(3): 57-61.
Objective: Human albumin solution is an expensive colloidal preparation which is commonly used in clinical practice. Due to high cost of albumin, increased rate of the inappropriate use worldwide, ...and many other reasons, it is imperative to establish a practical protocol to use albumin products and limit its usage. The aim of this study was to identify albumin utilization patterns in a teaching hospital and to demonstrate the importance of the need to reconsider prescribing strategies for albumin administration. Methods: This retrospective cross-sectional study was performed between August 2016 and December 2016 at Firoozgar Hospital affiliated to Iran University of Medical Sciences, Tehran, Iran. All albumin prescriptions for adult patients during the study period were enrolled for appropriateness evaluation according to the latest evidence-based studies and guidelines. Findings: Among 320 albumin prescriptions, 168 (52.5%) were inappropriate according to the current evidence. The most common irrational causes for the albumin usage were hypoalbuminemia (23.4%), nutritional support (13.7%), neuroprotection in subarachnoid hemorrhage (3%), pretreatment for cancer surgery (2.8%), edema (1.6%), hepatic failure (1.6%), and paracentesis (3%). The total amount of albumin used for 320 patients was 52,050 g, from which 28,470 g was inappropriate resulting in $97,398 wastage. Conclusion: These findings, along with aforementioned guidelines, support the requirement for physicians' educational programs and proper strategies for appropriate prescriptions and could also be important in modifying the available guidelines concerning expensive drugs such as albumin.
Background: To investigate the on-labeled and off-labeled indications of rituximab according to available evidence and the cost benefit of using this expensive drug.
Methods: This retrospective ...cross-sectional study was conducted between August 2016 and August 2017 at a teaching hospital affiliated to Iran University of Medical Sciences, Tehran, Iran. Patients’ demographic data and disease, indication for rituximab use, its dosage and treatment regimen and previous and concurrent treatments was assessed. The collected data were compared with the current criteria for the pattern of rituximab use. The last version of Lexicomp® acquired by Wolters Kluwer was used as the reference for on-labeled and off-labeled indications of the prescribed drug and its dosage. Level of evidences for applied indications and cost has also been evaluated.
Results: A total of 85 patients received rituximab during the study period. The most frequent reasons for rituximab prescription were: multiple sclerosis (50.58%), systemic sclerosis (10.58%), rheumatoid arthritis (7.05%) and Idiopathic inflammatory myopathies (4.70%).Rituximab was used in 8 (9.4%) cases according to on-labeled indications. There was level C evidence for rituximab use in off-labeled indications in 47 (55.29%) cases according to available evidences which accounts for the highest calculated cost.
Conclusion:Based on our results, rituximab was frequently administrated for off-labeled indications most of which are not supported by established levels of evidence. The total cost was higher for level C evidence indications of off labeled rituximab than for indications with a higher level of evidence (A and B). So, strong evidence is necessary for decision making regarding its effectiveness and its cost benefit.
J Pharm Care 2019; 7(1-2): 14-20.
Background
Chronic kidney disease (CKD) can progress over time and cause renal replacement therapy. Studies showed the association between metabolic syndrome (MetS) and CKD. Current evidence is from ...cross‐sectional studies. There is a need for the robust data from big prospective cohort studies with long‐term follow‐up. This study investigated the association between CKD and MetS after 18 years of follow‐up.
Material and Method
Among 15,255 participants aged ≥20 years at baseline (1999–2005), after exclusion of CKD, cancer, and use of corticosteroids, 8987 participants entered the study and followed at a three‐year cycle up to 2018. All participants were divided into five subgroups: (1) MetS‐free, (2) MetS (DM+, HTN−), (3) MetS+ (DM−, HTN+), (4) MetS+ (DM+, HTN+) and (5) MetS+ (DM−, HTN−).
Result
At baseline, the mean age of the participants was 39.8 ± 13.3 years; 4996 (55.6%) were females. CKD was developed in 2038 (22.7%) subjects during 18 years of follow‐up, of whom 1107 had MetS. After adjusting for the confounding variables, MetS (DM+, HTN+) subgroup had the highest risk of CKD (HR = 1.51, 95% CI = 1.32–1.71). MetS subjects with five components had a higher incidence rate of CKD (HR = 1.43, 95% CI = 1.22–1.68). There was no association between high waist circumference (WC) (HR = 1.08, 95% CI = 0.99–1.19) and high‐density lipoprotein (HDL) (HR = 1.07, 95% CI = 0.98–1.18) with CKD.
Conclusion
CKD significantly develops in patients with MetS. Metabolic syndrome was associated with the development of chronic kidney disease incidence. Hypertension, diabetes, and age were strong indicators, while abdominal obesity and reduced HDL were not associated with the incidence of CKD.
After an 18‐year follow‐up of 8987 participants, chronic kidney disease significantly developed in patients with metabolic syndrome, having diabetes or hypertension and more number of traits, especially in the elderly. Metabolic syndrome without having hypertension and diabetes was not associated with the increased risk of chronic kidney disease. Among components of metabolic syndrome, elevated waist circumference and reduced high‐density lipoprotein were not associated with the incidence of chronic kidney disease.
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