RESUMEN
BACKGROUND: Patients with diabetes mellitus are at high risk for onychomycosis, which is related to the development of foot ulcers. OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of the treatment of onychomycosis with local laser therapy. METHODS: In a single-centre, randomized (1:1), quadruple-blind, sham-controlled trial, patients and microbiological confirmation with diabetes mellitus, at risk for developing diabetic foot ulcers (Sims classification score 1, 2) and a clinical suspicion on onychomycosis, were randomized to either four sessions neodymium-doped yttrium aluminium garnet (Nd-YAG) 1064 nm laser or sham treatment. The primary outcome was clinical and microbiological cure of onychomycosis after 1-year follow-up. RESULTS: From March 2015 to July 2016, 64 patients were randomized; 63 could be analysed. Trichophyton rubrum was the most detected pathogen. There was no difference in the primary outcome between laser and sham treatment. With the exception of a subungual haematoma in the fifth toenail occurring 2 weeks after laser treatment, the results suggested that treatment with Nd-YAG 1064 nm laser is safe. CONCLUSION: At this moment, there is no evidence of any effect of laser treatment for onychomycosis in patients with diabetes at increased risk for foot ulcers, at least not within 1 year after treatment.
Asunto(s)
Pie Diabético/complicaciones , Úlcera del Pie/complicaciones , Terapia por Láser , Onicomicosis/complicaciones , Onicomicosis/cirugía , Anciano , Pie Diabético/epidemiología , Femenino , Úlcera del Pie/epidemiología , Humanos , Terapia por Láser/efectos adversos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Resultado del TratamientoRESUMEN
Background: orthostatic hypotension (OH) is one out of many risk factors believed to contribute to an increased fall risk in elderly subjects but it is unclear whether an independent association between OH and falling exists. Objectives: to perform an individual patient data (IPD) meta-analysis of prospective observational studies investigating the relationship between OH and falling. Design: MEDLINE, EMBASE, the Cochrane Library and the abstracts of annual meetings of selected hypertension societies were searched. Both one-stage (analysing all IPD from all studies simultaneously) and two-stage (analysing IPD per study, and then pooling the results) methods were used, and both logistic and cox regression analyses were performed. The study protocol was published on PROSPERO (2015:CRD42015019178). Results: from 34 selected abstracts, 6 studies were included. IPD were provided in 1,022 patients from 3 cohorts and were included in the IPD meta-analysis. The one-stage meta-analysis showed a significant relationship between OH and time to first fall incident (hazard ratio (HR) 1.52 (95% Confidence Interval (CI) 1.23-1.88)). No significant relationship between OH and falling was found in the one-stage logistic regression analysis and the two-stage logistic and cox regression analyses. Conclusions: this IPD meta-analysis of prospective observational studies showed a clear and significant relationship between OH and time to first fall incident. Although the ORs of falling was not significantly different for patients with and without OH, a the cox regression analyses reporting HRs and including time to incident provided more clinically relevant information in present meta-analysis.
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Accidentes por Caídas , Presión Sanguínea , Hipotensión Ortostática/complicaciones , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Femenino , Humanos , Hipotensión Ortostática/diagnóstico , Hipotensión Ortostática/fisiopatología , Modelos Logísticos , Masculino , Análisis Multivariante , Estudios Observacionales como Asunto , Oportunidad Relativa , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Health-related quality of life (HRQOL) in nursing home residents is generally low. The purpose of this study was to investigate the associations between HRQOL and two clinically relevant outcome measures, all-cause mortality and successful rehabilitation, in a nursing home population. METHODS: In an observational prospective cohort study in a nursing home population, HRQOL was assessed with the RAND-36. A total of 184 patients were included, 159 (86%) completed the RAND-36 and were included in the study. A Cox proportional hazard model was used to investigate the independent association between HRQOL, rehabilitation and mortality with adjustment for confounders. Risk prediction capabilities were assessed with Harrell's C statistics and the proportion of explained variance (R2). RESULTS: The median age (interquartile range) was 79 (75-85) years. The health dimensions vitality (HR 0.88 (95% CI 0.77-0.99)) and mental health (HR 0.86 (95% CI 0.75-0.98)) were inversely associated and role functioningphysical (HR 1.08 (95%CI 1.02-1.15)) was positively associated with mortality. The Harrell's C value and the R2 were ≤ 0.02 and ≤ 0.03 higher in the adjusted models with the dimensions role functioning- physical, mental health or vitality compared with the models without these dimensions. None of the health dimensions or summary scales were related to successful rehabilitation. CONCLUSION: HRQOL was significantly associated with mortality for three dimensions, but partly in opposite directions. Additional value of HRQOL in mortality prediction is very limited. There were no independent associations between HRQOL and successful rehabilitation. Although HRQOL is an important outcome, this study did not provide evidence for an association between HRQOL and successful rehabilitation.
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Estado de Salud , Mortalidad , Casas de Salud , Calidad de Vida , Rehabilitación , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Países Bajos , Pronóstico , Modelos de Riesgos Proporcionales , Estudios ProspectivosRESUMEN
Subperiosteal abscess formation is almost exclusively seen secondary to underlying hematogenous infected osteomyelitis or secondary as a result of a contagious focus. We present an unusual case of a 9-year-old girl with progressive ankle pain due to an isolated subperiosteal abscess of the distal fibula without concomitant osteomyelitis. The subperiosteal abscess was most likely caused by hematogenous spread to the periosteal region of the distal fibula located above the highly vascularized metaphysis. Remarkably, there were no signs of osteomyelitis on either MRI or during surgical inspection. She was successfully treated with debridement and antibiotic therapy. We hypothesize that subperiosteal abscess formation near the metaphysis originates in the periosteal region and not from outward extension from the sinusoidal veins in the intrametaphyseal area to the cortex and subperiosteal region.
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Absceso/cirugía , Desbridamiento/métodos , Peroné/cirugía , Osteomielitis/cirugía , Absceso/diagnóstico , Absceso/etiología , Niño , Femenino , Peroné/patología , Humanos , Imagen por Resonancia Magnética , Osteomielitis/complicaciones , Osteomielitis/diagnósticoRESUMEN
INTRODUCTION: Homozygosity for a 5-leucine repeat (5L-5L) in the carnosinase gene (CNDP1) has been associated with a reduced prevalence of diabetic nephropathy in cross-sectional studies in patients with type 2 diabetes, particularly in women. Prospective studies on mortality are not available. This study investigated whether 5L-5L was associated with mortality and progression of renal function loss and to what extent this effect is modified by sex. METHODS: In a prospective cohort of patients with type 2 diabetes, a Cox proportional hazard model was used to compare 5L-5L with other genotypes regarding (cardiovascular) mortality. Renal function slopes were obtained by within-individual linear regression of the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) equation, and were compared between 5L-5L and other genotypes. RESULTS: 871 patients were included (38% with 5L-5L). After 9.5 years of follow-up, hazards ratios (HR) for all-cause and cardiovascular mortality in 5L-5L versus other genotypes were 1.09 [95% confidence interval (CI) 0.88-1.36] and 1.12 (95% CI 0.79-1.58), respectively. There was a significant interaction between CNDP1 and sex for the association with cardiovascular mortality (p = 0.01), not for all-cause mortality (p = 0.32). Adjusted HR in 5L-5L for cardiovascular mortality was 0.69 (95% CI 0.39-1.23) in men and 1.77 (95% CI 1.12-2.81) in women. The slopes of eGFR-MDRD did not significantly differ between 5L-5L and other genotypes. CONCLUSIONS: The association between CNDP1 and cardiovascular mortality was sex-specific, with a higher risk in women with 5L-5L genotype. CNDP1 was not associated with all-cause mortality or change in eGFR.
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Enfermedades Cardiovasculares/genética , Enfermedades Cardiovasculares/mortalidad , Diabetes Mellitus Tipo 2/genética , Nefropatías Diabéticas/genética , Dipeptidasas/genética , Factores Sexuales , Anciano , Nefropatías Diabéticas/fisiopatología , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular/genética , Homocigoto , Humanos , Leucina/genética , Masculino , Persona de Mediana Edad , Polimorfismo Genético , Modelos de Riesgos Proporcionales , Estudios ProspectivosRESUMEN
BACKGROUND: Relative mortality differences between educational level in mortality have been reported among diabetic as well as among non-diabetic subjects in Europe, but data on absolute differences are lacking. We studied the effect of educational disparities on mortality in a Dutch prospective cohort of type 2 diabetes mellitus (T2DM) patients. METHODS: This study was part of the ZODIAC study, a prospective observational study of patients with T2DM. Data on educational level were first collected on 19 May 1998, and from this date on, 858 patients were included in 1998; educational level was known for 656 patients. Vital status was assessed in 2009. The relationship between mortality and educational level was studied using a Cox proportional hazard model, the relative index of inequality (RII), slope index of inequality (SII) and the population attributable risk (PAR). Educational level was divided into four categories; the highest educational level was used as reference. RESULTS: After a median follow-up time of 9.7 years, 365 out of 858 patients had died. The hazard ratio of primary education for total mortality was 3.02 (95% CI 1.44-6.34). The RII was 2.85 (95% CI 1.21-6.67), the absolute difference in the risk for mortality (SII) was 384 deaths (95% CI 49-719) per 10,000 follow-up years. PAR for patients with the lowest level of education was 51.4%. CONCLUSIONS: A low educational level had a higher impact on mortality than having a macrovascular complication. Given the substantial differences in mortality between educational levels in T2DM, more understanding of underlying (modifiable) mechanisms is necessary.
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Diabetes Mellitus Tipo 2/mortalidad , Escolaridad , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Modelos de Riesgos Proporcionales , Estudios ProspectivosAsunto(s)
Infecciones por Escherichia coli/microbiología , Escherichia coli/aislamiento & purificación , Fascitis Necrotizante/microbiología , Pirazoles/administración & dosificación , Anciano , Sangre/microbiología , Infecciones por Escherichia coli/diagnóstico , Infecciones por Escherichia coli/fisiopatología , Fascitis Necrotizante/diagnóstico , Fascitis Necrotizante/fisiopatología , Humanos , Quinasas Janus/antagonistas & inhibidores , Masculino , Nitrilos , Mielofibrosis Primaria/tratamiento farmacológico , Pirazoles/efectos adversos , PirimidinasRESUMEN
Although blood pressure control has undoubtedly proven its benefits in reducing the high cardiovascular risk in patients with type 2 diabetes mellitus (T2DM), it still remains unclear whether intensive antihypertensive treatment in old age (> 75 years) is beneficial. Many of the current guidelines recommend a systolic blood pressure (SBP) < 140 mmHg or lower, unless patients are at high risk for possible adverse events such as postural hypotension (1,2). This perspective aims to get a discussion started on the appropriate target SBP value for patients with T2DM aged older than 75 years.We would like to propose the less stringent value of< 160 mmHg in this specific population.
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Presión Sanguínea/fisiología , Diabetes Mellitus Tipo 2/fisiopatología , Angiopatías Diabéticas/fisiopatología , Hipertensión/diagnóstico , Anciano , Anciano de 80 o más Años , Determinación de la Presión Sanguínea , Diabetes Mellitus Tipo 2/mortalidad , Angiopatías Diabéticas/diagnóstico , Angiopatías Diabéticas/mortalidad , Femenino , Humanos , Hipertensión/mortalidad , Hipertensión/fisiopatología , Hipertensión/prevención & control , Masculino , Persona de Mediana Edad , Valores de ReferenciaRESUMEN
AIMS: Studies on macrovascular consequences of glucose control in elderly patients (>75 years) with type 2 diabetes mellitus (T2DM) are lacking. The present study aimed to investigate the relationship between HbA(1c) and mortality in this specific population. METHODS: Between 1998 and 1999, 374 primary care patients with T2DM aged older than 75 years participated in the Zwolle Outpatient Diabetes project Integrating Available Care study, a prospective observational study. Early 2009, data on mortality were collected. Updated means for annually measured HbA(1c) values were calculated after a follow-up time of 10 years. Updated mean HbA(1c) was used as a time-dependent covariate in a Cox proportional hazard model. Main outcome measures were all-cause and cardiovascular disease (CVD) mortality. Analyses were performed in strata according to diabetes duration (<5, 5-11 and ≥11 years). RESULTS: In the group with a diabetes duration <5 years, an increase of 1% in the updated mean HbA(1c) level was associated with an increase in all-cause and CVD mortality risk of 51% (95% CI 17-95%) and 72% (95% CI 19-148%), respectively. Glycaemic control was not related to mortality for patients with a diabetes duration ≥5 years. CONCLUSION: Poor glycaemic control is related to increased all-cause and CVD mortality in patients >75 years with T2DM of short duration (<5 years). DISCUSSION: Because of the observational study design, our results should be interpreted with caution. Nevertheless, they are suggestive that improving glycaemic control may be beneficial in elderly patients with T2DM, especially in those with recently diagnosed T2DM. Randomised-controlled trials are necessary to investigate whether this holds true.
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Glucemia/metabolismo , Diabetes Mellitus Tipo 2/mortalidad , Angiopatías Diabéticas/mortalidad , Hemoglobina Glucada/metabolismo , Anciano , Anciano de 80 o más Años , Causas de Muerte , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Angiopatías Diabéticas/sangre , Femenino , Humanos , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Masculino , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de RiesgoAsunto(s)
Antígenos Bacterianos/inmunología , Hipersensibilidad , Choque Séptico/inmunología , Infecciones Estafilocócicas/inmunología , Superantígenos/inmunología , Antibacterianos/uso terapéutico , Clindamicina/uso terapéutico , Humanos , Inmunoglobulinas Intravenosas/uso terapéutico , Choque Séptico/diagnóstico , Choque Séptico/tratamiento farmacológico , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/tratamiento farmacológicoAsunto(s)
Adenina/análogos & derivados , Desoxicitidina/análogos & derivados , Infecciones por VIH/tratamiento farmacológico , Lamivudine/uso terapéutico , Organofosfonatos/uso terapéutico , Adenina/uso terapéutico , Desoxicitidina/uso terapéutico , Didesoxinucleósidos , Combinación de Medicamentos , Emtricitabina , Humanos , Tenofovir , Resultado del TratamientoAsunto(s)
Angina de Ludwig/diagnóstico , Antibacterianos/uso terapéutico , Femenino , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Infecciones por Bacterias Grampositivas/microbiología , Humanos , Angina de Ludwig/tratamiento farmacológico , Angina de Ludwig/microbiología , Cuello , Dolor de Cuello/diagnóstico , Dolor de Cuello/tratamiento farmacológico , Dolor de Cuello/microbiología , Infecciones de los Tejidos Blandos/diagnóstico , Infecciones de los Tejidos Blandos/tratamiento farmacológico , Infecciones de los Tejidos Blandos/microbiología , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: It is unclear whether there is a relationship between type two diabetes and cancer mortality. It also is unclear whether obesity and body mass index (BMI) are associated with cancer in type 2 diabetes patients. PATIENTS AND METHODS: In 1998, 1,145 patients with type two diabetes mellitus were enrolled in the Zwolle Outpatient Diabetes project Intergrating Available Care (ZODIAC) study. In this project, general practitioners (GPs) were assisted by hospital-based diabetes specialist nurses. Vital status was assessed in September 2004. The cancer mortality rate was evaluated using standardized mortality ratio (SMR) and its association with BMI (kg/m2) and obesity (>30 kg/m2) with the Cox proportional hazard ratio. RESULTS: The median follow-up time was 5.8 years. A total of 335 patients had died, of whom 70 died from malignancy. The SMR for cancer mortality was 1.38 (95% CI 1.07-1.75). BMI and obesity were not associated with cancer death. CONCLUSION: An increased cancer mortality rate was found in type two diabetes mellitus patients but there was no significant association between BMI or obesity and cancer mortality.