Long-Term Prognosis of Diabetic Patients With Critical Limb Ischemia: A population-based cohort study

OBJECTIVE\u2014 To evaluate the long-term prognosis of critical limb ischemia (CLI) in diabetic patients. RESEARCH DESIGN AND METHODS\u2014 A total of 564 consecutive diabetic patients were hospitalized for CLI from January 1999 to December 2003; 554 were followed until December 2007. RESULTS\u2014 The mean follow-up was 5.93 1.28 years. Peripheral angioplasty (PTA) was performed in 420 (74.5%) and bypass graft (BPG) in 117 (20.6%) patients. Neither PTA nor BPG were possible in 27 (4.9%) patients. Major amputations were performed in 74 (13.4%) patients: 34 (8.2%) in PTA, 24 (21.1%) in BPG, and 16 (59.2%) in a group that received no revascularization. Restenosis occurred in 94 patients, bypass failures in 36 patients, and recurrent ulcers in 71 patients. CLI was observed in the contralateral limb of 225 (39.9%) patients; of these, 15 (6.7%) required major amputations (rate in contralateral compared with initial limb, P 0.007). At total of 276 (49.82%) patients died. The Cox model showed significant hazard ratios (HRs) for mortality with age (1.05 for 1 year [95% CI 1.03\u20131.07]), unfeasible revascularization (3.06 [1.40\u20136.70]), dialysis (3.00 [1.63\u20135.53]), cardiac disease history (1.37 [1.05\u20131.79]), and impaired ejection fraction (1.08 for 1% point [1.05\u20131.09]). CONCLUSIONS\u2014 Diabetic patients with CLI have high risks of amputation and death. In a dedicated diabetic foot center, the major amputation, ulcer recurrence, and major contralateral limb amputation rates were low. Coronary artery disease (CAD) is the leading cause of death, and in patients with CAD history the impaired ejection fraction is the major independent prognostic factor

Mechanosensitivity during lower extremity neurodynamic testing is diminished in individuals with Type 2 Diabetes Mellitus and peripheral neuropathy: a cross sectional study

<p>Abstract</p> <p>Background</p> <p>Type 2 Diabetes Mellitus (T2DM) and diabetic symmetrical polyneuropathy (DSP) impact multiple modalities of sensation including light touch, temperature, position sense and vibration perception. No study to date has examined the mechanosensitivity of peripheral nerves during limb movement in this population. The objective was to determine the unique effects T2DM and DSP have on nerve mechanosensitivity in the lower extremity.</p> <p>Methods</p> <p>This cross-sectional study included 43 people with T2DM. Straight leg raise neurodynamic tests were performed with ankle plantar flexion (PF/SLR) and dorsiflexion (DF/SLR). Hip flexion range of motion (ROM), lower extremity muscle activity and symptom profile, intensity and location were measured at rest, first onset of symptoms (P1) and maximally tolerated symptoms (P2).</p> <p>Results</p> <p>The addition of ankle dorsiflexion during SLR testing reduced the hip flexion ROM by 4.3° ± 6.5° at P1 and by 5.4° ± 4.9° at P2. Individuals in the T2DM group with signs of severe DSP (n = 9) had no difference in hip flexion ROM between PF/SLR and DF/SLR at P1 (1.4° ± 4.2°; paired t-test p = 0.34) or P2 (0.9° ± 2.5°; paired t-test p = 0.31). Movement induced muscle activity was absent during SLR with the exception of the tibialis anterior during DF/SLR testing. Increases in symptom intensity during SLR testing were similar for both PF/SLR and DF/SLR. The addition of ankle dorsiflexion induced more frequent posterior leg symptoms when taken to P2.</p> <p>Conclusions</p> <p>Consistent with previous recommendations in the literature, P1 is an appropriate test end point for SLR neurodynamic testing in people with T2DM. However, our findings suggest that people with T2DM and severe DSP have limited responses to SLR neurodynamic testing, and thus may be at risk for harm from nerve overstretch and the information gathered will be of limited clinical value.</p

Incidence, aetiology, and sequelae of viral meningitis in UK adults: a multicentre prospective observational cohort study

© 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: Viral meningitis is increasingly recognised, but little is known about the frequency with which it occurs, or the causes and outcomes in the UK. We aimed to determine the incidence, causes, and sequelae in UK adults to improve the management of patients and assist in health service planning. Methods: We did a multicentre prospective observational cohort study of adults with suspected meningitis at 42 hospitals across England. Nested within this study, in the National Health Service (NHS) northwest region (now part of NHS England North), was an epidemiological study. Patients were eligible if they were aged 16 years or older, had clinically suspected meningitis, and either underwent a lumbar puncture or, if lumbar puncture was contraindicated, had clinically suspected meningitis and an appropriate pathogen identified either in blood culture or on blood PCR. Individuals with ventricular devices were excluded. We calculated the incidence of viral meningitis using data from patients from the northwest region only and used these data to estimate the population-standardised number of cases in the UK. Patients self-reported quality-of-life and neuropsychological outcomes, using the EuroQol EQ-5D-3L, the 36-Item Short Form Health Survey (SF-36), and the Aldenkamp and Baker neuropsychological assessment schedule, for 1 year after admission. Findings: 1126 patients were enrolled between Sept 30, 2011, and Sept 30, 2014. 638 (57%) patients had meningitis: 231 (36%) cases were viral, 99 (16%) were bacterial, and 267 (42%) had an unknown cause. 41 (6%) cases had other causes. The estimated annual incidence of viral meningitis was 2·73 per 100 000 and that of bacterial meningitis was 1·24 per 100 000. The median length of hospital stay for patients with viral meningitis was 4 days (IQR 3–7), increasing to 9 days (6–12) in those treated with antivirals. Earlier lumbar puncture resulted in more patients having a specific cause identified than did those who had a delayed lumbar puncture. Compared with the age-matched UK population, patients with viral meningitis had a mean loss of 0·2 quality-adjusted life-years (SD 0·04) in that first year. Interpretation: Viruses are the most commonly identified cause of meningitis in UK adults, and lead to substantial long-term morbidity. Delays in getting a lumbar puncture and unnecessary treatment with antivirals were associated with longer hospital stays. Rapid diagnostics and rationalising treatments might reduce the burden of meningitis on health services. Funding: Meningitis Research Foundation and UK National Institute for Health Research

Dampak Agrowisata Berbasis Edukasi Pada Peternakan Sapi Perah Di Cv. Milkindo Berka Abadi Terhadap Kesempatan Kerja Dan Peluang Berusaha

Kabupaten Malang memiliki masalah mengenai angka pengangguran yang tinggi. Dengan jumlah pengangguran sebanyak 64.034 orang atau tingkat pengangguran terbuka sebesar 4.02%, maka Pemerintah Daerah Kabupaten Malang dituntut agar dapat menciptakan lapangan pekerjaan tambahan. Jika tidak, maka jumlah pengangguran akan terus bertambah, sehingga dapat menimbulkan dampak buruk, tidak hanya berdampak buruk bagi perekonomian, namun juga berdampak buruk secara sosial, seperti meningkatnya kejahatan. Agrowisata CV. Milkindo Berka Abadi yang terletak di Desa Tegalsari, Kecamatan Kepanjen Kabupaten Malang merupakan sebuah objek wisata berbasis edukasi peternakan sapi perah. Hal ini didukung oleh iklim Kepanjen yang sejuk sehingga daerah Kepanjen cocok dijadikan lokasi agrowisata bertema edukasi peternakan sapi perah. Kegiatan wisata yang diharapkan dari agrowisata CV. Milkindo Berka Abadi diharapkan dapat menciptakan kesempatan kerja serta peluang usaha bagi masyarakat yang berada di sekitarnya guna mengurangi angka pengangguran yang ada. Tujuan dari penelitian ini adalah untuk mengetahui dampak serta respon masyarakat yang timbul terhadap peluang usaha serta kesempatan kerja bagi masyarakat yang ada disekitar dengan adanya keberadaan agrowisata CV. Milkindo Berka Abadi. Hasil dari penelitian ini diharapkan dapat digunakan pelaku pariwisata sebagai bahan informasi dalam mengembangkan sebuah peternakan menjadi hiburan yang menarik bagi wisatawan. Penelitian ini dilaksanakan di CV. Milkindo Berka Abadi yang beralamat di Jalan Kolonel Kusno No.77 Desa Tegalsari Kabupaten Malang selama satu bulan pada tanggal 3 Juli hingga 4 Agustus 2017. Metode penelitian yang digunakan adalah metode penelitian kualitatif dengan melakukan wawancara mendalam terhadap subjek dan informan sebanyak 24 orang. Analisis data yang digunakan adalah analisis data deskriptif. Berdasarkan hasil penelitian, diketahui bahwa peternakan yang ada di Agrowisata CV. Milkindo Berka Abadi memiliki jumlah sapi sekitar 161 ekor dengan jumlah sapi laktasi sebanyak 61 ekor, bunting 25, dara 17, pedet betina 33, pedet jantan 14 dan jantan 11 ekor. Produksi susu setiap hari 500-600 liter. Susu yang dihasilkan diproduksi menjadi susu pasteurisasi dan sebagian lainnya dijual ke PT. Nestle. Peternakan sapi perah memiliki kontribusi yang banyak untuk agrowisata CV. Milkindo Berka Abadi, salah satunya adalah kontribusi terhadap pendapatan. Selain itu daya tarik utama dari agrowisata ini adalah mengintegrasikan peternakan sapi perah, taman, dan wahana bermain dalam satu lokasi. Kombinasi antara ketiga unit tersebut menjadi daya tarik agar wisatawan datang ke agrowisata CV. Milkindo Berka Abadi. Kegiatan wisata di agrowisata CV. Milkindo Berka Abadi memberikan dampak bagi masyarakat sekitar. Dampaknya adalah mampu untuk menciptakan kesempatan kerja dan memberikan peluang bagi masyarakat untuk memiliki wirausaha mandiri. Dampak nyata yang paling dirasakan yakni terciptanya kesempatan kerja bagi masyarakat sekitar karena lebih mendahulukan pekerja dari sekitar agrowisata, serta timbulnya peluang berusaha pada sektor informal bagi masyarakat sehingga dapat menambah penghasilan bagi masyarakat. Disimpulkan bahwa peternakan sapi perah memiliki kontribusi yang cukup penting bagi agrowisata CV. Milkindo Berka Abadi, selain itu yang menjadi daya tarik yaitu adanya integrasi antara peternakan sapi perah, taman dan wahana bermain. Disarankan bahwa kedepannya semakin banyak pelaku pariwisata yang mengembangkan objek wisata seperti di agrowisata CV. Milkindo Berka Abadi karena jenis wisat seperti ini masih jarang di Kabupaten Malang

Effect of Coupling Agent on Softwood Kraft Nanocellulose Fibril-Reinforced Polylactic Acid Biocomposite

The nanocellulose fibril produced by using natural sources can be used in developing sustainable and green products. The useful features of nanocellulose fibril can include valuable physical properties, appropriate surface chemistry, low toxicity, and biocompatibility. The study presented shows the use of polylactic acid with five different percentages of nanocellulose fibril and the use of 3% maleic anhydride as a coupling agent. The maleic anhydride acts as coupling agent which improves the thermochemical and thermomechanical characteristics of the end product. The addition of 3% maleic anhydride as coupling agent with 10% nanocellulose fibril improved the impact strength up to 14.3%, elastic modulus up to 40.6%, and tensile strength up to 30.1%. Furthermore, the dynamic mechanical analysis result indicates that the inclusion of maleic anhydride improved the toughness by reducing the tan δ peak and increases the storage modulus. Finally, the scanning electron micrograph shows that the interfacial compatibility between nanocellulose fibril and polylactic acid matrix is improved with the addition of maleic anhydride.</jats:p

Chest Pain from Pneumopericardium with Gastropericardial Fistula

Introduction. Gastropericardial fistula, a connection between the upper gastrointestinal tract and pericardium, is a rare clinical finding most commonly associated with postsurgical complications, as well as direct tissue invasion from gastric cancer. Case Report. We report a case of a 58-year-old Caucasian woman with metastatic colon cancer treated with FOLFOX, a combination chemotherapy regimen, and bevacizumab who presented with chest pain. She was ruled out for acute coronary syndrome, aortic dissection, or pulmonary embolism. A computed tomography (CT) scan of her chest showed pneumopericardium. A barium swallow ruled out esophageal ulceration, and esophagogastroduodenoscopy (EGD) showed a large penetrating gastric ulcer with no evidence of gastric dysplasia or malignancy or evidence of Helicobacter pylori (H. pylori). The patient underwent median sternotomy with gastric ulcer resection and repair, as well as pericardial washout and pericardial chest tube placement. After an uncomplicated course, she was safely discharged home. Conclusion. Given that gastrointestinal ulceration and perforation are known phenomena in patients taking vascular endothelial growth factor (VEGF) inhibitors, surveillance endoscopy may be beneficial to discover them before they result in potentially fatal complications such as gastropericardial fistulas.</jats:p