Optimal Revascularization in Diabetes After the FREEDOM Trial: Were the Controversies Finally Settled?

Optimal revascularization in diabetes after the FREEDOM trial: Were the controversies finally settled?

Cardiol J. 2013; 20(4): 331-6
Tenenbaum A, Fisman E

The prevalence of diabetes mellitus (DM) is growing worldwide. Prothrombotic and proinfl ammatory states, in adjunct to endothelial dysfunction and metabolic disorders, such as hyperglycemia, dyslipidemia, obesity, insulin resistance, and oxidative stress, are key features of the accelerated atherosclerotic progression observed in patients with DM. Moreover, drug-eluting stents (DES) thrombosis rate was higher in DM than in non-DM patients and DM itself was identifi ed as an independent predictor of stent thrombosis, particularly due to the impaired response to dual antiplatelet therapy. The accumulating data even before the FREEDOM trial provided strong evidence that in patients with DM and complex coronary artery disease, coronary artery bypass grafting (CABG) was superior to percutaneous coronary intervention (PCI) which was based on the fi rst-generation DES. The FREEDOM trial enrolled 1900 patients with DM and multivessel coronary artery disease treated with CABG surgery or PCI with the fi rst-generation DES. The patients were followed for a median 3.8 years; CABG was superior to PCI as it signifi cantly reduced rates of death and myocardial infarction (MI), with a higher rate of stroke. The benefi t of CABG was driven by differences in rates of both MI (p < 0.001) and death from any cause (p = 0.049). Following the FREEDOM results, patients with DM ought to be informed before coronary angiography about the potential survival benefi t from CABG for the treatment of a complex disease. However, it should be noticed that the second generation DES were associated with better outcomes compared to the fi rst-generation DES. New stent designs are continually being developed, with the aim of further improving the clinical effi cacy and the safety profi le of these devices. Therefore, although the results of the FREEDOM trial clearly demonstrated that CABG was superior to PCI in DM, a comparative analysis of the new incoming stents warrants further investigation. HubMed – rehab

Emergence of a VIM-1 MBL and CTX-M-15 ESbL-producing Klebsiella pneumoniae clone from acute and rehabilitation hospitals in Italy.

New Microbiol. 2013 Jul; 36(3): 279-82
Nucleo E, Spalla M, Piazza A, Caltagirone MS, Asticcioli S, Debiaggi M, Matti C, Daturi R, Navarra A, Labonia M, Migliavacca R

We report the emergence of VIM-1 MBL and CTX-M-15-producing K. pneumoniae isolates collected from patients at two acute care hospitals (I.R.C.C.S. ?S. Matteo” and ?Casa Sollievo della Sofferenza” Hospital) and a long-term rehabilitation facility in Northern Italy (I.R.C.C.S. ?S. Maugeri”). Between February 2007 and October 2008, 30 K. pneumoniae strains showing decreased susceptibility to carbapenems were collected. PCR and sequencing experiments revealed the presence of blaVIM-1 gene in 14/30 isolates. All the above isolates carried the blaSHV-5 determinant as well; interestingly, 8/14 VIM positive isolates were also CTX-M-1- like producers. VIM-1 positive strains were present in all hospitals. PFGE genomic profiles of the 14/30 isolates showed that 2 different clones, A and B, were responsible for outbreaks. The coexistence in the same bacterial cell of compatible plasmids carrying epidemiologically important emerging resistance genes, such as MBLs and CTX-Ms, is worrisome since it could predict the generation and spread of pan-resistant bacteria and the consequent treatment option limitations that can lead to significant morbidity and mortality. Control measures should be applied to detect MBL-producing strains and to contrast the vertical and plasmidic diffusion of carbapenem-resistant K. pneumoniae in acute care and rehabilitation facilities.K. pneumoniae, Metallo-b-lactamase, ESbL. HubMed – rehab

Bone Mineral Density Loss Following Combat-Related Lower Extremity Amputation.

J Orthop Trauma. 2013 Aug 1;
Flint LJ, Wade CA, Stocker CP, Pasquina CP, Howard RS, Potter MP

Determine the incidence, severity, and associated risk factors for the development of low bone mineral density (BMD) following combat-related lower extremity amputation.Retrospective, case-control comparison SETTING:: Tertiary care military treatment facility PATIENTS/PARTICIPANTS:: One hundred fifty-six lower extremity amputees, representing 182 amputations (121 unilateral, 35 bilateral).All patients underwent dual energy x-ray absorptiometry (DEXA) scanning during the treatment period.Z-score was the main outcome measure. We identified all patients with low BMD (Z<-1.0) and conducted multivariate analysis to identify significant risk factors for low BMD development.The observed rate of low BMD was 42%. The average Z-score was -0.6±1.1 among unilateral amputations, and -1.2 ±1.0 among bilateral amputations (p=0.005). Risk factors for the development of low BMD were prolonged time to first ambulation (OR=1.39; 95% CI: 1.003-1.93; p=0.048), prolonged time to DEXA (OR=1.10; 95% CI: 1.02-1.18; p=0.009), and more proximal amputation level (OR=7.27; 95% CI: 3.21-16.49; p<0.001). Among unilateral amputees, we detected a significant difference in the BMD of the intact and amputated limbs (-1.0; 95% CI: -1.1 to -0.8; p<0.001).Proximal amputation level and delayed ambulation demonstrated a significant relationship with low BMD following traumatic and trauma-related amputation. We conclude that transfemoral amputees are at greater risk of BMD loss, and that disuse atrophy is a primary factor in the development of low BMD. Prevention should focus on early and aggressive weight-bearing rehabilitation, as well as assessing levels and appropriately supplementing calcium and vitamin D. HubMed – rehab

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