The influence of diabetes mellitus on postoperative infections

Influence of Diabetes Mellitus on Postoperative Complications After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background and Objectives: Total knee arthroplasty (TKA) is an effective treatment option for severe knee osteoarthritis. Understanding the impact of diabetes mellitus (DM) on postoperative outcomes is crucial for improving patient satisfaction after TKA. This study aimed to investigate the influence of DM on postoperative complications and mortality after TKA. Materials and Methods: We conducted a systematic review and meta-analysis by searching relevant studies published before December 2023 in the PubMed, EMBASE, Cochrane Library, Medline, and Web of Science databases. The assessment included demographic data, comorbidities, and postoperative complications after primary TKA for both DM and non-DM patients. The odds ratio (OR) was used to represent the estimate of risk of a specific outcome. Results: Thirty-nine studies were finally included in this meta-analysis. Patients with DM had higher rates of periprosthetic joint infection (OR: 1.71, 95% confidence interval [CI]: 1.46-2.00, p < 0.01) and prosthesis revision (OR: 1.37, 95% CI: 1.23-1.52, p < 0.01). Moreover, patients with DM showed an elevated incidence of pneumonia (OR: 1.54, 95% CI: 1.15-2.07, p < 0.01), urinary tract infection (OR: 1.86, 95% CI: 1.07-3.26, p = 0.02), and sepsis (OR: 1.61, 95% CI: 1.46-1.78, p < 0.01). Additionally, the postoperative risk of cardiovascular (OR: 2.49, 95% CI: 1.50-4.17, p < 0.01) and cerebrovascular (OR: 2.38, 95% CI: 1.48-3.81, p < 0.01) events was notably higher in patients with DM. The presence of DM increased the risk of deep vein thrombosis (OR: 1.58, 95% CI: 1.22-2.04, p < 0.01), but did not lead to an increased risk of pulmonary embolism. Most importantly, DM was associated with a higher mortality rate within 30 days after TKA (OR: 1.27, 95% CI: 1.02-1.60, p = 0.03). Conclusions: Patients with DM exhibited a higher rate of postoperative complications after TKA, and DM was associated with a higher mortality rate within 30 days after TKA. It is crucial to educate patients about the perioperative risk and develop evidence-based guidelines to prevent complications after TKA.

Analysis of risk factors related to chronic non-healing wound infection and the construction of a clinical prediction model

This study is aimed to analyse the risk factors associated with chronic non-healing wound infections, establish a clinical prediction model, and validate its performance. Clinical data were retrospectively collected from 260 patients with chronic non-healing wounds treated in the plastic surgery ward of Shanxi Provincial People's Hospital between January 2022 and December 2023 who met the inclusion criteria. Risk factors were analysed, and a clinical prediction model was constructed using both single and multifactor logistic regression analyses to determine the factors associated with chronic non-healing wound infections. The model's discrimination and calibration were assessed via the concordance index (C-index), receiver operating characteristic (ROC) curve and calibration curve. Multivariate logistic regression analysis identified several independent risk factors for chronic non-healing wound infection: long-term smoking (odds ratio [OR]: 4.122, 95% CI: 3.412-5.312, p < 0.05), history of diabetes (OR: 3.213, 95% CI: 2.867-4.521, p < 0.05), elevated C-reactive protein (OR: 2.981, 95% CI: 2.312-3.579, p < 0.05), elevated procalcitonin (OR: 2.253, 95% CI: 1.893-3.412, p < 0.05) and reduced albumin (OR: 1.892, 95% CI: 1.322-3.112, p < 0.05). The clinical prediction model's C-index was 0.762, with the corrected C-index from internal validation using the bootstrap method being 0.747. The ROC curve indicated an area under the curve (AUC) of 0.762 (95% CI: 0.702-0.822). Both the AUC and C-indexes ranged between 0.7 and 0.9, suggesting moderate-to-good predictive accuracy. The calibration chart demonstrated a good fit between the model's calibration curve and the ideal curve. Long-term smoking, diabetes, elevated C-reactive protein, elevated procalcitonin and reduced albumin are confirmed as independent risk factors for bacterial infection in patients with chronic non-healing wounds. The clinical prediction model based on these factors shows robust performance and substantial predictive value.

Association between diabetes mellitus and risk of infection after trigger finger release: a systematic review and meta-analysis

PURPOSE

To investigate the association between diabetes mellitus and risk of infection after trigger finger release.

METHODS

Reports of adult trigger finger patients who had undergone trigger finger release that included details of patient diabetic status and post-surgery infections were included in the study. Reports of congenital trigger finger release and incomplete data on either diabetic status or infection after surgery were excluded. Search engines were PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science from inception to third December 2021. The risk of infection after trigger finger release was compared between diabetic and non-diabetic patients by evaluating the pooled risk ratio (RR) with a 95% confident interval (CI) under random effects modeling. Risk of bias in each study was assessed using Newcastle-Ottawa Scale (NOS).

RESULTS

A total of 213,071 trigger finger patients described in seven studies were identified. Overall, patients with diabetes mellitus had a 65% higher risk of infection after trigger finger release compared to non-diabetic patients (RR 1.65; 95% CI, 1.39-1.95). Diabetes mellitus increased the risk of infection following trigger finger surgery in both young and old age groups as well as obese and non-obese patients who underwent open release surgery. The risk of bias in each of the included studies was estimated as moderate to high.

CONCLUSION

Meta-analysis results demonstrated that diabetes mellitus increases the risk of infection after trigger finger release. Glycemic control and percutaneous rather than open surgery might be strategies to the reduce risk of infection after trigger finger release in diabetic patients.

Limited joint mobility of the hand correlates incident hospitalisation with infection in patients with type 2 diabetes

AIM

Limited joint mobility (LJM) of the hand is one of the important complications of diabetes. Diabetes is a risk factor for hospitalisation with infection. This study investigated the relationship between LJM of the hand and the incidence of hospitalisation with infection in type 2 diabetic patients.

MATERIALS AND METHODS

LJM of hand was defined as the 'prayer sign' or 'table test'. The association between LJM of the hand and incident hospitalisations was evaluated using Cox regression analysis. The number of incident hospitalisations was small over the course of the study, which we compensated for by calculating propensity scores using age, body mass index, sex, duration of diabetes, creatinine, smoking status, haemoglobin A1c and dyslipidaemia.

RESULTS

In this retrospective cohort study of 502 patients with type 2 diabetes, 102 patients had LJM of the hand. These patients were, on average, older and had worse renal function and glycaemic control, and a higher proportion of microangiopathy significantly. During the study period, 56 patients were hospitalised with infection. A Cox regression analysis showed that LJM of the hand was associated with an increased probability of incident hospitalisation with infection after adjustment for covariates (HR = 1.65 [95% CI 1.60-1.70], p < 0.001).

CONCLUSIONS

Our results reveal that LJM of the hand is associated with incident of hospitalisation with infection. A diagnosis of LJM of the hand might, therefore, be a useful indicator for assessing the risk of hospitalisation with infection in type 2 diabetic patients.

The Safety Level of Total Central Venous Access Port Implantation Performed by Residents

OBJECTIVE

The implantation of totally implantable venous access ports (TIVAPs) is one of the first procedures surgical residents learn. Complications after implantation procedures have a major impact on patient outcomes, as it may lead to a delay of chemotherapy regimens or of parenteral nutrition. The aim of this study was to compare the outcomes after totally implantable venous access ports implantations done by resident and attending surgeons.

DESIGN

The study was performed as a retrospective analysis.

SETTING

The study took place in primary care at the Department of General and Visceral Surgery at Frankfurt University Hospital.

PARTICIPANTS

A total of 760 primary totally implantable venous access ports implantations performed between March 2008 and December 2016 were included in a database. Three groups of surgeons doing the implantations were defined: Group A (residents alone), Group B (resident with help), and Group C (attending surgeons).

RESULTS

There was a significant difference between the surgeon groups in operation time (p < 0.001). The groups differed between Group A (mean, 49; SD, 22) and Group C (mean, 39; SD, 20); p < 0.001) and Group B (mean, 53; SD, 23) and Group C (mean, 39; SD, 20; p < 0.001). The incidence of surgical site infections between Groups A and C (3.6% vs. 0.3%; p = 0.003) and Groups B and C (2.5% vs. 0.3%; p = 0.027) differed also significantly. Based on multivariable logistic regression analysis operation time in minutes (OR, 1.04; 95%CI, 1.03-1.06; p < 0.001) was an independent risk factor for any intraoperative complications. For any postoperative complications younger age of the patient (OR, 0.98; 95%CI, 0.97-0.99; p = 0.004) and benign primary disease (OR, 3.25; 95%CI, 1.55-6.64; p = 0.002) were independent risk factors based on multivariable regression analysis. Based on multivariable regression analysis a lower body mass index of the patient (OR, 0.93; 95%CI, 0.86-0.99; p = 0.044), benign primary disease (OR, 2.89; 95%CI, 1.07-7.79; p = 0.036), and no chemotherapy (OR, 3.55; 95%CI, 1.50-8.39; p = 0.004) were independent risk factors for postoperative catheter infections. Surgeon group was no risk factor, neither for intraoperative and postoperative complications, nor for catheter explantation due to complications.

CONCLUSION

Residents performing alone or residents performing with help can safely handle a central venous access port implantation. In patients with several risk factors, however, an attending should assist.

Diabetes Shared Care Program (DSCP) and risk of infection mortality: a nationwide cohort study using administrative claims data in Taiwan

OBJECTIVE

The Diabetes Shared Care Program (DSCP) is an integrated care model in Taiwan that has been proven to improve the care quality of patients with diabetes. We aimed to evaluate the efficacy of DSCP in decreasing the hospital mortality of infectious diseases.

METHODS

From 1 662 929 patients with type 2 diabetes newly diagnosed between 1999 and 2013, we retrieved a total of 919 patients who participated in the DSCP with the first hospitalisation for an infectious disease as the study cohort and 9190 propensity score-matched patients with type 2 diabetes who did not participate as the comparison.The efficacy of DSCP was evaluated via the following comparisons between the DSCP and non-DSCP cohorts: hospital mortality, 1-year medical cost prior to and during the hospitalisation, and complications, such as receiving mechanical ventilation and intensive care unit admission. The ratio (OR) for hospital mortality of the DSCP participants was calculated by logistical regression. Further stratification analyses were conducted to examine which group of patients with type 2 diabetes benefited the most from the DSCP during hospitalisation for infectious diseases.

RESULTS

The DSCP cohort had a lower hospital mortality rate than the non-DSCP participants (2.18% vs 4.82%, p<0.001). The total medical cost during the hospitalisation was lower in the DSCP cohort than in the non-DSCP cohort (NT$72 454±30 429 vs NT$86 385±29 350) (p=0.006). In the logistical regression model, the DSCP participants exhibited a significantly decreased adjusted OR for hospital mortality (adjusted OR=0.42, 95% CI 0.26 to 0.66, p=0.0002). The efficacy of the DSCP was much more prominent in male patients with type 2 diabetes and in patients with lower incomes.

CONCLUSION

Participation in the DSCP was associated with a lower risk of hospital mortality for infectious diseases.

Hypoglycemia and Comorbidities in Type 2 Diabetes

Hypoglycemia is one of the major barriers in optimizing glycemic control. In type 2 diabetes, hypoglycemia is associated with multiple morbidities (eg, myocardial ischemia, cardiac arrhythmia, stroke, dementia, psychosocial dysfunction, obesity, microvascular complications, cancer, and diseases of respiratory, digestive, and dermatological systems). Risk factors associated with hypoglycemia in patients with type 2 diabetes include old age, long disease duration, low body mass index, high baseline glycated hemoglobin (HbA1c), treatment with insulin and sulphonylurea, renal dysfunction, albuminuria, reduced level of low density lipoprotein cholesterol, low triglyceride and depression. There are considerable overlaps between phenotypes associated with severe hypoglycemia and all-site cancer suggesting that hypoglycemia may be a marker of vulnerability. In patients with severe hypoglycemia, comprehensive assessment is recommended to detect silent conditions, such as renal dysfunction, cancer, depression as well as review of treatment strategies including drug use to prevent morbidities and mortality.

Part II: managing perioperative hyperglycemia in total hip and knee replacement surgeries

Perioperative hyperglycemia management is an important factor in reducing the risk of surgical site infections (SSIs) in all patients regardless of existing history of diabetes. Reduction of SSIs is one of the quality indicators reported by the National Healthcare Safety Networks of the Centers for Disease Control and Prevention (CDC). In 2009 and 2010, the orthopedic surgical unit had an increased number of SSIs above the CDC benchmark. This article describes the impact of an evidence-based practice standard for perioperative hyperglycemia management in the reduction of SSIs in patients having total hip and knee replacement surgery.

Preoperative hyperglycemia and complication risk following neurosurgical intervention: A study of 918 consecutive cases

Background:

Little is known about the relation between preoperative glycemic state and neurosurgical outcomes. Improved understanding of this relationship may identify patients at increased risk of complicated recovery and guide postoperative treatment strategies.

Methods:

Data were collected about 918 consecutive craniotomy or spine-related neurosurgical cases at the University of Michigan Hospitals. Univariate statistics, bivariate chi-square tests, and analysis of variance were used to assess relations between preoperative blood glucose, demographics, medical comorbidities, systemic glucocorticoid use, and postoperative complication risk and postoperative hospital and intensive care unit (ICU) stay. We fit a multivariable logistic regression model of 30-day complication risk by preoperative blood glucose adjusted for potential confounders, and used analysis of covariance to assess the relation between preoperative blood glucose and hospital, as well as ICU stay, adjusted for potential confounders.

Results:

Among all patients, 56.1% had peri-operative blood glucose levels below 100 mg/dl. 20.7% had levels from 100 to 120 mg/dl, 16.3% had levels from 121 to 160 mg/dl, and 6.9% had levels greater than 160 mg/dl. In multivariable regression models, blood glucose greater than 120 mg/dl was associated with increased risk of postoperative complications at all levels. Analysis of covariance showed that preoperative blood glucose above 120 mg/dl was associated with both increased length of ICU stay and length of hospital stay.

Conclusions:

Our findings suggest that even mild preoperative hyperglycemia is a predictor of postoperative complication risk, and prolonged hospital and ICU stay following neurosurgical intervention. Tight glycemic control may be in order when attempting to reduce risk of complications and limit postoperative recovery time.

Risk factors for postoperative spinal wound infections after spinal decompression and fusion surgeries

STUDY DESIGN

This is a multivariate analysis of a prospectively collected database.

OBJECTIVE

To determine preoperative, intraoperative, and patient characteristics that contribute to an increased risk of postoperative wound infection in patients undergoing spinal surgery.

SUMMARY OF BACKGROUND DATA

Current literature sites a postoperative infection rate of approximately 4%; however, few have completed multivariate analysis to determine factors which contribute to risk of infection.

METHODS

Our study identified patients who underwent a spinal decompression and fusion between 1997 and 2006 from the Veterans Affairs' National Surgical Quality Improvement Program database. Multivariate logistic regression analysis was used to determine the effect of various preoperative variables on postoperative infection.

RESULTS

Data on 24,774 patients were analyzed. Wound infection was present in 752 (3.04%) patients, 287 (1.16%) deep, and 468 (1.89%) superficial. Postoperative infection was associated with longer hospital stay (7.12 vs. 4.20 days), higher 30-day mortality (1.06% vs. 0.5%), higher complication rates (1.24% vs. 0.05%), and higher return to the operating room rates (37% vs. 2.45%). Multivariate logistic regression identified insulin dependent diabetes (odds ratios [OR] = 1.50), current smoking (OR = 1.19) ASA class of 3 (OR = 1.45) or 4 to 5 (OR = 1.66), weight loss (OR = 2.14), dependent functional status (1.36) preoperative HCT <36 (1.37), disseminated cancer (1.83), fusion (OR = 1.24) and an operative duration of 3 to 6 hours (OR = 1.33) or >6 hours (OR = 1.40) as statistically significant predictors of postoperative infection.

CONCLUSION

Using multivariate analysis of a large prospectively collected data from the National Surgical Quality Improvement Program database, we identified the most important risk factors for increased postoperative spinal wound infection. We have demonstrated the high mortality, morbidity, and hospitalization costs associated with postoperative spinal wound infections. The information provided should help alert clinicians to presence of these risks factors and the likelihood of higher postoperative infections and morbidity in spinal surgery patients.

Risk factors in a patient with fungemia caused by fluconazole-resistant Candida albicans

Blood stream infections due to Candida species are becoming increasingly important causes of morbidity and mortality in hospitalized patients. Risk factors that predispose patients to developing invasive Candida infections have been documented as, iatrogenic and/or nosocomial conditions and immunosuppression. In the present report, we want to emphasize the risk factors that predispose individuals to the development of candidemia, particularly those that are relevant to our patient. We describe a female patient with diabetes mellitus who had been receiving glucocorticoids for 20 years as replacement therapy for hypopituitarism resulting from hypophysis adenoma surgery. The patient received antibiotic therapy for recurrent wound infections and was hospitalized for a long time, including a period in the intensive care unit and instrumented. The patient eventually succumbed to fungemia caused by a fluconazole-resistant strain of C. albicans strain.

Evaluation of Nursing Work Effort and Perceptions About Blood Glucose Testing in Tight Glycemic Control

• Background Tight glycemic control is important in critically ill patients and involves insulin infusions and monitoring of blood glucose levels. Hourly measurements of blood glucose levels and adjustments of intravenous insulin doses require additional work by nurses.

• Objectives To evaluate the nursing work incurred with and nursing perceptions about tight glycemic control and blood glucose monitoring.

• Methods A variety of intensive care units were studied. Surveys were used to gain information about nurses’ perceptions. Time-in-motion observations were used to determine the time taken to measure blood glucose levels and adjust insulin doses.

• Results Nurses thought that tight glycemic control was important and that the work associated with it was substantial. Nurses thought that easier and automated forms of blood glucose monitoring are needed. They preferred using an arterial catheter to obtain blood samples to avoid excessive finger sticks. The total number of blood glucose measurements was 77 954. The mean time taken for hourly blood glucose monitoring and adjustment of insulin doses was 4.72 minutes. The estimated costs of time spent on glycemic control during a 1-year period were $182 488 for nurses’ salaries and $58 500 for supplies.

• Conclusions Although most nurses endorse tight glycemic control, the work associated with it is burdensome and costly. Because up to 2 hours might be required for tight glycemic control for a single patient in a 24-hour period, the costs in time and money are high. Easier clinical methods for monitoring blood glucose levels are needed.

Mandibular osteomyelitis and tooth exfoliation following zoster-CMV co-infection

Herpes zoster is a common viral infection, the oral soft tissue manifestations of which are widely known and recognized. Reports of spontaneous tooth exfoliation and jaw osteonecrosis following herpes zoster infection in the distribution of the trigeminal nerve are extremely infrequent and sporadic, with only 39 cases being reported in the literature. We report an additional case of mandibular osteomyelitis and spontaneous tooth exfoliation following herpes zoster infection, which occurred in the left mandible of a 70-year-old diabetic man; however, our case also showed CMV co-infection. The role of CMV in the pathogenesis of the osteonecrosis remains uncertain. Awareness of the possibility of CMV co-infection in various oral diseases including oral ulcers, Kaposi's sarcoma, and herpes zoster infections especially in immunocompromised patients is important, since spread of the CMV can easily occur to other sites with potentially fatal consequences. Early diagnosis can lead to effective treatment and prevention of complications.

Effects of a novel formulation of essential oils on glucose-insulin metabolism in diabetic and hypertensive rats: a pilot study

BACKGROUND

Insulin resistance and its most severe form type 2 diabetes mellitus are rapidly increasing throughout the world. It is generally recognized that natural products with a long history of safety can increase insulin sensitivity.

AIMS

The present investigation examined the ability of various combinations of essential oils such as fenugreek, cinnamon, cumin, oregano, etc. to enhance insulin sensitivity. As a first approximation, we examined the effects of these natural products on Zucker fatty rats (ZFRs), a model of obesity and insulin resistance, and spontaneously hypertensive rats (SHRs), a model of genetic hypertension.

MATERIAL AND METHODS

Water or essential oils were given orally via droplets, and insulin sensitivity was estimated by systolic blood pressure (SBP) changes and circulating glucose and/or insulin concentrations.

RESULTS

We have found that the ability to alter SBP in rat models is the most sensitive early index of insulin sensitivity. The combined essential oils lowered circulating glucose levels and SBP in both ZFRs and SHRs, suggesting that these natural products are enhancing insulin sensitivity. The second series of studies examined two additional combinations of essential oils along with the original formula. The major differences were in the types and proportions of individual oils contributing to a given formula.

CONCLUSIONS

Although all the three formulae decreased SBP in ZFRs, one of the formulae was more effective than the others in lowering circulating glucose in the glucose tolerance testing. Accordingly, some essential oils may be added to the long list of natural products that can affect insulin sensitivity.