The Association of Frailty with Hospitalizations and Mortality among Community Dwelling Older Adults with Diabetes

BACKGROUND

Diabetes (DM) is associated with an accelerated aging that promotes frailty, a state of vulnerability to stressors, characterized by multisystem decline that results in diminished intrinsic reserve and is associated with morbidity, mortality and utilization. Research suggests a bidirectional relationship between frailty and diabetes. Frailty is associated with mortality in patients with diabetes, but its prevalence and impact on hospitalizations are not well known.

OBJECTIVES

Determine the association of frailty with all-cause hospitalizations and mortality in older Veterans with diabetes.

DESIGN

Retrospective cohort.

SETTING

Outpatient.

PARTICIPANTS

Veterans 65 years and older with diabetes who were identified as frail through calculation of a 44-item frailty index.

MEASUREMENTS

The FI was constructed as a proportion of healthcare variables (demographics, comorbidities, medications, laboratory tests, and ADLs) at the time of the screening. At the end of follow up, data was aggregated on all-cause hospitalizations and mortality and compared non-frail (robust, FI≤ .10 and prefrail FI=>.10, <.21) and frail (FI≥.21) patients. After adjusting for age, race, ethnicity, median income, history of hospitalizations, comorbidities, duration of DM and glycemic control, the association of frailty with all-cause hospitalizations was carried out according to the Andersen-Gill model, accounting for repeated hospitalizations and the association with all-cause mortality using a multivariate Cox proportional hazards regression model.

RESULTS

We identified 763 patients with diabetes, mean age 72.9 (SD=6.8) years, 50.5% were frail. After a median follow-up of 561 days (IQR=172), 37.0% they had 673 hospitalizations. After adjustment for covariates, frailty was associated with higher all-cause hospitalizations, hazard ratio (HR)=1.71 (95%CI:1.31-2.24), p<.0001, and greater mortality, HR=2.05 (95%CI:1.16-3.64), p=.014.

CONCLUSIONS

Frailty was independently associated with all-cause hospitalizations and mortality in older Veterans with diabetes. Interventions to reduce the burden of frailty may be helpful to improve outcomes in older patients with diabetes.

Facial Dysmorphism, Hirsutism, and Failure to Thrive as Manifestation of Leigh Syndrome in a Child with SURF1 Mutation

Leigh syndrome (or subacute necrotizing encephalomyelopathy) is a rare neurodegenerative disorder characterized by psychomotor retardation or regression, typically occurring in stepwise decrements. Onset is typically between ages 3 and 12 months. Neurological manifestations include hypotonia, spasticity, movement disorders (including chorea), cerebellar ataxia, and peripheral neuropathy, whereas extraneurological manifestations may include hypertrophic cardiomyopathy, hypertrichosis, anemia, renal tubulopathy, liver involvement, ptosis, and muscle weakness. Approximately 50% of affected individuals die by age 3 years, most often as a result of respiratory or cardiac failure. We report a case of 22-month-old female child presenting to us with severe failure to thrive, dysmorphic features, hirsutism, external ophthalmoplegia epilepsy, and neuroregression with characteristic findings of Leigh's syndrome on neuroimaging and her muscle biopsy revealed evidence of mitochondrial respiratory chain defect involving complex IV and SURF1 mutation.

Tuberculous lymphadenitis is associated with altered levels of circulating angiogenic factors

BACKGROUND

Angiogenic factors are important in granuloma formation and serve as biomarkers in pulmonary tuberculosis (PTB). The relationship between these markers and tuberculous lymphadenitis (TBL) is not known.

OBJECTIVE AND DESIGN

To examine the association of vascular endothelial growth factor (VEGF) and angiopoietin (Ang) family molecules in TBL, we measured systemic levels of VEGF-A, C, D, R1 (VEGF-receptor 1), R2, R3, Ang-1, Ang-2 and TIE2 (tyrosine kinase with immunoglobulin-like and epidermal growth factor-like domains 2) levels in TBL, latent tuberculous infection (LTBI) and lymph node culture supernatants (VEGF-A, C and Ang-2) of the same TBL patients.

RESULTS

Circulating levels of VEGF-A and VEGF-C were significantly diminished, whereas VEGF-R2, R3, Ang-2 and TIE2 levels were significantly increased, in TBL. Likewise, VEGF-A, C and Ang-2 levels were significantly increased in lymph node supernatants compared with plasma in individuals with TBL. Receiver operating characteristic curve analysis showed that VEGF-C and VEGF-R2 markers clearly distinguished TBL from LTBI. Following treatment, VEGF-C and Ang-1 levels were significantly altered. No association was observed between angiogenic factors and culture grade or lymph node size, except for VEGF-A. VEGF-A was also significantly decreased in multiple lymph nodes compared with single lymph nodes.

CONCLUSIONS

Our data suggest that altered levels of circulating angiogenic factors in TBL might reflect underlying vasculo-endothelial dysfunction. Reversal of angiogenic markers after anti-tuberculosis treatment suggests that these angiogenic markers may serve as biomarkers of disease severity or response to treatment in TBL.

Sensitivity and specificity of screening tools and smear microscopy in active tuberculosis case finding

SETTING

Community based five pulmonary tuberculosis (PTB) surveys among adults.

OBJECTIVES

Estimate sensitivity and specificity of screening tools for PTB and sputum microscopy.

METHODS

For each survey site, we estimated sensitivity and specificity of different screening criteria and microscopy against culture; pooled estimates were obtained using Random Effects Model.

RESULTS

Sensitivity of cough alone, screening for any symptom (persistent cough ≥2 weeks, fever or chest pain ≥1 month, hemoptysis), any symptom or history of anti-TB treatment (h/o ATT) were 56.2%, 66% and 71.2% respectively; specificities were 95.3%, 93.8% and 92.7% respectively. X-ray when used alone for primary screening had sensitivity and specificity of 76.6% and 97.3% respectively. When used along with screening for cough, these figures were 94.3% and 93.1%, and 100% and 97.3% when used with any symptom and h/o ATT. When used for secondary screening, sensitivity and specificity of X-ray was 66.8% and 87.8% respectively after primary screening for cough, 65.0% and 89.8% after screening for any symptom, and 67.1% and 86.7% when used after screening for any symptom or h/o ATT. Pooled sensitivity and specificity of smear was 46.2% and 99.3% respectively.

CONCLUSION

Program managers may use these estimates while evaluating algorithms for active case finding.

Neuropsychological Difficulties Associated with Dopa Responsive Dystonia

A young girl with L-dopa responsive dystonia showed significant improvements in motor function but had ongoing complaints of neuropsychological difficulties. A neuropsychological evaluation was undertaken to understand the nature of her difficulties. Intellectual function, attention, executive function, and academic attainment were assessed using published psychometric tests. Verbal and non-verbal reasoning was found to be age appropriate. Particular difficulties were identified with working memory, visual selective attention, dual attention, and processing speed which were having a significant impact upon the child and her family. The importance of a thorough neuropsychological evaluation is discussed in helping to appropriately manage and support the child with this chronic but rare health condition.

Parasitic twin with gastroschisis is one of the rarest variant of conjoined twins: a case report

We report a case of parasitic twin or incomplete or heteropagus twining of extra portions of a pelvis, lower and upper limbs, duplication of genitalia and herniation of intestinal tract with spleen-variant of conjoined twinning (CT) consistent with fusion of two embryos followed by resorption of the caudal half of one of them, resulting in a normal male baby with the upper half of a male parasitic twin fused to his chest.

Could repeated prevalence surveys lead to decreasing tuberculosis prevalence in a community?

SETTING

Tiruvallur District, South India, where one baseline tuberculosis (TB) disease prevalence survey followed by three repeat prevalence surveys were conducted every 2.5 years between 1999 and 2008, and where the DOTS strategy was implemented in 1999.

OBJECTIVE

To rule out the possibility that the observed decline in TB prevalence was influenced by conducting repeat prevalence surveys, we compared the findings from two surveys: the third repeat survey conducted in 2006-2008 and an independent single survey in a neighbouring area conducted in 2008-2009.

DESIGN

An independent survey was conducted to estimate the prevalence of TB in the same district in 2008-2009 using a different set of villages and employing repeat survey methodology. The independent survey findings were compared with those of the third repeat survey.

RESULTS

The estimated prevalence rate of culture- and smear-positive TB was respectively 401 per 100,000 and 186 per 100,000 population in the third repeat survey area. The corresponding rates were 340 and 184/100,000 in the independent survey area. The difference in prevalence was not significant (culture P = 0.09; smear P = 0.93).

CONCLUSION

The estimated prevalence rates in the two different sample survey areas were comparable, indicating that the repeated prevalence surveys in the study area did not influence the observed decline in TB disease prevalence.

Trends in the prevalence of pulmonary tuberculosis over a period of seven and half years in a rural community in south India with DOTS

SETTING

Tiruvallur district In Tamil Nadu where DOTS was implemented by the State Government as the tuberculosis control measure in 1999, and monitored by the National Institute for Research in Tuberculosis for over five years.

OBJECTIVE

To estimate trends in TB prevalence in a rural community with DOTS.

DESIGN

Surveys of pulmonary tuberculosis were undertaken in representative samples of subjects aged > or =15 years (N = 83,000 - 92,000), initially and after two and half, five and seven and half years of implementation of DOTS. Sputa were collected from those with abnormal radiograph and/or presence of chest symptoms, and examined by direct smear and culture.

RESULTS

The prevalence of culture-positive tuberculosis was 607, 454, 309 and 388 per 100,000 in the four surveys, and that of smear-positive tuberculosis was 326, 259, 168 and 180. In the first five years; annual decrease was 12.4% (95% CI 10.4 - 14.4%) for culture-positive tuberculosis, and 12.2% (95% CI 8.0-16.2) for smear-positive tuberculosis. This was, however, followed by a significant increase in the next two and half years. The average new smear-positive case-notification rate was 75 per 100,000 during first four years but declined to 49 in subsequent years. There were no methodological differences during this period and information on changes in socio-economic indicators and nutritional standards was unavailable.

CONCLUSION

Despite the average annual success rate (78%) in this tuberculosis unit being lower than the expected rate of 85%, the implementation of DOTS was followed by a substantial decrease in the prevalence of pulmonary tuberculosis over the seven and half year period. Our findings suggest that sustaining the high effectiveness of DOTS programme needs vigilant supervision.

Purse string suturing in a neonatal prolapsed uterus

Prolapsed uterus in a newborn is a rare condition. We present our purse-string suturing as a new technique to restore it to its normal position to avoid complications. Prolapse is usually associated with congenital spinal defects, and is often resistant to simple reduction.

Extrarenal teratoid wilms' tumor in association with horseshoe kidney

Extrarenal teratoid Wilms' tumor is a rare variant of Wilms' tumor. Literature shows only 17 reported cases. We present this right-sided teratoid Wilms' tumor in a 3-year-old boy for its rarity in association with the horseshoe kidney. The tumor was found in the anterior aspect of the right kidney and consisted of triphasic Wilms' tumor element along with the presence of heterologous components.

[Activated leukemic oncogenes responsible for neoplastic transformation of hematopoietic cells]

Leukemia is a heterogeneous group of malignant blood diseases, it could be characterized by the expansion of immature blast cells. It's still stay unknown the point molecular mechanism of leukemogenesis. It has been previously found that leukemia patients frequently have the mutations in genes responsible for normal proliferation and differentiation of hematopoietic stem cells. At present, scientific groups worldwide engaged in biomedical studies of structural and functional aspects of leukemic oncogenes and their role in human and beast leukemogenesis. In this review we describe the most recent conceptions of molecular properties of oncogenes activation of which may lead to the development of CBF-AML, in case of mutation in core-binding factors AML1 (CBFalpha) or CBFbeta.

A Comparison of Target Gene Silencing using Synthetically Modified siRNA and shRNA That Express Recombinant Lentiviral Vectors

RNA-interference is an effective natural mechanism of post-transcriptional modulation of gene expression. RNA-interference mechanism exist as in high eukaryotes both animals and plants as well in lower eukaryotes and viruses. RNA-interference is now used as a powerful tool in study of functional gene activity and many essential for fundamental biology results was obtained with this approach. Also it's widely believed that RNA-interference could be used in working out of new therapeutic medicine against malignant, infectious and hereditary diseases. One of the main problems of these developments is search of effective methods of siRNA transfer into the target cells. At present time for these purpose different sorts of transfect ions or viral transduction are used. At present article the results of comparison of inhibition of expression of oncogene AML-ET O by synthetic siRNA and by recombinant lentiviruses coding for corresponding shRNA are presented.

Vitamin A levels in sputum-positive pulmonary tuberculosis patients in comparison with household contacts and healthy 'normals'

OBJECTIVE

To estimate serum vitamin A in pulmonary tuberculosis (PTB) patients at the start and end of anti-tuberculosis treatment.

DESIGN

Serum vitamin A was estimated in 47 PTB patients (pre and post treatment), 46 healthy household contacts and 30 healthy 'normals'.

RESULTS

Mean serum vitamin A in patients at the start of treatment was 21.2 microg/dl, which was significantly lower than in household contacts (42.2 microg/dl) and healthy 'normals' (48.1 microg/dl). The vitamin A levels in patients increased following treatment.

CONCLUSION

The low vitamin A levels observed in patients returned to normal at the end of anti-tuberculosis treatment without vitamin A supplementation.