Development and validation of a reference marker for identification of aerobic and anaerobic bacteria associated with diabetes chronic wound ulcers using PCR denaturing gradient gel electrophoresis

Introduction: Diabetes chronic wounds consist with a diverse microbial community and unculturablespecies may be highly prevalent.Objectives: This study aimed to establish a bacterial reference marker consisting of a group ofchronic wound related bacteria, using polymerase chain reaction-denaturing gradient gelelectrophoresis (PCR-DGGE) for profiling of bacteria in diabetes chronic wound infections.Methods: DNA was extracted from the known wound bacterial strains. PCR–DGGE was performedusing eubacterial specific primers targeting V2-V3 region of 16S rDNA. DGGE was performed usinga 30-55% denaturing gradient. Migration position of each organism was detected on DGGE gel andimportant organisms were selected. Equal volume from PCR products of each selected organism wasmixed, diluted with gel loading dye in 1:1.5 ratio and used for all DGGE gels. The ladder was thensubjected to species identification of fifteen tissue debridement specimens obtained from diabeteschronic wound ulcers. The identification efficacy was tested by sequencing.Results: DNA of bacterial pathogens which showed different migration distances on the gel werecombined and used as a reference panel. This bacterial ladder consisted of eleven different bacterialspecies including Bacteroides sp., S. aureus, Acineto bacter sp., P. aeruginosa, Streptococcus Group Aand Group B sp., E. faecalis, Providencia sp., Veillonella sp., E .coli and Enterobacter sp. Accordingto the reference panel, Pseudomonas species were abundant. Further the results were confirmed bysequencing.Conclusion: Reference marker allows comparative analysis of DGGE patterns and can be used as atool for presumptive identification of polymicrobial microbiota in chronic wound infections

Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-centre study

Background: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines. Methods: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level. Results: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384–1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually. Conclusion: This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning

Rhabdomyolysis: A rare presentation of aldosterone-producing adenoma

Rhabdomyolysis results from acute damage of the skeletal muscle brought on by various conditions of which hypokalemia is a recognized, but less common condition. Although primary aldosteronism may cause severe hypokalemia leading to rhabdomyolysis, the patients may have potassium levels within the normal range on routine biochemistry. In addition, hypokalemia may be triggered by initiation of diuretic therapy for control of hypertension. Here, we describe a patient with an aldosterone secreting adrenal adenoma, who presented with acute rhabdomyolysis secondary to severe hypokalemia triggered by initiation of diuretic therapy