Plantar thermography is useful in the early diagnosis of diabetic neuropathy

OBJECTIVES: This study evaluated plantar thermography sensitivity and specificity in diagnosing diabetic polyneuropathy using cardiac tests (heart rate variability) as a reference standard because autonomic small fibers are affected first by this disease. METHODS: Seventy-nine individuals between the ages of 19 and 79 years old (28 males) were evaluated and divided into three groups: control (n = 37), pre-diabetics (n = 13) and type 2 diabetics (n = 29). The plantar images were recorded at baseline and then minutes after a provocative maneuver (Cold Stress Test) using an infrared camera that is appropriate for clinical use. Two thermographic variables were studied: the thermal recovery index and the interdigital anisothermal technique. Heart rate variability was measured in a seven-test battery that included three spectral indexes (in the frequency domain) and four Ewing tests (the Valsalva maneuver, the orthostatic test, a deep breathing test, and the orthostatic hypotension test). Other classically recommended tests were applied, including electromyography (EMG), Michigan inventory, and a clinical interview that included a neurological physical examination. RESULTS: Among the diabetic patients, the interdigital anisothermal technique alone performed better than the thermal recovery index alone, with a better sensitivity (81.3%) and specificity (46.2%). For the pre-diabetic patients, the three tests performed equally well. None of the control subjects displayed abnormal interdigital anisothermal readouts or thermal recovery indices, which precluded the sensitivity estimation in this sample of subjects. However, the specificity (70.6%) was higher in this group. CONCLUSION: In this study, plantar thermography, which predominately considers the small and autonomic fibers that are commonly associated with a sub-clinical condition, proved useful in diagnosing diabetic neuropathy early. The interdigital anisothermal test, when used alone, performed best

Guideline for the management of clostridium difficile infection in children and adolescents with cancer and pediatric hematopoietic stem-cell transplantation recipients

Purpose The aim of this work was to develop a clinical practice guideline for the prevention and treatment of Clostridium difficile infection (CDI) in children and adolescents with cancer and pediatric hematopoietic stem-cell transplantation (HSCT) patients. Methods An international multidisciplinary panel of experts in pediatric oncology and infectious diseases with patient advocate representation was convened. We performed systematic reviews of randomized controlled trials for the prevention or treatment of CDI in any population and considered the directness of the evidence to children with cancer and pediatric HSCT patients. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to generate recommendations. Results The panel made strong recommendations to administer either oral metronidazole or oral vancomycin for the initial treatment of nonsevere CDI and oral vancomycin for the initial treatment of severe CDI. Fidaxomicin may be considered in the setting of recurrent CDI. The panel suggested that probiotics not be routinely used for the prevention of CDI, and that monoclonal antibodies and probiotics not be routinely used for the treatment of CDI. A strong recommendation to not use fecal microbiota transplantation was made in this population. We identified key knowledge gaps and suggested directions for future research. Conclusion We present a guideline for the prevention and treatment of CDI in children and adolescents with cancer and pediatric HSCT patients. Future research should include randomized controlled trials that involve children with cancer and pediatric HSCT patients to improve the management of CDI in this population

Baropodometria em indivíduos diabéticos e pré-diabéticos, com e sem neuropatia

Indivíduos diabéticos, principalmente aqueles que desenvolvem neuropatia periférica, são suscetíveis ao desenvolvimento de úlceras plantares relacionadas à neuropatia e ao aumento da pressão plantar na região anterior dos pés, decorrentes tanto da perda de sensibilidade quanto das deformidades nos pés, ambas associadas ao curso da doença. Indivíduos pré-diabéticos também apresentam risco em potencial para o desenvolvimento de neuropatias periféricas. A presente pesquisa teve como objetivo principal, estudar a distribuição da pressão plantar, através da baropodometria dinâmica, em um grupo de indivíduos diabéticos e um grupo de indivíduos pré-diabéticos (ambos com ou sem neuropatia periférica sensitivo motora ou autonômica cardíaca), em comparação à indivíduos controle. As variáveis baropodométricas foram comparadas entre os grupos e correlacionadas a fatores que podem interferir na distribuição da pressão plantar. O grupo diabético apresentou alteração na distribuição da pressão plantar, com aumento dos valores das variáveis picos de pressão plantar e integral da pressão versus o tempo nas regiões do mediopé, metatarsos e hálux, sem associação aos demais fatores intervenientes estudados, além de apresentar aumento do tempo de contato total do passo e do percentual do tempo de contato durante o passo na região do mediopé. O grupo pré-diabético apresentou um padrão similar ao diabético, em relação à distribuição da pressão plantar e aos demais parâmetros baropodométricos, exceto no tempo de contato total do passo que foi similar ao grupo controle. Conclui-se que indivíduos diabéticos sem deformidades nos pés, com e sem neuropatia periférica, apresentam alterações na distribuição da pressão plantar, e que os indivíduos pré-diabéticos já apresentam alterações similares às encontradas nos diabéticos.Subjects with diabetic disease, mainly that with peripheral neuropathy, are susceptible to develop plantar ulcers that could be associated with neuropathy or with the high plantar pressure values found in the plantar forefoot (midfoot, metatarsal heads and hallux) due the peripheral sensory loss and/or foot deformities that occurs as the developing of diabetes. Pre-diabetic subjects show a potential risk for peripheral neuropathy development, too. The main objective of this work was to study the plantar pressure distribution, through baropodometry access, in a group of diabetic and a group of pre-diabetic subjects (both the two groups with or without peripheral neuropathy or autonomic cardiac neuropathy) comparing to a group of healthy subjects. The baropodometric variables were compared among the three groups and correlated whit intervenient factors that could modify plantar pressure distribution. The diabetic group showed alterations in plantar pressure distribution with increased peak plantar pressures and pressure time integral at midfoot, metatarsal heads and hallux, without association whit other studied intervenient factors, and an increase in the total step time contact and percentage of contact time, during the roll over progress, in the midfoot. The pre-diabetic group presented a plantar pressure distribution pattern and baropodometric parameters similar to the diabetic group, excepting the total step time contact which was similar to the healthy group. This fact is been shown for the first time and points to a demand of interventions to pre-diabetic in order to prevent plantar injuries, like ulcers. In conclusion, diabetic subjects without foot deformities, with or without peripheral neuropathy show early modifications in plantar pressure distribuition and pre-diabetic sujtects can show modifications in plantar pressure distribution similar to those found in the diabetic subjects

Plantar thermography is useful in the early diagnosis of diabetic neuropathy

OBJECTIVES: This study evaluated plantar thermography sensitivity and specificity in diagnosing diabetic polyneuropathy using cardiac tests (heart rate variability) as a reference standard because autonomic small fibers are affected first by this disease. METHODS: Seventy-nine individuals between the ages of 19 and 79 years old (28 males) were evaluated and divided into three groups: control (n = 37), pre-diabetics (n = 13) and type 2 diabetics (n = 29). The plantar images were recorded at baseline and then minutes after a provocative maneuver (Cold Stress Test) using an infrared camera that is appropriate for clinical use. Two thermographic variables were studied: the thermal recovery index and the interdigital anisothermal technique. Heart rate variability was measured in a seven-test battery that included three spectral indexes (in the frequency domain) and four Ewing tests (the Valsalva maneuver, the orthostatic test, a deep breathing test, and the orthostatic hypotension test). Other classically recommended tests were applied, including electromyography (EMG), Michigan inventory, and a clinical interview that included a neurological physical examination. RESULTS: Among the diabetic patients, the interdigital anisothermal technique alone performed better than the thermal recovery index alone, with a better sensitivity (81.3%) and specificity (46.2%). For the pre-diabetic patients, the three tests performed equally well. None of the control subjects displayed abnormal interdigital anisothermal readouts or thermal recovery indices, which precluded the sensitivity estimation in this sample of subjects. However, the specificity (70.6%) was higher in this group. CONCLUSION: In this study, plantar thermography, which predominately considers the small and autonomic fibers that are commonly associated with a sub-clinical condition, proved useful in diagnosing diabetic neuropathy early. The interdigital anisothermal test, when used alone, performed best

The Burden of Mental Illness Among Survivors of Critical Care—Risk Factors and Impact on Quality of Life: A Multicenter Prospective Cohort Study

International audienceBackground: Survivors of critical care may demonstrate mental health disorders in the months after discharge. Research Question: What are risk factors for mental health disorders after ICU discharge and is there an association between the burden of mental illness and health-related quality of life (HRQoL)? Study Design and Methods: Multicenter prospective cohort study that included 579 adult ICU survivors with an ICU stay of > 72 h in 10 ICUs. Results: The outcomes were anxiety and depression assessed by the Hospital Anxiety and Depression Scale, posttraumatic stress disorder (PTSD) assessed by the Impact Event Scale 6, and HRQoL assessed by the Short Form 12 version 2. The 6-month prevalences of any mental health disorder were 36.2% (the prevalences of anxiety, depression, and PTSD were 24.2%, 20.9%, and 15.4%, respectively). ICU survivors with mental health disorders showed worse HRQoL scores in both physical and mental dimensions than those without. The higher the number of psychiatric syndromes manifested, the worse the mental dimension of HRQoL. Age of < 65 years (P = .009), history of depression (P = .009), anxiety (P = .003) and depression (P = .02) symptoms at ICU discharge, physical dependence (P = .01), and decreased physical functional status (P = .04) at 6 months were associated with anxiety. History of depression (P = .001), depression symptoms at ICU discharge (P < .001), and decreased physical functional status at 6 months (P = .01) were associated with depression. Depression symptoms at ICU discharge (P = .01), physical dependence (P = .01), and decreased physical functional status (P = .02) at 6 months were associated with PTSD. Interpretation: The network of potential risk factors for mental illness among patients discharged from an ICU is complex and involves multiple factors (age, premorbid mental health, acute emotional stress, and physical impairment after ICU stay). The negative impact of the burden of mental illness on HRQoL among critical care survivors is of concern

Statistical analysis plan for a cluster-randomized crossover trial comparing the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units (the ICU Visits Study)

Abstract Background Most adult intensive care units (ICUs) worldwide adopt restrictive family visitation models (RFVMs). However, evidence, mostly from non-randomized studies, suggests that flexible adult ICU visiting hours are safe policies that can result in benefits such as prevention of delirium and increase in satisfaction with care. Accordingly, the ICU Visits Study was designed to compare the effectiveness and safety of a flexible family visitation model (FFVM) vs. an RFVM on delirium prevention among ICU patients, and also to analyze its potential effects on family members and ICU professionals. Methods/design The ICU Visits Study is a cluster-randomized crossover trial which compares an FFVM (12 consecutive ICU visiting hours per day) with an RFVM (< 4.5 ICU visiting hours per day) in 40 Brazilian adult ICUs. Participant ICUs are randomly assigned to either an FFVM or RFVM in a 1:1 ratio. After enrollment and follow-up of 25 patients, each ICU is crossed over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome is the cumulative incidence of delirium measured by the Confusion Assessment Method for the ICU. Secondary and tertiary outcomes include relevant measures of effectiveness and safety of ICU visiting policies among patients, family members, and ICU professionals. Herein, we describe all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of this study. This pre-specified statistical analysis plan was written and submitted without knowledge of the study data. Discussion This a priori statistical analysis plan aims to enhance the transparency of our study, facilitating unbiased analyses of ICU visit study data, and provide guidance for statistical analysis for groups conducting studies in the same field. Trial registration ClinicalTrials.gov, NCT02932358. Registered on 11 October 2016