Parallels of diabetic foot infections antibiotic resistance at inpatient and outpatient stages of treatment

Introduction. The risk of infectious complications in patients with diabetic foot syndrome (DFS) is 25.2 to 58%, the risk of hospitalization among the patients with complications of DFI is 56 times, and the risk of amputation is 155 times higher than non-diabetics. Detection of the etiologic agent has a crucial role in effective treatment, prevention of dissemination of the infection, and avoiding amputation.Aim of the study: to analyze the specific characteristics of the severe diabetic foot infection and antibiotic resistance of the pathogens during the inpatient and outpatient stages of treatment.Materials and methods. We included 62 type 2 diabetic inpatients (38 male and 24 female, group 1) with severe foot infection in to the study. 102 diabetic foot outpatients (56 male and 46 female, group 2) with postoperative wounds were included after discharged from the hospital. Cultures were obtained after surgery interventions immediately and on 14 days of hospitalization in group 1 of patients and in group 2 of patients with clinical signs of infection. Microbe species and resistant of pathogens to antibiotic were assessed.Results. There were prevalence of multidrug resistant Staphilococcus aureus (MRSA), Enterobacterales and Acinetobacter baumannii both outpatient and inpatient stages of diabetic foot infections treatment. The multidrug resistant pathogens were associated with ineffective empiric antibiotic therapy, delay of wound healing and amputations. The presence of multidrug resistant pathogens should be expected in cases of wound size more than 18 sm2, history of diabetic foot amputations, chronic osteomyelitis and time before wound professional care more than 14 weeks.Conclusion. The multidrug resistant pathogens were the main risk factor of amputations in diabetic foot inpatients with severe infections. At the outpatient stage of treatment multidrug resistant pathogens along with chronic osteomyelitis lead to delay of wound healing and new cases of foot amputations in diabetic patients

Practical aspects of initiation and use of SGLT2 inhibitors: inpatient and outpatient perspectives

In today`s therapy of type 2 diabetes mellitus, SGLT2 inhibitors have taken their rightful place both due to their positive hypoglycemic and outstanding cardiorenometabolic effects. Recent randomized clinical trials, such as DAPA HF, EMPEROR-Reduced and EMPEROR-Preserved, show the benefits of their use in the treatment of patients with chronic heart failure without regard to the status of type 2 diabetes mellitus and so significantly expands the range of use of SGLT2 in the practice of doctors of various specialties. This review presents not only the results of the most significant studies of SGLT2 inhibitors, but also the main approaches to the starting therapy with this class of drugs in various clinical situations, both inpatient and outpatient. In addition, potential adverse events and limitations associated with the use of SGLT2 inhibitors are discussed in detail, which must be taken into account when prescribing in particular patient. The practical aspects of SGLT2 inhibitors` prescription are considered separately through the prism of their safe use in the perioperative and postinfarction periods, as well as during other special conditions. Particular attention is paid to the monitoring of physical and general examination data and laboratory instrumental tests, the consideration of which will minimize adverse events and best benefit for many cardiological, endocrinological and nephrological patients

Inhibitors of the sodium-glucose transporter type 2 and new possibilities for managing vascular age in patients with type 2 diabetes mellitus

The article discusses the pathophysiological mechanisms of the development of vascular aging as a combination of the influence on the  body of  genetic, environmental, regulatory, metabolic and other factors causing biochemical, enzymatic and cellular changes in the arterial vascular bed. The concept of “early vascular aging” and “healthy vascular aging” is defined depending on the ratio of the biological and chronological age of the vessels. The role of diabetes mellitus in increasing vascular stiffness, early vascular aging, as well as the  progression of  atherosclerotic cardiovascular diseases and their complications is considered in detail. Approaches to multifactorial management of vascular age in patients with type 2 diabetes (lifestyle modification with strategy of aggressive treatment of modifiers of atherosclerosis, rejection of bad habits, adherence to dietary recommendations and the use of modern organo- and vasoprotective antidiabetic drugs) are revealed. The mechanism of realization of vasoprotective effects of inhibitors of sodium-glucose transporter-2 (iNGLT-2) is described in detail. The results of completed large random ized trials EMPA-REG Outcome and EMPA-REG BP of the most studied representative of the IGLT-2 group, empagliflozin, are presented. It has been shown that due to their glucose and natriuretic effects, the ability to reduce body weight and blood pressure, improve myocardial metabolism and bioenergetics, decrease the activity of the sympathetic nervous system, as well as positive effects on vascular stiffness, NGLT-2 inhibitors are the drugs of choice in patients with type 2 diabetes mellitus (T2DM) and cardiovascular diseases. This makes it possible to widely use this group of drugs for managing the vascular age of patients and represents a new opportunity in the prevention of vascular aging in T2DM

Triple therapy in a single inhaler for chronic obstructive pulmonary disease: clinical studies and case report (real practice)

Algorithms for de-escalation of basic therapy, including the abolition of inhaled corticosteroids (ICS), in patients with chronic obstructive pulmonary disease (COPD), as well as the development of clear criteria for prescribing triple therapy in clinical practice remain the subject of numerous studies and discussions. The given case report of managing a patient with a long experience of smoking and severe COPD demonstrated an unsuccessful experience of de-escalation of therapy with the abolition of ICS due to concerns about the fact of pneumonia. The dual bronchodilator therapy prescribed in accordance with modern recommendations was insufficiently effective in preventing exacerbations, and the stabilization of the patient’s condition was observed after the appointment of a fixed triple combination of drugs in a single inhaler (VI/UMEC/FF), which contains vilanterol (VI), umeclidinium bromide (UMEC) and ICS fluticasone furoate (FF). An additional contribution to ensuring clinical success was made by such factors as strict compliance with medical prescriptions by the patient, smoking cessation and compliance with recommendations for maintaining physical activity, compliance with a strict self-isolation regime during the pandemic, which reduced the risks of respiratory viral infections. Additional clinical predictors of the effectiveness of ICS in COPD were the bronchitis type, the persistence of symptoms and the recurrence of exacerbations of the disease after discontinuation of the drug, the level of blood eosinophilia. When deciding whether to prescribe or cancel triple therapy, it is recommended to take into account the data on the effect of ICS on improving the functional parameters and clinical course of the disease with a decrease in symptoms, on reducing the risk of exacerbations, on increasing patient survival and a positive prognosis during COPD

Decrease of cardiovascular risk in patients with type 2 diabetes: review of the common strategies and clinical studies

Military Medical Academy of S.M. Kirov, Saint-Petersburg, Russia Recent clinical trials about the cardiovascular safety of empagliflozin and liraglutide demonstrated a convincing lowering effect on mortality from cardiovascular causes among the patients with type 2 diabetes. These findings resulted in many questions about why this phenomenon was seen in two drugs with widely different mechanisms of functioning. It is important to note that the glucose-lowering effect was moderate, although a feature seen in both empagliflozin and liraglutide was their ability to increase insulin sensitivity. In many fundamental studies, this feature was associated with a reduction of cardiovascular risks. Insulin resistance, which has always been a pathophysiological base for the development of cardiovascular disease in patients with type 2 diabetes, is a topic for this report. Different methods to manage insulin resistance, including lifestyle changes, drug treatment and metabolic surgery, are discussed. Furthermore, the most common features of glucose-lowering drugs are analysed, including protective effects for cardiovascular outcomes in patients with type 2 diabetes presented in randomised clinical trials. Studies include the United Kingdom Prospective Diabetes Study (UKPDS), PROspective pioglitAzone Clinical Trial In macroVascular Events (PROactive), Insulin Resistance Intervention After Stroke (IRIS), Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) and the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME). The current study shows that the potential to reduce the risk of cardiovascular disease is determined not only by effective lowering of glucose but also by the ability to lower insulin resistance, which causes a paradigm shift in the management of type 2 diabetes

Сarbohydrate metabolism disorders and their outcomes in the long-term period in hospitalized patients with COVID-19

BACKGROUND: Diabetes mellitus (DM) is a predisposing factor for the development of many infectious complications. Numerous studies have demonstrated the association of hyperglycemia in patients having DM with a high risk of a more unfavorable course of COVID-19. However, hyperglycemia is often detected in patients with a COVID-19 not having anamnesis of DM. The following remains unclear: the etiological factors causing such disorders of carbohydrate metabolism, the persistence of these disorders and the characteristics of the course, as well as their comparative effect on the outcomes of COVID-19 and the further prognosis of patients.AIM: To study the prevalence and nature of carbohydrate metabolism disorders in patients with moderate to severe course of COVID-19, as well as 6 months after it.MATERIALS AND METHODS: Hospitalized patients with a confirmed diagnosis of COVID-19 of moderate and severe course of the disease were examined. There were no medical interventions outside recommendations of patient management. The observation was carried out during two time periods: inpatient treatment of a COVID-19 and 6 months after discharge. The following were evaluated: anamnesis data, the level of fasting plasma glucose; HbA1c, the results of computed tomography of the lungs, the drug therapy taken in all patients. Descriptive statistics methods were used to evaluate the parameters.RESULTS: The study included 280 patients with a median age of 61.5±14,2 years. During the disease, a violation of  carbohydrate metabolism was detected in 188 people (67%), the remaining patients (33%) made up the normoglycemia group. Patients with hyperglycemia were stratified in a following way: a group with an established diagnosis of DM before COVID -19 included — 56 people (20%), a group with steroid-induced hyperglycemia (SIH) — 95 people (34%), a group of stress- induced hyperglycaemia — 20 people (7%), with undiagnosed diabetes — 17 people (6%). In the postcovid period (after 6 months), the normal level of glycemia in the same sample group was observed in 199 people (71.4%); 8 people (3%) were diagnosed with new cases of DM. The mortality rate was 10 people (3.6%) in the group of SIH (8 people) and undiagnosed DM (2 people).CONCLUSION: The use of glucocorticoids in hospitalized patients with COVID-19 leads to high incidence of SIH, which has reversible character. About 6% among hospitalized patients with a COVID-19 had undiagnosed DM and were not receiving antihyperglycemic therapy. The highest mortality was noted in the group of SIH, which allows us to conclude that SIH worsens the prognosis of patients to the greatest extent. Patients with newly diagnosed hyperglycemia, regardless of the level of hyperglycemia, are characterized by a more unfavorable course

Impairment of microvascular blood flow in patients with type 2 diabetes and cardiovascular autonomic neuropathy

BACKGROUND: Diabetic autonomic neuropathy is the reason for early morbidity and mortality on diabetic patients. The pathology not only cardiac innervation but microvascular is presented.AIMS: We estimated the parameters of skin microvascular blood flow in accordance with cardiovascular autonomic neuropathy (CAN) staging in diabetic patients. We also assessed other risk factors of CAN in patients with diabetes.MATERIALS AND METHODS: We included 76 patients with type 2 diabetes in the study (24 patients with resent-onset diabetes and/or diabetes without microvascular complications, 26 with diabetic sensorimotor neuropathy (SMN) and 26 with SMN and previous history of diabetic foot amputation). The SMN was diagnosed on the basis of patients complaints, anamnesis and data of clinical neurological examinations. CAN was detected using several cardiovascular autonomic reflex tests (CART) as a gold standard of diagnosis: the tilt-table test, a deepbreathing and Valsalva Maneuver, handgrip test, cold-stress vasoconstriction. According to the Toronto Diabetic Neuropathy Expert Group Recommendation all patients was separated on the groups: CAN 0 (all CARTs were normal), CAN 1 (possible/early CAN — one abnormal CART was presented), CAN 2 (definite/confirmed CAN –at least two abnormal CARTs were found), CAN 3 (severe/advanced CAN — in the cases of orthostatic hypotension in addition to CARTs abnormalities). Microvascular blood flow of skin at the nail roller of fingers skin was valuated at rest as well as in functional cold test by the method of High-frequency Ultrasonic Dopplerography using the “Minimax Doppler K” device (LLC JV “Minimax”, St. Petersburg, Russia).RESULTS: CAN 1 was found in 8% diabetic patients without microvascular complications, 42 and 21% patients with SMN and diabetic foot amputations respectively. CAN 2 was diagnosed in 27% patients with SMN and 58% patients history of diabetic foot amputations. CAN 3 in 8% and 19% cases in patients with SMN and history of diabetic foot amputations respectively. The parameters of microvascular blood flow at rest were significantly decreased in patients with confirmed/severe CAN in comparison with early staging of CAN and patients without CAN (Vm=2.5±0.66 sm/sec vs. 4.4±0.54 sm/sec and 5.1±1.01 sm/sec respectively; p=0.0033). The abnormal result of cold test was detected in 94% patients with confirmed/ severe CAN and 26% patients with CAN 1.CONCLUSIONS: This investigation has demonstrated in a cohort with type 2 diabetes patients with/without SMN and with/ without history of previously foot amputations that decrease the Vm (the variable of microvascular blood flow assessed by High-frequency Ultrasonic Dopplerography) lower than 2.4 sm/sec is associated with 6.4 times increased likelihood of confirmed/severe CAN as well as positive cold test result. That the patients with positive cold test results were 28.6 times more likely have confirmed/severe CAN

SGLT2 inhibitors and kidneys: mechanisms and main effects in diabetes mellitus patients

Type 2 diabetes mellitus (T2DM) is the cause of the development of diabetic nephropathy — a complication that determines the high degree of disability and mortality of such patients. Until recently, approaches to normalizing glucose levels did not have a significant possibility of influencing the outcome of kidney damage in diabetes. Type 2 sodium glucose cotransporter inhibitors (SGLT2) are a new class of glucose-lowering drugs that improve glycemic control due to an insulin-independent mechanism of action associated with increased urinary glucose excretion. The review provides an analysis of the results of studies on the assessment of nephroprotective actions — one of the pleiotropic actions of this drugs group. These materials show the properties of SGLT2 inhibitors to reduce the risk of developing and the progression of albuminuria, to save glomerular filtration rate, to reduce the frequency of end-stage renal disease and the need for renal replacement therapy in patients with T2DM. The article gives and analyzes the currently existing hypotheses of the mechanism of action of these glucose-lowering drugs. The risk of the most common renal complications with the use of SGLT2 inhibitors is considered. The practical aspects of the use of SGLT2 inhibitors in modern algorithms for the care of patients with T2DM are indicated, as well as the prospects for new randomized clinical trials

Multiple effects of bariatric surgery on human biochemical status

Beneficial effect of bariatric surgery is expressed not only in reducing body weight, but also in improving the functioning of the body as a whole. On the one hand, numerous studies devoted to the investigations of specific mechanisms of the influence of bariatric surgery on the general condition of an organism testify to the enormous interest of scientists in this problem. On the other hand, the range of changes is so vast that it covers almost all physiological and biochemical processes. The most noticeable response to bariatric surgery is from the digestive (including the composition of the microbiota), immune (reducing the level of systemic and local inflammation), cardiovascular (reducing the risks of atherosclerosis and other diseases) systems. Partial or complete compensation of type 2 diabetes mellitus and metabolic syndrome also occurs. Among the variety of data, there is insufficient research on only standard biomarkers: leptin, C-reactive protein, interleukin 6, etc. A detailed study of the profiles of both circulating biomarkers and local ones is necessary. At the same time, it is obligate to continue to accumulate evidence on the positive effect of bariatric surgery, since this type of surgical intervention has come into practice relatively recently. Unfortunately, at the present time in Russia bariatric surgery is not an affordable and popular treatment for morbid obesity (MO). Nevertheless, it is extremely important to change the current situation, since bariatric treatment is an optimal and effective solution to socially significant diseases such as MO or type 2 diabetes mellitus

Применение кислородно-гелиевой газовой смеси «ГелиОкс» для лечения дыхательной недостаточности у пациентов с новой коронавирусной инфекцией COVID- 19 (рандомизированное одноцентровое контролируемое исследование)

Introduction. Treatment of respiratory failure in pneumonia caused by coronavirus infection (COVID-19) is still an unsolved problem that requires a comprehensive approach and the development of new methods that expand the range of possibilities of modern therapy. There is evidence that the heated oxygenhelium mixture has a positive effect on gas exchange in the infiltration zone by improving both ventilation and diffusion.AIM of study. To evaluate the effectiveness of the inclusion of a heated oxygen-helium mixture HELIOX (70% Helium/ 30% Oxygen) in the complex intensive care of respiratory failure of pneumonia caused by SARS-CoV-2 infection.Material and methods. The study included 60 patients with confirmed viral pneumonia caused by COVID-19. The patients were randomized into two groups: group 1 (n=30) — patients who were treated with the standard COVID-19 treatment protocol with the heated oxygen-helium mixture HELIOX, and group 2 (control) (n=30) — patients who received standard therapy. Lethality was studied for 28 days, the time in days until a steady increase in SpO2>96% was achieved when breathing atmospheric air; the time until the patient is transferred from the intensive care unit (ICU) to the general department.Results. Inhalation of the HELIOX mixture (70% Helium / 30% Oxygen) resulted in a faster recovery of the hemoglobin oxygen saturation index (SpO2). Starting from day 3, these differences became statistically significant. The time in days from inclusion in the study to a persistent increase in the degree of oxygen saturation of hemoglobin (SpO2>96%) when breathing atmospheric air in the group with inhalation of the HELIOX mixture was less — 8 (7; 10), compared to 10 (8;13) in the control group (p=0.006). In the group with inhaled HELIOX mixture, the median treatment time in the ICU was 8 (7; 9.5) days vs 13 (8; 17) days (p<0.001) in the comparison group.Conclusions. Inhalation of the HELIOX mixture (70% Helium / 30% Oxygen) led to a faster recovery of the hemoglobin oxygen saturation index SpO2, which contributed to reduction in the duration of oxygen therapy and a decrease in mortality.Актуальность. Лечение дыхательной недостаточности при пневмонии, вызванной коронавирусной инфекцией (COVID-19), пока еще нерешенная проблема, требующая комплексного подхода и разработки новых методов, расширяющих диапазон возможностей современной терапии. Есть данные, что подогреваемая кислородно-гелиевая смесь оказывает положительное действие на газообмен в зоне инфильтрации за счет улучшения как вентиляции, так и диффузии.Цель исследования. Оценить эффективность включения подогреваемой кислородно-гелиевой смеси «ГелиОкс» (70% гелий/ 30% кислород) в комплексную интенсивную терапию дыхательной недостаточности пневмонии, вызванной инфекцией SARS-CoV-2.Материал и методы. В исследование были включены 60 пациентов с подтвержденной вирусной пневмонией, вызванной COVID-19. Пациенты были рандомизированы на две группы: 1-я группа (основная, n=30) — пациенты, которым в стандартный протокол лечения COVID-19 включена терапия подогреваемой кислородно-гелиевой смесью «ГелиОкс»; 2-я группа (сравнения, n=30) — пациенты, получавшие стандартную терапию. Исследовали летальность в течение 28 суток, время в сутках до стойкого достижения повышения насыщения гемоглобина кислородом (SpO2) более 96% при дыхании атмосферным воздухом; время до перевода пациента из отделений реанимации и интенсивной терапии в отделения общего профиля.Результаты. Введение в алгоритм лечения больных с COVID-19 курса ингаляции смесью «ГелиОкс» (70% гелий / 30% кислород) приводило к более быстрому восстановлению показателя насыщения гемоглобина кислородом (SpO2). Начиная с 3-х суток эти различия становились статистически значимыми. Время в сутках от включения в исследование до стойкого достижения повышения SpO2 более 96% при дыхании атмосферным воздухом в группе с ингаляцией смеси «ГелиОкс» было статистически значимо меньше — 8 (7; 10) суток против 10 (8; 13) в группе сравнения (р=0,006). Медиана времени лечения в отделении реанимации и интенсивной терапии при использовании смеси «ГелиОкс» также оказалась статистически значимо меньше и составила 8 (7; 9,5) суток против 13 (8; 17) (р<0,001) в группе сравнения.Заключение. Ингаляция смеси «ГелиОкс» (70% гелий / 30% кислород) приводит к более быстрому восстановлению насыщения гемоглобина кислородом (SpO2), что способствует сокращению сроков кислородотерапии и снижению летальности