RSS 1.0UHDB Division of Medicine
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End-of-life care in a major UK trauma centre.OBJECTIVES: Death occurs within the emergency department (ED) sadly not infrequently. There is limited evidence exploring the demographics of these patients and the experience they have in the ED when they die or are approaching the end of life (EOL). METHODS: A retrospective review of patients aged 18 years and over who died in our major trauma centre was conducted. Data collected included demographics, frailty scores, time of arrival, time of death, time of EOL decision, cause of death in the ED and who wrote do not attempt cardiopulmonary resuscitation (DNACPR) forms. RESULTS: From January to December 2023, 326 patients died in the ED. 76% of patients were aged 65 years or over, with 69% having a clinical frailty score of 5 or more. The average time from arrival to death was 5 hours 56 min, with the average time from EOL decision to death being 1 hour and 53 min. 60% of all patients had a DNACPR, with 75% of those being written by ED clinicians. CONCLUSION: EOL is becoming ever more important in the ED. Further work is needed to see if our local experience matches other EDs.
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Clinical Presentation, Diagnostic Delays, and Treatment Outcomes in Postural Orthostatic Tachycardia Syndrome (POTS): An Observational Case Series Study in a Single-Centre District General Hospital.BACKGROUND: Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous disorder of autonomic regulation characterised by unexplained orthostatic tachycardia in the absence of postural hypotension. POTS is a complex and challenging diagnosis owing to the non-specific nature of the presentations, which frequently overlap with other medical conditions. There is limited availability of data and research describing the spectrum of clinical presentations, diagnostic pathways, comorbidities, and management outcomes. This study aims to describe the above in a single-centre district general hospital setting. METHODS: We conducted a retrospective case series study of 37 patients diagnosed with POTS at Queen's Hospital Burton (QHB) between August 2023 and August 2024. We used electronic health records to acquire relevant data. This included demographics, presenting complaints, associated conditions, time to diagnosis, specialist involvement, management strategies, and treatment outcomes. 'Time to diagnosis' was defined as the period between the first symptom onset and obtaining a confirmed diagnosis with a positive tilt-table test. Microsoft Excel (Redmond, USA) was utilised for descriptive statistical analysis. RESULTS AND CONCLUSION: The cohort was predominantly female (n = 36, 97%) with a mean age of 28.2 years (SD, 8.3; range, 18-48). The most common presenting complaints were presyncope (49%) and presyncope with syncope (41%). These were often associated with palpitations and chest discomfort. Systemic conditions coexisting with POTS included anxiety/depression, hypermobility spectrum disorders (notably Ehlers-Danlos Syndrome), fibromyalgia, autoimmune diseases, and migraine. The median time to diagnosis was one year (IQR 1-4). However, delays of up to 20 years were observed. Speciality referrals involved cardiology (65%), neurology (13%), and internal medicine (10%). Management strategies included non-pharmacological therapy alone (19%), additionally pharmacological monotherapy (62%), and combination therapy with multiple drugs (19%). Symptomatic improvement was reported in 65% overall, with the highest rates observed in the multi-drug therapy group. This study highlights the demographic profile, burden of comorbidities, and diagnostic challenges in patients with POTS. Our single-centre study has demonstrated meaningful progress towards reducing the average time to diagnose POTS with varying treatment outcomes across therapeutic strategies. Multi-drug therapy in conjunction with non-pharmacological therapy proved to be the most efficacious in this cohort. These findings emphasise the importance of early recognition, streamlined referral pathways, and the need for further large-scale multi-centre research into patient-tailored, evidence-based management of POTS.
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Temporal Trends in Cardiometabolic Control Among Canadian Adults: A Comparative Analysis of Hypertension and Diabetes Using the Canadian Health Measures Survey (CHMS) 2008-2019.BACKGROUND: Hypertension and diabetes remain major contributors to cardiovascular morbidity and mortality in Canada. Monitoring their trends is critical to evaluating public health progress in prevention and disease management. OBJECTIVE: To descriptively summarize published Canadian Health Measures Survey (CHMS) estimates on the prevalence, awareness, treatment, and control of hypertension and diabetes among Canadian adults aged 20-79 years across the 2008-2019 survey cycles. METHODS: Descriptive analysis was conducted using aggregated CHMS combined-cycle data (2008-2011, 2012-2015, and 2016-2019). Weighted proportions and absolute counts published by Statistics Canada were organized and analyzed in Stata version 18. Data were stratified by sex and age group, and graphical visualization was applied to highlight temporal and demographic patterns. RESULTS: Hypertension prevalence remained stable over time, accompanied by modest improvements in treatment and control rates. Conversely, diabetes prevalence continued to rise, with limited gains in glycemic control. These patterns suggest differential progress in managing cardiometabolic conditions among Canadian adults. CONCLUSION: National strategies appear to have improved hypertension outcomes but less effectively addressed diabetes control. Strengthening preventive interventions, enhancing primary care integration, and improving access to chronic disease management resources remain essential for advancing cardiometabolic health in Canada.
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Clinical Profile, Endoscopic Findings, and Outcomes Among Inpatients With Upper Gastrointestinal Bleeding in a United Kingdom District General Hospital.Background Acute upper gastrointestinal bleeding (AUGIB) is a medical emergency associated with significant morbidity and mortality. Prognosis and management are typically determined by the patient's clinical features and findings on endoscopy. Objective This study aimed to evaluate the demographic characteristics, risk stratification, endoscopic findings, and therapeutic interventions in patients presenting with AUGIB at Queens Hospital, Burton, United Kingdom, in 2024. Methods A retrospective analysis was performed of all inpatients who underwent upper gastrointestinal endoscopy for hematemesis and/or melena from January to December 2024. Data on demographics, Glasgow-Blatchford Score (GBS), hemodynamic status, endoscopic diagnoses, interventions, and outcomes were obtained from electronic medical records and analyzed using SPSS Version 23 (IBM Corp., Armonk, NY, USA). Results Sixty-four patients (mean age 72.1±15.8; 71% male) were included. Nonvariceal bleeding accounted for 92% of cases, with duodenal ulcers (17%) and gastric ulcers (11%) as leading etiologies. All patients were risk-assessed using the GBS on admission. Twenty-five percent of patients with nonvariceal bleeding required therapeutic endoscopy, primarily using dual or triple modalities. Variceal bleeds (8%) were managed with terlipressin, antibiotics, and band ligation based on endoscopic grade. Re-bleeding occurred in 3.1% of patients, necessitating further interventions. Conclusion AUGIB predominantly affected elderly males, with nonvariceal etiologies, particularly peptic ulcers, being most common. Universal risk stratification and timely endoscopic intervention in line with best practices helped improve outcomes. The study recorded a low re-bleeding rate.
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Association Between Gut Microbiota Diversity and Body Mass Index (BMI) in Healthy Young Adults in the United States: Insights Into the Gut-Brain-Metabolic Axis Using the Curated Metagenomic Data.BACKGROUND: Emerging evidence suggests that gut microbiota diversity plays a critical role in metabolic regulation and may influence body mass index (BMI). However, findings in healthy populations remain inconsistent. OBJECTIVE: This study aims to determine whether gut microbiota alpha-diversity is associated with BMI among healthy young adults aged 18-39 years in the United States and to explore potential implications for the gut-brain-metabolic axis. METHODS: This cross-sectional study utilized publicly available metagenomic data from the CuratedMetagenomicData repository. After preprocessing in R version 4.5.0 (R Foundation for Statistical Computing, Vienna, Austria), data were analyzed using Stata version 18 (Released 2023; StataCorp LLC, College Station, TX). Alpha-diversity indices (Shannon, Simpson, and Richness) were computed and examined across BMI categories (normal, overweight, and obese) using one-way analysis of variance (ANOVA) and chi-square tests. Linear regression models were employed to assess associations between BMI and diversity measures, adjusting for age and gender. RESULTS: Among 147 participants, BMI differed significantly across weight categories (p < 0.001), but no significant association was observed between Shannon diversity and BMI (p = 0.527). Age emerged as the only significant predictor of BMI in adjusted models (p < 0.001). CONCLUSION: Gut microbial alpha-diversity was not significantly associated with BMI among healthy young adults. Functional microbial characteristics, rather than diversity alone, may better explain variations in metabolic status.
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Diabetes and Technology - an Update for the General Physician.Diabetes is a growing public health concern. Approximately 20% of acute NHS hospital beds are occupied by individuals with diabetes. Following the recent NICE (National Institute for Health and Care Excellence) updates, diabetes technologies are increasingly available in the NHS. Despite the benefits, they present challenges. e.g., unfamiliarity, insufficient education, and lack of confidence of general physicians who are increasingly likely to encounter people using these technologies, presenting with acute illnesses. This review aims to update the general physicians with diabetes technologies such as continuous glucose monitors, insulin pumps, hybrid closed loop system and how to troubleshoot in acute illnesses, diabetes emergencies, perioperative management and radiological investigations. While it is important to develop consistent inpatient-care pathways and out-of-hours support from diabetes teams, it is vital to enhance the knowledge and confidence of non-diabetes physicians. Further research is warranted to support the use of technology in inpatient settings and diabetes emergencies.
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An ethnographic study of pharmacist prescribers' competencies, collaboration, and barriers in hospital settings.OBJECTIVES: This ethnographic study explores hospital pharmacist prescribing practices in an inpatient multidisciplinary team (MDT) setting. This study aimed to identify the underlying mechanisms, including competencies, facilitators, and inhibitors, related to pharmacist prescribing practices in hospital settings. METHODS: Non-participant observations were conducted over six half-day sessions with three experienced prescribing pharmacists. Data were analysed using framework and thematic analysis. The RPS Competency Framework guided framework analysis, while thematic analysis identified overarching themes related to emotional intelligence and hierarchical dynamics. KEY FINDINGS: Key competencies frequently observed included interpreting patient records and collaborating with MDT members. Facilitators of effective prescribing included strong interdisciplinary collaboration and access to comprehensive patient information. Barriers such as fragmented IT systems, high workloads, and hierarchical constraints affected the pharmacists' ability to efficiently manage and document patient care. Emotional intelligence was identified as a critical skill for managing professional identity within hierarchical structures and handling the emotional toll of systemic inefficiencies. CONCLUSIONS: Pharmacist prescribers significantly enhance patient care through collaboration and proactive engagement in MDTs. However, systemic barriers, particularly IT-related inefficiencies and hierarchical dynamics, limit their full potential. Training in emotional intelligence and improved interdisciplinary support may enhance the effectiveness of prescribing pharmacists. Addressing systemic issues, especially IT infrastructure, could optimize prescribing efficiency and reduce cognitive load.
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Preventing kidney injury using carbon dioxide (KID trial): trial protocol for a multicentre randomised controlled trial.INTRODUCTION: Peripheral arterial disease (PAD) commonly coexists with chronic kidney disease (CKD). Patients with symptomatic PAD often require endovascular revascularisation to relieve pain or salvage limbs. However, the iodinated intra-arterial contrast routinely used in these procedures is nephrotoxic, placing patients with CKD at increased risk of acute kidney injury (AKI) and long-term renal decline. Carbon dioxide (CO₂) delivered via automated injection is a potential alternative imaging contrast medium. This trial will evaluate whether using CO₂ instead of iodinated contrast reduces the risk of AKI and short-term renal function decline in this high-risk group. METHODS AND ANALYSIS: This is a multicentre, open-label, prospective randomised controlled trial across six secondary-care National Health Service (NHS) vascular surgery centres. A total of 174 patients with PAD and CKD undergoing endovascular intervention will be randomised 1:1 to receive iodinated contrast (standard of care) or CO₂ via automated injector (Angiodroid). All perioperative care will follow local NHS protocols.The primary outcome is log serum creatinine at 2, 30 and 90 days postprocedure. Key secondary outcomes include: incidence and severity of AKI within 48 hours postprocedure, major adverse kidney events (death, dialysis or >25% estimated glomerular filtration rate decline) by 90 days, inpatient length of stay, procedural pain, quality of life, procedural success, reinterventions, acceptability and feasibility (patient/practitioner questionnaires) of using CO2, and cost-effectiveness (healthcare resource use analysis). A mixed-methods process evaluation will be undertaken with patients and clinicians. ETHICS AND DISSEMINATION: The trial has been approved by an NHS ethical review committee (24/WA/0332) and patients have been involved in trial design. Findings will be disseminated to participants, clinicians and the wider public through patient groups, lay summaries, social media, conferences, peer-reviewed journals and NHS policy channels. TRIAL REGISTRATION NUMBER: ISRCTN23564393.
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Association Between Metabolic Dysfunction-Associated Steatotic Liver Disease and Sarcopenia: A Systematic Review and Meta-analysis.This systematic review and meta-analysis evaluated the prevalence of sarcopenia in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) compared to controls. A comprehensive search across PubMed, Embase, Cochrane Library, and Web of Science databases was conducted from January 2015 to August 2025, identifying studies that compared the prevalence of sarcopenia between MASLD patients and non-MASLD controls. Sixteen studies comprising diverse populations from Korea, China, the United States, Italy, the Netherlands, and the United Kingdom were included, with sample sizes ranging from 57 to 18,815 participants. Sarcopenia assessment methods varied across studies, including dual-energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA), computed tomography (CT), and functional tests. Statistical analyses were performed using RevMan 5.4 (The Cochrane Collaboration, London, England, UK) with random-effects models to calculate pooled odds ratios (ORs). The meta-analysis revealed a significantly higher prevalence of sarcopenia in MASLD patients (14.86%) compared to controls (6.49%), with a pooled OR of 2.24 (95% CI: 1.74-2.89, p < 0.001). Substantial heterogeneity was observed (I² = 95%) across studies. Subgroup analyses demonstrated stronger associations in cohort studies versus cross-sectional studies, in populations under 50 years of age, and in studies from Korea and the United States. The bidirectional relationship between MASLD and sarcopenia is supported by shared pathophysiological mechanisms, including insulin resistance, chronic inflammation, and altered protein metabolism. These findings suggest that MASLD patients should undergo routine sarcopenia screening, and interventions targeting muscle health may benefit both conditions. The substantial burden of sarcopenia in MASLD patients highlights the need for integrated management approaches addressing both hepatic and muscular manifestations.
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Continuous glucose monitoring and microvascular complications in diabetes: Bridging glycemic metrics with clinical outcomes.Continuous glucose monitoring (CGM) has emerged as a complementary and more dynamic method for evaluating glycemic control in people with diabetes. Relevant studies examining the association between CGM parameters, including time in range (TIR), glycemic variability (GV), and time in tight range (TITR), and diabetic nephropathy, retinopathy, and neuropathy, were reviewed. Evidence consistently demonstrates that lower TIR and TITR, as well as higher GV, are associated with increased risk and severity of microvascular complications in both type 1 and type 2 diabetes. Studies employing corneal confocal microscopy and sudomotor function testing further support these associations for small-fibre neuropathy. Although CGM-guided therapy improves TIR and GV, data directly linking optimisation of these metrics to reduced complication rates remain limited. Most available studies are cross-sectional or retrospective, with short CGM durations and heterogeneous methodologies. CGM-derived indices provide valuable insights into glycemic quality beyond HbA1c and may serve as complementary tools for early risk stratification and individualised management of diabetic microvascular disease. However, prospective and interventional trials are required to confirm whether improving CGM metrics can translate into clinically meaningful reductions in microvascular morbidity. Broader access to CGM and standardisation of its key metrics will be essential to fully realise its potential in modern diabetes care.
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Carcinoid Heart Disease Revealing the Burden of a Neuroendocrine Tumour: A Case Report.Carcinoid heart disease (CHD) is a rare but serious complication of carcinoid syndrome (CS), typically arising in patients with metastatic neuroendocrine tumours (NETs). Prolonged exposure of the right side of the heart to vasoactive substances such as serotonin leads to progressive valvular fibrosis, predominantly affecting the tricuspid and pulmonary valves, and often culminates in right-sided heart failure. We report the case of a 67-year-old woman with a metastatic small bowel NET who developed CS and later presented with worsening exertional dyspnoea and peripheral oedema. Echocardiography demonstrated severe tricuspid regurgitation and moderate pulmonary regurgitation with preserved left ventricular systolic function. Despite aggressive diuretic therapy, her condition deteriorated, and she developed refractory right-sided heart failure with generalised anasarca. She was not a candidate for valve replacement or further disease-directed therapy due to advanced metastatic disease and frailty and was therefore managed palliatively until she passed away. This case highlights the severe burden of CHD in patients with serotonin-secreting NETs and emphasises the importance of early recognition and regular echocardiographic surveillance to facilitate timely intervention and potentially improve outcomes.
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Quality improvement project to enhance adherence to RCEM standards for patients with paracetamol overdose.BACKGROUND: Delayed or inconsistent administration of N-acetylcysteine (NAC) for paracetamol overdose in the emergency department (ED) poses a risk to patient safety, with current Royal College of Emergency Medicine (RCEM) standards often not being met. The traditional 21-hour NAC regimen is associated with adverse drug reactions, medication errors and prolonged admissions. The Scottish and Newcastle Acetylcysteine Protocol (SNAP) was introduced as a simpler alternative with comparable efficacy. This quality improvement project (QIP) aimed to improve compliance with RCEM standards by implementing targeted interventions while also reducing the length of inpatient stay and maintaining patient safety. METHOD: This QIP was conducted at Royal Derby Hospital using a multidisciplinary, systematic approach based on Plan-Do-Study-Act cycles. Baseline data were collected from 100 randomly selected patients (November 2021-May 2022) and compared with outcomes during a 52-week intervention period (September 2023-August 2024). Interventions included educational sessions, quick reference materials and enhanced prescribing tools. Data were analysed for compliance with RCEM standards, adverse events (liver function derangement and anaphylactoid reactions) and system-level measures, such as length of inpatient stay and timing of paracetamol plasma levels. RESULTS: A total of 214 patients were included. Compliance with RCEM standard 1 improved from 36% to 43%. No change was noted for standards 2 and 3. Median inpatient stay decreased from 35 hours to 30.5 hours. No significant differences were found in adverse events. Special cause variation was identified in paracetamol plasma level timing, attributed to early sampling in some cases. CONCLUSION: This QIP addressed problems of delayed or inconsistent NAC administration in the ED by improving compliance with RCEM standard 1 and reducing inpatient stay while maintaining patient safety. Although standards 2 and 3 did not improve, the interventions proved cost-effective, feasible and scalable. Future work should focus on sustaining improvements and exploring patient-centred outcomes across diverse healthcare settings.
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Continuous Glucose Monitoring in People at High Risk of Diabetes and Dysglycaemia: Transforming Early Risk Detection and Personalised CareContinuous glucose monitoring (CGM)-based interventions have been predominantly conducted in people with established diabetes. Recently, there has been an increasing interest in using CGM for clinical and research purposes in people without diabetes. In this review, we describe the current evidence regarding the use of CGM in people at high risk of diabetes. To date, there is no strong evidence to support the global implementation of CGM in individuals who are at risk of developing diabetes. However, there are promising results highlighting the benefits of CGM in specific populations such as people living with obesity, prediabetes, gestational diabetes mellitus, metabolic dysfunction-associated steatotic liver disease, other endocrinopathies, and genetic syndromes. Also, CGM has shown promising potential in people with positive islet autoantibodies and pre-symptomatic type 1 diabetes, those treated with medications that induce hyperglycaemia or diabetes, and individuals receiving solid organ transplantation who are at risk of post-transplant diabetes mellitus. However, larger studies are needed to confirm these preliminary results. CGM-derived data are not currently validated for the diagnosis of diabetes. There is no CGM-derived definition of normoglycaemia in people without diabetes. Looking to the future, CGM metrics, in tandem with physical activity, dietary intake, and clinical parameters, and eventually bioinformatics, may inform personalised risk scores for precision prevention of individuals at risk. We conclude that further research is needed to clarify the indications, drawbacks, and feasibility of CGM use in people at high risk of diabetes to identify those groups who could benefit most from this technology.
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Assessing Morbidity and Malignancy Risk in Patients Presenting with Pulmonary Embolism in an Ambulatory Care Setting.Objectives: Venous thromboembolism (VTE), especially pulmonary embolism (PE), can be treated in an outpatient setting after appropriate risk assessment. However, front-door physicians may be resistant to follow this practice. The possibility of cancer-associated VTE complicates the outpatient management of PE. This study aimed to assess the morbidity and mortality in patients with PE who were managed in an emergency/acute medicine-led outpatient clinic as per risk stratification as well as detecting diagnoses of new cancer sites (NCSs) in these patients. Methods: This retrospective study included all patients with confirmed PE managed in an acute medicine outpatient setting at Queens Hospital, Burton-on-Trent, United Kingdom, from 2019 to 2022. Biochemical findings, radiological findings, mortality and morbidity rates, treatment administered, simplified Pulmonary Embolism Severity Index (sPESI) scores, complications and NCS diagnosis were obtained. Results: A total of 82 patients were included in this study; their mean age was 63.3 +/- 16.7 years and 56.1% (n = 46) were male. The two commonest presenting complaints were new shortness of breath (25.6%, n = 21) and pleuritic chest pain (19.5%, n = 16). Unprovoked PE was observed in 52.4% (n = 43) of patients. Increased sPESI scores were related to increased mortality rates; sPESI scores of 0 and 3 were associated with 0% and 50% mortality rates within 90 days, respectively. NCS was reported in 13.4% (n = 11). Statistical analyses using logistic regression and classification tree methods revealed that NCS can be predicted with 70.6% sensitivity and 97% specificity using 2 variables (history of cancer and age >73 years). Conclusion: The sPESI can help in the risk stratification of patients with PE showing poor outcomes; patients at a high risk of NCS development can be identified using the classification tree method.
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Comparative Effects of P2Y12 Inhibitors on Thrombus Biology and Inflammatory Responses in Atherothrombotic Cardiovascular Disease: A Systematic Review of Randomized Controlled Trials.This systematic review investigates the biological impact of various P2Y12 receptor inhibitors on thrombus composition and inflammatory activity in patients with acute coronary syndromes undergoing percutaneous coronary intervention (PCI). A comprehensive literature search across four major databases identified four randomized controlled trials that met the inclusion criteria for evidence synthesis. These trials examined ticagrelor, prasugrel, cangrelor, and genotype-guided strategies in comparison to clopidogrel, assessing outcomes such as inflammatory cell infiltration, platelet reactivity, and myocardial reperfusion parameters. Overall, ticagrelor and prasugrel were associated with more favorable modulation of thromboinflammatory and vascular healing markers compared with clopidogrel; these effects were most evident in studies evaluating neutrophil infiltration, myeloperoxidase activity, and early post-PCI ischemic events. However, variations in study design, endpoints, and follow-up duration limited direct comparisons and precluded definitive conclusions. In addition, one mechanistic study protocol describing the assessment of extracellular vesicle-based biomarkers was identified but excluded from the evidence synthesis due to the absence of outcome data. Collectively, the available evidence provides preliminary mechanistic support for the hypothesis that certain P2Y12 inhibitors may exert anti-inflammatory and thrombus-modifying effects beyond their platelet-inhibiting effects. Larger, standardized, and mechanistically focused trials are warranted to validate these findings and guide precision-based antiplatelet therapy in cardiovascular disease.
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Gut Microbiota Modulation in Type 2 Diabetes and Cardiometabolic Risk: A Systematic Review.Cardiometabolic complications related to type 2 diabetes mellitus (T2DM) are often due to changes in the gut microbiota. The review analyzed studies looking at the effects of probiotics, prebiotics, high-fiber diets, and fecal microbiota transplantation (FMT) on glucose levels and heart and metabolic health in individuals either having T2DM or being at risk. The review followed the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. The literature was searched using text terms and controlled vocabulary, employing Boolean operators "AND," "OR," and various combinations across PubMed, Embase, and the Cochrane Library. Open-access, full-text English papers from 2005 to 2025, including those authored by people, were searched. The quality was assessed using the Risk of Bias 2.0 (RoB 2.0) tool, and the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Fifteen randomized controlled trials (RCTs) were analyzed for methodological quality, with three categorized as having a high risk of bias (RoB). The GRADE tool categorized two high RoB RCTs as "low quality." However, two RCTs had low RoB and were classified as "high quality." Ten RCTs had uncertain RoB, lowering the evidence by one point to "moderate quality." A comprehensive review of RCTs was conducted to assess outcomes related to glycemic parameters (e.g., glycated hemoglobin (HbA1c), fasting glucose), lipid profiles, inflammatory markers, anthropometric measures, and gut microbiota composition. Interventions included probiotic and prebiotic supplementation, high-fiber or Mediterranean-style diets, and FMT. Probiotic yogurt containing Lactobacillus acidophilus and Bifidobacterium lactis significantly improved lipid profiles by reducing low-density lipoprotein cholesterol (LDL-C) and total cholesterol. High-fiber diets consistently lowered fasting blood glucose, HbA1c, triglycerides, and LDL-C while elevating high-density lipoprotein cholesterol (HDL-C) and beneficial short-chain fatty acid (SCFA)-producing bacteria. Anti-inflammatory effects were observed across interventions, notably with probiotics and polyphenol-rich Mediterranean diets, which reduced tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and other inflammatory cytokines. The Green-Mediterranean diet significantly improved weight, insulin resistance, and Framingham risk scores. Novel mechanisms involving SCFAs and bile acid metabolism were also identified as key modulators of host metabolic response. Microbiota-based interventions offer promising avenues for glycemic control and cardiometabolic risk reduction in patients with T2DM.
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Revision of total elbow arthroplasty due to humeral loosening with large bone defect using humeral allograft-prosthesis composite: A case report.INTRODUCTION AND IMPORTANCE: Revision of total elbow arthroplasty is a challenging procedure, especially when associated with humeral bone deficiency. The purpose of this case report is to highlight the successful management of humeral-sided loosening due to bone defects, using an allograft-prosthesis composite with a humeral bone allograft. PRESENTATION OF CASE: A 70-year-old female patient under medication for rheumatoid arthritis underwent revision of left total elbow arthroplasty due to major bone defect and loosening on the humeral side. The allograft-prosthesis composite method was used to address the bone defect and loosening of the humeral side by using humeral allograft as well as plating the host humeral bone. CLINICAL DISCUSSION: There were no post-operative complications. The radiographic assessment at her latest follow-up was unremarkable, along with a significant improvement on the functional scores and range of motion. CONCLUSION: The use of a humeral allograft is a valuable option for the management of loosened total elbow arthroplasty with significant bone loss. However, more studies need to be conducted to determine the long-term outcomes of revision surgery of total elbow arthroplasty with humeral bone loss.
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Global prevalence of metabolic syndrome in patients with Rheumatoid arthritis: a systematic review and meta-analysis.BACKGROUND: Rheumatoid arthritis (RA) is a chronic autoimmune disorder that increases the risk of systemic complications, particularly metabolic syndrome (MetS). MetS, defined by central obesity, hypertension, hyperglycemia, and dyslipidemia, not only raises cardiovascular risk but also worsens the prognosis of RA. This meta-analysis aimed to estimate the global prevalence of MetS in RA patients and identify clinical factors contributing to its occurrence. METHODS: A comprehensive literature search was conducted in PubMed, Scopus, and Web of Science. Studies included in the analysis diagnosed RA and defined MetS using standardized guidelines. Pooled estimates were calculated using a random-effects model. Heterogeneity was assessed using the I² statistic. All statistical analyses were conducted using Stata. The study is registered with PROSPERO (CRD420251007337). RESULTS: The overall pooled prevalence of MetS among RA patients was 30.3% (95% CI: 28.5-32.2). Country-specific analyses showed the highest prevalence in Iraq (57.3%; 95% CI: 49.7-66.4), Croatia (49.6%; 95% CI: 35.8-63.3), and Singapore (47.1%; 95% CI: 42.7-51.6), and the lowest in Congo (12.0%; 95% CI: 5.5-20.5), Algeria (14.0%; 95% CI: 10.0-18.7), and South Korea (17.2%; 95% CI: 7.3-30.1). When stratified by continent, the estimates varied noticeably. In Africa, the proportion was 25.7% (95% CI: 21.6-30.0%); in Asia, the estimate rose to 30.8% (95% CI: 27.1-34.6%); Europe recorded a similar figure at 29.8% (95% CI: 26.9-32.7%); North America had an estimate of 31.1% (95% CI: 25.5-36.9%); and South America demonstrated the highest proportion at 38.8% (95% CI: 34.4-43.3%). Meta-regression analyses identified significant associations between MetS prevalence and key clinical variables, including waist circumference (WC) (β = 0.01; P = 0.01), body mass index (BMI) (β = 0.04; P < 0.01), triglycerides (TG) (β < 0.01; P = 0.04), and fasting blood glucose (FBG) (β < 0.01; P < 0.01), with high-density lipoprotein (HDL) levels showing an inverse association (β = -0.01; P < 0.01). Among various diagnostic criteria, the highest prevalence estimates were obtained with the National Cholesterol Education Program and International Diabetes Federation (NCEP/IDF) criteria (39.2%; 95% CI: 30.6-48.1), followed by the Joint Consensus (JC) criteria (37.2%; 95% CI: 28.0-46.9) and the 2004 revision of the National Cholesterol Education Program ATP III (NCEP 2004) criteria (35.4%; 95% CI: 29.0-42.0). CONCLUSION: The substantial prevalence of MetS among RA patients underscores the need for a proactive, integrated approach to cardiovascular risk management. Clinicians should consider routine screening for MetS components-such as central obesity, hypertension, dysglycemia, and dyslipidemia-particularly given the significant associations with WC, BMI, TG, and FBG levels. CLINICAL TRIAL NUMBER: Not applicable.
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More than roll, move and multiple-choice questions: Application of tabletop game mechanics in anatomy education.Anatomy is a challenging topic, and educators have used games as a tool to teach the content. The three-dimensional aspects of anatomy provide unique advantages and challenges for presentation in a tabletop game format. Games are built on mechanics, which include the actions players take, such as rolling dice to move a pawn. Integration of the game mechanics with learning goals can lead to better outcomes by allowing players to explore the content through gameplay. We hypothesize that educators making games for anatomy education will have adopted tabletop game mechanisms that facilitate this integration of the educational content with the gameplay. To explore this a body of games for anatomy education was generated from online sources of games and the literature. Online and literature content, including game rules or videos when available, were reviewed, and mechanisms were categorized by the framework in Building Blocks of Tabletop Game design. Thirty-two games with sufficient information for analysis were identified, and the relation of the game mechanics to the educational content is described. The most common mechanics connected to the learning goals were question and answers, communication limits and set collection. Strongly integrated examples included using tabletop mechanics to travel through neuroanatomy, collecting related sets of anatomic components and tracing pathways for the spread of oral infections. We have found designers of games for anatomy education have adopted variable tabletop game mechanics based on the content area being presented, ranging from games as a framework for quiz questions to more robustly integrated educational content.
