Search Results (44,167)

Background/Objectives: Refeeding syndrome (RFS) is challenging to prevent and manage in hospitalized patients receiving enteral nutrition (EN). Nebraska Medicine implemented an Electronic Medical Record (EMR) Refeeding Risk Order Set (RROS) to standardize prevention measures, including structured electrolyte monitoring, thiamine supplementation, and conservative EN initiation. This study evaluated whether RROS implementation reduced RFS occurrence or severity and assessed its operational impact. Methods: In this retrospective cohort study, adults receiving EN before and after RROS implementation were compared. Primary outcomes were RFS occurrence and severity; secondary outcomes included EN initiation and advancement rates, electrolyte trends, lab frequency, and electrolyte repletion. Results: RFS occurrence did not differ significantly between groups (92.3% vs. 91.3%, p = 0.694), nor did severity (p = 0.535). The post-RROS group received more electrolyte boluses on EN Day 0 (p = 0.027) and had a lower EN starting rate (15.7 vs. 18.3 mL/h, p = 0.045). Conclusions: Although the RROS did not reduce RFS occurrence or severity, integrating American Society for Parenteral and Enteral Nutrition (ASPEN)-based guidance into the EMR was highly feasible and adopted immediately. Automating electrolyte monitoring, micronutrient supplementation, and conservative feeding initiation reduces the risk of errors and promotes consistent care. These benefits improve workflow efficiency and support providers during high census periods, limited staffing, or when experience varies. Future research should explore combining EMR tools with predictive analytics to optimize early risk identification and individualized management. Full article

Biventricular Takotsubo cardiomyopathy (TCM) is a rare variant characterized by involvement of both the left and right ventricles. This variant is associated with greater hemodynamic instability and longer hospital stays compared to the isolated left ventricular-only variant. We report the case of a 67-year-old female patient who underwent elective resection of a left adrenal adenoma. While her preoperative and intraoperative courses were uneventful, she developed cardiogenic shock postoperatively, necessitating prolonged intensive care unit (ICU) management and vasopressor support. Further evaluation revealed elevated high-sensitivity troponin levels and reduced ejection fraction on echocardiography (30–35%). Hypokinesis was noted in the apical and mid-ventricular segments of both ventricles. A coronary angiogram performed two months prior to admission showed no significant coronary artery disease. Based on these findings, a diagnosis of biventricular TCM was established. The patient was managed supportively and discharged in stable condition with ongoing therapy, including beta-blockers, renin–angiotensin–aldosterone system inhibitors (RAASis), and statins. Follow-up echocardiography showed resolution of regional wall motion abnormalities. Although rare, biventricular TCM is associated with increased severity and a higher risk of complications. Early recognition and timely management are essential to improve outcomes in affected patients. Full article

Antimicrobial resistance (AMR) continues to represent a significant global public health concern. Gram-negative bacilli (GNB) are the primary causative agents of severe nosocomial infections and possess a notable capacity to develop resistance mechanisms that restrict therapeutic options. The objective of this study was to characterize the antimicrobial susceptibility profiles of GNB isolated at a secondary-level hospital in Guadalajara, Mexico, with the aim of identifying predominant resistance patterns and the most effective therapeutic alternatives. A descriptive, retrospective, cross-sectional study was conducted using clinical isolates of Acinetobacter spp., Pseudomonas spp., Escherichia coli, Klebsiella spp., Morganella morganii, Proteus spp., and Enterobacter spp. collected during 2024. The identification and susceptibility testing were carried out using the VITEK^® 2 automated system, and the results were interpreted in accordance with CLSI guidelines. High resistance rates were observed in Acinetobacter spp. and Pseudomonas spp., particularly to carbapenems (>50% and >40%, respectively). Escherichia coli and Klebsiella spp. demonstrated resistance to third-generation cephalosporins and trimethoprim/sulfamethoxazole, exhibiting high susceptibility to amikacin and carbapenems (>90%). New-generation β-lactam/β-lactamase inhibitor combinations, such as ceftazidime/avibactam and ceftolozane/tazobactam, have demonstrated high efficacy against resistant strains. Overall, GNB isolates in this secondary-level hospital demonstrated elevated resistance levels, particularly to β-lactams and carbapenems, which pose a significant therapeutic challenge. Nevertheless, amikacin, carbapenems, and new-generation β-lactams persist as valuable therapeutic options. In order to contain the spread of multidrug-resistant organisms, it is imperative to strengthen local surveillance, optimize antibiotic stewardship, and reinforce infection control measures. Full article

Background/Objectives: Population aging increases the healthcare burden of chronic diseases. We aimed to characterize the sociodemographic and clinical characteristics of Aged Madrid, a cohort comprising 98.6% of the population aged 75 years and older in Madrid, Spain. Methods: Observational study with a five-year retrospective baseline period (2015–2019) to assess baseline vascular and metabolic risk. Data were taken from primary care electronic medical records, hospital discharge summaries, and pharmacy records. Results: 587,603 individuals (mean age: 84 years ± 5.8 years, 61.3% women) were analysed. Obesity affected 31.3% (more frequent in women), while type 2 diabetes occurred in 23.8% (predominantly in men). Hypertension (52.8%), dyslipidaemia (61.6%), and chronic kidney disease (21.7%) were more frequent in women. Atrial fibrillation was the leading cardiovascular condition in women (15.1%), while acute myocardial infarction predominated in men (8.2%). The most prescribed drug classes were antihypertensives (53.8%), statins (44.2%), and oral antidiabetics (26.4%). Among antihypertensives, diuretics (53.9%), ACE inhibitors (27.4%), and ARBs (25.3%) were most used, often in combinations such as diuretics + ACE inhibitors (30.1%). Diabetes treatments favoured metformin and DPP-4 inhibitors; 5.2% received insulin. Conclusions: Sex-based differences emerged in biochemical, anthropometric, and lifestyle variables. Men showed a higher prevalence of cardiovascular diseases and several cardiometabolic risk factors, while women used fewer lipid-lowering and antidiabetic agents. Diuretics were the predominant antihypertensives, and antidiabetic therapy largely followed guideline recommendations. Although 60% of statin users had no prior cardiovascular disease, and their use was concentrated mainly among individuals with major cardiometabolic risk conditions and declined with advancing age, suggesting an age- and risk-sensitive prescribing pattern rather than indiscriminate use. Full article

Background/Objectives: Chronic low-grade inflammation and nutritional deficiencies, particularly vitamin D deficiency, have emerged as important contributors to Metabolic syndrome (MetS) pathogenesis but remain underexplored. This study aimed to comprehensively evaluate the associations between dietary intake, vitamin D status, and inflammatory biomarkers (high-sensitivity C-reactive protein -CRP- and ferritin) in patients with MetS. Methods: A cross-sectional observational study was conducted on 141 adult MetS patients at a Mexican hospital. Clinical, anthropometric, dietary (using a validated food frequency questionnaire), and biochemical data including serum 25-hydroxyvitamin D, CRP, ferritin, and neutrophil-to-lymphocyte ratio (NLR) were collected. Vitamin D deficiency was defined as serum 25(OH)D < 20 ng/mL, and high inflammation as CRP ≥ 3 mg/L. Logistic regression models adjusted for confounders were used to analyze associations. Mediation analysis assessed whether vitamin D deficiency mediated the link between dietary intake and high CRP or ferritin. Results: Patients with elevated CRP had significantly lower serum vitamin D levels (14.0 ± 5.1 vs. 22.1 ± 7.0 ng/mL; p < 0.001). Multivariable analysis showed vitamin D deficiency (adjusted OR 7.1; 95% CI 2.5–19.4; p < 0.001) and hyperferritinemia (ferritin ≥ 200 μg/L; aOR 8.0, 95% CI 3.5–18.2, p < 0.001) as predictors of high CRP. Conversely, hyperferritinemia was predicted by vitamin D deficiency (aOR 24.69; 95% CI 3.76–162.16; p = 0.001), elevated CRP (aOR 5.06; p = 0.014), Hb (aOR 63.23; p < 0.001), and inversely by grade 2 obesity (aOR 0.11; 95% CI 0.02–0.60; p = 0.03), confirming bidirectional CRP-ferritin associations and hyperferritinemia as an inflammation marker rather than iron overload indicator. Although Hb > 14.3 g/dL associated with hyperferritinemia, it did not independently predict CRP in multivariate analyses. Frequent consumption of vitamin D-rich foods (milk, fish, Manchego and Oaxaca cheese) was associated with lower inflammation. Mediation analysis confirmed that vitamin D deficiency mediated dietary intake-CRP and dietary intake-ferritin links (Sobel test p < 0.05). Conclusions: Vitamin D deficiency is a key mediator linking inadequate dietary vitamin D intake to systemic inflammation in MetS. Nutritional strategies emphasizing vitamin D repletion and consumption of vitamin D fortified foods may effectively reduce chronic inflammation and improve metabolic outcomes. Full article

Background: Cobras (Naja sp.) are medically important snakes in Thailand. Envenoming by the monocled cobra (N. kaouthia) often causes neurotoxicity, most notably ptosis, ophthalmoplegia, local tissue necrosis and progressive paralysis leading to respiratory failure. Early antivenom administration and respiratory support are medically significant for effective treatment. Methods: In this study, we determined the association between the time course of cobra envenoming and related neurotoxic outcomes using the clinical profiles of cobra envenomed patients. We also demonstrated histopathological changes in the neuromuscular junction of the diaphragm in experimentally envenomed rats. Results: A retrospective study of 69 cases of cobra envenoming in Central and Southern Thailand shows that delayed arrival beyond one hour at hospital was common among younger adults (47.0% aged 10–29) and associated with more severe neurotoxicity, including higher rates of ptosis (41.2%, p = 0.032) and referrals (41.2% vs. 15.4%, p = 0.040). Antivenoms (22 Monovalent and 1 Polyvalent) were administered to 23 (33.3%) envenomed victims and caused adverse reactions in 9 cases (39.1%). Neurotoxicity following cobra envenoming in the clinical section correlated with histopathological examination of envenomed rat diaphragms. Transmission electron microscopy (TEM) revealed degeneration of the neuromuscular junction and diaphragm within 1 h following experimental cobra envenomation, which worsened by 4 h. Intravenous administration of antivenom at recommended doses reduced diaphragmatic damage but failed to prevent presynaptic degeneration after 90 min of envenoming. Conclusions: Clinically, extraocular muscle paralysis was the earliest manifestation. Early monitoring and prompt administration of antivenom are essential to reduce neurotoxicity and relevant complications. Full article

Urinary tract infections (UTIs) represent a major cause of morbidity among adult women, with a disproportionate burden among postmenopausal patients. Limited data exist from Eastern Europe regarding pathogen distribution, antimicrobial resistance, and treatment patterns in hospitalized women. We conducted a retrospective cohort study of 948 adult female patients hospitalized with symptomatic UTIs between January 2021 and December 2023 in a Romanian multidisciplinary hospital. Demographic, clinical, and microbiological parameters were analyzed. Pathogen identification was performed by MALDI-TOF MS, and antimicrobial susceptibility testing followed EUCAST 2024 standards. Empiric treatment strategies and subsequent therapy modifications were assessed. Postmenopausal women accounted for 78.4% of cases and exhibited higher rates of recurrent UTIs, frailty, diabetes, urinary catheterization, and prior antibiotic exposure. Escherichia coli remained the predominant pathogen (52.6%), followed by Klebsiella spp. (18.4%) and Enterococcus spp. (12.1%). ESBL-producing organisms were found in 21.4% of E. coli and 38.7% of Klebsiella isolates. Pathogen distribution differed by age: younger women had a higher proportion of E. coli, whereas postmenopausal women showed a relative increase in opportunistic/healthcare-associated pathogens, particularly Klebsiella spp. and Enterococcus spp., consistent with higher catheter exposure and comorbidity burden. Carbapenem resistance was rare but present in a small subset of Klebsiella isolates with phenotypes compatible with OXA-48-like carbapenemase production. Empiric therapy most frequently included ceftriaxone or fluoroquinolones, but 27.8% of regimens required adjustment after susceptibility results. Independent predictors of prolonged hospitalization included age > 65 years, recurrent UTI, MDR infection, urinary catheterization, and delayed targeted therapy. UTIs among hospitalized adult women—especially postmenopausal patients—are strongly influenced by comorbidity burden and antimicrobial resistance. Local resistance patterns highlight the need for evidence-based empiric treatment and rapid therapy optimization. Strengthening stewardship and preventive interventions in elderly women is essential. Full article

Emerging antimicrobial resistance (AMR) in companion animals represents a global health concern as they serve as potential reservoirs for multidrug-resistant (MDR) bacteria, which can be transmitted to humans. Herein, we provide comprehensive surveillance data on resistance patterns in veterinary hospital settings, focusing on urinary tract infection. A total of 23 bacterial strains were isolated from urine specimens of hospitalized companion animals suspected of urinary tract infections (UTIs) between 2022 and 2024. 16S rRNA sequencing analysis revealed that Escherichia coli (47.8%), Klebsiella pneumoniae (21.7%), and Pseudomonas aeruginosa (8.7%) were predominant uropathogens. Minimum inhibitory concentration and minimum bactericidal concentration tests were employed to analyze AMR patterns across different classes of antibiotics. Moreover, antimicrobial susceptibility test exhibited 73.91% MDR according to the standard definition given by the Clinical and Laboratory Standards Institute (CLSI) M100 guidelines. Most Gram-negative bacteria have been shown to be resistant to beta-lactam antibiotics, especially carbapenems. Notably, an E. coli strain was confirmed to possess the bla_NDM-1 gene encoding the carbapenemase New Delhi metallo-β-lactamase. These findings support the implementation of targeted infection control measures and evidence-based treatment protocols to preserve antimicrobial efficacy in companion animal medicine to minimize potential public health risks through the One Health approach. Full article

Background: Computerized Provider Order Entry (CPOE) systems are critical for medication safety, but their effectiveness relies heavily on the completeness of entered data. Incomplete clinical and anthropometric information can disable Clinical Decision Support Systems (CDSSs), compromising patient safety. Objective: This study aimed to assess the longitudinal evolution of CPOE data completeness, specifically focusing on “Breadth Completeness” (the presence of essential clinical variables), and to identify factors predicting data integrity in a tertiary care setting. Methods: A retrospective cross-sectional study was conducted at a 500-bed tertiary referral center in Riyadh. Data were extracted from the Cerner Millennium CPOE system for three “steady-state” years (2015, 2017, and 2019); years involving major system overhauls (2016 and 2018) were excluded to avoid structural bias. A total of 600 unique patient encounters (200 per year) were selected using systematic random sampling from a chronologically ordered sampling frame to minimize temporal bias. The primary outcome was “Breadth Completeness,” defined as the presence of eight key variables: age, gender, marital status, weight, height, diagnosis, vital signs, and allergies. Secondary outcomes included documentation consistency (daily notes). Multivariable logistic regression, adjusted for potential confounders, was used to determine predictors of completeness. Results: The rate of primary data completeness (Breadth) improved significantly over the study period, rising from 5.5% in 2015 to 26% in 2017 and 49.5% in 2019. In the multivariable analysis, the year of documentation (OR = 17.47 for 2019 vs. 2015, p < 0.0001) and length of hospitalization (OR = 1.04, p = 0.045) were significant predictors of completeness. Pharmacist-led medication reconciliation was associated with a 2.5-fold increase in data completeness in bivariate analysis (p < 0.0001). Conclusions: While system maturity has driven substantial improvements in CPOE documentation, critical gaps persist, particularly in anthropometric data required for safety alerts. The study underscores the necessity of mandating “hard stops” for core variables and formalizing pharmacist involvement in data reconciliation to ensure patient safety. Full article

Ureterolithiasis is a common cause of ureteral obstruction in dogs, often leading to kidney injury. Medical expulsive therapy (MET) using α-adrenergic antagonists has been proposed as a nonsurgical treatment option in selected cases and is thought to facilitate ureteral stone passage by reducing ureteral smooth muscle tone. A 9-year-old castrated male Chihuahua weighing 1.78 kg was presented with anorexia. Physical examination revealed 7% dehydration and pale mucous membranes. Serum biochemistry demonstrated severe azotemia, with markedly elevated symmetric dimethylarginine (>100 μg/dL; reference interval [RI], 0–14 μg/dL), blood urea nitrogen (157.9 mg/dL; RI, 7–25 mg/dL), and creatinine (2.2 mg/dL; RI, 0.5–1.5 mg/dL). On day 4 of hospitalization, ultrasonography revealed dilation of the renal pelvis (16.1 mm), ureteral distention (3.74 mm), and multiple ureteroliths (maximum diameter, 3.31 mm) at the ureterovesical junction. Antegrade pyelography confirmed a right ureteral obstruction. As the owner declined surgical intervention, MET including tamsulosin, was initiated with close clinical monitoring. After 3 days, improvement in azotemia and resolution of ureteral obstruction were observed. Although concurrent medical treatments were administered, this case provides clinical insight into the potential role of tamsulosin as part of medical management of obstructive ureterolithiasis in a dog with small distal ureteral stones. Full article

Background: Helmet therapy is considered to be a treatment for infants with positional plagiocephaly. Although some studies suggest that anterior fontanelle (AF) size may also affect treatment outcomes, evidence and influence remain unclear. The aim of this study is to assess the impact of anterior fontanelle size on the effectiveness of helmet therapy, with the goal of determining the optimal timing and patient criteria for treatment. Methods: We conducted a retrospective study of 94 infants treated with helmet therapy for positional plagiocephaly at Kwangju Christian Hospital between January 2020 and December 2021. Patients were divided into two age groups (≤6 months and >6 months) and three SAF quartiles (≤25%, 25–75%, ≥75%). Parameters reflecting the degree of cranial asymmetry correction, including cranial vault asymmetry (CVA) and cranial vault asymmetry index (CVAI), were recorded at the start and end of treatment. Results: Infants aged ≤6 months showed significantly greater improvements in cranial vault asymmetry (CVA) and cranial vault asymmetry index (CVAI) compared to older infants (CVA: 4.57 ± 2.30 mm vs. 7.04 ± 3.85 mm, p = 0.003; CVAI: 3.10 ± 1.55% vs. 4.45 ± 2.44%, p = 0.011). When analyzed by anterior fontanelle (AF) size quartiles (≤25%, 25–75%, ≥75%), no significant differences in treatment outcomes were observed at the end of therapy for CVA (p = 0.88) or CVAI (p = 0.91). In infants ≤6 months, SAF quartile analysis also showed no significant differences in CVA (p = 0.97) or CVAI (p = 0.98) improvements. Conclusions: Our findings indicate that anterior fontanelle size is not a predictor of helmet therapy outcomes in positional plagiocephaly. Early initiation of helmet therapy (≤6 months) remains the most critical factor for achieving optimal results. Full article

Brazilian spotted fever (BSF) is a tick-borne acute febrile disease that can be lethal to humans, caused by the bacterium Rickettsia rickettsii. In the State of São Paulo, transmission occurs mainly through two tick species: Amblyomma sculptum and Amblyomma aureolatum. We analyzed trends in BSF incidence and mortality in relation to the spatial distribution of these vector species in the State of São Paulo from 2007 to 2017 and evaluated clinical outcomes according to hospitalization location. In A. sculptum areas, incidence and mortality showed significant increasing trends between 2007 and 2015 (p-value < 0.05). In contrast, A. aureolatum areas exhibited a significant decrease in incidence (p-value < 0.05), while mortality remained stable throughout the study period. Lethality was substantially higher in cases associated with A. aureolatum than in those linked to A. sculptum (67.1% versus 55.0%, p-value = 0.037). Most patients received care in hospitals located near the probable site of infection. Incidence and mortality patterns differed sharply between vector-specific areas, with notably higher mortality in A. aureolatum-related cases. These findings highlight the importance of incorporating vector distribution into surveillance, prevention, and clinical management strategies to better address the distinct epidemiological contexts within the State of São Paulo. Full article

Background/Objectives: Vitamin B₁₂ (cobalamin) and folate (vitamin B₉) are essential cofactors in one-carbon metabolism required for DNA synthesis, methylation, and genomic stability. Deficiencies in these nutrients can cause megaloblastic anemia, neurological dysfunction, and hyperhomocysteinemia, linking micronutrient imbalance to cardiovascular and neurocognitive outcomes. Population-based surveillance of these biomarkers provides insight into nutritional trends and supports analytical standardization. Methods: This retrospective study included all routine plasma (P) vitamin B₁₂ and folate measurements performed at Uppsala University Hospital from 2005 to 2024 (n = 647,302 and 578,509, respectively). Data were extracted from the laboratory information system and summarized using annual medians, percentile distributions, and coefficients of variation (CV). Linear regression was used to validate the method comparison and assess the impact of the 2021 transition from the Abbott Architect to the Roche cobas platform. Descriptive statistics summarized the temporal and seasonal patterns of P-vitamin B₁₂ and P-folate. Results: Median P-vitamin B₁₂ concentrations remained stable (340–370 pmol/L; median CV = 4.6%), while P-folate increased from 10.5 to 15.5 nmol/L (median CV = 12.9%) from 2005 to 2024. Low P-folate (<7 nmol/L) was observed in 7.1% of measurements and low or borderline P-vitamin B₁₂ (<250 pmol/L) in 22.6%. Females exhibited slightly higher concentrations of both analytes. Although no clear seasonal pattern was observed, small biological effects cannot be excluded. Sample volumes decreased during the summer. The transition to Roche assays introduced measurable methodological shifts, particularly for P-folate. Conclusions: Levels of P-vitamin B₁₂ remained stable over two decades, while P-folate status increased modestly. This reflects both dietary influences and assay-related differences following the 2021 platform transition. Continuous surveillance of biomarker medians provides a sensitive tool for detecting analytical drift and for monitoring long-term nutritional trends in clinical populations. Full article

Background/Objectives: The early and accurate identification of impacted teeth in the maxilla is critical for effective dental treatment planning. Traditional diagnostic methods relying on manual interpretation of radiographic images are often time-consuming and subject to variability. Methods: This study presents a deep learning-based approach for automated classification of impacted maxillary canines using panoramic radiographs. A comparative evaluation of four pre-trained convolutional neural network (CNN) architectures—ResNet50, Xception, InceptionV3, and VGG16—was conducted through transfer learning techniques. In this retrospective single-center study, the dataset comprised 694 annotated panoramic radiographs sourced from the archives of a university dental hospital, with a mildly imbalanced representation of impacted and non-impacted cases. Models were assessed using accuracy, precision, recall, specificity, and F1-score. Results: Among the tested architectures, VGG16 demonstrated superior performance, achieving an accuracy of 99.28% and an F1-score of 99.43%. Additionally, a prototype diagnostic interface was developed to demonstrate the potential for clinical application. Conclusions: The findings underscore the potential of deep learning models, particularly VGG16, in enhancing diagnostic workflows; however, further validation on diverse, multi-center datasets is required to confirm clinical generalizability. Full article

Background/Objectives: Frailty is a common geriatric syndrome associated with adverse outcomes such as disability, hospitalization, and mortality. This study aimed to assess the association between body mass index (BMI) trajectories over ten years and frailty among community-dwelling older adults in Brazil. Methods: This population-based longitudinal study used data from the COMO VAI? cohort, conducted with individuals aged ≥60 years in Pelotas, southern Brazil. Frailty was defined in 2024 using Fried’s phenotype, which evaluates weight loss, exhaustion, low physical activity, slowness, and weakness. BMI categories were defined as underweight (BMI < 22.0 kg/m²), eutrophy (22.0–27.0 kg/m²) and overweight (>27.0 kg/m²). BMI trajectories were identified using group-based trajectory modeling for 789 participants with data from at least two of three assessments (2014, 2019, 2024). Only trajectory groups comprising at least 5% of the sample were retained. Associations of baseline BMI and BMI trajectories with frailty were analyzed using Poisson regression with robust variance, adjusted for confounders and calf circumference. Results: Baseline underweight and overweight prevalence were 9.2% and 56.2%, respectively. Trajectory modeling identified three BMI groups: eutrophic (31.6%), overweight (56.4%), and obesity (12.0%). Obesity emerged as a distinct longitudinal trajectory rather than a baseline BMI category. Underweight did not emerge as a distinct BMI trajectory due to its low prevalence over time. Frailty prevalence in 2024 was 36.5%. Overweight trajectory participants had lower frailty prevalence after ten years (PR = 0.73; 95% CI: 0.54–0.99), while baseline underweight was associated with higher frailty ten years later (PR = 1.73; 95% CI: 1.05–2.84), consistent with the known risk of underweight and the potential protective effect observed in overweight older adults. Conclusions: Baseline underweight increased frailty risk, whereas an overweight trajectory showed a potential protective effect, consistent with the “obesity paradox” in older populations. Full article