Clinical outcomes with metformin use in diabetic patients with compensated cirrhosis: a systematic review and meta-analysis

BACKGROUND

Previous studies have demonstrated a beneficial effect of metformin in patients with cirrhosis, but no improvement in liver histology.

AIM

To investigate the impact of metformin on mortality and hepatic decompensation in people with diabetes with compensated cirrhosis.

METHODS

Medline, Embase and Cochrane databases were searched from inception to February 2023 for studies reporting results regarding the impact of metformin on all-cause mortality and hepatic decompensation in people with diabetes with compensated cirrhosis. The risk of bias was assessed by ROBINS-I Cochrane tool. R software 4.3.1 was used for all analyses.

RESULTS

Six observational studies were included in the final analysis. Metformin use was associated with reduced all-cause mortality or liver transplantation [hazard ratio (HR): 0.55; 95% confidence interval (CI) 0.37-0.82], while no benefit was shown in the prevention of hepatic decompensation (HR: 0.97; 95% CI: 0.77-1.22). In the subgroup analysis, metformin use was associated with reduced all-cause mortality or liver transplantation (HR: 0.50; 95% CI 0.38-0.65) in patients with metabolic-associated steatohepatitis cirrhosis, while two studies reported no survival benefit in patients with cirrhosis due to hepatitis C (HR: 0.39; 95% CI 0.12-1.20).

CONCLUSION

Metformin use is associated with reduced all-cause mortality, but not with the prevention of hepatic decompensation in people with diabetes with compensated cirrhosis. The mortality benefit is most likely driven by better diabetes and cardiovascular health control.

Characterization of Myocardial Injury With High-Sensitivity Troponin

BACKGROUND

High-sensitivity troponin I, cardiac form (hs-cTnI) accelerates the assessment of acute coronary syndrome. Little has been documented about its performance, how it relates to different types of myocardial injury, and its impact on morbidity and mortality. This study sought to expand understanding of hs-cTnI by characterizing types of myocardial injury, the impact of comorbidities, and 30-day outcomes.

METHODS

The study retrospectively evaluated 1,975 patients with hs-cTnI levels obtained in the emergency department or inpatient setting from June to September 2020. Troponin was considered elevated if it was higher than the 99th percentile for either sex. Charts were reviewed to determine the presence of myocardial injury. Troponin elevation was adjusted for demographics, comorbidities, and kidney dysfunction. Thirty-day mortality and readmission rates were calculated.

RESULTS

Of 1,975 patients, 468 (24%) had elevated hs-cTnI, and 330 (17%) had at least 1 type of myocardial injury, type 2 myocardial infarction being the most frequent. Sensitivity and specificity using the 99th percentile as a cutoff were 99% and 92%, respectively. The average maximum hs-cTnI level was significantly higher for type 1 myocardial infarction (P < .001). Being male, Black, non-Hispanic, and a hospital inpatient were all associated with higher initial and peak hs-cTnI levels (P < .001). Elevated hs-cTnI level, age, heart disease, kidney dysfunction, and inpatient status were predictive of 30-day mortality on multivariate analysis.

CONCLUSION

Elevated hs-cTnI levels in emergency department and inpatient settings occurs most commonly because of type 2 myocardial infarction. Maximum hs-cTnI level is associated with the patient's particular type of myocardial injury, certain demographics, and cardiovascular comorbidities, and it may be a predictor of 30-day outcomes.

Modifying the health teaching process to increase the patient awareness

Funding Acknowledgements

Type of funding sources: None.

Background

Health teaching is an essential part of the patient journey at any healthcare facility.

Internal audit was carried out in one of the renowned healthcare institutions in the middle east , specifically in the outpatient department. The audit revealed the existence of some issues regarding patients’ familiarity with some aspects of knowledge about their conditions, medications, healthy diets, etc.…. Therefore, it was necessary to assess the patient’s understanding and to re-evaluate the introduced instructions regarding these topics. Nursing leaders in the aforementioned institution were inspired to conduct a quality improvement project that enhanced the patients outcome by assessing patient understanding concerning inpatient health teaching.

Aim

A quality improvement project aimed at assessing patients’ understanding regarding health teaching after open-heart surgeries during their hospital stay.

Process

A survey was conducted to assess the patient understanding regarding healthy diet , wound care after surgery, taking the medications, understanding diagnosis, daily activities, follow-up visits and deal with an emergency. Nurse leaders formed a group of internship nursing students to conduct the survey immediately after a health teaching process.

Data was collected and analyzed. Some interventions were implemented to fill the gap of health teaching process and improve the patients outcome.

Interventions

There were no leaflets or other health teaching materials that could be offered to the patient. 15 health education leaflets were developed to fill in this gap. The health teaching process took place at the time of discharge and the decision was to proceed the patient education from the time of admission. We validated and reinforced the health teaching content with the patient and family before discharge.All patients agreed that their relatives should attend the health teaching sessions and these interventions affected positively the results of survey.

Data Analysis

A group of 100 patients were involved in this survey and results revealed the following. It was found that there was a significant impact of the intervention, as shown in ( Figure 1). 69% of patients were only aware about their healthy diet compared with 92% after intervention. Regarding wound care, there was a 14% increase of patient awareness after the intervention. There was a significant difference in terms of the patient understanding about their own diagnosis after the process intervention that reached 27%. The survey showed satisfying numbers before and after the teaching process of follow up date and emergency contact.

Recommendations

Patient teaching is a continuous process starts from the day of admission.Each patient has a suitable way to cope with the provided information in terms of many aspects such as the education level, availability of relative.

Effects of orexin A on proliferation, survival, apoptosis and differentiation of 3T3-L1 preadipocytes into mature adipocytes

Metabolic activities of orexin A (OXA) in mature adipocytes are mediated via PI3K/PKB and PPARγ. However, the effects of OXA on preadipocytes are largely unknown. We report here that OXA stimulates the proliferation and viability of 3T3-L1 preadipocytes and protects them from apoptosis via ERK1/2, but not through PKB. OXA reduces proapoptotic activity of caspase-3 via ERK1/2. Inhibition of ERK1/2 prevents the differentiation of preadipocytes into adipocytes. Unlike insulin, neither short-term nor prolonged exposure of 3T3-L1 preadipocytes to OXA induces preadipocyte differentiation to adipocytes, despite increased ERK1/2 phosphorylation. Unlike insulin, OXA fails to activate PKB, which explains its inability to induce the differentiation of preadipocytes.

Orexin A stimulates glucose uptake, lipid accumulation and adiponectin secretion from 3T3-L1 adipocytes and isolated primary rat adipocytes

AIMS/HYPOTHESIS

Orexin A (OXA) modulates body weight, food intake and energy expenditure. In vitro, OXA increases PPARγ (also known as PPARG) expression and inhibits lipolysis, suggesting direct regulation of lipid metabolism. Here, we characterise the metabolic effects and mechanisms of OXA action in adipocytes.

METHODS

Isolated rat adipocytes and differentiated murine 3T3-L1 adipocytes were exposed to OXA in the presence or absence of phosphoinositide 3-kinase (PI3K) inhibitors. Pparγ expression was silenced using small interfering RNA. Glucose uptake, GLUT4 translocation, phosphatidylinositol (3,4,5)-trisphosphate production, lipogenesis, lipolysis, and adiponectin secretion were measured. Adiponectin plasma levels were determined in rats treated with OXA for 4 weeks.

RESULTS

OXA PI3K-dependently stimulated active glucose uptake by translocating the glucose transporter GLUT4 from cytoplasm into the plasma membrane. OXA increased cellular triacylglycerol content via PI3K. Cellular triacylglycerol accumulation resulted from increased lipogenesis as well as from a decrease of lipolysis. Adiponectin levels in chow- and high-fat diet-fed rats treated chronically with OXA were increased. OXA stimulated adiponectin expression and secretion in adipocytes. Both pharmacological blockade of peroxisome proliferator-activated receptor γ (PPARγ) activity or silencing Pparγ expression prevented OXA from stimulating triacylglycerol accumulation and adiponectin production.

CONCLUSIONS/INTERPRETATION

Our study demonstrates that OXA stimulates glucose uptake in adipocytes and that the evolved energy is stored as lipids. OXA increases lipogenesis, inhibits lipolysis and stimulates the secretion of adiponectin. These effects are conferred via PI3K and PPARγ2. Overall, OXA's effects on lipids and adiponectin secretion resemble that of insulin sensitisers, suggesting a potential relevance of this peptide in metabolic disorders.

Venous air embolism during the use of a Nd YAG laser

We report a case of a 47-year-old female who suffered a cardiac arrest during sub-mucosal diathermy of the inferior turbinate using a Nd YAG laser. The possible causes of the cardiac arrest are discussed. Venous air embolism due to Nd YAG laser was thought to be the most likely cause in this case. Although venous air embolism has previously been reported during nasal sinus surgery and choanal atresia when using a Nd YAG laser, the occurrence of this complication during a relatively minor surgical procedure has not previously been reported. It is important, therefore, to raise the awareness of this life threatening complication during use of a Nd YAG laser regardless of the duration of surgery. We recommend the use of appropriate methods and techniques to avoid this life threatening complication during the use of Nd YAG laser even for relatively short procedures.

Ewing's sarcoma of the jaws

Ewing's sarcoma is an intraosseous malignant tumor of questionable pathogenesis which occurs only occasionally in the jaws. Seventeen cases, eight maxillary and nine mandibular, from the files of the Armed Forces Institute of Pathology (AFIP) are reported. This neoplasm primarily affects children and young adults. Swelling and pain are frequent symptoms. Radiographically, it is most often seen as a destructive, expansile, mottled radiolucent lesion, which may produce a laminated periosteal reaction. The prognosis is poor, although some reports of combined surgery, radiation, and chemotherapy protocols have offered encouragement for increased survival. Histopathologically, Ewing's sarcoma must be differentiated from other small, round-cell malignant neoplasms, such as neuroblastoma and reticulum cell sarcoma.

Adenomatoid hyperplasia of mucous salivary glands

Ten cases of an intraoral salivary gland lesion that is rarely reported and described. Clinically, these lesions appear as asymptomatic tumorlike nodules which are characterized histologically by a proliferation of mucous glandular tissue. The palate was the site of nine lesions. This entity may represent either a reactive hyperplastic phenomenon or a hamartomatous proliferation and should be distinguished from neoplasm.