1
|
Bea C, Vela S, García-Blas S, Perez-Rivera JA, Díez-Villanueva P, de Gracia AI, Fuertes E, Oltra MR, Ferrer A, Belmonte A, Santas E, Pellicer M, Colomina J, Doménech A, Bodi V, Forner MJ, Chorro FJ, Bonanad C. Infective Endocarditis in the Elderly: Challenges and Strategies. J Cardiovasc Dev Dis 2022; 9:jcdd9060192. [PMID: 35735821 PMCID: PMC9224959 DOI: 10.3390/jcdd9060192] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 12/12/2022] Open
Abstract
The specific management of infective endocarditis (IE) in elderly patients is not specifically addressed in recent guidelines despite its increasing incidence and high mortality in this population. The term "elderly" corresponds to different ages in the literature, but it is defined by considerable comorbidity and heterogeneity. Cancer incidence, specifically colorectal cancer, is increased in older patients with IE and impacts its outcome. Diagnosis of IE in elderly patients is challenging due to the atypical presentation of the disease and the lower performance of imaging studies. Enterococcal etiology is more frequent than in younger patients. Antibiotic treatment should prioritize diminishing adverse effects and drug interactions while maintaining the best efficacy, as surgical treatment is less commonly performed in this population due to the high surgical risk. The global assessment of elderly patients with IE, with particular attention to frailty and geriatric profiles, should be performed by multidisciplinary teams to improve disease management in this population.
Collapse
Affiliation(s)
- Carlos Bea
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.V.); (A.I.d.G.); (E.F.); (M.R.O.); (A.F.); (A.B.); (M.J.F.)
| | - Sara Vela
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.V.); (A.I.d.G.); (E.F.); (M.R.O.); (A.F.); (A.B.); (M.J.F.)
| | - Sergio García-Blas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (S.G.-B.); (E.S.); (M.P.); (V.B.); (F.J.C.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
| | | | | | - Ana Isabel de Gracia
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.V.); (A.I.d.G.); (E.F.); (M.R.O.); (A.F.); (A.B.); (M.J.F.)
| | - Eladio Fuertes
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.V.); (A.I.d.G.); (E.F.); (M.R.O.); (A.F.); (A.B.); (M.J.F.)
| | - Maria Rosa Oltra
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.V.); (A.I.d.G.); (E.F.); (M.R.O.); (A.F.); (A.B.); (M.J.F.)
| | - Ana Ferrer
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.V.); (A.I.d.G.); (E.F.); (M.R.O.); (A.F.); (A.B.); (M.J.F.)
| | - Andreu Belmonte
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.V.); (A.I.d.G.); (E.F.); (M.R.O.); (A.F.); (A.B.); (M.J.F.)
| | - Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (S.G.-B.); (E.S.); (M.P.); (V.B.); (F.J.C.)
| | - Mauricio Pellicer
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (S.G.-B.); (E.S.); (M.P.); (V.B.); (F.J.C.)
| | - Javier Colomina
- Servicio de Microbiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain;
| | - Alberto Doménech
- Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain;
| | - Vicente Bodi
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (S.G.-B.); (E.S.); (M.P.); (V.B.); (F.J.C.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain
- Centro de Investigación Biomédica en Red-Cardiovascular, 28029 Madrid, Spain
| | - Maria José Forner
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.V.); (A.I.d.G.); (E.F.); (M.R.O.); (A.F.); (A.B.); (M.J.F.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain
| | - Francisco Javier Chorro
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (S.G.-B.); (E.S.); (M.P.); (V.B.); (F.J.C.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain
- Centro de Investigación Biomédica en Red-Cardiovascular, 28029 Madrid, Spain
| | - Clara Bonanad
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (S.G.-B.); (E.S.); (M.P.); (V.B.); (F.J.C.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain
- Correspondence:
| |
Collapse
|
2
|
Vela-Bernal S, Fuertes E, Albiol P, de la Morena I, Bea C, de Gracia AI, de Castro A, Navarro L, Forner MJ. AB0440 USE OF BELIMUMAB IN CLINICAL PRACTICE. CLINICAL AND SEROLOGICAL EFFECTIVENESS AND CORTICOSTEROID-SPARING ACTIVITY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.3863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundSince 2011, the use of Belimumab for the treatment of Systemic Lupus Erythematosus (SLE)has demonstrated efficacy and safety in several randomised clinical trials. However, strict inclusion criteria may restrict those results limiting the interpretation of these results to routine clinical practice populations.ObjectivesThe aim of this study was to analyse the profile of patients using Belimumab as well as the clinical, serological and corticosteroid-sparing outcomes that may result from it use.MethodsRetrospective cohort study including patients diagnosed with SLE and treated with Belimumab. Epidemiological, clinical and analytical data were collected at 6, 12 and 24 months before and after starting treatment with Belimumab. To assess effectiveness, the SELENA-SLEDAI, SLICC, clinical changes, concomitant treatments, corticosteroid dose and ds-DNA and C3-C4 levels were used.Safety was evaluated by assessing the need and cause for discontinuation of Belimumab.ResultsThirty-one patients were included, mostly 28 (90.32%) women, with a mean age of 48.55 ± 1.95 years and a mean time of disease progression since diagnosis of 16.13 ± 1.77 years. The most prevalent affection before initiation of Belimumab were joint (83.87%), systemic (58.06%), skin (29.03%) and nephropathy (22.58%). The mean SELENA-SLEDAI score before Belimumab was 5.32 ± 0.46; 64.5% had elevated anti-dsDNA, 48.39% and 54.84% had low C3 and C4 levels, respectively.Before starting Belimumab, the most used treatments were both antimalarials (72.4%) and corticosteroids (80.6%). The main reason for starting Belimumab was the ineffectiveness of previous treatments (67.7%). The vast majority of patients were treated subcutaneously (90.3%) and there were no major adverse events leading to drug withdrawal, with a median duration of use of 19.3 months (IQR: 9.75-35.55).ConclusionAfter starting Belimumab, a decrease in the SELENA-SLEDAI activity scale, an increase in C3 and C4 levels, and a significant decrease in anti-dsDNA levels at 6 months were observed.At 12 and 24 months, continuity of this trend was observed, although statistical significance was not reached. As concerns corticosteroids, we observed a decrease in steroid use below 7.5mg/day and even 5mg/day after the introduction of Belimumab avoiding the undesirable effects of prolonged steroid use.Table 1.BEFORE BELIMUMAB (n=31)6 MONTHS (n=28)12 MONTHS (n=22)24 MONTHS (n=9)ESLEDAI x̄ (SD)5,32 (0,46)2,28 (0,44)2,90 (0,72)3,44 (1,39)P<0,001P<0,005p>0,05High dsDNA - n (%)18 (58,06)14 (61,29)14 (45,16)4 (12,9)P<0,001P=0,036P=0,7Low C3 (<90mg/dl) - n (%)15 (48,39)11 (35,48)9 (29,03)3 (9,68)P=0,006P=0,193P=0,06Low C4 (<16mg/dl) - n (%)17 (54,84)14 (45,16)11 (35,48)5 (16,13)P<0,001P=0,003P=0,217)Figure 1.Disclosure of InterestsNone declared
Collapse
|
3
|
Calderon JM, Martinez F, Diaz J, Fernandez A, Sauri I, Uso R, Trillo JL, Vela S, Bea C, Redon J, Forner MJ. Real-World Data of Anticoagulant Treatment in Non-valvular Atrial Fibrillation. Front Cardiovasc Med 2022; 8:733300. [PMID: 35127843 PMCID: PMC8814520 DOI: 10.3389/fcvm.2021.733300] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022] Open
Abstract
AimsTo assess the impact of anticoagulant treatment on risk for stroke and all-cause mortality of patients with atrial fibrillation using real-world data (RWD).MethodsPatients with prevalent or incident atrial fibrillation were selected throughout a study period of 5 years. Stroke, transitory ischemic attack, hemorrhagic stroke, and all-cause mortality were identified in the claims of the electronic health records (EHRs). Subjects were classified according to the anticoagulant treatment in four groups: untreated, vitamin K antagonists (VKAs), New Oral Anticoagulants (NOACs), and antiplatelet (AP). Risk of events and protection with anticoagulant therapy were calculated by Cox proportional hazard models adjusted by potential confounders.ResultsFrom a total population of 3,799,884 patients older than 18,123,227 patients with incident or prevalent atrial fibrillation (AF) were identified (mean age 75.2 ± 11.5 years old; 51.9% women). In a follow-up average of 3.2 years, 17,113 patients suffered from an ischemic stroke and transitory ischemic attack (TIA), 780 hemorrhagic stroke, and 42,558 all-cause death (incidence of 46, 8, 2, and 120 per 1,000 patients/year, respectively). Among CHA2DS2, VASc Score equal or >2, 11.7% of patients did not receive any anticoagulant therapy, and a large proportion of patients, 47%, shifted from one treatment to another. Although all kinds of anticoagulant treatments were significantly protective against the events and mortality, NOAC treatment offered significantly better protection compared to the other groups.ConclusionIn the real world, the use of anticoagulant treatments is far from guidelines recommendations and is characterized by variability in their use. NOACs offered better protection compared with VKAs.
Collapse
Affiliation(s)
- Jose Miguel Calderon
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
| | - Fernando Martinez
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
- Internal Medicine Hospital Clínico de Valencia, Valencia, Spain
| | - Javier Diaz
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
| | - Antonio Fernandez
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
| | - Inmaculada Sauri
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
| | - Ruth Uso
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
| | - Jose Luis Trillo
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
| | - Sara Vela
- Internal Medicine Hospital Clínico de Valencia, Valencia, Spain
| | - Carlos Bea
- Internal Medicine Hospital Clínico de Valencia, Valencia, Spain
| | - Josep Redon
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
- Internal Medicine Hospital Clínico de Valencia, Valencia, Spain
- CIBERObn Carlos III Institute, Madrid, Spain
- *Correspondence: Josep Redon
| | - Maria Jose Forner
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
- Internal Medicine Hospital Clínico de Valencia, Valencia, Spain
| |
Collapse
|
4
|
Lopez C, Holgado JL, Fernandez A, Sauri I, Uso R, Trillo JL, Vela S, Bea C, Nuñez J, Ferrer A, Gamez J, Ruiz A, Redon J. Impact of Acute Hemoglobin Falls in Heart Failure Patients: A Population Study. J Clin Med 2020; 9:jcm9061869. [PMID: 32549339 PMCID: PMC7355985 DOI: 10.3390/jcm9061869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 02/05/2023] Open
Abstract
Aims: This study assessed the impact of acute hemoglobin (Hb) falls in heart failure (HF) patients. Methods: HF patients with repeated Hb values over time were included. Falls in Hb greater than 30% were considered to represent an acute episode of anemia and the risk of hospitalization and all-cause mortality after the first episode was assessed. Results: In total, 45,437 HF patients (54.9% female, mean age 74.3 years) during a follow-up average of 2.9 years were analyzed. A total of 2892 (6.4%) patients had one episode of Hb falls, 139 (0.3%) had more than one episode, and 342 (0.8%) had concomitant acute kidney injury (AKI). Acute heart failure occurred in 4673 (10.3%) patients, representing 3.6/100 HF patients/year. The risk of hospitalization increased with one episode (Hazard Ratio = 1.30, 95% confidence interval (CI) 1.19-1.43), two or more episodes (HR = 1.59, 95% CI 1.14-2.23, and concurrent AKI (HR = 1.61, 95% CI 1.27-2.03). A total of 10,490 patients have died, representing 8.1/100 HF patients/year. The risk of mortality was HR = 2.20 (95% CI 2.06-2.35) for one episode, HR = 3.14 (95% CI 2.48-3.97) for two or more episodes, and HR = 3.20 (95% CI 2.73-3.75) with AKI. In the two or more episodes and AKI groups, Hb levels at the baseline were significantly lower (10.2-11.4 g/dL) than in the no episodes group (12.8 g/dL), and a higher and significant mortality in these subgroups was observed. Conclusions: Hb falls in heart failure patients identified those with a worse prognosis requiring a more careful evaluation and follow-up.
Collapse
Affiliation(s)
- Cristina Lopez
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
| | - Jose Luis Holgado
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
| | - Antonio Fernandez
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
| | - Inmaculada Sauri
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
| | - Ruth Uso
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
| | - Jose Luis Trillo
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
| | - Sara Vela
- Internal Medicine Hospital Clínico de Valencia, 46010 Valencia, Spain; (S.V.); (C.B.); (A.R.)
| | - Carlos Bea
- Internal Medicine Hospital Clínico de Valencia, 46010 Valencia, Spain; (S.V.); (C.B.); (A.R.)
| | - Julio Nuñez
- Cardiology Hospital Clínico de Valencia, 46010 Valencia, Spain;
| | - Ana Ferrer
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
| | - Javier Gamez
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
| | - Adrian Ruiz
- Internal Medicine Hospital Clínico de Valencia, 46010 Valencia, Spain; (S.V.); (C.B.); (A.R.)
| | - Josep Redon
- Cardiovascular and Renal Research Group INCLIVA Research Institute University of Valencia, 46010 Valencia, Spain; (C.L.); (J.L.H.); (A.F.); (I.S.); (R.U.); (J.L.T.); (A.F.); (J.G.)
- Internal Medicine Hospital Clínico de Valencia, 46010 Valencia, Spain; (S.V.); (C.B.); (A.R.)
- CIBERObn Carlos III Institute Madrid, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-658-909-676
| |
Collapse
|
5
|
Dunner DL, Hendrickson HE, Bea C, Budech CB, O'Connor E. Dysthymic disorder: treatment with mirtazapine. Depress Anxiety 2000; 10:68-72. [PMID: 10569129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
Dysthymic disorder is a form of chronic depression which often has its onset in childhood or adolescence and is generally persistent throughout life. Although originally hypothesized to be preferentially treated with psychotherapy, recent pharmacological studies support the use of antidepressants to treat patients with dysthymic disorder. Mirtazapine is an antidepressant which has been recently released on the U.S. market. We studied the effects of 15 to 45 mg of mirtazapine in 15 patients with dysthymic disorder on an open label basis over a 10-week period. Four patients discontinued treatment because of sedation. Mirtazapine was effective and well tolerated in the remaining patients.
Collapse
Affiliation(s)
- D L Dunner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
| | | | | | | | | |
Collapse
|
6
|
Abstract
BACKGROUND Dysthymic disorder is a chronic depression that is usually characterized by depression rating scale scores that are lower than those for major depressive disorder. Recent studies suggest that pharmacotherapy is quite effective in the treatment of patients with this condition and, in particular, that the newer antidepressants may be better tolerated than older tricyclic antidepressants. The purpose of this study was to investigate the use of a structurally novel antidepressant, venlafaxine, in the treatment of dysthymic disorder. METHOD Seventeen patients with dysthymic disorder were entered into the study, and 14 completed it. A psychiatric interview was used to establish diagnosis, and behavior was assessed by using the Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory (BDI). Patients were seen over a 9-week period, and venlafaxine treatment proceeded on an open-label basis, from a starting dose of 18.75 mg b.i.d. to a maximum dose of 225 mg/day. RESULTS Two patients discontinued early because of side effects, and 1 patient took a single dose, felt better, and did not complete the trial. Analyses of all 17 patients showed significant improvement in HAM-D and BDI scores at the end of the study. Among the completers, there were two response patterns: one group of 7 patients responded quickly to low-dose (75 mg) venlafaxine, and a second group of 7 required the maximum dose. Three of the 7 high-dose patients showed considerable improvement. Side effects in this study were generally in keeping with what has been reported using venlafaxine in treatment of major depressive disorder. No patients evidenced increased blood pressure. CONCLUSION Our study supports the treatment of dysthymic patients with venlafaxine, which has equal efficacy and greater tolerability than tricyclic antidepressants.
Collapse
Affiliation(s)
- D L Dunner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle 98105, USA
| | | | | | | |
Collapse
|
7
|
Abstract
We studied the effects of a fixed dose of fluoxetine (20 mg) or cognitive psychotherapy in a 16 week trial of patients with dysthymic disorder. More patients assigned to fluoxetine dropped out of the 16 week treatment (33%) than those assigned to cognitive therapy (9%), but this difference did not attain statistical significance. Both treatments showed improvement over baseline conditions at 8 weeks and further improvement at 16 weeks. There were no statistically significant group differences in treatment response. No follow-up data were collected so the enduring effects of the treatments are unknown. An optimal treatment for dysthymic disorder may be combined psychotherapy and pharmacotherapy for a longer period of time.
Collapse
Affiliation(s)
- D L Dunner
- Outpatient Psychiatry Center, Seattle, WA 98105-6099, USA
| | | | | | | | | | | |
Collapse
|
8
|
Abstract
Primary adenocarcinoma of the fallopian tube is a rare neoplasm that constitutes less than 1% of gynecologic malignancies. Although the triad of menorrhagia, leukorrhea, and pain is said to be pathognomonic, preoperative diagnosis of this lesion is most unusual. The radiographic appearance at hysterosalpingography has only rarely been described in the English literature previously. This therefore is an unusual documentation of the preoperative appearance of fallopian adenocarcinoma by hysterosalpingography and sonography.
Collapse
Affiliation(s)
- A Hinton
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232
| | | | | | | |
Collapse
|