Screening Versus Brief Domain-specific Tests to Assess Long-term Postoperative Cognitive Dysfunction After Concomitant Aortic Valve Replacement and Coronary Artery Bypass Grafting.

BACKGROUND: Although postoperative cognitive dysfunction is a relevant complication after surgery, assessment for the condition is not routine in clinical practice. OBJECTIVE: The aim of this study was to compare the use of screening versus brief domain-specific cognitive tests in assessing long-term cognitive dysfunction after concomitant aortic valve replacement and coronary artery bypass grafting. METHODS: In this observational prospective study, we evaluated 70 patients preoperatively and after 1, 6, and 12 months using 2 screening tests (Mini-Mental State Examination and Clock Drawing Test) and 2 brief domain-specific cognitive tests (Trail Making Test to evaluate attention and executive function, and Semantic and Phonological Tests to evaluate verbal fluency). RESULTS: The brief domain-specific cognitive tests detected significant postoperative worsening in performances (up to 19% on the Trail Making Test and 15.4% on verbal fluency tests at 6 months). Postoperative mild attention/executive dysfunction or inferior normal performance was detected with the maximums being seen at 6 months (44.6%, P < .001). Performances on screening tests did not significantly change during the study period. CONCLUSIONS: A brief domain-specific cognitive evaluation could be routinely implemented in perioperative care practice to detect postoperative cognitive dysfunction.

Management of older hospitalized patients with type 2 diabetes using linagliptin: Lina-Older study.

BACKGROUND: Older patients managed with intensive antidiabetic therapy are more likely to be harmed. Our study's primary endpoint was to analyze the safety and efficacy of linagliptin in combination with basal insulin versus basal-bolus insulin in patients with 75 years of age or older hospitalized in medicine and surgery departments in real-world clinical practice. METHODS: We retrospectively enrolled non-critically patients ≥75 years with type 2 diabetes admitted to medicine and non-cardiac surgery departments with admission glycated hemoglobin <8%, admission blood glucose <240 mg/dL, and without at-home injectable therapies managed with our hospital's antihyperglycemic protocol (basal-bolus or linagliptin-basal regimens) between January 2016 and December 2018. To match each patient who started on the basal-bolus regimen with a patient who started on the linagliptin-basal regimen, a propensity matching analysis was used. RESULTS: Postmatching, 198 patients were included in each group. There were no significant differences in mean daily blood glucose levels after admission (P=0.203); patients with mean blood glucose 100-140mg/dL (P=0.134), 140-180mg/dL (P=0.109), or >200mg/dL (P=0.299); and number and day of treatment failure (P=0.159 and P=0.175, respectively). The total insulin dose and the number of daily injections were significantly lower in the linagliptin-basal group (both, P<0.001). Patients on the basal-bolus insulin regimen had more total hypoglycemic events than patients on the linagliptin-basal insulin regimen (P<0.001). CONCLUSIONS: The linagliptin-basal insulin regimen was an effective alternative with fewer hypoglycemic events and daily insulin injections than intensive basal-bolus insulin in very old patients with type 2 diabetes with mild-to-moderate hyperglycemia treated at home without injectable therapies.

Simplified glycaemic management for patients with type 2 diabetes admitted for acute decompensated heart failure using linagliptin.

INTRODUCTION AND OBJECTIVES: Hyperglycaemia in hospitalized patients with type 2 diabetes is preferably managed with insulin. We aimed to analyse the glycaemic efficacy, treatment simplicity, and safety of our hospital's antihyperglycemic regimens (linagliptin-basal insulin versus basal-bolus insulin) in patients with type 2 diabetes admitted for heart failure decompensation. PATIENTS AND METHODS: In this real-world study, we included patients with mild-to-moderate hyperglycaemia managed with our antihyperglycemic regimens between 2016 and 2018. To match patients who started one of the regimens, a propensity matching analysis was used. RESULTS: After propensity matching, 146 patients were included in each group. There were no differences in mean blood glucose levels (163.6±21.2 vs 159.6±19.2mg/dl, p=.210). Patients on the linagliptin-basal insulin regimen had a lower total number of hypoglycaemic episodes (36 vs 64, p<.001), lower total insulin dose (24.1±5.3 vs 32.0±5.6 units, p<.001), and lower number of daily injections (2.4±.8 vs 4.0±.0, p<.001) than those on the basal-bolus regimen. CONCLUSIONS: Linagliptin-basal insulin was a safe, simple, and efficacious regimen and could be considered standard of care for these vulnerable, high complex patients to simplify in-hospital management.

Clinical benefits of empagliflozin in very old patients with type 2 diabetes hospitalized for acute heart failure.

BACKGROUND: There is little evidence on the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in older patients with heart failure. This work analyzed the clinical efficacy and safety of empagliflozin continuation in very old patients with type 2 diabetes hospitalized for acute decompensated heart failure. METHODS: We conducted a real-world observational study between September 2015 and June 2021. Patients ≥80 years were grouped by antihyperglycemic regimen: (1) continuation of preadmission empagliflozin combined with basal insulin regimen and (2) conventional basal-bolus insulin regimen. A propensity score matching analysis matched patients in both groups in a 1:1 manner. The primary outcome was differences in clinical efficacy measured by the visual analogue scale dyspnea score, NT-proBNP levels, diuretic response, and cumulative urine output. Safety endpoints such as adverse events, worsening heart failure, discontinuation of empagliflozin, length of hospital stay, and in-hospital deaths were also analyzed. RESULTS: After propensity score matching, 79 patients were included in each group. At discharge, the N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were lower in the empagliflozin continuation group than in the insulin group (1699 ± 522 vs. 2303 ± 598 pg/ml, p = 0.021). Both the diuretic response and cumulative urine output were greater in patients treated with empagliflozin than in patients with basal-bolus insulin during the hospitalization (at discharge: -0.14 ± -0.06 vs. -0.24 ± -0.10, p = 0.044; and 16,100 ± 1510 vs. 13,900 ± 1220 ml, p = 0.037, respectively). No differences were observed in safety outcomes. CONCLUSIONS: In very old patients with type 2 diabetes hospitalized for acute heart failure, continuing preadmission empagliflozin reduced NT-proBNP levels and increased diuretic response and urine output compared to a basal-bolus insulin regimen. The empagliflozin regimen also showed a good safety profile.

Efficacy and Safety of Empagliflozin Continuation in Patients with Type 2 Diabetes Hospitalised for Acute Decompensated Heart Failure.

There is little evidence on the use of sodium-glucose cotransporter 2 inhibitors in hospitalised patients. This work aims to analyse the glycaemic and clinical efficacy and safety of empagliflozin continuation in patients with type 2 diabetes hospitalised for acute decompensated heart failure. This real-world observational study includes patients treated using our in-hospital antihyperglycaemic regimens (basal-bolus insulin vs. empagliflozin-basal insulin) between 2017 and 2020. A propensity matching analysis was used to match a patient on one regimen with a patient on the other regimen. Our primary endpoints were the differences in glycaemic control, as measured via mean daily blood glucose levels, and differences in the visual analogue scale dyspnoea score, NT-proBNP levels, diuretic response, and cumulative urine output. Safety endpoints were also analysed. After a propensity matching analysis, 91 patients were included in each group. There were no differences in mean blood glucose levels (152.1 ± 17.8 vs. 155.2 ± 19.7 mg/dL, p = 0.289). At discharge, NT-proBNP levels were lower and cumulative urine output greater in the empagliflozin group versus the basal-bolus insulin group (1652 ± 501 vs. 2101 ± 522 pg/mL, p = 0.032 and 16,100 ± 1510 vs. 13,900 ± 1220 mL, p = 0.037, respectively). Patients who continued empagliflozin had a lower total number of hypoglycaemic episodes (36 vs. 64, p < 0.001). No differences were observed in adverse events, length of hospital stay, or in-hospital deaths. For patients with acute heart failure, an in-hospital antihyperglycaemic regimen that includes continuation of empagliflozin achieved effective glycaemic control, lower NT-proBNP, and greater urine output. It was also safer, as it reduced hypoglycaemic episodes without increasing other safety endpoints.

Glycaemic efficacy and safety of linagliptin for the management of non-cardiac surgery patients with type 2 diabetes in a real-world setting: Lina-Surg study.

Introduction: The use of dipeptidyl peptidase-4 inhibitors in hospitalized patients is an area of active research. We aimed to compare the efficacy and the safety of the basal-bolus insulin regimen versus linagliptin-basal insulin in non-critically ill non-cardiac surgery patients in a real-world setting. Methods: We enrolled patients with type 2 diabetes hospitalized in non-cardiac surgery departments with admission glycated haemoglobin level < 8%, admission blood glucose concentration < 240 mg/dL, and no at-home injectable treatments who were treated with basal-bolus (n = 347) or linagliptin-basal (n = 190) regimens between January 2016 and December 2017. To match patients on the two regimens, a propensity matching analysis was performed. Results: After matching, 120 patients were included in each group. No differences were noted in mean blood glucose concentration after admission (p = .162), number of patients with a mean blood glucose 100-140 mg/dL (p = .163) and > 200 mg/dL (p = .199), and treatment failures (p = .395). Total daily insulin and number of daily insulin injections were lower in the linagliptin-basal group (both p < .001). Patients on linagliptin-basal insulin had fewer hypoglycaemic events (blood glucose < 70 mg/dL) (p < .001). Conclusion: For type 2 diabetes surgery patients with mild to moderate hyperglycaemia without pre-hospitalization injectable therapies, linagliptin-basal insulin was an effective, safe alternative with fewer hypoglycaemic events in real-world practice. Key messages Treatment with basal-bolus insulin regimens is the standard of care for non-critically ill hospitalized patients with type 2 diabetes. A differentiated treatment protocol that takes into account glycaemic control and clinical factors should be implemented in the hospital setting. Linagliptin-basal insulin is an effective, safe alternative with fewer hypoglycaemic events during the hospitalization of non-critically ill non-cardiac surgery patients with T2D in real-world practice.

Assessment of long-term cognitive impairment after off-pump coronary-artery bypass grafting and related risk factors.

OBJECTIVES: To assess cognitive impairment after off-pump coronary-artery bypass grafting, with a particular emphasis on long-term follow-up and related risk factors. DESIGN: Prospective study. SETTING: Virgen de la Victoria University Hospital, Málaga, Spain. PARTICIPANTS: Participants were 36 patients undergoing off-pump coronary-artery bypass grafting. MEASUREMENTS: Changes in the neuropsychological test battery administered from before to after surgery (1, 6, and 12 months). Postoperative cognitive impairment was defined by a significant decrease. RESULTS: A significantly multidomain (attention-executive functions, P < .01; immediate and delayed memory, P < .001; and verbal fluency, P < .05) postoperative cognitive impairment was shown, being maximum at 6 months (more than 50% of patients) and still presented at 12 months (more than 30% of patients), but partially recovered. Related risk factors as smoking (P < .01), diabetes mellitus (P < .01), peripheral arteriopathy (P < .01), obesity (P < .05), lower hematocrit (P < .01), and hemoglobin (P < .05) levels and diastolic blood pressure (P < .05) were identified as predictors of cognitive impairment. Better New York Heart Association class (P < .01) and less severity of angina (P < .01) were associated with partial postoperative recovering. CONCLUSION: A multidomain long-term postoperative cognitive impairment and a partial neurocognitive recovering were detected after off-pump coronary-artery bypass grafting and were associated with several nonspecific surgery factors. These findings may be useful when counseling patients before surgery and suggest the importance of long-term neurocognitive evaluation.

Simplified glycaemic management for patients with type 2 diabetes admitted for acute decompensated heart failure using linagliptin

Introduction and objectives:Hyperglycaemia in hospitalized patients with type 2 diabetes is preferably managed with insulin. We aimed to analyse the glycaemic efficacy, treatment simplicity, and safety of our hospital's antihyperglycemic regimens (linagliptin-basal insulin versus basal-bolus insulin) in patients with type 2 diabetes admitted for heart failure decompensation.Patients and methods:In this real-world study, we included patients with mild-to-moderate hyperglycaemia managed with our antihyperglycemic regimens between 2016 and 2018. To match patients who started one of the regimens, a propensity matching analysis was used.Results:After propensity matching, 146 patients were included in each group. There were no differences in mean blood glucose levels (163.6±21.2 vs 159.6±19.2mg/dl, p=.210). Patients on the linagliptin-basal insulin regimen had a lower total number of hypoglycaemic episodes (36 vs 64, p<.001), lower total insulin dose (24.1±5.3 vs 32.0±5.6 units, p<.001), and lower number of daily injections (2.4±.8 vs 4.0±.0, p<.001) than those on the basal-bolus regimen.Conclusions:Linagliptin-basal insulin was a safe, simple, and efficacious regimen and could be considered standard of care for these vulnerable, high complex patients to simplify in-hospital management.

Fundamentos y objetivos:La hiperglucemia hospitalaria se maneja preferiblemente con insulina. Nuestro objetivo fue analizar la eficacia glucémica, simplificación del tratamiento y seguridad de los regímenes hospitalarios de manejo de la hiperglucemia (insulina basal-linagliptina versus insulina basal-bolo) en pacientes con diabetes mellitus de tipo 2 ingresados por insuficiencia cardíaca descompensada.Material y métodos:En este estudio de vida real, se incluyó a pacientes con hiperglucemia leve/moderada manejados con nuestros regímenes entre 2016 y 2018. Para emparejar a los pacientes que comenzaban alguno de los regímenes se usó un análisis de propensiones.Resultados:Tras el análisis de propensiones, 146 pacientes fueron incluidos en cada grupo. No hubo diferencias en los niveles de glucosa medios (163,6±21,2 vs. 159,6±19,2mg/dl; p=0,210). Los pacientes con el régimen de insulina basal-linagliptina tuvieron menos hipoglucemias (36 vs. 64; p<0,001), menos insulina total (24,1±5,3 vs. 32±5,6 unidades; p<0,001) y menos inyecciones diarias (2,4±0,8 vs. 4±0; p<0,001) que los pacientes del régimen basal-bolo.Conclusiones:El régimen de insulina basal-linagliptina fue seguro, simple y eficaz y podría ser considerado como tratamiento de referencia para estos pacientes vulnerables y con alta complejidad clínica, con lo que se simplificaría el manejo hospitalario. (AU)

Evaluación y tratamiento de los problemas de sueño en niños diagnosticados de trastorno por déficit de atención/hiperactividad: actualización de la evidencia / Evaluation and treatment of sleep problems in children diagnosed with attention deficit hyperactivity disorder: an update of the evidence

Introducción. El trastorno por déficit de atención/hiperactividad (TDAH) afecta aproximadamente al 5% de los niños y adolescentes, y los problemas del sueño son comunes en estos pacientes. Sin embargo, la asociación entre los trastornos del sueño y el TDAH es multifacética y compleja. Objetivo. Explorar la relación entre los trastornos del sueño y el TDAH. Desarrollo. Los problemas del sueño en niños con TDAH incluyen alteraciones del sueño y trastornos específicos per se o debidos a trastornos psiquiátricos comórbidos o a los fármacos estimulantes para el TDAH. Actualmente se recomienda la evaluación de las condiciones del sueño en niños con TDAH antes de la iniciación del tratamiento farmacológico. La primera línea de actuación para el manejo de los problemas de sueño es la higiene del sueño y la psicoterapia cognitivo-conductual. Otra opción es considerar la modificación de la posología y formulación de los fármacos estimulantes. La atomoxetina y la melatonina son alternativas terapéuticas para los niños con TDAH y problemas del sueño más graves. Para los trastornos respiratorios y del movimiento en el sueño existen tratamientos específicos. Conclusiones. Es importante evaluar el sueño en los niños que presentan síntomas sugestivos de TDAH, ya que los problemas en el sueño pueden desempeñar un papel causal o exacerbar la clínica del TDAH. Una correcta evaluación y tratamiento de los trastornos del sueño aumentan la calidad de vida de la familia y del niño y pueden disminuir la gravedad de los síntomas del TDAH (AU)

Introduction. Attention deficit hyperactivity disorder (ADHD) affects approximately 5% of all children and adolescents, and these patients frequently suffer from sleep problems. The association between sleep disorders and ADHD, however, is multifaceted and complex. AIMS. To explore the relationship between sleep disorders and ADHD. DEVELOPMENT. Sleep problems in children with ADHD include altered sleep and specific disorders per se or that may be due to comorbid psychiatric disorders or to the stimulants they receive as treatment for their ADHD. Today, an evaluation of the sleep conditions in children with ADHD is recommended before starting pharmacological treatment. The first step in managing their sleep problems is good sleep hygiene and cognitive-behavioural psychotherapy. Another option is to consider modifying the dosage and formulation of the stimulants. Atomoxetine and melatonin are therapeutic alternatives for children with ADHD and more severe sleep problems. Specific treatments exist for respiratory and movement disorders during sleep. Conclusions: It is important to evaluate sleep in children who present symptoms suggestive of ADHD, since problems during sleep can play a causal role or exacerbate the clinical features of ADHD. Correct evaluation and treatment of sleep disorders increase the family’s and the child’s quality of life and can lessen the severity of the symptoms of ADHD (AU)