Factors Associated with Surrogate Self-Efficacy in Decision-Making for Patients with End-Stage Renal Disease.

AIM: The aim of the study is to assess which factors are associated with self-efficacy for making these decisions in surrogates of end-stage kidney disease patients. MATERIALS AND METHODS: Cross-sectional study conducted in the hemodialysis clinic of a private hospital in Mexico City. A total of 124 surrogates of patients in hemodialysis were included in the study. Self-efficacy for decision-making was assessed with the Family Decision-Making Self-Efficacy Scale. As factors related to decision-making self-efficacy, sociodemographic data, health information, and professional help received for dealing with end-of-life issues were assessed in both patients and surrogates. Functional status and advanced directives of the patient as well as prior experience in decision-making of the surrogates were also included. Logistic regression models were used to establish the associations. RESULTS: The mean age of participants was 49.4 years (standard deviation: 14). Factors associated to decision-making self-efficacy were awareness of the surrogate about the terminal disease of the patient (P < 0.001), prior conversation between the surrogate and the patient about end-of-life preferences (P = 0.037), time between the patient was told dialysis was required and accepting it inferior to 1 month (P = 0.016), and visual impairment of the patient (0.040). CONCLUSIONS: This study provides information of which factors are associated with self-effectiveness in surrogates of terminally ill renal patients so that strategies based on these considerations might be implemented in the future.

[Results of the First Mexican Consensus of Vaccination in the Adult]. / Resultados del Primer Consenso Mexicano de Vacunación en el Adulto.

For years our efforts have been focused on vaccination during childhood. Today we know that this is not enough to ensure health in the rest of the life. Childhood is as important as any other stage and, therefore, vaccination must be permanent and differentiated, according to our age, throughout life. Introducing a life course perspective in vaccination programs, with emphasis on adult vaccination, particularly in older adults, offers us the opportunity to review the performance of health programs, actions, and services in the field of immunization, as well as strengthening health promotion actions. In this context, the first Mexican Consensus on Adult Vaccination was carried out in a joint effort of the National Institute of Geriatrics, bringing together a group of specialists who worked on three central objectives: establishing vaccination guidelines throughout the life course, with emphasis on new vaccines; defining priority groups according to their risk factors; and contributing to the effort to promote healthy aging.

[First Mexican Consensus of Vaccination in Adults]. / 1º Consenso Mexicano de Vacunación en el Adulto.

For years our efforts have been focused on vaccination during childhood. Today we know that this is not enough to ensure health in the rest of the life. Childhood is as important as any other stage and, therefore, vaccination must be permanent and differentiated, according to our age, throughout life. Introducing a life course perspective in vaccination programs, with emphasis on adult vaccination, particularly in older adults, offers us the opportunity to review the performance of health programs, actions, and services in the field of immunization, as well as strengthening health promotion actions. In this context, the first Mexican Consensus on Adult Vaccination was carried out in a joint effort of the National Institute of Geriatrics, bringing together a group of specialists who worked on three central objectives: establishing vaccination guidelines throughout the life course, with emphasis on new vaccines; defining priority groups according to their risk factors; and contributing to the effort to promote healthy aging.

Influence of aortic regurgitation after TAVI on left ventricular filling pattern.

BACKGROUND: Paravalvular aortic regurgitation after transcatheter aortic valve implantation is associated with a hemodynamic deterioration and a poor outcome. We aim to determine the early hemodynamic effect of paravalvular aortic regurgitation in relation with the change in the left ventricle filling pattern and to assess their clinical outcome. MATERIAL AND METHODS: Eighty-two consecutive patients referred for transcatheter aortic valve implantation were included. Patients were classified according to the change in the left ventricular filling pattern, and significant paravalvular aortic regurgitation (grade ≥ 2) was reported. Follow-up and incidence of death and hospitalization for heart failure were reported. RESULTS: Sixteen patients (19·5%) presented a worsening of left ventricular filling pattern. The incidence of significant paravalvular aortic regurgitation was higher in the group with a worsening of left ventricular filling pattern (56·3% vs. 19·7%; P = 0·009). In the multivariate analysis, the only variable significantly associated with the worsening of left ventricular filling pattern was the significant paravalvular aortic regurgitation (OR 4·84; 95% CI 1·23 - 19·1; P = 0·024). During the follow-up (642·5 days), there was a higher incidence of the endpoint of death or hospitalization for heart failure in the group with a worsening of left ventricular filling pattern (62·5% vs. 31·8%; P = 0·042) and a lower event-free survival rate (long rank test = 0·013). CONCLUSIONS: The presence of a significant paravalvular aortic regurgitation is associated with a worsening in parameters of diastolic function. This finding should alert the cardiologist as patients with a worsening of left ventricular filling pattern present a higher incidence of paravalvular aortic regurgitation and a less favourable outcome.

De-escalating treatment indications for patients who achieve metabolic goals.

INTRODUCTION: Robust evidence exists regarding initiation, intensification or modification of treatments. Recommendations to de-escalate therapy are lacking, specifically in diabetes. A successful treatment de-intensification reduces overtreatment, polypharmacy, and risk of adverse effects. OBJECTIVE: To encompass current recommendations for deprescribing common drugs and create a consensus among health professionals. METHODS: We reviewed four databases for deprescribing approaches published between 2010 and 2022. Articles were divided into different groups of drugs (for uric-acid, hypoglycemic, lipid-lowering, and psychotropic drugs). RESULTS: Hypoglycemic agents: strategies were limited to newer agents and insulin regimens for elderly individuals. Reducing insulin was associated with 1.1% reduction of A1c over time. SGLT2i and GLP-1RAs dose reduction depends on adverse events. Lipid-lowering agents: studies show that patients with very low cholesterol have fewer cardiovascular events without associated increased risk. Antihypertensive agents: Younger patients, lower systolic blood pressure, and few comorbidities are ideal characteristics for discontinuation. Uric acid therapy: we found no recommendation for dose de-escalation. Poor treatment adherence is associated with episodes of gout and deforming arthritis in the long term. CONCLUSION: Deprescribing hypoglycemic, statins, antihypertensives, and urate-lowering agents may be feasible in selected patients, but periodic surveillance is important. More evidence is necessary to support this decision entirely.

Optical coherence tomography assessment of pulmonary vascular remodeling in advanced heart failure. The OCTOPUS-CHF study.

INTRODUCTION AND OBJECTIVES: Pulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data. METHODS: This observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery. RESULTS: OCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017). CONCLUSIONS: Direct morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.

Percutaneous coronary intervention with rotational atherectomy for severely calcified unprotected left main: immediate and two-years follow-up results.

INTRODUCTION: According to current practice guidelines, coronary bypass surgery is the standard care option for unprotected left main (ULM) stenosis. However, a group of high surgical risk patients who are not eligible for coronary bypass surgery could benefit from percutaneous coronary intervention (PCI). Severe calcification hampers PCI in this setting, and rotational atherectomy (RA) could be of great help. METHODS: We retrospectively analyzed a cohort of 40 patients with severely calcified ULM stenosis, not eligible for coronary artery bypass grafting, who underwent RA in our center. RESULTS: Forty patients (mean age, 73 ± 8 years; 26 males) with ULM stenosis were treated with RA. Twenty-seven (67%) had distal stenosis. The mean number of treated vessels was 2.38 ± 0.74, with a mean lesion length of 30 ± 18 mm. Abciximab was used in 12 (30%) cases and an intra-aortic balloon pump in three cases. One patient died during the procedure and another two patients died in the first 24 hr after the procedure. The major events registered after the procedure included one significant branch loss, and two minor and one major case of bleeding (the latter requiring transfusion) at the puncture point. After a median of 24.7 (IQR 19.6-34.3) months of follow-up, 12 cardiac deaths were recorded. Survival free of cardiac death was 71 ± 7% and clinical guided target vessel revascularization 19.3 ± 7% at 2 years. CONCLUSION: In a group of high surgical risk patients, RA on severely calcified left main stenosis is feasible and, in spite of high mortality rates, could pose the only possible effective treatment.

Contact pathway in surgical and transcatheter aortic valve replacement.

Background: Aortic valve replacement is the gold standard treatment for severe symptomatic aortic stenosis, but thrombosis of bioprosthetic valves (PVT) remains a concern. Objective: To analyze the factors involved in the contact pathway during aortic valve replacement and to assess their impact on the development of thromboembolic complications. Methods: The study was conducted in 232 consecutive patients who underwent: transcatheter aortic valve replacement (TAVR, N = 155), and surgical valve replacement (SAVR, N = 77) (MUVITAVI project). Demographic and clinical data, outcomes including a combined end point (CEP) of thrombotic events, and imaging controls were recruited. Samples were collected 24 h before and 48 h after valve replacement. FXII, FXI and (pre)kallikrein were evaluated by Western Blot and specific ELISA with nanobodies. Results: The CEP of thrombotic events was reached by 19 patients: 13 patients presented systemic embolic events and 6 patients subclinical PVT. Valve replacement did not cause FXII activation or generation of kallikrein. There was a significant reduction of FXI levels associated with the procedure, which was statistically more pronounced in SAVR than in TAVR. Cases with reductions of FXI below 80% of basal values had a lower incidence of embolic events during the procedure than patients in whom FXI increased above 150%: 2.7 vs. 16.7%; p: 0.04. Conclusion: TAVR or SAVR did not significantly activate the contact pathway. A significant reduction of FXI, was observed, particularly in SAVR, associated with lower incidence of thrombotic events. These results encourage evaluating the usefulness and safety of FXI-directed antithrombotic treatments in these patients.

Pulmonary Vascular Remodeling and Prognosis in Patients Evaluated for Heart Transplantation: Insights from the OCTOPUS-CHF Study.

OBJECTIVE: In patients with advanced heart failure, the intravascular optical coherence tomography (OCT) of subsegmental pulmonary artery measurements is correlated with right heart catheterization parameters. Our aim was to study the prognostic value of pulmonary OCT, right heart catheterization data, and the echocardiographic estimation of pulmonary pressure in patients studied for elective heart transplants. METHODS: This research is an observational, prospective, multicenter study involving 90 adults with a one-year follow-up. RESULTS: A total of 10 patients (11.1%) died due to worsening heart failure before heart transplantation, 50 underwent a heart transplant (55.6%), and 9 died in the first year after the transplant. The patients with and without events (mortality or heart failure-induced hospitalization) had similar data regarding echocardiography, right heart catheterization, and pulmonary OCT (with a median estimated pulmonary artery systolic pressure of 42.0 mmHg, interquartile range (IQR) of 30.3-50.0 vs. 47.0 mmHg, IQR 34.6-59.5 and p = 0.79, median pulmonary vascular resistance of 2.2 Wood units, IQR 1.3-3.7 vs. 2.0 Wood units, IQR 1.4-3.2 and p = 0.99, and a median pulmonary artery wall thickness of 0.2 ± 0.5 mm vs. 0.2 ± 0.6 mm and p = 0.87). CONCLUSION: Pulmonary vascular remodeling (evaluated with echocardiography, right heart catheterization, and pulmonary OCT) was not associated with prognosis in a selected sample of adults evaluated for elective heart transplants. Pulmonary OCT is safe and feasible for the evaluation of these patients.

[Pharmacological treatment of diabetes in the elderly]. / Tratamiento farmacológico de la diabetes en el anciano.

Diabetes mellitus (DM) is a highly prevalent disease in the geriatric population. The elderly are at increased risk for adverse drug reactions (hypoglycemia) compared with the young due to physiological changes associated with age, high number of comorbidities and polypharmacy usually present, causing changes in drugs pharmacokinetics and pharmacodynamics. At present, there are wide therapeutic options to treat DM, so it is important to know the different drug families and their potential side effects. As a general principle, metformin remains an appropriate option for the management of DM in the elderly, first-generation sulfonylureas (chlorpropamide) is preferable not to use due the high risk of hypoglycemia. Some thiazolidinediones have been associated with heart failure, as their use in the elderly is controversial. About the new drugs that act on the DPP-4, results are promising with a low risk profile of adverse reactions. We must consider the use of human insulin or insulin analogues in the elderly when not achieved with other hypoglycaemic agents. At the start of therapy is important to establish the most appropriate management goals based on patient comorbidities and their life expectancy.

The metabolic syndrome, diabetes, and Alzheimer's disease.

BACKGROUND: The metabolic syndrome (MS) is a cluster of metabolic abnormalities that has been controversially associated with Alzheimer's disease (AD), so the purpose of this report was to investigate the association between these two chronic diseases a sample of older persons. METHODS: Case-control study of 90 consecutive outpatients with AD and 180 non-demented controls from a dementia clinic at a tertiary care hospital in Mexico City. Probable or possible AD was diagnosed according to the guidelines of the Consortium to Establish a Registry for Alzheimer's Disease, whereas control participants where those classified as normal by the same instrument. MS was defined according to the World Health Organization criteria. Patients were matched 1:2 by age, sex, and years of education. Conditional regression analysis was used to test the association between MS and AD. RESULTS: Compared to controls, MS was more frequent among AD patients (72.2% vs. 23.3%; P < 0.01). While all components of MS were more frequent among cases than control patients, only diabetes was statistically significant, whereas hypertriglyceridemia and low HDL cholesterol were marginally associated. Conditional regression analysis showed that among AD participants, the probability of having MS was about sevenfold higher than for their non-demented counterparts (OR 6.72, 95% CI 3.72-12.13; P < 0.01). CONCLUSIONS: The MS is a clinical entity that encompasses a diverse range of chronic diseases, which could be a better risk indicator than any individual MS component for adverse health outcomes, like AD. Our findings underscore the harmful role of MS in the health status of the elderly.

Hypertension as a risk factor for developing depressive symptoms among community-dwelling elders.

OBJECTIVE: To determine whether hypertension (HTA) is an independent predictor of depressive symptoms (DS) in a sample of elderly Mexican community-dwelling persons. MATERIAL AND METHODS: Two-year longitudinal study of 3,276 community-dwelling persons aged 60 years and older, participating in the Mexican Health and Aging Study. Subjects that self-reported both having or not having HTA while denying DS at baseline were included. Two-year follow-up data were analyzed, and multiple regression analyses were used to test whether HTA is an independent predictor of incident DS after adjusting for many potential confounders. RESULTS: Mean age of participants was 68.4 +/- 6.9 years. Prevalence of HTA was 36.6%. At follow-up, 28.7% developed DS. After adjusting for multiple covariates (age, sex, education level, relationship status, self-reported health and economic status, diabetes, arthritis, stroke, ischemic cardiopathy, falls, pain, hearing impairment, visual impairment, urinary incontinence, cognitive impairment, smoking, alcohol use, and baseline disability), HTA was an independent predictor of DS at two years followup (Adjusted Odds Ratio = 1.18; 95% confidence interval = 1.01-1.40). CONCLUSIONS: Hypertension is an independent risk factor for the development of depressive symptoms. Programs to support early treatment of cardiovascular disease and hypertension should be implemented in order to prevent late-onset of depressive symptoms.

A new simple method to assess global left ventricular systolic function based on the sum of regional myocardial velocities.

The relations between left ventricular (LV) function and global tissue Doppler velocity, strain rate, and strain were assessed in 99 studies. Significant correlations were found between the LV ejection fraction and global tissue Doppler velocity, strain, and strain rate (r = 0.50, r = 0.63, and r = 0.46, respectively, all p <0.001), suggesting that this global assessment may be useful in evaluating LV function.

Prognostic value of exercise echocardiography in patients with diabetes mellitus and known or suspected coronary artery disease.

To assess the prognostic value of exercise echocardiography in subjects who had diabetes, we studied 214 patients who had 28 hard cardiac events (cardiac death in 15, myocardial infarction in 13) during a follow-up of 44 +/- 16 months. Independent risk factors for predicting cardiac events were insulin therapy (odds ratio 2.313), peak left ventricular ejection fraction (odds ratio 0.973), and ischemia detected by exercise echocardiography (odds ratio 2.513).

The severity of urinary incontinence decreases health-related quality of life among community-dwelling elderly.

BACKGROUND: Urinary incontinence (UI) is an important geriatric syndrome that has been associated with a wide range of health-related outcomes. However, UI severity has rarely been examined in the context of a comprehensive geriatric assessment. Therefore, the aim of this study is to examine the association between UI severity and health-related quality of life (QoL) when frequent geriatric issues are taken into account. METHODS: We performed a cross-sectional study of 1,124 participants aged 70 y and older. UI was diagnosed when difficulty with urinary continence was reported, and its severity was assessed through a modified version of the Sandvik Index. Health-related QoL was measured using the SF-36, including its physical and mental component summaries. Multivariate linear regression was performed to determine the association between UI severity and health-related QoL. RESULTS: Prevalence of UI was 18%, and it was severe in 29.3% of cases. Severely incontinent subjects were older and had worse self-perceived health status, greater disability, and more depressive symptoms in comparison with continent participants or with those affected to a lesser degree. Multivariate regression analysis showed a significant inverse association between the physical component summaries and moderate (B = -4.54) as well as severe UI (B = -6.72). The mental component summaries showed similar results (B = -1.44 and -4.43, respectively). CONCLUSIONS: UI severity is associated with lower QoL scores in both its components. This association appears to be more important as severity increases. UI severity must be evaluated thoroughly in the elderly because of its potential adverse effects on physical and mental health.

Optical coherence tomography and highly sensitivity troponin T for evaluating cardiac allograft vasculopathy.

Cardiac allograft vasculopathy (CAV) is a major impediment to long-term graft survival after heart transplantation. Intravascular ultrasound (IVUS) is more sensitive than coronary angiography for diagnosis, but the identification of specific plaque components or plaque composition is limited. In addition, there is an evident need for other noninvasive tools for diagnosing CAV. The aim of this study was to assess the utility of 2 new techniques for evaluating CAV: optical coherence tomography (OCT), and new high-sensitivity troponin T (hsTnT) assays. In 21 heart transplantation patients, coronary arteriography with IVUS and OCT were performed. Maximal intimal thickness (MIT) and luminal area at the most severe site were measured using the 2 techniques. Immediately before cardiac catheterization, blood samples were obtained and hsTnT levels measured. The evaluation of CAV by OCT showed a good correlation with IVUS measurements, with a mean difference in MIT of 0.0033 (95% confidence interval -0.049 to 0.043), taking advantage of lower interobserver variability (r = 0.94 for OCT vs r = 0.78 for IVUS) and better plaque characterization. When independent predictors of MIT were assessed in a multiple linear regression model, time after transplantation (ß = 0.488, p = 0.004) and hsTnT (ß = 0.392, p = 0.011) were the only independent predictors of MIT (R(2) = 0.591). In conclusion, this study is the first to evaluate 2 new techniques, OCT and hsTnT, in the challenging setting of CAV. The findings suggest that OCT provides lower interobserver variability and better plaque characterization than IVUS. Also, hsTnT could become a useful tool for ruling out CAV.