ABSTRACT
Background: We investigated whether abatacept, a selective costimulation modulator, provides additional benefit when added to standard-of-care for patients hospitalized with Covid-19. Methods: We conducted a master protocol to investigate immunomodulators for potential benefit treating patients hospitalized with Covid-19 and report results for abatacept. Intravenous abatacept (one-time dose 10 mg/kg, maximum dose 1000 mg) plus standard of care (SOC) was compared with shared placebo plus SOC. Primary outcome was time-to-recovery by day 28. Key secondary endpoints included 28-day mortality. Results: Between October 16, 2020 and December 31, 2021, a total of 1019 participants received study treatment (509 abatacept; 510 shared placebo), constituting the modified intention-to-treat cohort. Participants had a mean age 54.8 (SD 14.6) years, 60.5% were male, 44.2% Hispanic/Latino and 13.7% Black. No statistically significant difference for the primary endpoint of time-to-recovery was found with a recovery-rate-ratio of 1.14 (95% CI 1.00-1.29; p=0.057) compared with placebo. We observed a substantial improvement in 28-day all-cause mortality with abatacept versus placebo (11.0% vs. 15.1%; odds ratio [OR] 0.62 [95% CI 0.41- 0.94]), leading to 38% lower odds of dying. Improvement in mortality occurred for participants requiring oxygen/noninvasive ventilation at randomization. Subgroup analysis identified the strongest effect in those with baseline C-reactive protein >75mg/L. We found no statistically significant differences in adverse events, with safety composite index slightly favoring abatacept. Rates of secondary infections were similar (16.1% for abatacept; 14.3% for placebo). Conclusions: Addition of single-dose intravenous abatacept to standard-of-care demonstrated no statistically significant change in time-to-recovery, but improved 28-day mortality. Trial registration: ClinicalTrials.gov ( NCT04593940 ).
ABSTRACT
BACKGROUND: Hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) are associated with high mortality rates. We evaluated the efficacy and safety of tedizolid (administered as tedizolid phosphate) for treatment of gram-positive ventilated HABP/VABP. METHODS: In this randomized, noninferiority, double-blind, double-dummy, global phase 3 trial, patients were randomized 1:1 to receive intravenous tedizolid phosphate 200 mg once daily for 7 days or intravenous linezolid 600 mg every 12 hours for 10 days. Treatment was 14 days in patients with concurrent gram-positive bacteremia. The primary efficacy end points were day 28 all-cause mortality (ACM; noninferiority margin, 10%) and investigator-assessed clinical response at test of cure (TOC; noninferiority margin, 12.5%) in the intention-to-treat population. RESULTS: Overall, 726 patients were randomized (tedizolid, n = 366; linezolid, n = 360). Baseline characteristics, including incidence of methicillin-resistant Staphylococcus aureus (31.3% overall), were well balanced. Tedizolid was noninferior to linezolid for day 28 ACM rate: 28.1% and 26.4%, respectively (difference, -1.8%; 95% confidence interval [CI]: -8.2 to 4.7). Noninferiority of tedizolid was not demonstrated for investigator-assessed clinical cure at TOC (tedizolid, 56.3% vs linezolid, 63.9%; difference, -7.6%; 97.5% CI: -15.7 to 0.5). In post hoc analyses, no single factor accounted for the difference in clinical response between treatment groups. Drug-related adverse events occurred in 8.1% and 11.9% of patients who received tedizolid and linezolid, respectively. CONCLUSIONS: Tedizolid was noninferior to linezolid for day 28 ACM in the treatment of gram-positive ventilated HABP/VABP. Noninferiority of tedizolid for investigator-assessed clinical response at TOC was not demonstrated. Both drugs were well tolerated. CLINICAL TRIALS REGISTRATION: NCT02019420.
Subject(s)
Methicillin-Resistant Staphylococcus aureus , Pneumonia, Bacterial , Skin Diseases, Bacterial , Anti-Bacterial Agents/adverse effects , Double-Blind Method , Hospitals , Humans , Linezolid/adverse effects , Organophosphates , Oxazoles , Pneumonia, Bacterial/drug therapy , Skin Diseases, Bacterial/drug therapy , Ventilators, MechanicalABSTRACT
BACKGROUND: Imipenem combined with the ß-lactamase inhibitor relebactam has broad antibacterial activity, including against carbapenem-resistant gram-negative pathogens. We evaluated efficacy and safety of imipenem/cilastatin/relebactam in treating hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP). METHODS: This was a randomized, controlled, double-blind phase 3 trial. Adults with HABP/VABP were randomized 1:1 to imipenem/cilastatin/relebactam 500 mg/500 mg/250 mg or piperacillin/tazobactam 4 g/500 mg, intravenously every 6 hours for 7-14 days. The primary endpoint was day 28 all-cause mortality in the modified intent-to-treat (MITT) population (patients who received study therapy, excluding those with only gram-positive cocci at baseline). The key secondary endpoint was clinical response 7-14 days after completing therapy in the MITT population. RESULTS: Of 537 randomized patients (from 113 hospitals in 27 countries), the MITT population comprised 264 imipenem/cilastatin/relebactam and 267 piperacillin/tazobactam patients; 48.6% had ventilated HABP/VABP, 47.5% APACHE II score ≥15, 24.7% moderate/severe renal impairment, 42.9% were ≥65 years old, and 66.1% were in the intensive care unit. The most common baseline pathogens were Klebsiella pneumoniae (25.6%) and Pseudomonas aeruginosa (18.9%). Imipenem/cilastatin/relebactam was noninferior (Pâ <â .001) to piperacillin/tazobactam for both endpoints: day 28 all-cause mortality was 15.9% with imipenem/cilastatin/relebactam and 21.3% with piperacillin/tazobactam (difference, -5.3% [95% confidence interval {CI}, -11.9% to 1.2%]), and favorable clinical response at early follow-up was 61.0% and 55.8%, respectively (difference, 5.0% [95% CI, -3.2% to 13.2%]). Serious adverse events (AEs) occurred in 26.7% of imipenem/cilastatin/relebactam and 32.0% of piperacillin/tazobactam patients; AEs leading to treatment discontinuation in 5.6% and 8.2%, respectively; and drug-related AEs (none fatal) in 11.7% and 9.7%, respectively. CONCLUSIONS: Imipenem/cilastatin/relebactam is an appropriate treatment option for gram-negative HABP/VABP, including in critically ill, high-risk patients. CLINICAL TRIALS REGISTRATION: NCT02493764.
Subject(s)
Cilastatin , Imipenem , Adult , Aged , Anti-Bacterial Agents/adverse effects , Azabicyclo Compounds , Cilastatin/adverse effects , Hospitals , Humans , Imipenem/adverse effects , Piperacillin , Tazobactam , Ventilators, MechanicalABSTRACT
OBJETIVO: Determinar el control de la presión arterial sistólica (PAS) de forma retrospectiva según las recomendaciones de la guía ESC/ESH-2018 y su probable asociación con la mortalidad en pacientes octogenarios con demencia. PACIENTES Y MÉTODOS: Estudio preliminar, longitudinal, observacional y retrospectivo que incluyó 65 pacientes ≥80 años con diagnóstico de demencia e hipertensión arterial ingresados en una unidad de psicogeriatría durante 2015. Las variables principales fueron: control de la PAS según las recomendaciones de la guía ESC/ESH-2018, considerando PAS deseable (130-139mmHg), PAS no deseable (subóptima <130mmHg, elevada ≥140mmHg) y la mortalidad a 3 años en aquellos pacientes con tratamiento antihipertensivo al alta (n=53). RESULTADOS: Edad media, 86,7±4,31 años (63% mujeres); dependencia funcional severa (índice de Barthel <40): 67,7%; deterioro cognitivo grave (GDS-Riesberg ≥6): 86,3%; elevada comorbilidad: 49%; mortalidad a 3 años: 41 (63,1%). Los pacientes con hipertensión arterial y comorbilidad cardiovascular presentaron mayor prescripción de antihipertensivos (2,07 vs.1,18; p = 0,002). La mortalidad a 3 años fue menor en aquellos con PAS deseable (44,4%) respecto a PAS no deseable (72,7%), aunque no fue estadísticamente significativo. CONCLUSIONES: El porcentaje de pacientes en tratamiento con PAS subóptima fue elevado especialmente en hipertensos sin comorbilidad cardiovascular. Encontramos una tendencia a mayor mortalidad en los grupos de PAS no deseable respecto a PAS deseable
OBJECTIVE: To determine the control of systolic blood pressure (SBP) retrospectively according to the recommendations of the ESC/ESH-2018 guideline and its relationship with mortality in octogenarian patients with dementia. PATIENTS AND METHODS: Preliminary, longitudinal, observational, retrospective study, including 65 patients ≥80 years with diagnosis of dementia and arterial hypertension admitted to a psychogeriatric unit during 2015. The main variables were SBP control according to the recommendations of the ESC/ESH-2018 guideline, considering desirable SBP (130-139mmHg), undesirable SBP (suboptimal <130mmHg and elevated SBP ≥140mmHg) and mortality at 3 years in patients with antihypertensive treatment at discharge (n = 53). RESULTS: Mean age, 86.7±4.31 years (63% women); severe functional dependence (Barthel index <40): 67.7%; severe cognitive impairment (GDS-Riesberg ≥6): 86.3%; high comorbidity: 49%; mortality at 3 years: 41 (63.1%). Patients with arterial hypertension and cardiovascular comorbidity had a higher prescription of antihypertensive drugs (2.07 vs.1.18, p=.002). Three years mortality was lower in patients with desirable SBP (44.4%) versus undesirable SBP (72.7%) groups, although it was not statistically significant. CONCLUSIONS: The percentage of patients in treatment with suboptimal SBP was elevated especially in hypertensive patients without cardiovascular comorbidity. We found a trend for higher mortality in undesirable SBP groups compared to desirable SBP
Subject(s)
Humans , Female , Aged, 80 and over , Hypertension/therapy , Dementia/diagnosis , Blood Pressure/drug effects , Practice Guidelines as Topic/standards , Retrospective Studies , Longitudinal Studies , Hypertension/mortality , Cognitive Dysfunction/diagnosis , Hospital Mortality , Kaplan-Meier EstimateABSTRACT
OBJECTIVE: To determine the control of systolic blood pressure (SBP) retrospectively according to the recommendations of the ESC/ESH-2018 guideline and its relationship with mortality in octogenarian patients with dementia. PATIENTS AND METHODS: Preliminary, longitudinal, observational, retrospective study, including 65 patients ≥80 years with diagnosis of dementia and arterial hypertension admitted to a psychogeriatric unit during 2015. The main variables were SBP control according to the recommendations of the ESC/ESH-2018 guideline, considering desirable SBP (130-139mmHg), undesirable SBP (suboptimal <130mmHg and elevated SBP ≥140mmHg) and mortality at 3 years in patients with antihypertensive treatment at discharge (n = 53). RESULTS: Mean age, 86.7±4.31 years (63% women); severe functional dependence (Barthel index <40): 67.7%; severe cognitive impairment (GDS-Riesberg ≥6): 86.3%; high comorbidity: 49%; mortality at 3 years: 41 (63.1%). Patients with arterial hypertension and cardiovascular comorbidity had a higher prescription of antihypertensive drugs (2.07 vs. 1.18, p=.002). Three years mortality was lower in patients with desirable SBP (44.4%) versus undesirable SBP (72.7%) groups, although it was not statistically significant. CONCLUSIONS: The percentage of patients in treatment with suboptimal SBP was elevated especially in hypertensive patients without cardiovascular comorbidity. We found a trend for higher mortality in undesirable SBP groups compared to desirable SBP.
Subject(s)
Dementia , Hypertension , Aged, 80 and over , Antihypertensive Agents/therapeutic use , Blood Pressure , Dementia/epidemiology , Female , Follow-Up Studies , Humans , Hypertension/complications , Hypertension/drug therapy , Hypertension/epidemiology , Male , Retrospective Studies , Risk FactorsABSTRACT
La presencia de deterioro cognitivo y del síndrome demencial es un hecho conocido desde la antigüedad. Desde la aceptación del termino demencia como un deterioro cognitivo adquirido y de causa orgánica a finales del siglo XIX la medicina ha buscado sus posibles etiologías y ha ensayado diferentes terapéuticas para su tratamiento. Se consideran demencias reversibles aquellos procesos demenciales en los que se detecta una causa o factor etiológico curable, en las que una vez corregido, el proceso demencial revierte parcial o totalmente. Hasta finales de los años ochenta se pensaba que la prevalencia de la de las demencias reversibles oscilaba entre un 10 y un 40%. Sin embargo, posteriormente se constata que a pesar de corregir posibles factores reversibles, en la mayoría de los casos la demencia permanece y se empieza a utilizar el término demencias potencialmente reversibles, objetivándose que la reversibilidad de las demencias es un hecho real pero bastante infrecuente. La detección y el tratamiento de los factores reversibles dentro de una evaluación integral del paciente con demencia comportan un mejor control sintomático global y una mejor calidad de vida en la mayoría de ocasiones para el paciente y la familia (AU)
Cognitive impairment and dementia syndrome are historically well-known conditions. Since the term "dementia" was accepted as an organically-caused, acquired cognitive impairment by the end of the 19th century, medical research has looked into their potential aetiologies and has tried different therapies for a successful treatment. Some dementias are reversible: that is, they have a treatable aetiological cause or factor that, once corrected, results in a partial or total reversion of the dementia-related symptoms. Until as recently as the late 1980s, researchers thought that reversible dementias amounted to somewhere between 10 and 40 percent of all dementias. As of late, though, new evidence has shown that, in spite of the fact that some reversible factors are effectively reverted, dementia stays inmost cases. Hence the use of "potentially reversible dementias" as a more accurate description, as it highlights the fact that dementia reversibility is possible, yet rather unusual. Detecting and treating reversible factors within a comprehensive evaluation process of the dementia patient result in an improved overall symptomatic control and a better quality of life for most dementia patients and their relatives (AU)
Subject(s)
Humans , Male , Female , Aged , Dementia/therapy , Cognition Disorders/therapy , Recovery of Function , Dementia/diagnosisABSTRACT
Se presenta un estudio retrospectivo realizado en la unidad de cuidados intensivos del nuevo Hospital Civil de Guadalajara con paciente que desarrolló preeclampsia severa y síndrome HELLP, 70 pacientes de las cuales 30 desarrollaron insuficiencia renal aguda, de éstas 25 fueron catalogadas como necrosis tubular aguda y cinco con necrosis cortical bilateral. Todas las pacientes (30) con insuficiencia renal aguda presentaron hipertensión arterial severa, además de depleción de volumen plasmático circulante con un promedio de PVC de 6 cm de agua (en 20 pacientes), los promedios de urea de 64.2 mg/dl y creatinina 4.2 mg/dl. Seis pacientes del grupo fallecieron, tres por hemorragia cerebral, dos choque hipovolémico y una paciente por falla multisistémica. La causa del desarrollo de insuficiencia renal aguda se debe a disminución del volumen circulante, endoteliosis glomerular y vasoconstricción severa
Subject(s)
Humans , Female , Adolescent , Adult , Acute Kidney Injury/etiology , Cerebral Hemorrhage/etiology , Cerebral Hemorrhage/mortality , Renal Insufficiency, Chronic/complications , Multiple Organ Failure/etiology , Multiple Organ Failure/mortality , Pre-Eclampsia/complications , Retrospective Studies , Shock/etiology , Shock/mortality , HELLP Syndrome/complications , Time FactorsABSTRACT
Se presentan dos casos de síndrome de hellp complicados con hematoma subcapsular e infarto hepáticos. La presentación de ambas pacientes fue con tendencia a la hipotensión posterior a la interrupción quirúrgica del embarazo, con grandes requerimientos de sangre y hemoderivados leucocitosis importante, insuficiencia renal e insuficiencia hepática severa que ocasionó que ambas pacientes desarrollan encefalopatía hepatíca grado III-IV, una paciente falleció con falla multisistémica y la otra paciente sobrevivió pero con signos de daño hepático residual
Subject(s)
Humans , Female , Adult , Abortion, Induced , Hepatic Encephalopathy/diagnosis , Hepatic Encephalopathy/etiology , Hematoma/diagnosis , Hematoma/etiology , Liver/blood supply , Hepatic Insufficiency/diagnosis , Hepatic Insufficiency/etiology , Liver Diseases/diagnosis , Liver Diseases/etiology , Multiple Organ Failure/etiology , HELLP Syndrome/complications , HELLP Syndrome/diagnosis , Liver Function TestsABSTRACT
Se describe el caso clínico de una paciente de 14 años de edad, la cual presentó un embarazo molar, hipertención e infarto cerebral isquémico en región temporoparietal izquierda. Se determinaron anticuerpos anticoagulantes lúpicos, resultados positivos, correspondiendo el cuadro clínico a un síndrome de anticuerpos antifosfolípidos, el cual clínicamente se asocia a trastornos oclusivos arteriales o venosos en diversas regiones del organismo, así como también a trombosis venosas profundas en extremidades, cerebro y pulmón, además de relacionarse con pérdidas recurrentes de embarazos tempranos, preeclampsia severa de aparición temprana de retardo en el crecimiento intrauterino
Subject(s)
Humans , Female , Adolescent , Cerebral Infarction , Cerebral Infarction/diagnosis , Cerebral Infarction/etiology , Cerebrum , Pregnancy Complications, Neoplastic/diagnosis , Follow-Up Studies , Hydatidiform Mole/diagnosis , Pregnancy Complications, Cardiovascular/diagnosis , Pregnancy Complications/diagnosis , Antiphospholipid Syndrome/complications , Antiphospholipid Syndrome/diagnosis , Time Factors , Tomography, X-Ray Computed , Uterine Neoplasms/diagnosisABSTRACT
Respectivamente revisamos 15 casos de preclampsia severa con síndrome HELLP. Las pacientes presentaron hipertensión arterial severa, los síntomas principales fueron dolor en epigastrio e hipocondrio derecho que se presentó en 66.6 por ciento de las pacientes, náuseas y vómitos en 53.8 por ciento y edema de miembros inferiores en 60 por ciento. La principal edad de afección fue en la tercera década de la vida, y el tercer trimestre del embarazo en el que se presentaron todos los cuadros, la complicación principal fue insuficiencia renal aguda en 80 por ciento de las pacientes, tres pacientes fallecieron 20 por ciento, las causas fueron SIRPA, hemorragia cerebral y choque hipovolémico
