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BACKGROUND: A new classification of type 1 and 2 myocardial infarction (MI) derived from the fourth universal definition of MI (UDMI) has been recently proposed, based on pathophysiology of coronary artery disease (CAD). We assessed the impact of this new MI categorization on epidemiology and outcomes, considering type 1 MI (T1MI) and type 2 MI (T2MI), with and without CAD. METHODS: Retrospective study including all consecutive patients hospitalized for an acute MI in a multicenter database (RICO). MI was defined according to current UDMI. Rates and outcomes of T1MI and T2MI were addressed according to the new classification. RESULTS: Among the 4,573 patients included in our study, 3,710 patients (81.1%) were initially diagnosed with T1M1 and 863 (18.9%) with T2MI. After reclassification, 96 T2MI patients were moved into the T1MI category. Out of the remaining 767 patients with T2MI, 567 underwent coronary angiography, and were adjudicated as type 2A MI (68.6%) with obstructive CAD, and type 2B MI (31.4%) without obstructive CAD. When compared with T1MI and T2BMI, T2AMI patients had worse in-hospital outcomes, including severe heart failure (P < .001), atrial fibrillation or flutter (P < .001) and severe bleeding (P < .001). Kaplan-Meier 1-year survival curves showed higher all-cause and CV causes mortality in T2AMI patients compared to T1MI and T2BMI (P < .001). In multivariate Cox regression analysis, type of MI was independent predictor of death. CONCLUSION: Our large observational multicenter study shows major disparities in mortality according to type of MI and support the relevance of the new MI classification to improve risk classification, taking into account CAD in T2MI. Our findings may help identifying specific phenotypes and considering personalized diagnostic and management strategies.
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Infarto Miocárdico de Parede Anterior , Doença da Artéria Coronariana , Infarto do Miocárdio , Humanos , Estudos Retrospectivos , Prognóstico , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologiaRESUMO
PURPOSE: Apyrexia is increasingly recognized as an indicator of inadequate inflammatory response in older patients with suspected infection. We aimed to evaluate whether temperature at admission could improve the prognostic value of the Quick Sequential Organ Failure Assessment (qSOFA) for predicting in-hospital mortality after acute infection. METHODS: We created a new score, named qSOFAGE (qSOFA in GEriatrics), by adding apyrexia as an item to the existing qSOFA (+ 1 point if temperature at admission ≤ 38 °C). We compared the prognostic value of the qSOFA, the qSOFAGE and temperature at admission for predicting in-hospital mortality after acute infection in two cohorts including older patients with acute pneumonia (AP) or bacteremic urinary tract infection (UTI). RESULTS: 217 consecutive patients aged ≥ 75 hospitalized for AP (first cohort) and 105 for bacteremic UTI (second cohort) were recorded. Temperature at admission was strongly inversely correlated with in-hospital mortality in both cohorts (Odds Ratios per °C (95% Confidence Interval): 0.60 (0.45-0.80) and 0.46 (0.27-0.79) for AP and UTI. respectively). Adding the temperature ≤ 38 °C item to the qSOFA markedly improved its predictive value for in-hospital mortality in the two groups: C-statistics for qSOFAGE vs. qSOFA: 0.63 (0.53-0.73) vs. 0.56 (0.46-0.67) in AP cohort; 0.74 (0.58-0.89) vs. 0.69 (0.53-0.85) in UTI cohort. For patients with qSOFAGE ≥ 3, in-hospital mortality reached 37% after AP and 55% after bacteremic UTI. CONCLUSION: Temperature at admission was strongly correlated with mortality in these two cohorts of older patients hospitalized for acute infection. The next step will be to validate this score in cohorts of older patients with suspected infection.
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Bacteriemia , Infecções , Pneumonia , Sepse , Infecções Urinárias , Humanos , Idoso , Prognóstico , Escores de Disfunção Orgânica , Mortalidade Hospitalar , Curva ROC , Estudos Retrospectivos , Unidades de Terapia IntensivaRESUMO
Sepsis is a frequent disease in older people, characterised by an inappropriate systemic inflammatory response following an infection, leading to life-threatening organ dysfunctions. In the very old, sepsis is often difficult to diagnose, given the frequent atypical presentation. While there is no gold standard for the diagnosis of sepsis, new definitions published in 2016, aided by clinical-biological scores, namely Sequential Organ Failure Assessment (SOFA) and quick SOFA scores, allow earlier recognition of septic states at risk of poor outcome. The management of sepsis in itself differs little in older patients compared to younger subjects. However, the key question of whether or not to admit the patient to an intensive care setting has to be anticipated, depending on the sepsis severity but also on patient's comorbidities and wishes. The earliness of acute management in older subjects with decreased immune defences and physiological reserves is an essential prognostic element. The early control of comorbidities is the main plus value of the geriatrician in the acute and post-acute management of older patients with sepsis.
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Sepse , Humanos , Idoso , Sepse/diagnóstico , Sepse/terapia , Cuidados Críticos , Geriatras , Hospitalização , Reconhecimento PsicológicoRESUMO
After a review of inappropriate admissions of residents of residential care facilities for the dependent elderly (Ehpad) to the emergency room, we propose ways to reduce them. They include giving the coordinating physician a clinical role, organizing continuity and permanence of care in all Ehpad, signing agreements between Ehpad and hospital for direct hospitalization and collaboration with mobile teams and geriatric hotlines, generalizing the level of medical intervention in Ehpad, and deepening the training of Ehpad caregivers in geriatrics.
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Geriatria , Casas de Saúde , Humanos , Idoso , Hospitalização , Serviço Hospitalar de Emergência , CuidadoresRESUMO
Type 2 myocardial infarction (MI) is characterised by a functional imbalance between myocardial oxygen supply and demand in the absence of a thrombotic process, leading to myocardial necrosis. This type of MI was relatively unknown among clinicians until the third universal definition of MI was published in 2017, differentiating Type 2 from Type 1 MI, which follows an acute atherothrombotic event. The pathogenesis, diagnostic and therapeutic aspects of Type 2 MI are described in the present review. Type 2 MI is a condition that is strongly linked to age because of vascular ageing concerning both epicardic vessels and microcirculation, age-related atherosclerosis and stress maladaptation. This condition predominantly affects multimorbid individuals with a history of cardiovascular disease. However, the conditions that lead to the functional imbalance between oxygen supply and demand are frequently extra-cardiac (e.g. pneumonia or anaemia). The great heterogeneity of the underlying etiological factors requires a comprehensive approach that is tailored to each case. In the absence of evidence for the benefit of invasive reperfusion strategies, the treatment of Type 2 MI remains to date essentially based on the restoration of the balance between oxygen supply and demand. For older co-morbid patients with Type 2 MI, geriatricians and cardiologists need to work together to optimise etiological investigations, treatment and prevention of predisposing conditions and precipitating factors.
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Infarto do Miocárdio , Idoso , Envelhecimento , Comorbidade , Humanos , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , OxigênioRESUMO
OBJECTIVE: Direct oral anticoagulants (DOACs) are increasingly prescribed to elderly people, but the epidemiologic data for this population remains scarce. We compared the elderly population taking DOACs and those not taking DOACs (noDOAC). METHOD: We included individuals over 75 years old, affiliated to Mutualité Sociale Agricole of Burgundy (a French regional health insurance agency), who had been refunded for a prescribed DOAC between 1st and 30th September 2017. The DAOC group (DAOCG) and noDOAC group (noDOACG) were compared in terms of demographic conditions, registered chronic diseases (RCD), and number and types of prescribed drugs. In the DOACG, we compared the type of prescribing physician and laboratory monitoring for novel prescriptions (initial) and prescription refills (≥ 3 months). RESULTS: Of the 19 798 included patients, 1518 (7.7%) were prescribed DAOCs and 18 280 (92.3%) were not. Mean and median age was 85 years in the 2 groups (DOACG and noDOACG). In the DOACG, there were more men (50% vs 40.2%), more RCD (88.9% vs 68.7%) and more drugs per prescription (6 ± 2.8 vs 5 ± 2.9) (All P < .01). The DOACG also took more antihypertensive drugs. The most commonly prescribed DOACs were apixaban (42.9%) followed by rivaroxaban (38.4%) and dabigatran (18.6%). Complete blood count, serum creatinine and coagulation function tests were requested for 69.4%, 75% and 22.2%, respectively, of patients prescribed DAOCs. CONCLUSIONS: The DOACG had more RCD and drugs per prescription than the noDOACG; routine laboratory monitoring was insufficient. What's known Platelet aggregation inhibitors (low-dose) are recommended for secondary prevention of cardiovascular events in patients suffering from symptomatic atherosclerosis. The main risk of this treatment is bleeding. What's new A prescription for platelet aggregation inhibitors was found in 34% of geriatric inpatients in this prospective study. Compliance to guidelines was better for symptomatic peripheral artery disease than for primary prevention in accordance with recent publications. Geriatric comorbidities had no impact on the prescription of platelet aggregation inhibitors. Underuse of platelet aggregation inhibitors was observed in 11.3% of cases and overuse in 13.7% of cases.
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Anticoagulantes/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Contagem de Células Sanguíneas/estatística & dados numéricos , Testes de Coagulação Sanguínea/estatística & dados numéricos , Doença Crônica/epidemiologia , Creatinina/sangue , Dabigatrana/uso terapêutico , Feminino , França/epidemiologia , Humanos , Testes de Função Renal/estatística & dados numéricos , Masculino , Inibidores da Agregação Plaquetária/uso terapêutico , Estudos Prospectivos , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Rivaroxabana/uso terapêuticoRESUMO
OBJECTIVE: Despite the frequent use of antiplatelet medication (AM) in the elderly patients, very few studies have investigated its prescription. We describe AM prescription through retrospective study in ambulatory elderly patients. METHOD: All subjects aged over 80 years with a medical prescription delivered in March 2015 and affiliated to the Mutualité Sociale Agricole de Bourgogne. Subjects with prescriptions for AM were compared with those without. RESULTS: A total of 15 141 ambulatory elderly patients (83-89 years, 61.3% of women) were included and 4412 (29.14%) had a prescription for AM. The latter were more frequently men than those without AM (43% vs 36.93%, P < .0001) and more frequently had chronic comorbidities (77.24% vs 64.65%, P < .0001). Compared with ambulatory subjects without AM, those with AM more frequently had coronary heart disease (35.15% vs 14.49%), severe hypertension (30% vs 25.65%), diabetes (27.42% vs 20.64%), peripheral arterial diseases (16.28% vs 5.96%) and disabling stroke (9% vs 5.56% (all P < .0001). In addition, they had more prescriptions of beta-blockers (45.24% vs 36.90%), angiotensin conversion enzyme inhibitor (31.35% vs 25.44%), calcium channel blockers (33.34% vs 27.90%), nitrate derivatives (10.6% vs 6.03%) or hypolipidemic agents (HA; 49.81% vs 29.72%) (all P < .0001) than those without AM. CONCLUSION: In this study, which is very interested for its size and the advanced age of the subjects, long-course AM was prescribed in one third of ambulatory elderly patients. Coronary heart disease, severe hypertension and diabetes were more frequent in AM subjects. However, the low percentage of declared strokes was surprising. We provide additional data to doctors following subjects with AM.
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Prescrições de Medicamentos/estatística & dados numéricos , Inibidores da Agregação Plaquetária/uso terapêutico , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Doença das Coronárias/epidemiologia , Diabetes Mellitus/epidemiologia , Feminino , França/epidemiologia , Humanos , Hipertensão/epidemiologia , Hipolipemiantes/uso terapêutico , Masculino , Doença Arterial Periférica/epidemiologia , Polimedicação , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologiaRESUMO
OBJECTIVE: Little is known about furosemide prescription modalities in elderly people. We describe furosemide prescription in ambulatory elderly patients. METHODS: All patients aged over 80 years, affiliated to Mutualité Sociale Agricole de Bourgogne, a French regional health insurance plan, with a medical prescription delivered in March 2015, were retrospectively included. RESULTS: Among 15 141 patients with a median age of 86 years, comprising 61.3% of women, 3937 patients (26%) had a prescription for furosemide. Severe heart failure was the most common chronic comorbidity (27.7%). Furosemide was considered a long-term therapy for almost all patients (98.7% with prescriptions for 3 months or more). Recommended indications for long-term furosemide therapy included severe heart failure (50.9%), chronic nephropathy (3%) and cirrhosis (0.1%). The furosemide prescription rate increased with age (81-85: 20.4%, 86-90: 28.5%, 91-95: 35.6%, >95: 42.7%, P<.001), and the increase was associated with a decrease in recommended heart failure therapeutics (beta-blockers, angiotensin-conversion-enzyme-inhibitors or angiotensin-receptor-blockers). Prescribers were mostly general practitioners (81.3%). Plasma electrolytes were controlled in less than a half of the patients with furosemide. CONCLUSIONS: In this large study, long-course furosemide was prescribed in a quarter of ambulatory patients. Half of those taking furosemide suffered from severe heart failure. Age was associated with a linear increase in furosemide use and a decrease in recommended heart failure therapeutic prescriptions. A large part of these prescriptions do not seem to be in accordance with recommendations.
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Diuréticos/uso terapêutico , Furosemida/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Antagonistas Adrenérgicos beta/uso terapêutico , Fatores Etários , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Prescrições de Medicamentos , Feminino , Humanos , Prescrição Inadequada , Cirrose Hepática/tratamento farmacológico , Masculino , Insuficiência Renal Crônica/tratamento farmacológico , Estudos RetrospectivosRESUMO
INTRODUCTION AND OBJECTIVES: Proton pump inhibitors (PPI) are widely prescribed in France and could be responsible for adverse drug reactions especially in elderly persons (EP). In order to reduce the misuse of PPI and the excess cost to the Social Security Agency, the French health authorities (Haute Autorité de santé [HAS]) have published strict guidelines for their prescription. We conducted a study in EP to determine the proportion of PPI prescriptions outside HAS guidelines. METHOD: This was a prospective, single-centre observational study in persons aged≥75 years admitted to a geriatric acute-care unit over a period of 6months. The prevalence of prescriptions for PPI and the proportion of prescriptions outside the guidelines were calculated. The sociodemographic and medical characteristics of EP treated with PPI were studied as were the reasons for the prescription of PPI. RESULTS: Among the 818 patients hospitalized during the study period, 270 were taking PPI on admission (33%). Among these prescriptions, 60% were outside the HAS guidelines. Gastro-oesophageal reflux was the leading indication for PPI (30%), followed by dyspepsia (19%). CONCLUSION: This study confirms the high prevalence of prescriptions for PPI and their misuse. As these drugs are apparently well tolerated, prescriptions are often renewed with no medical re-evaluation.
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Prescrição Inadequada/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Inibidores da Bomba de Prótons/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Dispepsia/tratamento farmacológico , Dispepsia/epidemiologia , Feminino , França , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/epidemiologia , Fidelidade a Diretrizes , Hospitalização , Humanos , Masculino , Padrões de Prática Médica/estatística & dados numéricos , Estudos Prospectivos , Inibidores da Bomba de Prótons/efeitos adversosRESUMO
BACKGROUND: Current recommendations for empirical antimicrobial therapy in spontaneous bacterial peritonitis (SBP) are based on quite old trials. Since microbial epidemiology and the management of patients have changed, whether these recommendations are still appropriate must be confirmed. METHODS: An observational study that exhaustively collected the clinical and biological data associated with positive ascitic fluid cultures was conducted in four French university hospitals in 2010-2011. RESULTS: Two hundred and sixty-eight documented positive cultures were observed in 190 cirrhotic patients (median age 61.5 years, 58.5% Child score C). Of these, 57 were classified as confirmed SBP and 140 as confirmed bacterascites. The predominant flora was Gram-positive cocci, whatever the situation (SBP, bacterascites, nosocomial/health-care related or not). Enteroccocci (27.7% E. faecium) were isolated in 24% of the episodes, and in 48% from patients receiving quinolone prophylaxis. E. coli were susceptible to amoxicillin-clavulanate and to third-generation cephalosporins in 62.5% and 89.5% of cases, respectively. No single antibiotic allowed antimicrobial coverage of more than 60%. Only combinations such as amoxicillin + third-generation cephalosporin or cotrimoxazole allowed coverage close to 75-80% in non-nosocomial episodes. Combinations based on broader spectrum antibiotics should be considered for empirical therapy of nosocomial infections. CONCLUSIONS: Our study confirmed the changing spectrum of pathogens in SBP and bacterascites, and the need for more complex antibiotic strategies than those previously recommended. Our findings also underline the need for new clinical trials conducted in the current epidemiological context.
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Antibacterianos/uso terapêutico , Infecções Bacterianas/epidemiologia , Farmacorresistência Bacteriana/efeitos dos fármacos , Peritonite/epidemiologia , Peritonite/microbiologia , Idoso , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Anti-Infecciosos/uso terapêutico , Líquido Ascítico/microbiologia , Infecções Bacterianas/tratamento farmacológico , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Escherichia coli/efeitos dos fármacos , Escherichia coli/patogenicidade , Feminino , Humanos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
Objectives: This real-life study aimed to evaluate the safety of acetazolamide (ACZ), a carbonic anhydrase inhibitor with diuretic effects. ACZ has recently been proven to improve decongestion in the context of patients hospitalized for acute heart failure (HF). However, data in terms of safety are lacking. Methods: We conducted a monocentric observational prospective study from November 2023 to February 2024 in a 12-bed cardiology department, recording adverse events (hypotension, severe metabolic acidosis, severe hypokalemia and renal events) during in-hospital HF treatment. All patients hospitalized for acute HF during the study period treated with ACZ (500 mg IV daily for 3 days) on top of IV furosemide (n = 28, 48.3%) were compared with patients who have been treated with IV furosemide alone (n = 30, 51.7%). Results: The patients treated with ACZ were younger than those without (median age 78 (range 67-86) vs. 85 (79-90) years, respectively, p = 0.01) and had less frequent chronic kidney disease (median estimated glomerular fraction rate (60 (35-65) vs. 38 (26-63) mL/min, p = 0.02). As concerned adverse events during HF treatment, there were no differences in the occurrences of hypotension (three patients [10.7%] in the ACZ group vs. four [13.3%], p = 0.8), renal events (four patients [14.3%] in the ACZ group vs. five [16.7%], p = 1) and severe hypokalemia (two [7.1%] in the ACZ group vs. three [10%], p = 1). No severe metabolic acidosis occurred in either group. Conclusions: Although the clinical characteristics differed at baseline, with younger age and better renal function in patients receiving ACZ, the tolerance profile did not significantly differ from patients receiving furosemide alone. Additional observational data are needed to further assess the safety of ACZ-furosemide combination in the in-hospital management of HF, especially in older, frail populations.
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Both underweight and obesity have been associated with poor prognosis in COVID-19. In an older populations of patients hospitalized for SARS-CoV-2 infection, we aimed to evaluate the association between body mass index (BMI) and short and long-term prognosis. Among 434 consecutive patients aged ≥ 70 years and hospitalized for suspected COVID-19 at a university hospital, 219 patients (median age of 83 years, 53% male) testing positive for COVID-19 and for whom BMI was recorded at admission, agreed to participate. Among them, 39 had a BMI < 20 kg/m2, 73 had a BMI between 20 and 24.9 kg/m2 and 107 had a BMI ≥ 25 kg/m2. After adjustment for confounders, BMI < 20 kg/m2 was associated with a higher risk of one-year mortality (hazard ratio (HR) [95% confidence interval]: 1.75 [1.00-3.05], p = 0.048), while BMI ≥ 25 kg/m2 was not (HR: 1.04 [0.64-1.69], p = 0.9). However, BMI was linearly correlated with both in-hospital acute respiratory failure (p = 0.02) and cardiovascular events (p = 0.07). In this cohort of older patients hospitalized for COVID-19, low BMI, rather than high BMI, appears as an independent risk factor for death after COVID-19. The pathophysiological patterns underlying this excess mortality remain to be elucidated.
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COVID-19 , Humanos , Masculino , Idoso , Idoso de 80 Anos ou mais , Feminino , COVID-19/complicações , Índice de Massa Corporal , SARS-CoV-2 , Obesidade/complicações , Obesidade/epidemiologia , Fatores de Risco , Estudos RetrospectivosRESUMO
BACKGROUND: From a large observational acute coronary syndrome registry in Côte d'Ivoire, we aimed to assess incidence, clinical presentation, management, and in-hospital outcomes for type 2 myocardial infarction (T2MI) compared with type 1 MI. METHODS AND RESULTS: We conducted a cross-sectional monocentric study using data from REACTIV (Registre des Infarctus de Côte d'Ivoire) at the Abidjan Heart Institute. All patients hospitalized with MI between 2018 and 2022 who underwent coronary angiography were included. For each patient, sociodemographic data, cardiovascular risk factors and history, and clinical and paraclinical presentation were collected at admission. In-hospital outcomes, including major adverse cardiovascular events and mortality, were reported. Among 541 consecutive patients hospitalized with MI, 441 met the definition of type 1 MI or T2MI. T2MI accounted for 14.1% of cases. Patients with T2MI showed a trend toward slightly younger age (54 versus 58 years, P=0.09). Patients with T2MI seemed to have less severe coronary artery disease, with less frequent multivessel disease (P<0.001). Main triggering factors for T2MI were coronary embolism (24.2%), severe hypertension with or without left ventricular hypertrophy (22.6%), and tachyarrhythmia (16.1%). In-hospital event rates were low in both MI types. Although the difference was nonsignificant, death rates for patients with type 1 MI tended to be higher than for patients with T2MI, as well as occurrence of major adverse cardiovascular events. CONCLUSIONS: Our study revealed disparities in clinical characteristics, angiographic features, cause, and in-hospital outcomes in T2MI in our population compared with Western populations. These results suggest the heterogeneity of T2MI and the potential causative and demographic variability depending on geographical area.
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Infarto do Miocárdio , Sistema de Registros , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Transversais , Incidência , Idoso , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Angiografia Coronária , Fatores de Risco , Mortalidade Hospitalar/tendênciasRESUMO
Background: There is increasing evidence regarding the association between endotoxemia and the pathogenesis of atherosclerosis and myocardial infarction (MI). During the acute phase of MI, endotoxemia might increase inflammation and drive adverse cardiovascular (CV) outcomes. We aimed to explore the risk factors and prognostic value of endotoxemia in patients admitted for acute MI. Methods: Patients admitted to the coronary care unit of Dijon University Hospital for type 1 acute MI between 2013 and 2015 were included. Endotoxemia, assessed by plasma lipopolysaccharide (LPS) concentration, was measured by mass spectrometry. Major adverse CV events were recorded in the year following hospital admission. Results: Data from 245 consecutive MI patients were analyzed. LPS concentration at admission markedly increased with age and diabetes. High LPS concentration was correlated with metabolic biomarkers (glycemia, triglyceride, and total cholesterol) but not with CV (troponin Ic peak and N-terminal pro-brain natriuretic peptide) or inflammatory biomarkers (C-reactive protein, IL6, IL8, and TNFα). LPS concentration was not associated with in-hospital or 1-year outcomes. Conclusions: In patients admitted for MI, higher levels of endotoxins were related to pre-existing conditions rather than acute clinical severity. Therefore, endotoxins measured on the day of MI could reflect metabolic chronic endotoxemia rather than MI-related acute gut translocation.
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BACKGROUND: In geriatrics, explicit criteria for potentially inappropriate prescriptions (PIPs) are useful for optimizing drug use. OBJECTIVE: To produce an expert consensus on explicit definitions of antibiotic-PIPs for hospitalized older patients. METHODS: We conducted a Delphi survey involving French experts on antibiotic stewardship in hospital settings. During the survey's rounds, the experts gave their opinion on each explicit definition, and could suggest new definitions. Definitions with a 1-to-9 Likert score of between 7 and 9 from at least 75% of the participants were adopted. The results were discussed during consensus meetings after each round. RESULTS: Of the 155 invited experts, 128 (82.6%) participated in the whole survey: 59 (46%) infectious diseases specialists, 45 (35%) geriatricians, and 24 (19%) other specialists. In Round 1, 65 explicit definitions were adopted and 21 new definitions were suggested. In Round 2, 35 other explicit definitions were adopted. The results were validated during consensus meetings (with 44 participants after Round 1, and 54 after Round 2). CONCLUSIONS: The present study is the first to have provided a list of explicit definitions of potentially inappropriate antibiotic prescriptions for hospitalized older patients. It might help to disseminate key messages to prescribers and reduce inappropriate prescriptions of antibiotics.
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OBJECTIVES: Aspiration pneumonia (AsP), a leading cause of death in older people, remains poorly studied. We aimed to evaluate short- and long-term prognosis after AsP in older inpatients. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: All consecutive patients aged ≥75 years hospitalized in a 62-bed acute geriatric unit during a 1-year period. METHODS: We compared clinical characteristics and overall 2-year survival between patients with a main diagnosis of AsP, patients with other types of acute pneumonia (non-AsP), and patients hospitalized for another cause. RESULTS: Among the 1774 patients hospitalized over 1 year (median age: 87 years, 41% female), 125 (7%) had a primary diagnosis of acute pneumonia, of whom 39 (31%) had AsP and 86 (69%) non-AsP. Patients with AsP were more frequently male, lived more frequently in a nursing home, and had a more frequent history of stroke or neurocognitive disorders. Mortality rates were much higher after AsP, reaching 31% at 30 days (vs 15% after Non-AsP and 11% in the rest of the cohort, P < .001), and 69% 2 years after admission (vs 56% and 49%, P < .001). After adjustment for confounders, AsP was significantly associated with mortality but non-AsP was not [adjusted hazard ratio (95% CI): 3.09 (1.72-5.57) at 30 days and 1.67 (1.13-2.45) at 2 years for AsP; 1.36 (0.77-2.39) and 1.14 (0.85-1.52) for non-AsP]. However, among patients who survived at 30 days, mortality did not significantly differ between the 3 groups (P = .1). CONCLUSIONS AND IMPLICATIONS: In an unselected cohort of patients hospitalized in an acute geriatric unit, a third of AsP patients died within the first month after admission. However, among those surviving at 30 days, long-term mortality did not significantly differ from the rest of the cohort. These findings underline the importance of optimizing the early management of AsP.
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Pneumonia Aspirativa , Pneumonia , Acidente Vascular Cerebral , Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Pacientes Internados , Pneumonia/complicações , Acidente Vascular Cerebral/complicações , Pneumonia Aspirativa/diagnósticoRESUMO
Underlying coronary artery disease (CAD) is increasingly considered to be a key issue in the pathophysiology of type 2 myocardial infarction (T2MI). In T2MI, which is attributable to a mismatch between oxygen supply/demand, CAD is common and appears to be more severe than in type 1 myocardial infarction (T1MI). Little is known about the heterogeneous mechanisms that cause supply/demand imbalance and non-coronary triggers leading to myocardial ischemia or about how they are potentially modulated by the presence and severity of CAD. CAD seems to be underrecognized and undertreated in T2MI, even though previous studies have demonstrated both the short and long-term prognostic value of CAD in T2MI. In this literature review, we attempt to address the prevalence and severity of CAD, challenges in the discrimination between T2MI and T1MI in the presence of CAD, and the prognostic value of CAD among patients with T2MI.
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Two main types of oral anticoagulants are available in France: vitamin K antagonists (VKA) and, more recently, direct oral anticoagulants (DOAC). The benefit−risk profile appears to be favorable for DOAC, which is as effective as VKA but safer (fewer cases of severe and cerebral bleeding). In a study in 2017, we observed that older adults did not seem to receive the same modalities of oral anticoagulants as younger individuals for various reasons. To assess anticoagulation prescribing practices over time, we repeated this cross-sectional study by comparing very old individuals taking DOAC to those taking VKA. Ambulatory individuals aged 80 years and older were included. They were affiliated with the Mutualité Sociale Agricole of Burgundy and were refunded for a medical prescription of oral anticoagulation in March 2021. The demographic characteristics, registered chronic diseases (RCD), number and types of prescribed drugs, and mortality of the DOAC group and the VKA group were compared. A total of 4275 subjects were included in the study: 67.44% (2883) received DOAC and 32.56% (1392) received VKA. The two groups were similar in age. In the DOAC group, there were more women (54.98% vs. 46.98%) (p < 0.001), fewer RCD (91.47% vs. 93.68%) (p = 0.014), and lower rates of venous thromboembolism (2.53% vs. 6.75%) (p < 0.001), severe heart failure (56.50% vs. 68.03%) (p < 0.001), and severe kidney diseases (1.38% vs. 3.59%) (p < 0.001), but there were more subjects with Alzheimer's disease (7.49% vs. 4.31%) (p = 0.001). Individuals in the DOAC group had fewer prescriptions of furosemide (48.53% vs. 55.75%) (p < 0.001) and fibrates (2.32% vs. 3.88%) (p = 0.044). They also had more prescriptions of proton pump inhibitors (43.95% vs. 39.44%) (p = 0.006) and antirheumatics (1.60% vs. 0.65%) (p = 0.009) than those in the VKA group. There was no difference in mortality. This study revealed that prescribing practices for DOAC have changed over time.