Introduction of a new scoring tool to identify clinically stable heart failure patients

Introduction Heart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking. Methods The Maastricht Instability Score—Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0–2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (> 2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre. Results Of the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (> 2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up (29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20–5.14). No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36–1.47) was found between patients with a low MIS-HF treated in primary versus secondary care. Conclusion The MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care.

AGEs and sRAGE Variations at Different Timepoints in Patients with Chronic Kidney Disease

Patients with chronic kidney disease (CKD) are affected by enhanced oxidative stress and chronic inflammation, and these factors may contribute to increase advanced glycation end-products (AGEs). In this study we quantified AGEs and soluble receptors for AGE (sRAGE) isoforms and evaluated the association between their variations and eGFR at baseline and after 12 months. We evaluated 64 patients. AGEs were quantified by fluorescence intensity using a fluorescence spectrophotometer, and sRAGE by ELISA. Median age was 81 years, male patients accounted for 70%, 63% were diabetic, and eGFR was 27 ± 10 mL/min/1.73 m2. At follow up, sRAGE isoforms underwent a significant decrement (1679 [1393;2038] vs. 1442 [1117;2102], p < 0.0001), while AGEs/sRAGE ratios were increased (1.77 ± 0.92 vs. 2.24 ± 1.34, p = 0.004). Although AGEs and AGEs/sRAGE ratios were inversely related with eGFR, their basal values as well their variations did not show a significant association with eGFR changes. In a cohort of patients with a stable clinical condition at 1 year follow-up, AGEs/sRAGE was associated with renal function. The lack of association with eGFR suggests that other factors can influence its increase. In conclusion, AGEs/sRAGE can be an additional risk factor for CKD progression over a longer time, but its role as a prognostic tool needs further investigation.

Bleeding Complication in a Patient with Concomitant Use of Rivaroxaban and Saffron Supplement: A Case Report

Background Direct oral anticoagulants (DOACs) carry a lower potential risk of food/herb and drug interactions compared with oral vitamin K antagonists. However, as a new class of medications some of these interactions have not been fully known. Case presentation: A 64-year old male with a medical history of non-valvular atrial fibrillation presented to the emergency department with a complaint of acute onset epistaxis and bleeding gums following the concomitant use of rivaroxaban and saffron supplement. Rivaroxaban plasma concentration was 54 ng/ml with a post-intake delay of 17 hours. The results of laboratory tests were unremarkable except for platelet function tests. Whole blood multiple electrode aggregometry was performed to assess platelet function. Area under the aggregation curve (AUC) values were 83 and 51 aggregation unit (AU)*min by arachidonic acid and adenosine diphosphate-induced platelet aggregation tests, respectively. As the patient had not taken any antiplatelet medication, platelet dysfunction was greatly attributed to the saffron supplement. The patient was immediately admitted to hospital and received local hemostatic measures and tranexamic acid. Moreover, saffron was discontinued permanently and rivaroxaban was paused for 24 hours. The bleeding stopped a few hours later and the patient was discharged after 2 days in a good general condition. Subsequently, he was followed up at 4, 8, and 12-week intervals. He was in a stable clinical condition with no bleeding complications. The patient was advised to consult with his doctor or pharmacist before taking any supplement or herbal medicine to ensure possible interactions. Conclusions It seems that coadministration of DOACs and saffron supplements should be avoided due to the potential drug-herbal interactions and possible risk of subsequent bleeding complications. However, further studies are needed to confirm the findings and assess the clinical significance.

Six-Minute Walking Test as a Predictor of Clinical Decompensation in Patients with Cirrhosis

Background and Aims: The 6-minute walk test (6MWT) is a measure of the overall functional capacity and is associated with the risk of mortality in patients with liver cirrhosis and in those listed for liver transplantation. Nevertheless, physical performance has not yet been established as a predictor of the risk of clinical decompensation in patients with cirrhosis. We aimed to determine the capacity of the 6MWT to predict the clinical decompensation in patients with cirrhosis after 1 year of follow-up. Methods: This prospective cohort study included patients with compensated cirrhosis of several etiologies. All participants had stable clinical conditions for at least 6 months prior to baseline. At baseline, patients performed the 6MWT and were followed up for 1 year to detect the decompensation outcomes. Results: A total of 55 participants completed the evaluation and follow-up. The mean age was 56.3±10.5 years, and 65% were men. Around 65.4% were classified as Child-Pugh class A. In the receiver operating characteristic analysis, a walking distance ≤ 401.8 m during the 6MWT was set as the threshold for predicting clinical decompensation with 64% sensitivity and 82% specificity. Kaplan-Meier curve analysis revealed that patients who covered a distance of < 401.8 m during the test had a decompensation-free outcome rate of 30% as compared to the rate of 75% of those who walked > 401.8 m (p<0.001). Conclusions: The 6MWT was a significant predictor of clinical decompensation in patients with cirrhosis. A cutoff of 401.8 m was related to an increased risk of clinical decompensation in cirrhotic patients with a stable clinical condition at baseline. The 6MWT should be added to the clinical assessment of the cirrhotic population.

Ventriculosubgaleal shunting in the treatment of posthemorrhagic hydrocephalus of premature infants: case series

Introduction: Posthemorrhagic hydrocephalus(PHH) comprises the most common complication in preterm infants (PTI) who suffered germinative matrix hemorrhage (GMH), and its treatment is still matter of controversies. These infants usually weigh less than 1,500g and a temporary CSF diversion is needed. VSGS is preferred in those cases because it is a simple and rapid method, no need for repetitive aspiration for the evacuation of CSF, gives a permanent decompression without causing electrolyte and nutritional losses, and still protects the cerebral development of newborns with GMH. Methods: We analyzed a series of 22 PTI who underwent VSGS for PHH, between July 2015 and April 2019, and minimum follow-up 6 months. The median gestation age was 28 weeks (range 23-32). The median weigh was 985g (range 625-1615). The mean period harboring de VSGS was 61,8 days (range 35-80). Results: The cases were studied for: 1) Shunt dependency: 11 children (50%) showed persistent hydrocephalus at further investigation and underwent to VP shunt after stable clinical condition. 2) Infection: 6 subjects (27,2%) showed positive cultures, and were converted to External Ventricular Device (EVD), and further VP shunt; 3) Outcome: the results were separated in Excellent/Good (GOS 5-4) 12 subjects (54%); Poor (GOS 3-2): 8 subjects (36%) and Death (GOS 1): 2 subjects (10%). Conclusions: VSGS is a good alternative method to treat PHH, especially in a preterm infant who needs a temporary shunt device. The low rate of severe complications and encouraging results about persistent hydrocephalus should guide further investigation and larger cases series.

Pulmonary artery thrombosis in home patient with a mild COVID-19 disease

COVID-19 has been described as the cause for a proinflammatory and hypercoagulable state that induces thrombotic vascular lesions and, in more severe cases, disseminated intravascular coagulation. Increased values of d-dimers are related to the severity of the disease and are associated with worst prognosis. Intensive care studies reported an increased risk of pulmonary embolism and venous thrombosis diseases in COVID-19 compared with the historical control group even in patients who underwent the low-molecular-weight heparin (LWMH) prophylaxis. Patients with COVID-19 who have a stable clinical condition do not require hospitalisation and are treated at home with symptomatic therapy. LWMH is reserved for those with reduced mobility. In this case report, we describe a COVID-19 patient with pulmonary artery thrombosis treated at home.

Retrospective analysis of endocarditis patients to investigate the eligibility for oral antibiotic treatment in routine daily practice

Background According to the current guidelines of the European Society of Cardiology, patients with left-sided infective endocarditis are treated with intravenous antibiotics for 4–6 weeks, leading to extensive hospital stay and high costs. Recently, the Partial Oral Treatment of Endocarditis (POET) trial suggested that partial oral treatment is effective and safe in selected patients. Here, we investigated if such patients are seen in our daily clinical practice. Methods We enrolled 119 adult patients diagnosed with left-sided infective endocarditis in a retrospective, observational study. We identified those that would be eligible for switching to partial oral antibiotic treatment as defined in the POET trial (e.g. stable clinical condition without signs of infection). Secondary objectives were to provide insight into the time until each patient was eligible for partial oral treatment, and to determine parameters of longer hospital stay and/or need for extended intravenous antibiotic treatment. Results Applying the POET selection criteria, the condition of 38 patients (32%) was stable enough to switch them to partial oral treatment, of which 18 (47.3%), 8 (21.1%), 9 (23.7%) and 3 patients (7.9%) were eligible for switching after 10, 14, 21 days or 28 days of intravenous treatment, respectively. Conclusion One-third of patients who presented with left-sided endocarditis in routine clinical practice were possible candidates for switching to partial oral treatment. This could have major implications for both the patient’s quality of life and healthcare costs. These results offer an interesting perspective for implementation of such a strategy, which should be accompanied by a prospective cost-effectiveness analysis.

Orthostatic Hypotension in a Complex Clinical Setting Use of the Heart Rate Increase/Systolic Blood Pressure Decrease Ratio as a Diagnostic Aid

A simple bedside test to distinguish neurogenic from non-neurogenic causes of orthostatic hypotension (OH) is the ratio of heart rate increase during OH to the simultaneous decrease in systolic blood pressure (SBP), i.e. the ΔHR/ΔSBP ratio. In a patient suffering from persistent OH we monitored the ΔHR/ΔSBP ratio to aid with a targeted therapy. During a six-week period four pairs of postural tests were performed, one in the fasting and the other in the postprandial state. Inconsistency of the ΔHR/ΔSBP ratio under the patient's apparently stable clinical condition was confusing. So, the ΔHR/ΔSBP ratio did not help in taking therapeutic decisions.

The switch from etanercept originator to SB4: data from a real-life experience on tolerability and persistence on treatment in joint inflammatory diseases

Aims: Switching from originator to biosimilar is part of current practice in inflammatory rheumatic musculoskeletal diseases (iRMDs) such as rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondylarthritis (axSpA), with evidences derived from both etanercept (ETN) to SB4-switching randomized controlled trials and real-life registries. We investigated the safety and treatment persistence of ETN/SB4 in a multi-iRMD cohort derived from two rheumatology departments in our region. Methods: Adult patients with iRMDs, treated with ETN for at least 6 months and switched to SB4 in stable clinical condition, were eligible for this retrospective evaluation. Retrospective data on adverse events, loss of efficacy and persistence on treatment were collected until latest available follow-up. Results: A total of 220 patients (85 RA, 81 PsA, 33 axSpA, 14 juvenile idiopathic arthritis and seven other conditions; 142 females, mean age 58 ± 7 years, disease duration 12 ± 4 years, ETN duration 7 ± 4 years) were enrolled, with median follow-up of 12.1 (9.7–15.8) months. A total of 50 patients (22.7%) presented with at least one adverse event, with 36 (16.4%) disease flares and 30 (13.6%: 11 for safety and 19 loss of efficacy) SB4 withdrawals. Cumulative SB4 treatment persistence was 99.1%, 88.6% and 64.6% at 6, 12 and 18 months respectively. Back-switch to ETN was performed in 17/30 cases, the remaining cases were managed with change of biologic disease modifying or conventional synthetic anti-rheumatic drug. Age was the only significant predictor of SB4 interruption at 6 months. Conclusion: Our real-life data confirm the safety profile of switching from ETN to SB4, with slightly higher treatment persistence rates compared with other real-life registries.

Late Diagnosis of Silent Thoracic Aortic Rupture Presented as a Right Pleural Effusion

Patients with ruptured thoracic aortic aneurysm rarely present in a stable clinical condition. A man was referred to our hospital with the diagnosis of ruptured saccular aneurysm of the descending thoracic aorta. He successfully underwent both endovascular graft repair and open thoracotomy.