ABSTRACT
Background Thiopurines such as azathioprine (AZA) and mercaptopurine (MP) are commonly utilized to treat inflammatory bowel disease (IBD). Their use is frequently restricted due to gastrointestinal intolerance (GI). Previous retrospective studies have reported that AZA-intolerant patients may benefit from a switch to MP; yet the effectiveness of this strategy has not been prospectively evaluated.AimsTo assess GI tolerance to MP in patients who are intolerant to AZA, and to identify clinical predictors of GI intolerance to AZA or MP.MethodsA prospective, observational, single-cohort study was performed in 92 thiopurine-naïve IBD patients. They were started on a 50mg dose of AZA and escalated to 2.5mg/kg per day by week 2. Those with GI intolerance were rechallenged with a 50% dose of AZA, after which another dose escalation attempt was made. If symptoms persisted, they were switched to MP.ResultsThirty (32.6%) of the recruited patients suffered from GI intolerance to AZA. Of these, 15 did not present recurrence of symptoms after rechallenge with lower doses. Of 15 intolerant patients, 14 were switched to MP. Within the MP cohort, 8 patients (57%) were also intolerant to MP, 5 (36%) had no symptoms, and 1 (7%) was lost to follow-up. Female gender was the only independent predictor of GI intolerance to AZA.ConclusionsUp to half of the AZA-intolerant patients tolerated a 50% dose rechallenge that was successfully escalated. A switch to MP was tolerated in over a third of cases whom rechallenge failed. Our strategy (challengerechallengeswitch) achieved an overall GI tolerance to thiopurines in most of the patients. (AU)
Antecedentes Las tiopurinas como la azatioprina (AZA) y la mercaptopurina (MP) se utilizan comúnmente para tratar la enfermedad inflamatoria intestinal (EII). Su uso está frecuentemente restringido debido a la intolerancia gastrointestinal. Estudios retrospectivos anteriores han informado que los pacientes intolerantes a la AZA pueden beneficiarse de un cambio a MP; sin embargo, la eficacia de esta estrategia no ha sido evaluada prospectivamente.ObjetivosEvaluar la tolerancia gastrointestinal a MP en pacientes que son intolerantes a AZA e identificar predictores clínicos de intolerancia gastrointestinal a AZA o MP.MétodosSe realizó un estudio prospectivo, observacional y de cohorte única en 92 pacientes con EII que nunca habían recibido tiopurinas. Comenzaron con una dosis de 50mg de AZA y se aumentó a 2,5mg/kg por día en la semana 2. En aquellos con intolerancia gastrointestinal se administró una dosis del 50% de AZA que se fue incrementando en función de la tolerancia. Si los síntomas persistían, se cambiaba a MP.ResultadosTreinta (32,6%) de los pacientes reclutados presentaron intolerancia gastrointestinal a la AZA. De estos, 15 no presentaron recurrencia de los síntomas después de la nueva exposición. De los 15 pacientes que no toleraron una dosis más baja, 14 recibieron MP. De los que recibieron MP, 8 pacientes (57%) también eran intolerantes a MP, 5 (36%) no tenían síntomas y uno (7%) se perdió durante el seguimiento. El género femenino fue el único predictor independiente de intolerancia gastrointestinal a la AZA.ConclusionesHasta la mitad de los pacientes intolerantes a la AZA toleran una nueva exposición al 50% de la dosis. Se toleró un cambio a MP en más de un tercio de los casos en los que la reexposición fracasó. Nuestra estrategia logró la tolerancia gastrointestinal a tiopurinas en la mayoría de los pacientes. (AU)
Subject(s)
Humans , Inflammatory Bowel Diseases/drug therapy , Azathioprine/administration & dosage , Azathioprine/adverse effects , Prospective Studies , Cohort Studies , Mercaptopurine/administration & dosage , Mercaptopurine/adverse effectsABSTRACT
BACKGROUND: Thiopurines such as azathioprine (AZA) and mercaptopurine (MP) are commonly utilized to treat inflammatory bowel disease (IBD). Their use is frequently restricted due to gastrointestinal intolerance (GI). Previous retrospective studies have reported that AZA-intolerant patients may benefit from a switch to MP; yet the effectiveness of this strategy has not been prospectively evaluated. AIMS: To assess GI tolerance to MP in patients who are intolerant to AZA, and to identify clinical predictors of GI intolerance to AZA or MP. METHODS: A prospective, observational, single-cohort study was performed in 92 thiopurine-naïve IBD patients. They were started on a 50mg dose of AZA and escalated to 2.5mg/kg per day by week 2. Those with GI intolerance were rechallenged with a 50% dose of AZA, after which another dose escalation attempt was made. If symptoms persisted, they were switched to MP. RESULTS: Thirty (32.6%) of the recruited patients suffered from GI intolerance to AZA. Of these, 15 did not present recurrence of symptoms after rechallenge with lower doses. Of 15 intolerant patients, 14 were switched to MP. Within the MP cohort, 8 patients (57%) were also intolerant to MP, 5 (36%) had no symptoms, and 1 (7%) was lost to follow-up. Female gender was the only independent predictor of GI intolerance to AZA. CONCLUSIONS: Up to half of the AZA-intolerant patients tolerated a 50% dose rechallenge that was successfully escalated. A switch to MP was tolerated in over a third of cases whom rechallenge failed. Our strategy (challenge-rechallenge-switch) achieved an overall GI tolerance to thiopurines in most of the patients.
ABSTRACT
INTRODUCTION AND OBJECTIVES: Outcomes of liver transplantation (LT) with donors after circulatory death (DCD) have been considered suboptimal due to higher rates of ischemic cholangiopathy, especially when the super-rapid recovery (SRR) technique is used. This study aimed to compare the incidence of complications between recipients receiving DCD vs those receiving donors after brain death (DBD) in a large-volume liver transplant centre. METHODS: We performed a retrospective cohort study (LT from January 2015 to December 2018) comparing recipients who underwent a LT with DCD vs. a control group of LT with DBD, matched 1:1 without replacement by propensity score matching that included the following variables: LT indication, recipient sex and age, donor age and MELD score. RESULTS: 51 recipients with DCD-LT (29 SRR, 22 normothermic regional perfusion [NRP]) were matched with 51 DBD-LT recipients. Biliary complications were more frequent in DCD, 10% (n=5), all with SRR technique, vs 2% (n=1) in the DBD group, p=0.2. Two patients (4%) suffered primary graft non-function in the DCD group (1 SRR and 1 NRP) versus zero in the DBD group (p=0.49). Postoperative bleeding and reinterventions were also higher in the DCD group: 7 (13.7%) vs 1 (1.95%) and 8 (15.7%) vs 2 (3.9%) respectively (p=0.06 and 0.09). On the 1st postoperative day AST/ALT peak was higher in DCD (p≤0001). The incidence of rejection, vascular complications, renal injury, hospital stay, and readmissions were similar in both groups. Cumulative 1-, 2-, 3- and 4-year graft and patient survival were also similar. CONCLUSIONS: DCD donors are an adequate option to increase the donor pool in LT, achieving similar graft and patient survival rates to those achieved with DBD donors, especially when the NRP technique is used.
Subject(s)
Graft Survival , Tissue and Organ Procurement , Brain Death , Cohort Studies , Humans , Liver , Propensity Score , Retrospective Studies , Tissue DonorsSubject(s)
Humans , Female , Adolescent , Adult , Gastroenteritis , Stomach Ulcer , Therapeutics , Omeprazole , Diarrhea , Vomiting , Inpatients , Physical Examination , Gastroenterology , Gastrointestinal Diseases , GastroscopySubject(s)
Enteritis/complications , Eosinophilia/complications , Gastritis/etiology , Adolescent , Adult , Enteritis/diagnostic imaging , Enteritis/pathology , Eosinophilia/diagnostic imaging , Eosinophilia/pathology , Female , Gastritis/complications , Gastritis/diagnostic imaging , Gastritis/pathology , Humans , Tomography, X-Ray ComputedABSTRACT
No disponible
Subject(s)
Humans , Male , Middle Aged , Colitis, Ulcerative/chemically induced , Sigmoid Diseases/pathology , Antibodies, Monoclonal/adverse effects , Colitis, Ulcerative/immunology , Psoriasis/drug therapy , Abdominal Pain/etiology , Proctoscopy , Biopsy , Adrenal Cortex Hormones/administration & dosage , Prednisone/administration & dosage , Mesalamine/administration & dosage , Colonoscopy , Biological Products/adverse effectsABSTRACT
No disponible
Subject(s)
Humans , Female , Middle Aged , Intestinal Obstruction/etiology , Endometriosis/complications , Intussusception/diagnostic imaging , Abdominal Pain/etiology , Intestine, Small/diagnostic imaging , Intestine, Small/pathology , Intussusception/surgery , Laparotomy , Intestinal Obstruction/surgery , Endometriosis/surgerySubject(s)
Endometriosis/complications , Ileal Diseases/etiology , Intestinal Obstruction/etiology , Emergencies , Endometriosis/diagnostic imaging , Endometriosis/pathology , Endometriosis/surgery , Female , Humans , Ileal Diseases/diagnostic imaging , Ileal Diseases/surgery , Intestinal Obstruction/diagnostic imaging , Intestinal Obstruction/surgery , Laparotomy , Middle Aged , Pneumatosis Cystoides Intestinalis/etiology , Tomography, X-Ray ComputedABSTRACT
BACKGROUND: Although electronic health interventions are considered safe and efficient, evidence regarding the cost-effectiveness of telemonitoring in inflammatory bowel disease is lacking. OBJECTIVE: We aimed to evaluate the cost-effectiveness and cost-utility of the Telemonitorización de la Enfermedad de Crohn y Colitis Ulcerosa (Telemonitoring of Crohn's Disease and Ulcerative Colitis [TECCU]) Web platform (G_TECCU intervention group) for telemonitoring complex inflammatory bowel disease, compared with standard care (G_control) and nurse-assisted telephone care (G_NT intervention group). METHODS: We analyzed cost-effectiveness from a societal perspective by comparing the 3 follow-up methods used in a previous 24-week randomized controlled trial, conducted at a tertiary university hospital in Spain. Patients with inflammatory bowel disease who initiated immunosuppressants or biologic agents, or both, to control inflammatory activity were recruited consecutively. Data on the effects on disease activity (using clinical indexes) and quality-adjusted life-years (using the EuroQol 5 dimensions questionnaire) were collected. We calculated the costs of health care, equipment, and patients' productivity and social activity impairment. We compared the mean costs per patient, utilities, and bootstrapped differences. RESULTS: We included 63 patients (21 patients per group). TECCU saved 1005 (US $1100) per additional patient in remission compared with G_control (95% CI -13,518 to 3137; US $-14,798 to 3434), with a 79.96% probability of being more effective at lower costs. Compared with G_NT, TECCU saved 2250 (US $2463) per additional patient in remission (95% CI -15,363 to 11,086; US $-16,817 to 12,135), and G_NT saved 538 (US $589) compared with G_control (95% CI -6475 to 5303; US $-7088 to 5805). G_TECCU and G_NT showed an 84% and 67% probability, respectively, of producing a cost saving per additional quality-adjusted life-year (QALY) compared with G_control, considering those simulations that involved negative incremental QALYs as well. CONCLUSIONS: There is a high probability that the TECCU Web platform is more cost-effective than standard and telephone care in the short term. Further research considering larger cohorts and longer time horizons is required. TRIAL REGISTRATION: ClinicalTrials.gov NCT02943538; https://clinicaltrials.gov/ct2/show/NCT02943538 (http://www. webcitation.org/746CRRtDN).
Subject(s)
Colitis, Ulcerative/economics , Colitis, Ulcerative/epidemiology , Cost-Benefit Analysis/methods , Crohn Disease/economics , Crohn Disease/epidemiology , Telemedicine/methods , Adult , Female , Humans , Male , Middle Aged , Young AdultABSTRACT
Introducción: Las infecciones por bacterias multirresistentes en pacientes cirróticos se encuentran en aumento y se asocian a una mayor morbimortalidad. Objetivos: Estudiar la epidemiología y los factores de riesgo y pronósticos de las infecciones por gérmenes multirresistentes en pacientes cirróticos. Pacientes y métodos: Estudio retrospectivo en el que se analizaron a pacientes con cirrosis hepática que presentaron una infección al ingreso o durante la hospitalización entre julio del 2014 y agosto del 2016 en el Hospital Universitario y Politécnico La Fe (Valencia, España). Resultados: La infección urinaria (30,2%) y la peritonitis bacteriana espontánea (22,1%) fueron las infecciones más frecuentes. Se analizaron 102 aislamientos microbiológicos: el 50% en infecciones comunitarias, el 36% en asociadas a los cuidados de la salud y el 14% en nosocomiales. Escherichia coli fue el germen más frecuentemente aislado (29,4%). La tasa de multirresistencia fue del 28,4%. El análisis univariante mostró que la infección por gérmenes multirresistentes (28,4%) se asoció a infección nosocomial respecto a las asociadas a los cuidados de la salud (OR 5,46; IC del 95%: 1,22-24,43; p = 0,039) y asociada a los cuidados de la salud (respecto a las comunitarias OR 3,39; IC del 95%: 1,09-10,54; p = 0,048), uso de antibióticos (OR 4,37; IC del 95%: 1,59-11,99; p = 0,005) e ingreso hospitalario en los últimos 90 días (OR 3,18; IC del 95%: 1,19-8,47; p = 0,018), neoplasia activa (OR 2,93; IC del 95%: 1,08-7,99; p = 0,038) y toma de norfloxacino profiláctico (OR 3; IC del 95%: 1,02-8,79; p = 0,012). Además, se asoció a mayor frecuencia de sepsis (OR 3,13; IC del 95% 1,18-8,32; p = 0,025). El fracaso del tratamiento inicial se relacionó con mayor desarrollo de insuficiencia renal aguda (p < 0,001), sepsis (p = 0,012), shock séptico (p = 0,002), ingreso en UCI (p < 0,001) y mortalidad (p < 0,001). Conclusión: La tasa de infecciones por gérmenes multirresistentes en nuestro centro es comparable con la de otros centros europeos de características similares. Los resultados obtenidos hacen recomendable la adopción de las pautas de tratamiento antibiótico contempladas en las guías de práctica clínica actuales, limitando el uso de carbapenemes a las infecciones nosocomiales y a las asociadas a los cuidados de salud con otros factores de riesgo de multirresistencia o con signos de gravedad. Un tratamiento empírico adecuado de forma precoz se correlaciona con un mejor pronóstico
Introduction: Infections in cirrhotic patients caused by multidrug-resistant bacteria are currently increasing and are associated with greater morbidity and mortality. Objectives: To assess the epidemiology, risk factors and prognoses of infections caused by multidrug-resistant bacterial infections in cirrhotic patients. Patients and methods: Retrospective study on patients with liver cirrhosis who developed an infection during hospitalisations between July 2014 and August 2016 at our centre (Hospital Universitari i Politècnic La Fe, Valencia, Spain). Results: Urinary tract infection (30.2%) and spontaneous bacterial peritonitis (22.1%) were the most common infections. A total of 102 microbiological isolates were analysed: 50% in community-acquired infections, 36% in isolates associated with healthcare infections and 14% in nosocomial infections. Escherichia coli was the main aetiology (29.4%). The overall multiresistance rate was 28.4%. The univariate analysis showed that infection caused by multidrug-resistant bacteria (28.4%) was associated with nosocomial infection compared to those associated with healthcare (OR 5.46; 95% CI: 1.22-24.43; P=.039) and healthcare-associated infections (compared to community-acquired infections, OR 3.39; 95% CI: 1.09-10.54; P=.048), use of antibiotics (OR 4.37; 95% CI: 1.59-11.99; P=.005), hospital admission in the previous 90 days (OR 3.18; 95% CI: 1.19-8.47; P=.018), active cancer (OR 2.93; 95% CI: 1.08-7.99; P=.038), and use of prophylactic norfloxacin (OR 3; 95% CI: 1.02-8.79; P=.012). Moreover, it was associated with a higher rate of sepsis (OR 3.13; 95% CI: 1.18-8.32; P=.025). The failure of initial treatment was related to greater development of acute renal failure (P<.001), sepsis (P=.012), septic shock (P=.002), ICU admission (P<.001) and mortality (P<.001). Conclusion: The rate of multidrug-resistant bacteria infections in our centre is comparable to that of other European centres with similar characteristics. The results obtained make it recommendable to implement the antibiotic treatment guidelines in current clinical practice guidelines, limiting the use of carbapenems to nosocomial infections and healthcare-associated infections with other risk factors of multidrug resistance or signs of severe sepsis. Early and adequate empirical treatment correlates with a better prognosis
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Drug Resistance, Multiple, Bacterial , Liver Cirrhosis/microbiology , Gram-Negative Bacterial Infections/epidemiology , Gram-Negative Bacterial Infections/microbiology , Gram-Positive Bacterial Infections/epidemiology , Gram-Positive Bacterial Infections/microbiology , Anti-Bacterial Agents/therapeutic use , Tertiary Care Centers , Prevalence , Spain/epidemiology , Risk Factors , Retrospective Studies , Gram-Negative Bacterial Infections/diagnosis , Gram-Negative Bacterial Infections/drug therapy , Gram-Positive Bacterial Infections/diagnosis , Gram-Positive Bacterial Infections/drug therapyABSTRACT
INTRODUCTION: Infections in cirrhotic patients caused by multidrug-resistant bacteria are currently increasing and are associated with greater morbidity and mortality. OBJECTIVES: To assess the epidemiology, risk factors and prognoses of infections caused by multidrug-resistant bacterial infections in cirrhotic patients. PATIENTS AND METHODS: Retrospective study on patients with liver cirrhosis who developed an infection during hospitalisations between July 2014 and August 2016 at our centre (Hospital Universitari i Politècnic La Fe, Valencia, Spain). RESULTS: Urinary tract infection (30.2%) and spontaneous bacterial peritonitis (22.1%) were the most common infections. A total of 102 microbiological isolates were analysed: 50% in community-acquired infections, 36% in isolates associated with healthcare infections and 14% in nosocomial infections. Escherichia coli was the main aetiology (29.4%). The overall multiresistance rate was 28.4%. The univariate analysis showed that infection caused by multidrug-resistant bacteria (28.4%) was associated with nosocomial infection compared to those associated with healthcare (OR 5.46; 95% CI: 1.22-24.43; P=.039) and healthcare-associated infections (compared to community-acquired infections, OR 3.39; 95% CI: 1.09-10.54; P=.048), use of antibiotics (OR 4.37; 95% CI: 1.59-11.99; P=.005), hospital admission in the previous 90 days (OR 3.18; 95% CI: 1.19-8.47; P=.018), active cancer (OR 2.93; 95% CI: 1.08-7.99; P=.038), and use of prophylactic norfloxacin (OR 3; 95% CI: 1.02-8.79; P=.012). Moreover, it was associated with a higher rate of sepsis (OR 3.13; 95% CI: 1.18-8.32; P=.025). The failure of initial treatment was related to greater development of acute renal failure (P<.001), sepsis (P=.012), septic shock (P=.002), ICU admission (P<.001) and mortality (P<.001). CONCLUSION: The rate of multidrug-resistant bacteria infections in our centre is comparable to that of other European centres with similar characteristics. The results obtained make it recommendable to implement the antibiotic treatment guidelines in current clinical practice guidelines, limiting the use of carbapenems to nosocomial infections and healthcare-associated infections with other risk factors of multidrug resistance or signs of severe sepsis. Early and adequate empirical treatment correlates with a better prognosis.
