Liapikou A.,Consultant in Respiratory Medicine |
Rosales-Mayor E.,Institute Clinic del Torax |
Torres A.,University of Barcelona
Expert Opinion on Pharmacotherapy | Year: 2014
Introduction: Hospital-Acquired pneumonia is the most common life-threatening hospital-Acquired infection, and the majority of cases are associated with mechanical ventilation. Once pneumonia develops, the appropriateness of the initial antibiotic regimen is a vital determinant of outcome. The slow rate of development of newer antimicrobials has led to the rediscovery of the 'old' and 'forgotten' antibiotic 'Colistin', and it is increasingly being used as salvage therapy in patients with multidrug-resistant gram-negative bacteria infections. Areas covered: This article covers medical literature published in any language since 1990 until November 2011, on 'hospital pneumonia', identified using PubMed, MEDLINE and clinicaltrial.gov. The search terms used were 'ventilator associated pneumonia', 'management' and 'new antibiotics'. Expert opinion: Many controversies still remain in the management of hospital-Acquired pneumonia. A continuous evaluation of the antimicrobial therapeutic options, along with their pharmacodynamic and pharmacokinetic profiles, is mandatory to optimize therapy and reduce hospital pneumonia-related mortality. © 2014 Informa UK, Ltd.
Ewig S.,Thoraxzentrum Ruhrgebiet |
Welte T.,Medizinische Hochschule Hanover |
Chastre J.,Institute Of Cardiologie |
Torres A.,Institute Clinic del Torax
The Lancet Infectious Diseases | Year: 2010
The increasing numbers of patients who are elderly and severely disabled has led to the introduction of a new category of pneumonia management: health-care-associated pneumonia (HCAP). An analysis of the available evidence in support of this category, however, reveals heterogeneous and misleading definitions of HCAP, reliance on microbiological data of questionable validity, failure to recognise the contribution of aspiration pneumonia, failure to control microbial patterns for functional status, and failure to recognise frequently applied restrictions of treatment escalation as bias in assessing outcomes. As a result, the concept of HCAP contributes to confusion more than it provides a guide to pneumonia management, and it potentially leads to overtreatment. We suggest a reassignment of the criteria for HCAP to reconstruct the triad of community-acquired pneumonia (with a recognised core group of elderly and disabled patients and a subgroup of younger patients), hospital-acquired pneumonia, and pneumonia in immunosuppressed patients. © 2010 Elsevier Ltd. All rights reserved.
Roig E.,Servicio de Cardiologia |
Almenar L.,Polytechnic University of Valencia |
Crespo-Leiro M.,Hospital Universitario runa |
Segovia J.,Servicio de Cardiologia |
And 6 more authors.
Journal of Heart and Lung Transplantation | Year: 2015
Background The lengthy waiting time for heart transplantation is associated with high mortality. To increase the number of donors, new strategies have emerged, including the use of hearts from donors ≥50 years old. However, this practice remains controversial. The aim of this study was to evaluate outcomes of patients receiving heart transplants from older donors. Methods We retrospectively analyzed 2,102 consecutive heart transplants in 8 Spanish hospitals from 1998 to 2010. Acute and overall mortality were compared in patients with grafts from donors ≥50 years old versus grafts from younger donors. Results There were 1,758 (84%) transplanted grafts from donors < 50 years old (Group I) and 344 (16%) from donors ≥50 years old (Group II). Group I had more male donors than Group II (71% vs 57%, p = 0.0001). The incidence of cardiovascular risk factors was higher in older donors. There were no differences in acute mortality or acute rejection episodes between the 2 groups. Global mortality was higher in Group II (rate ratio, 1.40; 95% confidence interval, 1.18-1.67; p = 0.001) than in Group I. After adjusting for donor cause of death, donor smoking history, recipient age, induction therapy, and cyclosporine therapy, the differences lost significance. Group II had a higher incidence of coronary allograft vasculopathy at 5 years (rate ratio, 1.67; 95% confidence interval, 1.22-2.27; p = 0.001). Conclusions There were no differences in acute and overall mortality after adjusting for confounding factors. However, there was a midterm increased risk of coronary allograft vasculopathy with the use of older donors. Careful selection of recipients and close monitoring of coronary allograft vasculopathy are warranted in these patients. © 2015 International Society for Heart and Lung Transplantation.
Ewig S.,Thoraxzentrum Ruhrgebiet |
Welte T.,Medizinische Hochschule Hanover MHH |
Torres A.,Institute Clinic del Torax
Current Opinion in Infectious Diseases | Year: 2012
PURPOSE OF REVIEW: Healthcare-associated pneumonia (HCAP) was introduced in 2005 by American Thoracic Society/Infectious Diseases Society of America guidelines as a new entity of pneumonia, resembling nosocomial pneumonia rather than community-acquired pneumonia (CAP) in terms of frequency of multidrug-resistant (MDR) pathogens and outcomes, thus requiring broad spectrum initial antimicrobial coverage in order to prevent inadequate treatment and, as a consequence, excess mortality. This concept continues to be a subject of controversy. Main concerns relate to the definition of HCAP, the true frequency of MDR pathogens, and the impact of MDR pathogens on outcomes. RECENT FINDINGS: Definitions of HCAP and the relative frequencies of HCAP defining subgroups were highly variable. All studies demonstrated an increased severity of pneumonia at presentation and an excess mortality from HCAP as compared to CAP. The incidence of MDR pathogens in different observational studies was slightly increased but generally low in most studies originating from Europe, South Korea, Canada, and Japan. However, the data do not support a causal relationship of MDR incidence and excess mortality. Instead, after adjustment for confounders, mortality might be related to hidden or documented treatment restrictions in elderly and severely disabled patients. Accordingly, HCAP guideline concordant antimicrobial treatment did not improve outcomes. SUMMARY: The HCAP concept is based on varying definitions poorly predictive of MDR pathogens. The incidence of MDR pathogens is far lower than supposed in the original guideline document, and MDR pathogens do not seem to be the main cause of excess mortality. Broad antimicrobial coverage does not alter outcomes. As the HCAP concept results in a tremendous overtreatment without any evidence for improved outcomes, it should not be implemented in clinical practice prior to clear evidence that it is superior to a careful assessment of individual risk factors for MDR pathogens. © 2012 Lippincott Williams & Wilkins, Inc.
Marquez-Martin A.,Autonomous University of Barcelona |
Jimenez-Altayo F.,Autonomous University of Barcelona |
Dantas A.P.,Institute Clinic del Torax |
Caracuel L.,Autonomous University of Barcelona |
And 2 more authors.
Journal of Applied Physiology | Year: 2012
Chronic cerebral hypoperfusion (CHP) induces microvascular changes that could contribute to the progression of vascular cognitive impairment and dementia in the aging brain. This study aimed to analyze the effects of CHP on structural, mechanical, and myogenic properties of the middle cerebral artery (MCA) after bilateral common carotid artery occlusion (BCCAO) in adult male Wistar rats. Sham animals underwent a similar surgical procedure without carotid artery (CA) ligation. After 15 days of occlusion, MCA and CA were dissected and MCA structural, mechanical, and myogenic properties were assessed by pressure myography. Collagen I/III expression was determined by immunofluorescence in MCA and CA and by Western blot in CA. mRNA levels for 1A1, 1A2, and 3A1 collagen subunits were quantified by quantitative real-time PCR in CA. Matrix metalloproteinase (MMP-1, MMP-2, MMP-9, and MMP-13) and hypoxia-inducible factor-1α (HIF-1α) protein expression were determined in CA by Western blot. BCCAO diminished cross-sectional area, wall thickness, and wall-to-lumen ratio. Nevertheless, whereas wall stress was increased, stiffness was not modified and myogenic response was diminished. Hypoperfusion triggered HIF-1α expression. Collagen I/III protein expression diminished in MCA and CA after BCCAO, despite increased mRNA levels for 1A1 and 3A1 collagen subunits. Therefore, the reduced collagen expression might be due to proteolytic degradation, since the expression of MMP-1 and MMP-9 increased in the CA. These data suggest that BCCAO induces hypotrophic remodeling by a mechanism that involves a reduction of collagen I/III in association with increased MMP-1 and MMP-9 and that decreases myogenic tone in major arteries supplying the brain. Copyright © 2012 the American Physiological Society.