Anticoagulation in AF and Elderly Frail Patient: How to Face New Challenges

Aging is an important risk factor for patients with atrial fibrillation. The estimated prevalence of atrial fibrillation in patients aged ≥80 years is 9–10%, with four- to fivefold increased risk of embolic stroke and with an estimated increased stroke risk of 1.45-fold per decade in aging. Older age is also associated with increased risk of major bleeding with oral anticoagulant (OAC) therapy. In this chapter, we will focus on the role of oral anticoagulation with new oral anticoagulants, non-vitamin K antagonist, in populations with common comorbid conditions, including age; chronic kidney disease; coronary artery disease, on multiple medication; and frailty. In patients 75 years and older, randomized trials have shown new oral anticoagulants to be as effective as warfarin, or in some cases superior, with an overall better safety profile, consistently reducing rates of intracranial hemorrhages. Prior to considering oral anticoagulant therapy in an elderly frail patient, a comprehensive assessment should be performed to include the risk and benefits, stroke risk, baseline kidney function, cognitive status, mobility and falling risk, multiple medication, nutritional status assessment, and life expectancy

Oral anticoagulant use and appropriateness in elderly patients with atrial fibrillation in complex clinical conditions: CONVENIENCE study

Non-valvular atrial fibrillation (NVAF) is the most common arrhythmia in older patients. Although direct-acting oral anticoagulants (DOAC) are the antithrombotic treatment of choice, irrespective of age, certain factors may limit their use. The aim of the ACONVENIENCE study was to consult the opinion of a multidisciplinary panel of experts on the appropriateness of using OACs in elderly patients (>75 years) with NVAF associated with certain complex clinical conditions. A consensus project was performed on the basis of a systematic review of the literature, and application of a two-round Delphi survey. The agreement of 79 panellists on 30 Delphi-type statements was evaluated, and their opinion on the appropriateness of different oral anticoagulants in 16 complex clinical scenarios was assessed. A total of 27 consensus statements were agreed upon, including all statements addressing anticoagulation in older patients and in patients at high risk of bleeding complications, and most of those addressing frailty, dementia, risk of falling, and complex cardiac situations. It was almost unanimously agreed upon that advanced age should not influence the anticoagulation decision. Apixaban was the highest-rated therapeutic option in 14/16 situations, followed by edoxaban. There is a high degree of agreement on anticoagulation in older patients with NVAF. Age should not be the single limiting factor when prescribing OACs, and the decision should be made based on net clinical benefit and a comprehensive geriatric assessment. Apixaban, followed by edoxaban, was considered the most appropriate treatment in the various complex clinical situations examined

Поліваріантність ефектів біоактивної води Нафтуся на вегетативну реактивність, їх ендокринний і імунний супровід та можливість прогнозування

Выявлены разнонаправленные изменения (а также отсутствие оных) в результате питьевой монотерапии биоактивной водой Нафтуся вегетативной реактивности у женщин детородного возраста с хронической гинекологически-эндокринной патологией. Прослежены сопутствующие изменения ряда эндокринных и иммунных показателей. Доказана возможность надежного прогнозирования (точность - 92%) типа эффекта по 30 исходным показателям, отобранным методом дискриминантного анализа.Are revealed various changes (and also absence these) as a result of drinking monotherapy by bioactive water Naftussya of vegetative reactivity at the women of reproductive age with chronic ginecological and endocrine pathology. Are investigated accompanying changes of line of endocrine and immune parameters. The opportunity of reliable forecasting (accuracy - 92 %) such as effect on 30 initial parameters selected method of discriminant analysis is proved

Effects of Vivifrail multicomponent intervention on functional capacity: a multicentre, randomized controlled trial

Background: physical exercise is an effective strategy for preserving functional capacity and improving the symptoms of frailty in older adults. In addition to functional gains, exercise is considered to be a cornerstone for enhancing cognitive function in frail older adults with cognitive impairment and dementia. We assessed the effects of the Vivifrail exercise intervention for functional capacity, cognition, and well-being status in community-dwelling older adults. Methods: in a multicentre randomized controlled trial conducted in three tertiary hospitals in Spain, a total of 188 older patients with mild cognitive impairment or mild dementia (aged >75 years) were randomly assigned to an exercise intervention (n = 88) or a usual-care, control (n = 100) group. The intervention was based on the Vivifrail tailored multicomponent exercise programme, which included resistance, balance, flexibility (3 days/week), and gait-retraining exercises (5 days/week) and was performed for three consecutive months (http://vivifrail.com). The usual-care group received habitual outpatient care. The main endpoint was change in functional capacity from baseline to 1 and 3 months, assessed with the Short Physical Performance Battery (SPPB). Secondary endpoints were changes in cognitive function and handgrip strength after 1 and 3 months, and well-being status, falls, hospital admission rate, visits to the emergency department, and mortality after 3 months. Results: the Vivifrail exercise programme provided significant benefits in functional capacity over usual-care. The mean adherence to the exercise sessions was 79% in the first month and 68% in the following 2 months. The intervention group showed a mean increase (over the control group) of 0.86 points on the SPPB scale (95% confidence interval [CI] 0.32, 1.41 points; P  0.05). Conclusions: the Vivifrail exercise training programme is an effective and safe therapy for improving functional capacity in community-dwelling frail/prefrail older patients with mild cognitive impairment or mild dementia and also seems to have beneficial effect on cognition, muscle function, and mood status.This study has been funded by a Gobierno de Navarra projectgrant and fondos FEDER (Resolución 426/2016, del 30 deseptiembre 28/16). Mikel Izquierdo is funded by a researchgrant PI17/01814 of the Ministerio de Economía, Industria yCompetitividad (ISCIII, FEDER)

ドイツ企業買収法をめぐる最近の動向と実務からの提案 (ドイツM&A弁護士との対話3)

OBJECTIVE: To assess the psychometric quality of an instrument designed to measure functional independence (Functional Independence Scale [FIS]) in several activities of daily living domains and to be applied by trained non-health-related interviewers. The study was carried out in the autonomous region of Madrid in community-dwelling elders. METHODS: We performed a cross-sectional validation study. In addition to the FIS, Pfeiffer's questionnaire, the Depression Subscale of the Hospital Anxiety and Depression Scale, the Comorbidity Index, the Barthel Index, and EQ-5D were used. These measures were cross-sectionally applied to community-dwelling elders (n=500) and outpatients in a general hospital (n=100) aged 65 years. The following FIS psychometric attributes were analyzed: acceptability, scaling assumptions, internal consistency, construct validity, and precision. RESULTS: A fully computable FIS total score was obtained in 94.3% of the subjects. A ceiling effect (60.65%), but no floor effect (0.22%) was evident in the community-dwelling elders. No floor or ceiling effects were detected in the hospital sample. Scaling assumptions and internal consistency were satisfactory (item-total correlations: 0.57-0.91; Cronbach's alpha: 0.94). Factor analysis identified three factors that explained 74.3% of the variance. Indexes of convergent, internal, and known-groups validity were satisfactory. The scale's precision, determined by the standard error of measurement (2.49; 95%CI=4.88), was also satisfactory. CONCLUSION: The FIS is an easy-to-use instrument with appropriate metric attributes. This scale can be usefully applied in broad samples of non-institutionalized elders by non-health related personnel.Estudio financiado por la Dirección General de Universidades e Investigación de la Comunidad de Madrid (PlanRegionalI+D+I. Ref.06/HSE/0417/2004) y por el Plan Nacional I+D+I del Ministerio de CienciayTecnología (Ref.BSO2003-00401).S

Efecto del control metabólico sobre las respuestas vasculares en la diabetes mellitus: papel del estrés oxidativo

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid. Facultad de Medicina. Departamento de Medicina. Fecha de lectura: 23 de Septiembre de 200