Contribution of Clinical Trial Event Data by Data Source: A Prespecified Analysis of the ADAPTABLE Randomized Clinical Trial

Importance

Pragmatic randomized clinical trials (RCTs) often use multiple data sources to examine clinical events, but the relative contribution of data sources to clinical end-point rates is understudied.

Objective

To assess the contribution of data sources (electronic health records [EHRs], public/private insurance claims, and/or participant-reported data) to clinical end points among ADAPTABLE participants who had available data.

Design, Setting, and Participants

The ADAPTABLE study was an open-label, pragmatic RCT from April 2016 through June 2019 conducted in research networks within clinical practice. Participants had existing atherosclerotic cardiovascular disease and available data to analyze. The characteristics of patients by combinations of data source availability were compared to examine the contribution of each of the data sources to end-point ascertainment. Data for this prespecified analysis were examined from January 2022 to June 2023.

Exposures

Randomized exposure to 81 mg or 325 mg of aspirin daily.

Main Outcomes and Measures

Number of events for the primary end point (composite of death, hospitalization for myocardial infarction, and hospitalization for stroke) that were contributed by EHR or claims data and then number of events contributed by each additional data source.

Results

Of 15 006 participants randomized with at least 1 other source of data available beyond participant-reported data, there were 8756 (58.3%) with participant-reported and EHR data; 4291 (28.6%) with participant-reported, EHR, and claims data; 1412 (9.4%) with EHR-only data; 262 (1.7%) with participant-reported and claims data; 202 (1.3%) with EHR and claims data; and 83 (0.6%) with claims-only data. Participants with EHR-only data were younger (median age, 63.7 years; IQR, 55.8-71.4) compared with the other groups (range, 65.6-71.9 years). Among participants with both EHR and claims data, with or without participant-reported data (n = 4493), for each outcome, most events (92%-100%) were identified in the EHR or in claims data. For all clinical end points, participant-reported data contributed less than 10% of events not otherwise available from claims or EHR data.

Conclusions and Relevance

In this analysis of a pragmatic RCT, claims and EHR data provided the most clinical end-point data when compared with participant-reported events. These findings provide a framework for collecting end points in pragmatic clinical trials. Further work is needed to understand the data source combinations that most effectively provide clinical end-point data in RCTs.

Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease and Diabetes Mellitus: A Subgroup Analysis of the ADAPTABLE Trial

OBJECTIVE

Patients with diabetes mellitus (DM) and concomitant atherosclerotic cardiovascular disease (ASCVD) must be on the most effective dose of aspirin to mitigate risk of future adverse cardiovascular events.

RESEARCH DESIGN AND METHODS

ADAPTABLE, an open-label, pragmatic study, randomized patients with stable, chronic ASCVD to 81 mg or 325 mg of daily aspirin. The effects of aspirin dosing was assessed on the primary effectiveness outcome, a composite of all-cause death, hospitalization for myocardial infarction, or hospitalization for stroke, and the primary safety outcome of hospitalization for major bleeding. In this prespecified analysis, we used Cox proportional hazards models to compare aspirin dosing in patients with and without DM for the primary effectiveness and safety outcome.

RESULTS

Of 15,076 patients, 5,676 (39%) had DM of whom 2,820 (49.7%) were assigned to 81 mg aspirin and 2,856 (50.3%) to 325 mg aspirin. Patients with versus without DM had higher rates of the composite cardiovascular outcome (9.6% vs. 5.9%; P < 0.001) and bleeding events (0.78% vs. 0.50%; P < 0.001). When comparing 81 mg vs. 325 mg of aspirin, patients with DM had no difference in the primary effectiveness outcome (9.3% vs. 10.0%; hazard ratio [HR] 0.98 [95% CI 0.83-1.16]; P = 0.265) or safety outcome (0.87% vs. 0.69%; subdistribution HR 1.25 [95% CI 0.72-2.16]; P = 0.772).

CONCLUSIONS

This study confirms the inherently higher risk of patients with DM irrespective of aspirin dosing. Our findings suggest that a higher dose of aspirin yields no added clinical benefit, even in a more vulnerable population.

Effectiveness and Safety of Enteric-Coated vs Uncoated Aspirin in Patients With Cardiovascular Disease: A Secondary Analysis of the ADAPTABLE Randomized Clinical Trial

Importance

Clinicians recommend enteric-coated aspirin to decrease gastrointestinal bleeding in secondary prevention of coronary artery disease even though studies suggest platelet inhibition is decreased with enteric-coated vs uncoated aspirin formulations.

Objective

To assess whether receipt of enteric-coated vs uncoated aspirin is associated with effectiveness or safety outcomes.

Design, Setting, and Participants

This is a post hoc secondary analysis of ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness), a pragmatic study of 15 076 patients with atherosclerotic cardiovascular disease having data in the National Patient-Centered Clinical Research Network. Patients were enrolled from April 19, 2016, through June 30, 2020, and randomly assigned to receive high (325 mg) vs low (81 mg) doses of daily aspirin. The present analysis assessed the effectiveness and safety of enteric-coated vs uncoated aspirin among those participants who reported aspirin formulation at baseline. Data were analyzed from November 11, 2019, to July 3, 2023.

Intervention

ADAPTABLE participants were regrouped according to aspirin formulation self-reported at baseline, with a median (IQR) follow-up of 26.2 (19.8-35.4) months.

Main Outcomes and Measures

The primary effectiveness end point was the cumulative incidence of the composite of myocardial infarction, stroke, or death from any cause, and the primary safety end point was major bleeding events (hospitalization for a bleeding event with use of a blood product or intracranial hemorrhage). Cumulative incidence at median follow-up for primary effectiveness and primary safety end points was compared between participants taking enteric-coated or uncoated aspirin using unadjusted and multivariable Cox proportional hazards models. All analyses were conducted for the intention-to-treat population.

Results

Baseline aspirin formulation used in ADAPTABLE was self-reported for 10 678 participants (median [IQR] age, 68.0 [61.3-73.7] years; 7285 men [68.2%]), of whom 7366 (69.0%) took enteric-coated aspirin and 3312 (31.0%) took uncoated aspirin. No significant difference in effectiveness (adjusted hazard ratio [AHR], 0.94; 95% CI, 0.80-1.09; P = .40) or safety (AHR, 0.82; 95% CI, 0.49-1.37; P = .46) outcomes between the enteric-coated aspirin and uncoated aspirin cohorts was found. Within enteric-coated aspirin and uncoated aspirin, aspirin dose had no association with effectiveness (enteric-coated aspirin AHR, 1.13; 95% CI, 0.88-1.45 and uncoated aspirin AHR, 0.99; 95% CI, 0.83-1.18; interaction P = .41) or safety (enteric-coated aspirin AHR, 2.37; 95% CI, 1.02-5.50 and uncoated aspirin AHR, 0.89; 95% CI, 0.49-1.64; interaction P = .07).

Conclusions and Relevance

In this post hoc secondary analysis of the ADAPTABLE randomized clinical trial, enteric-coated aspirin was not associated with significantly higher risk of myocardial infarction, stroke, or death or with lower bleeding risk compared with uncoated aspirin, regardless of dose, although a reduction in bleeding with enteric-coated aspirin cannot be excluded. More research is needed to confirm whether enteric-coated aspirin formulations or newer formulations will improve outcomes in this population.

Trial Registration

ClinicalTrials.gov Identifier: NCT02697916.

Aspirin Dosing for Secondary Prevention of Atherosclerotic Cardiovascular Disease in Patients Treated With P2Y12 Inhibitors

Background The ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) was a large, pragmatic, randomized controlled trial that found no difference between high- versus low-dose aspirin for secondary prevention of atherosclerotic cardiovascular disease. Whether concomitant P2Y12 inhibitor therapy modifies the effect of aspirin dose on clinical events remains unclear. Methods and Results Participants in ADAPTABLE were stratified according to baseline use of clopidogrel or prasugrel (P2Y12 group). The primary effectiveness end point was a composite of death, myocardial infarction, or stroke; and the primary safety end point was major bleeding requiring blood transfusions. We used multivariable Cox regression to compare the relative effectiveness and safety of aspirin dose within P2Y12 and non-P2Y12 groups. Of 13 815 (91.6%) participants with available data, 3051 (22.1%) were receiving clopidogrel (2849 [93.4%]) or prasugrel (203 [6.7%]) at baseline. P2Y12 inhibitor use was associated with higher risk of the primary effectiveness end point (10.86% versus 6.31%; adjusted hazard ratio [HR], 1.40 [95% CI, 1.22-1.62]) but was not associated with bleeding (0.95% versus 0.53%; adjusted HR, 1.42 [95% CI, 0.91-2.22]). We found no interaction in the relative effectiveness and safety of high- versus low-dose aspirin by P2Y12 inhibitor use. Overall, dose switching or discontinuation was more common in the high-dose compared with low-dose aspirin group, but the pattern was not modified by P2Y12 inhibitor use. Conclusions In this prespecified analysis of ADAPTABLE, we found that the relative effectiveness and safety of high- versus low-dose aspirin was not modified by baseline P2Y12 inhibitor use. Registration https://www.clinical.trials.gov. Unique identifier: NCT02697916.

Comparison of the effectiveness and safety of 2 aspirin doses in secondary prevention of cardiovascular outcomes in patients with chronic kidney disease: A subgroup analysis of ADAPTABLE

BACKGROUND

Among patients with established cardiovascular disease, the ADAPTABLE trial found no significant differences in cardiovascular events and bleeding rates between 81 mg and 325 mg of aspirin (ASA) daily. In this secondary analysis from the ADAPTABLE trial, we studied the effectiveness and safety of ASA dosing in patients with a history of chronic kidney disease (CKD).

METHODS

ADAPTABLE participants were stratified based on the presence or absence of CKD, defined using ICD-9/10-CM codes. Within the CKD group, we compared outcomes between patients taking ASA 81 mg and 325 mg. The primary effectiveness outcome was defined as a composite of all cause death, myocardial infarction, or stroke and the primary safety outcome was hospitalization for major bleeding. Adjusted Cox proportional hazard models were utilized to report differences between the groups.

RESULTS

After excluding 414 (2.7%) patients due to missing medical history, a total of 14,662 patients were included from the ADAPTABLE cohort, of whom 2,648 (18%) patients had CKD. Patients with CKD were older (median age 69.4 vs 67.1 years; P < .0001) and less likely to be white (71.5% vs 81.7%; P < .0001) when compared to those without CKD. At a median follow-up of 26.2 months, CKD was associated with an increased risk of both the primary effectiveness outcome (adjusted HR 1.79 [1.57, 2.05] P < .001 and the primary safety outcome (adjusted HR 4.64 (2.98, 7.21), P < .001 and P < .05, respectively) regardless of ASA dose. There was no significant difference in effectiveness (adjusted HR 1.01 95% CI 0.82, 1.23; P = .95) or safety (adjusted HR 0.93; 95% CI 0.52, 1.64; P = .79) between ASA groups.

CONCLUSIONS

Patients with CKD were more likely than those without CKD to have adverse cardiovascular events or death and were also more likely to have major bleeding requiring hospitalization. However, there was no association between ASA dose and study outcomes among these patients with CKD.

Internet Versus Noninternet Participation in a Decentralized Clinical Trial: Lessons From the ADAPTABLE Study

Background Internet-based participation has the potential to enhance pragmatic and decentralized trials, where representative study populations and generalizability to clinical practice are key. We aimed to study the differences between internet and noninternet/telephone participants in a large remote, pragmatic trial. Methods and Results In a subanalysis of the ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) study, we compared internet participants with those who opted for noninternet participation. Study process measures examined included participant characteristics at consent, study medication adherence, and study retention. The clinical outcome examined was a composite of all-cause mortality, hospitalization for myocardial infarction, or hospitalization for stroke. Noninternet participants were older (mean 69.4 versus 67.4 years), more likely to be female (38.9% versus 30.2%), more likely to be Black (27.3% versus 6.0%) or Hispanic (11.1% versus 2.0%), and had a higher number of comorbid conditions. The composite clinical outcome was more than twice as high in noninternet participants. The hazard of nonadherence to the assigned aspirin dosage was 46% higher in noninternet participants than internet participants. Conclusions Noninternet participants differed from internet participants in notable demographic characteristics while having poorer baseline health. Over the course of ADAPTABLE, they also had worse clinical outcomes and greater likelihood of study drug nonadherence. These results suggest that trials focused on internet participation select for younger, healthier participants with a higher proportion of traditionally overrepresented patients. Allowing noninternet participation enhances diversity; however, additional steps may be needed to promote study retention and study medication adherence. Registration Information clinicaltrials.gov. Identifier: NCT02697916.

Hemorrhagic cystitis following allogeneic hematopoietic stem cell transplantation: experience in a pediatric oncological institution

OBJECTIVE

To analyze the risk factors associated with hemorrhagic cystitis (HC) severity and the treatment strategies available in HC patients following allogeneic hematopoietic stem cell transplantation (AHSCT).

MATERIALS AND METHODS

A retrospective study of medical records was carried out. Patients with HC following AHSCT treated from 2017 to 2021 were divided into two groups according to severity -mild and severe. Demographic data, disease-specific characteristics, urological sequelae, and overall mortality were compared between both groups. The hospital's protocol was used for patient management.

RESULTS

33 episodes of HC were collected in 27 patients, 72.7% of whom were male. HC incidence following AHSCT was 23.4% (33/141). 51.5% of HCs were severe (grades III-IV). Severe graft host disease (GHD) (grades III-IV) and thrombopenia at HC onset were associated with severe HC (p= 0.043 and p= 0.039, respectively). This group had longer hematuria times (p< 0.001) and required more platelet transfusions (p= 0.003). In addition, 70.6% required bladder catheterization, but only 1 case needed percutaneous cystostomy. None of the patients with mild HC required catheterization. No differences were found in terms of urological sequelae or overall mortality.

CONCLUSIONS

Severe HC could be predicted thanks to the presence of severe GHD or thrombopenia at HC onset. Severe HC can be managed with bladder catheterization in most of these patients. A standardized protocol may help reduce the need for invasive procedures in patients with mild HC.

A retrospective study of Cerebrolysin in patients with moderate to severe traumatic brain injury: Cognitive and functional outcomes

In this retrospective study, we aimed to evaluate the effects of the neurotrophic compound Cerebrolysin on executive, cognitive, and functional performance in patients with traumatic brain injury (TBI) with a highly severe disability level. A total of 44 patients were included in the study, with 33 patients in the control group and 11 patients in the interventional group who received intravenous infusions of 30 mL Cerebrolysin. Both groups received standard rehabilitation therapy following the rehabilitation protocol for patients with TBI at Hospital Clínico Mutual de Seguridad. Functional and cognitive scales were evaluated at baseline, at four months, and at the endpoint of the intervention therapy at seven months (on average). The results revealed a significant improvement in the Cerebrolysin-treated group compared to the control group. Specifically, patients who received Cerebrolysin showed a moderate residual disability and a significant reduction in the need for care. Concerning the promising results and considering the limitations of the retrospective study design, we suggest that randomized controlled studies be initiated to corroborate the positive findings for Cerebrolysin in patients with moderate to severe brain trauma.

Pharmacotherapy and clinical outcomes of hospitalized COVID-19 patients in Chile during the first wave of pandemic

BACKGROUND

The largest growth in cases of COVID-19 worldwide during 2020 was in the Americas, and Chile was one of the most affected countries.

AIM

To describe, characterize, and evaluate the use of drugs as treatment for COVID-19 in hospitalized patients in Chile during the first wave of the pandemic.

METHODS

We performed a multicenter, observational study that included 442 patients with confirmed SARS-CoV-2 infection admitted in Chilean hospitals between March 21 and September 22, 2020. The analysis included demographics, comorbidities, specific drug therapy, and outcomes over a 28-day follow-up period.

RESULTS

The median age of patients was 68 years (IQR 55-73), and 38.9% were women. The most common comorbidities were hypertension (57.7%) and diabetes (36.9%). Fifty-seven (12.9%) patients died. Hypertension (HR 2.99; CI 95% 1.43-6.26) and age ≥ 65 (2.14; CI 95% 1.10- 4.17) were the main predictors of mortality. Primary drugs were azithromycin (58.8%) and corticosteroids (51.1%). In this sample, azithromycin was a protective factor regarding mortality (HR 0.53; CI 95% 0.31-0.90), increasing clinical improvement and avoiding progression.

CONCLUSIONS

The patterns of use of drugs to treat COVID-19 in Chile during the first wave of the pandemic were very dynamic and followed the international, evidence-based guidelines. The low mortality rate indicates that the clinical management of hospitalized patients was adequate.

Outcomes among patients with peripheral artery disease in the Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) study

BACKGROUND

We aimed to understand the effects of aspirin dose on outcomes in patients with peripheral artery disease (PAD) as well as their participation in a pragmatic randomized controlled trial.

METHODS

In a subanalysis of the Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) study, we compared aspirin doses (81 vs 325 mg) among participants with PAD and study participation metrics in patients with and without PAD. The primary outcome composite was all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke.

RESULTS

Among 14,662 participants enrolled in ADAPTABLE with PAD status available, 3493 (23.8%) had PAD. Participants with PAD were more likely to experience the primary composite (13.76% vs 5.31%, p < 0.001), all-cause mortality (7.55% vs 3.01%, p < 0.001), myocardial infarction (5.71% vs 2.09%, p < 0.001), stroke (2.45% vs 0.86%, p < 0.001), and major bleeding (1.19% vs 0.44%, p < 0.001). A higher aspirin dose did not reduce the primary outcome in patients with PAD (13.68% vs 13.84% in 81 mg and 325 mg groups; OR 1.05, 95% CI 0.88-1.25). Participants with PAD were less likely to enroll via email (33.0% vs 41.9%, p < 0.0001), less likely to choose internet follow-up (79.2% vs 89.5%, p < 0.0001), and were more likely to change their aspirin doses (39.7% vs 30.7%, p < 0.0001).

CONCLUSIONS

ADAPTABLE participants with PAD did not benefit from a higher dose of aspirin and participated in the study differently from those without PAD. These results reinforce the need for additional PAD-specific research and suggest that different trial strategies may be needed for optimal engagement of patients with PAD. (ClinicalTrials.gov Identifier: NCT02697916).

Análisis secuencial de golpeos finales del punto en pádel mediante árbol decisional

El objetivo de este estudio fue analizar la secuencia de los dos últimos golpeos del punto en pádel, y clasificarlos a través de árbol decisional multivariante. Se analizaron un total de 2110 acciones de juego, siendo las variables analizadas: golpeo, zona de la pista, eficacia, dirección, resultado y lado de juego. Los partidos fueron analizados mediante observación sistemática. Los resultados mostraron que mantener posiciones cercanas a la red aumenta las probabilidades de victoria, observándose que las secuencias de finalización más frecuentes son las de fondo-volea y globo-remate. Las parejas ganadoras realizan mayor número de puntos ganadores en la red y menos errores en el fondo de la pista. Además, utilizar trayectorias cruzadas en el penúltimo golpe aumentará las posibilidades de un error posterior de los rivales. Estos datos tienen aplicación práctica en el entrenamiento perceptivo y decisional del jugador de pádel, y la aplicación de feedbacks por parte del entrenador.

Sex differences in endocannabinoids during 3 years of Mediterranean diet intervention: Association with insulin resistance and weight loss in a population with metabolic syndrome

Background

Excess circulating endocannabinoids (eCBs) and imbalanced N-acylethanolamines (NAEs) related eCBs abundance could influence dietary weight loss success. We aimed to examine sex differences in the impact of a 3-years Mediterranean diet (MedDiet) intervention on circulating eCBs, NAEs and their precursor fatty acids, and to analyze the interplay between changes in eCBs or NAEs ratios, insulin resistance and the achievement of clinically meaningful weight reductions.

Methods

Prospective cohort study in a subsample of N = 105 participants (54.3% women; 65.6 ± 4.6 years) with overweight or obesity and metabolic syndrome that underwent a 3-years MedDiet intervention (PREDIMED-Plus study). Plasma eCBs and NAEs, including 2-arachidonoylglycerol (2-AG), anandamide (AEA), oleoylethanolamide (OEA) and palmitoylethanolamide (PEA), fatty acids, diet, glycemic homeostasis (including the assessment of insulin resistance-HOMA-IR), and cardiovascular risk markers were monitored (at 0-6-12-36 months).

Results

Mediterranean diet adherence increased in both sexes and remained high during the 3 years of follow-up. Reductions in body weight, glycemic and cardiovascular parameters were larger in men than in women. Women presented higher concentrations of NAEs than men throughout the study. In both sexes, AEA and other NAEs (including OEA, and PEA) decreased after 6 months (for AEA: −4.9%), whereas the ratio OEA/AEA increased after 1 year (+5.8%). Changes in 2-AG (−3.9%) and the ratio OEA/PEA (+8.2%) persisted over the 3 years of follow-up. In women, 6-months changes in AEA (OR = 0.65) and the ratio OEA/AEA (OR = 3.28) were associated with the achievement of 8% weight reductions and correlated with HOMA-IR changes (r = 0.29 and r = −0.34). In men, OEA/PEA changes were associated with 8% weight reductions (OR = 2.62) and correlated with HOMA-IR changes (r = −0.32).

Conclusion

A 3-years MedDiet intervention modulated plasma concentrations of eCBs and NAEs. Changes in AEA and in the relative abundance of NAEs were associated with clinically meaningful weight reductions. However, marked sex differences were identified in eCBs and NAEs, as well as in the efficacy of the intervention in terms of glycemic and cardiovascular parameters, which could be related to post-menopause alterations in glucose metabolism. These findings support a sex-balanced research strategy for a better understanding of the mechanisms underlying the regulation of body weight loss.

EFICACIA Y DISTRIBUCIÓN DE LOS GOLPES FINALISTAS DE ATAQUE EN PÁDEL PROFESIONAL

El objetivo de este estudio fue analizar la distribución y la eficacia de los golpes finalistas de ataque en el pádel profesional en función de la distancia de golpeo a la red y el género de los jugadores. La muestra incluyó 633 acciones técnico-tácticas de ataque que finalizaron el punto. Las variables analizadas fueron: acciones técnico-tácticas de ataque, eficacia del golpe y distancia a la red. Los partidos fueron analizados a través de observación sistemática. Los resultados mostraron que los hombres utilizan significativamente más el remate potente para finalizar el punto, mientras que las mujeres utilizan significativamente más la bandeja. Además, el mayor porcentaje de acciones finalistas se produce en zonas cercanas a la red (2-4metros), en ambos géneros. Finalmente, las acciones de ataque más efectivas para conseguir punto son los remates, aunque la eficacia de las acciones disminuye a medida que los jugadores se alejan de la red.

Association of Physician Coordination With Interfacility Transfer Acceptance Timeliness

Objectives

Interfacility transfer for time-sensitive emergencies involves rapid and complex care transitions between facilities. We sought to validate relational coordination, a 7-dimension measure of coordination in which a higher score reflects higher-quality coordination, to examine how the quality of coordination affects timeliness in an emergency care setting.

Study Design

Retrospective observational cohort design.

Methods

We used a novel method to examine how the quality of coordination between physicians at the time of transfer affects timeliness of physician acceptance. We recorded physician-to-physician conversations from the transfer of patients with ST-segment elevation myocardial infarction (STEMI), a time-sensitive emergency requiring immediate intervention to prevent morbidity and mortality.

Results

We identified 81 patients experiencing STEMI who were transferred between August 1, 2016, and March 31, 2018. Descriptive statistics, interrater reliability (Spearman correlation coefficients), and generalized linear models were used to examine the association between relational coordination and the physician time-to-acceptance duration. Median (IQR) relational coordination score was 445 (403-493) of a maximum of 700, and median (IQR) time to acceptance was 90.4 (60.2-140.8) seconds. Agreement between abstractors was high (ρ = 0.76). There was a significant, negative relationship between relational coordination and time to acceptance (ρ = -0.38; P < .001). Every 40-point increase in relational coordination was associated with a 25% reduction in time to acceptance.

Conclusions

Relational coordination not only demonstrated high interrater reliability, but we also found that higher-quality coordination was associated with faster physician acceptance during time-sensitive transfers. Use of such measures may provide a mechanism to improve the quality of care and outcomes for patients with STEMI who experience interfacility transfers.

Effect of CYP3A4, CYP3A5, MDR1 and POR Genetic Polymorphisms in Immunosuppressive Treatment in Chilean Kidney Transplanted Patients

Cyclosporine (CsA) and tacrolimus (TAC) are immunosuppressant drugs characterized by a narrow therapeutic range and high pharmacokinetic variability. The effect of polymorphisms in genes related to the metabolism and transport of these drugs, namely CYP3A4, CYP3A5, MDR1 and POR genes, has been evaluated in diverse populations. However, the impact of these polymorphisms on drug disposition is not well established in Latin American populations. Using TaqMan® probes, we determined the allelic frequency of seven variants in CYP3A4, CYP3A5, MDR1 and POR in 139 Chilean renal transplant recipients, of which 89 were treated with CsA and 50 with TAC. We tested associations between variants and trough and/or 2-hour concentrations, normalized by dose (C₀/D and C₂/D) at specific time points post-transplant. We found that CYP3A5*3/*3 carriers required lower doses of TAC. In TAC treated patients, most CYP3A5*3/*3 carriers presented higher C₀/D and a high proportion of patients with C₀ levels outside the therapeutic range relative to other genotypes. These results reinforce the value of considering CYP3A5 genotypes alongside therapeutic drug monitoring for TAC treated Chilean kidney recipients.

Four-year safety and effectiveness data from patients with multiple sclerosis treated with fingolimod: The Spanish GILENYA registry

Objective

To describe the profile of patients with multiple sclerosis (MS) treated with fingolimod in Spain and to assess the effectiveness and safety of fingolimod after 4 years of inclusion in the Spanish Gilenya Registry.

Methods

An observational, retrospective/prospective, multicenter case registry, including all patients with relapsing-remitting MS (RRMS) starting treatment with fingolimod in 43 centers in Spain. Analyses were performed in the overall population and in subgroups according to prior disease-modifying therapy (DMT): glatiramer acetate/interferon beta-1 (BRACE), natalizumab, other treatment, or naïve.

Results

Six hundred and sixty-six evaluable patients were included (91.1% previously treated with at least one DMT). The mean annualized relapse rate (ARR) prior to fingolimod was 1.12, and the mean EDSS at fingolimod initiation was 3.03. Fingolimod reduced the ARR by 71.4%, 75%, 75.5%, and 80.3%, after 1, 2, 3 and 4 years, respectively (p<0.001). This significant reduction in the ARR continued to be observed in all subgroups. After 4 years, the EDSS showed a minimal deterioration, with the EDSS scores from year 1 to year 4 remaining mostly stable. The percentage of patients without T1 Gd+ lesions progressively increased from 45.6% during the year prior to fingolimod initiation to 88.2% at year 4. The proportion of patients free from new/enlarged T2 lesions after 4 years of fingolimod treatment was 80.3%. This trend in both radiological measures was also observed in the subgroups. Adverse events (AEs) were experienced by up to 41.6% of patients (most commonly: lymphopenia [12.5%] and urinary tract infection [3.7%]). Most AEs were mild in severity, 3.6% of patients had serious AEs.

Conclusions

The patient profile was similar to other observational studies. The results obtained from the long-term use of fingolimod showed that it was effective, regardless of prior DMT, and it had adequate safety results, with a positive benefit-risk balance.

3-Week passive acclimation to extreme environmental heat (100± 3 °C) in dry sauna increases physical and physiological performance among young semi-professional football players

This manuscript aims to evaluate the influence of a novel passive heat acclimation program among human participants in the physical performance, as well as in several physiological parameters. 36 male football players were acclimated using a dry sauna bath to extreme hot (100 ± 3 °C), performing a total of nine sauna sessions with a weekly frequency of three sessions. The players were randomly into the sauna group (SG; n = 18; age: 20.69 ± 2.09 years) and the control group (CG; n = 18; age: 20.23 ± 1.98 years). All participants performed maximal effort test until exhaustion as well as hamstring flexibility test before and after the acclimation program. Anthropometric, respiratory, circulatory, hematological and physiological variables were evaluated at the beginning and at the end of the survey. Statistical analysis consisted of a Mann-Whitney U test to determine differences between groups at the beginning and at the end of the survey and a Wilcoxon test for paired samples to compare the differences for each group separately. Additionally, size effects of the pre-post acclimation changes were calculated. After the acclimation program SG participants experienced a diminution in body weight (p < 0.01), body mass index (p < 0.01), body fat (p < 0.05) and fat percentage (p < 0.05) decreased. Hamstring flexibility (p < 0.05) and work capacity (p < 0.05) increased. External basal temperature decreased (p < 0.05) as well as post-exercise systolic and diastolic blood pressures (p < 0.05). Finally, maximal oxygen uptake (ml Kg^-1 min^-1) (p < 0.05), maximal minute ventilation (p < 0.05) and maximal breath frequency (p < 0.05) increased at the end of the intervention. There were no significant changes in the CG in any variable. Favorable adaptations have been observed in this survey, suggesting a beneficial effect of extreme heat acclimation on physical performance. Several of the observed responses seem interesting for sport performance and health promotion as well. However, this is a novel, extreme protocol which requires further research.

Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease

BACKGROUND

The appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy.

METHODS

Using an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis.

RESULTS

A total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]).

CONCLUSIONS

In this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily. (Funded by the Patient-Centered Outcomes Research Institute; ADAPTABLE ClinicalTrials.gov number, NCT02697916.).

Clinical features of 47 patients infected with COVID-19 admitted to a Regional Reference Center

BACKGROUND

During the first pandemic wave, Covid-19 reached Latin America cities.

AIM

To report clinical features and outcomes of a group of patients with Covid-19 admitted to a Chilean regional reference Center.

MATERIAL AND METHODS

Cases were identified by a compatible clinical picture and a positive PCR or serological test. Clinical features of patients were retrieved from medical records.

RESULTS

Forty-seven adult patients (45 diagnosed by PCR, 2 by serology) were admitted between epidemiological weeks 13 to 33, corresponding to 4.4% of total regional cases. Hospitalization occurred at a median of 10 days after onset of symptoms. Fifty one percent of patients had 60 years or more. Hypertension, obesity and diabetes mellitus were present in 57, 45 and 32 % of cases, respectively. Nineteen percent of patients had no comorbid condition nor were elderly. Two cases were women in their second trimester of pregnancy. Positive IgM or IgM/IgG results obtained by rapid serological testing, had limited sensitivity during the first week (67%). Seventeen patients (36.2%) were transferred to an intensive care unit (ICU) due to respiratory failure. Chest imaging demonstrated a classical COVID-19 pattern in 87%. By univariate analysis, admission to ICU was significantly associated with tachypnea and higher CALL (comorbidity, age, lymphocyte count and lactate dehydrogenase) score. Four patients died (rendering a hospital mortality of 8.5%) and length of stay was ≥ 14 days in 46.8% of patients. By univariate analysis, mortality was associated with immunosuppression and ICU admission.

CONCLUSIONS

In our regional Center, patients admitted with COVID-19 had usual risk factors and had a prolonged stay. Hospital mortality was associated with immunosuppression and ICU admission.

DISEÑO Y VALIDACIÓN DE UN INSTRUMENTO OBSERVACIONAL PARA ACCIONES FINALISTAS EN PÁDEL

El pádel es uno de los deportes con mayor crecimiento en España, lo que se ve reflejado en un número cada vez mayor de investigaciones. El objetivo del presente trabajo fue diseñar un instrumento de observación que permita analizar las acciones finalistas en el pádel (IPAAFP) y, además, comprobar su validez y fiabilidad. Un grupo de jueces expertos (n=10), evaluaron en una escala 1-10 la Adecuación y Redacción de 17 items que componen el instrumento. La validez de contenido fue evaluada con la V de Aiken (V=0,83) y la congruencia interna con el ? de Cronbach (0,838). Ningún ítem tuvo que ser eliminado, pero sobre la base de las valoraciones cualitativas de los expertos se realizaron modificaciones en la redacción de los items. Tras el proceso de validación del instrumento, se puede concluir que el IPAAFP es válido y fiable para el análisis de las acciones finalistas en el pádel.