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.

Characterization of Gas Electron Multiplier-based detector for external beam radiation therapy dosimetry

PURPOSE

Electronic portal imaging devices (EPIDs) are commonly installed on modern linear accelerators (LINACs) and are convenient for imaging and, potentially, dosimetry. However, owing to their construction with metal and scintillating layers of high atomic number, they exhibit nonwater-equivalent response and oversensitivity to low-energy photons. Therefore, EPIDs are not ideal for dosimetry purposes. Additionally, nonlinearities due to the combined use of scintillators and photodiodes have been reported. Here, an EPID which employs a variable gain Gas Electron Multiplier (GEM) and direct detection of electrons is introduced. To investigate its dosimetric performance, measurements characterizing the novel EPID are performed and compared with measurements from ionization chambers and conventional EPIDs.

METHODS

Linearity, dose rate dependence, field size dependence, off-axis response, and transmission response were measured for all available energy settings (6, 10, 6 MV Flattening Filter Free (FFF) and 10 MVFFF) using three different detector gain settings. Additionally, an evaluation of the ghosting and image lag of the panel was completed. Reference ionization chamber measurements were performed for the off-axis and transmission response and existing data for conventional EPIDs and ionization chambers from equivalent measurements were used for comparison of the field size dependence. Elsewhere, values from the linac monitoring chambers were used.

RESULTS

In the range from 10 to 1000 Monitor Units (MU), the detector was linear within 1% for all combinations of gain settings and energies. The dose rate dependence was also within 1% for all energies and for two out of three gain settings. Regarding field size dependency, the ratio of ionization chamber and panel values was 0.94 and 0.98 for the conventional EPID and GEMini respectively, at 20 × 20 cm² and 10 MV. For 6 MV, 6 MVFFF, and 10MVFFF these ratios were 0.97, 0.98, and 0.99 for the GEMini, and 0.95, 0.97, and 0.97 for the conventional EPID. Similar performance between the GEMini and conventional EPID is observed for field sizes smaller than 10 × 10 cm² . The transmission response was within 5% for all energies for thicknesses up to 30 cm, compared to 10-20% for a conventional EPID. The off-axis response for shifts up to 16 cm was within 1% and 3% for 6 MV and 10 MV, with and without phantom. The rise and fall of the signal from the detector correspond well to monitor chamber measurements indicating little ghosting and image lag, regardless of gain setting.

CONCLUSION

The GEM EPID exhibits dose rate dependence and linearity within 1%, and negligible ghosting and image lag. In this regard, it performs particularly well using 50 and 250 V of gain, and either could be chosen. For higher sensitivity, 250 V is the recommended base gain setting, although other applications may warrant different gains. For most tests performed in this study, the GEM EPID demonstrates a more water-equivalent response than conventional EPIDs making GEMs a viable technology for dosimetry in radiation therapy.

Examining the Timeliness of ST-elevation Myocardial Infarction Transfers

Introduction

Despite large-scale quality improvement initiatives, substantial proportions of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention centers do not receive percutaneous coronary intervention within the recommended 120 minutes. We sought to examine the contributory role of emergency medical services (EMS) activation relative to percutaneous coronary intervention center activation in the timeliness of care for patients transferred with STEMI.

Methods

We conducted a retrospective analysis of interfacility transfers from emergency departments (ED) to a single percutaneous coronary intervention center between 2011–2014. We included emergency department (ED) patients transferred to the percutaneous coronary intervention center and excluded scene transfers and those given fibrinolytics. We calculated descriptive statistics and used multivariable linear regression to model the association of variables with ED time intervals (arrival to electrocardiogram [ECG], ECG-to-EMS activation, and ECG-to-STEMI alert) adjusting for patient age, gender, mode of arrival, weekday hour presentation, facility transfers in the past year, and transferring facility distance.

Results

We identified 159 patients who met inclusion criteria. Subjects were a mean of 59 years old (standard deviation 13), 22% female, and 93% White; 59% arrived by private vehicle, and 24% presented after weekday hours. EDs transferred a median of 9 STEMIs (interquartile range [IQR] 3, 15) in the past year and a median of 65 miles (IQR 35, 90) from the percutaneous coronary intervention center. Median ED length of stay was 65 minutes (IQR 51, 85). Among component intervals, arrival to ECG was 6%, ECG-to-EMS activation 32%, and ECG-to-STEMI alert was 49% of overall ED length of stay. Only 18% of transfers had EMS activation earlier than STEMI alert. ECG-to-EMS activation was shorter in EDs achieving length of stay ≤60 minutes compared to those >60 minutes (12 vs 31 minutes, P<0.001). Multivariable modeling showed that after-hours presentation was associated with longer ECG-to-EMS activation (adjusted relative risk [RR] 1.05, P<0.001). Female gender (adjusted RR 0.81, P<0.001), prior facility transfers (adjusted RR 0.84, P<0.001), and initial ambulance presentation (adjusted RR 0.93, P = 0.02) were associated with shorter ECG-to-EMS activation.

Conclusion

In STEMI transfers, faster EMS activation was more likely to achieve a shorter ED length of stay than a rapid, percutaneous coronary intervention center STEMI alert. Large-scale quality improvement efforts such as the American Heart Association’s Mission Lifeline that were designed to regionalize STEMI have improved the timeliness of reperfusion, but major gaps, particularly in interfacility transfers, remain. While the transferring EDs are recognized as the primary source of delay during interfacility STEMI transfers, the contributions to delays at transferring EDs remain poorly understood.

Three weeks of passive and intervallic heat at high temperatures (100±2 °C) in a sauna improve acclimation to external heat (42±2 °C) in untrained males

Currently, the effect of passive heat acclimation on aerobic performance is still controversial. Therefore, this study aimed to observe the effect of passive and intervallic exposure to high temperatures (100 ± 2 °C) in untrained males. Forty healthy untrained men participated in this investigation. They were randomised into a Control Group (CG; n = 18) and an Experimental Group (EG; n = 22). Both groups performed maximum incremental tests until exhaustion in normothermia (GXT1; 22 ± 2 °C), and 48h afterwards, in hyperthermia (GXT2; 42 ± 2 °C). The EG performed 9 sessions of intervallic exposure to heat (100 ± 2 °C) over 3 weeks. Subsequently, both groups performed two maximal incremental trials in normothermia (GXT3; 22 ± 2 °C) and 48h later, in hyperthermia (GXT4; 42 ± 2 °C). In each test, the maximal ergospirometric parameters and the aerobic (VT1), anaerobic (VT2) and recovery ventilatory thresholds were recorded. The Wilcoxon Test was used for intra-group comparisons and the Mann-Whitney U for inter-group comparisons. There were improvements in absolute VO₂max (p = 0.049), W (p = 0.005) and O₂pulse (p = 0.006) in hyperthermia. In VT1 there was an increase in W (p = 0.046), in VO₂ in absolute (p = 0.025) and relative (p = 0.013) values, O₂pulse (p = 0.006) and VE (p = 0.028) in hyperthermia. While W increased in hyperthermia (p = 0.022) at VT2. The results suggest that passive and intervallic acclimation at high temperatures improves performance in hyperthermia. This protocol could be implemented in athletes when they have to compete in hot environments.

Rationale and Design of the Aspirin Dosing-A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial

Importance

Determining the right dosage of aspirin for the secondary prevention treatment of atherosclerotic cardiovascular disease (ASCVD) remains an unanswered and critical question.

Objective

To report the rationale and design for a randomized clinical trial to determine the optimal dosage of aspirin to be used for secondary prevention of ASCVD, using an innovative research method.

Design, Setting, and Participants

This pragmatic, open-label, patient-centered, randomized clinical trial is being conducted in 15 000 patients within the National Patient-Centered Clinical Research Network (PCORnet), a distributed research network of partners including clinical research networks, health plan research networks, and patient-powered research networks across the United States. Patients with established ASCVD treated in routine clinical practice within the network are eligible. Patient recruitment began in April 2016. Enrollment was completed in June 2019. Final follow-up is expected to be completed by June 2020.

Interventions

Participants are randomized on a web platform in a 1:1 fashion to either 81 mg or 325 mg of aspirin daily.

Main Outcomes and Measures

The primary efficacy end point is the composite of all-cause mortality, hospitalization for nonfatal myocardial infarction, or hospitalization for a nonfatal stroke. The primary safety end point is hospitalization for major bleeding associated with a blood-product transfusion. End points are captured through regular queries of the health systems' common data model within the structure of PCORnet's distributed data environment.

Conclusions and Relevance

As a pragmatic study and the first interventional trial conducted within the PCORnet electronic data infrastructure, this trial is testing several unique and innovative operational approaches that have the potential to disrupt and transform the conduct of future patient-centered randomized clinical trials by evaluating treatments integrated in clinical practice while at the same time determining the optimal dosage of aspirin for secondary prevention of ASCVD.

Trial Registration

ClinicalTrials.gov Identifier: NCT02697916.

Penicillin desensitization in allergic pregnant women with syphilis. Report of two cases

Syphilis during pregnancy has a high risk of congenital transmission with disastrous fetal consequences. Penicillin (PNC) is the only effective antimicrobial for the treatment of pregnant women with syphilis. Chilean guidelines do not consider desensitization to PNC in these women. We report two cases of pregnant women aged 32 and 23 years, with immediate allergy to PNC and syphilis who were safely and successfully desensitized using a four-hour intravenous protocol in the critical care unit and who subsequently received benzathine G PNC. An electronic survey was conducted among approximately 100 Clinical Pharmacists (CP) in the country. Of these, 16 answered and 13 reported having experience in drug desensitization, in at least five cases with PNC and none reported deaths or cardiorespiratory arrest. Desensitization to PNC can be carried out safely and in Chile, this alternative should be incorporated to the management of pregnant women with syphilis and immediate allergy to PNC, instead of using erythromycin.

Effectiveness of a physiologic voice therapy program based on different semioccluded vocal tract exercises in subjects with behavioral dysphonia: A randomized controlled trial

PURPOSE

The present study aimed to assess the effectiveness of a physiologic voice therapy program based on different semioccluded vocal tract exercises in subjects with behavioral dysphonia.

METHODS

Thirty-four participants with behavioral dysphonia were randomly assigned to one of two treatment groups: 1) voice treatment with physiologic voice therapy plus vocal hygiene program (n=20), and 2) vocal hygiene program only (n=14). Laryngoscopic assessment was performed in all subjects. Before and after voice therapy, participants underwent aerodynamic, electroglottographic, and acoustic assessment. The Voice Handicap Index (VHI), Voice symptom scale (VoiSs), Vocal tract discomfort scale (VTDS), and self-assessment of resonant voice quality were also performed. The treatment included eight voice therapy sessions. For the experimental group, the exercises consisted of a sequence of seven phonatory tasks performed with four different semioccluded vocal tract exercises (SOVTE). Comparison for all variables were performed between experimental group and control group.

RESULTS

Wilcoxon test showed significant improvements for experimental group for VHI, VoiSs, VTDS (decrease), and self-perception of resonant voice quality (increase). Significant decrease for experimental groups was observed on subglottic pressure, phonation threshold pressure, and glottal airflow across the implemented tasks.

CONCLUSION

Physiologic voice therapy based on semioccluded vocal tract exercises seems to be an effective tool to improve voice in subjects diagnosed with behavioral dysphonia. Apparently, most changes should be expected in variables related to physical and functional aspects compared to objective variables. Subglottic pressure and phonation threshold pressure seem to be the most change-sensitive parameters and they may reflect a reduction in phonatory effort reported by patients after voice therapy.

Magnetosomes could be protective shields against metal stress in magnetotactic bacteria

Magnetotactic bacteria are aquatic microorganisms with the ability to biomineralise membrane-enclosed magnetic nanoparticles, called magnetosomes. These magnetosomes are arranged into a chain that behaves as a magnetic compass, allowing the bacteria to align in and navigate along the Earth’s magnetic field lines. According to the magneto-aerotactic hypothesis, the purpose of producing magnetosomes is to provide the bacteria with a more efficient movement within the stratified water column, in search of the optimal positions that satisfy their nutritional requirements. However, magnetosomes could have other physiological roles, as proposed in this work. Here we analyse the role of magnetosomes in the tolerance of Magnetospirillum gryphiswaldense MSR-1 to transition metals (Co, Mn, Ni, Zn, Cu). By exposing bacterial populations with and without magnetosomes to increasing concentrations of metals in the growth medium, we observe that the tolerance is significantly higher when bacteria have magnetosomes. The resistance mechanisms triggered in magnetosome-bearing bacteria under metal stress have been investigated by means of x-ray absorption near edge spectroscopy (XANES). XANES experiments were performed both on magnetosomes isolated from the bacteria and on the whole bacteria, aimed to assess whether bacteria use magnetosomes as metal storages, or whether they incorporate the excess metal in other cell compartments. Our findings reveal that the tolerance mechanisms are metal-specific: Mn, Zn and Cu are incorporated in both the magnetosomes and other cell compartments; Co is only incorporated in the magnetosomes, and Ni is incorporated in other cell compartments. In the case of Co, Zn and Mn, the metal is integrated in the magnetosome magnetite mineral core.

Erythrocyte concentrations of chromium, copper, manganese, molybdenum, selenium and zinc in subjects with different physical training levels

Background

The aim of the present study was to determine changes occurring in the erythrocyte concentrations of chromium (Cr), copper (Cu), manganese (Mn), molybdenum (Mo), selenium (Se) and zinc (Zn) in male subjects with different training levels living in the same region (Spain).

Methods

Thirty sedentary subjects (24.34 ± 3.02 years) formed the control group (CG); 24 moderately trained (4–7 h/week) subjects (23.53 ± 1.85 years) formed the group with a moderate degree of training (MTG) and 22 professional cyclists (23.29 ± 2.73 years), who performed more than 20 h/week of training, formed the high-level training group (HTG). Erythrocyte samples were collected from all subjects in fasting conditions, washed and frozen at − 80 °C until analysis. Erythrocyte analysis of trace elements was performed by inductively coupled plasma mass spectrometry (ICP-MS).

Results

The results showed that there was a statistically significant lower erythrocyte concentration of Cu, Mn, Mo and Zn in the MTG and HTG than CG. Se was only significantly lower in HTG than CG. The correlation analysis indicates that this change was correlated with training in the case of Cu, Mn, Se and Zn. All results are expressed in μg/g Hb.

Conclusions

We can conclude that physical training produces a decrease in erythrocyte concentrations of Cu, Mn, Se and Zn, which can cause a decrement in athletes’ performance given the importance of these elements. For this reason, erythrocyte monitoring during the season would seem to be advisable to avoid negative effects on performance.

Fenofibrate -a PPARα agonist- increases alcohol dehydrogenase levels in the liver: implications for its possible use as an ethanol-aversive drug

After ethanol consumption, disulfiram increases blood-acetaldehyde levels, generating an aversive reaction that deters alcohol drinking. Given the major secondary effects of disulfiram, finding other effective drugs to reduce alcohol consumption in individuals with alcohol-use-disorder is highly desirable. It has been reported that administering fenofibrate to high-drinking rats increases hepatic catalase levels and blood acetaldehyde after administering ethanol and a 60-70% inhibition of voluntary alcohol intake. This work evaluated whether fenofibrate has an additional effect on the activity of other ethanol-metabolizing enzymes, which could contribute to the high acetaldehyde levels generated upon administering ethanol. Male high-drinker rats were allowed to voluntary drink 10% ethanol or water for 2 months. Subsequently, fenofibrate (100 mg/kg/day) or vehicle was administered orally for 14 days. Then, alcohol dehydrogenase (ADH1) and aldehyde dehydrogenase (ALDH2) protein levels and enzymatic activities in the livers were quantified. Fenofibrate treatment produced a marked increase in ADH1 protein levels (396% ± 18%, p < 0.001) and enzymatic activity (425% ± 25%, p < 0.001). Fenofibrate did not result in differences in ALDH2 activity or in ALDH2 protein levels. The studies show that treatment with fenofibrate not only increased the activity of catalase in the liver of alcohol-drinking rats, as reported earlier, but also increased the levels and enzymatic activity of ADH1, while ALDH2 remained unchanged. The increases in ADH1 contribute to explaining the remarkable effect of fenofibrate in raising blood levels of acetaldehyde in ethanol-consuming animals, in which a marked reduction of alcohol intake is recorded.

Effects of exposure to high temperatures on serum, urine and sweat concentrations of iron and copper

The objective of this research was to determine the acute effect of a maximum test until exhaustion in normothermia and hyperthermia, and after repeated exposure to heat at high temperatures on the homeostasis of Fe and Cu. The sample was composed of twenty-nine male university students. The participants were divided into a control group (CG) and an experimental group (EG). All of them underwent an incremental test until exhaustion in normothermia and hyperthermia before and after the repeated exposure of EG to heat at high temperatures, consisting of 9 heat acclimatisation sessions in the sauna. Samples of urine and blood were taken before and after each test. Additionally, sweat samples were collected in the hyperthermia test. The samples were frozen at -80 °C for further analysis by ICP-MS. None of the metal concentrations in serum were affected by hyperthermia or exposure to heat. Urinary Fe increased in CG in the hyperthermia test before Heat exposure at High Temperature (HEHT)(p < 0.05) and in both groups after HEHT (p < 0.05). In EG there was an increase in the urinary excretion of Cu after HEHT (p < 0.01) in both trials. Fe suffered a decrease in sweat in EG after exposure to heat (p < 0.05). The concentrations of Fe and Cu in serum were not affected by acute exercise and exposure to high temperatures. However, there was a decrease in excretion of Fe in sweat due to HEHT, and an increase in urinary excretion in both. Therefore, we think that in conditions of high temperatures for long periods of time, attention should be paid to the body levels of these metals.

Influence of a high-temperature programme on serum, urinary and sweat levels of selenium and zinc

INTRODUCTION

The effect of hyperthermia on the antioxidant system in the human organism is well known.

AIM

The objective of this study was to observe the effects of heat on the concentration of Se and Zn, elements related to antioxidant systems.

METHODS

Twenty-nine subjects voluntarily participated in this study. They were divided into a control group (CG; n = 14) and an experimental group (EG; n = 15). All of them underwent two incremental tests until exhaustion in normothermia (22 °C, 20-40%RH) and hyperthermia (42 °C, 20-40%RH). EG experienced nine sessions of repeated heat exposure at high temperatures (100 °C, 20%RH) for three weeks (HEHT). After the intervention, the initial measurements were repeated. Urine and blood samples were collected before and after each test. Additionally, sweat samples were collected after tests in hyperthermia.

RESULTS

There were no significant changes in serum. An increase in the elimination of Zn and Se in EG was observed in urine after HEHT (p < .05). The elimination of Zn by sweating decreased after HEHT in EG (p < .05).

CONCLUSIONS

Exposure to heat at high temperatures increases the urinary excretion of Se and Zn.

Effect of exposure to high temperatures in the excretion of cadmium and lead

OBJECTIVE

This study aims to observe the effect on urine and sweat excretion levels of cadmium (Cd) and lead (Pb) in healthy men in a maximum incremental test until exhaustion and repeated exposure to heat.

METHODS

twenty-nine adult men divided into control group (CG; n = 14) and experimental group (EG; n = 15) performing two maximum tests until exhaustion in normothermia (22 °C) and hyperthermia (42 °C). EG experienced 9 sessions of heat exposure at high temperatures (100 °C) (HEHT). After the nine sessions, the initial tests were repeated in both groups. Urine samples were collected before and after each test. After the hyperthermia tests, sweat samples were gathered.

RESULTS

Urinary Cd increased after initial tests in GC and in hyperthermia in EG (p < 0.05). Urinary excretion of Pb rose after HEHT (p < 0.05). Pb in sweat was higher in EG than in CG after HEHT (p < 0.05).

CONCLUSION

Heat exercise and constant exposure to heat can be a valid method to increase the excretion of toxic metals.

Spatial Navigation Is Distinctively Impaired in Persistent Postural Perceptual Dizziness

Objective: To determine whether performance in a virtual spatial navigational task is poorer in persistent postural perceptual dizziness (PPPD) patients than in healthy volunteers and patients suffering other vestibular disorders.

Methods: Subjects were asked to perform three virtual Morris water maze spatial navigational tasks: (i) with a visible target, (ii) then with an invisible target and a fixed starting position, and finally (iii) with an invisible target and random initial position. Data were analyzed using the cumulative search error (CSE) index.

Results: While all subjects performed equally well with a visible target, the patients with PPPD (n = 19) performed poorer (p < 0.004) in the invisible target/navigationally demanding tasks (CSE median of 8) than did the healthy controls (n = 18; CSE: 3) and vestibular controls (n = 19; CSE: 4). Navigational performance in the most challenging setting allowed us to discriminate PPPD patients from controls with an area under the receiver operating characteristic curve of 0.83 (sensitivity 78.1%; specificity 83.3%). PPPD patients manifested more chaotic and disorganized search strategies, with more dispersion in the navigational pool than those of the non-PPPD groups (standard distance deviation of 0.97 vs. 0.46 in vestibular controls and 0.20 in healthy controls; p < 0.001).

Conclusions: While all patients suffering a vestibular disorder had poorer navigational abilities than healthy controls did, patients with PPPD showed the worst performance, to the point that this variable allowed the discrimination of PPPD from non-PPPD patients. This distinct impairment in spatial navigation abilities offers new insights into PPPD pathophysiology and may also represent a new biomarker for diagnosing this entity.

Quality of physician care coordination during inter-facility transfer for cardiac arrest patients

AIM

We sought to evaluate whether the quality of coordination between physicians transferring comatose cardiac arrest survivors to a high-volume cardiac arrest center for targeted temperature management (TTM) was associated with timeliness of care.

METHODS

We conducted a retrospective analysis of inter-facility transfers to Vanderbilt University Medical Center for TTM between October 2016 and October 2018. We examined the relationship between Relational Coordination (RC) - a measure of communication and relationship quality - during phone conversations between transferring physicians and time-to-acceptance.

RESULTS

We identified 18 patients meeting criteria. TTM was initiated or continued in 72%, and in-hospital mortality was 75%. Median time-to-acceptance was 2.77 (interquartile range [IQR] 2.0, 4.1) minutes, and duration of calls was 3.95 (IQR 2.7, 5.2) minutes. Interrater reliability for overall RC was high (rho = 0.87). The correlation between RC and the time-to-acceptance was significant in univariate analyses (adjusted relative risk = 0.96, 95%CI 0.93, 1.0, p = 0.05). Secondary analyses did not find a significant relationship between RC and timeliness measures.

CONCLUSION

In this sample of patients transferred for TTM, we found that RC as a measure of care coordination, was reliable. Higher quality care coordination for cardiac arrest survivors was associated with faster physician acceptance. Future work using a larger cohort should explore if higher RC among a broader set of stakeholders (physicians, EMS, families, etc.) is associated with timeliness measures after adjusting for other factors, to better understand how the quality of care coordination impacts timeliness of care and patient outcomes.

Data on the endogenous conversion of tyrosol into hydroxytyrosol in humans

Here we present new and original data on the endogenous conversion of tyrosol (Tyr) into hydroxytyrosol (OHTyr) in humans and its effects on the cardiovascular system. A randomized, crossover, controlled clinical trial was performed with individuals at cardiovascular risk (n = 33). They received white wine (WW) (females 1, males 2 standard drinks/day), WW plus Tyr capsules (WW + Tyr) (25mg Tyr capsule, one per WW drink), and water (control) ad libitum. Intervention periods were of 4 weeks preceded by three-week wash-out periods. We assessed the conversion of Tyr to OHTyr, its interaction with a polygenic activity score (PAS) from CYP2A6 and CYP2D6 genotypes, and the effects on cardiovascular risk markers. For further details and experimental findings please refer to the article “Cardiovascular benefits of tyrosol and its endogenous conversion into hydroxytyrosol in humans. A randomized, controlled trial” [1].

Race and Sex Differences in Modifiable Risk Factors and Incident Heart Failure

OBJECTIVES

The purpose of this study was to examine race- and sex-based variation in the associations between modifiable risk factors and incident heart failure (HF) among the SCCS (Southern Community Cohort Study) participants.

BACKGROUND

Low-income individuals in the southeastern United States have high HF incidence rates, but relative contributions of risk factors to HF are understudied in this population.

METHODS

We studied 27,078 black or white SCCS participants (mean age: 56 years, 69% black, 63% women) enrolled between 2002 and 2009, without prevalent HF, receiving Centers for Medicare and Medicaid Services. The presence of hypertension, diabetes mellitus, physical underactivity, high body mass index, smoking, high cholesterol, and poor diet was assessed at enrollment. Incident HF was ascertained using International Classification of Diseases-9th revision, codes 428.x in Centers for Medicare and Medicaid Services data through December 31, 2010. Individual risk and population attributable risk for HF for each risk factor were quantified using multivariable Cox models.

RESULTS

During a median (25th, 75th percentile) 5.2 (3.1, 6.7) years, 4,341 (16%) participants developed HF. Hypertension and diabetes were associated with greatest HF risk, whereas hypertension contributed the greatest population attributable risk, 31.8% (95% confidence interval: 27.3 to 36.0). In black participants, only hypertension and diabetes associated with HF risk; in white participants, smoking and high body mass index also associated with HF risk. Physical underactivity was a risk factor only in white women.

CONCLUSIONS

In this high-risk, low-income cohort, contributions of risk factors to HF varied, particularly by race. To reduce the population burden of HF, interventions tailored for specific race and sex groups may be warranted.

Cardiovascular benefits of tyrosol and its endogenous conversion into hydroxytyrosol in humans. A randomized, controlled trial

INTRODUCTION

The simple phenol hydroxytyrosol (OHTyr) has been associated with the beneficial health effects of extra virgin olive oil. Pre-clinical studies have identified Tyr hydroxylation, mediated by cytochrome P450 isoforms CYP2A6 and CYP2D6, as an additional source of OHTyr.

AIM

We aimed to (i) confirm Tyr to OHTyr bioconversion in vivo in humans, (ii) assess the cardiovascular benefits of this bioconversion, and (iii) determine their interaction with a polygenic activity score (PAS) from CYP2A6 and CYP2D6 genotypes.

METHODS

Randomized, crossover, controlled study. Individuals at cardiovascular risk (n = 33) received: white wine (WW) (females 1, males 2 standard drinks/day), WW plus Tyr capsules (WW + Tyr) (25  mg Tyr capsule, one per WW drink), and water (control) ad libitum. Participants were classified by a PAS as low versus normal activity metabolizers.

RESULTS

OHTyr recovery following WW + Tyr was higher than after other interventions (P < 0.05). Low PAS individuals had lower OHTyr/Tyr ratios compared to individuals with normal PAS. WW + Tyr improved endothelial function, increased plasma HDL-cholesterol and antithrombin IIII, and decreased plasma homocysteine, endothelin 1, and CD40L, P65/RELA, and CFH gene expression in peripheral blood mononuclear cells (p < 0.05). Combining Tyr capsule(s) with WW abolished the increase in iNOS, eNOS, VEGFA, and CHF expressions promoted by WW (p < 0.05).

CONCLUSIONS

Tyr, and its partial biotransformation into OHTyr, promoted cardiovascular health-related benefits in humans after dietary doses of Tyr. The study design allowed the health effects of individual phenols to be singled out from the dietary matrix in which they are naturally found.

Serum, erythrocyte and urinary concentrations of iron, copper, selenium and zinc do not change during an incremental test to exhaustion in either normothermic or hyperthermic conditions

AIM

The aim of this study was to evaluate the effect of the performance of an incremental exercise test until exhaustion in normothermic and hyperthermic conditions on serum, erythrocyte and urine concentrations of Iron (Fe), Copper (Cu), Selenium (Se) and Zinc (Zn).

METHODS

Nineteen adult males (age: 22.58 ± 1.06 years) performed two maximum incremental exercise tests on a cycloergometer in normothermia (22 ± 2 °C) and hyperthermia (42±2 °C) separated by 48 h. Urine, serum and erythrocyte samples were collected before and after each test.

RESULTS

Serum Se (p < 0.01) and Cu (p < 0.05) levels were altered after each test, but the significance disappeared with the correction for haematocrit. The rest of the values did not undergo alterations in either condition.

CONCLUSIONS

It seems that a higher stimulus is necessary to obtain changes in these minerals. The study reveals the need to correct serum concentrations concerning possible changes in these volumes after an acute effort.

Revisiting the Role of Aspirin for the Primary Prevention of Cardiovascular Disease

Aspirin is the cornerstone of the antithrombotic management of patients with established atherosclerotic cardiovascular disease, but major guidelines provide conflicting recommendations for its use in primary prevention. Findings from recent randomized trials totaling >47 000 patients called into question the net clinical benefits of aspirin in primary prevention for 3 key populations: patients with diabetes mellitus, community-dwelling elderly individuals, and patients without diabetes mellitus who are at intermediate risk for atherosclerotic events. In the context of increasing emphasis on the use of other treatments for primary prevention in patients with moderate-high future risk of developing atherosclerotic cardiovascular disease, the efficacy and safety of aspirin for primary prevention has become uncertain. Key unresolved questions regarding the role of aspirin in primary prevention include the optimal drug formulation, dosing schedule, weight-based dose selection, and interplay between sex and treatment response. In the current era, most patients without established atherosclerotic cardiovascular disease should not be prescribed aspirin. Rather, aggressive management of comorbidities tailored to the expected cardiovascular risk needs to be emphasized. In this context, informed shared decision making between clinicians and patients regarding the use of aspirin for primary prevention of cardiovascular events is a suitable and laudable approach. In this article, we revisit the role of aspirin for the primary prevention of cardiovascular diseases by critically reviewing the key scientific literature, highlight key areas of uncertainties for future research, and propose a decisional framework for clinicians to support prescription of aspirin in primary prevention.

Polypill for Cardiovascular Disease Prevention in an Underserved Population

BACKGROUND

Persons with low socioeconomic status and nonwhite persons in the United States have high rates of cardiovascular disease. The use of combination pills (also called "polypills") containing low doses of medications with proven benefits for the prevention of cardiovascular disease may be beneficial in such persons. However, few data are available regarding the use of polypill therapy in underserved communities in the United States, in which adherence to guideline-based care is generally low.

METHODS

We conducted a randomized, controlled trial involving adults without cardiovascular disease. Participants were assigned to the polypill group or the usual-care group at a federally qualified community health center in Alabama. Components of the polypill were atorvastatin (at a dose of 10 mg), amlodipine (2.5 mg), losartan (25 mg), and hydrochlorothiazide (12.5 mg). The two primary outcomes were the changes from baseline in systolic blood pressure and low-density lipoprotein (LDL) cholesterol level at 12 months.

RESULTS

The trial enrolled 303 adults, of whom 96% were black. Three quarters of the participants had an annual income below $15,000. The mean estimated 10-year cardiovascular risk was 12.7%, the baseline blood pressure was 140/83 mm Hg, and the baseline LDL cholesterol level was 113 mg per deciliter. The monthly cost of the polypill was $26. At 12 months, adherence to the polypill regimen, as assessed on the basis of pill counts, was 86%. The mean systolic blood pressure decreased by 9 mm Hg in the polypill group, as compared with 2 mm Hg in the usual-care group (difference, -7 mm Hg; 95% confidence interval [CI], -12 to -2; P = 0.003). The mean LDL cholesterol level decreased by 15 mg per deciliter in the polypill group, as compared with 4 mg per deciliter in the usual-care group (difference, -11 mg per deciliter; 95% CI, -18 to -5; P<0.001).

CONCLUSIONS

A polypill-based strategy led to greater reductions in systolic blood pressure and LDL cholesterol level than were observed with usual care in a socioeconomically vulnerable minority population. (Funded by the American Heart Association Strategically Focused Prevention Research Network and the National Institutes of Health; ClinicalTrials.gov number, NCT02278471.).

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association