Implementation of an eFAST guideline and teaching to improve documentation practices and saving of ultrasound images

OBJECTIVES

To investigate whether implementation of a hospital-based Extended Focused Assessment with Sonography in Trauma (eFAST) guideline and teaching improved documentation and saving of images.

METHODS

A retrospective cohort study was conducted on trauma patients aged ≥16 years presenting to St Vincent's Hospital Sydney Emergency Department over two, three-month periods in 2023.

RESULTS

Guideline and teaching implementation resulted in statistically significant improvement in documentation on the Trauma Response Form, 85% (113/133) to 93% (120/129), odds ratio (OR) 2.4 (95% confidence interval [CI] = 1.03-5.40), P = 0.04, and images saved, 4% (5/133) to 21% (27/129), OR 6.7 (95% CI = 2.5-18.2), P < 0.001.

CONCLUSIONS

Developing an eFAST Standard of Care Guideline and education was associated with improvements in documentation and saving of images to ultrasound machines.

Multiple anthelmintic drug resistant Ancylostoma caninum in foxhounds

Ancylostoma caninum is the most common and important gastrointestinal nematode of dogs in the United States. Despite recent reports of A. caninum isolates resistant to all classes of anthelmintics, little is known about the frequency and extent of this anthelmintic resistance. The study aim was to evaluate the efficacy of three commercial anthelmintic products in the treatment of foxhound dogs with a history of persistent A. caninum infections. In the first phase of this study, 35 foxhounds were randomly divided into three treatment groups: moxidectin/imidacloprid (MI), pyrantel pamoate/febantel/praziquantel (PFP), and emodepside/praziquantel (EP). Fecal samples were collected on day 0, 11, and 33 post-treatment (PT), and hookworm eggs were quantified using the mini-FLOTAC technique with a multiplication factor of 5 eggs per gram (EPG). The fecal egg count reduction (FECR) on day 11 PT was 65% (95% CI: 62%-68%) for MI, 69% (95% CI: 66%-72%) for PFP, and 96% (95% CI: 94%-97%) for EP. On day 33 PT, the FEC in the MI and PFP groups returned to almost the same values as on day 0, while in the EP group, the FEC remained low. Since MI and PFP proved ineffective, 32 animals were randomly divided into two groups in the second phase. They were treated either with a combination of MI/PFP or EP. The FECR at day 13 PT for the combination MI/PFP was 89% (95% CI: 87%-91%) and 99% (95% CI: 98%-99%) for EP. These results suggest that this A. caninum population is resistant to multiple anthelmintics. Although the combination of MI/PFP improved the anthelmintic efficacy, the FECR remained below 90%. Future studies are indicated to evaluate further the epidemiology of persistent hookworm infections in dogs in the US and to identify more effective treatment protocols as they pose a significant health risk to canine and human health.

Comparison of skin and shoe marker placement on metatarsophalangeal joint kinematics and kinetics during running

This study investigated the effects of marker placement (skin- vs shoe-mounted) on metatarsophalangeal joint (MTP) kinematics and kinetics during running. Fifteen trained men ran on a 15-m track at 10 and 13 km/h with three (low, standard and high stiffness) shoe longitudinal bending stiffnesses (LBS). Reflective markers were fixed on the shoe upper, and on the skin using holes cut in the shoe. Three-dimensional marker positions and ground reaction forces were recorded at 200 and 2000 Hz, respectively. Kinematic and kinetic parameters were analyzed using one-dimensional metrics (statistical parametric mapping). MTP joint was less dorsiflexed at midstance ([57% to 100%] of braking phase and [0% to 48%] of pushing phase), and the MTP joint plantarflexion moment was higher ([22% to 55%] of pushing phase) with the shoe markerset in comparison with the skin markerset. The effect of LBS on MTP angle was found to be significant for a larger percentage of each stride using the shoe markerset compared to the skin markerset. However, the effect of LBS on plantarflexion moment was significant with the shoe markerset only. The effect of running speed on MTP angle was significant for a larger percentage of each stride with the skin markerset. This study demonstrates that the placement of markers influences the measurement of MTP kinematics and kinetics and that these effects are mediated by other variables such as LBS or running speed. It is concluded that the shoe markerset does not fully reflect the movement of the MTP joint.

An innovative cardiac rehabilitation based on the power-force-velocity profile to further improve cardiorespiratory capacities in coronary artery disease patients

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Doctoral contract 2018-2022

Background

Several studies have shown the importance of the relationship between the power-force-velocity profile (PFVP) and sport performance in elite athletes through optimised exercise training.[1] Optimising the training programme is constantly sought in rehabilitation among patients always younger with coronary artery disease. Nowadays, it is well established that intermittent training should be offered to coronary patients during the rehabilitation cycle.[2] In this continuity, the assessment of the PFVP at the beginning of the cardiac rehabilitation (CR) would allow to better adapt the CR training programme for each patient.

Purpose

The aim of this study was to compare the effects of two exercise training programmes: a traditional CR versus a new CR relied on patient’s PFVP on cardiorespiratory, functional and autonomic systems in coronary patients.

Methods

This prospective randomized controlled trial was conducted from May 2020 to July 2021 in an university hospital. A total of 89 patients were randomly assigned (1:1) to test or control group. Before starting CR, participants performed two sprints of 8 s on a cycle ergometer to define the PFVP. The PFVP was analysed to determine whether the participant had a force or velocity deficit. Patients included in test group followed a specific cycling training programme based on their weak point (i.e., specific force training with high resistance and low pedalling frequency on the cycle if the PFVP was oriented in velocity and reversely). While control patients attended a conventional CR programme.

The 3-week training intervention consisted of 40 min of cycling, 30 min of walking on treadmill and 20 min of strength training (4/week).

Cardiopulmonary exercise test (VO2 at the first ventilatory threshold, SV1 and VO2 peak in ml/min/kg), functional assessments (distance of 6-min walk test, handgrip strength, 10 sit-to-stand repetitions, cholesterol levels, LDL-C and quality of life) and autonomic nervous system (heart rate variability and sensitivity baroreflex) were performed at the baseline and after CR.

A two-way ANOVA with one repeated measure (pre vs. post) and one independent factor (test vs. control) was realized.

Results

The mean age was 61.0 ± 9.6 years, 18% were women. A significant difference was observed in VO2 peak (test: +22.0 ± 19.1% vs. control: +10.2 ± 15.8%, p=0.003) and VO2 SV1 (test: +35.9 ± 33.9% vs. control: +11.9 ± 34.4%, p&lt;0.001), LDL-C (p=0.016) and quality of life (p&lt;0.001). No significant change between groups in other functional tests and autonomic activity occurred after CR programme.

Conclusion

Cardiopulmonary activity, cholesterol and quality of life were improved after 3-week exercise programme. The novel CR depending on initial PFVP showed greater cardiorespiratory benefits than a conventional CR. Therefore, the PFVP can be used in CR to adapt specifically the content of training sessions.

Abstract MP07: Metabolic Signature Improves Heart Failure Risk Prediction In Older Adults

Introduction: Circulating metabolome profiling holds promise in predicting HF risk, but its prediction performance among older adults is not well established.

Hypothesis: We hypothesize that metabolic signatures are associated with the risk of HF and its subtypes (HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF)), and they can improve HF risk prediction beyond established risk factors.

Methods: We measured 828 serum metabolites among 4,030 African and European Americans free of HF from the Atherosclerosis Risk in Communities (ARIC) study visit 5 (2011-2013). We regressed incident HF on each metabolite using Cox proportional hazards models. A metabolite risk score (MRS) was derived by summing individual metabolite levels weighted by beta coefficients estimated from least absolute shrinkage and selection operator (LASSO) regularized regressions. We regressed incident HF, HFpEF and HFrEF on the MRS. Harrell’s C-statistics were calculated to evaluate risk discrimination. We replicated the association between MRS and HF in 3,697 independent ARIC participants with metabolite measured at visit 1 (1987-1989).

Results: Among 4,030 participants, the mean (SD) age was 76 (5) years. Adjusting for HF risk factors, 302 metabolites were associated with incident HF (false discovery rate < 0.05). One SD increase of the MRS, constructed from 51 metabolites selected by LASSO, was associated with two to three-fold high risk of HF, HFpEF and HFrEF in the fully adjusted models ( Table ). Five-year risk prediction analysis showed that C statistics improved from 0.850 to 0.884 by adding MRS over ARIC HF risk factors, kidney function and NT-proBNP (ΔC (95%CI) = 0.034 (0.017,0.052)). In the replication analysis, a more parsimonious MRS constructed using 15 metabolites, was associated with incident HF ( Table ).

Conclusions: We identified a metabolic signature that was associated with the risk of HF and improved HF risk prediction. Our findings may shed light on pathways in HF development and at-risk populations.

Coronary revascularization outcomes in relation to skilled nursing facility use following hospital discharge

Background

Observational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential.

Hypothesis

We hypothesized that skilled nursing facility (SNF) use after revascularization is a measure of relative frailty associated with outcomes following coronary revascularization.

Methods

We used a 20 percent sample of Medicare beneficiaries aged 65 years or older who received inpatient PCI or CABG between 2007–2014. Key explanatory variables were the revascularization strategy and SNF use after revascularization. We used Cox regression to evaluate death and repeat revascularization within one year and logistic regression to evaluate SNF use and 30‐day readmissions/death.

Results

CABG patients were 25.1 percentage points [95% confidence interval: 24.7, 25.5] more likely to use SNF following revascularization than inpatient PCI patients. SNF use was associated with a higher death rate (hazard ratio (HR): 3.19 [3.02, 3.37]) and a 16.2 percentage point (15.5, 16.9) increase in 30‐day readmissions/death. Among patients with SNF use, CABG was associated with a decrease in 30‐day readmissions/death compared to PCI.

Conclusions

While CABG was associated with higher rates of SNF use and 30‐day readmission/death overall, CABG was associated with significantly lower rates of 30‐day readmissions/death among patients with SNF use. The findings suggest that caution is needed in treatment selection for patients at high‐risk for SNF use and that selection of inpatient PCI over CABG may be associated with frailty and worse outcomes for some patients.

Peripheral vascular disease and/or need for dialysis predicts mortality in acute myocardial infarction with shock treated with mechanical circulatory support

Background

Acute myocardial infarction (AMI) with left ventricular systolic dysfunction remains the largest cause for cardiogenic shock (CS) admissions. Aside for prompt revascularization few therapies have been shown to improve survival in this patient population. In the last decade, the use of mechanical circulatory support devices (MCS) for CS has increased, despite little evidence guiding their use.

Purpose

To explore for different baseline factors which may favor treatment with MCS vs pharmacological circulatory support (PCS) in AMI related CS.

Methods

Baseline clinical and procedural variables were retrospectively collected for all patient presenting to the cardiac cath lab with an AMI and CS at a large health care system. Patients were stratified by whether they received MCS or only PCS. The outcomes of interest were 30 day and one year mortality.

Results

Between 01/2014 andv08/2018, 205 patients presented to the cath lab with an AMI complicated by CS. The vast majority of cases were STEMIs (133/205, 65%). Overall mortality for the cohort at 30 days and one year were 41% and 50% respectively. There was no difference in 30 day or 1 year mortality between the MCS and PCS groups. A STEMI presentation was associated with increase 30 day mortality in the MCS group but the association was not seen at one year. Interestingly having a prior history peripheral vascular disease (PVD) and/or being on dialysis prior to the procedure was predictive of one year mortality in the MCS group (OR 3.8, 1.4–10.6, p=0.006) but not in the PCS.

Conclusion

Patients presenting with AMI complicated by CS have a high mortality despite successful revascularization. In our cohort having PVD and/or needing dialysis was predictive of mortality in patients receiving MCS. Patient selection is an important factor in choosing appropriate circulatory support, further prospective studies are needed.

Figure 1

Funding Acknowledgement

Type of funding source: None

Effects of the foot strike pattern on muscle activity and neuromuscular fatigue in downhill trail running

Minimizing musculo-skeletal damage and fatigue is considered paramount for performance in trail running. Our purposes were to investigate the effects of the foot strike pattern and its variability on (a) muscle activity during a downhill trail run and (b) immediate and delayed neuromuscular fatigue. Twenty-three runners performed a 6.5-km run (1264 m of negative elevation change). Electromyographic activity of lower-limb muscles was recorded continuously. Heel and metatarsal accelerations were recorded to identify the running technique. Peripheral and central fatigue was assessed in knee extensors (KE) and plantar flexors (PF) at Pre-, Post-, and 2 days post downhill run (Post2d). Anterior patterns were associated with (a) higher gastrocnemius lateralis activity and lower tibialis anterior and vastus lateralis activity during the run and (b) larger decreases in KE high-frequency stimulus-evoked torque Post and larger decrements in KE MVC Post2d. High patterns variability during the run was associated with (a) smaller decreases in KE Db100 Post and MVC Post2d and (b) smaller decreases in PF MVC Post and Post2d. Anterior patterns increase the severity of KE peripheral fatigue. However, high foot strike pattern variability during the run reduced acute and delayed neuromuscular fatigue in KE and PF.

Abstracts of the 24th international isotope society (UK group) symposium: synthesis and applications of labelled compounds 2015

The 24th annual symposium of the International Isotope Society's United Kingdom Group took place at the Møller Centre, Churchill College, Cambridge, UK on Friday 6th November 2015. The meeting was attended by 77 delegates from academia and industry, the life sciences, chemical, radiochemical and scientific instrument suppliers. Delegates were welcomed by Dr Ken Lawrie (GlaxoSmithKline, UK, chair of the IIS UK group). The subsequent scientific programme consisted of oral presentations, short 'flash' presentations in association with particular posters and poster presentations. The scientific areas covered included isotopic synthesis, regulatory issues, applications of labelled compounds in imaging, isotopic separation and novel chemistry with potential implications for isotopic synthesis. Both short-lived and long-lived isotopes were represented, as were stable isotopes. The symposium was divided into a morning session chaired by Dr Rebekka Hueting (University of Oxford, UK) and afternoon sessions chaired by Dr Sofia Pascu (University of Bath, UK) and by Dr Alan Dowling (Syngenta, UK). The UK meeting concluded with remarks from Dr Ken Lawrie (GlaxoSmithKline, UK).

Acute and delayed peripheral and central neuromuscular alterations induced by a short and intense downhill trail run

Downhill sections are highly strenuous likely contributing to the development of neuromuscular fatigue in trail running. Our purpose was to investigate the consequences of an intense downhill trail run (DTR) on peripheral and central neuromuscular fatigue at knee extensors (KE) and plantar flexors (PF). Twenty-three runners performed a 6.5-km DTR (1264-m altitude drop) as fast as possible. The electromyographic activity of vastus lateralis (VL) and gastrocnemius lateralis (GL) was continuously recorded. Neuromuscular functions were assessed Pre-, Post-, and 2-day Post-DTR (Post2d). Maximal voluntary torques decreased Post (∼ -19% for KE, ∼ -25% for PF) and Post2d (∼ -9% for KE, ∼ -10% for PF). Both central and peripheral dysfunctions were observed. Decreased KE and PF voluntary activation (VA), evoked forces, VL M-wave amplitude, and KE low-frequency fatigue were observed at Post. Changes in VL M-wave amplitude were negatively correlated to VL activity during DTR. Changes in PF twitch force and VA were negatively correlated to GL activity during DTR. The acute KE VA deficit was about a third of that reported after ultramarathons, although peripheral alterations were similar. The prolonged force loss seems to be mainly associated to VA deficit likely induced by the delayed inflammatory response to DTR-induced ultrastructural muscle damage.

Influence of Ergometer Design on Physiological Responses during Rowing

The aim of this study was to compare the physiological responses and rowing efficiency on 2 different rowing ergometers: stationary vs. dynamic ergometers manufactured by Concept2. 11 oarswomen and oarsmen rowed 4 min at 60% and 70% of peak power output on both ergometers (randomized order). Power output, stroke rate, heart rate, oxygen uptake, carbon dioxide production, lactate accumulation and rating of perceived exertion were recorded at each stage on the 2 ergometers. Gross and net efficiencies were computed. Exercise intensity was associated with increases in all parameters. Rowing on dynamic ergometer was associated with higher heart rate, oxygen uptake, carbon dioxide production and stroke rate, concomitantly to lower blood lactate accumulation but also to lower gross and net efficiencies. The present study showed that rowing efficiency and blood lactate accumulation were lower on the Concept2 dynamic ergometer than on its stationary counterpart. If the use of the Concept2 dynamic ergometer may provide some advantages (reduced risk of injuries), its utilization requires a specific evaluation of physiological responses during an incremental exercise for an adapted management of training.

Influencing weight bias: The impact of biased questionnaire anchors on stereotype beliefs and judgments

OBJECTIVES

In this investigation, biased questionnaire response anchors were designed to indirectly manipulate respondents' estimates of their peers' stereotypic beliefs or the estimates of scientific research findings about individuals with obesity. The current study tested the hypothesis that biased response anchors could influence personal beliefs about obesity.

METHODS

Two-hundred adults participated in the study. A simple manipulation of questionnaire items (i.e., asking respondents to estimate peers' beliefs or scientific research findings) using biased response scale anchors was designed to subtly relay information about certain personality traits of individuals with obesity.

RESULTS

The anchor manipulation significantly influenced participants' immediate and follow-up weight biased beliefs as well as participants' evaluation of an obese job applicant's potential for employment.

CONCLUSION

Social judgments about obese individuals may be susceptible to subtle manipulation of response anchors and may be impacted by the source of comparison information (e.g., peers; scientific research).

The sourdough microflora. Interactions between lactic acid bacteria and yeasts: metabolism of amino acids

Co-culture of Lactobacillus brevis subsp. lindneri or L. plantarum with Saccharomyces cerevisiae or S. exiguus from sourdough did not modify the yield of the yeasts but gave higher growth rates and final yields of both lactic acid bacteria (LAB) than in their respective mono-cultures. Co-cultures of L. brevis subsp. lindneri with S. cerevisiae or S. exiguus in a medium without valine or leucine, which are essential for growth of the LAB, led to growth of the LAB due to excretion of these amino acids by the yeasts.

Vasopressin antagonists in the management of heart failure

Vasopressin antagonists have been studied in a variety of clinical settings, including patients with acute and chronic heart failure. The clinical trials published to date have sought to describe the clinical and physiologic effects of these agents in an effort to prove clinical efficacy and safety. A variety of agents with varying effects on V2 and V1a vasopressin receptor subtype have been studied. They have been shown to reduce bodyweight and improve serum sodium without worsening renal function. They may also decrease the need for loop diuretic use and may be particularly useful in patients with hyponatremia in the setting of volume overload. Further studies are underway that are powered to assess for morbidity and mortality benefits. The beneficial effects have been well documented but, until outcomes are understood more fully, the use of these agents should be limited to currently approved indications. In the USA, this includes only the treatment of euvolemic hyponatremia.

Learning safe practice by improving care: student-led intervention on oxygen prescribing in a respiratory ward

BACKGROUND AND OBJECTIVE

The primary aim of this intervention was to improve oxygen prescribing in accordance with the 2008 British Thoracic Society guidelines for the prescription of emergency oxygen in adults.

METHODS

Eight final year medical students reviewed the drug charts of all patients admitted to the respiratory ward on a daily basis in order to collect data on five audit questions: (1) Has oxygen (O2) been prescribed? (2) Has an O2 target saturation level been indicated? (3) Has O2 been prescribed as an 'as required' (PRN) or 'continuous therapy'? (4) Has the prescription been signed? (5) Has O2 been signed for in every drug round since the original prescription? Following an initial audit cycle an educational poster was distributed to all clinical staff via email and hard copies of the poster were placed strategically throughout the ward before its effectiveness was measured.

RESULTS

During the pre-intervention phase, compliance with all five measures varied from 0 to 25%. There was an increase in the variation in compliance after the poster intervention to 14-44%; however, this masked better overall compliance with all five investigative questions with figures of 44%, 39% and 42% being recorded in three of the four post-intervention days. Overall there was increased compliance with four of the five audit questions. Indeed compliance with question 3 rose from 14% to 83%.

CONCLUSIONS

The poster intervention was marginally effective while also showing that students can improve prescribing in a clinical setting.

228 IN VITRO EMBRYO PRODUCTION AFTER EXPOSURE OF BOVINE OOCYTES TO DIFFERENT TRANSPORTATION MEDIA AND PERIODS: PRELIMINARY RESULTS

This study was designed to evaluate the effect of different oocyte transportation media and time. Immature oocytes were recovered from slaughterhouse bovine ovaries. Oocytes (n = 492) of quality grades I to III were randomly allotted to one of the following transportation media based on TCM-199, either buffered with HEPES (control) or buffered with NaHCO3 and added with FSH/LH (maturing). Both media were supplemented with pyruvate, penicillin G (10 000 IU), streptomycin (0.05 mg mL–1), and 10% fetal bovine serum (FBS). In control medium, the oocytes were kept for 1 or 8 h at 37°C, and thereafter were transferred to maturing medium until the maturation period (24 h) was completed, under controlled atmosphere (5% CO2) and temperature, in an incubator. The maturing oocytes were distributed in two types of equipment developed for oocyte and embryo transportation, with and without 5% CO2, and kept for 1, 8, or 24 h before maturation or fecundation (IVF) procedures. The oocytes kept for 24 h in the transportation device were placed directly for IVF. All procedures used for in vitro maturation, IVF, and in vitro culture were the same as those adopted for commercial in vitro embryo production at Biotran LTDA (Alfenas, Minas Gerais, Brazil). The cleavage rate was evaluated on Day 3 post-insemination, and the blastocyst production was evaluated on Day 7. The statistical model included the main effects of treatment (control and maturing with or without 5% CO2), time, replicate, and the interaction of media × time. Data (3 replicates) were analysed by ANOVA and differences were identified by Tukey’s test. The time before in vitro maturation at the incubator negatively (P < 0.007) affected cleavage rates (76.4 ± 16.9 v. 58.8 ± 13.2 and 52.2 ± 18.5%, respectively, for 1, 8, and 24 h). However, treatment had no effects (P = 0.3) on cleavage (66.9 ± 15.0, 57.8 ± 19.7, and 67.7 ± 19.8% for the control and maturation with and without 5% CO2, respectively). Similarly, blastocyst production rates differed (P < 0.04) between 1 h (33.4 ± 14.7) and 24 h (19.3 ± 17.0%), whereas blastocyst production at 8 h did not show significant effects (19.3 ± 17.0). Although it was not significant (P > 0.05), only 14.1% of the oocytes kept in medium 2 with a controlled atmosphere for 24 h became embryos. This difference was probably related to the trend in treatment effect (P = 0.06) and the lower rate of embryo production (22.2 ± 13.6%) in this treatment compared with the control (33.8 ± 18.1%) and maturation without 5% CO2 (29.8 ± 17.3%). These results showed that 24 h of transportation is detrimental for the oocyte development potential and that the buffered medium used in this study with 5% CO2 did not efficiently maintain embryo production. Supported by CNPq, CAPES, FAPEMIG, and Biotran LTDA.

Bivalirudin versus unfractionated heparin during percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndrome initially treated with fondaparinux: results from an international, multicenter, randomized pilot study (SWITCH III)

We aimed to determine the optimal adjunctive anticoagulation regimen for percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS) initially treated with fondaparinux. The optimal adjunctive anticoagulation regimen for PCI in these patients is unclear. In this open-label, prospective, randomized, multicenter pilot study, we compared treatment with unfractionated heparin (UFH) versus bivalirudin in patients with non-ST-segment elevation ACS initially treated with fondaparinux and undergoing early invasive strategy. The randomized population consisted of 100 patients (62.7 ± 12.7 years, 68% men), all of whom were on clopidogrel. During the angioplasty, patients were randomized to either bivalirudin or UFH therapy in a 1:1 fashion. Baseline clinical and angiographic characteristics were similar except for a higher body mass index in the UFH group (29.4 ± 4.7 vs. 27.3 ± 4.2, P = 0.02). Major bleeding was the primary outcome; a major bleeding event was documented in only 1 patient from the bivalirudin group (2%) and in none from the UFH group (P = 0.49). There was no death, Q-wave MI, or acute revascularization in either group. There was no documentation of stent thrombosis, reinfarction, and catheter thrombus. Data from this prospective, multicenter pilot study suggest that bivalirudin, compared to standard-dose UFH, has a similar safety profile in terms of peri-PCI bleeding and thrombotic events and can be used safely in ACS patients initially treated with upstream fondaparinux who undergo PCI.