Wellbeing Training Based on Contemplative Practices in a Sample of Intensive Care and Homecare Professionals: A Pilot and Feasibility Non-Randomized Clinical Trial.

BACKGROUND: Intensive care unit (ICU) and homecare unit professionals are susceptible to higher levels of stress and burnout than other healthcare professionals, which has an impact on their well-being, and in turn on their patients. In terms of data, there is not much research about the effects of psychological interventions on ICU and homecare professionals. The aim of this study was to investigate the effectiveness of Wellbeing Training based on Contemplative Practices (WTCP) for the increase of psychological functioning in a sample of ICU and homecare professionals. METHODS: A pilot and feasibility non-randomized clinical trial was conducted. Participants in the WTCP group (n = 19) attended an at-work 8-session/2 h group WTCP program aimed at directly training four basic skills: (a) sustained positive emotions, (b) recovery from negative emotions, (c) pro-social behavior and generosity, and (d) mind wandering, mindfulness, and "affective stickiness". Nineteen professionals were allocated in the control group. RESULTS: Results indicated that WTCP had a positive impact on self-compassion, personal accomplishment (burnout), and frequency of negative emotions. Moreover, a thematic analysis of participant interviews (n = 14) was conducted. CONCLUSIONS: These preliminary results are promising, though future research is needed to evaluate the effectiveness of WTCP using randomized controlled trial methodologies.

SARS-CoV-2 N-antigenemia in critically ill adult COVID-19 patients: Frequency and association with inflammatory and tissue-damage biomarkers.

The current study aimed at characterizing the dynamics of SARS-CoV-2 nucleocapsid (N) antigenemia in a cohort of critically ill adult COVID-19 patients and assessing its potential association with plasma levels of biomarkers of clinical severity and mortality. Seventy-three consecutive critically ill COVID-19 patients (median age, 65 years) were recruited. Serial plasma (n = 340) specimens were collected. A lateral flow immunochromatography assay and reverse-transcription polymerase chain reaction (RT-PCR) were used for SARS-CoV-2 N protein detection and RNA quantitation and in plasma, respectively. Serum levels of inflammatory and tissue-damage biomarkers in paired specimens were measured. SARS-CoV-RNA N-antigenemia and viral RNAemia were documented in 40.1% and 35.6% of patients, respectively at a median of 9 days since symptoms onset. The level of agreement between the qualitative results returned by the N-antigenemia assay and plasma RT-PCR was moderate (k = 0.57; p < 0.0001). A trend towards higher SARS-CoV-2 RNA loads was seen in plasma specimens testing positive for N-antigenemia assay than in those yielding negative results (p = 0.083). SARS-CoV-2 RNA load in tracheal aspirates was significantly higher (p < 0.001) in the presence of concomitant N-antigenemia than in its absence. Significantly higher serum levels of ferritin, lactose dehydrogenase, C-reactive protein, and D-dimer were quantified in paired plasma SARS-CoV-2 N-positive specimens than in those testing negative. Occurrence of SARS-CoV-2 N-antigenemia was not associated with increased mortality in univariate logistic regression analysis (odds ratio, 1.29; 95% confidence interval, 0.49-3.34; p = 0.59). In conclusion, SARS-CoV-2 N-antigenemia detection is relatively common in ICU patients and appears to associate with increased serum levels of inflammation and tissue-damage markers. Whether this virological parameter may behave as a biomarker of poor clinical outcome awaits further investigations.

Similar Clinical Course and Significance of Circulating Innate and Adaptive Immune Cell Counts in STEMI and COVID-19.

This study aimed to assess the time course of circulating neutrophil and lymphocyte counts and their ratio (NLR) in ST-segment elevation myocardial infarction (STEMI) and coronavirus disease (COVID)-19 and explore their associations with clinical events and structural damage. Circulating neutrophil, lymphocyte and NLR were sequentially measured in 659 patients admitted for STEMI and in 103 COVID-19 patients. The dynamics detected in STEMI (within a few hours) were replicated in COVID-19 (within a few days). In both entities patients with events and with severe structural damage displayed higher neutrophil and lower lymphocyte counts. In both scenarios, higher maximum neutrophil and lower minimum lymphocyte counts were associated with more events and more severe organ damage. NLR was higher in STEMI and COVID-19 patients with the worst clinical and structural outcomes. A canonical deregulation of the immune response occurs in STEMI and COVID-19 patients. Boosted circulating innate (neutrophilia) and depressed circulating adaptive immunity (lymphopenia) is associated with more events and severe organ damage. A greater understanding of these critical illnesses is pivotal to explore novel alternative therapies.

Procalcitonin and long-term prognosis after an admission for acute heart failure.

BACKGROUND: Traditionally, procalcitonin (PCT) is considered a diagnostic marker of bacterial infections. However, slightly elevated levels of PCT have also been found in patients with heart failure. In this context, it has been suggested that PCT may serve as a proxy for underrecognized infection, endotoxemia, or heightened proinflammatory activity. Nevertheless, the clinical utility of PCT in this setting is scarce. We aimed to evaluate the association between PCT and the risk of long-term outcomes. METHODS AND RESULTS: We measured at admission PCT of 261 consecutive patients admitted for acute heart failure (AHF) after excluding active infection. Cox and negative binomial regression methods were used to evaluate the association between PCT and the risk of death and recurrent rehospitalizations, respectively. At a median follow-up of 2years (IQR: 1.0-2.8), 108 deaths, 170 all-cause rehospitalizations and 96 AHF-rehospitalizations were registered. In an adjusted analysis, including well-established risk factors such as natriuretic peptides and indices of renal function, the logarithm of PCT was associated with a higher risk of death (HR=1.43, CI 95%: 1.12-1.82; p=0.004), all-cause rehospitalizations (IRR=1.22, CI 95% 1.02-1.44; p=0.025) and AHF-rehospitalizations (IRR=1.28, CI 95%: 1.02-1.61; p=0.032). The association with these endpoints persisted after adjustment for other inflammatory biomarkers such as white blood cells, C-reactive protein and interleukins. CONCLUSION: In patients with AHF and no evidence of infection, PCT was independently and positively associated with the risk of long-term death and recurrent rehospitalizations.

Prognostic value of admission glycated haemoglobin in unknown diabetic patients with acute myocardial infarction.

BACKGROUND: Acute glycometabolic derangement in non-diabetic patients with acute myocardial infarction (AMI) has been reported with discrepant prognostic results. The aim of the present study was to assess the prognostic impact of glycated haemoglobin (HbA1c) levels, reflecting long-term glycometabolic disturbance, in a population of patients without known diabetes mellitus. METHODS: We examined 601 consecutive prospective patients diagnosed with AMI and unknown diabetes mellitus. We analysed metabolic function as a stratified variable using three groups of patients according to HbA1c: Group 1 (< 5.5%): 222 patients (37%); Group 2 (5.5 to 6.4%): 337 patients (56%); Group 3 (>6.4%): 42 patients (7%). Association between HbA1c groups and classic cardiovascular risk factor and in-hospital outcomes were assessed through univariate and multivariate analysis. RESULTS: In-hospital mortality was 5% (32/601 patients). Higher HbA1c was associated with poor glycometabolic control, older patients, obesity, hypertension, Killip's class>1, increased heart rate, initial bundle branch block, atrial fibrillation and higher mortality during follow-up. In a multivariate adjusted risk, in-hospital mortality was associated with age (odds ratio (OR)= 1.056; 1-1.1; p=0.006), Killip's class>1 (OR=2.4; 1-6.1; p=0.05) and HbA1c (OR=1.5; 1.15-1.9; p=0.002). Hypertension (OR=0.39; 0.18-0.87; p=0.022) and angiotensin-converting enzyme inhibitors (OR=0.28; 0.12-0.69; p=0.005) were protective factors. CONCLUSIONS: HbA1c is an important risk marker in the absence of a history of diabetes mellitus in patients with AMI. The optimal management strategy in these patients may contribute to decreased in-hospital mortality.

Acute myocardial infarction: high risk ventricular tachyarrhythmias and admission glucose level in patients with and without diabetes mellitus.

OBJECTIVE: The aim of this study was to evaluate the impact of glucose levels on admission and High Risk Ventricular Tachyarrhythmia (HRVT) in hospital mortality in patients with Acute Myocardial Infarction (AMI). METHODS: We studied 1.258 consecutive patients admitted to the Coronary Care Unit with a diagnosis of AMI. Ventricular Fibrillation, sustained and nonsustained Ventricular Tachycardia were considered as HRVT. Association between admission glucose, in-hospital mortality and HRVT was assessed with Cox regression analysis. RESULTS: The overall incidence of in-hospital HRVT was 20% (254/1258 patients) and in-hospital mortality (115/1.258) was higher in patients with HRVT (20% vs 6%) (p< 0.001). Diabetes Mellitus (DM) was present in 441 patients (35%). Optimal threshold level of glycemia admission to predict ventricular arrhythmia was 180 mg/dl (AUC = 0.716; 0.66- 0.76)(p<0.001). Patients with euglycemia on admission (< 120 mg/dL) had lowest prevalence of HRVT (13%)(OR=0.6;0.46-0.78) in contrast to non DM patients who presented glucose 180 mg/dL that exhibited 2-fold increase of in-hospital HRVT (36%; OR=2.2; 1.6-3)(p<0.001). Multivariate risk adjusted hazard ratio (HR) analysis showed that, blood pressure < 100 mmHg (HR=2.4; 1.6-3.6)(p<0.001), White Blood Count (WBC)>10.000 cell count (HR=1.44;1.02-2)(p=0.04) and admission glycemia 180 mg/dL (HR=1.5; 1.04-2.3)( p=0.03) had a significantly increased risk in in-hospital HRTV only in NDM patients. CONCLUSIONS: The higher glycemia on admission the higher prevalence of life-threatening arrhythmia and mortality regardless diabetes status in patients presenting with AMI. Elevated initial glucose level and WBC count considered along with other clinical data can assist in life-threatening ventricular arrhythmia in non diabetic patients.

One-week and 6-month cardiovascular magnetic resonance outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction.

INTRODUCTION AND OBJECTIVES: Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction. METHODS: Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004-2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007-2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated. RESULTS: At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29±15 vs. 29±17%, P=.9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and end-systolic volume index (P>.2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients (P=.7). CONCLUSIONS: A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplasty.

Therapeutic implications of low lymphocyte count in non-ST segment elevation acute coronary syndromes.

BACKGROUND: Low lymphocyte count (LLC), a surrogate for inflammation, has emerged as a potential risk factor for cardiovascular outcomes, especially new ischemic events. To identify patients with non-ST segment elevation acute coronary syndromes (NSTEACS) who benefit from an invasive revascularization strategy remains a challenge. We sought to determine if patients with high-risk NSTEACS who exhibited LLC have a greater reduction in long-term post-discharge myocardial infarction (MI) when managed under a revascularization invasive strategy (RIS) as compared with conservative strategy (CS). METHODS: Nine hundred seventy two consecutive patients with high-risk NSTEACS were treated under two revascularization strategies (RS): 1) CS, from January 2001 to October 2002 (345 patients; 35.5%) and 2) RIS, from November 2002 to May 2005 (627 patients; 64.5%). LLC was defined as lymphocytes count < or =1200 cells/ml (1 vs. 2-4 quartiles). The association between the type of RS and MI was stratified by lymphocyte count status and assessed by Cox regression adapted for competing events. RESULTS: At 3-year follow-up, 145 deaths (14.9%), 135 MI (13.9%) and 76 revascularization procedures (7.8%) were registered. In a multivariable setting, LLC patients exhibited a greater MI risk reduction when managed under RIS (HR: 0.40; 95% CI=0.22-0.72, p=0.003). Conversely, when LLC was not present, no difference in the rate of MI was detected between the two RS. CONCLUSIONS: LLC identifies a subgroup of patients with greater reduction in the risk of postdischarge MI when a RIS is applied.

[Influence of antecedent of hypertension in patients with acute coronary syndrome without ST elevation]. / Influencia del antecedente de hipertensión arterial en los pacientes ingresados por síndrome coronario agudo sin elevación del segmento ST.

BACKGROUND AND OBJECTIVE: There are few studies evaluating the effect of a previous history of hypertension on long term prognosis after an acute coronary syndrome, using the new definitions and incorporating new risk markers in the analysis. The aim of our study was to determinate if hypertensive patients differ from non-hypertensives in the epidemiological profile, clinical presentation, treatment prescribed at discharge and prognosis after admission with non ST segment elevation acute coronary syndrome. PATIENTS AND METHOD: A total of 1,029 consecutive patients admitted with high suspicion of non ST segment elevation acute coronary syndrome were evaluated. Prognostic variables were determined during admission (epidemiological and biochemical), as it was the discharge treatment. The primary endpoint was defined as all cause mortality at one year follow up. RESULTS: 65.8% (n = 677) of patients had hypertension. Hypertensive patients displayed a worst epidemiological and biochemical profile, and different discharge treatment. There were 139 (13.5%) deaths at one year follow up. The all cause mortality for non-hypertensive patients was 12.5% and for hypertensives 14.6% (p = NS). In the multivariate analysis (Cox regression) there were no differences in mortality between these groups. CONCLUSIONS: A previous history of hypertension is an important factor to explain differences in the presence of other risk factors or the treatment, but is not a mortality predictor.

[Prognostic value of white blood cell count in acute myocardial infarction: long-term mortality]. / Valor pronóstico del recuento leucocitario en el infarto agudo de miocardio: mortalidad a largo plazo.

INTRODUCTION AND OBJECTIVES: Although traditionally an elevated white blood cell count (WBC), an indicator of systemic inflammation, has been accepted as part of the healing response following acute myocardial infarction (AMI), it has frequently been shown to be a predictor of adverse cardiovascular events. The present study was designed to assess the association between WBC and long-term mortality in AMI patients either with ST-segment elevation (STEMI) or without ST-segment elevation (non-STEMI). Patients and method. The study included 1118 consecutive patients who were admitted with the diagnosis of AMI: 569 non-STEMI and 549 STEMI. The WBC was measured in the 24 hours following admission. Patients were divided into 3 groups: WBC1 (count, <10 x 103 cells/mL), WBC2 (count, 10-14.9 x 10(3) cells/mL), and WBC3 (count, > or =15x10(3) cells/mL). All-cause mortality was recorded during a median follow-up period of 10+/-2 months. The relationship between WBC and mortality was assessed by Cox regression analysis for both types of AMI. RESULTS: Long-term mortality during follow-up was 18.5% in non-STEMI patients and 19.9% in STEMI patients. In non-STEMI patients, the adjusted hazard ratios for those in the WBC3 and WBC2 groups compared with those in the WBC1 group were 2.07 (1.08-3.94; P=.027) and 1.61 (1.03-2.51; P=.036), respectively. The corresponding figures in STEMI patients were 2.07 (1.13-3.76; P=.017) and 2.22 (1.35-3.63; P=.002), respectively. CONCLUSIONS: WBC on admission was an independent predictor of long-term mortality in both non-STEMI and STEMI patients.

[Prognostic value of Charlson comorbidity index at 30 days and 1 year after acute myocardial infarction]. / Papel del índice de Charlson en el pronóstico a 30 días y 1 año tras un infarto agudo de miocardio.

INTRODUCTION AND OBJECTIVES: The Charlson comorbidity index (CCI), an indicator of comorbidity, has been used as an adjusting variable in multivariate models. Because of its prognostic value per se for cardiovascular complications after acute myocardial infarction (AMI), we sought to determine the predictive value of the CCI for all-cause mortality and recurrent AMI 30 days and 1 year after the index event. PATIENTS AND METHOD: We analyzed 1035 consecutive patients admitted with the diagnosis of AMI (ST elevation=508 and non-ST elevation=527). The composite endpoint was determined after 30 days (13.9%) and 1 year (26.3%) of follow-up. The CCI was calculated on admission, and other variables with prognostic value were also recorded. CCI was stratified in 4 categories: 1: CCI=0 (control), 2: CCI=1, 3: CCI=2,4: CCI> or =3. Cox proportional risks analysis was used for the multivariate analysis, and the C-statistic was calculated to assess the discriminative power of the models. RESULTS: Hazard ratios (95% CI) estimated for each category of CCI were: 2=1.69 (1.10-2.59), 3=1.78 (1.08-2.92) and 4=1.57 (0.87-2.83) at 30 days; 2=1.62 (1.18-2.23), 3=2.00 (1.39-2.89) and 4=2.24 (1.50-3.36) at 1 year. Comparisons with the C-statistic between the nested multivariate models (with and without CCI) yielded values of 0.765 vs 0.750 after 30 days, and 0.751 vs 0.735 after 1 year. CONCLUSIONS: Our data indicate that CCI is an independent predictor of mortality or recurrent AMI 30 days and 1 year after the index AMI.

[Short-term prognosis of patients admitted for probable acute coronary syndrome without ST-segment elevation. Role of new myocardial damage markers and acute-phase reactants]. / Pronóstico a corto plazo de los pacientes ingresados por probable síndrome coronario agudo sin elevación del segmento ST. Papel de los nuevos marcadores de daño miocárdico y de los reactantes de fase aguda.

OBJECTIVES: The relative value of classic markers, myocardial damage variables, and levels of acute-phase reactants in establishing the pre-discharge prognosis of acute coronary syndrome without ST-segment elevation was analyzed. METHOD: We prospectively studied 385 consecutive patients admitted from our chest pain unit with a high-probability diagnosis of acute coronary syndrome without ST-segment elevation. The clinical and electrocardiographic data, myocardial damage markers (troponin I, CK-Mb mass, myoglobin), and acute-phase reactants (high-sensitivity C-reactive protein, fibrinogen) were recorded. RESULTS: During admission, 15 deaths (3.9%) and 16 complicative infarctions (4.2%) occurred, for a total of 31 major events (death and/or infarction: 8.1%). Age (p = 0.03), insulin-dependent diabetes (p = 0.009), and C-reactive protein (p = 0.05) were independently related to death. Fibrinogen was related to infarction (p = 0.01); by fibrinogen quartiles: 1.4%; 1.4%; 2.9%, and 11.7% (p = 0.02). Age (p = 0.01), insulin-dependent diabetes (p = 0.02), and C-reactive protein (p = 0.04) were independent predictors of major events; by C-reactive protein quartiles: 1.4%; 5.5%; 5.4%, and 16.7% (p = 0.004). Troponin I was related to major events (p = 0.03), but it was not an independent predictor. CONCLUSIONS: Acute-phase reactants add independent information to clinical variables in the short-term risk stratification of patients with an acute coronary syndrome. The predictive power of troponins is lower than that of other variables.