Clinical profile, management and outcomes of patients with cardiogenic shock undergoing transfer between centers in Spain.

INTRODUCTION AND OBJECTIVES: The aim of this study was to analyze the clinical profile, management, and prognosis of ST segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) requiring interhospital transfer, as well as the prognostic impact of structural variables of the treating centers in this setting. METHODS: This study included patients with STEMI-CS treated at revascularization-capable centers from 2016 to 2020. The patients were divided into the following groups: group A: patients attended throughout their admission at hospitals with interventional cardiology without cardiac surgery; group B: patients treated at hospitals with interventional cardiology and cardiac surgery; and group C: patients transferred to centers with interventional cardiology and cardiac surgery. We analyzed the association between the volume of STEMI-CS cases treated, the availability of cardiac intensive care units (CICU), and heart transplant with hospital mortality. RESULTS: A total of 4189 episodes were included: 1389 (33.2%) from group A, 2627 from group B (62.7%), and 173 from group C (4.1%). Transferred patients were younger, had a higher cardiovascular risk, and more commonly underwent revascularization, mechanical circulatory support, and heart transplant during hospitalization (P<.001). The crude mortality rate was lower in transferred patients (46.2% vs 60.3% in group A and 54.4% in group B, (P<.001)). Lower mortality was associated with a higher volume of care and CICU availability (OR, 0.75, P=.009; and 0.80, P=.047). CONCLUSIONS: The proportion of transfers in patients with STEMI-CS in our setting is low. Transferred patients were younger and underwent more invasive procedures. Mortality was lower among patients transferred to centers with a higher volume of STEMI-CS cases and CICU.

Impact of annual volume of cases and intensive cardiac care unit availability on mortality of patients with acute myocardial infarction-related cardiogenic shock treated at revascularization capable centres.

AIMS: Cardiogenic shock (CS) is associated with high mortality. The purpose of this study was to assess the impact of hospital structure-related variables on mortality in patients with CS treated at percutaneous and surgical revascularization capable centres (psRCC) from a large nationwide registry. METHODS AND RESULTS: Retrospective observational study including consecutive patients with main or secondary diagnosis of CS and ST elevation myocardial infarction (STEMI). Patients discharged from Spanish National Healthcare System psRCC were included (2016-20). The association between the volume of CS cases attended by each centre, availability of intensive cardiac care unit (ICCU) and heart transplantation (HT) programmes, and in-hospital mortality was assessed by multilevel logistic regression models. The study population consisted of 3074 CS-STEMI episodes, of whom 1759 (57.2%) occurred in 26 centres with ICCU. A total of 17/44 hospitals (38.6%) were high-volume centres, and 19/44 (43%) centres had HT programmes availability. Treatment at HT centres was not associated with a lower mortality (P = 0.121). Both high volume of cases and ICCU showed a trend to an association with lower mortality in the adjusted model [odds ratio (OR): 0.87 and 0.88, respectively]. The interaction between both variables was significantly protective (OR 0.72; P = 0.024). After propensity score matching, mortality was lower in high-volume hospitals with ICCU (OR 0.79; P = 0.007). CONCLUSION: Most CS-STEMI patients were attended at psRCC with high volume of cases and ICCU available. The combination of high volume and ICCU availability showed the lowest mortality. These data should be taken into account when designing regional networks for CS management.

Comparative Safety and Effectiveness of Ticagrelor versus Clopidogrel in Patients With Acute Coronary Syndrome: An On-Treatment Analysis From a Multicenter Registry.

Background: The net clinical benefit of ticagrelor over clopidogrel in acute coronary syndrome (ACS) has recently been questioned by observational studies which did not account for time-dependent confounders. We aimed to assess the comparative safety and effectiveness of ticagrelor vs. clopidogrel accounting for non-adherence in a real-life setting. Methods: This is a prospective, multicenter cohort study of patients with ACS discharged on ticagrelor or clopidogrel between 2015 and 2019. Major exclusions were previous intracranial bleeding, and the use of prasugrel or oral anticoagulation. Association of P2Y12 inhibitor therapy with 1-year risk of Bleeding Academic Research Consortium Type 3 or 5 bleeding; major adverse cardiac events (MACEs), a composite endpoint of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, or urgent target lesion revascularization; definite/probable stent thrombosis; vascular death; and net adverse clinical event (a composite endpoint of major bleeding and MACE) were analyzed according to the "on-treatment" principle, using fully adjusted Cox and Fine-Gray regression models with doubly robust inverse probability of censoring weighted estimators. Results: Among 2,070 patients (mean age 63 years, 27% women, 62.5% ST-elevation MI), 1,035 were discharged on ticagrelor and clopidogrel, respectively. Ticagrelor-treated patients were younger and had few comorbidities, but high rates of medication non-compliance, compared with clopidogrel users. After comprehensive multivariate adjustments, ticagrelor did not increase the risk of major bleeding compared with clopidogrel [subhazard ratio, 1.40; 95% confidence interval (CI), 0.96-2.05], while proved superior in reducing MACE (hazard ratio 0.62; 95% CI, 0.43-0.90), vascular death (subhazard ratio, 0.71; 95% CI, 0.52-0.97) and definite/probable stent thrombosis (subhazard ratio, 0.54; 95% CI, 0.30-0.79); thereby resulting in a favorable net clinical benefit (hazard ratio 0.78; 95% CI, 0.60-0.98) compared with clopidogrel. Results from sensitivity analyses were consistent with those from the primary analysis, whereas those from the intention-to-treat (ITT) analysis went in the opposite direction. Conclusion: Among all-comers with ACS, ticagrelor did not significantly increase the risk of major bleeding, while resulting in a net clinical benefit compared with clopidogrel. Further research is warranted to confirm these findings in high bleeding risk populations. CREA-ARIAM Andalucía: (ClinicalTrials.gov Identifier: NCT02500290); Current pre-specified analysis (ClinicalTrials.gov Identifier: NCT04630288).

Fondaparinux versus enoxaparin in the contemporary management of non-ST-elevation acute coronary syndromes. Insights from a multicenter registry.

BACKGROUND: Fondaparinux is thought to have the most favorable risk-benefit profile among all anticoagulants in non-ST-elevation acute coronary syndrome (NSTE-ACS). However, conflicting findings exist whether this holds true in current clinical practice. We aimed to assess the net clinical benefit of fondaparinux versus enoxaparin in the contemporary management of NSTE-ACS. METHODS: Analysis of prospective multicenter registry data of NSTE-ACS patients who received fondaparinux or enoxaparin from February 2015, through December 2017. Survival models within a competing risks framework including site-specific random effects, were used to assess the composite of clinically relevant bleedings and major adverse cardiovascular events at 30 days. RESULTS: Of 2094 patients, 1724 (82%) received enoxaparin and 370 (18%) fondaparinux. Both groups were comparable except for a lower prevalence of diabetes and renal impairment, and greater use of transradial approach in the fondaparinux group. Multivariate analysis revealed a net clinical benefit in favour of fondaparinux versus enoxaparin (Subhazard Ratio [SHR] 0.59; 95%CI 0.37-0.92), mainly driven by a reduction in bleeding (SHR 0.57; 95%CI 0.37-0.89). Exploratory analysis suggested greater reductions in bleeding with fondaparinux among patients undergoing transradial approach, revealing a significant interaction between treatment and vascular access on the multiplicative scale (Pinteraction = 0.0056), but not on an additive scale (P = 0.457). Propensity-score-matching analysis yielded similar results. CONCLUSIONS: In contemporary management of NSTE-ACS, fondaparinux seems to provide a favorable net clinical benefit compared with enoxaparin, primarily driven by a bleeding reduction. Effect modification on the safety profile of fondaparinux by the vascular access approach warrants further investigation.

Lupus eritematoso sistémico: impacto educativo en la calidad de vida de los pacientes / Systemic lupus erythematosus: educational impact on the quality life of patients

Objetivo: analizar el impacto de un programa educativo y su efecto en la calidad de vida de los pacientes con lupus eritematoso sistémico adscritos a la unidad de reumatología del Hospital Dr. Miguel Pérez Carreño durante el 2016. Métodos: se realizó un estudio experimental, donde se comparó dos grupos: 1 grupo al cual se intervino educativamente sobre Lupus, y 1 grupo donde se intervino educativamente sobre otros temas relacionados con la salud, todos, pacientes adscritos a la unidad de reumatología del Hospital Pérez Carreño. Resultados: se incluyeron 50 pacientes en el estudio, 25 en cada grupo. Se encontró un bajo nivel de conocimiento sobre su patología en ambos grupos (puntuación media: 9,4 experimental vs 11,1 control). La calidad de vida relacionada con la salud tanto física como mental no fue favorable pre intervención educativa en los dos grupos. La adherencia al tratamiento mejoró luego de la intervención educativa (p<0,05). Conclusión: Los resultados de la investigación indican que el impacto del programa educativo fue favorable al mejorar de forma significativa el conocimiento de la enfermedad, la calidad de vida física y mental, lograr una mejor adherencia al tratamiento indicado y disminuyendo a su vez el nivel de actividad del LES(AU)

Objective: To analyze the impact of an educational program in patients with systemic lupus erythematosus and its effect on the quality of life attached to the unit rheumatology Dr. Miguel Perez Carreño Hospital during 2016. Methods: An experimental study where two groups were compared: 1 group which was intervened educationally about Lupus and 1 group which was intervened educationally about other health-related issues. All patients were chosen from the unit of rheumatology at the Hospital Dr Miguel Perez Carreño. Results: 50 patients were included in the study, 25 in each group. It was demonstrated in both groups no knowledge about their condition (points mean: experimental: 9.4 vs control: 11.1). the quality of life related to health in both groups both physical and mental was not favorable pre educational intervention. Adherence to treatment improved ther the educational intervention (p <0.05). Conclusion: the results of the research indicate that the impact of the educational program was favorable by significantly improving the knowledge of the disease, the quality of physical and mental life, achieving a better adherence to the indicated treatment and decreasing in turn the level of activity of the LES(AU)

Highly Conductive Carbon Fiber Reinforced Concrete for Icing Prevention and Curing.

This paper aims to study the feasibility of highly conductive carbon fiber reinforced concrete (CFRC) as a self-heating material for ice formation prevention and curing in pavements. Tests were carried out in lab ambient conditions at different fixed voltages and then introduced in a freezer at -15 °C. The specimens inside the freezer were exposed to different fixed voltages when reaching +5 °C for prevention of icing and when reaching the temperature inside the freezer, i.e., -15 °C, for curing of icing. Results show that this concrete could act as a heating element in pavements with risk of ice formation, consuming a reasonable amount of energy for both anti-icing (prevention) and deicing (curing), which could turn into an environmentally friendly and cost-effective deicing method.

Rhombohedral-scalenohedral calcite transition produced by adjusting the solution electrical conductivity in the system Ca(OH)2-CO2-H2O.

This work is aimed to investigate the effects of the adjustment of the electrical conductivity (kappa25) during the semicontinuous carbonation of Ca(OH)2 suspension (slaked lime) on the morphology of the precipitated calcite (CaCO3) particles. The experiments were carried out at 30, 45, and 60 degrees C. A gradual morphological change from rhombohedral to scalenohedral shapes was produced with an increase of kappa25 from 1 to 7 mS/cm at each temperature. The explanation of this morphological change is given in terms of the increase of both the supersaturation and the ratio between concentrations of charged species containing calcium and carbonate ([Ca]ch/[CO3]ch) in the aqueous phase as the kappa25 set-point increases, prior to the precipitation process. In addition to the rise of the supersaturation this change most probably takes place because the increase of the [Ca]ch/[CO3]ch ratio affects the growth rate of the rhombohedral {104} and scalenohedral {21-1} faces in a different manner: (i) favoring the equality between the surface coverage of Ca2+ and CO3(2-) on the stoichiometric {104} face, thus enhancing the formation of CaCO3(0) growth units and then its growth rate and (ii) inhibiting the growth of the {21-1} face by adsorption of the excess calcium species.