The Atrial Fibrillation Better Care (ABC) Pathway and Clinical Outcomes in Patients with Atrial Fibrillation: the Prospective Murcia AF Project Phase II Cohort.

BACKGROUND: The Atrial fibrillation Better Care (ABC) pathway was proposed for a more holistic or integrated care approach to atrial fibrillation (AF) management. We investigated whether adherence with the ABC pathway reduced the risk of adverse clinical outcomes in real-world AF patients starting vitamin K antagonist (VKAs) therapy. METHODS: Prospective cohort study including AF outpatients starting VKA therapy from July 2016 to June 2018. Patients were considered as adherent if all ABC pathway criteria (A: Avoid stroke; B: Better symptom control; and C: Cardiovascular risk factors/comorbidities management) were fulfilled. The primary endpoints were all-cause mortality, net clinical outcomes (NCOs), major adverse cardiovascular events (MACE), and composite thrombotic/thromboembolic events at 2 years. RESULTS: We enrolled 1045 patients (51.6% female; median age 77 [70-83] years). Of these, 63.0% (658) were adherent to the ABC pathway and 37% (387) were considered non-adherent. Compared to non-adherent patients, those who were ABC adherent had lower event rates for all-cause mortality (13.76 vs. 6.56; p<0.001), NCOs (19.65 vs. 11.94; p<0.001), and MACE (11.88 vs. 7.75; p=0.006) during the follow-up. Adjusted Cox regression analyses demonstrated that the ABC pathway adherent care reduced the risks of all-cause mortality (aHR 0.57, 95% CI 0.42-0.78), NCOs (aHR 0.72, 95% CI 0.56-0.92), and cardiovascular mortality (aHR 0.54, 95% CI 0.32-0.90). Event-free survivals for all-cause mortality, NCOs (both log-rank p-values <0.001), and MACE (log-rank p-value = 0.004) were also higher in ABC pathway adherent patients. CONCLUSIONS: In this real-world prospective cohort of AF patients starting VKA therapy, adherence to the ABC pathway management at baseline significantly reduced the risk of NCOs, all-cause mortality, and cardiovascular death at 2 years.

A meta-analysis of preclinical studies using antioxidants for the prevention of cisplatin nephrotoxicity: implications for clinical application.

Cisplatin is an effective chemotherapeutic drug whose clinical use and efficacy are limited by its nephrotoxicity, which affects mainly the renal tubules and vasculature. It accumulates in proximal and distal epithelial tubule cells and causes oxidative stress-mediated cell death and malfunction. Consequently, many antioxidants have been tested for their capacity to prevent cisplatin nephrotoxicity. In this study, we made a systematic review of the literature and meta-analyzed 152 articles, which tested the nephroprotective effect of isolated compounds or mixtures of natural origin on cisplatin nephrotoxicity in preclinical models. This meta-analysis identified the most effective candidates and examined the efficacy obtained by antioxidants administered by the oral and intraperitoneal routes. By comparing with a recent, similar meta-analysis performed on clinical studies, this article identifies a disconnection between preclinical and clinical research, and contextualizes, discusses, and integrates the existing preclinical information toward the optimized selection of candidates to be further explored (clinical level). Despite proved efficacy, this article discusses the barriers limiting the clinical development of natural mixtures, such as those in extracts from Calendula officinalis flowers and Heliotropium eichwaldii roots. On the contrary, isolated compounds are more straightforward candidates, among which arjunolic acid and quercetin stand out in this meta-analysis.

Perspectivas clínicas del manejo de la hemorragia en el paciente tratado con anticoagulante oral: estudio DECOVER / Clinical perspectives on the management of bleeding in patients on oral anticoagulants: the DECOVER Study (DElphi Consensus on oral COagulation and therapy action reVERsal)

Objetivo: Evaluar el grado de acuerdo entre hematólogos y urgenciólogos respecto a las mejores prácticas para el manejo de hemorragias y la reversión de la anticoagulación oral. Método: Estudio Delphi multicéntrico español con médicos expertos en anticoagulación y manejo de hemorragias. Se realizaron dos rondas de preguntas entre abril y septiembre de 2015. Se obtenía consenso cuando el 75% o más de los panelistas puntuaban en el mismo tercil. Resultados: Se encuestó a 15 hematólogos y 17 urgenciólogos de 14 comunidades autónomas. La hemodiálisis y la administración de concentrados de complejo protrombínico (CCP) activado fueron tratamientos consensuados para antagonizar una hemorragia relevante/mayor en pacientes tratados con dabigatrán. Para rivaroxabán y apixabán solo se consideró el CCP. El panel no valoró ningún CCP como eficaz y seguro a la vez. Los tiempos de tromboplastina parcial activado, trombina, ecarina y de trombina diluido se indicaron para pacientes tratados con dabigatrán y la actividad anti-Xa específica para los tratados con rivaroxabán y apixabán cuando presentan una hemorragia. Disponer de un antídoto específico para el tratamiento de los anticoagulantes orales de acción directa (ACOD) sería útil en caso de hemorragia grave (97%) y supondría un cambio sustancial en el algoritmo de tratamiento actual (97%). Conclusiones: Los resultados estuvieron en general alineados con las guías de práctica clínica, pero mostraron que existen áreas de mejora en la unificación de criterios sobre el manejo de los pacientes con hemorragias, y destacan la necesidad de disponer de antídotos específicos para ACOD (AU)

Objective: To evaluate the level of agreement between hematologists and emergency medicine physicians regarding the best clinical practices for managing bleeding and anticoagulant reversal. Methods: Nationwide Spanish multicenter Delphi method study with a panel of experts on anticoagulation and the management of bleeding. Two survey rounds were carried out between April and September 2015. Consensus was reached when more than 75% of the panelists scored items in the same tertile. Results: Fifteen hematologists and 17 emergency medicine specialists from 14 Spanish autonomous communities participated. Consensus was reached on the use of both hemodialysis and an activated prothrombin complex concentrate (PCC) to antagonize significant/major bleeding in patients taking dabigatran. Use of an activated PCC was considered sufficient for patients on rivaroxaban or apixaban. The panel did not consider any PCC to be both effective and safe. Tests for activated partial thromboplastin, thrombin, diluted thrombin, and ecarin clotting times were considered useful in patients treated with dabigatran. A specific anti-Xa activity assay was suggested for patients who developed bleeds while treated with rivaroxaban or apixaban. Specific antidotes for direct-acting oral anticoagulants would be useful when severe bleeding occurs according to 97% of the panelists. Such antidotes would substantially change current treatment algorithms. Conclusion: The points of consensus were generally in line with clinical practice guidelines, but the Delphi process revealed that there are aspects of the clinical management of bleeding that require unified criteria. The need for specific antidotes for direct-acting oral anticoagulants was emphasized (AU)

A systematic meta-analysis on the efficacy of pre-clinically tested nephroprotectants at preventing aminoglycoside nephrotoxicity.

Nephrotoxicity limits the use of aminoglycoside antibiotics. Kidney damage is produced mainly in the renal tubule due to an inflammatory and oxidative process. At preclinical level, many drugs and natural products have been tested as prospective protectors of aminoglycoside nephrotoxicity. The main objective of this work was to make a systematic literature review of preclinical studies about aminoglycoside nephrotoxicity protection and a statistical analysis based on the meta-analysis methodology. Studies published up to January 2016 were identified. After applying inclusion criteria, 54 studies were chosen. The size of the experimental groups, means and standard deviations of data on renal function (i.e. plasma creatinine and blood urea nitrogen [BUN] concentrations) were extracted and registered in a database. The studies were grouped according to the mechanism of nephroprotection and their route of administration. The Mean Difference (95% confidence interval) was calculated for each study and group. 40 of 54 products tested produced an amelioration of aminoglycoside nephrotoxicity based on creatinine results. Also a dose dependent protective effect was observed (both in creatinine and BUN). Products orally administered were more effective than via i.p. Products with attributed antioxidant activity were the most used and those which proved statistically significant nephroprotection as a class effect. Aminoglycoside tubular reuptake inhibitors, excretion inducers and calcium channel blockers also showed a promising and rather homogeneous class tendency towards nephroprotection, although more research is necessary to obtain solid and conclusive results, based on a larger number of studies.

Solicitud de sangre preoperatoria en cirugía programada de colon: ¿necesidad o rutina? / Preoperative blood ordering in elective colon surgery: Requirement or routine?

INTRODUCCIÓN: La solicitud de sangre preoperatoria en cirugía programada de colon es una norma frecuente, incluso en aquellos procedimientos con escasa probabilidad de transfusión. El objetivo de este estudio es evaluar la proporción de pacientes que reciben transfusión peroperatoria y determinar sus factores asociados. Métodos Estudio retrospectivo de pacientes consecutivos en cirugía electiva de colon en el periodo 2007-2012. Se analizan variables clinicopatológicas, quirúrgicas y se calculan la ratio sangre «en reserva»/sangre transfundida (ratio C/T), la probabilidad de transfusión y el índice transfusional. Los pacientes se dividen en 2 grupos en función de haber recibido o no transfusión peroperatoria. RESULTADOS: Se contabilizan 457 pacientes, transfundiéndose 171 unidades sanguíneas en 74 pacientes, siendo la probabilidad de transfusión del 16,2%, la ratio C/T de 5,34 y el índice transfusional de 0,18. Las variables que se han asociado significativamente a recibir transfusión sanguínea tras el análisis multivariable son: la cifra preoperatoria de hemoglobina inferior a 10 g/dl (OR: 309,8; IC 95%: 52,7-985,2), enfermedad pulmonar obstructiva crónica (OR: 3,7; IC 95%: 1,3-10,7), anticoagulación oral (OR: 5,7; IC 95%: 1,7-19,4) y tiempo quirúrgico superior a 120 min (OR: 10,7; IC 95%: 4,7-24,1).Conclusiones La probabilidad de necesidad de transfusión en pacientes a los que se les realiza cirugía electiva de colon es baja. Entre los factores asociados, la cifra de hemoglobina preoperatoria inferior a 10 g/dl es el que presenta una mayor fuerza de asociación. Los pacientes con dichas cifras de hemoglobina preoperatoria no deberían ser intervenidos en cirugía electiva de colon hasta haber recibido tratamiento apropiado

BACKGROUND: Preoperative blood ordering is frequently in elective colon surgery, even for procedures that rarely require blood transfusion. Most often this procedure is performed without proper analysis of the real needs. The aim of this study was to evaluate the patients who receive transfusion and determining their associated factors. METHODS: Retrospective study of all consecutive patients scheduled for elective colon surgery was carried out at 2007-2012. Several clinico-pathological and surgical variables were analyzed and predictive blood transfusion indices such as the cross-matched/transfusion ratio (C/T ratio), transfusion index and transfusion probability were calculated. Patients were divided in 2 groups according have received perioperative surgical transfusion or not. RESULTS: There were 457 surgery patients. A total of 171 blood units, in a 74 patients were perioperative transfused. Overall cross-matched transfused ratio was 5.34, the transfusion probability 162%, and the transfusion index 0.18. Variables that were significantly associated with receiving blood transfusion in a multivariable analysis were a preoperative haemoglobin level less than 10 g/dl (OR: 309.8; 95% CI: 52.7-985.2), chronic pulmonary obstructive disease (OR: 3.7; 95% CI: 1.3-10.7), oral anticoagulant therapy (OR: 5.7; 95% CI: 1.7-19.4) and surgical time over 120 min (OR: 10.7; 95% CI: 4.7-24.1). CONCLUSIONS: Likelihood of receiving perioperative transfusion in elective colon surgery is very low. Among their associated factors, the haemoglobin level less than 10 g/dl is the one with strongest association. Those patients with such low preoperative haemoglobin level should not be scheduled for elective colon surgery until they received specific treatment

Safety evaluation and nutritional composition of a Fraxinus excelsior seed extract, FraxiPure™.

A natural extract obtained from the seeds of Fraxinus excelsior L. (FraxiPure™) has been previously reported to reduce glycemia in animal models and in humans. The objective of this work was to evaluate the safety of FraxiPure™ at in vitro, in vivo and human levels. In addition, nutritional analyses revealed an extract high in carbohydrates, with minor levels of protein, dietary fiber, glucose and sucrose. IC(50) and IC(90) values of 1.447 and 2.530 mg/mL, respectively, after 72 h incubation were calculated using the MTT assay. FraxiPure™ conferred a magnitude of protection of 69.2% against the formation of micronuclei in irradiated human lymphocytes as determined by the micronucleus assay. An LD(50) of greater than 2500 mg/kg was concluded following an acute oral toxicity study in Sprague-Dawley rats. A human safety evaluation in a double-blind, placebo-controlled parallel study of 100 healthy volunteers revealed no significant differences between daily consumption of 1000 mg of FraxiPure™ for 90 days and placebo (maltodextrin) for any of the biochemical or hematological parameters studied. Numbers of adverse events were similar in both groups, and were deemed mild to moderate. These results demonstrate, for the first time, the safety and tolerability of FraxiPure™ for consumption in healthy subjects.

La exposición crónica al uranio, un riesgo potencial de nefrotoxicidad / Uranium is a naturally occurring element widely distributed in the crust

El uranio es un elemento natural que se encuentra ampliamente distribuido en la corteza terrestre. Cierta cantidad de este metal se encuentra presente en los alimentos, en el aire, en el suelo y en el agua, por lo que el ser humano se encuentra expuesto al mismo de forma natural. Pero también puede ser objeto de una sobreexposición patológica como consecuencia de la deposición de uranio natural desde la atmósfera o debido a actividades industriales humanas que vierten productos de desecho directamente sobre el terreno. Actualmente la exposición debida a la actividad industrial se ha incrementado debido a que el uranio representa una de las pocas fuentes energéticas que cumplen con el “Protocolo de Kyoto”, sumándole la ventaja de que es muy económico. España, es uno de los países Europeos con más contenido de uranio en su suelo y por ello, susceptible de exposición natural, pero también industrial, ya que dada la demanda energética se están reabriendo algunas de sus minas. La nefrotoxicidad es el principal efecto observado tras exposición aguda a uranio. Este efecto se ha descrito en múltiples estudios realizados en animales de experimentación y en algunos casos de humanos expuestos a dosis elevadas de uranio de forma accidental. Sin embargo, la producción de daño renal por exposición crónica está poco documentada. Existen escasos estudios experimentales en los que se administren bajas dosis de uranio durante largos periodos de tiempo y los referidos en humanos son muy heterogéneos en cuanto a la vía de exposición, la dosis, el tipo de uranio etc, por lo que resulta muy difícil extraer conclusiones sobre los efectos renales por sobreexposición crónica. En esta revisión se pretende hacer una recopilación y discusión de gran parte de estudios epidemiológicos y de experimentación, a fin de obtener una idea de la nefrotoxicidad real que supone la exposición crónica a este metal para el ser humano (AU)

Certain amount of this metal is present in food, air, soil and water, for that humans are exposed to it naturally. But it can also be pathological overexposure as a result of natural uranium deposition from the atmosphere or due to human industrial activities that discharge waste products directly on the ground. Currently exposure due to industrial activity has increased because the uranium is one of the few sources of energy that meet the "Kyoto Protocol", adding the advantage that it is very economical. Spain is one of most European countries with uranium content in soil and thus susceptible to natural exposure, but also industrial, as given energy demand are reopening some of its mines. Nephrotoxicity is the main effect observed after acute exposure to uranium. This effect has been described in multiple studies in experimental animals and in some cases of humans accidentally exposed to high doses of uranium. However, the production of kidney damage from chronic exposure is poorly documented. There are few experimental studies in which low doses are administered uranium for long periods of time. Moreover, data in humans are very heterogeneous regarding the route of exposure, dose, type of uranium etc, so it is very difficult to draw findings on chronic renal effects of overexposure. In this review we tried to make a compilation and discussion of several epidemiological and experimental studies in order to get an idea of the real nephrotoxicity involving chronic exposure to this metal to humans (AU)

Effect of quercetin on platelet spreading on collagen and fibrinogen and on multiple platelet kinases.

alpha(2)beta(1) and alpha(IIb)beta(3) integrins, that support platelet adhesion to collagen and fibrinogen, respectively, share common signaling molecules. The effect of quercetin on platelet static adhesion to collagen and fibrinogen was assessed and correlated with its kinase inhibitory activity. Quercetin strongly abrogated PI3K and Src kinases, mildly inhibited Akt1/2, and slightly affected PKC, p38 and ERK1/2. Quercetin or the combined use of adenosine diphosphate and thromboxane A(2) inhibitors abrogated platelet spreading on these surfaces to a similar extent. We suggest that the inhibitory effect of quercetin on platelet kinases blocks early signaling events preventing a complete platelet spreading.

Inhibition of proteasome by bortezomib causes intracellular aggregation of hepatic serpins and increases the latent circulating form of antithrombin.

Conformational diseases include heterogeneous disorders sharing a similar pathological mechanism, leading to intracellular aggregation of proteins with toxic effects. Serpins are commonly involved in these diseases. These are structurally sensitive molecules that modify their folding under even minor genetic or environmental variations. Indeed, under normal conditions, the rate of misfolding of serpins is high and unfolded serpins must be degraded by the proteasome system. Our aim was to study the effects of bortezomib, a proteasome inhibitor, on conformationally sensitive serpins. The effects of bortezomib were analysed in patients with multiple myeloma, HepG2 cells, and Swiss mice, as well as in vitro. Levels, anti-FXa activity, heparin affinity, and conformational features of antithrombin, a relevant anticoagulant serpin, were analysed. Histological, ultrastructural features and immunohistological distribution of antithrombin and alpha1-antitrypsin (another hepatic serpin) were evaluated. We also studied the intracellular accumulation of conformationally sensitive (fibrinogen) or non-sensitive (prothrombin) hepatic proteins. The inhibition of the proteasome caused intracellular accumulation and aggregation of serpins within the endoplasmic reticulum that was associated with confronting cisternae and Mallory body formation. These effects were accompanied by a heat stress response. Bortezomib also increased the levels of intracellular fibrinogen, but has no significant effect on prothrombin. Finally, bortezomib had only minor effects on the mature circulating antithrombin, with increased amounts of latent antithrombin in plasma. These results suggest that the impairment of proteasomal activities leads to an intracellular accumulation of conformationally sensitive proteins and might facilitate the release of misfolded serpins into circulation where they adopt more stable conformations.