Optimization of hydrochar synthesis conditions for enhanced Cd(II) and Pb(II) adsorption in mono and multimetallic systems.

The characterisation of hydrochars derived from Sargassum biomass collected along the Mexican Caribbean coast reveals their favourable morphology and chemical composition for incorporating metal ions, including Cd(II) and Pb(II). Among the synthesized materials, HCS-3, produced at 180 °C with a 2 h residence time, exhibited superior yield, specific area, carbon content, and capacity for removing Cd(II) and Pb(II). Adsorption equilibrium studies demonstrate the presence of adsorption processes during Cd(II) and Pb(II) retention on HCS-3, with adsorption capacities slightly exceeding 140 and 340 mg g⁻1, respectively. Notably, HCS-3 shows a greater affinity for Pb(II) over Cd(II) when both elements are present concurrently. The physicochemical analysis through FTIR spectroscopy, functional group analysis, point of zero charge determination, SEM/EDS, and other techniques evidenced that HCS-3 possesses favourable characteristics to serve as a heavy metal adsorbent. These findings underscore the efficacy of hydrochars from Sargassum biomass in removing heavy metals, suggesting their potential as superior adsorbents compared to traditional or novel materials, and advising its possible versatility for other pollutants. Utilizing these hydrochars could mitigate the economic and environmental impact of Sargassum biomass by repurposing it for valuable applications.

Impact of prior oral anticoagulation therapies on post-discharge outcomes after COVID-19: Results from a global federated health network analysis.

BACKGROUND: The impact of chronic oral anticoagulant (OACs) use on long-term post-discharge outcomes after coronavirus disease 2019 (COVID-19) hospitalisation remains unclear. Herein, we compared clinical outcomes up to 2-years after COVID-19 hospitalisation between patients on vitamin K antagonists (VKAs), direct-acting OACs (DOACs) and no OAC therapy. METHODS: Data from TriNetX, a global federated health research network, were used. Adult patients on VKAs, DOACs or no OAC therapy at diagnosis of COVID-19 between 20 January 2020 and 31 December 2021, who were hospitalised for COVID-19, were included. The primary outcomes were all-cause mortality, ischaemic stroke/transient ischaemic attack (TIA)/systemic embolism (SE) and the composite of intracranial haemorrhage (ICH)/gastrointestinal bleeding, at 2 years after COVID-19 hospitalisation. RESULTS: We included 110,834 patients with COVID-19. Following propensity score matching (PSM), we identified a decreased mortality risk in DOAC-treated patients compared to the no OAC cohort (RR .808, 95% CI .751-.870). A higher risk of ischaemic stroke/TIA/SE was observed in VKA users compared to DOAC users (RR 1.100, 95% CI 1.020-1.220) and in VKA users compared to patients not taking OAC (RR 1.400, 95% CI 1.140-1.720). VKA use was associated with a greater risk of ICH/gastrointestinal bleeding than DOAC users (RR 1.198, 95% CI 1.066-1.347), while DOAC users had a lower risk compared to no OAC-treated patients (RR .840, 95% CI .754-.936). CONCLUSION: COVID-19 patients taking prior DOACs were associated with lower long-term mortality risk and ICH/gastrointestinal bleeding than patients not taking OAC. Compared to patients on DOACs, VKA users were associated with higher risks of mortality, ischaemic stroke/TIA/SE and ICH/gastrointestinal bleeding.

Patients with atrial fibrillation and common exclusion criteria from clinical trials are at high risk of clinical events: the Murcia AF Project II (MAFP-II) cohort study.

BACKGROUND: Some clinical characteristics and comorbidities in atrial fibrillation (AF) patients are exclusion criteria in randomized clinical trials (RCTs) investigating oral anticoagulants (OAC). However, these conditions are present also in everyday clinical practice patients. We compared the risk of adverse clinical outcomes between patients with and without RCT exclusion criteria. METHODS: The Murcia AF Project II was an observational cohort study including AF outpatients starting vitamin K antagonists (VKAs) from July 2016 to June 2018. For the selection of the exclusion criteria, the four pivotal RCTs of direct-acting OAC (DOACs) were used as reference. During 2 years, all ischemic strokes/transient ischemic attacks, major adverse cardiovascular events (MACEs), major bleeds, and all-cause deaths were recorded. RESULTS: 1050 patients (51.5% female, median age 77 years) were included, of whom 368 (35%) met at least one exclusion criterion for RCTs. During follow-up, the incidence rate ratios for major bleeding, MACE and all-cause mortality were higher among patients with exclusion criteria (all p < 0.001). Patients fulfilling at least one exclusion criterion had increased risks of major bleeding (aHR 1.48; 95% CI 1.22-1.81; p < 0.001), MACE (aHR 1.51, 95% CI 1.10-2.09, p = 0.012), and mortality (aHR 3.22, 95% CI 2.32-4.48, p < 0.001), as well as a lower event-free survival (all log-rank p < 0.001). CONCLUSIONS: In this AF cohort taking VKAs, more than one-third had at least one RCT exclusion criteria, which translates into higher risk of major bleeding, MACE, and death. These observations should be considered when translating RCTs results to AF patients for a proper and a more patient-centered management.

Incidence and clinical impact of inappropriate periprocedural and perioperative management of antiplatelet therapy.

BACKGROUND AND AIMS: There is little evidence on the impact of current recommendations on the use of antiplatelet therapy during the perioperative and periprocedural period in our setting. The aim of this study was to analyze the incidence and clinical impact of inappropriate use of antiplatelet therapy in a population of patients undergoing surgery or a diagnostic or therapeutic procedure in "real life" in Spain. METHODS: A prospective multicenter observational study of patients treated with antiplatelet agents requiring intervention was conducted. The incidence of thrombotic and hemorrhagic events at 30 days was analyzed according to peri-intervention management of antiplatelet therapy. RESULTS: We included 643 patients (31.9% women, 39.0% over 75 years of age), most of them (87.7%) receiving aspirin as antiplatelet therapy at a dose of 100mg/day. Indications for antiplatelet therapy were ischemic heart disease (44.9%), cerebrovascular disease (21.7%), and peripheral vascular disease (23.0%). Ischemic risk was low in 74.3%, while 51.6% had a low bleeding risk of the intervention. Periprocedural management was considered appropriate in 61.7% of cases. 30-day incidence of the combined primary endpoint of thrombotic events and major bleeding (12.1% versus 5.0%; p=0.002) and 30-day mortality (5.2% versus 1.5%; p=0.008) were significantly higher in patients with inappropriate periprocedural management of antiplatelet agents. CONCLUSIONS: Despite current recommendations for the use of antiplatelet drugs in the perioperative/periprocedural period, their implementation in the "real world" remains low. Inappropriate use is associated with an increased incidence of adverse events, both thrombotic and hemorrhagic.

Synallactesmcdanieli sp. nov., a new species of sea cucumber from British Columbia, Canada and the Gulf of Alaska, USA (Holothuroidea, Synallactida).

Background: The family Synallactidae comprises mostly deep-sea forms and is the least-studied large taxon amongst deep-sea cucumbers. They are part of the abyssal megafauna and play an important role in modifying the sediment landscape and structuring the communities that live within it. The family embraces the genus Synallactes, which contains approximately twenty-five species from the Pacific, Atlantic (six species), Indian (seven species) and Antarctic Oceans (one species). New information: Synallactesmcdanieli sp. nov. is described from the Northeast Pacific, Knight Inlet, British Columbia, Canada to Kodiak Island, Gulf of Alaska, USA, at depths from 21 to 438 m. This new species is unique amongst the species of the genus Synallactes because of the number and arrangement of dorsal papillae, number of Polian vesicles, together with the entire ossicle arrangement. In addition, this species has the shallowest bathymetric distribution ever recorded for this genus.

Antibiotic Degradation via Fenton Process Assisted by a 3-Electron Oxygen Reduction Reaction Pathway Catalyzed by Bio-Carbon-Manganese Composites.

Bio-carbon-manganese composites obtained from olive mill wastewater were successfully prepared using manganese acetate as the manganese source and olive wastewater as the carbon precursor. The samples were characterized chemically and texturally by N2 and CO2 adsorption at 77 K and 273 K, respectively, by X-ray photoelectron spectroscopy (XPS) and X-ray diffraction. Electrochemical characterization was carried out by cyclic voltammetry (CV) and linear sweep voltammetry (LSV). The samples were evaluated in the electro-Fenton degradation of tetracycline in a typical three-electrode system under natural conditions of pH and temperature (6.5 and 25 °C). The results show that the catalysts have a high catalytic power capable of degrading tetracycline (about 70%) by a three-electron oxygen reduction pathway in which hydroxyl radicals are generated in situ, thus eliminating the need for two catalysts (ORR and Fenton).

Advances in the medical treatment and diagnosis of intracranial hemorrhage associated with oral anticoagulation.

INTRODUCTION: With the increasing prevalence of atrial fibrillation (AF), it entails expanding oral anticoagulants (OACs) use, carrying a higher risk of associated hemorrhagic events, including intracranial hemorrhage (ICH). Despite advances in OACs development with a better safety profile and reversal agent for these anticoagulants, there is still no consensus on the optimal management of patients with OACs-associated ICH. AREAS COVERED: In this review, the authors have carried out an exhaustive search on the advances in recent years. The authors provide an update on the management of ICH in anticoagulated patients, as well as an update on the latest evidence on anticoagulation resumption, recent therapeutic strategies, and investigational drugs that could play a role in the future. EXPERT OPINION: Following an ICH event in an anticoagulated patient, a comprehensive clinical evaluation is imperative. Anticoagulation should be promptly withdrawn and reversed. Once the patient is stabilized, a reintroduction of anticoagulation should be considered, typically within a timeframe of 4-8 weeks, if feasible. If re-anticoagulation is not possible, alternative options such as Left Atrial Appendage Occlusion are available.

Potential Impact of Bioactive Peptides from Foods in the Treatment of Hypertension.

SCOPE: High blood pressure (BP) is the main preventable risk factor for cardiovascular diseases (CVDs). Much research is aimed at finding natural alternatives to control or prevent hypertension (HT), since some hypertensive patients do not respond to current pharmacological treatments or show undesirable side effects. METHODS AND RESULTS: Forty relevant articles have been selected from various scientific literature databases. The results reveal that angiotensin-converting enzyme (ACE) inhibition is the most reported mechanism of action of antihypertensive peptides. The active peptides have a great variety of origins. Biopeptides with a molecular weight of <3 kDa, short chain <20 amino acids, and a hydrophobic amino acid sequence at the C- and N-terminus exhibit higher antihypertensive activity. They also show good stability to enzymatic hydrolysis and gastrointestinal digestion, and no toxicity. To determine antihypertensive effectiveness, in vitro and in vivo animal studies are the most frequent developed, with few in silico studies and only one human clinical trial. CONCLUSION: There is interesting potential for antihypertensive peptides as promising natural candidates for the development of functional foods, nutraceuticals and drugs for preventive or therapeutic treatment of hypertension. The aim of this review is to study the role of food-derived bioactive peptides in HT.

Elevated Troponins after COVID-19 Hospitalization and Long-Term COVID-19 Symptoms: Incidence, Prognosis, and Clinical Outcomes-Results from a Multi-Center International Prospective Registry (HOPE-2).

Background: Acute cardiac injury (ACI) after COVID-19 has been linked with unfavorable clinical outcomes, but data on the clinical impact of elevated cardiac troponin on discharge during follow-up are scarce. Our objective is to elucidate the clinical outcome of patients with elevated troponin on discharge after surviving a COVID-19 hospitalization. Methods: We conducted an analysis in the prospective registry HOPE-2 (NCT04778020). Only patients discharged alive were selected for analysis, and all-cause death on follow-up was considered as the primary endpoint. As a secondary endpoint, we established any long-term COVID-19 symptoms. HOPE-2 stopped enrolling patients on 31 December 2021, with 9299 patients hospitalized with COVID-19, of which 1805 were deceased during the acute phase. Finally, 2382 patients alive on discharge underwent propensity score matching by relevant baseline variables in a 1:3 fashion, from 56 centers in 8 countries. Results: Patients with elevated troponin experienced significantly higher all-cause death during follow-up (log-rank = 27.23, p < 0.001), and had a higher chance of experiencing long-term COVID-19 cardiovascular symptoms. Specifically, fatigue and dyspnea (57.7% and 62.8%, with p-values of 0.009 and <0.001, respectively) are among the most common. Conclusions: After surviving the acute phase, patients with elevated troponin on discharge present increased mortality and long-term COVID-19 symptoms over time, which is clinically relevant in follow-up visits.

Size Control of Carbon Xerogel Spheres as Key Factor Governing the H2O2 Selectivity in Metal-Free Bifunctional Electro-Fenton Catalysts for Tetracycline Degradation.

Carbon xerogel spheres co-doped with nitrogen and eco-graphene were synthesized using a typical solvothermal method. The results indicate that the incorporation of eco-graphene enhances the electrochemical properties, such as the current density (JK) and the selectivity for the four transferred electrons (n). Additionally, nitrogen doping has a significant effect on the degradation efficiency, varying with the size of the carbon xerogel spheres, which could be attributed to the type of nitrogenous group doped in the carbon material. The degradation efficiency improved in the nanometric spheres (48.3% to 61.6%) but decreased in the micrometric-scale spheres (58.6% to 53.4%). This effect was attributed to the N-functional groups present in each sample, with N-CNS-5 exhibiting a higher percentage of graphitic nitrogen (35.7%) compared to N-CMS-5 (15.3%). These findings highlight the critical role of sphere size in determining the type of N-functional groups present in the sample. leading to enhanced degradation of pollutants as a result of the electro-Fenton process.

Autism Detection in Early Childhood (ADEC) in a Low-Income Spanish-Speaking Population in Guayaquil (Ecuador).

Autism Spectrum Disorder (ASD) must be present early in development, but may not fully manifest until social demands exceed capacities. In the absence of adequate biological or brain imaging markers to detect and diagnose autism, diagnosis relies on clinical judgment based on observation of symptoms. Many tools have been developed in English-speaking countries (questionnaires for parents, symptom checklists for professionals, observation systems, etc.). Screening in countries with other languages requires cultural and linguistic adaptation of these instruments. This paper presents the adaptation of the ADEC (Autism Detection in Early Childhood). METHODS: The original version of the ADEC was translated and culturally and linguistically adapted to the characteristics of the population of Guayaquil (Ecuador). PARTICIPANTS: A pilot study was conducted with a sample of 613 children aged 18-48 months. RESULTS: Cronbach's alpha values (0.89) indicate high internal consistency. The correlation between the MCHAT-R/F follow-up interview and the ADEC (mean r = 0.93) indicates high construct validity. In terms of predictive validity, using the original cut-off points of the ADEC, they show excellent diagnostic ability. The sensitivity and specificity results (sensitivity 1.00; specificity 0.92; positive predictive value 0.83; negative predictive value 0.99) are even better than those obtained in a similar study in the Mexican population. CONCLUSIONS: Considering that the MCHAT R/F is a parent-reported instrument, the Guayaquil Spanish version of the ADEC (ADEC-GU) seems to be a suitable instrument to be used in a complementary way as a second-level screening instrument for autism, before resorting to a full diagnostic process.

Cellulose-based materials in tailoring a novel defective titanium­carbon­phosphorus hybrid composites for highly efficient photocatalytic activity.

Until now, black titania has attracted much interest as a potential photocatalyst. In this contribution, we report the first demonstration of the effective strategy to fundamentally improve the photocatalytic performance using a novel sustainable defective titanium­carbon-phosphorous (TCPH) hybrid nanocomposite. The prepared TCPH was used for photocatalytic degradation of the main organic pollutants, which is methyl orange (MO) dye. The physico-chemical properties of as-prepared samples were characterized by various techniques to observe the transformations after carbonization and the interaction between different composite phases. The existence of Ti+3 and oxygen vacancies at the surface, and a notable increase in surface area, are all demonstrated by TCPH, together with the distinct core-shell structure. These unique properties exhibit excellent photocatalytic performance due to the boosted charge transport and separation. The highest degradation efficiency of methyl orange (MO) was attained in the case of TCPH when compared with titanium-cellulose-phosphorous (TCeP) and titanium­carbon-phosphorous (TCPN). Accordingly, the highest degradation efficiency was achieved by applying the optimal operational conditions of 1 g/L of TCPH catalyst, 10 mg/L of MO, pH of 7 and the temperature at 25 ± 3 °C after 3 min under LED lamp (365 nm) with light intensity 100 mW/cm2. The degradation mechanism was investigated, and the trapping tests showed the dominance of hydroxyl radicals in the degradation of MO. TCPH showed high stability under a long period of operation in five consecutive cycles, which renders the highly promising on an industrial scale. The fabrication of highly active defective titanium­carbon-phosphorous opens new opportunities in various areas, including water splitting, and CO2 reduction.

Comparison of the Influence of Oxygen Groups Introduced by Graphene Oxide on the Activity of Carbon Felt in Vanadium and Anthraquinone Flow Batteries.

An increasing number of studies focus on organic flow batteries (OFBs) as possible substitutes for the vanadium flow battery (VFB), featuring anthraquinone derivatives, such as anthraquinone-2,7-disulfonic acid (2,7-AQDS). VFBs have been postulated as a promising energy storage technology. However, the fluctuating cost of vanadium minerals and risky supply chains have hampered their implementation, while OFBs could be prepared from renewable raw materials. A critical component of flow batteries is the electrode material, which can determine the power density and energy efficiency. Yet, and in contrast to VFBs, studies on electrodes tailored for OFBs are scarce. Hence, in this work, we propose the modification of commercial carbon felts with reduced graphene oxide (rGO) and poly(ethylene glycol) for the 2,7-AQDS redox couple and to preliminarily assess its effects on the efficiency of a 2,7-AQDS/ferrocyanide flow battery. Results are compared to those of a VFB to evaluate if the benefits of the modification are transferable to OFBs. The modification of carbon felts with surface oxygen groups introduced by the presence of rGO enhanced both its hydrophilicity and surface area, favoring the catalytic activity toward VFB and OFB reactions. The results are promising, given the improved behavior of the modified electrodes. Parallels are established between the electrodes of both FB technologies.

Use of Digitalisation and Machine Learning Techniques in Therapeutic Intervention at Early Ages: Supervised and Unsupervised Analysis.

Advances in technology and artificial intelligence (smart healthcare) open up a range of possibilities for precision intervention in the field of health sciences. The objectives of this study were to analyse the functionality of using supervised (prediction and classification) and unsupervised (clustering) machine learning techniques to analyse results related to the development of functional skills in patients at developmental ages of 0-6 years. We worked with a sample of 113 patients, of whom 49 were cared for in a specific centre for people with motor impairments (Group 1) and 64 were cared for in a specific early care programme for patients with different impairments (Group 2). The results indicated that in Group 1, chronological age predicted the development of functional skills at 85% and in Group 2 at 65%. The classification variable detected was functional development in the upper extremities. Two clusters were detected within each group that allowed us to determine the patterns of functional development in each patient with respect to functional skills. The use of smart healthcare resources has a promising future in the field of early care. However, data recording in web applications needs to be planned, and the automation of results through machine learning techniques is required.

Modeling and experimental analysis of CO2 methanation reaction using Ni/CeO2 monolithic catalyst.

In this study, the effect of the cell density of monolithic catalysts was investigated and further mathematically modeled on cordierite supports used in CO2 methanation. Commercial cordierite monoliths with 200, 400, and 500 cpsi cell densities were coated by immersion into an ethanolic suspension of Ni/CeO2 active phase. SEM-EDS analysis confirmed that, owing to the low porosity of cordierite (surface area < 1 m2 g-1), the Ni/CeO2 diffusion into the walls was limited, especially in the case of low and intermediate cell density monoliths; thus, active phase was predominantly loaded onto the channels' external surface. Nevertheless, despite the larger exposed surface area in the monolith with high cell density, which would allow for better distribution and accessibility of Ni/CeO2, its higher macro-pore volume resulted in some introduction of the active phase into the walls. As a result, the catalytic evaluation showed that it was more influenced by increments in volumetric flow rates. The low cell density monolith displayed diffusional control at flow rates below 500 mL min-1. In contrast, intermediate and high cell density monoliths presented this behavior up to 300 mL min-1. These findings suggest that the interaction reactants-catalyst is considerably more affected by a forced non-uniform flow when increasing the injection rate. This condition reduced the transport of reactants and products within the catalyst channels and, in turn, increased the minimum temperature required for the reaction. Moreover, a slight diminution of selectivity to CH4 was observed and ascribed to the possible formation of hot spots that activate the reverse water-gas shift reaction. Finally, a mathematical model based on fundamental momentum and mass transfer equations coupled with the kinetics of CO2 methanation was successfully derived and solved to analyze the fluid dynamics of the monolithic support. The results showed a radial profile with maximum fluid velocity located at the center of the channel. A reactive zone close to the inlet was obtained, and maximum methane production (4.5 mol m-3) throughout the monolith was attained at 350 °C. Then, linear streamlines of the chemical species were developed along the channel.

Crinoidea y Asteroidea (Echinodermata) del talud de la península de Yucatán, de la Colección Nacional de Equinodermos de México / Crinoidea and Asteroidea (Echinodermata) from the slope of the Yucatan Peninsula, Colección Nacional de Equinodermos, Mexico

Resumen Introducción: Las especies de las clases Crinoidea y Asteroidea se distribuyen en gran variedad de hábitats en todos los océanos desde la zona intermareal hasta grandes profundidades, existen pocos registros en aguas mexicanas, a profundidades superiores a los 200 m, los escasos registros existentes datan de documentos históricos de la literatura especializada y los ejemplares se resguardan en colecciones científicas extranjeras. Objetivo: Contribuir a la recopilación de información de los ejemplares resguardados en la Colección Nacional de Equinodermos (CNE) del Instituto de Ciencias del Mar y Limnología (ICML), UNAM y proveer un inventario de las especies de crinoideos y asteroideos que habitan en zonas profundas del talud de la Península de Yucatán, México. Métodos: Del año 2005 al 2014 se recolectaron ejemplares de crinoideos y asteriodeos en cuatro cruceros en el B/O "Justo Sierra" BIOREPES 1 y 2 y COBERPES 2 y 6. Se realizaron arrastres con red camaronera en 80 estaciones de muestreo. Resultados: El listado taxonómico comprende 1146 ejemplares, de los cuales 204 son crinoideos del orden Comatulida, distribuidos en tres familias tres géneros y tres especies y 942 asteroideos distribuidos en seis órdenes, 11 familias, 21 géneros y 28 especies. Se obtuvieron los registros nuevos para la CNE: Democrinus rawsonii y Atelecrinus balanoides en crinoideos. Astropecten alligator, Hymenaster modestus, Calyptraster personatus, Pteraster militarioides militarioides, Sclerasterias contorta en asteroideos. Con esta información se incrementan los registros de crinoideos y asteroideos (de profundidad mayor a 200 m) para los estados de Yucatán (16) y Quintana Roo (16).

Abstract Introduction: The species of the Crinoidea and Asteroidea classes are distributed in a wide variety of habitats in all oceans from the intertidal zone to great depths, there are few Mexican records in depths greater than 200 m, the few existing records date from historical documents in the specialized literature and the specimens are kept in foreign scientific collections. Objective: Contribute to the collection of information on the specimens kept in the Colección Nacional de Equinodermos (CNE) of Instituto de Ciencias del Mar y Limnología (ICML), UNAM and provide an inventory of the species of crinoids and asteroids that inhabit deep areas of the slope of the Yucatan Peninsula, Mexico. Methods: From 2005 to 2014, specimens of crinoids and asterioids were collected through four cruises in the B/O "Justo Sierra" BIOREPES 1 and 2 and COBERPES 2 and 6, shrimp net trawls were carried out at 80 sampling stations. Results: The taxonomic list includes 1146 specimens, of which 204 crinoids are of the order Comatulida, distributed in three families, three genera and three species and 942 asteroids distributed in six orders, 11 families, 21 genera and 28 species. New records were obtained for CNE: Democrinus rawsonii and Atelecrinus balanoides in crinoids. Astropecten alligator, Hymenaster modestus, Calyptraster personatus, Pteraster militarioides militarioides, Sclerasterias contorta in asteroids. With this information, the records of crinoids and asteroids (deeper than 200 m) increase for the states of Yucatan (16) and Quintana Roo (16).

Practical approach for atrial cardiomyopathy characterization in patients with atrial fibrillation.

Atrial fibrillation (AF) causes progressive structural and electrical changes in the atria that can be summarized within the general concept of atrial remodeling. In parallel, other clinical characteristics and comorbidities may also affect atrial tissue properties and make the atria susceptible to AF initiation and its long-term persistence. Overall, pathological atrial changes lead to atrial cardiomyopathy with important implications for rhythm control. Although there is general agreement on the role of the atrial substrate for successful rhythm control in AF, the current classification oversimplifies clinical management. The classification uses temporal criteria and does not establish a well-defined strategy to characterize the individual-specific degree of atrial cardiomyopathy. Better characterization of atrial cardiomyopathy may improve the decision-making process on the most appropriate therapeutic option. We review current scientific evidence and propose a practical characterization of the atrial substrate based on 3 evaluation steps starting with a clinical evaluation (step 1), then assess outpatient complementary data (step 2), and finally include information from advanced diagnostic tools (step 3). The information from each of the steps or a combination thereof can be used to classify AF patients in 4 stages of atrial cardiomyopathy, which we also use to estimate the success on effective rhythm control.

Invasive Treatment Strategy in Adults With Frailty and Non-ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of a Randomized Clinical Trial.

Importance: The MOSCA-FRAIL randomized clinical trial compared invasive and conservative treatment strategies in patients with frailty with non-ST-segment elevation myocardial infarction (NSTEMI). It showed no differences in the number of days alive and out of the hospital at 1 year. Objective: To assess the outcomes of the MOSCA-FRAIL trial during extended follow-up. Design, Setting, and Participants: The MOSCA-FRAIL randomized clinical trial was conducted at 13 hospitals in Spain between July 7, 2017, and January 9, 2021, and included 167 adults (aged ≥70 years) with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. In this preplanned secondary analysis, follow-up was extended to January 31, 2023. Data analysis was performed from April 5 to 29, 2023, using the intention-to-treat principle. Interventions: Patients were randomized to a routine invasive (coronary angiography and revascularization if feasible [n = 84]) or a conservative (medical treatment with coronary angiography only if recurrent ischemia [n = 83]) strategy. Main outcomes and measures: The primary end point was the difference in restricted mean survival time (RMST). Secondary end points included readmissions for any cause, considering recurrent readmissions. Results: Among the 167 patients included in the analysis, the mean (SD) age was 86 (5) years; 79 (47.3%) were men and 88 (52.7%) were women. A total of 93 deaths and 367 readmissions accrued. The RMST for all-cause death over the entire follow-up was 3.13 (95% CI, 2.72-3.60) years in the invasive and 3.06 (95% CI, 2.84-3.32) years in the conservative treatment groups. The RMST analysis showed inconclusive differences in survival time (invasive minus conservative difference, 28 [95% CI, -188 to 230] days). Patients under invasive treatment tended to have shorter survival in the first year (-28 [95% CI, -63 to 7] days), which improved after the first year (192 [95% CI, 90-230] days). Kaplan-Meier mortality curves intersected, displaying higher mortality to 1 year in the invasive group that shifted to a late benefit (landmark analysis hazard ratio, 0.58 [95% CI, 0.33-0.99]; P = .045). Early harm was more evident in the subgroup with a Clinical Frailty Scale score greater than 4. No differences were found for the secondary end points. Conclusions and Relevance: In this extended follow-up of a randomized clinical trial of patients with frailty and NSTEMI, an invasive treatment strategy did not improve outcomes at a median follow-up of 1113 (IQR, 443-1441) days. However, a differential distribution of deaths was observed, with early harm followed by later benefit. The phenomenon of depletion of susceptible patients may be responsible for this behavior. Trial registration: ClinicalTrials.gov Identifier: NCT03208153.

Dynamic assessment of CHA2DS2-VASc and HAS-BLED scores for predicting ischemic stroke and major bleeding in atrial fibrillation patients.

INTRODUCTION AND OBJECTIVES: Stroke and bleeding risks in atrial fibrillation (AF) are often assessed at baseline to predict outcomes years later. We investigated whether dynamic changes in CHA2DS2-VASc and HAS-BLED scores over time modify risk prediction. METHODS: We included patients with AF who were stable while taking vitamin K antagonists. During a 6-year follow-up, all ischemic strokes/transient ischemic attacks (TIAs) and major bleeding events were recorded. CHA2DS2-VASc and HAS-BLED were recalculated every 2-years and tested for clinical outcomes at 2-year periods. RESULTS: We included 1361 patients (mean CHA2DS2-VASc and HAS-BLED 4.0±1.7 and 2.9±1.2). During the follow-up, 156 (11.5%) patients had an ischemic stroke/TIA and 269 (19.8%) had a major bleeding event. Compared with the baseline CHA2DS2-VASc, the CHA2DS2-VASc recalculated at 2 years had higher predictive ability for ischemic stroke/TIA during the period from 2 to 4 years. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) showed improvements in sensitivity and better reclassification. The CHA2DS2-VASc recalculated at 4 years had better predictive performance than the baseline CHA2DS2-VASc during the period from 4 to 6 years, with an improvement in IDI and an enhancement of the reclassification. The recalculated HAS-BLED at 2-years had higher predictive ability than the baseline score for major bleeding during the period from 2 to 4 years, with significant improvements in sensitivity and reclassification. A slight enhancement in sensitivity was observed with the HAS-BLED score recalculated at 4 years compared with the baseline score. CONCLUSIONS: In AF patients, stroke and bleeding risks are dynamic and change over time. The CHA2DS2-VASc and HAS-BLED scores should be regularly reassessed, particularly for accurate stroke risk prediction.