Basic host response parameters to classify mortality risk in COVID-19 and community-acquired pneumonia.

Improved phenotyping in pneumonia is necessary to strengthen risk assessment. Via a feasible and multidimensional approach with basic parameters, we aimed to evaluate the effect of host response at admission on severity stratification in COVID-19 and community-acquired pneumonia (CAP). Three COVID-19 and one CAP multicenter cohorts including hospitalized patients were recruited. Three easily available variables reflecting different pathophysiologic mechanisms-immune, inflammation, and respiratory-were selected (absolute lymphocyte count [ALC], C-reactive protein [CRP] and, SpO2/FiO2). In-hospital mortality and intensive care unit (ICU) admission were analyzed as outcomes. A multivariable, penalized maximum likelihood logistic regression was performed with ALC (< 724 lymphocytes/mm3), CRP (> 60 mg/L), and, SpO2/FiO2 (< 450). A total of 1452, 1222 and 462 patients were included in the three COVID-19 and 1292 in the CAP cohort for the analysis. Mortality ranged between 4 and 32% (0 to 3 abnormal biomarkers) and 0-9% in SARS-CoV-2 pneumonia and CAP, respectively. In the first COVID-19 cohort, adjusted for age and sex, we observed an increased odds ratio for in-hospital mortality in COVID-19 with elevated biomarkers altered (OR 1.8, 3, and 6.3 with 1, 2, and 3 abnormal biomarkers, respectively). The model had an AUROC of 0.83. Comparable findings were found for ICU admission, with an AUROC of 0.76. These results were confirmed in the other COVID-19 cohorts Similar OR trends were reported in the CAP cohort; however, results were not statistically significant. Assessing the host response via accessible biomarkers is a simple and rapidly applicable approach for pneumonia.

Extreme Metastability of Diamond and its Transformation to the BC8 Post-Diamond Phase of Carbon.

Diamond possesses exceptional physical properties due to its remarkably strong carbon-carbon bonding, leading to significant resilience to structural transformations at very high pressures and temperatures. Despite several experimental attempts, synthesis and recovery of the theoretically predicted post-diamond BC8 phase remains elusive. Through quantum-accurate multimillion atom molecular dynamics (MD) simulations, we have uncovered the extreme metastability of diamond at very high pressures, significantly exceeding its range of thermodynamic stability. We predict the post-diamond BC8 phase to be experimentally accessible only within a narrow high pressure-temperature region of the carbon phase diagram. The diamond to BC8 transformation proceeds through premelting followed by BC8 nucleation and growth in the metastable carbon liquid. We propose a double-shock compression pathway for BC8 synthesis, which is currently being explored in experiments at the National Ignition Facility.

Is the long-term mortality similar in COVID-19 and community-acquired pneumonia?

Introduction: There are no data on the association of type of pneumonia and long-term mortality by the type of pneumonia (COVID-19 or community-acquired pneumonia [CAP]) on long-term mortality after an adjustment for potential confounding variables. We aimed to assess the type of pneumonia and risk factors for long-term mortality in patients who were hospitalized in conventional ward and later discharged. Methods: Retrospective analysis of two prospective and multicentre cohorts of hospitalized patients with COVID-19 and CAP. The main outcome under study was 1-year mortality in hospitalized patients in conventional ward and later discharged. We adjusted a Bayesian logistic regression model to assess associations between the type of pneumonia and 1-year mortality controlling for confounders. Results: The study included a total of 1,693 and 2,374 discharged patients in the COVID-19 and CAP cohorts, respectively. Of these, 1,525 (90.1%) and 2,249 (95%) patients underwent analysis. Until 1-year follow-up, 69 (4.5%) and 148 (6.6%) patients from the COVID-19 and CAP cohorts, respectively, died (p = 0.008). However, the Bayesian model showed a low probability of effect (PE) of finding relevant differences in long-term mortality between CAP and COVID-19 (odds ratio 1.127, 95% credibility interval 0.862-1.591; PE = 0.774). Conclusion: COVID-19 and CAP have similar long-term mortality after adjusting for potential confounders.

Análisis ecocardiográfico de la variabilidad de la presión sistólica arterial pulmonar en la hipertensión pulmonar / Echocardiographic analysis of pulmonary arterial systolic pressure in pulmonary hypertension

Resumen Introducción: La confiabilidad de la presión sistólica arterial pulmonar por ecocardiografía transtorácica se encuentra limitada por su variabilidad para definir la hipertensión pulmonar. Objetivo: Conocer la variabilidad en la presión sistólica arterial pulmonar estimada por ecocardiografía en la hipertensión pulmonar. Métodos: En el periodo 2016-2020 se captaron sujetos con hipertensión pulmonar que tuvieron estimada la presión sistólica de la arteria pulmonar por ecocardiografía transtorácica y por cateterismo cardiaco derecho. Se obtuvieron sus variables demográficas. Los datos se analizaron con el estadístico descriptivo de Bland-Altman y el coeficiente de correlación intraclase (intervalo de confianza al 95%). Resultados: Se estudiaron 152 sujetos, edad 60 ± 12 años. Índice de masa corporal 27.64 ± 4.69 kg/m2. La presión sistólica de la arteria pulmonar por ecocardiografía transtorácica 58.99 ± 18.62 vs. cateterismo cardiaco 55.43 ± 16.79. Diferencia media (sesgo) -3.6 (29.1, -36.2) y coeficiente de correlación intraclase 0.717 (0.610, 0.794). Conclusiones: La variabilidad es amplia y el acuerdo es sustancial con la presión sistólica de la arteria pulmonar. Se aconseja estimarla solo como tamizaje de la hipertensión pulmonar.

Abstract Introduction: The reliability of pulmonary arterial systolic pressure by transthoracic echocardiography is limited by its variability to define pulmonary hypertension. Objective: To know the variability of pulmonary arterial systolic pressure estimated by echocardiography in pulmonary hypertension. Their demographic variables were obtained. Methods: From 2016-2020 subjects with pulmonary hypertension were recruited, with pulmonary artery systolic pressure estimated by transthoracic echocardiography and by right heart catheterization. Data were analyzed using the Bland-Altman descriptive statistic and the intraclass correlation coefficient (95% confidence interval). Results: 152 subjects, age 60 ± 12 years, were studied. Body mass index 27.64 ± 4.69 kg/m2. The pulmonary artery systolic pressure estimated by transthoracic echocardiography 58.99 ± 18.62 vs. cardiac catheterization 55.43 ± 16.79 mmHg. Mean difference (bias) -3.6 (29.1, -36.2) and intraclass correlation coefficient 0.717 (0.610, 0.794). Conclusions: Variability is wide, and agreement is substantial for pulmonary artery systolic pressure. It is recommended to estimate only as screening for pulmonary hypertension.

Prueba de caminata de 6 minutos: del sujeto normal a la obesidad mórbida / Six minute walk test: from normal to morbid obesity subject

Resumen Introducción: La obesidad mórbida se asocia a alteraciones de la capacidad de caminar, sin embargo se desconoce cómo es el comportamiento de la prueba de caminata de 6 minutos en sujetos con incrementos del índice de masa corporal (IMC). Objetivo: Describir el comportamiento de la prueba de caminata de 6 minutos en sujetos con IMC normal hasta la obesidad mórbida. Métodos: Mediante un diseño transversal analítico se estudiaron sujetos de ambos sexos de 18 a 60 años con IMC: normal (18.5-24.9 kg/m2), sobrepeso (25-29.9 kg/m2), obesidad (30-39.9 kg/m2), obesidad mórbida (> 40 kg/m2). Se les realizó prueba de caminata de 6 minutos, se acotaron variables demográficas y antecedentes personales patológicos. Se analizaron las categorías de IMC con ANOVA de una vía y ajuste de Bonferroni y los sexos con prueba t, ambos para grupos independientes y correlaciones de Pearson para las diversas variables. Una p < 0.05 fue considerada estadísticamente significativa. Resultados: Se estudiaron 480 sujetos de ambos sexos en cuatro grupos. Edad: hombres 43 ± 11 y mujeres 45 ± 10 años. Porcentaje diabetes mellitus (6.7%), hipertensión arterial (18.3%). Metros caminados hombres vs. mujeres por IMC (normal: 483 ± 56 vs. 449 ± 61; sobrepeso: 471 ± 55 vs. 441 ± 44; obesidad: 455 ± 70 vs. 421 ± 47; obesidad mórbida: 443 ± 49 vs. 403 ± 54; p < 0.05). Correlación IMC-metros caminados r: -0.446 (p < 0.0001). Conclusiones: Los metros caminados en la prueba de caminata de 6 minutos disminuyeron conforme incrementó el IMC. El sexo masculino caminó más metros en todas las categorías.

Abstract Introduction: Morbid obesity is associated with alterations in the ability to walk, however, the behavior of the 6-minute walk test in subjects with increases in body mass index is unknown. Objective: To describe the behavior of the 6-minute walk test in subjects with normal body mass index to morbid obesity. Methods: Through an analytical cross-sectional design, subjects of both genders from 18 to 60 years old with body mass index were studied: Normal (BMI: 18.5-24.9); overweight (BMI: 25-29.9); obesity (BMI: 30-39.9); morbid obesity (BMI: > 40) kg/m2. A 6-minute walk test was performed, demographic variables and pathological personal history were delimited. BMI categories were analyzed with one-way ANOVA and Bonferroni adjustment, and gender with t-test, both for independent groups, and Pearson's correlations for the various variables. Results: 480 subjects of both genders were studied in four groups. Age: men 43 ± 11 and women 45 ± 10 years old. Percentage diabetes mellitus (6.7%), arterial hypertension (18.3%). Meters walked men vs. women by body mass index (normal: 483 ± 56 vs. 449 ± 61; overweight: 471 ± 55 vs. 441 ± 44; obesity: 455 ± 70 vs. 421 ± 47; morbid obesity: 443 ± 49 vs. 403 ± 54, p < 0.05). Correlation body mass index-meters walked: r: -0.446 (p < 0.0001). Conclusions: Meters walked in the 6-minute walk test decreased as body mass index increased. The male gender walked more meters in all categories.

Echocardiographic analysis of pulmonary arterial systolic pressure in pulmonary hypertension.

INTRODUCTION: The reliability of pulmonary arterial systolic pressure by transthoracic echocardiography is limited by its variability to define pulmonary hypertension. OBJECTIVE: To know the variability of pulmonary arterial systolic pressure estimated by echocardiography in pulmonary hypertension. Their demographic variables were obtained. METHODS: From 2016-2020 subjects with pulmonary hypertension were recruited, with pulmonary artery systolic pressure estimated by transthoracic echocardiography and by right heart catheterization. Data were analyzed using the Bland-Altman descriptive statistic and the intraclass correlation coefficient (95% confidence interval). RESULTS: 152 subjects, age 60 ± 12 years, were studied. Body mass index 27.64 ± 4.69 kg/m2. The pulmonary artery systolic pressure estimated by transthoracic echocardiography 58.99 ± 18.62 vs. cardiac catheterization 55.43 ± 16.79 mmHg. Mean difference (bias) -3.6 (29.1, -36.2) and intraclass correlation coefficient 0.717 (0.610, 0.794). CONCLUSIONS: Variability is wide, and agreement is substantial for pulmonary artery systolic pressure. It is recommended to estimate only as screening for pulmonary hypertension.

INTRODUCCIÓN: La confiabilidad de la presión sistólica arterial pulmonar por ecocardiografía transtorácica se encuentra limitada por su variabilidad para definir la hipertensión pulmonar. OBJETIVO: Conocer la variabilidad en la presión sistólica arterial pulmonar estimada por ecocardiografía en la hipertensión pulmonar. MÉTODOS: En el periodo 2016-2020 se captaron sujetos con hipertensión pulmonar que tuvieron estimada la presión sistólica de la arteria pulmonar por ecocardiografía transtorácica y por cateterismo cardiaco derecho. Se obtuvieron sus variables demográficas. Los datos se analizaron con el estadístico descriptivo de Bland-Altman y el coeficiente de correlación intraclase (intervalo de confianza al 95%). RESULTADOS: Se estudiaron 152 sujetos, edad 60 ± 12 años. Índice de masa corporal 27.64 ± 4.69 kg/m2. La presión sistólica de la arteria pulmonar por ecocardiografía transtorácica 58.99 ± 18.62 vs. cateterismo cardiaco 55.43 ± 16.79. Diferencia media (sesgo) ­3.6 (29.1, ­36.2) y coeficiente de correlación intraclase 0.717 (0.610, 0.794). CONCLUSIONES: La variabilidad es amplia y el acuerdo es sustancial con la presión sistólica de la arteria pulmonar. Se aconseja estimarla solo como tamizaje de la hipertensión pulmonar.

Impact of severe lymphopenia on the early prediction of clinical outcome in hospitalized patients with pneumococcal community-acquired pneumonia.

PURPOSE: To evaluate the impact of an optimal and reproducible cutoff value set according to a predefined lymphopenia scale as an early predictor of in-hospital mortality and other outcomes in patients hospitalized with pneumococcal pneumonia and positive urinary antigen at admission to the emergency department. METHODS: An observational cohort study was conducted based on analysis of a prospective registry of consecutive immunocompetent adults hospitalized for pneumococcal pneumonia in two tertiary hospitals. Generalized additive models were constructed to assess the smooth relationship between in-hospital mortality and lymphopenia. RESULTS: We included 1173 patients. Lymphopenia on admission was documented in 686 (58.4%). No significant differences were observed between groups regarding the presence of comorbidities. Overall, 299 (25.5%) patients were admitted to intensive care and 90 (7.6%) required invasive mechanical ventilation. Fifty-nine (5%) patients died, among them 23 (38.9%) in the first 72 h after admission. A lymphocyte count < 500/µL, documented in 282 (24%) patients, was the predefined cutoff point that best predicted in-hospital mortality. After adjustment, these patients had higher rates of intensive care admission (OR 2.9; 95% CI 1.9-4.3), invasive mechanical ventilation (OR 2.2; 95% CI 1.2-3.9), septic shock (OR 1.8; 95% CI 1.1-2.9), treatment failure (OR 2.1; 95% CI 1.2-3.5), and in-hospital mortality (OR 2.2; 95% 1.1-4.9). Severe lymphopenia outperformed PSI score in predicting early and 30-day mortality in patients classified in the higher-risk classes. CONCLUSION: Lymphocyte count < 500/µL could be used as a reproducible predictor of complicated clinical course in patients with an early diagnosis of pneumococcal pneumonia.

Early Recognition of Low-Risk SARS-CoV-2 Pneumonia: A Model Validated With Initial Data and Infectious Diseases Society of America/American Thoracic Society Minor Criteria.

BACKGROUND: A shortage of beds in ICUs and conventional wards during the COVID-19 pandemic led to a collapse of health care resources. RESEARCH QUESTION: Can admission data and minor criteria by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) help identify patients with low-risk SARS-CoV-2 pneumonia? STUDY DESIGN AND METHODS: This multicenter cohort study included 1,274 patients in a derivation cohort and 830 (first wave) and 754 (second wave) patients in two validation cohorts. A multinomial regression analysis was performed on the derivation cohort to compare the following patients: those admitted to the ward (assessed as low risk); those admitted to the ICU directly; those transferred to the ICU after general ward admission; and those who died. A regression analysis identified independent factors for low-risk pneumonia. The model was subsequently validated. RESULTS: In the derivation cohort, similarities existed among those either directly admitted or transferred to the ICU and those who died. These patients could, therefore, be merged into one group. Five independently associated factors were identified as being predictors of low risk (not dying and/or requiring ICU admission) (ORs, with 95% CIs): peripheral blood oxygen saturation/Fio2 > 450 (0.233; 0.149-0.364); < 3 IDSA/ATS minor criteria (0.231; 0.146-0.365); lymphocyte count > 723 cells/mL (0.539; 0.360-0.806); urea level < 40 mg/dL (0.651; 0.426-0.996); and C-reactive protein level < 60 mg/L (0.454; 0.285-0.724). The areas under the curve were 0.802 (0.769-0.835) in the derivation cohort, and 0.779 (0.742-0.816) and 0.801 (0.757-0.845) for the validation cohorts (first and second waves, respectively). INTERPRETATION: Initial biochemical findings and the application of < 3 IDSA/ATS minor criteria make early identification of low-risk SARS-CoV-2 pneumonia (approximately 80% of hospitalized patients) feasible. This scenario could facilitate and streamline health care resource allocation for patients with COVID-19.

COVID-19 in young and middle-aged adults: predictors of poor outcome and clinical differences.

INTRODUCTION: Young and middle-aged adults are the largest group of patients infected with SARS-CoV-2 and some of them develop severe disease. OBJECTIVE: To investigate clinical manifestations in adults aged 18-65 years hospitalized for COVID-19 and identify predictors of poor outcome. Secondary objectives: to explore differences compared to the disease in elderly patients and the suitability of the commonly used community-acquired pneumonia prognostic scales in younger populations. METHODS: Multicenter prospective registry of consecutive patients hospitalized for COVID-19 pneumonia aged 18-65 years between March and May 2020. We considered a composite outcome of "poor outcome" including intensive care unit admission and/or use of noninvasive ventilation, continuous positive airway pressure or high flow nasal cannula oxygen and/or death. RESULTS: We identified 513 patients < 65 years of age, from a cohort of 993 patients. 102 had poor outcomes (19.8%) and 3.9% died. 78% and 55% of patients with poor outcomes were classified as low risk based on CURB and PSI scores, respectively. A multivariate Cox regression model identified six independent factors associated with poor outcome: heart disease, absence of chest pain or anosmia, low oxygen saturation, high LDH and lymphocyte count < 800/mL. CONCLUSIONS: COVID-19 in younger patients carries significant morbidity and differs in some respects from this disease in the elderly. Baseline heart disease is a relevant risk factor, while anosmia and pleuritic pain are associated to better prognosis. Hypoxemia, LDH and lymphocyte count are predictors of poor outcome. We consider that CURB and PSI scores are not suitable criteria for deciding admission in this population.

Caracterización de pacientes con cavidad anoftálmica en un centro médico en Colombia, en 10 años / Characterization of patients with anophthalmic cavity in a medical center in Colombia, in 10 years

Objetivo: Caracterizar a pacientes con anoftalmos atendidos en el Hospital Militar Central durante los años 2009 y 2020. Diseño: Estudio observacional, descriptivo, de tipo corte transversal. Metodología: Se incluyeron pacientes de cualquier sexo y edad atendidos entre los años 2009 y 2020 en el Hospital Militar Central de Bogotá, Colombia, con diagnóstico de anoftalmos congénito o por cirugía de evisceración, enucleación o exenteración. Se llevó a cabo un muestreo no probabilístico y los datos fueron analizados mediante estadística descriptiva y un análisis de correspondencias múltiples. Resultados: Se incluyeron 180 pacientes, de los cuales el 73.9% era de sexo masculino y el 41.7% tenía entre 27-59 años. Las etiologías más frecuentes fueron trauma en el 56.1% de los casos, seguido por causas médicas en el 40.6%. De las intervenciones realizadas, la evisceración fue el más común (81%). Se encontró una correlación entre el tipo de intervención con la edad del paciente, la lateralidad y la etiología (p < 0.01). Conclusión: El trauma ocular permanece como la mayor causa de anoftalmos quirúrgico. En la mayoría de los casos se trataron de hombres adultos a quienes se les realizó evisceración. Se requieren otros estudios para identificar las características de la población colombiana con cavidades anoftálmicas.

Objective: To characterize patients with anophthalmic sockets treated at the Hospital Militar Central from 2009 until 2020. Design: Observational, descriptive, cross-sectional study. Methods: We included patients of any sex and age treated from 2009 to 2020 at the Hospital Militar Central de Bogotá, Colombia, with a diagnosis of congenital anophthalmos, or by evisceration, enucleation, or exenteration surgery. We analyzed data through descriptive statistics and multiple correspondence analysis. Results: 180 patients were included, of which 73.9% were male, and 41.7% were between 27-59 years old. The most frequent etiologies were trauma in 56.1% of the cases, followed by medical causes in 40.6%. Of the interventions carried out, evisceration was the most common (81%). A correlation was found between the type of intervention and the patient's age, laterality, and etiology (p < 0.01). Conclusion: Ocular trauma remains to be the primary cause of surgical anophthalmos. Most cases were adult men who underwent evisceration. Other studies are required to identify the characteristics of the Colombian population with anophthalmic sockets

Analysis of the quality of anticoagulation with vitamin K antagonists in three clinical scenarios in Mexico.

INTRODUCTION: Vitamin K antagonists (VKA) are a therapeutic alternative in patients with venous thromboembolic disease; however, numerous factors affect their pharmacology. OBJECTIVE: To evaluate the quality of VKA anticoagulation at three different time periods in Mexico. METHODS: Prospective study, nested in patient cohorts at three different clinical scenarios between 2013 and 2019. Outpatients with indication for treatment with VKAs for at least 12 months were included. Patients were managed according to the criteria of the treating physician. RESULTS: Patient general characteristics were similar between groups, except for the VKA indication. The results of 4,148 patients and 38,548 INR assessments were analyzed. The times in therapeutic range during the three phases of the study and pooled data were significantly higher for the anticoagulation clinic. Only the number of patient visits was significantly associated with the results, unlike age, gender, and type of VKA. CONCLUSIONS: VKAs are widely used, but it is difficult for therapeutic goals to be achieved, especially in non-specialized clinical services. Creation of anticoagulation clinics is an urgent need for the Mexican health system.

INTRODUCCIÓN: Los antagonista de la vitamina K (AVK) son una alternativa terapéutica en los pacientes con enfermedad tromboembólica venosa; sin embargo, numerosos factores afectan su farmacología. OBJETIVO: Evaluar la calidad de la anticoagulación AVK durante tres diferentes periodos en México. MÉTODOS: Estudio prospectivo, anidado en cohortes de pacientes en tres escenarios clínicos entre los años 2013-2019. Se incluyeron pacientes no hospitalizados con indicación para recibir AVK por al menos 12 meses, quienes fueron manejados de acuerdo con el criterio del médico tratante. RESULTADOS: Las características generales de los pacientes fueron similares entre los grupos, excepto por la indicación para usar los AVK. Se analizaron los resultados de 4148 pacientes y 38 548 evaluaciones de INR. Los tiempos en rango terapéutico durante las tres fases del estudio y los datos acumulados fueron significativamente mayores en la clínica de anticoagulación. Solo el número de visitas de control de los pacientes se asoció significativamente con los resultados, a diferencia de la edad, el sexo y el tipo de AVK. CONCLUSIONES: Los AVK se utilizan ampliamente, pero es difícil alcanzar la meta terapéutica, sobre todo en servicios clínicos no especializados. La creación de clínicas de anticoagulación es una necesidad urgente en el sistema mexicano de salud.

Análisis de la calidad de la anticoagulación con antagonistas de la vitamina K en tres escenarios clínicos en México / Analysis of the quality of anticoagulation with vitamin K antagonists in three clinical scenarios in Mexico

Resumen Introducción: Los antagonista de la vitamina K (AVK) son una alternativa terapéutica en los pacientes con enfermedad tromboembólica venosa; sin embargo, numerosos factores afectan su farmacología. Objetivo: Evaluar la calidad de la anticoagulación AVK durante tres diferentes periodos en México. Métodos: Estudio prospectivo, anidado en cohortes de pacientes en tres escenarios clínicos entre los años 2013-2019. Se incluyeron pacientes no hospitalizados con indicación para recibir AVK por al menos 12 meses, quienes fueron manejados de acuerdo con el criterio del médico tratante. Resultados: Las características generales de los pacientes fueron similares entre los grupos, excepto por la indicación para usar los AVK. Se analizaron los resultados de 4148 pacientes y 38 548 evaluaciones de INR. Los tiempos en rango terapéutico durante las tres fases del estudio y los datos acumulados fueron significativamente mayores en la clínica de anticoagulación. Solo el número de visitas de control de los pacientes se asoció significativamente con los resultados, a diferencia de la edad, el sexo y el tipo de AVK. Conclusiones: Los AVK se utilizan ampliamente, pero es difícil alcanzar la meta terapéutica, sobre todo en servicios clínicos no especializados. La creación de clínicas de anticoagulación es una necesidad urgente en el sistema mexicano de salud.

Abstract Introduction: Vitamin K antagonists (VKA) are a therapeutic alternative in patients with venous thromboembolic disease; however, numerous factors affect their pharmacology. Objective: To evaluate the quality of VKA anticoagulation at three different time periods in Mexico. Methods: Prospective study, nested in patient cohorts at three different clinical scenarios between 2013 and 2019. Outpatients with indication for treatment with VKAs for at least 12 months were included. Patients were managed according to the criteria of the treating physician. Results: Patient general characteristics were similar between groups, except for the VKA indication. The results of 4,148 patients and 38,548 INR assessments were analyzed. The times in therapeutic range during the three phases of the study and pooled data were significantly higher for the anticoagulation clinic. Only the number of patient visits was significantly associated with the results, unlike age, gender, and type of VKA. Conclusions: VKAs are widely used, but it is difficult for therapeutic goals to be achieved, especially in non-specialized clinical services. Creation of anticoagulation clinics is an urgent need for the Mexican health system.

Atomistic insights into metal hardening.

For millennia, humans have exploited the natural property of metals to get stronger or harden when mechanically deformed. Ultimately rooted in the motion of dislocations, mechanisms of metal hardening have remained in the cross-hairs of physical metallurgists for over a century. Here, we performed atomistic simulations at the limits of supercomputing that are sufficiently large to be statistically representative of macroscopic crystal plasticity yet fully resolved to examine the origins of metal hardening at its most fundamental level of atomic motion. We demonstrate that the notorious staged (inflection) hardening of metals is a direct consequence of crystal rotation under uniaxial straining. At odds with widely divergent and contradictory views in the literature, we observe that basic mechanisms of dislocation behaviour are the same across all stages of metal hardening.

Effect of Gymnema sylvestre Administration on Glycemic Control, Insulin Secretion, and Insulin Sensitivity in Patients with Impaired Glucose Tolerance.

Gymnema sylvestre, a plant typical of India, has long been known for its hypoglycemic effects. The objective of this study was to evaluate the effect of G. sylvestre administration on glycemic control, insulin secretion, and insulin sensitivity in patients with impaired glucose tolerance (IGT). A randomized, double-blind, placebo-controlled clinical trial was conducted in 30 patients with IGT. Fifteen patients randomly received G. sylvestre in doses of 300 mg b.i.d. and the other 15 received placebo in the same way. Before and after the intervention, anthropometric and metabolic measurements were taken, including 2-h oral glucose tolerance test (2-h OGTT), fasting plasma glucose, glycated hemoglobin A1c (A1C), and the lipid profile panel. Areas under the curve of glucose and insulin were calculated, as well as the insulinogenic, Stumvoll, and Matsuda indices. Wilcoxon, Mann-Whitney U, and chi-square or Fisher's exact tests were performed, and a P-value ≤.05 was considered statistically significant. There was a significant reduction in 2-h OGTT (9.1 ± 1.2 vs. 7.8 ± 1.7 mmol/L, P = .003), A1C (5.8 ± 0.3% vs. 5.4 ± 0.4%, P = .025), body weight, body mass index, and low-density lipoprotein cholesterol levels in the G. sylvestre group, with an increment in the Matsuda index (1.8 ± 0.8 vs. 2.4 ± 1.2, P = .008). At the end of the intervention, 46.7% of the patients obtained normal values in A1C. In conclusion, G. sylvestre administration in patients with IGT decreased 2-h OGTT and A1C, increasing insulin sensitivity. There were also improvements in anthropometric measures and the lipid profile.

New-onset atrial fibrillation in patients with pneumococcal pneumonia. Impact of timing and duration on short- and medium-term mortality.

OBJETIVES: To assess the incidence, related factors, timing and duration of new- onset atrial fibrillation in a cohort of consecutive patients diagnosed with pneumococcal pneumonia. METHODS: Observational study including all immunocompetent adults hospitalized for pneumococcal pneumonia. Patients were classified by time (atrial fibrillation recognized on emergency room arrival or developed during hospitalization) and duration (paroxysmal or persistent). Patients were followed-up for 6 months after discharge. RESULTS: We included 1092 patients, of whom 109 (9.9%) had new-onset atrial fibrillation. An early event was documented in 87 (79.8%) cases. Arrhythmia was classified as paroxysmal in 78 patients. Older age, heavy drinking, respiratory rate ≥ 30/minute, leukopenia, severe inflammation and bacteremia were independent risk factors for developing new-onset atrial fibrillation on admission. Overall, 48 (4.4%) patients died during hospitalization, the rate being higher in those patients who developed new-onset arrhythmia (17.9% vs 2.9% p<0.001). Among patients with events recognized at admission, in-hospital mortality was higher in those with persistent arrhythmia (34.8% vs 6.3%, p = 0.002) and 6-month survival was better among those who developed paroxysmal event. CONCLUSIONS: The development of new-onset atrial fibrillation was associated with pneumonia severity, and higher in-hospital mortality. Bacteremia and severe systemic inflammation were factors associated with its development.

Non-bacteremic pneumococcal pneumonia: general characteristics and early predictive factors for poor outcome.

Purpose: Nowadays, most cases of pneumococcal community-acquired pneumonia (PCAP) are diagnosed by positive urinary antigen. Our aims were to analyse process of care in patients hospitalised with non-bacteremic PCAP (NB-PCAP) and identify factors associated with poor outcome (PO) in this population.Methods: We conducted a prospective study, including patients hospitalised for NB-PCAP (positive urinary antigen and negative blood culture) over a 15 year period. We performed multivariate analysis of predisposing factors for PO, defined as need for mechanical ventilation and/or shock and/or in-hospital death.Results: Of the 638 patients included, 4.1% died in hospital and 12.8% had PO. Host-related factors were similar in patients with and without PO, but patients with PO had higher illness severity on admission. Adjusted analysis revealed the following independent factors associated with PO: being a nursing home resident (OR: 6.156; 95% CI: 1.827-20.750; p = .003), respiratory rate ≥30 breaths/min (OR: 3.030; 95% CI: 1.554-5.910; p = .001), systolic blood pressure <90 mmHg (OR: 4.789; 95% CI: 1.967-11.660; p = .001), diastolic blood pressure <60 mmHg (OR: 2.820; 95% CI: 1.329-5.986; p = .007), pulse rate ≥125 beats/min (OR: 3.476; 95% CI: 1.607-7.518; p = .002), pH <7.35 (OR: 9.323; 95% CI: 3.680-23.622; p < .001), leukocytes <4000/µL (OR: 10.007; 95% CI: 2.960-33.835; p < .001), and severe inflammation (OR: 2.364; 95% CI 1.234-4.526; p = .009). The area under the curve for predicting PO was 0.890 (95% CI: 0.851-0.929).Conclusions: Since patients with PO seem different and had worse in-hospital course, we identified eight independent risk factors for PO measurable on admission.