CONUT: a tool to assess nutritional status. First application in a primary care population.

OBJECTIVES: Malnutrition is an unfavorable prognostic factor associated with an increase in mortality, hospital stays, readmissions and resources consumption. The aim was to screen primary care patients for risk of malnutrition by using the control nutritional (CONUT) score, calculated through total lymphocytes count, serum albumin and total cholesterol, when the three markers were requested, and to compare results between primary care centers (PCC). METHODS: The clinical laboratory located in a 370-bed suburban University Community Hospital serves the Health Department inhabitants (2,34,551), attended in nine PCC. The laboratory information system (LIS) automatically calculated the CONUT score in every primary care patient over 18 years old, when all three laboratory markers were ordered by the General Practitioner. For all primary care patients, we collected demographic data, CONUT index and PCC. We classified results by PCC, and compared them. RESULTS: The clinical laboratory received 74,743 requests from primary care. The CONUT score was calculated in 7,155 (12.28%) patients. Nine hundred seventy-six (13.6%) were at risk of malnutrition according to the CONUT score, mainly male (p<0.01) and over 65 (p<0.01). Detected cases of malnutrition were all mild, except 48 patients (4.9%) with moderate, and one (0.1%) with severe risk. The percentage of patients at risk of malnutrition was not significantly different among PCC, with the exception of one with patients at lower malnutrition risk. CONCLUSIONS: It is possible to use CONUT score as a front-line population-wide laboratory marker to screen for the risk for malnutrition in primary care patients that was lower in one PCC.

Automatic laboratory interventions to unmask and treat hypomagnesemia in the Emergency Department.

INTRODUCTION: The significance of hypomagnesemia and the need for treatment are under-recognized in clinical practice. Our objective was to design, establish, and test two interventions to screen for patients with hypomagnesemia and increase the rate of treatment of hypomagnesemia in the Emergency Department (ED). MATERIAL AND METHODS: A prospective two-year study was conducted. The Laboratory Information System was set to automatically order plasma magnesium in ED patients with plasma calcium < 7.5 mg/dL (1.9 mmol/L) and/or plasma potassium < 2.5 mEq/L (2.5 mmol/L). We counted the number of identified cases of hypomagnesemia, and calculated the total economic cost per identified patient. The study had three periods "Central lab" "Stat lab" and "Stat lab with comment" according to the availability to measure plasma magnesium levels in the stat laboratory and the inclusion of an automatic comment in the laboratory report in cases of hypomagnesemia. We retrospectively reviewed the medical records of patients with magnesium < 1.5 mg/dL (0.6 mmol/L), to investigate whether they have been appropriately treated. RESULTS: A total of 410 plasma magnesium were measured due to our intervention; 179 due to hypokalemia and 231 due to hypocalcemia. Two hundred thirty (56.1%) of 410 showed hypomagnesemia. Each detected case resulted in reagent cost of 0.7$, when prompted by hypocalcemia, and 0.6$ when prompted by hypokalemia. The rate of patients with hypomagnesemia that were appropriately treated increased from 15% to 75% along the study period. CONCLUSIONS: Our strategies successfully identified patients with hypomagnesemia in the ED at a very affordable cost, and increased the percentage of patients with hypomagnesemia that received treatment.

Inhibition of enzymes involved in collagen cross-linking reduces vascular smooth muscle cell calcification.

Vascular smooth muscle cells (VSMCs) transdifferentiate into osteoblast-like cells during vascular calcification, inducing active remodeling and calcification of the extracellular matrix (ECM). Intracellular and extracellular enzymes, such as lysyl hydroxylase 1 (PLOD1) and lysyl oxidase (LOX), contribute to ECM maturation and stabilization. We assessed the contribution of these enzymes to hyperphosphatemia-induced calcification. Human and murine VSMCs were differentiated into functional osteoblast-like cells by high-phosphate medium (HPM) conditioning. HPM promoted ECM calcification and up-regulated osteoblast markers associated with induction of LOX and PLOD1 expression and with an increase in ECM-insoluble collagen deposition. Murine VSMCs from transgenic mice overexpressing LOX (TgLOX) exhibited an increase in HPM-dependent calcification and osteoblast commitment compared with wild-type cells. Similarly, enhanced HPM-induced calcification was detected in aorta from TgLOX. Conversely, ß-aminopropionitrile (a LOX inhibitor) and LOX knockdown abrogated VSMC calcification and transdifferentiation. We found a significant positive association between LOX expression and vascular calcification in human atherosclerotic lesions. Likewise, 2,2'-dipyridil (a PLOD inhibitor) and PLOD1 knockdown impaired HPM-induced ECM mineralization and osteoblast commitment. Our findings identify LOX and PLOD as critical players in vascular calcification and highlight the importance of ECM remodeling in this process.-Jover, E., Silvente, A., Marín, F., Martínez-González, J., Orriols, M., Martinez, C. M., Puche, C. M., Valdés, M., Rodriguez, C., Hernández-Romero, D. Inhibition of enzymes involved in collagen cross-linking reduces vascular smooth muscle cell calcification.

Puntuación SAMe-TT 2R2: ¿es útil en todos los pacientes con fibrilación auricular no valvular? Respuesta / SAMe-TT 2R2 score: Useful in all patients with nonvalvular atrial fibrillation? Response

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La puntuación SAMe-TT2R2 no predice el tiempo en rango terapéutico tras un ingreso por insuficiencia cardiaca aguda en pacientes con fibrilación auricular / SAMe-TT2R2 score does not predict time in therapeutic range in atrial fibrillation patients after hospitalization for acute decompensated heart failure

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Repercusiones en la posología de los anticoagulantes orales no antagonistas de la vitamina K por las variaciones de la función renal de los pacientes con fibrilación auricular e insuficiencia cardiaca aguda reciente / Impact of variations in kidney function on nonvitamin k oral anticoagulant dosing in patients with atrial fibrillation and recent acute heart failure

Introducción y objetivos: El deterioro de la función renal y las fluctuaciones de esta son frecuentes en los pacientes recientemente hospitalizados por insuficiencia cardiaca aguda que presentan fibrilación auricular. El objetivo de este estudio es evaluar la necesidad hipotética de ajustes de dosis (según las fluctuaciones de la función renal) de dabigatrán, rivaroxabán y apixabán durante los 6 meses siguientes al alta hospitalaria a los pacientes con fibrilación auricular e insuficiencia cardiaca concomitantes. Métodos: Se llevó a cabo un estudio observacional en 162 pacientes con fibrilación auricular no valvular después de una hospitalización por insuficiencia cardiaca aguda descompensada a los que se practicaron determinaciones de creatinina durante el seguimiento. Se determinaron las posologías hipotéticas recomendadas de dabigatrán, rivaroxabán y apixabán según la función renal al alta. Se identificaron las variaciones aparecidas en la creatinina sérica y el aclaramiento de creatinina y los consiguientes cambios en las dosis recomendadas de estos fármacos durante 6 meses de seguimiento. Resultados: De la población total del estudio, el 44% de los pacientes habría necesitado un ajuste de la posología de dabigatrán durante el seguimiento; el 35%, la de rivaroxabán y el 29%, la de apixabán. Hubo mayor proporción de pacientes con aclaramiento de creatinina < 60 ml/min o de edad avanzada (≥ 75 años) que habrían necesitado ajuste de la dosis durante el seguimiento. Conclusiones: La necesidad de un ajuste de la posología de los anticoagulantes orales no antagonistas de la vitamina K durante el seguimiento es frecuente en los pacientes con fibrilación auricular después de una insuficiencia cardiaca aguda descompensada, sobre todo los de mayor edad y con deterioro de la función renal. Se necesitan nuevos estudios para esclarecer la importancia clínica de estas necesidades de ajuste de la dosis de los fármacos y la pauta idónea de seguimiento de la función renal de los pacientes con insuficiencia cardiaca y otros subgrupos de pacientes con fibrilación auricular (AU)

Introduction and objectives: Renal impairment and fluctuations in renal function are common in patients recently hospitalized for acute heart failure and in those with atrial fibrillation. The aim of the present study was to evaluate the hypothetical need for dosage adjustment (based on fluctuations in kidney function) of dabigatran, rivaroxaban and apixaban during the first 6 months after hospital discharge in patients with concomitant atrial fibrillation and heart failure. Methods: An observational study was conducted in 162 patients with nonvalvular atrial fibrillation after hospitalization for acute decompensated heart failure who underwent creatinine determinations during follow-up. The hypothetical recommended dosage of dabigatran, rivaroxaban and apixaban according to renal function was determined at discharge. Variations in serum creatinine and creatinine clearance and consequent changes in the recommended dosage of these drugs were identified during 6 months of follow-up. Results: Among the overall study population, 44% of patients would have needed dabigatran dosage adjustment during follow-up, 35% would have needed rivaroxaban adjustment, and 29% would have needed apixaban dosage adjustment. A higher proportion of patients with creatinine clearance < 60 mL/min or with advanced age (≥ 75 years) would have needed dosage adjustment during follow-up. Conclusions: The need for dosage adjustment of nonvitamin K oral anticoagulants during follow-up is frequent in patients with atrial fibrillation after acute decompensated heart failure, especially among older patients and those with renal impairment. Further studies are needed to clarify the clinical importance of these needs for drug dosing adjustment and the ideal renal function monitoring regime in heart failure and other subgroups of patients with atrial fibrillation (AU)

Impact of Variations in Kidney Function on Nonvitamin K Oral Anticoagulant Dosing in Patients With Atrial Fibrillation and Recent Acute Heart Failure.

INTRODUCTION AND OBJECTIVES: Renal impairment and fluctuations in renal function are common in patients recently hospitalized for acute heart failure and in those with atrial fibrillation. The aim of the present study was to evaluate the hypothetical need for dosage adjustment (based on fluctuations in kidney function) of dabigatran, rivaroxaban and apixaban during the first 6 months after hospital discharge in patients with concomitant atrial fibrillation and heart failure. METHODS: An observational study was conducted in 162 patients with nonvalvular atrial fibrillation after hospitalization for acute decompensated heart failure who underwent creatinine determinations during follow-up. The hypothetical recommended dosage of dabigatran, rivaroxaban and apixaban according to renal function was determined at discharge. Variations in serum creatinine and creatinine clearance and consequent changes in the recommended dosage of these drugs were identified during 6 months of follow-up. RESULTS: Among the overall study population, 44% of patients would have needed dabigatran dosage adjustment during follow-up, 35% would have needed rivaroxaban adjustment, and 29% would have needed apixaban dosage adjustment. A higher proportion of patients with creatinine clearance < 60 mL/min or with advanced age (≥ 75 years) would have needed dosage adjustment during follow-up. CONCLUSIONS: The need for dosage adjustment of nonvitamin K oral anticoagulants during follow-up is frequent in patients with atrial fibrillation after acute decompensated heart failure, especially among older patients and those with renal impairment. Further studies are needed to clarify the clinical importance of these needs for drug dosing adjustment and the ideal renal function monitoring regime in heart failure and other subgroups of patients with atrial fibrillation.

Usefulness of N-terminal pro-B-type natriuretic Peptide levels for stroke risk prediction in anticoagulated patients with atrial fibrillation.

BACKGROUND AND PURPOSE: Oral anticoagulation is highly effective in reducing stroke and mortality in atrial fibrillation (AF). Several risk stratification schemes have been developed using clinical characteristics. Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) are important markers of increased mortality and morbidity in congestive heart failure and general community population. The aim of our study was to assess the predictive value of NT-proBNP levels in an unselected real-world cohort of anticoagulated patients with AF. METHODS: We studied 1172 patients (49% male; median age, 76 years) with permanent AF who were well stabilized on oral anticoagulation (international normalized ratio, 2.0-3.0). Plasma NT-proBNP levels were quantified at baseline. We recorded thrombotic and vascular events, mortality, and major bleeding. The best cutoff points were assessed by receiver-operating characteristic curves. RESULTS: Median levels (interquartile range) of NT-proBNP were 610 (318-1037) pg/mL. Median follow-up was 1007 (806-1279) days. On multivariate analysis, high NT-proBNP was significantly associated with the risk of stroke (hazards ratio, 2.71; P=0.001) and composite vascular events (acute coronary syndrome or acute heart failure; hazards ratio, 1.85; P=0.016), as well as a significant association with mortality (adjusted hazards ratio, 1.66; P=0.006). No association with bleeding was found (P=0.637). The integrated discrimination improvement (IDI) analysis demonstrated that NT-proBNP improved the Congestive heart failure, Hypertension, Age≥75 (doubled), Diabetes mellitus, Stroke (doubled)-Vascular disease and Sex category (female); CHA2DS2-VASc score for predicting embolic events (relative IDI, 2.8%; P=0.001) and all-cause death (relative IDI, 1.8%; P=0.001). CONCLUSIONS: In real-world cohort of anticoagulated patients with AF, NT-proBNP provided complementary prognostic information to an established clinical risk score (CHA2DS2-VASc) for the prediction of stroke/systemic embolism. NT-proBNP was also predictive of all-cause mortality, suggesting that this biomarker may potentially be used to refine clinical risk stratification in anticoagulated patients with AF.

High-sensitivity troponin T and copeptin in non-ST acute coronary syndromes: implications for prognosis and role of hsTnT and copeptin in non-STEACS.

UNLABELLED: High-sensitivity TnT (hsTnT) has been proposed to improve the diagnosis and stratification in acute coronary syndromes. Copeptin has been proposed for a rapid and accurate rule out of acute myocardial infarction, but some doubts exist about its use out of the first hours from admission. Abnormalities of serum hsTnT and copeptin levels in non-STEACS and negative TnT, could have prognostic implications. METHODS: We included 122 non-STEACS patients without raised TnT, 33 disease controls and 43 healthy controls. We measured hsTnT and copeptin levels. Clinical follow-up at 12 months was performed for adverse endpoints. RESULTS: Non-STEACS patients had raised hsTnT compared with both control groups (P = 0.036 and P < 0.001). Copeptin levels were higher in non-STEACS patients than healthy controls (P = 0.021), without differences with disease controls. Raised levels of hs-TnT presented prognostic implications [HR 3.29 (95%CI: 1.33-7.49), P = 0.010]. hs-TnT could be used for invasive approach decision, as it shows prognostic relevance in conservative approach-patients whereas remains unrelevant for catheterized-patients. Copeptin levels were not associated with adverse events. CONCLUSION: hsTnT levels increased in non-STEACS, were predictive of adverse events and could be important for recommending an invasive management. We cannot confirm a predictive role of copeptin out of the first hours from admission.