In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018.

BACKGROUND: The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known. METHODS: Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases. RESULTS: From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70). CONCLUSION: In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.

Aspirin in diabetic patients at primary prevention: insights of the VITAL cohort.

PURPOSE: Aspirin use among patients with diabetes in primary prevention is still a matter of debate. We aimed to evaluate the potential cardiovascular risk benefit of aspirin in primary prevention, using data from a contemporary cohort. METHODS: Retrospective analysis of the VITAL cohort with > 20,000 individuals at primary prevention who were followed for a median of 5.3 years. The population was evaluated according to the baseline diabetes status, and then aspirin use was evaluated among diabetic patients. Cox regression models were used to estimate the risks of mortality and cardiovascular outcomes. The estimates were reported using adjusted hazard ratio (HR) and 95% confidence intervals (95%CI). RESULTS: Diabetic patients (n = 3549; 13.7%) showed to increase the risk of all-cause mortality (HR 1.61, 95%CI 1.33-1.94), and major adverse cardiovascular events (MACE) (HR 1.36 95%CI 1.11-1.68) than non-diabetic population. Diabetic patients taking aspirin were older, more frequently man, hypertensive, current users of statins, and current smokers compared with diabetic patients who did not use aspirin at baseline. There was no difference between diabetic aspirin users and non-users regarding all-cause mortality (HR 0.80, 95%CI 0.59, 1.10), MACE (HR 0.92, 95%CI 0.64, 1.33), coronary heart disease (HR 0.98, 95%CI 0.67, 1.43), or stroke (HR 0.87, 95%CI 0.48, 1.58). CONCLUSIONS: The VITAL data confirmed diabetes as an important risk factor for cardiovascular events in a contemporary cohort but did not show cardiovascular benefits of aspirin in primary prevention among people with diabetes who were shown to be at higher risk of cardiovascular events.

Does Parkinson's disease increase the risk of cardiovascular events? A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: The impact of Parkinson's disease (PD) on the risk of cardiovascular disease is poorly known. The aim was to systematically review observational studies evaluating the association between PD and cardiovascular events. METHODS: MEDLINE through PubMed, the Web of Science and Cochrane Central Register of Controlled Trials with conference proceedings were searched from inception to 4 July 2019. Two reviewers independently selected studies comparing cardiovascular events between Parkinson's disease and control groups. Ischaemic stroke, myocardial infarction and cardiovascular mortality were the outcomes of interest. Pooled estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were derived by random effects meta-analysis. Heterogeneity was assessed using the I2 test. The study protocol was registered at PROSPERO: CRD42017076527. RESULTS: Eleven studies were included: nine cohort studies and two case-control studies. PD was associated with a significantly increased risk of stroke (nine studies: OR 1.66, 95% CI 1.19, 2.34; I2  = 50%). No significant differences were detected regarding myocardial infarction risks (eight studies: OR 1.15, 95% CI 0.72, 1.83; I2  = 76%) nor cardiovascular mortality risks (seven studies: OR 1.11, 95% CI 0.85, 1.45; I2  = 47%) in PD patients. CONCLUSIONS: The best evidence available showed an association between PD and increased risk of stroke. The risk of myocardial infarction and cardiovascular mortality was not different in PD and non-PD individuals.

Systematic review with meta-analysis: the risk of major gastrointestinal bleeding with non-vitamin K antagonist oral anticoagulants.

BACKGROUND: Gastrointestinal (GI) bleeding is a common complication among anticoagulated patients. Non-vitamin K antagonist oral anticoagulants (NOACs) are associated with increased risk of GI (major and clinically relevant non-major) bleeding. However, more information is needed regarding severe events. AIM: To evaluate the risk of NOACs major GI bleeding. METHODS: We searched for phase III randomised clinical trials (RCT) evaluating NOACs (apixaban, dabigatran, edoxaban and rivaroxaban) and reporting major GI bleeding events, in MEDLINE, Cochrane Library, SciELO collection and Web of Science databases (July 2015). Meta-analysis was performed to estimate risk ratio (RR) and 95% confidence intervals (95% CIs). Heterogeneity was assessed with the I(2) test. RESULTS: A total of 23 studies were included. Among patients with atrial fibrillation, the risk of major GI bleeding was not different between NOACs and vitamin K antagonists (VKA) (RR 1.08, 95% CI 0.85-1.36, I(2)  = 78%; 5 RCTs) or acetylsalicylic acid (RR 0.78, 95% CI 0.36-1.72; 1 RCT). Similar results were found for patients undergoing orthopaedic surgery and those with venous thromboembolism. NOACs were not found to increase the risk compared to low-molecular-weight heparin (LWMH) alone (RR 1.42, 95% CI 0.55-3.71, I(2)  = 7%; 8 RCTs), the sequential treatment with LMWH-VKA (RR 0.77, 95% CI 0.49-1.21, I(2)  = 43%; 7 RCTs) or placebo (RR 1.48, 95% CI 0.15-14.84, I(2)  = 21%; 2 RCTs). CONCLUSION: Despite previous evidence supporting the association of non-vitamin K antagonist oral anticoagulants and overall GI bleeding, non-vitamin K antagonist oral anticoagulants are not associated with increased risk of major GI bleeding compared to other anticoagulant drugs (with known increased risk of these events).

Efficacy and safety of low molecular weight heparin in patients with mechanical heart valves: systematic review and meta-analysis.

BACKGROUND: Low molecular weight heparins (LMWHs) are not approved for patients with mechanical heart valves (MHVs). However, in several guidelines, temporary LMWH off-label use in this clinical setting is considered to be a valid treatment option. Therefore, we reviewed the efficacy and safety of LMWHs in patients with MHVs. METHODS: MEDLINE and CENTRAL databases were searched from inception to June 2013. Review articles and references were also searched. We included experimental and observational studies that compared LMWHs with unfractionated heparin (UFH) or vitamin K antagonists (VKAs). Data were analyzed and pooled to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for thromboembolic and major bleeding events. Statistical heterogeneity was evaluated with the I(2) -test. RESULTS: Nine studies were included: one randomized controlled trial (RCT) and eight observational studies, with a total of 1042 patients. No differences were found between LMWHs and UFH/VKAs in the risk of thromboembolic events (OR 0.67; 95% CI 0.27-1.68; I(2) = 9%) or major bleeding events (OR 0.66; 95% CI 0.36-1.19; I(2) = 0%). CONCLUSIONS: The best evidence available might support the temporary use of LMWHs as a prophylactic treatment option in patients with MHVs. However, conclusions are mostly based on observational data (with large CIs), and an adequately powered RCT is urgently needed in this clinical setting.

Humoral and cellular immunity in chromium picolinate-supplemented lambs.

The effects of oral supplementation of chromium picolinate (CrPic) on humoral and cellular immunity in sheep were investigated. Twenty-four male lambs divided into four treatments and received different dosages of CrPic: placebo (0), 0.250, 0.375, and 0.500 mg of chromium/animal/day during 84 days. The base ration was Panicum maximum cv Massai hay and concentrate. Blood samples were collected fortnightly for total and differential leukocyte counts. On days 28 and 56, the lambs were challenged with chicken ovalbumin I.M. Serum samples were collected on days 46 and 74 and subjected to an indirect enzyme-linked immunosorbent assay to measure IgG anti-ovalbumin. The cell-mediated immune response was determined by a delay-type hypersensitivity test using phytohemagglutinin. CrPic did not significantly affect humoral immunity in lambs but there was a negative effect on cellular immunity (P < 0.05) as Cr supplementation increased. Therefore, the level of Cr supplementation for lambs must be better studied to address its effect on stressed animals or the possible toxic effects of Cr on the animal itself or its immune system.

Skin antiseptics in venous puncture-site disinfection for prevention of blood culture contamination: systematic review with meta-analysis.

Blood cultures drawn by venous puncture are common clinical procedures for the detection of bacteraemia. Blood culture contamination (BCC) can lead to clinical misinterpretation and unnecessary expenses. We aimed to systematically review randomised controlled trials (RCTs) with skin antiseptics for prevention of contamination in venous-puncture drawn blood cultures. We conducted database search using CENTRAL (Cochrane Library issue April 2010), MEDLINE, EMBASE and mRCT, in June 2010. All RCTs testing skin antiseptics in venous-puncture drawn blood cultures were retrieved. Relative risk (RR) of the BCC outcome was analysed by random effects method using confidence interval (CI) of 95%. Studies were assessed by one review author and checked by another. Six studies were identified. Single-trial comparisons showed that alcoholic iodine tincture was better than non-alcoholic povidone-iodine, and isopropyl/acetone/povidone-iodine showed superiority against isopropyl/povidone-iodine. Meta-analysis demonstrated that alcoholic chlorhexidine was better than non-alcoholic povidone-iodine (RR: 0.33; 95% CI: 0.24-0.46) in 4757 blood cultures from two trials. Alcoholic solutions were better than non-alcoholic products (0.53; 0.31-0.90) in 21,300 blood cultures from four studies. Two trials with 13,418 blood cultures showed that iodine tincture was not superior to povidone-iodine in BCC prevention (0.79; 0.54-1.18). Alcoholic iodine was not different from non-alcoholic iodine (0.79; 0.53-1.17). Comparison of chlorhexidine vs iodine compounds was not conclusive. Alcohol alone was not inferior to iodinated products for prevention of contamination in venous-puncture drawn blood cultures. The association of alcohol and povidone-iodine did not seem to be useful. Alcoholic chlorhexidine solutions reduced blood culture false positives compared with aqueous povidone-iodine.

Performance and ruminal protozoa in lambs with chromium supplementation.

The effects of chromium picolinate (CrPic) oral supplementation on the performance and ruminal protozoa population in sheep was investigated. Twenty-four male lambs were treated with four different levels of CrPic: placebo, 0.250, 0.375 and 0.500mg of chromium/animal/day during 84 days. The base ration was Panicum maximum cv Massai hay and concentrate. Feed intake was measured three times a week. Lambs were weighed every 2 weeks. Ruminal content was sampled five times during the trial to quantify ruminal protozoa. No difference (p>0.05) between treatments was recorded for any parameter measured: initial and final mean body weight, dry matter intake, daily gain and total body weight gain. There was a negative linear relationship between Cr supplementation and protozoa count (p=0.0013) with no additional decrease when CrPic supplemental levels were higher than 0.375mg/day. Therefore, Cr supplementation must be carried out carefully and more studies need to address stressed animals or possible toxic effects of Cr in the animal itself or to the ruminal protozoa population.