Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a Joint Position Paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

© The Author 2020. This is a pre-copyedited, author-produced version of an article accepted for publication in European Heart Journal - Cardiovascular Pharmacotherapy following peer review. The version of record [Gorog et al., Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a Joint Position Paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Journal - Cardiovascular Pharmacotherapy, pvaa009] is available online at: https://doi.org/10.1093/ehjcvp/pvaa009.Peer reviewedFinal Accepted Versio

Low-dose ticagrelor with or without acetylsalicylic acid in patients with acute coronary syndrome: Rationale and design of the ELECTRA-SIRIO 2 trial

© 2022 Via Medica. This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0). https://creativecommons.org/licenses/by-nc-nd/2.0/Peer reviewedFinal Published versio

A new approach to ticagrelor-based de-escalation of antiplatelet therapy after acute coronary syndrome. A rationale for a randomized, double-blind, placebo-controlled, investigator-initiated, multicenter clinical study

© 2021 Via Medica. This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license. https://creativecommons.org/licenses/by/4.0/The risk of ischemic events gradually decreases after acute coronary syndrome (ACS), reaching a stable level after 1 month, while the risk of bleeding remains steady during the whole period of dual antiplatelet treatment (DAPT). Several de-escalation strategies of antiplatelet treatment aiming to enhance safety of DAPT without depriving it of its efficacy have been evaluated so far. We hypothesized that reduction of the ticagrelor maintenance dose 1 month after ACS and its continuation until 12 months after ACS may improve adherence to antiplatelet treatment due to better tolerability compared with the standard dose of ticagrelor. Moreover, improved safety of treatment and preserved anti-ischemic benefit may also be expected with additional acetylsalicylic acid (ASA) withdrawal. To evaluate these hypotheses, we designed the Evaluating Safety and Efficacy of Two Ticagrelor-based De-escalation Antiplatelet Strategies in Acute Coronary Syndrome — a randomized clinical trial (ELECTRA-SIRIO 2), to assess the influence of ticagrelor dose reduction with or without continuation of ASA versus DAPT with standard dose ticagrelor in reducing clinically relevant bleeding and main-taining anti-ischemic efficacy in ACS patients. The study was designed as a phase III, randomized, multicenter, double-blind, investigator-initiated clinical study with a 12-month follow-up.Peer reviewedFinal Published versio

Prolonged antithrombotic therapy in patients after acute coronary syndrome: A critical appraisal of current European Society of Cardiology guidelines

The increased risk of non-cardiovascular death in patients receiving clopidogrel or prasugrel in comparison with the placebo group in the Dual Antiplatelet Therapy (DAPT) trial in contrast to the decreased risk of cardiovascular death and all-cause death seen in patients treated with low-dose ticagrelor in the EU label population of the PEGASUS-TIMI 54 trial, resulted in inclusion in the 2020 ESC NSTE-ACS guidelines the recommendation for use of clopidogrel or prasugrel only if the patient is not eligible for treatment with ticagrelor.The prevalence of the primary outcome composed of cardiovascular death, stroke, or myocardial infarction was lower in the low-dose rivaroxaban and acetylsalicylic acid (ASA) group than in the ASA-alone group in the COMPASS trial. Moreover, all-cause mortality and cardiovascular mortality rates were lower in the rivaroxaban-plus-ASA group.Comparison of the PEGASUS-TIMI 54 and COMPASS trial patient characteristics clearly shows that each of these treatment strategies should be addressed at different groups of patients. A greater benefit in post-acute coronary syndrome (ACS) patients with a high risk of ischemic events and without high bleeding risk may be expected with ASA and ticagrelor 60 mg b.i.d. when the therapy is continued without interruption or with short interruption only after ACS. On the other hand, ASA and rivaroxaban 2.5 mg b.i.d. seems to be a better option when indications for dual antithrombotic therapy (DATT) appear after a longer time from ACS (more than 2 years) and/or from cessation of DAPT (more than 1 year) and in patients with multiple vascular bed atherosclerosis. Thus, both options of DATTs complement each other rather than compete, as can be presumed from the recommendations. However, a direct comparison between these strategies should be tested in future clinical trials

Prolonged antithrombotic therapy in patients after acute coronary syndrome: A critical appraisal of current European Society of Cardiology guidelines

The increased risk of non-cardiovascular death in patients receiving clopidogrel or prasugrel in comparison with the placebo group in the dual antiplatelet therapy (DAPT) trial in contrast to the decreased risk of cardiovascular death and all-cause death seen in patients treated with low-dose ticagrelor in the EU label population of the PEGASUS-TIMI 54 trial, resulted in inclusion in the 2020 ESC NSTE-ACS guidelines the recommendation for use of clopidogrel or prasugrel only if the patient is not eligible for treatment with ticagrelor. The prevalence of the primary outcome composed of cardiovascular death, stroke, or myocardial infarction was lower in the low-dose rivaroxaban and acetylsalicylic acid (ASA) group than in the ASA-alone group in the COMPASS trial. Moreover, all-cause mortality and cardiovascular mortality rates were lower in the rivaroxaban-plus-ASA group. Comparison of the PEGASUS-TIMI 54 and COMPASS trial patient characteristics clearly shows that each of these treatment strategies should be addressed at different groups of patients. A greater benefit in postacute coronary syndrome (ACS) patients with a high risk of ischemic events and without high bleeding risk may be expected with ASA and ticagrelor 60 mg b.i.d. when the therapy is continued without interruption or with short interruption only after ACS. On the other hand, ASA and rivaroxaban 2.5 mg b.i.d. seems to be a better option when indications for dual antithrombotic treatment (DATT) appear after a longer time from ACS (more than two years) and/or from cessation of DAPT (more than one year) and in patients with multiple vascular bed atherosclerosis. Thus, both options of DATTs complement each other rather than compete, as can be presumed from the recommendations. However, a direct comparison between these strategies should be tested in future clinical trials

Supply chain planning for bioenergy and biofuel production from forest-based residues in interior British Columbia : a simulation study

This thesis analyzes a forest-based biomass supply chain network considering uncertainties and variations. It is based on the Williams Lake Timber Supply Area (TSA) located in British Columbia, Canada. The network includes: five conversion facilities distributed in three locations, two types of forest-based biomass, sourced from 337 cutblocks, and two types of sawmill residues sourced from three local sawmills. The main objective of this research is to evaluate the supply chain of forest-based residues for bioenergy and biofuel production considering uncertainties and variations. The specific objectives of this research are to: 1) Develop a simulation model to evaluate a forest-based biomass supply chain for bioenergy and biofuel production considering uncertainties and variations; and 2) apply the simulation model to a case study. To achieve the objectives, a discrete-event simulation model is developed using the commercial software Anylogic 7® (Anylogic 7, 2000). Evaluating a network with various supply and demand points, with various biomass types, and a hybrid push-pull biomass flow management distinguishes this work from previous research. The results show the demand is fulfilled to at least 95%, requiring 23 to 24 trucks during the peak season. Furthermore, the cost and CO₂ equivalent emissions vary per location, from $56.52 to$87.36 and from 19.66 to 72.61 (kg/odt), respectively. Long transportation distances and transportation cycle times greatly affected the number of required resources, and consequently the final cost per oven dry tonne. This results in higher costs than similar studies performed in less remote areas. Finally, a sensitivity analysis is performed to evaluate the effect of changes in moisture content and in supply and demand. Extreme changes in biomass supply and demand affected dramatically the demand fulfillment. By increasing the biomass demand 20% while simultaneously decreasing the biomass supply 20%, reduced the demand fulfillment by 23.18%. Finally, this model can be improved in several ways, one of them being by including the possibility of routing between different cutblocks to consolidate biomass pick-ups, therefore increasing the demand fulfillment of the supply chain and possibly reducing costs.Forestry, Faculty ofGraduat

A Market-Driven Investigation of Pallet Trends in Grocery Chains

This research project involved a review of literature, personal interviews, and first-hand observations to assess the current role and future trends for pallet usage in the grocery-distribution industry. It explores the grocery retailer's point of view. Interviews were conducted with eleven experts in the warehousing and material-handling industry and with thir­ teen high-level managers of grocery chain distribution centers (DCs) across the United States and overseas. Eight geographically diverse grocery DCs were visited for observation. We also visited an automobile manufacturing plant, two overseas distribution centers, and three pallet-manufacturing facilities. Economic conditions have an impact on the transportation economics of pallets. As fuel prices continue to rise, there is a trend toward maximizing the utilization of space within the trailer, and new regulations reducing a driver's "hours of service" favor the quick unloading afforded by pallets, reinforcing the flow in the supply chain. The humble wooden pallet plays a vital role in modem grocery distribution as a "sustainable" packaging form for United States and Canada. This research shows that plastic pallets are increasing and serve a clear need, even in a sys­ tem that is full of "free" wooden pallets. But to focus on wooden pallets alone is a marketing myopia. To serve future supply chains, the industry must redefine the business as material handling, movement, and flow