Ambulatory postural blood pressure changes and history allow a better selection of patients that should undergo a head-up tilt test

Background: Syncope is a common symptom and in most cases it is of a neurally mediated origin. Such patients have to be studied with a careful history and a physical exploration that should include simple maneuvers such as blood pressure (BP) recordings in decubitus and standing position. These tools can suggest diagnosis in a good percentage of patients without the need for expensive or invasive testing. Methods: We carried out a prospective observational study measuring BP and heart rate (HR) with the patients in decubitus and just as they stood up. The patients were sent for a tilt table test in different specialized centers. The BP changes were compared to the results of the tilt test. Results: We included 215 patients, 36.1 ± 18.8 years old, 118 (54.9%) feminine, of which 143 (66.5%) had a positive tilt test. Patients with a positive test showed a rise in systolic BP (SBP) (121.7 ± 19.1 vs. 124.2 ± 20, p < 0.005) and in diastolic BP (DBP) (75 ± 11 vs. 78 ± 11.3, p < 0.005) when compared to people with a negative one. On the other hand, per­centage BP changes were significantly different (SBP 2.24% vs. 0.48%, p = 0.02; DBP 4.1% vs. 1.2%, p = 0.009). Patients with a positive test had also a lower HR on standing up (72.1 ± ± 11.1 vs. 78.3 ± 17.2, p = 0.01). Conclusions: Patients with neurally mediated syncope showed an elevation of SBP and DBP when standing up actively, unlike subjects with a negative tilt test

Diseño de un registro multicéntrico para evaluar control de ritmo contra control de la frecuencia en fibrilación auricular: Registro Mexicano de Fibrilación Auricular (ReMeFA)

La fibrilación auricular es una arritmia muy frecuente y afecta predominantemente a individuos mayores de 70 años. Se dispone de poca información sobre su manejo en México por lo que se diseñó el Registro Mexicano de Fibrilación Auricular (ReMeFA). Método: Se trata de un estudio multicéntrico, observacional, prospectivo sobre el tratamiento de la fibrilación auricular. Se incluyeron sujetos de ambos géneros, mayores de 18 años de edad, con fibrilación auricular documentada. Se excluyeron aquellos con fibrilación auricular secundaria a una causa reversible, sometidos a ablación de venas pulmonares (quirúrgica o por catéter), portadores de marcapasos o desfibriladores, aquellos con expectativa de vida menor a un año o incapacitados física o mentalmente para cumplir con los requisitos del protocolo. Se recolectaron datos clínicos y demográficos en forma basal y en visitas programadas a los seis y doce meses. Especialmente, se recabó información acerca del tratamiento farmacológico para control del ritmo o de la frecuencia. Resultados preliminares: Entre el ocho de diciembre y el 29 de julio de 2009 se incluyeron 1201 pacientes provenientes de 79 centros, con diagnóstico de fibrilación auricular. Conclusión: El registro proporcionará información valiosa sobre las estrategias actualmente empleadas en la República Mexicana para el tratamiento de la fibrilación auricular, sea mediante control del ritmo o control de la frecuencia

Gender differences and management of stroke risk of nonvalvular atrial fibrillation in an upper middle-income country: Insights from the CARMEN-AF registry

Background: Atrial Fibrillation (AF) is associated with an increased risk of stroke and systemic embolism. Several studies have suggested that female AF patients could have a greater risk for stroke. There is scarce information about clinical characteristics and use of antithrombotic therapies in Latin American patients with nonvalvular AF. Objective: To describe the gender differences in clinical characteristics, thromboembolic risk, and antithrombotic therapy of patients with nonvalvular AF recruited in Mexico, an upper middle-income country, into the prospective national CARMEN-AF Registry. Methods: A total of 1423 consecutive patients, with at least one thromboembolic risk factor were enrolled in CARMEN-AF Registry during a three-year period (2014–2017). They were categorized according to Gender. Results: Overall, 48.6% were women, mean age 70 ± 12 years. Diabetes, smoking, alcoholism, non-ischemic cardiomyopathy, coronary artery disease, and obstructive sleep apnea were higher in men. Most women were found with paroxysmal AF (40.6%), and most men with permanent AF (44.0%). No gender differences were found in the use of vitamin K antagonists (VKA) (30.5% in women vs. 28.0% in men). No gender differences were found in the use of direct oral anticoagulants (DOAC) (33.8% women vs 35.4% men). Conclusions: CARMEN-AF Registry demonstrates that in Mexico, regardless of gender, a large proportion of patients remain undertreated. No gender differences were found in the use of VKA or DOAC. Keywords: Atrial fibrillation, Gender, Thromboembolic risk, Antithrombotic therapy, Stroke, Mexic

Tópicos de marketing

Lograr un equilibrio entre acciones humanas, armonía con la naturaleza, y satisfacer las necesidades del mercado actual sin poner en riesgo aquellos recursos que pudieran precisar las futuras generaciones, es lo importante de impulsar la aplicación del marketing sostenible en las organizaciones. Esto se logra a través de la elaboración de un plan de marketing sostenible que permitirá promover un consumo responsable a través de información clara y oportuna sobre los beneficios personales y sociales que genera la adquisición de productos sostenibles; implantar el reciclado a través de la logística de reversa, procedimiento que origina poca o nula generación de desechos, proporcionar empleos seguros, apoyar al medio ambiente y con responsabilidad social, son algunos beneficios que aporta. El presente capítulo tiene como objetivo proporcionar los principales aspectos que abordan el marketing sostenible, mostrar la importancia de la realización de este marketing para las empresas, así como aportar los pasos para desarrollar un plan de marketing sostenible

Rationale, design, and baseline characteristics in Evaluation of LIXisenatide in Acute Coronary Syndrome, a long-term cardiovascular end point trial of lixisenatide versus placebo

BACKGROUND: Cardiovascular (CV) disease is the leading cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). Furthermore, patients with T2DM and acute coronary syndrome (ACS) have a particularly high risk of CV events. The glucagon-like peptide 1 receptor agonist, lixisenatide, improves glycemia, but its effects on CV events have not been thoroughly evaluated. METHODS: ELIXA (www.clinicaltrials.gov no. NCT01147250) is a randomized, double-blind, placebo-controlled, parallel-group, multicenter study of lixisenatide in patients with T2DM and a recent ACS event. The primary aim is to evaluate the effects of lixisenatide on CV morbidity and mortality in a population at high CV risk. The primary efficacy end point is a composite of time to CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina. Data are systematically collected for safety outcomes, including hypoglycemia, pancreatitis, and malignancy. RESULTS: Enrollment began in July 2010 and ended in August 2013; 6,068 patients from 49 countries were randomized. Of these, 69% are men and 75% are white; at baseline, the mean ± SD age was 60.3 ± 9.7 years, body mass index was 30.2 ± 5.7 kg/m(2), and duration of T2DM was 9.3 ± 8.2 years. The qualifying ACS was a myocardial infarction in 83% and unstable angina in 17%. The study will continue until the positive adjudication of the protocol-specified number of primary CV events. CONCLUSION: ELIXA will be the first trial to report the safety and efficacy of a glucagon-like peptide 1 receptor agonist in people with T2DM and high CV event risk

Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe

Background Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors. Methods The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760. Findings Between April 1, 2014, and Jan 31, 2015, 31â127 anaesthetic procedures in 30â874 children with a mean age of 6·35 years (SD 4·50) were included. The incidence of perioperative severe critical events was 5·2% (95% CI 5·0â5·5) with an incidence of respiratory critical events of 3·1% (2·9â3·3). Cardiovascular instability occurred in 1·9% (1·7â2·1), with an immediate poor outcome in 5·4% (3·7â7·5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10â000. This was independent of type of anaesthesia. Age (relative risk 0·88, 95% CI 0·86â0·90; p<0·0001), medical history, and physical condition (1·60, 1·40â1·82; p<0·0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0·99, 0·981â0·997; p<0·0048 for respiratory critical events, and 0·98, 0·97â0·99; p=0·0039 for cardiovascular critical events), rather than the type of health institution or providers. Interpretation This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia. Funding European Society of Anaesthesiology

Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe

Background Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors. Methods The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760. Findings Between April 1, 2014, and Jan 31, 2015, 31 127 anaesthetic procedures in 30 874 children with a mean age of 6.35 years (SD 4.50) were included. The incidence of perioperative severe critical events was 5.2% (95% CI 5.0-5.5) with an incidence of respiratory critical events of 3.1% (2.9-3.3). Cardiovascular instability occurred in 1.9% (1.7-2.1), with an immediate poor outcome in 5.4% (3.7-7.5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10 000. This was independent of type of anaesthesia. Age (relative risk 0.88, 95% CI 0.86-0.90; p<0.0001), medical history, and physical condition (1.60, 1.40-1.82; p<0.0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0.99, 0.981-0.997; p<0.0048 for respiratory critical events, and 0.98, 0.97-0.99; p=0.0039 for cardiovascular critical events), rather than the type of health institution or providers. Interpretation This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia