Is hospital admission valuable in managing syncope? Results from the STePS study

The proper way to test the usefulness of hospitalization in syncope patients would be to conduct a randomized controlled trial. However, this approach is characterized by major theoretical and ethical limitations which make this procedure unfeasible. Data from observational studies indirectly show that hospitalization might help reduce the short-term risk of death and adverse events by promptly identifying and treating life-threatening events or conditions. Future research should focus on identifying which patients will benefit from hospitalization. In this regard, we should be able both to correctly risk-stratify patients and to analyze syncope observation units and protocols, which may provide a safe alternative for the evaluation of intermediate-risk patients

Personalized risk stratification through attribute matching for clinical decision making in clinical conditions with aspecific symptoms: the example of syncope

Background Risk stratification is challenging in conditions, such as chest pain, shortness of breath and syncope, which can be the manifestation of many possible underlying diseases. In these cases, decision tools are unlikely to accurately identify all the different adverse events related to the possible etiologies. Attribute matching is a prediction method that matches an individual patient to a group of previously observed patients with identical characteristics and known outcome. We used syncope as a paradigm of clinical conditions presenting with aspecific symptoms to test the attribute matching method for the prediction of the personalized risk of adverse events. Methods We selected the 8 predictor variables common to the individual-patient dataset of 5 prospective emergency department studies enrolling 3388 syncope patients. We calculated all possible combinations and the number of patients in each combination. We compared the predictive accuracy of attribute matching and logistic regression. We then classified ten random patients according to clinical judgment and attribute matching. Results Attribute matching provided 253 of the 384 possible combinations in the dataset. Twelve (4.7%), 35 (13.8%), 50 (19.8%) and 160 (63.2%) combinations had a match size 6550, 6530, 6520 and <10 patients, respectively. The AUC for the attribute matching and the multivariate model were 0.59 and 0.74, respectively. Conclusions Attribute matching is a promising tool for personalized and flexible risk prediction. Large databases will need to be used in future studies to test and apply the method in different conditions

Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis

Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients’ data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7–10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7–10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7–10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7–10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial

Chronic Treatment with Ivabradine Does Not Affect Cardiovascular Autonomic Control in Rats

A low resting heart rate (HR) would be of great benefit in cardiovascular diseases. Ivabradine a novel selective inhibitor of hyperpolarization-activated cyclic nucleotide gated (HCN) channels- has emerged as a promising HR lowering drug. Its effects on the autonomic HR control are little known. This study assessed the effects of chronic treatment with ivabradine on the modulatory, reflex and tonic cardiovascular autonomic control and on the renal sympathetic nerve activity (RSNA). Male Wistar rats were divided in 2 groups, receiving intraperitoneal injections of vehicle (VEH) or ivabradine (IVA) during 7 or 8 consecutive days. Rats were submitted to vessels cannulation to perform arterial blood pressure (AP) and HR recordings in freely moving rats. Time series of resting pulse interval and systolic AP were used to measure cardiovascular variability parameters. We also assessed the baroreflex, chemoreflex and the Bezold-Jarish reflex sensitivities. To better evaluate the effects of ivabradine on the autonomic control of the heart, we performed sympathetic and vagal autonomic blockade. As expected, ivabradine treated rats showed a lower resting (VEH: 362 +/- 16 bpm vs. IVA: 260 +/- 14 bpm, p = 0.0005) and intrinsic HR (VEH: 369 +/- 9 bpm vs. IVA: 326 +/- 11 bpm, p = 0.0146). However, the chronic treatment with ivabradine did not change normalized HR spectral parameters LF (nu) (VEH: 24.2 +/- 4.6 vs. IVA: 29.8 +/- 6.4p > 0.05)HF (nu) (VEH: 75.1 +/- 3.7 vs. IVA: 69.2 +/- 5.8p > 0.05), any cardiovascular reflexes, neither the tonic autonomic control of the HR (tonic sympathovagal indexVEH: 0.91 +/- 0.02 vs. IVA: 0.88 +/- 0.03, p = 0.3494). We performed the AP, HR and RSNA recordings in urethane-anesthetized rats. The chronic treatment with ivabradine reduced the resting HR (VEH: 364 +/- 12 bpm vs. IVA: 207 +/- 11 bpm, p < 0.0001), without affecting RSNA (VEH: 117 +/- 16 vs. IVA: 120 +/- 9 spikes/s, p = 0.9100) and mean arterial pressure (VEH: 70 +/- 4 vs. IVA: 77 +/- 6 mmHg, p = 0.3293). Our results suggest that, in health rats, the long-term treatment with ivabradine directly reduces the HR without changing the RSNA modulation and the reflex and tonic autonomic control of the heart.Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq)Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (CAPES)Fundacao de Amparo a Pesquisa de Minas Gerais (FAPEMIG)Universidade Federal de Ouro Preto (UFOP)Universidade Federal do Triangulo Mineiro (UFTM), BrazilUniv Fed Ouro Preto, Inst Exact & Biol Sci, Dept Biol Sci, Lab Cardiovasc Physiol, Ouro Preto, BrazilUniv Fed Ouro Preto, CBIOL NUPEB, Grad Program Biol Sci, Ouro Preto, BrazilUniv Fed Minas Gerais, Inst Biol Sci, Dept Physiol & Biophys, Lab Hypertens, Belo Horizonte, MG, BrazilUniv Fed Sao Paulo, Inst Sci & Technol, Biomed Engn Lab, Sao Jose Dos Campos, BrazilUniv Uberaba, Dept Physiol, Uberaba, BrazilUniv Milan, Osped Maggiore Policlin, IRCCS Ca Granda Fdn, Dept Clin Sci & Community Hlth, Milan, ItalyFed Univ Trianaulo Pvlineiro, Inst Biol & Nat Sci, Dept Physiol, Uberaba, BrazilUniv Fed Sao Paulo, Inst Sci & Technol, Biomed Engn Lab, Sao Jose Dos Campos, BrazilCNPq: 400851/2014-8Web of Scienc

Early career researchers want Open Science : Comment

Creative Commons Attribution License (CC BY 4.0)Open Science is encouraged by the European Union and many other political and scientific institutions.However, scientific practice is proving slow to change.We propose, as early career researchers, that it is our task to change scientific research into open scientific research and commit to Open Science principles.Non peer reviewe

Priorities for Emergency Department Syncope Research

Study objectives There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research. Methods We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process. Results There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management. Conclusion We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED

Chronic treatment with ivabradine does not affect cardiovascular autonomic control in rats.

A low resting heart rate (HR) would be of great benefit in cardiovascular diseases. Ivabradine-a novel selective inhibitor of hyperpolarization-activated cyclic nucleotide gated (HCN) channels- has emerged as a promising HR lowering drug. Its effects on the autonomic HR control are little known. This study assessed the effects of chronic treatment with ivabradine on the modulatory, reflex and tonic cardiovascular autonomic control and on the renal sympathetic nerve activity (RSNA). Male Wistar rats were divided in 2 groups, receiving intraperitoneal injections of vehicle (VEH) or ivabradine (IVA) during 7 or 8 consecutive days. Rats were submitted to vessels cannulation to perform arterial blood pressure (AP) and HR recordings in freely moving rats. Time series of resting pulse interval and systolic AP were used to measure cardiovascular variability parameters. We also assessed the baroreflex, chemoreflex and the Bezold-Jarish reflex sensitivities. To better evaluate the effects of ivabradine on the autonomic control of the heart, we performed sympathetic and vagal autonomic blockade. As expected, ivabradine-treated rats showed a lower resting (VEH: 362 ? 16 bpm vs. IVA: 260 ? 14 bpm, p = 0.0005) and intrinsic HR (VEH: 369 ? 9 bpm vs. IVA: 326 ? 11 bpm, p = 0.0146). However, the chronic treatment with ivabradine did not change normalized HR spectral parameters LF (nu) (VEH: 24.2 ? 4.6 vs. IVA: 29.8 ? 6.4; p > 0.05); HF (nu) (VEH: 75.1 ? 3.7 vs. IVA: 69.2 ? 5.8; p > 0.05), any cardiovascular reflexes, neither the tonic autonomic control of the HR (tonic sympathovagal index; VEH: 0.91? 0.02 vs. IVA: 0.88 ? 0.03, p = 0.3494). We performed the AP, HR and RSNA recordings in urethane-anesthetized rats. The chronic treatment with ivabradine reduced the resting HR (VEH: 364 ? 12 bpm vs. IVA: 207 ? 11 bpm, p < 0.0001), without affecting RSNA (VEH: 117 ? 16 vs. IVA: 120 ? 9 spikes/s, p = 0.9100) and mean arterial pressure (VEH: 70 ? 4 vs. IVA: 77 ? 6 mmHg, p = 0.3293). Our results suggest that, in health rats, the long-term treatment with ivabradine directly reduces the HR without changing the RSNA modulation and the reflex and tonic autonomic control of the heart

The role of immune suppression in COVID-19 hospitalization: clinical and epidemiological trends over three years of SARS-CoV-2 epidemic

Specific immune suppression types have been associated with a greater risk of severe COVID-19 disease and death. We analyzed data from patients &gt;17 years that were hospitalized for COVID-19 at the “Fondazione IRCCS Ca′ Granda Ospedale Maggiore Policlinico” in Milan (Lombardy, Northern Italy). The study included 1727 SARS-CoV-2-positive patients (1,131 males, median age of 65 years) hospitalized between February 2020 and November 2022. Of these, 321 (18.6%, CI: 16.8–20.4%) had at least one condition defining immune suppression. Immune suppressed subjects were more likely to have other co-morbidities (80.4% vs. 69.8%, p &lt; 0.001) and be vaccinated (37% vs. 12.7%, p &lt; 0.001). We evaluated the contribution of immune suppression to hospitalization during the various stages of the epidemic and investigated whether immune suppression contributed to severe outcomes and death, also considering the vaccination status of the patients. The proportion of immune suppressed patients among all hospitalizations (initially stable at &lt;20%) started to increase around December 2021, and remained high (30–50%). This change coincided with an increase in the proportions of older patients and patients with co-morbidities and with a decrease in the proportion of patients with severe outcomes. Vaccinated patients showed a lower proportion of severe outcomes; among non-vaccinated patients, severe outcomes were more common in immune suppressed individuals. Immune suppression was a significant predictor of severe outcomes, after adjusting for age, sex, co-morbidities, period of hospitalization, and vaccination status (OR: 1.64; 95% CI: 1.23–2.19), while vaccination was a protective factor (OR: 0.31; 95% IC: 0.20–0.47). However, after November 2021, differences in disease outcomes between vaccinated and non-vaccinated groups (for both immune suppressed and immune competent subjects) disappeared. Since December 2021, the spread of the less virulent Omicron variant and an overall higher level of induced and/or natural immunity likely contributed to the observed shift in hospitalized patient characteristics. Nonetheless, vaccination against SARS-CoV-2, likely in combination with naturally acquired immunity, effectively reduced severe outcomes in both immune competent (73.9% vs. 48.2%, p &lt; 0.001) and immune suppressed (66.4% vs. 35.2%, p &lt; 0.001) patients, confirming previous observations about the value of the vaccine in preventing serious disease