The Myocardial Ischemia Reduction with Acute Cholesterol Lowering trial: MIRACuLous or not, it's time to change current practice

The Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study was the first trial to assess whether statins might be of clinical benefit in those with recently unstable coronary disease. MIRACL found that high-dose atorvastatin was safe and reduced the incidence of the composite endpoint, death, non-fatal myocardial infarction, resuscitated sudden cardiac death or emergent rehospitalization for recurrent ischemia at 16 weeks when compared with placebo. Despite a number of important study limitations, MIRACL's findings and the prior observation that inpatient initiation of lipid-lowering therapy is associated with higher rates of subsequent utilization, suggest that it is prudent to begin statin therapy when patients present with an acute coronary syndrome

Mineralogical attenuation for metallic remediation in a passive system for mine water treatment

Passive systems with constructed wetlands have been consistently used to treat mine water from abandoned mines. Long-term and cost-effective remediation is a crucial expectation for these water treatment facilities. To achieve that, a complex chain of physical, chemical, biological, and mineralogical mechanisms for pollutants removal must be designed to simulate natural attenuation processes. This paper aims to present geochemical and mineralogical data obtained in a recently constructed passive system (from an abandoned mine, Jales, Northern Portugal). It shows the role of different solid materials in the retention of metals and arsenic, observed during the start-up period of the treatment plant. The mineralogical study focused on two types of materials: (1) the ochre-precipitates, formed as waste products from the neutralization process, and (2) the fine-grained minerals contained in the soil of the wetlands. The ochre-precipitates demonstrated to be poorly ordered iron-rich material, which gave rise to hematite upon artificial heating. The heating experiments also provided mineralogical evidence for the presence of an associated amorphous arsenic-rich compound. Chemical analysis on the freshly ochre-precipitates revealed high concentrations of arsenic (51,867 ppm) and metals, such as zinc (1,213 ppm) and manganese (821 ppm), indicating strong enrichment factors relative to the water from which they precipitate. Mineralogical data obtained in the soil of the wetlands indicate that chlorite, illite, chlorite–vermiculite and mica–vermiculite mixedlayers, vermiculite, kaolinite and goethite are concentrated in the fine-grained fractions (<20 and <2 μm). The chemical analyses show that high levels of arsenic (up to 3%) and metals are also retained in these fractions, which may be enhanced by the low degree of order of the clay minerals as suggested by an XRD study. The obtained results suggest that, although the treatment plant has been receiving water only since 2006, future performance will be strongly dependent on these identified mineralogical pollutant hosts.Fundação para a Ciência e a Tecnologia (FCT

Undertreatment of Hyperlipidemia in the Secondary Prevention of Coronary Artery Disease

OBJECTIVES: To determine adherence to national guidelines for the secondary prevention of coronary artery disease (CAD) using lipid-lowering drugs (LLDs), by studying the rate of use of LLDs, predictors of use, and the rate of achieving lipid goals, among eligible patients recently hospitalized with acute myocardial infarction. DESIGN: Cross-sectional analysis of 2,938 medical records, collected from July 1995 to May 1996. SETTING: Thirty-seven community-based hospitals in Minnesota. PATIENTS: The 622 patients had previously established CAD and hyperlipidemia (total cholesteroverline>200 mg/dL or currently using LLDs), and were eligible for LLDs according to the National Cholesterol Education Program II (NCEP II) Guidelines. MEASUREMENTS: The use of LLDs in eligible patients (primary outcome) and successful achievement of NCEP II goals (total cholesterol <160 mg/dL) among treated patients (secondary outcome). MAIN RESULTS: Only 230 (37%) of 622 eligible patients received LLDs. In multivariate logistic regression, factors independently related to LLD use included age greater than 74 years (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.35, 0.88) and severe comorbidity (AOR 0.60; 95% CI 0.38, 0.95), managed care enrollee (AOR 1.56; 95% CI 1.02, 2.39), past smoker (AOR 1.72; 95% CI 0.98, 3.01), prior revascularization (AOR 2.31; 95% CI 1.51, 3.53), and the use of aspirin (AOR 1.59; 95% CI 1.07, 2.38) or ≥4 medications (AOR 2.89; 95% CI 2.19, 3.84). Of the treated patients who had lipid levels measured (n =149), 15% achieved the recommended goal of a total cholesterol below 160 mg/dL. Of the untreated patients (n =392), 89% were discharged from hospital without a LLD prescription. CONCLUSIONS: Lipid-lowering drugs, although proven effective for the secondary prevention of CAD, were used by only one third of eligible patients. Among patients receiving LLDs, few achieved recommended lipid goals. Directed quality improvement interventions, such as starting LLDs during hospitalization, may have the potential to substantially reduce CAD morbidity and mortality in this vulnerable population