Sodium Zirconium Cyclosilicate in HFrEF and Hyperkalemia: REALIZE-K Design and Baseline Characteristics.

BACKGROUND: Mineralocorticoid receptor antagonists (MRAs) improve outcomes in patients with heart failure and reduced ejection fraction (HFrEF). However, MRAs are often underused because of hyperkalemia concerns. OBJECTIVES: The purpose of this study was to assess whether sodium zirconium cyclosilicate (SZC), a nonabsorbed crystal that traps and rapidly lowers potassium, enables MRA use in patients with HFrEF and prevalent hyperkalemia (or at high risk). METHODS: REALIZE-K is a prospective, double-blind, placebo-controlled trial in patients with HFrEF (NYHA functional class II-IV; left ventricular ejection fraction ≤40%), optimal therapy (except MRA), and prevalent hyperkalemia (or at high risk). During the open-label run-in, all participants underwent protocol-mandated spironolactone titration (target: 50 mg daily); those with prevalent (cohort 1) or incident (cohort 2) hyperkalemia during titration started SZC. Participants achieving normokalemia while on spironolactone ≥25 mg daily were randomized to continuing SZC or matching placebo for 6 months. The primary composite endpoint was proportion of participants with optimal response (normokalemia, on spironolactone ≥25 mg daily, no rescue for hyperkalemia [months 1-6]). RESULTS: Of 365 patients (run-in), 202 were randomized. Baseline characteristics included mean age 70 years, prevalent comorbidities (78% estimated glomerular filtration rate <60 mL/min/1.73 m2, 38% atrial fibrillation/flutter), high N-terminal pro B-type natriuretic peptide (median 1,136 pg/mL), and high HFrEF therapy use (64% sacubitril/valsartan, 96% beta-blocker, 42% sodium glucose co-transporter 2 inhibitor). At randomization, 78% were receiving spironolactone 50 mg daily. CONCLUSIONS: REALIZE-K is the first trial to evaluate whether SZC can enable rapid and safe MRA optimization and long-term continuation in patients with HFrEF and prevalent/high risk of hyperkalemia. (Study to Assess Efficacy and Safety of SZC for the Management of High Potassium in Patients with Symptomatic HFrEF Receiving Spironolactone; NCT04676646).

In vivo fluid dynamics of the Ventura interatrial shunt device in patients with heart failure.

AIMS: Interatrial shunts are under evaluation as a treatment for heart failure (HF); however, their in vivo flow performance has not been quantitatively studied. We aimed to investigate the fluid dynamics properties of the 0.51 cm orifice diameter Ventura shunt and assess its lumen integrity with serial transesophageal echocardiography (TEE). METHODS AND RESULTS: Computational fluid dynamics (CFD) and bench flow tests were used to establish the flow-pressure relationship of the shunt. Open-label patients from the RELIEVE-HF trial underwent TEE at shunt implant and at 6 and 12 month follow-up. Shunt effective diameter (Deff) was derived from the vena contracta, and flow was determined by the continuity equation. CFD and bench studies independently validated that the shunt's discharge coefficient was 0.88 to 0.89. The device was successfully implanted in all 97 enrolled patients; mean age was 70 ± 11 years, 97% were NYHA class III, and 51% had LVEF ≤40%. Patency was confirmed in all instances, except for one stenotic shunt at 6 months. Deff remained unchanged from baseline at 12 months (0.47 ± 0.01 cm, P = 0.376), as did the trans-shunt mean pressure gradient (5.1 ± 3.9 mmHg, P = 0.316) and flow (1137 ± 463 mL/min, P = 0.384). TEE measured flow versus pressure closely correlated (R2 ≥ 0.98) with a fluid dynamics model. At 12 months, the pulmonary/systemic flow Qp/Qs ratio was 1.22 ± 0.12. CONCLUSIONS: When implanted in patients with advanced HF, this small interatrial shunt demonstrated predictable and durable patency and performance.

Sacubitril/valsartan compared to ramipril in high-risk post-myocardial infarction patients stratified according to use of mineralocorticoid receptor antagonists: Insight from the PARADISE MI trial.

AIM: It is unknown whether safety and clinical endpoints by use of sacubitril/valsartan (an angiotensin receptor-neprilysin inhibitor [ARNI]) are affected by mineralocorticoid receptor antagonists (MRA) in high-risk myocardial infarction (MI) patients. The aim of this study was to examine whether MRA modifies safety and clinical endpoints by use of sacubitril/valsartan in patients with a MI and left ventricular systolic dysfunction (LVSD) and/or pulmonary congestion. METHODS AND RESULTS: Patients (n = 5661) included in the PARADISE MI trial (Prospective ARNI vs. ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI) were stratified according to MRA. Primary outcomes in this substudy were worsening heart failure or cardiovascular death. Safety was defined as symptomatic hypotension, hyperkalaemia >5.5 mmol/L, or permanent drug discontinuation. A total of 2338 patients (41%) were treated with MRA. Safety of ARNI compared to ramipril was not altered significantly by ± MRA, and both groups had similar increase in symptomatic hypotension with ARNI. In patients taking MRA, the risk of hyperkalaemia or permanent drug discontinuation was not significantly altered by ARNI (p > 0.05 for all comparisons). The effect of ARNI compared with ramipril was similar in those who were and were not taking MRA (hazard ratio [HR]MRA 0.96, 95% confidence interval [CI] 0.77-1.19 and HRMRA- 0.87, 95% CI 0.71-1.05, for the primary endpoint; p = 0.51 for interaction [Clinical Endpoint Committee adjudicated]); similar findings were observed if investigator-reported endpoints were evaluated (p = 0.61 for interaction). CONCLUSIONS: Use of a MRA did not modify safety or clinical endpoints related to initiation of ARNI compared to ramipril in the post-MI setting in patients with LVSD and/or congestion.

Derivation and external validation of machine-learning models for risk stratification in chest pain with normal troponin.

AIMS: Risk stratification of patients with chest pain and a high-sensitivity cardiac troponin T (hs-cTnT) concentration 180 min). Probability thresholds for safe discharge were derived in the derivation cohort. The endpoint occurred in 105 (2.6%) patients in the training set and 98 (2.7%) in the external validation set. Gradient boosting full (GBf) showed the best discrimination (area under the curve = 0.808). Calibration was good for the reduced neural network and LR models. Gradient boosting full identified the highest proportion of patients for safe discharge (36.7 vs. 23.4 vs. 27.2%; GBf vs. LR vs. u-cTn, respectively) with similar safety (missed endpoint per 1000 patients: 2.2 vs. 3.5 vs. 3.1, respectively). All derived models were superior to the HEART and GRACE scores (P < 0.001). CONCLUSION: Machine-learning and LR prediction models were superior to the HEART, GRACE, and u-cTn for risk stratification of patients with chest pain and a baseline hs-cTnT

Primeros rastros de la teoría bacteriológica en el discurso médico peruano: el debate entre Francisco Almenara e Ignacio de la Puente, 1895 / First tracks of the bacteriological theory in the peruvian medical speech: the debate between Francisco Almenara and Ignacio de la Puente, 1895

El presente artículo pretende analizar el estado de los conocimientos sobre tuberculosis pulmonar presentes en el discurso médico peruano en la segunda mitad del siglo XIX, analizando específicamente la importancia que empezaron a tener los postulados de la Bacteriología concerniente a la tuberculosis pulmonar valiéndose para ello de una fuente maravillosa como es el debate sostenido entre los médicos Francisco Almenara Butler e Ignacio de la Puente Requena acerca de la construcción del Sanatório de Tamboraque.

Medicina, prostitución y sífilis en Lima y Callao: 1910-1930 / Medicine, prostitution and syphilis in Lima and Callao: 1910-1930

El presente artículo tiene como propósito ofrecer un panorama de las diferentes etapas por las que atravesaron las políticas oficiales promovidas por el Estado destinadas al combate de las enfermedades venéreas, especialmente la sífilis, en Lima y el Callao entre los años 1910 y 1930. Estas iniciativas públicas revelan la continuidad de un programa regulamentarista que se concetró principalmente en el control médico y social de la prostitución, considerada como la causa más seria del 'contágio venéreo' en el Perú. Es importante destacar que esta reglamentación se mantuovo casi inalterable hasta la segunda y tercera década del siglo XX cuando empezó a coexistir con otras propuestras de lucha antivenérea como la educación sexual.

Primeros rastros de la teoría bacteriológica en el discurso médico peruano: el debate entre Francisco Almenara e Ignacio de la Puente, 1895 / First tracks of the bacteriological theory in the peruvian medical speech: the debate between Francisco Almenara and Ignacio de la Puente, 1895

El presente artículo pretende analizar el estado de los conocimientos sobre tuberculosis pulmonar presentes en el discurso médico peruano en la segunda mitad del siglo XIX, analizando específicamente la importancia que empezaron a tener los postulados de la Bacteriología concerniente a la tuberculosis pulmonar valiéndose para ello de una fuente maravillosa como es el debate sostenido entre los médicos Francisco Almenara Butler e Ignacio de la Puente Requena acerca de la construcción del Sanatório de Tamboraque. [AU]

Medicina, prostitución y sífilis en Lima y Callao: 1910-1930 / Medicine, prostitution and syphilis in Lima and Callao: 1910-1930

El presente artículo tiene como propósito ofrecer un panorama de las diferentes etapas por las que atravesaron las políticas oficiales promovidas por el Estado destinadas al combate de las enfermedades venéreas, especialmente la sífilis, en Lima y el Callao entre los años 1910 y 1930. estas iniciativas públicas revelan la continuidad de un programa regulamentarista que se concetró principalmente en el control médico y social de la prostitución, considerada como la causa más seria del 'contágio venéreo' en el Perú. Es importante destacar que esta reglamentación se mantuovo casi inalterable hasta la segunda y tercera década del siglo XX cuando empezó a coexistir con otras propuestras de lucha antivenérea como la educación sexual. [AU]

[Brachial plexus injury after interescalenic block in a patient with arthroscopic acromioplasty. Report of a case]. / Lesión del plexo braquial secundario a bloqueo interescalénico en un paciente de acromioplastía vía artroscópica. Presentación de un caso.

The brachial plexus is formed by union of C5, C6, C7, C8 and T1 root levels. Bachial plexus injuries can be categorized by ther causative mechanism as gunshot injuries, sharp injuries, traction injuries, motor accidents and radiation. The objective of the present study is to show the risk of interscalenic block as permanent lesion of brachial plexus in arthroscopic acromioplasty surgery. We present a 35 years old female administration worker. She was sent from second level unit with subacromial impingement diagnosis. At the moment of surgery the patient presented incomplete sensitive block, so general anesthesia was performed. At the next day the patient had a numb arm, difficulty in mobilization with no edema. She was re-evaluated by anesthesiology the next day, and they thought of prolonged action of the anesthetic used (bupivacaine). An electromyography was performed and it reported moderate axonal plexopathy, with affection of superior trunk and lateral cord. We must take into account the possibility of lesion of brachial plexus by interscalenic block and not by arthroscopic surgery.