Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial.

STUDY OBJECTIVE: The real-world effectiveness and safety of a 0/1-hour accelerated protocol using high-sensitivity cardiac troponin (hs-cTn) to exclude myocardial infarction (MI) compared to routine care in the United States is uncertain. The objective was to compare a 0/1-hour accelerated protocol for evaluation of MI to a 0/3-hour standard care protocol. METHODS: The RACE-IT trial was a stepped-wedge, randomized trial across 9 emergency departments (EDs) that enrolled 32,609 patients evaluated for possible MI from July 2020 through April 2021. Patients undergoing high-sensitivity cardiac troponin I testing with concentrations less than or equal to 99th percentile were included. Patients who had MI excluded by the 0/1-hour protocol could be discharged from the ED. Patients in the standard care protocol had 0- and 3-hour troponin testing and application of a modified HEART score to be eligible for discharge. The primary endpoint was the proportion of patients discharged from the ED without 30-day death or MI. RESULTS: There were 13,505 and 19,104 patients evaluated in the standard care and accelerated protocol groups, respectively, of whom 19,152 (58.7%) were discharged directly from the ED. There was no significant difference in safe discharges between standard care and the accelerated protocol (59.5% vs 57.8%; adjusted odds ratio (aOR)=1.05, 95% confidence interval [CI] 0.95 to 1.16). At 30 days, there were 90 deaths or MIs with 38 (0.4%) in the standard care group and 52 (0.4%) in the accelerated protocol group (aOR=0.84, 95% CI 0.43 to 1.68). CONCLUSION: A 0/1-hour accelerated protocol using high-sensitivity cardiac troponin I did not lead to more safe ED discharges compared with standard care.

Is rapid acute coronary syndrome evaluation with high-sensitivity cardiac troponin less costly? An economic evaluation.

Objective: Protocols to evaluate for myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) have the potential to drive costs upward due to the added sensitivity. We performed an economic evaluation of an accelerated protocol (AP) to evaluate for MI using hs-cTn to identify changes in costs of treatment and length of stay compared with conventional testing. Methods: We performed a planned secondary economic analysis of a large, cluster randomized trial across nine emergency departments (EDs) from July 2020 to April 2021. Patients were included if they were 18 years or older with clinical suspicion for MI. In the AP, patients could be discharged without further testing at 0 h if they had a hs-cTnI < 4 ng/L and at 1 h if the initial value were 4 ng/L and the 1-h value ≤7 ng/L. Patients in the standard of care (SC) protocol used conventional cTn testing at 0 and 3 h. The primary outcome was the total cost of treatment, and the secondary outcome was ED length of stay. Results: Among 32,450 included patients, an AP had no significant differences in cost (+$89, CI: -$714, $893 hospital cost, +$362, CI: -$414, $1138 health system cost) or ED length of stay (+46, CI: -28, 120 min) compared with the SC protocol. In lower acuity, free-standing EDs, patients under the AP experienced shorter length of stay (-37 min, CI: -62, 12 min) and reduced health system cost (-$112, CI: -$250, $25). Conclusion: Overall, the implementation of AP using hs-cTn does not result in higher costs.

The Impact of Sociodemographic Factors, Comorbidities, and Physiologic Responses on 30-Day Mortality in Coronavirus Disease 2019 (COVID-19) Patients in Metropolitan Detroit.

BACKGROUND: The relationship of health disparities and comorbidities in coronavirus disease 2019 (COVID-19)-related outcomes are an ongoing area of interest. This report assesses risk factors associated with mortality in patients presenting with COVID-19 infection and healthcare disparities. METHODS: We conducted a retrospective cohort study of consecutive patients presenting to emergency departments within an integrated health system who tested positive for COVID-19 between 7 March and 30 April 2020 in metropolitan Detroit. The primary outcomes were hospitalization and 30-day mortality. RESULTS: A total of 3633 patients with a mean age of 58 years were included. The majority were female and Black non-Hispanic. Hospitalization was required for 64% of patients, 56% of whom were Black. Hospitalized patients were older, more likely to reside in a low-income area, and had a higher burden of comorbidities. By 30 days, 433 (18.7%) hospitalized patients died. In adjusted analyses, the presence of comorbidities, an age >60 years, and more severe physiological disturbance were associated with 30-day mortality. Residence in low-income areas (odds ratio [OR], 1.02; 95% confidence interval [CI], .76-1.36) and public insurance (OR, 1.24; 95% CI, .76-2.01) were not independently associated with a higher risk of mortality. Black female patients had a lower adjusted risk of mortality (OR, 0.46; 95% CI, .27-.78). CONCLUSIONS: In this large cohort of COVID-19 patients, those with comorbidities, advanced age, and physiological abnormalities on presentation had higher odds of death. Disparities in income or source of health insurance were not associated with outcomes. Black women had a lower risk of dying.

Establishment of pressurized-liquid extraction by response surface methodology approach coupled to HPLC-DAD-TOF-MS for the determination of phenolic compounds of myrtle leaves.

Myrtus communis L. (myrtle) is native to the Mediterranean region and Western Asia. Its leaves have demonstrated its potential effect towards different bioactivities like anti-diabetic, anti-diarrheic, anti-ulcer, anti-cancer, among others. These activities have been associated with its phenolic content. In this sense, the aim of this work has been to develop a new pressurized-liquid extraction procedure (PLE), by using a response surface methodology (RSM), to evaluate the phenolic composition from myrtle leaves by HPLC-DAD-TOF-MS. Previously, different solvents such as methanol, ethanol, and acetone/water mixtures were tested by using ultrasound-assisted extraction (UAE) in order to select the most suitable one. Subsequently, a Box-Behnken design (BBD) was performed according to the effect of ethanol/water ratio (50, 75, and 100% (v/v)), temperature (50, 125, and 200 °C), and extraction time (5, 18, and 30 min). The optimal conditions achieved with the established method were 71% ethanol/water, 137 °C, and 19 min. The analysis of the obtained extracts by HPLC-DAD-TOF-MS allowed the characterization of 15 new compounds in myrtle leaves. Finally, high amounts of gallic and ellagic acid were found in the optimized PLE extracts (3.31 ± 0.03 and 3.88 ± 0.09 mg/g leaf dry weight (d.w.), respectively), and PLE reported greater recovery of total phenolic compounds than UAE (30 ± 1 and 22.4 ± 0.6 mg/g leaf d.w., respectively).

[Round ligament suspension in laparoscopic hepatic surgery: technical advantages]. / La sospensione del legamento rotondo in chirurgia epatica laparoscopica: vantaggi tecnici.

Transabdominal suspension sutures are generally described in different laparoscopic surgical techniques. During the different phases of the surgical procedure, this solution permits the surgeon to achieve better exposure of the "target organ" or adequate stabilisation of it without adding more ports and instruments. In a limited working space, the use of many instruments may interfere with the surgeon's movements. In the present paper, we present the use of suspension sutures of the round ligament in different hepatic surgical techniques performed laparoscopically in our department of surgery, analysing the technical advantages.