Multinational Study Research Articles

Timing of coronary angiography in high-risk non-ST-elevation acute coronary syndrome: results from the Portuguese Registry for Acute Coronary Syndromes (ProACS).

Current guidelines recommend an early invasive coronary angiography (ICA) within 24 h of admission for high-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). Nevertheless, meta-analyses failed to demonstrate a clear advantage of this strategy in reducing hard endpoints such as death or nonfatal myocardial infarction compared to a delayed approach. Thus, the optimal timing of ICA in high-risk NSTE-ACS remains undetermined. This study aimed to determine the optimal timing for ICA in high-risk NSTE-ACS, regarding 1-year all-cause mortality and cardiovascular rehospitalizations. We conducted a national multicenter retrospective study of high-risk NSTE-ACS patients included in the Portuguese Registry for Acute Coronary Syndromes. Patients were divided into three groups according to the time of ICA: within the first 24 h, between 24 and 48 h, and between 48 and 72 h. The incidence of in-hospital complications and mortality, 1-year mortality, and cardiovascular rehospitalizations were assessed. Of the 9949 patients included, 46.7% underwent early ICA. This was associated with a lower incidence of acute heart failure (8.5% vs. 11.1% vs. 11.5%, P < 0.001) and shorter length of stay (3 vs. 4 vs. 6 days, P = 0.012). It, however, did not reduce in-hospital complications or mortality (1.2 vs. 0.7 vs. 0.8%, P = 0.066). We also found no significant association with the composite endpoint of 1-year mortality or cardiovascular rehospitalization (15.1 vs. 15.9 vs. 15.7%, P = 0.887). Early ICA was associated with a lower incidence of acute heart failure and shorter length of stay, without a significant impact on 1-year mortality risk or cardiovascular rehospitalizations.

Clinical Decision-Making of Repair vs. Replacement of Defective Direct Dental Restorations: A Multinational Cross-Sectional Study With Meta-Analysis.

This web-based survey, conducted across multiple countries, sought to explore the factors that impact the decision-making of clinicians when it comes to managing defective direct restorations. A survey consisting of 14 questions was sent out to dentists in 21 countries through various online platforms. The survey consisted of two sections. The first contained five questions about demographic information, while the second involved eight clinical scenarios. In the second part, participants were tasked with deciding whether to repair or replace defective composite and amalgam restorations. Three thousand six hundred eighty dental practitioners completed the survey. For composite restorations, repair was preferred in scenarios like partial loss or fracture (RR:0.72; 95% CI: 0.58, 0.89; p = 0.002), whereas replacement was favored for secondary caries (RR:2.43; 95% CI: 1.87, 3.16; p < 0.001) and open/defective margins (RR:3.93; 95% CI: 2.68, 5.76;p < 0.001). Amalgam restorations were mostly replaced across all scenarios. The main factors influencing decision-making were caries risk, restoration size, and patient oral hygiene. Substantial heterogeneity was observed across countries. This study underscores the complexity of the decision-making process and the need for evidence-based guidelines to inform clinicians' decisions regarding restoration management. Patient-level factors predominantly influence decision-making, emphasizing the need for individualized approaches. The study reveals that the material type in the original restoration is a critical determinant, with composite restorations being repaired in specific scenarios, while amalgam restorations are consistently replaced across different countries. Key patient and tooth-level factors, such as high caries risk, poor oral hygiene, and restoration size, significantly impact clinicians' decisions, often favoring replacement over repair. These findings underscore the necessity for evidence-based guidelines to assist clinicians in making informed choices, ultimately enhancing the quality of patient care.

Association between Semaglutide and Non-Arteritic Anterior Ischemic Optic Neuropathy: A Multinational Population-Based Real-World Study

ObjectiveTo investigate whether semaglutide increases the risk of non-arteritic anterior ischemic optic neuropathy (NAION) in the general population. DesignThis retrospective cohort study utilized a de-identified global electronic medical records database. The enrollment period was extended from January 2017 to August 2023, with observations concluding in August 2024. ParticipantsThis study included individuals with type 2 diabetes mellitus (T2DM) or obesity. They were further categorized into T2DM-only, obesity-only, and T2DM with obesity groups to assess the differences among these subgroups. The effects of semaglutide were compared with those of glucose-lowering or weight loss medications other than glucagon-like peptide receptor agonists. MethodsPatient data were obtained from 160 healthcare organizations across 21 countries. Outcomes were evaluated at one, two, and three years of follow-up. A 1:1 propensity score matching was performed to balance age, sex, body mass index, hemoglobin A1C, medications, and underlying comorbidities. Cox regression models were used to compute hazard ratios (HR) and 95% confidence intervals (CI). Main Outcome MeasuresThe occurrence of NAION. ResultsThe final analysis included 37,245 participants with T2DM-only, 33,537 participants with obesity-only, and 64,989 participants with both T2DM and obesity. The results indicated that the administration of semaglutide was not associated with the development of NAION in the T2DM-only group (1 year follow-up: HR, 2.32; 95% CI, 0.60–8.97; 2 years: HR, 2.31; 95% CI, 0.86–6.17; 3 years: HR, 1.51; 95% CI, 0.71–3.25), the obesity-only group (1 year follow-up: HR, 0.25; 95% CI, 0.03–2.28; 2 years: HR, 0.44; 95% CI, 0.09–2.21; 3 years: HR, 0.44; 95% CI, 0.09–2.21), and the T2DM with obesity group (1 year follow-up: HR, 0.81; 95% CI, 0.42–1.57; 2 years: HR, 1.2; 95% CI, 0.74–1.94; 3 years: HR, 1.19; 95% CI, 0.78–1.82). ConclusionsThe findings suggest that semaglutide may not be associated with an increased risk of NAION in the general population. Therefore, avoidance of semaglutide based solely on concerns regarding the risk of NAION may not be warranted, as its potential benefits for blood glucose control and cardiovascular health likely outweigh its potential risks.

Variation of subclinical psychosis as a function of population density across different European settings: Findings from the multi-national EU-GEI study.

Urbanicity is a well-established risk factor for psychosis. Our recent multi-national study found an association between urbanicity and clinical psychosis in Northern Europe but not in Southern Europe. In this study, we hypothesized that the effect of current urbanicity on variation of schizotypy would be greater in North-western Europe countries than in Southern Europe ones. We recruited 1080 individuals representative of the populations aged 18-64 of 14 different sites within 5 countries, classified as either North-western Europe (England, France, and The Netherlands) with Southern Europe (Spain and Italy). Our main outcome was schizotypy, assessed through the Structured Interview for Schizotypy-Revised. Our main exposure was current urbanicity, operationalized as local population density. A priori confounders were age, sex, ethnic minority status, childhood maltreatment, and social capital. Schizotypy variation was assessed using multi-level regression analysis. To test the differential effect of urbanicity between North-western and Southern European, we added an interaction term between population density and region of recruitment. Population density was associated with schizotypy (β = 0.248,95%CI = 0.122-0.375;p < 0.001). The addition of the interaction term improved the model fit (likelihood test ratio:χ2 = 6.85; p = 0.009). The effect of urbanicity on schizotypy was substantially stronger in North-western Europe (β = 0.620,95%CI = 0.362-0.877;p < 0.001) compared with Southern Europe (β = 0.190,95%CI = 0.083-0.297;p = 0.001). The association between urbanicity and both subclinical schizotypy and clinical psychosis, rather than being universal, is context-specific. Considering that urbanization is a rapid and global process, further research is needed to disentangle the specific factors underlying this relationship.

Critical care unit bed availability and postoperative outcomes: a multinational cohort study.

Critical care beds are a limited resource, yet research indicates that recommendations for postoperative critical care admission based on patient-level risk stratification are not followed. It is unclear how prioritisation decisions are made in real-world settings and the effect of this prioritisation on outcomes. This was a prespecified analysis of an observational cohort study of adult patients undergoing inpatient surgery, conducted in 274 hospitals across the UK and Australasia during 2017. The primary outcome was postoperative morbidity at day 7. Logistic regression models were used to evaluate the relationship between critical care admission and patient and health system factors. The causal effect of critical care admission on outcome was estimated using variation in critical care occupancy as a natural experiment in an instrumental variable analysis. A total of 19,491 patients from 248 hospitals were eligible for analysis, of whom 2107 were directly admitted to critical care postoperatively. Postoperative morbidity occurred in 2829/19,491 (15%) patients. Increasing surgical risk was associated with critical care admission, as was increased availability of critical care beds (odds ratio (95%CI) 1.04 (1.01-1.06), p = 0.002) per available bed; however, the probability of admission varied significantly between hospitals (median odds ratio 3.05). There was no evidence of a difference in postoperative morbidity with critical care admission (odds ratio (95%CI) 0.91 (0.57-1.45), p = 0.710). Postoperative critical care admission is variable and related to bed availability. Statistical methods that adjust for unobserved confounding lowered the estimates of harm previously reported to have been associated with postoperative critical care admission. Our findings provide a rationale for a clinical trial which would evaluate any potential benefits for postoperative critical care admission for patients in whom there is no absolute indication for admission.

Outcomes and inflammation changes in different types of immunocompromised patients with critically ill COVID-19 admitted to ICU: a national multicenter study

BackgroundImmunocompromised patients face higher risks of Severe Acute Respiratory Syndrome Coronavirus 2 infection and co-infections, leading to a possibility of high disease severity and poor outcomes. Conversely, immunosuppression can mitigate the excessive inflammatory response induced by the virus, potentially reducing disease severity. This study aims to investigate the prognostic differences and early inflammatory response characteristics in various types of immunocompromised patients with severe coronavirus disease 2019 (COVID-19) admitted to intensive care unit (ICU), summarize their clinical features, and explore potential mechanisms.MethodsA retrospective analysis was conducted on critically ill COVID-19 patients admitted to the ICU of 59 medical centers in mainland China during the Omicron outbreak from November 2022 to February 2023. Patients were categorized into two groups based on their immunosuppression status: immunocompromised and immunocompetent. Immunocompromised patients were further subdivided by etiology into cancer patients, solid organ transplant (SOT) patients, and other immunocompromised groups, with immunocompetent patients serving as controls. The mortality rates, respiratory support, complications, and early inflammatory cytokine dynamics upon ICU admission among different populations were analyzed.ResultsA total of 2030 critically ill COVID-19 patients admitted to ICU were included, with 242 in the immunocompromised group and 1788 in the immunocompetent group. Cancer patients had a higher median age of 69 years (IQR 59, 77), while SOT patients were generally younger and had less severe illness upon ICU admission, with a median APACHE II score of 12.0 (IQR 8.0, 20.0). Cancer patients had a twofold increased risk of death (OR = 2.02, 95% CI 1.18–3.46, P = 0.010) compared to immunocompetent patients. SOT and cancer patients exhibited higher C-reactive protein and serum ferritin levels than the immunocompetent group in their early days of ICU admission. The CD8+ T cells dynamics were inversely correlated in cancer and SOT patients, with Interleukin-6 levels consistently lower in the SOT group compared to both immunocompetent and cancer patients.ConclusionCritically ill COVID-19 patients admitted to the ICU exhibit distinct clinical outcomes based on their immunosuppression status, with cancer patients facing the highest mortality rate due to variations in inflammatory responses linked to their immunosuppression mechanisms. Monitoring dynamic changes in inflammatory markers and immune cells, particularly CD8+ T lymphocytes and IL-6, may offer valuable prognostic insights for these patients.

The Cancer-Specific Health Economic Measure QLU-C10D is Valid and Responsive for Assessing Health Utility in Patients with Thyroid Cancer.

Background: Health economic appraisals often rely on the assessment of health utilities using preference-based measures (PBM). The cancer-specific PBM, European Organisation for Research and Treatment of Cancer Quality of Life Utility - Core 10 Dimensions (EORTC QLU-C10D), was developed recently, and now needs to be validated in various clinical populations. Methods: In a multicenter, multinational prospective cohort study, we longitudinally collected EORTC QLQ-C30 and EQ-5D-5L data from patients with thyroid cancer. We applied seven country-specific value sets to the QLQ-C30 data to derive country-specific utility values and used the EQ-5D-5L as a comparator PBM. Criterion validity was assessed by correlating index scores and Bland-Altman plots. Construct validity was investigated by correlating domain scores. Known-group comparisons and responsiveness were assessed using external clinical criteria. Results: A total of 181 patients with thyroid cancer from nine countries (three continents) provided analyzable data. Patients were included if they had differentiated, medullary, or anaplastic thyroid cancer. Mean utility values of both instruments were generally lower compared to general population norms. No floor or ceiling effects were present for the QLU-C10D. The intra-class correlation for EQ-5D-5L and QLU-C10D index values ranged from 0.761 to 0.901 across the measurement timepoints, supporting criterion validity. Spearman's correlation coefficients ranged from 0.289 to 0.716 for theoretically corresponding domain pairs. The QLU-C10D detected differences in 9 of 15 known-group comparisons, supporting sensitivity. Clinically important changes were detected by all QLU-C10D country specific value sets, supporting responsiveness. Further, the QLU-C10D had higher statistical efficiency than the EQ-5D-5L in 74.7% of comparisons. Conclusions: The QLU-C10D is a valid PBM for health economic evaluations in thyroid cancer studies. We recommend its use to estimate health utilities in economic evaluations of thyroid cancer therapies.

Inter-Reader Agreement for Contrast-Enhanced Ultrasound Liver Imaging Reporting and Data System Major Features and Final Categorization: A Subanalysis From a Prospective Multicenter Study.

Contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS) is used to definitively diagnose hepatocellular carcinoma (HCC) in patients at risk. However, the user variability associated with CEUS LI-RADS has not been validated in North American and European patients. This study aims to evaluate the inter-reader agreements of CEUS LI-RADS features for, and final categorization of, HCC in patients at risk. This retrospective multicenter clinical study used the database of a previous prospective multinational study, evaluating the accuracy of CEUS LI-RADS for HCC diagnosis in patients at risk. All cases were first evaluated by a site physician performing/supervising the CEUS examination. Randomly selected cases were re-evaluated by a blinded central reader. Final diagnosis was confirmed with the reference standard, which was a composite of imaging tests and histology. Cohen's kappa test was used to evaluate inter-reader agreement. This study included 150 liver nodules and 58.0% (87/150) were confirmed as HCC, 4.7% (7/150) non-HCC malignancies, 22.7% (34/150) had no confirmed final diagnosis, and 14.7% (22/150) were nonmalignant. Inter-reader agreements were substantial for CEUS LI-RADS categorization (κ = 0.61; 95% confidence interval [CI]: 0.51-0.71) and major features assessment (ranged κ = 0.64-0.78), LR-5 (κ = 0.65; 95% CI: 0.52-0.77), and LR-M (κ = 0.67; 95% CI: 0.44-0.90), while for LR-1 and LR-2 categorization was almost perfect (κ = 0.85; 95% CI: 0.65-1.00). Our study reported a substantial inter-reader agreement for overall CEUS LI-RADS categorization, especially for LR-5 and LR-M, and major imaging features of HCC, further confirming CEUS LI-RADS as a valuable and reliable tool for diagnosis of HCC.

Passing the hot potato: a multinational study on public trust in the health policy process

Abstract Background Health data-sharing initiatives are central to European and national e-health strategies, aiming to improve healthcare quality, inform policymaking, and drive research. Public trust is crucial for their success, influencing public participation and policymakers’ legitimacy. This study investigates the role of public trust in the health policy process at both the European level and in Italy, France, and Switzerland to determine 1) if a common conceptual understanding of public trust across different countries and policy stages exists, and 2) if policymakers explicitly discuss and implement trust-building measures in their legislative work Methods A total of 60 interviews were conducted with 16 European, 15 Italian, 14 French, and 15 Swiss policymakers from the World Health Organization, the Council, Parliament, and Commission at the European level, along with representatives from the Ministry of Health, Parliament, regional councils, local health authorities, frontline staff, and relevant agencies at the national levels Results Preliminary results reveal that a common definition of public trust in health data sharing is missing. Associations to public trust are observed at the European level with citizens’ reassurance about their sensitive data being shared, and in Switzerland with data security. In France, public trust is connected to public engagement, while no distinct patterns were identified in Italy. Findings also reveal a consensus among interviewees on the central role public trust plays in health data-sharing initiatives; yet public trust is perceived as a vague concept, often addressed implicitly without a clear strategy Conclusions The study reveals widespread ambiguity among policymakers regarding the definition of public trust and its translation into policy. Practical guidance is crucial to effectively integrate elements of public trust into policymaking, thereby actively reinforcing trust in health data sharing through legislative efforts Key messages • While policymakers recognize the importance of public trust for data-driven health initiatives, they lack a common conceptual understanding on what trust is and how to build it. • Guidance is needed to help policymakers actively contributing building trust in health data sharing through their legislative work.

The sooner the better? What is the optimal timing for coronary angiography in high-risk non-ST-elevation acute coronary syndrome

Abstract Introduction current guidelines recommend an early invasive coronary angiography (ICA), in the first 24 hours, for high-risk non-ST elevation acute coronary syndrome (NSTE-ACS) patients. However, several studies have failed to demonstrate a significant improvement in all-cause mortality, with controversial results regarding recurrent ischemia and myocardial infarction. Purpose to evaluate the optimal timing of ICA in high-risk NSTE-ACS. Methods this was a national multicentre retrospective study of patients hospitalized for NSTE-ACS between October 2010 and October 2023. Patients presenting in Killip class IV, mechanical complications, life-threatening arrhythmias or cardiac arrest were excluded. Participants were divided into three groups, according to the timing of ICA: in the first 24 hours (D0), between 24 and 48 hours (D1) and between 48 and 72 hours (D2). The incidence of in-hospital complications and mortality, as well as 1-year mortality rate and cardiovascular rehospitalization, was compared for the three groups. Results a total of 9949 patients was included, 98.2% with non-ST elevation myocardial infarction (NSTEMI) and 1.8% with unstable angina with high-risk criteria (GRACE risk score &amp;gt;140 or transient ST-segment elevation). Most patients were submitted to early ICA (46.7%), with 26.7% and 26.6% in D1 and D2, respectively. Interestingly, patients in higher Killip class (II or III) were referred for ICA latter than patients in Killip class I (9.0% in D0 vs. 11.3% in D1 vs. 13.5% in D2, p&amp;lt;0.001). Regarding in-hospital complications, early ICA was associated with a lower incidence of acute heart failure (8.5% vs. 11.1% vs. 11.5%, p&amp;lt;0.001) and shorter length of stay (7 vs. 6 vs. 10 days, p=0.01). However, it did not reduce in-hospital mortality (1.2% vs. 0.7% vs. 0.8%, p=0.07), recurrent myocardial infarction (0.9% vs. 1.5% vs. 1.3%, p=0.09), cardiogenic shock (7.9% vs. 5.7% vs. 5.4%, p=0.19), mechanical complications (0.1% vs. 0.2% vs. 0.1%, p=0.50) or sustained ventricular tachycardia (0.8% vs. 0.6% vs. 0.4%, p=0.12). Left ventricular ejection fraction was also similar between groups (54%±12, p=0.97). There were also no significant differences between groups regarding 1-year mortality or cardiovascular rehospitalization (15.1% vs. 15.9% vs. 15.7%, p=0.89). Conclusion in high-risk NSTE-ACS patients, early ICA resulted in lower incidence of acute heart failure and shorter length of stay. However, timing of ICA didn’t show a significant impact on in-hospital mortality or complications, nor in 1-year mortality rate or cardiovascular rehospitalization.

Real-life impact of complete revascularization of non-ST elevation myocardial infarction during index hospitalization

Abstract Introduction patients with non-ST elevation acute myocardial infarction (NSTEMI) frequently present multivessel disease (MVD) with significant stenosis in non-infarct-related arteries (non-IRA). Unlike for ST elevation acute myocardial infarction, there is a paucity of studies evaluating the prognostic impact of complete revascularization in these patients. In fact, recommendation for complete revascularization is based in observational and non-randomized studies suggesting a possible benefit regarding mortality and major cardiovascular events. Purpose to evaluate the prognostic impact of complete revascularization during the index hospitalization in the Portuguese patients with NSTEMI and MVD. Methods patients hospitalized for NSTEMI with MVD included in a national multicentre retrospective study between October 2010 and December 2022 were divided into two groups: group 1 was submitted to complete percutaneous revascularization during the index hospitalization (IRA and non-IRA with diameter stenosis ≥50% on angiography), and group 2 performed IRA-only revascularization. The impact of complete revascularization on the probability of cardiovascular re-hospitalization, as well as on in-hospital and one-year mortality rates was evaluated. Results a total of 3084 patients was included, 74.8% were males, with a mean age of 67.8±11.9 years. Most patients were submitted to IRA-only revascularization (72.9%). From the remaining, 81.4% performed complete revascularization during the index procedure and 18.6% staged during index hospitalization. Group 1 patients were younger (65.5±11.8 vs. 68.6±11.8 years, p&amp;lt;0.001), with fewer comorbidities and slightly higher left ventricular ejection fraction (55±11 vs. 51±11%, p&amp;lt;0.001). On the other hand, group 2 patients revealed a significantly higher percentage of previous, revascularization (14.8% vs. 1.6%), mostly surgical. Besides overall similar incidence of in-hospital complications, including recurrence of acute myocardial infarction, patients submitted to complete revascularization showed a non-significant trend to an inferior in-hospital mortality rate (0.7 vs. 1.6%, p=0.06). Also, 1-year mortality rate was similar between groups (4.2 vs. 5.0%, p=0.54). However, complete revascularization appeared to result in a long-term prognostic benefit, halving the incidence of unplanned cardiovascular re-hospitalizations at one year of follow-up (9.3 vs. 18.8%, p&amp;lt;0.001). Conclusion complete revascularization led to an overall long-term benefit, mainly due to a reduction in cardiovascular re-hospitalizations, without a significant impact on 1-year mortality rate.

Patient-reported outcomes, postoperative pain and pain relief after day case surgery (POPPY): methodology for a prospective, multicentre observational study.

In the UK, approximately 70% of surgical procedures are undertaken as day-cases. Little information exists about recovery from day-case surgery, yet international data highlights patients are at risk of developing significant longer-term health problems including chronic post-surgical pain and persistent postoperative opioid use. The Patient-reported Outcomes, Postoperative Pain and pain relief after daY case surgery (POPPY) study was a national prospective multicentre observational study, measuring short- and longer-term patient-reported outcomes, postoperative pain and pain relief after day-case surgery. This was a collaborative project led by resident anaesthetists under the Research and Audit Federation of Trainees umbrella. Adult day-case surgical patients were recruited on the day of surgery. Baseline data including patient characteristics; procedure details; pre-operative analgesic use; pre-existing pain; and quality of life scores were recorded. Patients were followed up through automated short message service messages. Short-term (postoperative days 1, 3 and 7) outcomes included: quality of recovery; pain severity; impact of pain on function; and analgesic use. Longer-term outcomes (postoperative day 97) included: quality of life; analgesic use; incidence of chronic post-surgical pain; and incidence persistent postoperative opioid use. Additional outcomes were completed by those patients with chronic post-surgical pain and persistent postoperative opioid use, with 30 patients recruited to a qualitative semi-structured interview study exploring postoperative expectations, recovery, postoperative pain and opioid use. An embedded pilot study at four sites recruited 129 patients. Responses to the automated short message service were gained from 129 patients (100%) at day 1; 116 (89.9%) at day 3; 108 (83.7%) at day 7; and 77 (59.7%) at day 97 postoperatively. The pilot enabled refinement of the methods and processes before the national roll out. This paper outlines the methods for the POPPY study, the largest UK multicentre prospective observational study considering short- and longer-term outcomes following day-case surgery.

Cardiovascular emergency in indonesian primary health care (PUSKESMAS): a national multicentre service evaluation study based on ESC guidelines adherence

Abstract Background Early diagnosis and prompt treatment are crucial in reducing cardiovascular (CVD) burden in the global level, especially in Indonesia with more than a half million CVD death annually. As frontliner, more than 10,000 primary healthcare (PUSKESMAS) spreading around Indonesia are pivotal in delivering CVD emergency care. However, due to the scarcity of healthcare resources, significant disparities exist between guideline recommendations and their implementation in Indonesian primary health care. Purpose Our study aims to describe current cardiovascular emergency care, assess guideline adherence, and identify key factors influencing the trend. Methods This multicentre study was conducted in 40 PUSKESMAS across Indonesia from October to December 2023. Data related to cardiovascular emergencies diagnosis, work-ups, treatment, and outcomes were gathered and then evaluated according to the ESC Guidelines. Recommendations, particularly Class I, were converted into points with respect to diagnostic and treatment domains. Guideline adherence scores were then calculated based on the percentage of accomplished points. Linear regression analysis was employed to identify factors that could explain variations in guideline adherence across all PUSKESMAS. Results 215 CVD emergency patients were reported. The most prevalent diagnosis was hypertensive crisis (n=137; 64%) with ECG done in only 26% of cases and none underwent imaging. Oral amlodipine (59%) and captopril (55%) were mostly used as antihypertensive, with none receiving intravenous. The second most common diagnosis was ACS (n=42; 20%), with ECG performed in only 71% of cases. Among 13 patients with STEMI, 69% only received aspirin, and 46% were given DAPT. Malignant arrhythmia occurred in 26 patients, with none receiving cardioversion. The most used anti-arrhythmic are bisoprolol, propranolol, and atropine. Among 23 cases of acute HF, only 39% received oxygen, while IV furosemide was used in only one case. Cardiac arrest occurred in two patients, both received CPR and epinephrine. In terms of guideline adherence, mean diagnostic score (%) was demonstrated highest in Cardiac Arrest at 100 and the lowest in Hypertensive Crisis and Acute HF at 53, while mean treatment score (%) was highest in Hypertensive Crisis at 86 and lowest in arrhythmia at 25. Linear regression suggests that human resources have a positive and significant association with diagnostic adherence scores (R2: 0.3485, p-value: 0.0450), whereas essential medicine has a strong but non-significant correlation with treatment adherence score (R2: 1.0768, p-value: 0.460). Conclusion This study has demonstrated a huge disparity between the current CVD emergency practices and guidelines in Indonesian primary healthcare. These gaps emphasised the need for improved human resources and essential medicine for primary healthcare along with the implementation of data-driven policy making concerning cardiovascular disease in Indonesia.Cardiovascular Emergency Diagnosis in InCardiovascular Emergency Work-up and Tre

Efficacy of vortioxetine versus desvenlafaxine in the treatment of functional impairment in patients with major depressive disorder: Results from the multinational VIVRE study.

In VIVRE (NCT04448431), vortioxetine was associated with significantly higher rates of symptomatic and functional remission, better daily and social functioning, and greater treatment satisfaction than desvenlafaxine in patients with major depressive disorder (MDD) and partial response to selective serotonin reuptake inhibitor (SSRI) therapy. This analysis further explored the relative improvement in patient functioning with vortioxetine versus desvenlafaxine. VIVRE was a randomized, double-blind study of vortioxetine (10 or 20mg/day) versus desvenlafaxine (50mg/day) in adults with MDD and partial response to initial SSRI monotherapy. Mean percentage changes from baseline to week 8 in Functioning Assessment Short Test (FAST) total and domain scores were analyzed by treatment group in the overall population and in working patients. In the overall population, the mean reduction in FAST total score from baseline after 8weeks of treatment was 37.2% in vortioxetine-treated patients versus 31.8% in desvenlafaxine-treated patients (P=0.04). Significantly greater improvements versus desvenlafaxine were seen in vortioxetine-treated patients for FAST autonomy, cognitive functioning, and interpersonal-relationships scores (all P<0.05). In working patients, the mean reduction in FAST total score from baseline at week 8 was 38.7% versus 32.1% in the vortioxetine and desvenlafaxine groups, respectively (P=0.04). Significant correlations were seen between absolute changes in patient functioning, and those in depression severity and health-related quality of life. Vortioxetine was significantly better than desvenlafaxine in improving overall functioning as well as daily, social, and cognitive functioning in patients with MDD with inadequate response to prior SSRI therapy.

Healthcare workers' knowledge, attitudes, and practices towards cardiovascular disease prevention: a multi-national cross-sectional study

Abstract Introduction Prior studies have shown that improved primordial prevention of cardiovascular disease (CVD) may significantly delay its onset. Healthcare workers (HCWs) are well-placed to influence healthy lifestyle habits for CVD prevention. However, it is unclear how well HCWs fare in this role given the multiple demands on their time in clinical practice. Purpose We sought to understand the CVD prevention knowledge, attitudes and practices (KAPs) of HCWs across 25 nations. Insights gained could help inform efforts to optimise CVD prevention by HCWs. Methodology: Data was collected via an anonymous, online questionnaire which consisted of pre-validated CVD prevention and smoking cessation subscales adapted from the Preventive Medicine Attitudes and Activities Questionnaire (PMAAQ). The subscales have been previously validated in a study population of primary care residents in the US, demonstrating validity and reliability. Results 668 HCWs (60% doctors, 28% nurses, 12% medical students) from 25 nations responded to the survey. Overall, 74.86% of HCWs routinely assessed patients’ cardiovascular (CV) risk profiles in clinical practice. 65.65% of HCWs counselled patients who were asymptomatic for CVD on tangible lifestyle changes to improve their CV risk profiles, while 68.22% of HCWs did so when patients were overweight. Of note, only 51.26% of HCWs implemented comprehensive smoking cessation interventions for their patients. Practising HCWs demonstrated higher levels of CVD prevention promotion than medical students in all aspects (Fig 1b), except for self-reported importance of CVD risk factor counselling in primary prevention (Tukey HSD diff: 0.31, p-value: 0.051). Among practising HCWs, there were no significant differences in their promotion of CVD prevention across varying lengths of clinical practice. HCWs from higher income nations[1] tended to fare worse than their lower income counterparts in the promotion of CVD prevention (Fig 1a). Conclusion A large multi-national survey reveals significant gaps in the promotion of CVD prevention by HCWs, highlighting key differences in CVD prevention practices based on national income status. The results also demonstrate significant differences between medical students and practising HCWs’ CVD prevention behaviours, highlighting the role of continuing education for the promotion of long-term positive CVD prevention clinical practices amongst HCWs. Further efforts may target the medical education of early-career HCWs, especially in higher income nations. [1] National income level is defined as per the World Bank's classification, with the exception of Taiwan which is not classified as an independent nation under the World Bank. However, Taiwan is still labelled as a high income nation as her GNI (US$33,565) fits the criterion of the World Bank's definition of a high income nation (GNI per capita of &amp;gt;US$13,846).Table 1:Participant demographicsFigure 1a and 1b

Clinical characteristics and treatment patterns of new users of dapagliflozin for heart failure with reduced ejection fraction: an observational study programme across 12 countries (EVOLUTION HF)

Abstract Background Clinical trials have shown that dapagliflozin, a sodium–glucose cotransporter-2 inhibitor (SGLT-2i), reduces cardiovascular mortality and worsening heart failure (HF). Adoption of new therapies has historically been slow despite robust evidence. Furthermore, treatment profiles of patients in real-world settings are scarce. Purpose EVOLUTION HF is a multinational study programme that aims to describe clinical characteristics and treatment patterns among patients initiating dapagliflozin for HF with reduced ejection fraction (HFrEF) in routine clinical practice. Methods The EVOLUTION HF primary data study programme consists of prospective, observational, descriptive studies of new users of dapagliflozin for HFrEF in 12 countries (Italy, Portugal, UK and the Central and Eastern Europe and Baltic [CEEBA] region [Bulgaria, Croatia, Estonia, Hungary, Latvia, Lithuania, Poland, Romania and Slovenia]). Patients with type 1 diabetes or prior SGLT-2i treatment were excluded. Clinical characteristics were obtained from electronic health records. A total of 2170/2555 (85%) patients were enrolled from November 2021 to November 2023; 1736 patient profiles were assessed using descriptive statistics in this interim analysis. Results In total, 256, 228, 125 and 1127 new dapagliflozin users were analysed from Italy, Portugal, the UK and the CEEBA region, respectively (Table 1). Across the 12 countries, mean patient age in the studies was 65–70 years. Patients were predominantly male (67–76%) and generally had HF with an ischaemic aetiology (35–56%) and New York Heart Association functional class II (52–85%). Mean left ventricular ejection fraction in the studies was 29–32% and estimated glomerular filtration rate was 61–77 mL/min/1.73m². Hypertension and atrial fibrillation were common comorbidities. Mean time between HF diagnosis and dapagliflozin initiation in the studies was 23–52 months. Background therapy included angiotensin receptor-neprilysin inhibitors (36–72%), angiotensin receptor blockers (4–12%) and angiotensin-converting enzyme inhibitors (9–33%). At 6 and 12 months after dapagliflozin initiation, respectively, treatment discontinuation rates across the CEEBA region were 5.22% (59/1131) and 4.66% (50/1072). Conclusions The EVOLUTION HF primary data study programme provides novel insights into clinical characteristics and treatment patterns in patients with HFrEF initiating dapagliflozin in real-world practice across a broad European population. At dapagliflozin initiation, a large proportion of patients were receiving other HF therapeutics, suggesting dapagliflozin is one of the later therapies to be initiated. Indeed, this study identified a substantial delay (23–52 months) in dapagliflozin initiation following HF diagnosis. Treatment discontinuation rates following dapagliflozin initiation were also low, reinforcing the findings of the EVOLUTION HF secondary data studies.

The Climate-Asthma Connection: Examining the Influence of Climate Change Anxiety on Asthma Control and Quality of Life: A Multi-National Study.

This study aims to identify the impact of climate change anxiety and asthma control on asthmatics' quality of life and examine the moderating role of climate change anxiety in this linkage. A multi-national cross-sectional study was conducted in four Arabian countries on 1266 asthmatics selected by convenience sampling. Data were collected from November 2023 to February 2024 using a climate anxiety scale, mini-asthma quality of life questionnaire, and an asthma control questionnaire. Climate anxiety was higher among middle-aged participants, as well as those with longer disease durations and previous hospitalisations. Climate anxiety showed strong negative correlations with asthma control (r = -0.704, p ≤ 0.05) and asthma quality of life (r = - 0.638, p ≤ 0.05). Climate anxiety and asthma control are powerful predictors of quality of life among asthmatics. Climate anxiety moderates the relationship between asthma control and quality of life, making it less positive (B = -0.094, p > 0.001). Covariates such as gender, age, comorbidities, employment status, disease duration, and previous hospitalisation showed significant associations with asthma quality of life. Assessment and mitigation of climate anxiety among asthmatics is a key strategy for controlling asthma and improving the quality of life. So, nurses must incorporate climate anxiety assessment into the care plan for asthmatics. Climate change is a global concern, and insights into how climate-related psychological stressors exacerbate asthma symptoms and overall health outcomes are necessary. The findings provide actionable data for healthcare professionals to underscore the need for integrated healthcare approaches considering environmental and psychological factors. This study adheres to strengthening the reporting of observational studies in epidemiology (STROBE) statement. Clients with asthma across multiple nationalities actively contributed to our paper.

Predictors and Outcomes of Excellent Recanalization Versus Successful Recanalization After Thrombectomy in Proximal and Distal Medium Vessel Occlusion Strokes: A Multinational Study

BACKGROUND Acute ischemic stroke arising from medium vessel occlusions (MeVO) poses substantial challenges in treatment and management. This study aims to elucidate the outcomes and factors contributing to achieving excellent recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] 2c–3) versus successful recanalization (mTICI 2b) in patients with MeVO stroke undergoing mechanical thrombectomy (MT). METHODS We conducted a multinational study analyzing data from the MAD‐MT (Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy) registry, encompassing 37 centers across North America, Asia, and Europe, collected between September 2017 and July 2023. The study included acute ischemic stroke patients with MeVO treated with MT, with or without intravenous thrombolysis, who achieved mTICI 2b–3 post‐MT. RESULTS Among 1463 patients with successful recanalization (mTICI 2b–3), 523 achieved mTICI 2b recanalization, and 940 achieved mTICI 2c–3. Distal occlusions exhibited higher odds of excellent recanalization compared with proximal MeVO vessel occlusions (odds ratio, 1.58; 95% CI, 1.17–2.15; P = 0.003). Cardioembolic stroke pathogenesis was associated with a higher likelihood of excellent recanalization (1.67; 95% CI, 1.07–2.59; P = 0.018). Patients achieving mTICI 2c–3 recanalization demonstrated lower initial National Institutes of Health Stroke Scale scores, significant improvements in postprocedural National Institutes of Health Stroke Scale shift, and a higher percentage of favorable 90‐day outcomes compared with those with mTICI 2b. However, no significant difference in 90‐day mortality rates was observed. CONCLUSION This study underscores that among patients with MeVO stroke with successful recanalization (mTICI 2b–3) there is higher likelihood of achieving excellent recanalization (mTICI 2c–3) in distal occlusions and cardioembolic pathogenesis. mTICI 2c–3 scores post‐MT correlate with improved clinical outcomes compared with mTICI 2b, affirming the superiority of excellent recanalization over successful recanalization in patients with MeVO stroke. Further prospective studies and randomized controlled trials are warranted for validation.

Polymer Everolimus-Eluting Stent as Bailout Stenting for Below-the-Knee Artery Repair in Patients with Critical Limb-Threatening Ischemia: A Real-World National Registry.

Percutaneous old balloon angioplasty is still the preferred treatment for the treatment of below-the-knee (BTK) arteries in chronic limb-threatening ischemia (CLTI). In the case of a suboptimal angioplasty result, a bailout stenting is required. So far, few data are available to assess the outcomes of bailout stenting after BTK angioplasty. This study aims to investigate the 1-year efficacy and safety after implantation of a polymer everolimus-eluting stent (PEES) as bailout stenting for BTK repair in patients with CLTI in a real-world setting. This was a national multicenter prospective observational study. Patients with CLTI (Rutherford 4 to 6) BTK lesions (including P3) and requiring a bailout PEES due to dissection, thrombosis, or residual stenosis ≥30% after angioplasty were included. The freedom of a major adverse limb event at 12 months of the target limb was the primary endpoint. XIENCE assessed 106 limbs (CLTI, 96.2%; chronic total occlusion, 2.8%) in 106 patients (mean age 77.1 years; males, 71.7%; diabetes mellitus, 66.9%; chronic kidney failure, 36.8%) with CLTI undergoing PEES stenting as a bailout for BTK lesions. Bailout stenting was required after 75.5% and 26.4% of residual stenosis and dissection, respectively. The mean diameter and length of the PEES were 3 mm and 3.4 ± 0.5 cm, respectively. At 1 year, the freedom of a major adverse limb event was 79.6% (95% CI, 71.5%-88.7%), the major amputation rate was 6.2% (95% CI, 1.3%-11%), and the target revascularization rate was 14.9% (95% CI, 6.5%-22.5%). In CLTI patients with BTK lesions, PEES stenting showed safety and efficacy as bailout stenting for BTK arterial lesions. This confirms the need for PEES stenting in a real-world practice. The XIENCE study introduces the PEES as an effective bailout stenting option for patients with CLTI undergoing BTK revascularization, particularly for lesions under 4 cm. The study focuses on real-world cases where POBA alone is insufficient, demonstrating that PEES significantly improves outcomes by enhancing limb salvage and reducing the need for major amputations. For clinicians, this innovation offers a precise, size-adaptable solution, especially in cases where bailout stenting is required for short, focal lesions, improving both clinical and procedural results.

A global snapshot on health systems capacity for detection, monitoring, and management of acute kidney injury: A multinational study from the ISN-GKHA.

Acute kidney injury (AKI) is a significant cause of morbidity and mortality, especially in low and lower-middle income countries. Data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) were used to evaluate the organization of structures and services for the provision of AKI care in world countries and ISN regions. An international survey of key stakeholders (clinicians, policymakers, and patient advocates) from countries affiliated with the ISN was conducted from July to September 2022 to assess structures and services for AKI care across countries. Main findings of the study show that overall, 167 countries or jurisdictions participated in the survey, representing 97.4% of the world's population. Only 4% of countries had an AKI detection program based on national policy or guideline, and 50% of these countries used a reactive approach for AKI identification (i.e., cases managed as identified through clinical practice). Only 19% of national governments recognized AKI as a healthcare priority. Almost all countries (98% of the countries surveyed) reported capacity to provide acute hemodialysis (HD) for AKI, but in 31% of countries, peritoneal dialysis (PD) was unavailable for AKI. About half of all countries (44% of countries surveyed) provided acute dialysis (HD or PD) via public funding, but funding availability varied across ISN regions, including less than a quarter of countries in Oceania and South East Asia (17%) and Africa (24%) and highest availability in Western Europe (91%). Availability increased with the increasing country income level. Initiatives have been developed to propose and promote optimal care for AKI (including the ISN 0-by-25 initiative), but capacity for optimal AKI care remains low, particularly in low- and lower-middle-income countries. Concerted efforts by the global community are required to close these gaps, to improve AKI outcomes across the world.