Publications by authors named "Oscar Miró"

418 Publications

Acute heart failure in subtropical climates: clinical characteristics, management, and outcomes in the Canary Islands versus continental Spain - the CANAR-ICA study results.

Emergencias 2021 Dec;33(6):413-420

Servicio de Urgencias, Hospital Universitario de Canarias, Universidad de La Laguna, Tenerife, España.

Objectives: To determine whether there are differences in the clinical characteristics, management, and outcome of episodes of acute heart failure (AHF) in residents of the Canary Islands, where the climate is subtropical, and episodes in continental Spain.

Material And Methods: Cases were identified in the registry for Epidemiology of Acute Heart Failure in Emergency Departments and categorized as in the Canary Islands or continental Spain. Data for 38 demographic, baseline, clinical, and therapeutic variables were extracted. We analyzed statistics for in-hospital and 30-day mortality, long hospital stay (more than 7 days), and a composite outcome after discharge (revisits or death within 30 days). The results for island and continental patients were compared and adjusted for between-group differences.

Results: A total of 18 390 patients were studied, 697 islanders (3.8%) and 17 673 continental patients (96.2%). Comparisons showed that the islanders were younger; more often women; and more likely to have hypertension, diabetes, and a prior AHF episode. Their New York Heart Association functional class was also likely to be higher. However, their rates of dyslipidemia, valve disease, and functional dependence were lower, and they were also less likely to be on reninangiotensin system blockers. Although the severity of cardiac decompensation was similar in island and continental patients, the islanders received more intravenous treatments in the emergency department and were admitted less often. The adjusted risk of a long hospital stay was higher for the islanders (odds ratio [OR], 2.36; 95% CI, 1.52-3.02) but their risk for mortality and the composite outcome did not differ: in-hospital mortality, OR 0.97 (95% CI, 0.68-1.37); 30-day mortality, OR, 0.9 (95% CI, 0.67-1.27); and the post-discharge composite, OR, 1.19 (95% CI, 0.93-1.53).

Conclusion: Baseline patient characteristics and clinical management of AHF episodes differ between the subtropical region and those in southern continental Europe. Hospitalization was required less often, but hospital stays were longer.
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December 2021

Rationale and Design of the Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure Study.

ESC Heart Fail 2021 Oct 28. Epub 2021 Oct 28.

I-BioStat, Data Science Institute, Hasselt University, Diepenbeek, Belgium.

Aims: Although acute heart failure (AHF) with volume overload is treated with loop diuretics, their dosing and type of administration are mainly based upon expert opinion. A recent position paper from the Heart Failure Association (HFA) proposed a step-wise pharmacologic diuretic strategy to increase the diuretic response and to achieve rapid decongestion. However, no study has evaluated this protocol prospectively.

Methods And Results: The Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure (ENACT-HF) study is an international, multicentre, non-randomized, open-label, pragmatic study in AHF patients on chronic loop diuretic therapy, admitted to the hospital for intravenous loop diuretic therapy, aiming to enrol 500 patients. Inclusion criteria are as follows: at least one sign of volume overload (oedema, ascites, or pleural effusion), use ≥ 40 mg of furosemide or equivalent for >1 month, and a BNP > 250 ng/L or an N-terminal pro-B-type natriuretic peptide > 1000 pg/L. The study is designed in two sequential phases. During Phase 1, all centres will treat consecutive patients according to the local standard of care. In the Phase 2 of the study, all centres will implement a standardized diuretic protocol in the next cohort of consecutive patients. The protocol is based upon the recently published HFA algorithm on diuretic use and starts with intravenous administration of two times the oral home dose. It includes early assessment of diuretic response with a spot urinary sodium measurement after 2 h and urine output after 6 h. Diuretics will be tailored further based upon these measurements. The study is powered for its primary endpoint of natriuresis after 1 day and will be able to detect a 15% difference with 80% power. Secondary endpoints are natriuresis and diuresis after 2 days, change in congestion score, change in weight, in-hospital mortality, and length of hospitalization.

Conclusions: The ENACT-HF study will investigate whether a step-wise diuretic approach, based upon early assessment of urinary sodium and urine output as proposed by the HFA, is feasible and able to improve decongestion in AHF with volume overload.
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http://dx.doi.org/10.1002/ehf2.13666DOI Listing
October 2021

The Clinical outcomes, healthcare resource utilization, and related costs (COHERENT) model. Application in heart failure patients.

Rev Esp Cardiol (Engl Ed) 2021 Oct 20. Epub 2021 Oct 20.

Servei d'Urgències, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.

Introduction And Objectives: Composite endpoints are widely used but have several limitations. The Clinical Outcomes, HEalthcare REsource utilizatioN and relaTed costs (COHERENT) model is a new approach for visually displaying and comparing composite endpoints including all their components (incidence, timing, duration) and related costs. We aimed to assess the validity of the COHERENT model in a patient cohort.

Methods: A color graphic system displaying the percentage of patients in each clinical situation (vital status and location: at home, emergency department [ED] or hospital) and related costs at each time point during follow-up was created based on a list of mutually exclusive clinical situations coded in a hierarchical fashion. The system was tested in a cohort of 1126 patients with acute heart failure from 25 hospitals. The system calculated and displayed the time spent in each clinical situation and health care resource utilization-related costs over 30 days.

Results: The model illustrated the times spent over 30 days (2.12% in ED, 23.6% in index hospitalization, 2.7% in readmissions, 65.5% alive at home, and 6.02% dead), showing significant differences between patient groups, hospitals, and health care systems. The tool calculated and displayed the daily and cumulative health care-related costs over time (total, €4 895 070; mean, €144.91 per patient/d).

Conclusions: The COHERENT model is a new, easy-to-interpret, visual display of composite endpoints, enabling comparisons between patient groups and cohorts, including related costs. The model may constitute a useful new approach for clinical trials or observational studies, and a tool for benchmarking, and value-based health care implementation.
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http://dx.doi.org/10.1016/j.rec.2021.08.009DOI Listing
October 2021

Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature.

ESC Heart Fail 2021 Oct 19. Epub 2021 Oct 19.

ICCU Department, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Bucharest, Romania.

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.
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http://dx.doi.org/10.1002/ehf2.13643DOI Listing
October 2021

Elevated Plasma Bioactive Adrenomedullin and Mortality in Cardiogenic Shock: Results from the OptimaCC Trial.

J Clin Med 2021 Sep 29;10(19). Epub 2021 Sep 29.

Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France.

Aims: Bioactive adrenomedullin (bio-ADM) was recently shown to be a prognostic marker in patients with acute circulatory failure. We investigate the association of bio-ADM with organ injury, functional impairment, and survival in cardiogenic shock (CS).

Methods: OptimaCC was a multicenter and randomized trial in 57 patients with CS. In this post-hoc analysis, the primary endpoint was to assess the association between bio-ADM and 30-day all-cause mortality. Secondary endpoints included adverse events and parameters of organ injury or functional impairment.

Results: Bio-ADM values were higher in 30-day non-survivors than 30-day survivors at inclusion (median (interquartile range) 67.0 (54.6-142.9) pg/mL vs. 38.7 (23.8-63.6) pg/mL, = 0.010), at 24 h ( = 0.012), and up to 48 h ( = 0.027). Using a bio-ADM cutoff of 53.8 pg/mL, patients with increased bio-ADM had a HR of 3.90 (95% confidence interval 1.43-10.68, = 0.008) for 30-day all-cause mortality, and similar results were observed even after adjustment for severity scores. Patients with the occurrence of refractory CS had higher bio-ADM value at inclusion (90.7 (59.9-147.7) pg/mL vs. 40.7 (23.0-64.7) pg/mL = 0.005). Bio-ADM values at inclusion were correlated with pulmonary vascular resistance index, estimated glomerular filtration rate, and N-terminal pro-B-type natriuretic peptide (r = 0.49, r = -0.47, and r = 0.64, respectively; < 0.001).

Conclusions: In CS patients, the values of bio-ADM are associated with some parameters of organ injury and functional impairment and are prognostic for the occurrence of refractory CS and 30-day mortality.
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http://dx.doi.org/10.3390/jcm10194512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8509471PMC
September 2021

Undertriage of patients requiring direct admission to intensive care from the emergency department for medical conditions: impact on prognosis and associated factors.

Emergencias 2021 10;33(5):361-367

Área de Urgencias, Hospital Clínic, Universitat de Barcelona, Barcelona, España.

Objectives: To determine whether undertriage affects the outcome for patients requiring direct admission to the intensive care unit (ICU) from the emergency department due to a medical condition. To identify factors associated with undertriage.

Material And Methods: Retrospective review of patients treated in 2018 for medical emergencies requiring direct admission to the ICU from the emergency department. The cases were classified in 2 groups according to the assigned triage level. Underestimation was defined as a triage level of III or more. Independent variables were demographic and epidemiologic data and indicators of severity recorded in the emergency department. The main outcome was 30-day mortality. Secondary outcomes were in-hospital mortality, prolonged ICU stay, and prolonged hospital stay.

Results: We included 470 patients with a median age of 68 years (first-third quartile range, 57-78 years); 61.1% were men, and 151 (32.1%) were undertriaged. Factors directly related to undertriage according to odds ratios (ORs) were age (OR = 1.017; 95% CI, 1.003-1.032), Quick Sequential Organ Failure Assessment score of 0 or 1 (OR = 1.761; 95% CI, 1.038-2.988), ratio of oxygen saturation to fraction of inspired oxygen greater than 300 (OR = 2.447; 95% CI, 1.418-4.223), a diagnosis of infection (OR = 5.003, 95% CI 2.727-9.188) whether respiratory (OR = 3.993, 95% CI 1.919-8.310) or other (OR = 1.980, 95% CI, 1.036-3.785) versus a diagnosis of cardiovascular disease. Factors inversely related to undertriage were admission during the afternoon (OR = 0.512, 95% CI, 0.306-0.856) and ambulance transfer (OR = 0.373; 95% CI, 0.232-0.600). Ninety patients (19.1%) died within 30 days. Undertriage was not related to 30-day mortality or the other outcomes analyzed.

Conclusion: Undertriage was not associated with a worse outcome in patients requiring direct admission to the ICU for a medical emergency. The factors we found to be associated with undertriage, such as patient age and time of day admitted, merit special attention given that these factors should not be affecting the triage process.
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October 2021

Spanish Research Network on Drugs in Hospital Emergency Departments - the REDUrHE registry: general analysis and comparisons between weekend and weekday poisonings.

Emergencias 2021 10;33(5):335-344

Departamento de Medicina Física y Farmacología, Universidad de La Laguna, Tenerife, España.

Objectives: To describe the sociodemographic characteristics, drug use patterns, and the severity of drug overdoses treated in hospital emergency departments according to the registry of the Spanish Research Network on Drugs in Hospital Emergency Departments (REDUrHE project), and to identify differences between patterns on weekdays and weekends/national holidays.

Material And Methods: Eleven hospitals participated in the REDUrHE project, studying consecutive patients with symptoms of drug overdose over a 24-month period. The drugs implicated were extracted from clinical records or toxicology reports. An overdose was considered severe if management required intubation, cardiopulmonary resuscitation, or admission to the intensive care unit, or if in-hospital death occurred (composite event). Each of these variables was also analyzed by itself.

Results: A total of 4526 patients were studied (2218 [49%] on weekends/holidays; 2308 [51%] on workdays). The mean (SD) age was 33 (11) years, and 75.5% were men. The most commonly used drugs were cocaine (47.8%), paciencannabis (44.4%), amphetamine derivatives (25.5%), benzodiazepines (8.8%), and opioids (7.3%). Patients treated on weekends/holidays were younger (32.1 vs 33.1 years on weekdays, P = .006), and they were more often taken to the hospital in an ambulance (60.5% vs 57.3%, P = .035). Hospitals in large cities (Barcelona and Madrid) saw more patients on weekends/holidays (55.8%). Major tourist destinations (the Balearic and Canary Islands) saw fewer patients on weekends/holidays (44.7%, P .001). Alcohol was ingested along with a drug by 58.2%; this combination was more common on weekends/holidays (in 63.3% vs 52.9% on weekdays, P .001), and 39.4% used more than 1 drug. Use of more than 1 drug was less common on weekends (in 37.6% vs 41.2%, P = .013). Opioid emergencies were also less frequent on weekends (6.0% vs 8.6%, P = .001), when gamma-hydroxybutyrate (GHB) overdoses were more common (5.8% vs 3.6%, P .001). Severity indicators were present (the composite event) more often on weekends (in 3.6% vs 2.2%, P = .006). Likewise, weekends saw more intubations (in 2.3% vs 1.0%, P = .001) and intensive care unit admissions (2.4% vs 1.6%, P = .047). Twelve patients (0.3%) died; mortality was similar on weekends (0.2%) and weekdays (0.3%) (P = .826). After adjusting for age, sex, combined use of alcohol, and type of drug, the risk of the severe-event composite was greater on weekends (odds ratio, 1.569; 95% CI, 1.088-2.263).

Conclusion: Weekend and holiday emergencies due to drug overdoses are more frequent in large city hospitals. Weekend emergencies share certain distinctive characteristics: patients are younger, alcohol more often is ingested with drugs but multiple-drug combinations are less common, and GHB is used more often while opioids are used less often. Severe poisonings occur more often on weekends and holidays.
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October 2021

Early intravenous nitroglycerin use in prehospital setting and in the emergency department to treat patients with acute heart failure: Insights from the EAHFE Spanish registry.

Int J Cardiol 2021 Dec 20;344:127-134. Epub 2021 Sep 20.

Momentum Research, Inc., Durham, NC, USA; INSERM U-942 (Biotherapy in the critically ill), Paris, France.

Background And Objective: Although recommended for the treatment of acute heart failure (AHF), the use of intravenous (IV) nitroglycerin (NTG) is supported by scarce and contradicting evidence. In the current analysis, we have assessed the impact of IV NTG administration by EMS or in emergency department (ED) on outcomes of AHF patients.

Methods: We analyze AHF patients included by 45 hospitals that were delivered to ED by EMS. Patients were grouped according to whether treatment with IV NTG was started by EMS before ED admission (preED-NTG), during the ED stay (ED-NTG) or were untreated with IV NTG (no-NTG, control group). In-hospital, 30-day and 365-day all-cause mortality, prolonged hospitalization (>7 days) and 90-day post-discharge combined adverse events (ED revisit, hospitalization or death) were compared in EMS-NTG and ED-NTG respect to control group.

Results: We included 8424 patients: preED-NTG = 292 (3.5%), ED-NTG = 1159 (13.8%) and no-NTG = 6973 (82.7%). preED-NTG group had the most severely decompensated cases of AHF (p < 0.001) but it had lower in-hospital (OR = 0.724, 95%CI = 0.459-1.114), 30-day (HR = 0.818, 0.576-1.163) and 365-day mortality (HR = 0.692, 0.551-0.869) and 90-day post-discharge events (HR = 0.795, 0.643-0.984) than control group. ED-NTG group had mortalities similar to control group (in-hospital: OR = 1.164, 0.936-1.448; 30-day: HR = 0.980, 0.819-1.174; 365-day: HR = 0.929, 0.830-1.039) but significantly decreased 90-day post-discharge events (HR = 0.870, 0.780-0.970). Prolonged hospitalization rate did not differ among groups. Five different analyses confirmed these findings.

Conclusions: Early prehospital IV NTG administration was associated with lower mortality and post-discharge events, while IV NTG initiated in ED only improved post-discharge event rate. Further studies are needed to assess the role of early prehospital administration of IV NTG to patients with AHF.
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http://dx.doi.org/10.1016/j.ijcard.2021.09.031DOI Listing
December 2021

Performance of the ESC 0/2h-algorithm using high-sensitivity cardiac troponin I in the early diagnosis of myocardial infarction.

Am Heart J 2021 12 9;242:132-137. Epub 2021 Sep 9.

Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network. Electronic address:

The 2020 guidelines of the European Society of Cardiology (ESC) recommend a novel ESC 0/2h-algorithm as the preferred alternative to the ESC 0/1h-algorithm in the early triage for rule-out and/or rule-in of Non-ST-segment-elevation myocardial infarction (NSTEMI). The aim was to prospectively validate the performance of the ESC 0/2h-algorithm using the high-sensitivity cardiac troponin I (hs-cTnI) assay (ARCHITECT) in an international, multicenter diagnostic study enrolling patients presenting with acute chest discomfort to the emergency department.
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http://dx.doi.org/10.1016/j.ahj.2021.08.008DOI Listing
December 2021

A case-control analysis of stroke in COVID-19 patients: Results of unusual manifestations of COVID-19-study 11.

Acad Emerg Med 2021 11 29;28(11):1236-1250. Epub 2021 Sep 29.

Emergency Department, Hospital Clínico San Carlos, IDISSC, Univesidad Complutense, Madrid, Spain.

Objective: We investigated the incidence, predictor variables, clinical characteristics, and stroke outcomes in patients with COVID-19 seen in emergency departments (EDs) before hospitalization.

Methods: We retrospectively reviewed all COVID-19 patients diagnosed with stroke during the COVID-19 outbreak in 62 Spanish EDs. We formed two control groups: COVID-19 patients without stroke (control A) and non-COVID-19 patients with stroke (control B). We compared disease characteristics and four outcomes between cases and controls.

Results: We identified 147 strokes in 74,814 patients with COVID-19 seen in EDs (1.96‰, 95% confidence interval [CI] = 1.66‰ to 2.31‰), being lower than in non-COVID-19 patients (6,541/1,388,879, 4.71‰, 95% CI = 4.60‰ to 4.83‰; odds ratio [OR] = 0.42, 95% CI = 0.35 to 0.49). The estimated that standardized incidences of stroke per 100,000 individuals per year were 124 and 133 for COVID-19 and non-COVID-19 individuals, respectively (OR = 0.93 for COVID patients, 95% CI = 0.87 to 0.99). Baseline characteristics associated with a higher risk of stroke in COVID-19 patients were hypertension, diabetes mellitus, and previous cerebrovascular and coronary diseases. Clinically, these patients more frequently presented with confusion, decreased consciousness, and syncope and higher D-dimer concentrations and leukocyte count at ED arrival. After adjustment for age and sex, the case group had higher hospitalization and intensive care unit (ICU) admission rates (but not mortality) than COVID-19 controls without stroke (OR = 3.41, 95% CI = 1.27 to 9.16; and OR = 3.79, 95% CI = 1.69 to 8.50, respectively) and longer hospitalization and greater in-hospital mortality than stroke controls without COVID-19 (OR = 1.55, 95% CI = 1.24 to 1.94; and OR = 1.77, 95% CI = 1.37 to 2.30, respectively).

Conclusions: The incidence of stroke in COVID-19 patients presenting to EDs was lower than that in the non-COVID-19 reference sample. COVID-19 patients with stroke had greater need for hospitalization and ICU admission than those without stroke and longer hospitalization and greater in-hospital mortality than non-COVID-19 patients with stroke.
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http://dx.doi.org/10.1111/acem.14389DOI Listing
November 2021

Impact of co-ingestion of ethanol on the clinical symptomatology and severity of patients attended in the emergency department for recreational drug toxicity.

Am J Emerg Med 2021 Aug 23;50:422-427. Epub 2021 Aug 23.

Department of Physical Medicine and Pharmacology, Universidad de La Laguna, Tenerife, Spain. Electronic address:

Objective: Investigate whether there are differences in the drugs involved, symptomatology and severity of drug intoxication in patients with co-ingestion of alcohol attended in hospital emergency departments (ED).

Method: Patients attended in 11 Spanish EDs due to drug intoxication were included. Sociodemographic and clinical characteristics were collected. A combined adverse event of cardiorespiratory arrest, need for intubation, and admission to intensive care or death was considered as the primary indicator of severity. The symptomatology and severity were compared adjusted for age, sex and type of drug based on whether or not ethanol had been co-ingested.

Results: 3925 patients (alcohol co-ingestion: 2290, 58.3%) with a mean age of 33 (±11) years were included, and 25% were women. Co-ingestion of alcohol was observed in younger patients, in EDs in areas with high leisure tourism, on holidays and during the early morning hours. It was also more frequent in individuals intoxicated by amphetamine derivatives (66.2%) and cocaine (65.7%), and was more frequently associated with a reduction in consciousness (odds ratio [OR] = 2.13, 95% confidence interval [CI] 1.69-2.67) and agitation/aggressiveness (OR = 1.22, 95% = 1.04-1.43). A combined adverse event was observed in 114 patients (2.9%) with no differences between individuals co-ingesting or not ethanol (3.1% vs. 2.7%; OR = 1.11, 95% CI = 0.74-1.65).

Conclusion: Co-ingestion of alcohol is more frequent in individuals intoxicated by cocaine and amphetamines and predisposes a greater reduction in the level of consciousness or agitation, although there are no differences in the severity of the episodes of drug intoxication.
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http://dx.doi.org/10.1016/j.ajem.2021.08.046DOI Listing
August 2021

Prospective Validation of the ESC 0/1h-Algorithm Using High-Sensitivity Cardiac Troponin I.

Am J Cardiol 2021 11 30;158:152-153. Epub 2021 Aug 30.

Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.08.007DOI Listing
November 2021

Outcomes of patients with heart failure with preserved ejection fraction discharged on treatment with neurohormonal antagonists after an episode of decompensation.

Eur J Intern Med 2021 Aug 23. Epub 2021 Aug 23.

Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; The GREAT network, Rome, Italy. Electronic address:

Aims: To analyze the frequency with which patients with heart failure with preserved ejection fraction (HFpEF) discharged after an acute heart failure (AHF) episode are treated with antineurohormonal drugs (ANHD), the variables related to ANHD prescription and their relationship with outcomes.

Methods: We included consecutive HFpEF patients (left ventricular ejection fraction ≥50%) discharged after an AHF episode from 45 Spanish hospitals whose chronic medications and treatment at discharge were available. Patients were classified according to whether they were discharged with or without ANHD, including beta-blockers (BB), renin-angiotensin-aldosterone-system inhibitors (RAASi) and mineralcorticosteroid-receptor antagonists (MRA). Co-primary outcomes consisted of 1-year all-cause mortality and 90-day combined adverse event (revisit to emergency department -ED-, hospitalization due to AHF or all-cause death). Secondary outcomes were 90-day adverse events taken individually. Adjusted associations of ANHD treatment with outcomes were calculated.

Results: We analyzed 3,305 patients with HFpEF (median age: 83, 60% women), 2,312 (70%) discharged with ANHD. The ANHD most frequently prescribed was BB (45.8%). The 1-year mortality was 26.9% (adjusted HR for ANHD patients:1.17, 95%CI=0.98-1.38) and the 90-day combined adverse event was 54.4% (HR=1.14, 95%CI=0.99-1.31). ED revisit was significantly increased by ANHD (HR=1.15, 95%CI=1.01-1.32). MRA and BB were associated with worse results in some co-primary or secondary endpoints, while RAASi (alone) reduced 90-day hospitalization (HR=0.73, 98%CI=0.56-0.96).

Conclusion: 70% of HFpEF patients are discharged with ANHD after an AHF episode. ANHD do not seem to reduce mortality or adverse events in HFpEF patients, only RAASi could provide some benefits, reducing the risk of hospitalization for AHF.
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http://dx.doi.org/10.1016/j.ejim.2021.07.013DOI Listing
August 2021

Cardiac risk factors and the probability of acute myocardial infarction in the emergency department.

Eur J Emerg Med 2021 10;28(5):407-408

Emergency Department, Hospital Clinic de Barcelona, Barcelona, Spain.

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http://dx.doi.org/10.1097/MEJ.0000000000000848DOI Listing
October 2021

[ENCOVUR-2 study: Analysis of the protocols of action, management and availability of intensive care resources for patients with severe COVID-19 attended in spanish Emergency Departments during the first peak of the pandemic.]

Rev Esp Salud Publica 2021 Aug 11;95. Epub 2021 Aug 11.

Servicio de Urgencias. Hospital Universitario de Canarias. Tenerife. España.

Objective: During the first wave of the COVID-19 pandemic, the availability of a critical care bed was insufficient. The aim of this work was to evaluate the presence of protocols, management in the emergency department (ED) and the availability of intensive care unit (ICU) beds for severe COVID-19 patients attended in Spanish hospital EDs during the first peak of the 2020 pandemic.

Methods: Questionnaire collecting data regarding ED care in March-April 2020 aimed at all Spanish public health care EDs. The respondents were the Chiefs of EDs. The variables of interest were: 1) Presence and of compliance with ED protocols for decision making and adequacy of therapeutic effort; 2) management of COVID-19 patients with non-invasive mechanical ventilation (NIMV) or high flow nasal cannula (HFNC) in the ED; and 3) ICU bed accessibility for ED patients. The results were compared based on the characteristics of the hospital, impact of the pandemic and autonomous community. A descriptive and inferential analysis of the variables studied was performed using the chi-square test and analysis of variance.

Results: A total of 246 questionnaires (89%) were received. Protocols were available in 136 EDs (57.1%). Globally, the protocol was applied in >95% of the EDs, although this was less frequent (76%) in EDs with high impact of the pandemic. 53% of the EDs managed patients with severe COVID-19 with NIMV/HFNC in the ED itself, and 19.4% suffered from lack of ICU beds. The lack of ICU beds for severe COVID-19 patients in the ED significantly differed among periods, and more marked in hospitals with ICU and with high pandemic impact.

Conclusions: It is needed to generalize the implementation of protocols in EDs for the management of severe COVID-19 patients and improve the capacity of the ICUs to homogeneously adjust to the needs.
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August 2021

Novel Criteria for the Observe-Zone of the ESC 0/1h-hs-cTnT Algorithm.

Circulation 2021 Sep 11;144(10):773-787. Epub 2021 Aug 11.

Cardiovascular Research Institute Basel and Department of Cardiology (P.L.-A., T.N., J.B., L.K., P.D.R., I.S., J.G., S.M., J.W., E.M., R.T., C.M.), University Hospital Basel, University of Basel, Switzerland.

Background: The non-ST-segment-elevation myocardial infarction (NSTEMI) guidelines of the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cutoff for further triage is endorsed. Recently, a specific cutoff for 0/3h high-sensitivity cardiac troponin T (hs-cTnT) change (7 ng/L) was proposed, warranting external validation.

Methods: Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by 2 independent cardiologists applying the fourth universal definition of myocardial infarction, on the basis of complete cardiac workup, cardiac imaging, and serial hs-cTnT. Hs-cTnT concentrations were measured at presentation, after 1 hour, and after 3 hours. The objective was to externally validate the proposed cutoff, and if necessary, derive and internally as well as externally validate novel 0/3h-criteria for the observe-zone of the ESC 0/1h-hs-cTnT-algorithm in an independent multicenter cohort.

Results: Among 2076 eligible patients, application of the ESC 0/1h-hs-cTnT-algorithm triaged 1512 patients (72.8%) to either rule out or rule in NSTEMI, leaving 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence, 120/564 patients, 21.3%). The suggested 0/3h-hs-cTnT-change of <7 ng/L triaged 517 patients (91.7%) toward rule-out, resulting in a sensitivity of 33.3% (95% CI, 25.5-42.2), missing 80 patients with NSTEMI, and ≥7 ng/L triaged 47 patients toward rule-in (8.3%), resulting in a specificity of 98.4% (95% CI, 96.8-99.2). Novel derived 0/3h-criteria for the observe-zone patients ruled out NSTEMI with a 3h hs-cTnT concentration <15 ng/L and a 0/3h-hs-cTnT absolute change <4 ng/L, triaging 138 patients (25%) toward rule-out, resulting in a sensitivity of 99.2% (95% CI, 96.0-99.9), missing 1 patient with NSTEMI. A 0/3h-hs-cTnT absolute change ≥6 ng/L triaged 63 patients (11.2%) toward rule-in, resulting in a specificity of 98% (95% CI, 96.2-98.9) Thereby, the novel 0/3h-criteria reduced the number of patients in the observe zone by 36%s and the number of type 1 myocardial infarction by 50%. Findings were confirmed in both internal and external validation.

Conclusions: A combination of a 3h-hs-cTnT concentration (<15 ng/L) and a 0/3h absolute change (<4 ng/L) is necessary to safely rule out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-hs-cTnT-algorithm. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT00470587.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.052982DOI Listing
September 2021

Authors' reply.

Emergencias 2021 08;33(4):327

Área de Urgencias, Hospital Clínic, Barcelona, España.

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August 2021

Mortality in patients treated for COVID-19 in the emergency department of a tertiary care hospital during the first phase of the pandemic: Derivation of a risk model for emergency departments.

Emergencias 2021 08;33(4):273-281

Área de Urgencias, Hospital Clinic, Barcelona, España. Universitat de Barcelona, España.

Objectives: To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19.

Material And Methods: Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses.

Results: All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score.

Conclusion: This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department.
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August 2021

Screening for undiagnosed human immunodeficiency virus infection in Spanish emergency departments: current attitudes, inclination, and perception of obstacles related to the implementation of measures to improve detection.

Emergencias 2021 08;33(4):254-264

Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, España. Facultad de Medicina, Universidad Complutense de Madrid, España.

Objectives: To describe current attitudes toward screening for undiagnosed human immunodeficiency virus (HIV) infection in Spanish hospital emergency departments (EDs). To describe staff willingness to implement screening protocols and the obstacles they foresee.

Material And Methods: Structured survey of all chiefs of hospital EDs seeing adults 24 hours per day within the Spanish national health system. The ED chiefs were asked about their departments' routine HIV screening practices, their willingness to screen, and the perceived obstacles to implementing measures to improve screening. Findings were compared according to hospital size (large hospitals, 500 beds; small-medium hospitals, 500 beds), ED caseload (high, 200 patients/d; low, 200 patients/d), and Spanish autonomous community.

Results: The chiefs of 250 of the 282 EDs (88.7%) responded. Fifty-nine (23.6%) were in large hospitals, and 114 (45.6%) had high caseloads. HIV serology for suspected HIV infection is never or hardly ever ordered in 65.2% of the EDs. If serology is ordered, 17.6% request rapid processing. Nearly half (47.8%) thought that EDs should not screen for undiagnosed HIV infection; in Asturias, Castile and Leon, Extremadura, and Navarre over 75% of respondents expressed that opinion. Three of the 9 proposed measures to improve HIV screening in EDs were considered quite difficult or very difficult to implement. One measure that was considered problematic was nurse identification of highrisk patients during triage (for 61% of respondents overall and > 75% in the communities of Madrid and Valencia, Murcia, Aragon, and Navarre). A second foreseen difficulty was gaining hospital directors' and administrators' acceptance of universal HIV screening (for 59% overall and > 75% in Madrid, Aragon, and Navarre). The third was gaining emergency physicians' acceptance of screening (57% overall and > 75% in Madrid, Navarre, Basque Country, and Extremadura). In the remaining autonomous communities, fewer than 35% of the ED chiefs foresaw difficulties. ED chiefs in large hospitals and with high caseloads accepted HIV screening more readily, both in terms of current practice and the implementation of improved screening protocols.

Conclusion: There is considerable room for improvement in hospital ED screening for undiagnosed HIV infection. Some measures aimed at better screening would be more acceptable to the surveyed EDs, but there are marked differences in attitudes between autonomous communities.
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August 2021

Factors associated with late presentation to the emergency department in patients complaining of chest pain.

Patient Educ Couns 2021 Jun 29. Epub 2021 Jun 29.

Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy.

Objective: We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP).

Methods: All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was >6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS).

Results: The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS.

Conclusion: Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS.

Practice Implications: Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.
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http://dx.doi.org/10.1016/j.pec.2021.06.029DOI Listing
June 2021

Response.

Chest 2021 07;160(1):e89

Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain.

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http://dx.doi.org/10.1016/j.chest.2021.02.060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261027PMC
July 2021

Socio-Demographic Health Determinants Are Associated with Poor Prognosis in Spanish Patients Hospitalized with COVID-19.

J Gen Intern Med 2021 Jul 8. Epub 2021 Jul 8.

Department of Emergency, Hospital Clínico San Carlos, Calle Profesor Martín-Lagos s/n, 28040, Madrid, Spain.

Introduction: Social vulnerability is a known determinant of health in respiratory diseases. Our aim was to identify whether there are socio-demographic factors among COVID-19 patients hospitalized in Spain and their potential impact on health outcomes during the hospitalization.

Methods: A multicentric retrospective case series study based on administrative databases that included all COVID-19 cases admitted in 19 Spanish hospitals from 1 March to 15 April 2020. Socio-demographic data were collected. Outcomes were critical care admission and in-hospital mortality.

Results: We included 10,110 COVID-19 patients admitted to 18 Spanish hospitals (median age 68 (IQR 54-80) years old; 44.5% female; 14.8% were not born in Spain). Among these, 779 (7.7%) cases were admitted to critical care units and 1678 (16.6%) patients died during the hospitalization. Age, male gender, being immigrant, and low hospital saturation were independently associated with being admitted to an intensive care unit. Age, male gender, being immigrant, percentile of average per capita income, and hospital experience were independently associated with in-hospital mortality.

Conclusions: Social determinants such as residence in low-income areas and being born in Latin American countries were associated with increased odds of being admitted to an intensive care unit and of in-hospital mortality. There was considerable variation in outcomes between different Spanish centers.
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http://dx.doi.org/10.1007/s11606-020-06584-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8266293PMC
July 2021

Direct comparison of high-sensitivity cardiac troponin T and I in the early differentiation of type 1 vs. type 2 myocardial infarction.

Eur Heart J Acute Cardiovasc Care 2021 Jul 1. Epub 2021 Jul 1.

Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.

Aims: To directly compare the diagnostic accuracy of high-sensitivity cardiac troponin (hs-cTn) T vs. hs-cTnI in the early non-invasive differentiation of Type 1 myocardial infarction (T1MI) due to plaque rupture and atherothrombosis from Type 2 myocardial infarction (T2MI) due to supply-demand mismatch.

Methods And Results: In a prospective multicentre diagnostic study, two independent cardiologists centrally adjudicated the final diagnosis of T1MI vs. T2MI according to the fourth universal definition of myocardial infarction (MI), using all available clinical information including cardiac imaging in patients presenting with acute chest pain. Diagnostic accuracy was quantified by the area under the receiver operating characteristics curve (AUC). The most extensively validated hs-cTnT-Elecsys and hs-cTnI-Architect assays were measured at presentation, 1 h, and 2 h. Among 5887 patients, 1106 (19%) had a final diagnosis of MI, including 860 (78%) T1MI and 246 (22%) T2MI. The AUC of hs-cTnT-Elecsys to differentiate T1MI from T2MI was moderate and comparable to that provided by hs-cTnI-Architect: hs-cTnT-Elecsys AUC-presentation 0.67 [95% confidence interval (CI) 0.64-0.71], AUC-1 h 0.70 (95% CI 0.66-0.74), and AUC-2 h 0.71 (95% CI 0.66-0.75) vs. hs-cTnI-Architect AUC-presentation 0.71 (95% CI 0.67-0.74), AUC-1 h 0.72 (95% CI 0.68-0.76), and AUC-2 h 0.74 (95% CI 0.69-0.78), all P = not significant (NS). Similarly, the AUC of absolute changes was moderate and comparable for hs-cTnT-Elecsys and hs-cTnI-Architect (all P = NS). Cut-off concentrations achieving at least 90% specificity for the differentiation of T1MI vs. T2MI were >114 ng/L for hs-cTnT-Elecsys [odds ratio (OR) 4.2, 95% CI 2.7-6.6] and >371 ng/L for hs-cTnI-Architect (OR 4.0, 95% CI 2.6-6.2).

Conclusion: hs-cTnT-Elecsys and hs-cTnI-Architect provided comparable, albeit only moderate, diagnostic accuracy for the early differentiation of T1MI vs. T2MI.

Clinical Trial Registration: ClinicalTrials.gov number, NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.
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http://dx.doi.org/10.1093/ehjacc/zuab039DOI Listing
July 2021

From Spain with love.

Authors:
Òscar Miró

Eur J Emerg Med 2021 08;28(4):247-248

Emergency Department, Hospital Clínic, Barcelona, Catalonia, Spain.

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http://dx.doi.org/10.1097/MEJ.0000000000000838DOI Listing
August 2021

Pulmonary embolism in patients with COVID-19: incidence, risk factors, clinical characteristics, and outcome.

Eur Heart J 2021 08;42(33):3127-3142

Emergency Department, Hospital Clínico San Carlos, IDISSC, UnivesdadComplutenseCalle del Prof Martín Lagos, s/n, 28040 Madrid, Spain.

Aims: We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization.

Methods And Results: We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51-9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65-1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97-2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66-4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations.

Conclusions: PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.
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http://dx.doi.org/10.1093/eurheartj/ehab314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344714PMC
August 2021

Thirty-day outcomes in frail older patients discharged home from the emergency department with acute heart failure: effects of high-risk criteria identified by the DEED FRAIL-AHF trial.

Emergencias 2021 06;33(3):165-173

Área de Urgencias, Hospital Clínic, Barcelona, Grupo de Investigación "Urgencias: Procesos y Patologías", IDIBAPS, Barcelona, España.

Objectives: To study the effect of high-risk criteria on 30-day outcomes in frail older patients with acute heart failure (AHF) discharged from an emergency department (ED) or an ED's observation and short-stay areas.

Material And Methods: Secondary analysis of discharge records in the Older AHF Key Data registry. We selected frail patients (aged > 70 years) discharged with AHF from EDs. Risk factors were categorized as modifiable or nonmodifiable. The outcomes were a composite endpoint for a cardiovascular event (revisits for AHF, hospitalization for AHF, or cardiovascular death) and the number of days alive out-of-hospital (DAOH) within 30 days of discharge.

Results: We included 380 patients with a mean (SD) age of 86 (5.5) years (61.2% women). Modifiable risk factors were identified in 65.1%, nonmodifiable ones in 47.8%, and both types in 81.6%. The 30-day cardiovascular composite endpoint occurred in 83 patients (21.8%). The mean 30-day DAOH observed was 27.6 (6.1) days. Highrisk factors were present more often in patients who developed the cardiovascular event composite endpoint: the rates for patients with modifiable, nonmodifiable, or both types of risk were, respectively, as follows in comparison with patients not at high risk: 25.0% vs 17.2%, P = .092; 27.6% vs 16.7%, P = .010; and 24.7% vs 15.2%, P = .098). The 30-day DAOH outcome was also lower for at-risk patients, according to type of risk factor present: modifiable, 26.9 (7.0) vs 28.4 (4.4) days, P = .011; nonmodifiable, 27.1 (7.0) vs 28.0 (5.0) days, P = .127; and both, 27.1 (6.7) vs 28.8 (3.4) days, P = .005). After multivariate analysis, modifiable risk remained independently associated with fewer days alive (adjusted absolute difference in 30-day DAOH, -1.3 days (95% CI, -2.7 to -0.1 days). Nonmodifiable factors were associated with increased risk for the 30-day cardiovascular composite endpoint (adjusted absolute difference, 10.4%; 95% CI, -2.1% to 18.7%).

Conclusion: Risk factors are common in frail elderly patients with AHF discharged home from hospital ED areas. Their presence is associated with a worse 30-day prognosis.
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June 2021
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