The proposed approach, methods, and solutions provide a conceptual, methodological, and programming framework for the implementation of a simulation of complex and diverse scenarios within a flow of patients for different purposes: decision making, training, management optimization, and others.
De-escalation from ticagrelor to clopidogrel in acute coronary syndrome (ACS) may occur for a variety of reasons, including side effects (bleeding and non-bleeding) and costs. This study sought to assess the prevalence of de-escalation from ticagrelor to clopidogrel and the occurrence of adverse clinical outcomes following de-escalation. We conducted a systematic review of clinical trials and real-world studies in ACS patients treated with ticagrelor. Real-world data on the prevalence of de-escalation during hospitalization or at discharge, after hospital discharge, and during the whole study period were included for meta-analysis. Major adverse cardiovascular events (MACE) and bleeding events occurring after de-escalation were also assessed. A total of 12 studies were eligible for meta-analysis of the prevalence of de-escalation. De-escalation from ticagrelor to clopidogrel therapy occurred with a mean prevalence of 19.8% [95% confidence interval (CI) 11.2–28.4%]. De-escalation occurred more frequently in-hospital or at discharge than after hospital discharge (23.7% vs. 15.8%). For assessment of clinical outcomes, a total of six studies were eligible for meta-analysis. Mean rate of MACE for patients with de-escalation was 2.1% (95% CI 1.1–4.1%) and the rate of major bleeding events was 1.3% (95% CI 0.4–4.5%). In conclusion, de-escalation commonly occurs in real-world practice. Although rates of major cardiovascular and bleeding events in this analysis were generally low, the profile of patients suitable for de-escalation, the impact of de-escalation on adverse clinical outcomes and how this is affected by the timing after index ACS warrants further large-scale investigation.
Electronic supplementary material
The online version of this article (10.1007/s11239-019-01860-7) contains supplementary material, which is available to authorized users.
The poor water resistance property of a commercial Mn 4+ -activated narrow-band red-emitting fluoride phosphor restricts its promising applications in high-performance white LEDs and wide-gamut displays. Herein, we develop a structural rigidity-enhancing strategy using a novel KHF 2 :Mn 4+ precursor as a Mn source to construct a proton-containing water-resistant phosphor K 2 (H)TiF 6 :Mn 4+ (KHTFM). The parasitic [HMnF 6 ] − complexes in the interstitial site from the fall off the KHF 2 :Mn 4+ are also transferred to the K 2 TiF 6 host by ion exchange to form KHTFM with rigid bonding networks, improving the water resistance and thermostability of the sample. The KHTFM sample retains at least 92% of the original emission value after 180 min of water immersion, while the non-water-resistant K 2 TiF 6 :Mn 4+ (KTFM) phosphor maintains only 23%. Therefore, these findings not only illustrate the effect of protons on fluoride but also provide a novel insight into commercial water-resistant fluoride phosphors.
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