Baseline frailty status and outcomes important for shared decision-making in older adults receiving transcatheter aortic valve implantation, a prospective observational study.

AIMS: The objective of this study was to examine baseline frailty status (including cognitive deficits) and important clinical outcomes, to inform shared decision-making in older adults receiving transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: We conducted a prospective, observational study of 82 TAVI patients, recruited 2013 to 2015, with 2-year follow-up. Mean age was 83 years (standard deviation (SD) 4.7). Eighteen percent of the patients were frail, as assessed with an 8-item frailty scale. Fifteen patients (18%) had a Mini-Mental Status Examination (MMSE) score below 24 points at baseline, indicating cognitive impairment or dementia and five patients had an MMSE below 20 points. Mean New York Heart Association (NYHA) class at baseline and 6 months was 2.5 (SD 0.6) and 1.4 (SD 0.6), (p < 0.001). There was no change in mean Nottingham Extended Activities of Daily Living (NEADL) scale between baseline and 6 months, 54.2 (SD 11.5) and 54.5 (SD 10.3) points, respectively, mean difference 0.3 (p = 0.7). At 2 years, six patients (7%) had died, four (5%, n = 79) lived in a nursing home, four (5%) suffered from disabling stroke, and six (7%) contracted infective endocarditis. CONCLUSIONS: TAVI patients had improvement in symptoms and maintenance of activity of daily living at 6 months. They had low mortality and most patients lived in their own home 2 years after TAVI. Complications like death, stroke, and endocarditis occurred. Some patients had cognitive impairment before the procedure which might influence decision-making. Our findings may be used to develop pre-TAVI decision aids.

Evaluation of comprehensive geriatric assessment in older patients undergoing pacemaker implantation.

BACKGROUND: This study evaluated the use of comprehensive geriatric assessment (CGA) in older patients undergoing pacemaker implantation. METHODS: In this prospective cohort, CGA was performed in 197 patients ≥75 years at pacemaker implantation and yearly thereafter. CGA embraced the following domains: cognition, mobility, nutrition, activities of daily living (ADLs), and falls (with or without loss of consciousness). Based on comorbidities, the Charlson comorbidity index (CCI) was calculated. For predictive analysis, logistic regression was used. RESULTS: During a mean follow-up duration of 2.4 years, the incidence rates of syncope decreased from 0.46 to 0.04 events per year (p < 0.001), and that of falls without loss of consciousness from 0.27 to 0.15 (p < 0.001) before vs. after implantation. Sixty-three patients (32.0%) died. Impaired mobility (OR 2.60, 95%CI 1.22-5.54, p = 0.013), malnutrition (OR 3.26, 95%CI 1.52-7.01, p = 0.002), and a higher CCI (OR per point increase 1.25, 95%CI 1.04-1.50, p = 0.019) at baseline were significant predictors of mortality. Among 169 patients who survived for more than 1 year and thus underwent follow-up CGA, CGA domains did not deteriorate during follow-up, except for ADLs. This decline in ADLs during follow-up was the strongest predictor of later nursing home admission (OR 9.29, 95%CI 1.82-47.49, p = 0.007). Higher baseline age (OR per year increase 1.10, 95%CI 1.02-1.20, p = 0.018) and a higher baseline CCI (OR per point increase 1.32, 95%CI 1.05-1.65, p = 0.017) were associated with a decline in ADLs during follow-up. CONCLUSIONS: CGA is useful to detect functional deficits, which are associated with mortality or nursing home admission after pacemaker implantation. The present study seems to support the use of CGA in older patients undergoing pacemaker implantation as functional deficits and falls are amenable to geriatric interventions.

Comprehensive geriatric assessment in patients undergoing transcatheter aortic valve implantation - results from the CGA-TAVI multicentre registry.

BACKGROUND: In older patients with aortic stenosis (AS) undergoing TAVI, the potential role of prior CGA is not well established. To explore the value of comprehensive geriatric assessment (CGA) for predicting mortality and/or hospitalisation within the first 3 months after transcatheter aortic valve implantation (TAVI). METHODS: An international, multi-centre, prospective registry (CGA-TAVI) was established to gather data on CGA results and medium-term outcomes in geriatric patients undergoing TAVI. Logistic regression was used to evaluate the predictive value of a multidimensional prognostic index (MPI); a short physical performance battery (SPPB); and the Silver Code, which was based on administrative data, for predicting death and/or hospitalisation in the first 3 months after TAVI (primary endpoint). RESULTS: A total of 71 TAVI patients (mean age 85.4 years; mean log EuroSCORE I 22.5%) were enrolled. Device success according to VARC criteria was 100%. After adjustment for selected baseline characteristics, a higher (poorer) MPI score (OR: 3.34; 95% CI: 1.39-8.02; p = 0.0068) and a lower (poorer) SPPB score (OR: 1.15; 95% CI: 1.01-1.54; p = 0.0380) were found to be associated with an increased likelihood of the primary endpoint. The Silver Code did not show any predictive ability in this population. CONCLUSIONS: Several aspects of the CGA have shown promise for being of use to physicians when predicting TAVI outcomes. While the MPI may be useful in clinical practice, the SPPB may be of particular value, being simple and quick to perform. Validation of these findings in a larger sample is warranted. TRIAL REGISTRATION: The trial was registered in ClinicalTrials.gov on November 7, 2013 ( NCT01991444 ).

Temporal trends in the treatment and outcomes of elderly patients with acute coronary syndrome.

AIMS: To determine whether treatment and outcomes of older acute coronary syndrome (ACS) patients changed over time. METHODS AND RESULTS: We analysed the use of guideline-recommended therapies and in-hospital outcomes of 13 662 ACS patients ≥70 years enrolled in the prospective Acute Myocardial Infarction in Switzerland (AMIS) cohort between 2001 and 2012 according to 4-year periods (2001-2004, 2005-2008, and 2009-2012). Between first and last 4-year period, percutaneous coronary intervention (PCI) use increased from 43.8 to 69.6% of older ACS patients ( ITALIC! P < 0.001). Use of guideline-recommended drugs as well increased. At the same time, in-hospital mortality of the overall population decreased from 11.6% in the first to 10.0% in the last 4-year period ( ITALIC! P = 0.020), and in-hospital major adverse cardiac and cerebrovascular events from 14.4 to 11.3% ( ITALIC! P < 0.001). Percutaneous coronary intervention was used in increasingly older and co-morbid patients over time (mean age of patients treated with PCI 76.2 years in 2001-2004 and 78.1 years in 2009-2012, ITALIC! P < 0.001; Charlson score ≥2 was found for 27.6% of patients treated with PCI in 2001-2004 and for 32.1% in 2009-2012, ITALIC! P = 0.003). Percutaneous coronary intervention use was associated with similar odds ratios (ORs) of in-hospital mortality over time (adjusted OR 0.29, 95% confidence interval, CI, 0.22-0.40, in 2001-2004; and, adjusted OR 0.26, 95% CI 0.20-0.35, in 2009-2012). CONCLUSION: Use of guideline-recommended therapies for ACS increased and in-hospital outcomes improved over the observed 12-year period. Though PCI was used in increasingly older and co-morbid patients, PCI use was associated with similar ORs of in-hospital mortality over time. This study suggests that increasing use of guideline-recommended therapies was appropriate. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01305785.

A critical evaluation of the clinical evidence for pomegranate preparations in the prevention and treatment of cardiovascular diseases.

This study attempts a critical evaluation of the clinical evidence behind the use of dietary pomegranate preparations in the prevention and treatment of cardiovascular diseases. A search of PubMed on August 10, 2014 identified 228 references, which yielded extractable data from 24 clinical studies of pomegranate preparations. Hand searching identified two further studies. The quality of the studies and evidence of effectiveness of pomegranate were assessed by an established set of conventional criteria. Overall, the study quality was poor. Even in the best studies, indications of benefit did not reach the conventional levels of statistical significance. The only study with a definitive design had a biochemical rather than a clinical endpoint: it showed the expected difference in blood concentrations of myeloperoxidase after a single dose of either pomegranate or placebo. Only 10 of the 26 studies provided HPLC data on the amounts of co-active ingredients in the preparations that were consumed by the subjects. If pomegranate has a role in the prevention and treatment of cardiovascular diseases, there is a pressing need for dose-finding and long-term confirmatory studies. The ultimate endpoint for definitive studies would be mortality, but reductions in blood pressure or demonstrable decreases in atherosclerotic plaques would be useful surrogates. Sample sizes for various assumptions are provided. Future studies need to prove the clinical benefit.

A novel multidimensional geriatric screening tool in the ED: evaluation of feasibility and clinical relevance.

PURPOSES: Geriatric problems frequently go undetected in older patients in emergency departments (EDs), thus increasing their risk of adverse outcomes. We evaluated a novel emergency geriatric screening (EGS) tool designed to detect geriatric problems. BASIC PROCEDURES: The EGS tool consisted of short validated instruments used to screen 4 domains (cognition, falls, mobility, and activities of daily living). Emergency geriatric screening was introduced for ED patients 75 years or older throughout a 4-month period. We analyzed the prevalence of abnormal EGS and whether EGS increased the number of EGS-related diagnoses in the ED during the screening, as compared with a preceding control period. MAIN FINDINGS: Emergency geriatric screening was performed on 338 (42.5%) of 795 patients presenting during screening. Emergency geriatric screening was unfeasible in 175 patients (22.0%) because of life-threatening conditions and was not performed in 282 (35.5%) for logistical reasons. Emergency geriatric screening took less than 5 minutes to perform in most (85.8%) cases. Among screened patients, 285 (84.3%) had at least 1 abnormal EGS finding. In 270 of these patients, at least 1 abnormal EGS finding did not result in a diagnosis in the ED and was reported for further workup to subsequent care. During screening, 142 patients (42.0%) had at least 1 diagnosis listed within the 4 EGS domains, significantly more than the 29.3% in the control period (odds ratio 1.75; 95% confidence interval, 1.34-2.29; P<.001). Emergency geriatric screening predicted nursing home admission after the in-hospital stay (odds ratio for ≥3 vs <3 abnormal domains 12.13; 95% confidence interval, 2.79-52.72; P=.001). PRINCIPAL CONCLUSIONS: The novel EGS is feasible, identifies previously undetected geriatric problems, and predicts determinants of subsequent care.

Predictors of functional decline in elderly patients undergoing transcatheter aortic valve implantation (TAVI).

Aims This study aimed to assess functional course in elderly patients undergoing transcatheter aortic valve implantation (TAVI) and to find predictors of functional decline. Methods and results In this prospective cohort, functional course was assessed in patients ≥70 years using basic activities of daily living (BADL) before and 6 months after TAVI. Baseline EuroSCORE, STS score, and a frailty index (based on assessment of cognition, mobility, nutrition, instrumental and basic activities of daily living) were evaluated to predict functional decline (deterioration in BADL) using logistic regression models. Functional decline was observed in 22 (20.8%) of 106 surviving patients. EuroSCORE (OR per 10% increase 1.18, 95% CI: 0.83-1.68, P = 0.35) and STS score (OR per 5% increase 1.64, 95% CI: 0.87-3.09, P = 0.13) weakly predicted functional decline. In contrast, the frailty index strongly predicted functional decline in univariable (OR per 1 point increase 1.57, 95% CI: 1.20-2.05, P = 0.001) and bivariable analyses (OR: 1.56, 95% CI: 1.20-2.04, P = 0.001 controlled for EuroSCORE; OR: 1.53, 95% CI: 1.17-2.02, P = 0.002 controlled for STS score). Overall predictive performance was best for the frailty index [Nagelkerke's R(2) (NR(2)) 0.135] and low for the EuroSCORE (NR(2) 0.015) and STS score (NR(2) 0.034). In univariable analyses, all components of the frailty index contributed to the prediction of functional decline. Conclusion Over a 6-month period, functional status worsened only in a minority of patients surviving TAVI. The frailty index, but not established risk scores, was predictive of functional decline. Refinement of this index might help to identify patients who potentially benefit from additional geriatric interventions after TAVI.

Effects of geriatric clinical skills training on the attitudes of medical students.

BACKGROUND: Physicians' attitudes, knowledge and skills are powerful determinants of quality of care for older patients. Previous studies found that using educational interventions to improve attitude is a difficult task. No previous study sought to determine if a skills-oriented educational intervention improved student attitudes towards elderly patients. METHODS: This study evaluated the effect of a geriatric clinical skills training (CST) on attitudes of University of Bern medical students in their first year of clinical training. The geriatric CST consisted of four 2.5-hour teaching sessions that covered central domains of geriatric assessment (e.g., cognition, mobility), and a textbook used by students to self-prepare. Students' attitudes were the primary outcome, and were assessed with the 14-item University of California at Los Angeles Geriatrics Attitudes Scale (UCLA-GAS) in a quasi-randomized fashion, either before or after geriatric CST. RESULTS: A total of 154 medical students participated. Students evaluated before the CST had a median UCLA-GAS overall scale of 49 (interquartile range 44-53). After the CST, the scores increased slightly, to 51 (interquartile range 47-54; median difference 2, 95% confidence interval 0-4, P = 0.062). Of the four validated UCLA-GAS subscales, only the resource distribution subscale was significantly higher in students evaluated after the geriatric CST (median difference 1, 95% confidence interval 0-2, P = 0.005). CONCLUSIONS: Teaching that targets specific skills may improve the attitudes of medical students towards elderly patients, though the improvement was slight. The addition of attitude-building elements may improve the effectiveness of future skills-oriented educational interventions.

Impact of cardiac computed tomography of the interatrial septum before pulmonary vein isolation.

BACKGROUND: Multidetector computed tomography (MDCT) may be useful to identify patients with patent foramen ovale (PFO). The aim of this study was to analyze whether a MDCT performed before pulmonary vein isolation reliably detects a PFO that may be used for access to the left atrium. METHODS AND RESULTS: In 79 consecutive patients, who were referred for catheter ablation of symptomatic paroxysmal or persistent atrial fibrillation (AF), the presence of a PFO was explored by MDCT and transesophageal echocardiography (TEE). TEE was considered as the gold standard, and quality of TEE was good in all patients. In 16 patients (20.3%), MDCT could not be used for analysis because of artifacts, mainly because of AF. On TEE, a PFO was found in 15 (23.8%) of the 63 patients with usable MDCT. MDCT detected six PFO of which four were present on TEE. This corresponded to a sensitivity of 26.7%, a specificity of 95.8%, a negative predictive value of 80.7%, and a positive predictive value of 66.7%. The receiver operating characteristics curve of MDCT for the detection of PFO was 0.613 (95% confidence interval 0.493-0.732). CONCLUSIONS: MDCT may detect a PFO before pulmonary isolation. However, presence of AF may lead to artifacts on MDCT impeding a meaningful analysis. Furthermore, in this study sensitivity and positive predictive value of MDCT were low and therefore MDCT was not a reliable screening tool for detection of PFO.

MEDPass versus conventional administration of oral nutritional supplements - A randomized controlled trial comparing coverage of energy and protein requirements.

BACKGROUND & AIMS: The use of oral nutritional supplements (ONS) in the hospital setting is important to reach individual protein and energy goals in patients at risk for malnutrition. Compliance with ONS can be challenging but may be improved by prescribing ONS in smaller portions with medication rounds (MEDPass). We compared the likelihood of meeting energy and protein requirements in patients receiving ONS with MEDPass versus conventional ONS administration. METHODS: The MEDPass Trial is a randomized, controlled, open-label superiority trial conducted on medical and geriatric wards in a University Hospital in Switzerland. The MEDPass group was allocated to receive 50 ml of ONS four times per day with the medication rounds. The control group received ONS per conventional care between the meals. The primary outcome was the percentage of energy in relation to the individual requirement. Secondary outcomes included the coverage of protein intake in relation to the individual requirement, the amount of daily consumed ONS, the course of handgrip strength (HGS), body weight appetite and nausea. Furthermore, we compared 30-day mortality and hospital length of stay (LOS) was studied in medical patients. RESULTS: From November 22nd, 2018 until November 30th, 2021, 204 patients were included in the trial (MEDPass group n = 100, control group n = 104). A total of 203 patients at nutritional risk were analyzed in the intention-to-treat analysis (ITT). Regarding the primary endpoint, there was no difference in the coverage of energy requirement between the MEDPass and control group (82 vs. 85% (Δ -3%, 95%CI -11 to 4%), p = 0.38). Similarly, no differences were found for the secondary outcomes including coverage of protein requirement (101 vs. 104% (Δ -3%, 95% CI -12 -7%), p = 0.57, average daily intake of ONS (170 vs 173 ml (Δ - 3 ml, 95% CI -14 to 8 ml), p = 0.58) and 30-day mortality (3 vs. 8 patients, OR 0.4 (95% CI 0.1-1.4), p = 0.15). The course of HGS, body weight, appetite and nausea did not differ between the groups (p = 0.29, p = 0.14, p = 0.65 and p = 0.94, respectively). The per protocol analysis including 178 patients showed similar results. CONCLUSION: Within this controlled trial setting, we found a high compliance for ONS intake and high coverage of protein requirements but no further improvement when ONS was administered using MEDPass compared to conventional care. MEDPass administration may provide an alternative that is easy to integrate into nursing routines, which may lead to lower workload with cost benefits and reduction of food waste. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03761680.

Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists.

INTRODUCTION: Burnout and low job satisfaction are increasing among the General Internal Medicine (GIM) workforce. Whether part-time compared to full-time clinical employment is associated with better wellbeing, job satisfaction and health among hospitalists remains unclear. MATERIALS AND METHODS: We conducted an anonymized cross-sectional survey among board-certified general internists (i.e. hospitalists) from GIM departments in 14 Swiss hospitals. Part-time clinical work was defined as employment of <100% as a clinician. The primary outcome was well-being, as measured by the extended Physician Well-Being Index (ePWBI), an ePWBI ≥3 indicating poor wellbeing. Secondary outcomes included depressive symptoms, mental and physical health, and job satisfaction. We compared outcomes in part-time and full time workers using propensity score-adjusted multivariate regression models. RESULTS: Of 199 hospitalists invited, 137 (69%) responded to the survey, and 124 were eligible for analysis (57 full-time and 67 part-time clinicians). Full-time clinicians were more likely to have poor wellbeing compared to part-time clinicians (ePWBI ≥3 54% vs. 31%, p = 0.012). Part-time compared to full-time clinical work was associated with a lower risk of poor well-being in adjusted analyses (odds ratio 0.20, 95% confidence interval 0.07-0.59, p = 0.004). Compared to full-time clinicians, there were fewer depressive symptoms (3% vs. 18%, p = 0.006), and mental health was better (mean SF-8 Mental Component Summary score 47.2 vs. 43.2, p = 0.028) in part-time clinicians, without significant differences in physical health and job satisfaction. CONCLUSIONS: Full-time clinical hospitalists in GIM have a high risk of poor well-being. Part-time compared to full-time clinical work is associated with better well-being and mental health, and fewer depressive symptoms.

T-cadherin is present on endothelial microparticles and is elevated in plasma in early atherosclerosis.

AIMS: The presence of endothelial cell (EC)-derived surface molecules in the circulation is among hallmarks of endothelial activation and damage in vivo. Previous investigations suggest that upregulation of T-cadherin (T-cad) on the surface of ECs may be a characteristic marker of EC activation and stress. We investigated whether T-cad might also be shed from ECs and in amounts reflecting the extent of activation or damage. METHODS AND RESULTS: Immunoblotting showed the presence of T-cad protein in the culture medium from normal proliferating ECs and higher levels in the medium from stressed/apoptotic ECs. Release of T-cad into the circulation occurs in vivo and in association with endothelial dysfunction. Sandwich ELISA revealed negligible T-cad protein in the plasma of healthy volunteers (0.90 ± 0.90 ng/mL, n = 30), and increased levels in the plasma from patients with non-significant atherosclerosis (9.23 ± 2.61 ng/mL, n = 63) and patients with chronic coronary artery disease (6.93 ± 1.31 ng/mL, n = 162). In both patient groups there was a significant (P = 0.043) dependency of T-cad and degree of endothelial dysfunction as measured by reactive hyperaemia peripheral tonometry. Flow cytometry analysis showed that the major fraction of T-cad was released into the EC culture medium and the plasma as a surface component of EC-derived annexin V- and CD144/CD31-positive microparticles (MPs). Gain-of-function and loss-of-function studies demonstrate that MP-bound T-cad induced Akt phosphorylation and activated angiogenic behaviour in target ECs via homophilic-based interactions. CONCLUSION: Our findings reveal a novel mechanism of T-cad-dependent signalling in the vascular endothelium. We identify T-cad as an endothelial MP antigen in vivo and demonstrate that its level in plasma is increased in early atherosclerosis and correlates with endothelial dysfunction.

Effects of right ventricular pacing on left ventricular ejection fraction in a pacemaker clinic.

BACKGROUND: The aim of this study was to evaluate whether a change of left ventricular ejection fraction (LVEF) depending on percentage of right ventricular pacing is found in a real-life setting of a pacemaker clinic. METHODS AND RESULTS: 269 patients with either a pacemaker or an ICD and who are regularly followed at the pacemaker clinic of the Luzerner Kantonsspital participated in the study. We tested whether LVEF measured by echocardiography between the first measurement at the time of the pacemaker implantation and the last measurement at the time of the last pacemaker control is dependent on the extent of ventricular pacing. Mean follow-up was 3.9 +/- 2.9 years. Mean LVEF most significantly decreased in the group of patients with baseline LVEF > or = 45% and an extent of right ventricular pacing > or = 66% (from 57.6 +/- 7.2% to 53.1 +/- 10.2%, P < 0.001). In patients with an extent of right ventricular pacing < 66% no decrease of LVEF was observed. Analysis of variance showed that LVEF decrease between the first measurement at the time of the pacemaker implantation and the last measurement at the time of the last pacemaker control was dependent on the extent of right ventricular pacing, even if other factors such as age, gender and previous myocardial infarction are incorporated in the analysis. CONCLUSION: In a real-life population of a pacemaker clinic right ventricular pacing was associated with a decrease in LVEF.

[Hypertension in the elderly]. / Die arterielle Hypertonie im Alter.

Many aspects of hypertension diagnosis and treatment are similar in young and old patients. However, some differences exist. Due to the increasing vascular stiffness most elderly patients have isolated systolic hypertension and its prevalence in the population is high. Blood pressure should be measured in the sitting position and also with the patient standing to exclude orthostatic hypotension, a frequent problem in elderly patients. Pseudohypertension, a source of inadequate measurements in elderly patients, should be recognized. In comparison to other health problems there is good scientific evidence for antihypertensive treatment in elderly patients. As treatment does not only improve survival, but also reduces cardiovascular events such as non-fatal stroke or myocardial infarction, antihypertensive therapy is an important measure to prevent functional decline and disability.

Impact of Cardiovascular Risk Factors on Arterial Stiffness in a Countryside Area of Switzerland: Insights from the Swiss Longitudinal Cohort Study.

INTRODUCTION: Cardiovascular disease is the leading cause of morbidity and mortality. Besides traditional cardiovascular risk factors, arterial stiffness is a recognized predictor of cardiovascular risk. METHODS: We investigated the relationship between traditional cardiovascular risk factors, sex, and aortic pulse wave velocity in subjects living in a countryside area of Southern Switzerland. For this aim, we performed a cross-sectional analysis of data from adult participants of the Swiss Longitudinal Cohort Study, which, initiated in 2015, follows health status and disease risk factors in a Swiss countryside cohort at least 6 years of age. RESULTS: A total of 387 people (205 women and 182 men) were included. Hyperlipidemia, overweight, and obesity were more common (p ≤ 0.001) and LDL-cholesterol, triglycerides, and hemoglobin A1c were higher (p < 0.03) in men than women. Systolic and diastolic brachial and aortic blood pressures were higher in men (p < 0.02), whereas aortic pulse wave velocity and aortic pulse pressure were higher in women (p < 0.05). The aortic pulse wave velocity was significantly higher in subjects with hypertension, hyperlipidemia, diabetes, and obesity, and significantly increased with age (p < 0.0001). Multiple linear regression analysis showed a significant correlation between pulse wave velocity and age, female sex, brachial systolic blood pressure, and heart rate (p < 0.005). CONCLUSION: Also in a countryside area, the aortic pulse wave velocity is higher in subjects with hypertension, hyperlipidemia, diabetes and obesity, and significantly increases with age. Furthermore, with advancing age, aortic pulse wave velocity is higher in women than men. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT02282748.

Bacterial colonization and infection of electrophysiological cardiac devices detected with sonication and swab culture.

BACKGROUND: Electrophysiological cardiac devices are increasingly used. The frequency of subclinical infection is unknown. We investigated all explanted devices using sonication, a method for detection of microbial biofilms on foreign bodies. METHODS AND RESULTS: Consecutive patients in whom cardiac pacemakers and implantable cardioverter/defibrillators were removed at our institution between October 2007 and December 2008 were prospectively included. Devices (generator and/or leads) were aseptically removed and sonicated, and the resulting sonication fluid was cultured. In parallel, conventional swabs of the generator pouch were performed. A total of 121 removed devices (68 pacemakers, 53 implantable cardioverter/defibrillators) were included. The reasons for removal were insufficient battery charge (n=102), device upgrading (n=9), device dysfunction (n=4), or infection (n=6). In 115 episodes (95%) without clinical evidence of infection, 44 (38%) grew bacteria in sonication fluid, including Propionibacterium acnes (n=27), coagulase-negative staphylococci (n=11), Gram-positive anaerobe cocci (n=3), Gram-positive anaerobe rods (n=1), Gram-negative rods (n=1), and mixed bacteria (n=1). In 21 of 44 sonication-positive episodes, bacterial counts were significant (>or=10 colony-forming units/mL of sonication fluid). In 26 sterilized controls, sonication cultures remained negative in 25 cases (96%). In 112 cases without clinical infection, conventional swab cultures were performed: 30 cultures (27%) were positive, and 18 (60%) were concordant with sonication fluid cultures. Six devices and leads were removed because of infection, growing Staphylococcus aureus, Streptococcus mitis, and coagulase-negative staphylococci in 6 sonication fluid cultures and 4 conventional swab cultures. CONCLUSIONS: Bacteria can colonize cardiac electrophysiological devices without clinical signs of infection.

SARS-CoV-2 Ig G among Healthcare Workers and the General Population.

It is assumed that healthcare workers are at the highest risk to be infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, few data from healthcare workers who do not primarily take care of patients with SARS-CoV-2 infection support this assumption. We investigated the prevalence of immunoglobulin G (Ig G) against SARS-CoV-2 among healthcare workers who do not primarily take care of patients with SARS-CoV-2 infection and the general population in a well-defined geographical area. The first part of the study was conducted in May 2020 in Val Mesolcina (Southern Switzerland), a valley with ~8000 inhabitants. All healthcare workers were invited. All participants (n = 488) of the Swiss Longitudinal Cohort Study (SWICOS), a cohort representative of the general population, were also invited. Circulating Ig G against spike protein subunit 1 of SARS-CoV-2 were tested in each subject. Subjects with positive Ig G were tested again after 6 months. The condition of being a healthcare worker, rather than a part of the general population, was tested as a predictor of seroprevalence positivity by both simple and multiple (adjusted for age and sex) logistic regression. Eleven (2.6%) of the 423 SWICOS participants and 46 (16%) out of 289 healthcare workers were positive for antibodies against SARS-CoV-2. The seroprevalence OR was 7.01 (95% CI: 3.53-15.47) for healthcare workers as compared to SWICOS participants. After adjusting for age and gender, the seroprevalence OR was 5.13 (95% CI: 2.54-10.40). About three quarters of the subjects in the SWICOS (73%) and in healthcare (79%) group with a previous positive serology still presented positive Ig G against the SARS-CoV-2 after 6 months. The present seroprevalence data point out that the SARS-CoV-2 infection is seven times higher among healthcare workers than in the general population of Val Mesolcina. Efforts to effectively protect all the healthcare personnel are needed.

Prevalence of ideal cardiovascular health in a community-based population - results from the Swiss Longitudinal Cohort Study (SWICOS).

AIMS OF THE STUDY: The American Heart Association (AHA) developed a concept to measure cardiovascular health in populations. We aimed to analyse participants in the Swiss Longitudinal Cohort Study (SWICOS) according to the AHA concept. METHODS: We analysed cardiovascular health according to the AHA concept in all 474 participants of the prospective, population-based SWICOS study who were 18 years or older. The AHA concept uses seven health metrics of known cardiovascular risk factors (blood pressure, total cholesterol, blood glucose, smoking, body weight, physical activity and diet), and classifies each health metric according to three levels (ideal, intermediate and poor) using pre-defined cut-offs. RESULTS: Ideal cardiovascular health for three or more of the seven health metrics was found in 259 participants (54.9%; 95% confidence interval [CI] 50.1-59.4%), but a relevant number of participants (n = 213, 45.1%, 95% CI 40.6-49.7%) showed ideal cardiovascular health for only two or fewer of the seven health metrics. Poor cardiovascular health for three or more of the seven health metrics was found in 40 participants (8.5%; 95% CI 6.1-11.4%); a majority of 432 participants (91.5%; 95% CI 88.6-93.9%) showed a poor level for only two or fewer of the seven health metrics. CONCLUSIONS: Overall, we found favourable results for cardiovascular health in the population-based SWICOS cohort. Nevertheless, we see the need for further health prevention campaigns given the fact that a relevant proportion of the participants could optimise their cardiovascular health.

Energy and protein intake in medical and geriatric inpatients with MEDPass versus conventional administration of oral nutritional supplements: study protocol for the randomized controlled MEDPass Trial.

BACKGROUND: Disease-related malnutrition is highly prevalent in hospitalized medical and geriatric inpatients. It is associated with negative outcomes such as muscle wasting, decline of functional status, and increased morbidity and mortality. Oral nutritional supplements (ONS) are frequently used in nutritional therapy to increase intake. However, compliance to ONS is often limited and maybe improved by prescribing ONS in small portions timed with the medication (MEDPass). However, it is unknown whether the MEDPass administration enhances patients' total energy and protein intake. METHODS: The MEDPass Trial is a randomized, controlled, open-label superiority trial. Patients in the MEDPass group receive 50 ml of ONS four times per day, distributed with the medication rounds. Patients in the control group receive ONS between meals. The primary outcome is average daily energy intake (% of calculated daily requirement). For our power analysis, we assumed that administration of ONS in the MEDPass administration mode increases energy intake by at least 10% (i.e., by 200 kcal for an average energy requirement of 2200 kcal/day). Thus, with the inclusion of 200 patients, this trial has 80% power to demonstrate that intervention group patients have an average intake of 2200 kcal/day (SD 500 kcal) versus 2000 kcal/day (SD 500 kcal) in control group patients. Energy and protein intakes from ONS and all food consumed are monitored continuously throughout the hospital stay and are statistically compared to the patient's requirements. Secondary outcomes include average daily protein intake (% of calculated daily requirement), average intake of ONS/day, the course of body weight, handgrip strength, appetite, and nausea. Furthermore, hospital length of stay and 30-day mortality are assessed. The primary statistical analysis will be performed as an intention-to-treat analysis adjusted for the stratification factors used in randomization. DISCUSSION: To our knowledge, this is the first randomized controlled trial assessing total energy and protein intake for the entire hospitalization period in patients receiving MEDPass versus conventional ONS administration. Thus, the MEDPass Trial will fill a gap and answer this relevant clinical question. TRIAL REGISTRATION: ClinicalTrials.gov NCT03761680 . Registered on 3 December 2018. Kofam.ch SNCTP000003191 . Registered on 15 October 2018.