Physiological processes of inflammation and edema initiated by sustained mechanical loading in subcutaneous tissues: A scoping review.

Deep tissue injuries are pressure ulcers which initiate in the subcutaneous tissues and extend through a bottom-up pathway. Once deep tissue injuries are visual at skin level, serious irreversible tissue damage has already occurred. In pressure ulcer development, inflammation and edema are coupled physiological processes associated with tissue damage arising due to sustained mechanical loading. This study aimed to provide an in-depth overview of the physiological processes of inflammation and edema initiated by sustained mechanical loading in subcutaneous tissues, in the context of pressure ulceration. A scoping review was performed according to the framework by Arksey and O'Malley. The databases MEDLINE, EMBASE, Web of Science, and Scopus, and the reference lists of included studies were searched for in vivo (animal, human), and in vitro studies matching the study objectives (from inception to 28 May 2018). No restrictions for inclusion were applied for study design, setting, participants, and year of publication. A total of 12 studies were included, varying in study design, sample characteristics, amount and duration of mechanical loads that were applied, follow-up time, and assessment methods. Neutrophil infiltration and edema occur in the subcutaneous tissues nearly immediately after the application of load on soft tissues. The amount of neutrophils and edema increase in the first days after the mechanical insult and decrease once healing has been initiated and no supplementary mechanical load was applied. One study indicated that edema may extend up to the level of the dermo-epidermal junction. Further research should focus on how deep tissue inflammation and edema are reflected into unique tissue changes at skin level, and how abnormal inflammatory responses manifest (e.g. when the nervous system is not functioning normally).

Outcome measurement instruments for erythema associated with incontinence-associated dermatitis: Systematic review.

AIM: To: (a) examine which outcome measurement instruments for erythema associated with incontinence-associated dermatitis (IAD) with supporting evidence about measurement properties are available; (b) evaluate the methodological quality of the studies and the quality of the measurement properties; and (c) identify eligible instruments to measure erythema in incontinence-associated dermatitis research. DESIGN: Systematic review. DATA SOURCES: MEDLINE, EMBASE, CINAHL and CENTRAL were systematically searched until July 2018 (update December 2018). Additional input was gathered from 151 incontinence-associated dermatitis experts. Cited and citing references of included studies were screened. REVIEW METHODS: The COSMIN Risk of Bias checklist was applied to evaluate the methodological quality of the studies. Reported measurement properties were rated against criteria for good measurement properties. RESULTS: Fourteen studies, describing 10 measurement instruments, were included. In five instruments, erythema was captured as a separate concept, two studies provided empirical evidence about the measurement properties. The most studied measurement properties were reliability (9 studies), measurement error (4 studies) and criterion validity (4 studies). In one study, internal consistency was examined. CONCLUSION: No instrument measuring exclusively erythema associated with incontinence-associated dermatitis exists. There is no single composite incontinence-associated dermatitis measurement instrument that outperforms others. Development or adaption of an instrument to measure erythema associated with incontinence-associated dermatitis is one option to solve this challenge. IMPACT: The evidence about measurement properties of instruments measuring erythema associated with incontinence-associated dermatitis has not been summarized to date. The lack of an instrument should trigger activities to measure this domain accurately in future clinical trials.

Clustering of multiple energy balance related behaviors is associated with body fat composition indicators in adolescents: Results from the HELENA and ELANA studies.

The objective of this study was to identify clustering patterns of four energy balance-related behaviors (EBRB): television (TV) watching, moderate and vigorous physical activity (MVPA), consumption of fruits and vegetables (F&V), and consumption of sugar-sweetened beverages (SSB), among European and Brazilian adolescents. EBRB associations with different body fat composition indicators were then evaluated. Participants included adolescents from eight European countries in the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescents) study (n = 2,057, 53.8% female; age: 12.5-17.5 years) and from the metropolitan region of Rio de Janeiro/Brazil in the ELANA study (the Adolescent Nutritional Assessment Longitudinal Study) (n = 968, 53.2% female; age: 13.5-19 years). EBRB data allowed for sex- and study-specific clusters. Associations were estimated by ANOVA and odds ratios. Five clustering patterns were identified. Four similar clusters were identified for each sex and study. Among boys, different cluster identified was characterized by high F&V consumption in the HELENA study and high TV watching and high MVPA time in the ELANA study. Among girls, the different clusters identified was characterized by high F&V consumption in both studies and, additionally, high SSB consumption in the ELANA study. Regression analysis showed that clusters characterized by high SSB consumption in European boys; high TV watching, and high TV watching plus high MVPA in Brazilian boys; and high MVPA, and high SSB and F&V consumption in Brazilian girls, were positively associated with different body fat composition indicators. Common clusters were observed in adolescents from Europe and Brazil, however, no cluster was identified as being completely healthy or unhealthy. Each cluster seems to impact on body composition indicators, depending on the group. Public health actions should aim to promote adequate practices of EBRB.

Core outcome domains in incontinence-associated dermatitis research.

AIM: To report the development of a core set of outcome domains for clinical research involving adults with incontinence-associated dermatitis or at risk, independently from any geographical location or skin colour. BACKGROUND: The management of incontinence-associated dermatitis is important in caring for incontinent patients. The lack of comparability of clinical trial outcomes is a major challenge in the field of evidence-based incontinence-associated dermatitis prevention and treatment. Core outcome sets may therefore be helpful to improve the value of clinical incontinence-associated dermatitis research. DESIGN: Systematic literature review, patient interviews and consensus study using Delphi procedure. METHODS: A list of outcome domains was generated through a systematic literature review (no date restrictions-April 2016), consultation of an international steering committee and three patient interviews. The project team reviewed and refined the outcome domains prior to starting a three-round Delphi procedure conducted between April-September 2017. The panellists, including healthcare providers, researchers and industry were invited to rate the importance of the outcome domains. RESULTS: We extracted 1,852 outcomes from 244 articles. Experts proposed 56 and patients 32 outcome domains. After refinement, 57 panellists from 17 countries rated a list of 58 outcome domains. The final list of outcome domains includes erythema, erosion, maceration, IAD-related pain and patient satisfaction. CONCLUSION: Erythema, erosion, maceration, incontinence-associated dermatitis -related pain and patient satisfaction are the most important outcome domains to be measured in incontinence-associated dermatitis trials. Based on this international consensus on what to measure, the question of how to measure these domains now requires consideration. Registration: This project has been registered in the Core Outcome Measures in Effectiveness Trials (COMET Initiative) database and is part of the Cochrane Skin Group-Core Outcomes Set Initiative (CSG-COUSIN).

Minimum Data Set for Incontinence-Associated Dermatitis (MDS-IAD) in adults: Design and pilot study in nursing home residents.

STUDY AIM: The aim of this study was to develop a Minimum Data Set for Incontinence-Associated Dermatitis (MDS-IAD), to psychometrically evaluate and pilot test the instrument in nursing homes. Comparable to the MDS for pressure ulcers, the MDS-IAD aims to collect epidemiological data and evaluate the quality of care. MATERIALS AND METHODS: After designing and content/face validation by experts and clinicians, staff nurses assessed 108 residents (75.9% female, 77.8% double incontinent) in a convenience sample of five wards. A second nurse independently assessed fifteen residents to calculate inter-rater agreement (p0) and reliability [Cohen's Kappa (ĸ)]. RESULTS: The ĸ-value for 'urinary incontinence' was 0.68 [95% confidence interval (CI) 0.37-0.99] and 0.55 (95% CI 0.27-0.82) for 'faecal incontinence'. The p0 for severity categorisation according to the Ghent Global IAD Categorisation Tool (GLOBIAD) was 0.60. IAD was diagnosed in 21.3% of the residents. IAD management mainly involved the application of a leave-on product (66.7%), no-rinse foams (49.1%), toilet paper (47.9%), and water and soap (38.8%). Fully adequate prevention or treatment was provided to respectively 3.6% and 8.7% of the residents. CONCLUSION: This instrument provides valuable insights in IAD prevalence at organisational level, will allow benchmarking between organisations, and will support policy makers. Future testing in other healthcare settings is recommended.

The Ghent Global IAD Monitoring Tool (GLOBIAD-M) to monitor the healing of incontinence-associated dermatitis (IAD): Design and reliability study.

The aim of this study was to design and evaluate the reliability of the Ghent Global incontinence-associated dermatitis (IAD) Monitoring Tool (GLOBIAD-M). The tool was designed based on the internationally validated Ghent Global IAD Categorisation Tool (GLOBIAD). After designing and validation by experts, one trained researcher carried out 36 observations of 9 patients affected with IAD. Photographs of the IAD lesions were independently assessed by a second trained researcher. Measures for inter-rater agreement (po ) and reliability [Cohen's Kappa (ĸ) and intra-class correlation coefficients (ICC)] were analysed. The po ranged between 0.86 for the item 'maceration' and 0.97 for the item 'clinical signs of infection'. The ĸ for the item 'GLOBIAD classification' was 0.61 [95% confidence interval (CI) 0.28-0.95] and 0.72 (95% CI 0.50-0.95) for 'maceration'. The lowest ĸ was found for the item 'oedema' (0.27; 95% CI -0.24-0.79). The ICC of the item 'redness' was 0.83 (95% CI 0.69-0.91) and 0.87 (95% CI 0.76-0.93) for 'skin loss'. The inter-rater agreement and reliability of the GLOBIAD-M appears to be good for the assessment of photographs by experts. This tool could support clinical decision-making for IAD treatment. Further validation with clinicians is, however, needed.

Belgian primary school children's hydration status at school and its personal determinants.

PURPOSE: Dehydration has been related to several health aspects, and children are especially vulnerable. Since children spend a large time at school, we aim to examine children's hydration status at school-start and its change during the school-day by objective measures. To identify subpopulations at risk, determinants of hydration were tested. METHODS: In 371 Belgian 7-13-year-old children, hydration was measured by (1) urinary osmolality at school-start and by a pooled school-day sample; (2) body water% by impedance; (3) parental reported beverage consumption; (4) urination frequency. Linear regression analyses were used to test putative predictors of hydration status: age, sex, parental education, region (Dutch-speaking versus French-speaking part of Belgium), diet quality and adiposity. RESULTS: A mean osmolality of 888 mosmol/kg was found in the school-start sample and 767 mosmol/kg in the school-day sample. This resulted in, respectively, 76 and 54 % of the children being dehydrated (>800 mosmol/kg). In 45 % of the children, the hydration level decreased over the school-day. Also the body water% as derived from bio-impedance (57 % ±4), the reported average daily beverage intake (911 ml) and the lower urination frequency during weekdays versus weekend days confirmed the low hydration status in our school population. Boys, Walloon children and those with higher adiposity were at increased risk of low hydration level. Diet quality was not the predictor of hydration status. CONCLUSIONS: Hydration status at school appeared problematic in this population. This emphasizes the need for more resources and attention by school management and governmental organizations. Herein, especially Walloon schools and boys should be reached.

CONSIDER - Core Outcome Set in IAD Research: study protocol for establishing a core set of outcomes and measurements in incontinence-associated dermatitis research.

AIM: This study protocol describes the methodology for the development of a core set of outcomes and a core set of measurements for incontinence-associated dermatitis. BACKGROUND: Incontinence is a widespread disorder with an important impact on quality of life. One of the most common complications is incontinence-associated dermatitis, resulting from chemical and physical irritation of the skin barrier, triggering inflammation and skin damage. Managing incontinence-associated dermatitis is an important challenge for nurses. Several interventions have been assessed in clinical trials, but heterogeneity in study outcomes complicates the comparability and standardization. To overcome this challenge, the development of a core outcome set, a minimum set of outcomes and measurements to be assessed in clinical research, is needed. DESIGN: A project team, International Steering Committee and panelists will be involved to guide the development of the core outcome set. The framework of the Harmonizing Outcomes Measures for Eczema roadmap endorsed by Cochrane Skin Group Core Outcomes Set Initiative, is used to inform the project design. METHODS: A systematic literature review, interviews to integrate the patients' perspective and a consensus study with healthcare researchers and providers using the Delphi procedure will be performed. The project was approved by the Ethics review Committee (April 2016). DISCUSSION: This is the first project that will identify a core outcome set of outcomes and measurements for incontinence-associated dermatitis research. A core outcome set will reduce possible reporting bias, allow results comparisons and statistical pooling across trials and strengthen evidence-based practice and decision-making. REGISTRATION: This project has been registered in the Core Outcome Measures in Effectiveness Trials (COMET) database and is part of the Cochrane Skin Group Core Outcomes Set Initiative (CSG-COUSIN).

PROTECT - trial: a multicentre prospective pragmatic RCT and health economic analysis of the effect of tailored repositioning to prevent pressure ulcers - study protocol.

AIM: The aims of this trial were as follows: (1) to compare the (cost-) effectiveness of a turning and repositioning system and an algorithm for a tailored repositioning vs. usual care to improve reposition frequency in patients at risk; and (2) to compare the (cost-) effectiveness of standardized incontinence care vs. usual care. BACKGROUND: Pressure ulcers are a serious and common problem for hospitalized patients. In many countries, pressure ulcers are recognized as a national health issue and governments designate pressure ulcers as one of the most important sentinel events for health care. International guidelines recommend the use of pressure redistributing support surfaces, systematic patient repositioning and preventive skin care to prevent pressure ulcers. Interventions should be patient-tailored and based on a thorough assessment of both the patient and contextual risk factors. There is a lack of rigorous research addressing the effectiveness of a turning and repositioning system and it is unclear how to tailor the frequency and posture to specific patient needs. DESIGN: Multicentre, cluster, three-arm, randomized, controlled pragmatic trial and a cost-effectiveness analysis. The ward is the unit of randomization. METHODS: Tailored repositioning, the use of a device to facilitate patient repositioning and an optimal procedure for incontinence care will be combined. Participating wards will be intensive care units, geriatric and rehabilitation wards. A sample size calculation was performed (80% power, α = 0·05). This study is approved by the Ethics Committee (February 2016). DISCUSSION: Data collection is currently ongoing. The results are expected to be obtained in March 2017.

Independent risk factors for the development of skin erosion due to incontinence (incontinence-associated dermatitis category 2) in nursing home residents: results from a multivariate binary regression analysis.

The aim of this study was to identify characteristics independently associated with a higher risk of developing skin damage because of incontinence [incontinence-associated dermatitis (IAD) category 2] in nursing home residents. As part of a larger randomised controlled trial, IAD incidence was monitored for 1 month in a sample of 381 incontinent residents using a validated IAD Severity Categorisation Tool. Data on demographical, physical, functional and psychological characteristics were collected. The overall IAD incidence (category 1-2) was 30·0%, and 6% of the participants developed skin damage (IAD category 2). Residents who developed IAD category 2 were less mobile [odds ratio (OR) 2·72, 95% confidence interval (CI) 1·06-6·94], had more friction and shear issues (OR 2·54; 95% CI 1·02-6·33) and had more erythema due to incontinence (OR 3·02; 95% CI 1·04-8·73) before IAD category 2 occurrence. Care providers should give full attention to risk factors to both detect residents at risk for IAD development and to start prevention in time.

Interventions for preventing and treating incontinence-associated dermatitis in adults.

BACKGROUND: Incontinence-associated dermatitis (IAD) is one of the most common skin problems in adults who are incontinent for urine, stool, or both. In practice, products and procedures are the same for both prevention and treatment of IAD. OBJECTIVES: The objective of this review was to assess the effectiveness of various products and procedures to preventand treat incontinence-associated dermatitis in adults. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 28 September 2016). Additionally we searched other electronic databases: CENTRAL(2015, Issue 4), MEDLINE (January 1946 to May Week 3 2015), MEDLINE In-Process (inception to 26 May 2015), CINAHL(December 1981 to 28 May 2015), Web of Science (WoS; inception to 28 May 2015) and handsearched conference proceedings (to June 2015) and the reference lists of relevant articles, and contacted authors and experts in the field. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) and quasi-RCTs, performed in any healthcare setting, with included participants over 18 years of age, with or without IAD. We included trials comparing the (cost) effectiveness of topical skin care products such as skin cleansers, moisturisers, and skin protectants of different compositions and skin care procedures aiming to prevent and treat IAD. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles, abstracts and full-texts, extracted data, and assessed the risk of bias of the included trials. MAIN RESULTS: We included 13 trials with 1295 participants in a qualitative synthesis. Participants were incontinent for urine, stool, or both, and were residents in a nursing home or were hospitalised.Eleven trials had a small sample size and short follow-up periods. .The overall risk of bias in the included studies was high. The data were not suitable for meta-analysis due to heterogeneity in participant population, skin care products, skin care procedures, outcomes, and measurement tools.Nine trials compared different topical skin care products, including a combination of products. Two trials tested a structured skin care procedure. One trial compared topical skin care products alongside frequencies of application. One trial compared frequencies of application of topical skin care products.We found evidence in two trials, being of low and moderate quality, that soap and water performed poorly in the prevention and treatment of IAD (primary outcomes of this review). The first trial indicated that the use of a skin cleanser might be more effective than the use of soap and water (risk ratio (RR) 0.39, 95% confidence interval (CI) 0.17 to 0.87; low quality evidence). The second trial indicated that a structured skin care procedure, being a washcloth with cleansing, moisturising, and protecting properties, might be more effective than soap and water (RR 0.31, 95% CI 0.12 to 0.79; moderate quality evidence). Findings from the other trials, all being of low to very low quality, suggest that applying a leave-on product (moisturiser, skin protectant, or a combination) might be more effective than not applying a leave-on product. No trial reported on the third primary outcome 'number of participants not satisfied with treatment' or on adverse effects. AUTHORS' CONCLUSIONS: Little evidence, of very low to moderate quality, exists on the effects of interventions for preventing and treating IAD in adults. Soap and water performed poorly in the prevention and treatment of IAD. Application of leave-on products (moisturisers, skin protectants, or a combination) and avoiding soap seems to be more effective than withholding these products. The performance of leave-on products depends on the combination of ingredients, the overall formulation and the usage (e.g. amount applied). High quality confirmatory trials using standardised, and comparable prevention and treatment regimens in different settings/regions are required. Furthermore, to increase the comparability of trial results, we recommend the development of a core outcome set, including validated measurement tools. The evidence in this review is current up to 28 September 2016.

Core outcome Set for Cardio-oncology (COS-CO): development of a set of outcomes for the cardiovascular assessment and monitoring of cancer patients and survivors.

AIMS: There is an increasing awareness of the evidence-based selection of outcomes to be measured in clinical trials and clinical practice. Currently, there is no core outcome set (COS) for cardio-oncology, which may hinder the (inter)national comparison of the effectiveness of research and the quality of cardio-oncology care. The aim of this study is to develop a standard and pragmatic patient-centred outcome set to assess and monitor cancer patients and survivors at risk of or with cardiovascular diseases. METHODS & RESULTS: A list of outcome domains was generated through a review of registries and guidelines, and six patient interviews. The project team reviewed and refined the outcome domains prior to starting a two-round Delphi procedure conducted between January-June 2022. The panellists, including healthcare providers and researchers, were invited to rate the importance of the outcomes. 26 experts from 11 countries rated a list of 93 outcomes (round 1) and 63 outcomes (round 2) to gain consensus on a list of outcome measures, and of demographic factors, health status and treatment variables. The final COS includes 15 outcome measures, reflecting four core areas: life impact (n = 2), pathophysiological manifestations (n = 9), resource use/economic impact (n = 1), and mortality/survival (n = 3). Next, six demographic factors, 21 health status, three cardiovascular and nine cancer variables were included. CONCLUSION: This is the first international development of a COS for cardio-oncology. This set aims to facilitate (inter)national comparison in cardio-oncology care, using standardised parameters and meaningful patient-centred outcomes for research and quality of care assessments.

Depression and Malnutrition for Prediction of Mortality after Transcatheter Aortic Valve Replacement: A Registry Study of a Tertiary Referral Hospital.

Moderate to severe frailty is a predictor of a poor outcome after transcatheter aortic valve replacement (TAVR), but little is known about the prognostic importance of different geriatric frailty markers in an overall fit or pre-frail geriatric population undergoing TAVR. This retrospective study aimed to examine the incremental value of adding patient frailty markers to conventional surgical risk score to predict all-cause mortality in relatively fit elderly patients undergoing TAVR. Overall patient frailty was assessed using the comprehensive geriatric assessment frailty index (CGA-FI). Multivariable Cox regression models were used to evaluate relationships of different geriatric frailty markers with all-cause mortality and single and combined frailty models were compared to a baseline model that included EuroSCORE II factors. One hundred relatively fit geriatric patients (84 ± 4 years old, mean CGA-FI 0.14 ± 0.05) were included, and 28% died during a median follow-up of 24 months. After adjustment, risk of depression (geriatric depression scale 15 (GDS-15)) and malnutrition remained significantly associated with all-cause mortality (HR 4.381, 95% CI 1.787-10.743; p = 0.001 and HR 3.076, 95% CI 1.151-8.217; p = 0.025, respectively). A combined frailty marker model including both GDS-15 and malnutrition on top of EuroSCORE II improved the discriminative ability to predict all-cause mortality (change in c-index: + 0.044). Screening for those frailty markers on top of the traditionally used EuroSCORE II may improve risk stratification and prognosis in relatively fit geriatric patients undergoing TAVR.

Influence of birth weight on calcaneal bone stiffness in Belgian preadolescent children.

The aim of this study was to investigate the relation between birth weight and calcaneal bone stiffness in a large sample of Belgian, healthy, preadolescent children. Participants were 827 children (3.6-11.2 years, 51.6 % boys) from the Belgian cohort of the IDEFICS study. Birth weight was obtained using a parental questionnaire, and quantitative ultrasound (QUS) measurements were performed to determine calcaneal broadband ultrasound attenuation (BUA), speed of sound (SOS), and stiffness index (SI) using the Lunar Achilles device. Average birth weights were 3435.7 ± 512.0 g for boys and 3256.9 ± 471.1 g for girls. Average calcaneal QUS measurements were 89.6 ± 24.0 (23.3-153.9) dB/MHz for BUA, 1621.4 ± 49.6 (1516.3-1776.5) m/s for SOS, and 92.8 ± 15.6 (49.0-163.0) for SI. Birth weight was positively associated with BUA (r = 0.13, p = 0.002) and SOS (r = -0.16, p < 0.001). The associations remained after correcting for age and sex in multiple regression analyses but disappeared after correcting for anthropometric covariates. Our findings suggest that birth weight, as a rough proxy indicator for genetic and environmental influences during intrauterine life, is associated with BUA and SOS in preadolescent children and may therefore influence the risk of osteoporosis later in life. Further studies using QUS are needed to investigate the consistency of the results of this study.

Subclinical Myocardial Dysfunction in Patients with Persistent Dyspnea One Year after COVID-19-Why Should Screening for Cardiovascular Diseases Be Performed? Reply to Vankrunkelsven, P. Tendentious Paper-Titles and Wrong Conclusions Lead to Fear in the Population and Medical Overconsumption. Comment on "Luchian et al. Subclinical Myocardial Dysfunction in Patients with Persistent Dyspnea One Year after COVID-19. Diagnostics 2022, 12, 57".

We have read with interest the comment by Vankrunkelsven P. [...].

Guiding Myocardial Revascularization by Algorithmic Interpretation of FFR Pullback Curves: A Proof of Concept Study.

Background: Coronary artery disease distribution along the vessel is a main determinant of FFR improvement after PCI. Identifying focal from diffuse disease from visual inspections of coronary angiogram (CA) and FFR pullback (FFR-PB) are operator-dependent. Computer science may standardize interpretations of such curves. Methods: A virtual stenting algorithm (VSA) was developed to perform an automated FFR-PB curve analysis. A survey analysis of the evaluations of 39 vessels with intermediate disease on CA and a distal FFR <0.8, rated by 5 interventional cardiologists, was performed. Vessel disease distribution and PCI strategy were successively rated based on CA and distal FFR (CA); CA and FFR-PB curve (CA/FFR-PB); and CA and VSA (CA/VSA). Inter-rater reliability was assessed using Fleiss kappa and an agreement analysis of CA/VSA rating with both algorithmic and human evaluation (operator) was performed. We hypothesize that VSA would increase rater agreement in interpretation of epicardial disease distribution and subsequent evaluation of PCI eligibility. Results: Inter-rater reliability in vessel disease assessment by CA, CA/FFR-PB, and CA/VSA were respectively, 0.32 (95% CI: 0.17-0.47), 0.38 (95% CI: 0.23-0.53), and 0.4 (95% CI: 0.25-0.55). The raters' overall agreement in vessel disease distribution and PCI eligibility was higher with the VSA than with the operator (respectively, 67 vs. 42%, and 80 vs. 70%, both p < 0.05). Compared to CA/FFR-PB, CA/VSA induced more reclassification toward a focal disease (92 vs. 56.2%, p < 0.01) with a trend toward more reclassification as eligible for PCI (70.6 vs. 33%, p = 0.06). Change in PCI strategy did not differ between CA/FFR-PB and CA/VSA (23.6 vs. 28.5%, p = 0.38). Conclusions: VSA is a new program to facilitate and standardize the FFR pullback curves analysis. When expert reviewers integrate VSA data, their assessments are less variable which might help to standardize PCI eligibility and strategy evaluations. Clinical Trial Registration: https://www.clinicaltrials.gov/ct2/show/NCT03824600.

Prognostic Value of Coronary Artery Calcium Score in Hospitalized COVID-19 Patients.

Background: The association of known cardiovascular risk factors with poor prognosis of coronavirus disease 2019 (COVID-19) has been recently emphasized. Coronary artery calcium (CAC) score is considered a risk modifier in the primary prevention of cardiovascular disease. We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients. Materials and methods: We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with history of coronary artery disease were excluded. Chest computed tomography (CT) was performed in all patients. Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in-hospital treatment, and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined. Results: Two hundred eighty patients (63.2 ± 16.7 years old, 57.5% male) were included in the analysis. 46.7% patients had a CAC score of 0. MACE rate was 21.8% (61 patients). The absence of CAC was inversely associated with MACE (OR 0.209, 95% CI 0.052-0.833, p = 0.027), with a negative predictive value of 84.5%. Conclusion: The absence of CAC had a high negative predictive value for MACE in patients hospitalized with COVID-19, even in the presence of cardiac risk factors. A semi-qualitative assessment of CAC is a simple, reproducible, and non-invasive measure that may be useful to identify COVID-19 patients at a low risk for developing cardiovascular complications.

Subclinical Myocardial Dysfunction in Patients with Persistent Dyspnea One Year after COVID-19.

Long coronavirus disease 2019 (COVID-19) was described in patients recovering from COVID-19, with dyspnea being a frequent symptom. Data regarding the potential mechanisms of long COVID remain scarce. We investigated the presence of subclinical cardiac dysfunction, assessed by transthoracic echocardiography (TTE), in recovered COVID-19 patients with or without dyspnea, after exclusion of previous cardiopulmonary diseases. A total of 310 consecutive COVID-19 patients were prospectively included. Of those, 66 patients (mean age 51.3 ± 11.1 years, almost 60% males) without known cardiopulmonary diseases underwent one-year follow-up consisting of clinical evaluation, spirometry, chest computed tomography, and TTE. From there, 23 (34.8%) patients reported dyspnea. Left ventricle (LV) ejection fraction was not significantly different between patients with or without dyspnea (55.7 ± 4.6 versus (vs.) 57.6 ± 4.5, p = 0.131). Patients with dyspnea presented lower LV global longitudinal strain, global constructive work (GCW), and global work index (GWI) compared to asymptomatic patients (-19.9 ± 2.1 vs. -21.3 ± 2.3 p = 0.039; 2183.7 ± 487.9 vs. 2483.1 ± 422.4, p = 0.024; 1960.0 ± 396.2 vs. 2221.1 ± 407.9, p = 0.030). GCW and GWI were inversely and independently associated with dyspnea (p = 0.035, OR 0.998, 95% CI 0.997-1.000; p = 0.040, OR 0.998, 95% CI 0.997-1.000). Persistent dyspnea one-year after COVID-19 was present in more than a third of the recovered patients. GCW and GWI were the only echocardiographic parameters independently associated with symptoms, suggesting a decrease in myocardial performance and subclinical cardiac dysfunction.

Troponin T in COVID-19 hospitalized patients: Kinetics matter.

BACKGROUND: Coronavirus disease 2019 (COVID-19) emerged as a worldwide health crisis, overwhelming healthcare systems. Elevated cardiac troponin T (cTn T) at admission was associated with increased in-hospital mortality. However, data addressing the role of cTn T in major adverse cardiovascular events (MACE) in COVID-19 are scarce. Therefore, we assessed the role of baseline cTn T and cTn T kinetics for MACE and in-hospital mortality prediction in COVID-19. METHODS: Three hundred and ten patients were included prospectively. One hundred and eight patients were excluded due to incomplete records. Patients were divided into three groups according to cTn T kinetics: ascending, descending, and constant. The cTn T slope was defined as the ratio of the cTn T change over time. The primary and secondary endpoints were MACE and in-hospital mortality. RESULTS: Two hundred and two patients were included in the analysis (mean age 64.4 ± 16.7 years, 119 [58.9%] males). Mean duration of hospitalization was 14.0 ± 12.3 days. Sixty (29.7%) patients had MACE, and 40 (19.8%) patients died. Baseline cTn T predicted both endpoints (p = 0.047, hazard ratio [HR] 1.805, 95% confidence interval [CI] 1.009-3.231; p = 0.009, HR 2.322, 95% CI 1.234-4.369). Increased cTn T slope predicted mortality (p = 0.041, HR 1.006, 95% CI 1.000-1.011). Constant cTn T was associated with lower MACE and mortality (p = 0.000, HR 3.080, 95% CI 1.914-4.954, p = 0.000, HR 2.851, 95% CI 1.828-4.447). CONCLUSIONS: The present study emphasizes the additional role of cTn T testing in COVID-19 patients for risk stratification and improved diagnostic pathway and management.

School Policy on Drinking and Toilets: Weaknesses and Relation With Children's Hydration Status.

OBJECTIVE: To investigate school policies and practices related to drinking fluids and toileting and test their association with children's hydration status and toilet behaviors. DESIGN: Cross-sectional study in 2014. SETTING: Seventeen Belgian primary schools. PARTICIPANTS: A total of 416 children (aged 7-13 years). MAIN OUTCOME MEASURES: Hydration was measured by urinary osmolality in a pooled school-day sample and by impedance-based body water percentage. Children reported how much they liked school toilets. School policy and practices were reported by schools on 59 items over 10 policy components. ANALYSIS: Multilevel logistic regression analyses adjusted for age, sex, region and socioeconomic status. RESULTS: School's weaknesses were the lack of policy participation by parents and children; official agreements (only in 11%); organizing education on drinking and toilet visits; and toilet infrastructure. Children's hydration was higher in schools that (1) made water available, (2) organized toilet and drinking related education, (3) had formal agreements on drinking and toilet visits, and (4) had good toilet maintenance. Children liked school toilets more in schools that (1) organized toilet and drinking related education, (2) had an official policy on drinking, (3) had good toilet infrastructure, and (4) allowed policy participation by parents and children. CONCLUSIONS AND IMPLICATIONS: Specific action points for school management and government to improve children's hydration at school were detected by focusing on both drinking and toilet practices/infrastructure.