COVID-19-mediated patient delay caused increased total ischaemic time in ST-segment elevation myocardial infarction.

BACKGROUND: The current study aimed to evaluate changes in treatment delay and outcome for ST-segment elevation myocardial infarction (STEMI) in the Netherlands during the first coronavirus disease 2019 (COVID-19) outbreak, thereby comparing regions with a high and low COVID-19 hospitalisation rate. METHODS: Clinical characteristics, STEMI timing variables, 30-day all-cause mortality and cardiovascular complications of all consecutive patients admitted for STEMI from 1 January to 30 June in 2020 and 2019 to six hospitals performing a high volume of percutaneous coronary interventions were collected retrospectively using data from the Netherlands Heart Registry, hospital records and ambulance report forms. Patient delay, pre-hospital delay and door-to-balloon time before and after the outbreak of COVID-19 were compared to the equivalent periods in 2019. RESULTS: A total of 2169 patients were included. During the outbreak median total treatment delay significantly increased (2 h 51 min vs 2 h 32 min; p = 0.043) due to an increased patient delay (1 h 20 min vs 1 h; p = 0.030) with more late presentations > 24 h (1.1% vs 0.3%) in 2020. This increase was particularly evident during the peak phase of COVID-19 in regions with a high COVID-19 hospitalisation rate. During the peak phase door-to-balloon time was shorter (38 min vs 43 min; p = 0.042) than in 2019. All-cause 30-day mortality was comparable in both time frames (7.8% vs 7.3%; p = 0.797). CONCLUSIONS: During the outbreak of COVID-19 patient delay caused an increase in total ischaemic time for STEMI, with a more pronounced delay in high-endemic regions, stressing the importance of good patient education during comparable crisis situations.

Effects of seasonality and previous logging on faecal helminth-microbiota associations in wild lemurs.

Gastrointestinal helminth-microbiota associations are shaped by various ecological processes. The effect of the ecological context of the host on the bacterial microbiome and gastrointestinal helminth parasites has been tested in a number of ecosystems and experimentally. This study takes the important step to look at these two groups at the same time and to start to examine how these communities interact in a changing host environment. Fresh faecal samples (N = 335) from eight wild Eulemur populations were collected over 2 years across Madagascar. We used 16S ribosomal RNA gene sequencing to characterise the bacterial microbiota composition, and faecal flotation to isolate and morphologically identify nematode eggs. Infections with nematodes of the genera Callistoura and Lemuricola occurred in all lemur populations. Seasonality significantly contributed to the observed variation in microbiota composition, especially in the dry deciduous forest. Microbial richness and Lemuricola spp. infection prevalence were highest in a previously intensely logged site, whereas Callistoura spp. showed no such pattern. In addition, we observed significant correlations between gastrointestinal parasites and bacterial microbiota composition in these lemurs, with 0.4-0.7% of the variation in faecal bacterial microbiota composition being explained by helminth infections. With this study, we show effects of environmental conditions on gastrointestinal nematodes and bacterial interactions in wild lemurs and believe it is essential to consider the potential role of microbiome-parasite associations on the hosts' GI stability, health, and survival.

The ECG of high-level junior soccer players: comparing the ESC vs. the Seattle criteria.

INTRODUCTION: Sudden cardiac death in young athletes is a devastating event. The screening and detection of potentially life-threatening cardiac pathology by ECG is difficult due to high numbers of false-positive results, especially in the very young. The Seattle ECG criteria (2013) were introduced to decrease false-positive results. We compared the Seattle ECG criteria with the European Society of Cardiology (ESC) ECG criteria of 2005 and 2010 for cardiac screening in high-level junior soccer players. METHODS: During the 2012-2013 season, all data from cardiovascular screenings performed on the youth division of two professional soccer clubs were collected. The total study population consisted of 193 male adolescent professional soccer players, aged 10-19 years. Five players dropped out of this study. RESULTS: Applying the ESC criteria of 2005 and 2010 to our population resulted in a total of 89 (47%) and 62 (33%) abnormal ECGs. When the Seattle ECG criteria were applied, the number of abnormal ECGs was 6 (3%). The reduction was mainly due to a reclassification of the long QT cut-off value and the exclusion of right atrial enlargement criteria. All ECG abnormalities using the Seattle criteria related to T-wave inversion criteria. CONCLUSION: The Seattle ECG criteria seem very promising for decreasing false-positive screening results for high-level junior soccer players.

The diagnostic value of soluble CD163 in patients presenting with chest pain.

BACKGROUND: CD163 is a scavenger receptor for the uptake of haptoglobin-hemoglobin (Hpt-Hb) complexes. The Hpt-Hb complexes are being formed in the plaque in response to intraplaque hemorrhage, a hallmark of atherosclerotic plaque instability. We therefore investigated whether soluble CD163 (sCD163) was elevated in patients with an acute coronary syndrome. METHODS: All subjects presenting with chest pain suggestive of myocardial ischemia referred to either the emergency department or the coronary care unit were included in a prospective follow-up study. Plasma was collected and frozen at -80 degrees C until assayed. sCD163 was measured using a commercially available Elisa assay. RESULTS: Of 526 included chest pain patients, the final diagnosis was non-cardiac chest pain in 244 (46%) patients, non-STEMI in 67 (13%), and STEMI in 215 (41%). The non-STEMI patients were older, used more medication, had undergone more often coronary interventions, but did not differ with respect to risk factors, except for a higher incidence in dyslipidemia. Unexpectedly, sCD163 did not differentiate between patients with non-STEMI or STEMI and the non-cardiac chest pain patients (2.09+/-0.76 versus 2.24+/-0.86). CONCLUSION: Although ACS is characterized by intraplaque hemorrhage, the amount of intraplaque Hb release seems not to be substantial enough to result in a measurable difference in sCD163.

The Lausanne recommendations: a Dutch experience.

OBJECTIVE: This study presents the results of 28 months of preparticipation cardiovascular screening using the Lausanne recommendations, which include a personal and family history, physical examination and electrocardiogram (ECG). DESIGN: From January 2006 to April 2008 the data of the Lausanne screenings carried out at the University Centre of Sports Medicine in Groningen were collected. PARTICIPANTS: 825 cardiovascular screenings were performed of which 397 were excluded. Exclusion criteria were age under 12 or over 35 years, multiple screenings (only the first was included) and known cardiovascular disease. MAIN OUTCOME MEASURES: Negative screening result, (false) positive screening result, medical consumption and number needed to screen. RESULTS: A total of 371 (87%) athletes had a negative screening result. Fifty-five athletes (13%) underwent additional (stage 2) testing and seven (1.6%) further (stage 3) testing. Only 27 athletes (6.3%) were referred for additional testing based only on abnormalities of their ECG. Forty-seven athletes (11%) had a false-positive screening result. Ten athletes (2%) had a positive screening result and three (0.7%) were ultimately restricted from sports participation. Stage 2 medical consumption was 62%, 20% and 18% for one, two and three or more additional tests, respectively. Stage 3 medical consumption was 1.6%. The number of athletes needed to screen to find a single athlete with a potentially lethal cardiovascular disease was 143. CONCLUSION: This study found that when the Lausanne recommendations are implemented in The Netherlands, screening results resemble those found in previous studies. The number of athletes needed to screen to detect one athlete with a potentially lethal cardiovascular disease is also within an acceptable range.

[Myocardial contusion after blunt thoracic trauma: possible indication for rhythm observation]. / Myocardcontusie na een stomp thoraxtrauma: mogelijk indicatie tot ritmeobservatie.

A 65-year-old man had a pneumohaemothorax and fractured ribs after an automobile accident. Troponine concentrations were normal and the initial electrocardiographic abnormalities resolved within 24 hours. A 46-year-old man who was also in an automobile accident developed a seat-belt haematoma and lung oedema. Troponine concentrations were increased, the electrocardiogram was abnormal and transthoracic ultrasound revealed severe myocardial contusion. After a few weeks of treatment, both patients were discharged without cardiac complications. It is clinically important to identify patients at risk of developing myocardial contusion following blunt thoracic trauma. A combination oftroponine and electrocardiography is necessary to differentiate between risk categories. Echocardiography has a role in haemodynamically unstable patients and whenever the clinical condition of the patient deteriorates. A structured approach to screening and evaluation, as presented in an algorithm, can be used as a guide in the follow-up of patients with myocardial contusion.

[Non-pharmacological treatment of heart failure: implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy]. / Niet-farmacologische behandeling van hartfalen: implanteerbare cardioverter-defibrillator (ICD) en cardiale-resynchronisatietherapie.

The non-pharmacological therapy of heart failure, in particular an implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy or biventricular stimulation, improves symptoms and survival in patients with heart failure. An ICD is indicated in many patients with heart failure following cardiac arrest unless reversible causes are demonstrable. Selected patients with a left ventricular ejection fraction < or = 35% due to either ischaemic (>40 days after a myocardial infarction) or nonischaemic cardiomyopathy are candidates for ICD implantation as the primary prevention of sudden cardiac death. Patients who continue to have severe symptoms despite maximal pharmacotherapy, with a left ventricular ejection fraction < or = 35% and a wide QRS complex, are candidates for cardiac resynchronisation therapy to improve both symptoms and survival.

Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease.

OBJECTIVES: We sought to study the influence of frequency of exercise training during cardiac rehabilitation on functional capacity (i.e., peak oxygen consumption [VO2] and ventilatory anaerobic threshold [VAT]) and quality of life (QoL). BACKGROUND: Although the value of cardiac rehabilitation is now well established, the influence of the different program characteristics on outcome has received little attention, and the effect of frequency of exercise training is unclear. Functional capacity is regularly evaluated by peak VO2 but parameters of submaximal exercise capacity such as VAT should also be considered because submaximal exercise capacity is especially important in daily living. METHODS: Patients with coronary artery disease (n = 130, 114 men; mean age 52 +/- 9 years) were randomized to either a high- or low-frequency program of six weeks (10 or 2 exercise sessions per week of 2 h, respectively). Functional capacity and QoL were assessed before and after cardiac rehabilitation. Global costs were also compared. RESULTS: Compared with baseline, mean exercise capacity increased in both programs: for high- and low-frequency, respectively: peak VO2 = 15% and 12%, Wmax = 18% and 12%, VAT = 35% and 12% (all p < 0.001). However, when the programs were compared, only VAT increased significantly more during the high-frequency program (p = 0.002). During the high-frequency program, QoL increased slightly more, and more individuals improved in subjective physical functioning (p = 0.014). We observed superiority of the high-frequency program, especially in younger patients. Mean costs were estimated at 4,455 and 2,273 Euro, respectively, for the high- and low-frequency programs. CONCLUSIONS: High-frequency exercise training is more effective in terms of VAT and QoL, but peak VO2 improves equally in both programs. Younger patients seem to benefit more from the high-frequency training.

Effect of high- versus low-frequency exercise training in multidisciplinary cardiac rehabilitation on health-related quality of life.

BACKGROUND: The authors examined the importance of the frequency of aerobic exercise training in multidisciplinary rehabilitation in improving health-related quality of life in the short run in patients with documented coronary artery disease. METHODS: Patients (114 males and 16 females; age range, 32-70 years) were randomized into either a high-frequency or a low-frequency exercise training program (10 versus 2 sessions per week, respectively) as part of a 6-week multidisciplinary cardiac rehabilitation program. The General Health Questionnaire and the RAND-36 were used to assess changes in psychological distress and subjective health status. RESULTS: After 6 weeks, high-frequency patients reported significantly more positive, change in "psychological distress" (P < 0.05), "mental health" (P = 0.05), and "health change" (P < 0.01), than low-frequency patients. Apart from changes in mean scores, individual effect sizes indicated that a significantly greater percentage of high-frequency patients experienced substantial improvements in "psychological distress" (P < 0.01), "physical functioning" (P < 0.05), and "health change" (P < 0.05), compared with low-frequency patients. In addition, deterioration of quality of life was observed in a considerable number of high-frequency patients (ranging from 1.7% to 25.8% on the various measures). CONCLUSIONS: The frequency of aerobic exercise has a positive, independent effect on psychological outcomes after cardiac rehabilitation. However, this benefit after high-frequency rehabilitation appears to be limited to a subgroup of patients. Further investigation is required to identify these patients. Results provide input into recent controversies regarding the role of exercise training in cardiac rehabilitation.

Change in self-efficacy during cardiac rehabilitation and the role of perceived overprotectiveness.

Self-efficacy (SE) is an important outcome following cardiac rehabilitation (CR) when claiming benefits to patients and improving existing programs. This study evaluated change in SE during 6 weeks of multidisciplinary CR with either a high or low-frequency exercise training program. The role of overprotectiveness of the spouse, as it potentially counteracts improvement in SE, was examined. Coronary patients (n = 114) were randomized into both types of program. Overprotectiveness (patient perception) was assessed prior to rehabilitation. Self-efficacy in the domains controlling symptoms (SE-CS) and maintaining function (SE-MF), were assessed prior to and immediately after rehabilitation. Three findings pertain to program improvement: (1) As predicted, the low-frequency program enhanced SE-CS more than the high-frequency program, suggesting that experiencing success in daily activities and active engagement of the patient seem more decisive factors in improving SE than the frequency of exercise. (2) Changes in SE in both programs fell short of clinical meaning, suggesting the need to use self-efficacy theory more vigorously. (3) Overprotectiveness significantly predicted adverse change in SE in the high-frequency program, suggesting the need to include counseling for cardiac couples in CR when applicable.

Impairment of exercise capacity and peak oxygen consumption in patients with mild left ventricular dysfunction and coronary artery disease.

AIMS: Most studies in chronic heart failure have only included patients with marked left ventricular systolic dysfunction (i.e. ejection fraction < or =0.35), and patients with mild left ventricular dysfunction are usually excluded. Further, exercise capacity strongly depends on age, but age-adjustment is usually not applied in these studies. Therefore, this study sought to establish whether (age-adjusted) peak VO2 was impaired in patients with mild left ventricular dysfunction. METHODS: Peak VO2 and ventilatory anaerobic threshold were measured in 56 male patients with mild left ventricular dysfunction (ejection fraction 0.35-0.55; study population) and in 17 male patients with a normal left ventricular function (ejection fraction >0.55; control population). All patients had an old (>4 weeks) myocardial infarction. By using age-adjusted peak VO2 values, a 'decreased' exercise capacity was defined as < or = predicted peak VO2 - 1 x SD (0.81 of predicted peak VO2), and a severely decreased exercise capacity as < or = predicted peak VO2 - 2 x SD (0.62 of predicted peak VO2). RESULTS: Patients in the study population (age 52+/-9 years; ejection fraction 0.46+/-0.06) were mostly asymptomatic (NYHA class I: n=40, 76%), while 16 patients (24%) had mild symptoms, i.e. NYHA class II. All 17 controls (age 57+/-8 years) were asymptomatic. Mean peak VO2 was lower in patients with mild left ventricular dysfunction (23.6+/-5.7 vs 27.1+/-4.6 ml x min(-1) x kg(-1) in controls, P<0.05). In 75% of the study population patients (n=42) age-adjusted peak VO2 was decreased (NYHA I/II: n=29/13) and in 18% of them severely decreased (n=10; NYHA I/II: n=6/4). In contrast, only three patients (18%) in the control population had a decreased and none a severely decreased age-adjusted peak VO2. CONCLUSION: In patients with mild left ventricular dysfunction, who have either no or only mild symptoms of chronic heart failure, a substantial proportion has an impaired exercise capacity. By using age-adjustment, impairment of exercise capacity becomes more evident in younger patients. Patients with mild left ventricular dysfunction are probably under-diagnosed, and this finding has clinical and therapeutic implications.

Training effects on peak VO2, specific of the mode of movement, in rehabilitation of patients with coronary artery disease.

Training effects on peak oxygen consumption (VO2), specific to the mode of movement, are well-known in exercise training of young, healthy adults. However, these specific training effects were never studied in patients with coronary artery disease, but may be important in the evaluation of training effects of cardiac rehabilitation programs. Exercise training programs dominated by, for example, cycling might improve peak VO2, measured during cycling, more than during treadmill testing. Therefore, the effects of an exercise training program dominated by cycling and of a program with both cycling and walking/jogging during a 6-weeks cardiac rehabilitation program were evaluated on both cycle ergometer and treadmill. Male patients (aged between 35 and 70 years) with coronary artery disease (history of myocardial infarction and/or angina pectoris and/or coronary artery bypass surgery) were randomly assigned to either a program dominated by cycling (Group I: n=18,mean age 53+/-6.7) or a program with both cycling and jogging (Group II: n=20, mean age 48+/-9.1). Before and after the program peak VO2 was measured on both cycle ergometer and treadmill. At baseline peak VO2 on treadmill was significantly greater than on cycle ergometer in both groups. Peak VO2 (both cycle and treadmill) increased highly significantly during both programs; in group I the increase of peak VO2 on cycle ergometer was greater than on treadmill (respectively, 28.1% versus 18.8%; p<0.05), in contrast to group II (respectively, 22.8% and 16.6%; n.s.). As a result, the difference between peak VO2 on treadmill and cycle ergometer decreased significantly more during the program in group I (p<0.05). These results suggest specific training effects in patients with coronary artery disease and should be considered outcome assessment and exercise prescription of cardiac rehabilitation programs.

Use of fluoride by young children and prevalence of mottled enamel.

The prevalence of mottled enamel in the permanent dentition of children participating in a fluoride (F-) program at the dental school of the Vrije Universiteit (Amsterdam) was investigated in a study utilizing the Thylstrup-Fejerskov (TF) index. The randomly chosen children received a F- regime considered optimal by the Dutch Advisory Committee for Prevention of Oral and Dental Diseases. From the children examined (n = 83; 49 boys and 34 girls; mean age, 13 years and 5 months), 74% exhibited mottled enamel in a slight to moderate degree. More teeth were affected and the degree of mottling was higher when children started to use F- at an earlier age. Unintentional ingestion of toothpaste containing 0.15% F- during frequent toothbrushing in combination with the daily intake of F- tablets before the age of four may explain the high prevalence of mottled enamel. After these treatments, F- concentrations in plasma of young children can reach values which can directly affect the developing tooth germ.

Prevalence of mottled enamel in permanent dentition of children participating in a fluoride programme at the Amsterdam dental school.

The prevalence of mottled enamel in the permanent dentition of children participating a fluoride (F-) programme at the Amsterdam Dental School has been investigated in a pilot study, utilizing the Thylstrup-Fejerskov (TF) index. From all children examined (n = 83) 74% exhibited mottled enamel, in a slight to moderate degree. More teeth were affected and the degree of mottling was higher when children started to use F- at an earlier age. Unintentional ingestion of toothpaste containing 0.15% F- during frequent tooth brushing in combination with the daily intake of F- tablets before the age of four may explain the high prevalence of mottled enamel.

[Fluoride and mottled enamel]. / Fluoridegebruik. Gvelekt glazuur bij kinderen.

The prevalence of mottled enamel in permanent teeth of children, visiting the pediatric clinic of the Dental School ACTA in Amsterdam and using fluoride, has been examined utilizing the Thylstrup-Fejerskov index for enamel fluorosis. Of all children examined (n = 83) 74% exhibited mottled enamel, varying from a very mild to a moderate degree. The amount and degree of mottling increased when children started using fluoride at an earlier age. A high frequency of toothbrushing along with a high concentration of 0.15% fluoride in toothpaste, in combination with ingesting fluoride tablets, may be responsible for the high prevalence of enamel fluorosis.