Ghio S, Temporelli PL, Arena R. Tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis. Am J Physiol Heart Circ Physiol 305: H1373-H1381, 2013. First published August 30, 2013; doi:10.1152/ajpheart.00157.2013.-Echoderived pulmonary arterial systolic pressure (PASP) and right ventricular (RV) tricuspid annular plane systolic excursion (TAPSE; from the end of diastole to end-systole) are of basic relevance in the clinical follow-up of heart failure (HF) patients, carrying two-to threefold increase in cardiac risk when increased and reduced, respectively. We hypothesized that the relationship between TAPSE (longitudinal RV fiber shortening) and PASP (force generated by the RV) provides an index of in vivo RV length-force relationship, with their ratio better disclosing prognosis. Two hundred ninety-three HF patients with reduced (HFrEF, n ϭ 247) or with preserved left ventricular (LV) ejection fraction (HFpEF, n ϭ 46) underwent echo-Doppler studies and N-terminal pro-brain-type natriuretic peptide assessment and were tracked for adverse events. The median follow-up duration was 20.8 mo. TAPSE vs. PASP relationship showed a downward regression line shift in nonsurvivors who were more frequently presenting with higher PASP and lower TAPSE. HFrEF and HFpEF patients exhibited a similar distribution along the regression line. Given the TAPSE, PASP, and TAPSE-to-PASP ratio (TAPSE/PASP) collinearity, separate Cox regression and Kaplan-Meier analyses were performed: one with TAPSE and PASP as individual measures, and the other combining them in ratio form. Hazard ratios for variables retained in the multivariate regression were as follows: TAPSE/PASP Ͻ/Ն 0.36 mm/mmHg [hazard ratio (HR): 10.4, P Ͻ 0.001]; TAPSE Ͻ/Ն 16 mm (HR: 5

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We thank Dr Lown et al and Dr Miceli et al for their comments about our article. 1 They raise several different and interesting points.It is of course possible that the selection of a limited number of variables for the risk model may better benefit from other more sophisticated statistical approaches. However, even if our model is apparently simplistic, it seems to work better than other complex models. We agree that an area under curve value of 0.744 is probably inadequate for clinical purposes, but this is the value reached by the widely used EuroSCORE in many clinical settings. 2 Actually, in the validation series, the area under curve value of the ACEF score (age, creatinine, ejection fraction) was higher than 0.8. 2 As stated in our article, it is a matter of terminology. We could say that the ACEF and the EuroSCORE are equally good or equally bad models. To answer the authors' question, we did sensitivity analyses in a subgroup of patients at low, medium, and high risk, and the worst accuracy was achieved in the high-risk patients (EuroSCORE Ͼ5). However, it should be considered that the ACEF is built for elective patients. When addressing the whole range of cardiac surgery population, more variables are needed to improve the accuracy of the model, up to 5 for medium-risk patients and even 12 in high-risk patients. 2 Dichotomization of continuous variables is always arbitrary in statistics but is a common practice in the development of risk scores. The important point is to dichotomise according to a method that may guarantee the best specificity and sensitivity of the identified cutoff value. We did dichotomise the serum creatinine value (as in the great majority of the existing scores) using the sensitivity and specificity values of the receiver operating characteristics curve coordinates and the Youden index. We agree that every kind of preoperative renal function impairment may strongly affect the operative mortality, and we cannot exclude that using serum creatinine as a continuous variable (as we did for age and ejection fraction) may improve the accuracy of the model, however at the expenses of more complex calculations.We agree with Lown et al about the limitations of area under curve-based systems and the risk of overfitted models, availability of data, and subjectivity, and these last reasons led us to propose a parsimonious model. Conversely, we are not sure that simple models may be more adequate for acute settings and complex models for elective settings. Actually, our experience is that when acute risk conditions intervene, more factors are needed to stratify the risk. 2 It was demonstrated that when severe acute conditions are present, the current scores are inadequate to stratify mortality risk. 3 When developing this model, we considered many potential factors that could be independently associated with operative mortality after cardiac surgery. Among these factors are those mentioned by Miceli et al (gender, chronic obstructive pulmonary disease, operations other than isolated coronary a...

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Background-Several mortality risk scores exist in cardiac surgery. All include a considerable number of independent risk factors. In elective cardiac surgery patients, the operative mortality is low, the number of events recorded per year is limited, and the risk model may be overfitted. The present study aims to develop and validate an operative mortality risk score for elective patients based on a limited number of factors. Methods and Results-The development series included 4557 adult patients who had undergone an elective cardiac operation at our institution from 2001 to 2003; the validation series includes the 4091 patients who subsequently underwent an operation. Three independent factors were included in the mortality risk model: age, creatinine, and left ventricular ejection fraction (ACEF). The ACEF score was computed as follows: age (years)/ejection fraction (%)ϩ1 (if serum creatinine value was Ͼ2 mg/dL). The ACEF score was compared with 5 other risk scores in the validation series. Discriminatory power (accuracy) was defined with a receiver-operating characteristics analysis. The best accuracy was achieved by the Cleveland Clinic score (0.812), with ACEF score just below it (0.808). In coronary operations, the 2 scores performed equally well (0.815 versus 0.813), and in isolated coronary operations, the best accuracy was achieved by ACEF (

Healthcare Associated Infections (HAI) are a global concern, further threatened by the increasing drug resistance of HAI-associated pathogens. On the other hand, persistent contamination of hospital surfaces contributes to HAI transmission, and it is not efficiently controlled by conventional cleaning, which does not prevent recontamination, has a high environmental impact and can favour selection of drug-resistant microbial strains. In the search for effective approaches, an eco-sustainable probiotic-based cleaning system (Probiotic Cleaning Hygiene System, PCHS) was recently shown to stably abate surface pathogens, without selecting antibiotic-resistant species. The aim of this study was to determine whether PCHS application could impact on HAI incidence. A multicentre, pre-post interventional study was performed for 18 months in the Internal Medicine wards of six Italian public hospitals (January 1st 2016—June 30th 2017). The intervention consisted of the substitution of conventional sanitation with PCHS, maintaining unaltered any other procedure influencing HAI control. HAI incidence in the pre and post-intervention period was the main outcome measure. Surface bioburden was also analyzed in parallel. Globally, 11,842 patients and 24,875 environmental samples were surveyed. PCHS was associated with a significant decrease of HAI cumulative incidence from a global 4.8% (284 patients with HAI over 5,930 total patients) to 2.3% (128 patients with HAI over 5,531 total patients) (OR = 0.44, CI 95% 0.35–0.54) (P<0.0001). Concurrently, PCHS was associated with a stable decrease of surface pathogens, compared to conventional sanitation (mean decrease 83%, range 70–96.3%), accompanied by a concurrent up to 2 Log drop of surface microbiota drug-resistance genes (P<0.0001; Pc = 0.008). Our study provides findings which support the impact of a sanitation procedure on HAI incidence, showing that the use of a probiotic-based environmental intervention can be associated with a significant decrease of the risk to contract a HAI during hospitalization. Once confirmed in larger experiences and other target populations, this eco-sustainable approach might be considered as a part of infection control and prevention (IPC) strategies.Trial registration—ISRCTN International Clinical Trials Registry, ISRCTN58986947.

The largest cohort to date of patients with secundum ASD shows that treatment by a percutaneous approach has a significantly lower rate of either total or major early postprocedural complications compared to surgery.

Objective: To evaluate whether a school-based multicomponent educational program could improve adiposity measures in middle-school adolescents. Methods: A non-randomized controlled pilot study was conducted in six state middle schools (487 adolescents, 11-15 years) in townships in an urban area around Milan, three schools (n 5 262 adolescents) being assigned to the intervention group and three schools (n 5 225 adolescents) to the control group. The twoschool-year intervention included changes in the school environment (alternative healthy vending machines, educational posters) and individual reinforcement tools (school lessons, textbook, text messages, pedometers, re-usable water bottles). The main outcome measure was change in BMI z-score. The secondary outcomes were changes in waist-to-height ratio (WHtR) and behavioral habits. Results: The intervention was associated with a significant difference in BMI z-score (20.18 6 0.03, P<0.01) and in WHtR (20.04 6 0.002, P < 0.001), after controlling for baseline covariates. Subgroup analysis showed the maximum association between the intervention and the difference in BMI z-score for girls with overweight/obesity. Physical activity increased and consumption of sugar-sweetened beverages and high-energy snacks decreased in adolescents after the intervention. Conclusions: A school-based multicomponent intervention conducted at both environmental and individual levels may be effective for reducing adiposity measures mainly in adolescents with overweight/obesity.