Role of subcutaneous implantable loop recorder for the diagnosis of arrhythmias in Brugada syndrome: A United Kingdom single-center experience.

BACKGROUND: Experience with implantable loop recorders (ILRs) in Brugada syndrome (BrS) is limited. OBJECTIVE: The purpose of this study was to evaluate the indications and yield of ILR monitoring in a single-center BrS registry. METHODS: Demographic, clinical and follow-up data of BrS patients with ILR were collected. RESULTS: Of 415 BrS patients recruited consecutively, 50 (12%) received an ILR (58% male). Mean age at ILR implantation was 44 ± 15 years. Thirty-one (62%) had experienced syncopal or presyncopal episodes, and 23 (46%) had palpitations. During median follow-up of 28 months (range 1-68), actionable events were detected in 11 subjects (22%); 7 had recurrences of syncope/presyncope, with 4 showing defects in sinus node function or atrioventricular conduction. New supraventricular tachyarrhythmias were recorded in 6 subjects; a run of fast nonsustained ventricular tachycardia was detected in 1 patient. Patients implanted with an ILR were less likely to show a spontaneous type 1 pattern or depolarization electrocardiographic (ECG) abnormalities compared to those receiving a primary prevention implantable-cardioverter defibrillator. Age at implantation, gender, Shanghai score, and ECG parameters did not differ between subjects with and those without actionable events. ILR-related complications occurred in 3 cases (6%). CONCLUSION: In a large cohort of BrS patients, continuous ILR monitoring yielded a diagnosis of tachy- or bradyarrhythmic episodes in 22% of cases. Recurrences of syncope were associated with bradyarrhythmic events. Use of ILR can be helpful in guiding the management of low-/intermediate-risk BrS patients and ascertaining the cause of unexplained syncope.

Comparison of automated interval measurements by widely used algorithms in digital electrocardiographs.

BACKGROUND: Automated measurements of electrocardiographic (ECG) intervals by current-generation digital electrocardiographs are critical to computer-based ECG diagnostic statements, to serial comparison of ECGs, and to epidemiological studies of ECG findings in populations. A previous study demonstrated generally small but often significant systematic differences among 4 algorithms widely used for automated ECG in the United States and that measurement differences could be related to the degree of abnormality of the underlying tracing. Since that publication, some algorithms have been adjusted, whereas other large manufacturers of automated ECGs have asked to participate in an extension of this comparison. METHODS: Seven widely used automated algorithms for computer-based interpretation participated in this blinded study of 800 digitized ECGs provided by the Cardiac Safety Research Consortium. All tracings were different from the study of 4 algorithms reported in 2014, and the selected population was heavily weighted toward groups with known effects on the QT interval: included were 200 normal subjects, 200 normal subjects receiving moxifloxacin as part of an active control arm of thorough QT studies, 200 subjects with genetically proved long QT syndrome type 1 (LQT1), and 200 subjects with genetically proved long QT syndrome Type 2 (LQT2). RESULTS: For the entire population of 800 subjects, pairwise differences between algorithms for each mean interval value were clinically small, even where statistically significant, ranging from 0.2 to 3.6milliseconds for the PR interval, 0.1 to 8.1milliseconds for QRS duration, and 0.1 to 9.3milliseconds for QT interval. The mean value of all paired differences among algorithms was higher in the long QT groups than in normals for both QRS duration and QT intervals. Differences in mean QRS duration ranged from 0.2 to 13.3milliseconds in the LQT1 subjects and from 0.2 to 11.0milliseconds in the LQT2 subjects. Differences in measured QT duration (not corrected for heart rate) ranged from 0.2 to 10.5milliseconds in the LQT1 subjects and from 0.9 to 12.8milliseconds in the LQT2 subjects. CONCLUSIONS: Among current-generation computer-based electrocardiographs, clinically small but statistically significant differences exist between ECG interval measurements by individual algorithms. Measurement differences between algorithms for QRS duration and for QT interval are larger in long QT interval subjects than in normal subjects. Comparisons of population study norms should be aware of small systematic differences in interval measurements due to different algorithm methodologies, within-individual interval measurement comparisons should use comparable methods, and further attempts to harmonize interval measurement methodologies are warranted.

Normal limits of the electrocardiogram in Indians.

AIMS: The objective of the study was to develop normal limits of the ECG in an apparently healthy population of South Asians living in India. METHODS: Three centres contributed to recording 12 lead ECGs on identical digital electrocardiographs. Apparently healthy volunteers were recruited and ECGs were first transferred to a local database and then to Glasgow where all ECGs were analysed by the same University of Glasgow ECG Interpretation Program. RESULTS: A total of 963 individuals were recruited into the study (30.4% female) with an age range of 18-83 years. QRS duration was longer in males than females, QT interval was longer in females than males, and QRS voltages in general were higher in males than females and in younger compared to older individuals. CONCLUSION: Findings in general paralleled those in other populations and suggested that criteria for a white Caucasian population could be applied to a South Asian Indian population.

The concentration of iron in real-world geogenic PM10 is associated with increased inflammation and deficits in lung function in mice.

BACKGROUND: There are many communities around the world that are exposed to high levels of particulate matter <10 µm (PM10) of geogenic (earth derived) origin. Mineral dusts in the occupational setting are associated with poor lung health, however very little is known about the impact of heterogeneous community derived particles. We have preliminary evidence to suggest that the concentration of iron (Fe) may be associated with the lung inflammatory response to geogenic PM10. We aimed to determine which physico-chemical characteristics of community sampled geogenic PM10 are associated with adverse lung responses. METHODS: We collected geogenic PM10 from four towns in the arid regions of Western Australia. Adult female BALB/c mice were exposed to 100 µg of particles and assessed for inflammatory and lung function responses 6 hours, 24 hours and 7 days post-exposure. We assessed the physico-chemical characteristics of the particles and correlated these with lung outcomes in the mice using principal components analysis and multivariate linear regression. RESULTS: Geogenic particles induced an acute inflammatory response that peaked 6 hours post-exposure and a deficit in lung mechanics 7 days post-exposure. This deficit in lung mechanics was positively associated with the concentration of Fe and particle size variability and inversely associated with the concentration of Si. CONCLUSIONS: The lung response to geogenic PM10 is complex and highly dependent on the physico-chemical characteristics of the particles. In particular, the concentration of Fe in the particles may be a key indicator of the potential population health consequences for inhaling geogenic PM10.

Comparison of automated measurements of electrocardiographic intervals and durations by computer-based algorithms of digital electrocardiographs.

BACKGROUND AND PURPOSE: Automated measurements of electrocardiographic (ECG) intervals are widely used by clinicians for individual patient diagnosis and by investigators in population studies. We examined whether clinically significant systematic differences exist in ECG intervals measured by current generation digital electrocardiographs from different manufacturers and whether differences, if present, are dependent on the degree of abnormality of the selected ECGs. METHODS: Measurements of RR interval, PR interval, QRS duration, and QT interval were made blindly by 4 major manufacturers of digital electrocardiographs used in the United States from 600 XML files of ECG tracings stored in the US FDA ECG warehouse and released for the purpose of this study by the Cardiac Safety Research Consortium. Included were 3 groups based on expected QT interval and degree of repolarization abnormality, comprising 200 ECGs each from (1) placebo or baseline study period in normal subjects during thorough QT studies, (2) peak moxifloxacin effect in otherwise normal subjects during thorough QT studies, and (3) patients with genotyped variants of congenital long QT syndrome (LQTS). RESULTS: Differences of means between manufacturers were generally small in the normal and moxifloxacin subjects, but in the LQTS patients, differences of means ranged from 2.0 to 14.0 ms for QRS duration and from 0.8 to 18.1 ms for the QT interval. Mean absolute differences between algorithms were similar for QRS duration and QT intervals in the normal and in the moxifloxacin subjects (mean ≤6 ms) but were significantly larger in patients with LQTS. CONCLUSIONS: Small but statistically significant group differences in mean interval and duration measurements and means of individual absolute differences exist among automated algorithms of widely used, current generation digital electrocardiographs. Measurement differences, including QRS duration and the QT interval, are greatest for the most abnormal ECGs.

Variability and consistency in lung inflammatory responses to particles with a geogenic origin.

BACKGROUND AND OBJECTIVE: Particulate matter <10 µm (PM10 ) is well recognized as being an important driver of respiratory health; however, the impact of PM10 of geogenic origin on inflammatory responses in the lung is poorly understood. This study aimed to assess the lung inflammatory response to community sampled geogenic PM10 . METHODS: This was achieved by collecting earth material from two regional communities in Western Australia (Kalgoorlie-Boulder and Newman), extracting the PM10 fraction and exposing mice by intranasal instillation to these particles. The physicochemical characteristics of the particles were assessed and lung inflammatory responses were compared to control particles. The primary outcomes were cellular influx and cytokine production in the lungs of the exposed mice. RESULTS: The physical and chemical characteristics of the PM10 from Kalgoorlie and Newman differed with the latter having a higher concentration of Fe and a larger median diameter. Control particles (2.5 µm polystyrene) caused a significant influx of inflammatory cells (neutrophils) with little production of proinflammatory cytokines. In contrast, the geogenic particles induced the production of MIP-2, IL-6 and a significant influx of neutrophils. Qualitatively, the response following exposure to particles from Kalgoorlie and Newman were consistent; however, the magnitude of the response was substantially higher in the mice exposed to particles from Newman. CONCLUSIONS: The unique physicochemical characteristics of geogenic particles induced a proinflammatory response in the lung. These data suggest that particle composition should be considered when setting community standards for PM exposure, particularly in areas exposed to high geogenic particulate loads.

Normal limits of the electrocardiogram in Nigerians.

BACKGROUND: There has been no large study of ECG measures derived by automated methods in an apparently healthy indigenous West African population. METHODS: ECGs were recorded from apparently healthy Nigerians and analysed using automated methods. Age and sex based normal ranges were then established. RESULTS: A total of 782 males and 479 females aged between 20 and 87years were studied. Mean QRS duration in males was 87.9±9.4ms and 83.4±7.6ms in females (P<.0001). Mean QTc (Hodges) was 393±16ms in males and 406±16ms in females (P<.0001). The Cornell index (SV3+RaVL) was higher in males and decreased with increasing age in males though the reverse was true in females (P<.0001). STj amplitude was lower in older compared to younger males and higher in males. CONCLUSION: This is the first large study of automated ECG measurements from healthy blacks living in West Africa which allows the determination of ECG normal limits in such a population.

Recycled water: potential health risks from volatile organic compounds and use of 1,4-dichlorobenzene as treatment performance indicator.

Characterisation of the concentrations and potential health risks of chemicals in recycled water is important if this source of water is to be safely used to supplement drinking water sources. This research was conducted to: (i) determine the concentration of volatile organic compounds (VOCs) in secondary treated effluent (STE) and, post-reverse osmosis (RO) treatment and to; (ii) assess the health risk associated with VOCs for indirect potable reuse (IPR). Samples were examined pre and post-RO in one full-scale and one pilot plant in Perth, Western Australia. Risk quotients (RQ) were estimated by expressing the maximum and median concentration as a function of the health value. Of 61 VOCs analysed over a period of three years, twenty one (21) were detected in STE, with 1,4-dichlorobenzene (94%); tetrachloroethene (88%); carbon disulfide (81%) and; chloromethane (58%) most commonly detected. Median concentrations for these compounds in STE ranged from 0.81 µg/L for 1,4-dichlorobenzene to 0.02 µg/L for carbon disulphide. After RO, twenty six (26) VOCs were detected, of which 1,4-dichlorobenzene (89%); acrylonitrile (83%) chloromethane (63%) and carbon disulfide (40%) were the more frequently detected. RQ(max) were all below health values in the STE and after RO. Median removal efficiency for RO was variable, ranging from -77% (dichlorodifluoromethane) to 91.2% (tetrachloroethene). The results indicate that despite the detection of VOCs in STE and after RO, their human health impact in IPR is negligible due to the low concentrations detected. The results indicate that 1,4-dichlorobenzene is a potential treatment chemical indicator for assessment of VOCs in IPR using RO treatment.

Extracting dust from soil: Improved efficiency of a previously published process.

A previously published procedure describing how to simply and cheaply extract a sufficient quantity of dust particles sized smaller than 10µm (PM(10)) from soil to be used in air quality analysis has been modified and improved. These modifications are described in detail and are significant because they will enable extraction of a greater quantity of the PM(10) fraction for a given soil sample, in less time and without the need for building specialised equipment. Less water is also used in the modified procedure, and thus a smaller risk of dissolution of metals of interest.

Indirect potable reuse: a sustainable water supply alternative.

The growing scarcity of potable water supplies is among the most important issues facing many cities, in particular those using single sources of water that are climate dependent. Consequently, urban centers are looking to alternative sources of water supply that can supplement variable rainfall and meet the demands of population growth. A diversified portfolio of water sources is required to ensure public health, as well as social, economical and environmental sustainability. One of the options considered is the augmentation of drinking water supplies with advanced treated recycled water. This paper aims to provide a state of the art review of water recycling for drinking purposes with emphasis on membrane treatment processes. An overview of significant indirect potable reuse projects is presented followed by a description of the epidemiological and toxicological studies evaluating any potential human health impacts. Finally, a summary of key operational measures to protect human health and the areas that require further research are discussed.

Effect of protective filters on fire fighter respiratory health: field validation during prescribed burns.

BACKGROUND: Bushfire smoke contains a range of air toxics. To prevent inhalation of these toxics, fire fighters use respiratory equipment. Yet, little is known about the effectiveness of the equipment on the fire ground. Experimental trials in a smoke chamber demonstrated that, the particulate/organic vapor/formaldehyde (POVF) filter performed best under simulated conditions. This article reports on the field validation trials during prescribed burns in Western Australia. METHODS: Sixty-seven career fire fighters from the Fire and Emergency Services Authority of Western Australia were allocated one of the three types of filters. Spirometry, oximetry, self-reported symptom, and personal air sampling data were collected before, during and after exposure to bushfire smoke from prescribed burns. RESULTS: Declines in FEV(1) and SaO(2) were demonstrated after 60 and 120 min exposure. A significant higher number of participants in the P filter group reported increases in respiratory symptoms after the exposure. Air sampling inside the respirators demonstrated formaldehyde levels significantly higher in the P filter group compared to the POV and the POVF filter group. CONCLUSIONS: The field validation trials during prescribed burns supported the findings from the controlled exposure trials in the smoke chamber. Testing the effectiveness of three types of different filters under bushfire smoke conditions in the field for up to 2 hr demonstrated that the P filter is ineffective in filtering out respiratory irritants. The performance of the POV and the POVF filter appears to be equally effective after 2 hr bushfire smoke exposure in the field.

Respiratory irritants in Australian bushfire smoke: air toxics sampling in a smoke chamber and during prescribed burns.

Bushfire smoke contains an array of organic and inorganic compounds, including respirable and inspirable particles, aldehydes, and carbon monoxide. These compounds have been found to be a health hazard for firefighters in the United States. Despite the high frequency of bushfires in Australia, analyses of bushfire smoke components are scarce. As part of an occupational health study investigating the respiratory health effects of bushfire smoke in firefighters, air toxics sampling was undertaken in a smoke chamber and during prescribed burns. Levels of formaldehyde and acrolein were demonstrated at respectively 60% and 80% of the Short Term Exposure Limit in the smoke chamber. Carbon monoxide levels exceeded the peak limit of 400 ppm significantly. Although concentrations were lower during the prescribed burns, the study shows that Australian bushfire smoke contains air toxics of concern and provides justification for further research into the levels of air toxics measured at bushfires and the associated health impacts.

Dioxins, furans and PCBs in recycled water for indirect potable reuse.

An assessment of potential health impacts of dioxin and dioxin-like compounds in recycled water for indirect potable reuse was conducted. Toxic equivalency factors (TEFs) for 2,3,7,8-substituted polychlorinated dibenzo-p-dioxins (PCDD) and dibenzofurans (PCDFs) and dioxin-like polychlorinated biphenyls (PCBs) congeners have been developed by the World Health Organization to simplify the risk assessment of complex mixtures. Samples of secondary treated wastewater in Perth, Australia were examined pre-and post-tertiary treatment in one full-scale and one pilot water reclamation plant. Risk quotients (RQs) were estimated by expressing the middle-bound toxic equivalent (TEQ) and the upper-bound TEQ concentration in each sampling point as a function of the estimated health target value. The results indicate that reverse osmosis (RO) is able to reduce the concentration of PCDD, PCDF and dioxin-like PCBs and produce water of high quality (RQ after RO=0.15). No increased human health risk from dioxin and dioxin-like compounds is anticipated if highly treated recycled water is used to augment drinking water supplies in Perth. Recommendations for a verification monitoring program are offered.

A proposed approach for the assessment of chemicals in indirect potable reuse schemes.

The city of Perth in Western Australia is facing a future of compromised water supplies. In recent years, this urban region has been experiencing rapid population growth, coupled with drying climate, which has exacerbated water shortages. As part of the government strategy to secure water sustainability and to address an agenda focused on all elements of the water cycle, a target of 20% reuse of treated wastewater by 2012 was established. This includes a feasibility review of managed aquifer recharge for indirect potable reuse. A characterization of contaminants in wastewater after treatment and an assessment of the health implications are necessary to reassure both regulators and the public. To date, the commonly used approach involves a comparison of measured contaminant concentrations with the established drinking-water standards or other toxicological guidelines for the protection of human health. However, guidelines and standards have not been established for many contaminants in recycled water (unregulated chemicals). This article presents a three-tiered approach for the preliminary health risk assessment of chemicals in order to determine key contaminants that need to be monitored and managed. The proposed benchmark values for the calculation of risk quotients are health based, systematically defined, scientifically defensible, easy to apply, and clear to interpret. The proposed methodology is based on the derivation of health-based levels for unregulated contaminants with toxicity information and a "threshold of toxicological concern" for unregulated contaminants without toxicity data. The application of this approach will help policymakers set guidelines regarding unregulated chemicals in recycled water.

Effect of protective filters on fire fighter respiratory health during simulated bushfire smoke exposure.

BACKGROUND: Bushfire fighters are potentially subject to risks from bushfire smoke. Although many different protective masks and filters are available, it is not clear which is the most effective from a health and safety perspective. The effect of protective filters on the respiratory health of Western Australian urban career fire fighters under controlled simulated conditions is investigated. METHODS: Sixty-four healthy Fire and Emergency Services Authority of Western Australia (FESA) urban career fire fighters were subjected to controlled simulated bushfire smoke in an open smoke chamber for 15 min. The fire fighters were allocated one of the three types of protective filters: particulate only (P), particulate/organic vapor (POV), and a particulate/organic vapor/formaldehyde (POVF) filter using a double-blind randomized procedure. Personal air sampling inside the fire fighters' masks, spirometry, oximetry, and self-reported symptom data were collected at baseline and at two time intervals after the smoke exposure. RESULTS: A significant decline in oxygen saturation was seen immediately after exposure, however, the decline was small and no significant relationships could be established between this and the type of filter used. A significantly higher number of participants in the P and POV filter groups self-reported an increase in coughing, wheezing, and shortness of breath compared to the POVF group. Air sampling demonstrated a significantly higher level of formaldehyde and acrolein inside the masks fitted with P filters compared to POV and POVF filters. CONCLUSIONS: Testing the effectiveness of P, POV, and POVF filters under controlled conditions has demonstrated that the POVF filter provides statistically significant better protection for the fire fighters' airways in a simulated bushfire exposure chamber.

Modification of ACC/ESC criteria for acute myocardial infarction.

The American College of Cardiology (ACC) and European Society of Cardiology (ESC) recently proposed criteria for acute ST elevation myocardial infarction (STEMI). These criteria were based on STj >0.1 mV in limbs leads and V4-V6, or STj >0.2 mV in V1 to V3 with criteria being met in two contiguous leads. The criteria were neither age nor sex dependent and the aim of the present study was to evaluate whether or not improved STEMI criteria that were age and gender dependent could be developed. A training set of 789 ECGs from patients presenting with chest pain due to cardiac and other causes was available for study. Revised criteria for STEMI were developed using these data as well as ECGs from a normal adult population of 859 males and 637 females. A test set of ECGs was available in the form of 1220 ECGs recorded from a separate hospital from patients presenting with chest pain. 248 patients had an acute myocardial infarction on the basis of conventional clinical criteria while 972 did not. There was an improvement in sensitivity using the new criteria compared to the old criteria from 41.5% to 46.7% while specificity improved from 96.0% to 98.5%. Specificity in normals improved from 92.6% to 99.8%. The conclusion drawn is that while the ACC/ESC criteria are simple to apply, they are not particularly specific and can be improved by being supplemented by other ECG measures and optimized for age and sex.