Diagnostic yield and cost analysis of electrocardiographic screening in Swiss paediatric athletes.

OBJECTIVES: Athletes performing sports on high level are at increased risk for sudden cardiac death. This includes paediatric athletes, even though data on screening strategies in this age group remain scarce. This study aimed to assess electrocardiogram interpretation criteria in paediatric athletes and to evaluate the cost of screening. METHODS: National, multicentre, retrospective, observational study on 891 athletes of paediatric age (<18 years) evaluated by history, physical examination and 12-lead electrocardiogram. The primary outcome measure was abnormal electrocardiogram findings according to the International Recommendations for Electrographic Interpretation in Athletes. The secondary outcome measure was cost of screening. RESULTS: 19 athletes (2.1%) presented abnormal electrocardiogram findings requiring further investigations, mainly abnormal T-wave inversion. These 19 athletes were predominantly males, performing endurance sports with a mean volume of 10 weekly hours for a mean duration of 6 years of training. Further investigations did not identify any relevant pathology. All athletes were cleared for competition with regular follow-up. Total costs of the screening were 108,860 USD (122 USD per athlete). CONCLUSIONS: Our study using the International Recommendations for Electrographic Interpretation in Athletes identified a low count of abnormal findings in paediatric athletes, yet raising substantially the cost of screening. Hence, the utility of electrocardiogram-inclusive screening of paediatric athletes remains to be elucidated by longitudinal data.

Iron Rims in Patients With Multiple Sclerosis as Neurodegenerative Marker? A 7-Tesla Magnetic Resonance Study.

Introduction: Multiple sclerosis (MS) is a demyelinating and neurodegenerative disease of the central nervous system, characterized by inflammatory-driven demyelination. Symptoms in MS manifest as both physical and neuropsychological deficits. With time, inflammation is accompanied by neurodegeneration, indicated by brain volume loss on an MRI. Here, we combined clinical, imaging, and serum biomarkers in patients with iron rim lesions (IRLs), which lead to severe tissue destruction and thus contribute to the accumulation of clinical disability. Objectives: Subcortical atrophy and ventricular enlargement using an automatic segmentation pipeline for 7 Tesla (T) MRI, serum neurofilament light chain (sNfL) levels, and neuropsychological performance in patients with MS with IRLs and non-IRLs were assessed. Methods: In total 29 patients with MS [15 women, 24 relapsing-remitting multiple sclerosis (RRMS), and five secondary-progressive multiple sclerosis (SPMS)] aged 38 (22-69) years with an Expanded Disability Status Score of 2 (0-8) and a disease duration of 11 (5-40) years underwent neurological and neuropsychological examinations. Volumes of lesions, subcortical structures, and lateral ventricles on 7-T MRI (SWI, FLAIR, and MP2RAGE, 3D Segmentation Software) and sNfL concentrations using the Simoa SR-X Analyzer in IRL and non-IRL patients were assessed. Results: (1) Iron rim lesions patients had a higher FLAIR lesion count (p = 0.047). Patients with higher MP2Rage lesion volume exhibited more IRLs (p <0.014) and showed poorer performance in the information processing speed tested within 1 year using the Symbol Digit Modalities Test (SDMT) (p <0.047). (2) Within 3 years, patients showed atrophy of the thalamus (p = 0.021) and putamen (p = 0.043) and enlargement of the lateral ventricles (p = 0.012). At baseline and after 3 years, thalamic volumes were lower in IRLs than in non-IRL patients (p = 0.045). (3) At baseline, IRL patients had higher sNfL concentrations (p = 0.028). Higher sNfL concentrations were associated with poorer SDMT (p = 0.004), regardless of IRL presence. (4) IRL and non-IRL patients showed no significant difference in the neuropsychological performance within 1 year. Conclusions: Compared with non-IRL patients, IRL patients had higher FLAIR lesion counts, smaller thalamic volumes, and higher sNfL concentrations. Our pilot study combines IRL and sNfL, two biomarkers considered indicative for neurodegenerative processes. Our preliminary data underscore the reported destructive nature of IRLs.

A Prospective Pilot Study to Identify a Myocarditis Cohort who may Safely Resume Sports Activities 3 Months after Diagnosis.

International cardiovascular society recommendations to return to sports activities following acute myocarditis are based on expert consensus in the absence of prospective studies. We prospectively enrolled 30 patients with newly diagnosed myocarditis based on clinical parameters, laboratory measurements and cardiac magnetic resonance imaging with mildly reduced or preserved left ventricular ejection fraction (LVEF) with a follow-up of 12 months. Cessation of physical activity was recommended for 3 months. The average age was 35 (19-80) years with 73% male patients. One case of non-sustained ventricular tachycardia was recorded during 48-h-Holter electrocardiogram. Except for this case, all patients were allowed to resume physical exercise after 3 months. At 6- (n = 26) and 12-month (n = 19) follow-up neither cardiac events nor worsening LVEF were recorded. The risk of cardiac events at 1 year after diagnosis of myocarditis appears to be low after resumption of exercise after 3 months among patients who recover from acute myocarditis.

F-MARC: promoting the prevention and management of sudden cardiac arrest in football.

Sudden cardiac death is the most common cause of unnatural death in football. To prevent and urgently manage sudden cardiac arrest on the football field-of-play, F-MARC (FIFA Medical and Research Centre) has been fully committed to a programme of research, education, standardisation and practical implementation. This strategy has detected football players at medical risk during mandatory precompetition medical assessments. Additionally, FIFA has (1) sponsored internationally accepted guidelines for the interpretation of an athlete's ECG, (2) developed field-of-play-specific protocols for the recognition, response, resuscitation and removal of a football player having sudden cardiac arrest and (3) introduced and distributed the FIFA medical emergency bag which has already resulted in the successful resuscitation of a football player who had a sudden cardiac arrest on the field-of-play. Recently FIFA, in association with the Institute of Sports and Preventive Medicine in Saarbrücken, Germany, established a worldwide Sudden Death Registry with a view to documenting fatal events on the football field-of-play. These activities by F-MARC are testimony to FIFA's continued commitment to minimising sudden cardiac arrest while playing football.

Sudden cardiac death in athletes.

A 'paradox of sport' is that in addition to the undisputed health benefits of physical activity, vigorous exertion may transiently increase the risk of acute cardiac events. In general, the risk of sudden cardiac death (SCD) approximately doubles during physical activity and is 2- to 3-fold higher in athletes compared to nonathletes. The incidence of SCD in young athletes is in fact very low, at around 1-3 per 100,000, but attracts much public attention. Variations in incidence figures may be explained by the methodology used for data collection and more importantly by differences between subpopulations of athletes. The incidence of SCD in older (≥ 35 years) athletes is higher and may be expected to rise, as more and older individuals take part in organized sports. SCD is often the first clinical manifestation of a potentially fatal underlying cardiovascular disorder and usually occurs in previously asymptomatic athletes. In the young (<35 years), SCD is mainly due to congenital/inherited cardiac abnormalities, whilst coronary artery disease (CAD) is the most common cause in older athletes. Cardiac screening including family/personal history, physical examination and resting electrocardiogram (ECG) may identify individuals at risk and has the potential to decrease the risk of SCD in young athletes. Screening including the ECG has a high sensitivity for underlying disease in young athletes, but the specificity needs to be improved, whereas the sensitivity of screening without the use of ECG is very low. The screening modality recommended for young athletes is of limited value in older athletes, who should receive individualized screening with cardiac stress testing for patients with high risk of underlying CAD. As cardiovascular screening will never be able to identify all athletes at risk, adequate preparedness is vital in case of a potentially fatal event at the sporting arena/facility. Firstly, we will review the magnitude of the problem of SCD in athletes of different ages, as well as the aetiology. Secondly, we will focus on how to prevent SCD in athletes of all ages, reviewing cardiovascular screening recommendations as well as emergency preparedness and arena safety.

Cardiac findings in the precompetition medical assessment of football players participating in the 2009 African Under-17 Championships in Algeria.

OBJECTIVES: To screen all players registered for the 8th CAF African Under-17 Championship for risk factors of sudden cardiac death. DESIGN: Standardised cardiac evaluation prior to the start of the competition. STUDY POPULATION: 155 male football players from all eight qualified teams; mean age 16.4 (SD 0.68) years (range 14 to 17). METHODS: The cardiac evaluation consisted of a medical history, clinical examination, 12-lead resting electrocardiogram (ECG) and echocardiography, and was performed by three experienced cardiologists using established guidelines. RESULTS: Nine (5.8%) players reported cardiac symptoms, and the clinical examination was abnormal in only two players with elevated blood pressure. A total of 40 players (25.8%) showed abnormal ECG patterns. None of the players with a positive ECG showed correlating echocardiographic findings. The echocardiogram of one player appeared highly suspicious for early-stage hypertrophic cardiomyopathy, and in another player the myocardium was suspicious for non-compaction cardiomyopathy, but both had normal ECGs. Thirteen (8.4%) players showed echocardiographic findings that needed further follow-up. The percentage of players with pathological ECG patterns and some abnormal echocardiographic measurements varied substantially between different ethnic groups. CONCLUSION: Cardiological screening for risk factors of sudden cardiac death of football players prior to an international competition proved feasible, and conduction by independent experts allowed high-quality standards and a consistent protocol for the examinations. Differences observed between ethnic groups indicate that guidelines for the analysis of ECGs and echocardiography might be adjusted to the target population.

Stroking different body regions of dairy cows: effects on avoidance and approach behavior toward humans.

Understanding perception of dairy cows to common human contact such as stroking is important for improving the human-animal relationship, animal welfare, and production. We hypothesized that repeated stroking of body regions licked most during social grooming, especially the ventral neck, would reduce cows' avoidance of and increase their approach to humans. Sixty tethered dairy cows were randomly allocated to 4 treatment groups that received 5 min of daily human contact 5 d/wk during 3 consecutive weeks: 3 groups were stroked on different body regions. The first group was stroked on the ventral part of the neck (neck); the second group on the withers (both licked often in social grooming); the third group on the lateral side of the chest (chest, licked rarely); and the last group (control) was exposed to simple human presence. The reactions to the person who had provided the treatment were measured using 2 tests in the home tie-stall assessing avoidance from an approaching person who tried to touch the head (approaching person test) and avoidance/approach reactions to a stationary person (stationary person test). Approach behavior was recorded in a novel environment using a standard arena test. In the home tie-stall, cows stroked on the neck showed less avoidance (median avoidance score: 3.33) in the approaching person test compared with cows stroked on the chest and the controls (both: 4.00). That is, at least 75% of the animals stroked on the neck tolerated the touching of their heads (75th percentile

Heart rate variability in dairy cows-influences of breed and milking system.

Heart rate variability parameters in the time, frequency and nonlinear domains were investigated in two breeds of dairy cows (Austrian Simmental and Brown Swiss) milked either in an automatic milking system with partially forced cow traffic or in a herringbone milking parlour. Recordings were made of 24 cows (six of each breed and milking system) during lying, standing idle, and standing being milked, and analysed with linear mixed effects models taking the covariates time of day, live body weight, milk yield, stage of lactation and stage of pregnancy into account. Heart rate and nonlinear deterministic shares were higher, and heart rate variability in the time and frequency domains was lower, later in the day, in cows with higher body weight and in Simmental compared to Brown Swiss cows. Differences in the linear and nonlinear domains during lying indicated an increased level of chronic stress in cows in the automatic milking system with partially forced cow traffic, compared to cows milked in the herringbone milking parlour. No effects of milking system were found during milking, indicating that the stressor in the automatic milking system was not the milking process itself.

Treatment of eczema with a mixture of triamcinolone acetonide and retinoic acid: a double-blind study.

Dermo-epidermal atrophy is one of the main side effects of long-term treatment with topical corticosteroids (TC). Retinoic acid (RA) may prevent and even reverse these effects in animals. It has been previously established that topical RA (TRA) does not inhibit corticosteroid-induced vasoconstriction in humans, thus suggesting that RA, combined with TC, does not interfere with its anti-inflammatory property. The next step was to test this association in patients with inflammatory skin disorders. In this symmetrical double-blind study, triamcinolone acetonide (TA) cream 0.1% and a cream containing TA 0.1% plus RA 0.025% (TARA) were compared in 18 subjects with eczema. No statistical difference between both treatments was observed after 1, 2 and 3 weeks, although on the TARA-treated sides the anti-inflammatory responses were slightly less pronounced. Subjective irritation was significantly more frequent in TARA-treated side (3/17, p = 0.05) but did not lead to interruption of the treatment. This indicates that addition of RA 0.025% to a medium-range potency topical steroid does not abrogate the anti-inflammatory property of the latter and that the association can be tolerated by inflamed skin.

Topical retinoic acid does not alter the vasoconstrictive properties of topical corticosteroids in humans.

Dermo-epidermal atrophy is one of the main side effects of long-term treatment with topical corticosteroids. Retinoic acid may prevent and even reverse these effects in animals. Extension of this concept to therapy in humans implies that several studies have been performed; among others, it has to be established that treatment with topical retinoic acid does not interfere with the anti-inflammatory action of topical corticosteroids. The present study on the cutaneous vasoconstriction test comprised two different double-blind approaches: (i) vasoconstriction tests with betamethasone dipropionate (Diprolene) and clobetasone butyrate (Emovate) were carried out on skin that had previously been treated for 10 days with retinoic acid 0.01, 0.025 or 0.05% (or excipient); (ii) vasoconstriction tests with a combination of triamcinolone acetonide 0.1% and retinoic acid 0.025% were compared with triamcinolone acetonide 0.1% alone. Pretreatment for 10 days with retinoic acid did not alter the vasoconstriction induced by corticosteroids: no decrease or increase in the vasoconstriction score was observed, whether the skin had been previously treated with retinoic acid or with excipient. The vasoconstriction scores obtained with a combination of retinoic acid and triamcinolone acetonide were identical with those obtained with the steroid alone. This study indicates that retinoic acid does not inhibit the vasoconstriction induced by topical corticosteroids and suggests that the anti-inflammatory effect of the latter should be maintained in association with retinoic acid.

[Cutaneous manifestations of tuberculosis]. / Manifestations cutanées de la tuberculose.

Tuberculous lesions of the skin occur rarely nowadays. We therefore have mostly lost the knowledge to recognize this entity. Furthermore, the great variability of the clinical and particularly dermatologic manifestations of the disease can tax the most astute clinician. The challenge is even greater, when the patient has an intercurrent condition such as a malignancy or AIDS. In order to make understanding easier, we replace all descriptive terms, some carried over from the last century, by a useful pathogenetic and clinical, algorithmic classification. Finally the necessity of biopsy and specific cultures for proper diagnosis and treatment of any skin lesion consistent with skin tuberculosis is emphasized.

[Pasteurellosis in human pathology]. / Pasteurellose en pathologie humaine.

Pasteurella are common bacteria among healthy animals. Humans usually are infected by dog and cat bites or scratches. Besides, local skin infection, Pasteurella may spread, in some cases, to lungs, joints, bones or, less frequently, to other organs.

[Hoigné's syndrome or pseudo-anaphylactic reaction to procaine penicillin G: a still current classic]. / Syndrome de Hoigné ou réaction pseudo-anaphylactique à la procaïne-pénicilline G: un classique d'actualité.

In this journal in 1959 R. Hoigné described the first cases of pseudo-anaphylactic reactions induced by intramuscular administration of procaine penicillin G. This complication, characterized by acute psychological and neurological manifestations, is still of current interest since recently three cases of Hoigné's syndrome were diagnosed at the University Hospital of Geneva. This entity deserves consideration because it must be differentiated from authentic anaphylactic shock due to penicillin. The distinction is important from a therapeutic viewpoint since Hoigné's syndrome allows continuation of treatment, whereas it is absolutely contraindicated in anaphylactic shock.

[Leg ulcer complicated by secondary amyloidosis]. / Ulcère de jambe compliqué d'amyloïdose secondaire.

A 76-year-old woman with a chronic leg ulcer for the last thirty-seven years was hospitalized in our institution for chronic diarrhea and terminal kidney failure with proteinuria. The diagnosis of secondary amyloidosis due to persistent skin inflammation was confirmed by aspiration of subcutaneous abdominal fat and by kidney biopsy which showed AA type systemic amyloidosis. This appears to be a rare complication of chronic leg ulcers as there have been only eight publications covering eleven cases in the literature.