Contemporary management of patients with atrial fibrillation in the Netherlands and Belgium: a report from the EORP-AF long-term general registry.

BACKGROUND: Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. METHODS: We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1­year follow-up data were gathered. RESULTS: At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). CONCLUSIONS: Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.

Assessment of pops contaminated sites and the need for stringent soil standards for food safety for the protection of human health.

Persistent organic pollutants (POPs) including PCDD/Fs, PCBs and organochlorine pesticides (OCPs) are among the most important and hazardous pollutants of soil. Food producing animals such as chicken, beef, sheep and goats can take up soil while grazing or living outdoors (free-range) and this can result in contamination. In recent decades, large quantities of brominated flame retardants such as polybrominated diphenyl ethers (PBDEs), short-chain chlorinated paraffins (SCCPs) and per- and polyfluorinated alkylated substances (PFAS) have been produced and released into the environment and this has resulted in widespread contamination of soils and other environmental matrices. These POPs also bioaccumulate and can contaminate food of animal origin resulting in indirect exposure of humans. Recent assessments of chicken and beef have shown that surprisingly low concentrations of PCBs and PCDD/Fs in soil can result in exceedances of regulatory limits in food. Soil contamination limits have been established in a number of countries for PCDD/Fs but it has been shown that the contamination levels which result in regulatory limits in food (the maximum levels in the European Union) being exceeded, are below all the existing soil regulatory limits. 'Safe' soil levels are exceeded in many areas around emission sources of PCDD/Fs and PCBs. On the other hand, PCDD/F and dioxin-like PCB levels in soil in rural areas, without a contamination source, are normally safe for food producing animals housed outdoors resulting in healthy food (e.g. meat, eggs, milk). For the majority of POPs (e.g. PBDEs, PFOS, PFOA, SCCP) no regulatory limits in soils exist. There is, therefore, an urgent need to develop appropriate and protective soil standards minimising human exposure from food producing animals housed outdoors. Furthermore, there is an urgent need to eliminate POPs pollution sources for soils and to control, secure and remediate contaminated sites and reservoirs, in order to reduce exposure and guarantee food safety.

HCH contamination from former pesticide production in Brazil--a challenge for the Stockholm Convention implementation.

Hexachlorocyclohexane (HCH) isomers (α-, ß- and γ- HCH [lindane]) were recently added to the list of persistent organic pollutants regulated by the Stockholm Convention, and therefore, the legacy of HCH and lindane production has become an issue of global relevance. The production of lindane with the much larger quantities of associated waste isomers has generated large waste deposits and contaminated sites. This article presents an overview of HCH-polluted sites in Brazil as a basis for further activities related to the Stockholm Convention. The locations of HCH stockpiles and contaminated sites in Brazil arising from production and formulation have been compiled and mapped. This shows that the measures taken over the past 25 years have not resulted in remediation of the HCH pollution. An exposure risk study has been summarised for one major site and is included to demonstrate the contemporary relevance of the contamination. Major site remediation efforts are planned at one site but people live close to several other sites, and there is an urgent need of further assessments and remediation to ensure the protection of human health and the environment. The Stockholm Convention requires a systematic approach and should be adopted for the assessment of all sites and appropriate isolation/remediation measures should be facilitated. The appropriate planning of these activities for the production site in Rio de Janeiro could be a positive contribution for Rio+20 highlighting that green economy and sustainable production also include the appropriate management of legacies of historic production of an industrial sector (here the organochlorine industry).

Chronotropic incompetence: a case report.

Chronotropic incompetence is generally defined as an inadequate heart rate response to exercise, but manifestations can vary. The incidence depends on underlying cardiac pathology and, to a lesser degree, on the cut-off value of the predicted heart rate during exercise. Different pathologies induce chronotropic incompetence. Its presence indicates an adverse outcome and is strongly correlated with coronary artery disease. Treatment consists of rate-responsive pacemakers; dual-sensor, adaptive pacemakers are superior to single-sensor, rate-augmenting pacemakers. This case report illustrates the negative effect of chronotropic incompetence on daily activities and its amelioration by implantation of a rate-responsive pacemaker. (c)2001 by CHF, Inc.

Coronary embolization of the membrane fixing a "Multilink" stent to its delivery balloon.

We report on a case of coronary embolization of an elastic membrane fixing the ACS RX Multilink stent over its balloon, after a successful stent delivery. The membrane was dislodged from the balloon in the ostium of the right coronary artery as the delivery balloon was being pulled back into the guiding catheter. All attempts to retrieve the membrane, to cover it with another stent, or to push it into a terminal segment of the artery to limit the jeopardized myocardial mass were unsuccessful. No CABG was performed because the left coronary system was normal and the procedure occurred 2 months after an incomplete inferior myocardial infarction. There was no increase in cardiac enzymes nor electrocardiographic signs of a new myocardial infarction at discharge or at 1-mo follow-up. It seems preferable to avoid further use of stents tied to their balloons with an intermediary, and possibly detachable, element.

Tachycardia-induced cardiomyopathy secondary to right ventricular outflow tract ventricular tachycardia: improvement of left ventricular systolic function after radiofrequency catheter ablation of the arrhythmia.

INTRODUCTION: Several reports describe development of cardiomyopathies secondary to supraventricular tachycardia. Few reports have described cardiomyopathies secondary to ventricular tachycardia. METHODS AND RESULTS: We describe a patient who presented with dilated cardiomyopathy and repetitive nonsustained monomorphic ventricular tachycardia. Cardiac catheterization showed hemodynamically insignificant coronary artery disease. Radiofrequency ablation of a right ventricular outflow tract ventricular tachycardia resulted in improvement of the left ventricular systolic function and resolution of heart failure symptoms. CONCLUSIONS: This report suggests that right ventricular outflow tract ventricular tachycardia may cause reversible tachycardia-induced cardiomyopathy.

Occult T wave alternans in long QT syndrome.

T wave alternans that is visually apparent on the ECG is a known risk factor for sudden death in idiopathic long QT syndrome (LQTS). To determine if occult and visually undetectable forms of T wave alternans are also present in LQTS, we measured T wave alternans from a 16-year-old girl with LQTS during exercise using spectral analysis methods and a recording system designed to minimize exercise-related noise. While there was no alternans at rest, statistically significant, yet visually inapparent T wave alternans were measured both during exercise and recovery. Using identical recording techniques, no significant T wave alternans was detected from the subject's mother, who had a prolonged QT interval but was not experiencing arrhythmias, nor from five healthy volunteers with normal QT intervals. This report suggests that electrocardiographically occult, yet prognostically important forms of T wave alternans may be present in patients with LQTS.

Activation of the cAMP-dependent signaling pathway downregulates the expression of interleukin-3 and granulocyte-macrophage colony-stimulating factor in activated human T lymphocytes.

Expression of cytokines by T lymphocytes is a highly balanced process, involving stimulatory and inhibitory intracellular signaling pathways. We have examined the modulating effects of the cAMP-dependent signaling pathway on the expression of interleukin-3 (IL-3) and granulocyte-macrophage colony-stimulating factor (GM-CSF) in activated human T lymphocytes. 2'-O-dibutyryl-cAMP (db-cAMP), prostaglandin E2 (PGE2), isoproterenol (ISO), and isobutyl-methyl-xantin (IBMX) costimulated with concanavalin A (Con A) or Con A plus the phorbolester phorbol myristate acetate (PMA) inhibited IL-3 and GM-CSF mRNA accumulation compared to the effects of Con A or Con A plus PMA alone. Nuclear run-on experiments revealed that the inhibitory effect of db-cAMP could partially be ascribed to a five-fold reduction in transcription rate of both the IL-3 and GM-CSF gene in the presence of Con A or Con A plus PMA. mRNA stability studies demonstrated that PMA increased the stability of both transcripts. db-cAMP did not affect the stability of IL-3 and GM-CSF mRNAs in Con A activated cells. In contrast, in Con A plus PMA activated cells, db-cAMP significantly reduced the half-life of both transcripts: IL-3 >240 minutes vs. 90 minutes and GM-CSF 90 minutes vs. 60 minutes. Finally, in accordance with the mRNA data, db-cAMP, PGE2, and ISO reduced the secretion of IL-3 and GM-CSF protein in Con A and Con A plus PMA activated cells. In conclusion, these data demonstrate that the protein kinase A (PKA)-dependent signaling pathway is an important regulatory mechanism in controlling IL-3 and GM-CSF gene expression in activated human T lymphocytes.

Chronic amiodarone use decreases implantable cardioverter defibrillator shock efficacy

To evaluate the effect of amiodarone on implantable cardioverter defibrillator efficacy, we compared first shock conversion rates for ventricular fibrillation in 113 patients who received amiodarone to those in 641 patients who did not receive the drug. All patients received a CPI VENTAK P2 implantable cardioverter defibrillator. The first shock conversion rate for spontaneous ventricular fibrillation was lower for patients taking amiodarone (62 por cento vs 88 por cento. p < 0.01). Multivariate anysis selected amiodarone use (odds ratio 5.3) and lower first shock energy (odds ratio 0.9) as predictors of first shock failure. Conclusions: amiodarone use was associated with decreased implantable cardioverter defibrillator shock efficacy.

Independent ablation of retrograde and anterograde accessory connection conduction at the atrial and ventricular insertion sites: evidence supporting the impedance mismatch hypothesis for unidirectional block.

INTRODUCTION: The impedance mismatch hypothesis has been proposed as one of the mechanisms responsible for accessory connection conduction block. METHODS AND RESULTS: We describe a case in which retrograde conduction across a posteroseptal accessory connection was ablated at the atrial insertion site in the coronary sinus os, whereas anterograde conduction was ablated at the ventricular insertion site in the left ventricle. CONCLUSION: The evidence supports the impedance mismatch concept as the cause of unidirectional conduction block and shows that the distal junction between the accessory connection and the myocardium is more vulnerable to ablation.

Clinical spectrum of pulmonary tuberculosis in older patients: comparison with younger patients.

We compared the clinical-radiographic presentations of bacteriologically proven tuberculosis in 72 elderly (mean age: 71 yr) and 73 younger patients (mean age: 39 yrs). The tuberculin test (2 TU PPD) was positive in 55% and 92%, respectively. The prevalence of cough, dyspnea, anorexia, and weight loss was higher in the elderly (p less than .05), and night sweats were more prevalent in the younger patients (p less than .01). The radiographic pattern was not different between both groups (p greater than .10): "usual" apicoposterior lesions (with or without other abnormalities) were found in more than 70% of both groups; isolated "unusual" lesions consisted in both groups mainly of anterobasal infiltrations and sometimes of pleural effusions, rounded nodules, or miliary patterns. Yet, initially a wrong diagnosis was made more often in the elderly (p = .05). Malignancy, chronic pulmonary disease, and immunosuppression were more frequently encountered in the elderly (p less than .05), whereas alcoholism and smoking were more frequent in the younger patients (p less than .001). Tuberculosis-related mortality occurred in 6 elderly and 1 younger patient.

Isolated intrathoracic tuberculous lymphadenopathy.

We report an 82 yr old man with isolated intrathoracic lymphadenopathy of tuberculous origin, which is an extremely uncommon presentation of tuberculosis especially in elderly Caucasian patients. The diagnosis was suggested by the computerized tomographic (CT)-scan showing central hypodense areas after contrast, and was subsequently proved by mediastinoscopic biopsy with histological and microbiological analysis. The atypical presentation of tuberculosis together with a negative two-step 5 international units of purified protein derivative (IU-PPD) tuberculin skin test and a frequent contact with a cavernous index case points towards a primary infection in this patient.