Fragmentation of the QRS Complex Is Associated with Right Ventricular Dilatation and Mortality in Critically Unwell Coronavirus Disease 2019 Patients.

BACKGROUND: QRS fragmentation (fQRS) is a depolarization disorder that can be detected on routine electrocardiography (ECG). Current evidence suggests that fQRS is a prognosticator of adverse cardiovascular events. This study aimed to assess the relationship between fQRS and all-cause mortality in critically unwell coronavirus disease 2019 (COVID-19) patients and to investigate the significance of associated abnormalities on echocardiography. METHODS: A retrospective cohort study of COVID-19 patients in a critical care setting was performed. Electrocardiography was performed on presentation to hospital, admission to the critical care unit, and at subsequent points according to clinical need. Transthoracic echocardiography was performed at clinical discretion to assess for structural and functional cardiac abnormalities. Primary outcome was in-hospital mortality and secondary outcome was the need for mechanical invasive ventilation. RESULTS: Totally, 212 consecutive patients were included of which 120 (57%) exhibited fQRS and inferior leads were involved in 88% of the patients. Overall, fQRS was a significant predictor of mortality [65% vs. 44% P =.003; multivariate odds ratio = 2.96, 95% confidence interval (CI): 1.42-6.40, P =.005] and inferior fQRS itself was a significant predictor of mortality (P =.03). There was no significant association between fQRS and the need for invasive mechanical ventilation. A total of 112 patients underwent echocardiography. There was a greater incidence of right ventricular (RV) dilatation in the fQRS group (16% vs. 2% respectively, P =.02) and pulmonary hypertension (33% vs. 14% respectively, P =.03) based on echocardiographic criteria. CONCLUSION: Our study demonstrates that fQRS is significantly associated with RV dilation, pulmonary hypertension, and mortality in critically unwell COVID-19 patients.

Incorporation of antimony-bearing mining wastes into clinker Portland raw feed: The difficulty of Sb analysis in calcium silicates.

Within the global trend to valorise various mineral wastes as substituents in Portland cement clinker raw feed, mining wastes are promising candidates. However, they might still contain high levels of metallic elements. Their fate in the kiln is not always understood as well as their incorporation within the various clinker's phases. This is especially the case for antimony. Its in situ microanalysis by the means of energy-dispersive spectroscopy is tricky since several of its L lines (Lα1 = 3604,72 eV, Lα2 = 3595,32 eV) overlap with calcium lines (Kα1 = 3691,68 eV, Kα2 = 3688,09 eV). Hence, at low concentrations, it is not possible to visualise its characteristics peaks. Increasing the counting rate by increasing the acceleration current results in the generation of spurious sum peaks, rendering the analysis not viable. Wavelength dispersive spectroscopy (i.e. electron microprobe) allows a better spectral resolution and quantification of Sb in the clinker phases. In a Portland cement clinker doped with 1% of Sb-bearing mining waste, the Sb2O3 content in belite and alite is in the 0.2-0.4 wt.% range as well as for C3A; in C4AF the content is higher, from 1.4 wt.% to 2 wt.%. However, there are microstructural evidence that Sb forms blebs from less than 1 µm in diameter up to 10 µm, included in calcium silicates. Hence, its incorporation in the lattice of calcium silicates is dubious. However, for ferrites and aluminates there is no microstructural evidence for remaining Sb-bearing phases, suggesting a direct incorporation in crystal lattices.

Polypharmacy and cumulative anticholinergic burden in older adults hospitalized with fall.

Introduction: Polypharmacy is a growing phenomenon associated with adverse effects in older adults. We assessed the potential confounding effects of cumulative anticholinergic burden (ACB) in patients who were hospitalized with falls. Methods: A noninterventional, prospective cohort study of unselected, acute admissions aged ≥ 65 years. Data were derived from electronic patient health records. Results were analyzed to determine the frequency of polypharmacy and degree of ACB and their relationship to falls risk. Primary outcomes were polypharmacy, defined as prescription of 5 or more regular oral medications, and ACB score. Key Results: Four hundred eleven (411) consecutive subjects were included, mean age 83.8 ± 8.0 years: 40.6% men. There were 38.4% patients who were admitted with falls. Incidence of polypharmacy was 80.8%, (88.0% and 76.3% among those admitted with and without fall, respectively). Incidence of ACB score of 0, 1, 2, ≥ 3 was 38.7%, 20.9%, 14.6%, and 25.8%, respectively. On multivariate analysis, age [odds ratio (OR) = 1.030, 95% CI:1.000 ~ 1.050, P = 0.049], ACB score (OR = 1.150, 95% CI:1.020 ~ 1.290, P = 0.025), polypharmacy (OR = 2.140, 95% CI:1.190 ~ 3.870, P = 0.012), but not Charlson Comorbidity Index (OR = 0.920, 95% CI:0.810 ~ 1.040, P = 0.172) were significantly associated with higher falls rate. Of patients admitted with falls, 29.8% had drug-related orthostatic hypotension, 24.7% had drug-related bradycardia, 37.3% were prescribed centrally acting drugs, and 12.0% were taking inappropriate hypoglycemic agents. Conclusion: Polypharmacy results in cumulative ACB and both are significantly associated with falls risk in older adults. The presence of polypharmacy and each unit rise in ACB score have a stronger effect of increasing falls risk compared to age and comorbidities.

The long-term outcomes of cardiac implantable electronic devices implanted via the femoral route.

BACKGROUND: Conventional superior access for cardiac implantable electronic devices (CIEDs) is not always possible and femoral CIEDs (F-CIED) are an alternative option when leadless systems are not suitable. The long-term outcomes and extraction experiences with F-CIEDs, in particular complex F-CIED (ICD/CRT devices), remain poorly understood. METHODS: Patients referred for F-CIEDs implantation between 2002 and 2019 at two tertiary centers were included. Early complications were defined as ≤30 days following implant and late complications >30 days. RESULTS: Thirty-one patients (66% male; age 56 ± 20 years; 35% [11] patients with congenital heart disease) were implanted with F-CIEDs (10 ICD/CRT and 21 pacemakers). Early complications were observed in 6.5% of patients: two lead displacements. Late complications at 6.8 ± 4.4 years occurred in 29.0% of patients. This was higher with complex F-CIED compared to simple F-CIED (60.0% vs. 14.3%, p = .02). Late complications were predominantly generator site related (n = 8, 25.8%) including seven infections/erosions and one generator migration. Eight femoral generators and 14 leads (median duration in situ seven [range 6-11] years) were extracted without complication. CONCLUSIONS: Procedural success with F-CIEDs is high with clinically acceptable early complication rates. There is a notable risk of late complications, particularly involving the generator site of complex devices following repeat femoral procedures. Extraction of chronic F-CIED in experienced centers is feasible and safe.

Drug-related bradycardia precipitating hospital admission in older adults: an ongoing problem.

BACKGROUND: Drug-related bradycardia (DRB) is a common clinical conundrum and can result in multiple hospital admissions as a result of the increased prescription of rate-limiting medications that can predispose to presyncopal or syncopal episodes. AIM: To evaluate the incidence of DRB in elderly hospital inpatients. METHODS: We conducted a retrospective analysis of all patients admitted to our acute medical unit between November 2018 and February 2019 and identified patients over the age of 70 with more than one diurnal bradycardic episode during their admission. We extracted patient demographics, presenting complaint, admission 12-lead ECG and medications from the hospital electronic database. RESULTS: We screened 2312 adults and identified 100 patients over the age of 70 years with two or more episodes of diurnal bradycardia during their hospital admission. This constituted 4.32% of total admissions. Beta blockers were the most commonly prescribed rate-limiting medication (n=54, 87.1%), of which bisoprolol was the most frequently prescribed (n=41) and sinus bradycardia was the most commonly identified rhythm disturbance in our cohort of patients (n=41, 41%). Syncope was the most common presenting symptom and occurred in 23 patients, 14 (60.9%) of which were diagnosed with a DRB. Atrial fibrillation was more common in those with DRB compared with those with bradycardia not caused by medications (35.5% vs 10.5%, p=0.006), and atrial fibrillation was a significant predictor of DRB (OR=10.2, 95% CI 3.3 to 31.6, p<0.001). CONCLUSION: Bradycardia is a significant cause of hospital admissions in older adults and can be avoided with pharmacovigilance. Caution should be exercised when initiating or changing the dose of rate-limiting agents in these patients; while those with atrial fibrillation should undergo regular review of their heart rate followed by appropriate medication dose adjustments.

Strength curve data for slender geopolymer concrete columns with GFRP, steel and hybrid reinforcement.

This article provides a wide range of circular columns strength values under different loading conditions. The provided strength values are dependent on various parameters including the longitudinal and transverse reinforcement ratios. Results for GFRP, steel and hybrid reinforcement configurations are provided. The results were collected from analysis output files of more than 60,000 columns, and tabulated in a form that is suitable for generating analytical strength curves. The provided data format allows the generation of strength curves for a wide range of slenderness ratios and the applied load eccentricities. Inspecting the analytical strength curves could provide insights on the slenderness limits for maintaining specific strength thresholds. Also, further investigations of data could provide a group of recommendations to avoid longitudinal and transverse reinforcement underutilization. Additional data processing could provide axial load-bending moment interaction diagrams for different columns` configurations taking into consideration the slenderness effects. The use of interaction diagrams in inspecting slender columns behavior is a ubiquitous subject that has been utilized in many recent research papers. Moreover, the results of a sensitivity analysis are provided within the article.

Predictors and Mechanisms of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy.

Atrial fibrillation (AF) in hypertrophic cardiomyopathy (HC) is associated with significant symptomatic deterioration, heart failure, and thromboembolic disease. There is a need for better mechanistic insight and improved identification of at risk patients. We used cardiovascular magnetic resonance (CMR) to assess predictors of AF in HC, in particular the role of myocardial fibrosis. Consecutive patients with HC referred for CMR 2003 to 2013 were prospectively enrolled. CMR parameters including left ventricular volumes, presence and percentage of late gadolinium enhancement in the left ventricle (%LGE) and left atrial volume index (LAVi) were measured. Overall, 377 patients were recruited (age 62 ± 14 years, 73% men). Sixty-two patients (16%) developed new-onset AF during a median follow up of 4.5 (interquartile range 2.9 to 6.0) years. Multivariable analysis revealed %LGE (hazard ratio [HR] 1.3 per 10% (confidence interval: 1.0 to 1.5; p = 0.02), LAVi (HR 1.4 per 10 mL/m2[1.2 to 1.5; p < 0.001]), age at HC diagnosis, nonsustained ventricular tachycardia and diabetes to be independent predictors of AF. We constructed a simple risk prediction score for future AF based on the multivariable model with a Harrell's C-statistic of 0.73. In conclusion, the extent of ventricular fibrosis and LA volume independently predicted AF in patients with HC. This finding suggests a mechanistic relation between fibrosis and future AF in HC. CMR with quantification of fibrosis has incremental value over LV and LA measurements in risk stratification for AF. A risk prediction score may be used to identify patients at high risk of future AF who may benefit from more intensive rhythm monitoring and a lower threshold for oral anticoagulation.

Outcomes and predictors of mortality and stroke after on-pump and off-pump coronary artery bypass surgery in octogenarians.

OBJECTIVE: Octogenarians, as the fastest growing stratum of the population and with the highest prevalence of coronary artery disease, are being increasingly referred for coronary artery bypass grafting (CABG). The general perception is that the presence of comorbidities and the propensity for neurological injury expose them to a higher risk for mortality and morbidity after conventional on-pump CABG, and therefore, off-pump CABG should be preferentially offered to octogenarians to improve outcomes. This study evaluates the in-hospital outcomes and predictors of mortality and stroke in octogenarians undergoing on- and off-pump CABG at our institution. METHODS: From January 2000 to December 2010, a total of 290 octogenarians underwent off-pump (n = 217) and on-pump (n = 73) CABG. Their data were prospectively entered into the cardiac surgery database (Patients Analysis & Tracking System; Dendrite Clinical Systems, Ltd, Oxford, England, United Kingdom) and analyzed retrospectively. Outcome measures included in-hospital mortality, major complications, and length of stay. Multivariate analysis was performed to identify predictors of combined outcome of in-hospital mortality and stroke. RESULTS: The mean ± SD age of the patients was 82 ± 2.0 years. Preoperative demographics were similar for the on-pump and off-pump groups. The patients who underwent off-pump CABG had a lower number of distal anastomoses performed compared with the patients who underwent on-pump CABG [mean difference, 0.2; 95% confidence interval (CI), 0.02-0.4; P = 0.03]. However, the ratio of grafts (received/needed) was the same in both groups. In-hospital mortality for the entire cohort was 7.2%, with no significant difference between the groups for death (6.0% vs 11.0%; P = 0.08), stroke (2.8% vs 2.8%; P = 1.0), other major complications, and length of hospital stay. Independent predictors of combined outcome identified from the multiple logistic model included heart failure [odds ratio (OR), 4.4; 95% CI, 1.5-13.0; P = 0.008], diabetes (OR, 2.6; 95% CI, 1.0-6.0; P = 0.046), nitrate infusion (OR, 2.9; 95% CI, 1.1-8.0; P = 0.04), postoperative renal failure requiring hemofiltration (OR, 8.6; 95% CI, 3.5-21.1; P < 0.001), and postoperative ventricular arrhythmias (OR, 7.3; 95% CI, 1.9-27.8; P = 0.009). CONCLUSIONS: Both on-pump and off-pump CABG are reasonable revascularization strategies in octogenarians. Careful patient selection and individualized treatment decisions can minimize postoperative mortality and morbidity in octogenarians undergoing on- and off-pump CABG.

In-hospital outcomes of pedicled bilateral internal mammary artery use in diabetic and nondiabetic patients undergoing off-pump coronary artery bypass grafting: single-surgeon, single-center experience.

OBJECTIVE: A common perception is that use of pedicled bilateral internal mammary arteries (BIMA) increases the risk of sternal wound complications in diabetic patients undergoing coronary artery bypass grafting (CABG). The purpose of this study was to compare the in-hospital outcomes of CABG using pedicled BIMA in diabetic and nondiabetic patients. METHODS: From September 1998 to September 2010, 390 consecutive diabetic patients and 519 nondiabetic patients underwent isolated off-pump CABG using pedicled BIMA. The 2 groups had comparable preoperative demographics except for a higher prevalence of acute myocardial infarction (18.9% versus 6.1%, P = .01), peripheral vascular disease (17.2% versus 2.7%, P = .001), an ejection fraction <30% (17.7% versus 8.5%, P = .02), and chronic renal failure (4.5% versus 0.9%, P = .01) in the diabetic patients. RESULTS: The operative mortality rate of the diabetic patients was comparable to that of the nondiabetic patients (2.8% versus 2.1%, P = .87). The in-hospital outcomes, including occurrence of superficial and deep sternal wound infections, were similar except for an increased occurrence of wound infection at the vein harvest site (6.6% versus 1.1%, P = .04) and a need for hemofiltration (11.8% versus 2.1%, P = .02) in the diabetic patients. CONCLUSIONS: Pedicled BIMA use is associated with comparable incidences of sternal wound complications and other outcomes in diabetic patients and nondiabetic patients. Strict perioperative glycemic control, adherence to meticulous closure technique, and postoperative management of surgical wounds can make pedicled BIMA use a default strategy for diabetic patients.

Concomitant off-pump coronary artery bypass grafting results in improved in-hospital outcomes for patients with ischemic mitral regurgitation undergoing surgery.

OBJECTIVE: Surgical management of ischemic mitral regurgitation (IMR) has primarily consisted of revascularization with or without the addition of mitral valve repair or replacement. We hypothesize that performing off-pump coronary artery bypass (OPCAB) grafting before fixing MR improves in-hospital outcomes for patients with IMR undergoing surgery. METHODS: From January 2000 through December 2010, a total of 96 consecutive patients with moderate or severe IMR, as determined by preoperative echocardiography, underwent on-pump coronary artery bypass grafting (CABG) (n = 66) or OPCAB (n = 30) revascularization with concomitant mitral valve repair or replacement. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. In addition, medical notes and charts were reviewed for all study patients. RESULTS: The 2 groups had similar preoperative demographic and EuroSCORE risk-stratification characteristics. The operative mortality rate for the entire cohort was 9.4%. Patients who underwent OPCAB grafting had a lower operative mortality than those who underwent CABG (3.3% versus 12.1%; P = .006). The mean ±SD cardiopulmonary bypass time (82.7 ± 34.7 minutes versus 160.7 ± 45.2 minutes; P < .001) and cross-clamp time (49.0 ± 22.4 minutes versus 103.4 ± 39.5 minutes; P < .001) were significantly shorter in the off-pump group than in the on-pump group. The OPCAB group also had significantly less in-hospital morbidity and shorter stays in the intensive care unit and the hospital. CONCLUSION: Our analysis shows that OPCAB grafting (compared with conventional CABG) before repairing MR is associated with favorable in-hospital outcomes for patients undergoing surgery for IMR.

In situ stabilization of trace metals in a copper-contaminated soil using P-spiked Linz-Donawitz slag.

PURPOSE: A former wood exploitation revealing high Cu and As concentration of the soils served as a case study for assisted phytoextraction. METHOD: P-spiked Linz-Donawitz (LD) slag was used as a soil additive to improve physico-chemical soil properties and in situ stabilize Cu and other trace metals in a sandy Cu-contaminated soil (630 mg kg⁻¹ soil). The LD slag was incorporated into the contaminated soil to consist four treatments: 0% (T1), 1% (T2), 2% (T3), and 4% (T4). A similar uncontaminated soil was used as a control (CTRL). After a 1-month reaction period, potted soils were used for a 2-week growth experiment with dwarf beans. RESULTS: Soil pH increased with the incorporation rate of LD slag. Similarly the soil electrical conductivity (EC, in millisiemens per centimetre) is ameliorated. Bean plants grown on the untreated soil (T1) showed a high phytotoxicity. All incorporation rates of LD slag increased the root and shoot dry weight yields compared to the T1. The foliar Ca concentration of beans was enhanced for all LD slag-amended soil, while the foliar Mg, K, and P concentrations were not increased. Foliar Cu, Zn, and Cr concentrations of beans decreased with the LD slag incorporation rate. CONCLUSIONS: P-spiked LD slag incorporation into polluted soil allow the bean growth and foliar Ca concentration, but also to reduce foliar Cu concentration below its upper critical value avoiding an excessive soil EC and Zn deficiency. This dual effect can be of interest for soil remediation at larger scale.

Single coronary artery presenting as angina.

The authors present an unusual case of chest pain in an 84-year-old Caucasian woman.

Restenosis after successful ostial stent implantation: the role of statins compared with conventional treatment.

Despite the introduction of coronary stents and effective anticoagulation regimens, the treatment of ostial lesions is limited by high restenosis rates. Initial results have been published asserting that statin therapy is associated with a significant reduction in restenosis after stent deployment. However, no information is available about the effect of statins after ostial stenting. Between 1993 and 2000, 122 patients required ostial placement of coronary stents at the Royal Brompton Hospital in London, United Kingdom. Statin treatment was continued or begun in 52 patients with a documentated hypercholesterolemia. Follow-up was feasible in 97 patients undergoing successful stent implantation. Restenosis rate was lower in patients receiving statins, but did not differ significantly from the nonstatin group (34.6% as against 42.2%, P = 0.531).