Etiological diagnosis, prognostic significance and role of electrophysiological study in patients with Brugada ECG and syncope.

BACKGROUND: Syncope is considered a risk factor for life-threatening arrhythmias in Brugada patients. Distinguishing a benign syncope from one due to ventricular arrhythmias is often difficult, unless an ECG is recorded during the episode. Aim of the study was to analyze the characteristics of syncopal episodes in a large population of Brugada patients and evaluate the role of electrophysiological study (EPS) and the prognosis in the different subgroups. METHODS AND RESULTS: One hundred ninety-five Brugada patients with history of syncope were considered. Syncope were classified as neurally mediated (group 1, 61%) or unexplained (group 2, 39%) on the basis of personal and family history, clinical features, triggers, situations, associated signs, concomitant therapy. Most patients underwent EPS; they received ICD or implantable loop-recorder on the basis of the result of investigations and physician's judgment. At 62±45months of mean follow-up, group 1 showed a significantly lower incidence of arrhythmic events (2%) as compared to group 2 (9%, p<0.001). Group 2 patients with positive EPS showed the highest risk of arrhythmic events (27%). No ventricular events occurred in subjects with negative EPS. CONCLUSION: Etiological definition of syncope in Brugada patients is important, as it allows identifying two groups with different outcome. Patients with unexplained syncope and ventricular fibrillation induced at EPS have the highest risk of arrhythmic events. Patients presenting with neurally mediated syncope showed a prognosis similar to that of the asymptomatic and the role of EPS in this group is unproven

Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the Emergency Department with syncope: An international meta-analysis.

BACKGROUND: Syncope remains challenging for Emergency Department (ED) physicians due to difficulties in assessing the risk of future adverse outcomes. The aim of this meta-analysis is to establish the incidence and etiology of adverse outcomes as well as the predictors, in patients presenting with syncope to the ED. METHODS: A systematic electronic literature review was performed looking for eligible studies published between 1990 and 2010. Studies reporting multivariate predictors of adverse outcomes in patients presenting with syncope to the ED were included and pooled, when appropriate, using a random-effect method. Adverse events were defined as 'incidence of death, or of hospitalization and interventional procedures because of arrhythmias, ischemic heart disease or valvular heart disease'. RESULTS: 11 studies were included. Pooled analysis showed 42% (CI 95%; 32-52) of patients were admitted to hospital. Risk of death was 4.4% (CI 95%; 3.1-5.1) and 1.1% (CI 95%; 0.7-1.5) had a cardiovascular etiology. One third of patients were discharged without a diagnosis, while the most frequent diagnosis was 'situational, orthostatic or vasavagal syncope' in 29% (CI 95%; 12-47). 10.4% (CI 95%; 7.8-16) was diagnosed with heart disease, the most frequent type being bradyarrhythmia, 4.8% (CI 95%; 2.2-6.4) and tachyarrhythmia 2.6% (CI 95%; 1.1-3.1). Palpitations preceding syncope, exertional syncope, a history consistent of heart failure or ischemic heart disease, and evidence of bleeding were the most powerful predictors of an adverse outcome. CONCLUSION: Syncope carries a high risk of death, mainly related to cardiovascular disease. This large study which has established the most powerful predictors of adverse outcomes, may enable care and resources to be better focused at high risk patients. Copyright \ua9 2011 Elsevier Ireland Ltd. All rights reserved

Sailing into the wind : new disciplines in Australian higher education

Much is made of the potential of lifelong learning for individuals and organisations. In this article we tend to make much less of it, certainly with respect to its use in universities to discipline academics. Nevertheless, we argue that academics now need to re-learn the positions they occupy and the stances they take in response to the marketisation of Australian universities. In particular, we suggest that the position of (pure) critique no longer commands attention in Australian contexts of higher education, although the paper does not suggest a disregard for a critical stance purely for the sake of participation. It is in understanding the interconnections between position and stance , and how they might be strategically performed during the everyday practices of academics, that a more promising way of engaging with the venalities of the market is envisaged; a strategy that could be described as \u27sailing into the wind\u27. In discussing these matters, the paper draws on semi-structured interviews with academics located in university faculties/departments/schools of education along Australia\u27s eastern seaboard

In silico investigation of a KCNQ1 mutation associated with short QT syndrome

Short QT syndrome (SQTS) is a rare condition characterized by abnormally ‘short’ QT intervals on the ECG and increased susceptibility to cardiac arrhythmias and sudden death. This simulation study investigated arrhythmia dynamics in multi-scale human ventricle models associated with the SQT2-related V307L KCNQ1 ‘gain-of-function’ mutation, which increases slow-delayed rectifier potassium current (IKs). A Markov chain (MC) model recapitulating wild type (WT) and V307L mutant IKs kinetics was incorporated into a model of the human ventricular action potential (AP) for investigation of QT interval changes and arrhythmia substrates. In addition, the degree of simulated IKs inhibition necessary to normalize the QT interval and terminate re-entry in SQT2 conditions was quantified. The developed MC model accurately reproduced AP shortening and reduced effective refractory period associated with altered IKs kinetics in homozygous (V307L) and heterozygous (WT-V307L) mutation conditions, which increased the lifespan and dominant frequency of re-entry in 3D human ventricle models. IKs reductions of 58% and 65% were sufficient to terminate re-entry in WT-V307L and V307L conditions, respectively. This study further substantiates a causal link between the V307L KCNQ1 mutation and pro-arrhythmia in human ventricles, and establishes partial inhibition of IKs as a potential anti-arrhythmic strategy in SQT2

Напряженное состояние призабойной части массива при проведении горных выработок с конической формой забоя

У рамках механіки пружно-деформованого тіла розроблена методика та розв’язана задача про напружений стан гірського масиву навколо горизонтальної циліндричної виробки. Чисельними дослідженнями виявлено значну концентрацію розтягуючих напружень у зоні ведення гірничих робіт.A method of stress state of a rock massif near the horizontal cylindrical working is developed, and a problem of mechanics of elastically deformed bodies is solved. A considerable concentration of tensile stresses in the mining working zone is revealed by numerical calculations

Gender Differences in Patients with Brugada Syndrome and Arrhythmic Events: Data from a Survey on Arrhythmic Events in 678 Patients.

BACKGROUND: There is limited information on gender differences in patients with Brugada syndrome (BrS) who experienced arrhythmic events (AEs). OBJECTIVES: To compare clinical, electrocardiographic (ECG), electrophysiologic (EP) and genetic characteristics between males and females in BrS-patients with their first AE. METHODS: The multicenter Survey on AE in BrS (SABRUS) collected data on first AE in 678 BrS-patients including 619 (91.3%) males and 59 (8.7%) females aged 0.27 to 84 (mean 42.5±14.1) years at the time of AE. RESULTS: After excluding pediatric patients, females were older than males (49.5±14.4 vs. 43±12.7 years, respectively, P=0.001). Higher proportions of females were observed in the pediatric and elderly populations. In Asians, male/female ratio of AE was ≈9-fold higher compared to Caucasians. Spontaneous type 1 BrS-ECG was associated with earlier onset of AE in pediatric females. A similar prevalence (≈65%) of spontaneous type 1 BrS-ECG was present in males and females above age of 60 years. Females less frequently showed a spontaneous type-1 BrS-ECG (31% vs. 59%, P<0.001) or arrhythmia-inducibility at EP study (34% vs. 64%, P<0.001). An SCN5A mutation was more frequently found in females (47.6% vs. 27.8% in males, P=0.007). CONCLUSIONS: This study confirms that female BrS-patients are much rarer, display less type 1 Brugada-ECG and exhibit lower inducibility rates than males. It shows for the first time that BrS females with AE have higher SCN5A mutation rates as well as the relationship between gender vs. age at onset of AE and ethnicity

Developing elementary algebraic reasoning through counting with patterns activities

Las tareas de recuento con patrones son un contexto privilegiado para el desarrollo del razonamiento algebraico. La complejidad ontosemiótica de las tareas permite identificar procesos de estudio para hacer progresar el desempeño en sucesivos niveles de algebrización, desde la manipulación meramente aritmética hasta una práctica con un nivel algebraico consolidado. El objetivo es doble: por un lado, elaborar indicadores que permitan valorar el desempeño de una práctica operatoria y discursiva en la resolución de tareas de recuento de patrones; por otro lado, proponer una secuencia que tenga en cuenta las restricciones epistemológicas, cognitivas y de enseñanza propias de estas prácticas. Un diseño pre-test y post-test mediante un cuestionario de preguntas abiertas y el análisis cualitativo de las respuestas por estudio de casos aporta información relevante sobre el desarrollo del razonamiento algebraico de los sujetos en los sucesivos niveles de algebrización. Se concluye que el Pensamiento Matemático Flexible es un indicador clave de la competencia algebraica de los sujetos, y se aporta una secuencia de enseñanza que parte de una estrategia inicial, basada en manipulaciones concretas y generalizaciones cercanas hasta el análisis de distintas expresiones analíticas.The counting tasks with patterns are a privileged context for the development of algebraic reasoning. The onto-semiotic complexity of tasks allows the identification of study processes to improve performance in successive algebrization levels, from purely arithmetic manipulation to a practice with a consolidated algebraic level. The objective is twofold: on the one hand, to elaborate indicators that allow evaluating the performance of an operative and discursive practice in the task resolution of counting patterns. On the other hand, to propose a sequence that takes into account the epistemological, cognitive, and teaching restrictions common to these practices. A pre-test and post-test design is proposed using an open-ended questionnaire. A qualitative analysis is carried out through a case study, which provides relevant information on the development of the subjects' algebraic reasoning in the successive algebrization levels. It is concluded that Flexible Mathematical Thinking is a key indicator of the subjects' algebraic competence; we also provided a teaching sequence that start from a basic strategy based on concrete manipulations and close generalizations to the analysis of different analytical expressions

Profile of Brugada Syndrome Patients Presenting with Their First Documented Arrhythmic Event. Data from the Survey on Arrhythmic Events in BRUgada Syndrome (SABRUS).

BACKGROUND: Detailed information on the profile of Brugada syndrome (BrS) patients presenting their first arrhythmic event (AE) after prophylactic implantation of a cardioverter defibrillator (ICD) is limited. OBJECTIVES: 1) To compare clinical, electrocardiographic, electrophysiologic and genetic profiles of patients who exhibited their first documented AE as aborted cardiac arrest (CA) (group A) with those in whom the AE was documented after prophylactic ICD implantation (group B); 2) To characterize group B patients' profile using the Class II indications for ICD implantation established by HRS/EHRA/APHRS Expert Consensus Statement in 2013. METHODS: A survey of 23 centers from 10 Western and 4 Asian countries enabled data collection of 678 BrS patients with AE (group A, n=426; group B, n=252). RESULTS: First AE occurred in group B patients 6.7 years later than in group A (46.1+ 13.3 vs. 39.4+15.1, P<0.001). Group B patients had a higher incidence of family history of sudden cardiac death (SCD) and SCN5A mutations. Of the 252 group B patients, 189 (75%) complied with the HRS/EHRA/APHRS indications whereas the remaining 63 (25%) did not. CONCLUSION: BrS patients with first AE documented after prophylactic ICD implantation exhibited their AE at a later age with a higher incidence of positive family history of SCD and SCN5A mutations compared to those presenting with an aborted CA. Only 75% of patients who suffered an AE after receiving a prophylactic ICD complied with the 2013 Class II indications, suggesting efforts are still required for improving risk stratification

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology

Background: In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines. Methods: A total of 6187 patients (18–80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012–2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys. Results: A total of 2846 (46%) patients had no diabetes, 1158 (19%) newly diagnosed diabetes and 2183 (35 %) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60%, respectively. A blood pressure target of 9.0% (>75 mmol/mol). Of the patients with diabetes 69% reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40%) and only 27% of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets. Conclusions: Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease

Aesthetic experience and spiritual well-being: locating the role of theological commitments

I discuss three accounts of the spiritual significance of aesthetic experience. Two of these perspectives I have taken from the recent literature in theological aesthetics, and the third I have constructed, building on Thomas Aquinas’s conception of the goods of the infused moral virtues. This broadly Thomistic approach occupies, I argue, a middle ground between the other two, on account of its distinctive understanding of the role of theological context in defining spiritually significant goods. These perspectives are not mutually exclusive, but they do present rather different conceptions of the ways in which aesthetic goods can contribute to spiritual well-being, and provide a focus for religious practice