Inter-observer agreement in athletes ECG interpretation using the recent international recommendations for ECG interpretation in athletes among observers with different levels of expertise

Abstract INTRODUCTION: International criteria for the interpretation of the athlete's electrocardiogram (ECG) have been proposed. We aimed to evaluate the inter-observer agreement among observers with different levels of expertise. METHODS: Consecutive ECGs of Swiss elite athletes (?14 years), recorded during routine pre-participation screening between 2013 and 2016 at the Swiss Federal Institute of Sports were analysed. A medical student (A), a cardiology fellow (B) and an electrophysiologist (C) interpreted the ECG's independently according to the most recent criteria. The frequencies and percentages for each observer were calculated. An inter-observer reliability analysis using Cohen Kappa (?) statistics was used to determine consistency among observers. RESULTS: A total of 287 ECGs (64.1% males) were analysed. Mean age of the athletes was 20.4±4.9 years. The prevalence of abnormal ECG findings was 1.4%. Both, normal and borderline findings in athletes showed moderate to good agreement between all observers. ? scores for abnormal findings resulted in excellent agreement (? 0.855 in observer A vs C and B vs C to ? 1.000 in observer A vs B). Overall agreement ranged from moderate (? 0.539; 0.419-0.685 95% CI) between observer B vs C to good agreement (? 0.720; 0.681-0.821 95% CI) between observer A vs B. CONCLUSIONS: Our cohort of elite athletes had a low prevalence of abnormal ECGs. Agreement in abnormal ECG findings with the use of the recently published International recommendations for ECG interpretation in athletes among observers with different levels of expertise was excellent. ECG interpretation resulted in moderate to good overall agreement

Multi-messenger observations of a binary neutron star merger

On 2017 August 17 a binary neutron star coalescence candidate (later designated GW170817) with merger time 12:41:04 UTC was observed through gravitational waves by the Advanced LIGO and Advanced Virgo detectors. The Fermi Gamma-ray Burst Monitor independently detected a gamma-ray burst (GRB 170817A) with a time delay of ~1.7 s with respect to the merger time. From the gravitational-wave signal, the source was initially localized to a sky region of 31 deg2 at a luminosity distance of 40+8-8 Mpc and with component masses consistent with neutron stars. The component masses were later measured to be in the range 0.86 to 2.26 Mo. An extensive observing campaign was launched across the electromagnetic spectrum leading to the discovery of a bright optical transient (SSS17a, now with the IAU identification of AT 2017gfo) in NGC 4993 (at ~40 Mpc) less than 11 hours after the merger by the One- Meter, Two Hemisphere (1M2H) team using the 1 m Swope Telescope. The optical transient was independently detected by multiple teams within an hour. Subsequent observations targeted the object and its environment. Early ultraviolet observations revealed a blue transient that faded within 48 hours. Optical and infrared observations showed a redward evolution over ~10 days. Following early non-detections, X-ray and radio emission were discovered at the transient’s position ~9 and ~16 days, respectively, after the merger. Both the X-ray and radio emission likely arise from a physical process that is distinct from the one that generates the UV/optical/near-infrared emission. No ultra-high-energy gamma-rays and no neutrino candidates consistent with the source were found in follow-up searches. These observations support the hypothesis that GW170817 was produced by the merger of two neutron stars in NGC4993 followed by a short gamma-ray burst (GRB 170817A) and a kilonova/macronova powered by the radioactive decay of r-process nuclei synthesized in the ejecta

Opioid antagonists and adrenergic agonists for the management of opioid withdrawal

The definitive version may be found at www.wiley.comBackgroundManaged withdrawal, or detoxification, is not in itself a treatment for opioid dependence, but it is a required first step for many forms of longer-term treatment. It may also represent the end point of an extensive period of treatment such as methadone maintenance. As such, managed withdrawal is an essential component of an effective treatment system. This review is one of a series that aims to assess the evidence as to the effectiveness of approaches to managing opioid withdrawal.ObjectivesTo assess the effectiveness of interventions involving the combined use of opioid antagonists an adrenergic agonists to manage the acute phase of opioid withdrawal.Search strategyMultiple electronic databases, including Medline, Embase, Psychlit, Australian Medical Index and Current Contents, were searched using a strategy designed to retrieve references broadly addressing the management of opioid withdrawal. Reference lists of retrieved studies, reviews and conferences were handsearched.Selection criteriaStudies that were included: involved administration of an opioid antagonist in combination with an alpha2 adrenergic agonist; had modification of the signs and symptoms of withdrawal as the aim of the intervention; involved participants who had been diagnosed as primarily opioid dependent and were undergoing clinically managed withdrawal; had as their primary focus the acute phase of withdrawal; reported detail of the type and dose of drugs used and the characteristics of study participants; reported information on the nature of withdrawal symptoms experienced, the occurrence of side effects OR rates of completion of withdrawal; and were randomized or quasi-randomized controlled clinical trials or prospective controlled cohort studies comparing the combination of opioid antagonists and adrenergic antagonists with another form of treatment. (The findings of prospective single group studies or case series, and controlled studies without a comparison treatment modality were considered in the narrative component of the review without being identified as included studies).Data collection and analysisPotentially relevant studies were assessed for inclusion by one reviewer (LRG). Inclusion decisions were confirmed by consultation between all three reviewers. Included studies were assessed by all reviewers. One reviewer (LRG) undertook data extraction with the process confirmed by consultation between all three reviewers. Three studies compared treatment using an opioid antagonist-clonidine combination with treatment using clonidine only. This review incorporates data tables comparing maximum withdrawal scores and numbers of participants completing withdrawal for these three studies.. The capacity for data analysis is limited by differences in the assessment outcomes in the three studies and the likelihood of allocation bias in one study. Consequently, meta-analysis has not been undertaken to combine the findings of the three studies.Main resultsThree studies (four reports) met the criteria for inclusi on in analytical components of this review. Six further studies were identified that managed withdrawal using opioid antagonists in combination with adrenergic agonists, but which did not meet the inclusion criteria (four were single group studies, 2 were controlled studies but did not include a comparison treatment modality). Findings of these studies are considered in narrative components of the review. Naltrexone was the primary opioid antagonist used to induce withdrawal. The most common approach was to administer naltrexone once a day, using an initial dose of 12.5mg, usually on day one or day two of treatment. Doses of clonidine were generally in the range of 01.-0.3mg three times a day. Five studies provided treatment on an outpatient basis, but all studies provided extended care on the day naltrexone was first administered. (ABSTRACT TRUNCATED)L Gowing, R Ali, J Whit

Opioid antagonists with minimal sedation for opioid withdrawal

Background Managed withdrawal is a necessary step prior to drug-free treatment or as the end point of long-term substitution treatment. Objectives To assess the effectiveness of opioid antagonists in combination with minimal sedation to manage opioid withdrawal. Search strategy We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966-July 2008), EMBASE (January 1985-2008 Week 31), PsycINFO (1967 to 7 August 2008) and reference lists of articles. Selection criteria Controlled studies of interventions involving the use of opioid antagonists in combination with minimal sedation to manage withdrawal in opioid-dependent participants compared with other approaches or different opioid antagonist regimes. Data collection and analysis One author assessed studies for inclusion and undertook data extraction. Inclusion decisions and the overall process were confirmed by consultation between all authors. Main results Nine studies (6 randomised controlled trials), involving 837 participants, met the inclusion criteria for the review. The quality of the evidence is low, but suggests that withdrawal induced by opioid antagonists in combination with an adrenergic agonist is more intense than withdrawal managed with clonidine or lofexidine alone, while the overall severity is less. Delirium may occur following the first dose of opioid antagonist, particularly with higher doses (> 25mg naltrexone). In some situations antagonist-induced withdrawal may be associated with significantly higher rates of completion of treatment, comp[ared to withdrawal managed primarily with adrenergic agonists. However, this outcome has not been produced consistently, and the extent of any benefit is highly uncertain. Authors' conclusions The use of opioid antagonists combined with alpha2-adrenergic agonists is a feasible approach to the management of opioid withdrawal. However, it is unclear whether this approach reduces the duration of withdrawal or facilitates transfer to naltrexone treatment to a greater extent than withdrawal managed primarily with an adrenergic agonist. A high level of monitoring and support is desirable for several hours following administration of opioid antagonists because of the possibility of vomiting, diarrhoea and delirium. Further research is required to confirm the relative effectiveness of antagonist-induced regimes, as well as variables influencing the severity of withdrawal, adverse effects, the most effective antagonist-based treatment regime, and approaches that might increase retention in subsequent naltrexone maintenance treatment.Linda Gowing, Robert Ali and Jason M Whit