Master athletes'ECG and the diagnostic accuracy of contemporary ECG interpretation criteria

Background

Over the last years, several efforts have been made to refine the ECG criteria for interpretation of young (16–35 years) competitive athlete's ECG in order to improve specificity maintaining good sensitivity. However, few data exist about the efficacy of such interpretation criteria in master athletes (over 35 years). We aimed to assess the diagnostic performance of screening based on 2017 International ECG recommendation (2017-International), 2010 European Society of Cardiology recommendation (2010-ESC) and Seattle criteria in a cohort of master athletes competing at regional and national level.

Methods

506 Caucasian master athletes (mean ages 47.9±8.7, 85,6% male, 65% endurance athletes) underwent standardized medical history, physical examination, resting and exercise ECG during their pre-participation screening. ECGs were retrospectively interpreted based on 2010-ESC, Seattle-criteria and 2017-International. For the purpose of the study we included also a transthoracic echocardiography as reference, to calculate the sensibility and specificity, area under the ROC curve (AUC) was estimated as measure of discriminative ability of each ECG criteria. Athletes with abnormalities underwent further examinations according to the European Guidelines.

Results

Twelve athletes (2,3%) were diagnosed with a condition potentially related to SCD (1 hypertrophic cardiomyopathy, 1 Type1 Brugada Syndrome, 4 Chronic Coronary Syndromes, 2 Dilated Cardiomyopathy, 3 Aortic Dilation, 1 Moderate aortic stenosis) during the pre-participation screening. International criteria failed to identify two athletes with DCM and left axis deviation on ECG while no athletes with complete right bundle branch block showed serious structural abnormalities. The most common ECG abnormalities were left axis deviation (7,1%), left atrial enlargement (4,2%) and T wave inversion (3%). 29 athletes (5,7%) exhibited a long QT interval according to 2010-ESC and 1 athlete according to International and Seattle criteria. The false positive ECG rate was 15% for 2017-International based screening, 21,9% for Seattle based screening and 30,40% for 2010-ESC based screening while the diagnostic accuracy for pathologies at risk of SCD was 0,73 (95% CI 0,69–0,77) for 2017 International based screening; 0,81 (95% CI 0,77–0,84) for Seattle Criteria based screening and 0,77 (95% CI 0,73–0,80) for 2010-ESC based screening.

Conclusion

In master athletes the 2017-International ECG criteria showed inferior accuracy compared to the Seattle criteria and 2010-ESC, the least showing a higher false positive rate mostly due to lower cut-off for long QT. Furthermore complete right bundle branch block may be considered a normal finding also in master asymptomatic athletes.

Accuracy of ECG criteria

Funding Acknowledgement

Type of funding source: None

[Can the occupational health physician promote work as a health factor?]

This report answers the question: "In carrying out his/her institutional tasks, can the Occupational Health Physician (MC--medico competente--in Italian) promote work as a health factor?" The answer is in the affirmative, with identification of the social and regulatory framework within which the occupational health physician operates, examples of professional activities directed towards this aim and stressing the fact that the physician requires clinical skills so that he/she can work actively in the process of diagnosis-treatment-rehabilitation of the sick worker. Furthermore technological and organizational knowledge of the enterprise is required together with knowledge of the "social safeguards", that are useful for both the worker and the enterprise that employs him/her. In the current social and regulatory context the occupational health physician can promote work as a health factor both through cooperation in the process of improvement of the workplace, and by actively participating in the most appropriate placement of "frail" workers' (elderly people, disease sufferers, the disabled). It is necessary for the occupational health physician to develop a close working cooperation with the business system to achieve these aims.

Continuous veno-venous hemofiltration with regional citrate anticoagulation: a four-year single-center experience

BACKGROUND

Hemofiltration protocols using a citrate-buffered replacement solution offer the advantage of regional anticoagulation and a buffer effect. The role played by such fluids in clinical practice is not yet well established. The risk of electrolytic disorders, acid-base imbalance, or citrate accumulation should be clarified. We report on a renal therapy protocol based on a citrate isonatremic replacement solution.

METHOD

We considered all patients needing renal replacement therapy admitted to our cardiovascular intensive care unit between January 2003 and June 2007. A citrate-buffered fluid was delivered in predilution mode to a post-filter ionized calcium target < or = 0.25 mmol/L. Extracorporeal blood flow was set at a constant of 140+/-10 ml/min. Blood calcemia was maintained by a 5% calcium-chloride solution infused into the patient. We recorded the patients' acid-base variables, ionized calcium, daily electrolytes, albumin, urea and filter life-span.

RESULTS

We observed 101 consecutive patients out of 2,523; incidence 4%, overall mortality was 57% at ICU discharge. Mean replacement rate was 2,554+/-475 ml/h corresponding to 34+/-5 ml/kg/h. Mean patient ionized calcium level was 1.07+/-0.04 mmo/L, maintained by 13+/-2 ml/h of infused calcium-chloride. All other electrolytes remained in the normal range. The Stewart biophysical approach confirmed a strong anion gap of 3.1+/- 3 meq/L. Acid-base balance showed a buffer effect. Mean filter life-span was 52+/-11 h.

CONCLUSION

Renal replacement therapy based on citrate-buffered fluid may be useful in clinical practice. This methodology presented an adequate metabolic control and allowed regional anticoagulation. A sufficient calcium supply was mandatory to avoid hypocalcemia. The small strong ion gap suggested a modest citrate accumulation.

[Research and formal demonstration of evidence of efficiency in occupational medicine]

There is an increasing pressure on occupational health professionals to ensure that their practice is based on a quality standard and an evidence of appropriateness. The efficacy-effectiveness of their activity strictly depends on their intellectual and professional integrity, their technical and legal competence, but also on the quality of the relations with the company organisation they are able to establish. We asked to some occupational physician when they considered their interventions in the workplace to be efficacious. Then, accordingto our epexrience, we propose some effectiveness indicators, particular concerning health surveillance and health educttaon, that should be evaluated to verify the health professional agccvity agreement to quality standards.

[Good practices and quality in the practice of occupational physicians]

This contribution describes practice and tools which allow occupational physicians the realization of theirs tasks not only respecting law and ethical codes, but also in view of a continuous improvement of their activities and customers (companies) and consumers (workers) care.

[Health surveillance: from risk presumption to risk assessment]

A working group of the Occupational Medicine and Industrial Hygiene Association of Lombardy, the National Association of Occupational Health Physicians the National Society of Prevention Operators made a paper in order to rationalize the sanitary surveillance, observing the laws in force and following the European Directives. The authors, thinking that everyday experience not very useful health examinations are carried out and that the sanitary surveillance should be planned according to the real working risks, give methodological directives about the way to make the mandatory clinical examinations less frequent, to the firms, to the occupational health physician and to the public occupational health operators of the local health units that must supervise the sanitary surveillance.

[Application of article 35 of the DPR 303/56: experience of the competent physicians]

The "competent" doctor is much interested in the extensive application of the article 35 of DPR 303/56. As a matter of fact, that permits him a sanitary surveillance less concerned in formal performances and more related to work risk. The employers are often reluctant to require the derogation foreseen by the article 35 of DPR 303/56 because from such a request interventions on part the vigilance organ could derive causing instruction report report, notices and sanctions regarding situation independent from the risk which the derogation was requested. As a result, the modality for the derogation application has to be uniform all over the territory: an action at regional level is strictly necessary as well as check activity on part of the competent offices of the region.

[Competent occupational physicians: privileges from the UOOML]

The author analyzes the role of the workphysician in order to the new laws of prevention, safety and health promotion on the work-places. Especially, the author emphasizes the synergic actions and the collaborations between workphysicians and public health structures, as the Hospital Units for Occupational Medicine.

[Endophthalmitis and pseudophakia]

The authors describe seven cases of endophthalmitis following cataract surgery and intraocular lens implantation. The patients were treated with antibiotics together with mydriatics or with mydriatics and antiinflammatory medication only. Rapid healing of the endophthalmitis was observed in both series, with good restitution of visual acuity. According to various articles on this complication, approximately 75% of the aqueous humor samples taken are bacteriologically positive. The present authors therefore took samples of aqueous humor intraoperatively in randomly chosen cases, in order to establish whether there were any false-positive results due to external contamination. A brief review of the literature is presented.

Low-pH method for the enzymatic assay of D-glucaric acid in urine

The enzymatic methods for measuring D-glucaric acid in urine are based on the conversion of D-glucaric acid into its 1,4-lactone and measurement of inhibition of 1,4-lactone against beta-glucuronidase at pH 5.0. All the enzymatic methods described suffer from the disadvantage of a procedure that is complicated and inherently inaccurate, because the nature of glucaric acid/1,4-lactone equilibrium has not been properly considered in the development of such methods. After elucidating the factors influencing glucaric acid/1,4 lactone equilibrium in more detail, a low-pH enzymatic method has been developed in which the 1,4-lactone is formed in the urine sample by acid boiling at pH 3.8 and assayed at the same pH using beta-glucuronidase from Limpets. This procedure allows the acid/lactone equilibrium to remain stable during both the lactonization step and the enzymatic assay. The coefficient of variation for the proposed method (within-run and between-day precision) was from 4.2 to 8.7. The analytical recovery varied from 92-108%.