Atrial flutter with multilevel atrioventricular block and cyclical occurrence of varying QRS morphologies.

An electrocardiogram showing atrial flutter in which varying ratios of AV conduction and the cyclical recurrence of varying QRS morphologies are observed is presented.

Pre-excitation Due to Fascicular-Ventricular Pathway: An Electrocardiographic Diagnosis: A Case Report.

A 79-year-old Caucasian male was referred to cardiology clinic because the electrocardiogram showed premature atrial complexes and pre-excitation (delta waves) thought to be consistent with Wolff-Parkinson-White (WPW) syndrome. He did not report symptoms of palpitations or syncope. Careful analysis of the electrocardiogram revealed a fascicular-ventricular pathway (FVP) responsible for pre-excitation. Differentiating FVP from WPW syndrome is essential as the risk profile is different with each. Electrocardiographic observations that could help identify the presence of an FVP and its diagnostic, prognostic, and therapeutic implications are presented.

Differential diagnosis of wide QRS tachycardia: A review.

Differential diagnosis of wide QRS tachycardia (WQRST) on the electrocardiogram remains a challenging exercise. Correct diagnosis is important for prescribing appropriate therapy and determining prognosis. Differential diagnosis of wide QRS tachycardia revolves around differentiation between supraventricular tachycardia with aberrant conduction and ventricular tachycardia. Observations such as clinical history, findings of physical examination during tachycardia, AV dissociation, QRS morphology in lead V1 and lead V6, precordial concordance, RS complexes in precordial leads, contralateral bundle branch block during wide QRS tachycardia, R wave morphologies in lead aVR, and ventricular initial/terminal velocity of conduction ratio can help arrive at the correct diagnosis with reasonable accuracy. The observations described here can help arrive at the correct diagnosis of WQRST with both reasonable accuracy and confidence.

Greening a Steel Mill Slag Brownfield with Biosolids and Sediments: A Case Study.

The former US Steel Corporation's South Works site in Chicago, IL, is a 230-ha bare brownfield consisting of steel mill slag fill materials that will need to be reclaimed to support and sustain vegetation. We conducted a case study to evaluate the suitability of biosolids and dredged sediments for capping the steel mill slag to establish good quality turfgrass vegetation. Eight study plots were established on a 0.4-ha parcel that received biosolids and dredged sediment blends of 0, 25, 50, or 100% biosolids (v/v). Turfgrass was successfully established and was thicker and greener in biosolids-amended sediments than in unamended sediments. Concentrations of N, P, K, and micronutrients in turfgrass tissues increased with increasing biosolids. Soil organic carbon, N, P, and micronutrients increased with increasing biosolids. Cadmium, Cu, Ni, and Zn concentrations in biosolids-amended sediments also increased with increasing biosolids but were far below phytotoxicity limits for turfgrass. Lead and Cr concentrations in biosolids-amended plots were comparable to concentrations in unamended sediments. Groundwater monitoring lysimeters and wells below the study site and near Lake Michigan were not affected by nutrients leaching from the amendments. Overall, the results from this case study demonstrated that blends of biosolids and dredged sediments could be successfully used for capping steel mill slag brownfield sites to establish good quality turfgrass vegetation.

Acute myocardial infarction in pregnancy: a statewide analysis.

OBJECTIVE: Acute myocardial infarction (AMI) during pregnancy and the puerperium is a rare but devastating event. The objective of this study was to describe the clinical and epidemiological features of pregnancy-related AMI. METHODS: A retrospective study was conducted using Texas hospital inpatient data (years 2004-2007). Diagnoses and procedures had been coded using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Adjusted odds ratios (OR) for hospital mortality and length of stay >4 days (prolonged length of stay [PLOS]) were calculated using logistic regression with Firth's bias correction and multiple imputation. RESULTS: 103 women with pregnancy-related AMI were identified in the statewide hospital database (6.5 cases per 100,000 births). The prevalence of cardiomyopathy was 16.5%. Approximately 14% of the pregnancies were complicated by preeclampsia/eclampsia. A history of cocaine use was noted in 3 patients. Congestive heart failure was present in 18 patients (17.5%). Two patients had attempted suicide and 1 died in the hospital. The overall hospital mortality rate was 9.7%. Placement of coronary artery stents was the most common coronary revascularization procedure (11 patients or 10.7%). The adjusted hospital mortality OR for women 35-39 years old (versus 30-34 years old) was 6.29 (P = .07). Patients with preeclampsia were more likely to have PLOS than patients whose deliveries were not complicated by preeclampsia (OR, 3.84; P = .06). CONCLUSIONS: While AMI in pregnancy remains a rare occurrence, it is associated with significant morbidity and a high case-fatality rate.

Incidence of new onset atrial fibrillation in patients with permanent pacemakers and the relation to the pacing mode.

BACKGROUND: Atrial fibrillation is a relatively common arrhythmia often seen in patients with permanent pacemakers. In this study we aimed to assess the incidence of atrial fibrillation in patients whose pacemakers were programmed to pace in the right ventricle (VVI) and compared it with patients whose pacemakers were programmed in non-VVI mode(i.e. AAI or DDD). MATERIAL AND METHODS: Records of the patients with permanent pacemaker or implantable-cardioverter-defibrillator were evaluated and analyzed. These patients had regular periodic follow-up evaluation over the last 10 years. (January 1, 2002 to December 31, 2012). Patient demographic, pacemaker data, pacing mode, review and analysis of arrhythmia log for occurrence of new atrial fibrillation and echocardiographic findings for left atrial size, mitral regurgitation, were analyzed and recorded. Left atrial size was classified as mild, moderate or severe enlargement, depending on the left atrial dimension. RESULTS: Average age was 68 years. There was no gender predominance (51% male). Mean follow-up duration was 6 years and 3 months. Hispanic population represented the majority of the patients (65.4%). Majority of the devices (80.0%) were programmed as DDD pacing mode. Fifty-five patients (52.8%) did not develop atrial fibrillation. 85.7% of the patients paced in VVI-mode had atrial fibrillation while atrial fibrillation occurred in 37.4% among patients paced in non-VVI-mode. This difference was statistically significant (P<0.0001). CONCLUSIONS: Right ventricular pacing in a VVI mode was associated with higher incidence of atrial fibrillation, mitral regurgitation and left atrial enlargement. Non-VVI based pacing demonstrated lower incidence of new onset atrial fibrillation.

Pyridostigmine-induced high grade SA-block in a patient with myasthenia gravis.

PATIENT: Female, 70 FINAL DIAGNOSIS: SA block induced by pyridostigmine Symptoms: Asymptomatic Medication: Pyridostigmine Clinical Procedure: Pacemaker insertion Specialty: Electrophysiology. OBJECTIVE: Unusual clinical course. BACKGROUND: Myasthenia gravis requires a long-term treatment with a parasympathomimetic agent, which may result in bradycardia and asystole. Pharmacologic treatment with a reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH) and Methylprednisolone is seen to improve the muscular symptoms but may reinforce potential bradyarrhythmias. This potential side effect can be treated with the levo isomer of atropine, Hyoscyamine, or Glycopyrollate in an intact conduction system. CASE REPORT: A 70-year old Caucasian female patient with a family history of myasthenia gravis presented with mild weakness of the bilateral facial muscles, moderate dysarthria, dysphagia, diplopia predominantly on the right side and difficulty tracking ocular movements bilaterally. The treatment with pharmacological agents was initiated. Subsequently she developed asymptomatic bradycardia and SA-block. An improvement on Hyoscyamine failed to appear. A dual chamber pacemaker was placed. CONCLUSIONS: In symptomatic or asymptomatic bradycardia with significant high grade SA-block in patients with myasthenia gravis the insertion of a permanent pacemaker can be the definitive solution.

Effect of long-term application of biosolids for mine land reclamation on groundwater chemistry: nutrients and other selected qualities.

Leaching of nitrogen (N) and phosphorus (P) to groundwater can limit the land application of fertilizer, biosolids, and other soil amendments. Groundwater quality monitoring data collected over a 34-yr period at a 1790-ha site in Fulton County, Illinois, where strip-mined land was reclaimed with biosolids, were used to evaluate long-term impacts of biosolids on groundwater N, P, and other parameters. Seven strip-mined fields repeatedly treated with biosolids at 801 to 1815 Mg ha cumulative rate (equivalent to 24-55 dry Mg ha yr) between 1972 and 2004 were compared with another seven fields treated annually with chemical fertilizer at agronomic rates. Groundwater from wells installed in each of the fields and two public wells that served as background (reference) were sampled for 35 yr, monthly between 1972 and 1986 and quarterly between 1987 and 2006. Data show greater chloride (Cl), sulfate (SO) and electrical conductivity (EC) of groundwater from wells in biosolids fields than those in fertilizer fields. Also, groundwater nitrate N (NO-N) concentrations were greater in biosolids-amended fields than in fertilizer fields, but below regulatory limit of 10 mg L in Illinois Part 620 regulation. Conversely, groundwater P concentrations were consistently lower in biosolids than in chemical fertilizer wells throughout the 35-yr monitoring period. The study demonstrates that the repeated application of biosolids, even at higher than agronomic rate, would cause only minor nitrate increase and no P increase in groundwater.

Effects of long-term application of biosolids for mine land reclamation on groundwater chemistry: trace metals.

Data collected for 35 yr from a 1790-ha strip mine reclamation site in Fulton County, Illinois, where biosolids were applied from 1972 to 2004, were used to evaluate the impacts of long-term biosolids application on metal concentrations in groundwater. Groundwater samples were collected between 1972 and 2006 from wells installed in seven strip-mined fields treated with biosolids at cumulative loading rates of 801 to 1815 dry Mg ha and from another seven fields (also strip mined) treated with mineral fertilizer. Samples were collected monthly between 1972 and 1986 and quarterly between 1987 and 2004 and were analyzed for total metals. The concentrations of metals in groundwater were generally below regulatory limits. Lead, Cd, Cu, Cr, Ni, and Hg concentrations in groundwater were similar for the biosolids-amended and fertilizer-treated sites across all sampling intervals. Zinc concentration was increased by biosolids application only for samples collected before the 1993 promulgation of the USEPA 40 CFR Part 503 rule. Iron and Mn were the only metals that were consistently increased after biosolids application; however, Mn concentrations did not exceed the 10 mg L regulatory limits. Zinc, Cu, Cd, Pb, Fe, Al, and Mn concentrations in groundwater decreased with time, coupled with the change from pre-part 503 to post-Part 503 biosolids. The concentrations of other metals, including Ni, Cr, and Hg, did not increase in groundwater with the prolonged biosolids application. The study suggests that the long-term application of biosolids at high loading rates does not result in trace metal pollution of groundwater.

Effect of ferric chloride addition and holding time on gravity belt thickening of waste activated sludge.

Phosphorus removal using ferric chloride (FeCl3) addition was demonstrated at the Egan Water Reclamation Plant. Concurrently, sludge thickening performance problems occurred in the gravity belt thickeners (GBTs). Blinding problems and polymer demand change were attributed to FeCl3 and long sludge holding times. Laboratory tests were conducted to gain insight to the GBT problems. Sludge holding time effects before polymer conditioning and thickening and prolonged contact of the solids with FeCl3 were evaluated via modified time-to-filter and blinding tests developed for this study. The tests assessed the sludge filterability under polymer and FeCl3 conditioning treatments and varying sludge holding and FeCl3 contact times. It was determined that fresh sludge was the easiest to thicken compared with sludge stored for any length of time. The FeCl3 improved thickening; however, when both the FeCl3 and polymer were used as conditioners, higher FeCl3 concentrations resulted in thickening inhibition compared with polymer alone.

Levels of dioxins in soil and corn tissues after 30 years of biosolids application.

Detectable levels of dioxins have been reported in biosolids, but very little information is available on the effect of long-term application of biosolids on dioxins accumulation in soil and uptake by plants. We analyzed dioxins in soil and corn tissue samples from field plots after 30 continuous applications of biosolids at 0 (Control), 16.8, and 67.2 Mg biosolids ha(-1) yr(-1) resulting in 0, 504, and 2016 Mg ha(-1) cumulative loadings of biosolids, respectively. The levels of dioxins in soil were only 79.9, 115.5, and 247.5 ng toxic equivalents (TEQs) kg(-1) in the 0, 504, and 2016 Mg biosolids ha(-1) plots, respectively. Dioxins were not detected in the corn grain, and only trace levels (6.8-7.5 ng TEQs kg(-1)) were found in the corn stover; however, these values were not statistically different between control and biosolids-amended soils. These observations suggest that although long-term application of biosolids may increase the levels of dioxins in soil, it does not affect dioxins uptake by corn.