BEAT-IT: A de-novo cardiac screening programme in Maltese adolescents.

AIMS: Sudden cardiac death (SCD) in young individuals is often unexpected, provoking substantial emotional stress for family and friends of the deceased. Cardiac screening may identify individuals who harbour disorders linked to SCD. The feasibility and diagnostic yield of a nationwide cardiac screening programme in adolescents has never been explored. METHODS: All individuals eligible for cardiac screening (students aged 15 years) were systematically invited to enrol. Students were provided with a health questionnaire. ECGs were acquired at school. A physician led consultation was carried out on site. Participants with an abnormal screen were then referred for secondary evaluation to the nation's tertiary centre. Feasibility criteria included a) participation rate >60%, b) adherence to secondary evaluation >80%, and c) cost per individual screened equating to <€100. The diagnostic yield was also evaluated. RESULTS: At the end of enrolment, 2708 students gave consent (mean 15 years, 50.4% male), equating to 67.9% of the eligible cohort. Overall, 109 participants (4.0%) were referred for further evaluation. An abnormal electrocardiogram (ECG) was the most common reason for referral (3.7%). Fifteen individuals (0.6%) were diagnosed with a cardiac condition. Nine (0.3%) had a condition linked to SCD (n = 1 Long-QT syndrome, n = 1 Hypertrophic Cardiomyopathy, n = 5 Wolff-Parkinson White, n = 2 coronary anomalies). The yield was similar in athletes and non-athletes (p = 0.324). The cost per cardiac individual screened equated to €51.15. CONCLUSION: A nationwide systematic cardiac screening programme for adolescent athletes and non-athletes is feasible and cost-efficient, provided that responsible centres have the appropriate infrastructure.

Native T1 and T2 reference values for maltese healthy cohort.

Cardiac Magnetic Resonance (CMR) is increasingly being used for diagnosing various cardiac conditions. Parametric mapping enables quantitative myocardial characterization by directly measuring myocardial T1 and T2 values. However, reference values of parametric mapping are not standardized across different vendors and scanners, causing drawbacks for clinical implementation of this technique across different sites. We assessed the reference ranges of native T1 and T2 values in a healthy Maltese cohort to establish a local parametric mapping service. Healthy subjects [n = 51; mean age 36.0 (range 19-59) years] with normal cardiac function on CMR were recruited. Subjects underwent uniform parametric mapping pulse sequences [MOLLI 5b(3b)3b for native T1 mapping, and gradient echo single shot FLASH readout for T2 mapping] on a 3 T Siemens MAGNETOM Vida scanner. Native T1 and T2 values were measured by placing a region of interest within the interventricular septum at midventricular level. Intra- and inter-observer variability were assessed using Bland-Altman plots. Mean ± 1.96 SD was used as a reference range. Mean native T1 and T2 values were 1200.1 ± 30.7 ms and 39.5 ± 1.8 ms, respectively. There was no significant bias in repeated measurements by the same and different observers. For the first time in Malta, we established the native T1 and T2 parametric mapping reference values for healthy Caucasian Maltese individuals. This will assist cardiologists to establish diagnosis, disease progression, and response to treatment of various myocardial diseases locally.

The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT).

BACKGROUND: Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain. AIM: This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years. METHODS: Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V1-V2 or extended TWI (V1-V3/4). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance. RESULTS: The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months). CONCLUSION: Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.

A review article of the cardiovascular sequalae in esport athletes: A cause for concern?

The esports industry has grown exponentially and is expected to flourish rapidly in the coming years. Awareness about the cardiovascular sequalae in elite esports athletes has gained considerable momentum. Evidence supporting systematic screening in esports athletes is however lacking. In this narrative review, we discuss potential negative health effects on the cardiovascular system in esports enthusiasts. The pathophysiological mechanisms discussed in this narrative review may put esports athletes at an increased risk of cardiovascular events. Although large studies in esports athletes to substantiate these claims are inexistent, case reports or case-controlled studies have been included to support our hypotheses. Sleep deprivation, psychological stress, altered arterial stiffness, hypertension, and heart rate variability are some of these proposed mechanisms. The available data are unfortunately extrapolated from small cohorts. Nevertheless, the risk of sudden cardiac death is an important health concern, which should be addressed appropriately. This review will raise awareness about the possible negative impact on the cardiovascular system in esports athletes.

Case report of Campylobacter jejuni-associated myopericarditis: rare case of cardiac involvement by a common gastroenteritis pathogen.

BACKGROUND: Myocarditis is caused by inflammation affecting the heart muscle. The usual aetiological factor is viral, especially in immunocompetent hosts and developed countries. Campylobacter jejuni is a common cause of bacterial gastroenteritis but has rarely been associated with myocarditis. CASE SUMMARY: We report a case of a 22-year-old male admitted with pleuritic chest pain and a diarrhoeal illness. Thorough evaluation of the patient history did not reveal any sources for contracting the diarrhoea. Stool cultures confirmed that the patient had C. jejuni infection as well as myopericarditis confirmed on cardiac magnetic resonance imaging (cardiac MRI). Treatment with colchicine 0.5 mg BD, ibuprofen 600 mg TDS, and ciprofloxacin 500 mg BD orally for 5 days was started, together with an intravenous infusion of 0.9% normal saline 1 L TDS. The patient showed signs of improvement over a span of three days and the ST changes on electrocardiogram resolved. DISCUSSION: Although C. jejuni-associated myopericarditis is uncommon, it can be potentially life-threatening if not considered in the differential. Its diagnosis involves good history taking, examination, and investigation with electrocardiography, troponins and inflammatory markers, echocardiography, and cardiac MRI. Several mechanisms of infection have been suggested, including direct insult by toxin or bacterium as well as an immune-mediated response. Both supportive and causative treatments are important to ensure recovery while reducing the risk of complications. It is therefore crucial to ensure that the patient receives adequate follow-up to ascertain patient progress and to mitigate any complications that may arise as well as tackle patient concerns. The patient had a rapid recovery.

Predictors of yearly influenza vaccination in hospitalized and community based patients.

BACKGROUND: Understanding positive and negative influences on adult immunization status can help healthcare providers to better identify and target patients who are likely to need immunization. Our aim was to assess and compare influenza and pneumococcal (IV/PV) immunisation rates to identify vaccination predictors in Malta. METHOD: One group consisted of all medical patients discharged from Mater Dei Hospital (MDH) over a one week period in February 2013. Patients were administered a phone questionnaire. A second group of patients receiving community-based care at local health centres over a one week period in March 2013 were interviewed, identifying vaccination eligibility as per 2010 WHO recommendations. RESULTS: A total of 150 community (Mean age 61.5 SD 15.8, Male 60%) and 149 hospitalised (Mean age 66.8, SD 13.6%, Male 48.3%) patients in whom influenza vaccine was indicated were recruited. In the current year, 44 and 48.3% received the seasonal influenza vaccine, while 32.0, and 49% vaccinated yearly respectively. Pneumococcal vaccination advice was less than 5% in both groups. On stepwise binary regression, vaccination predictors for the current year were regular yearly influenza vaccination (OR 93.62, CI: 31.8-275.5, p < 0.001) and vaccination reminders (OR 27.5, CI: 9.63-78.31, p < 0.001). Nursing home residence (OR 5.78, CI: 1.22-27.4,p = 0.011), congestive cardiac failure (OR 2.11, CI: 1.1-4.08, p = 0.02) and diabetes mellitus (OR 1.68, CI: 1.04-2.72, p = 0.034) were all predictors for vaccination on exclusion of the strongest two predictors. For successive yearly vaccination, influenza vaccine recommendation by healthcare professionals (OR 12.35, CI: 4.5-33.91, p < 0.001) and vaccination reminders (OR 5.99, CI: 3.13-11.45, p < 0.01) were main predictors. Congestive cardiac failure (OR 2.37, CI: 1.20-4.7, p = 0.13) and nursing home residence (OR 7.07, CI: 1.45-34.5, p = 0,005) were also positive predictors. Male gender was a negative predictor (OR 0.51, CI: 0.31-0.83, p = 0.006). Some of those who did not vaccinate were unaware of such need (40.5% of community and 15.6% of hospitalised patients). CONCLUSIONS: Just under half of the patient population received the IV during 2012-2013 period. Hospitalized patients are more likely to vaccinate regularly while a large proportion of community patients are unaware of the indication to vaccinate.

Structure of russellite (Bi2WO6): origin of ferroelectricity and the effect of the stereoactive lone electron pair on the structure.

The structure of the low-temperature polar (orthorhombic) phase of russellite (Bi2WO6) was examined on artificial specimens with precise single-crystal X-ray diffraction experiments. The final atomic arrangement thus obtained was identical to that reported by Knight [Miner. Mag. (1992), 56, 399-409] with powder neutron diffraction. The residual density attributable to a stereochemically-active lone pair of electrons of bismuth was prominent at approximately the centre of a larger cap of BiO8 square antiprisms, that is on the line from the Bi sites to an adjacent WO42- slab along the b-axis direction. Quite uneven Bi-O distances and the formation of a vacant coordination hemisphere (within 3 Å) should, therefore, be ascribed to the strong demand of bismuth to form shorter Bi-O bonds to use up its electrostatic charge within its coordination environment. The shift of bismuth along -c propagates via the correlated shift of the W site and these cooperative shifts cause ferroelectricity in the compound. This propagation was easily effected by the intrusion of molecules such as acetone into the structure.

Squamous cell carcinoma of unknown origin metastasising to the right atrium causing acute heart failure.

We describe a case of metastasis to the heart, which was initially suspected to be a myxoma, causing acute right heart failure. Emergency surgery was carried out by opening the right atrium and superior vena cava, and debulking the tumour in a piecemeal fashion, providing temporary relief of symptoms. The histology showed this to be metastatic squamous cell carcinoma possibly of head and neck origin. This is extremely rare, with few published cases. Full endoscopic and CT, including positron emission tomography CT, investigation of the head and neck was performed with no primary findings. Only two such cases of squamous cell carcinoma of unknown origin metastasising to the heart have been described, and, in both cases, the patients died within several weeks of diagnosis. This patient remains alive 2 months postoperatively and is receiving radiotherapy to the chest, but his prognosis remains poor.