Electromagnetic interference to infusion pumps. Update2008 from GSM mobile phones

Electromagnetic interference (EMI) to critical care medical devices has been reported by various groups. Previuos study demonstrated that infusion pumps are susceptible of false alarm buzzing and block of infusion, when exposed to various EMI sources. Aim of this paper is to investigate the changes in the risk of EMI from the estimates of our previous 2005 survey and to extend the EMI risk assessment to newer telecommunication products: DECT phones and WiFi terminals. With regards to GSM phones, compare to the results obtained in 2005, we observed a decrease in the rate of failure (from 58% to 30%). From our findings, the use of WiFi and DECT does not pose a real risk to infusion systems.

Efficient isolation of the subunits of recombinant and pituitary glycoprotein hormones

Complete dissociation into subunits was attained by incubating Chinese hamster ovary (CHO)-derived or native human thyrotropin, follitropin and lutropin overnight at 37 degrees C in acetic acid. The alpha-and beta-subunits of the pituitary glycoprotein hormones were rapidly and quantitatively isolated by reversed-phase high-performance liquid chromatography (RP-HPLC). A dissociation efficiency of > 98% was obtained on the basis of mass determinations of the heterodimers and subunits carried out via mass spectrometry. CHO-derived or native subunits were isolated on a C4 column (80-90% total recovery) and characterized comparatively for purity, hydrophobicity, molecular mass and charge distribution by HPLC, mass spectrometry, sodium dodecylsulfate-polyacrylamide gel electrophoresis and isoelectric focusing. Thyrotropin was used as a model for showing that, after subunit reassociation, the in vivo bioactivity of the hormone was completely restored. The method described is mild, practical, flexible, and can be adapted to dissociate microgram amounts of native or recombinant glycoprotein hormones, allowing characterization of each subunit.

Radiofrequency dosimetry in subjects implanted with metallic straight wires: a numerical study

A numerical study to investigate the effects of the exposure to electromagnetic fields (EMF) at 900 and 1800 MHz on biological tissues implanted with thin metallic structures has been carried out, using the finite difference time domain (FDTD) solution technique. The results of the model show that the presence of a metallic wire yields to a significant increase in the local specific energy absorption rate (SAR). The present standards and/or guidelines on safe exposures of humans to EMF does not cover persons with implanted devices and thus the threshold levels to define safe exposure conditions might not apply in presence of high SAR gradients, such as the ones generated by thin metallic implanted objects. However, exposure to EMF fields below the actual safe levels even in presence of thin conductive structures cause rather low temperature rises (1 degrees C).

Analysis of a heterodyne-detected transient-grating experiment on a molecular supercooled liquid. I. Basic formulation of the problem

We present the basic equations necessary to interpret heterodyne-detected transient-grating experiments performed on a supercooled liquid composed of anisotropic molecules. The final expressions are given under a form suitable for their direct application to a test case.

Analysis of a heterodyne-detected transient-grating experiment on a molecular supercooled liquid. II. Application to m-toluidine

This paper reports the first detailed analysis of a transient grating (TG) experiment on a supercooled molecular liquid, m-toluidine, from 330K (1.75Tg) to 190K (1.01Tg) based on the theoretical model presented in Paper I of this series. This method allows one to give a precise description, over a wide dynamical range, of the different physical phenomena giving rise to the signals. Disentangling the isotropic and the anisotropic parts of the TG response, a careful fitting analysis yields detailed information on the rotation-translation coupling function. We also extract the structural relaxation times related to the "longitudinal" viscosity over almost 10 decades in time and the corresponding stretching coefficient. The value of some other parameters and information on their thermal behavior is also reported.

Electromagnetic interference to infusion pumps from GSM mobile phones

Electromagnetic interference (EMI) to critical care medical devices has been reported by various groups. Previuos studies have demonstrated that infusion and syringe pumps are susceptible of false alarm buzzing and block, when exposed to various EMI sources. Whether these events may have clinical relevance is still debated. The risk of EMI depends on several factors such as phone emitted power, distance and carrier frequency. We investigated the EMI on infusion and siringe pumps from GSM phones at various distances and emitted powers. Malfunctions were observed in 4/7 infusion pumps and 1/4 syringe pumps exposed to mobiles at their maximum output, for distances as long as 30 cm. The maximum power not inducing any malfunction even at 0 cm distance was also determined. The selection of a proper maximum power class reduces significantly the risk of EMI. Such a function is already built in the GSM standard and thus represents one of the feasible solutions to the EMI problem in hospitals.

P-Wave Morphology Assessment by a Gaussian Functions-Based Model in Atrial Fibrillation Patients

Aim of this study was to present a P-wave model, based on a linear combination of Gaussian functions, to quantify morphological aspects of P-wave in patients prone to atrial fibrillation (AF). Five-minute ECG recordings were performed in 25 patients with permanent dual chamber pacemakers. Patients were divided into high-risk and low-risk groups, including patients with and without AF episodes in the last 6 mo preceding the study, respectively. ECG signals were acquired using a 32-lead mapping system for high-resolution biopotential measurement (ActiveTwo, Biosemi, The Netherlands, sample frequency 2 kHz, 24-bit resolution). Up to 8 Gaussian models have been computed for each averaged P-wave extracted from every lead. The P-wave morphology was evaluated by extracting seven parameters. Classical time-domain parameters, based on P-wave duration estimation, have been also estimated. We found that the P-wave morphology can be effectively modeled by a linear combination of Gaussian functions. In addition, the combination of time-domain and morphological parameters extracted from the Gaussian function-based model of the P-wave improves the identification of patients having different risks of developing AF.

Temperature and SAR measurement errors in the evaluation of metallic linear structures heating during MRI using fluoroptic probes

The purpose of this work is to evaluate the error associated with temperature and SAR measurements using fluoroptic temperature probes on pacemaker (PM) leads during magnetic resonance imaging (MRI). We performed temperature measurements on pacemaker leads, excited with a 25, 64, and 128 MHz current. The PM lead tip heating was measured with a fluoroptic thermometer (Luxtron, Model 3100, USA). Different contact configurations between the pigmented portion of the temperature probe and the PM lead tip were investigated to find the contact position minimizing the temperature and SAR underestimation. A computer model was used to estimate the error made by fluoroptic probes in temperature and SAR measurement. The transversal contact of the pigmented portion of the temperature probe and the PM lead tip minimizes the underestimation for temperature and SAR. This contact position also has the lowest temperature and SAR error. For other contact positions, the maximum temperature error can be as high as -45%, whereas the maximum SAR error can be as high as -54%. MRI heating evaluations with temperature probes should use a contact position minimizing the maximum error, need to be accompanied by a thorough uncertainty budget and the temperature and SAR errors should be specified.

Heart rate and blood pressure variability in patients implanted with rate-responsive pacemaker

Rate-responsive pacemakers (PMs) aim at having pacing rates as similar to physiological cardiac rhythms as possible. The pacemaker INOS(2+)-CLS (Biotronik, Germany) implements a closed loop strategy (CLS) based on indirect measures of right ventricle contractility using intracardiac impedance signal. The contractility is, in turn, related to the autonomic nervous system control to the heart. Aim of this study was to evaluate the 24h beat-to-beat heart rate and blood pressure profiles in patients implanted with CLS rate adaptive PM. 24h ECG and arterial pressure waveform acquisition were performed by a digital Holter system by the Portapres equipment, respectively. A proper-designed algorithm was developed to classify PM pacing modalities. For each beat we estimated the heart rate (HR), and the systolic and diastolic pressure values (SP, DP). So far, 6 patients have been studied: 4 patients have been analyzed both with and without rate responsive modalities (DDD-R and DDD, respectively); 2 patients have been studied only with rate-responsive modality. Results obtained in 6 patients show that this rate adaptive PM accurately preserve the heart rate and blood pressure variability throughout the 24h. In particular, the rate adaptation of PM based on impedance measurements succeeds in maintaining the spontaneous HR, SP and DP on a beat-to-beat basis.

Physico-chemical and biological characterizations of two human prolactin analogs exhibiting controversial bioactivity, synthesized in Chinese hamster ovary (CHO) cells

The synthesis, purification and characterization of G129R-hPRL and S179D-hPRL, the two better-studied antagonists of human prolactin (hPRL), is described. Both of these have been expressed for the first time, in their authentic form, by a stable CHO cell line, at secretion levels of 7.7 and 4.3 microg/10(6) cells/day, respectively. Previous studies had shown that these hPRL analogs, when produced in bacterial cytoplasm, consistently contained misfolded forms and multimers according to the specific denaturation, refolding and purification conditions. These versions also have an N-terminal extra methionine. An extensive physico-chemical characterization was carried out after a practical two-step purification process and included SDS-PAGE and Western blotting analysis, matrix-assisted laser-desorption ionization time-of-flight mass spectral (MALDI-TOF-MS) analysis, high-performance size-exclusion chromatography (HPSEC) and reversed-phase high-performance liquid chromatography (RP-HPLC). This last technique revealed a considerable difference in hydrophobicity due to a single amino acid substitution, with S179D-hPRL less (t(RR) = 0.85 +/- 0.010) and G129R-hPRL more (t(RR) = 1.10 +/- 0.013) hydrophobic than hPRL, where t(RR) is the relative retention time. The biological characterization was based on further refinement of a sensitive proliferation assay using the pro-B murine cell line (Ba/F3) transfected with the long form hPRL receptor cDNA such that the minimal detectable dose was 0.04 ng of hPRL/mL, the Ba/F3-LLP assay. On the basis of this assay, the relative residual agonistic activity of these two products, determined against a hPRL international standard in four independent assays, was 53 x 10(-3) for S179D-hPRL and 70 x 10(-5) for G129R-hPRL. We believe that the present synthesis and characterization could be extremely helpful for studies of these two proteins, which have been reported to antagonize tumor growth-promoting effects of hPRL in vivo in animal models of breast and prostate cancer.

Evaluation of Electromagnetic Interference of GSM Mobile Phones with Pacemakers Featuring Remote Monitoring Functions

The aim of this study was to evaluate whether global system for mobile communication (GSM) cellular phones can affect the home monitoring (HM) function implemented in last generation pacemakers (PM).

METHODS

We performed in vitro and in vivo tests on the BA03 PM (Biotronik GmbH, Berlin, Germany). In vitro we evaluated whether an improper HM procedure or an altered patient-activated HM function occurred. We used two cellular phone models, with a fixed external or internal antenna, positioned close to both the PM and the mobile phone-like device, during handover, ringing, and talking. All the tests were done with the PM in air, at 900 and 1,800 MHz GSM bands, under worst case conditions. A subset of these tests was repeated in 17 patients: the mobile phones were moved both around the PM implant site and the mobile cell phone-like device, during talking.

RESULTS

In vitro, neither the HM procedure nor PM functioning were corrupted by the GSM communications: all the transmissions were correctly received, with a maximum transmission delay of about 110 seconds. In vivo, the rate of successful transmissions was 93%.

CONCLUSION

Our data show that HM function does not call for specific restrictions on the use of GSM cellular phones.

Morphological analysis of P-wave in patients prone to atrial fibrillation

Aim of this study was to present a P-wave model, based on a linear combination of Gaussian functions, to quantify morphological aspects of Pwave in patients prone to atrial fibrillation. Five minutes ECG recordings were performed in 25 patients with permanent dual chamber pacemakers set at 40/min in order to have spontaneous beats. ECG signals were acquired using a 32-lead mapping system for high-resolution biopotential measurement (ActiveTwo, Biosemi, The Netherlands, sample frequency 2 kHz, 24 bit resolution). Four healthy subjects were also recorded as a control group. Up to 8 Gaussian models have been computed for each averaged P-wave extracted from every lead. The P-wave morphology is then evaluated by the following parameters: best model orders @ degrees of freedom adjusted R-square (AdjRsq) =97.5%; minimum (sigmamin) and maximum (sigmamax) standard deviation of the Gaussians included in the model, number of relative maxima and minima (max+min), and zeroes of the fit. Significant differences in the best model order were obtained between the control group and patients group. Accordingly, the number of relative maxima and minima was higher in the patient group. These parameters might all be markers of the fractionated electrical activity that characterizes paroxysmal AF patients in sinus rhythm.

MRI induced heating of pacemaker leads: effect of temperature probe positioning and pacemaker placement on lead tip heating and local SAR

The radio frequency field used in magnetic resonance imaging (MRI) procedures leads to temperature and local absorption rate (SAR) increase for patients with implanted pacemakers (PM). In this work a methodological approach for temperature and SAR measurements using fluoroptic probes is presented. Experimental measures show how the position of temperature probes affects the temperature and SAR value measured at the lead tip. The transversal contact between the active portion of the probe and the lead tip is the configuration associated with the highest values for temperature and SAR, whereas other configurations may lead to an underestimation close to 11% and 70% for temperature and SAR, respectively. In addition measurements were performed on a human-shaped phantom inside a real MRI system, in order to investigate the effect of the PM placement and of the lead geometry on heating and local SAR.

Effects of subthreshold shocks on wavelet propagation during atrial fibrillation in humans

OBJECTIVES

Our objectives are: first to investigate the effects of internal cardioversion energies on the wave fronts propagation in the right atrium immediately after the energy delivery; second, to track the time course of these effects.

METHODS

The study is based on a measure of organization of the endoatrial electrograms obtained by a multipolar basket catheter inserted in the right atrium. We estimated the level of organization by computing the percentage of points laying on the signal baseline (i.e., number of occurrences, NO). NO values were computed on two-second long windows. Six non-overlapped windows were selected, one just before and five just after the last unsuccessful shock.

RESULTS

Immediately after the shock most of the patients exhibited an increase in the organization patterns. This increase was more evident in those patients with rather disorganized patterns and higher energy threshold. This effect fades within a few seconds after the shock delivery.

CONCLUSIONS

Our data confirm the idea that the electrical shock causes a widespread extinction of electrical wavefronts, which regenerates after the shock. Since an increase of organization may lead to a reduction of energy threshold, a potential application of these findings might consist in the delivery of multiple subthreshold shocks instead of a single one.

Nonlinear Coupling Among Heart Rate, Blood Pressure, and Respiration in Patients Susceptible to Neuromediated Syncope

The aim of this study is to evaluate the degree of coupling between the cardiovascular variability series and the respiration in subjects susceptible to neurally mediated syncope. Twenty-one informed patients susceptible to syncope and ten sex- and age-matched control subjects were enrolled in the study. ECG, respiration activity, and arterial blood pressure were simultaneously recorded at rest (controlled and free breathing) and during the 70 degrees head-up TILT test (free breathing). The degree of nonlinear coupling among heart rate variability (HRV), blood pressure variability (BPV), and respiration was quantified by means of two indices according to a multivariate embedding-based approach. Eleven patients developed syncope during the TILT test. We found that during the late TILT phase, the TILT-positive group experienced a significant increase in nonlinear coupling respect to the mid TILT phase (p < 0.01, Wilcoxon nonparametric test for pair data) while the TILT-negative group did not (p < 0.01, Mann-Whitney U-test). If the proposed nonlinear coupling indexes can be considered expression of the coupling mechanisms involved in the vagal regulation of the cardiovascular system, an increase in vagal tone accompanied by a decrease in sympathetic activity seem to occur before a vasovagal event.

A novel heart/trunk simulator for the study of electromagnetic interference with active implantable devices

This paper describes a portable heart simulator for the study of electromagnetic interference with active implantable devices. The simulator consists of plexiglas box divided into three chambers simulating the left atrium and the ventricles, plus a lateral compartment for the implantable device. The box is linked to a laptop computer by an analogue-to-digital convertor board, and the three chambers are monitored and driven by dedicated hardware and software interfaces. Synthetic endocardial atrial and ventricle signals for 13 cardiac rhythms are stored in the computer. They are applied to the cardiac chambers by AgCl plates. Sensing electrodes are in the form of AgCl needles inserted in saline. The simulator was able to demonstrate the behaviour of three pacemakers tested in the absence and presence of electromagnetic interference, generated by mobile phones (European GSM 900 and 1800 MHz) that emitted up to 2W (1 W at 1800 MHz). Pacemakers can be programmed with sensitivity from 0.1 mV to 5 mV, pulse width from 0.1 ms to 1.5 ms and pulse amplitude from 0.5 V to 5 V. The structural separation in three cardiac chambers (plus the one for the device) allowed a fast analysis procedure for dual- and tri-chamber implantable devices.

On the mechanisms of interference between mobile phones and pacemakers: parasitic demodulation of GSM signal by the sensing amplifier

The aim of this study was to investigate the mechanisms by which the radiated radiofrequency (RF) GSM (global system for mobile communication) signal may affect pacemaker (PM) function. We measured the signal at the output of the sensing amplifier of PMs with various configurations of low-pass filters. We used three versions of the same PM model: one with a block capacitor which short circuits high-frequency signals; one with a ceramic feedthrough capacitor, a hermetically sealed mechanism connecting the internal electronics to the external connection block, and one with both. The PMs had been modified to have an electrical shielded connection to the output of the sensing amplifier. For each PM, the output of the sensing amplifier was monitored under exposure to modulated and non-modulated RF signals, and to GSM signals (900 and 1800 MHz). Non-modulated RF signals did not alter the response of the PM sensing amplifier. Modulated RF signals showed that the block capacitor did not succeed in short circuiting the RF signal, which is somehow demodulated by the PM internal non-linear circuit elements. Such a demodulation phenomenon poses a critical problem because digital cellular phones use extremely low-frequency modulation (as low as 2 Hz). which can be mistaken for normal heartbeat.

Experimental studies of the ortho-toluidine glass transition

The thermodynamic and dynamics proprieties of ortho-toluidine, in the vicinity of a glass transition, have been studied by calorimetric and by two light scattering techniques, depolarized light scattering and time-resolved optical Kerr effect. Differential scanning microcalorimetry clearly detects a glass transition in o-toluidine and it measures some thermodynamics critical parameters, in particular, the transition temperature. The light scattering data have been analyzed according to the mode-coupling theory. This theory gives a good interpretation of our data and it allows to extract safely the critical parameters of the o-toluidine dynamics. We found a fair agreement between the analysis outputs performed in the frequency domain and in the time domain. Finally, we compared the glass transition features of o-toluidine with that of its isomer meta-toluidine, looking for some general idea about the molecular aspects of the glass transition.