Impact on Health-Related Quality of Life of Induction Chemotherapy Compared With Concurrent Cisplatin and Radiation Therapy in Patients With Head and Neck Cancer.

AIMS: Organ preservation, an important goal in the treatment of head and neck squamous cell carcinoma (HNSCC), may include induction chemotherapy and cisplatin with radiation therapy (CRT). To our knowledge, no reports have directly compared the impact of induction chemotherapy with that of CRT on health-related quality of life (HRQOL). MATERIALS AND METHODS: In a phase II trial, we assessed the HRQOL of patients treated with induction chemotherapy followed by CRT. Eligible patients had stage III-IV HNSCC. HRQOL questionnaires were administered at baseline, the end of induction (EOI), the end of CRT (EOCRT) and after CRT. Functional Assessment of Cancer Therapy (FACT version 4) assessed HRQOL. We carried out a comparison of changes in HRQOL from baseline to EOI and from EOI to EOCRT. This trial is registered with ClinicalTrials.gov (NCT01566435). RESULTS: Thirty patients were enrolled in the study. Most HRQOL questionnaires were completed (88%). The mean total FACT scores did not differ from baseline to EOI (general: 83.8 versus 79.1, P = 0.08; head and neck: 109.7 versus 105.8, P = 0.33; Total Outcome Index: 69.7 versus 62.3, P = 0.03; respectively, using P ≤ 0.01 to adjust for multiple simultaneous tests of differences). However, total FACT scores significantly worsened from EOI to EOCRT (79.1 versus 62.3, P = 0.01; 105.8 versus 74.2, P < 0.01; 62.3 versus 34.2, P = 0.01; respectively). Within domains, the head and neck cancer subscale score did not differ from baseline to EOI (median 28.5 versus 27.0, P = 0.69), but significantly worsened from EOI to EOCRT (27.0 versus 9.5, P < 0.01). Swallowing, oral pain and voice quality improved from baseline to EOI, but worsened from EOI to EOCRT. Physical and functional scores worsened from baseline to EOI and from EOI to EOCRT. The emotional well-being score improved from baseline to EOI but worsened from EOI to EOCRT. CONCLUSIONS: Overall, HRQOL did not significantly change from baseline to EOI but dramatically worsened from EOI to EOCRT.

The role of oral hygiene in head and neck cancer: results from International Head and Neck Cancer Epidemiology (INHANCE) consortium.

BACKGROUND: Poor oral hygiene has been proposed to contribute to head and neck cancer (HNC) risk, although causality and independency of some indicators are uncertain. This study investigates the relationship of five oral hygiene indicators with incident HNCs. METHODS: In a pooled analysis of 8925 HNC cases and 12 527 controls from 13 studies participating in the International Head and Neck Cancer Epidemiology Consortium, comparable data on good oral hygiene indicators were harmonized. These included: no denture wear, no gum disease (or bleeding), <5 missing teeth, tooth brushing at least daily, and visiting a dentist ≥once a year. Logistic regression was used to estimate the effects of each oral hygiene indicator and cumulative score on HNC risk, adjusting for tobacco smoking and alcohol consumption. RESULTS: Inverse associations with any HNC, in the hypothesized direction, were observed for <5 missing teeth [odds ratio (OR) = 0.78; 95% confidence interval (CI) 0.74, 0.82], annual dentist visit (OR = 0.82; 95% CI 0.78, 0.87), daily tooth brushing (OR = 0.83, 95% CI 0.79, 0.88), and no gum disease (OR = 0.94; 95% CI 0.89, 0.99), and no association was observed for wearing dentures. These associations were relatively consistent across specific cancer sites, especially for tooth brushing and dentist visits. The population attributable fraction for ≤ 2 out of 5 good oral hygiene indicators was 8.9% (95% CI 3.3%, 14%) for oral cavity cancer. CONCLUSION: Good oral hygiene, as characterized by few missing teeth, annual dentist visits, and daily tooth brushing, may modestly reduce the risk of HNC.

Vitamin E intake from natural sources and head and neck cancer risk: a pooled analysis in the International Head and Neck Cancer Epidemiology consortium.

BACKGROUND: Evidence for the possible effect of vitamin E on head and neck cancers (HNCs) is limited. METHODS: We used individual-level pooled data from 10 case-control studies (5959 cases and 12 248 controls) participating in the International Head and Neck Cancer Epidemiology (INHANCE) consortium to assess the association between vitamin E intake from natural sources and cancer of the oral cavity/pharynx and larynx. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using unconditional logistic regression models applied to quintile categories of non-alcohol energy-adjusted vitamin E intake. RESULTS: Intake of vitamin E was inversely related to oral/pharyngeal cancer (OR for the fifth vs the first quintile category=0.59, 95% CI: 0.49-0.71; P for trend <0.001) and to laryngeal cancer (OR=0.67, 95% CI: 0.54-0.83, P for trend <0.001). There was, however, appreciable heterogeneity of the estimated effect across studies for oral/pharyngeal cancer. Inverse associations were generally observed for the anatomical subsites of oral and pharyngeal cancer and within covariate strata for both sites. CONCLUSION: Our findings suggest that greater vitamin E intake from foods may lower HNC risk, although we were not able to explain the heterogeneity observed across studies or rule out certain sources of bias.

Outcomes of seafarer work fitness qualifications in the Netherlands.

BACKGROUND: Seafaring is a dangerous profession involving high fatality rates and little research has been done to identify conditions that may lead to failing the seafarer's medical qualification (SMQ). AIMS: To determine the proportion of seafarers failing to pass the SMQ in the Netherlands during 2012, to analyse the outcomes of the SMQ according to qualification, age, duties and requirements of additional evaluations and to describe the reasons for considering a seafarer unfit for duty. METHODS: A retrospective descriptive study of SMQs registered in the Netherlands Shipping Inspectorate database. RESULTS: Less than 1% (46 cases; 0.6%) of the 7617 final SMQ candidates were considered unfit for duty with 53% (24) of these being temporarily unfit. Four per cent (276) of cases were classified 'fit with restrictions' and 1% (66) 'fit by exemption' (FEx). Re-examination was required in 2% (122) of cases. A second opinion from a medical referee was sought in 4% of cases. The highest rate of FEx was found in older seafarers (aged over 55) due to restrictions in hearing and vision in the majority (59%) of cases. The leading causes of unfitness were other medical reasons, mainly associated with cardiovascular conditions and morbid obesity, in 52% of cases and visual impairment in 34%. CONCLUSIONS: The proportion of seafarers considered unfit in the SMQ carried out in the Netherlands in 2012 is relatively low. The proportion of FEx was higher in older groups, mainly due to hearing or visual impairments.

Quality of life after management of advanced osteoradionecrosis of the mandible.

Osteoradionecrosis (ORN) of the mandible is a severe complication of radiation therapy for head and neck cancer. In this case series, the authors analyzed their treatment and quality of life outcomes over the past 6 years. A retrospective chart review of 42 patients treated surgically for advanced ORN was conducted. A telephone survey was conducted and quality of life (QOL) questionnaires were completed in a subset of patients. 30 patients responded to the telephone survey assessing QOL for speech, swallowing and overall functioning correlated with oral nutrition and performance status. Surgery for ORN can result in an improved QOL. Functional outcomes of oral intake, speech intelligibility, and eating in public correlated with patient rated QOL measures. A lack of improvement in QOL, despite the restoration of an intact mandible, relates to the persistent effects of chemoradiotherapy.

[Early prediction of severity in acute pancreatitis]. / Predicción precoz de severidad en pancreatitis aguda.

OBJECTIVE: To identify the score that best predicts early severity in patients with acute pancreatitis. MATERIALS AND METHODS: A prospective cohort study was performed from December 2009 to December 2011. Cases of pancreatitis were classified as mild or severe based on the organ failure criteria and/or local complications according to the Atlanta Symposium. APACHE-II, BISAP and urea were calculated using data from the first 24 hours. Ranson was calculated using data from the first 48 hours. Hemoconcentratión was assessed 24 hours from admission, after adequate hydration. To assess the predictive value of the different scores the area under the curve ROC was used. RESULTS: 329 patients with acute pancreatitis were included: 214 women (65%) and 115 males (35%). The most common etiology was biliary 245 (74.3%). Two hundred and forty were mild cases of pancreatitis (73%) and 89 were severe (27%). The areas under the curve ROC were: APACHE-II: 0.74; BISAP: 0.78; Ranson: 0.48; urea: 0.70; hemoconcentratión: 0.73. There were 10 deaths (mortality: 3%). There were no significant differences between BISAP and APACHE-II, urea or hemoconcentration, but a significant difference existed with Ranson score. CONCLUSION: BISAP is a simple score that applied early in the emergency room identifies patients with severe pancreatitis with an efficacy similar to APACHE-II, urea and hemoconcentration, and KEY WORDS: acute pancreatitis, BISAP, severity, prognostic scoring.

Predicción precoz de severidad en pancreatitis aguda / Early prediction of severity in acute pancreatitis

OBJETIVO: Identificar el indicador que mejor predice la severidad en forma temprana en pacientes con pancreatitis aguda. MATERIALES Y MÉTODOS: Se realizó un estudio de cohorte prospectiva entre diciembre del 2009 y diciembre del 2011. Se clasificó los cuadros de pancreatitis aguda en leve y severa en base a los criterios de falla orgánica o complicaciones locales según el Simposio de Atlanta. Los indicadores de APACHE-II, BISAP y urea fueron calculados usando los datos de las primeras 24 horas de admisión. El indicador de Ranson se calculó con datos de las primeras 48 horas. La hemoconcentración se calculó a las 24 horas de la admisión después de una adecuada hidratación. Para evaluar la capacidad predictiva de los diferentes indicadores se utilizó el área bajo la curva ROC. RESULTADOS: Ingresaron al estudio 329 pacientes con pancreatitis aguda: doscientos catorce mujeres (65%) y 115 varones (35%). La etiología más frecuente fue la biliar 245 (74.3%). Doscientos cuarenta fueron pancreatitis leves (73%) y 89 pancreatitis severas (27%). Las áreas bajo la curva ROC de los indicadores fueron: APACHE-II: 0.74; BISAP: 0.78; Ranson: 0.48; urea: 0.70; hematocrito a las 24 horas: 0.73. Se registraron 10 muertes (mortalidad: 3%). No se observó diferencias significativas del indicador BISAP con el indicador de APACHE-II, con la urea ni la hemoconcentración, pero sí con el puntaje de Ranson. CONCLUSIÓN: BISAP es un score sencillo que aplicado tempranamente en la emergencia identifica pacientes con cuadro clínico severo con eficacia similar al APACHE-II, urea y hemoconcentración; y mejor que Ranson.

OBJECTIVE: To identify the score that best predicts early severity in patients with acute pancreatitis. MATERIALS AND METHODS: A prospective cohort study was performed from December 2009 to December 2011. Cases of pancreatitis were classified as mild or severe based on the organ failure criteria and/or local complications according to the Atlanta Symposium. APACHE-II, BISAP and urea were calculated using data from the first 24 hours. Ranson was calculated using data from the first 48 hours. Hemoconcentratión was assessed 24 hours from admission, after adequate hydration. To assess the predictive value of the different scores the area under the curve ROC was used. RESULTS: 329 patients with acute pancreatitis were included: 214 women (65%) and 115 males (35%). The most common etiology was biliary 245 (74.3%). Two hundred and forty were mild cases of pancreatitis (73%) and 89 were severe (27%). The areas under the curve ROC were: APACHE-II: 0.74; BISAP: 0.78; Ranson: 0.48; urea: 0.70; hemoconcentratión: 0.73. There were 10 deaths (mortality: 3%). There were no significant differences between BISAP and APACHE-II, urea or hemoconcentration, but a significant difference existed with Ranson score. CONCLUSION: BISAP is a simple score that applied early in the emergency room identifies patients with severe pancreatitis with an efficacy similar to APACHE-II, urea and hemoconcentration, and better than Ranson.

Factores Asociados a la Infección por Hepatitis C en casos Incidentes en Hemodiálisis Crónica / Factors associated with Hepatitis C infection in patients with chronic hemodyalisis

ANTECEDENTES: La infección por hepatitis C (HCV) es un problema relevante en pacientes tratados con hemodiálisis crónica en el Perú. Se ha referido en estudios previos que lastransfusiones de sangre y el tiempo en hemodiálisis han sido identificados como factores de riesgo. OBJETIVO: Estudiar otros factores probables asociados a la infección por el virus de hepatitis C en un gran centro de hemodiálisis de Lima, Perú. MATERIAL Y MÉTODO: El estudio fue un modelo de casos y controles para población incidente. Se estudió un caso negativo por cada positivo para anticuerpos HCV pareados por edad, sexo y procedencia. Odds ratio (OR) y su intervalo de confianza (IC 95 por ciento) fue usado para evaluar la fuerza de asociación de variables. RESULTADOS: El tiempo en hemodiálisis (OR 7.13, IC95 por ciento 3.04-17.02), mas de dos hospitalizaciones (OR 4.49, IC95 por ciento 1.28-17.28), tratamiento en múltiples centros de diálisis (p<0.05), haber sido trasplantado p<0.01) y haber recibido transfusión de sangre (OR 2.61IC95 por ciento 1.04-6.68) fueron factores asociados a infección por HCV.CONCLUSIONES: La permanencia en hemodiálisis, las hospitalizaciones, haber sido dializado en múltiples centros, el trasplante y las transfusiones sanguíneas, fueron variables asociadas a la infección por HCV en la población estudiada.

BACKGROUND: Hepatitis C Infection (HCV) is a significant problem in patients treated with chronic hemodialysis in Peru. In prior studies, it has been reported that blood transfusions and time on hemodialysis have been identified as risk factors. Purpose: Study other probable factors associated with the Hepatitis C virus in a large hemodyalisis center in Lima, Peru.MATERIALS AND METHOD: The study consisted of a case model and controls for incident population. A negative case was studied in relation to each case with positive results for HCV antibodies paired by age, sex and origin. Odds ratio (OR) and its confidence interval (CI 95 per cent) were used to assess the degree of association between variables.RESULTS: Time on hemodialysis (OR 7.13, CI 95 per cent), 3.04-17.02), more than two hospitalizations (OR 4.49, CI 95 per cent), 1.28-17.28), treatment in multiple dialysis centers (p<0.5), having undergone a transplant (p<0.01) and having received a blood transfusion (OR 2.61 CI 95 per cent 1.04-6.68) were factors associated with HCV. Conclusion: Permanence on hemodialysis, hospitalizations, receiving dialysis at multiple centers, transplantation and blood transfusions were variables associated with HCV infection in the studied population.

Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon.

BACKGROUND: Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health. METHODS: Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought. RESULTS: Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation. CONCLUSION: Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

[Rate of serological markers of hepatitis B and C viruses in first-time users of the hemodialysis program at Hospital Nacional Cayetano Heredia (HNCH)]. / Frecuencia de marcadores serológicos de hepatitis viral B y C en pacientes que ingresan por primera vez al programa de hemodiálisis en el Hospital Nacional Cayetano Heredia.

PURPOSE: Determine the rate of markers of hepatitis B (HBV) and C (HCV) viruses in patients with terminal chronic kidney failure (TCKF) prior to the start of a chronic hemodialysis program (CHD), and assess the time relation between infection and epidemiological history. MATERIALS AND METHODS: This was a prospective and analytical study. The study population was composed of the entire group of TCKF patients using the CHD program for the first time at the HNCH, Lima, from June 2002 to September 2003. HbsAg and HBV Anti-HBc, and HCV anti-VHC markers were assessed. RESULTS: 86 patients were studied, 45 female (52.3%) and 41 male (47.7%). During the study, the total rate of HBV markers was 20.9%, HBsAg(+) was 2.3%, and anti-HBcT(+) was only 18.7%. Anti-HCV rate was 4.65%. Related factors for potential carriers of only anti-HBcT(+) were: elder age, sexual intercourse with prostitutes OR=6.1 (1.5-25.3), food consumption at restaurants OR=5.2 (1.6-16.4), or being born in the jungle area OR=6.7 (1.5-30.5). Multi-variance analysis showed that only elder age OR=1.03 (1.00-1.06), being born in the jungle area OR=13.1 (1.8-91.1), and food consumption in restaurants OR=5.0 (1.4-18.0) were related to total anti-HBc count. CONCLUSIONS: The study results suggest a low rate of serological markers of HBV and HCV in TCKF patients using chronic hemodialysis treatment for the first time at HNCH.

Frecuencia de marcadores serológicos de hepatitis viral B y C en pacientes que ingresan por primera vez al programa de hemodiálisis en el Hospital Nacional Cayetano Heredia / Rate of serological markers of hepatitis B and C viruses in first-time users of the hemodialysis program at Hospital Nacional Cayetano Heredia

Objetivo: Determinar la frecuencia de marcadores de hepatitis viral B (VHB) y C (VHC) en pacientes con insuficiencia renal crónica terminal (IRC-T) antes de ingresar a un programa de hemodiálisis crónica (HDC) y evaluar la relación temporal de la infección con antecedentes epidemiológicos. Materiales y métodos: Se realizó un estudio de serie de casos prospectivo y analítico. La población se conformó por la totalidad de pacientes nuevos con IRC-T que ingresaron por primera vez al programa de HDC del HNCH-Lima, desde Junio del 2002 hasta Setiembre del 2003, se evaluaron los marcadores HBsAg y anti-HBcTotal del VHB y anti-VHC del VHC. Resultados: Se estudiaron 86 pacientes , 45 (52.3 por ciento) fueron mujeres y 41 (47.7 por ciento) varones. En el periodo de estudio se halló una frecuencia total de marcadores de VHB del 20.9 por ciento, siendo 2.3 por ciento HBsAg(+) y 18.7 por ciento sólo anti-HBcT(+). En tanto la frecuencia de anti-VHC fue de 4.65 por ciento. Los factores relacionados para ser portador de sólo anti-HBcT(+) fueron: edad avanzada, relaciones sexuales con prostitutas OR=6.1 (1.5-25.3), ingerir alimentos en restaurantes OR=5.2(1.6-16.4) y haber nacido en la Selva OR=6.7 (1.5-30.5). En el análisis multivariado solo la edad avanzada OR=1.03 (1.00-1.06), haber nacido en la Selva OR=13.1 (1.8-91.1) e ingerir alimentos en restaurantes OR=5.0 (1.4-18.0), se relacionaron con la presencia de anti-HBcTotal. Conclusión: Los resultados de este estudio sugieren baja frecuencia de los marcadores serológicos de VHB y VHC en pacientes con IRCT que ingresan por primera vez al tratamiento de HDC en el HNCH.

Purpose: Determine the rate of markers of hepatitis B (HBV) and C (HCV) viruses in patients with terminal chronic kidney failure (TCKF) prior to the start of a chronic hemodyalisis program (CHD), and assess the time relation between infection and epidemiological history. Materials and Methods: This was a prospective and analytical study. The study population was composed of the entire group of TCKF patients using the CHD program for the first time at the HNCH, Lima, from June 2002 to September 2003. HbsAg and HBV Anti-HBc, and HCV anti-VHC markers were assessed. Results: 86 patients were studied, 45 female (52.3 per cent) and 41 male (47.7 per cent). During thestudy, the total rate of HBV markers was 20.9 per cent, HBsAg(+) was 2.3 per cent, and anti-HBcT(+) was only 18.7 per cent. Anti-HCV rate was 4.65 per cent. Related factors for potentialcarriers of only anti-HBcT(+) were: elder age, sexual intercourse with prostitutes OR=6.1 (1.5-25.3), food consumption at restaurants OR=5.2 (1.6-16.4), or being born in the jungle area OR=6.7 (1.5-30.5). Multi-variance analysis showed that only elder age OR=1.03 (1.00-1.06), being born in the jungle area OR=13.1 (1.8-91.1), and food consumption in restaurants OR=5.0 (1.4-18.0) were related to total anti-HBc count. Conclusions: The study results suggest a low rate of serological markers of HBV and HCV in TCKF patients using chronic hemodyalisis treatment for the first time atHNCH.

Smoking in Ecuador: prevalence, knowledge, and attitudes.

OBJECTIVE: To evaluate the prevalence of, attitudes towards, and knowledge about cigarette smoking in Ecuador in 1991. DESIGN: Survey using in-person interviews; stratified and multiple regression analyses. SUBJECTS AND SETTING: Eight hundred people (> or = 18 years old) representative of the adult populations in the cities of Quito and Guayaquil, Ecuador. MAIN OUTCOME MEASURES: Smoking prevalence, daily cigarette consumption, reasons for smoking, desire to quit smoking, knowledge about the health effects of smoking. RESULTS: About a third of the population in the two major cities of Ecuador are cigarette smokers. Men are not only more likely to be smokers than women (45% vs 17%, respectively), but when they do smoke, they also smoke significantly more cigarettes per day (60% more) than women. Cigarette smoking appears to be more common among younger populations, and among more educated people. Housekeepers are significantly less likely to be smokers compared with people in other occupations. About 80% of smokers consume fewer than 10 cigarettes per day. In Quito, a 40% increase in the number of cigarettes smoked per day on weekdays compared with weekends suggests an effect of the environment on smoking patterns. About 60% of smokers stated their desire to quit smoking, and there was almost universal knowledge about the harmful effects of cigarette smoking on the health of active and passive smokers. CONCLUSIONS: About a third of the population in the two major cities of Ecuador reported smoking cigarettes. Smoking is more common among men, those of younger age, and the more educated. The findings in this study should help the development of antismoking policies in Ecuador and other countries in the region.

Prognosis of acute myocardial infarction complicated by complete heart block (the Worcester Heart Attack Study).

As part of a community-based study of patients hospitalized with acute myocardial infarction (AMI) in the Worcester, Massachusetts, metropolitan area, changes over time in the incidence rates of complete heart block (CHB) complicating AMI, and the prognostic impact of CHB on the in-hospital and long-term survival of these patients were examined. In all, 4,762 patients with validated AMI hospitalized at 16 hospitals in the Worcester metropolitan area during 1975, 1978, 1981, 1984, 1986 and 1988 constituted the study sample. The incidence rates of CHB complicating AMI remained relatively stable at 5.8% over the 13-year (1975 to 1988) period studied. The incidence rates of CHB were approximately twice as high in patients with inferior/posterior wall AMI (7.7%) as in those with anterior wall AMI (3.9%). Use of a multivariate regression analysis to control for factors affecting the incidence rates of CHB revealed that patients were at highest risk for developing CHB during the latter 2 study years (1986 and 1988). Patients with AMI developing CHB had higher in-hospital case fatality rates than did those without CHB overall, as well as during each of the 6 periods studied. The in-hospital survival associated with CHB did not improve over time. After use of a multivariate regression analysis to control for additional prognostic factors, the independent effect of CHB on in-hospital prognosis remained (adjusted risk of dying = 2.10; 95% confidence intervals = 1.37, 3.21). Patients with inferior wall AMI complicated by CHB were at significantly increased risk of dying during hospitalization compared with those without CHB (adjusted risk of dying = 2.71; 95% confidence intervals = 1.60, 4.59).(ABSTRACT TRUNCATED AT 250 WORDS)

[The P loop in atrioventricular septal defect. Embryologico-vectorcardiographic correlation]. / El asa P en el defecto del septum atrio-ventricular. Correlación embriológico-vectocardiográfia.

Atrial vectorcardiograms (vcg) were analysed in 23 patients with partial (n = 15) or complete (n = 8) forms of atrioventricular septal defect (AVSD). The rotation and the projection of the maximum left atrial vector (MLAV) on the frontal plane (FP) and on the horizontal plane (HP) were noted. To assess the possible influence of the degree of left-to-right shunting and the right atrial and right ventricular pressures on the rotation and MLAV projection, these vcg data were correlated with hemodynamic values obtained at the time of preoperative cardiac catheterization. Vcg characteristics of the patients were also compared with those of 25 healthy individuals. No significant differences were noted between the vcg of patients with the partial form and those with the complete form of AVSD. Also, there was no apparent influence of the hemodynamic values on the loop rotation or the MLAV projection in either plane among the patients. However, the MLAV showed a more posteriorly and superior location in the FP and HP than in normal subjects (p = 0.0001). Moreover, 67% of the cases showed a clockwise rotation of the loop in the HP and 33% in the FP; in contrast, normal subjects always showed a counterclockwise rotation in both planes. A more posterior and superior MLAV is consistent with direct observations in human embryos with AVSD which have shown that deficiencies of the posterior portion of the interventricular septum are the basic feature in all cases. The adaptation of the conductive tissue to such deficiency occurs in early phases of cardiac development.

[Pre- and postoperative ECG-VCG study of the correction of atrioventricular septal defects]. / Estudio ECG-VCG pre y postoperatorio de la corrección del defecto del septum atrio-ventricular.

In order to determine the possible implication of the right bundle branch block (RBBB) in the superior axis deviation of patients (pt) affected with AV septal (Canal) defect, we studied the preoperative and postsurgical ECG of 50 patients who underwent radical correction of the malformation complex. 36 pt had the complete form and 14 a partial form. In 14 of them it was also possible to perform a VCG before and after surgery. The amplitude of S1, R' in a VR and V1 modified significantly (p less than 0.0001), the AQRS showed a clockwise displacement of 19 degrees (p less than 0.002). The terminal forces in the VCG frontal plane changed significantly 62 degrees (p less than 0.0001). Nevertheless the D.I. in a VL and V6 made no difference. Postoperative ECG patterns of pt with partial or complete forms did not differ substantially. Results allowed us to conclude that the major determinant of the AV septal defect ECG pattern is the posterior (inlet) deficiency of the interventricular septum. Surgical correction of the right ventricle overload leads to a clockwise AQRS displacement in the frontal plane. The conduction asynchronism through the left branch showed no modifications.

Developmental aspects of atrioventricular septal defects.

Three human embryos with an atrioventricular septal defect were studied. Their morphology was compared with that of 67 autopsy specimens, in which particular attention was paid to the septal attachments of the bridging leaflets. The malformed embryos showed deficiency of the inlet component of the ventricular septum. They had distinct superior and inferior bridging leaflets, which were nearly completely muscular. Myocardial undermining had taken place at two independent sites but had not been able to lead to the formation of a valve of mitral morphology. Normal delamination of myocardium to form the leaflets could not continue directly below the aortic root because the rim of the inlet septum had a more apical position. From this, we conclude that the deficiency of the inlet septum is the cause of the typical morphology of the left valve in these hearts. The role of endocardial cushion tissue is probably restricted to glueing together myocardial structures, thus determining the variable septal attachment of the bridging leaflets in atrioventricular septal defect.

[Double outlet right ventricle. Angiographic study]. / Ventricolo destro a doppia uscita. Studio angiografico.

Cineangiographic study in 41 patients with double outlet right ventricle was performed. Segmental approach was utilized to describe the anatomical features. Atrial situs was inversus in 5 cases, ambiguous in 3 and solitus in the other cases. Atrio-ventricular (a-v) connections were biventricular in 34 and univentricular in 7. A common a-v valve was found in 2 cases. Mitral valve was imperforated in 1 and straddling in 1. The most frequent relationship between aorta and pulmonary artery was side by side (41.1%). Ventricular septal defect was subaortic in 14, subpulmonary in 9, double committed in 5 and non committed in 6. In 27 cases a double infundibulum was present; in 7 patients we described a subpulmonary conus only. Some nosological aspects of this congenital heart disease are discussed particularly in conformity with the surgical needs.

[Ebstein disease and pregnancy]. / Malattia di Ebstein e gravidanza.

Three patients with Ebstein's disease became pregnant 11 times, 6 of which ended as spontaneous abortion, 2 newborn deaths and 3 successful term pregnancies. Ventricular overloading, arterial hypoxemia and arrhythmias are the major physiopathologic determinants. The ventricular overloading is the most important risk factor for the mother, so as the hypoxemia and the arrhythmias for the fetus. Pregnancy in these patients must be considered at high risk, and a close cardiologic assess with continuous hormonal controls of fetus maturity during the last trimester should be done. A team including obstetricians, cardiologists and anesthesiologists is suggested for the care of these patients in the view of a successful outcome.

[Electro-vectorcardiographic analysis of the negative, diphasic and bifid T wave in right precordial leads in young subjects]. / Análisis electro-vectocardiográfico de la onda T negativa, difásica y bífida en las derivaciones precordiales derechas en sujetos jóvenes.

Morphology, genesis and incidence of isolated T wave abnormalities on right precordial leads of healthy young individuals were studied in this work. ECG were obtained from 1510 healthy subjects aged 14 to 40 years consecutively submitted to a cardiological evaluation in order to assess their fitness for sport. In 510 of them a VCG was made too. The results showed that T waves were rarely negative beyond V1 (0.46%) and even more rarely negative from V1 to V3 (0.13%); diphasic T waves were present in 2.38% and bifid T waves in 6.15% of our cases. The T loop of VCG tended to be more posteriorly displaced and evolved from a counterclockwise to a clockwise rotation as the presence of negative T waves spread toward left on precordial leads. The "+-" type of diphasic T wave corresponded to a counterclockwise rotation of the T loop, the "-+" type to a clockwise rotation. Bifid T waves were associated with figure of eight or "arched" T loops of VCG. The T loops of those subjects who underwent a second evaluation after several years tended to be displaced more anteriorly, with counterclockwise rotation. The causes of these T wave abnormalities have not been clearly explained yet, even if a slight delay in the right final vectors was present in the majority of our cases.