Unveiling Charles II, the last King of the Habsburg Spanish Empire, in a portrait by Juan Carreño de Miranda (1685).

PURPOSE: Charles II (1661-1700) was the last King of the Habsburg dynasty. He was physically and mentally disabled and died at just 39 years old. Here, the authors attempt to investigate the correlations between his signs and symptoms and the physical appearance on the painting. METHODS: Charles II has been portraited by Juan Carreño de Miranda in a painting that may provide precious information about his premature death. RESULTS: It has been suggested that inbreeding beside other endocrinological disorders were of the major causes responsible for illness and ultimately his death. CONCLUSION: Possible endocrinological diseases have been hypothesized.

Nipple-areola complex reconstruction techniques: A literature review.

Many techniques for nipple-areola complex (NAC) reconstruction are described. Clarity is required on the currently available options. Since a complete list of all the techniques described until now is not available, a possibly comprehensive literature overview was carried out from 75 papers (years 1946-2015). The local flap was the most frequently described technique for the nipple reconstruction with no significant difference in complications' rate among the various types of techniques. Complications in nipple reconstruction were 46.9% after graft, 7.9% after local flap, and 5.3% in case of flaps with autologous graft/alloplastic/allograft augmentation, while complications in areola reconstruction were 10.1% after graft, and 1.6% after areola tattoo. Flaps appear to be more reliable than grafts in nipple reconstruction, while tattoo is thought to be safer than graft in areola reconstruction. The loss of projection, although considerable (45%-75%), had not significant impact on patients' satisfaction. Due to contraction, overcorrection of 25-50% of the desired result is advisory when adopting local flaps, in order to prevent loss of projection. The use of flaps with autologous graft/alloplastic/allograft augmentation (cartilage, fat, calcium hydroxylapatite, acellular dermal matrix, polymethylmethacrylate, biologic collagen) showed a minor loss of nipple projection but may expose to a relative increased number of postoperative flap necrosis.

Vulvar melanoma: a 33 years single Italian center experience.

AIM: Vulvar melanoma is a rare disease with a poor prognosis. The purpose of this study was to report our experience on vulvar melanoma. METHODS: This is a retrospective study on patients with primary melanoma of the vulva admitted to our hospital during the last 33 years. Clinical characteristics, surgical therapy and follow-up are reported. Patients were classified following the 2009 edition of the melanoma staging system. RESULTS: The predominant symptom was pain; five patients reported ulceration and one patient presented bleeding from the vulvar lesions. The average age at diagnosis was 61.4 years. Surgical treatment was performed: radical vulvectomy in five cases, emivulvectomy in three cases, large regional excision in one case. Average time to follow-up was 50.2 months. In four cases (44.4%), regional recurrence occurred and the patients died as a result of the tumor; one patient died of other causes; four patients were still alive at the time of the study. CONCLUSION: Current treatment protocols have moved towards less aggressive treatment in view of the current available evidence. Sentinel lymph node biopsy and adjuvant therapy are still under debate. Our study confirms the overall poor prognosis for vulvar melanoma.

[AV nodal reentrant tachycardias: what is the place of cryoablation?]. / Cryoablation : quel apport dans la prise en charge des tachycardies par réentrée intranodale ?

Radiofrequency ablation is the reference method for the interventional treatment of AV nodal reentrant tachycardias. Even if risks are low, one of the complications of radiofrequency ablation is auriculoventricular block. Cryoablation is an alternative to radiofrequency ablation. The most important advantage of this technique is a lack of permanent AV-block. This article reviews principles of cryotherapy, its main results in ablation of AV nodal reentrant tachycardias, its advantages and disadvantages. A proposal is made about its indications.

Transvenous cryo-ablation of the slow pathway for the treatment of atrioventricular nodal re-entrant tachycardia: a single-centre initial experience study.

AIMS: Within the last several years, transvenous cryo-ablation has become an alternative method to perform ablation of the slow-pathway. This study evaluated the acute and long-term safety and effectiveness of atrio-ventricular nodal re-entrant tachycardia (AVNRT) cryo-ablation. METHODS AND RESULTS: The first 69 consecutive patients with AVNRT (60 slow-fast, 4 fast-slow, and 5 slow-slow) who underwent slow-pathway cryo-ablation were included. Mean age was 37 +/- 15, body weight 68 +/- 14 kg, symptom duration 125 +/- 104 months, and number of ineffective antiarrhythmic (AA) drugs 1.8 +/- 1.4. A 7 Fr cryo-catheter (Cryocath(A)) was used, with initially 4-mm-tip and later with 6-mm-tip electrode. Cryo-mapping (n = 7.9 +/- 8.4 per pt) was performed at the temperature of -30 degrees C to test the effect on the target ablation site. Successful cryo-mapping was defined as abolition of nodal conduction jump or AV nodal refractory period prolongation. Cryo-ablation (n = 5.1 +/- 4.9 per pt) was then applied by freezing to -75 degrees C for 4 min in duration if no AV-block occurred. Acute procedural success (defined as AVNRT non-inducibility) after the first cryo-ablation attempt was achieved in 60/69 patients (87%). During cryo-ablation, inadvertent transient AV-block was encountered in 14 patients (five I AV-block and nine II-III AV-block). A mid-septal target site was the only variable correlated with inadvertent AV-block occurrence during cryo-ablation (P < 0.02). Long-term clinical success after cryo-ablation was globally achieved in 56/66 (85%) with a mean follow-up of 18 +/- 9 months (3 pts dropped-out). After the first procedure, 41/66 (62%) had no relapse, eight had a dramatic reduction in AVNRT duration-frequency and considered themselves cured, and five needed previously ineffective AA (with no relapse in three, drastic reduction in AVNRT duration-frequency in two). The five last patients needed one or more procedures, after which one had no recurrence and one had reduction in duration-frequency. Absence of recurrence after the first procedure was positively correlated with 6-mm-tip cryo-catheter use (<0.001) and negatively with acute procedural success (<0.001). At multivariate analysis, both were independently significant (<0.04 and <0.008, respectively). Long-term clinical success was correlated only with 6-mm-tip cryo-catheter use (<0.001). CONCLUSIONS: Slow pathway cryo-ablation is associated with an acute success but a higher recurrence rate. A 6-mm-tip cryo-catheter seems to assure during cryo-ablation a large acute and long-term success. AV-block seems non-guaranteed by a negative cryo-mapping, stressing on need of a careful surveillance. Nevertheless, the theoretical advantage of avoiding the risk of permanent AV-block when compared with radiofrequency needs larger series to be demonstrated.