Usefulness of the Calgary Syncope Symptom Score for the diagnosis of vasovagal syncope in the elderly.

AIMS: The Calgary Syncope Symptom Score (CSSS) has been validated as a simple point score of historical features with high sensitivity and specificity for the diagnosis of vasovagal syncope (VVS) in younger populations without evidence of structural heart disease. Our purpose was to evaluate the performance of the CSSS in an elderly population with suspected VVS. METHODS AND RESULTS: Hundred and eighty patients of ≥60 years of age (mean 73.4 ± 7.8) with suspected clinical diagnosis of VVS were studied. The CSSS (VVS score ≥-2) was calculated in all patients prior to undergoing head-up tilt test (HUT). A standardized HUT protocol with active nitroglycerin phase was used to reproduce syncopal symptoms as gold standard for diagnosis of VVS. Hundred and forty patients had positive HUT response. Eighty-three patients (42.3%) had CSSS ≥-2 suggesting a diagnosis of VVS. The Calgary Syncope Symptom Score sensitivity was 0.51 [95% confidence interval (CI) 0.42-0.59] and specificity 0.73 (95% CI 0.52-0.85) with positive predictive value and negative predictive value of 0.87 (95% CI 0.77-0.93) and 0.30 (95% CI 0.21-0.40), respectively. One hundred (55.6%) patients had previous history of mild cardiovascular disease documented during assessment prior to HUT. In this population sensitivity and specificity was markedly reduced: 0.13 (95% CI 0.05-0.29) and 0.70 (95% CI 0.57-0.80), respectively. CONCLUSION: The CSSS has a lower sensitivity and specificity in an elderly population presenting with syncope compared to previously validated data in young adults, particularly in elderly patients with previous history of mild cardiovascular disease. A modified CSSS may be needed to improve specificity and sensitivity in this population.

[Rhabdomyosarcoma of soft palate. A case on purpose]. / Rabdomiosarcoma de paladar blando. A propósito de un caso.

The rabdomiosarcoma (RMS) are infrequent tumors. They are principally described in infancy and located in 35% of the cases in head and neck. The nasopharynx localisation is relatively rare, being in these cases the tongue, palate and oral mucosa the preferent places of establishment. Classically the patient presented very low standard healing with surgery and radiotherapy. The introduction in the middle 70 of systematic chimiotherapy as complementary treatment, improved the survival rate in large scale. In this article the case of an adolescent patient, who presented a RMS at the level of the soft palate, the diagnostic procedure and the therapeutic decision adopted, after revision of the last studies at this respect, are described.

[Malignant external otitis. A pattern to bear always in mind]. / Otitis externa maligna. Un cuadro a tener siempre presente.

Malignant external otitis (M.E.O.) is a severe and rare affection, consisting in an infection of the external auditory canal (EAC) whit extension and compromising the structures of the skull base, produced mainly by Ps. Aeruginosa in patients affected by diabetes type II of long evolution and or deterioration of the immunity system. We present a case of a patient affected by this pathology, commenting the caracteristics of this disease, how we arrived to the diagnosis, and the evolution of the case with an exclusively medical treatment.

[Big profound cervical abscess in a diabetic patient]. / Gran absceso cervical profundo en paciente diabético.

With antibiotics and an increasing dental care and hygiene, the profound neck spaces infections have decreased their incidence. Nevertheless we can found them in the clinical practice, and they present a big morbidity and severe complications. We present in this paper a case of profound cervical abscess in a diabetic patient, discussing the clinical and therapeutics aspects.

[Otogenic cerebral abscess: a persistent problem]. / Absceso cerebral otógeno: un problema persistente.

A young man with otitis media and cholesteatoma of the left ear developed secondary cerebral abscess. The clinical debut was non-specific, with headache, mild fever, and mild persistent otalgia in spite of early antibiotic treatment. Studies revealed a cerebral abscess, so ENT surgery in collaboration with the neurosurgery department was decided. This case illustrates that clinical manifestations in such cases can be mild and highlights the need to exclude this type of serious pathology.

Single-chamber ICD, single-zone therapy in primary and secondary prevention patients: the simpler the better?

BACKGROUND: It is now well established that implantable cardioverter defibrillator (ICD) implantation reduces mortality in patients at increased risk of sudden cardiac death. However, the best programming parameters remain controversial. Our traditional policy has followed a simple approach in the vast majority of patients. In accordance with ICD programming in the major randomized clinical trials, we programmed a single high-rate, shock-only therapy zone. We aimed to demonstrate in this observational study that simple programming is not associated with higher shock rates or mortality when compared to other published studies. METHODS: Consecutive patients who underwent single-chamber ICD implantation with single-zone, high-rate programming at our institution between 1993 and 2008 were retrospectively studied. Data were collected prospectively in a database regarding details of ICD implantation, demographic data, and indication. RESULTS: Three hundred thirty-two patients were included in our study, 31 % primary prevention and 68 % secondary prevention. Mean ejection fraction (EF) is 33.7 ± 15.3. Over a mean follow-up period of 62.5 ± 38.1 months, 135 patients experienced ICD shock (annualized event rate 7.7 %); 89 patients (26.8 %) appropriate shock in VT-ventricular fibrillation (VF), 68 patients (20.5 %) inappropriate shocks, and 22 patients (6.6 %) both. Twenty-nine patients (8.7 %) were reprogrammed to additional VT-ATP zones. Twenty-two (6.6 %) patients underwent heart transplantation. Sixty-two patients (18.6 %) died during follow-up, 43.6 % out of them due to cardiac cause, mainly progressive heart failure. CONCLUSION: Our results show that simpler settings with single-zone, high-rate programming is associated with ICD shock rates and long-term mortality that does not appear to be worse when compared with contemporary studies which include multizone ICD programming with antitachycardia pacing activated.

Atrial flutter after heart transplantation: mechanism and catheter ablation.

BACKGROUND: Atrial flutter is a frequent arrhythmia after heart transplantation, but little is known about its mechanism and treatment. We report the results of an electrophysiologic study in patients with atrial flutter after orthotopic heart transplantation, describing its mechanism and demonstrating the acute and long-term efficacy of catheter ablation for treating this arrhythmia. METHODS: We included 14 patients with symptomatic atrial flutter after orthotopic heart transplantation. All of them underwent an electrophysiologic study to determine the mechanism of the arrhythmia and catheter ablation when possible. RESULTS: Counterclockwise right atrial circuit around the tricuspid annulus involving the cavotricuspid isthmus was demonstrated in 13 patients (86%). Catheter ablation of the isthmus was performed with good acute results in all but 1. During a mean follow-up of 24 ± 17 months, recurrent atrial flutter was documented in 3 patients and atrial fibrillation in 2. In another patient, we demonstrated a left atrial origin. CONCLUSIONS: The most common mechanism of atrial flutter in heart transplant recipients is a counterclockwise circuit around the tricuspid annulus involving the cavotricuspid isthmus. Catheter ablation of the isthmus between tricuspid annulus and posterior atrial suture line represents an effective treatment in these patients. This condition may be avoided by changing the surgical technique to a bicaval anastomosis.

Rabdomiosarcoma de paladar blando. A propósito de un caso / Rabdomiosarcoma of soft palate. A case on purpose

Los rabdomiosarcomas (RMS) son tumores poco frecuentes. Descritos principalmente en la infancia y localizados en un 35% de los casos en cabeza y cuello. La localización orofaríngea es relativamente rara, siendo en estos casos la lengua, paladar, y mucosa bucal los lugares preferentes de asentamiento. Clásicamente los pacientes presentaban tasas muy bajas de curación con cirugía más radioterapia. La introducción a mediados de los años 70 de la quimioterapia sistémica como tratamiento complementario ha mejorado la supervivencia de manera importante. En este artículo se describe el caso de un paciente adolescente que presentó un RMS a nivel del paladar blando, el procedimiento diagnóstico y la decisión terapéutica adoptada tras revisión de los últimos estudios al respecto

The rabdomiosarcoma (RMS) are infrequent tumors. They are principally described in infancy and located in 35% of the cases in head and neck. The nasopharynx localisation is relatively rafe, being in these cases the tongue, palate and oral mucosa the preferent places of establishment. Classically the patient presented very low standard healing with surgery and radiotherapy. The introduction in the middle 70 of systematic chimiotherapy as complementary treatment, improved the survival rate in large scale. In this article the case of an adolescent patient, who presented a RMS at the level of the soft palate, the diagnostic procedure and the therapeutic decision adopted, after revision of the last studies at this respect, are described

Otitis externa maligna. Un cuadro a tener siempre presente / Malignant external otitis. Pattern to bear always in mind

La otitis externa maligna (OEM) es una afección grave y poco frecuente que consiste en una infección del conducto auditivo externo (CAE) con extensión y compromiso de estructuras de la base de cráneo producida mayoritariamente por Ps. Aeruginosa en pacientes que presentan diabetes tipo II de larga evolución y/o deterioro del sistema inmunitario.Presentamos el caso de un paciente afecto de esta patología, comentando las características de esta enfermedad, como se llegó al diagnóstico y la evolución del caso con tratamiento exclusivamente médico

Malignant external otitis (M.E.O.) is a severe and rare affection, consisting in an infection of the external auditory canal (EAC) whit extension and compromising the structures of the skull base, produced mainly by Ps. Aeruginosa in patients affected by diabetes type II of long evolution and or deterioration of the immunity system. We present a case of a patient affected by this pathology, commenting the caracteristics of this disease, how we arrived to the diagnosis, and the evolution of the case with an exclusively medical treatment

Artrodesis de rodilla con clavo intramedular / Arthrodesis of the knee with intramedullary nailing

Se revisan 21 artrodesis de rodilla realizadas en 20 pacientes mediante enclavado intramedular, a lo largo de diez años, con un seguimiento medio mayor de 3 años. La causa más frecuente, en 18 casos, fue el fracaso de la artroplastia de rodilla tanto séptico como aséptico. La consolidación primaria de la artrodesis se obtuvo en 16 casos (76 por ciento), en un tiempo medio de 8,1 meses (AU)

Absceso cerebral otógeno: un problema persistente / Otogenic cerebral abscess: a persistent problem

Presentamos el caso de un joven afecto de otitis media colesteatomatosa de oído izquierdo que desarrolló un absceso cerebral piógeno secundario. El debut clínico fue muy inespecífico, con cefalea holocraneal, febrícula y otalgia leve persistente a pesar del tratamiento antibiótico instaurado precozmente. Se evidenció un absceso cerebral tras pruebas de imagen, por lo que decidimos un abordaje conjunto junto a neurocirugía. Este caso es muy ilustrativo, de lo larvada que puede ser la clínica de estos procesos intracraneales y de la necesidad de descartar este tipo de patología, por la gravedad de la, misma (AU)

A young man with otitis media and cholesteatoma of the left ear developed secondary cerebral abscess. The clinical debut was non-specific, with headache, mild fever, and mild persistent otalgia in spite of early antibiotic treatment. Studies revealed a cerebral abscess, so ENT surgery in collaboration with the neurosurgery department was decided. This case illustrates that clinical manifestations in such cases can be mild and highlights the need to exclude this type of serious pathology (AU)