Representativeness of initial skin biopsies showing pure desmoplastic melanoma: implications for management.

Desmoplastic melanoma (DM) is an uncommon subtype of melanoma with distinct clinicopathological features. It is classified into pure desmoplastic melanoma (PDM) when the proportion of desmoplastic melanoma is ≥90% of the dermally-invasive component, and mixed desmoplastic melanoma (MDM) when the proportion of desmoplastic melanoma is <90%. Studies have reported a lower sentinel lymph node biopsy (SLNB)-positivity rate in PDM compared to MDM and non-DM. As a result, some have recommended not performing SLNB in PDM patients. When PDM is identified in a partial biopsy of a melanoma, there is a risk that sampling bias may under-recognise MDM, but to the best of our knowledge this has not been previously assessed or quantified. The aim of this study was to assess the concordance of the proportion of desmoplastic melanoma in an initial partial biopsy of PDM with the proportion in the entire tumour following complete excision, in patients with cutaneous melanoma. A secondary aim was to determine how frequently this potentially resulted in a patient not receiving a SLNB. Seventy-eight cases of cutaneous melanoma were identified from the Melanoma Institute Australia (MIA) database and 23 cases from the Memorial Sloan Kettering Cancer Centre (MSKCC), where an initial biopsy contained PDM and a subsequent wide excision had residual invasive melanoma. Clinicopathological features were analysed in all patients, including whether a SLNB was performed, the results of SLNB, and any subsequent recurrence. Ninety percent (91/101) of cases were still classified as PDM in the complete wide excision specimen while 10% (10/101) of cases were reclassified as MDM, which was a significant change in classification of final desmoplastic melanoma subtype (p<0.001). The proportion of desmoplastic melanoma was also significantly different between the initial and excisional biopsies (p=0.004). Forty-eight (48/101) patients had a SLNB, of which two (4.5%) were positive for metastatic melanoma; both cases were PDM in the excision specimen. Of the 10 cases demonstrating MDM in the excision specimen, the initial biopsy was a punch biopsy in six cases, shave biopsy in two cases and subcutaneous tissue was sampled in two patients (one punch biopsy, one incisional biopsy). Four of these 10 patients underwent SLNB which was negative in all cases. Twenty-two patients developed recurrence in the follow-up period (median 30 months, range 1-192 months), three with MDM in their excision specimen. One patient did not have a SLNB and developed regional lymph node recurrence. In this study there was a 10% risk that the percentage of desmoplastic melanoma in an initial biopsy of PDM was not representative of the entire lesion, resulting in reclassification as MDM in the excision specimen. If a SLNB is not performed in such cases, a positive SLNB may be missed (one patient in our study) which could impact treatment options for the patient. We recommend caution in not offering a SLNB in the setting of an initial biopsy of PDM if the biopsy is small compared with the overall lesion. If a SLNB is not procured at the time of wide excision in such cases, the SLNs should still be mapped by lymphoscintigraphy to facilitate careful follow up and to enable earlier detection and treatment of nodal disease.

[Factors associated with the hospital at home workload: A Delphi consensus study]. / Factores relacionados con la carga de trabajo en hospitalización a domicilio: estudio de consenso Delphi.

OBJECTIVES: To identify and prioritize a list of factors that contribute to the workload of the hospital at home (HaH) professionals. MATERIAL AND METHODS: A qualitative methodology study performed between January and December 2019 in the 10 HAH units of the Basque Country. The data were obtained in 4phases: 1. Systematic literature search and review; 2. Expert group meeting; 3. Consensus method: Delphi technique (2 survey rounds) and nominal group meeting; 4. Meeting of the research team. RESULTS: In the systematic literature search and review 85 factors were initially identified. These were reduced to 38 after the 8-person expert group meeting, in which 10 new factors were added. After the 2 Delphi rounds (106 and 57 professionals, respectively), 17 factors were maintained and 12 remained in doubt. The latter were evaluated at the nominal group meeting, consisting of 13 professionals who decided to eliminate 5 factors, include 3, and keep 3 as doubt. After the 8-person research team meeting, 14 potential factors were finally selected. They are related to the place of residence, the health state and social situation of the patients, as well as the health care provided at home. CONCLUSIONS: The identified factors could serve for improving the organization and optimize the daily word of the HaH professionals.

Fístula biliobronquial secundaria a quiste hidatídico hepático en tránsito torácico: caso clínico / Bronchobiliary fistula secondary to hepatic hydatid cyst in thoracic transit: clinical case

Resumen Introducción: En un quiste hidatídico hepático pueden ocurrir una serie de complicaciones de diversa gravedad. Una es el tránsito hepatotorácico (THT), que es el compromiso simultáneo de hígado, diafragma y pulmón secundario a migración de un quiste hidatídico hepático. Objetivo: Presentar una complicación de baja incidencia de un quiste hidatídico hepático como lo es el THT con fistula biliobronquial y posterior resolución quirúrgica. Materiales y Método: Registro clínico, imagenológico y fotográfico del episodio clínico. Resultados: Paciente con diagnóstico de quiste hidatídico en tránsito hepatotorácico con fístula biliobronquial fue sometida a toracotomía, resección en cuña del pulmón incluyendo bronquios comunicantes con el quiste. Paciente presenta evolución clínica e imagenológica favorable. Discusión: Se discuten formas de presentación, complicaciones de la evolución, grados de progresión y ubicaciones anatómicas frecuentes. Se hace énfasis en rol de la clínica e imagenología para diagnóstico y lo controversial del manejo. Conclusión: Tratamiento quirúrgico dependerá de localización de la lesión, estado del quiste, tamaño y experiencia del equipo quirúrgico, siendo una quistectomía con tratamiento de los trayectos fistulosos una buena alternativa.

Introduction: A variety of severe complications can occur in a hepatic hydatid cyst. One of them is the transit from liver to thorax through the diaphragm (HTT). Aim: To present a low impact complication of a hepatic hydatid cyst such as HTT with bronchobiliary fistula and subsequent surgical procedure. Materials and Method: Clinical, imaging, and photographic record of the clinical event. Results: A patient with a diagnosis of hydatid cyst in hepatothoracic transit with bronchobiliary fistula underwent thoracotomy with a wedge resection of the lung, including a cyst-bronchial communication. The patient presents good clinical and imaging evolution. Discussion: Forms of presentation, evolutionary complications, stages of progression, and frequent anatomical locations are discussed. Emphasis is made on the role of the clinical examination and imaging tests for diagnosis and controversial management. Conclusión: Surgical treatment will depend on location of the lesion, experience of the surgical team, condition and size of the cyst, being a cystectomy with the treatment of the fistulous tracts a good alternative.

HEALTH STATUS AND LIFESTYLE HABITS OF VULNERABLE, COMMUNITY-DWELLING OLDER PEOPLE DURING THE COVID-19 LOCKDOWN.

This study evaluated the health status and lifestyle habits of vulnerable, community-dwelling older adults during the first COVID-19 lockdown in Spain. A telephone assessment was carried out in 38 individuals (71% women), with a Barthel index ≥85 who were frail or had a high risk of falls. Data were compared with those from an assessment performed 9 months earlier. In the latter part of the lockdown, a high percentage of the studied individuals showed difficulties in walking up 10 steps and reported sleep problems (66%) and pain (74%). On the other hand, participants were not anxious/depressed (71%) and the majority did not report loneliness (60%). Compared to the earlier assessment, we identified a decline in functional capacity and worsening of nutritional status, but an increase in family support. Efforts should be made to implement intervention programs seeking to avoid accelerated decline under the current pandemic situation, and especially during possible new lockdowns.

Immunomodulatory properties of molecules from animal venoms.

The immune system can amplify or decrease the strength of its response when it is stimulated by chemical or biological substances that act as immunostimulators, immunosuppressants, or immunoadjuvants. Immunomodulation is a progressive approach to treat a diversity of pathologies with promising results, including autoimmune disorders and cancer. Animal venoms are a mixture of chemical compounds that include proteins, peptides, amines, salts, polypeptides, enzymes, among others, which produce the toxic effect. Since the discovery of captopril in the early 1980s, other components from snakes, spiders, scorpions, and marine animal venoms have been demonstrated to be useful for treating several human diseases. The valuable progress in fields such as venomics, molecular biology, biotechnology, immunology, and others has been crucial to understanding the interaction of toxins with the immune system and its application on immune pathologies. More in-depth knowledge of venoms' components and multi-disciplinary studies could facilitate their transformation into effective novel immunotherapies. This review addresses advances and research of molecules from venoms that have immunomodulatory properties.

Antivenom effect on lymphatic absorption and pharmacokinetics of coral snake venom using a large animal model.

Context: Historically, administration and dosing of antivenom (AV) have been guided primarily by physician judgment because of incomplete understanding of the envenomation process. As demonstrated previously, lymphatic absorption plays a major role in the availability and pharmacokinetics (PK) of coral snake venom injected subcutaneously, which suggests that absorption from subcutaneous tissue is the limiting step for venom bioavailability, supporting the notion that the bite site is an ongoing venom depot. This feature may underlie the recurrence phenomena reported in viperid envenomation that appear to result from a mismatch between venom and AV PK. The role of lymphatic absorption in neutralization of venom by AV administered intravenously remains unclear. Methods: The effect of AV on systemic bioavailability and neutralization of Micrurus fulvius venom was assessed using a central lymph-cannulated sheep model. Venom was administered by subcutaneous injection in eight sheep, four with and four without thoracic duct cannulation and drainage. Two hours after venom injection, AV was administered intravenously. Venom and AV concentrations in serum and lymph were determined by ELISA assay from samples collected over a 6-h period and in tissues harvested post-mortem. Results: After AV injection, venom levels in serum fell immediately to undetectable with a subsequent increase in concentration attributable to non-toxic venom proteins. In lymph, AV became detectable 6 min after treatment; venom levels dropped concurrently but remained detectable 4 h later. Post-mortem samples from the venom injection site confirmed the presence of venom near the point of injection. Neither venom nor AV was detected at significant concentrations in major organs or contralateral skin. Conclusions: Intravenous AV immediately neutralizes venom in the bloodstream and can extravasate to neutralize venom absorbed by lymph but this neutralization seems to be slow and incomplete. Residual venom in the inoculation site demonstrates that this site functions as a depot where it is not neutralized by AV, which allows the venom to remain active with slow delivery to the bloodstream for ongoing systemic distribution.

Availability and use of healthcare resources in prisons according to the transference model: a comparative study in Spain.

OBJECTIVE: In most European countries, correctional healthcare provision is under strain or in the process of change regarding its management model and the implications that such modifications may entail for the improvement of inmates' health. This paper compares the functioning and the results of health management in a facility whose healthcare service is integrated within an autonomic health system and others which depend on the department of corrections. MATERIALS AND METHODS: Cross-sectional study where the study unit is the facility itself. From the data collected from the record of Monthly Health Statistics of Penitentiary Institutions we have constructed a series of indicators according to the recommendations of the National Health System. RESULTS: The physician to nurse ratio per inmate is higher in the transferred facility. Only the transferred establishment has telemedicine resources. Attendance to primary health services is higher that in all non-transferred establishments, while the mean attendance to specialized consultation in the transferred facility doubles that of the remaining centers. DISCUSSION: We have observed greater access to specialized care in the correctional facility managed by the community health system when compared to that of the facilities managed by Penitentiary Institutions. This statement is based on a series of effectivity indicators and results that have provided significantly improved outcome in the transferred facility.

Disponibilidad y uso de recursos de asistencia sanitaria en prisión según el modelo de transferencia: estudio comparativo en España / Availability and use of healthcare resources in prisons according to the transference model: a comparative study in Spain

Objetivo: En la mayoría de los países europeos, los servicios sanitarios penitenciarios se encuentran sometidos a tensión o en proceso de cambio en lo que respecta a su modelo de gestión y a las repercusiones que estos cambios puedan tener en la mejora de la salud de los reclusos. Este trabajo compara el funcionamiento y los resultados de la gestión sanitaria en una prisión cuyo servicio sanitario está integrado en un servicio de salud autonómico con otros dependientes de instituciones penitenciarias. Materiales y métodos: Estudio transversal en el que la unidad de estudio es el centro. A partir de datos obtenidos del registro de Estadística Sanitaria Mensual de Instituciones Penitenciarias se han construido una serie de indicadores propuestos por el Sistema Nacional de Salud. Resultados: La ratio de médicos y de enfermeros por interno es mayor en el centro transferido. Solo el centro transferido dispone de recursos de telemedicina. La frecuentación de los servicios de atención primaria es superior en todos los centros no transferidos, mientras que la frecuentación de consultas especializadas del centro transferido duplica la media de las consultas especializadas de los demás centros. Discusión: Se ha evidenciado una mayor accesibilidad de la asistencia especializada en el centro penitenciario gestionado por el servicio comunitario de salud, si lo comparamos con el gestionado por Instituciones Penitenciarias. Esta afirmación se sustenta en unos indicadores de efectividad y resultados que han proporcionado datos significativamene mejores en el centro transferido (AU)

Objective: In most European countries, correctional healthcare provision is under strain or in the process of change regarding its management model and the implications that such modifications may entail for the improvement of inmates’ health. This paper compares the functioning and the results of health management in a facility whose healthcare service is integrated within an autonomic health system and others which depend on the department of corrections. Materials and methods: Cross-sectional study where the study unit is the facility itself. From the data collected from the record of Monthly Health Statistics of Penitentiary Institutions we have constructed a series of indicators according to the recommendations of the National Health System. Results: The physician to nurse ratio per inmate is higher in the transferred facility. Only the transferred establishment has telemedicine resources. Attendance to primary health services is higher that in all non-transferred establishments, while the mean attendance to specialized consultation in the transferred facility doubles that of the remaining centers. Discussion: We have observed greater access to specialized care in the correctional facility managed by the community health system when compared to that of the facilities managed by Penitentiary Institutions. This statement is based on a series of effectivity indicators and results that have provided significantly improved outcome in the transferred facility (AU)

[A reform proposal to strengthen public health care]. / Propuesta de reformas a los prestadores públicos de servicios médicos en Chile: “fortaleciendo la opción pública”.

Currently, there is no discussion on the need to improve and strengthen the institutional health care modality of FONASA (MAI), the health care system used by the public services net and by most of the population, despite the widely known and long lasting problems such as waiting lists, hospital debt with suppliers, lack of specialists and increasing services purchase transference to the private sector, etc. In a dichotomous sectorial context, such as the one of health’s social security in Chile (the state on one side and the market on the other), points of view are polarized and stances tend to seek refuge within themselves. As a consequence, to protect the public solution is commonly associated with protecting the “status quo”, creating an environment that is reluctant to change. The author proposes a solution based on three basic core ideas, which, if proven effective, can strengthen each other if combined properly. These are: network financing management, governance of health care services in MAI and investments and human resources in networked self-managed institutions. The proposal of these core ideas was done introducing a reality testing that minimizes the politic complexity of their implementation.

Propuesta de reformas a los prestadores públicos de servicios médicos en Chile: “fortaleciendo la opción pública” / A reform proposal to strengthen public health care

Currently, there is no discussion on the need to improve and strengthen the institutional health care modality of FONASA (MAI), the health care system used by the public services net and by most of the population, despite the widely known and long lasting problems such as waiting lists, hospital debt with suppliers, lack of specialists and increasing services purchase transference to the private sector, etc. In a dichotomous sectorial context, such as the one of health’s social security in Chile (the state on one side and the market on the other), points of view are polarized and stances tend to seek refuge within themselves. As a consequence, to protect the public solution is commonly associated with protecting the “status quo”, creating an environment that is reluctant to change. The author proposes a solution based on three basic core ideas, which, if proven effective, can strengthen each other if combined properly. These are: network financing management, governance of health care services in MAI and investments and human resources in networked self-managed institutions. The proposal of these core ideas was done introducing a reality testing that minimizes the politic complexity of their implementation.

Adaptación transcultural al castellano del cuestionario Nursing Home Survey on Patient Safety Culture / Cross-cultural adaptation into Spanish of the Nursing Home Survey on Patient Safety Culture questionnaire

Objetivo. El artículo presenta los resultados de la primera fase de un estudio de investigación destinado a proporcionar al ámbito sociosanitario español un instrumento adecuado para valorar la cultura de seguridad en los espacios residenciales para personas mayores. Material y métodos. Se ha traducido y adaptado al castellano el cuestionario Nursing Home on Patient Safety Culture, desarrollado por la Agency for Health Care Research and Quality. Se siguió el protocolo International Quality of Life Assessment: traducción, evaluación de la equivalencia conceptual, retrotraducción, validez de contenido y pilotaje del cuestionario. Resultados. Tres de los 42 ítems que forman parte de la escala fueron modificados con respecto a la versión original. El resto de modificaciones introducidas correspondieron a la sección F de información sociodemográfica y preguntas relativas al puesto de trabajo. Conclusiones. La herramienta proporcionada permitirá valorar el nivel de cultura de seguridad del residente entre los profesionales de estos centros, identificar áreas de mejora y analizar su evolución ante la introducción de cambios organizativos (AU)

Objective. This article presents the first phase of a research project aimed at adapting a tool for assessing safety culture in nursing homes into Spanish. Material and methods. The Nursing Home on Patient Safety Culture of the Agency for Health Care Research and Quality was translated and culturally adapted. The International Quality of Life Assessment protocol was followed, which included, translation, conceptual equivalence evaluation, back-translation, content validity and a pilot study. Results. Three of the 42 items were modified with respect to the original version. The remaining modifications were introduced in the F Section, containing sociodemographic information and job related questions. Conclusions. The adapted questionnaire will help to assess the level of safety of the resident culture among healthcare professionals in these centres, to identity areas for improvement, and to analyze how to evolve when organizational changes are introduced (AU)

[Cross-cultural adaptation into Spanish of the Nursing Home Survey on Patient Safety Culture questionnaire]. / Adaptación transcultural al castellano del cuestionario Nursing Home Survey on Patient Safety Culture.

OBJECTIVE: This article presents the first phase of a research project aimed at adapting a tool for assessing safety culture in nursing homes into Spanish. MATERIAL AND METHODS: The Nursing Home on Patient Safety Culture of the Agency for Health Care Research and Quality was translated and culturally adapted. The International Quality of Life Assessment protocol was followed, which included, translation, conceptual equivalence evaluation, back-translation, content validity and a pilot study. RESULTS: Three of the 42 items were modified with respect to the original version. The remaining modifications were introduced in the F Section, containing sociodemographic information and job related questions. CONCLUSIONS: The adapted questionnaire will help to assess the level of safety of the resident culture among healthcare professionals in these centres, to identity areas for improvement, and to analyze how to evolve when organizational changes are introduced.

A genomic classifier predicting metastatic disease progression in men with biochemical recurrence after prostatectomy.

BACKGROUND: Due to their varied outcomes, men with biochemical recurrence (BCR) following radical prostatectomy (RP) present a management dilemma. Here, we evaluate Decipher, a genomic classifier (GC), for its ability to predict metastasis following BCR. METHODS: The study population included 85 clinically high-risk patients who developed BCR after RP. Time-dependent receiver operating characteristic (ROC) curves, weighted Cox proportional hazard models and decision curves were used to compare GC scores to Gleason score (GS), PSA doubling time (PSAdT), time to BCR (ttBCR), the Stephenson nomogram and CAPRA-S for predicting metastatic disease progression. All tests were two-sided with a type I error probability of 5%. RESULTS: GC scores stratified men with BCR into those who would or would not develop metastasis (8% of patients with low versus 40% with high scores developed metastasis, P<0.001). The area under the curve for predicting metastasis after BCR was 0.82 (95% CI, 0.76-0.86) for GC, compared to GS 0.64 (0.58-0.70), PSAdT 0.69 (0.61-0.77) and ttBCR 0.52 (0.46-0.59). Decision curve analysis showed that GC scores had a higher overall net benefit compared to models based solely on clinicopathologic features. In multivariable modeling with clinicopathologic variables, GC score was the only significant predictor of metastasis (P=0.003). CONCLUSIONS: When compared to clinicopathologic variables, GC better predicted metastatic progression among this cohort of men with BCR following RP. While confirmatory studies are needed, these results suggest that use of GC may allow for better selection of men requiring earlier initiation of treatment at the time of BCR.

Lymphatic route of transport and pharmacokinetics of Micrurus fulvius (coral snake) venom in sheep.

The contribution of the lymphatic system to the absorption and systemic bioavailability of Micrurus fulvius venom after subcutaneous (SC) administration was assessed using a central lymph-cannulated sheep model. Micrurus fulvius venom was administered either by intravenous bolus (IV) or subcutaneous injection (SC) in 12 sheep with and without thoracic duct cannulation and drainage. Venom concentration in serum and lymph was determined by a sandwich enzyme-linked immunosorbent assay (ELISA) in samples collected over a 6-hour period and in tissues harvested at the end of the experiment. Pharmacokinetic parameters were determined by a non-compartmental analysis. In the lymphatic cannulated group, over the 6 hours after the venom was administered, 69% of administered dose was accounted for in blood (45%) and lymph (25%). Negligible levels of venom were detected in organs and urine implying that the steady state observed after SC administration is maintained by a slow absorption process. Comparison of kinetics of the thoracic duct cannulated and non-cannulated groups showed that lymphatic absorption contributed in an important way to maintenance of this steady state. These results show that the limiting process in the pharmacokinetics of Micrurus fulvius venom following SC administration is absorption, and that the lymphatic system plays a key role in this process.

Experiencia internacional en relación al reposo médico y a la protección de los trabajadores frente a la incapacidad transitoria de generar ingresos: referente para el caso chileno / International policies towards sick leave: A referent to analyze the Chilean situation

This is a comparative review of sick leave and wage replacement policies among countries of the Organization for Economic Co-operation and Development (EOCD), an organism that Chile joined recently. This review also deals with the main transfor-mations applied to the system to improve its effciency and the variables that explain such changes. The Chilean system is analyzed from the perspective of substitution rates, waiting time and protection length. According to these parameters, Chile is located below countries such as Scandinavian countries, that provide a universal protection, and over those countries that provide a focalized protection according to worker’s needs.

Home-based pulmonary rehabilitation in very severe COPD: is it safe and useful?

OBJECTIVE: To determine the safety and usefulness of a home-based pulmonary rehabilitation program for patients with very severe chronic obstructive pulmonary disease (COPD) who receive long-term treatment with oxygen. METHODS: A randomized prospective study that included 50 patients with very severe COPD undergoing long-term treatment with oxygen. At the start of the program and after 12 months, the following evaluations were performed: pulmonary function tests, submaximal exercise capability, and quality of life. The rehabilitation program lasted for 1 year, with periodic home visits by a physiotherapist and included respiratory reeducation training of the respiratory muscles and muscular training. RESULTS: Forty-two patients completed the study (27 in the rehabilitation group and 15 in the control group). There were no initial differences between the 2 groups. No complications arising from the performance of the exercises were observed. The rehabilitation group showed a clinically significant increase in the distance covered in the 6-minute walk test (313 +/- 72 m vs 392 +/- 82 m, P = .0001) and a clinically significant reduction in the St George's Respiratory Questionnaire score (55.3 +/- 15.0 vs 40.5 +/- 13.8, P = .0001). No significant changes were found in any of the parameters studied in the control group. CONCLUSION: A home-based pulmonary rehabilitation program for patients with very severe COPD under long-term oxygen treatment is safe and useful, as it achieves an improvement in exercise tolerance, reduces dyspnea after effort, and improves quality of life without causing any complication arising from the performance of the exercises.

[Ventricular reentry tachycardia within the bundle branches. Report of 3 cases]. / Taquicardia ventricular por reentrada de rama a rama: presentación de tres casos.

Vientricular tachycardia due to reentry within the bundle branches occurs in the presence of left ventricular dilatation and conduction alterations in the His-Purkinje system. A macro-reentry is formed by the His bundle, left and right bundles and ventricular myocardium. The anatomical substrate of this arrhythmia is ventricular dilatation. However, it may appear in healthy hearts. Alterations of intraventricular conduction are reflected by a prolongation of PR interval and bundle branch block in the surface EKG and prolongation of HV interval in the endocavitary registry. During tachycardia, His activation precedes ventricular activation. We report three patients aged 55, 58 and 78 years old with a dilated cardiomyopathy and ventricular tachycardia due to reentry within the bundle branches. All had a left bundle branch block and a prolonged HV internal. The arrhythmia was induced during the study in two patients. All were subjected to radiofrequency fulguration of the right branch of the His bundle. After fulguration, two remained with a pattern of complete right bundle branch block and one with a complete intermittent AV block. All three are free of arrhythmic events.

[Radiofrequency ablation of right accessory pathways]. / Fulguración con radiofrecuencia de haces paraespecíficos derechos.

BACKGROUND: Accessory pathways are muscular connections between auricles and ventricles, present in different points of mitral and tricuspid annuluses. These pathways participate in 50% of paroxysmal supraventricular tachycardias and the definitive cure of the arrhythmia is their ablation. AIM: To report our experience in patients with right accessory pathways. PATIENTS AND METHODS: Fifty consecutive patients treated between 1990 and 1996 are reported. Eight had a history of syncope, two had a diagnosis of Ebstein disease and 36 had a pre-excitation in the surface electrocardiogram. RESULTS: Fifty four accessory pathways were identified, since four patients had two pathways. Twenty four pathways were posteroseptal, 15 were lateral, 9 were medioseptal and 6 were anteroseptal. One patient had also a nodal reentry tachycardia. Fulguration was attempted in 39 patients and it was finally successful in 32. Three patients required more than one session. There were six relapses and all were successfully ablated in a second session. A mean of 28 radiofrequency applications were done (range 1-76), mean laboratory time was 6 hours and mean radioscopy time was 70 min. Four patients had a transient atrioventricular conduction blockade. CONCLUSIONS: Radiofrequency ablation of accessory pathways has a high degree of success and a low rate of complications.

Ventricular tachycardia and fibrillation in normal hearts.

Although ventricular tachyarrhythmias usually occur in the setting of definable heart disease, up to 15% of ventricular tachycardias and 10% of ventricular fibrillation occur in patients without heart disease. Of the various clinical entities comprising these idiopathic ventricular tachyarrhythmias, a few well-defined clinical syndromes have been described, such as idiopathic right ventricular outflow tract tachycardia, idiopathic left posterior fascicular ventricular tachycardia, and the right bundle branch block and ST segment elevation syndrome of idiopathic ventricular fibrillation. Many advances have been made in the past few years in our understanding and treatment of idiopathic ventricular tachyarrhythmias, and these advances are the subject of this review.

[Late effects of radiofrequency fulguration: report of five cases]. / Efectos tardíos post fulguración con radiofrecuencia: experiencia clínica en 5 casos.

Radiofrequency fulguration is the definitive treatment of several supraventricular and ventricular arrhythmias. During radiofrequency application, the conduction in a specific zone is interrupted as a consequence of cellular necrosis and edema. The disappearance of edema, minutes or hours after the procedure, allows the reappearance of conduction and arrhythmias. On the other hand, the definitive lesion is larger than the one caused acutely, due to the progression of the scar. We report five patients, in whom there was an apparent failure of the fulguration, since at the end of the procedure there was conduction in the fulgurated zone, the tachycardia was inducible or pre excitation and arrhythmias reappeared during the follow up. All five were subjected to a new electrophysiological study and in all, fulguration had been effective. We conclude that these late effects of fulguration are due to the slow progression of fibrosis, that continues days or weeks after the procedure.