Global assessment of the knowledge and confidence in managing allergic disorders among primary care pediatricians across Europe: An EAACI task force report.

BACKGROUND: Pediatricians are often the first point of contact for children in Primary Care (PC), but still perceive gaps in their allergy knowledge. We investigated self-perceived knowledge gaps and educational needs in pediatricians across healthcare systems in Europe so that future educational initiatives may better support the delivery of allergy services in PC. METHOD: A multinational survey was circulated to pediatricians who care for children and adolescents with allergy problems in PC by the EAACI Allergy Educational Needs in Primary Care Pediatricians Task Force from February to March 2023. A 5-point Likert scale was used to assess the level of agreement with questionnaire statements. Thirty surveys per country were the cut-off for inclusion and statistical analysis. RESULTS: In this study, 1991 respondents were obtained from 56 countries across Europe and 210 responses were from countries with a cut-off below 30 participants per country. Primary care pediatricians (PCPs) comprised 74.4% of the respondents. The majority (65.3%) were contracted to state or district health services. 61.7% had awareness of guidelines for onward allergy referral in their countries but only 22.3% were aware of the EAACI competencies document for allied health professionals for allergy. Total sample respondents versus PCPs showed 52% and 47% of them have access to allergy investigations in their PC facility (mainly specific IgE and skin prick tests); 67.6% and 58.9% have access to immunotherapy, respectively. The main barrier to referral to a specialist was a consideration that the patient's condition could be diagnosed and treated in this PC facility, (57.8% and 63.6% respectively). The main reasons for referral were the need for hospital assessment, and partial response to first-line treatment (55.4% and 59.2%, 47% and 50.7%, respectively). Learning and assessment methods preference was fairly equally divided between Traditional methods (45.7% and 50.1% respectively) and e-learning 45.5% and 44.9%, respectively. Generalist physicians (GPs) have the poorest access to allergy investigations (32.7%, p = .000). The majority of the total sample (91.9%) assess patients with allergic pathology. 868 (43.6%) and 1117 (46.1%), received allergy training as undergraduates and postgraduates respectively [these proportions in PCPs were higher (45% and 59%), respectively]. PCPs with a special interest in allergology experienced greater exposure to allergy teaching as postgraduates. GPs received the largest amount of allergy teaching as undergraduates. Identifying allergic disease based on clinical presentation, respondents felt most confident in the management of eczema/atopic dermatitis (87.4%) and rhinitis/asthma (86.2%), and least confident in allergen immunotherapy (36.9%) and latex allergy (30.8%). CONCLUSION: This study exploring the confidence of PCPs to diagnose, manage, and refer patients with allergies, demonstrated knowledge gaps and educational needs for allergy clinical practice. It detects areas in need of urgent improvement especially in latex and allergen immunotherapy. It is important to ensure the dissemination of allergy guidelines and supporting EAACI documents since the majority of PCPs lack awareness of them. This survey has enabled us to identify what the educational priorities of PCPs are and how they would like to have them met.

Prevalence of convergence insufficiency among Spanish school children aged 6 to 14 years

Clinical relevanceConvergence insufficiency (CI) at an early age can lead to learning difficulties affecting school performance. The aim of this study was to examine the prevalence of CI in a non-clinical population of Spanish children using well defined clinical criteria and to determine whether sex is a risk factor.MethodsVisual acuity and binocular vision tests were performed in 628 children aged 6–14 years (mean age 9.6 ± 1.3 years) at three schools in the Madrid Community, Spain. To assess CI prevalence we used CITT (Convergence Insufficiency Treatment Trial) criteria. The three signs considered were: i) exophoria at least 4∆ greater at near than at far; ii) near break point of convergence (NPC) ≥ 6 cm; and iii) reduced positive fusional vergence (PFV) at near (≤ 15∆ base-out break or failed Sheard's criterion).ResultsThe CI prevalence detected was 5.30% (33 children). Proportions of children with one or two signs of CI were 23.76% (148 children) and 12.20% (76 children), respectively. No differences in these CI rates by sex were detected.ConclusionThe clinically significant CI prevalence observed here suggests the need for more binocular vision screening programmes in school settings. (AU)

Indications and practice of diverting ileostomy after colorectal resection and anastomosis in ovarian cancer cytoreduction.

OBJECTIVE: To determine the factors related with diverting ileostomy performance after colorectal resection and anastomosis, in advanced ovarian cancer cytoreductive surgery. METHODS: We have previously demonstrated the risk factors associated with anastomotic leak after colorectal anastomosis: Advanced age at surgery, low serum albumin level, additional bowel resections, manual anastomosis and distance of the anastomosis from the anal verge. However, use of diverting ileostomy is strongly variable and depends on individual surgeon preferences and training. Eight hospitals participated in this retrospective study. Data of 695 patients operated for ovarian cancer with primary colorectal anastomosis were included (January 2010-June 2018). Fourteen pre-/intraoperatively defined variables were identified and analysed as justification factors for use of diverting ileostomy. RESULTS: The rate of diverting ileostomy in the entire cohort was 19.13% (133/695; range within individual centers 4.6-24.32%). Previous treatment with bevacizumab [OR 2.8 (1.3-6.1); p=0.01]; additional bowel resections [OR 3.0 (1.8-5.1); p<0.001]; extended operating time [OR 1.005 (1.003-1.006); p<0.001] and intra-operative red blood transfusion [OR 2.7 (1.4-5.3); p<0.001] were found to be independently associated with diverting ileostomy performance. Assuming a 7% AL rate cut-off, up to 51.8% of DI presented an AL risk below 7% and might have been spared. CONCLUSIONS: The risk factors that drive the gynecologic oncology surgeons to perform a diverting ileostomy, seem to differ from the actual risk factors that we have identified to be associated with postoperative anastomotic leak. Broader awareness of the risk factors that contribute to a higher perioperative risk profile, will facilitate a better risk stratification process and possibly avoid unnecessary stoma formation in ovarian cancer patients.

A prospective observational study of the clinical and pathological impact of stereotactic body radiotherapy (SBRT) as a neoadjuvant strategy of chemoradiation in pancreatic cancer.

PURPOSE/OBJECTIVE(S): To improve the curative resection rates and prognoses, a variety of neoadjuvant (NA) strategies have been explored in PDAC. In our institution, non-metastatic PDACs have been treated with a NA intent with induction multiagent chemotherapy and SBRT. The primary endpoint was to increase R0 resection rate. The secondary endpoints were the analysis of the clinical tolerance, the pathological response, the local control (LC) and the OS. MATERIALS/METHODS: All consecutive patients with non-metastatic PDAC underwent SBRT as part of the NA strategy were included. A total dose of 40-62 Gy were delivered in 5-10 fractions. Surgery was performed after SBRT and restaging. RESULTS: Since February 2014 to December 2018, 45 patients were enrolled. Thirty-two patients underwent surgery (71.1%), 10 out of 15 were initially unresectable disease patients (66.75%). R0 resection rate was 93% (30 patients) and pN0 status was achieved in 20 patients (60.6%). Tumour regression grade (TRG): 12 patients with complete response or marked response (TRG 0-1: 37.5%), 16 patients with moderate response (TRG 2: 50%) and four patients with poor response (TRG 3: 12.5%). The median follow-up was 16.2 m (range 6.6-59.6 m) since diagnosis. The LC rate achieved was very high (95.5%). Actuarial 12 and 24 m OS was 67.4% and 35.9% respectively. No grade 3 or higher toxicity related to SBRT was observed. CONCLUSION: The results are encouraging, suggesting that SBRT has a significant role in the management of these patients and further studies will be necessary to prove these findings.

Pathology findings and clinical outcomes after risk reduction salpingo-oophorectomy in BRCA mutation carriers: a multicenter Spanish study.

OBJECTIVE: To determine the incidence of serous tubal intraepithelial carcinoma (STIC) after risk reduction salpingo-oophorectomy(RRSO), and to describe oncological outcomes after RRSO. MATERIALS AND METHODS: BRCA pathogenic mutation carriers who had undergone an RRSO were evaluated in this retrospective multicenter observational study. Patients were only included when fallopian tubes were analyzed following the protocol for Sectioning and Extensively Examining the FIMbria (SEE-FIM). Surgeries were performed between June 2010 and April 2017 at eight Spanish hospitals. RESULTS: A total of 359 patients met the inclusion criteria. STIC was diagnosed in 3 (0.8%) patients; one of them underwent surgical staging due to positive peritoneal washing, with absence of disease at the final pathology report. None of the three patients received adjuvant chemotherapy and were free of disease at last follow-up. Fallopian tube and ovarian carcinoma were diagnosed in 5 (1.4%) and 1 (0.3%), respectively. At a median (range) follow-up time of 29 (3-92) months, five patients had a newly diagnosed breast cancer. Other types of cancer, which were diagnosed during the follow-up time, included: serous primary peritoneal carcinoma (n = 1), serous endometrial carcinoma (n = 1), colon (n = 1), pancreas (n = 1), jaw (n = 1), and lymphoma (n = 1). Seven patients died due to different types of cancer: breast (n = 4), pancreas (n = 1), jaw (n = 1), and colon (n = 1). CONCLUSION: The incidence of STIC after RRSO in BRCA mutation carriers is low (0.8%) and it presents an excellent oncological outcome. Patients after RRSO, however, run the risk to develop other types of cancer during follow-up and should be properly advised before the prophylactic surgery.

Evaluation of an Online Educational Program for Parents and Caregivers of Children With Food Allergies.

BACKGROUND AND OBJECTIVE: The increasing prevalence of food allergy affects both patients and their families. Objective: The aim of this study was to evaluate the impact of an online educational program designed for parents and caregivers of children with food allergies. The program was developed by a multidisciplinary group comprising health care professionals, researchers, and expert patients under the participatory medicine model. MATERIAL AND METHODS: Participants took a 2-week online educational program covering major topics in food allergy management. General knowledge about the disease, symptoms, treatment, and topics relevant to families' daily lives were evaluated. The contents included educational videos, online forums, and live video chats. A pretest/posttest questionnaire survey was used to evaluate the impact of the program. RESULTS: A total of 207 participants enrolled in the educational program, which was completed by 130 (62.8%). Knowledge acquisition improved significantly following participation in the program in 15 out of 30 items (50%), reaching P<.001 for 8 items (26.7%). Of the 207 participants who started the program, 139 (67.1%) visited online forums, and 27.5% attended video chats. Average overall satisfaction with the educational program was 8.78 (on a scale of 0 to 10). CONCLUSIONS: The results obtained show that parents improved their knowledge in all areas of food allergy. The high level of satisfaction among participants suggests that digital learning tools are effective and motivational, enabling patients to acquire appropriate knowledge and thus increasing their quality of life.

Feasibility of robotic radical hysterectomy after neoadjuvant chemotherapy in women with locally advanced cervical cancer.

OBJECTIVE: To evaluate the safety and feasibility of robotic radical hysterectomy (RRH) in women with locally advanced cervical cancer (LACC) after neoadjuvant chemotherapy (NACT). MATERIAL AND METHODS: A retrospective comparative longitudinal observational study was performed in 30 patients with LACC FIGO stage IB2-IIB who underwent RRH after NACT between February 2008 and September 2014. This group was compared with a cohort of 176 patients underwent RRH with cervical cancer FIGO stage IA2-IB1 in the same period of time. RESULTS: Patients' age, BMI, ASA score, comorbidity, and previous abdominal surgery, was similar between groups. FIGO stage significantly differed between groups; 29 (96.6%) of patients had FIGO stage IB2 in NACT group and 163 (92.6%) were FIGO stag IB1 in women without NACT, p < 0.001. Type of RRH was also significantly different between groups. Type C1 RRH was significantly more common in NACT group, p = 0.015. Mean (SD) tumor size was significantly bigger in NACT, 27.0 (13.7) mm versus 20.9 (9.0) mm in early stage versus LACC, respectively. p = 0.023. Mean (SD) surgical time was significantly longer in NACT group (307.8 (40.2) min versus 277.4 (45.4) min, p = 0.001). Estimated blood loss and length of the hospital stay were similar between groups. There were no significant differences in terms of intraoperative and postoperative complications. CONCLUSIONS: RRH after NACT in women with LACC seems to be safe and feasible. These results need to be confirmed in studies with a larger patients sample.

Análisis del valor predictivo positivo de las subcategorías BI-RADS ®4: resultados preliminares en 880 lesiones / Analysis of the positive predictive value of the subcategories of BI-RADS ® 4 lesions: preliminary results in 880 lesions

Objetivos. Las subcategorías BI-RADS®4A/B/C comprenden amplios rangos de valores predictivos positivos (VPP) y no se ha definido su correlación con descriptores específicos. Nuestro objetivo es analizar el VPP de las subcategorías y los descriptores asignados a ellas en lesiones mamográficas y ecográficas. Material y método. Analizamos 880 lesiones confirmadas histológicamente y subclasificadas prospectivamente como BI-RADS®4A/B/C entre 2003-2010. El estudio estadístico incluyó pruebas de significación, tablas de contingencia y estudio de riesgos relativos (RR) sobre 545 lesiones mamográficas y 627 ecográficas. Resultados. Los VPP por subcategoría fueron 8,8%-4A, 18,9%-4B y 58,3%-4C. La correlación entre VPP y lesiones fue la esperada, excepto: VPP 4A>4B en nódulos ecográficos irregulares/márgenes no circunscritos y microcalcificaciones con distribución segmentaria, asignación de BI-RADS®4 a lesiones BI-RADS®3 y consideración de lesiones idénticas en distintas subcategorías. En el estudio por tablas de contingencia, las lesiones mamográficas estuvieron en rangos de 4B/C y las ecográficas en 4B. Los RR fueron significativos en nódulos mamográficos para morfología irregular (RR=3,205) y márgenes espiculados (RR=2,469), y para microcalcificaciones pleomórficas (RR=2,531), amorfas (RR=0,334) y distribución segmentaria (RR=1,895). En la ecografía, los RR fueron significativos en todos los descriptores, con valores mayores de uno en morfología irregular (RR=1,977) y márgenes no circunscritos (RR=2,277). Conclusiones. Nuestros resultados concuerdan con los publicados. Las excepciones encontradas pueden justificarse por aspectos relacionados con la variabilidad y factores no radiológicos con posible influencia en la categorización y VPP. Es necesario elaborar modelos matemáticos que permitan la categorización objetiva e incluyan factores no relacionados con la imagen(AU)

Objectives. The positive predictive values (PPV) of the subcategories of BI-RADS® 4 lesions (A/B/C) vary widely, and their correlation with specific descriptors has yet to be defined. We aimed to analyze the PPV of the subcategories and of the mammographic and ultrasonographic descriptors assigned to each. Material and methods. We analyzed 880 histologically confirmed lesions prospectively classified as BI-RADS® 4 A/B/C between 2003 and 2010. The statistical analysis included significance tests, contingency tables, and relative risk (RR) ratios, calculated for 545 mammographic lesions and 627 ultrasonographic lesions. Results. The PPV was 8.8% for subcategory 4A, 18.9% for subcategory 4B, and 58.3% for subcategory 4C. The correlation between PPV and lesions was what we expected, with three exceptions: a) the PPV of 4A was greater than that of 4B in nodules that were irregular or had uncircumscribed margins on ultrasonography and in microcalcifications with segmental distribution on mammography, b) BI-RADS® 3 lesions classified as BI-RADS® 4, and c) identical lesions classified in distinct subcategories. In the contingency table analysis, the mammographic lesions were 4B/C and the ultrasonographic lesions were 4B. On mammography, the RR was significant for nodules with irregular shape (RR=3.205) and for those with spiculated margins (RR=2.469), as well as for microcalcifications that were pleomorphic (RR=2.531) or amorphous (RR=0.334), and for those with segmental (RR=1.895). On ultrasonography, the RR were significant for all the descriptors, with values greater than 1 for irregular shape (RR=1.977) and uncircumscribed margins (RR=2.277). Conclusions. Our results corroborate previous reports. The exceptions can be explained by aspects related to variability and nonradiological factors that might influence the classification and PPV. Mathematical models should be developed to enable the objective classification and these should include factors not related to imaging(AU)

[Analysis of the positive predictive value of the subcategories of BI-RADS(®) 4 lesions: preliminary results in 880 lesions]. / Análisis del valor predictivo positivo de las subcategorías BI-RADS(®)4: resultados preliminares en 880 lesiones.

OBJECTIVES: The positive predictive values (PPV) of the subcategories of BI-RADS(®) 4 lesions (A/B/C) vary widely, and their correlation with specific descriptors has yet to be defined. We aimed to analyze the PPV of the subcategories and of the mammographic and ultrasonographic descriptors assigned to each. MATERIAL AND METHODS: We analyzed 880 histologically confirmed lesions prospectively classified as BI-RADS(®) 4 A/B/C between 2003 and 2010. The statistical analysis included significance tests, contingency tables, and relative risk (RR) ratios, calculated for 545 mammographic lesions and 627 ultrasonographic lesions. RESULTS: The PPV was 8.8% for subcategory 4A, 18.9% for subcategory 4B, and 58.3% for subcategory 4C. The correlation between PPV and lesions was what we expected, with three exceptions: a) the PPV of 4A was greater than that of 4B in nodules that were irregular or had uncircumscribed margins on ultrasonography and in microcalcifications with segmental distribution on mammography, b) BI-RADS(®) 3 lesions classified as BI-RADS(®) 4, and c) identical lesions classified in distinct subcategories. In the contingency table analysis, the mammographic lesions were 4B/C and the ultrasonographic lesions were 4B. On mammography, the RR was significant for nodules with irregular shape (RR=3.205) and for those with spiculated margins (RR=2.469), as well as for microcalcifications that were pleomorphic (RR=2.531) or amorphous (RR=0.334), and for those with segmental (RR=1.895). On ultrasonography, the RR were significant for all the descriptors, with values greater than 1 for irregular shape (RR=1.977) and uncircumscribed margins (RR=2.277). CONCLUSIONS: Our results corroborate previous reports. The exceptions can be explained by aspects related to variability and nonradiological factors that might influence the classification and PPV. Mathematical models should be developed to enable the objective classification and these should include factors not related to imaging.

[Systemic embolism after reversion to sinusal rhythm of persistent atrial flutter]. / Embolismo sistémico tras reversión a ritmo sinusal del aleteo auricular persistente.

BACKGROUND: The incidence of embolism in atrial flutter has been underestimated in the routine clinical practice. PATIENTS AND METHODS: In this study the incidence of thromboembolic events after restoration of sinus rhythm (by catheter ablation or cardioversion) was compared in two groups of consecutive patients, with a different anticoagulation protocol. A total of 169 patients were evaluated. A first retrospective analysis of 79 non anticoagulated patients (group I). A second prospective group of 90 patients who were treated with an anticoagulation protocol (group II) similar to that for patients with atrial fibrillation. All had typical atrial flutter of at least one month's duration before the procedure. RESULTS: The mean age of patients in group I was 61 12 years and the mean left ventricular ejection fraction was 57 6%. Patients in group II had a mean age of 61 10 years and the mean left ventricular ejection fraction was 56 9%. No differences were observed regarding prevalence of structural cardiopathy, arterial hypertension, diabetes mellitus, left ventricular dysfunction, atrial size or atrial fibrillation between the two groups of patients. Four patients in the retrospective analysis (5%) had an embolic event associated with the procedure, compared with 0 (0%) in the group of patients treated with the anticoagulation protocol. The efficient anticoagulation was associated with a lower risk of thromboembolic events (p < 0.05). CONCLUSIONS: The incidence of embolic events after reversion to sinusal rhythm of persistent atrial flutter can be decreased. These patients should follow the same recommendations of anticoagulation that apply for patients with persistent atrial fibrillation that are going to be reverted to sinus rhythm.

Embolismo sistémico tras reversión a ritmo sinusaldel aleteo auricular persistente / Systemic embolism after reversion to sinusal rhythm of persistent atrial flutter

Pacientes y métodos. En este estudio se compara la incidencia de eventos tromboembólicos después de restaurar el ritmo sinusal (por ablación con catéter o cardioversión) en dos grupos consecutivos de pacientes con un protocolo de anticoagulación diferente. Se evaluaron 169 pacientes. Un primer análisis retrospectivo de 79 pacientes no anticoagulados (grupo I). Un segundo grupo prospectivo de 90 pacientes se trató con un protocolo de anticoagulación (grupo II) similar al de los pacientes con fibrilación auricular. Todos presentaban aleteo auricular típico de al menos un mes de duración antes del procedimiento. Resultados. Grupo I: la edad media fue 61ñ12 años y la fracción de eyección ventricular izquierda media de 57 ñ 6 por ciento. Grupo II: tuvo una edad media 61 ñ 10 años y fracción de eyección ventricular izquierda media de 56 ñ 9 por ciento. No hubo ninguna diferencia en la prevalencia de cardiopatía estructural, hipertensión arterial, diabetes mellitus, disfunción ventricular izquierda, tamaño auricular o fibrilación auricular entre los dos grupos de pacientes. Cuatro pacientes del análisis retrospectivo (5 por ciento) presentaron un episodio embólico asociado con el procedimiento, comparado con 0 (0 por ciento) de los pacientes tratados con un protocolo de anticoagulación. La anticoagulación eficaz se asoció con un menor riesgo de tromboembolismo (p < 0,05). Conclusiones. Es posible reducir la incidencia de eventos embólicos después de la reversión a ritmo sinusal del aleteo auricular persistente. Estos pacientes deben seguir las mismas recomendaciones de anticoagulación que los pacientes con fibrilación auricular persistente que van a ser revertidos a ritmo sinusal (AU)

Randomized comparison of efficacy of cooled tip catheter ablation of atrial flutter: anatomic versus electrophysiological complete isthmus block.

There is a subset of patients with failed ablation of the cavotricuspid isthmus (CTI) using standard catheters and with 10% of the patients having recurrences. The purpose of this study was to compare the cooled and standard ablation with regard to acute successful electrophysiological achievement of bidirectional isthmus block and the subacute anatomic characteristics of the lesions. This randomized, experimental study compares the effects of ablation on the isthmus using a cooled catheter with those of a standard ablation catheter in 16 pigs. In 12 animals, CTI block was achieved after ablation (8/8 cooled and 4/8 standard). In two animals, it was not possible to achieve complete isthmus block and two had persistent slow conduction (all four using the standard catheter). After 1 week, the animals were slaughtered. The size of the lesion was greater with the irrigated tip catheters. Transmural lesions were found in 14 animals. A complete line of anatomic isthmus block was not documented after thefirst line in six animals, four with the standard and two with the cooled catheter. A conduction block was never present across gaps > or = 5 mm. In conclusion cooled catheters achieved a complete line of electrophysiological and anatomical block in a significantly higher percentage than the standard catheters.

[Evaluation of the anatomopathological characteristics and the safety of radiofrequency lesions at the atrial level with two different systems of irrigated tip catheters on an experimental level]. / Estudio de las características anatomopatológicas y la seguridad de las lesiones producidas en la aurícula con dos diferentes sistemas de catéteres de punta irrigada en un modelo experimental.

INTRODUCTION AND OBJECTIVES: We performed this study to evaluate the security and efficacy in the lesions produced on the atrial wall by different irrigated catheters in an experimental model. We evaluated the anatomopathologic characteristics of the lesions produced by two different systems of irrigated tip catheters, with opened or closed circuit. METHODS: This study was performed in 16 pigs applying 60 sec radiofrequency pulses with three different energy levels (15, 25 y 50 Watts). Two different systems of radiofrequency ablation irrigated catheters were used, opened and closed. We used 4 pigs in which we performed ablation with a standard catheter as a control group. Under fluoroscopic guidance, catheters were placed on the high and low right atrial lateral wall, where lesions were produced. After 7 days, animals were sacrificed for anatomopathological study. RESULTS: A total of 27 lesions were performed with irrigated catheters (11 closed circuit and 16 opened) and 6 with standard catheters in the control group. We did not find significant differences in the lesion characteristics between the two different systems of irrigated tip catheter used, nevertheless lesions performed with the closed system were slightly greater. Th lesions produced with irrigated catheters were always superior in the control group. Transmurality in the free atrial wall is frequent with both systems. We did not see any perforation in the atrial wall. CONCLUSIONS: We did not find significant differences in the size of the lesions produced with the two systems of irrigated catheters used. These data from an experimental model can provide useful information for atrial tachycardia radiofrequency ablation procedures in humans.

[Macroscopic and microscopic study of the right coronary artery after radiofrequency catheter ablation of cavotricuspid isthmus in an experimental model]. / Estudio macro y microscópico de la arteria coronaria derecha tras ablación con catéter y radiofrecuencia del istmo cavotricuspídeo en un modelo experimental.

INTRODUCTION AND OBJECTIVES: The right coronary artery (RCA) is found in the AV groove, just below the ablation target of atrial flutter, the cavotricuspid isthmus (ICT). After radiofrequency (RF) ablation with standard catheters, there have been no reports of complications, but it may not be successful in 10% of the cases. However, the use of irrigated tip catheters, which create deeper lesions, might potentially damage the coronary tree. METHODS: We analyzed the effects of ICT RF ablation on the coronary tree, with macroscopic and microscopic anatomopathological study. Ablation on ICT was performed using an irrigated tip catheter in 16 pigs and was randomly compared with a standard ablation catheter. There were no clinical problems, modifications of ST or new arrhythmias during the ablation. The heart was extracted at 1 week. RESULTS: The macroscopic study demonstrated that the right coronary artery was preserved, along the ICT, surrounded by the epicardial fat. The microscopic study showed an inflammatory reaction in the epicardial fat that reached the adventitia of the coronary artery, but never produced necrosis in 14 cases. The muscular wall of the artery had signs of focal inflammation without endothelium involvement in 2 cases. However, we found a subepicardial vein completely damaged by the radiofrequency. CONCLUSIONS: Although the right coronary artery is located just below the isthmus, no necrosis was observed in any case. However, there was an inflammatory reaction that focally reached the muscular wall. The veins may be damaged in RF ablation, perhaps due to the different blood flow of each vessel.

[Radiofrequency ablation of recurrent monomorphic ventricular tachycardia in a patient with severe systemic scleroderma]. / Ablación con radiofrecuencia de taquicardia ventricular monomorfa recurrente en una paciente con esclerodermia sistémica severa.

A case of progressive systemic scleroderma in a 33 year-old woman who was referred to our Arrhythmia Unit due to daily palpitations and dizziness is presented. The 24-hour Holter recording showed monomorphic ventricular tachycardia which lasted several minutes. Hemodynamic study showed dilated right chambers and right ventricular dysfunction, without pulmonary hypertension. Left ventricular angiography and coronary arteries were normal. During programmed electrical stimulation, two different ventricular tachycardia were induced and ablated with radiofrequency on the right ventricle. The patient remains free of recurrence of tachycardia after (10 months of follow up). Patients with progressive systemic scleroderma may present several different cardiac arrhythmias. Involvement of the right ventricle is particularly frequent as is the origin of ventricular tachycardia in this ventricle. Radiofrequency catheter ablation is safe and effective in the management of these patients.

[Anatomopathological and biochemical correlation of lesions produced by standard and irrigated 4 mm radiofrequency catheters]. / Correlación anatomopatológica y bioquímica de las lesiones producidas por la radiofrecuencia con catéteres estándar e irrigados de 4 mm.

INTRODUCTION AND OBJECTIVES: The influence on the size of radiofrequency lesions by cooling of the tip of the electrode remains unclear. Moreover, the possible effects of two different cooling systems, closed and open, have not been well differentiated. We designed this study to compare both systems of irrigated-tip catheters and the lesions produced with standard 4 mm catheters and also to evaluate the pathological and biochemical marker release correlation (cardiac troponin I) in an experimental model. METHODS: The study was performed in 20 pigs. Applying between 1-8 radiofrequency pulses, at a power of 15, 25 or 50 watts, for 15-60 seconds to each animal. After 7 days, the pigs were sacrificed for anatomopathological study. RESULTS: A total of 54 lesions were produced, 25 with standard catheters and 29 with irrigated catheters. The mean volume of the lesions produced with standard catheters was 146 +/- 110 microl and with irrigated-tip catheters 856 +/- 864 microl (p < 0.001). Peak values of cardiac troponin I were also higher for irrigated catheters (18 +/- 15 ng/ml) than for standard (6.5 +/- 3 ng/ml). The correlation between the size of the lesion and the levels of cardiac troponin I were 0.86 and 0.79 with the standard and irrigated-tip catheters, respectively. The incidence of cratering was higher with standard catheters (60%) than with irrigated (27%). CONCLUSIONS: The lesions produced with an irrigated catheter are greater than those observed with standard catheters. The mean peak value of postablation cardiac troponin demonstrate a good correlation with the real size of the necrosis.

[Recurrent ventricular fibrillation during a febrile illness in a patient with the Brugada syndrome]. / Fibrilación ventricular recurrente durante un proceso febril en un paciente con síndrome de Brugada.

Different situations have been involved in the origin of ventricular arrhythmic events in patients with the Brugada syndrome such as bradycardia, alcohol consumption and mental stress. We present a 30 year old male with recurrent ventricular fibrillation due to a febrile illness with intense sweating. He had been previously studied at our Unit in 1995 because of an episode of resuscitated cardiac arrest due to ventricular fibrillation. The twelve-lead electrocardiogram showed the typical characteristics of a patient with the Brugada syndrome. Different invasive and non-invasive tests performed were normal. He received a defibrillator and had no recurrences during 4 years of follow up. In March,1999, after an upper respiratory tract infection he had high fever treated with paracetamol but at down he had sweating and chills, followed by 3 defibrillator shocks. Late interrogation showed 5 episodes of ventricular fibrillation, two of them non-sustained, and the rest adequately treated by the defibrillator. Activation and inactivation kinetics for early INa are twofold faster at higher temperature, and shift activation and steady-state inactivation. This may explain the role of the temperature as a trigger for ventricular arrhythmias in our patient.

Biochemical markers and cardiac troponin I release after radiofrequency catheter ablation: approach to size of necrosis.

BACKGROUND: We designed this study to determine the value of serum levels of several cardiac markers in patients who underwent radiofrequency ablation and to establish the utility of cardiac troponin I (cTnI). After radiofrequency ablation there is always a small localized endomyocardial necrosis. The volume of the necrosis may be estimated by the rise of several biochemical marker levels, classically creatinine kinase (CK) and CK-MB. cTnI is a newly available biochemical marker with a high cardiac specificity. METHODS AND RESULTS: We analyzed the data from 51 patients who underwent radiofrequency ablation and from 16 control patients who underwent an electrophysiologic study without ablation. The levels of CK, CK-MB mass, cTnI, and myoglobin were compared with clinical findings, ST-T wave abnormalities, and the presence of arrhythmias. The study shows that there is a higher release of cTnI compared with the standard markers CK, CK-MB, and myoglobin. A pathologic value of cTnI was found in 92% of the patients of the ablation group. CK-MB had a lower sensitivity (63%). The area under the receiver operating characteristic curve for cTnI was 0.9375, significantly superior to the other biochemical markers (P <.05). We found a moderate level of correlation between the number of radiofrequency pulses and cardiac cTnI release (r = 0.69, P <.0001). CONCLUSIONS: The serum level of cTnI detects the minor myocardial damage produced by radiofrequency ablation. This would be useful information to have in patients who might have the potential for other ischemic events. The other biochemical or ablation parameters usually reported, including the radiofrequency ablation parameters, have no good correlation with the size of the myocardial necrosis. Therefore we suggest that monitoring of cTnI is the best way to detect and quantify the size of myocardial necrosis created by radiofrequency ablation.

[Electromagnetic interference between automatic defibrillators and digital and analog cellular telephones]. / Interferencias electromagnéticas entre los desfibriladores automáticos y los teléfonos móviles digitales y analógicos.

BACKGROUND AND OBJECTIVES: Functional pacemaker interference by mobile telephones has been described with analogical systems and with possible greater influence, digital systems, including inhibition and inadequate pacing. The influence of both system has not been extensively studied in patients with implantable cardioverter defibrillators (ICD). PATIENTS AND METHODS: We studied the influence of mobile phones, both digital and analogic network, on the performance of several models of defibrillators, in a standardised test set up designed to provide high sensitivity. The purpose of our study was to establish whether there are any influences on ICD functions, both in in vivo and in in vitro models. Several mobile phones, with different transmission powers, were moved towards the defibrillator and the electrode, under continuous documentation of defibrillator sensing and interrogation afterwards. The experimental model was performed with the aid of an arrhythmia simulator (Intersim) and demo-defibrillators. The tests were repeated both in and out of a solution of saline water with an impedance within normal human limits. RESULTS: Partial loss of telemetry was found in 14 patients, 8 with analogical phones and 6 with digital phones. Fourteen patients showed alterations only on the surface electrocardiogram channel and five on the intracavitary channel. The same results were reproduced in the in vitro model. However, the in vitro test allowed us to simulate multiple ventricular arrhythmias, and demonstrate the normal sensing and functioning of the defibrillator during a "spontaneous" arrhythmia. After testing, we demonstrate that no real oversensing/undersensing was documented in any device. There was no evidence of ICD reprogramming or pacing inhibition. In particular, no inadequate therapies were delivered. CONCLUSIONS: a) in our series, we have not demonstrated clinically significant electromagnetic interferences with mobile phones of digital or analogical networks: b) the in vitro model allowed us to conclude that even if a spontaneous arrhythmia appears, the function of the defibrillator is not altered; c) the use of mobile phones seems to be safe for defibrillator patients, and d) however, some basic rules, such as to maintain the phone at least 15 cm away from the defibrillator, are advised.