[Pterigium colli: secondary surgical correction of one severe case]. / Pterygium colli: reprise d'une correction chirurgicale d'un cas sévère.

Congenital web neck is a deformity hardly ever reported in the English literature. It is usually associated to Ulrrich-Turner syndrome. There are several options to correct this deformity, but in severe cases complete correction of the web and the abnormal back hair is not always possible. We present our experience with a secondary case where previous butterfly method was employed, a combined procedure was used achieving a satisfactory result. We considered that this technique is useful and offers an important improvement of the contour.

Thrombolysis and Q wave versus non-Q wave first acute myocardial infarction: a GUSTO-I substudy. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries Investigators.

OBJECTIVES: We assessed the outcomes of patients with a first myocardial infarction with ST segment elevation, with and without the development of abnormal Q waves after thrombolysis. BACKGROUND: Prethrombolytic era studies report conflicting short-versus long-term mortality in the overall non-Q wave population, probably related to its heterogeneity. METHODS: Patients with no electrocardiographic (ECG) confounding factors or evidence of previous infarction were included. Q wave infarction was defined as a Q wave duration > or = 30 ms in lead aVF; R wave > or = 40 ms in lead V1; any Q wave or R wave < or = 10 ms and < or = 0.1 mV in lead V2; or Q wave > or = 40 ms in at least two of the following leads: I, aVL, V4, V5 or V6. In-hospital clinical events and mortality at 30 days and 1 year were assessed. RESULTS: No Q waves developed in 4,601 (21.3%) of the 21,570 patients. This group comprised more women and had a lower Killip class, lower weight and less anterior baseline ST elevation. The non-Q wave group had less in-hospital cardiogenic shock (2.1% vs. 3.3%, p < 0.0001), less heart failure (8.5% vs. 13.9%, p < 0.0001) and a trend toward less stroke (0.7% vs. 1.0%, p = 0.07) but an increased use of angioplasty (28% vs. 24%, p = 0.0001). The unadjusted mortality rate in the non-Q wave group was lower at 30 days (0.9% vs. 1.8%, p = 0.0001) and 1 year (2.7% vs. 4.2%, p = 0.0001), as was the adjusted 30-day mortality rate (4.8% vs. 5.3%, p < 0.0001). CONCLUSIONS: Patients with no ECG confounding factors or evidence of previous infarction who do not develop Q waves after thrombolysis have a better 30-day and 1-year prognosis than patients with a Q wave infarction.

Use of resources, quality of life, and clinical outcomes in patients with and without new Q waves after thrombolytic therapy for acute myocardial infarction (from the GUSTO-I trial).

Previous reports indicate that patients who do not develop Q waves after thrombolytic therapy are a different population with a better long-term survival than those who do develop Q waves. However, the use of resources, quality of life, and health status of this population have not been fully evaluated. Using data from the Economics and Quality of Life subset of the Global Utilization of Streptokinase and tPA for Occluded Arteries study, we examined 30-day and 1-year mortality, use of resources, and quality-of-life measures among 1,830 of 3,000 patients with acute myocardial infarction and ST-segment elevation treated with thrombolytic therapy. At hospital discharge, 555 patients (30.2%) had not developed Q waves. These patients had lower mortality than patients with Q waves at 30 days (1.6% vs 4.5%, p <0.01) and at 1 year (4.7% vs 6.8%, p <0.04). Recurrent chest pain and dyspnea were similar at 30 days and 1 year. Patients without Q waves had significantly more angiography and trends toward higher readmission, revascularization, and use of calcium antagonists at 30 days. Angiography, revascularization, readmission, and quality of life were equivalent from 30 days to 1 year, with no sign of late instability. Logistic regression analysis showed an association between in-hospital revascularization and better survival and quality of life at 1 year. Conversely, there was no association between in-hospital use of calcium antagonists and outcome to explain the lower mortality in non-Q-wave patients. The absence of Q waves after thrombolytic therapy is a marker of success, implying better prognosis and equivalent quality of life, use of resources, and health status than for patients with Q-wave acute myocardial infarction and no sign of long-term unstable clinical course.

Successive myocardial infarctions in a patient with Mahaim fiber syndrome.

A patient with Mahaim fiber syndrome suffered two acute myocardial infarctions during the last two years. Anomalous atrioventricular excitation was intermittent. Diagnosis of both anteroseptal and anterolateral electrocardiographic myocardial infarction could be made despite ventricular pre-excitation. These findings have not been previously published, to our knowledge.

Total myocardial revascularization with arterial conduits: radial artery combined with internal thoracic arteries.

OBJECTIVE: We prospectively tested the feasibility of achieving total arterial revascularization with the use of the radial artery to revascularize the circumflex, diagonal, and right coronary arteries combined with a left internal thoracic artery graft to the left anterior descending artery and, in some cases, a right internal thoracic artery graft to the right coronary artery. METHODS: In 164 patients, the radial artery was used as a free Y or T graft from the left internal thoracic artery. Of 568 grafts (3.5 +/- 1 [standard deviation] per patient), 296 (1.8 +/- 0.8 per patient) were constructed with the radial artery as single grafts or as double, triple, or quadruple sequential anastomoses to the circumflex, diagonal, and posterior descending arteries. Diltiazem was administered to prevent spasm. Forty-six patients underwent coronary angiography before discharge from the hospital. Follow-up time was 1 to 19 (9.5 +/- 6.1) months. RESULTS: Total arterial revascularization was achieved in 137 patients (83.5%). Three (1.8%) died postoperatively of sepsis, ventricular fibrillation, and heart failure, respectively. Three (1.8%) had postoperative myocardial infarction. No hand ischemia occurred. Angiography showed patency of all arterial conduits. Radial artery spasm appeared in 3 (6.5%) of 46 angiograms. Two patients (1.2%) died during the follow-up period of pneumonia and gastrointestinal tract bleeding, respectively. No other events or reoperations occurred, and 95.1% of the patients are free of symptoms. CONCLUSIONS: The radial artery, as a free Y or T graft from the left internal thoracic artery to the circumflex, diagonal, and right coronary arteries, permits total arterial revascularization with excellent patency rates, minimal morbidity and mortality, and no need for reoperation. Longer follow-up times are necessary to draw definitive conclusions.

Subacute pneumopathy during amiodarone therapy.

A patient with types A and B of Wolff-Parkinson-White syndrome developed subacute pneumonitis during long-term treatment with amiodarone. The pneumopathy occurred only when the maintenance dose was increased to 800 mg/day. Lung specimens obtained by transbronchial biopsy showed chronic pneumonitis with C3 deposition by immunofluorescence. Pulmonary signs spontaneously disappeared two months after the drug was discontinued.

Captopril versus hydralazine in primary pulmonary hypertension.

Captopril was tested as the treatment for a patient with primary pulmonary hypertension (PPH) and its effects were compared with those of hydralazine. Captopril induced a rise in pulmonary pressures and in intrapulmonary shunt; hydralazine lowered pulmonary resistances and increased paO2 and blood O2 transport. Prospective studies in PPH treated with captopril are recommended and evaluation of all drugs not only by hemodynamic but also respiratory and O2 transport measurements.

Transient tachycardia- and bradycardia-dependent left anterior and left posterior hemiblocks. Effects of isoproterenol.

Tachycardia- and bradycardia-dependent, left anterior and left posterior hemiblocks as transient phenomena were registered in two patients spontaneously, and especially as a consequence of isoproterenol infusion. A chronic trifascicular type of A-V block was present in the first case, whereas in the second case a bradycardia-dependent left posterior hemiblock was registered during an acute myocardial infarction. In the first patient the isoproterenol effects were: (1) a shortening of the refractoriness and an increase of the conduction velocity in the injured fascicle, (2) an increase in the slope of phase-4 depolarization on the left posterior fascicle, and (3) a presumably shifting toward zero of threshold potential on the left anterior fascicle. Isoproterenol effects disappeared from 30 to 40 min after it was discontinued. In the second case the bradycardia-dependent left posterior hemiblock was registered during very fast heart rates (150 beats min). This finding supports the view that enhanced phase-4 depolarization is the main factor in the development of bradycardia-dependent intraventricular blocks in the course of acute myocardial ischemia.

Reassessment of electrovectorcardiographic signs of left atrial enlargement.

Echocardiographic left atrial size was correlated with 27 electrovectorcardiographic parameters in 93 subjects. In 20 of them hemodynamic studies, including calculation of the left atrial volume, were performed. Subjects were divided into four groups as follows: Group I, 21 healthy subjects; group II, 45 patients with heart disease but no left atrial enlargement; group III, 15 patients with heart disease and left atrial size from 4.1 to 5 cm; and group IV, 12 patients with heart disease and a left atrial size exceeding 5 cm. A good correlation was found between left atrial size and the following parameters: Duration of P wave in standard lead II, voltage of both terminal forces of P wave in lead V1 and its maximal vector in the frontal and sagittal planes. A new index (duration/voltage of P wave in lead II) was postulated, which showed an excellent correlation with left atrial size (p less than 0.001). In all cases the superposition between groups was excessive. These findings indicate the limitations of the classical patterns and raise interest in new parameters concerning the electrocardiographic diagnosis of left atrial enlargement.

[Is there a clinical value of endomyocardial biopsy and immunosuppressive treatment in idiopathic dilated cardiomyopathy? Study by meta analysis]. / Tienen valor clínico la biopsia endomiocárdica y el tratamiento inmunosupresor en la miocardiopatía dilatada idiopática? Estudio por metanálisis.

This study was intended to answer two questions: 1) whether the prognosis of patients with dilated cardiomyopathy and myocardial inflammatory changes, and 2) whether immunosuppressive agents may modify survival. The meta-analysis technique was employed as a tool in order to homogenize the results of several reports that were not conclusive and often contradictory due to the small number of patients studied. Twenty one reports were included; in 12, there was a follow up study of patients with acute inflammatory changes. Four reports compared the follow up of groups showing acute inflammatory changes with controls with dilated cardiomyopathy lacking inflammatory phenomena in the biopsy, including a total of 272 patients; 47 (17.3%) disclosed inflammatory changes. Total mortality for this group was 25.6% while that for the control group was 28.4% (p = NS). Thirteen reports dealt with the effect of immunosuppressive treatment with myocarditis; 7 studies included an untreated control group, summing up 119 patients. Mortality did not differ between these groups: 31.3% and 30.9%, respectively (p = NS). It is concluded that 1) there are very few controlled and conclusive reports available on the prognostic value of endomyocardial biopsy and immunosuppressive treatment in idiopathic dilated cardiomyopathy; 2) the presence of inflammatory changes did not worsen the prognosis; and 3) immunosuppressive treatment did not improve survival.

[Hepatic artery aneurysm]. / Aneurisma de la arteria hepática.

We report the case of a 45-year old man who presented a common hepatic artery aneurysm. He had alcoholic habits and after an episode of upper gastrointestinal tract bleeding underwent an abdominal ultrasound study. This showed a large fluid-filled upper abdominal mass related to the pancreatic head. Both T scan and an angiogram showed an hepatic artery aneurysm. It was resected and the artery repaired interposing a saphenous vein graft. The patient was discharged a week after surgery. Most of the hepatic artery aneurysms are free of symptoms and difficult to palpate and only a few patients can be operated before the occurrence of aneurysmal fissure. Broad use of ultrasound and selective angiography has increased the number of cases diagnosed before complications, reducing the mortality rate, which, in the past, has been reported up to 59%.

[Thrombolytic therapy in a case of prosthetic aortic valve thrombosis]. / Trombolíticos en el tratamiento de un caso de trombosis valvular protésica en posición aórtica.

We present the case of a 40 year old woman, who had an aortic prosthetic valve, of the Björk Shiley type. Three months before admission she began with progressive dyspnea. She was admitted to the Cardiovascular Care Unit with a global cardiac failure. An aortic prosthetic valve thrombosis was diagnosed clinically (absence of the prosthetic click) and by radioscopy (a decrease in the movement of the valve disk, with an incomplete shunt). It was attributed to a secondary failure of the anticoagulant treatment. Despite the treatment she quickly developed a cardiogenic shock. A treatment with 750,000 UI of streptokinase in 30 min was started, followed by 100,000 UI during 12 hours, with total reversion of the hemodynamic features, as judged by clinical examination (recurrence of the prosthetic click), radioscopy (recurrence of the valve movement) and by Doppler echocardiography (reduction of the transvalvular gradient). No complications were observed, and in a follow up of 12 months she persisted asymptomatic. The prosthetic valve thrombosis is an infrequent and almost fatal complication. The classical therapy consists in surgery which is a procedure with a high mortality in patients with severe cardiac failure, and an emergency procedure, as it occurred in our patient. Despite the known success of the thrombolytic therapy in the prosthetic valve thrombosis of the right heart (tricuspid position) it was only in the last years that this treatment was reported in aortic or mitral position. Peripheric embolies were found in 13% of the cases, always with transitory symptoms. There are only 45 cases described in the world, and more experience is needed for definitive conclusions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Elevation of ST segment and Bezold Jarisch reflex as evidence of early post-thrombolysis reperfusion]. / Supradesnivel del segmento ST y reflejo de Bezold Jarisch como evidencias de reperfusión precoz post-trombolisis.

The prognosis of patients with acute myocardial infarction (AMI) depends on the patency of the infarct-related coronary artery. This is the reason why the early recognition of the result of thrombolysis is very important in order to implement more aggressive studies and more complex treatments in case of failure. A clinical syndrome of "early coronary reperfusion" with an excellent correlation with angiographic data has been identified, characterized by: 1) pain decrease in more than 50%, 2) descent of ST segment elevation of more than 50%, 3) early elevation of creatinine phosphokinase (CPK) enzyme; other signs of reperfusión described are the Bezold Jarisch reflex (bradycardia and arterial hypotension) in patients with inferior AMI, an additional elevation of ST segment during thrombolytic infusion. These two signs of successful thrombolysis were seen early and together in our patient. He was a 41 year old male who had an anterior AMI 4 months before admission to our Coronary Care Unit with diagnosis of unstable angina (rest angina). After 10 hours he began with intensive precordial pain of 30 minutes with 2 mm of ST segment elevation in inferior leads. Streptokinase (STK) (1,500,000 units) by infusion was administered during 45 minutes; at 30 minutes of infusion the patient had an increase of ST segment elevation in the same leads which reached 3 mm and decreased to basal line after 2 hours. He also had bradycardia and hypotension which improved with atropine 1 mg IV. An episode of acute heart failure (confirmed by clinical, radiological and hemodynamic data) resolved just before the end of STK infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Memory beyond expression.

The idea that memories are not invariable after the consolidation process has led to new perspectives about several mnemonic processes. In this framework, we review our studies on the modulation of memory expression during reconsolidation. We propose that during both memory consolidation and reconsolidation, neuromodulators can determine the probability of the memory trace to guide behavior, i.e. they can either increase or decrease its behavioral expressibility without affecting the potential of persistent memories to be activated and become labile. Our hypothesis is based on the findings that positive modulation of memory expression during reconsolidation occurs even if memories are behaviorally unexpressed. This review discusses the original approach taken in the studies of the crab Neohelice (Chasmagnathus) granulata, which was then successfully applied to test the hypothesis in rodent fear memory. Data presented offers a new way of thinking about both weak trainings and experimental amnesia: memory retrieval can be dissociated from memory expression. Furthermore, the strategy presented here allowed us to show in human declarative memory that the periods in which long-term memory can be activated and become labile during reconsolidation exceeds the periods in which that memory is expressed, providing direct evidence that conscious access to memory is not needed for reconsolidation. Specific controls based on the constraints of reminders to trigger reconsolidation allow us to distinguish between obliterated and unexpressed but activated long-term memories after amnesic treatments, weak trainings and forgetting. In the hypothesis discussed, memory expressibility--the outcome of experience-dependent changes in the potential to behave--is considered as a flexible and modulable attribute of long-term memories. Expression seems to be just one of the possible fates of re-activated memories.

Food odor, visual danger stimulus, and retrieval of an aversive memory trigger heat shock protein HSP70 expression in the olfactory lobe of the crab Chasmagnathus granulatus.

Although some of the neuronal substrates that support memory process have been shown in optic ganglia, the brain areas activated by memory process are still unknown in crustaceans. Heat shock proteins (HSPs) are synthesized in the CNS not only in response to traumas but also after changes in metabolic activity triggered by the processing of different types of sensory information. Indeed, the expression of citosolic/nuclear forms of HSP70 (HSC/HSP70) has been repeatedly used as a marker for increases in neural metabolic activity in several processes, including psychophysiological stress, fear conditioning, and spatial learning in vertebrates. Previously, we have shown that, in the crab Chasmagnathus, two different environmental challenges, water deprivation and heat shock, trigger a rise in the number of glomeruli of the olfactory lobes (OLs) expressing HSC/HSP70. In this study, we initially performed a morphometric analysis and identified a total of 154 glomeruli in each OL of Chasmagnathus. Here, we found that crabs exposed to food odor stimuli also showed a significant rise in the number of olfactory glomeruli expressing HSC/HSP70. In the crab Chasmagnathus, a powerful memory paradigm based on a change in its defensive strategy against a visual danger stimulus (VDS) has been extensively studied. Remarkably, the iterative presentation of a VDS caused an increase as well. This increase was triggered in animals visually stimulated using protocols that either build up a long-term memory or generate only short-term habituation. Besides, memory reactivation was sufficient to trigger the increase in HSC/HSP70 expression in the OL. Present and previous results strongly suggest that, directly or indirectly, an increase in arousal is a sufficient condition to bring about an increase in HSC/HSP70 expression in the OL of Chasmagnathus.