Isolated Potentials and Pace‐Mapping as Guides for Ablation of Ventricular Tachycardia in Various Types of Nonischemic Cardiomyopathy

Nonischemic Cardiomyopathy and Ventricular Tachycardia. Background: In patients with prior infarction, isolated potentials (IPs) during sinus rhythm reflect fixed scar and often indicate sites critical for ventricular tachycardia (VT). The purpose of this study was to determine the value of IPs in conjunction with pace‐mapping to guide VT ablation in patients with various types of nonischemic cardiomyopathy. Methods: Mapping and ablation of VT were performed in 35 consecutive patients (26 men, age 55 ± 13 years, ejection fraction 0.31 ± 0.14) with VT and various etiologies of nonischemic cardiomyopathy. Pace‐mapping was performed at sites with low voltage. Radiofrequency energy was delivered at sites with concealed entrainment or matching pace‐maps. Results: One hundred ninety‐five VTs (mean cycle length 363 ± 88 ms) were induced. Sites with prespecified ablation criteria displaying IPs during sinus rhythm were recorded in 21 of 35 patients (60%, IP‐positive). In these patients, a total of 216 sites meeting prespecified ablation criteria were identified and 146 of 216 sites (68%) displayed IPs. Fifteen of 21 IP‐positive patients (71%) no longer had inducible VT after ablation. In 14 of 35 patients, no sites with IPs where prespecified ablation criteria were met were identified (IP‐negative) despite combined endocardial and epicardial mapping in 7 of 14 patients. Only 1 of 14 IP‐negative patients (7%) no longer had inducible VT at the end of the ablation procedure. During a mean follow‐up of 18 ± 13 months, 14 of 21 IP‐positive patients (67%) remained arrhythmia‐free, compared to 1 of 14 IP‐negative patients (7%; P < 0.01). Half of the IP‐negative patients had major adverse events due to recurrent arrhythmias, compared to none in IP‐positive patients. Conclusion: IPs in conjunction with pace‐mapping are helpful for identifying critical isthmus areas for ablation of VT in patients with various types of nonischemic cardiomyopathy. Patients with nonischemic cardiomyopathy in whom the arrhythmogenic substrate is characterized by IPs have a more favorable outcome than patients in whom IPs are absent. J Cardiovasc Electrophysiol, Vol. 21, pp. 1017‐1023, September 2010)     

Mapping and Ablation of Frequent Post‐Infarction Premature Ventricular Complexes

Mapping of Post‐Infarction PVCs . Introduction: Premature ventricular complexes (PVCs) occur frequently in patients with heart disease. The sites of origin of PVCs in patients with prior myocardial infarction and the response to catheter ablation have not been systematically assessed. Methods and Results: In 28 consecutive patients (24 men, age 60 ± 10, ejection fraction [EF] 0.37 ± 0.14) with remote myocardial infarction referred for catheter ablation of symptomatic refractory PVCs, the PVCs were mapped by activation mapping or pace mapping using an irrigated‐tip catheter in conjunction with an electroanatomic mapping system. The site of origin (SOO) was classified as being within low‐voltage (scar) tissue (amplitude ≤1.5 mV) or tissue with preserved voltage (>1.5 mV). The SOO was confined to endocardial scar tissue in 24/28 patients (86%). The SOO was outside of scar in 3 patients and could not be identified in 1 patient. At the SOO, local endocardial activation preceded the PVC by 46 ± 19 ms, and the electrogram amplitude during sinus rhythm was 0.48 ± 0.34 mV. The PVCs were effectively ablated in 25/28 patients (89%), resulting in a decrease in PVC burden on a 24‐hour Holter monitor from 15.6 ± 12.3% to 2.4 ± 4.2% (P < 0.001). The SOO most often was confined to scar tissue located in the left ventricular septum and the papillary muscles. Conclusion: Similar to post‐infarction ventricular tachycardia, PVCs after remote myocardial infarction most often originate within scar tissue. Catheter ablation of these PVCs has a high‐success rate. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1002‐1008, September 2010)     

A Randomized Study of Secondary Prevention of Early Stage Problem Drinkers in Primary Health Care

The subjects were recruited from participants in a health examination of random samples of the adult population in Stockholm county. Those aged 18–64years who admitted a high alcohol consumption (>40 g 100% ethanol/day) among men and <30 g among women) or had an elevated value of serum-gammaglutamyltransferase (GOT) (cut-off point 1.0 microkatal/l for men and 0.6 microkatal/l for women) or had certain other indications of a high alcohol consumption were included. More severe cases, and those with an elevated GOT due to reasons other than alcohol, were excluded. The remaining subjects, 70 men and 13 women, were allocated at random to either an intervention or a comparison group. An elevated GGT was the main inclusion criteria. The subjects in the comparison group were advised by the general practitioner to cut their alcohol consumption, while those in the intervention group made further visits to their general practitioner, who gave general support and used an elevated GGT as an indication of the recent level of alcohol consumption at consecutive visits. There were three visits on average, so we are comparing a group receiving advice with a group receiving further minimal intervention. At the one-year follow-up there were greater, however not significant, reductions in GGT-level, in self-reported alcohol consumption and in a ‘problem index’ in the minimal intervention group than in the comparison group.     

Adenosquamous carcinoma of the prostate

Adenosquamous carcinoma of the prostate is an unusual histological variant of prostate cancer. The histogenesis of this tumor remains uncertain. The stimulus for the development of the squamous metaplastic cells had been thought to be related to hormone and/or radiation therapy. This report presents a case of adenosquamous carcinoma of the prostate with abscence of previous hormone or radiation therapy. The case showed negative prostate-specific antigen and high molecular weight cytokeratin staining of the adenocarcinoma component, and negative prostate-specific antigen and positive high molecular weight cytokeratin staining of the squamous cell carcinoma component. The adenocarcinoma component stained intraluminally with periodic acid schiff. The staining features and the distinct localizations of the components with intermingling, but no transition, are against the collision-type tumor theory and support the theory that the adenocarcinoma and squamous components arise de novo from pluripotent stem cells. The patient had a rapid downhill clinical course and died 3 weeks after the diagnosis was made.     

Does demographic entrapment challenge the two-child paradigm?

Local demographic entrapment has been discussed informally formany years, but is taboo to the UN agencies and to much of academia.There are also indications that the world as a whole may bedemographically trapped in that global per capita grain productionis falling. Arguments for and against recognizing entrapmentare discussed. Policy implications of entrapment are outlinedin the light of the 1994 International Conference on Populationand Development (ICPD). The case for a one-child world is argued.Carrying capacity, disentrapment, the two-child paradigm, abortion,Rwanda and North/South tensions are considered.     

Epidermodysplasia Verruciformis: An Unusual Presentation

BACKGROUND Epidermodysplasia verruciformis (EV) is a rare autosomal recessive genetic disorder of the immune system manifested by increased susceptibility to cutaneous human papillomavirus (HPV) infection beginning from the early years of life, and compromising lesions resembling flat warts, especially on the distal extremities and the face; but malignant transformation occurs in sun-exposed areas within the third or fourth decade of life.OBJECTIVE We describe two case reports of epidermodysplasia verruciformis, one of which was onset and had more aggressive features than the usual presentation.METHODS Intermittent surgical excision of the tumoral lesions were performed in the first case, whereas only one surgical intervestion was sufficient in the second case.RESULTS The early onset case was more aggressive, and new tumoral lesions were seen, whereas the other patients was free of the disease for 2 years.CONCLUSION Epidermodysplasia verruciformis possess multi factorial etiologies, and the main prognostic factor of the behavior of the disease may be the family history and genetic susceptibility.     

Infant mortality Social inequality in a Swedish city

Infant mortality rates for geographical areas of Göteborg(Gothenburg), Sweden, were studied for 78,357 infants livingin Göteborg from 1971 to 1985. During this time 637 infantdeaths occurred. The 32 parishes of Göteborg were dividedinto three groups referred to as high, medium and low incomeareas. The difference in infant mortality among the areas wasstatistically significant and increased over time. The relativerisk of Infant death was 1.8 in the medium and 2.0 in the lowcompared to the high income areas in 1981–1985. The infantmortality rate varied from 3.8 to 7.6/1000. The high incomeareas had lower death rates overall, in congenital malformationsand in perinatal conditions. The low income areas had a significantlyhigher rate of sudden infant death syndrome than the other groups.Political and administrative decentralization was implementedin Sweden in the 1980s. Local area research thus has a directrelevance for policy, planning and provision of services. Theresults reflect the social segregation, associated not onlywith economic stratification but also with differences in lifestylesand cultural environment. Further analyses are necessary toprovide Information on preventable risk factors In order todecrease the observed socio-economic differences. The resultscan, however, be used for targeting infant mortality levelsand for the allocation of resources.