Right Bundle Branch Block of Unknown Age in the Setting of Acute Anterior Myocardial Infarction: An Attempt to Define Who Should Be Paced Prophylactically

It is widely accepted that patients presenting with acute anterior myocardial infarction and acute onset of right bundle branch block should be prophylactically paced in contrast with those who have a chronic bundle branch block. The admitting physician is faced with the dilemma of how to act if the age of this conduction disturbance is unknown. This problem has further intensified in recent years, with the introduction of thrombolytic treatment, where insertion of a central vascular line is associated with increased morbidity. The objectives of this study were to define clinical or electrocardiographic parameters that may help the admitting physician to decide whether patients presenting with an anterior wall myocardial infarction and a right bundle branch block of unknown age should be prophylactically paced. We examined prospectively the in-hospital clinical course of 39 consecutive patients presenting with an acute myocardial infarction in whom the age of a right bundle branch block upon admission was unknown (group C, n = 39) and compared it with two similar groups of patients who presented with an acute right bundle branch block (group A, n = 38) and with a known chronic right bundle branch block (group B, n = 22). Thirty-three patients (33%) died, with cardiogenic shock being the leading cause of death in the entire population. Prophylactic pacing, which was carried out in 66% and 54% of patients in groups A and C, respectively, did not reduce mortality rates. No clinical or electrocardiographic variables on admission were predictive to support prophylactic pacing in group C. In 10 of 46 (22%) patients who were prophylactically paced with a transvenous electrode, the following complications attributed to the procedure were detected: (1) either rapid sustained ventricular tachycardia (during implantation) that was unresponsive to overdrive pacing, or ventricular fibrillation necessitating electrical defibrillation (4 patients); (2) recurrent episodes of rapid nonsustained ventricular tachycardia, which stopped only after the pacemaker was turned off (1 patient); (3) complete AV block (1 patient); (4) fever appearing on the third or fourth day after implantation (3 patients); and (4) a large hematoma in the groin in 1 patient who was treated with thrombolysis shortly before pacemaker electrode insertion. Thus, the complications of transvenous temporary pacing in the era of thrombolysis may outweigh any theoretical advantage. (PACE 1995; 18:1496-1508)     

A Population-based Study of Toenail Onychomycosis in Israeli Children

Abstract:   Onychomycosis is widespread in the adult population, but considered to be rare in children. A number of studies in recent years show a rise in the prevalence of toenail onychomycosis in children. Of these, only a few were population-based. Here, we present a comprehensive cross-sectional population-based survey of toenail onychomycosis in primary school children in Israel. The survey included 1148 children, 598 boys, and 550 girls aged 5 to 14 from primary schools in the Jerusalem vicinity. Each child underwent a physical examination and completed a personal questionnaire, which provided background information of predisposing factors. The survey shows a prevalence of 0.87% of toenail onychomycosis. Although this figure is too small for statistical analysis, some important conclusions could be drawn: prevalence increased with age: boy/girl ratio was 2.2; the dominant etiologic agent was Trichophyton rubrum followed by Trichophyton mentagrophytes and Candida albicans . Infections were probably transferred from adults via the environment to children. Infected children came from different socio-economic backgrounds. This condition should be considered in the differential diagnosis of nail diseases in children.     

Magnesium Therapy in Ventricular Arrhythmias

Magnesium (Mg) is the known activator of 300 enzymes which govern energy utilization, cell permeability, and ionic membrane currents in the cardiac conducting cells. This may explain the antiarrhythmic efficacy of Mg in specific clinical settings, despite its only modest electrophysiological effects. This review summarizes the effect of Mg administration in four clinical conditions: in digitalis toxicity; in drug-induced torsade de pointes; in patients with chronic diuretic therapy; and in acute myocardial infarction. Mg effectively abolished ventricular tachyarrhythmias associated with digitalis intoxication. This effect of Mg is related to the activation of sodium-potassium ATP-ase, which is inhibited by digitalis. Drug-induced torsade de pointes was promptly abolished by Mg sulfate in the clinical setting. Experimental studies showed that Mg suppresses the early afterdepolarizations and the triggered activity responsible for occurrence of the arrhythmia. In diuretic-treated hypertensives, potassium depletion has been associated with increased ventricular ectopy and sudden death. Mg has been found to be an important adjuvant for intracellular repletion of potassium in these patients. Several randomized, double-blind studies in patients with acute infarction showed that Mg administered on admission improved survival or reduced the incidence of complex ventricular arrhythmias. Thus, Mg should be employed as first-line therapy in digitalis intoxication and drug-related torsade de pointes, and should be considered an important adjuvant therapy in hypertensives treated with diuretics and patients with acute myocardial infarction.     

COMPLICATIONS OF LAPAROSCOPIC PROCEDURES AFTER CONCENTRATED TRAINING IN UROLOGICAL LAPAROSCOPY

PURPOSE: To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. MATERIALS AND METHODS: Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. RESULTS: During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. CONCLUSIONS: The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.     

Effect of magnesium on restenosis after percutaneous transluminal coronary angioplasty: a clinical and angiographic evaluation in a randomized patient population: A pilot study

Restenosis is a major clinical problem following successfulpercutaneous transluminal coronary angioplasty. Since magnesiumhas vasodilator and antithrombotic effects, this study was designedto evaluate its potential to decrease the rate of restenosis. In an open-labelled, randomized controlled study, 148 patientsunderwent successful coronary angioplasty. Ninety-eight patientswere treated with 46—52 mmoll 18–20 h intravenousmagnesium sulphate (groups Ml and M2), and 49 of them continuedwith oral supplements of magnesium hydroxide 600 mg. day^–1(group M2).The other 50 patients served as controls (group C).Coronary angiography was performed before, immediately afterand at 6 months follow-up or earlier if clinically indicated.Clinical, laboratory, ergometric and radionuclide evaluationswere also carried out. One hundred and thirty-nine patients (94%) with 163 dilatedsegments completed the study. Intravenous magnesium was welltolerated The cross-sectional area at the site of angioplastyincreased by 3.55 ± 201 mm2 in groups Ml and M2 comparedwith an increase of 2.90 ± 163 mm2 in the control group,(P=003). A trend towards a lower rate of restenosis (>50%reduction in luminal diameter) was noticed in the magnesiumgroups (28/110, 25%) compared with the control group (20/53,38%) P=0.10. Oral administration of magnesium was well tolerated,did not have an additive effect on restenosis, but an improvedclinical course was noted. It is concluded that intravenous administration of magnesiumin patients undergoing coronary angioplasty is feasible andsafe and that the beneficial trend of magnesium to prevent acuterecoil and late (within 6 months) restenosis is encouragingand should promote further investigation in a larger patientpopulation.