Improvement in electrocardiographic parameters of repolarization related to sudden death in patients with ventricular dysfunction and left bundle branch block after cardiac resynchronization through His bundle pacing.

BACKGROUND: Cardiac resynchronization therapy (CRT) through permanent His bundle pacing (p-HBP) normalizes interventricular conduction disorders and QRS. Similarly, there are immediate and long-term changes in repolarization, which could be prognostic of a lower risk of sudden death (SD) at follow-up. We aimed to compare the changes in different electrocardiographic (ECG) repolarization parameters related to the risk of SD before and after CRT through p-HBP. METHODS: In this prospective, descriptive single-center study (May 2019 to December 2021), we compared the ECG parameters of repolarization related to SD in patients with non-ischemic dilated cardiomyopathy, left bundle branch block (LBBB), and CRT indications, at baseline and after CRT through p-HBP. RESULTS: Forty-three patients were included. Compared to baseline, after CRT through p-HBP, there were immediate significant changes in the QT interval (ms): 445 [407.5-480] vs 410 [385-440] (p = 0.006), QT dispersion (ms): 80 [60-100] vs 40 [40-65] (p < 0.001), Tp-Te (ms): 90 [80-110] vs 80 [60-95] (p < 0.001), Tp-Te/QT ratio: 0.22 [0.19-0.23] vs 0.19 [0.16-0.21] (p < 0.001), T wave amplitude (mm): 6.25 [4.88-10] vs - 2.5 [- 7-2.25] (p < 0.001), and T wave duration (ms): 190 [157.5-200] vs 140 [120-160] (p = 0.001). In the cases of the corrected QT (Bazzett and Friederichia) and the Tp-Te dispersion, changes only became significant at 1 month post-implant (468.5 [428.8-501.5] vs 440 [410-475.25] (p = 0.015); 462.5 [420.8-488.8] vs 440 [400-452.5] (p = 0.004), and 40 [30-52.5] vs 30 [20-40] (p < 0.001), respectively) (Table 1). Finally, two parameters did not improve until 6 months post-implant: the rdT/JT index, 0.25 [0.21-0.28] baseline vs 0.20 [0.19-0.23] 6 months post-implant (p = 0.011), and the JT interval, 300 [240-340] baseline vs 280 [257-302] 6 months post-implant (p = 0.027). Additionally, most of the parameters continued improving as compared with immediate post-implantation. CONCLUSIONS: After CRT through His bundle pacing and LBBB correction, there was an improvement in all parameters of repolarization related to increased SD reported in the literature.

His bundle pacing success and electrical parameter stability regardless of three-dimensional transthoracic echocardiography lead localization.

BACKGROUND OR PURPOSE: His bundle pacing (HBP) is the most physiological form of ventricular pacing. Few prospective studies have analyzed lead localization using imaging techniques and its relationship with electrical parameters and capture patterns. The objective of this study is to examine the correlation between electrical parameters and lead localization using three-dimensional transthoracic echocardiography (3D TTE). METHODS: This single-center, prospective, nonrandomized clinical research study (January 2018 to June 2020) included patients with an indication of permanent pacing, in whom 3D TTE was performed to define lead localization as supravalvular or subvalvular. RESULTS: A total of 92 patients were included: 56.5% of leads were supravalvular, and 43.5% were subvalvular, which resembles previous anatomic descriptions of autopsied hearts of His bundle localization within the triangle of Koch (ToK). R-wave sensing was higher when the His lead was localized subvalvular instead of supravalvular. His lead localization was not associated with HBP threshold or impedance differences, nor with the two different HBP patterns of capture, or with the ability of HBP to correct baseline BBB. The thresholds remained stable during follow-up visits, regardless of His lead localization. Higher R-wave sensing was observed during follow-up than at baseline, mainly in the subvalvular His leads. However, lead impedances in both positions decreased during follow-up. CONCLUSIONS: Lead localization in relation to the tricuspid valve did not influence the electrical performance of HBPs. Wide anatomical variations of the His bundle within the ToK explain our findings, reinforcing the idea that the technique for HBP should be fundamentally guided by electrophysiological and not anatomical parameters.

Cardiac resynchronization therapy in non-ischemic cardiomyopathy: a comparative non-randomized study of His Bundle pacing versus biventricular pacing.

BACKGROUND: Cardiac resynchronization therapy (CRT) via permanent His bundle pacing (pHBP) has gained acceptance globally, but robust studies comparing pHBP-CRT with classic CRT are lacking. In this study, we aimed to compare the improvement in left ventricular ejection fraction (LVEF) after pHBP-CRT versus classic CRT. METHODS: This was a single-center study comparing a prospective series of pHBP-CRT with a historical series of CRT via classic biventricular pacing (BVP). Patients with non-ischemic cardiomyopathy, baseline LVEF < 35%, left bundle branch block (LBBB), and CRT indications were selected. RESULTS: Fifty-one patients underwent classic CRT and 52 patients underwent pHBP-CRT. In the classic CRT group, the median (interquartile range) basal LVEF was 30% (IQR, 29-35%) before implantation and 40% (35-48%) at follow-up. In the pHBP-CRT group, the median basal LVEF was 30% (28-34%) before implantation and 55% (45-60%) at follow-up, with significant differences between both modalities at follow-up (p = 0.001). The median long term His recruitment threshold with LBBB correction was 1.25 (1-2.5) V at 0.4 ms in cases of pHBP-CRT, compared to a left ventricular coronary sinus threshold of 1.25 (1-1.75) V in cases of classic CRT (p = 0.48). After CRT, the median paced QRS was 135 (120-145) ms for pHBP-CRT versus 140 (130-150) ms for BVP-CRT (p = 0.586). CONCLUSIONS: The improvement in LVEF was superior with pHBP-CRT than with classic CRT. The thresholds at follow-up were similar in both groups.

Recomendaciones para profesionales no anestesiólogos en procedimientos de sedoanalgesia / Recommendations for non-anaesthesia providers in sedation and analgesia procedures

El dolor, y la ansiedad que este produce, son las primeras causas de sufrimiento en los niños que acuden a los servicios de urgencias, motivando un aumento del interés de padres y sanitarios para proporcionar una adecuada analgesia y sedación.Por ello, en los últimos años se ha producido un incremento en el número de procedimientos diagnósticos y terapéuticos en niños que requieren sedoanalgesia en urgencias pediátricas, lo que ha originado una necesidad de formación de personal no anestesiólogo para cubrir ese requisito sin afectar a la seguridad del paciente.El objetivo de este documento de consenso es establecer recomendaciones basadas en la evidencia científica, elaboradas y consensuadas por el Grupo de Trabajo de Sedoanalgesia de la Sociedad Española de Urgencias de Pediatría, sobre las competencias y la capacitación del personal que realiza procedimientos de sedoanalgesia para conseguir un óptimo manejo del paciente pediátrico antes, durante y después del procedimiento en los servicios de urgencias pediátricas.El documento de consenso se ha estructurado en dos partes: la primera hace referencia a las competencias del personal no anestesiólogo que realiza procedimientos de sedoanalgesia, y la segunda, a la forma de obtener la capacitación necesaria. Se ha elaborado un listado de preguntas de investigación, se han definido unas palabras clave y se ha realizado una búsqueda bibliográfica desglosando la evidencia disponible. Los resultados se muestran como conclusiones, sometidas a votación anónima por cada uno de los miembros del Grupo de Trabajo. En cada conclusión se indica el porcentaje obtenido en la votación. (AU)

Pain and the anxiety that it produces are the main sources of suffering in children managed in emergency departments, eliciting a growing interest in parents and health care providers in the adequate provision of sedation and analgesia.In consequence, the number of diagnostic and therapeutic procedures that require sedation and/or analgesia in paediatric emergency departments has increased in recent years, which has generated a need to train non-anaesthesiologists on how to provide this care without affecting patient safety.The objective of this document is to establish evidence-based recommendations, developed by consensus by the Working Group on Sedation and Analgesia of the Sociedad Española de Urgencias de Pediatría, regarding the competencies and training of staff who perform sedation or analgesia procedures to achieve the greatest possible quality in the management of paediatric patients before, during and after these procedures in the paediatric emergency care setting.The consensus document has been structured in two parts: the first addresses the competencies of non-anaesthesiologists who perform sedoanalgesia procedures, and the second how to obtain the necessary training. A list of research questions was prepared, keywords defined and a literature search carried out to break down and summarise the available evidence. The results are presented in the form of conclusions, which were subjected to anonymous voting by each of the members of the working group. For each of the conclusions, we provide the percent agreement obtained in the voting. (AU)

Recommendations for non-anaesthesia providers in sedation and analgesia procedures.

Pain and the anxiety that it produces are the main sources of suffering in children managed in emergency departments, eliciting a growing interest in parents and health care providers in the adequate provision of sedation and analgesia. In consequence, the number of diagnostic and therapeutic procedures that require sedation and/or analgesia in paediatric emergency departments has increased in recent years, which has generated a need to train non-anaesthesiologists on how to provide this care without affecting patient safety. The objective of this document is to establish evidence-based recommendations, developed by consensus by the Working Group on Sedation and Analgesia of the Sociedad Española de Urgencias de Pediatría, regarding the competencies and training of staff who perform sedation or analgesia procedures to achieve the greatest possible quality in the management of paediatric patients before, during and after these procedures in the paediatric emergency care setting. The consensus document has been structured in two parts: the first addresses the competencies of non-anaesthesiologists who perform sedoanalgesia procedures, and the second how to obtain the necessary training. A list of research questions was prepared, keywords defined and a literature search carried out to break down and summarise the available evidence. The results are presented in the form of conclusions, which were subjected to anonymous voting by each of the members of the working group. For each of the conclusions, we provide the percent agreement obtained in the voting.

Effectiveness and safety of AV node ablation after His bundle pacing in patients with uncontrolled atrial arrhythmias.

INTRODUCTION: In patients with uncontrolled atrial fibrillation, atrioventricular (AV) node ablation after permanent His bundle pacing (p-HBP) could be a therapeutic option for heart rate (HR) control. We aimed to demonstrate the advantages of AV node ablation with p-HBP, and to describe its effectiveness and safety. METHODS: This descriptive observational study included patients with uncontrolled permanent atrial arrhythmias who were candidates for HR control (January 2019 to July 2020) and underwent p-HBP and AV node ablation. RESULTS: A total of 39 patients were included. The median left ventricular ejection fraction (LVEF) was 55% (45-60); 46.1% in NYHA class II and 43.6% in NYHA class III. p-HBP was achieved in 92.3% (n = 36), and AV node ablation was successfully performed in all patients. The LVEF improved in patients with reduced LVEF (baseline, 35% [23.8-45.3%]; follow-up, 40% [35-56.5%], p < 0.05); the NYHA class also showed improvement (baseline, 71.4% patients in class III and 7.1% in class II, and at follow-up, 78.6% patients in class II and 14.3% in class I). In patients with previously normal LVEF, LVEF remained stable; nevertheless, a significant NYHA class improvement was observed (baseline, 63.6% class II and 31.8% class III patients; follow-up, 54.5% class I and 45.5% class II patients). The His thresholds and lead parameter values did not significantly change during the follow-up and remained stable. CONCLUSIONS: In patients with uncontrolled atrial arrhythmias who underwent AV node ablation after p-HBP, the NYHA class improved and the LVEF increased in those with reduced baseline LVEF. The values of pacing parameters were acceptable and remained stable during the follow-up.

Electrocardiographic patterns predictive of left bundle branch block correction with His bundle pacing.

INTRODUCTION: Permanent His bundle pacing (p-HBP) could be an alternative for traditional cardiac resynchronization therapy (CRT), but an important limitation is that p-HBP cannot always correct the left bundle branch block (LBBB). The purpose of this article is to assess electrocardiographic patterns of LBBB that can predict electrocardiographic response (QRS narrowing) to His bundle pacing. METHODS: We designed a prospective descriptive study of patients with LBBB and CRT indication proposed for CRT by p-HBP. We analyzed the correlation between the different electrocardiographic patterns and the correction of conduction disturbance (LBBB). RESULTS: We included 70 patients. Pacing at the location where His bundle electrogram was recorded narrowed the QRS in 81.4% (n = 57). Basically, we identified two electrocardiographic patterns in lead V1: QS or rS. The QS pattern was a sensitivity of 56%, a specificity of 84.6%, and a positive predictive value (PPV) of 94.1% to predict the correction of the LBBB (area under the curve [AUC] = .70). In patients with rS pattern, a ratio between the descending and the ascending S wave component duration ≥0.64 was a very good predictor of the correction of the LBBB (AUC = .968); with a value ≥0.64, the sensitivity, specificity, and PPV was 92%, 100%, and 100%, respectively. CONCLUSIONS: In patients with LBBB and CRT indication, the QS pattern in lead V1 predicts the correction of the QRS with HBP. In the case of rS pattern in lead V1, the ratio descending/ascending S wave component duration has a strong correlation with the LBBB correction.

Early improvement of left ventricular ejection fraction by cardiac resynchronization through His bundle pacing in patients with heart failure.

AIMS: Permanent His bundle pacing (p-HBP) can correct intraventricular conduction disorders and could be an alternative to traditional cardiac resynchronization therapy (CRT) via the coronary sinus. We describe the short-term impact of HBP on left ventricular ejection fraction (LVEF) and improvement of left intraventricular synchrony. METHODS AND RESULTS: This prospective descriptive study, performed from January 2018 to February 2019, included patients with left bundle branch block (LBBB) and an CRT indication who were resynchronized by p-HBP. We used the Medtronic C315 His catheter or a combination of the CPS-Direct-Universal introducer, CPS-AIM™-Universal subselector (Abbot), and SelectSecure™ MRI-SureScan™ 3830 lead. Correction of the LBBB by HBP had been previously checked. At 1 month of follow-up, we analysed the quantification of LVEF and measurement of the delay of the septal wall with the posterior wall as a parameter of intraventricular synchrony. We included 48 patients with LBBB and an indication for CRT. With HBP, we corrected the LBBB in 81% of patients (n = 39), and we achieved cardiac resynchronization through permanent HBP in 92% of these patients (n = 36). Left ventricular ejection fraction and intraventricular mechanical resynchronization improved in all patients, which was demonstrated by echocardiography through the improvement of the delay of the septal wall with the posterior wall from 138 ms (range 131-151) to 41 ms (19-63). CONCLUSION: There is early improvement after p-HBP in LVEF and left ventricular electromechanical synchronization in patients with LBBB, heart failure, and an indication for CRT.

Ablación de fibrilación auricular, ictus y hemorragia digestiva: desenlace fatal / Atrial fibrillation ablation, stroke, and hematemesis: fatal outcome

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Implicación de un brote nacional de infección por Serratia marcescens asociado a clorhexidina contaminada en un hospital pediátrico / Implication of a national outbreak of Serratia marcescens associated with a contaminated solution of chlorhexidine in a paediatric hospital

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Evaluation and Impact of the "Advanced Pediatric Life Support" Course in the Care of Pediatric Emergencies in Spain.

INTRODUCTION: The Advanced Pediatric Life Support (APLS) course was introduced in the training of professionals who care for pediatric emergencies in Spain in 2005. OBJECTIVE: To analyze the impact of the APLS course in the current clinical practice in Spanish PEDs. METHODS: The directors of APLS courses were asked about information regarding the courses given to date, especially on the results of the satisfaction survey completed by students at the end of the course. Furthermore, in December 2014, a survey was conducted through Google Drive, specifically asking APLS students about the usefulness of the APLS course in their current clinical practice. RESULTS: In the last 10 years since the APLS course was introduced in Spain, there have been 40 courses in 6 different venues. They involved a total of 1520 students, of whom 958 (63.0%) felt that the course was very useful for daily clinical practice. The survey was sent to 1,200 students and answered by 402 (33.5%). The respondent group most represented was pediatricians, 223 (55.5%), of whom 61 (27.3%) were pediatric emergency physicians, followed by pediatric residents, 122 (30.3%). One hundred three (25.6%) respondents had more than 10 years of professional practice and 291 (72.4%) had completed the course in the preceding four years. Three hundred forty-one of the respondents (84.9%: 95% confidence interval [CI], 81.9-87.9) said that they always use the pediatric assessment triangle (PAT) and 131 (32.6%: 95% CI, 28-37.1) reported that their organization has introduced this tool into their protocols. Two hundred twenty-three (55.5%: 95% CI, 50.6-60.3) believed that management of critically ill patients has improved, 328 (81.6%: 95% CI, 77.8-85.3) said that the PAT and the systematic approach, ABCDE, help to establish a diagnosis, and 315 (78.4%: 95% CI, 74.3-82.4) reported that the overall number of treatments has increased but that these treatments are beneficial for patients. Hospital professionals (191; 47.5%) include the PAT in their protocols more frequently than pre-hospital professionals (68.5% vs 55.4%; p <0.01) and consider PAT useful in the management of patients (60.2% vs 51.1%; p <0.05). Neither the time elapsed since the completion of the course, nor category and years of professional experience had any influence on the views expressed about the impact of the APLS course in clinical practice. CONCLUSIONS: Most health professionals who have received the APLS course, especially those working in the hospital setting, think that the application of the systematic methods learned, the PAT and ABCDE, has a major impact on clinical practice.

[Accidental cannabis poisoning in children: report of four cases in a tertiary care center from southern Spain]. / Intoxicación accidental por cannabis: presentación de cuatro casos pediátricos en un hospital terciario del sur de España.

INTRODUCTION: Cannabis is the most frequently consumed illicit substance in Spain. Pediatric accidental cannabis poisoning is an uncommon but life-threatening intoxication. OBJECTIVE: To describe clinical findings, diagnosis and management of children with accidental cannabis poisoning in a tertiary care pediatric hospital. We report four patients with accidental cannabis poisoning. Clinical presentation included reduced level of consciousness, drowsiness, ataxia, tremble, apnea, hypotonia, and seizures. Tetrahydrocannabinol (THC) was detected by urine screening for cannabinoids and other toxic substances in all cases. The four patients were treated with supportive care. All cases recovered uneventfully and were discharged within 24 hours of admission. CONCLUSION: The possibility of cannabis poisoning should be considered in cases of unexplained acute onset of neurological findings in previously healthy children.

Intoxicación accidental por cannabis: presentación de cuatro casos pediátricos en un hospital terciario del sur de España / Accidental cannabis poisoning in children: report of four cases in a tertiary care center from southern Spain

Introducción. El cannabis es la droga ilegal más consumida en España. La intoxicación accidental por cannabis es una forma infrecuente de intoxicación en niños; pero potencialmente grave.Objetivo. Describir la presentación clínica, diagnóstico y tratamientode niños con intoxicación accidental por cannabis en un hospital pediátrico de tercer nivel.Presentamos 4 pacientes con intoxicación accidental por cannabis.La clínica de presentación fue deterioro brusco del nivel de conciencia, tendencia al sueño, ataxia, temblor, apnea, hipotonía y convulsión. La pesquisa de tóxicos en orina detectó tetrahidrocannabinol (THC) en todos los casos. En los cuatro pacientes se establecieron medidas de soporte. Todos los casos se recuperaron satisfactoriamente y fueron dados de alta a las 24 horas del ingreso.Conclusión. Se ha de mantener un alto índice de sospecha para la intoxicación por cannabis en niños previamente sanoscon aparición brusca de síntomas neurológicos de etiología desconocida.

Intoxicación accidental por cannabis: presentación de cuatro casos pediátricos en un hospital terciario del sur de España / Accidental cannabis poisoning in children: report of four cases in a tertiary care center from southern Spain

Introducción. El cannabis es la droga ilegal más consumida en España. La intoxicación accidental por cannabis es una forma infrecuente de intoxicación en niños; pero potencialmente grave.Objetivo. Describir la presentación clínica, diagnóstico y tratamientode niños con intoxicación accidental por cannabis en un hospital pediátrico de tercer nivel.Presentamos 4 pacientes con intoxicación accidental por cannabis.La clínica de presentación fue deterioro brusco del nivel de conciencia, tendencia al sueño, ataxia, temblor, apnea, hipotonía y convulsión. La pesquisa de tóxicos en orina detectó tetrahidrocannabinol (THC) en todos los casos. En los cuatro pacientes se establecieron medidas de soporte. Todos los casos se recuperaron satisfactoriamente y fueron dados de alta a las 24 horas del ingreso.Conclusión. Se ha de mantener un alto índice de sospecha para la intoxicación por cannabis en niños previamente sanoscon aparición brusca de síntomas neurológicos de etiología desconocida.(AU)

Carcinoma primario mucinoso vulvar en estadio avanzado, asociado con enfermedad de Paget / Primary advanced stage mucinous vulvar carcinoma associated with Paget’s disease

Introducción: La enfermedad de Paget (EP) vulvar esde baja incidencia (menos de 1% de los tumores de esa localización)y corresponde a un adenocarcinoma mucosointraepitelial. La asociación con un tumor infiltrante de lamisma estirpe y subtipo, plantea la relación entre ambasneoplasias así como su origen, habiendo sido descrito comomás frecuente la extensión Pagetoide de tumores metastásicosen la vulva, sobre todo del carcinoma recto-sigmoideo.Pacientes y Métodos: Se presenta el caso de una mujer de71 años que debutó con metástasis inguinales de un carcinomasecretor y que post-vulvectomía presentó ese mismotumor infiltrante, además de una EP extensa. Se realizaestudio morfológico de rutina e inmunohistoquímico con unpanel diferencial de queratinas, CEA, EMA, C-erb2,CA125, CA19-9, receptores de estrógenos y de progesterona,S100 y HMB45 para tratar de conocer el origen de laneoplasia. Resultados: Ambas neoplasias corresponden aun adenocarcinoma secretor, infiltrante e intraepitelial. Elinmunofenotipo con negatividad para queratina 20 y laexpresión de AE1-3, CAM5.2, CQ7, CEA, EMA, CA125 yCA19-9 en ambos tumores infiltrante e intraepitelial, favoreceel diagnóstico de EP primaria con adenocarcinomamucoso infiltrante, de probable origen en glándulas vulvaresanejas. Conclusiones: A pesar del correcto diagnósticoy tratamiento adecuado, la enferma tuvo un pronóstico desfavorabledebido al estadio avanzado de la enfermedad

Introduction: Vulvar Paget´s disease (VPD) is infrequent(less than 1% of vulvary tumours) and corresponds toa mucous intraepithelial adenocarcinoma. The associationof VPD with an infiltrating tumour of the same lineagerequires investigation of the relationship between the twoneoplasias. Primary VPD is less common than the «pagetoid» involvement of metastatic vulvar carcinomas arisingin the recto-sigmoid tract. Patients and methods: Femalepatient, 71 years old, with inguinal metastatic tumour isreported. After a total vulvectomy, a mucous infiltratingadenocarcinoma and VPD were diagnosed. A routine morphologicalstudy and a complete panel of Immunohistochemistrywere done in order to differentiate the origin andaggressivity of both neoplasms. Results: The two tumourswere adenocarcinomas with positive Mucicarmin stainingone without (VPD) and the second with infiltrative characteristics.Immunophenotype favours the diagnosis of primaryVPD and probable carcinoma of glandular vulvarappendages (negativity for keratin-20, Cerb 2, S100,HMB45, estrogen and progesteron receptors and positivityfor AE1-3 and CAM5.2 Keratin, keratin-7, CEA, EMA,CA125 and CA19-9). Conclusions: In spite of a correctdiagnosis and treatment, the patient underwent an unfavourableclinical course because of the advanced stage of thedisease

Capacidades de autocuidado del adulto con diabetes tipo 2 / Self-care capabilities of adult patients with type 2 diabetes

El propósito de este estudio fue definir las capacidades especializadas de autocuidado del paciente diabético tipo 2 a partir de lo que ellos expresan sobre el cuidado de su enfermedad. Los sujetos de estudio fueron ocho diabéticos: seis hombres y dos mujeres, con edad promedio de 53,6 años; escolaridad de 13,5 años, y provenientes de tres estratos socioeconómicos diferentes. El método utilizado fue el de entrevista de preguntas abiertas a partir de cuestiones sobre el cuidado de la diabetes. La información se analizó con la técnica análisis de contenido. Los resultados mostraron acciones de autocuidado relacionadas con la condición de diabético, con el tratamiento y sus efectos, y con cambios de hábitos y actitudes. Las capacidades especializadas necesarias son de tipo físico, mental, emocional y de orientación. Estas categorías corresponden con el modelo presentado por Backscheider y pueden ser utilizados como marco de referencia al elaborar programas educativos en pacientes con diabetes tipo 2.