An 80‐year‐old woman received a dual chamber pacemaker (Boston Scientific Accolade MRI DR) for pre‐syncopal episodes associated with transient II‐degree atrioventricular block type 1 and 2:1, recorded in 24‐h Holter monitoring. Due to residual AV conduction with I‐degree AV block, the pacemaker was set with the RYTHMIQ® algorithm, in order to reduce inappropriate ventricular pacing. A month later the patient started to complain of severe asthenia and bradycardia (46‐48 bpm). Telemetry‐supported pacemaker control revealed III‐degree AV block with junctional escape rhythm, unmasking missed switch of RYTHMIQ® algorithm.

A 17-years-old woman with type 1 diabetes mellitus known since the age of 9 was admitted in the high-dependency unit for diabetic ketoacidosis. She had a history of poor glycemic control and many previous hospitalizations. Two years earlier, she reported the appearance of a red-brown, telangiectatic and hyperpigmented patch, localized in the pretibial skin of her left leg (Fig. 1). The lesion was well-circumscribed with erythema at the periphery. Two months before a spontaneous ulceration appeared in the middle of the lesion, apparently without any trauma. No other lesions were present all over the body. She denied pain, pruritus or burning sensation. Patient voluntary discharged from the hospital, for this reason it was not possible to continue the diagnostic testing with the biopsy of the lesion. After about three months we contacted the patient again. During this time, she started a successful treatment with topical corticosteroids. The greatest outcome was a fast epithelization and clarification of the lesion (Fig. 2).Fig. 2Pretibial skin lesion after treatment with topical corticosteroids.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Necrobiosis lipoidica (NL) is a rare, chronic granulomatous dermatitis. Skin involvement usually begins with red-brown or violaceous papules, plaques, or nodules and rapidly progresses to yellow-brown, atrophic, telangiectatic plaques. It usually presents on the lower extremities, especially on the pretibial area. Ulceration is a common complication (10–20% of patients). NL primarily affects young and middle-aged adults, more frequently women. NL is strongly but not necessary associated with diabetes mellitus and can precede the diagnosis of this condition (the prevalence of NL among diabetic patients is estimated to be 0.3 - 1.2%). The etiology is unclear, probably it is a consequence of diabetic microangiopathy secondary to deposition of glycoproteins in blood vessels. [[1]Tong Lana X Penn Lauren Meehan Shane A Kim Randie H Necrobiosis lipoidica Dermatol.Online J. 2018; 24 (Dec 1513030/qt0qg3b3zw)Google Scholar] Nevertheless, glucose control does not appear to correlate with disease activity. Patients are usually asymptomatic, but sometimes they report pruritus or dysesthesia at the site of skin injury. Histological findings demonstrate zones of necrobiosis of collagen with a surrounding inflammatory infiltrate, composed by histiocytes, multinucleated giant cells, lymphocytes and plasma cells. [[2]Adam S Richardson, Eric W Hossler Necrobiosis lipoidica diabeticorum Cutis. 2015 May;95(5):252, 265–6.Google Scholar] Histologically it can be difficult to distinguish necrobiosis lipoidica from other non-infectious granulomatous disorders so clinical evaluation still has a fundamental role in the diagnosis. Standard treatment consists of topical or intralesional corticosteroids but it does not always show satisfactory results. Topical tacrolimus and photochemotherapy have been used as second line. [[3]Ginocchio Luke Draghi Lisa Darvishian Farbod Ross Frank L Refractory ulcerated necrobiosis lipoidica: closure of a difficult wound with topical tacrolimus.Adv Skin Wound Care. 2017; 30 (Oct): 469-472https://doi.org/10.1097/01.ASW.0000521867.98577.a5Google Scholar] Spontaneous remission is reported in about 20% of patients.

BACKGROUND Differentiation of Type 2 Brugada Pattern (BP) from incomplete right bundle branch block or normal rSr' pattern can be insidious. The aim of this study was to assess inter-observer and intra-observer agreement in the diagnosis of type 2 BP in a cohort of cardiologists with different skills. METHODS We collected 14 ECGs with a positive terminal deflection of the QRS complex in lead V1 and V2 at the 4th intercostal space. We proposed these ECGs, specifying to use 2012 Consensus conference criteria for diagnosis of type 2 BP, to 42 participants: 14 arrhythmologists, 14 general cardiologists and 14 electrophysiology (EP) fellows. The same 14 ECGs, with a different order, were proposed fifteen days later to the same cohort to assess intra-observer variability. Authors analyzed all 14 ECGs in order to assess whether or not 2012 Consensus Conference criteria for BP were fulfilled. All patients underwent provocative test with IC antiarrhythmics drugs (flecainide) in order to exclude or confirm the diagnosis of Brugada Syndrome (BrS). RESULTS Slight inter-observer agreement (Fleiss K<0.20) in the diagnosis of type 2 BP was observed in all three categories of cardiologists. Considering five operators per class, intra-observer agreement is variable (k ranging from 0,000 to 0,857), with a slight superiority of arrhytmologists (k minimum value 0,276; k maximum value 0,857). CONCLUSIONS This study demonstrated, for the first time, a low inter-observer agreement in diagnosis of type 2 BP in categories of cardiologists with different abilities. Reproducibility of type 2 BP diagnosis (intra-observer agreement) is poor, even among experts. These findings highlight the difficulties in analysis of ECG with BrS suspicion and, therefore, underscore the key role of clinical and anamnestic data.

El control lipídico óptimo es difícil de conseguir. Se evalúa el cumplimiento previo de los objetivos de la Sociedad Europea de Cardiología para el control del colesterol unido a lipoproteínas de baja densidad (cLDL) de los pacientes que ingresaron por síndrome coronario agudo.Se midió el cLDL en ayunas de 3.164 pacientes ingresados entre 2010 y 2017 y se analizó la frecuencia de un control adecuado, con objetivos según el riesgo cardiovascular individual, y los predictores de control inadecuado.La mediana de cLDL fue 104 (80-130) mg/dl. La mayoría de los pacientes tenían un riesgo cardiovascular alto o muy alto y solo el 34,2% tenía un cLDL dentro del objetivo recomendado para su nivel de riesgo. Se apreció un pequeño aumento en la consecución de los objetivos de cLDL a lo largo del periodo estudiado. El control adecuado de cLDL se relacionó inversamente con el riesgo de los pacientes. La dislipemia, el tabaquismo, la diabetes mellitus o un índice de masa corporal ≥ 25 fueron predictores independientes de un control lipídico inadecuado, mientras que el tratamiento previo con estatinas se asoció con un control apropiado.Poco más de un tercio de los pacientes ingresados por síndrome coronario agudo tiene valores de cLDL al ingreso acordes con los objetivos recomendados. Hay un amplio campo de mejora en prevención primaria y secundaria, especialmente para los pacientes con exceso de peso u otros factores de riesgo cardiovascular.Optimal lipid control is difficult to attain. We assessed preadmission achievement of the European Society of Cardiology targets for low-density lipoprotein-cholesterol (LDL-C) control in patients admitted for acute coronary syndrome.Fasting LDL-C levels were measured in 3164 patients admitted between 2010 and 2017. We assessed the frequency of adequate LDL-C control, with targets defined according to individual cardiovascular risk, and the predictors of inadequate control.The median LDL-C value was 104 (80-130) mg/dL. Most patients had high or very high cardiovascular risk and only 34.2% had LDL-C levels below the recommended target for their estimated risk. Achievement of LDL-C goals increased moderately throughout the study period. Adequate LDL-C control was inversely associated with patient risk. Dyslipidemia, active smoking, diabetes mellitus, and body mass index ≥ 25 were independent predictors of inadequate lipid control, while ongoing statin therapy was associated with adequate control.Only slightly more than one third of patients admitted for acute coronary syndrome meet recommended LDL-C targets on admission. There is broad scope for improvement in primary and secondary prevention, especially among patients who are overweight or have other cardiovascular risk factors.

This report describes Spanish cardiac pacing activity during 2019: quantities and types of devices and demographic and clinical factors.The analysis is based on data obtained from the European Pacemaker Patient Identification Card, data submitted to the online platform cardiodispositivos.es, and supplier-reported data on the total number of implanted pacemakers.Information was received on 15 833 procedures from 102 implantation centers, representing 39% of the estimated total activity. The implantation rates of conventional and resynchronization pacemakers were 832 and 32 units per million population, respectively. A total of 431 leadless pacemakers were implanted. Most implantations were performed in elderly patients (mean age, 78.7 years). Most electrodes were bipolar and with active fixation and 34.1% were magnetic resonance imaging-compatible. Atrioventricular block was the most common electrocardiographic abnormality. Dual-chamber sequential pacing predominated; nonetheless, up to 20% of patients in sinus rhythm received a single-chamber ventricular pacemaker, mainly those older than 80 years of age and women. Remote monitoring capability was present in 41% of cardiac resynchronization therapy pacemakers and in 14.8% of conventional pacemakers.Consumption of pacing generators increased by 1.6%, mainly due to a 15.1% increase in cardiac resynchronization therapy pacemakers. Sequential pacing predominates; its use is influenced by age and sex. Remote monitoring increased by 20.6% in cardiac resynchronization therapy pacemakers and continues to be scarce in conventional pacemakers.Se describe la actividad realizada en España en estimulación cardiaca durante 2019: cuantía y tipo de dispositivos, factores demográficos y clínicos.Se analiza la información aportada por la tarjeta europea del paciente portador de marcapasos, los datos incluidos en la plataforma online cardiodispositivos.es y la información remitida por empresas proveedoras sobre el número total de dispositivos.Se registran 15.833 procedimientos de 102 centros implantadores, lo que representa el 39% de la actividad total estimada. La tasa de implante de generadores de marcapasos convencionales es de 832 unidades/millón y la de resincronizadores de baja energía, 32 unidades/millón. Se implantaron 431 marcapasos sin cables. Predomina el implante en pacientes de edad avanzada (media, 78,7 años). Los electrodos utilizados son principalmente bipolares y de fijación activa y el 34,1% son compatibles con resonancia magnética. El bloqueo auriculoventricular es la alteración electrocardiográfica más frecuente y predomina la estimulación secuencial bicameral, a pesar de lo cual hasta un 20% de los pacientes en ritmo sinusal reciben un marcapasos monocameral en ventrículo, fundamentalmente mayores de 80 años y mujeres. Se incluyen en monitorización a distancia el 41% de los resincronizadores de baja energía y el 14,8% de los marcapasos convencionales.En 2019 ha aumentado el consumo de generadores de estimulación cardiaca en un 1,6%, sobre todo los resincronizadores de baja energía, que aumentan en un 15,1%. Predomina la estimulación secuencial, influida por la edad y el sexo. Aumenta en un 20,6% la monitorización a distancia de pacientes con resincronización cardiaca con marcapasos y continúa siendo escasa la de los marcapasos convencionales.

Bone marrow granulomatosis is not a common finding and remains a diagnostic challenge. Here below we report two bizarre but not so rare cases of bone marrow granulomatosis: bone marrow involvement by Mycobacterium avium-intracellulare and reaction to intravesical administration of Bacillus Calmette-Guérin for non-muscle-invasive bladder cancer; two distinct culprits suggesting the wide range of possible causative factors of this histopathological pattern. In the discussion we provide a brief overview of causes and suggestions for a diagnostic approach.

12 h after the implant of a S-ICD the patient accused an inappropriate shock due to noise oversensing. ICD interrogation showed undersensing of ventricular signals on primary vector and significative noise on alternative vector. Surprisingly, 2 days full recovery of sensing of primary vector was observed. Trapped air was likely to be the cause of malfunctioning. (c) 2017 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.