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This case report presents the clinical evolution and management of a patient with a hereditary paraganglioma syndrome. This disease is characterized by rare tumors of neural crest origin that are symmetrically distributed along the paravertebral axis from the base of the skull and neck to the pelvis. In addition, these patients may develop renal cancer, gastrointestinal stromal tumors, pituitary adenomas, and bone metastasis in some cases. To date no successful therapeutic treatment has been reported. Total resection with postoperative radiotherapy and chemotherapy have been advocated, especially for the multiple metastasis. Here we show how the combination of high doses of the beta blocker propranolol (3 mg/Kg/day) and the DNA intercalating agent, temozolomide, has been successful in the treatment of a SDHA metastatic paraganglioma., Competing Interests: No competing interests were disclosed.

Objectives: The aim of this study was to investigate the rate at which the alumni of basic life support courses witnessed and intervened in out-of-hospital emergency situations, and to identify the variables characterizing those alumni associated with a greater number of witnessing events and interventions. An analysis of the efficiency of the courses was also carried out., Design: A descriptive, cross-sectional study was made., Setting: A district in the province of Almería (Spain)., Patients: Alumni of a mass basic life support training program targeted to the general population «Plan Salvavidas» conducted between 2003-2009., Interventions: In 2010 the alumni were administered a telephone survey asking whether they had witnessed an emergency situation since attending the program, with the collection of information related to this emergency situation., Main Variables of Interest: Rate of out-of-hospital emergencies witnessed by the alumni. Rate of intervention of the alumni in emergency situations. Variables characterizing alumni with a greater likelihood of witnessing an emergency situation., Results: A total of 3,864 trained alumni were contacted by telephone. Of 1,098 respondents, 63.9% were women, and the mean age was 26.61±10.6 years. Of these alumni, 11.75% had witnessed emergency situations, an average of three years after completing the course. Of these emergencies, 23.3% were identified as cardiac arrest. The alumni intervened in 98% of the possible cases. In 63% of the cases, there was no connection between the alumni and the victim. The majority of the emergency situations occurred in the street and in public spaces. A greater likelihood of witnessing an emergency situation was associated with being a healthcare worker and with being over 18 years of age., Conclusions: The rate of out-of-hospital emergencies witnessed by these alumni after the course was 11.75%. The level of intervention among the alumni was high. The most efficient target population consisted of healthcare workers., (Copyright © 2013 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.)

Objective: Myocardial stunning frequently has been described in patients with an acute coronary syndrome. Recently, it has also been described in critically ill patients without ischaemic heart disease. It is possible that the most severe form of any syndrome, leading to cardio-respiratory arrest, may cause myocardial stunning. Myocardial stunning appears to have been demonstrated in experimental studies, though this phenomenon has not been sufficiently studied in human models. The aim of the present work has been to study and describe the possible development of myocardial dysfunction in patients resuscitated after cardio-respiratory arrest, in the absence of acute or previous coronary artery disease., Design: Descriptive study of a case series., Setting: The intensive care unit (ICU) of a provincial hospital., Patients and Participants: The study period was from April 1999 to June 2001. All patients admitted to the ICU with critical, non-coronary artery pathology, with no past history of cardiac disease, and those who were resuscitated after cardio-respiratory arrest, were included in the study., Measurements and Results: Transthoracic and transoesophageal echocardiography was used to assess left ventricular ejection fraction (LVEF) and disturbances of segmental contractility. This study was carried out within the first 24h after admission, during the first week, during the second or third week, after 1 month, and between 3 and 6 months. Twenty-nine patients with a median age of 65 years (range 24--76) were included in the study. Twelve patients died. Twenty patients developed myocardial dysfunction; the initial LVEF in these patients was 0.28 (0.12--0.51), showing improvement over time in the patients who survived. All of these patients presented disturbances of segmental contractility which also became normal over time., Conclusions: After successful CPR, reversible myocardial dysfunction, consisting of systolic myocardial dysfunction and disturbances of segmental contractility, may occur.

Objective: The aim of this study has been to investigate the factors predisposing to primary or secondary ventricular fibrillation (VF) and the prognosis in Spanish patients with acute myocardial infarction (AMI) during their admission to the intensive care unit or the coronary care unit., Design: A retrospective, observational study., Setting: The intensive care units and coronary care units of 119 Spanish hospitals., Patients: A retrospective cohort study including all the AMI patients listed in the ARIAM registry (Analysis of Delay in Acute Myocardial Infarction), a Spanish multicenter study. The study period was January 1995 to January 2001., Measurements and Main Results: Factors associated with the onset of VF were studied by univariate analysis. Multivariate analysis was used to evaluate the independent factors for the onset of VF and for mortality. A total of 17,761 patients with AMI were included in the study; 964 (5.4%) developed VF (primary in 735 patients, secondary in 229). In multivariate analysis, the variables that continued to show an association with the development of VF were the Killip and Kimball class, peak creatine kinase, APACHE II score, age, and time from the onset of symptoms to the initiation of thrombolysis. The mortality in the patients with any VF was 31.8% (27.8% in patients with primary VF and 49.1% in patients with secondary VF). The development of VF is an independent predictive factor for mortality in patients with AMI, with a crude odds ratio of 5.12 (95% confidence interval, 4.41-5.95) and an adjusted odds ratio of 2.73 (95% confidence interval, 2.12-3.51)., Conclusions: Despite the considerable improvement in the treatment of AMI in recent years, the onset of either primary or secondary VF is associated with a poor prognosis. It is usually accompanied by extensive necrosis.

Background: The purpose of our study was to compare the efficacy and safety of alteplase in acute myocardial infarction (AMI), when administered in a double bolus regimen or an accelerated regimen during admission to an intensive care or coronary care unit (ICU/CCU)., Material/methods: A retrospective cohort study including all the AMI patients treated with alteplase recorded in the ARIAM register (Analysis of Delay in AMI), a multi-center register in which 77 Spanish hospitals participate. The study period was from January 1995 to January 2000., Results: 4,615 AMI patients were studied. The accelerated regimen (Group I) was administered to 57.51% (2,654 patients) and the remaining 42.49% (1,961 patients) received the double bolus regimen (Group II). There were no differences in mortality or in the incidence of hemorrhagic stroke between the groups. The mortality was 7.15% in Group I versus 6.43% in Group II (not significant). The incidence of hemorrhagic stroke was 1.09% in Group I versus 1.22% in Group II (not significant). Fewer coronary angiographies were required in Group I (6.28% vs. 8.99%; p<0.001) and fewer rescue angioplasties (10.67% vs. 21.88%, p=0.03). Group I also showed a smaller requirement for stent insertion (2.45% vs. 4.77%; p<0.0001) and for assistance using intra-aortic balloon contrapulsation (0.47% vs. 1.36%; p=0.02)., Conclusions: The two regimens appear to be similar in efficacy and safety. Nevertheless, from these results it may be hypothesized that further revascularization techniques are required after double bolus administration.

Background: To assess age-related differences in cardiovascular risk factors, clinical course and management of patients with acute myocardial infarction (AMI) in intensive care (ICU) or coronary care units (CCU)., Methods: A retrospective cohort study was conducted of all AMI patients listed in the ARIAM register (Analysis of Delay in AMI), a multi-centre register in which 119 Spanish hospitals participated. The study period was from January 1995 to January 2001. A univariate analysis was carried out to evaluate differences between different age groups. Multivariate analysis was used to assess whether age difference was an independent predisposing factor for mortality and for differences in patient management., Results: 17,761 patients were admitted to the ICUs/CCUs with a diagnosis of AMI. The distribution by ages was: <55 years, 3,954 patients (22.3%); 55-64 years, 3,593 (22.2%); 65-74 years, 5,924 (33.4%); 75-84 years, 3,686 (20.8%); and >84 years, 604 (3.4%) (P<0.0001); 24.6% of the patients were female, and the relative proportion of females increased with age. There were clear differences in risk factors between the different age groups, with a predominance of tobacco, cholesterol and family history of heart disease in the younger patients. The incidence of complications, including haemorrhagic complications, increased significantly with age. The older age groups had a lower rate of thrombolysis and less use of revascularisation techniques. The mortality of the above groups was 2.6, 5.4, 10.7, 17.7 and 25.8%, respectively. Age difference was an independent predictive variable for mortality and the administration of thrombolysis., Conclusions: The distinct age groups differed in cardiovascular risk factors, management and mortality. Age is a significant independent predictive variable for mortality and for the administration of thrombolysis.

Background: The purpose of this study was to assess the incidence, clinical course, prognosis and mean length of stay in acute myocardial infarction (AMI) complicated by high-grade atrioventricular block (HAVB)., Material/methods: A retrospective cohort study including all AMI patients listed from January 1995 to September 2000 in the ARIAM multi-center register. Univariate analysis was carried out to study the factors associated with the development of HAVB, the mortality rate, and the mean length of stay, and multivariate logistic regression analysis to study whether HAVB is an independent predictive variable for mortality or prolongation of stay., Results: Of the 14,181 AMI patients included in the register, 837 (5.9%) presented with HAVB, which was associated with age, female sex, increased severity, diabetes, inferior and Q-wave AMIs, and a higher peak creatine phosphokinase (CPK) level. The HAVB patients developed more complications, required more diagnostic-therapeutic resources, and showed significantly higher mortality (p<0.0001) and increased mean length of stay (p<0.0001). The independent risk factors for HAVB were age, maximum peak CPK, inferior or combined localization of the AMI, Q-wave AMI, diabetes, a Killip and Kimball score > 1, and thrombolysis. HAVB was found to be an independent predictive variable for mortality and increased mean length of stay., Conclusions: AMI patients with HAVB, despite thrombolytic treatment, are at risk for complications, mortality and longer mean admissions. Further study is needed on the outcome of a more active reperfusion policy, such as direct, rescue angioplasty etc.

Objective: To describe our outcomes using thrombolysis during the cardiopulmonary resuscitation (CPR) of patients in cardiorespiratory arrest (CA) caused by fulminant pulmonary embolism (FPE)., Design: A case series., Setting: Intensive care units of a district hospital and a referral centre., Patients: Six patients that suffered CA secondary to an FPE., Interventions: Administration of recombinant tissue plasminogen activator during usual CPR manoeuvres when there was a strong suspicion of FPE. Permission for the thrombolytic therapy was sought from family members in all cases., Results: Four out of the six patients survived and remain symptom-free. The thrombolysis was not associated with any fatal complications., Conclusions: Early thrombolysis during CPR manoeuvres for CA apparently caused by an FPE may reduce the mortality rate among these patients.

Objectives: We describe our experience with peripartum cardiomyopathy., Design and Setting: A case series in intensive care units (ICU) of a district hospital and a referral center., Patients: Six patients who required admission to an ICU after the onset of peripartum cardiomyopathy., Results: Five of the six patients survived, with total recovery of ventricular function. After 1 year of follow-up all five survivors were symptom free with a normal ventricular function., Conclusions: There is a low rate of ICU admissions for peripartum cardiomyopathy, which has a potentially fatal prognosis. However, this disease can be detected by echocardiography among patients without the semiology.

The use of anti-lymphocyte globulins (ATG, ALG, OKT3) for the control or organ rejection in humans, has been of major importance both in preventing and treating organ rejection resistant to other treatments. We present here the results of our immunosuppression protocol using two different therapeutic associations. To the first group consisting of 29 patients, low doses of cyclosporine, steroids and anti-lymphocyte globulins were given, and to another group of 11 patients azathioprine was given together with cyclosporine and steroids at the same doses as in the first group. We want to point out that the incidence of acute rejections was similar in both groups (17.2% vs 18.1%) immediately after surgery and a greater incidence of rejections at a later time during the follow up period in the group treated with azathioprine (34.4% vs 54.6%). The incidence of chronic rejections was similar in both groups (10.3% vs 8.9%). During the follow up period, the incidence of infections was higher in the group treated with azathioprine (13.7% vs 36.4%) as well as bacteremia episodes (17.2% vs 45.4%) (p less than 0.1). We also want to highlight that patients with graft complications (primary graft rejection) suffered infections (p less than 0,001) and had a higher mortality rate (p less than 0,05) in association to the infection.

To examine the clinical course of patients with acute myocardial infarction complicated by "extension", we studied prospectively 141 patients who had been diagnosed as having acute myocardial infarction. The serum CKMB level of these patients was determined at 8-h intervals during the first 5 days following admission. The patients were classified into 3 groups. Group A (early extension): patients who showed CKMB re-elevation before the CKMB values reached normal levels (28%). Group B (late extension): patients who showed CKMB re-elevation after the normalization of serum CKMB levels (21%). Group C (control group): patients without CKMB re-elevation (51%). Patients in group A showed the most unfavourable clinical course with a greater rate of haemodynamic deterioration compared with patients in the B or C groups, and a higher rate of recurrent ischemic pain. We found no significant differences in these parameters between the B and C groups. We were unable to find any risk factor associated with the development of extension. The pattern of the serum CKMB curve may allow a separation of two different subgroups of patients with acute myocardial infarct extension: patients with early extension, who show a high prevalence of haemodynamic deterioration, and patients with late extension, characterized by small infarcts and a benign clinical course.