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BackgroundPacing the right ventricle is established practice, but there remains controversy as to the optimal site to preserve hemodynamic function.AimsTo evaluate clinical and hemodynamic differences between apical and septal pacing in pacemaker-dependent patients.MethodsPatients receiving their first pacemaker for advanced atrioventricular block, with the atria in sinus rhythm, were randomized to receive apical (Group A) or septal (Group S) ventricular leads. After implant, with the device programmed VVI 70 beats/min fixed rate, patients underwent a 6-minute walk test and a transthoracic echocardiogram. Then, DDDR was programmed at nominal settings. The same tests were performed at 6 months and 12 months follow-up. If ventricular pacing was less than 98%, the patient was excluded.ResultsA total of 142 patients were included in the study. During the study year, 71 (50%) were excluded for not fulfilling the condition of 98% ventricular pacing. Groups A and S had 34 and 37 patients, respectively. Age and gender were similar in the groups. At implant, QRS duration was significantly greater in Group A (158 ms) than Group S (146 ms; P = 0.018), and the QRS axis was different: –74.5° in Group A and 1° in Group S (P < 0.001). At 1 year, the 6-minute walk improved significantly in both groups: Group A 15% (P = 0.048) and Group S 24% (P = 0.001). Left ventricular ejection fraction (LVEF) increased from 0.57 to 0.61 (P = 0.008) in Group S, without significant change in Group A.ConclusionsAfter 1 year, pacemaker-dependent patients with septal ventricular leads have better clinical and functional (LVEF) outcome.

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Struma ovarii is a rare monodermal variant of ovarian teratoma that contains at least 50% thyroid tissue. Less than 8% of struma ovarii cases present with clinical and biochemical evidence of thyrotoxicosis due to ectopic production of thyroid hormone and only 5% undergo malignant transformation into a papillary thyroid carcinoma. Only isolated cases of hormonally active papillary thyroid carcinoma developing within a struma ovarii have been reported in the literature. We report the case of a 36-year-old woman who presented with clinical signs and symptoms of hyperthyroidism as well as a left adnexal mass, which proved to be a thyroid hormone-producing, malignant struma ovarii.

Background: Requests for physician-assisted death (PAD) in patients with cognitive impairment are complex and require careful consideration. Of particular difficulty is determination of whether the request is voluntary and well considered. Results: Euthanasia and physician-assisted suicide (PAS) are both legal in The Netherlands, Luxemburg, Colombia, and Canada. Euthanasia is legal in Belgium, while PAS is legal in Switzerland and Oregon, Washington, Montana, Vermont, and California (USA). Upon a PAD request, evaluation of the capacity to consent medical treatment is relevant for the decision-making process, while evaluation of testamentary capacity is appropriate before an advance euthanasia directive is written. Anosognosia assessment throughout the Alzheimer’s disease continuum provides essential and relevant information regarding the voluntary and well-considered nature of the PAD request; meanwhile, early assessment of hypernosognosia or subjective cognitive decline assists in formulation of a clinical prognosis. Furthermore, the assessment of physical and psychological suffering should incorporate verbal and nonverbal cues as well as consideration of the psychosocial factors that might affect due care criteria. Conclusion: The clinical approach to a PAD request should consider the legal framework and the decision-making capacity, assess memory deficit awareness and the perception of suffering, and evaluate mental competency when considered pertinent.