Takotsubo syndrome and complete heart block, which came first? A case report

Background In 2018 the European society of cardiology published two consensus documents on takotsubo syndrome which include the current consensus on nomenclature, diagnosis, management and complications. However, little is mentioned on the association with complete heart block, except that “AV block [occurs in] 2.9% of cases”. Complete heart block is a recognised rare association of takotsubo syndrome, but causation is often unclear. Does complete heart block trigger takotsubo syndrome or vice-versa? Here we present a case of takotsubo syndrome associated with complete heart block. Case summary An 89-year-old woman presented with a transient loss of consciousness, acute chest pain and dyspnoea. A few days prior to this her daughter died suddenly of a myocardial infarction. On presentation troponin levels were elevated, the ECG showed complete heart block with a broad QRS and an echo showed apical akinesis and ballooning. Angiographic investigation excluded significant coronary artery disease. A dual chamber pacemaker was implanted after a brief period of temporary pacing. Ventricular function normalized during Follow-up and her underlying rhythm remained complete heart block. Discussion Takotsubo syndrome may be triggered by both emotional and physical stressors. Complete heart block is recognised association but causation is often unclear. In our case a clear emotional trigger was identified suggesting the takotsubo syndrome may have precipitated complete heart block not vice versa.

The Eye of the Beholder: Applying Visual Analysis in an Historical Study of Lynxes’ Representations in the Bavarian Forest Region

Representation is never neutral, especially when it comes to agents devoid of their own voice. As such, wildlife has often been employed as a sort of leverage point, an emotional trigger aimed to deliver a certain message (see e.g., Cronin, 2011). The establishment of the Bavarian Forest National Park (BFNP) coincided with the return of large carnivores to the region, in particular, lynxes. Lynxes are endemic to the area; however, as in many other parts of Europe, the last free-roaming individuals were eradicated in the middle of the nineteenth century. In the past few decades, slowly, lynxes were both reintroduced or came back on their own volition, and that has created a considerable response from the population. There has been extensive coverage of the return of these animals both in local and regional media. Lynxes are also kept in the enclosures of the BFNP to afford visitors an unmediated look at the native charismatic megafauna. In this chapter, I analyse how lynxes have been represented in the local media, the newspaper Grafenauer Anzeiger, and discuss merits and drawbacks of visual analysis research method in understanding the change in attitudes towards these animals’ presence in the BFNP area. For that, I look at the archival and contemporary publications of the newspaper. It has been said that the precondition for people’s understanding of reality lays in fantasy, in imagining things to be true (Bergman, 2013). A visual analysis method can help uncover stories that do not necessarily come to the fore in text, and that, in turn, makes it possible to have a fuller grasp of one’s research object. Andrew Isenberg once said that “[our] representations of wildlife are inescapably expressions of human values” (Isenberg, 2002), and while texts are important in their own regard, visual analysis gives an opportunity to look behind a textual narrative to discern whether what we see of the wildlife corresponds to what we understand.

Memory as State Behaviour

This chapter shows how collective memory channels a country’s international behaviour. To that end, it first lays out the nexus between memory and state behaviour put forward by the temporal security concept. It then goes on to distinguish it from international relations’ classical realist and ontological security approaches and their predictions on state behaviour. To keep their temporal security intact, countries are assumed to enter into an ‘in-between-time’ conversation with their ‘significant historical others’. Through the emotional trigger of shame, policymakers avoid potential disconnects with their country’s ‘narrated self in the past’, thus bringing their courses of action in line with collective memory. To illustrate this process, the empirical case study looks at the reaction of West Germany and Austria to two wars in the Middle East. It contrasts their support for either of the warring parties during the Six Day War of 1967 and the Yom Kippur War and international oil crisis of 1973. The qualitative analysis demonstrates that West Germany and Austria’s different collective memories of the Nazi legacy channelled their behaviour along diverse reasonings to support either the Israeli or the Arab side.

Anxiety and Panic Buying Behaviour during COVID-19 Pandemic—A Qualitative Analysis of Toilet Paper Hoarding Contents on Twitter

Background: The coronavirus disease 2019 (COVID-19) pandemic had increased population-level anxiety and had elicited panic buying behaviour across the world. The over-hoarding of toilet paper has received a lot of negative public attention. In this work, we used Twitter data to qualitatively analyse tweets related to panic buying of toilet paper during the crisis. Methods: A total of 255,171 tweets were collected. Of these 4081 met our inclusion criteria and 100 tweets were randomly selected to develop a coding scheme in the initial phase. Random samples of tweets in folds of 100 were then qualitatively analysed in the focused coding phase until saturation was met at 500 tweets analysed. Results: Five key themes emerged: (1) humour or sarcasm, (2) marketing or profiteering, (3) opinion and emotions, (4) personal experience, and (5) support or information. About half of the tweets carried negative sentiments, expressing anger or frustration towards the deficiency of toilet paper and the frantic situation of toilet paper hoarding, which were among the most influential tweets. Discussion: Panic buying of toilet paper was seen during the 2020 pandemic period with a mass amount of related content spread across social media. The spontaneous contagion of fear and panic through social media could fuel psychological reactions in midst of crises. The high level of negative social media posts regarding the toilet paper crisis acts as an emotional trigger of public anxiety and panic. Conclusions: Social media data can provide rapid infodemiology of public mental health. In a pandemic or crisis situation, real-time data could be monitored and content-analysed for authorities to promptly address public concerns.

Remembering rhythm and rhyme: memorability of narratives for science communication

Once upon a time, narratives were considered to be a non-reliable way of representing and communicating science. Nowadays, narratives are widely accepted as an accurate way of conveying science; they represent an effective emotional trigger, a lasting memory structure and a powerful aid for learning. To study how memorable different ways of presenting information can be is a fundamental task for science communication in order to evaluate materials that not only need to be understood by the general public but also need to be retained in the long term as a part of the communication process. In this paper, I will give a brief introduction to cognitive psychology and the study of memory in relation to narratives. Evidence from the field of memory studies suggests that narratives represent a good recall device. They can generate emotion, and this in turn is a way of focusing attention, promoting rehearsal in memory and inducing long-term potentiation. Similarly, a story produces semantic links that might assist in storing and retrieving information from memory. Studies suggest that memory span and paired-associate recall have implications in storing and recalling narratives. Evidence also suggests that the use of stories as modelling tools can organise information, provide schemas and allow extrapolation or prediction. Finally, literature in memory suggests that narratives have value as mnemonic devices.

Triggers of stress cardiomyopathy and their association with clinical outcomes

Background Stress cardiomyopathy can be a result of physical stress, emotional stress, or both. Whether the type of trigger affects clinical outcomes is not well studied. Purpose The objectives of this study were to identify the prevalence of emotional and physical stressors and to assess differences in patient characteristics and mortality based on the type of trigger. Methods We conducted a retrospective review of 523 consecutive patients who presented to our institution from 2006 to 2016. All patients presented with acute coronary syndrome. Triggers for stress cardiomyopathy were abstracted from reviewing patients' medical records. Patients were categorized into those with 1) physical trigger, 2) emotional trigger, 3) both physical and emotional trigger, or 4) no known trigger. Baseline characteristics and clinical outcomes were reported. Results Among 523 patients with stress cardiomyopathy, 151 (28.9%) had a physical trigger, 189 (36.1%) had an emotional trigger, 30 (5.7%) had both physical and emotional triggers, and 153 (29.3%) had no known triggers identified. Men comprised the higher proportion of patients with physical triggers. Comorbidities including diabetes, pulmonary disease, chronic kidney disease and hypothyroidism were more prevalent among patients with physical triggers. Compared to patients with no obvious triggers, patients with a physical trigger had a much higher mortality rate (hazard ratio 2.0, 95% CI 1.2–3.3, p=0.007), whereas patients with an emotional trigger had significantly lower mortality (hazard ratio 0.40, 95% CI 0.21–0.89, p=0.007). Conclusion Different triggers for stress cardiomyopathy is associated with different baseline characteristics and clinical outcomes. Overall survival is worst in the group with an identified physical trigger. Figure 1 Funding Acknowledgement Type of funding source: None

1258 No Laughing Matter - Laughter Induced Syncope (Gelastic Syncope) Mimicking Cataplexy

Introduction Laughter is a common emotion and may rarely be a manifestation of neurological illnesses. It has been associated with cataplexy as well. Cataplexy is usually triggered by strong emotions. Gelastic syncope is an uncommon phenomenon which may be mistaken for cataplexy. We summarize 3 cases referred to the Sleep Medicine clinic for evaluation for Narcolepsy. Report of Case 55 yo male comes with 2 episodes of blacking out and falling down relating to episodes of laughter in 3 months. Patient describes loss of consciousness and no episodes of freezing. Reported 15 years of snoring and witnessed apneas along with grinding his teeth while sleeping. Polysomnogram revealed Obstructive Sleep Apnea (OSA) with an AHI of 20. 60 yo male comes with episodes of loss of consciousness over the past 6 months, including sitting in a chair, laughing, urinating, washing dishes while standing, expressing strong emotions (father’s funeral), etc. Also reports bugs crawling over his legs when trying to sleep, loud snoring and waking up choking while sleeping. Polysomnogram revealed OSA with an AHI of 20. 43 yo male comes 3 episodes of loss of consciousness, 2 of them related to laughing and the last one related to stretching his arms out. He passes out for 5-10 seconds at a time and a period of 20-30 seconds before passing out where he feels dizzy when he is unable to respond at this time, no post episode confusion. Positive on the Cataplexy Emotional Trigger Questionairre. Reported witnessed apneas, snoring and sleep talking. Polysomnogram revealed OSA, hence the Multiple Sleep Latency Testing ordered was not completed. Conclusion While the first two episodes point towards Gelastic Syncope based on symptoms, the third did warrant MSLT if there was no OSA on PSG. It is important to recognize gelastic syncope as an entity and differentiate it from cataplexy.

Delayed onset Takotsubo syndrome following exercise ECG: a case report

Background Takotsubo syndrome usually occurs immediately following a physical or emotional trigger. In some cases, a triggering stress may not be evident. A delayed manifestation of the syndrome may account for such cases. Case summary An asymptomatic 69-year-old woman presented for a routine cardiac check-up, which revealed normal electrocardiogram (ECG), echocardiography, and exercise ECG. She did not complain of any chest pain during or immediately after the tests. After about 24 h, she developed chest pain for which she was admitted with the provisional diagnosis of acute coronary syndrome. ECG showed dynamic T-wave changes with QTc prolongation. Cardiac biomarkers were mildly elevated. Characteristic reversible left ventricular dysfunction in absence of coronary stenosis ultimately led to the diagnosis of Takotsubo syndrome. Discussion Our case represents a delayed occurrence of Takotsubo syndrome triggered by a treadmill exercise stress test, which manifested about 24 h following the stressor. Such delayed manifestation may account for those cases of Takotsubo syndrome where no immediate triggering stressor is evident.