Stroke and Respiratory Failure: Mind the Shunt!

When stroke patients present with respiratory failure, the first thought that clinicians have is that it is probably related to aspiration pneumonia. However, other causes should be considered, such as intracardiac or intrapulmonary shunts, that could present with paradoxical embolism. Paradoxical embolism is a rare entity defined by the occurrence of a venous thrombotic event associated with a systemic arterial embolism. Frequently, paradoxical embolism presents with platypnoea-orthodeoxia syndrome. Platypnoea-orthodeoxia syndrome is uncommon and is characterized by dyspnoea and hypoxaemia induced by orthostatic position, where symptoms and oxygenation are relieved by recumbency. The authors report a case of a patient who presented with an ischaemic stroke and progression to platypnoea-orthodeoxia syndrome with documentation of simultaneous pulmonary embolism and pulmonary arteriovenous malformations.

Coalizão da articulação talocalcaneana com Os sustentaculum - Uma coalizão incomum / Coalition of the medial portion of the talocalcaneal with the associated Os sustentaculum – An uncommon coalition

Introdução: O Os sustentaculum é um osso acessório raro localizado na extremidade posterior do sustentaculum tali. A coalizão tarsal pode ser considerada uma anomaliacongênita que pode se tornar sintomática. Frequentemente, é necessária a TC ou a RM para confirmar o diagnóstico de coalizão talo-calcânea quando os achados nas radiografiassão ambíguos. Objetivo: Relatar um caso incomum de Coalizão da articulação talocalcaneana com Os sustentaculum, diagnosticado por exames de imagem. Relatodo Caso: Mulher de 26 anos com “caroço” no tornozelo direito há 10 anos promovendo dor intermitente. Apresenta piora ao usar salto – independentemente do tempo, ao andar ou ao ficar em posição ortostática por mais de 1 hora, referindo dor a palpação e irradiação para o pé. A radiografia do tornozelo direito apresenta ossículo acessório na porção medial da articulação talo-calcânea – Os sustentaculum, confirmada pela tomografia computadorizada. A ressonância magnética diagnostica coalizão talo-calcânea extra-articular com Os ustentaculum. Conclusão: É importante ressaltar que o Os sustentaculum não é apenasum ossículo acessório ou uma fratura antiga, ele é um componente de um tipo de coalizão talo-calcânea extra-articular, o que faz com que essa condição seja geralmente sintomática. Portanto, se um paciente com Os sustentaculum apresentar sintomas na área articular talo-calcânea medial, uma coalizão talo-calcânea extra-articular com Os sustentaculum deve ser considerada. Palavras-chave: Coalizão tarsal, Tomografia computadorizada por raios X, Imagem por ressonância magnética, Radiografia ABSTRACT Introduction: The Os sustentaculum is a rare accessory bone located at the posterior end of the sustentaculum tali. The tarsal coalition can be considered a congenital anomaly that can become symptomatic. Often, CT or MRI is required to confirm the diagnosis of the talo-calcaneus coalition when the findings on radiographs are ambiguous. Objective: To report an unusual case of a coalition of the talocalcaneal joint with Os sustentaculum, diagnosed by imaging exams. Case Report: A 26-year-old woman with a “lump” in her right ankle for 10 years causing intermittent pain. She worsens when wearing heels - regardless of the time when walking or standing in an orthostatic position for more than 1 hour, referring to pain on palpation and irradiation to the foot. The right ankle radiograph shows an accessory ossicle in the medial portion of the talocalcaneal joint – Os Sustentaculum, confirmed by computed tomography. Magnetic resonance imaging diagnoses extra-articular talo-calcaneus coalition with Os sustentaculum. Conclusion: It is important to emphasize that the Os sustentaculum is not just an accessory ossicle or an old fracture, it is a component of a type of extra-articular talo-calcaneus coalition, which makes this condition generally symptomatic. Therefore, if a patient with Os sustentaculum shows symptoms in the medial talo-calcaneus joint area, an extra-articular talo-calcaneus coalition with Os sustentaculum should be considered. Keywords: Tarsal coalition, X-ray computed tomography, Magnetic resonance imaging, Radiography

Upright exercise stress echocardiography may unmask dynamic left ventricular obstruction also beyond hypertrophic cardiomyopathy

Background Dynamic left ventricular outflow obstruction (LVOTO) during exercise stress echocardiography (ESE) is recommended in hypertrophic cardiomyopathy (HCM) to identify the obstructive phenotype. Aim To assess left ventricular outflow gradient (LVOTG) during ESE in different conditions. Methods In a single-group, prospective, observational study, we performed peak and/or post-treadmill ESE with systematic assessment of LVOTG in the orthostatic position by continuous-wave Doppler in 1333 subjects (837 males, mean age 38,2±20 ranging from 6 to 87 years) recruited over a period of twenty years, from 2001 to 2021. Peak LVOTG ≥30 mm Hg was considered abnormal for LVOTO during ESE. We enrolled 7 different populations: asymptomatic healthy controls (n=35); HCM (n=81); genotype-positive, phenotype negative asymptomatic HCM (n=6); patients with chest pain symptoms, suspected myocardial ischemia and either normal coronary arteries (INOCA, n=131,or with very low pre-test probability of coronary artery disease (probable INOCA, n=416) and; fatigue and suspected heart failure with preserved ejection fraction (HFpEF, n=206); amateur athletes with ischemia-like ECG changes during exercise-test or symptoms such as near syncope or chest pain or dizziness (n=457); aborted sudden death and with negative screening (n=1). Results Technical success rate of LVOTG assessment was 1333/1333 at rest and at peak stress (feasibility 100%). Imaging and analysis time were <1 minute. LVOTG at rest was present in 25 pts (2.8%) of the overall population: 23 HCM, 1 INOCA, and 1 HFpEF. Overall prevalence during ESE was 432/1333 (32%). During ESE, LVOTO (see Figure 1 and 2) was 0% (0/35) in normals, 58% (47/81) in HCM (23 with obstruction at rest), 33% (2/6) in genotype-positive, phenotype negative HCM, 37% (33/131) in INOCA, 40% (135/416) in athletes and 1/1 in the patient with aborted sudden death on strenuous exercise. Conclusion LVOTO in orthostatic position is detectable during treadmill ESE in several cardiovascular conditions associated with symptoms such as dyspnea, chest pain or near syncope, and even in asymptomatic patients with genotype-positive, phenotype-negative HCM. The identification of the obstructive phenotype is easy to capture during ESE without any significant additional imaging and analysis burden and can be important also outside HCM. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

The validity and reliability of ultra-short-term heart rate variability parameters and the influence of physiological covariates

Background: Ultra-short-term (UST) heart rate variability (HRV) metrics have increasingly been proposed as surrogates for short-term HRV metrics. However, the concurrent validity, within-day reliability, and between-day reliability of UST HRV have yet to be comprehensively documented. Methods: Thirty-six adults (18 males, age: 26 ± 5 years, BMI: 24 ± 3 kg/m2) were recruited. Measures of HRV were quantified in a quiet-stance upright orthostatic position via three-lead electrocardiogram (ADInstruments, FE232 BioAmp). All short-term data recordings were 300-seconds in length and five UST time points (i.e., 30-seconds, 60-seconds, 120-seconds, 180-seconds, and 240-seconds) were extracted from the original 300-second recording. Bland-Altman plots with 95% limits of agreement, repeated measures ANOVA, and two-tailed paired t-tests demarcated differences between UST and short-term recordings. Linear regressions, coefficient of variation, intraclass correlation coefficients, and other tests examined the validity and reliability in both time- and frequency-domains. Results: No group differences were noted between all short-term and UST measures, for either time- (all p>0.202) or frequency-domain metrics (all p>0.086). A longer recording duration was associated with augmented validity and reliability, that was less impacted by confounding influences from physiological variables (e.g., respiration rate, carbon dioxide end-tidals, and blood pressure). Conclusively, heart rate, time-domain, and relative frequency-domain HRV metrics were acceptable with recordings greater or equal to 60s, 240s, and 300s, respectively. Conclusions: Future studies employing UST HRV metrics, should thoroughly understand the methodological requirements to obtain accurate results. Moreover, a conservative approach should be utilized regarding the minimum acceptable recording duration, which ensures valid/reliable HRV estimates are obtained.

Evaluation of Cardiac Circadian Rhythm Deconditioning Induced by 5-to-60 Days of Head-Down Bed Rest

Head-down tilt (HDT) bed rest elicits changes in cardiac circadian rhythms, generating possible adverse health outcomes such as increased arrhythmic risk. Our aim was to study the impact of HDT duration on the circadian rhythms of heart beat (RR) and ventricular repolarization (QTend) duration intervals from 24-h Holter ECG recordings acquired in 63 subjects during six different HDT bed rest campaigns of different duration (two 5-day, two 21-day, and two 60-day). Circadian rhythms of RR and QTend intervals series were evaluated by Cosinor analysis, resulting in a value of midline (MESOR), oscillation amplitude (OA) and acrophase (φ). In addition, the QTc (with Bazett correction) was computed, and day-time, night-time, maximum and minimum RR, QTend and QTc intervals were calculated. Statistical analysis was conducted, comparing: (1) the effects at 5 (HDT5), 21 (HDT21) and 58 (HDT58) days of HDT with baseline (PRE); (2) trends in recovery period at post-HDT epochs (R) in 5-day, 21-day, and 60-day HDT separately vs. PRE; (3) differences at R + 0 due to bed rest duration; (4) changes between the last HDT acquisition and the respective R + 0 in 5-day, 21-day, and 60-day HDT. During HDT, major changes were observed at HDT5, with increased RR and QTend intervals’ MESOR, mostly related to day-time lengthening and increased minima, while the QTc shortened. Afterward, a progressive trend toward baseline values was observed with HDT progression. Additionally, the φ anticipated, and the OA was reduced during HDT, decreasing system’s ability to react to incoming stimuli. Consequently, the restoration of the orthostatic position elicited the shortening of RR and QTend intervals together with QTc prolongation, notwithstanding the period spent in HDT. However, the magnitude of post-HDT changes, as well as the difference between the last HDT day and R + 0, showed a trend to increase with increasing HDT duration, and 5/7 days were not sufficient for recovering after 60-day HDT. Additionally, the φ postponed and the OA significantly increased at R + 0 compared to PRE after 5-day and 60-day HDT, possibly increasing the arrhythmic risk. These results provide evidence that continuous monitoring of astronauts’ circadian rhythms, and further investigations on possible measures for counteracting the observed modifications, will be key for future missions including long periods of weightlessness and gravity transitions, for preserving astronauts’ health and mission success.

Post-spinal anesthesia headache: a literature review

Background: Headache is the most common neurological symptom and is an important complication of cerebrospinal fluid access (CSF) techniques, reported by 1/3 of the patients after 48 hours of puncture. Objective: Present the most relevant information about the clinic and influential factors of headache after spinal anesthesia. Method: A literature review was conducted in pubmed, Scielo, Lilacs and Google academic databases, having as inclusion criteria articles of great relevance published in English, Portuguese and Spanish in the period 2016 to 2021 and exclusion criteria articles published outside that period. Results: Post-spinal anesthesia headache or post-dural puncture headache (DPC) belongs to the group of secondary headaches resulting from nonvascular disorders. The condition is composed of headache in the occipital and frontal region, which worsens in orthostatic position and may be accompanied by other symptoms such as neck stiffness, hearing disorders, photophobia, and nausea. The incidence of headache after the procedure varies according to the technique used, which can be medial or para - medial; more frequent in females; with the use of calibrated needles and in young patients. Regarding the recovery time, according to the reviewed literature, 72% of the patients had resolved the case within 7 days. Conclusion: Therefore, the correct performance of the procedure, with attention to modifiable factors, and the careful evaluation of clinical aspects for early diagnosis are essential to reduce the incidence and morbidity of this potentially disabling headache.

Irrational use of alendronate sodium by the elderly

Introduction: The effectiveness and safety of alendronate sodium are dependent on patient adherence to very specific guidelines regarding use. This study aims to estimate the rational use of alendronate sodium in the elderly. Methods: This is a cross-sectional study carried out with a structured questionnaire containing form of use and occurrence of adverse events related to alendronate sodium. The patients were recruited in their own homes. Rational use was considered as being the participants who: a) took the tablet in the morning; b) were fasting; c) waited at least 30 minutes before eating; d) ingested with a full glass of water; e) ingested the whole tablet; f) and remained in the orthostatic position for at least 30 minutes after use. Additionally, the odds ratio (OR) was used to analyze the association between the irrational use of alendronate sodium and the independent variables. Results and Discussion: Of the 248 participants in the study, most of the participants administered the medication in the morning (95.2%), with fasting (89.1%), waited at least 30 minutes to eat the first meal of the day (87.9%), and were in the orthostatic position until the time of the first meal (78.6%), but less than half ingested the tablet with a full glass of water (43.6%). Rational use of the medication was observed in only 30.7% of the participants. Regarding possible adverse events, 13.3% of the participants reported some event. Among the most prevalent were dry cough (6.5%), stomach pain (5.2%) and some throat discomfort (4.8%). The irrational use of this medication is associated with age and education level. Conclusion: The prevalence of irrational use of alendronate sodium in the elderly is high, and this use is associated with patients’ sociodemographic factors.

Pseudotumor cerebri secondary to secondary hypoparathyroidism and association to Fahr´s yndrome: a case report

Introduction Headaches are extremely common complications in emergency departments, accounting for up to 16% of visits, according to some studies and are observed in almost all patients with Idiopathic Intracranial Hypertension (IIH), which is characterized by signs and symptoms that include, in addition to headache, nausea, vomiting, diplopia, decreased visual acuity, pulsatile tinnitus, back and neck pain, among other possible manifestations. However, the clinical presentation is highly variable, which can delay diagnosis. Case report A.T.F, female, 33 years old, BMI 40.17 kg / m², with grade 3 obesity, caucasian, single, with Down Syndrome. Presents a history of post-surgical hypothyroidism, whose thyroidectomy was performed 10 years ago, due to nodular goiter. This patient presented subacute nausea, visual turbidity, diarrhea and pulsatile holocranial headache, which worsened in the horizontal position and presented slight relief in the orthostatic position. Conclusion The conduct of Fahrs Syndrome, in this case, was focused on the treatment of hypoparathyroidism and which consists of correcting metabolism disorders of phosphorus and calcium, which naturally resulted in clinical and radiological improvement, however, without definitive resolution of the condition.

Thermal Variations in Osteoporosis After Aclasta® Administration: Case Study

Osteoporosis is a metabolic disease characterized by an imbalance between bone formation and resorption, that results in an increasing risk of fracture. The aim of the present study was to investigate changes in the thermal pattern of a 50-year-old female patient after intravenous infusion of zaledronic acid Aclasta® in the treatment of osteoporosis. Thermal images were acquired in orthostatic position of the dorsal region between the lumbar and sacral portions using a FLIR® T530 camera with a thermal sensitivity (NETD) < 30 mK and the sensor array size of 320 x 240 pixels, with an accuracy of ±2% of the reading. The image analysis was performed using the Flir Tools® 6.4 software in order to identify the minimum, average and maximum temperature values in the region of interest; and MATLAB® 2017a software to extract histograms from images. The results present a good agreement between the temperature measurements and the painful symptomatology of the sacroiliac region of the vertebral column affected by the disease. Thermography might be a promising method for monitoring bone healing process.