Cardiac amyloidosis at a glance

Amyloidosis can affect any organ in the body by deposition of amyloid fibrils. When these aggregate in the heart, it leads to cardiac amyloidosis a life-threatening and progressive disease. Although considered a rare condition, advances in imaging techniques and raised awareness have shown that it might be more frequent than has been historically estimated. Cardiac amyloidosis can be hereditary or occur as a consequence of the ageing process but, regardless of type, patients experience a heavy symptomatic burden. This article provides an overview of its pathophysiology, signs and symptoms and how any nurse can look for the main red flags in clinical practice. Early referral for specialist care can have a significant impact on disease progression and patient quality of life.

Non-invasive and contemporaneous cardiac imaging in heart failure

This article reviews the current non-invasive cardiac imaging modalities used in the diagnosis and management of heart failure patients. Heart failure is a complex syndrome secondary to functional and structural changes of the heart, with a wide range of possible causes for its onset. Different imaging investigations can inform diagnosis and guide care plans, so nurses across clinical practice will benefit from having knowledge on when these modalities are used. Echocardiography remains the most common investigation due to its low cost and reproducible nature when compared with other methods. It allows quantification of left ventricular function, which is an important prognostic marker in heart failure. Through cardiac magnetic resonance imaging, identification of potential reversible causes is possible, and further identification of underlying causes, when other modalities fail to do so. Finally, computed tomography coronary angiography is the currently recommended test in all patients presenting with typical or atypical anginal symptoms, diagnostically comparable to invasive coronary angiography.

The renal system and associated disorders

Disorders of the renal system, including the kidneys and urinary tract, are increasingly recognised as a public health concern, accounting for 830 000 deaths worldwide. Patients often have comorbidities, with many presenting with other diseases. Health professionals require good knowledge of the renal system and associated disorders to create holistic care plans to meet individual patients' needs. This article covers the pathophysiology of some of the most common problems, patient assessment and investigations, and considerations in helping patients with self-management.

The challenges of formal volunteering in hospitals

The role and tasks performed by hospital volunteers (HV), their relationship with other stakeholders and the management of volunteers, are controversial topics, not widely explored in literature. Through an exploratory study, which incorporated the collection and analysis of qualitative data, involving 46 interviews with volunteers, staff and hospital administration from three hospitals in Portugal, we analyze hospital volunteers, as well as the tasks they perform, how these tasks are assigned, and how they relate to other stakeholders. As a result, we conclude that the job definition of HV is generic, open to different interpretations and that the assigned functions of HV are not known from all stakeholders. This problem can have negative repercussions in the relationship between volunteers and health professionals, potentially fostering conflict. Nevertheless, most respondents are satisfied with the current format of volunteer management.

Hyperandrogenism, oligomenorrhea, and erythrocytosis caused by an ovarian Leydig cell tumor: A case report

Leydig cell tumors are rare ovarian neoplasms. Affected individuals typically present with amenorrhea/oligomenorrhea and rapidly progressive features of virilization. Erythrocytosis can also occur as a result of high testosterone levels.

Systematic screening for SARS-CoV-2 in pregnant women admitted for delivery in a Portuguese maternity

Objectives The burden of undocumented SARS-Cov-2 infections in Portuguese pregnant women is unknown. At our institution, routine COVID-19 testing was implemented from 19th of March on to all pregnant women who were admitted for delivery. The purpose of the study was to estimate the SARS-CoV-2 infection rate in our obstetric population admitted for delivery. Mathods Between 19th March and May 4th, 184 pregnant women were screened for SARS-CoV-2 infection upon admission. Results Eleven women were positive for SARS-CoV-2, corresponding to a global prevalence of 6.0%. Of these, only two reported symptoms at admission. The prevalence of asymptomatic infection was 4.9%. We report a lower rate of positive cass than other studies. Eighty-two percent of our cases had no symptoms at admission. Conclusions The proportion of asymptomatic infection highlights the importance of universal laboratory screening for all women admitted for delivery as opposed to symptom-based screening.

Choroid plexus is an additional source of melatonin in the brain

The cerebrospinal fluid melatonin is released from the pineal gland, directly into the third ventricle, or produced de novo in the brain from extrapineal melatonin sources leading to a melatonin concentration gradient in the cerebrospinal fluid. Despite the interest on this topic, the brain areas capable of producing melatonin are not yet clear. Bearing this in mind, we hypothesized that the choroid plexus (CP) could be one of these melatonin sources. We analyzed and confirmed the presence of the four enzymes required for melatonin synthesis in rat CP and demonstrated that arylalkylamine N-acetyltransferase shows a circadian expression in female and male rat CP. Specifically, this enzyme colocalizes with mitochondria in rat CP epithelial cells, an organelle known to be involved in melatonin function and synthesis. Then, we demonstrated that melatonin is synthesized by porcine CP explants, although without a circadian pattern. In conclusion, our data show that the CP is a local source of melatonin to the central nervous system, probably contributing to its high levels in the cerebrospinal fluid. We believe that in the CP, melatonin might be regulated by its endogenous clock machinery and by the hormonal background.

24/7 Presence of Medical Staff in the Labor Ward; No Day-Night Differences in Perinatal and Maternal Outcomes

Objective The objective of this study was to assess possible day-night differences in perinatal and maternal labor outcomes in a hospital setting with no day-night differences in the presence of experienced medical staff. Design This was a retrospective study conducted over 5 years between 2008 and 2012. Setting This study was set at the obstetric delivery unit in a tertiary hospital. Population A total of 9,143 singleton deliveries were assessed after 34 weeks of gestation and after exclusion of major congenital malformations, inductions of labor, and elective cesarean sections. Materials and Methods Data were collected using the hospital electronic medical records. Time periods of 8 hours were defined (daytime between 8 am and 4 pm, evening time between 4 pm and 12 pm, and nighttime between 12 pm and 8 am). Differences between the three time periods were assessed using software R Core Team (2013). Main outcome measures were neonatal birth asphyxia, neonatal intensive care unit admission, and neonatal death. Results There were no differences in perinatal and maternal outcomes in the course of the day, apart from a higher incidence of third- and fourth-degree tears during the evening. Neonatal outcome after obstetric emergencies (uterine rupture, partial placental abruption, and cord prolapse) also showed no day-night differences. Conclusion Adverse nighttime-related outcomes may be avoided by the 24/7 presence of experienced medical staff.

Interobserver agreement in CTG interpretation using the 2015 FIGO guidelines for intrapartum fetal monitoring

BACKGROUND

Visual analysis of cardiotocographic (CTG) tracings has been shown to be prone to poor intra- and interobserver agreement when several interpretation guidelines are used, and this may have an important impact on the technology's performance.

OBJECTIVES

The aim of this study was to evaluate agreement in CTG interpretation using the new 2015 FIGO guidelines on intrapartum fetal monitoring.

STUDY DESIGN

A pre-existing database of intrapartum CTG tracings was used to sequentially select 151 cases acquired with a fetal electrode, with duration exceeding 60minutes, and signal loss less than 15%. These tracings were presented to six clinicians, three with more than 5 years' experience in the labor ward, and three with 5 or less years' experience. Observers were asked to evaluate tracings independently, to assess basic CTG features: baseline, variability, accelerations, decelerations, sinusoidal pattern, tachysystole, and to classify each tracing as normal, suspicious or pathologic, according to the 2015 FIGO guidelines on intrapartum fetal monitoring. Agreement between observers was evaluated using the proportions of agreement (Pa), with 95% confidence intervals (95%CI).

RESULTS

A good interobserver agreement was found in the evaluation of most CTG features, but not bradycardia, reduced variability, saltatory pattern, absence of accelerations and absence of decelerations. For baseline classification Pa was 0.85 [0.82-0.90], for variability 0.82 [0.78-0.85], for accelerations 0.72 [0.68-0.75], for tachysystole 0.77 [0.74-0.81], for decelerations 0.92 [0.90-0.95], for variable decelerations 0.62 [0.58-0.65], for late decelerations 0.63 [0.59-0.66], for repetitive decelerations 0.73 [0.69-0.78], and for prolonged decelerations 0.81 [0.77-0.85]. For overall CTG classification, Pa were 0.60 [0.56-0.64], for classification as normal 0.67 [0.61-0.72], for suspicious 0.54 [0.48-0.60] and for pathologic 0.59 [0.51-0.66]. No differences in agreement according to the level of expertise were observed, except in the identification of accelerations, where it was better in the more experienced group.

CONCLUSIONS

A good interobserver agreement was found in evaluation of most CTG features and in overall tracing classification. Results were better than those reported in previous studies evaluating agreement in overall tracing classification. Observer experience did not appear to play a role in agreement.

DETERMINATION OF SHELF-LIFE OF JABOTICABA´S FRUITS CV. ‘SABARÁ’

The jaboticaba is a fruit tree with great potential, both for fresh consumption, as for industrialization. The objective of this study was to evaluate the shelf-life of jaboticabas’s fruits cv. ‘Sabará’ stored under refrigeration and at room temperature. After harvest, the fruits were washed, screened, packed in plastic trays, in single layer, and stored under refrigeration (5 °C, and 49% UR), and at room temperature (27 ºC, and 33% UR). The determinations performed in triplicate immediately after harvest and every other day, until the disposal of the fruit, were: pH, soluble solids (°Brix), total titratable acidity (% citric acid), total and reducer sugars (%), vitamin C (mg/100g) and phytopathological. The design adopted was entirely randomized, realized the analysis of variance (F test) and comparison of averages by Tukey test to 5% of significance. Under refrigeration, the storage was more than 9 days to 12 days, the fruits showed intense shriveling (loss of moisture), being unsuitable for marketing. The soluble solids remained stable during this period, but there was decrease of pH and the levels of total and reducer sugars, in addition to increased acidity, facts that indicate occurrence of fermentation process. The losses of vitamin C were of the order of 72,5, from 4,952mg/100g in zero time, and 3,593mg/100g at the end of this period. The stored fruits at room temperature were discarded at the beginning of storage, by shriveling, incidence of microorganisms and strange odor.

Bem te Quero – Da Educação Parental à Promoção dos Direitos da Criança

É durante a primeira infância (até aos 18 meses) que existe maior disponibilidade das figuras parentais para o estabelecimento de relações positivas e de afeto e é, também, neste período que muitos cuidadores parecem sentir maiores dificuldades em responder às necessidades das crianças, principalmente às de ordem afetiva, assegurando as melhores condições à sua sobrevivência, ao desenvolvimento, à protecção e à livre participação. Desejando ajudar os pais a enfrentarem o desafio da parentalidade positiva, isto é, a serem mais efetivos na sua ação de zelar pelo desenvolvimento e bem-estar das crianças, num enquadramento balizado pelo princípio da responsabilidade parental e da prevalência da família, têm sido criados alguns programas de apoio socioeducativo. Porém, estes têm visado, sobretudo, pais com crianças de idade superior a dois anos. Para famílias com bebés, o número de programas específicos parece ser mais reduzido. Relevam-se os trabalhos de Olds (1988), voltados para mães grávidas e para famílias com crianças até aos dois anos. O Bem-Te-Quero (BTQ), sendo um programa de competências familiares, coloca a ênfase na promoção de competências parentais favorecedoras da qualidade da relação pais-bebé, dado aquela ser apontada como um dos principais preditores da saúde psicológica nos vários estádios do desenvolvimento, assim como, nos ganhos desenvolvimentais do bebé. De acordo com vários autores, os programas dirigidos a pais e cuidadores, em geral, que se focam no desenvolvimento dos saberes, capacidades e competências, não só parecem constituir excelentes oportunidades para o desenvolvimento dos próprios pais/cuidadores, como têm surgido associados a resultados positivos em termos de perceção de auto-eficácia e de satisfação daqueles relativamente ao desempenho da função parental. Espera-se, assim, que o BTQ se possa transformar num programa de educação para a parentalidade que, através da promoção da reflexão e da ação dos pais, concorra para a promoção do desenvolvimento da criança em contexto de família. Mais especificamente, aspira-se a que os pais/cuidadores se sintam mais capacitados para cuidar dos seus bebés, que os processos de funcionamento familiar saiam robustecidos e facilitados, que a relação diádica seja fortalecida e vivida positivamente e que haja franco benefício para o comportamento e/ou desenvolvimento da criança.

Influence of age, sex and breeding status on mercury accumulation patterns in the wandering albatross Diomedea exulans

Although mercury bio-amplifies through the food chain and accumulates in top predators, mercury concentrations in tissues of the wandering albatross are greater than in any other vertebrate, including closely related species. In order to explore the alternative explanations for this pattern, we measured total mercury concentrations in feathers, plasma and blood cells of wandering albatrosses of known age, sex and breeding status sampled at South Georgia. Mercury concentrations were low in feathers and blood components of chicks, and higher in the feathers of young pre-breeders than in feathers or blood of older pre-breeders and breeding adults. There was no effect of sex on mercury concentrations in the feathers of pre-breeders or breeding adults, whereas levels were significantly higher in blood cells of breeding females than males. The high feather mercury concentrations of young pre-breeders compared with older birds suggest an increase in moult frequency as birds approach maturity.

Tics en niños y adolescentes: análisis retrospectivo de 78 casos

INTRODUCTION

Tics are the most frequent abnormal movement in children. A familial history of tics and a personal and familial history of neurobehavioral disturbances are common in children with this abnormality. Tics may seriously compromise daily activities in affected individuals.

OBJECTIVE

To identify the characteristics of tics in children and adolescents followed-up in the Neuropediatric Unit of the Hospital Geral de Santo António.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with tics based on information collected from medical records. The diagnostic criteria of the DSM IV-TR 2000 of the American Psychiatric Association were used.

RESULTS

The medical records of 78 children were analyzed, 84.6 % of whom were boys. More than one third of the patients were aged 4 to 8 years old. In 5.1 % of the patients tics developed before the age of 2 years. A familial history of tics, depression and obsessive disorder traits was found in approximately 30 % of patients. The most frequent comorbidity was attention deficit hyperactivity disorder (67.9 %). The occurrence of pediatric autoimmune neuropsychiatric disorders associated with streptococcus infection (PANDAS) was suggested in five patients. In all patients, motor tics occurred before vocal tics. In more than two thirds of the patients, tics were simple. In 59.0 % of the patients, tics were chronic, and in 45.7 % of these met the criteria for Tourette's syndrome. A total of 43.1 % of the patients with chronic tics received pharmacotherapy, risperidone being the most frequently used drug.

CONCLUSIONS

In general the results of the present study are in agreement with those of previous studies, underlining the need to consider a diagnosis of tics in young children and highlighting the importance of identification and appropriate treatment of comorbidities.

[Rolandic epilepsy. An analysis of the clinical and electrophysiological characteristics, treatment and prognosis in 87 patients]

INTRODUCTION

Rolandic epilepsy is the most common epileptic syndrome in infancy. It usually has a favourable prognosis and seizures disappear during the teenage years.

AIMS

The aim of this study was to describe a sample of children diagnosed with rolandic epilepsy in clinical, electrophysiological and imaging terms. We also intend to compare the results obtained with those described in the literature.

PATIENTS AND METHODS

We conducted a retrospective, descriptive study of the children diagnosed with rolandic epilepsy who had been submitted to a follow-up at the Neuropaediatrics Unit at the HGSA since 1989. Children who were less than 2 years old when they suffered their first seizures or who had abnormal neurological/imaging examinations were excluded. Two groups were defined (typical and atypical), several variables were characterised and these were then analysed statistically.

RESULTS

A total of 87 children (51 males) were included in this study, their mean age being 13.6 years. The population was divided into two groups: A (typical cases; n = 69) and B (atypical cases; n = 18). The mean age at the onset of seizures was 6.2 and 6 years for groups A and B, respectively. The predominant type of seizures was simple partial for group A and complex partial for group B; they were mainly sporadic and nocturnal in both groups. Medication was administered to 51 (73.9%) of the children in group A, with a good response in 78.4% of them; 13 members of group B (72.2%) received medication, with a positive response in 76.9% of them.

CONCLUSIONS

Rolandic epilepsy has a broad clinical spectrum and usually courses with normal psychomotor development, but may coexist with learning disabilities. In this study, no significant differences were found between the typical and atypical forms of presentation, as far as their progress and response to treatment are concerned.

A biomechanical study of four different meniscal repair systems, comparing pull-out strengths and gapping under cyclic loading

Most studies comparing the biomechanical properties of different meniscal repair systems have simply investigated load to failure. Meniscal tissue is highly anisotropic, and far weaker under tension in the radial direction. Radially oriented loading to failure may not therefore be the most physiologically relevant in vitro test for repair of circumferential tears, and determining gapping across repair sites under cyclical loading at lower loads may be of greater importance. Using bovine menisci, vertical circumferential incisions were repaired using a simple vertical 2-0 PDS suture, Meniscal Arrow, Meniscal Fastener or T-Fix. Repairs were tested by simple loading to failure in a materials testing machine, and by cyclic loading between 5 and 10 N for 25 cycles. Initial gapping across the repairs was measured using a digital micrometer, and the increase in gapping under cyclic loading measured using a Differential Voltage Reluctance Transducer. The mean loads to failure for each of the repair groups were: sutures 72.7 N, Arrows 34.2 N, Fasteners 40.8 N and T-Fix 49.1 N. The load to failure was significantly greater with sutures than with Arrows or Fasteners. The mean gapping across the repairs for each of the repair groups after 25 loading cycles were: sutures 3.29 mm, Arrows 2.18 mm, Fasteners 3.99 mm and T-Fix 3.47 mm. The mean gapping was significantly less with Arrows than with Sutures, Fasteners or T-Fix. These results confirm that meniscal repair by suturing gives the highest load to failure, but show that Arrows give superior hold under lower loads, with the least gapping across repairs under cyclic loading of the four methods tested.

Sexual behavior in sleep, sleepwalking and possible REM behavior disorder: a case report

Seven cases of sexual behavior during sleep (SBS) have been recently reported. The subjects had histories of behavioral parasomnias as well as positive family histories of parasomnia. A 27 year-old man with a history of sexual behavior during sleep was reported. His sleep history disclosed sleepwalking (SW) since 9 years of age. He also developed episodes of highly disruptive and violent nocturnal behavior with dream enactment at age 20 years, which often resulted in physical injuries either to himself or his wife and infant. His wife also reported episodes of amnestic sexual behavior that began 4 years before referral. During the episodes, the patient typically procured his wife, achieving complete sexual intercourse with total amnesia. Physical and neurological diagnostic workups were unremarkable. Family history disclosed sleepwalking in his brother. He was put on 2mg/day of bedtime clonazepam with a remarkable clinical improvement. This case involves either the combination of violent and non-violent sleepwalking with SBS, or the superimposition of presumed REM sleep behavior disorder (RBD) on top of preexisting SW in a man who also developed SBS in adulthood. Thus, this is a case report of probable parasomnia overlap syndrome.

Excessive somnolence

Excessive somnolence can be quite a incapacitating manifestation, and is frequently neglected by physicians and patients. This article reviews the determinant factors, the evaluation and quantification of diurnal somnolence, and the description and treatment of the main causes of excessive somnolence.

Bilateral rupture of the quadriceps tendon associated with anabolic steroids

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Mandibular-Lingual Repositioning Device--MLRD: preliminary results of 8 patients with obstructive sleep apnea syndrome--OSAS

Dental devices have been employed in the treatment of snoring and obstructive sleep apnea syndrome (OSAS) of mild to moderate degrees. The authors disclose the preliminary results in 8 patients with clinically diagnosed obstructive sleep apnea polisomnographically confirmed and treated with a dental device (Mandibular-Lingual Repositioning Device--MLRD) developed by one of the authors (RCB). Cephalometrics was performed before usage of MLRD, Epworth Sleepiness Scale (ESS) tests were conducted before and after the MLRD and a questionnaire that subjectively qualified the Overall Subjective Improvement of the patient (OSI) was filled out. The tests were repeated 4 weeks after the application of the MLRD. The average subjective overall improvement was 73.75% and the Epworth Sleepiness Scale was 13.88 (pre-MLRD) and 6.63 (post-MLRD) representing a significant statistical variation (p = 0.05). The authors discuss probable factors involved in the improvement of the subjective measurements of excessive sleepiness.

Fibrodysplasia ossificans progressiva. Report of a case in Trinidad and Tobago

A case of fibrodysplasia ossificans progressiva is herein reported in a 27-year-old black woman. This is a very rare condition, the first to be reported from Trinidad and Tobago.

Acute reversal of flunitrazepam effects by Ro 15-1788 and Ro 15-3505: inverse agonism, tolerance, and rebound

A phase 1 double blind crossover comparison of a new benzodiazepine antagonist (Ro 15-3505) with Ro 15-1788 and placebo, in the reversal of sedative and psychophysiological effects of single IV doses of flunitrazepam (2 mg), was carried out in 12 normal volunteers. The antagonists were equally effective, leading to full reversal of all effects with a potency ratio of approximately 2.5 mg Ro 15-1788 for 1 mg Ro 15-3505. Inverse agonism, in the form of unpleasant feelings and symptoms, was reported by all subjects following Ro 15-3505 but none after Ro 15-1788. Adaptational phenomena such as acute tolerance and rebound of sedative effects of flunitrazepam were also detected and their potential implications are discussed.

Management of penetrating cardiac injuries: the role of emergency room thoracotomy

Sixty-four consecutive patients with penetrating cardiac injuries were treated between January, 1977, and January, 1983, at the University of Maryland Hospital. Twenty-eight patients had major associated injuries of other organs. The patients were divided into groups according to their clinical status on arrival. An aggressive approach was utilized including early emergency room (ER) thoracotomy for "lifeless" or deteriorating patients. Three patients required immediate cardiopulmonary bypass for repair of their injuries. Twenty-one (57%) of the 37 patients undergoing ER thoracotomy survived; most of the deaths occurred in patients arriving "lifeless" from gunshot wounds. Twenty-four (89%) of the 27 patients who were in stable enough condition to undergo initial repair in the operating room (OR) survived. Overall survival was 45 patients (70%). Though superficial wound infections developed in 18 patients, there were no deep or systemic infections. None of the survivors sustained severe neurological sequelae. Five patients underwent late reoperations for closure of a ventricular septal defect (2), mitral valve replacement (1), and pericardiectomy (2) with no deaths. Though repair of penetrating cardiac injuries should preferably be carried out in the OR, immediate thoracotomy for "lifeless" or deteriorating patients can be performed in the ER with a low incidence of direct surgical complications and with high patient survival.

Subclavian flap repair of coarctation of the aorta in neonates. Realization of growth potential?

The subclavian flap repair for coarctation of the aorta allows potential for growth by utilizing autogenous tissue. Although well documented in young children, its promise in the tiny neonate warrants further evaluation. Since August, 1979, 29 patients, including 24 infants, have undergone subclavian flap repair at the University of Maryland Hospital. Weights ranged from 1.4 to 5 kg (mean 3.2 kg). All patients less than 6 months old had associated intracardiac defects and were in severe congestive failure. Fifteen responded to preoperative prostaglandin infusions. The overall early mortality was 14%; among the neonates it was 21%; and among those operated upon within the first week of life, 33%. There was one intraoperative death among the eight patients who underwent simultaneous pulmonary artery banding. There were no deaths among patients older than 5 days at operation. Four of the five neonates who died had some variant of hypoplastic left heart syndrome, with severe stenosis or atresia of the systemic atrioventricular valve, critical aortic stenosis, or hypoplastic left ventricle. Twenty-two survivors continue to do well up to 3.7 years postoperatively (mean follow-up 26 months). At follow-up all patients are normotensive with brisk lower extremity pulses. Patients now weigh 1.3 to 6.9 (mean 2.3) times their operative weight, and only one patient has a measured arm-to-leg gradient greater than 10 mm Hg (mean gradient 3.7 mm Hg). Seven of the neonates have undergone repeat catheterization, and all had satisfactory growth of the subclavian flap segment of repair and no gradient. Two older patients (3 and 4 years old at operation) have undergone exercise testing 3.7 years after repair, with peak exercise gradients of only 7 and 15 mm Hg. We therefore continue to utilize this technique for the treatment of coarctation even in tiny neonates.

Migration of Kim-Ray Greenfield umbrella to the heart

We have described a case of migration of a Kim-Ray Greenfield umbrella from the inferior vena cava to the heart for unknown reason. The umbrella was surgically removed and the patient recovered fully. This complication has not been previously reported. Despite this complication, we believe that the Kim-Ray Greenfield umbrella, when placed with particular attention to technique, effectively prevents pulmonary emboli and offers minimal associated morbidity.