Clinical Application of Exercise Stress Echocardiography in an Outpatient Pediatric Population.

Background: Exercise stress echocardiography (ESE) is commonly employed in adults, but its applicability in pediatric populations remains to be clarified. Methods: A total of 309 consecutive children (C), with a mean age of 14.1 ± 2.6 years (range 6-17 years), underwent treadmill ESE starting in 2002. They were divided into two groups: Group I comprised 258 children, including 237 with symptoms related to exercise (such as chest pain, fatigue, lipothymia/syncope, or one aborted sudden death), 15 with electrocardiogram (ECG) abnormalities, and 6 with a positive ECG stress test showing ST changes. Group II consisted of 10 asymptomatic children whose parents requested routine screening, 11 with symptoms unrelated to exercise, 12 with a family history of sudden death, and 17 with known pathologies (including 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, and the remainder with various conditions, such as Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, and aortic switch operation). Regional wall motion abnormalities (RWMAs) and transvalvular or intraventricular (IVG) gradients were assessed using 2D and continuous-wave Doppler, respectively, in all cases. Results: The success rate was 100% (309/309). Stress-induced RWMAs were observed in two children. A significant IVG (>30 mmHg) was detected in 101 out of the 258 children (39%) in Group I, who presented with exercise-related symptoms, ECG abnormalities, or positive stress ECG. In Group I, the odds ratio (OR) of ESE reproducing the symptoms in children with IVG compared to those without IVG was 8.22 (95% CI: 4.84-13.99, p < 0.001). Conclusions: Treadmill ESE is both feasible and safe for pediatric populations. RWMAs demonstrated limited utility in our cohort of children, while IVG induced by exercise was frequently observed in symptomatic children.

PROXIMAL HUMERAL LOCKING PLATE: A VIABLE ALTERNATIVE FOR FIXATION OF DISTAL FEMORAL FRACTURES IN CHILDREN.

Distal femoral metaphyseal fractures are rare in children, and the proximity of the fracture to the growth plate makes their approach challenging. Objective: Evaluate outcomes and complications of treatment of distal femoral metaphyseal fractures in children with proximal humeral locking plates. Method: Retrospective study between 2018 and 2021, including seven patients. The analysis included general characteristics, trauma mechanism, classification, clinical and radiographic outcomes, and complications. Results: The mean follow-up was 20 months, the average age was nine years, five patients were boys, and six fractured on the right side. Five fractures were caused by car accidents, one by falling from their own height and one by playing soccer. Five fractures were classified as 33-M/3.2 and two as 33-M/3.1. Three fractures were open, Gustilo IIIA. All seven patients recovered mobility and resumed their pre-trauma activities. All seven healed, and one fracture was reduced to 5 degrees valgus, without any other complications. Six patients had the implant removed and did not present refracture. Conclusion: Treatment of distal femoral metaphyseal fractures with proximal humeral locking plates is a viable option that offers good results and fewer complications, saving the epiphyseal cartilage. Level of Evidence II; Controlled study without randomization.

As fraturas metafisárias distais do fêmur são raras em crianças, a proximidade da fratura com a placa de crescimento torna a sua abordagem desafiadora. Objetivo: Avaliar resultados e complicações do tratamento das fraturas da metáfise distal do fêmur em crianças com placas de úmero proximal. Método: Estudo retrospectivo entre 2018 e 2021 incluindo sete pacientes. A análise incluiu características gerais, mecanismo do trauma, classificação, resultados clínicos, radiográficos e complicações. Resultados: A média do acompanhamento foi de 20 meses, a idade média foi de nove anos, cinco pacientes eram meninos e seis fraturas do lado direito. Cinco fraturas por acidentes automobilísticos, uma por queda da própria altura e uma jogando futebol. Cinco fraturas classificadas como 33-M/3,2 e duas como 33-M/3,1. Três fraturas foram expostas, Gustilo IIIA. Todos os sete pacientes recuperaram a mobilidade e retomaram às atividades anteriores ao trauma. Todas as sete fraturas consolidaram, uma fratura foi reduzida com valgo de 5 graus, e não houveram outras complicações. Seis pacientes tiveram o implante removido e não apresentaram refratura. Conclusão: O tratamento das fraturas da metáfise distal do fêmur com placas de úmero proximal é uma opção viável que oferece bons resultados com poucas complicações, poupando a cartilagem epifisária. Nível de Evidência II; Estudo controlado sem randomização.

Proximal humeral locking plate: a viable alternative for fixation of distal femoral fractures in children / Placa de fixação de úmero proximal: uma alternativa para fixação de fraturas do fêmur distal em criança

ABSTRACT Distal femoral metaphyseal fractures are rare in children, and the proximity of the fracture to the growth plate makes their approach challenging. Objective Evaluate outcomes and complications of treatment of distal femoral metaphyseal fractures in children with proximal humeral locking plates. Method Retrospective study between 2018 and 2021, including seven patients. The analysis included general characteristics, trauma mechanism, classification, clinical and radiographic outcomes, and complications. Results The mean follow-up was 20 months, the average age was nine years, five patients were boys, and six fractured on the right side. Five fractures were caused by car accidents, one by falling from their own height and one by playing soccer. Five fractures were classified as 33-M/3.2 and two as 33-M/3.1. Three fractures were open, Gustilo IIIA. All seven patients recovered mobility and resumed their pre-trauma activities. All seven healed, and one fracture was reduced to 5 degrees valgus, without any other complications. Six patients had the implant removed and did not present refracture. Conclusion Treatment of distal femoral metaphyseal fractures with proximal humeral locking plates is a viable option that offers good results and fewer complications, saving the epiphyseal cartilage. Level of Evidence II; Controlled study without randomization.

RESUMO As fraturas metafisárias distais do fêmur são raras em crianças, a proximidade da fratura com a placa de crescimento torna a sua abordagem desafiadora. Objetivo Avaliar resultados e complicações do tratamento das fraturas da metáfise distal do fêmur em crianças com placas de úmero proximal. Método Estudo retrospectivo entre 2018 e 2021 incluindo sete pacientes. A análise incluiu características gerais, mecanismo do trauma, classificação, resultados clínicos, radiográficos e complicações. Resultados A média do acompanhamento foi de 20 meses, a idade média foi de nove anos, cinco pacientes eram meninos e seis fraturas do lado direito. Cinco fraturas por acidentes automobilísticos, uma por queda da própria altura e uma jogando futebol. Cinco fraturas classificadas como 33-M/3,2 e duas como 33-M/3,1. Três fraturas foram expostas, Gustilo IIIA. Todos os sete pacientes recuperaram a mobilidade e retomaram às atividades anteriores ao trauma. Todas as sete fraturas consolidaram, uma fratura foi reduzida com valgo de 5 graus, e não houveram outras complicações. Seis pacientes tiveram o implante removido e não apresentaram refratura. Conclusão O tratamento das fraturas da metáfise distal do fêmur com placas de úmero proximal é uma opção viável que oferece bons resultados com poucas complicações, poupando a cartilagem epifisária. Nível de Evidência II; Estudo controlado sem randomização.

Exercise stress echocardiography: Where are we now?

Exercise stress echocardiography (ESE) is a widely used diagnostic test in cardiology departments. ESE is mainly used to study patients with coronary artery disease; however, it has increasingly been used in other clinical scenarios including valve pathology, congenital heart disease, hypertrophic and dilated cardiomyopathies, athlete evaluations, diastolic function evaluation, and pulmonary circulation study. In our laboratories, we use an established methodology in which cardiac function is evaluated while exercising on a treadmill. After completing the exercise regimen, patients remain in a standing position or lie down on the left lateral decubitus, depending on the clinical questions to be answered for further evaluation. This method increases the quality and quantity of information obtained. Here, we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail. We also present alternatives to ESE that may be used and their advantages and disadvantages. We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.

The Perception of the Müller-Lyer Visual Illusion in Schizophrenics and Non-human Primates: A Translational Approach.

The Müller-Lyer Illusion (MLI) has been suggested as a potential marker for the perceptual impairments observed in schizophrenia patients. Along with some positive symptoms, these deficits are not easily modeled in rodent experiments, and novel animal models are warranted. Previously, MK-801 was shown to reduce susceptibility to MLI in monkeys, raising the prospects of an effective perception-based model. Here, we evaluate the translational feasibility of the MLI task under NMDA receptor blockage as a primate model for schizophrenia. In Experiment 1, eight capuchin monkeys (Sapajus spp.) were trained on a touchscreen MLI task. Upon reaching the learning criteria, the monkeys were given ketamine (0.3 mg/kg; i.m.) or saline on four consecutive days and then retested on the MLI task. In Experiment 2, eight chronic schizophrenia patients (and eight matching controls) were tested on the Brentano version of the MLI. Under saline treatment, monkeys were susceptible to MLI, similarly to healthy human participants. Repeated ketamine administrations, however, failed to improve their performance as previous results with MK-801 had shown. Schizophrenic patients, on the other hand, showed a higher susceptibility to MLI when compared to healthy controls. In light of the present and previous studies, the MLI task shows consistent results across monkeys and humans. In spite of potentially being an interesting translational model of schizophrenia, the MLI task warrants further refinement in non-human primates and a broader sample of schizophrenia subtypes.

The Portuguese Validation of the Basic Psychological Need Satisfaction and Frustration Scale: Concurrent and Longitudinal Relations to Well-being and Ill-being.

This research comprises two studies based on Self Determination Theory. In Study 1, we translate and examine the factor structure of the Basic Psychological Needs Satisfaction and Frustration Scale (BPNSFS; Chen, Vansteenkiste et al., 2015) in a sample of Portuguese undergraduate students. Further, in Study 2 we used an independent longitudinal sample of 12th grade students to inspect whether the six subscales differently predict adjustment over time. Confirmatory factor analysis showed that a six-factor solution best fitted the BPNSFS data. Subsequent structural equation modelling indicated that the dimensions of need satisfaction and need frustration predicted unique variance in participants' well-being and ill-being over time, even after controlling for reciprocal and baseline effects. Taken together the findings support the 6-factor multidimensional structure of the BPNSFS and provide extensive support for the distinction between the satisfaction and frustration dimensions of needs, suggesting that they should be measured and interpreted as relatively distinct motivational constructs.

Perceived Parenting and Basic Need Satisfaction among Portuguese Adolescents.

We examined the psychometric properties of the Parenting Questionnaire in a sample of Portuguese high school students. Two measurement models were specified. Model 1m,f specifies a bi-dimensional structure of parental need-support and behavioral control. Model 2m,f proposes a tripartite structure of parental need-support, psychological control and behavioral control. Model 2m,f. best-fitted the data, being also supported in terms of convergent, discriminant validity. Regression results found the unique effect of autonomy-support (M2mr, b = .25 p < .001; M2fr, b = .14 p < .01), responsiveness-warmth (Model 2mr, b = .19, p .05). Notably, psychological control predicted low need-satisfaction (M2mr: b = -.10) and moderated of the positive effect of parental need-support on need-satisfaction, M2mr: F(3, 367) = 11.62, p < .001. Psychological control and need-support also moderated the positive effect of behavior control on competence satisfaction, with parental need-support amplifying this effect and psychological control buffering it. Overall the findings support the substantive distinction between the parenting dimensions, suggesting that need-satisfaction is enhanced by need-supportive and behavioural control and undermined by psychological control.

A 72-year-old woman with an uncorrected tetralogy of Fallot presenting with possible pulmonary endocarditis: a case report.

INTRODUCTION: Tetralogy of Fallot is one of the most common forms of cyanotic congenital heart disease and in the absence of surgical correction it has an elevated early mortality, with most patients dying in childhood.The authors reported this case because of the unusual course of an uncorrected tetralogy of Fallot. There are only a few reports of patients with an uncorrected tetralogy of Fallot who reach an advanced age and to the best of our knowledge this is the first case report of a possible endocarditis in a patient with an uncorrected tetralogy of Fallot who is older than 70 years. CASE PRESENTATION: The authors present a case of a 72-year-old Caucasian woman with uncorrected tetralogy of Fallot who was admitted with fever and heart failure to our Cardiology Department with possible infective endocarditis. CONCLUSIONS: The longevity of this patient is probably due to the association between a large ventricular septal defect, a balanced subpulmonary stenosis and to the presence of systemic hypertension. After empiric antibiotic therapy, the patient was discharged and no surgical intervention was performed due to her previous benign evolution.

Pseudoaneurysm inside of a true aneurysm.

Left ventricular pseudoaneurysms and true aneurysms are two possible complications of myocardial infarction. However, while pseudoaneuryms require urgent surgical resection, true aneuryms can often be managed medically, making imperative an accurate diagnosis.The authors describe a case of a delayed rupture of a true aneurysm that was contained and gave rise to a pseudoaneurysm inside of a true aneurysm. The echocardiography allowed the differential diagnosis for a timely surgical intervention which resulted in the patient's full recovery.

School Motivation Questionnaire for the Portuguese population: structure and psychometric studies.

It is presented the structure and psychometric studies of the "School Motivation Questionnaire". The SMQ is a self-report questionnaire with 101 items, organized in sixteen scales that measure the students' goal orientations, the perceived classroom goal structures, the perceived teacher's autonomy support and the use of learning strategies. Twelve scales are adapted from the "Learning Climate Questionnaire", "Perceptions of Instrumentality" and "Cuestionário a Estudiantes". Four scales and five additional items are created new. The psychometric studies rely on a convenience sample consisting of 9th and 12th grade students (N = 485) of Portuguese schools. The factorial and construct validity, verified through several exploratory factorial analyses to the data, presents a final solution of six factors, labelled Strategies (F1), Teacher Extrinsic Goals (F2), Student Extrinsic Goals, Externally Regulated (F3) Teacher Intrinsic Goals (F4), Student Extrinsic Goals, Internally Regulated (F5), and Student Intrinsic Goals (F6). The six-factor solution explains a significant variance of the scale results (53.95%). Good coefficients of internal consistency are obtained for all factors, never below (.858; F6). In sum there is strong evidence to support the multi-dimensionality of SMQ, upholding that the data obtained is exploratory and applies for future validation studies.

Mortality, severe acute respiratory infection, and influenza-like illness associated with influenza A(H1N1)pdm09 in Argentina, 2009.

INTRODUCTION: While there is much information about the burden of influenza A(H1N1)pdm09 in North America, little data exist on its burden in South America. METHODS: During April to December 2009, we actively searched for persons with severe acute respiratory infection and influenza-like illness (ILI) in three sentinel cities. A proportion of case-patients provided swabs for influenza testing. We estimated the number of case-patients that would have tested positive for influenza by multiplying the number of untested case-patients by the proportion who tested positive. We estimated rates by dividing the estimated number of case-patients by the census population after adjusting for the proportion of case-patients with missing illness onset information and ILI case-patients who visited physicians multiple times for one illness event. RESULTS: We estimated that the influenza A(H1N1)pdm09 mortality rate per 100,000 person-years (py) ranged from 1.5 among persons aged 5-44 years to 5.6 among persons aged ≥ 65 years. A(H1N1)pdm09 hospitalization rates per 100,000 py ranged between 26.9 among children aged <5 years to 41.8 among persons aged ≥ 65 years. Influenza A(H1N1)pdm09 ILI rates per 100 py ranged between 1.6 among children aged <5 to 17.1 among persons aged 45-64 years. While 9 (53%) of 17 influenza A(H1N1)pdm09 decedents with available data had obesity and 7 (17%) of 40 had diabetes, less than 4% of surviving influenza A(H1N1)pdm09 case-patients had these pre-existing conditions (p ≤ 0.001). CONCLUSION: Influenza A(H1N1)pdm09 caused a similar burden of disease in Argentina as in other countries. Such disease burden suggests the potential value of timely influenza vaccinations.

Three cases of pregnancy in patients with severe pulmonary arterial hypertension: experience of a single unit.

Pregnancy in patients with severe pulmonary arterial hypertension is a high risk situation, which makes pregnancy prevention or termination in the first trimester advisable. For this reason, patients of reproductive age with this pathology are referred for gynecology consultation. Since our unit began operating in 1999, we have had three pregnant patients with severe pulmonary arterial hypertension--one our patient and the other two referred from other centers. In this article we describe these three cases and review the literature on pregnancy and pulmonary arterial hypertension.

The role of echocardiography in assessing parachute mitral valve.

Treadmill exercise echocardiography with Doppler evaluation during effort has been used for several years in our department. The usefulness of this methodology in the management of patients with coronary heart disease is recognized but it is being increasingly used in patients with valvular heart disease. We report the case of a 44-year-old man with parachute mitral valve, in which transesophageal echocardiography characterized the pathology and exercise stress echocardiography was important for accurate functional assessment and clinical decisions.

Echocardiography during treadmill exercise testing in a patient with mitral stenosis.

Treadmill exercise echocardiography with Doppler during effort has been used for several years in our department. This form of echocardiography is used mainly in evaluation of patients with coronary heart disease and it is being increasingly used in valvular heart disease. We report the case of a 49-year-old woman with moderate mitral stenosis, in which stress echocardiography was important in making correct clinical decisions.

Echocardiography during treadmill exercise testing for evaluation of pulmonary artery systolic pressure: advantages of the method.

INTRODUCTION: Determination of pulmonary artery systolic pressure by Doppler echocardiography (based on the pressure gradient between the right ventricle and right atrium - DeltaP RV/RA) or by right heart catheterization is useful in evaluating the severity and prognosis of cardiac disease. The aim of the study was to evaluate DeltaP RV/RA non-invasively during treadmill exercise in patients with tricuspid regurgitation and without coronary artery disease. METHODS: Of a total of 149 patients referred to our echo laboratory, we completed the study in 142 (95%), of whom 120 were women, mean age 52+/-13 years (23 to 82). We studied 68 patients with valvular heart disease (of whom 56 had mitral valve stenosis and sinus rhythm on ECG), 42 with systemic sclerosis, 10 with severe pulmonary hypertension, 12 with a history of pulmonary embolism and 10 healthy controls. The DeltaP RV/RA was determined from the tricuspid regurgitation jet using continuous wave Doppler in left lateral decubitus (LLD) before exercise testing (BLLD), in a standing position (SP), at peak workload (PW) before termination of the test, and in the first 60 seconds of the recovery period in LLD (RLLD). RESULTS: The DeltaP RV/RA in BLLD was 36+/-21 mmHg (range 18 to 147); the SP [symbol: see text]P RV/RA was 32+/-24 mmHg (range 12 to 137), p<0.001 vs. BLLD DeltaP RV/RA; the PW DeltaP RV/RA was 58+/-26 mmHg (range 28 to 177), p<0.0001 vs. SP DeltaP RV/RA; and the RLLD DeltaP RV/RA was 47+/-25 mmHg (range 20 to 152), p<0.001 vs. PW DeltaP RV/RA. The differences between PW DeltaP RV/RA and RLLD DeltaP RV/RA changed therapeutic decisions in 10 patients (18%) with mitral stenosis, and modified the management of 13 patients (30%) with systemic sclerosis (who then underwent right heart catheterization). CONCLUSIONS: Echocardiography during treadmill exercise testing was feasible in most patients. The DeltaP RV/RA decreases in response to the standing position. The DeltaP RV/RA rises considerably with exercise in the majority of patients and is significantly higher at peak workload than in the recovery period. The differences between PW DeltaP RV/RA and RLLD DeltaP RV/RA influenced patient management.

Five cases of transient left ventricular apical ballooning--the experience of a Portuguese center.

Transient left ventricular apical dyskinesia (apical ballooning syndrome, ABS) is characterized by transient alterations in regional wall motion, involving the mid and apical segments of the left ventricle, as well as electrocardiographic alterations, mimicking ST-elevation acute myocardial infarction, in the absence of obstructive disease of the epicardial coronary arteries. In this article, we present a series of five cases of ABS and a theoretical review of the syndrome.

Syncope caused by severe hypotension and intraventricular gradient during dobutamine stress echocardiography.

Dobutamine stress echocardiography is widely used for the evaluation of coronary artery disease. This form of stress echocardiography is safe but not without complications. We report a case of hypotension and syncope during dobutamine stress echocardiography in which a severe intraventricular gradient of over 200 mmHg and systolic anterior movement of the mitral valve were observed.

Evaluation of left ventricular outflow tract gradient during treadmill exercise and in recovery period in orthostatic position, in patients with hypertrophic cardiomyopathy.

BACKGROUND: Left ventricular outflow tract obstruction is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). The classical quantification of intraventricular obstruction is performed in resting conditions in supine position, but this assessment does not reflect what happens in HCM patients (pts) in their daily activities, neither during effort nor during orthostatic recovery. AIM: To assess intraventricular gradients with echocardiography during treadmill exercise and in the recovery period in upright position, in HCM pts. METHODS: We studied 17 HCM pts (9 males, mean age 53 +/- 16 years, 11 with obstructive HCM). Each pt had 2 echocardiographic evaluations at rest (left lateral decubitus (LLD) and orthostatic position). The pts then underwent a treadmill exercise test and intraventricular gradients were measured at peak exercise and during recovery in orthostatic position. RESULTS: 3 pts with non-obstructive HCM at rest developed intraventricular gradients during exercise. 1 pt developed this gradient only during orthostatic recovery. The mean intraventricular gradient in LLD was 49 +/- 24 mmHg; in orthostatic position was 62 +/- 29 mmHg (p < 0.001 versus in LLD); at peak exercise was 83 +/- 35 mmHg (p < 0.001 versus supine rest); during recovery it was 96 +/- 35 mmHg (p < 0.001 versus peak exercise) CONCLUSION: In HCM pts the intraventricular gradient increases in orthostatic position, increases significantly during treadmill exercise and continues increasing in the recovery period in orthostatic position. This type of evaluation can help us to better understand the physiopathology, the symptoms and the efficacy of different therapeutic modalities in this disease and should be routinely used in the assessment of HCM pts.