Left atrial strain evaluation to assess left ventricle diastolic dysfunction and heart failure with preserved ejection fraction: a guide to clinical practice : Left atrial strain and diastolic function.

Although frequently unrecognized, left atrium (LA) function plays a key role in global cardiac performance as it modulates left ventricle (LV) filling through three main functions: the LA reservoir, conduit and booster pump. Given the interdependence between the LA and the LV, it is known that LA dimension and/or LA function can be used as a surrogate for LV diastolic function.Recently, LA deformation analysis using 2-dimensional (2D) speckle tracking echocardiography (STE) strain emerged as a promising non-invasive technique that can help to estimate LV filling pressures (LVFP) and diagnose heart failure with preserved ejection fraction (HFpEF), as recently proposed in the recent 2022 European Association of Cardiovascular Imaging (EACVI) consensus which included LA reservoir strain as an additive parameter to estimate LVFP.This article aims to review the latest evidence regarding the role of LA strain in the assessment and management of LV diastolic dysfunction (LVDD) and HFpEF, providing a clinical guide with tips and tricks to use LA strain as a new technique to help to estimate LVFP.

Automated macular segmentation can distinguish glaucomatous from compressive optic neuropathy.

PURPOSE: To compare macular damage in glaucomatous optic neuropathy (GON) and compressive optic neuropathy (CON) and assess its diagnostic accuracy in distinguishing between diseases. METHODS: Observational, cross-sectional, single-center study. Patients with GON, CON, and healthy controls were included according to the eligibility criteria. An automated spectral-domain optical coherence tomography (SD-OCT) algorithm was used to segment the circumpapilary retinal nerve fiber layer (cpRNFL) and macula. The layer thickness was measured in each sector according to the Early Treatment Diabetic Retinopathy Study and the 6-sector Garway-Heath-based grids. Data was compared across all study groups, and the significance level was set at 0.05. RESULTS: Seventy-five eyes of 75 participants, 25 with GON, 25 with CON, and 25 healthy controls (CG), were included. Macular thickness was diminished in the ganglion cell complex of GON and CON patients compared to CG (p<0.05). The best Garway-Heath-based grid parameters for distinguishing GON and CON were the nasal-inferior (NI) and nasal-superior sectors and the NI/temporal inferior (TI) damage ratios in the macular ganglion cell (mGCL) and inner plexiform (IPL) layers. Moreover, the combination of the NI sector and NI/TI damage ratios in both layers had higher discriminative power (AUC 0.909; 95% CI 0.830-0.988; p<0.001) than combining parameters in each layer separately. CONCLUSION: Our findings suggest that the evaluation of macular segmented layers damage by SD-OCT may be a helpful add-on tool in the differential diagnosis between GON and CON.

Disseminated Tuberculosis Associated With Adalimumab Therapy.

Therapeutic blockade of tumour necrosis factor alpha (anti-TNF-α) is the mainstay treatment of several rheumatologic diseases. They are unfrequently associated with opportunistic infections and latent tuberculosis (TB) screening is paramount before immunosuppression. A 62-year-old man with psoriatic arthritis was under treatment with adalimumab for over 5 years. The screening for latent tuberculosis infection (LTBI) prior to the start of immunosuppression was negative, and a subsequent interferon gamma release assay 4 years later was also negative. He presented in the emergency department complaining of asthenia, anorexia, fever, night sweats and weight loss for over 5 months. He also complained of memory loss, despite his normal cognitive and neurological examination. After an exhaustive workup, he was diagnosed with a disseminated tuberculosis (cerebral, pulmonary and peritoneal) and treated accordingly. TB diagnosis remains challenging in certain situations. Latent TB screening tests may lack sensitivity and immunosuppressive therapy increases the risk of disseminated infection. We discuss the workup and management of a central nervous system disseminated TB related to adalimumab therapy.

Disseminated Nocardiosis: The Complexity of the Diagnosis.

Nocardiosis is a rare infection in immunocompetent patients. Nocardia spp. is an uncommon cause of prostate abscesses and is responsible for only 1-2% of brain abscess. Hematogenous dissemination can occur, and presentation of abscesses in more than two locations is required to determine a disseminated nocardiosis. The microbiological diagnosis of this agent is still a challenge due to the complexity of its identification in regular laboratories. An early diagnosis and adequate treatment with effective antibiotics are critical for treating this entity. We report a case of a patient who presented with brain abscess with a previous medical history of prostate abscess to Nocardia spp. which evolved to disseminated nocardiosis.

Brugada Pattern: Unraveling Possible Cardiac Manifestation of SARS-CoV-2 Infection.

We report the case of a 41-year-old patient with no family history of sudden cardiac death. The patient presented with high fever and vomiting and was diagnosed with acute pyelonephritis. Screening for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was positive. An electrocardiogram (ECG) performed during a fever episode revealed a Brugada pattern. Fever can be a trigger for induction of the electrocardiographic Brugada pattern but it is still unknown if the cardiac involvement by coronavirus disease 2019 (COVID-19) can interfere with myocardial ion channels.

After All, It was Not Lung Cancer: When The Evidence is Misleading.

The aetiology of pulmonary nodules is varied, with malignant lesions being the most important and requiring rapid diagnosis and treatment. However, although clinical presentation and imaging may suggest a specific diagnosis, it should be kept in mind that some benign pathologies mimic more serious disease. A 50-year-old man presented with left pleuritic chest pain. A CT scan showed an ipsilateral pulmonary spiculated nodule. Pneumonia was assumed and the patient was started on antibiotic therapy. In the absence of improvement, positron emission tomography and a transthoracic aspiration biopsy were performed. Lung cancer was diagnosed and the patient underwent an upper lobectomy. However, examination of the surgical specimen showed no malignancy. LEARNING POINTS: Although complementary diagnostic exams are increasingly available and widely used, they may produce false positive or false negative results.A correct diagnostic approach can lead to an incorrect diagnosis.The preoperative diagnosis of pulmonary nodules can be a challenge.

Mesalazine-induced Hypersensitivity Pneumonitis.

A 57-year-old woman with Crohn's disease (ulcerative proctitis) treated with mesalazine (5-ASA) developed worsening respiratory distress and cough. The lack of response to antibiotics and the results of bronchoalveolar lavage led to the diagnosis of mesalazine-related hypersensitivity pneumonitis, an infrequent entity. Symptoms improved after discontinuation of mesalazine and the administration of corticosteroid therapy. The authors discuss the diagnosis and management of this rare condition. LEARNING POINTS: A diagnosis of mesalazine-related hypersensitivity pneumonitis should be considered when unexplained respiratory symptoms develop during treatment with mesalazine.It is important to distinguish pulmonary manifestations in patients with inflammatory bowel disease secondary to drug-related toxicity from the disease process itself.Amelioration of symptoms and improvement in imaging and lung function seem to occur only upon abrupt discontinuation of the drug; severe symptoms such as respiratory failure may justify corticosteroid therapy.

Abdominal Splenosis Mimicking a Colon Tumour.

Splenosis is a benign condition which results from the self-implantation of splenic tissue on intra or extraperitoneal surfaces, after splenic trauma or splenectomy. Patients are usually asymptomatic but may present with varied symptoms related to the implantation site. The diagnosis is a challenge because abdominal splenosis can mimic several diseases, including neoplasm. The gold standard examination for its diagnosis is scintigraphy with 99mTc-labelled heat-denatured erythrocyte. When splenosis is found in an asymptomatic patient, surgical removal is not indicated. A 57-year-old male patient presented with sporadic epigastric pain and a suspected mass in the recto-sigmoid transition. Abdominal ultrasound, CT and MRI identified this mass, its characteristics and location, but failed to distinguish its nature. However, given the patient's past history of splenectomy and because the mass showed a similar sign to that of the splenic parenchyma, a hypothesis of abdominal splenosis was raised, which was confirmed by scintigraphy with 99mTc-labelled heat-denatured erythrocyte. In this case, the diagnosis was obtained before the patient was subjected to more invasive procedures, which are associated with high morbidity, and, as in most cases, no targeted intervention was necessary. LEARNING POINTS: Increasing numbers of cases of abdominal trauma will result in more frequent splenosis.Diagnosis is sometimes complex as splenosis mimics several diseases.The usual complementary imaging studies often fail to diagnose this entity so clinical suspicion is fundamental for correct diagnosis and treatment.

Current role and future perspectives of cardiac rehabilitation in coronary heart disease.

Ischaemic heart disease (IHD) is a major cause of morbidity and mortality worldwide. While there have been major advances in this field, these patients are still a higher risk subgroup. As such, strategies to mitigate risk and tailor secondary prevention measures are of the utmost relevance. Cardiac rehabilitation (CR), encompassing several domains including exercise training, cardiovascular risk factor optimization, nutritional and psychological assessments, as well as other ancillary interventions has shown to be one of the pillars in the contemporary management of patients with IHD. Indeed, CR is associated with several benefits in this population, ranging from functional capacity to improvements in outcomes. Whilst this, there are still several issues concerning the optimal application of CR which are still not fully ascertained, such as lack of referral and completion, as well as questions related to programme design (particularly among patients with multiple comorbidities). In this review, we aim at presenting a pragmatic overview on the current role of CR in the management of individuals with IHD, while also discussing some of the caveats in the current data, as well as future concepts which could help improve the uptake and personalization of this pivotal time-tested intervention.

Differential impact of a cardiac rehabilitation program in functional parameters according to patient gender.

INTRODUCTION: Exercise-based cardiac rehabilitation (EBCR) programs are of paramount importance in the management of acute myocardial infarction (AMI) survivors. Albeit this, female patients tend to be less referred for these programs, while also having a poorer prognosis. We aimed at assessing the impact of a contemporary EBCR program on functional parameters after an AMI, and specifically the impact of gender on its potential benefits. METHODS: Observational, retrospective cohort study including all patients admitted to a tertiary center due to an AMI who completed a phase II EBCR program after discharge, between November 2012 and April 2017. Functional parameters were assessed by a symptom-limited cardiopulmonary exercise test (CPET). Patients were dichotomized according to gender. RESULTS: A total of 379 patients were included, 19% of whom were women. After the program, peak oxygen uptake (pVO2) and exercise duration increased significantly (P<0.001). Though female patients presented a lower pVO2 and completed a shorter CPET at both the beginning and end of the study, there were no differences in the magnitude of improvement in these parameters between both groups [pVO2 delta 1.37 ± 3.08 vs 1.31 ± 2.62 mL/kg/min, P=0.876; CPET duration delta 120 (60-167) vs 85 (60-146), P=0.176]. CONCLUSIONS: A contemporary EBCR program was associated with significant improvements in functional parameters, as assessed by CPET. Though female patients had lower levels of pVO2, the benefits of this program were similar among groups. These results highlight the importance of EBCR among this higher risk subset of patients.

Diplopia After Coronary Revascularization.

Percutaneous coronary intervention is a coronary revascularization procedure that may rarely result in thromboembolic events. Although infrequent, ophthalmological complications of percutaneous interventions include a wide range of clinical presentations, with differing severity and outcomes. In this case report, an 83-year-old woman, with multiple cardiovascular risk factors, presents with horizontal diplopia after a percutaneous transluminal coronary angioplasty. After ophthalmological evaluation and a head computed tomography scan, the diagnosis of isolated ischemic internuclear ophthalmoplegia was established. After six months of follow-up, the patient showed complete recovery of her symptoms and ocular movements. We discuss the post-percutaneous intervention ophthalmic complications that, although uncommon, must be recognized by health care providers.

A intervenção coronária percutânea é um procedimento de revascularização coronária que pode, raramente, resultar em eventos tromboembólicos. Apesar de incomuns, as complicações oftalmológicas da intervenção percutânea incluem um largo espectro de manifestações clínicas com diferentes prognósticos. Reportamos um caso clínico de uma mulher de 83 anos, com múltiplos fatores de risco cardiovascular, que apresenta diplopia horizontal após uma angioplastia coronária percutânea. O diagnóstico de oftalmoplegia internuclear isquémica isolada foi estabelecido após avaliação oftalmológica e realização de tomografia computorizada cranioencefálica. Seis meses após a apresentação, a doente apresentava recuperação completa dos sintomas e dos movimentos oculares. Os autores discutem as complicações oftalmológicas da intervenção percutânea que, apesar de incomuns, devem ser reconhecidas pelos profissionais de saúde.

Treatment of benign eyelid lesions with Nd:YVO laser: a prospective study.

The purpose of this prospective cohort study, including consecutively selected patients, was to evaluate the outcomes of Nd:YVO laser-assisted photocoagulation for the removal of benign eyelid lesions. An emulsion of lidocaine and prilocaine was used for dermal analgesia and subcutaneous injection of 2% lidocaine was performed as needed. Follow-up included two visits, at day 15 and 45 postoperatively, in order to assess time of wound healing, postoperative complications, need for additional treatment, and patient's satisfaction. A total of 101 lesions of 66 patients were included, with a mean age of 55.4 ± 15.3 years. All patients were Caucasian and 62% were female. Papilloma was the most common lesion identified (61%). No major complications were reported during and after the procedure. Complete epithelization occurred in 82% and 100%, at the 15 and 45-day visit, respectively. All patients were satisfied with the cosmetic result. Only one patient was proposed for additional therapy during the follow-up period. In conclusion, this study supports Nd:YVO laser-assisted treatment as an effective and safe alternative to conventional surgery for the removal of benign eyelid lesions. The technique is well accepted, easy to perform, and provides excellent cosmetic and functional results.

Bruch's Membrane Opening Minimum Rim Width in the Differential Diagnosis of Optic Neuropathies.

Observing optic disc pallor during a patient's first visit frequently raises a diagnostic challenge, particularly in regards to whether the cause is due to glaucoma or another form of optic neuropathy. Bruch's membrane opening (BMO) was recently discovered as the anatomical border of the optic disc. BMO minimum rim width (BMO-MRW) seems to be a reliable representation of the neuroretinal rim. In our study, we demonstrate the ability of BMO-MRWs to differentiate between glaucomatous and non-glaucomatous. Additionally, we propose an MRW ratio which may allow discrimination of open angle glaucoma from either non-arteritic anterior ischaemic optic neuropathy or compressive optic neuropathy.

Refractory Myopic Retinal Detachment and Macular Hole Closure with Autologous Neurosensory Retinal Free Flap.

The purpose of this case report is to describe a modified technique involving the use of an autologous neurosensory retinal free flap for closure of a macular hole (MH) during retinal detachment (RD) surgery. A 50-year-old female presented with sudden vision loss (light perception only) and a recurrent myopic RD associated with an MH. An autologous neurosensory retinal free flap was obtained and moved toward the MH. Silicone oil was used as an endotamponade and removed after 6 months. Two months after oil removal visual acuity improved to 20/400 and remained stable thereafter; however, the patient developed central retinal atrophy. One year after surgery the MH was closed and the retina attached. This modified technique with the use of an autologous neurosensory retinal flap provides an alternative approach for recurrent MH in RD procedures.

Tocilizumab in refractory juvenile idiopathic arthritis with associated uveitis: a case report.

INTRODUCTION: We report a 9-year follow-up of a child with refractory juvenile idiopathic arthritis (JIA) with associated uveitis in which tocilizumab proved to be effective in achieving disease control. CASE REPORT: A 16-month child was diagnosed with JIA and at the age of 3 developed bilateral non-granulomatous anterior uveitis. Throughout the follow-up, the patient presented frequent joint and ocular flares. Refractory anterior uveitis and topical corticosteroid therapy resulted in the development of bilateral cataract and high intraocular pressure (IOP). The patient underwent multiple ocular surgeries along with corticosteroids, immunosuppressive therapy with Methotrexate and Adalimumab failing to reach disease control. Only after the introduction of Tocilizumab a lower disease activity was achieved. DISCUSSION: Management of JIA-associated uveitis is challenging and requires a close collaboration between paediatric rheumatologists and ophthalmologists. Clinical remission can be difficult to achieve. However, one should always pursuit JIA inactivity with IOP and inflammation control. This report supports Tocilizumab as a useful therapeutic option for JIA-associated uveitis.

Kaposi's sarcoma of the conjunctiva and the eyelid leads to the diagnosis of human immunodeficiency virus infection - a case report.

BACKGROUND: The purpose of this case report is to describe a conjunctiva and eyelid Kaposi's sarcoma (KS) as the initial manifestation of acquired immunodeficiency syndrome (AIDS), which led to the diagnosis of HIV infection. There are only 3 reported cases of ocular KS as an initial manifestation of HIV infection. CASE PRESENTATION: A 32-year old white man presented to our department with a 1 month history of eye redness. The patient had an enlarged violet-coloured mass on the right superior eyelid which had evolved over the course of 1 week. There was also a mobile bulbar conjunctival lesion with a bright red colour, approximately 5 mm × 5 mm, in the superior temporal quadrant of his left eye. The lesions looked like a chalazion and a subconjunctival haemorrhage, respectivly. Presumed KS diagnosis was confirmed with HIV-1 positive testing and histopathology from tissue biopsy. The patient's CD4 count was 23/mm3 and viral RNA load 427,000/ml. Further systemic evaluation showed a diffuse sarcoma. CONCLUSION: This case report demonstrates the importance of recognizing the ocular manifestations of AIDS in establishing the correct diagnosis of KS and subsequently diagnosing occult HIV infection. Although ocular KS as the initial manifestation of HIV-AIDS is an extremely rare event, a proper diagnosis may contribute to prompt management with personal and social relevance.