Inhaler training and asthma knowledge are associated with a higher proportion of patients with correct inhaler technique in young but not in elderly asthmatic patients.

Objective: Incorrect inhaler usage is frequent, particularly in elderly asthmatic patients. This study aimed at comparing inhaler technique errors and their determinants, as well inhaler technique self-perception versus real performance, between elderly and non-elderly asthmatics. Methods: Cross-sectional assessment of 92 elderly and 100 non-elderly asthmatics followed at specialty clinics. A standardized questionnaire was applied and inhaler technique demonstration was requested. Errors were assessed using checklists based on manufacturers' instructions and inhaler technique was graded as correct, acceptable or incorrect. Chi-Square Test and Fischer's Exact Test were used for comparative analysis of nominal variables. A p value equal to or less than 0.05 was considered statistically significant. Results: Inhaler technique was correct in a minority of elderly and young patients, without significant differences between study groups. Only 11.1% of the elderly who classified their inhaler as easy and 12.7% who stated their technique was correct had no errors. Previous regular inhaler training was associated with better actual performance in young but not in elderly patients. Conclusion: Our study showed that in spite of regular follow up at specialized outpatient clinics, inhaler devices are associated with a high frequency of errors in elderly and non-elderly asthmatics. In addition, most patients tend to overestimate their technique as correct. Finally, previous, frequent training was associated with a significantly higher percentage of patients showing correct or acceptable technique but only in non-elderly asthmatics, which suggests that elderly asthmatics may need specifically tailored inhaler education programs.

Ultrasound-Guided Percutaneous Radiofrequency Thermal Neuroablation for the Treatment of Adductor and Rectus Femoris Spasticity.

Spasticity is a very frequent complication of spinal cord injury (SCI) that can limit activities of daily living, reduce the quality of life, and augment caregiver burden. This problem has many treatment options that should be selected according to the clinical and functional scenario.  This case study presents a 60-year-old female patient with complete spastic paraplegia after a spinal stroke. Spasticity interfered with activities of daily living, mainly with intermittent catheterization and transfers, and botulinum toxin injections failed to efficiently treat this issue. It was decided to perform an ultrasound-guided radiofrequency thermal ablation of the anterior and posterior branches of the obturator nerve and motor branches to the rectus femoris of the femoral nerve to treat the adductors and rectus femoris spasticity. One year after the radiofrequency treatment, the patient showed considerably reduced spasticity, allowing her caregiver to do transfers and easier intermittent urinary catheterizations. Nerve radiofrequency thermal ablation has the potential to be an effective therapy in lower limb spasticity, with long-lasting effects.

A Case Report on a Young Male Taking Methylphenidate With Fasciculations and Dysphagia: Correlation or Causation?

Concurrent fasciculations and oropharyngeal dysphagia (OD) can be presenting signs of motor neuron disease (MND); however, there are other causes for OD (neoplasms, surgery, and gastroesophageal diseases, among others). Fasciculations (anxiety, benign, or iatrogenic) are an uncommon side effect (<1%) of methylphenidate. A 30-year-old male noticed fasciculations in both gastrocnemii, reporting gradual cranial progression, culminating in diffuse fasciculations with facial involvement. One month later, he reported OD for solids and occasional cough for liquids. He denied weakness, fatigue, or weight loss. He has no relevant personal history, apart from attention deficit hyperactivity disorder diagnosed a year before and since then medicated with methylphenidate 40 mg id. He had no abnormal findings on neurological examination. Electromyography (EMG) and sinus CT were normal. Upper gastrointestinal (GI) endoscopy (EGD) showed reflux esophagitis grade C, which could explain OD, and he started esomeprazole 40 mg id. As there were no findings on EMG, an iatrogenic etiology for fasciculations was considered. He suspended methylphenidate for a month and, two months later, reported a substantial improvement in fasciculations and resolution of the OD with the introduction of esomeprazole. Two simultaneous symptoms do not mean they are related. In this specific case, OD was the first symptom of gastroesophageal reflux disease (GERD), and fasciculations happened as a side effect of methylphenidate. This must be taken into consideration, as it can represent a confounding factor making the differential diagnosis more difficult. To the best of our knowledge, there are no published articles similar to this case report.

Good Bronchial Hygiene Reaches the Left Lung: Successful Extubation in a Tetraplegic Patient With Spinal Cord Injury.

Ineffective coughing affects bronchial hygiene and is a major contributor to respiratory complications after spinal cord injury (SCI). Mechanical insufflation-exsufflation (MIE) therapy increases inspiratory and expiratory flow to assist bronchial secretions clearance. We present a case of a 67-year-old cervical SCI patient with lung infection and partial atelectasis in the lower left lung, associated with difficult ventilator weaning. About one day after the beginning of MIE therapy, an improvement of the atelectasis was verified. The patient was extubated six days after the beginning of bronchial hygiene with MIE therapy and safely transitioned to non-invasive ventilatory support.

Polymyalgia Rheumatica After ChAdOx1 nCov-19 Vaccine: A Case Report.

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease characterized by severe pain and morning stiffness, mainly affecting the shoulder girdle. A 75-year-old woman, previously healthy, received the first dose of ChAdOx1 vaccine and two weeks later started with pain in the shoulder and pelvic girdles and knees of inflammatory characteristics, accompanied by morning stiffness (about one hour), anorexia, asthenia, and activities of daily living (ADL) dependence. She started analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) with no improvement. The symptoms aggravated three days after the second vaccine dose, and she was referred to our center. At observation, she presented shoulder, hip, and knee active range of motion limitation. Blood analysis revealed an Erythrocyte Sedimentation Rate (ESR) of 120mm/h (reference value < 20mm/h) and C-Reactive Protein (CRP) of 80mg/L (reference value < 5mg/L). Ultrasound showed effusion on both shoulders, hips, and knees. The paraneoplastic syndrome was ruled out. She started oral corticosteroids and a rehabilitation program, and a month later, she presented controlled pain, normal analysis, and ADL independence. This case shows symptomatic and analytic features of PRM after the first vaccine dose and aggravation soon after the second. As such, we consider establishing a potential relationship between the inoculation and the development of PRM. A few cases were published reporting a PRM-like syndrome following a COVID-19 vaccine; however, the underlying mechanism and prognosis are still unknown.

Hexosamine Biosynthetic Pathway and Glycosylation Regulate Cell Migration in Melanoma Cells.

The Hexosamine Biosynthetic Pathway (HBP) is a branch of glycolysis responsible for the production of a key substrate for protein glycosylation, UDP-GlcNAc. Cancer cells present altered glucose metabolism and aberrant glycosylation, pointing to alterations on HBP. Recently it was demonstrated that HBP influences many aspects of tumor biology, including the development of metastasis. In this work we characterize HBP in melanoma cells and analyze its importance to cellular processes related to the metastatic phenotype. We demonstrate that an increase in HBP flux, as well as increased O-GlcNAcylation, leads to decreased cell motility and migration in melanoma cells. In addition, inhibition of N- and O-glycosylation glycosylation reduces cell migration. High HBP flux and inhibition of N-glycosylation decrease the activity of metalloproteases 2 and 9. Our data demonstrates that modulation of HBP and different types of glycosylation impact cell migration.