Effects of two external cooling strategies on physiological and perceptual responses of athletes with tetraplegia during and after exercise in the heat.

Athletes with tetraplegia may experience marked hyperthermia while exercising under environmental heat stress due to their limited ability to dissipate heat through evaporative means. This study investigated the effectiveness of two external cooling strategies (i.e., spraying water onto the body surface or using a cooling vest) on physiological and perceptual variables in tetraplegic athletes during and after an aerobic exercise session in a hot environment. Nine male wheelchair rugby players performed an incremental test to determine their maximum aerobic power output. After that, they were subjected to three experimental trials in a counter-balanced order: control (CON, no body cooling), cooling vest (CV), and water spraying (WS). During these trials, they performed 30 min of a submaximal exercise (at 65% of their maximum aerobic power) inside an environmental chamber set to maintain the dry-bulb temperature at 32 °C. The following variables were recorded at regular intervals during the exercise and for an additional 30 min following the exertion (i.e., post-exercise recovery) with the participants also exposed to 32 °C: body core temperature (TCORE), skin temperature (TSKIN), heart rate (HR), rating of perceived exertion (RPE), thermal comfort (TC), and thermal sensation (TS). While exercising in CON conditions, the tetraplegic athletes had the expected increases in TCORE, TSKIN, HR, RPE, and TC and TS scores. HR, TC, and TS decreased gradually toward pre-exercise values after the exercise, whereas TCORE and TSKIN remained stable at higher values. Using a cooling vest decreased the temperature measured only on the chest and reduced the scores of RPE, TC, and TS during and after exercise but did not influence the other physiological responses of the tetraplegic athletes. In contrast, spraying water onto the athletes' body surface attenuated the exercise-induced increase in TSKIN, led to lower HR values during recovery, and was also associated with better perception during and after exercise. We conclude that water spraying is more effective than the cooling vest in attenuating physiological strain induced by exercise-heat stress. However, although both external cooling strategies do not influence exercise hyperthermia, they improve the athletes' thermal perception and reduce perceived exertion.

Current Technologies and Practices to Assess External Training Load in Paralympic Sport: A Systematic Review.

CONTEXT: Knowing the methods to assess the external load in Paralympic sports can help multidisciplinary teams rely on scientific evidence to better prescribe and monitor the athlete's development, improving sports performance and reducing the risk of injury/illness of Paralympic athletes. OBJECTIVES: This review aimed to systematically explore the current practices of quantifying the external load in Paralympic sports and provide an overview of the methods and techniques used. EVIDENCE ACQUISITION: A search in PubMed, Web of Science, Scopus, and EBSCO was carried out until November 2022. The measures of interest were objective methods for quantifying the external load of training or competition. The inclusion criteria for the studies were as follows: (1) peer-reviewed article; (2) the population were Paralympic athletes; (3) evaluated during training or competition; (4) reported at least one external load measure; and (5) published in English, Portuguese, or Spanish. EVIDENCE SYNTHESIS: Of the 1961 articles found, 22 were included because they met the criteria, and 8 methods were identified to quantify the external load in training or competition in 8 Paralympic sports. The methods varied according to the characteristics of the Paralympic sports. To date, the devices used included an internal radiofrequency-based tracking system (wheelchair rugby) a miniaturized data logger (wheelchair tennis, basketball, and rugby); a linear position transducer (powerlifting and wheelchair basketball); a camera (swimming, goalball, and wheelchair rugby); a global positioning system (wheelchair tennis); heart rate monitors that assess external load variables in set (paracycling and swimming) and an electronic timer (swimming). CONCLUSIONS: Different objective methods were identified to assess the external load in Paralympic sports. However, few studies showed the validity and reliability of these methods. Further studies are needed to compare different methods of external load quantification in other Paralympic sports.

The Sleep Parameters of Paralympic Athletes: Characteristics and Assessment Instruments.

CONTEXT: Sleep serves many important functions for athletes, particularly in the processes of learning, memory, recovery, and cognition. OBJECTIVES: Define the sleep parameters of Paralympic athletes and identify the instruments used to assess and monitor sleep Paralympic athletes. EVIDENCE ACQUISITION: This systematic review was carried out based on the PRISMA guidelines. The survey was conducted in April 2020, the searches were carried out again in September 2021 to check whether there were new scientific publications in the area of sleep and Paralympic sport, searches were performed in the following databases: PubMed, Web of Science, Scopus, SPORTDiscus, Virtual Health Library (BIREME), and SciELO. This systematic review has included studies that investigated at least one of the following sleep parameters: total sleep time, sleep latency, sleep efficiency, number of awakenings, quality of sleep, daytime sleepiness, and chronotype; the participants were comprised of athletes with disabilities. Studies published at any time in English, Portuguese, and Spanish, were included. EVIDENCE SYNTHESIS: Data extraction and study selection were performed by 2 researchers independently, and a third author was consulted as necessary. The search returned a total of 407 studies. Following the screening based on exclusion and inclusion criteria, a total of 13 studies were considered. Paralympic athletes have a low amount (7.06 h) of sleep with poor quality and sleep latency (28.05 min), and 57.2% have daytime sleepiness, with the majority belonging to the indifferent chronotype (53, 5%). Moreover, 11 studies assess sleep using subjective instruments (questionnaires), and 2 studies used an objective instrument (actigraphy). CONCLUSIONS: Sleep disorders are common among Paralympic athletes, poor sleep quality and quantity, and high rates of daytime sleepiness. Subjective methods are most commonly used to assess sleep.

Sleep-disordered breathing patterns in hospitalized patients with acute heart failure across the entire spectrum of ejection fraction.

BACKGROUND: Sleep-disordered breathing (SDB) is prevalent in heart failure (HF). Yet, scarce data exist on sleep-patterns in acute HF and differences in specific subgroups. Our goal was to assess SDB prevalence in hospitalized patients with decompensated HF across the entire spectrum of left ventricle ejection fraction (LVEF). METHODS: Single-center retrospective study enrolling patients admitted for acute HF between 2013 and 2018. All patients were screened for SDB with an ApneaLink™ Plus device before discharge while euvolemic and receiving oral therapy. Those with a sleep study time < 3 h were excluded. HF with reduced, moderately reduced, and preserved LVEF (HFrEF, HFmrEF, and HFpEF) was defined by a LVEF < 40%, 40-49%, and ≥ 50%, respectively. SDB was defined by an apnea-hypopnea index (AHI) ≥ 5/h. RESULTS: Overall, 221 patients were included (mean age 75 ± 11 years). Seventy-two (33%) had HFrEF, 26 (11%) HFmrEF, and 123 (56%) HFpEF. In total, 176 (80%) met the criteria for mild SDB, while 59% and 38% had an AHI ≥ 15/h or ≥ 30/h, respectively. SDB prevalence was high and similar between HFrEF, HFmrEF, and HFpEF. Yet, SDB was often more severe in HFrEF when compared to HFpEF. HFmrEF had intermediate characteristics, with an AHI closer to HFrEF. CONCLUSION: In a cohort of patients admitted for acute HF, SDB was highly prevalent in all subgroups, including HFmrEF. The pervasiveness and severity of SDB was particularly noted in HFrEF. These findings suggest that routine SDB screening may be warranted following acute HF.

Dapagliflozin in a Real-World Chronic Heart Failure Population: How Many Are Actually Eligible?

BACKGROUND: In patients with heart failure (HF) and reduced ejection fraction (HFrEF) with or without type 2 diabetes mellitus, the sodium-glucose cotransporter 2 inhibitor (SGLT2i) dapagliflozin was recently shown to reduce the risk of worsening HF or death from cardiovascular causes in the dapagliflozin in patients with heart failure and reduced ejection fraction (DAPA-HF) trial. Our goal was to investigate how many patients in a real-world setting would be eligible for dapagliflozin according to the DAPA-HF enrolment criteria. METHODS: This is a single-center retrospective study enrolling consecutive, unselected patients followed up in an HF clinic from 2013 to 2019. Key DAPA-HF inclusion criteria (i.e., left ventricular ejection fraction [LVEF] ≤40% and NT-proBNP ≥600 pg/mL [or ≥900 pg/mL if atrial fibrillation]) and exclusion criteria (estimated glomerular filtration rate [eGFR] <30 mL/kg/1.73 m2 and systolic blood pressure [SBP] <95 mm Hg) were considered. RESULTS: Overall, 479 patients (age 76 ± 13 years; 50.5% male; 78.9% hypertensive; 45.1% with an eGFR <60 mL/min/1.73 m2; 36.5% with TD2M; and 33.5% with ischaemic HF) were assessed. The median SBP was 128.5 (112.0-146.0) mm Hg, mean eGFR was 50.8 ± 23.7 mL/min/1.73 m2, and median NT-proBNP was 2,183 (IQR 1,010-5,310) pg/mL. Overall, 155 (32.4%) patients had LVEF ≤40%. According to the DAPA-HF trial key criteria, 90 patients (18.8%) would be eligible for dapagliflozin. The remainder would be excluded due to LVEF >40% (67.6%), eGFR <30 mL/min/1.73 m2 (19.4%), NT-proBNP below the cutoff (16.7%), and/or SBP <95 mm Hg (6.5%). If we center the analysis to those with LVEF ≤40%, 58.1% would be eligible for dapagliflozin. The remainder would be excluded due to an eGFR <30 mL/min/1.73 m2 (20%), NT-proBNP below the cutoff (16.1%), and/or SBP <95 mm Hg (8.4%). CONCLUSION: Roughly half of our real-world HFrEF cohort would be eligible for dapagliflozin according to the key criteria of the DAPA-HF trial. The main reason for non-eligibility was an eGFR <30 mL/min/1.73 m2. However, two-thirds of patients had LVEF >40%. These findings show that dapagliflozin is a promising complementary new drug in the therapeutic armamentarium of most patients with HFrEF, while highlighting the urgent need for disease-modifying drugs in mid-range and preserved LVEF and the need to assess the efficacy and safety of SLGT2i in advanced kidney disease patients. The results of ongoing SGLT2i trials in these LVEF subgroups are eagerly awaited.

Training load, sleep, reaction time, sports performance, and mood in paralympic swimmers before a competition.

BACKGROUND: Coaches usually reduce the training load (tapering) before competition to improve performance; however, in paralympic athletes this strategy had not yet been tested and we did not know which variables are associated with improved performance. Therefore, the objective was to compare the sleep, mood, sports performance, and reaction time (RT) of paralympic swimmers (PS) during tapering and to investigate whether there is a relationship between the variables during this training phase. METHODS: Eight PS were monitored for 17 days before the main competition, with an actigraphy to record sleep in 16 days. Evaluations were performed on Mondays (Evaluation 1 = E1) and Fridays (E2) during the first and second weeks (E3 and E4), and on Tuesday (E5) of the third week, the day traveling to the competition. Brunel Mood Scale, RT (Psychomotor Vigilance Test), and sports performance (50 m in the pool) were assessed before training on each assessment day. Internal training load (ITL) was evaluated using ratings of perceived exertion. RESULTS: ITL decreased gradually between assessments. Performance and RT were better on E5 than on E1. Fatigue was higher on E1 and E2 than on E4 and E5. Sleep parameters (total sleep time [TST], awakenings after sleep onset, and sleep efficiency) improved in the second week compared with the first week. Furthermore, TST from the previous night was correlated with RT, and RT and fatigue correlated with sports performance. CONCLUSIONS: The increase in TST and the reduction in fatigue just before competition achieved by tapering correlated with the improvement in RT and sports performance. In addition, the tapering improved sports performance, RT, sleep parameters, and decreased fatigue.

Insights into the organic matter composition of soda lakes in the Pantanal, Brazil, through fatty acids analysis in sediments.

We conducted a geochemical analysis on three sediment cores collected from soda and freshwater lakes in the Pantanal region, in Brazil. Our objective was to identify the primary sources of organic matter associated with the Pleistocene-Holocene transition, as previously documented in that area. The Nhecolandia region, located in the Pantanal, encompasses over 10,000 lakes, with approximately 10% of them exhibiting alkaline characteristics. Soda lakes became highly saline and alkaline after ~ 910 cal yr BP, which influences biogeochemistry and aquatic ecology. They have high electrical conductivity and pH can reach 10.5. In contrast to freshwater, soda lakes are absent of surrounding vegetation. Literature suggests a strong influence by the Last Glacial Maximum on the region. We hypothesized that periods of aridity and increased precipitation influenced the composition of organic matter present in sediments and preserved within these cores. Our analysis focused on examining the presence and distribution of fatty acids, organic carbon content, and total nitrogen. In general, the cores exhibited two distinct parts in terms of organic matter sources: the upper sections of the cores were primarily composed by terrestrial sources, identified by the presence of long-chain fatty acids, while the deeper sections were dominated by aquatic sources, therefore short-chain fatty acids. We did not find significant difference among fatty acid profile that could distinguish freshwater from soda lakes, the only remarkable difference was the occurrence of saturated fatty acids, which is lower in freshwater lake. These findings suggest the occurrence of humid and arid periods in the region. The C/N ratio displayed a similar trend to the fatty acid's profiles, exhibiting an abrupt change that was likely induced by climate variations. Although diagenesis can alter the composition of organic matter and, subsequently, the C/N values, it is noteworthy that the abrupt change observed in the Salina da Ponta (soda lake) core corresponds to 3,200 years BP. This coincides with documented climate changes that occurred during the Holocene. Our study revealed the influence of past climatic conditions on the sources and variations of organic matter in sediment cores from the Pantanal's soda and freshwater lakes. Consideration of diagenesis and climate variations is crucial for interpreting sedimentary records.

Co-Administration of Albumin and Furosemide in Acute Heart Failure with Diuretics Resistance.

Acute heart failure is a frequent cause of hospital admission in Portugal, and has an increasing tendency given the aging population. Although most admissions for acute heart failure are caused by congestive conditions, not all patients have a congestive phenotype, reflecting the complexity of a process with multiple pathophysiological pathways. The use of diuretics, usually loop diuretics, is the mainstay of treatment for congestion. However, many patients develop resistance, thus constituting a challenge with no consensual solution to date, despite extensive debate over the years. Despite its frequent use in clinical practice, the co-administration of albumin and furosemide remains controversial in the management of patients with acute heart failure, hypoalbuminemia, and diuretic resistance. This review addresses the pathophysiological mechanisms of congestion in patients with acute heart failure and explores the theoretical basis that supports the co-administration of albumin and furosemide in this clinical context. It is intended to clarify the potential benefit of the combined approach in this specific population and identify possible gaps in the literature that could be the subject of future studies.

Thinking Outside the Box.

Clinical decision-making process is very complex and influenced by multiple aspects. As diagnosis likelihood assessment is often based on intuitive thinking, data misinterpretation, and diagnostic errors may commonly occur. We present a peculiar clinical case of a 27-year-old obese woman admitted to the emergency department after an inaugural episode of seizures. She had an oncologic disease. She was febrile and hypertensive at first evaluation. The report evolves around the diagnostic assessment, hampered by incongruent anamneses, incorrect data interpretation, and a pinch of clinical obstination, which nearly culminated in two deaths. Then, we discuss the series of biases that have confused the physicians. The only way to escape the intuitive thinking trap is to be humbly aware of our own thinking method's limitations and to learn about the biases that often lead us into errors. Sometimes, thinking outside the box is the key.

Sleep regularity in athletes: Comparing sex, competitive level and sport type.

This study aims to describe the athletes' sleep regularity using the Sleep Regularity Index (SRI) and determine whether factors, such as sex, competitive level and sport type, could affect the sleep/wake rhythm. It is a descriptive, cross-sectional study consisting of 172 athletes (25 ± 7 y old; 45 women). Seventy-three competed in team sports and 99 in individual sports. Furthermore, 56 competed in the international level, 95 in the national and 21 in the regional. We recorded the SRI values for at least 5 d via continuous actigraphy. We recorded a mean SRI value of 73 ± 12. We found no significant differences between athletes' sleep parameters in relation to sleep regularity. Furthermore, SRI data showed no correlations (Spearman's ρ) with sleep parameters, bed time and wake time. Female athletes (p = 0.001) and individual sport athletes (p = 0.001) reported better sleep regularity than their counterparts. International-level athletes reported better sleep regularity than those in other competitive levels (national: p = 0.001; regional: p = 0.024). Our study showed that international level athletes, female athletes and individual sport athletes reported better sleep regularity. Additionally, SRI data showed no correlation with athletes' sleep parameters, bed and wake time.

Acute affective responses to high-intensity interval exercise: Implications on the use of different stimulus-recovery amplitudes.

The effect of high-intensity interval exercise (HIIE) on affective responses is unclear due to the several variables of HIIE, which may be minimized by using derived variables (e.g. amplitude). The amplitude reflects the difference between stimulus and recovery intensities, being more representative of the physiological changes than central tendency variables such as average intensity. This study aimed to compare the affective responses in HIIE sessions in different amplitudes with a vigorous-intensity continuous exercise (VICE) session. Eleven participants completed five sessions. The peak oxygen consumption (VO2Peak) and peak power (Wpeak) were measured. Participants performed one VICE and three HIIE sessions (10x[1min-90%WPeak/1min-50%WPeak]; 10x[1min-100%WPeak/1min-40%WPeak]; and 10x[1min-110%WPeak/1min-40%WPeak]). The exercise sessions were performed at the same average intensity (70%WPeak) and duration (20 min). The Feeling Scale (FS) was applied in each minute throughout the exercise sessions. Regarding the FS responses, a two-way repeated-measures ANOVA showed no significant interaction for FS (P=0.093) or main effect for condition (P=0.206) and time (P=0.078), indicating that irrespective of the amplitude of the HIIE, FS results were similar between conditions. The effect size (ES) analysis showed a small effect in favour of HIIE-90/50 (ES=0.30) and HIIE-100/40 (ES=0.26) and a null effect on HIIE-110/30 (ES=0.08) when compared to VICE. Chi-squared analysis showed no significant differences between conditions in the number of participants that reduced, maintained, or increased the FS from pre-exercise to last stimulus and recovery indicating a high variability of the affective responses. HIIE sessions provide similar affective responses when performed at the same average intensity, even with different amplitudes.Highlights HIIE amplitude reflects the difference between stimulus and recovery intensities and seems not to modulate the affective responses to HIIE sessions configured with different amplitudes.HIIE sessions performed at the same average intensity and different amplitudes result in similar affective responses.High inter-individual variability of affective responses occurs in HIIE sessions configured based on the amplitude.

Predicting Prognosis in Internal Medicine: A Short and Long-Term Mortality Comparison Analysis.

Introduction The marked increase in life expectancy seen in Portugal in the last five decades led to a change in the profile of patients being most commonly admitted in internal medicine wards. In deciding the best care for these patients, prognostication models are needed in order to reduce readmissions, mortality, and adequate care. We aimed to study short and long-term mortality and predictors of all-cause mortality, independently of cause admission, of patients admitted in an internal medicine ward. Methods This two-part, single-center study enrolled patients from October 2013 to October 2014 with a follow-up of 60 months. Results A total of 681 patients were included; the mean age was 75.86 years with 60.4% females. The most frequent comorbidities were anemia, hypertension, and renal impairment. More than half of the population died in the follow-up period (51.5%). Deaths were significantly higher in the first six months after discharge (53% of all deaths) and then decreased abruptly to 11.6% in the second half-year after discharge. Based on the multivariate logistic regression model, with age over 80 years, anemia and neoplasm were independent predictors of short-term (p<0.001, p=0.001, p<0.001, respectively) and long-term (p<0.001 for the three conditions) mortality. Heart failure (p=0.018) and diabetes (p=0.025) were also predictors of long-term mortality. Conclusion High mortality, mainly in the first six months after discharge, elicits strategies targeting transition of care and close follow-up in the first months, which can be the key to improving outcomes. Identification of patients at higher risk may help design realistic models aiming to improve care for this frail population and decrease morbimortality.

Sleep in Paralympic athletes and its relationship with injuries and illnesses.

OBJECTIVES: To evaluate sleep characteristics and investigate the relationship of sleep with injuries and illnesses in Paralympic athletes. DESIGN: Cross-sectional. SETTING: Sports Training Center. PARTICIPANTS: 20 Paralympic athletes of athletics, swimming, and powerlifting. OUTCOMES: Injury and illnesses were recorded during the sports season through the Oslo Sports Trauma Research Center questionnaire (OSTRC-BR). Sleep-wake pattern was monitored for 2 weeks using actigraphy. Chronotype, sleep quality, sleep behavior, and sleep complaints were cross-sectionally collected. RESULTS: Poor sleep quality and poor sleep behavior were highly prevalent. The mean total sleep time was 6.57 ± 49.91. Duration of naps (r= -0.46; p=0.04) was associated with occurrence of health problems; frequency of insomnia (r= 0.51; p= 0.02), Pittsburgh Sleep Quality Index score (r= 0.45; p=0.04), and frequency of awakenings at night (r= 0.58; p= 0.01) were associated with severity of health problems; frequency of movements during sleep was associated with OSTRC-BR cumulative score (r= 0.58; p=0.00); and frequency of nightmares was associated with OSTRC mean score. CONCLUSIONS: Paralympic athletes tend to report poor sleep quality, have poor sleep behavior and sleep less than the recommended. Insomnia symptoms, awakenings at night, movements during sleep and poor sleep quality were associated with the occurrence and/or severity of health problems.

Mitral Valve Subacute Endocarditis Caused by Abiotrophia Defectiva: A Case Report.

Abiotrophia defectiva is a rare agent of endocarditis and subacute presentation may delay the diagnosis. We present the case of a 41-year-old male who was admitted to the hospital for further investigation regarding a consumptive syndrome with microcytic anaemia. Past medical history included new-onset mitral insufficiency followed by an ischaemic stroke due to small vessel disease. Thoraco-abdominal computed tomography revealed a splenic infarction. In the presence of two ischaemic events associated with mitral valve disease of unknown aetiology, we considered the possibility of subacute endocarditis. Blood cultures were positive for Abiotrophia defectiva, and transoesophageal echocardiography confirmed the diagnosis. As a subacute presentation of endocarditis, the paucity of symptoms caused a five-month delay in diagnosis. New-onset valvular disease and a stroke in an otherwise healthy young patient should always prompt proper investigation. This case highlights several complications caused by septic emboli of undiagnosed and untreated endocarditis.

Left Atrial Appendage Occlusion: A Therapeutic Option in a Patient With Atrial Fibrillation and Hereditary Hemorrhagic Telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is a predominantly inherited disorder of blood vessel structure, characterized by mucocutaneous telangiectasias, multiple arteriovenous malformations, and frequent epistaxis. A 67-year-old female with atrial fibrillation and high thromboembolic risk (CHADs2Vasc2: 4) with renal arterial thrombosis started oral anticoagulation (OAC). The patient had multiple episodes of heavy nasal and gastrointestinal bleeding (requiring multiple blood transfusions) such that OAC had to be interrupted, and a complementary investigation led to the diagnosis of HHT. Due to concomitant high thromboembolic and hemorrhagic risks, the patient was proposed left atrial appendage occlusion as an alternative to OAC intolerance. After the procedure, there were no new episodes of bleeding or thrombotic events.

Palliative Care in Heart Failure: Challenging Prognostication.

Heart failure (HF) is a chronic progressive disease with high morbimortality and poor quality of life (QoL). Palliative care significantly improves clinical outcomes but few patients receive it, in part due to challenging decisions about prognosis. This retrospective study, included all patients consecutively discharged from an Acute Heart Failure Unit over a period of one year, aiming to assess the accuracy of the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in predicting mortality. Additionally, predictors of death at one and three years were explored using a multivariate regression model. The MAGGIC score was useful in predicting mortality, without significant difference between mortality observed at three-years follow-up compared with a mortality given by the score (p=0.115). Selected variables were statistically compared showing that poor functional status, high New York Heart Association (NYHA) at discharge, psychopharmacs use, and high creatininemia were associated with higher mortality (p<0.05). The multivariate regression model identified three predictors of one-year mortality: psychopharmacs baseline use (OR=4.110; p=0.014), angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) medication at discharge (OR=0.297; p=0.033), and higher admission's creatinine (OR=2.473; p=0.028). For three-year mortality outcome, two variables were strong independent predictors: psychopharmacs (OR=3.330; p=0.022) and medication with ACEI/ARB at discharge (OR=0.285; p=0.018). Models' adjustment was assessed through the receiver operating characteristic (ROC) curve. The best model was the one-year mortality (area under the curve, AUC 81%), corresponding to a good discrimination power. Despite prognostication, when setting goals of care an individualised patient-centred approach is imperative, based on the patient's objectives and needs. Risk factors related to poorer outcomes should be considered, in particular, higher NYHA at discharge which also represents symptom burden. Hospitalisation is an opportunity to optimize global care for heart failure patients including palliative care.

Pain in an Internal Medicine Ward: An Undervalued Reality?

Introduction Pain is prevalent in most pathologic situations that require healthcare and is very common in hospitalised patients. However, there is limited evidence about the prevalence and the actual management of pain in medical wards. The aim of this work was to evaluate and characterise pain management in an internal medicine ward. Methods Retrospective analysis of clinical data of patients consecutively discharged from the internal medicine ward of a central tertiary hospital over a period of five months in 2018. Results 199 patients evaluated, the median age was 78 years and 63% were female. Of these, 14% had a previous diagnosis of chronic pain, 24% were on chronic pain medication, and in 29% medication was interrupted. Pain was noted in medical records of 118 patients, with moderate to severe intensity in 67%. Among those, 71% had pain occurrence registered in the medical notes but not characterised in duration in 61%. The most common attributed etiologies of pain were musculoskeletal (16%), visceral (9%), and headache (8%); no identifiable cause was specified in 57%. In the group of patients reporting pain, 63% received analgesics. Opioids were used in 35% and 47% of patients with moderate and severe pain, respectively. At discharge, 12 patients were still referred pain, 16 had pain listed as a diagnosis, 45 were medicated for pain, and eight were referred for pain consultation. Conclusions Despite being highly prevalent in the internal medicine ward, pain is still under-recognised, undervalued, and under-treated. Education of healthcare staff and adoption of treatment protocols is essential to improve care for these patients.

Does the compromised sleep and circadian disruption of night and shiftworkers make them highly vulnerable to 2019 coronavirus disease (COVID-19)?

Rotating and permanent night shiftwork schedules typically result in acute and sometimes chronic sleep deprivation plus acute and sometimes chronic disruption of the circadian time structure. Immune system processes and functionalities are organized as circadian rhythms, and they are also strongly influenced by sleep status. Sleep is a vital behavioral state of living beings and a modulator of immune function and responsiveness. Shiftworkers show increased risk for developing viral infections due to possible compromise of both innate and acquired immunity responses. Short sleep and sleep loss, common consequences of shiftwork, are associated with altered integrity of the immune system. We discuss the possible excess risk for COVID-19 infection in the context of the common conditions among shiftworkers, including nurses, doctors, and first responders, among others of high exposure to the contagion, of sleep imbalance and circadian disruption. ABBREVIATIONS: ACE2: Angiotensin-converting enzyme 2; APC: Antigen.-presenting .cells; CCL: Chemokine (C-C motif) ligand; CD+: .Adhesion molecule expression; COVID-19: 2019 coronavirus disease; DCs: Dendritic cells; GH: Growth hormone; HPA: Hypothalamic-pituitary-adrenal; HSF: Heat shock factor; HSP70: Heat shock protein 70; HSP90: Heat shock protein 90; IL: Interleukin; INFγ: Interferon-gamma; LT/LB: T/B lymphocytes; MHC: Major histocompatibility complex; NK: Natural .killer; RAAS: renin-angiotensin-aldosterone system; SARS: .Severe acute respiratory syndrome; SCN: Suprachiasmatic nucleus;SD: Sleep deprivation; SNS: Sympathetic nervous system; Th1/Th2: T helper lymphocytes 1/2; TLR2/TLR4: Toll-like receptor 2/4; TNF-α: Tumor .necrosis .factor alpha; VEGF: Vascular endothelial growth factor.

A Patient with Severe Malaria and COVID-19: How Do You Tell the Difference between These Infections?

Coronavirus infection, known as COVID-19, is characterized by clinical, epidemiological and biological features similar to those of malaria. In each case, fever, myalgia, fatigue, headaches and gastrointestinal symptoms may be present. Both diseases can also induce a cytokine storm and pro-coagulant states. An appropriate epidemiological approach and differential diagnosis are very important so that the right clinical intervention can be selected. Malaria remains a serious global public health issue, especially in endemic countries. Elimination campaigns are helping to control the disease, but in many countries these programs are now at risk of failure due to logistic and economic problems caused by COVID-19. The authors describe the case of a patient with co-infection with malaria and COVID-19, reminding us that during this coronavirus pandemic it is critical to consider other diagnoses, particularly in people traveling between countries. LEARNING POINTS: As far as we know, this is one of the first case reports of co-infection with COVID-19 and Plasmodium falciparum malaria.It is important to be aware of the clinical challenges of diagnosing the cause of fever in returned travellers.

Sleep debt induces skeletal muscle injuries in athletes: A promising hypothesis.

Sleep is a physiological state and it is fundamental for physical and cognitive recovery of athletes. Due to strenuous training and competitions, athletes may present sleep complaints compromising good quality and quantity of sleep. Studies have related sleep debt to the occurrence of musculoskeletal injuries in athletes, but the mechanisms that can lead to this are not entirely clear. Studies involving animals and humans have shown that poor sleep quality can cause significant changes in hormones and cytokines. Demonstrating that this hormones changes lead to a decrease of testosterone and growth hormone levels and increased cortisol levels, important hormones in the process of protein synthesis and degradation. In athletes, the sport itself is a risk factor of injuries, and sleep debt may result in overtraining syndrome associated with inflammatory markers and ultimately to immune system dysfunction. Thus, we hypothesize that athletes who have sleep debt are more susceptible to musculoskeletal injuries due to increased catabolic pathway signaling, i.e. protein degradation and decreased anabolic pathway signaling, compromising muscle integrity. In this sense, we indicate the relationship between musculoskeletal injuries and sleep debt involving new targets for immunological signaling pathways that start the reduction of the muscle recovery process.