Flexibility and achilles tendon: a brief review / Flexibilidade e tendão de aquiles: uma breve revisão

Performing flexibility training in an exercise program is important to improve range of motion (ROM). Tendons have a profound impact on the general function of the musculoskeletal system, influence the limitation of ROM, and its structure and mechanical properties can benefit from stretching protocols. The systematic use of lower limbs in locomotion caused the Achilles tendon to become the largest and strongest tendon in the human body. Therefore, understanding the best prescription and frequency of flexibility exercise leads to changes in tendon properties is essential for an appropriate and effective exercise routine. Thus, the aim of this review was to organize and discuss publications about the implications of triceps surae stretching in ROM, as well as its influence on tendon properties. Acute studies show that continuous stretching times between five and 10 minutes cause decreased tendon stiffness, which is not seen in fractionated stretching times less than five minutes. Chronic studies, in turn, also don't present significant results in stiffness with fractionated times and studies with continuous times were not found. Thus, it is not possible to know if a continuous stretching time (longer than one minute) or a total time longer than five minutes but fractionated, can influence the tendon stiffness. (AU)

A realização de treino de flexibilidade como rotina em um programa de exercícios é importante para melhorar amplitude de movimento (ADM). Os tendões têm um impacto profundo na função geral do sistema musculoesquelético, influenciam na limitação da ADM, e sua estrutura e propriedades mecânicas podem se beneficiar de protocolos de alongamento. O uso sistemático dos membros inferiores na locomoção fez com que o tendão de Aquiles se tornasse o maior e mais forte tendão do corpo humano. Portanto, entender qual a melhor prescrição e frequência de exercício de flexibilidade para que ocasione alterações nas propriedades tendíneas é essencial para uma rotina de exercícios adequada e eficaz. Sendo assim, o objetivo dessa revisão de literatura foi organizar e discutir publicações sobre as implicações do alongamento do tríceps sural na ADM, bem como sua influência nas propriedades tendíneas. Estudos agudos mostram que tempos contínuos entre cinco e 10 minutos de alongamento estático causam diminuição da rigidez tendínea, o que não é visto em tempos intervalados inferiores a cinco minutos. Os estudos crônicos, por sua vez, também não apresentam resultados significativos na rigidez com protocolos de alongamento intervalados e estudos com protocolos contínuos não foram encontrados. Dessa forma, não é possível saber se um tempo contínuo de alongamento (superior a um minuto) ou um tempo superior a cinco minutos, intervalado, podem influenciar na rigidez tendínea. (AU)

Efeitos do treinamento de caminhada em esteira sobre o equilíbrio e sintomas motores de pessoas com doença de parkinson: uma revisão da literatura / Effects of treadmill walking training on balance and motor symptoms in parkinson's disease: a literature review

A doença de Parkinson (DP) apresenta prejuízo no equilíbrio e piora de sintomas motores, os quais podem aumentar o risco de quedas. O exercício físico tem se mostrado uma estratégia eficaz para combater os sintomas e o avanço da DP. A caminhada parece ser uma das estratégias mais utilizadas dentro da reabilitação na DP. Além disso, a caminhada realizada em esteira parece ser segura e eficaz para o tratamento da DP. No entanto, para nosso conhecimento, não foi realizada uma revisão abrangente da literatura que aborde os efeitos do treinamento físico de caminhada em esteira sobre o equilíbrio e sintomas motores de indivíduos com DP. Diante disso, o objetivo do presente estudo foi comparar os efeitos do treinamento físico de caminhada em esteira sobre o equilíbrio, medido por meio da escala de equilíbrio de Berg (EEB) e sintomas motores, medido por meio da escala UPDRS-III ou UPDRS-M (Unified Parkinson's disease rating scale ­ III ou motor scale) em indivíduos com DP. Foi realizada uma busca na literatura nas bases de dados PubMed e SciELO utilizando as seguintes palavras-chave: "Parkinson disease", "Walking" e "Exercise". Um total de 11 artigos foram incluídos para leitura na íntegra. Ao fim do processo de leitura, foram incluídos oito artigos para extração dos dados. Foi observado que existem diferentes modelos de treinamento físico de caminhada em esteira, sendo que o mais utilizado é com a suspensão do peso corporal, aparecendo em cinco artigos. Além disso, um estudo investigou os efeitos da caminhada nórdica em esteira, e outros dois investigaram os efeitos da caminhada convencional em esteira com modelo de prescrição baseado na velocidade autosselecionada. Todos estudos demonstraram efeito positivo do treinamento físico de caminhada, demonstrando melhora no equilíbrio funcional e sintomas motores de indivíduos com DP quando comparados a um grupo controle. (AU)

Parkinson's disease (PD) impairs balance and worsens motor symptoms, increasing the risk of falls. Physical exercise has been shown to be an effective strategy to combat the symptoms and progress of PD. Walking seems to be one of the most used strategies within PD rehabilitation. In addition, walking on a treadmill appears to be safe and effective for the treatment of PD. However, to our knowledge, a comprehensive literature review that addresses the effects of physical walking training on the treadmill on balance and motor symptoms of individuals with PD has not been performed. Therefore, the aim of the present study was to compare the effects of physical training in treadmill walking on balance, measured using the Berg balance scale and motor symptoms, measured using the UPDRS-III or UPDRS-M scale (Unified Parkinson's disease rating scale - III or motor scale) in individuals with PD. A literature search was performed in the PubMed and SciELO databases using the following keywords: "Parkinson's disease", "Walking" and "Exercise". At the end of the selection process, eight articles were included for data extraction. It was observed that there are different models of physical training for walking on a treadmill, the most used being with the suspension of body weight, appearing in five articles. In addition, one study investigated the effects of Nordic walking on a treadmill, and two others investigated the effects of conventional walking on a treadmill with a prescription model based on self-selected speed. All studies demonstrated a positive effect of physical walking training, showing improvement in the functional balance and motor symptoms of individuals with PD when compared with control group. (AU)

Tratamiento conservador de la artrosis de cadera / Conservative treatment of hip osteoarthritis

Ante un escenario clínico de coxalgia por artrosis de cadera se planteó la necesidad de conocer los tratamientos con-servadores más seguros y efectivos para el manejo del dolor. El tratamiento de la artrosis requiere un enfoque integral e individualizado en función de las preferencias del paciente para lograr el máximo beneficio clínico. Existen numerosas estrategias útiles para el manejo del dolor en pacientes con artrosis de cadera siendo fuertemente recomendados de inicio la actividad física, los antiinflamatorios no esteroideos (AINE) orales y en ciertos casos los corticoides intraarticulares, tramadol o duloxetina, siempre asociado con la actividad física. Los ejercicios más recomendados son los aeróbicos y el Tai Chi o yoga. (AU)

Faced with a clinical scenario of coxalgia due to hip osteoarthritis, the need to know the safest and most effective conservative treatments for pain management arose. The treatment of osteoarthritis requires a comprehensive and individualised approach based on the patient's preferences to achieve maximum clinical benefit. There are numerous useful strategies for pain management in patients with hip osteoarthritis being strongly recommended from the beginning such as physical activity, oral non-steroidal anti-inflammatory drugs (NSAID) and in certain cases intra-articular corticosteroids, tramadol or duloxetine, always associated with physical activity. The most recommended exercises are aerobics and Tai Chi or yoga. (AU)

Analysis of the relationship of the vertical extension of mouth opening with muscle rigidity and sociodemographic factors in Parkinson's disease / Análise da relação da extensão vertical da abertura de boca com a rigidez muscular e fatores sociodemográficos na doença de Parkinson

Introduction: Changes caused by the rigidity of Parkinson's Disease (PD) can affect the mandibular musculature. However, few studies have been published about its impact on the oral opening. Objective: To analyze the relationship of the vertical extension of the oral opening with muscular rigidity and sociodemographic factors of the elderly with PD. Material and method: This is a cross-sectional, quantitative study that collected data from a primary study conducted at the Hospital das Clínicas of the Federal University of Pernambuco in 2018. Data were collected from medical records and from the questionnaire, Research Diagnostic Criterion for Temporomandibular Disorders (RDC/TMD). The sample was composed of 81 parkinsonians and characterized using: sociodemographic variables and the presence or absence of muscular rigidity. The measures of vertical extension of the oral opening evaluated were: mouth opening without assistance and without pain (ABASD), and maximum mouth opening without assistance (AMBSA). The Pearson's linear correlation and Spearman's correlation tests were applied to investigate the relationship among the continuous variables. Analyses of association were conducted using simple logistic regression. The level of significance was set at p<0.05. Result: Limitation of the oral opening was not related to age or sex. The greatest level of significance was between mouth opening without assistance and without pain and muscular rigidity (p=0.012), and years of schooling (p=0.038). Conclusion: The limitation of mouth opening in people with PD was shown to be related to muscular rigidity and fewer years of schooling.

Introdução: As alterações causadas pela rigidez na Doença de Parkinson (DP) podem afetar a musculatura mandibular, mas há uma escassez de estudos publicados sobre seu impacto na abertura bucal. Objetivo: Analisar a relação da extensão vertical da abertura de boca com a rigidez muscular e os fatores sociodemográficos de idosos com a DP. Material e método: Trata-se de um estudo transversal, quantitativo, que coletou dados de uma pesquisa primária realizada no Hospital das Clínicas da Universidade Federal de Pernambuco, em 2018. Apanhou-se dados dos prontuários e do questionário: Critério de Diagnóstico de Pesquisa para Disfunções Temporomandibulares (RDC/TMD). A amostra foi composta por 81 parkinsonianos e caracterizadas em: variáveis sociodemográficas e presença ou ausência de rigidez muscular. As medidas de extensão vertical de abertura de boca avaliadas foram: abertura de boca sem auxílio e sem dor (ABASD) e abertura máxima da boca sem auxílio (AMBSA). Aplicou-se os testes de correlação linear de Pearson e de correlação de Spearman para averiguar relação entre as variáveis contínuas. Análises de associações foram realizadas através da regressão logística simples. Nível de significância de p<0,05. Resultado: A limitação de abertura de boca não apresentou relação com a idade e o sexo. O maior nível de significância foi entre a abertura de boca sem auxílio e sem dor e a rigidez muscular (p= 0,012) e a escolaridade (p= 0,038). Conclusão: A limitação de abertura de boca nas pessoas com DP se mostrou relacionada a rigidez muscular e a escolaridade mais baixa.

Síndrome de persona rígida: presentación de caso clínico y abordaje terapéutico / Stiff man Syndrome Clinical case presentation and therapeutic approach

Introducción: El síndrome del hombre rígido representa una rara enfermedad neuromuscular caracterizada por rigidez muscular progresiva y espasmos musculares dolorosos que afecta a 1 persona por cada millón de habitantes por año en el mundo. En la mayoría de los pacientes se encuentran niveles elevados de anticuerpos descarboxilasa del ácido glutámico. En Colombia solo se han publicado alrededor de 3 casos, lo que motiva la presentación de un nuevo informe que aporte a la discusión actual en el campo de la neurología clínica. Caso clínico: Paciente de sexo femenino de 35 años con cuadro clínico progresivo de varios años, caracterizado por contracciones paroxísticas dolorosas, parestesias y pérdida de fuerza. Se documentó la presencia de anticuerpos anti-GAD compatibles con el síndrome del hombre rígido. Tras un tratamiento integral, que incluyó la infusión farmacológicamente intratecal con baclofeno, se obtuvo mejoría clínica en el índice de Barthel. Conclusiones: El síndrome del hombre rígido es una condición infradiagnosticada que se asocia a un deterioro de la calidad de vida de quienes lo padecen.

Introduction: Stiff man syndrome represents a rare neuromuscular disease characterized by progressive muscle rigidity and painful muscle spasms that affects 1 person for every million habitants per year in the world. High levels of glutamic acid antibodies decarboxylase are found in most patients. In Colombia, only around 3 cases have been published, which motivates the presentation of a new report that contributes to the current discussion in the field of clinical neurology. Clinical Case: 35-year-old female patient with a progressive clinical picture of several years, characterized by painful paroxysmal contractions, paresthesias and loss of strength. The presence of anti-GAD antibodies was documented, compatible with Stiff man syndrome. After comprehensive treatment, which included pharmacologically intrathecal infusion with baclofen, clinical improvement was obtained in the Barthel index. Conclusions: Stiff man syndrome is an underdiagnosed condition which is associated with a deterioration in the quality of life for those who suffer from it.

Estratégia educativa com profissionais de enfermagem sobre hipertermia maligna em um centro cirúrgico cardiovascular / Educational strategy with nursing professionals on malignant hypertermia in a cardiovascular surgical center / Estrategia educativa con profesionales de enfermería en hipertermia maligna en un centro quirúrgico cardiovascular

Objetivos: Avaliar o conhecimento da equipe de enfermagem do centro cirúrgico (CC) sobre hipertermia maligna (HM), antes e depois de aula expositiva, e implantar kit para tratamento da HM com os anestesiologistas. Método: Estudo quase experimental do tipo antes e depois. Coleta de dados com 43 profissionais (três enfermeiros, sete técnicos e 33 auxiliares) do CC de um hospital de cardiologia de São Paulo. Aplicaram-se cinco questões antes e depois de aula expositiva, e utilizaram-se teste exato de Fisher e teste de McNemar. Após análise da literatura e dos materiais do setor e reunião com equipe médica, elaborou-se um kit de tratamento. Resultados: Houve diferença significante (p<0,05) em relação ao conhecimento da equipe sobre HM; após a aula, viu-se progresso nas três categorias (auxiliares 89,42%, técnicos 90% e enfermeiros 100%). As questões com porcentagem acima de 90%, após a aula, foram: definição de HM, agentes desencadeantes e tratamento. Foi elaborado e implantado um kit de tratamento. Conclusão: Avaliou-se o conhecimento da equipe de enfermagem sobre HM, antes e depois da aula expositiva, e implantou-se kit de tratamento. O conhecimento da equipe foi satisfatório após a aula ministrada.

Objectives: To evaluate the knowledge of the nursing staff of the surgical center (SC) about malignant hyperthermia (MH), before and after lecture, and to implant a kit for the treatment of MH with anesthesiologists. Method: Quasi-experimental before and after study. Data collection with 43 professionals (three nurses, seven technicians and 33 assistants) from the SC of a cardiology hospital in São Paulo. Five questions were applied before and after lecture, and McNemar and Fisher's exact tests were used. After analyzing the literature and industry materials and meeting with the medical team, a treatment kit was prepared. Results: There was a significant difference (p <0.05) regarding the team's knowledge about MH; After class, progress was seen in the three categories (assistants 89.42%, technicians 90%, and nurses 100%). The questions with percentage above 90% after class were: definition of MH, triggering agents, and treatment. A treatment kit was developed and implemented. Conclusion: The knowledge of the nursing staff about MH before and after the lecture was evaluated, and a treatment kit was implemented. The knowledge of the team was satisfactory after the taught class.

Objetivos: Evaluar el conocimiento del personal de enfermería del quirófano (CQ) sobre la hipertermia maligna (HM), antes y después de la conferencia, e implantar un kit para el tratamiento de HM con anestesiólogos. Método: Cuasi-experimental antes y después del estudio. Recopilación de datos con 43 profesionales (tres enfermeras, siete técnicos y 33 asistentes) del CQ de un hospital de cardiología en São Paulo. Se aplicaron cinco preguntas antes y después de la conferencia, y se utilizaron la prueba exacta de Fisher y la prueba de McNemar. Después de analizar la literatura y los materiales de la industria y de reunirse con el equipo médico, se preparó un kit de tratamiento. Resultados: Hubo una diferencia significativa (p<0.05) con respecto al conocimiento del equipo sobre MH; Después de la clase, se observó progreso en las tres categorías (auxiliares 89.42%, técnicos 90% y enfermeras 100%). Las preguntas con un porcentaje superior al 90% después de la clase fueron: definición de MH, agentes desencadenantes y tratamiento. Se desarrolló e implementó un kit de tratamiento. Conclusión: Se evaluó el conocimiento del personal de enfermería sobre MH antes y después de la conferencia, y se implementó un kit de tratamiento. El conocimiento del equipo fue satisfactorio después de la clase impartida.

Head and neck symptoms as predictors of outcome in tetanus patients

@#Objective: This study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. Methods: Design: Retrospective Cohort Study Setting: Tertiary National University Hospital Patients: Seventy-three (73) pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the Philippine General Hospital between January 1, 2013 and December 31, 2017. Demographic characteristics, incubation periods, periods of onset, routes of entry, head and neck symptoms, stage, and outcomes were retrieved from medical records and analyzed. Results: Of the 73 patients included, 53 (73%) were adults, while the remaining 20 (27%) were pediatric. The three most common head and neck symptoms were trismus (48; 66%), neck pain/ rigidity (35; 48%), and dysphagia to solids (31; 42%). Results of multivariate logistic regression analysis showed that only trismus (OR = 3.742, p = .015) and neck pain/ rigidity (OR = 4.135, p = .015) were significant predictors of decannulation. No dependent variable/symptoms had a significant effect in predicting discharge and mortality. Conclusion: Clinically diagnosed tetanus can be easily recognized and immediately treated. Most of the early complaints are head and neck symptoms that can help in early diagnosis and treatment resulting in better prognosis. In particular, trismus and neck pain/rigidity may predict the outcome of decannulation after early tracheotomy, but not of discharge and mortality.

Rigidez muscular, trastorno de sensorio y antipsicóticos: Reporte de caso / Muscle rigidity, sensory disorder and antipsychotics: a case report

En los servicios de emergencias que atienden a una gran población, muchas veces se encuentran cuadros aislados, como deshidratación severa, hipernatremia o hiponatremia, injuria renal aguda, trastorno de sensorio, entre otras. Sin embargo, muchos de estos cuadros forman parte de una sola patología, y si no se hace una unidad clínica en el momento adecuado, la morbimortalidad se puede incrementar drásticamente. Sobre todo, en enfermedades con baja frecuencia, muy raras o poco habituales, como la que se narrará a continuación, podría empeorar el estado crítico del paciente si no se detecta a tiempo o no se maneja adecuadamente. Este caso clínico es el de una paciente mujer de 74 años, con antecedente de patología psicótica con tratamiento irregular que, tras ingerir carbamazepina y risperidona, presenta los síntomas típicos y poco frecuentes del síndrome neuroléptico maligno (SNM).

In emergency rooms with large numbers of assigned population, we often see isolated conditions, such as severe dehydration, hypernatremia or hyponatremia, acute kidney injury, sensory disorder, among others. However, many of these conditions are part of a single disease and, if they are not gathered together as a medical unit at the right time, morbidity and mortality may drastically increase, especially in the event of diseases with a very rare or unusual frequency. Such is the case of the following disorder, which could worsen the critical condition of the patient if it is not detected on time or not treated appropriately. This clinical case addresses a 74-year-old female patient who reports a history of psychotic disorder with irregular treatment and, after the intake of carbamazepine and risperidone, presents the typical and infrequent symptoms of neuroleptic malignant syndrome (NMS).

Nódulo pulmonar solitario por Cryptococcus en paciente HIV positivo. Reporte de un caso / Solitary pulmonary nodule by c ryptoc oc cus in HIV pos itiv e patient. Case repor

Se presenta el caso de un paciente masculino VIH positivo con historia de cefalea y rigidez nucal. Dada su condición clínica el paciente es hospitalizado en sala. La radiografía de tórax es normal y se realiza tomografía de tórax de alta resolución debido a la historia clínica de VIH encontrándose un nódulo pulmonar solitario en el pulmón derecho con márgenes irregulares al cual se realiza biopsia dirigida por tomografía resultando un diagnóstico de micosis pulmonar.

A case of a positive VHI male patient with a history of headache and nuchal stiffness is reported. Gi­ven his clinical condition, the patient is hospitalized in the emergency room. The chest x­ray is nor­mal and a high­resolution chest tomography is performed due to the clinical history of HIV, finding a solitary pulmonary nodule in the right lung with irregular margins to which a biopsy directed by tomo­graphy is performed, resulting in a diagnosis of pulmonary mycosis.

Uso de plasmaféresis para el manejo del síndrome de la persona rígida / Use of plasmapheresis for the management of the syndrome of the rigid person

Introducción: el síndrome de la persona rígida (SPR) es una patología infrecuente caracterizada por la activación involuntaria de la unidad motora, causando rigidez fluctuante de la musculatura axial, espasmos musculares dolorosos y actividad motora continua en la electromiografía. En la mayoría de pacientes se encuentran niveles elevados de anticuerpos antiácido glutámico descarboxilasa. Presentación del caso: paciente de género femenino de 60 años de edad, con persistencia de sintomatología espasmódica muscular a pesar del manejo con medicamentos agonistas GABA e inmunomoduladores, por lo que se consideró el uso de plasmaféresis como tercera línea de tratamiento. Conclusiones: la experiencia con el uso de la técnica es favorable, hay disminución de los espasmos musculares en más del 50% al cabo de 7 sesiones. Aunque la plasmaféresis produjo alivio sintomático, son necesarios nuevos ensayos clínicos y reportes de caso para determinar su beneficio clínico y así protocolizar su aplicación.

Introduction: Stiff person syndrome (SPS) is an infrequent pathology, characterized by the involuntary activation of the motor unit, causing fluctuating rigidity of the axial muscles, painful muscle spasms and continuous motor activity in electromyography. In most patients, high levels of anti-glutamic acid decarboxylase antibodies are found. Case presentation: Female patient of 60 years of age, with persistence of muscular spasmodic symptoms despite management with GABA agonist drugs and immuno modulators, for which the use of plasmapheresis as the third line of treatment was considered. Conclusions: The experience in the use of the technique is favorable, with a decrease in muscle spasms greater than 50% after 7 sessions. Although plasmapheresis produced symptomatic relief, new clinical trials and case reports are necessary to determine its clinical benefit and thus protocolize its application

A Neuroleptic Malignant Syndrome Without Rigidity

Neuroleptic malignant syndrome (NMS) is an uncommon but potentially lethal idiosyncratic reaction which may emerge in the aftermath of the treatments with neuroleptics demonstrating itself with the symptoms of altered consciousness, high fever, impaired autonomic functions, and muscle rigidity. Although various risk factors have been identified for NMS, its etiology is not completely known. The mortality and morbidity related with NMS could be reduced by early diagnosis, interruption of the neuroleptics used within a short period and aggressive treatment. Our case is different from general NMS cases due to lack of rigidity. A NMS case which developed within a short time in the aftermath of multiple antipsychotic use and wherein no rigidity was observed shall be discussed in this case report.

The efficacy and safety of coenzyme Q10 in preventing the progression of early Parkinson's disease: A meta-analysis

INTRODUCTION: Coenzyme Q10, also known as Ubiquinone, is a substance now being used as a dietary supplement in many countries including the Philippines. It has also been the focus of several researches as treatment for several diseases including Parkinson's Disease. Several studies have shown that Coenzyme Q10 inhibits mitochondrial dysfunction in Parkinson's Disease, hence delaying its progression.OBJECTIVES: The objective of this study is to assess and summarize the available evidence on the efficacy and safety of Coenzyme Q10 administration in the prevention of the progression of early Parkinson's Disease.METHODS: This is meta-analysis of randomized controlled trials on the use of Coenzyme Q10 in Parkinson's Disease. A literature search in several databases was conducted for relevant studies. Three randomized controlled trials met the inclusion criteria. The efficacy of Coenzyme Q10 were measured using the total and the component scores of the Unified Parkinson Disease Rating Scale on follow-up. On the other hand, safety were measured using the withdrawal rate and the associated adverse reactions during the therapy of CoQ10. The Review Manager Software was utilized for the meta-analysis.RESULTS: Compared to Placebo, treatment of CoQ10 did not show any significant difference in the mean scores of the UPDRS mental and ADL scores. Interestingly, the UPDRS motor score showed a significant difference between Coenzyme Q10 and placebo, but no significant difference when a subgroup analysis between high-dose (-4.03 [-15.07-7.01], p-value 0.47, I2 67%, P for heterogeneity 0.08) and low-dose Coenzyme Q10 (0.53 [-0.89-1.94], p-value 0.47, I2 34%, P for heterogeneity 0.22) was done. Overall, there was no significant difference in the total UPDRS score (0.68 [-0.61-1.97], p-value 0.30, I2 0%, P for heterogeneity 0.70). The anxiety, back pain, headache, sore throat, nausea, dizziness and constipation.CONCLUSION: Contrary to some animal and human studies, this meta-analysis showed that the use of CoQ10 results to non-significant improvement in all components of the UPDRS scores as opposed to placebo. However, the use of CoQ10 is tolerated and seems to be safe but further studies are needed to validate this finding.

A fatal case of acute bentazone overdose despite cricothyroidotomy during cardiopulmonary resuscitation

Bentazone is classified as a moderately hazardous (class II) herbicide by the World Health Organization. A 53-year-old Korean woman was transferred to the emergency department after a suicide attempt using approximately 500 mL of bentazone one hour prior to admission. Upon admission, she was alert and tachycardia of 125/min was observed. She was treated with gastric lavage and activated charcoal, during which she experienced diarrhea. Two hours after bentazone ingestion, cardiac arrest and muscle rigidity throughout the body occurred. Cardiopulmonary resuscitation was immediately started. Endotracheal intubation after administration of a muscle relaxant (succinylcholine) was unsuccessful because of temporomandibular joint muscle rigidity. Surgical cricothyroidotomy was performed by the emergency physician, but the patient was not resuscitated. For cardiac arrest patients with muscle rigidity caused by bentazone overdose, endotracheal intubation may be challenging because of muscle rigidity, despite appropriate use of muscle relaxants. Early surgical cricothyroidotomy may be the preferred method of airway management in these patients.

Neuroleptic Malignant Syndrome Associated with Valproate in an Adolescent

Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction that usually occurs after the administration of antipsychotic drugs. Antidepressants, benzodiazepines, and antiepileptic drugs are also suggested to be associated with NMS. It is believed to result from a dopaminergic blockade in the central nervous system. NMS is manifested by hyperthermia, muscle rigidity, autonomic dysfunction, altered mental status, leukocytosis, and elevated serum creatinine phosphokinase. Valproate is commonly used in the treatment of many psychiatric and neurologic disorders. Valproate can precipitate NMS, especially when used with antipsychotic drugs concurrently. A 17-year-old male patient, who presented with fever, muscular rigidity, confusion, sweating, and tachycardia was admitted to the emergency room. He had been taking only valproate for the last two months for bipolar disorder. His laboratory analyses revealed raised serum hepatic enzymes, creatinine phosphokinase, and myoglobin levels. Considering fever, rigidity, autonomic dysfunction, cognitive alteration, and high creatinine phosphokinase levels, the patient was diagnosed with NMS. In this paper, we aim to discuss the association between valproate and NMS.

Postoperative Psychogenic Non-epileptic Seizure in the Post-Anesthesia Recovery Unit

A 43-year-old woman with left facial pain caused by occipital neuralgia was scheduled for C2 ganglionotomy and adhesiolysis of left C2 root. General anesthesia, surgical procedure, and emergence have done uneventfully. However, she developed seizure after 5 minutes postoperatively in post-anesthesia recovery unit. She showed loss of consciousness and generalized muscular rigidity after shouting “I want to die”. Neurologic examination and neuroimaging revealed no neuronal damage. Her generalized muscular rigidity improved by her daughter's visit and worsened by mention about her husband, and disappeared after 40 minutes spontaneously.

Recurrent Desaturation Events due to Opioid-Induced Chest Wall Rigidity after Low Dose Fentanyl Administration / 대한구급학회지

Opioid-induced chest wall rigidity is an uncommon complication of opioids. Because of this, it is often difficult to make a differential diagnosis in a mechanically ventilated patient who experiences increased airway pressure and difficulty with ventilation. A 76-year-old female patient was admitted to the intensive care unit (ICU) after surgery for periprosthetic fracture of the femur neck. On completion of the surgery, airway pressure was increased, and oxygen saturation fell below 95% after a bolus dose of fentanyl. After ICU admission, the same event recurred. Manual ventilation was immediately started, and a muscle relaxant relieved the symptoms. There was no sign or symptom suggesting airway obstruction or asthma on physical examination. Early recognition and treatment should be made in a mechanically ventilated patient experiencing increased airway pressure in order to prevent further deterioration.

Malignant Neuroleptic Syndrome following Deep Brain Stimulation Surgery of Globus Pallidus Pars Internus in Cerebral Palsy / 대한구급학회지

Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal outcome caused by sudden discontinuation or dose reduction of dopaminergic agents. We report an extremely rare case of NMS after deep brain stimulation (DBS) surgery in a cerebral palsy (CP) patient without the withdrawal of dopaminergic agents. A 19-year-old girl with CP was admitted for DBS due to medically refractory dystonia and rigidity. Dopaminergic agents were not stopped preoperatively. DBS was performed uneventfully under monitored anesthesia. Dopaminergic medication was continued during the postoperative period. She manifested spasticity and muscle rigidity, and was high fever resistant to anti-pyretic drugs at 2 h postoperative. At postoperative 20 h, she suffered cardiac arrest and expired, despite vigorous cardiopulmonary resuscitation. NMS should be considered for hyperthermia and severe spasticity in CP patients after DBS surgery, irrespective of continued dopaminergic medication.

Malignant Neuroleptic Syndrome following Deep Brain Stimulation Surgery of Globus Pallidus Pars Internus in Cerebral Palsy / 대한중환자의학회지

Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal outcome caused by sudden discontinuation or dose reduction of dopaminergic agents. We report an extremely rare case of NMS after deep brain stimulation (DBS) surgery in a cerebral palsy (CP) patient without the withdrawal of dopaminergic agents. A 19-year-old girl with CP was admitted for DBS due to medically refractory dystonia and rigidity. Dopaminergic agents were not stopped preoperatively. DBS was performed uneventfully under monitored anesthesia. Dopaminergic medication was continued during the postoperative period. She manifested spasticity and muscle rigidity, and was high fever resistant to anti-pyretic drugs at 2 h postoperative. At postoperative 20 h, she suffered cardiac arrest and expired, despite vigorous cardiopulmonary resuscitation. NMS should be considered for hyperthermia and severe spasticity in CP patients after DBS surgery, irrespective of continued dopaminergic medication.

Serotonin Syndrome following Duloxetine Administration in a Fibromyalgia Patient: Case Report and Literature Review

Serotonin syndrome, an adverse drug reaction, is a consequence of excess serotonergic agonism of central nervous system receptors and peripheral serotonergic receptors. Serotonin syndrome has been associated with large numbers of drugs and drug combinations, and serotonin-norepinephrine reuptake inhibitor-induced serotonin syndrome is rare. It is often described as a sign of excess serotonin ranging from tremor in mild cases to delirium, neuromuscular rigidity, and hyperthermia in life-threatening cases. Diagnosis is based on the symptoms and patient's history, and several diagnostic criteria have been developed. We experienced a rare case of fibromyalgia accompanied by tremor, hyperreflexia, spontaneous clonus, muscle rigidity, and diaphoresis after 10 days of single use of duloxetine 30 mg. Only one case of serotonin syndrome resulting from administration of duloxetine has been reported in Korea, however that case resulted from co-administration of fluoxetine. We report here on this case along with a review of the relevant literature.