10-year success story in CTEPH treatment: breaking the myth of rareness.

Unlike acute pulmonary embolism (PE), the resolution of thrombi is ineffective in chronic thromboembolic pulmonary hypertension (CTEPH), leading to reorganisation and fibrotic changes within the pulmonary arteries. The authors report the case of a man in his 60s with polycythemia vera, under warfarin, following an acute PE. He was admitted a year later with right heart failure and haemodynamic instability. Acute over chronic PE caused this severe presentation, confirmed by right heart catheterisation and pulmonary scintigraphy. The challenging diagnosis and management involved transfer to a centre specialised in pulmonary vascular disease. Normalisation of functional and haemodynamic parameters, sustained in 10-year follow-up, was achieved with anticoagulation and triple therapy with prostanoids as a bridge to pulmonary thromboendarterectomy. Targeted medical therapy, not standard at that time, was crucial to recovering conditions for transfer. An individualised approach, integrating multidisciplinary pulmonary hypertension expertise, provides the basis for the best care for CTEPH.

Transitioning intravenous epoprostenol to oral selexipag in idiopathic pulmonary arterial hypertension: a case report.

Intravenous (i.v.) prostacyclin is the cornerstone treatment in high-risk pulmonary arterial hypertension (PAH) patients. Selexipag is an orally available prostacyclin receptor agonist. Limited data are available regarding the feasibility of transitioning from i.v. epoprostenol to selexipag. A 50-year-old woman with idiopathic PAH was diagnosed in a World Health Organization (WHO) Functional Class (FC) IV. She improved with upfront triple combination therapy, including i.v. epoprostenol. Over 2 years of follow-up, the patient remained at low risk and expressed strong preference towards oral therapies. After careful risk-benefit clinical consideration, she was transitioned from i.v. epoprostenol to selexipag. Selexipag was started at dosage of 200 µg twice daily (b.i.d.) and titrated up to 1600 µg b.i.d. over 8 weeks (up-titration of 200 µg b.i.d. every week). Simultaneously, i.v. epoprostenol was down-titrated 3.0 ng/kg/min every week from a dosage of 27.5 ng/kg/min. The transition occurred under strict medical surveillance and was well tolerated. One year after discontinuation of epoprostenol, the patient remains in WHO FC I and has no signs of clinical deterioration. Although not generalizable to most PAH patients, this case highlights that a carefully planned transition from epoprostenol to selexipag is feasible in selected low-risk patients within a shared medical decision-making framework.

Point of Care Ultrasound-Diagnostic Approach of an Atypical Negative Pressure Pulmonary Oedema.

A 42 years old patient who underwent laparoscopic appendectomy developed negative pressure pulmonary oedema (NPPO) with an atypical presentation. Point of care ultrasound (POCUS) played a decisive role in the diagnostic approach. POCUS, as a goal-orientated tool, can provide key elements for a prompt diagnosis of respiratory and airway complications in the surgical patient. The identification of a B-line pattern, as an imagiological surrogate of alveolar oedema, with a specific distribution and the exclusion of other differential diagnosis using POCUS allowed for an early NPPO diagnosis. NPPO is a rare, potentially life threatening complication whose early diagnosis and direct treatment may lead to better outcomes. Our case emphasizes the diagnostic role of ultrasound in the operating theatre in the identification of life threatening airway and pulmonary complications, such as NPPO.

Autoimmune Hepatitis after AstraZeneca Coronavirus Disease 2019 (COVID-19) vaccine: need for epidemiological study / Hepatitis Autoinmune tras vacunación con la vacuna AstraZeneca contra la COVID-19: necesidad de un estudio epidemiologico

This case-report and brief review of literature were written concerning autoimmune hepatitis potentially triggered by virus vaccines. Soon after the Astrazeneca COVID-19 vaccine, a 70-year-old women presented with jaundice and nausea, with significant hepatic injury (aspartate aminotransferase (AST) 746 U/L; hyperbilirubinemia 9,30 mg/dL (conjugated bilirubin 7,14 mg/dL), elevated immunoglobulin (Ig) G and antinuclear, anti-smooth muscle and anti-actin F antibodies were detected. Considering autoimmune hepatitis (AIH) as a possible cause, a liver biopsy was performed and compatible with AIH. Prednisolone therapy was initiated, with optimal response. This report suggests that immunization against COVID-19 might precipitate or induce AIH. Further data regarding confirmed cases of AIH are mandatory in order to establish a causal link. Therefore, long-term pharmacovigilance surveillance of large cohorts of patients is needed. (AU)

Physical activity and its clinical correlates in chronic thromboembolic pulmonary hypertension.

Limited data are available on physical activity (PhA) levels in chronic thromboembolic pulmonary hypertension (CTEPH) patients, as well as on the clinical utility of PhA measurements using questionnaires and accelerometers. We aimed to study PhA levels of CTEPH patients and their clinical correlates, and to compare PhA levels measured by the International Physical Activity Questionnaire (IPAQ) with measures from accelerometers. This is a cross-sectional study (n = 50). PhA levels were measured using accelerometers and questionnaires (IPAQ). Clinical parameters evaluated were walked distance on the 6-min-walking test (6MWT), pulmonary vascular resistance, N-terminal brain natriuretic peptide and quality of life (HRQoL) (Cambridge Pulmonary Hypertension Outcome Review questionnaire). Time spent in sedentary behavior was lower in self-reported measurement (279 ± 165 min/day) compared with accelerometry (446 ± 117 min/day, p < 0.000). Accelerometer-derived data showed that CTEPH patients spent 60% of the recorded time in sedentary behaviors and 2% in moderate-to-vigorous PhA (MVPA). Correlation analysis showed that MVPA was significantly correlated with 6MWT (p = 0.023) and symptom domain of HRQoL (p = 0.044). Self-reported MVPA was significantly higher than the one registered by the accelerometer (411 ± 569 vs. 131 ± 108 min/week, p = 0.027). Bland-Altman analysis indicated poor agreement between the two methods. Our results showed that CTEPH patients spend most of their days in sedentary behaviors and only a small amount of time in MVPA. Only MVPA was associated with HRQoL and CTEPH severity. In addition, we showed a poor agreement between self-reported and accelerometer-derived PhA in CTEPH patients, with the former overestimating the overall PhA.

External validation of different clinical and echocardiographic scores to distinguish post- from precapillary pulmonary hypertension.

BACKGROUND: Even though right heart catheterization (RHC) is the gold-standard method to characterise Pulmonary Hypertension (PH), it cannot be performed in all the patients with suspected PH. Clinical and echocardiographic scores have been developed to differentiate PH secondary to heart failure with preserved ejection fraction (PH-HFpEF) from pre-capillary PH. We aimed to compare the performance of non-invasive parameters in a population with suspected PH. METHODS: We retrospectively included consecutive patients who underwent RHC for suspected PH. Patients with a non-invasive evaluation clearly suggestive of left heart disease were excluded. We assessed the performance of non-invasive pulmonary vascular resistance (PVR), echocardiographic pulmonary to left atrial ratio (ePLAR), and Opotowsky, Richter, Berthelot, and D'Alto scores using the area under curve (AUC) of the receiver operating characteristic curves. RESULTS: Of the 142 included patients, 61 patients had pre-capillary PH, 49 had PH-HFpEF, and 32 patients did not meet invasive criteria for PH. We were able to perform the aforementioned scores in 71-100% of our patients. Using the original cut-offs, Opotowsky was the score that best predicted precapillary PH (96% sensitivity, 41% specificity, AUC .69), followed by D'Alto (98% sensitivity, 22% specificity, AUC .60) and Berthelot (32% sensitivity, 90% specificity, AUC .60). Richter score did not discriminate between phenotypes (AUC .50). Using optimised cut-offs, a Berthelot score < 9 predicted precapillary PH with 73% sensitivity and 74% specificity (AUC .73). Single echocardiographic parameters as non-invasive PVR (85% sensitivity, 59% specificity, AUC .72) and ePLAR (73% sensitivity, 76% specificity, AUC .75) showed better prediction performance than the composite studied scores. CONCLUSION: Combined clinical and echocardiographic characteristics can be used to predict pre-capillary PH with moderate performance. The application of these non-invasive parameters in clinical practice can help refine referral to RHC in a population with clinically suspected PH.

Sphenopalatine Ganglion Block May Be an Efficient Treatment of Headache After Lumboperitoneal Shunt Placement: A Case Report.

A 20-year-old man submitted to surgical insertion of a lumboperitoneal drain as a treatment for intracranial hypertension, secondary to venous sinus thrombosis, developed severe headache accompanied by nausea, vomiting, and diplopia 24 hours postoperative. Cerebral spinal fluid low-pressure headache was diagnosed. A transnasal sphenopalatine ganglion block with ropivacaine was performed without complications. Pain relief was immediate, complete, and sustained for about 24 hours; a second block was performed effectively with pain control, and the patient was discharged. Sphenopalatine ganglion block may be a safe and efficient treatment for the cerebral spinal fluid hypotension headache secondary to lumboperitoneal shunt.

Disability and its clinical correlates in pulmonary hypertension measured through the World Health Organization Disability Assessment Schedule 2.0: a prospective, observational study.

OBJECTIVE: To characterise the degree of disability in pulmonary hypertension (PH) patients based on the World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0). METHOD: A prospective and observational study of patients with documented PH (N = 46). Patients completed the WHODAS 2.0 questionnaire during a scheduled routine clinical visit, and their demographic and clinical characteristics were retrieved from electronic medical records (EMR). In subsequent visits, selected clinical variables were registered to assess disease progression. RESULTS: WHODAS 2.0 scores were indicative of mild to moderate disability for the domains of mobility (22.0 ± 23.2), life activities (23.7 ± 25.5), and participation in society (17.2 ± 15.9), as well as total WHODAS 2.0 score (15.3 ± 15.2). For the domains of cognition (9.1 ± 14.1), self-care (8.3 ± 14.4), and interpersonal relationships (11.7 ± 15.7), scores were lower. Disability scores were, generally, proportional to the PH severity. The main baseline correlates of disability were World Health Organisation (WHO) functional class, fatigue, dyspnoea, 6-minute walking distance (6MWD), and N-terminal pro b-type natriuretic peptide (NTproBNP). Baseline WHODAS 2.0 scores showed significant associations with disease progression. However, this effect was not transversal to all domains, with only a few domains significantly associated with disease progression variables. CONCLUSIONS: This PH population shows mild disability, with higher degree of disability in the domains of mobility and life activities. This study is the first one to assess disability in PH using WHODAS 2.0. Further studies should apply this scale to larger PH populations with suitable representations of more severe PH forms.

Disability and its clinical correlates in pulmonary hypertension measured through the World Health Organization Disability Assessment Schedule 2 0: a prospective, observational study / Deficiência e seus correlatos clínicos na hipertensão pulmonar medidos pelo World Health Organization Disability Assessment Schedule 2 0: um estudo prospectivo e observacional

ABSTRACT Objective: To characterise the degree of disability in pulmonary hypertension (PH) patients based on the World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0). Method: A prospective and observational study of patients with documented PH (N = 46). Patients completed the WHODAS 2.0 questionnaire during a scheduled routine clinical visit, and their demographic and clinical characteristics were retrieved from electronic medical records (EMR). In subsequent visits, selected clinical variables were registered to assess disease progression. Results: WHODAS 2.0 scores were indicative of mild to moderate disability for the domains of mobility (22.0 ± 23.2), life activities (23.7 ± 25.5), and participation in society (17.2 ± 15.9), as well as total WHODAS 2.0 score (15.3 ± 15.2). For the domains of cognition (9.1 ± 14.1), self-care (8.3 ± 14.4), and interpersonal relationships (11.7 ± 15.7), scores were lower. Disability scores were, generally, proportional to the PH severity. The main baseline correlates of disability were World Health Organisation (WHO) functional class, fatigue, dyspnoea, 6-minute walking distance (6MWD), and N-terminal pro b-type natriuretic peptide (NTproBNP). Baseline WHODAS 2.0 scores showed significant associations with disease progression. However, this effect was not transversal to all domains, with only a few domains significantly associated with disease progression variables. Conclusions: This PH population shows mild disability, with higher degree of disability in the domains of mobility and life activities. This study is the first one to assess disability in PH using WHODAS 2.0. Further studies should apply this scale to larger PH populations with suitable representations of more severe PH forms.

RESUMO Objetivo: Caracterizar o nível de deficiência em pacientes com hipertensão pulmonar (HP) com base no World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Método: Estudo prospectivo e observacional em pacientes com HP documentada (N = 46). Os pacientes completaram o questionário WHODAS 2.0 durante uma consulta de rotina, e seus dados demográficos e clínicos foram retirados de prontuários médicos eletrônicos. Nas visitas subsequentes, variáveis clínicas específicas foram registradas para avaliar a progressão da doença. Resultados: a pontuação no WHODAS 2.0 indicaram deficiência leve a moderada para os domínios de mobilidade (22,0 ± 23,2), atividades da vida (23,7 ± 25,5) e participação em sociedade (17,2 ± 15,9), assim como a pontuação total do WHODAS 2.0 (15,3 ± 15,2). Para os domínios de cognição (9,1 ± 14,1), autocuidado (8,3 ± 14,4) e relações interpessoais (11,7 ± 15,7), a pontuação foi mais baixa. Os pontos referentes à deficiência foram, em geral, proporcionais à gravidade da HP. Os principais parâmetros da deficiência foram a classificação de funcionalidade da Organização Mundial da Saúde (OMS), fatiga, dispneia, teste de caminhada de 6 minutos (TC6M), e a porção N-terminal do pró-hormônio do peptídeo natriurético do tipo B (NT-proBNP). Os valores de parâmetro do WHODAS 2.0 mostraram associações significativas com a progressão da doença. Porém, este efeito não foi transversal a todos os domínios; apenas alguns estiveram significativamente associados às variáveis da progressão da doença. Conclusão: Esta população com HP mostra deficiência leve, com níveis mais altos nos domínios de mobilidade e atividades da vida diária. Este estudo é o primeiro a avaliar a deficiência em HP usando o WHODAS 2.0. Outros estudos devem aplicar esta escala em populações maiores com HP, com representações de formas mais graves da HP.

Age-adjusted Charlson Comorbidity Index Does Not Predict Outcomes in Patients Submitted to Noninvasive Ventilation / El índice de comorbilidad de Charlson ajustado por edad no predice los resultados de pacientes sometidos a ventilación no invasiva

Introduction: Comorbidities are thought to have prognostic impact on outcomes of patients submitted to noninvasive ventilation (NIV). Our goal was to determine if age-adjusted Charlson comorbidity index (ACCI) could predict outcomes in patients undergoing NIV due to acute respiratory failure. Methods:Patients in respiratory failure submitted to NIV were prospective evaluated comparing patien's characteristics and outcomes according to ACCI ≤ median vs. ACCI > median. Each comorbidity composing the index was tested as predictor of NIV failure and readmission/mortality risk at 30 and 90 days, using logistic regression analysis. NIV failure was defined as need for invasive mechanical ventilation and/or death. Results: 177 patients were enrolled. Median ACCI score was 5 points. Comparing patients with ACCI > 5 with ACCI ≤ 5, the former group was older but APACHE II was similar. Time to first NIV disconnection was inferior for ACCI > 5 patients (OR 0.46, 95% CI 0.23-0.89, p = 0.021), after gender and age adjustment. No differences were found in length of stay, time on NIV, NIV complications or failure, and 30 and 90-day hospital readmission or death, before and after adjustment. None of the single comorbidities was predictive of NIV failure and readmission risk, when adjusted to sex and age. Conclusion: ACCI is not a good predictor for short and medium-term outcomes in patients submitted to NIV

Introducción: Las comorbilidades parecen tener un impacto en el pronóstico de los resultados de pacientes sometidos a ventilación no invasiva (VNI). Nuestro objetivo fue determinar si el ajuste por edad del índice de comorbilidad de Charlson (ICC) podía predecir los resultados de aquellos pacientes sometidos a VNI por insuficiencia respiratoria aguda. Métodos: Se evaluaron de forma prospectiva pacientes con insuficiencia respiratoria sometidos a VNI, comparando las características de los pacientes y sus resultados valorados como ICCmediana. Mediante un análisis de regresión logística, cada comorbilidad incluida en el índice se evaluó como predictor de fracaso de VNI y de riesgo de reingreso/mortalidad a los 30 y 90 días. Se definió fracaso de VNI como la necesidad de ventilación mecánica asistida y/o muerte. Resultados: Se incluyeron 177 pacientes. La mediana del valor del ICC fue de 5 puntos. En la comparación de pacientes con ICC>5 frente a pacientes con ICC≤5, el primer grupo resultó ser el de mayor edad, aunque la clasificación por APACHE II fue similar. El tiempo hasta la primera desconexión de VNI fue inferior en pacientes con ICC>5 (OR: 0,46; IC 95%: 0,23-0,89; p=0,021), tras el ajuste por género y edad. No se encontraron diferencias en la duración de la hospitalización, el tiempo con VNI, complicaciones o fracaso de la VNI y el reingreso hospitalario o la muerte a los 30 y 90 días, antes y después del ajuste. Ninguna de las comorbilidades analizadas era predictora de fracaso de la VNI o del riesgo de reingreso cuando se ajustaron por sexo edad. Conclusión: El ICC no es un buen predictor de los resultados a corto y medio plazo de pacientes sometidos a VNI

Ropivacaine use in transnasal sphenopalatine ganglion block for post dural puncture headache in obstetric patients - case series / Uso de ropivacaína em bloqueio do gânglio esfenopalatino via transnasal para cefaleia pós-punção dural em pacientes obstétricas - série de casos

Abstract Purpose Sphenopalatine ganglion block is widely accepted in chronic pain; however it has been underestimated in post dural puncture headache treatment. The ganglion block does not restore normal cerebrospinal fluid dynamics but effectively reduces symptoms associated with resultant hypotension. When correctly applied it may avoid performance of epidural blood patch. The transnasal approach is a simple and minimally invasive technique. In the cases presented, we attempted to perform and report the ganglion block effectiveness and duration, using ropivacaine. Clinical features We present four obstetrics patients with post dural puncture headache, after epidural or combined techniques, with Tuohy needle 18G that underwent a safe and successful sphenopalatine ganglion block. We performed the block 24-48 h after dural puncture, with 4 mL of ropivacaine 0.75% in each nostril. In three cases pain recurred within 12-48 h, although less intense. In one patient a second block was performed with complete relief and without further recurrence. In the other two patients a blood patch was performed without success. All patients were asymptomatic within 7 days. Conclusion The average duration of analgesic effect of the block remains poorly defined. In the cases reported, blocking with ropivacaine was a simple, safe and effective technique, with immediate and sustained pain relief for at least 12-24 h.

Resumo Justificativa e objetivo O bloqueio do gânglio esfenopalatino é amplamente aceito em dor crônica; porém, esse bloqueio tem sido subestimado no tratamento de cefaleia pós-punção dural. O bloqueio do gânglio não restaura a dinâmica normal do líquido cefalorraquidiano, mas reduz de modo eficaz os sintomas associados à hipotensão resultante. Quando aplicado corretamente, pode evitar a realização de tampão sanguíneo epidural. A abordagem transnasal é uma técnica simples e minimamente invasiva. Nos casos apresentados, tentamos realizar o bloqueio do gânglio e relatar sua eficácia e duração usando ropivacaína. Características clínicas Apresentamos quatro pacientes de obstetrícia com cefaleia pós-punção dural, após técnica epidural ou técnicas combinadas, com agulha Tuohy (18 G), que foram submetidas ao bloqueio do gânglio esfenopalatino de forma segura e bem-sucedida. Realizamos o bloqueio após 24 a 48 horas da punção dural, com 4 mL de ropivacaína a 0,75% em cada narina. Em três casos, a dor voltou em 1-48 horas, embora menos intensa. Em uma paciente, um segundo bloqueio foi realizado com alívio completo e sem recorrência. Nas outras duas pacientes, um tampão sanguíneo foi feito sem sucesso. Todas as pacientes estavam assintomáticas dentro de sete dias. Conclusão A duração média do efeito analgésico do bloqueio continua mal definida. Nos casos relatados, o bloqueio com ropivacaína foi uma técnica simples, segura e eficaz, com alívio imediato e prolongado da dor durante pelo menos 12-24 horas.

Association of severe and therapy-refractory systemic lupus erythematosus and neuromyelitis optica: a management challenge.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disorder. Neuromyelitis optica (NMO) is an infrequent neuroinflammatory disorder, whose association with SLE remains rare. The authors report the case of an 18-year-old woman, with SLE refractory to multiple immunosuppressive therapies and novel biological agents. Under immunosuppressive therapy, the patient presented with transverse myelitis with contiguous spinal cord lesions and urinary incontinence, having been diagnosed with seropositive NMO, which was also proven to be refractory to common treatments. Partial recovery of the neurological deficits occurred with plasmapheresis, although not averting the brain involvement by NMO that ensued. The patient was listed nationally for allogeneic bone marrow transplant, but, unfortunately, no match was found and the patient died of severe cerebral NMO flare with coma due to brain swelling and consequent respiratory failure. Although the association of SLE and NMO is very rare, early diagnosis is crucial to facilitate initiation of immunosuppressive therapy.

Age-adjusted Charlson Comorbidity Index Does Not Predict Outcomes in Patients Submitted to Noninvasive Ventilation.

INTRODUCTION: Comorbidities are thought to have prognostic impact on outcomes of patients submitted to noninvasive ventilation (NIV). Our goal was to determine if age-adjusted Charlson comorbidity index (ACCI) could predict outcomes in patients undergoing NIV due to acute respiratory failure. METHODS: Patients in respiratory failure submitted to NIV were prospective evaluated comparing patient's characteristics and outcomes according to ACCI≤median vs. ACCI>median. Each comorbidity composing the index was tested as predictor of NIV failure and readmission/mortality risk at 30 and 90 days, using logistic regression analysis. NIV failure was defined as need for invasive mechanical ventilation and/or death. RESULTS: 177 patients were enrolled. Median ACCI score was 5 points. Comparing patients with ACCI>5 with ACCI≤5, the former group was older but APACHE II was similar. Time to first NIV disconnection was inferior for ACCI>5 patients (OR 0.46, 95% CI 0.23-0.89, p=0.021), after gender and age adjustment. No differences were found in length of stay, time on NIV, NIV complications or failure, and 30 and 90-day hospital readmission or death, before and after adjustment. None of the single comorbidities was predictive of NIV failure and readmission risk, when adjusted to sex and age. CONCLUSION: ACCI is not a good predictor for short and medium-term outcomes in patients submitted to NIV.

Health-Related Quality of Life in Pulmonary Hypertension and Its Clinical Correlates: A Cross-Sectional Study.

BACKGROUND: Health-related quality of life (HRQoL) impairment is common in pulmonary hypertension (PH), but its clinical predictors are not well established. This study aims to characterize the HRQoL of patients with pulmonary arterial hypertension (PAH) and other precapillary forms of PH (pcPH) and to explore its clinical correlates. MATERIALS AND METHODS: A cross-sectional, observational study of patients with documented PAH and other forms of pcPH. Patients completed two patient-reported outcome measures (PROM): Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) and Nottingham Health Profile (NHP). Clinical characteristics were retrieved from electronic medical records. RESULTS: Mean CAMPHOR and NHP scores for the study population were indicative of a moderate HRQoL impairment. Patients in World Health Organisation Functional Classes (WHO FC) III/IV showed significantly worse HRQoL. The main clinical correlates of HRQoL were WHO FC, 6-minute walking distance (6MWD), and Borg dyspnoea index. Overall quality of life (QoL), assessed through CAMPHOR's QoL domain, showed patterns comparable to HRQoL measured by both instruments. CONCLUSIONS: HRQoL, measured by two different PROMs, is impaired in Portuguese patients with PAH and other forms of pcPH, particularly in patients with increased disease severity. WHO FC, 6MWD, and Borg dyspnoea index are highly correlated with HRQoL and QoL.

Tuberculous osteomyelitis of the wrist presenting as a monoarthritis syndrome.

Osteoarticular tuberculosis is the third most frequent location of tuberculosis after the lung and lymph nodes, accounting for approximately 10%-20% of all cases of extrapulmonary disease. Tuberculosis of the hand and wrist is the rarest osteoarticular location after the shoulder. The authors report the case of a 50-year-old woman without medical history who was diagnosed with isolated tuberculosis of the wrist presenting as monarthritis. The diagnosis was confirmed by histopathological and microbiological examination. Late stages of osteomyelitis are even rarer without any predisposing factors such as immunosuppression. This case underlines the importance of including tuberculosis in the differential diagnosis of monoarthritic syndromes to prevent delayed initiation of therapy and consequent complications and bone damage.

[Ropivacaine use in transnasal sphenopalatine ganglion block for post dural puncture headache in obstetric patients - case series]. / Uso de ropivacaína em bloqueio do gânglio esfenopalatino via transnasal para cefaleia pós­punção dural em pacientes obstétricas ­ série de casos.

PURPOSE: Sphenopalatine ganglion block is widely accepted in chronic pain; however it has been underestimated in post dural puncture headache treatment. The ganglion block does not restore normal cerebrospinal fluid dynamics but effectively reduces symptoms associated with resultant hypotension. When correctly applied it may avoid performance of epidural blood patch. The transnasal approach is a simple and minimally invasive technique. In the cases presented, we attempted to perform and report the ganglion block effectiveness and duration, using ropivacaine. CLINICAL FEATURES: We present four obstetrics patients with post dural puncture headache, after epidural or combined techniques, with Tuohy needle 18G that underwent a safe and successful sphenopalatine ganglion block. We performed the block 24-48h after dural puncture, with 4mL of ropivacaine 0.75% in each nostril. In three cases pain recurred within 12-48h, although less intense. In one patient a second block was performed with complete relief and without further recurrence. In the other two patients a blood patch was performed without success. All patients were asymptomatic within 7 days. CONCLUSION: The average duration of analgesic effect of the block remains poorly defined. In the cases reported, blocking with ropivacaine was a simple, safe and effective technique, with immediate and sustained pain relief for at least 12-24h.

Continuous subcutaneous levetiracetam in end-of-life care.

Seizures constitute a determining aspect in quality of life and are frequently challenging in palliative care-a field where treatment has yet to be standardised. Levetiracetam-a new generation anticonvulsant-has proved efficacy both through oral, as well as intravenous administration in the general population. This case reports on the use of continuous subcutaneous levetiracetam to effectively control seizures in a terminally ill patient without patent oral route.

Acute hepatitis B virus infection and severe non-immune haemolytic anaemia: a rare relationship.

The clinical presentation of acute hepatitis B virus (HBV) infection is usually related to the onset of liver failure and damage. Anaemia may occur, but it is only rarely attributed to haemolysis. The authors report about the case of a 41-year-old woman with the diagnosis of acute HBV infection and coagulopathy (without encephalopathy) who developed non-immune haemolytic anaemia. Total recovery of the analytical liver profile, coagulopathy and anaemia was achieved through treatment targeting HBV.This case shows that, although rare, non-immune haemolytic anaemia may occur in association with acute HBV infection and that HBV suppression seems to lead to progressive anaemia resolution.

Anesthetic management of late pressure angioedema / Manejo anestésico de angioedema de pressão tardio

Abstract Background and objectives: Late pressure angioedema is a rare form of angioedema in which light pressure stimulus can lead to edema after 1-12 h. This uncommon and unreported entity is especially important in patients who undergo general anesthesia, for whom the usual harmless supine position, intravenous catheter insertion, standard monitoring, airway management and ventilation can lead to life threatening consequences as the trigger is a physical stimulus. Case report: In this report, we describe a successful perioperative anesthetic management of a 30 year old patient, proposed for intra-ocular lens insertion, with a severe form of the disease with peri-oral, tongue and limb edema presentation. Conclusion: Due to lack of quality evidence, our conduct was based on the pathophysiology mechanisms of the syndrome, histamine and pro-inflammatory cytokines release, with special focus on a careful peri-operative assessment and prophylaxis, minimization of all the possible pressure stimulus, especially in the airway structures, and a strict post-operative monitoring.

Resumo Justificativa e objetivos: Angioedema de pressão tardio é uma forma rara de angioedema na qual um leve estímulo de compressão pode levar a edema após 1-12 horas. Essa entidade incomum e pouco relatada é especialmente importante em pacientes submetidos à anestesia geral, nos quais a habitual posição supina inofensiva, inserção intravenosa do cateter, monitoração padrão, manejo das vias aéreas e ventilação podem levar a consequências fatais, pois o gatilho é um estímulo físico. Relato de caso: Neste relato, descrevemos o manejo anestésico perioperatório bem-sucedido de um paciente de 30 anos idade, agendado para inserção de lente intraocular, com uma forma grave da doença, apresentava edema perioral, língual e nos membros. Conclusão: Devido à falta de evidências de qualidade, nossa conduta teve como base os mecanismos fisiopatológicos da síndrome, a liberação de histamina e citocinas pró-inflamatórias, com foco especial em uma avaliação cuidadosa no perioperatório e profilaxia, diminuição de todos os estímulos compressíveis possíveis, especialmente nas estruturas das vias aéreas, e um acompanhamento rigoroso no pós-operatório.