How to manage thromboembolic risk in patient with SARS-CoV-2-related disease in the Emergency Department: A case report of cardiogenic shock due to massive pulmonary embolism.

BACKGROUND: Although the most known feature of SARS-CoV-2 associated infection is a mild to severe pneumonia, increasing evidence suggests the existence of an infection-associated risk of both arterial and venous thromboembolism (VTE), but the exact magnitude of this phenomenon is still unknown.Given that, it is important for the Emergency Physician to remember that a SARS-CoV-2 associated respiratory failure can be caused not only by the pulmonary parenchymal inflammation that characterizes the pneumonia, but also by an associated pulmonary thromboembolism. CASE REPORT: A healthy 73-years old woman admitted to the ED for dyspnea, fever and thoracic pain. Cardiac ultrasound, electrocardiogram and clinical findings suggested a diagnosis of cardiogenic obstructive shock due to acute pulmonary embolism, successfully treated with thrombolysis. A CT angiography confirmed the pulmonary embolism (EP) diagnosis and showed bilateral pneumonia, caused by SARS-CoV-2 infection. CONCLUSION: Considering the high prevalence of thromboembolic events in COVID-19 patients it is mandatory for the emergency physician to systematically evaluate signs of pulmonary thromboembolism, in order to perform the most patient-tailored therapy as soon as possible.

Langerhans' cells histiocytosis.

Langerhans cell histiocytosis (LCH) is a rare disorder of unknown cause, characterized by the proliferation of histiocytic cells in various tissues and organs. The role of the otolaryngologist is important in the early and accurate evaluation, staging and diagnosis of LCH, because it may mimic more common diseases such as otitis externa and acute mastoiditis. We discuss a case report of bilateral mastoid involvement in a child with a history of otalgia unresponsive to medical therapy.

Effect of sample volume location on Doppler-derived transmitral inflow velocity values in 288 normal subjects 20 to 80 years old: an echocardiographic, two-dimensional color Doppler cooperative study.

The aims of the study were to evaluate in a population of 288 normal subjects 20 to 80 years old (1) the normal values of the indexes of the mitral flow velocity pattern measured either at the tips of the mitral leaflets or at the annulus; (2) whether there was a significant difference between the values obtained at the tips compared with those measured at the mitral annulus; (3) the correlation with aging between the indexes measured in the two different positions; and (4) whether certain physiological variables have different effects on diastolic function measured in the two different positions. The highest values were always measured at the tips of the mitral leaflets (p < 0.05); only atrial filling fraction, E acceleration time, and E deceleration velocity had higher values when measured at the level of the annulus (p < 0.05). The A-wave peak velocity had the same mean value when measured at both the tips and at the annulus. A significant difference in the correlation between parameters measured at the tips of the mitral leaflets with age and at the annulus (with age) was observed for the following parameters: (1) peak E velocity, E integral, total integral and E acceleration showed better correlation with age when measured at the annulus (p < 0.02); (2) peak A velocity and A integral showed better correlation with age when measured at the tips of the mitral leaflets (p < 0.001). Multivariate analysis showed that age was the variable that had the most influence on diastolic function parameters; heart rate had less influence on the diastolic function indexes.

High incidence of bites and stings by snakes and other animals among rubber tappers and Amazonian Indians of the Juruá Valley, Acre State, Brazil.

Among forest-dwelling Amazonian Indians and rubber tappers (seringueiros) of the Juruá valley in Acre State, north-western Brazil, snakebite is an important cause of morbidity and death. Overall, 13% of a surveyed population had been bitten during their lifetime. Seventeen per cent of Katukina Indians, but only 8% of Ashaninkas, had been bitten by snakes reflecting, perhaps, different levels of traditional knowledge of the forest and its dangers. Most bites occurred in the jungle or on jungle trails (56%), while people were working (41%) or walking (26%), and were inflicted on the feet (54%). Ninety per cent of bite victims received treatment, usually traditional (93%); the majority (80%) recovered fully. Mortality was estimated at about 400 deaths per 100,000 population per lifetime. Bites and stings from other venomous forest and river animals, especially the freshwater sting ray (Potamotrygon sp.), were also extremely common. One death from an ant bite was recorded.

Reduced cardiovascular sympathetic excitatory responses during iloprost infusion in conscious dogs.

STUDY OBJECTIVE: The aim was to determine the effects of the stable prostacyclin analogue iloprost (ZK 36374) on systemic haemodynamics and on cardiovascular neural control. DESIGN: The buffering effect was examined of intravenous and intracoronary iloprost infusion on the excitatory sympathetic reflexes elicited from the heart by (1) intracoronary injections of bradykinin and (2) transient coronary artery occlusion. SUBJECTS: 22 conscious mongrel dogs of either sex, weight 20-25 kg, were used. MEASUREMENTS AND MAIN RESULTS: ECG, systemic arterial pressure, left atrial pressure, and left ventricular pressure, and contractility (dP/dt) were continuously monitored for the duration of the experiments. Iloprost infusion reduced left ventricular pressure, mean arterial pressure, and dP/dt without causing significant changes in heart rate. Transient non-hypertensive coronary artery occlusion increased heart rate and depressed contractility. During intravenous iloprost infusion, coronary artery occlusion no longer elicited an increase in heart rate, while left ventricular dP/dt was more drastically reduced. This pattern of response was not substantially modified by beta adrenergic blockade, whereas the blockade of muscarinic receptors with atropine was accompanied by hypotension and a greater reduction of dP/dt. The observation of a reduced pressor response to the intracoronary injections of bradykinin during iloprost administration further indicated a restraining effect of iloprost on the sympathetic reflexes elicited from the heart. CONCLUSIONS: The data suggest the hypothesis that the protective effects on the ischaemic myocardium observed with iloprost infusions may arise not only from its vasodilator and antiplatelet properties, but also from its capacity to blunt excitatory sympathetic reflexes.

Analysis of short-term oscillations of R-R and arterial pressure in conscious dogs.

We studied the neural determinants of the second (i.e., high frequency, HF)- and third-order (i.e., low frequency, LF) spontaneous oscillations of heart period (R-R interval) and arterial pressure (AP) in conscious dogs, with the hypothesis that they might furnish quantitative markers of autonomic controlling activities. Spectral analysis of simultaneous R-R and AP variabilities quantified these oscillations that were also evaluated in units normalized by total power to focus on the balance of these two major components. At rest we observed a prevalent HF component (approximately 0.25 Hz) in R-R and AP variabilities that was synchronous with respiration. This HF component of R-R variability disappeared after atropine infusion and can be considered a marker mostly of vagal activity. When baroreceptor unloading, obtained by moderate hypotension, increased sympathetic activity the LF component increased in R-R, systolic, and diastolic AP variabilities. This increase in LF was not present after ganglionic blockade or after chronic arterial baroreceptor denervation. After chronic bilateral stellectomy, hypotension was not accompanied by an increase in LF component of R-R variability, while LF component remained in AP variability. An increase in LF component of R-R and AP variabilities was observed during transient coronary artery occlusion.

Spectral analysis of heart rate variability in the assessment of autonomic diabetic neuropathy.

We studied heart rate variability in 49 uncomplicated diabetics (27 with insulin therapy; 22 with oral hypoglycemic agents) and in 40 age-matched controls. An automatic autoregressive algorithm was used to compute the power spectral density (PSD) of beat by beat RR variability derived from the surface ECG. The PSD contains two major components (a low frequency approximately 0.1 Hz (LF) and a high frequency, respiratory linked, approximately 0.25 Hz (HF] that provide, respectively, quantitative markers of sympathetic and vagal modulatory activities and of their balance. As compared to controls, in diabetics, besides a reduced RR variance at rest (2722 +/- 300 and 1436 +/- 241 ms2, respectively), we observed during passive tilt an altered response of spectral indices of sympathetic activation and vagal withdrawal, suggestive of a complex modification in the neural control activities. In addition, we compared this approach to the commonly used clinical tests score, and observed that the latter provides overall results similar to those obtained with spectral changes induced by tilt (r = 0.42; P less than 0.01). Of potential clinical importance is that the data obtained with spectral analysis appear more thoroughly quantifiable and do not require the active collaboration of the patients.