Assessment of visuospatial functions in post-Covid 19 patients: Beyond the traditional paradigm.

Several studies indicate that some cognitive changes occur after COVID-19. Visuospatial alterations have been reported in 24-40 %. These alterations may be useful as early biomarkers of neurodegenerative disease. Thus, we can emphasize the importance of visuospatial processes in cognition through quantitative and qualitative analysis of performance on the Clock Test (CDT) and the Rey-Osterrieth Complex Figure (FCRO). Our objective was to describe the performance of post COVID 19 patients in visuospatial tests, with different degrees of respiratory impairment and to perform a qualitative analysis of the performance to check its relationship with alterations in attention and executive functions. This will allow highlighting the executive component of the performance of the CDT and ROCF and differentiate patients with possible cognitive impairment. 77 patients with SARS-CoV-2 infection were evaluated (3 months post-infection) with a complete neuropsychological battery and MRI. Overall, there is a significant difference between FCRO and CDT, with FCRO having only 9 % change and CDT having 51.9 % change. Regarding the correlations observed between groups (VM Inv, VM non I and non hospitalized) the highest correlations were observed between Boston with FCRO copy (r=0.497; p=0.001) and with FCRO memory (r=0.429; p=0.001). Comparing the performance between groups by severity, significant differences were observed only in the TMT A (13.706 p=0.001) and B (9.583 p=0.008) tests and in the phonological fluency letter A (13.445 p=0.001), we observed that the group of non-hospitalized patients had a better performance. Neuropsychological deficits often have a direct impact on daily life by affecting the ability to learn and adapt. Thus, a useful strategy for the neuropsychological characterization of post-COVID-19 patients is the qualitative analysis of visuospatial abilities in conjunction with executive functions that cannot be analyzed in isolation.

Impact of Regular Physical Activity on Adipocytokines and Cardiovascular Characteristics in Spinal Cord-Injured Subjects.

OBJECTIVE: To investigate the relationship of carotid artery intima-media thickness (IMT) and cardiac structure and function with adipocytokines in sedentary (S-SCI) and physically active (PA-SCI) subjects with spinal cord injury (SCI). DESIGN: Cross-sectional observational study. SETTING: Academic medical center. PARTICIPANTS: Men with chronic (>1y) SCI (N=41; 16 S-SCI, 25 PA-SCI) were evaluated. S-SCI subjects did not perform labor that required physical effort, recreational physical activity, or sports, while PA-SCI subjects included competing athletes who were regularly performing adapted sports. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical, laboratory, carotid ultrasonography, and echocardiography analysis. Plasma leptin, adiponectin, and plasminogen activating inhibitor-1 (PAI-1) levels were determined. RESULTS: PA-SCI subjects had similar levels of adipocytokines, but lower carotid IMT and carotid IMT/diameter, and better left ventricular diastolic function than S-SCI participants. Bivariate analysis showed that adiponectin was inversely correlated with triglycerides (r=-.85, P<.001), low-density lipoprotein cholesterol (r=-.57, P<.05), and carotid IMT/diameter (r=-.56, P<.05) in S-SCI but not in PA-SCI participants. Additionally, the leptin-adiponectin ratio showed a direct correlation with triglycerides (r=.84, P<.001) and low-density lipoprotein cholesterol (r=.53, P<.05) in S-SCI but not in PA-SCI individuals. By contrast, the studied adipocytokines did not correlate with cardiac structure and function in PA-SCI and S-SCI participants. CONCLUSIONS: Lower adiponectin levels and higher leptin-adiponectin ratio are related to adverse vascular and/or metabolic characteristics in individuals with SCI. This relationship, however, appears to be mitigated by regular physical activity.

Reduced Sympathetic Stimulus and Angiotensin 1-7 Are Related to Diastolic Dysfunction in Spinal Cord-Injured Subjects.

Chronic spinal cord injury (SCI) is often associated with reductions in left ventricular (LV) diastolic function. Impairments in sympathetic activity and activation of the renin-angiotensin system are reported in SCI individuals and may hypothetically be implicated in this association. Hence, the present study verified the relationship between these two neuro-hormonal and cardiac functional and structural characteristics in SCI individuals. Twenty-two men with SCI (injury level above T6 and no voluntary motion below the injury) and 11 able-bodied men were evaluated by clinical, hemodynamic, laboratory, and echocardiographic analysis and had plasmatic renin, angiotensin I (ANGI), angiotensin II (ANGII), angiotensin 1-7 (ANG1-7), and noradrenaline levels measured. SCI subjects had lower noradrenaline (p = 0.003) and higher ANG1-7 (p = 0.009), but similar renin, ANGI, and ANGII levels when compared with able-bodied individuals. In SCI individuals, results of multi-variable analysis showed that higher Em, a marker of better LV diastolic function, was directly associated with ANG1-7 (p = 0.05) or ANG1-7/ANGII ratio (p = 0.007), whereas lower noradrenaline levels were independently associated with worse LV diastolic function, as assessed by E/Em ratio (p = 0.028). In conclusion, these results suggest that reduced sympathetic activity and expression of ANG1-7 may be involved in SCI-related diastolic dysfunction.

Posture Influence on the Pendulum Test of Spasticity in Patients with Spinal Cord Injury.

The study aims to investigate the influence of different postures on spasticity results by pendulum test in patients with spinal cord injury (SCI). The setting was at the University of Campinas (UNICAMP), Campinas, SP, Brazil. Five individuals with SCI and five individuals in the control group were included. All individuals went through the pendulum test in three different positions: supine, semi-supine at an angle of 30°, and sitting up at an angle of 60°. An electrogoniometer was attached to the right leg for measurement of knee joint angles. All situations were performed five times. Blood pressure was monitored during tests. Relaxation index (RI), normalized relaxation index (RIn), test duration in seconds, initial flexion angle, and resting angle were analyzed at three different positions. Results were compared between different positions, and statistically no differences were found. In individuals with SCI, RI (1.83 ± 0.2), RIn (1.14 ± 0.13), and test duration values (13.95 ± 4.14), in sitting up position, were similar to the control group results. In sitting up position, patients showed spasticity reduction. However, the other two postures produce pain and increase blood pressure in patients with tetraplegia. Therefore, these postures should be avoided in patients with lesions above T6, due to possible autonomic dysreflexia symptoms.

Matrix metalloproteinases and left ventricular function and structure in spinal cord injured subjects.

Subjects with spinal cord injury (SCI) exhibit impaired left ventricular (LV) diastolic function, which has been reported to be attenuated by regular physical activity. This study investigated the relationship between circulating matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs) and echocardiographic parameters in SCI subjects and the role of physical activity in this regard. Forty-two men with SCI [19 sedentary (S-SCI) and 23 physically-active (PA-SCI)] were evaluated by clinical, anthropometric, laboratory, and echocardiographic analysis. Plasmatic pro-MMP-2, MMP-2, MMP-8, pro-MMP-9, MMP-9, TIMP-1 and TIMP-2 levels were determined by enzyme-linked immunosorbent assay and zymography. PA-SCI subjects presented lower pro-MMP-2 and pro-MMP-2/TIMP-2 levels and improved markers of LV diastolic function (lower E/Em and higher Em and E/A values) than S-SCI ones. Bivariate analysis showed that pro-MMP-2 correlated inversely with Em and directly with E/Em, while MMP-9 correlated directly with LV mass index and LV end-diastolic diameter in the whole sample. Following multiple regression analysis, pro-MMP-2, but not physical activity, remained associated with Em, while MMP-9 was associated with LV mass index in the whole sample. These findings suggest differing roles for MMPs in LV structure and function regulation and an interaction among pro-MMP-2, diastolic function and physical activity in SCI subjects.

Fragmented surface ECG was a poor predictor of appropriate therapies in patients with Chagas' cardiomyopathy and ICD implantation (Fragmented ECG in CHAgas' Cardiomyopathy Study).

BACKGROUND: Main causes of death in chronic Chagas' cardiomyopathy (CChC) are progressive congestive heart failure and sudden cardiac death. Implantable cardioverter defibrillators (ICD) have been proved an effective therapy to prevent sudden death in patients with CChC. Identification of predictors of sudden death remains a challenge. OBJECTIVE: To determine whether surface fragmented ECG (fQRS) helps identifying patients with CChC and ICDs at higher risk of presenting appropriate ICD therapies. METHODS: Multicenter retrospective study. All patients with CChC and ICDs were analyzed. Clinical demographics, surface ECG, and ICD therapies were collected. RESULTS: A total of 98 patients were analyzed. Another four cases were excluded due to pacing dependency. Mean age was 55.5 ± 10.4 years, male gender 65%, heart failure New York Heart Association class I 47% and II 38%. Mean left ventricular ejection fraction (LVEF) 39.6 ± 11.8%. The indication for ICD was secondary prevention in 70% of patients. fQRS was found in 56 patients (59.6%). Location of fragmentation was inferior (57.1%), lateral (35.7%), and anterior (44.6%). Rsr pattern was the more prevalent (57.1%). Predictors of appropriate therapy in the multivariate model were: increased age (P = 0.01), secondary prevention indication (P = 0.01), ventricular pacing >50% of the time (P = 0.004), and LVEF <30% (P = 0.01). The presence of fQRS did not identify patients at higher risk of presenting appropriate therapies delivered by the ICD (P = 0.87); regardless of QRS interval duration. CONCLUSIONS: fQRS is highly prevalent among patients with CChC. It has been found a poor predictor of appropriate therapies delivered by the ICD in this population.

Physical activity and improved diastolic function in spinal cord-injured subjects.

PURPOSE: Subjects with spinal cord injury (SCI) have been reported to present impaired left ventricular (LV) diastolic function in comparison with able-bodied (AB) ones. The present study investigated the effect of regular physical activity on the cardiac structure and function of SCI subjects. METHODS: Fifty-eight SCI men (29 sedentary [SCI-S] and 29 athletes [SCI-A]) and 29 AB men were cross-sectionally evaluated by clinical, laboratory, hemodynamic, and echocardiographic analysis. All enrolled subjects were normotensive, nondiabetic, nonsmoker, and normolipemic, and the studied groups presented similar age and body mass index. RESULTS: SCI-S presented similar LV structural and systolic parameters but higher E/Em (8.0 ± 0.5) and lower Em/Am (1.18 ± 0.09) ratios than SCI-A and AB (E/Em = 6.4 ± 0.3 and 5.9 ± 0.3, respectively; Em/Am = 1.57 ± 0.12 and 1.63 ± 0.08, respectively; all P < 0.05 compared with SCI-S). Analysis of SCI individuals according to injury level revealed that tetraplegic athletes had similar features compared with sedentary tetraplegic subjects, except for higher Em (10.9 ± 0.6 vs 8.6 ± 0.7 cm s, P < 0.05) and lower E/Em ratio (6.3 ± 0.4 vs 8.8 ± 0.8, P < 0.05), whereas paraplegic athletes had similar features compared with sedentary paraplegic individuals, except for higher LV end-diastolic diameter (49.4 ± 1.4 vs 45.0 ± 1.0 mm, P < 0.05) and Em/Am ratio (1.69 ± 0.20 vs 1.19 ± 0.08, P < 0.05) and lower LV relative wall thickness (0.330 ± 0.012 vs 0.369 ± 0.010, P < 0.05) and heart rate (67.1 ± 4.2 vs 81.9 ± 2.8 bpm, P < 0.05). CONCLUSION: Regular physical activity is associated with improved LV diastolic function in SCI subjects and might exert distinct cardiac structural effects in tetraplegic and paraplegic subjects.

Oxidized low-density lipoprotein, matrix-metalloproteinase-8 and carotid atherosclerosis in spinal cord injured subjects.

OBJECTIVE: Previous reports have indicated that subjects with chronic spinal cord injury (SCI) exhibit increased cardiovascular risk compared to able-bodied individuals. This study investigated the relationship between plasmatic oxidized low-density lipoprotein (OxLDL), matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs) levels and vascular remodeling in SCI subjects and the role of physical activity in this regard. METHODS: We studied 42 men with chronic (≥2 years) SCI [18 sedentary (S-SCI) and 24 physically active (PA-SCI)] and 16 able-bodied men by clinical, anthropometric, laboratory, and carotid intima-media thickness (IMT) analysis. All enrolled subjects were normotensive, non-diabetics, non-smokers and normolipemic. Plasmatic OxLDL, MMP-2, MMP-8, MMP-9, TIMP-1 and TIMP-2 levels were determined by enzyme-linked immunosorbent assay. RESULTS: Carotid IMT, IMT/diameter ratio and OxLDL levels of PA-SCI and able-bodied subjects were statistically similar. Conversely, S-SCI subjects exhibited higher IMT, IMT/diameter ratio and OxLDL levels compared to PA-SCI (p < 0.01, p < 0.001 and p = 0.01, respectively) and able-bodied (p < 0.001 for all) individuals. Results of bivariate correlation analysis including all injured subjects showed that carotid IMT and IMT/diameter ratio only correlated with OxLDL, MMP-8 and MMP-8/TIMP-1 ratio. Further stepwise regression analysis adjusted for the presence or not of physical activity and age showed that OxLDL was associated with carotid IMT and IMT/diameter ratio, while MMP-8 was associated with IMT/diameter ratio in SCI individuals. CONCLUSIONS: Plasmatic OxLDL and MMP-8 levels are associated with carotid atherosclerosis and there is an interaction among physical inactivity, atherosclerosis and OxLDL in SCI individuals.

Clinical assessment of spasticity in individuals with spinal cord injury.

OBJECTIVE: To evaluate the effect of neuromuscular electrical stimulation on spasticity in patients with spinal cord injury. METHODS: The study included eleven subjects with spinal cord injuries (C4 to T5). The modified Ashworth scale and pendulum test, which is accomplished through the Pendular Test Device - PTD (equipment which has a quartz crystal transducer accelerometer and optic fiber flexible electrogoniometer measuring the tensions and angular displacements). Patients underwent neuromuscular electrical stimulation (NMES) to the quadriceps muscle from fibular nerve, and the tests were administered before and after therapy. RESULTS: The data show a decrease in spasticity after NMES, with features such as increased variation between maximum and minimum peaks, i.e. increased amplitude of the curves. Furthermore, data from the subjective scale, and modified Ashworth scale after neuromuscular electrical stimulation also showed a reduction in the values of spasticity. CONCLUSION: The data suggest that NMES is effective in reducing spasticity immediately after completion. Level of Evidence II, Therapeutic Studies-Investigating the Results of Treatment .

Análise clinica da espasticidade em indivíduos com lesão medular / Clinical assessment of spasticity in individuals with spinal cord injury

OBJETIVO: Avaliar o efeito da estimulação elétrica neuromuscular na espasticidade nos pacientes com lesão medular.MÉTODOS: Participaram do estudo onze sujeitos lesados medulares (C4 a T5). Foram utilizados para esta avaliação a escala modificada de Ashworth e o teste pendular, que foi realizado através do Dispositivo de Teste Pendular - DTP (o equipamento possui um acelerômetro de transdutores de cristais de quartzo e eletrogoniômetro de fibra óptica flexível que mede as tensões e os deslocamentos angulares). Os pacientes realizaram estimulação elétrica neuromuscular (EENM) nos músculos quadríceps e nervo fibular, sendo que os testes foram aplicados antes e após o procedimento.RESULTADOS: Os dados mostram uma diminuição da espasticidade após a EENM, com características tais como um aumento na variação entre o pico máximo e o mínimo, ou seja, aumento da amplitude das curvas. Além disso, os dados da escala subjetiva, e escala modificada de Ashworth, após a estimulação elétrica neuromuscular também apresentaram uma redução nos valores da espasticidade.CONCLUSÃO: Os dados sugerem que a EENM é eficaz para reduzir a espasticidade imediatamente após a sua realização. Nível de Evidência II, Estudos Terapêuticos -Investigação dos Resultados do Tratamento.

OBJECTIVE: To evaluate the effect of neuromuscular electrical stimulation on spasticity in patients with spinal cord injury.METHODS: The study included eleven subjects with spinal cord injuries (C4 to T5). The modified Ashworth scale and pendulum test, which is accomplished through the Pendular Test Device - PTD (equipment which has a quartz crystal transducer accelerometer and optic fiber flexible electrogoniometer measuring the tensions and angular displacements). Patients underwent neuromuscular electrical stimulation (NMES) to the quadriceps muscle from fibular nerve, and the tests were administered before and after therapy.RESULTS: The data show a decrease in spasticity after NMES, with features such as increased variation between maximum and minimum peaks, i.e. increased amplitude of the curves. Furthermore, data from the subjective scale, and modified Ashworth scale after neuromuscular electrical stimulation also showed a reduction in the values of spasticity.CONCLUSION: The data suggest that NMES is effective in reducing spasticity immediately after completion. Level of Evidence II, Therapeutic Studies-Investigating the Results of Treatment.

Avaliação cinemática da transferência de paraplégicos da cadeira de rodas / Kinematic assessment of transfer of paraplegic subjects from the wheelchair

OBJETIVO: Avaliar a estratégia das transferências de paraplégicos da cadeira de rodas. MÉTODOS: Participaram do estudo doze sujeitos lesados medulares (T2 a T12), aptos a realizar independentemente a transferência da cadeira de rodas para um tablado com um metro quadrado (m²) de área por meio metro de altura. As imagens de marcadores reflexivos nos pontos anatômicos foram capturadas por seis câmeras de infravermelho ProReflex e processadas através de um software específico (QTrac). Parâmetros cinemáticos do tronco, cabeça, ombros e cotovelos foram avaliados. RESULTADOS: Os dados analisados comparam o lado preferencial do sujeito para realizar a transferência com o lado não preferencial, de acordo com as funções desempenhadas de cada segmento corporal. O deslocamento angular da cabeça no plano sagital (y-z) e ombros no plano transversal (x-y) mostraram significâncias estatísticas (p<0,05). Conclusão: Os dados obtidos neste estudo mostraram que há diferenças na estratégia da transferência dos paraplégicos do lado preferencial em comparação com o lado não preferencial. Nível de Evidência II, Desenvolvimento de critérios diagnósticos em pacientes consecutivos (com padrão de evidência "ouro" aplicado).

OBJECTIVE: To evaluate the transfer strategy of paraplegic subjects from their wheelchairs. METHODS: Twelve thoracic spinal cord injured subjects participated in this study (T2 to T12). The subjects were able to independently transfer from a wheelchair to a one square meter (m2) table, half a meter in height. Images of reflexive anatomic markers were captured by six ProReflex infrared cameras and processed using a QTRac Capture software. Kinematic parameters of the trunk, head, shoulders and elbows were evaluated. RESULTS: The data analyzed compared the subjects' preferential side for performing transfers, according to the functions performed by each body segment. Angular displacement of the head on sagittal plan (y-z), and the shoulders on the transversal plan (x-y), showed statistical differences (p<0.05). Conclusion: the data obtained on this study showed that there are differences in transfer strategies of paraplegic subjects to their preferential side, in comparison with the non-preferential side. Level of Evidence II, Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

Ablación del nódulo atrioventricular con descarga de consensadores y radiofrecuencia / Atrioventricular nodal catheter ablation with condenser discharge and radiofrequency

La ablación del nódulo atrioventricular (AV) en aquellos pacientes com arritmias supraventriculares refractarias a tratamiento farmacológico constituye una alternativa terapéutica que les permite mejorar la calidad de vida. Con este fin se han utilizado dos tipos de energía: corriente directa y radiofrecuencia. El objetivo del presente estudio fue evaluar la tasa de éxito primario y hacer el seguimiento a largo plazo de la ablación del nódulo AV comparando dos tipos de energía: descarga de condensadores y radiofrecuencia. Se realizó ablación del nódulo AV en 80 pacientes: 40 por descarga de condensadores (Grupo I) com una media de seguimiento de 76 + 49 meses y 40 por radiofrecuencia (Grupo II) con un seguimiento medio de 28.1 + 20.8 meses. Se logró bloqueo AV completo luego del primer procedimiento en el 45 por ciento de los pacientes y se observó modificación del nódulo AV en el 50 por ciento del Grupo I. En el 100 por ciento del Grupo II se logró bloqueo AV completo. Tres pacientes del Grupo I (7.5 por ciento) tuvieron arritmias auriculares rápidas durante el seguimiento. Dos de ellos recibieron medicación y 1 un nuevo procedimiento ablativo. En el Grupo II 1 paciente (2.5 por ciento) requirió un segundo procedimiento. En cuanto a las complicaciones no hubo diferencias entre los dos grupos tanto en las tempranas como a largo plazo, com registro de una muerte súbita en cada grupo. La ablación selectiva del nódulo AV con radiofrecuencia en pacientes com arritmia supraventricular refractaria es un método tan seguro como el utilizado previamente (descarga de condensadores) con la ventaja de una tasa de éxito primario cercana al 100 por ciento.

Ablación del nódulo atrioventricular con descarga de consensadores y radiofrecuencia / Atrioventricular nodal catheter ablation with condenser discharge and radiofrequency

La ablación del nódulo atrioventricular (AV) en aquellos pacientes com arritmias supraventriculares refractarias a tratamiento farmacológico constituye una alternativa terapéutica que les permite mejorar la calidad de vida. Con este fin se han utilizado dos tipos de energía: corriente directa y radiofrecuencia. El objetivo del presente estudio fue evaluar la tasa de éxito primario y hacer el seguimiento a largo plazo de la ablación del nódulo AV comparando dos tipos de energía: descarga de condensadores y radiofrecuencia. Se realizó ablación del nódulo AV en 80 pacientes: 40 por descarga de condensadores (Grupo I) com una media de seguimiento de 76 + 49 meses y 40 por radiofrecuencia (Grupo II) con un seguimiento medio de 28.1 + 20.8 meses. Se logró bloqueo AV completo luego del primer procedimiento en el 45 por ciento de los pacientes y se observó modificación del nódulo AV en el 50 por ciento del Grupo I. En el 100 por ciento del Grupo II se logró bloqueo AV completo. Tres pacientes del Grupo I (7.5 por ciento) tuvieron arritmias auriculares rápidas durante el seguimiento. Dos de ellos recibieron medicación y 1 un nuevo procedimiento ablativo. En el Grupo II 1 paciente (2.5 por ciento) requirió un segundo procedimiento. En cuanto a las complicaciones no hubo diferencias entre los dos grupos tanto en las tempranas como a largo plazo, com registro de una muerte súbita en cada grupo. La ablación selectiva del nódulo AV con radiofrecuencia en pacientes com arritmia supraventricular refractaria es un método tan seguro como el utilizado previamente (descarga de condensadores) con la ventaja de una tasa de éxito primario cercana al 100 por ciento. (AU)