Pectus excavatum with right ventricular compression-induced ventricular arrhythmias.

A 33-year-old woman, with palpitations since the age of 15, was referred to a cardiology consultation due to very frequent ventricular extrasystoles with morphology of left bundle branch block, inferior frontal axis, late precordial transition, rS in V1, R in V6 and rS in DI. She had pectus excavatum. The cardiac magnetic resonance showed severe pectus excavatum associated with exaggerated cardiac levoposition, compression and deformation of the right cardiac chambers. However, the patient became pregnant, and follow-up was delayed.

Spontaneous splenic rupture due to falciparum malaria successfully treated with a conservative approach.

Malaria is frequently associated with splenomegaly. However, spontaneous splenic rupture is a rare and life-threatening complication. It is mostly seen in acute infection in non-immune adults and Plasmodium vivax and Plasmodium falciparum have been associated with the majority of cases. We describe a case of splenic rupture in an adult with complicated malaria by Plasmodium falciparum in which a conservative approach was used.

Septic shock due to co-infection with Legionella pneumophila and Saprochaete clavata.

Septic shock is the most dreaded presentation of an infection, carrying a reserved prognosis. Appropriate antimicrobial therapy is therefore the mainstay of treatment, alongside organ support as needed. Legionnaires' disease is mainly due to Legionella pneumophila serogroup 1 but it can be caused by other serogroups and species not detected by the urinary antigen test. Anti-tumour necrosis factor α therapy may increase the risk of invasive fungal infection, which carry a poor prognosis. We present a challenging case of a septic shock due to Legionella pneumophila and Saprochaete clavata infections, with a review of the two infections presented.

Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology's] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation. / Documento de Consenso sobre Estratificação de Risco Cardiovascular e estudo da doença coronária em Portugal: a posição dos Grupos de Estudo de Cardiologia Nuclear, Ressonância Magnética e Tomografia Computorizada Cardíaca, de Ecocardiografia e de Fisiopatologia do Esforço e Reabilitação Cardíaca.

Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.

Extra Corporeal Membrane Oxygenation in the Treatment of Human Immunodeficiency Virus-Related P. jirovecii Pneumonia.

Despite the undeniable complexity one may encounter while managing critically ill patients with human immunodeficiency virus infection (HIV), intensive care unit-related mortality has declined in recent years, not only because of more efficacious antiretroviral therapy (ART) but also due to the advances in critical support. However, the use of extracorporeal membrane oxygenation (ECMO) in these patients remains controversial. We report four cases of HIV-infected patients with Pneumocystis jirovecii pneumonia (PJP) and acute respiratory distress syndrome (ARDS) treated with ECMO support and discuss its indications and possible role in the prevention of barotrauma and ventilator- induced lung injury (VILI). The eventually favorable clinical course of the patients that we present suggests that although immune status is an important aspect in the decision to initiate ECMO support, this technology can provide real benefit in some patients with severe HIV-related refractory ARDS.

Acute Myocardial Infarction with Non-Obstructive Coronary Arteries - Stratifying the Risk of a "new" Clinical Entity using an "Old" Tool

Abstract Background Some of the patients admitted for acute myocardial infarction have non-obstructive coronary artery disease (MINOCA). Their prognosis is not always benign, making it necessary the development of tools for risk stratification of these patients. Objectives To describe the characteristics of a sample of patients admitted for suspected MINOCA and to evaluate the prognostic value of GRACE score in this population. Methods This was a retrospective, observational, single-center, cohort study involving 56 consecutive patients with MINOCA. During one-year follow-up, patients were assessed for mortality and major adverse cardiovascular events (MACE) - a composite of all-cause mortality and hospitalization due to acute myocardial infarction, heart failure, ischemic stroke, and acute limb ischemia. Statistical analysis was performed using a non-parametric approach, with the Mann-Whitney U test for quantitative variables and ROC curves for assessing the discriminatory power of the Grace score in predicting cardiovascular events. The level of significance was set at 5%. Results Of the 56 MINOCA patients included in the study (median age 67 years), 55.4% were female. During the one-year follow-up, mortality rate was 5.5% and 9.1% of patients had MACE. A higher GRACE score was associated with mortality (p = 0.019; AUC 0.907; 95%CI 0.812-1.000; cut off 138) and MACE (p =0.034; AUC 0.790; 95%CI 0.632-0.948; cutoff 114). Conclusion The definition of MINOCA includes various diagnoses and prognoses, and the GRACE score is useful for risk stratification of patients with this condition.

Genetic diversity and population structure of Cynara cardunculus L. in southern Portugal.

Cynara cardunculus L. is a cardoon species native to the Mediterranean region, which is composed of three botanical taxa, each having distinct biological characteristics. The aim of this study was to examine wild populations of C. cardunculus established in Portugal, in order to determine their genetic diversity, geographic distribution, and population structure. Based on SSR markers, 121 individuals of C. cardunculus from 17 wild populations of the Portuguese Alentejo region were identified and analysed. Ten SSRs were found to be efficient markers in the genetic diversity analysis. The total number of alleles ranged from 9 to 17 per locus. The expected and observed means in heterozygosity, by population analysed, were 0.591 and 0.577, respectively. The wild population exhibited a high level of genetic diversity at the species level. The highest proportion of genetic variation was identified within a geographic group, while variation was lower among groups. Geographic areas having highest genetic diversity were identified in Alvito, Herdade da Abóboda, Herdade da Revilheira and Herdade de São Romão populations. Moreover, significant genetic differentiation existed between wild populations from North-Alentejo geographic locations (Arraiolos, Évora, Monte da Chaminé) and Centro Hortofrutícola, compared with other populations. This study reports genetic diversity among a representative number of wild populations and genotypes of C. cardunculus from Portugal. These results will provide valuable information towards future management of C. cardunculus germplasm.

A rare tumour, a singular indication: sleeve gastrectomy in a morbidly obese septuagenarian with gastric schwannoma.

Gastric schwannoma is an extremely rare mesenchymal tumour, representing only 0.2% of all gastric tumours. Obesity is an alarming worldwide disease whose only effective and sustained treatment seems to be surgical. We present a case of a 73-year-old female with epigastric pain and unspecific dyspeptic symptoms, whose diagnostic endoscopic procedures raised suspicion of a gastrointestinal stromal tumour. Given her good performance status, and since grade 2 obesity with high-risk comorbid conditions was present, she was considered a suitable candidate for laparoscopic sleeve gastrectomy. Both surgery and immediate postoperative period were uneventful. Histological and immunocytochemical analysis classified the tumour as benign gastric schwannoma. After 24 months, besides being disease-free, she presented an excess weight loss of 90.2%, with improvements in metabolic profile allowing withdrawal from chronic medication. The patient is healthier, satisfied and living an active life, showing that age by itself should not be a deterrent to bariatric surgery.

Publisher Correction: Transparent Danionella translucida as a genetically tractable vertebrate brain model.

The version of this paper originally published contained errors in reference citations: in the first paragraph of the Results section, the text "This extent of optical clarity probably results from the absence of skull above the brain22. In our specimens, Nissl-stained coronal sections through the head showed that the skull surrounds the brain only laterally and ventrally" should have read "This extent of optical clarity probably results from the absence of skull above the brain21. In our specimens, Nissl-stained coronal sections through the head22 showed that the skull surrounds the brain only laterally and ventrally." In addition, the unit abbreviation "µm" was incorrectly divided at a line break in the third paragraph of the Discussion, which might have led to some confusion. These errors have been corrected in the PDF and HTML versions of the article.

Transparent Danionella translucida as a genetically tractable vertebrate brain model.

Understanding how distributed neuronal circuits integrate sensory information and generate behavior is a central goal of neuroscience. However, it has been difficult to study neuronal networks at single-cell resolution across the entire adult brain in vertebrates because of their size and opacity. We address this challenge here by introducing the fish Danionella translucida to neuroscience as a potential model organism. This teleost remains small and transparent even in adulthood, when neural circuits and behavior have matured. Despite having the smallest known adult vertebrate brain, D. translucida displays a rich set of complex behaviors, including courtship, shoaling, schooling, and acoustic communication. In order to carry out optical measurements and perturbations of neural activity with genetically encoded tools, we established CRISPR-Cas9 genome editing and Tol2 transgenesis techniques. These features make D. translucida a promising model organism for the study of adult vertebrate brain function at single-cell resolution.

Worsening or 'pseudo-worsening' renal function? The prognostic value of hemoconcentration in patients admitted with acute heart failure.

INTRODUCTION: Renal insufficiency, as evidenced by an increase in creatinine, is associated with higher mortality in patients with acute heart failure (AHF). Conversely, hemoconcentration (HC) in AHF is associated with lower mortality, but can also cause an increase in creatinine. Our aim was to assess the prognosis of HC in patients hospitalized for AHF presenting with or without worsening renal function (WRF). METHODS: A total of 618 consecutive patients admitted for AHF were included. WRF was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria and HC was defined as an elevation of hemoglobin during hospitalization compared to the admission value. Six-month all-cause mortality was analyzed. RESULTS: The patients' mean age was 79±11 years; 58% were women. Mortality at six months was 38% and 49% of patients had WRF. HC occurred in 38.9% of patients with WRF and was associated with improved survival (HR 1.6, 95% CI 1.10-2.34; p=0.02) compared to WRF without HC. HC was associated with better survival in KDIGO stages 1 and 2 (HR 1.8; 95% CI 1.1-2.8; p=0.01). For patients without chronic kidney disease (CKD) with WRF in stages 1 and 2, HC was associated with significantly better survival (HR 2.3; 95% CI 1.2-4.2; p=0.01). CONCLUSION: In patients admitted for AHF without renal failure or CKD, WRF with HC is associated with a better prognosis, similar to that of patients without WRF, and should therefore be reclassified as 'pseudo-WRF'.

Mechanisms of social buffering of fear in zebrafish.

Some humans thrive whereas others resign when exposed to threatening situations throughout life. Social support has been identified as an important modulator of these discrepancies in human behaviour, and other social animals also exhibit phenomena in which individuals recover better from aversive events when conspecifics are present - aka social buffering. Here we studied social buffering in zebrafish, by exposing focal fish to an aversive stimulus (alarm substance - AS) either in the absence or presence of conspecific cues. When exposed to AS in the presence of both olfactory (shoal water) and visual (sight of shoal) conspecific cues, focal fish exhibited a lower fear response than when tested alone, demonstrating social buffering in zebrafish. When separately testing each cue's effectiveness, we verified that the visual cue was more effective than the olfactory in reducing freezing in a persistent threat scenario. Finally, we verified that social buffering was independent of shoal size and coincided with a distinct pattern of co-activation of brain regions known to be involved in mammalian social buffering. Thus, this study suggests a shared evolutionary origin for social buffering in vertebrates, bringing new evidence on the behavioural, sensory and neural mechanisms underlying this phenomenon.

Additional value of associating aortic valve calcification to coronary calcium as a gatekeeper for coronary tomography angiography.

BACKGROUND: Aortic valve calcification shares risk factors with coronary artery disease. Coronary calcium has been used has a gatekeeper to performing coronary tomography angiography. The aim of this study was to evaluate aortic valve calcification as a predictor of obstructive coronary artery disease by computed tomography, and its possible usefulness, alongside with coronary calcium, to improve the decision of whether or not to proceed with computed tomography angiography. METHODS: Transversal case-control study including 154 consecutive patients (62 ± 12 years, 57.6 % female, without known coronary or valve disease) undergoing calcium scoring and angiography through computed tomography (Phillips Brilliance, 16-slice). Predictors of aortic valve calcification and obstructive coronary artery disease were identified. Usefulness of aortic valve calcification when added to calcium score for prediction of obstructive coronary artery disease was assessed by binary logistic regression and net reclassification index. RESULTS: Aortic valve calcification was associated with higher coronary calcium, extent and prevalence of obstructive coronary disease, which was identified in 22.1 % of patients and was discriminated by aortic valve calcium with an area under curve 0.749 (p < 0.001, Youden index: 61). A higher discriminative power was achieved with a model based on coronary and aortic valve calcification (AUC 0.900, p < 0.001). Compared with calcium score >400 as a gatekeeper to angiography, the association of aortic calcium >61 allowed a net reclassification index of +7.7 % of patients. CONCLUSIONS: Aortic valve calcification is associated with the prevalence and extent of obstructive coronary artery disease by computed tomography angiography and is an easy, fast and useful method to improve the selection of patients for angiography.

Linking appraisal to behavioral flexibility in animals: implications for stress research.

In fluctuating environments, organisms require mechanisms enabling the rapid expression of context-dependent behaviors. Here, we approach behavioral flexibility from a perspective rooted in appraisal theory, aiming to provide a better understanding on how animals adjust their internal state to environmental context. Appraisal has been defined as a multi-component and interactive process between the individual and the environment, in which the individual must evaluate the significance of a stimulus to generate an adaptive response. Within this framework, we review and reframe the existing evidence for the appraisal components in animal literature, in an attempt to reveal the common ground of appraisal mechanisms between species. Furthermore, cognitive biases may occur in the appraisal of ambiguous stimuli. These biases may be interpreted either as states open to environmental modulation or as long-lasting phenotypic traits. Finally, we discuss the implications of cognitive bias for stress research.

Universal definition of myocardial infarction: clinical insights.

AIMS: The universal definition of myocardial infarction (MI) classifies acute ischaemia into different classes according to lesion mechanism. Our aim was to perform a detailed comparison between these different types of MI in terms of baseline characteristics, management and prognosis. METHODS AND RESULTS: An observational retrospective single-centre cohort study was performed, including 1,000 consecutive patients admitted for type 1 (76.4%) or type 2 MI (23.6%). Type 2 MI patients were older, had a higher prevalence of comorbidities and worse medical status at admission. In-hospital mortality did not differ significantly between the MI groups (8.8 vs. 9.7%, p = 0.602). However, mortality during follow-up was almost 3 times higher in type 2 MIs (HR 2.75, p < 0.001). Type 2 MI was an independent all-cause mortality risk marker, adding discriminatory power to the GRACE model. Finally, important differences in traditional risk score performances (GRACE, CRUSADE) were found between both MI types. CONCLUSIONS: Several important baseline differences were found between these MI types. Regarding prognosis, long-term survival is significantly compromised in type 2 MIs, potentially translating patients' higher medical complexity and frailty. Distinction between type 1 and type 2 MI seems to have important implications in clinical practice and likely also in the results of clinical trials.

Non-ST-elevation acute coronary syndromes in octogenarians: applicability of the GRACE and CRUSADE scores.

INTRODUCTION: Assessment of ischemic and bleeding risk is critical for the management of elderly patients with acute coronary syndromes, but it has been little studied. OBJECTIVE: This study aims to assess the applicability of the GRACE and CRUSADE scores in patients aged ≥80 years with non-ST-elevation acute coronary syndrome (NSTE-ACS), and to identify the main predictors of in-hospital mortality and major bleeding in this population. METHODS: We analyzed 544 patients aged ≥80 years with NSTE-ACS included in the Portuguese Registry on Acute Coronary Syndromes and identified the predictors of in-hospital mortality and major bleeding during hospitalization. Prediction models were created for these endpoints, then compared with the GRACE and CRUSADE scores, and their applicability to the study population was assessed. RESULTS: Use of coronary angiography was associated with reduced risk of in-hospital mortality, without increasing risk of major bleeding (OR 0.2, 95% CI 0.006-0.49, p=0.001). Major bleeding was an independent predictor of in-hospital mortality (OR 10.9, 95% CI 2.36-50.74, p=0.002), and was associated with comorbidities and pharmacological therapy during hospitalization. The GRACE score showed good diagnostic accuracy for in-hospital mortality (AUC 0.75, 95% CI 0.63-0.87, p<0.001), but the CRUSADE score had weak discriminatory capacity for major bleeding (AUC 0.51, 95% CI 0.30-0.63, p=0.942), unlike our prediction model (AUC 0.68, 95% CI 0.52-0.84, p=0032). CONCLUSIONS: The GRACE score is suitable for risk assessment in octogenarians with NSTE-ACS, but the CRUSADE score is inadequate, and new scores are required to assess bleeding risk in this age-group.

Improving risk stratification in non-ST-segment elevation myocardial infarction with combined assessment of GRACE and CRUSADE risk scores.

BACKGROUND: Risk assessment is fundamental in the management of acute coronary syndromes (ACS), enabling estimation of prognosis. AIMS: To evaluate whether the combined use of GRACE and CRUSADE risk stratification schemes in patients with myocardial infarction outperforms each of the scores individually in terms of mortality and haemorrhagic risk prediction. METHODS: Observational retrospective single-centre cohort study including 566 consecutive patients admitted for non-ST-segment elevation myocardial infarction. The CRUSADE model increased GRACE discriminatory performance in predicting all-cause mortality, ascertained by Cox regression, demonstrating CRUSADE independent and additive predictive value, which was sustained throughout follow-up. The cohort was divided into four different subgroups: G1 (GRACE<141; CRUSADE<41); G2 (GRACE<141; CRUSADE≥41); G3 (GRACE≥141; CRUSADE<41); G4 (GRACE≥141; CRUSADE≥41). RESULTS: Outcomes and variables estimating clinical severity, such as admission Killip-Kimbal class and left ventricular systolic dysfunction, deteriorated progressively throughout the subgroups (G1 to G4). Survival analysis differentiated three risk strata (G1, lowest risk; G2 and G3, intermediate risk; G4, highest risk). The GRACE+CRUSADE model revealed higher prognostic performance (area under the curve [AUC] 0.76) than GRACE alone (AUC 0.70) for mortality prediction, further confirmed by the integrated discrimination improvement index. Moreover, GRACE+CRUSADE combined risk assessment seemed to be valuable in delineating bleeding risk in this setting, identifying G4 as a very high-risk subgroup (hazard ratio 3.5; P<0.001). CONCLUSIONS: Combined risk stratification with GRACE and CRUSADE scores can improve the individual discriminatory power of GRACE and CRUSADE models in the prediction of all-cause mortality and bleeding. This combined assessment is a practical approach that is potentially advantageous in treatment decision-making.