Ultrasonography and procedures in intensive care medicine / Ecografía y procedimientos en Medicina Intensiva

The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist’s competencies, for which appropriate training should be achieved. (AU)

El uso de la ecografía no se limita al diagnóstico y/o monitorización del paciente crítico. Además, la guía ecográfica es de gran importancia para la ejecución exitosa y segura de diversos procedimientos en la Unidad de Cuidados Intensivos (UCI). En este artículo, revisamos el papel de la ecografía como guía intervencionista en la UCI. Los procedimientos ecodirigidos claves son, aunque no se limitan a estos, la canulación vascular, pericardiocentesis, toracocentesis, paracentesis, aspiración de colecciones de partes blandas/artrocentesis y la punción lumbar. Con el tiempo, los procedimientos realizados por los intensivistas se extenderán más allá de los descriptos en esta revisión. La guía ecográfica debe formar parte de las competencias del intensivista, para lo cual se requiere un entrenamiento adecuado. (AU)

Ultrasonography and procedures in intensive care medicine.

The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist's competencies, for which appropriate training should be achieved.

Diseño de un nuevo indicador de mortalidad en el síndrome coronario agudo al ingreso en la Unidad de Cuidados Intensivos / Design of a new mortality indicator in acute coronary syndrome on admission to the Intensive Care Unit

Objetivo: Diseñar un indicador de mortalidad del síndrome coronario agudo (SCA) en el servicio de medicina intensiva (SMI). Diseño: Estudio descriptivo observacional multicéntrico. Participantes: Pacientes con SCA ingresados en SMI incluidos en el registro ARIAM- SEMICYUC entre enero del 2013 y abril del 2019. Intervenciones: Ninguna. Variables de interés principales: Las variables analizadas fueron demográficas, tiempo de acceso al sistema sanitario y estado clínico. Se analizó la terapia de revascularización, los fármacos y la mortalidad. Se realizó un análisis de regresión logística de COX y posteriormente se diseñó una red neuronal. Se elaboró una curva ROC para calcula la potencia del nuevo score. Finalmente, la utilidad clínica o relevancia del indicador ARIAM se evaluará mediante un gráfico de Fagan. Resultados: Se incluyó a 17.258 pacientes, con una mortalidad al alta del SMI del 3,5% (605). Las variables analizadas con significación estadística (p<0,001) fueron introducidas en el modelo predictivo supervisado, una red neuronal artificial. El nuevo indicador ARIAM mostro una media de 0,0257 (IC del 95%, 0,0245-0,0267) en los pacientes dados de alta de UCI y de 0,27085 (IC del 95%, 0,2533-0,2886) en los que fallecieron, p <0,001. El área ROC del modelo conseguido fue de 0,918 (IC del 95%, 0,907-0,930). En el test de Fagan se demostró que el indicador ARIAM muestra que la probabilidad de fallecimiento es del 19% (IC del 95%, 18-20%) cuando es positivo y del 0,9% (IC del 95%, 0,8-1,01%) cuando es negativo. Conclusiones: Es posible crear un nuevo indicador de mortalidad del SCA en el SMI que sea más exacto, reproducible y actualizable periódicamente. (AU)

Objective: To design a mortality indicator for acute coronary syndrome (ACS) in the intensive care unit (ICU). Design: Multicenter observational descriptive study. Participants: ACS patients admitted to SMI included in the ARIAM-SEMICYUC registry between January 2013 and April 2019. Interventions: None. Main variables of interest: Variables analyzed were demographic, time of access to the health system, and clinical condition. Revascularization therapy, drugs, and mortality were analyzed. A COX regression analysis was performed and subsequently a neural network was designed. An ROC curve was developed to calculate the power of the new score. Finally, the clinical utility or relevance of the ARIAM's indicator will be evaluated using a Fagan test. Results: 17,258 patients were included, with a 3.5% (605) mortality at discharge from the ICU. The variables analyzed with statistical significance (p<0.001) were entered into the supervised predictive model, an artificial neural network. The new ARIAM's indicator showed a mean of 0.0257 (95% CI: 0.0245–0.0267) in patients discharged from the ICU and 0.27085 (95% CI: 0.2533–0.2886) in those who died, p<0.001. The ROC area of the model achieved was 0.918 (95% CI: 0.907–0.930). The Fagan test showed that the ARIAM's Indicator shows that the probability of death is 19% (95% CI: 18%–20%) when it is positive and 0.9% (95% CI: 0.8%–1.01%) when it is negative. Conclusions: It is possible to create a new mortality indicator for ACS in the ICU that is more accurate, reproducible, and periodically updated. (AU)

Audiovestibular Manifestations in Patients with Primary Raynaud's Phenomenon and Raynaud's Phenomenon Secondary to Systemic Sclerosis.

OBJECTIVES: To address the prevalence of audiovestibular disorders in patients with primary Raynaud's Phenomenon (RP). A series of patients with primary RP and secondary RP in the context of systemic sclerosis (SSc) were compared with healthy controls. METHODS: A prospective multicenter observational cross-sectional study was conducted in several Otolaryngology and Rheumatology Divisions of tertiary referral hospitals, recruiting 57 patients with RP and 57 age- and gender-matched controls. Twenty patients were classified as primary RP when unrelated to any other conditions and 37 patients who met the 2013 ACR/EULAR classification criteria for SSc were classified as having secondary RP associated with SSc. Audiometric and vestibular testing (vHIT), clinical sensory integration and balance testing (CTSIB), and Computerized Dynamic Posturography (CDP) were performed. RESULTS: As significant differences were found in the age of the two study groups, primary and secondary RP, no comparisons were made between both groups of RP but only with their control groups. No sensorineural hearing loss (SNHL) was recorded in any of our patients with primary RP and no differences were found in the voice audiometry tests with respect to controls. Four of 37 (10.8%) secondary RP patients presented SNHL. Those with SNHL were 7.03 times more likely to have a secondary RP than controls (p < 0.001). The audiometric curve revealed high-frequency hearing loss in 4 patients with RP secondary to SSc, and statistically significant differences were achieved when RP secondary was compared to controls in vHIT gain, caloric test, CTSIB, and CDP. CONCLUSIONS: Unlike patients with RP secondary to SSc, patients with primary RP do not show audiovestibular abnormalities. Regarding audiovestibular manifestations, primary RP can be considered a different condition than secondary RP.

Design of a new mortality indicator in acute coronary syndrome on admission to the Intensive Care Unit.

OBJECTIVE: To design a mortality indicator in acute coronary syndrome (ACS) in the intensive care unit (ICU). DESIGN: A multicenter, observational descriptive study was carried out. PARTICIPANTS: Patients with ACS admitted to the ICUs included in the ARIAM-SEMICYUC registry between January 2013 and April 2019. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Demographic parameters, time of access to the healthcare system, and clinical condition. Revascularization therapy, drugs and mortality were analyzed. Cox regression analysis was performed, followed by the design of a neural network. A receiver operating characteristic curve (ROC) was plotted to calculate the power of the new score. Lastly, the clinical utility or relevance of the ARIAM indicator (ARIAM's) was assessed using a Fagan test. RESULTS: A total of 17,258 patients were included in the study, with a mortality rate of 3.5% (n = 605) at discharge from the ICU. The variables showing statistical significance (P < .001) were entered into the supervised predictive model, an artificial neural network. The new ARIAM's yielded a mean of 0.0257 (95%CI: 0.0245-0.0267) in patients discharged from the ICU versus 0.27085 (95%CI: 0.2533-0.2886) in those who died (P < .001). The area under the ROC curve of the model was 0.918 (95%CI: 0.907-0.930). Based on the Fagan test, the ARIAM's showed the mortality risk to be 19% (95%CI: 18%-20%) when positive and 0.9% (95%CI: 0.8%-1.01%) when negative. CONCLUSIONS: A new mortality indicator for ACS in the ICU can be established that is more accurate and reproducible, and periodically updated.

What could posturography tell us about balance in essential tremor?

BACKGROUND: Essential tremor (ET) is a neurological disorder characterized primarily by action tremor. Balance impairments in ET patients were formerly considered to be uncommon and simply age-related. However quantitative assessment with posturography has revealed impairments in control of both static and dynamic balance. RESEARCH QUESTION: The aim of the present study is to assess postural stability with different posturographic techniques in ET patients. METHODS: A prospective cross-sectional study conducted in two University Hospitals. Eleven patients diagnosed with essential tremor and twelve healthy controls were included. Balance assessment were performed with: sensory organization test (SOT) and limits of stability (LOS) of the computer dynamic posturography (CDP), results of free-field body sway analysis with mobile posturography (Vertiguard®), modified timed up and go test (TUG), Dizziness handicap inventory (DHI) and activities-specific balance confidence scale (ABC). RESULTS: Patients with ET showed poorer scores in the SOT than controls for composite balance and somatosensory input. They also performed worse in LOS tests and Vertiguard® device indicated a higher risk of falling. There were no differences in the modified TUG. The mean score of DHI was 15.64 and 85.16 for ABC. SIGNIFICANCE: Posturography assessment (CDP and Vertiguard®) is more accurate in showing balance impairment in ET patients than clinical evaluation (modified TUG). Balance impairment involves deteriorated processing of somatosensory input which could be explained by cerebellar dysfunction. Balance deficits could be included into future diagnostic criteria.

Comparative Analysis of the Efficiency of Two Treatment Protocols for Posterior Canal Benign Paroxysmal Positional Vertigo.

BACKGROUND AND OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is the most common vertigo of labyrinthine origin, its social and healthcare impact is remarkable. It has recently been shown that single session treatment is as safe and effective as weekly treatment, which could have impact on direct and indirect costs related to the disease. The objective of this study is to determine whether single session treatment of unilateral posterior canal BPPV canalolithiasis is more efficient than conventional treatment. MATERIALS AND METHODS: A prospective randomized controlled trial was performed in 53 consecutive patients diagnosed with unilateral posterior canal BPPV canalolithiasis previously untreated: 26 patients were assigned to single session treatment and 27 patients to weekly treatment. Average and total cost of care, consultation time and the impact in terms of temporary disability and loss of productivity for the company due to patients' medical visits were compared. RESULTS: Average and total cost of care and loss of productivity for the company due to patients' medical visits were significantly lower in the single session group. Consultation time was also better in this group when travelling time was considered. CONCLUSIONS: The single session protocol is fast, effective and reduces direct and indirect cost of care related to disease justifying high resolution consultations.

Análisis comparativo de la eficiencia de dos protocolos de tratamiento del vértigo posicional paroxístico benigno del conducto semicircular posterior / Comparative Analysis of the Efficiency of Two Treatment Protocols for Posterior Canal Benign Paroxysmal Positional Vertigo

Antecedentes y objetivo: El vértigo posicional paroxístico benigno (VPPB) es la causa más frecuente de vértigo de origen laberíntico; su impacto social y en términos de cuidados de salud es notable. Recientemente se ha demostrado que es clínicamente posible realizar el tratamiento y su comprobación en la misma sesión, lo cual podría tener repercusión en los costes asistenciales directos e indirectos relacionados con la enfermedad. El objetivo de este trabajo es determinar si el protocolo de tratamiento unisesión del VPPB CP unilateral tipo conductolitiasis es más eficiente que el protocolo de tratamiento convencional. Materiales y métodos: Estudio prospectivo controlado y aleatorizado en 53 pacientes consecutivos diagnosticados de un VPPB CP unilateral tipo conductolitiasis no tratados previamente; 26 pacientes fueron asignados al grupo unisesión y 27 al semanal clásico. Se compararon los costes medio y total de la asistencia, el tiempo de consulta y el impacto en términos de incapacidad temporal y pérdida de productividad para la empresa asociada a la visita médica del paciente. Resultados: Los costes medio y total de la asistencia así como la pérdida de productividad para una empresa asociada a la visita médica de los pacientes laboralmente activos fueron significativamente menores en el protocolo unisesión. También el tiempo de consulta cuando se consideró el tiempo de desplazamiento al centro. Conclusiones: El protocolo de tratamiento unisesión es rápido, efectivo y reduce los costes asistenciales directos e indirectos relacionados con la enfermedad justificando consultas de alta resolución. (AU)

Background and objective: Benign paroxysmal positional vertigo (BPPV) is the most common vertigo of labyrinthine origin, its social and healthcare impact is remarkable. It has recently been shown that single session treatment is as safe and effective as weekly treatment, which could have impact on direct and indirect costs related to the disease. The objective of this study is to determine whether single session treatment of unilateral posterior canal BPPV canalolithiasis is more efficient than conventional treatment. Materials and methods: A prospective randomized controlled trial was performed in 53 consecutive patients diagnosed with unilateral posterior canal BPPV canalolithiasis previously untreated: 26 patients were assigned to single session treatment and 27 patients to weekly treatment. Average and total cost of care, consultation time and the impact in terms of temporary disability and loss of productivity for the company due to patients’ medical visits were compared. Results: Average and total cost of care and loss of productivity for the company due to patients’ medical visits were significantly lower in the single session group. Consultation time was also better in this group when travelling time was considered. Conclusions: The single session protocol is fast, effective and reduces direct and indirect cost of care related to disease justifying high resolution consultations. (AU)

Emotional intelligence and adult attachment: Effects on problematic smartphone usage

El uso del smartphone puede tornarse problemático cuando se presentan dificultades de regulación emocional. En la investigación se plan-tearon tres objetivos: analizar el efecto de las dimensiones de inteligencia emocional y el apego sobre el uso del smartphone; evaluar las diferencias en el uso problemático del móvil atendiendo a tipos y estilos de apego; ex-plorar el efecto del sexo y la edad. Se utilizaron la Escala de Dependencia y Adicción al Smartphone, la Escala de Inteligencia Emocional de Wong & Law y el Cuestionario de Apego adulto. El estudio incluyó a 552 jóvenes (M= 21.79, SD= 2.66; 74.1% mujeres)seleccionados por muestreo inten-cionaly clasificados en Generación Z y Millennials. Una baja conciencia de las propias emociones (inteligencia emocional), una pobre autoestima y ne-cesidad de aprobación, la resolución hostil de conflictos, rencor y posesivi-dad (apego) predecían el uso problemático. Además, el tipo inseguro de apego y los estilos negativos como el temeroso se relacionan más con este uso problemático. El sexo aportaba cierta capacidad explicativa, siendo las mujeres las que mostraron más problemas. Los hallazgos apoyan la rele-vancia de construir un apego seguro y positivoydeser capaces de evaluar las propias emociones para prevenir los usos problemáticos del smartpho-ne.(AU)

Smartphone usage can become problematic when individuals have difficulties in emotional regulation. To clarify riskfactors for prob-lematic smartphone usage, the study had three objectives: To analyze the effect of emotional intelligence and attachment dimensions on smartphone usage; to evaluate differences by types and styles of attachment in prob-lematic smartphone usage; to explore the roles of sex and age. For this purpose, the Smartphone Dependency and Addiction Scale, the Wong & Law Emotional Intelligence Scale, and the Adult Attachment Question-naire were used.The study included 552 young adults(M = 21.79, SD = 2.66; 74.1% women)selected by purposive sampling, and classified in Generation Z and Millennials. The results showed that low awareness of one's emotions (emotional intelligence), poor self-esteem and need for ap-proval, hostile conflict resolution, rancor, and possessiveness (attachment) predicted problematic smartphone usage. Furthermore, insecure type of at-tachment and negative styles such as fearfulnesswere closely related to smartphone addiction. Sex had some explanatory power with respect to device use, with women showing higher levels of problematic smartphone usage. In conclusion, the findings support the importance of the secure and positive attachment system, and being able to evaluate and regulate one’s own emotions for preventing problematic smartphone use.(AU)

Successful Treatment of 3 Dogs With Fluoroquinolone-Resistant Escherichia coli Associated Granulomatous Colitis.

Successful resolution of Escherichia coli associated granulomatous colitis (ECGC) is becoming a challenge due to the development of fluoroquinolone resistant E coli, which is associated with poor prognosis. Three dogs presented with signs of chronic colitis and were diagnosed with ECGC. All 3 were initially treated with enrofloxacin and trimethoprim-sulfamethoxazole, without clinical improvement. Despite the fact that culture and susceptibility testing results demonstrate resistance to fluoroquinolone and trimethoprim-sulfamethoxazole, the addition of amikacin fully resolved the clinical signs in all 3 cases. This case series describes the clinical presentation, diagnostic findings, and successful treatment of 3 dogs with fluoroquinolone-resistant ECGC. It suggests an alternative strategy for multidrug-resistance ECGC patients. Further investigations are required to confirm the efficacy of and to determine the molecular mechanisms underpinning the apparent success of aminoglycoside antibiotic combinations for treatment of ECGC.

Video Head Impulse Test in Darkness, Without Visual Fixation: A Study on Healthy Subjects.

OBJECTIVE: The head impulse test (HIT) is triggered by the vestibulo-ocular reflex (VOR), complemented by the optokinetic and pursuit systems. This study aimed to evaluate the possibility of individualizing the VOR contribution to the HIT. DESIGN: Thirty-six healthy individuals (19 males, 17 females; age 21-64 years, mean 39 years) underwent horizontal video HIT (vHIT). This was first conducted in darkness, without visual fixation, and then visually tracked. RESULTS: Seventy percent of the impulses delivered ocular responses opposite to the direction of the head, matching its velocity to a point where quick anticompensatory eye movements (SQEM) stopped the response (SQEM mean latency 58.21 ms, interquartile range 50-67 ms). Of these, 75% recaptured the head velocity after culmination. Thirty percent of the responses completed a bell-shaped curve. The completed bell-shaped curve gains and instantaneous gains (at 40, 60, and 80 ms) before SQEM were equivalent for both paradigms. Females completed more bell-shaped traces (42%) than males (15%); p = 0.01. The SQEM latency was longer (62.81 versus 55.71 ms, p < 0.01), and the time to recapture the bell-shaped curve was shorter (77.51 versus 92.52 ms, p < 0.01) in females than in males. The gains were comparable between sexes in both paradigms. CONCLUSIONS: The VOR effect can be localized in the first 70 ms of the vHIT response. In addition, other influences may take place in estimating the vHIT responses. The study of these influences might provide useful information that can be applied to patient management.

Comparative analysis of the efficiency of two treatment protocols for posterior canal benign paroxysmal positional vertigo. / Análisis comparativo de la eficiencia de dos protocolos de tratamiento del vértigo posicional paroxístico benigno del conducto semicircular posterior.

BACKGROUND AND OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is the most common vertigo of labyrinthine origin, its social and healthcare impact is remarkable. It has recently been shown that single session treatment is as safe and effective as weekly treatment, which could have impact on direct and indirect costs related to the disease. The objective of this study is to determine whether single session treatment of unilateral posterior canal BPPV canalolithiasis is more efficient than conventional treatment. MATERIALS AND METHODS: A prospective randomized controlled trial was performed in 53 consecutive patients diagnosed with unilateral posterior canal BPPV canalolithiasis previously untreated: 26 patients were assigned to single session treatment and 27 patients to weekly treatment. Average and total cost of care, consultation time and the impact in terms of temporary disability and loss of productivity for the company due to patients' medical visits were compared. RESULTS: Average and total cost of care and loss of productivity for the company due to patients' medical visits were significantly lower in the single session group. Consultation time was also better in this group when travelling time was considered. CONCLUSIONS: The single session protocol is fast, effective and reduces direct and indirect cost of care related to disease justifying high resolution consultations.

Ecografía en el manejo del paciente crítico con infección por SARS-CoV-2 (COVID-19): aplicaciones clínicas en Medicina Intensiva-una revisión narrativa / Ultrasound in the Management of the Critically Ill Patient with SARS-CoV-2 Infection (COVID-19): clinical applications in Intensive Care Medicine -a narrative review

La infección por SARS-CoV-2 (COVID-19) se caracteriza por producir en las formas graves, un cuadro de insuficiencia respiratoria que puede evolucionar hacia neumonía y síndrome de distrés respiratorio agudo (SDRA), presentar complicaciones como fenómenos trombóticos y disfunción cardiaca, lo que motiva el ingreso en la Unidad de Cuidados Intensivos (UCI).La ecografía, convertida en una herramienta de uso habitual en la UCI, puede ser muy útil durante la pandemia COVID-19 ya que la información obtenida por el clínico puede ser interpretada e integrada en la valoración global durante la exploración del paciente. Este documento describe algunas de sus aplicaciones con el objetivo de proporcionar una guía a los médicos responsables adaptado al paciente crítico con COVID-19. Alguna de sus aplicaciones desde el ingreso en la UCI incluyen confirmar la correcta posición del tubo endotraqueal, facilitar la inserción segura de las vías, e identificar complicaciones y fenómenos trombóticos. Además, la ecografía pleuropulmonar puede ser una alternativa diagnóstica válida que permite evaluar el grado de afectación pulmonar, mediante el análisis de patrones ecográficos específicos, identificación del derrame pleural y del barotrauma. La ecocardiografía proporciona información acerca de la afectación cardíaca, detección del cor pulmonaley estados de shock

The clinical picture of SARS-CoV-2 infection (COVID-19) is characterized in its more severe form, by an acute respiratory failure which can worsen to pneumonia and acute respiratory distress syndrome (ARDS), and get complicated with thrombotic events and heart dysfunction. Therefore, admission to the Intensive Care Unit (ICU) is common.Ultrasound, which has become an everyday tool in the ICU, can be very useful during COVID-19 pandemic, since it provides the clinician with information which can be interpreted and integrated within a global assessment during the physical examination A description of some of the potential applications of ultrasound is depicted in this document, in order to supply the physicians taking care of these patients with a adapted guide to the intensive care setting.Some of its applications since ICU admission include verification of the correct position of the endotracheal tube, contribution to safe cannulation of lines, and identification of complications and thrombotic events. Furthermore, pleural and lung ultrasound can be an alternative diagnostic test to assess the degree of involvement of the lung parenchyma by means of the evaluation of specific ultrasound patterns, identification of pleural effusions and barotrauma. Echocardiography provides information of heart involvement, detects cor pulmonaleand shock states

Can Benign Paroxysmal Positional Vertigo Be Treated in a One Session?

OBJECTIVE: To determine the reliability and safety of posterior canal BPPV (pc-BPPV) treatment with subsequent assessment of the effectiveness of the maneuver in a single session, compared to the classic weekly procedure. METHOD: A prospective study of two randomized groups of unilateral pc-BPPV was performed: a weekly management group (27 patients) and single-session treatment group (26 patients). The number of maneuvers required to clear pc-BPPV, incidence of side effects (re-entries and canal conversions), and recurrence rates were compared. RESULTS: There were no statistically significant differences in the number of maneuvers needed to resolve pc-BPPV, the incidence of side effects, or the recurrence rate between the two groups. Two re-entries were diagnosed in the single-session group, and both were easily and successfully treated. Three early recurrences were found in the single-session group and one spontaneous recovery was encountered in the weekly group. Time required to discharge patients to follow-up was significantly reduced in the single-session group. CONCLUSION: Managing pc-BPPV in one session is safe and reliable, resulting in fewer visits to outpatient clinics and optimization of treatment strategies.

Addison's Disease Secondary to Bilateral Adrenal Gland Metastatic Mammary Carcinoma in a Dog.

A 12 yr old intact female Siberian husky was referred with a 2 wk history of progressive weakness, paraparesis, anorexia, and panting. A 4 cm diameter grade 3 mammary solid carcinoma involving the fifth right mammary gland had been removed 2 days prior to the current visit. While hospitalized, the dog was diagnosed with Addison's disease based on electrolyte disturbances and low serum cortisol levels following adrenocorticotropic hormone stimulation test. An abdominal ultrasound revealed adrenal glands at the upper limit of normal size. Despite treatment, the dog deteriorated and died 4 days after presentation. A postmortem examination revealed a neoplastic infiltrate of epithelial malignant cells in both adrenal glands, popliteal lymph nodes, vertebral bodies, and paralumbar musculature, compatible with metastasis from mammary carcinoma. To our knowledge, this is the first reported case of Addison's disease secondary to metastatic mammary carcinoma in a dog.

Does patient environment have any influence on balance?

BACKGROUND: Although patient environment is a factor to consider when planning a vestibular rehabilitation program, there are no studies correlating this factor to outcomes of balance assessment. AIM: To evaluate whether there are differences in objective evaluation of balance in elderly patients at risk of falls according to the environment in which they live (urban or rural) and their lifestyle (considering cardiovascular risk factors). METHODS: Cross-sectional study of a sample of 139 elderly patients with high risk of falls assessed with objective outcome measures: Computer Dynamic Posturography (CDP), and the modified Timed Up-and-Go (TUG) test; and subjective outcome measures: Dizziness Handicap Inventory (DHI) and short Falls Efficacy Scale-International (short FES-I). Rural or urban environment was defined according to administrative and legal criteria. RESULTS: Elderly patients at risk of fall living in rural environment show better composite results in SOT with better scores in Condition 6 and fewer falls during the CDP. They also require fewer steps to perform the TUG test. DISCUSSION: The present study provides evidence that patient environment has an influence in balance. CONCLUSION: Patient environment should be considered when analyze tests evaluating static and dynamic balance.