Moderate Exertion Research Articles

Characterizing Bariatric Surgery Utilization and Complication Rates in the Adolescent Population

IntroductionBariatric surgery is an increasingly common treatment of morbid obesity in the United States and has demonstrated effective weight loss and improvement of comorbidities. We used the National Surgical Quality Improvement Program (NSQIP) data to characterize bariatric surgery utilization and complication rates in the adolescent population. MethodsDemographics, surgical procedures, comorbidities, and 30-day outcomes of 2625 adolescents ages 18–21 who underwent bariatric surgery were analyzed from NSQIP data-bank from 2005 to 2015. Results79.5% of patients were females. Majority of patients identified as Caucasian or Black/African American (BAA) at 66.7% (73% of US population) and 15.5% (12.6% of US population), respectively. 15.9% identified as Hispanic. Comorbidities included diabetes in 9.3% (7.8% NIDDM), hypertension (9.5%), and dyspnea on moderate exertion (13.2%).Sleeve Gastrectomy, Laparoscopic Roux-En-Y (RY) and Adjustable Gastric Banding (AGB) were the three most common procedures performed during the study period. There has been a sharp trend towards SG in recent years (11.4% in 2010, to 66.6% in 2015), while RY utilization declined (47.4% in 2010 to 28.6% in 2015). Surgical complications were 2.4%, with the most common being superficial surgical site infection (0.7%), UTI (0.7%), and organ-space infection (0.4%). Reoperation and readmission rates within 30-days post-operation were 1.5% and 4.1%, respectively. Those with complications had longer length-of-stays (2.7 vs. 1.8 days, P < 0.001), greater reoperation rates (OR = 9.6, P < 0.001) and readmission rates (OR = 11.8, P < 0.001). ConclusionMorbid obesity is associated with significant comorbidity. SG is increasingly the most utilized form of bariatric surgery. While complications are low, they are associated with greater hospital length-of-stay, readmission, and reoperation rates. Level of EvidenceTreatment Study, Level III.

Physical Exertion Immediately Prior to Placental Abruption: A Case-Crossover Study.

While there is consistent evidence that episodes of physical exertion are associated with an immediately higher risk of acute ischemic vascular events, the risk of placental abruption immediately following episodes of physical exertion has not been studied. In a multicenter case-crossover study, we interviewed 663 women with placental abruption at 7 Peruvian hospitals between January 2013 and August 2015. We asked women about physical exertion in the hour before symptom onset and compared this with their frequency of physical exertion over the prior week. Compared with times with light or no exertion, the risk of placental abruption was 7.8 (95% confidence interval (CI): 5.5, 11.0) times greater in the hour following moderate or heavy physical exertion. The instantaneous incidence rate ratio of placental abruption within an hour of moderate or heavy physical exertion was lower for women who habitually engaged in moderate or heavy physical activity more than 3 times per week in the year before pregnancy (rate ratio (RR) = 3.0, 95% CI: 1.6, 5.9) compared with more sedentary women (RR = 17.3, 95% CI: 11.3, 26.7; P for homogeneity < 0.001), and the rate ratio was higher among women with preeclampsia/eclampsia (RR = 13.6, 95% CI: 7.0, 26.2) than among women without (RR = 6.7, 95% CI: 4.4, 10.0; P for homogeneity = 0.07).

A Rare Cause of Supraventricular Ectopic Beats and Angina in a Young Patient

Abstract Introduction: We present the case of a young man with multiple atherosclerotic risk factors and a rare cause of angina and supraventricular ectopic beats. Case presentation: A 35-year-old man with one-year history of stable angina pectoris and supraventricular ectopic beats, without any medication, presented to the emergency room complaining of anterior chest pain that occurs at moderate physical exertion. The rest electrocardiogram, transthoracic echocardiography, and chest X-ray were normal; the exertion stress test was also normal, except for supraventricular ectopic beats (trigeminal rhythm). Due to the intermediate pre-test probability of coronary artery disease, he was evaluated using coronary computed tomography angiography. An anomalous origin of the right coronary artery from the left coronary sinus, with an inter-arterial course and without any atheroma plaques, was observed. During hospitalization the evolution was stable, without complications. The patient was further referred to a cardiac surgery clinic to evaluate the possibility of surgical treatment of this anomaly. Conclusions: Coronary artery anomalies are very rare; however, they present multiple implications in current practice. The most severe complication of this condition is represented by sudden death in young patients due to malignant ventricular arrhythmias. Imaging diagnostic techniques allow for a rapid, noninvasive diagnosis of this rare cause of angina.

Outcomes After Transcatheter Aortic Valve Replacement: A Propensity Matched Retrospective Cohort Study

To examine patient acuity and perioperative outcomes in a contemporary cohort of patients undergoing either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). A retrospective propensity-matched cohort study with univariable logistic regression to assess postoperative outcomes. Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. The study comprised 2,043 patients who underwent either TAVR or SAVR that was reported in the American College of Surgeons-National Surgical Quality Improvement Program. None. Age greater than 65 years, patients with dyspnea with moderate exertion or dependence in activities of daily living, high American Society of Anesthesiologists physical status classification, and history of chronic obstructive pulmonary disease were associated with TAVR, whereas body mass index greater than 25 was associated with SAVR. After propensity matching, no differences in 30-day mortality, length of stay, or most postoperative outcomes were observed between the 2 cohorts. Patients undergoing TAVR were less likely to require a perioperative blood transfusion and on an individual patient basis had a lower number of complications than patients in the SAVR group. Patients undergoing TAVR have similar mortality, length of stay, and risk for postoperative complications as do patients undergoing SAVR, but patients undergoing TAVR are less likely to have blood transfused.

Predictors of Readmission and Reoperation in Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism.

Objective Identify risk factors for 30-day reoperation and readmission after parathyroidectomy for primary hyperparathyroidism. Study Design Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012 through 2014. Subjects and Methods Patients undergoing parathyroidectomy and parathyroid reexploration for primary hyperparathyroidism. Univariate and multivariate analyses were conducted to determine risk factors for reoperation and readmission. Results Of the 9439 patients who underwent parathyroidectomy, 72 patients underwent 1 reoperation in the first 30 days after surgery, and 8 patients underwent 2 reoperations. The most common reasons were hematoma (25%) and persistent hyperparathyroidism (15.9%). Risk factors included smoking (odds ratio [OR], 1.86; 95% confidence interval [CI], 0.97-3.31), insulin-dependent diabetes (OR, 2.38; 95% CI, 1.02-4.86), and history of bleeding disorder (OR, 3.95; 95% CI, 1.48-8.79). In total, 182 (1.9%) patients were readmitted within 30 days of surgery; the most common cause was hypocalcemia (17.0%). Risk factors included operative time (hours) (OR, 1.3; 95% CI, 1.1-1.5), insulin-dependent diabetes mellitus (OR, 2.01; 95% CI, 1.2-3.3), dyspnea with moderate exertion (OR, 5.77; 95% CI, 0.86-14.67), and age (decade) (OR, 1.16; 95% CI, 1.02-1.32). Patients undergoing outpatient surgery were less likely to be readmitted (OR, 0.49; 95% CI, 0.35-0.69) or undergo reoperation (OR, 0.44; 95% CI, 0.27-0.73). Conclusions Thirty-day reoperation rate after parathyroidectomy was low and most commonly occurred due to hematoma. Risk factors for readmission were multifactorial and associated with perioperative factors, patient factors, and medical comorbidities. Preoperative counseling for patients at increased risk of readmission and reoperation may decrease these rates.

Perioperative Risk Factors Associated With Postoperative Unplanned Intubation After Lung Resection

Postoperative respiratory failure requiring reintubation is associated with a significant increase in mortality. However, perioperative risk factors and their effects on unplanned 30-day reintubation and postoperative outcomes after unplanned reintubation following lung resection are not described well. The aim of this study was to determine whether certain comorbidities, demographic factors, and postoperative outcomes are associated with 30-day reintubation after thoracic surgery. This was a retrospective observational study using multivariable logistic regression to identify preoperative risk factors and consequences of unplanned 30-day reintubation. Multi-institutional, prospective, surgical outcome-oriented database study. Using the American College of Surgeons National Surgical Quality Improvement Program database, video-assisted thorascopic surgery and thoracotomy lung resections (lobectomy, wedge resection, segmentectomy, bilobectomy, pneumonectomy) were analyzed by Common Procedural Terminology codes from the years 2007 to 2016 in 16,696 patients undergoing thoracic surgery. None. The final analysis included 16,696 patients, of who 593 (3.5%) underwent unplanned reintubation. Among the final study population, 137 (23%) of unplanned intubations occurred within 24 hours postoperatively and the median (25%, 75% quartile) day of reintubation was day 3 (2, 8 days). The final multivariable logistic regression analysis suggested that age, American Society of Anesthesiologists physical status classification score ≥4, dyspnea with moderate exertion and at rest, history of chronic obstructive pulmonary disease, male sex, smoking, functional dependence, steroid use, open thoracotomies, increased operation time, and preoperative laboratory results (albumin and hematocrit) were associated with unplanned intubation after lung resection (p < 0.05). Unplanned intubation was associated significantly with 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay (p < 0.05). Nonmodifiable and modifiable preoperative risk factors were associated with increased odds of unplanned reintubation. Patients who experienced unplanned intubation were at considerable risk for 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay.

Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery.

Morbidly obese patients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery. The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion. The rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9-7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05). Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.

Psychomotor performance of Polish Air Force cadets after 36 hours of survival training.

The preparation of Polish Air Force cadets for survival in isolation is a necessary element of their training, to demonstrate just how difficult can be the conditions they could encounter in a combat situation. Objective. The aim of the research was to assess the effect of long-term survival training on selected coordination motor skills in Air Force cadets. Fifteen air force cadets aged 19.6±0.3 years exercised for 36 hours during survival training without the possibility to sleep. They were examined 4 times: Day 1 - before effort (training), Day 2 - after 24 hours training, Day 3 - directly after 36 hours training, Day 4 - next day, after an all night rest. They were examined for shooting and reaction time, the ability to maintain body balance, running motor adjustment, handgrip force differentiation, and on Days 1 and 3, exercise capacity was evaluated with a 1 mile walking test. The survival training resulted in significant decreases in maximum handgrip strength, corrected 50% max handgrip, maintenance of body balance and heart rate. No changes occurred in reaction time, running motor adjustment and shooting performance. Overnight rest did not result in recovery of any of the examined factors to the values observed on Day 1. Survival training combined with sleep deprivation mostly affected peripheral factors depending on strong action from both muscles and nervous system, whereas complex tasks involving short-term central alertness and moderate exertion were maintained. In order to improve performance, more endurance strength training, if possible combined with sleep deprivation, should be introduced in military training.

Isolated subpulmonary ring accompanied by infundibular located hypertrophia

Congenital diseases causing obstruction of the right ventricular outflow tract (RVOT) are common, but the isolated subvalvular pulmonary stenosis is a very rare condition. Its diagnosis is obscure because of difficulty of comprehension of cardiac anatomy. We report a case of a 61-year-old female who presented for increasing shortness of breath on moderate exertion. Echocardiography showed an obstruction in the RVOT during systole by a subpulmonary fibrous ring with a mean gradient of 75mmHg through the ring. Under cardiopulmonary bypass, surgical resection was successfully performed. The patient continued to do well on follow-up in the out-patient clinic, 12 months postoperative.

Um caso clínico de sintomas urinários baixos

Introduction: Benign prostatic hyperplasia (BHP) is one of the most prevalent benign disorders in men. The diagnosis is essentially clinic and typically characterized by low urinary tract symptoms (LUTS), a frequent cause of clinical consultation with a significant impact on quality of life. However, as LUTS can have many etiologies, the journey to the final diagnosis can be a challenge for the family doctor. Case report: An 88 year-old male, with a previous history of BHP, knees osteoarthritis, arterial hypertension, atrial flutter, diabetes, parkinsonian tremor, heart failure and obesity. In June 2013, the patient reports a history of LUTS with years of evolution, with predominantly urine storage symptoms such as urgency, increased urinary frequency and a marked nocturia. He complains of progressive fatigue with years of evolution and dyspnea on moderate exertion. After introduction and optimization of therapy directed to BHP and heart failure, the patient kept avoiding the diuretic because it intensifies the urinary symptoms. In October 2014 after presenting failure of urinary symptom control despite therapy, the patient was referred to an urologist where the diagnosis of urethral stricture was made. Comment: The unusual urinary symptoms that the patient had, the inexistence of abnormal complementary tests results suggesting urethral stricture and the presence of several confounding factors (heart disease, diabetes and resistance in taking diuretic) contributed to the low suspicion of this diagnosis. However, the valorization of patient’s complaints and a systematic monitoring of patient’s symptoms over time were the key to the diagnosis and therapeutic choice in order to manage a better control of the patient’s complaints.

Aquatic activity and emotional experience in adults with severe mental illness

This study examined the relationship of aquatic activity to positive and negative emotion in individuals with a severe mental illness (SMI). Individuals with SMI have been found to experience decreased positive emotions and higher negative emotions as compared to controls. It was hypothesized that aquatic activity participation would be associated with greater positive emotion and lower negative emotion post participation. Eighteen participants with a severe mental illness were recruited from a community mental health center. The study employed a pre-post design with a structured aquatic activity designed for moderate physical exertion. Participants demonstrated statistically significant increase in positive emotion and decrease in negative emotion pre to post activity. The findings of this study provide support for the potential effect of aquatic activities in psychiatric rehabilitation.

Left main coronary artery compression due to pulmonary artery aneurysm: Three-year clinical and angiographic follow-up after stenting

We report a case of a 53-year-old male patient with typical angina and dyspnea with moderate exertion due to extrinsiccompression of the left main coronary artery (LMCA) by a pulmonary artery aneurysm. Coronary angiography demonstrated 90% stenosis of the LMCA ostium. Percutaneous coronary intervention was successfully performed with implantation of a 6.0 mm × 12 mm bare-metal stent guided by intravascular ultrasound (IVUS). He remained asymptomatic at three-years evaluation, and angiographic and IVUS follow-up showed no significant in-stent neointimal hyperplasia or luminal loss, with excellent apposition and covering of stent struts and minimal luminal area 23.3 mm 2 as measured by IVUS.

Reversible median nerve impairment after three weeks of repetitive work.

Objectives The aim of this study was to evaluate the development of impaired median nerve function in relation to hand-intensive seasonal work. We hypothesized that at end-season, median nerve conduction would be impaired and then recover within weeks. Methods Using nerve conduction studies (NCS), we examined median nerve conduction before, during, and after engaging in 22 days of mink skinning. For a subgroup, we used goniometry and surface electromyography to characterize occupational mechanical exposures. Questionnaire information on symptoms, disability, and lifestyle factors was obtained. Results The study comprised 11 male mink skinners with normal median nerve conduction at pre-season (mean age 35.7 years, mean number of seasons with skinning 8.9 years). Mink skinning was characterized by a median angle of wrist flexion/extension of 16º extension, a median velocity of wrist flexion/extension of 22 °/s, and force exertions of 11% of maximal voluntary electrical activity. At end-season, mean distal motor latency (DML) had increased 0.41 ms (P<0.001), mean sensory nerve conduction velocity (SNCV) digit 2 had decreased 6.3 m/s (P=0.004), and mean SNCV digit 3 had decreased 6.2 m/s (P=0.01); 9 mink skinners had decreases in nerve conduction, 5 fulfilled electrodiagnostic criteria and 4 fulfilled electrodiagnostic and clinical criteria (a positive Katz hand diagram) for carpal tunnel syndrome (CTS). Three to six weeks post-season, the changes had reverted to normal. Symptom and disability scores showed corresponding changes. Conclusions In this natural experiment, impaired median nerve conduction developed during 22 days of repetitive industrial work with moderate wrist postures and limited force exertion. Recovery occurred within 3-6 weeks post-season.

Association of Clinical Risk Factors and Postoperative Complications With Unplanned Hospital Readmission After Head and Neck Cancer Surgery

Unplanned hospital readmission is costly and in recent years has become a focus of health care legislation intended to reduce health care expenditures. Greater understanding of which perioperative complications are associated with hospital readmission after surgery for head and neck cancer is needed to reduce unplanned readmissions. To determine which clinical risk factors and complications are associated with 30-day unplanned readmission after surgery for malignant neoplasms of the head and neck. This retrospective longitudinal claims analysis included data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from January 1, 2012, to December 31, 2014. Patients undergoing surgery for malignant tumors of the head and neck were included; those with a primary diagnosis of thyroid malignant disease and those undergoing free autologous tissue transfer were excluded. Clinical risk factors and complications were analyzed for association with unplanned hospital readmission using multivariable regression analysis. Statistical significance was determined using P < .05. A total of 7605 patients (5007 men [65.8%]; mean [SD] age, 64.2 [0.2] years) were identified and included for analysis. Overall, 1472 complications occurred in 912 cases. Three hundred eighty-eight patients (5.1%) had an unplanned readmission, which was lower than the previously published overall readmission rate for noncardiac surgical procedures in the NSQIP (6.8%). Clinical factors that were independently associated with unplanned readmission were age (adjusted odds ratio [AOR], 1.12; 95% CI, 1.03-1.22), diabetes (AOR, 1.60; 95% CI, 1.01-2.43), preoperative dyspnea at rest (AOR, 2.89; 95% CI, 1.40-5.55) and with moderate exertion (AOR, 1.48; 95% CI, 1.01-2.11), long-term use of corticosteroids (AOR, 2.45; 95% CI, 1.63-3.58), disseminated cancer (AOR, 1.57; 95% CI, 1.14-2.20), and a contaminated wound (AOR, 2.05; 95% CI, 1.05-3.7). When specific complications were examined, superficial incisional surgical site infection (SSI) (AOR, 2.02; 95% CI, 1.14-3.40), deep incisional SSI (AOR, 2.57; 95% CI, 1.26-5.03), organ or space SSI (AOR, 13.27; 95% CI, 6.57-26.61), wound disruption (AOR, 3.58; 95% CI, 1.95-6.31), pneumonia (AOR, 3.39; 95% CI, 1.88-5.96), deep vein thrombosis (AOR, 5.60; 95% CI, 1.90-15.25), pulmonary embolism (AOR, 20.72; 95% CI, 7.86-55.68), urinary tract infection (AOR, 2.66; 95% CI, 1.00-6.34), stroke (AOR, 12.42; 95% CI, 3.99-36.50), sepsis (AOR, 2.64; 95% CI, 1.27-5.30), and septic shock (AOR, 4.12; 95% CI, 1.10-15.81) were all associated with 30-day unplanned hospital readmission. This study evaluated clinical factors and postoperative complications to determine which ones were associated with 30-day unplanned hospital readmission among patients undergoing surgery for malignant tumors of the head and neck. Further understanding of which complications are associated with unplanned readmission after head and neck surgery will allow for improved risk stratification and development of postoperative care protocols to reduce unplanned hospital readmission.

History Dependency of Muscle Strength Recovery from a Fatiguing Intermittent Task

Muscle fatigue and recovery are complex processes influencing muscle force generation capacity. While fatigue reduces this capacity, muscle recovery acts to restore the unfatigued muscle state. Many factors can potentially affect muscle recovery, among these may be a task dependency of recovery following an exercise. However, little has been reported regarding the history dependency of recovery after fatiguing contractions. Recently, we investigated the dependency of the fatigue process on cycle time during low to moderate exertion levels of intermittent muscle contraction (Rashedi &amp; Nussbaum, 2016). A dependency of localized muscle fatigue on cycle time was shown, even though there was a consistent level of overall physical demand. It was concluded that the difference in fatigue development might be related to recovery processes occurring during execution of the intermittent task. In the present study, we focused on the potential effect of contraction history on post-fatigue recovery. Based on the expected dependency of recovery to task demands during exercise, it was hypothesized that post-fatigue recovery will also be affected by the history of exercise-induced muscle fatigue. We examined the dependency of muscle recovery subsequent to four different histories of fatiguing muscle contractions, imposed using two cycle times (30 and 60 sec) during low to moderate levels (15% and 25% of maximum voluntary contraction (MVC)) of intermittent static exertions involving index finger abduction. All participants completed the intermittent contractions, in all four conditions, for 1 hour, and MVCs were obtained at fixed intervals during 1 hour of post-exercise recovery (i.e., at 0.2, 5, 10, 30, and 60 minutes). There was a clear and statistically-significant dependency of muscle recovery rate on the muscle capacity state existing immediately after fatiguing exercise. This dependency did not appear to be modified by either the cycle time or exertion level leading to that state. Similar results were found in the study of Iguchi et al. (2008), wherein the authors compared recovery between two different exertion histories while fatiguing muscles to the same level, though recovery was only monitored for 5 minutes. These results imply that the post-exercise rate of recovery is primarily influenced by the post-exercise muscle state. Such evidence may help improve existing models of muscle recovery (Rashedi &amp; Nussbaum, 2015b), facilitating more accurate predictions of localized muscle fatigue development (Rashedi &amp; Nussbaum, 2015a), and thereby helping to enhance muscle performance and reduce the risk of injury

English

AIM OF THE STUDY: Smokers with suspected COPD seek medical attention when they become dyspnoeic on mild to moderate exertion, but by than half of the ventilator reserves are lost irreversibly. Hence it seems logical to diagnose COPD early before development of significant symptoms. Since smoking cessation in COPD is found to reduce rapid decline of ventilator function in smokers and to make an attempt to quit smoking in south Indian population. MATERIALS AND METHODS: Patients attending outpatient department at MGM Govt. Hospital attached to KAPV Govt. Medical College, Tiruchirappalli. EASY ONE spirometer. TYPE OF STUDY: Unicentric Prospective description study. USEFULNESS OF THE STUDY: Chronic obstructive pulmonary disease (COPD) is a major case of chronic morbidity and mortality. Third leading cause of death in 2020Smoking cessation will improve quality of life and decrease the morbidity and mortality. CONCLUSION: 1. The most common age of first smoking is 18 years and all participants had started smoking by 26 years. 2. The youngest age of first smoking is at 16 years 3. The age of first smoking does not have significance with airflow limitation 4. The most common age group found is 39-49 years 5. The most prevalent BMI is 18.5-24.9 and does not have significance in respect to airflow obstruction . 6. SI has significant negative correlation with FEV1/FVC and Significant positive correlation coefficient with age. 7. The quantum of smoking correlates with severity of airflow obstruction as indicated by SI 8. There is 17.8% of asymptomatic smokers have airflow limitation in the form of obstructive lung disease. 9. There is 61.29% of asymptomatic smokers had mild COPD and 38.7% had moderate COPD as per GOLD guidelines 10. The FEV1/FVC ratio as a screening tool to detect the presence of COPD in asymptomatic smokers is established 11. Handheld in office spirometry is useful for screening the smokers for presence of airflow obstruction before significant symptoms. 12. MEF 25-75 also has significant positive correlation coefficient with FEV1/FVC ratio and significant negative correlation with SI

Viral Complications in an Elite Road Cyclist

HISTORY: A 48-year-old female elite road cyclist attended an international conference in Europe and contracted a virus while living in an isolated wing of housing with athletes she coached. During week 2, a Gulf region athlete became ill with 103°F degree fever, SOB, chest pain, coughing and joint pain; 2 additional athletes also became ill. Nine days after initial exposure to the symptomatic cyclists, the patient expressed the same symptoms. Treatment began after she was flown back to the USA. Chest pain has continued for over 1 year with moderate exercise. PHYSICAL EXAMINATION: In 2014, the athlete presented to the ED with 1020F fever, SOB, chest pain (8/10), nausea, vomiting. Symptoms changed to Strider breathing, SOB, chest pain, vomiting and muscle cramping. The patient was transferred to isolation ICU then released home after stabilization. Chest pain returned after increasing HR during moderate exercise, resulting in another hospital admission. DIFFERENTIAL DIAGNOSIS: Myopericarditis, MERS. TEST AND RESULTS: Echocardiogram: 6/2014 - EF 35-40% with posterior lateral wall motion abnormalities; 10/2014 - EF 60%, wall motion WNLs; 6/2015 - EF 48%, posterior lateral wall motion abnormalities; 10/2015 - EF 58%, wall motion WNLs. Heart catherizations (cath) indicated the following: 5/2014 EF 28%, posterior lateral wall motion abnormalities; 6/2014 EF 50%, no wall motion abnormalities, RHC WNLs; 12/2014 - RHC WNLs, 9/2015 EF - WNLs, RHC. EKG RESULTS: 6/2014 - Sinus bradycardia, nonspecific ST-T wave changes; same in 10/2014, and 10/2015. GXT RESULTS: 10/2014 - peak VO2 of 33.7, 9/2015 - peak VO2 of 34.4 - both stopped due to chest pain. Troponin: elevated in 6/2014, 10/2014, 6/2015, 9/2015. No evidence of troponin on 10/2015.; cMRI - no evidence of scarring. FINAL WORKING DIAGNOSIS: viral myopericarditis TREATMENT AND OUTCOMES: Treatment consisted of colchicine, indomethacin, and pain medications as needed (dilaudid, Norco). As of 10/2015, the athlete still remains on PRN dilaudid and still has unexplained chest pain with moderate exercise. There has been both physical and psychological improvement over time and less breakthrough pain with moderate exertion.

SIO management algorithm for patients with overweight or obesity: consensus statement of the Italian Society for Obesity (SIO).

In approaching the treatment of obesity, three major caveats, specific to this complex disease, need to be taken into consideration in order to avoid over-simplification. Firstly, obesity definition is currently based on the body mass index (BMI). However, BMI has two major limitations: it is not a measure of fat mass, and it does not convey any information on fat distribution and regional fat depots. These limitations are well known by the scientific community that is struggling to find ways to move beyond BMI in obesity classification. Secondly, for the reasons specified above, the development of comorbidities or complications, which occur in the vast majority of obese patients during the course of the disease, is not always linearly correlated with BMI. Many variables contribute to their manifestation beyond the degree of obesity: duration of disease, age, sex, fat distribution, genetic background, the degree of mechanical disability, etc. Thirdly, treatment options are now quite few. Their indications should take into account the severity of obesity together with the presence and severity of complications and age, in order to grade interventions; these varying from therapeutic lifestyle changes to bariatric surgery. In order to provide a staging system able to help clinicians in phenotyping obese patients, beyond BMI, Sharma and Kushner [1] developed the so-called EOSS (Edmonton Obesity Staging System) composed of the following five stages: 0. No apparent obesity-related risk factors (e.g., blood pressure, serum lipids, fasting glucose, etc., within normal range), no physical symptoms, no psychopathology, no functional limitations and/or impairment of well-being. 1. Presence of obesity-related subclinical risk factors (e.g., borderline hypertension, impaired fasting glucose, elevated liver enzymes, etc.), mild physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology, mild functional limitations, and/or mild impairment of well-being. 2. Presence of established obesity-related chronic disease (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate limitations in activities of daily living and/or well-being. 3. Established end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitations, and/or impairment of well-being. 4. Severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitations, and/or severe impairment of well-being. The EOSS has been validated as a system able to identify patients at increased mortality risk who therefore deserve more clinical and therapeutic attention [2]. We have taken advantage of this now well-established staging system to develop a therapeutic algorithmic chart (Fig. 1) that includes BMI, age and EOSS stages. At each intersection, a color code identifies the proposed preferred treatment option. Obviously, treatment options are not mutually exclusive, but have to be understood as additive (e.g., a patient eligible for bariatric surgery should continue to follow therapeutic lifestyle changes and, if needed, pharmacotherapy). Fig. 1 Treatment algorithm chart that takes advantage of the EOSS (Edmonton Obesity Staging System, see text and Ref. [1]). At each intersection a color code identifies the proposed preferred treatment option. Obviously, treatment options are not mutually exclusive ...

A rare case of ascending aortic stenosis

A 48-year-old woman was referred to an in-hospital cardiology evaluation after performing a transthoracic echocardiography (TTE) that indicated a severe aortic valvular stenosis. She had a cognitive delay, short stature and long-term symptoms of fatigue for moderate exertion. No history of syncope or angina. …

Community-acquired Stenotrophomonas maltophilia respiratory infection in an octogenarian patient

The opportunistic pathogen Stenotrophomonas maltophilia (SM) is an aerobic, gram-negative, glucose non-fermenting bacillus, which is associated with nosocomial infections including pneumonia, bacteraemia, urinary tract infections, endocarditis, meningitis, peritonitis, and others. It is isolated from 3.3% of respiratory cultures and 0.8% of positive blood cultures [1]. It is ubiquitous in the environment, but due to its low virulence does not usually cause community-acquired infections in healthy individuals. Almost 80% of infections caused by SM are nosocomial [2]. Few cases of community-acquired SM respiratory infections are described in the literature, and none of them in patient older than 80 years of age [3]. We present the case of an 85-year-old woman who attended the emergency department due to progressive dyspnoea over the previous 4 days, with coughing, hyaline expectoration, a fever of 38 8C, and tachypnea. Her medical history included hypertension, type-2 diabetes mellitus, obesity, chronic obstructive pulmonary disease, and chronic renal insufficiency. She was being treated with furosemide, prednisone, fluticasone propionate/salmeterol xinafoate, tiotropium bromide, aspirine, omeprazole, and insulin. Her baseline situation was defined as dyspnoea with moderate exertion. Her mobility was limited after a recent lumbar vertebral compression (Barthel index 25/100). She lived with a 24-h carer and had no cognitive deficits. Laboratory analyses revealed leucocyte and neutrophil counts of 15,900 [4000–10,000] and 14,600 [1800–7500], respectively; C-reactive protein, 14.70 mg/dL [0–5]; haemoglobin, 9.4 g/dL [11.5–15]; glucose, 302 mg/dL [70–110]; creatinine, 1.97 mg/dL [0.5–0.9]. Blood arterial gas showed pO2/pCO2 48/58 mmHg; 83% O2 saturation; pH, 7.34. Chest X-ray showed a mass in the apical