Moderate Exertion Research Articles

ECG de mayo de 2015

A 53-year-old woman without cardiovascular risk factors consulted for dyspnea on moderate exertion. She reported no further symptoms. She had blood pressure of 130/75 mmHg and no edema or other signs of congestion. She had no skin lesions or muscular weakness, although she reported that ‘‘exertion was difficult’’. Her mother died at 68 years of age after a stroke and a brother received a kidney transplant at 42. Both were told that they had ‘‘cardiac hypertrophy’’. A maternal aunt is hypertensive, has mild concentric ventricular hypertrophy, and required a pacemaker at 60 years of age. This is the ECG obtained in the clinic (Figure). What would your diagnosis be?

Ivemark syndrome with cor triatriatum, primum ASD, cleft mitrale and pulmonary stenosis

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.

Clothing Adjustments for Concealed Soft Body Armor During Moderate Physical Exertion

Previous research has studied the impact of Level II concealed soft body armor (SBA) on the augmentation of heat storage in a hot environment simulating a typical summer day in the southeastern United States (wet bulb globe temperature [WBGT] = 30°C) and noted a significant difference between macro- and micro-WBGTs. The purpose of this study was to characterize the microclimate (micro-WBGT) under a concealed Level II SBA during 60 min of moderately intense work at two separate macro-WBGTs (26°C and 30°C), and to establish WBGT corrections to allow prediction of heat strain in an individual wearing a concealed Level II SBA. A single trial was performed with nine volunteers (27 ± 4 years) outfitted with a simulated standard law enforcement uniform and a traditional concealed Level II SBA, in a moderately warm environment (WBGT = 26°C). Each participant performed cycles of 12 min of walking (1.25 L · min−1) and 3 min of arm curls (14.3 kg, 0.6 L · min−1) with a 5 min rest after every other cycle, for a total of 60 minutes. This trial was compared to an identical previously completed 60-min work bout at 30°C. A two-way repeated measures ANOVA with Post hoc Bonferroni and paired samples t-test analysis was conducted. A greater difference between macro- micro-WBGTs existed at 26°C compared to the 30°C macro-WBGT. Under these conditions, a moderate work in Level II SBA requires a WBGT correction of 8.9°C and 6.2°C at macro-WBGTs of 26°C and 30°C, respectively. A modified simple linear regression prediction model was established for mean Micro-WBGT for each macro-WBGTs after the plateau point at the 30 min mark. The derivation regressions at 26°C (R2 = 0.99), and 30°C (R2 = 0.99) indicate that micro-WBGT could be predicted for each 15 minutes time at both macro-WBGTs tested for individuals doing moderate intensity (300 Kcals · hr−1) work wearing concealed Level II SBA.

Giant Left Ventricular Pseudoaneurysm after Acute Myocardial Infarction Secondary to Cocaine Use

The patient is a 19-year-old male that reported a 7-year history of regular cocaine presenting at this moment with dyspnea after moderate exertion, orthopnea and paroxysmal nocturnal dyspnea for 30 days. The echocardiogram and the cardiac magnetic resonance imaging showed a giant left ventricle pseudoaneurysm secondary to the usage of cocaine and previous myocardial infarction. The combination of these situations made this patient a unique case. We showed that the surgical treatment may be an option.

Case Report: Autoimmune Hemolytic Anemia with Venous Thromboembolism, a Common Complication of a Rare Disease

IntroductionAutoimmune hemolytic anemia (AIHA) is accelerated erythrocyte destruction by binding of IgG (80%) or IgM (20%) antibodies with red blood cell (RBC) antigens, leading to formation of spherocytes and eventual phagocytosis in the spleen. Its incidence is 1 in 80,000 to 100,000 of a given population/year in the Caucasians. Its peak incidence is in 60-70 years of age with male: female ratio of 40:60. Although rare in incidence, AIHA is the most common cause of acquired hemolytic anemia. Multiple triggering factors have been described for AIHA that includes idiopathic, genetic, infection, inflammatory disorders, drugs and lymphoproliferative disorders. Venous thromboembolism (VTE) is a more serious, acute, overlooked and often-lethal complication of AIHA. Several studies including a review of 47 patients with AIHA supporting the existence of a prothrombotic state in patients with AIHA revealed that pulmonary embolism was the most common cause of death. It is essential to recognize and treat VTE, and thromoboprophylaxis measures should be taken to prevent VTE associated morbidity and mortality.Case summaryPatient is a 76 year-old-Caucasian-female with medical history significant for peptic ulcer disease and hypertension presented with 1-month history of dyspnea on moderate exertion and a near syncopal episode a week prior. Vital Signs revealed tachycardia at 100/min. Physical examination depicted marked pallor in the conjunctiva and on palmar creases with no lymphadenopathy, murmurs, hepatosplenomegaly, petechiae, purpura and peripheral edema. Lab test revealed hemoglobin 3.8 g/dl, platelets 205 X 109/L, reticulocytes 10.3%, absolute reticulocyte count 3.8, haptoglobin 142 and LDH 337 U/L. Peripheral smear revealed spherocytes, and schistocytes with unremarkable platelets and leukocytes. Direct coombs test revealed strongly positive IgG. Hemoglobin was stabilized after 4 units of packed red blood cells transfusion, started on oral methyl-prednisolone at 1 mg/Kg/d with a prolonged taper course and discharged upon clinical improvement. After 2 weeks, she presented with progressively increasing swelling of both legs and increasing tiredness. Vitals signs were stable. Physical examination was remarkable for bilateral mid-shin level pitting edema with normal distal pulsations. Lab values revealed low hemoglobin, slightly increased LDH and mildly high absolute reticulocyte count. Bilateral lower extremity venous doppler showed extensive deep vein thrombosis (DVT) of the right and left common femoral veins, right proximal femoral vein, left femoral vein and left popliteal vein. She was started on IV heparin and coumadin, continued oral methyl-prednisolone at 1 mg/Kg/d and added rituximab scheduled infusion. She was clinically improved on discharge.DiscussionThere are various proposed mechanisms of VTE formation in AIHA such as loss of RBC membrane with exposure of phosphotidyl serine and subsequent formation of tenase and prothrombinase complexes, increased tissue factor expression by the endothelial cells, and sequestration of nitric oxide released from RBC. In a recent review, it was found that 27% of AIHA patients suffered from an episode of VTE. Out of 8 patients with VTE, 5 had lupus anticoagulant antibody (LA) and 4 had anti-cardiolipin antibody (ACC). Thrombosis also occurred in 15% of AIHA with no LA and ACC, so multifactorial interplay seems more likely. In an audit of prophylactic anticoagulation in acute exacerbation of severe AIHA, VTE occurred in 5 of 15 patients without anticoagulant prophylaxis. VTE occurred in only 1 of 21 patients with anticoagulant prophylaxis. In conclusion, it is essential to recognize this acute, serious and deadly complication. It is premature to recommend routine use of thromboprophylaxis for all patients with hemolytic episodes from AIHA. Based on the studies, coexisting ACC and LA are strong predictive risk factors for VTE in AIHA and can benefit from thromboprophylaxis. We need more clinical investigations to develop core clinical and laboratory criteria to stratify VTE risk in AIHA patients. DisclosuresNo relevant conflicts of interest to declare.

Rating of perceived exertion and acute mountain sickness during a high-altitude trek.

There is a widely held belief that strenuous exercise should be avoided on arrival at high altitude (HA) and during acclimatization. Data from chamber studies are contradictory and the studies are usually of short duration, therefore differing from the "real world." We studied 48 trekkers during a 10-d ascent to 16,827 ft (5129 m) in the Cordillera Real area of Bolivia. Borg Rating of Perceived Exertion (RPE) scores were recorded for the hardest perceived exertion during the day after ascents to 12,576, 14,600, and 16,827 ft (3833, 4450, and 5129 m). Heart rate, Spo2, and Lake Louise Score (LLS) were recorded simultaneously. Statistical testing was performed using SPSS 21 software. A P-value of ≤ 0.05 was deemed significant. Acute mountain sickness (AMS) rates were higher after trekking days with higher levels of perceived exertion. The LLS was higher in those with a Borg RPE score ≥ 15 both following exercise (mean LLS 2.6 vs. 1.7) and at rest the following day (mean LLS 2.7 vs. 1.7). Heart rate was higher in those with high Borg RPE scores (80 vs. 87) and oxygen saturations lower at rest (86 vs. 83) the following morning. This data lends weight to the advice of moderate exertion during a trek to HA and suggests that reducing perceived exertion may reduce AMS.

Management of Type 2 Diabetes Mellitus in Self-Motivated Patients: Optimized Diet, Exercise, and Medication for Weight Loss and Cardiometabolic Fitness

Type 2 diabetes mellitus (T2DM) is a growing public health problem with significant lifetime health care costs. The majority of Americans do not achieve minimal targets for exercise, and individuals with T2DM typically engage in less exercise than the general adult population. However, those patients with T2DM who are sufficiently self-motivated to manage their condition have the potential to reverse diabetes and prevent its complications through behavioral and pharmacologic interventions. Marked improvements are possible through increased awareness and selection of healthy eating options, a willingness to incorporate vigorous exercise into their lifestyle, and the use of newer medications that essentially eliminate the risk of hypoglycemia while facilitating weight loss and the achievement of ideal glucose targets. For self-motivated patients, daily aerobic activity of 45 to 60 minutes per day may be a suitable target. For those who have cardiovascular clearance, high-intensity interval training accomplishes high levels of cardiometabolic fitness with shorter training periods by alternating moderate and intense exertion. Suitable medications that have a low risk of hypoglycemia during exercise include metformin, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, and sodium-glucose linked transporter-2 inhibitors. Specific daily caloric goals and incorporation of a mainly plant-based diet should be considered as a primary target for diabetes management. Self-management is important to achieving diabetes treatment goals, and mobile applications can be useful tools to support lifestyle changes in patients with T2DM.

Tai Chi and meditation-plus-exercise benefit neural substrates of executive function: a cross-sectional, controlled study.

We report the first controlled study of Tai Chi effects on the P300 event-related potential, a neuroelectric index of human executive function. Tai Chi is a form of exercise and moving meditation. Exercise and meditation have been associated with enhanced executive function. This cross-sectional, controlled study utilized the P300 event-related potential (ERP) to compare executive network neural function between self-selected long-term Tai Chi, meditation, aerobic fitness, and sedentary groups. We hypothesized that because Tai Chi requires moderate aerobic and mental exertion, this group would show similar or better executive neural function compared to meditation and aerobic exercise groups. We predicted all health training groups would outperform sedentary controls. Fifty-four volunteers (Tai Chi, n=10; meditation, n=16; aerobic exercise, n=16; sedentary, n=12) were tested with the Rockport 1-mile walk (estimated VO2 Max), a well-validated measure of aerobic capacity, and an ecologically valid visuo-spatial, randomized, alternating runs Task Switch test during dense-array electroencephalographic (EEG) recording. Only Tai Chi and meditation plus exercise groups demonstrated larger P3b ERP switch trial amplitudes compared to sedentary controls. Our results suggest long-term Tai Chi practice, and meditation plus exercise may benefit the neural substrates of executive function.

Does mental exertion alter maximal muscle activation?

Mental exertion is known to impair endurance performance, but its effects on neuromuscular function remain unclear. The purpose of this study was to test the hypothesis that mental exertion reduces torque and muscle activation during intermittent maximal voluntary contractions of the knee extensors. Ten subjects performed in a randomized order three separate mental exertion conditions lasting 27 min each: (i) high mental exertion (incongruent Stroop task), (ii) moderate mental exertion (congruent Stroop task), (iii) low mental exertion (watching a movie). In each condition, mental exertion was combined with 10 intermittent maximal voluntary contractions of the knee extensor muscles (one maximal voluntary contraction every 3 min). Neuromuscular function was assessed using electrical nerve stimulation. Maximal voluntary torque, maximal muscle activation and other neuromuscular parameters were similar across mental exertion conditions and did not change over time. These findings suggest that mental exertion does not affect neuromuscular function during intermittent maximal voluntary contractions of the knee extensors.

Intra-dialytic training accelerates oxygen uptake kinetics in hemodialysis patients.

End-stage renal disease is associated with several hemodynamic and peripheral muscle abnormalities that could slow the rate of change in oxygen uptake ([Formula: see text]O2) at the onset and at the end of exercise. This study was performed to determine whether an intra-dialytic aerobic training program would speed [Formula: see text]O2 kinetics at the transition to and from moderate and high-intensity exercise. This study was a randomized controlled trial. Twenty-four patients with end-stage renal disease (14 females; 47.0 ± 11.9 years) were randomly assigned to either 12-week cycle ergometer-based training at moderate exertion or a similar control period. At initial and final evaluations, patients underwent 6 min moderate and high-intensity tests to exercise intolerance (Tlim). Training improved Tlim by ∼90% (median (inter-quartile range) = 232 (59) s to 445 (451) s, p < 0.05); in contrast, Tlim decreased by ∼30% in controls (291 (134) s to 202 (131) s). [Formula: see text]O2 kinetics at the onset of moderate-intensity exercise were significantly accelerated with training leading to lower oxygen (O2) deficit (mean ± standard deviation (SD) = 3.2 ± 1.3 l vs 2.3 ± 1.2 l). Similar positive effects were found at the high-intensity test either at the onset of, or recovery from, exercise (p < 0.05). "Excess" [Formula: see text]O2 at the high-intensity test was also lessened with training. Changes in Tlim correlated with faster [Formula: see text]O2 kinetics and lower "excess" [Formula: see text]O2 (Spearman's ρ = -0.56 and -0.75, respectively; p < 0.01). A symptom-targeted intra-dialytic training program improved sub-maximal aerobic metabolism and endurance exercise capacity. [Formula: see text]O2 kinetics are valuable in providing relatively effort-independent information on the efficacy of exercise interventions in this patient population.

A 26-Year-Old Man With a Slowly Growing Heterogeneous Intrathoracic Mass

A 26-year-old man presented with complaints of left-sided chest pain and shortness of breath with moderate exertion, of 6 month duration. The patient had a history of asthma but reported that the exertional shortness of breath was not like his typical asthma symptoms and was not associated with wheezing. The left-sided chest pain was a dull and constant ache, without any aggravating or relieving factors. The patient denied fever, chills, night sweats, cough, or weight loss. Past medical history was significant for asthma since childhood, which was well controlled on budesonide inhaler. He had received a gunshot wound 1½ years earlier and had abdominal surgery at that time “to stop the bleeding,” but records of the procedure were not accessible.

Fatigue as a Predictor of Outcome in Patients With Heart Failure: Analysis of CORONA (Controlled Rosuvastatin Multinational Trial in Heart Failure)

The purpose of this study was to examine the relationship between fatigue and clinical outcomes, using dyspnea as a comparator, in patients with left ventricular ejection fraction (LVEF) ≤35% enrolled in the CORONA (Controlled Rosuvastatin Multinational Trial in Heart Failure) study. Although fatigue is a common symptom in heart failure (HF), little is known about its association with prognosis. At baseline in CORONA, fatigue "during the past few days" was measured using a 5-point exertion scale (0 = none, 1 = heavy exertion, 2 = moderate exertion, 3 = slight exertion, 4 = rest); a 4-point scale was used for dyspnea (1 to 4 as for fatigue). Patients were grouped into 3 categories: a fatigue score 0 to 1 (n = 535), fatigue score 2 (n = 1,632), and fatigue score 3 to 4 (n = 1,663); and a dyspnea score of 1 (n = 292), dyspnea score of 2 (n = 1,695), and dyspnea score of 3 to 4 (n = 1,843). The association between fatigue and dyspnea and the composite outcome of cardiovascular (CV) death or HF hospital stay and each component separately was examined using Kaplan-Meier analysis and Cox proportional-hazard models. We also examined all-cause mortality. In univariate analyses, symptom severity was associated with a higher risk of CV death or HF hospital stay (fatigue: group 3, 49% [n = 810], vs. group 1, 30% [n = 160]; dyspnea: group 3, 50% [n = 918], vs. group 1, 28% [n = 82]) and all-cause mortality (fatigue: group 3, 38% [n = 623], vs. group 1, 24% [n = 130]; dyspnea: group 3, 38% [n = 697], vs. group 1, 23% [n = 66], log-rank p < 0.0001 for all). After adjusting for other prognostic variables, including LVEF, New York Heart Association class, and N-terminal pro-B-type natriuretic peptide level, worse fatigue remained associated with higher risk of HF hospital stay but not mortality (worse dyspnea remained associated with a higher risk of both). An increase in fatigue (or dyspnea) between baseline and 6 months was also associated with worse outcomes. In HF, greater fatigue is associated with worse clinical outcomes. Closer attention should be paid to this symptom in clinical practice, with more done to standardize its measurement and understand its origins, with a view to improving treatment.

Abstract MP82: Exergaming and Physical Activity Guidelines- A Population-Based Study of Young Adults

Background: Compared to traditional non-active video games, exergaming may contribute significantly to overall daily physical activity (PA), but the association in population-based samples has not been fully explored. Objectives: To assess whether total minutes of PA per week among exergamers differs from non-exergamers, and whether the likelihood of meeting PA guidelines differs between exergamers and non-exergamers. Methods: Data were available from the 2011-2012 wave of the Nicotine Dependence in Teens (NDIT) study (n=829). Multivariable models assessed the association between exergaming with moderate, vigorous, and moderate-to-vigorous PA (MVPA) minutes in the past week, and the association between exergaming and meeting PA guidelines after adjusting for age, household income, employment status, education, weight status, and screen time. Exergaming was defined as use ≥ 1-3 times per month in the past year, and PA guidelines were defined as ≥ 150 minutes of moderately intense PA, or ≥ 75 minutes of vigorously intense PA, or a combination. Minutes of PA were measured using the well-validated International Physical Activity Questionnaire. Sex differences in exergaming use and exergaming beliefs and attitudes were also assessed. Results: In this population-based sample of young adults (mean age 24 [SD: 0.7] years, 55% female [n=455]), 18% (n=148) of the participants were exergamers (54% female, n=80). Exergaming males and females reported an average of 88.4 and 65.7 exergaming minutes in the past week, respectively. Compared to male exergamers, female exergamers were more likely to believe that exergaming is a good way to integrate PA into their lives (p&lt;0.001), were more likely to prefer exergaming to indoor/outdoor sports (p=0.03), and were more likely to use fitness-training exergames at home (p=0.006). Perceived levels of exertion were also significantly different between male and female exergamers. The majority of male exergamers reported light (51%, n=23) or moderate (44%, n=20) exergaming exertion, whereas female exergamers reported moderate (53%, n=30), as well as light (28%, n=16) and intense (19%, n=11) exertion (p=0.02). After adjusting for covariates, male exergamers were not significantly different from male non-exergamers in total minutes of PA per week, but female exergamers reported 47 more minutes of moderate PA in the past week compared to female non-exergamers (p=0.03). There was no association between exergaming and meeting PA guidelines in either males or females. Conclusions: Exergaming contributes to moderate-intensity PA among females but not among males in this population based sample of young adults. Exergaming may therefore be an important source of PA for women, but the current landscape of exergames may be inadequate to substantially increase minutes of PA among males. Differences in attitudes toward exergaming should be further explored.

Scimitar Syndrome: The Role of Cardiac Magnetic Resonance

A 35-year-old woman with no relevant medical history presented with dyspnea on moderate exertion. Physical examination detected a mild mid-systolic murmur, and the electrocardiogram showed negative T waves in the right precordial leads. On chest radiography, the right lung was mildly hypoplastic and showed a linear opacity (Figure 1A, arrow), corresponding to a vascular structure (scimitar sign). Transthoracic echocardiography showed dilation of the right chambers with no pulmonary hypertension, and venous flow entering the inferior vena cava (Figures 1B–D). The transesophageal echocardiogram additionally revealed an ostium secundum atrial septal defect with a left-to-right shunt (Figure 1E). Magnetic resonance imaging confirmed the diagnosis of a large supradiaphragmatic right pulmonary vein draining into the left inferior vena cava adjacent to the right atrium (Figures 1F and 2A, arrow). Based on the patient’s symptoms and the significant systemic-pulmonary shunt (Qp/Qs, 1.9:1.0), a decision was made to perform corrective surgery of the partial anomalous pulmonary venous drainage. The atrial septal defect was widened and a polytetrafluoroethylene tube was placed within the right atrium, redirecting flow from the inferior vena cava to the left atrium through the defect. The patient was discharged 7 days postprocedure, with no complications. At 3 weeks, cardiac magnetic resonance showed that the tube was patent (Figure 2B, asterisk) and the size of the right ventricle had returned to normal. At 6 months, the patient was asymptomatic. In this case, cardiac magnetic resonance imaging enabled confirmation of the diagnosis of partial anomalous pulmonary drainage, selection of the best surgical technique, and precise patient follow-up. Figure 1. Figure 2.

Fan-precooling effect on heat strain while wearing protective clothing

This study compared heat strain during walking while wearing impermeable protective suits between fan-precooling and nonprecooling conditions. Six males engaged in 60 min of walking at a moderate speed (∼2.5 km/h) in a hot environment (37 °C, 40% relative humidity). Fanning using a fan (4.5 m/s) and spraying water over the body before wearing the suits produced significantly lower rectal temperature before the walking (37.3 ± 0.1 °C vs. 37.0 ± 0.1 °C, P < 0.05). In addition, whilst walking, rectal temperature was significantly lower in the precooling condition (maximum difference: 0.4 °C at 15 min of walking; 38.0 ± 0.1 °C vs. 37.8 ± 0.1 °C at the end of walking, P < 0.05). Although skin temperature decreased during fanning, no difference was observed during walking. Heart rate was lower in the precooling condition during the early stages of walking. Thermal and fatigue perceptions whilst walking did not differ between the conditions. Body weight loss was significantly lower in the precooling condition. These results may indicate that fan precooling attenuates exertional heat strain while wearing impermeable protective clothing. The fan-cooling method is practical, convenient, and yields lower heat strain during prolonged moderate exertion.

The Inflammatory Response To Cardiopulmonary Exercise Testing In Children and Young Adults With Sickle Cell Anemia

Sickle cell anemia (SCA) is associated with a pro-inflammatory state that worsens during disease complications. Although exercise limitation and poor physical functioning are prevalent in SCA, concerns about the adverse effects of physical exertion in SCA have hampered development of exercise guidelines in this population. The acute phase inflammatory response to moderate or high grade physical exertion has not been examined in SCA. We aimed to characterize the acute inflammatory response to exercise in children and young adults with SCA undergoing maximal cardiopulmonary exercise testing (CPET). Methods60 subjects (mean age 15.1 ±3.4 years) with SCA (Hb SS or S/β0 thalassemia) and 25 race-matched, healthy controls (mean age 14.4 ±3.6 years) without sickle cell trait performed a maximal ramp cycle ergometry protocol. Blood was drawn at baseline before CPET (Pre) and at T0, T30, T60, and T120 min after CPET. Blood was analyzed for WBC, absolute neutrophil and monocyte counts, platelet count, CRP and D-dimer. Circulating levels of soluble vascular cell adhesion molecule (sVCAM) and IL-6 were determined by ELISA. Our primary outcome was the acute change in sVCAM from baseline to immediately after CPET (T0-Pre). Only subjects and controls with all available time points were analyzed. Continuous variables were compared between groups by Student t-test or Mann Whitney Wilcoxon Test. We used MANOVA to determine if inflammatory responses were similar in shape over time between groups. ResultsAll subjects with SCA and controls met criteria for maximal effort on CPET. We found no difference in the acute sVCAM response to exercise challenge in subjects with SCA vs. controls. Mean sVCAM level was significantly higher at baseline in subjects with SCA vs. controls (1644 ±888 vs. 1118 ±529 ng/mL, p = 0.043), and this difference remained significant at each time point after CPET. However, mean change in sVCAM level from baseline to T0 (T0-Pre) was not significantly different between groups (120 ±241 vs. 65 ±216 ng/mL, p = 0.461) even after controlling for fitness level, defined by peak VO2 (Table). The mean difference in sVCAM between subjects with SCA and controls by MANOVA was constant over time (F(3.3, 167.1) = 1.12, p = 0.347), indicating the acute sVCAM response to CPET through recovery followed similar trends in both groups. We found the acute sVCAM response to exercise was related to fitness in subjects with SCA. Mean change in sVCAM (T0-Pre) was inversely related to peak VO2 (Pearson's r = -0.41, p = 0.012) in subjects with SCA, supported by a downward trend in mean T0-Pre for sVCAM with increasing tertiles of fitness. We also examined the acute phase response to CPET of other inflammatory biomarkers. WBC, absolute neutrophil and monocyte counts, platelet count and D-dimer, but not IL-6 or CRP, were significantly higher at baseline in subjects with SCA vs. controls, and similar to sVCAM, this difference remained significant at each time point after CPET. Only the mean change from baseline to T0 (T0-Pre) for platelet count (8 ±59 vs. 42 ±23 x103/mL, p = 0.008) and D-dimer (0.13 ±0.28 vs. 0.01 ±0.09 mg/mL, p = 0.003) were significantly different between groups. We found no consistent relationship between secondary biomarkers and peak VO2 in subjects in SCA. Only the acute platelet response to CPET through recovery differed between groups over time (F(2.1, 153.8) = 4.07, p = 0.017) due to the greater mean T0-Pre for platelet count in controls. ConclusionsCompared to peers, children and young adults with SCA have similar trends in their acute phase response to maximal CPET through recovery regardless of fitness level and despite elevated inflammatory biomarkers at baseline and after CPET. This suggests that maximal exercise challenge in SCA is not associated with any greater escalation of inflammation. Further studies evaluating exercise and physical activity, even at maximal levels, should be encouraged in this population. Disclosures:Thompson:Novartis: Consultancy, Research Funding; ApoPharma: Consultancy, Honoraria; Glaxo Smith Kline: Research Funding; Eli Lilly: Research Funding; Amgen: Research Funding; bluebird bio: Research Funding. Liem:NHLBI: Research Funding.

Giant pulmonary mass complicating pulmonary homograft replacement

A 40-year-old male with a history of i.v. drug abuse was referred to our hospital because of dyspnoea. He had a history of pulmonary valve replacement for native valve endocarditis in 2001 and pulmonary homograft was implanted 2 years later because prosthetic endocarditis. The patient complained of dyspnoea on moderate exertion ( New York Heart …

Methotrexate lung toxicity

Methotrexate (MTRX) is a folic acid analogue with anticancer and immunomodulatory action. It is often used in the control of rheumatoid arthritis (RA). The toxicity may affect the lungs, liver and bone marrow. Case: a woman who is 64years old who has a history of RA controlled with MTRX of five years long. The recourse was to go to the hospital with complaints of dry cough and dyspnea on moderate exertion with one month of evolution and discharged from the hospital with the diagnostic of infection and treated with antibiotics.

Bronchiolitis Obliterans Associated with Stevens-Johnson Syndrome and Response to Azathioprine

To the Editor: Stevens-Johnson syndrome (SJS) is an acute, self-limiting, immune-complex mediated hypersensitivity disorder of skin and mucus membranes. Though acute pulmonary complications are well described, persistent pulmonary sequelae associated with SJS are rare [1]. We describe severe progressive form of bronchiolitis obliterans (BO) following SJS and good response to azathioprine. A 9-y-old boy developed SJS following oral ibuprofen prescribed for febrile illness. A week later, he developed persistent cough, wheezing and progressive respiratory distress. At admission, he had tachypnea, retractions, extensive wheezing and crepitations with hyperpigmented scars, cicatrical ectropion in the left eye and dystrophic changes in nails. Oxygen-saturation was 87 % in room-air. Pulmonary function test showed severe obstruction with no response to bronchodilators. Chest-radiograph and high-resolution computerized tomography were consistent with BO (Figs. 1 and 2). He received supplemental oxygen, β2-agonist and budesonide inhalations, chest-physiotherapy and prednisolone. Azithromycin three times a week was also added. At 2-mo follow-up, he had persistent cough, exertional dyspnea and wheeze for which azathioprine was added as a steroid sparing agent. At 1-year follow-up, the patient improved clinically and was able to do his daily activities at home. Oxygenation and PFT improved. Although, he had dyspnea on moderate exertion, intermittent cough with wheeze, the symptoms had not worsened and the disease appeared to be controlled. BO may occur within days after SJS even when the initial pulmonary involvement is not severe [1]. The association of non-steroidal anti-inflammatory drugs like ibuprofen with SJS is well known [2]. The findings of mosaic perfusion, vascular attenuation and central bronchiectasis onHRCTare diagnostic of BO obviating the need for lung-biopsy in a consistent clinical setting, as in index case [3]. The anti-inflammatory effects of corticosteroids justify their use in the early phases. We added immune-modulator azathioprine which suppresses lymphocyte proliferation and decreases CD8+ lymphocyte subpopulation, as a corticosteroid sparing agent for control of inflammation. Previous anaecdotal reports in adults have suggested that azathioprine might be useful as a corticosteroidsparing agent for the treatment of organizing pneumonia [4]. Moreover, drugs like mycophenolate mofetil and azathioprine have also been used for prevention of bronchiolitis obliterans

Typical angina without significant coronary stenosis

The spectrum of patients with 'angina and normal coronary arteries' ranges from severe vasospasm to atypical chest pain. Among those with typical angina, however, little is known about similarities in the clinical profile and circadian presentation between typical nonvasospastic angina and normal coronary arteries (tANCA) and vasospastic angina (VA). Clinical, ECG, and angiographic features as well as the circadian characteristics of angina were compared between 384 tANCA and 273 VA patients. Follow-up events were also analyzed. tANCA patients had greater female predominance (61 vs. 18%), higher incidence of dyspnea to moderate exertion (49 vs. 12%), lower incidence of tobacco smoking (25 vs. 67%), but a similar low rate of diabetes (8.9 vs. 4.4%). In both groups, however, dyspnea and smoking were associated with female and male sex, respectively. tANCA patients showed lower but non-negligible frequency of early morning (25 vs. 67%) and evening angina (37 vs. 54%), similar rate of nocturnal angina (47 vs. 50%), and higher rate of emotional angina (49 vs. 31%). Moreover, a high proportion of patients gained pain relief with nitroglycerin (97% in VA, 246/253, and 76% in tANCA, 231/306). At 140 months, frequent angina (>10 episodes/year) was rare (VA: 7.1% vs. tANCA: 6.3%) as was the rate of cardiac death/myocardial infarction (7.3 vs. 6.0%, P=0.524). Despite differences in the clinical profile between VA and tANCA patients, there is notable sharing of circadian presentation of rest angina, response to nitroglycerin, and long-term presence and frequency of angina that suggests more similarities in underlying mechanisms than heretofore suspected.