Hepatopulmonary syndrome in a 22 year old gentleman with liver cirrhosis

Background: Hepatopulmonary syndrome is a severe complication of end-stage liver disease characterized by triad of liver disease, intrapulmonary vascular dilatation, and arterial hypoxemia. Although the pathogenesis is not completely understood, pulmonary vascular dilatation occurs due to imbalance between vasodilators and vasoconstrictors. Liver injury is thought to increase endothelin production and cause bacterial translocation, causing increased nitric oxide production, causing vasodilation of pulmonary vasculature. History and physical examination are important in leading the physician to the correct diagnosis as the majority of these patients present with non-specific clinical manifestations and imaging. Identification of specific physical exam findings is important in not missing key features of a patient’s physical exam which will give you direction to a diagnosis of hepatopulmonary syndrome. Case Presentation: We are presenting a 22-year-old hispanic male with past medical history of nonalcoholic steatohepatitis-related liver cirrhosis with evidence of portal hypertensive gastropathy with esophageal varices who presented with intermittent dyspnea and desaturation. Physical exam did not have overt signs of volume overload and was positive for platypnea and orthodeoxia. ABG revealed hypoxemia with PaO2 of 66 and orthodeoxia. Diagnosis of hepatopulmonary syndrome was confirmed with contrast Echo ordered which revealed normal ejection fraction and showed R to L shunting by agitated saline contrast. The patient was managed with medical and oxygen therapy. He was discharged home on oxygen therapy as he improved. Patient evaluated by a hepatologist outpatient and placed on the liver transplant list. Discussion: Hepatopulmonary syndrome can often be missed due to its nonspecific presentation. Dyspnea is its most common presenting symptom. However, being aware of other presenting symptoms are key to diagnosis; such as platypnea and orthodeoxia, as present in our case. Obtaining Echo with contrast is important as it will confirm the presence of an intrapulmonary shunt. Differentiating an intracardiac shunt vs intrapulmonary shunt is important. With an intracardiac shunt, contrast appears in the left heart within three heart beats after injection, however, with an intrapulmonary shunt, contrast appears in the left heart after three beats as in our patient. Once diagnosed, oxygen therapy is recommended. Liver transplantation is the only effective therapy

Phase Coexistence and Edge Currents in the Chiral Lennard-Jones Fluid

We study a model chiral fluid in two dimensions composed of Brownian disks interacting via a Lennard-Jones potential and a non-conservative transverse force, mimicking colloids spinning at a rate $\omega$. The system exhibits a phase separation between a chiral liquid and a dilute gas phase that can be characterized using a thermodynamic framework. We compute the equations of state and show that the surface tension controls interface corrections to the coexisting pressure predicted from the equal-area construction. Transverse forces increase surface tension and generate edge currents at the liquid-gas interface. The analysis of these currents shows that the rotational viscosity introduced in chiral hydrodynamics is consistent with microscopic bulk mechanical measurements. Chirality can also break the solid phase, giving rise to a dense fluid made of rotating hexatic patches. Our work paves the way for the development of the statistical mechanics of chiral particles assemblies.Comment: 6 pages, 4 figures, Supplemental Materia

Takotsubo Cardiomyopathy, presentation as a cardiac arrest in a 67 year old female with depression and anxiety history

Background: Takotsubo cardiomyopathy also known as broken heart syndrome or stress induced cardiomyopathy is a sudden transient reversible dramatic left ventricular apical akinesis mimicking acute coronary syndrome, making it a diagnostic challenge. Most common mechanism for Taktosubo is stress induced catecholamine release causing sympathetic activation leading to microvascular dysfunction or direct toxicity. Mayo Clinic Criteria for making diagnosis at the time of presentation requires 1) transient hypokinesis, dyskinesis, or akinesis of the LV midsegments with or without apical involvement, and a stressful trigger is often but not always present. 2) absence of obstructive coronary disease or angiographic evidence of acute plaque rupture 3) new ECG abnormalities (either ST segment elevation and or T wave inversion) 4) absence of pheochromocytoma or myocarditis. Case presentation: A sixty-seven year old Hispanic woman with past medical history of depression and anxiety, presented to emergency department with generalized body weakness, chronic severe lower back pain. In emergency department, patient experienced cardiac arrest with return of spontaneous circulation achieved in 5 mins, was intubated for airway protection. Electrocardiogram showed sinus tachycardia with elevated cardiac troponins. Echocardiogram revealed large area of akinesis involving mid anteroseptal, lateral wall, inferoapical; severe left ventricular dysfunction with ejection fraction 30-35%. She was found to have pulmonary edema and was started on vasopressors, heparin drip, and aggressive diuresis for cardiogenic shock. Imaging negative. Eventually she was able to be weaned off vasopressor support and extubated. Her repeat echo three days later revealed improved left ventricular systolic function with ejection fraction of 45-50%. Patient underwent left heart catheterization which demonstrated no significant obstructive coronary disease. Patient improved clinically and was discharged to a skilled nursing facility for rehabilitation on beta blocker and angiotensin receptor blocker. Discussion: The exact etiology of our patient’s arrest remains unknown. Early suspicion and use of Mayo clinic criteria at time of presentation is important especially in patients with a history of psychiatric disorders as there is a high rate of recurrence and complications reported among them. Our patient has a history of anxiety and depression, which can be considered precipitating factors predisposing the patient to a stress induced cardiomyopathy

Influenze fenomeniche nella mislocalizzazione della posizione iniziale di uno stimolo in movimento

2011/2012In questo lavoro di tesi si prenderà in esame un effetto legato alla percezione del movimento e conosciuto con il nome di Effetto Fröhlich in onore di colui che nel 1923 lo studiò per la prima volta in maniera sistematica. Percepire la posizione degli oggetti nell’ambiente è senza dubbio uno degli scopi più importanti del sistema visivo. Tuttavia, quando gli oggetti sono in movimento la localizzazione della loro posizione può risultare più difficoltosa e può essere caratterizzata da piccoli ma consistenti errori definiti mislocalizzazioni spazio-temporali. Tali errori possono coinvolgere sia la localizzazione della posizione iniziale dello stimolo in movimento (Onset) sia la posizione finale dello stesso (Offset). Nel 1930 uno studioso, Fröhlich, osserverò che se a degli osservatori si chiedeva di identificare la posizione iniziale di uno stimolo in movimento questi tendevano a identificarla non nella posizione reale, ma in una posizione spostata nella direzione del movimento. Tale errore di localizzazione fu definito Fröhlich effect. Tutte le interpretazioni prevedevano l’influenza di fattori fisiologici nella spiegazione del fenomeno. Tuttavia ciò che emerge dai risultati degli esperimenti presentati in questo lavoro è che anche fattori fenomenici possono avere una qualche influenza sulla grandezza dell’errore. L’effetto sembra essere influenzato dalle caratteristiche dell’oggetto in movimento e dalle caratteristiche del contesto all’interno del quale gli stimoli si spostano.XXV - Ciclo198

How Things Take Up Space: A Grounded Theory of Presence and Lived Space

In cognitive science, it is unclear what precisely presence (both in the sense of objecthood and immersion) refers to in lived experience. The present study addresses the research question of what the relationship between presence is and lived space. A hundred and seventeen phenomenological interviews were conducted with 14 participants. We sampled their experience in a transdiagnostic manner. That is, we observed how the experience of presence changes both in circumstances appraised as positive (e.g., sexual intimacy) and negative (e.g., psychopathology). Our grounded theory suggests that presence is a phenomenon that is comprised of all available sensory knowledge, however, it itself is not present in any one sensory modality. Presence takes the form of a disembodied sense of solidity. Our findings can be related to the notion of transmodality in contemporary qualitative phenomenology (i.e., the idea that there are some aspects of experience that can be readily translated from one sensory modality to another. Further, how presence (in its capacity as immersion) is related to lived space can shed further light on the formation of delusions, suggesting that it is based on sensory alterations rather than changes in belief. Finally, the observation that presence as it appears in lived space need not perfectly correspond to the objective situation, can elucidate extant discussion on whether presence is an amodal aspect of consciousness

Esiti materno-fetali e glicemia a digiuno vs una o due ore dopo il carico orale di glucosio nelle donne con diabete gestazionale

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Mapping and analysis of urban green areas as urban environment quality indicator : case study of Paulinia-SP, Brazil

Orientador: Lindon Fonseca MatiasDissertação (mestrado) - Universidade Estadual de Campinas, Instituto de GeociênciasResumo: A presente dissertação teve como objetivo contribuir para os estudos geográficos relacionados ao planejamento urbano com o mapeamento e análise das áreas verdes urbanas como um indicador da qualidade ambiental urbana, por meio da utilização de técnicas de geoprocessamento, a fim de subsidiar políticas públicas para a cidade de Paulínia-SP. A metodologia utilizada neste trabalho mostrou-se eficiente para o mapeamento e análise da configuração espacial das áreas verdes urbanas do município. O mapeamento de tais áreas permitiu constatar que sua distribuição se dá de forma heterogênea no município, e que em sua grande maioria se apresentam na forma de pequenos fragmentos de vegetação arbórea remanescente. Os resultados indicam que o município tem apresentado uma acentuada redução da vegetação natural desde a sua emancipação, e como consequência possui um reduzido número de áreas verdes na área urbana. A diminuição da vegetação natural, assim como das áreas verdes urbanas, é entendida como apenas um dos diversos problemas resultantes do processo de apropriação desigual do espaço no município de Paulínia. O cálculo dos índices de áreas verdes por habitante em cada setor censitário possibilitou uma análise diferenciada da disponibilidade de áreas verdes por habitante no município. A espacialização das áreas de influência das áreas verdes urbanas em Paulínia revelou a carência destas áreas em algumas localidades da cidade e a necessidade de proteção das áreas verdes urbanas, visto à extensão das áreas que estas podem beneficiar por meio das suas funções ecológicas, estética e de lazer. A análise detalhada de três áreas verdes em Paulínia revelou a importância das análises de caráter qualitativo no estudo das áreas verdes do município. A pesquisa ajudou a constatar a importância das funções das áreas verdes para a qualidade ambiental urbanaAbstract: This work had as objective contribute to studies related to spatial planning thorough the mapping and analysis of urban green areas as urban environmental quality indicator using geospatial technologies to support public policies to the Paulinia city, state of São Paulo. The methodology used in this study was effective for mapping and analysis of the spatial configuration of urban green areas of the city. The mapping of these areas revealed that its distribution is heterogeneous, and that the majority is in the form of small fragments of woody vegetation remaining. The results indicate that the city has shown a high reduction of natural vegetation since their emancipation, and consequently presents a low quantity of green areas in urban areas. The decreasing of natural vegetation rate, as well as urban green areas, is only seen as one among many problems which have been arisen as resulted of the space unequal appropriation process in Paulínia. The calculation of green areas rates per inhabitant in each census tract allowed a differentiated analysis of availability of green areas per inhabitant in the city. The spatial distribution of influence areas of urban green areas in Paulinia revealed the lack of these areas in some localities and the need for protection of green areas, since the extent of these areas that may benefit through their ecological functions, aesthetic and of leisure. A detailed analysis of three green areas in Paulínia revealed the importance of qualitative analysis in the study of green areas of the city. The research helped establish the importance of the functions of green areas for urban environmental qualityMestradoAnálise Ambiental e Dinâmica TerritorialMestre em Geografi