#conditions costales

[chiropratiquesillery]

Clinique Chiropratique Sillery / Chiro à Ste-Foy, Québec - Une douleur à la cage thoracique? Ça pourrait être une irritation costovertébrale!

New Post has been published on https://chiropratiquesillery.ca/une-douleur-a-la-cage-thoracique-ca-pourrait-etre-une-irritation-costovertebrale/

Une douleur à la cage thoracique? Ça pourrait être une irritation costovertébrale!

Saviez-vous que les côtes pouvaient être à l’origine de certaines douleurs? Les conditions costales sont fréquemment rencontrées en chiropratique et lorsqu’elles sont d’origine neuromusculosquelettique, le chiropraticien possède généralement tous les outils pour aider son patient à retrouver un état de santé optimal. Dans cet article, vous découvrirez l’une des conditions costales les plus fréquentes, c’est-à-dire l’irritation costovertébrale, et vous apprendrez comment la chiropratique pourrait être votre allié dans le traitement de cette condition.

Les côtes et leurs articulations

Anatomiquement parlant, les côtes bougent. Si elles ne bougeaient pas, la respiration serait très difficile puisque leur mouvement permet à la cage thoracique de prendre de l’expansion lors de l’inspiration et l’expiration.

Le corps humain comprend généralement 12 paires de côtes. De ces 12 paires, les 2 dernières sont dites flottantes, c’est-à-dire qu’elles n’ont pas d’attache à l’avant, contrairement aux 10 autres paires de côtes.

Au niveau dorsal, chaque côte s’articule au niveau vertébral, d’où le nom de l’articulation costovertébrale :

Au niveau ventral, les côtes s’articulent pour la plupart avec le sternum, d’où le nom de l’articulation costosternale :

Même si les articulations ne sont pas du même type entre la région antérieure et postérieure du dos, le mouvement est possible à chaque niveau. Comme dans tout mouvement articulaire, il est possible qu’il y ait une diminution de la mobilité, ce qui peut causer des conditions neuromusculosquelettiques comme l’irritation costovertébrale.

Quand la perte de mobilité engendre la douleur

Chaque articulation a un mouvement qui lui est propre. Ce mouvement se doit d’être optimal si l’on souhaite que l’articulation fonctionne normalement. Plusieurs causes peuvent créer une perte de mobilité articulaire :

Traumatisme direct à l’articulation

Mauvaise posture de sommeil

Mauvaise posture de travail

Mouvement répétitif

Mauvaise utilisation de l’articulation (ex.: mauvaise technique de course)

Sédentarité (non-utilisation des articulations)

Le processus plus détaillé (mais imagé) menant à l’apparition de douleur ressemble à ceci :

Lorsqu’une articulation ne bouge pas optimalement, les récepteurs articulaires envoient un signal au niveau cérébral indiquant que le mouvement n’est pas idéal.

Lorsque le cerveau reçoit cette information, il la traduit comme un problème à régler et souhaite donc “protéger” le corps.

Les signaux de protection envoyés par le cerveau peuvent être ceux-ci :

Inflammation

Hypertonicités musculaires (contractions musculaires)

Restriction dans l’amplitude de mouvement, avec douleur

Restriction dans l’amplitude de mouvement, sans douleur

Raideur des muscles environnants

Oedème local

Douleur

Douleur au mouvement

Douleur au repos

Douleur intermittente

Douleur constante

Douleur légère

Douleur intense

Douleur locale, au toucher

Douleur irradiante

Vite, on se rend compte que les hypertonicités musculaires engendrent à leur tour une nouvelle diminution de l’amplitude de mouvement. C’est ainsi que le cercle vicieux de la restriction articulaire débute :

Perte d’amplitude de mouvement = hypertonicités musculaires

Hypertonicités musculaires = encore plus de perte d’amplitude

Encore plus de perte d’amplitude = encore plus de réponses de protection = encore plus d’hypertonicités musculaires

Ainsi de suite.

Les articulations costovertébrales ne font pas exception à ce mécanisme. En général, les douleurs liées à l’irritation costovertébrale sont celles-ci :

Sensation de point à droite ou à gauche de la colonne vertébrale, dépendamment de l’articulation ciblée.

Douleur possible lors de l’inspiration ou de l’expiration, en raison du mouvement de l’articulation impliquée.

Douleur possible lors du mouvement des bras/épaules, en raison du mouvement de l’articulation impliquée.

Sensation de douleur intense à la poitrine, vis-à-vis l’articulation costovertébrale touchée. Comme si un poignard transperçait la poitrine de l’arrière à l’avant.

Le chiropraticien à la rescousse

Lors de son examen, le chiropraticien aura la tâche de déterminer si la douleur perçue par son patient est d’origine neuromusculosquelettique. Pour se faire, il utilisera l’expertise qu’il a acquise au cours de son doctorat de premier cycle en chiropratique.

Des questions précises servent à orienter son cheminement clinique.

À quel moment survient la douleur?

La douleur est présente depuis quand?

La douleur est-elle irradiante?

Est-ce que l’intensité de la douleur varie?

Le patient a-t-il des difficultés respiratoires?

Le patient a-t-il d’autres symptômes?

Un examen physique complet en lien avec les réponses aux questions aide le chiropraticien à préciser graduellement son idée diagnostique :

Amplitudes de mouvement costovertébrales

Amplitudes de mouvement costosternales

Palpation chiropratique (subluxations) au niveau vertébral

Évaluation des hypertonicités musculaires potentielles

Des examens complémentaires en fonction des résultats obtenus (radiographies)

Puisque le chiropraticien a la capacité de prescrire et analyser les radiographies, il est possible qu’il veuille avoir une image plus précise de la région impliquée. Comment est la colonne vertébrale? Comment sont les articulations costovertébrales? Comment est la qualité osseuse? Toutes ces réponses peuvent aider à déterminer si le diagnostic est d’origine chiropratique et orienter vers le traitement le mieux adapté pour le patient.

Dans l’éventualité où un traumatisme soit à l’origine de la douleur, il est possible que le chiropraticien veuille évaluer l’intégrité osseuse. Si elle est compromise et qu’il suspecte une fracture, il aura à référer son patient du côté médical pour un suivi approprié pour confirmer le diagnostic.

Dans le cas d’un diagnostic d’irritation costovertébrale, un suivi chiropratique pourra être envisagé.

Puisque le chiropraticien évalue la présence de subluxations vertébrales, il traitera celles qu’il a trouvées lors de son examen. Sachant qu’il n’y a pas que les articulations vertébrales qui peuvent être subluxées, il traitera fort probablement l’articulation costovertébrale en cause dans le diagnostic qu’il a émis puisqu’elle présentera sans doute une perte de mouvement.

Si, à son examen, des hypertonicités musculaires ont été mises en lumière, il pourra les travailler afin de rendre le muscle plus souple et moins contracté. Cela aidera à redonner une amplitude de mouvement normale à l’articulation.

Puisqu’on retrouve généralement de l’inflammation au site de l’irritation costovertébrale, il est possible que des techniques complémentaires soient utilisées, selon la localisation, l’indication et les contrindications du patient :

TENS (neurostimulation électrique transcutanée)

Ultrasons

Glace

Chaleur

Optimiser la santé de son patient

La vision chiropratique est orientée sur la santé globale de son patient. En conséquence, le chiropraticien ne se penchera pas seulement sur la douleur. Il aura toujours en tête d’optimiser son suivi et la condition de vie des gens qui le consultent en donnant des conseils sur les habitudes de vie, les postures à adopter (sommeil et travail) et les exercices qu’ils pourraient faire afin d’aider leur condition et éviter les récidives.

Le chiropraticien sait très bien que l’absence de douleur n’est pas toujours en lien avec l’absence de maladie/condition de santé. Il pourra être présent pour vous suite à la gestion de la douleur afin de vous guider vers un état de santé optimal et vous proposer des soins d’optimisation. N’hésitez pas à le consulter!

[wildissylupus]

Just watched a playthrough of Rot in Paradise and holy shit. People have started coming to me for critiques on Australian characters (mainly overwatch), their writing and designs, and that is Australian rep done right!

Starting with the character designs, I have seen variations of all of those outfits on people here, not only that but the designs all communicate where the characters are actually from;

Carmen, McCoy and Vonnie are all from an urban area, likely a city. The characters never change clothes during the game so I'm going to assume these are their swimming clothes. All three of them are actively wearing swimwear covered by things you would typically wear to the beach if you aren't planning to immediately change clothes afterwards. Not only that but they are wearing a lot nicer clothes then June and Ryan, they are clothes specifically bought for swimming. Not only that but you can tell the they are from different cities or at least different parts of the same city, Carmen is more inland, her coat is think and the way it falls communicates that it's not really made from beach safe material, it's also very obvious that her swimmers are underneath her clothes and are not just her outfit. Meanwhile with McCoy and Vonnie they live more costal, they're outfits are made for the beach, McCoy's actively being just his swimmers. Vonnie is a little more complicated but though she is wearing clothes over her swimmers, they aren't the same as Carmen's. Vonnie is wearing loose fitting clothes specifically designed for the beach something that can easily be tied on and off again.

Meanwhile Ryan and June are dressed more rurally. Ryan can't swim and is implied to be afraid of the ocean, which communicates to me that he's from somewhere that is pretty land locked. That and his clothes are something I've seen worn by Aussie farmers (Aka my dad) wear on their days off, that and his tan lines indicate that he's in the sun a lot, possibly in an old button up considering where his tan lines are. Not only that but his drinking habits and taste in beer are very rural Australian coded. While June is dressed more as a person who grew up rural but has moved into a city later in life, she's wearing old looking shorts with a belt on them which signifies that they're not going to be taken off to get in the water, while her top is an actual swimming top and she's wearing a beach top over that, both look in good condition and fairly new. There's also June's dyed hair which is honestly common for people who grew up rurally to do once that move to a city. Also Ryan still living in a more rural area would also explain why his hair does seemed dyed but is a lot more faded and less maintained. In all honesty it wouldn't surprise me if June and Ryan grew together considering the similar dye jobs and the way June greets Ryan at the beginning of the game.

Also THANK YOU studio investigrave for not making all the characters white, it's such a common problem when people are writing Australians or Australia in general that they make everyone white. It feels so gross to me when I see that.

Next up in the language used and holy shit was the dialogue well written, "mate" was used in the correct context, "bloody hell" and "dickhead" where the most used slang and that is fully correct, Ryan bringing an esky (cooler, as everyone else says) full of beer on a vacation is such a relatable experience to me. In general I felt seen by the way that characters talked and acted, which is rare when looking at Australian characters.

Also the story involving the environment as the horror, and the environment explored being the water is so important to me. Australia is dangerous, but when that is explored in media it's usually just the outback. Meanwhile the bush and our oceans are usually never touched on, despite them being just as dangerous. Not only that but they used the theme of isolation without using the outback too, which again, is very rare for me to see.

Anyway this game was great and is going up there as one of my favorite games.

[15-lizards]

What are your thoughts on Northern fashion? You mentioned in an early post that it would be different depending on the location, can you elaborate on that? I also feel like the style changed soon after Catelyn married Ned, since she would bring styles from the Riverlands and Winterfell is the King's Landing of the North when it comes to fashion

Let’s goooo 🏃🏻‍♀️

Starting in the Neck, they would definitely be more like the riverlanders in terms of clothing. It’s a fairly similar wet and muggy climate. Everything is mostly made of wool and hemp and linen. Thinner clothes for the muggy summers and warmer, thicker ones for when winter comes. Leather/animal skin shoes to keep the mud off. Also whenever I imagine the Crannogmen I imagine cloaks and hoods to stay dry in the swamps. So lots of those.

To the East and a bit father to the north, that costal area around White Harbor is colder than the Neck. So theres a lot more layers, and clothing it way thicker. Also the Manderlys are dripped tf out they got that White Harbor money. Wyman has fur lined EVERYTHING his damask coats could put Cerseis to shame. Wylla and Wynafred pull up to the Sept with lace and silk and jewels eating all the other bitches up. Also since they follow the Faith and are originally southern, this area probably follows more southern customs (fabrics, headpieces, etc)

And we finally make it to winterfell 🤸🏻‍♀️At this point everyone’s freezing their tits off, so fur lined everything. Indoors, I think they can wear lighter stuff bc of those hot springs. Even in the spring months, you can catch Cat wearing at least one shift, underdress, overdress, AND a jacket bc I feel like she never acclimated to the cold. Lots of leather and wool for everyday wear, but when Ned throws a feast or something they get to wear more fur and velvet (even Jon gets to wear a nice velvet surcoat, as a treat). Since the Starks are bordering on ascetic sometimes, there isn’t a ton of ornamentation, but Sansa likes to wear southern-ish styles as much as she can, so you can frequently find her wearing clothes from white harbor (aka I want to see Sansa in a kokoshnik)

And then even farther north we start to see Bolton and Umber territory. The conditions are even more brutal than at Winterfell and they don’t even have hot springs :/ like Sansa and Arya could probably get away with not having to cover their ears during warmer days, but the girls of last hearth and the dreadfort have no warm days. At this point clothing becomes a bit bulky and harder to move around in. Dresses are lined stiffly and almost drag the floor, and everyone is always bundled up to the neck. However materials and fabrics are cohesive and nice atp.

And by the time we nearly reach the wall, conditions are almost unbearable during the winter. Even during spring, all the villagers in the gift are wearing at least four layers (bc I hate hate hate how the show made the people at and around the wall just chill in a thin jacket when they were near a gargantuan frozen block of ice). Clothing is a lot less structured here, resources are getting sparse so most people stitch together a patchwork of whatever furs they can get their hands on. You will rarely see a person without a big hood or thick gloves on. And even though they aren’t wildlings, you can probably see a lot of animal head hoods, bc these people do NOT waste any part of the animal

[styxbugg]

I learned today that one of the factors of sinkholes is the existence of limestone caves and tunnels under the ground, and that costal areas with those conditions are more likely to get sinkholes than non costal areas

Now who lives in limestone caves and tunnels under the ground? And who lives in a coastal area? The fraggles.

Anyway this is my pitch for a fraggle story based around sinkholes, whether it be a season of the reboot or a movie (👀 i really want a movie)

[melmedarda]

@meljaymicrofics ⸻ heatwave ⸻ wc: 975 ⸻ rated G

It’s insufferable.

Air too thick in her lungs, her throat and nose close around every inhale. Rebel with every exhale. Perhaps this is how she’ll die.

The woman on the television has a pretty, plastic smile on her face, make up perfect. Face without the sheen of sweat as she announces the weather report in her perfect, near robotic voice. Mel has never hated a woman more.

Hot winds blowing up towards the isthmus from the deserts of Shurima threaten to make this summer the hottest we’ve seen. With record breaking temperatures of 311K and above, the costal cities of Krexor, Holdrum, Piltover, Rokund, Trannit, and Zaun are facing several heatwaves in the summer season. This is Lady Sempescu with PNN, live from—”

The tele blinks off, Mel’s hand tight on the remote. Held like a spear, handled like a weapon within her grip.

There’s no one she can go to. Mel has few friends enough as it is, and the few she has are busy. Elora’s gone to some convention in Noxus. She hasn’t heard from Samira for upwards of two months, which means she’s on assignment. Shoola’s gone to Camavor on vacation, and she’d jump into the Pilt before ever asking Salo for a favor. And then, there is the manor.

She entertains the idea, stripped down to the barest of clothing. Reclined on the cool tile of the apartment, she relishes the feel of it against her heated skin. Stares at the ceiling and thinks of her childhood room in her too quiet apartment. Thinks of a place that has not been home for a long while now.

They have working AC there, no doubt. Ambessa would not tolerate anything otherwise. But if Mel was to leave Midtown Heights and return home, her mother would give her the look. The look which communicated that Ambessa was right, and that Mel should have never moved out in the first place.

Mel had left home to escape her mother’s controlling hand in her life. Tolerating Ambessa was much like this heatwave. Oppressive. Suffocating and smothering. Mel had worked hard to escape; to return for any would be humiliating. Not when she worked so hard to escape her mother’s world.

Mel would never live it down.

She calls the Midtown Heights office again, bare foot tapping impatiently as the line rings. Her skin is cooler after standing in front of her open freezer for some relief. But her core temperature is rising now, and her temper with it. Finally, she gets someone.

“Good morning, Midtown Heights Luxury Apartments, how may I help you?” the operator says. The cheeriness in her voice makes Mel want to reach through the phone and strangle her.

“Hello, this is Ms. Medarda, from the penthouse suite 1004. I’m calling to inform you of a issue with the air conditioning… yes, I left a message two days ago and have not heard back. Is the maintenance man available to come up today? Yes, please do. Thank you. You too.”

She’s near peeling her skin off her body by the time she hears the doorbell. The sky is too blue outside the large floor to ceiling windows, not a cloud on the horizon. The sun blinds, unrepentant. Beside her, the box of ice cream she’d picked up from the mart is half finished, containing a pool of melted Noxian citrus ice cream.

Mel opens the door and immediately, heat swirls and builds beneath her skin. The handyman is a vision. Smoking hot, as Samira would say. He smiles at her, and she feels his eyes rove over her as well. They leave a trail of new heat in their wake.

And Mel’s not one to feel embarrassed or self-conscious, but she cannot help her acute awareness of the too short night slip she wears, and the near sheerness of the material. Of how sweaty she is. Of how far from appropriate this situation is. Of how deeply the heat has addled her brain, because she realizes she hasn’t said anything as yet.

“Jayce Talis, Miss Medarda. Admin sent me to fix the HVAC?” Golden eyes flit back to her. Mel swallows thickly and nods, something bitter in her throat. Steps back. Opens the door wider to let him enter. Keeps her eyes on the deep blue of his henley as he walks past. She nearly swoons when he removes his work boots before stepping further into the house. Thoughtful.

He turns to face her, and Mel realizes she is simply standing. Watching. “Please, call me Mel.” Miss Medarda reminds too much of Ambessa. “And yes, the unit has been out for about two days. She gestures towards the hall, and he falls her through on near silent feet.

“It really is hot. Did you not want to go to a hotel until everything was fixed?” His curiosity betrays his real question. Why are you courting heatstroke by roasting in this glorified oven, no doubt.

“I have fish to feed,” is all she says as they pass her assortment of fans lining the hallway. “It’s just in here.” Her penthouse comes with a rooftop garden, within which the body of her problem lies. Jayce nods, and wordlessly gets to work.

She checks on him about 30 minutes later. Better clothes and bearing a glass filled with water and ice cubes. His broad back is the first thing the greet her, blue henley discarded. Then the toned muscles of his arms. Her eyes drink him in, greedy. A desire to paint overwhelms her. She says nothing, leaving the glass near enough that he might see it, and retreats into the house.

Perhaps she might see if there is anything else in the penthouse that needs…fixing.

[arcanarubinaito]

Headcanon Post (1)

“Leech Barometer”

Okay so we all know about the Leech Barometer right? No? Okay well if you don’t, it’s a contraption that utilizes leeches to create a storm warning system. You heard me right: leeches.

The Leech Barometer—originally named the “Tempest Prognosticator”—used natural leech behavior as a warning system for incoming storms. When atmospheric pressure falls and the oxygen content in the water drops, the leeches instinctively try to move to the surface. It’s a neat little trick to predict bad weather, so George Merryweather (talk about names reflecting one’s job lmao) created a device that took advantage of that fun little fact. The Leech Barometer essentially consists of twelve bottles in a circle under a bell. Small hammers would strike the bell once the leech climbed high enough. I’ll link the Wikipedia article below, it goes into more detail about the mechanics.

The leeches used were presumably medicinal leeches since that’s what Merryweather refers to when talking about their sensitivity to weather conditions, and the device was more or less inspired by poetry. (“The leech, disturbed, is newly risen, / Quite to the summit of his prison.” Edward Jenner, Signs of Rain) It was fairly accurate but couldn’t actually tell you when the potential storm would hit. The more rings from the bell, however, the more likely it was for a storm to show up.

I have such a strong mental image of Julian kicking down Nadia’s door one evening, as a storm is brewing on the horizon, and aggressively pointing at a jar he’s holding. It takes Nadia a minute or so to realize what Julian is saying, but once she does he has her full attention. The leeches climb when a storm is approaching? What a fascinating concept.

The two of them immediately start discussing how they could create a storm warning system with the leeches. One could always look at the jar, but when you’re as prone to getting lost in one’s work or thoughts like Julian and Nadia are? They’d completely forget.

Julian is the one to suggest bells. The actual logistics on how to get the leeches to ring said bells, however, was Nadia’s idea. They spend an entire night working on a prototype, but by the time it’s finished the storm had passed and the leeches had settled. It isn’t until the next storm rolls along—they don’t have to wait long, it is a costal city after all—that they get the chance to test it out.

By the Gods, it worked! Only… well now there are pieces of whalebone floating in the water, and it is difficult to set back up again. Far more of a hassle than it needs to be. Once they fish out the whalebone and realign everything, Julian makes sure to tie the whalebone up with a string so that they can easily place it again after the next storm.

For areas like Nopal, it would make a great signal for when rain water would come. And Vesuvians in areas prone to flooding could use it as a signal to prepare. It was a brilliant invention!

Just, ah… perhaps not very streamlined. It takes up quite a bit of space and producing the prototype alone wasn’t cheap. They have the device moved into the new research laboratory Nadia had commissioned a while back, and now the question they both share was why the leeches behave this way.

(Asra and Portia frequently stop by to make sure they’re both eating, drinking, and taking breaks whenever they have the time to go on a research binge.)

Links & Inspiration

Wikipedia - Tempest Prognosticator

Australian Museum - Leeches

Atlas Obscura - The Rise and Fall of the Leeches Who Could Predict the Weather

Here’s the inspiration for this post. I couldn’t find the original, so here’s the crappy cropped version from Reddit. If you can find the original, please send me the link!

[evil-jennifer-hamilton-wb]

My OC Worm cluster I talked about a few months back. The cluster is designed around powers that have unsettling or stranger-y aspects, the story set in a low-income immigrant area of Detroit being gentrified after damage to costal cities by endbringers revitalizes the city economy. From left to right (primary powers only), Descry/Brooke (15, she/they demigirl) has the power to hunt down anyone who thinks about her, and teleport to their location if her name (any name she uses to refer to herself, not just her civilian name) is directly mentioned. Aria/Penelope (13, she/her cis girl) Has the power to manipulate, still, and sense vibrations within a medium. Aria's power automatically and uncontrollably bends light and sound around her body, rendering her blind, deaf, and invisible. She interacts with the world through her vibration sense ability, and mobility aids. Micah/Myopia (15, he/him cis man) has the power to manipulate attention. People within myopia's range are forced to look at him and direct their emotions, positive or negative, towards him. Once people's focus has been forced his way, he can redistribute it to some extent. Cordyceps/Hayden (19, he/him trans man) Has the power to grow fungus on any organic material, and feel through the senses of the fungi. His range is seemingly infinite, but only applies to fungus he has grown or interacted with. The fungus grows at a rate standard for the external conditions, and he can only create spores for fungus he has ingested and then grown in his own body I'd love help with a name for the cluster if anyone has any ideas (mostly for tagging reasons), and any thoughts, criticism, or questions are appreciated!

[spamtonsmakemehappyyy]

IMMEDIATELY I'M GIVING A CW: CW FOR BLOOD, BLEEDING, DANGEROUS CONDITIONS OF THE BODY, VENOM Fun fact about Crossfade: He has snake blood, his species is a combination of the most deadly snakes alive. Black Mambas, Rattlesnakes, Eastern Brown snakes, Fer-De-Lances, Eastern Tiger snakes, Russell's Vipers, Saw-Scaled Vipers, Gaboon Vipers, Banded Kraits, King Cobras, Costal Taipans, Inland Taipans, Death Adders and Puff Adders. He is extremely dangerous and if provoked, he is extremely fatal unless help or a anti-venom vial is nearby...... due to the fact that he has a combination of venoms from the world's deadliest snakes, and just one of those snakes alone is said to kill in 15 minutes. He has neurotoxic, cytotoxic and hemotoxic venom. He also has other types of acting venom. For those that don't know[you can skip if you do],

Neurotoxic- Paralysis, convulsions or rapid muscle twitching, difficulty breathing and other respiratory issues Cytotoxic- Severe pain, swelling of area surrounding bite, necrosis (death of tissue) Hemotoxic- Swelling, internal bleeding, hemorrhaging, necrosis Cardiotoxin- [Long acting] causes cardiac muscle damage, arrhythmia and ultimately cardiac failure Myotoxin- Muscular tissue gets attacked -Immense pain -Inflamation -Bleeding that can't be stopped -Skin cells to self-destruct -Venom left to run its course could cause death -Works faster than normal -Tiny blood clots, can cause organ failure -Since his venom glands are so large, and his fangs are so long he dispenses much more venom, much deeper into the body of someone that has been bitten -A bite from him would be considered a urgent, life-threatening medical emergency So uhhh yeah! Don't make this guy angry- or do, since you're behind a screen and he can't getcha outside of the internet[technically if you asked me to I could have him be dangerous actually in a ask, to like bring immersion, but that's only if someone asks me. I won't do that without asking.] On a side note, he is usually extremely docile and will not resort to biting unless he is threatened, in danger or provoked heavily. He is a very docile, loving man......but when he has his moments, watch out. Also, to answer the inevitable "That sounds OP".... it does, doesn't it? Luckily there are readily available anti-venoms, and any type of anti-venom works for his bites. He is also not immortal, and can die if brutally hurt.

[aspiringwarriorlibrarian]

I still fell so weird thinking back at people that took Blake being daughter of menagerie chief to mean she was actually some privileged rich girl. Like, they were still living in a small costal town on a island that is half unhabitable. They might, possibly, have more that other people on the island but that still won't amount to much in those conditions.

I think people are forgetting that Ghira got that position by being an activist for most of his life and that he got it fairly recently. I don't think the Belladonnas are independently wealthy by any means, I think that's just "the house the Chief stays in".

[harpermoon85]

Diego

Oldest of three kids

Son of Adelina and Pedro

Grandson of Maria Fernanda and Joaquin

Strong work ethic

Married to Paula who was about to leave him before her death

Very similar to Maya before the loss of Paula

Maria Fernanda grew up very poor and fell in love with Joaquin, who’s family, while not wealthy, was well off. They owned a ranch in Michoacan and were not struggling. She made it her mission to never know poverty again and to make sure her children did not know it either. She managed the money in her home and by the time Adelina, their only child was born, they were doing very well. They had expanded their property and operations and were the wealthiest landowners in the region.

Maria Fernanda was not supportive when Adelina fell in love with a local musician (Pedro), whom she felt lacked any ambition. When Adelina married him, Maria Fernanda took an approach of harina de otro costal. If Adelina wanted to make her bed, then she’d have to lie in it. Joaquin was a quiet man and did not interfere in his wife’s managing of their daughter.

Pedro never did quite get things together, and Adelina having grown up in privilege did not have the skill set to overcome his shortcomings. She had three children: Diego, Luis, and Flora within five years and often couldn’t keep them fed. Pedro moved them to Ciudad Juarez when Diego was three because they were struggling so much and an opportunity had come up in a maquiladora.

Diego was a boy with his grandmother’s street smarts and within six months of moving to Juarez, the preschooler was selling gum on the streets to help keep his little brother and soon to be sister fed. By six, he’d moved on to shining shoes in the plaza and later that year, Pedro died leaving his wife a poverty stricken widow with three mouths to feed. Maria Fernanda and Joaquin were of no real help. The only financial help they ever gave the young family was to:

Pay for all three children to attend private school in El Paso. Maria Fernanda considered this only fair. She was giving her grandchildren the opportunity to make something of themselves when they grew up. Diego would start his day every day between 4 and 5 am to be at the bridge with his siblings by 6am to get to school because the line was so unpredictable and he refused to be late to school.

Send round trip tickets every summer for the children to come and stay with them until school began again. Diego made quite an impression on his grandparents during these summers. From a very young age, he insisted on getting up at the crack of dawn with his grandfather and working on the ranch. Impressed with his gumption, they paid him for his labor. They put most of it in an account to help him have a start in life as an adult, but he kept a portion and always gave it to his mother to help with bills upon returning home.

Paid for the paperwork and attorney’s fees to help Diego get his citizenship so that he could remain in the United States as an adult again seeing it as simply evening the playing field so that Diego could either become someone or not.

Maria Fernanda had a very hard time taking care of her children and became very frail and ill over the years from the hard labor under poor working conditions. When Diego was 12, things came to a head and she was hospitalized. Once released, the family made the move to El Paso permanently so that she could take up work cleaning offices and have a lighter workload that she did in Juarez. Diego began mowing lawns and doing handiwork when not at school to continue bringing in money for the family since his mother’s wages were not enough to keep them afloat, and she could no longer work multiple jobs like she had in Mexico due to her poor health.

History repeated itself in a way when he met Paula. Her father, Hector, owned a construction business that Diego did odd jobs for and her mother was a teacher. They had a comfortable life and did not approve of their daughter dating Diego due to his socioeconomic status. Diego was offended because he felt compared to Pedro, and this would be the hallmark of their marriage.

The chip on Diego’s shoulder never quite allowed him and Paula to be happy. He worked very hard and long hours. It wasn’t enough to have a roof over their heads, they had to own it and it had to be just as nice if not nicer than her parents’ home. Having food on the table was not enough either, the fridge had to be fully stocked. It was his job to provide and he had to prove that not only could he provide, but he could do it well, and Paula having grown up very differently did not help. She had no true understanding of where money comes from and could be very frivolous. Diego would never dream of telling her something about it though because to him that would be proof her parents were right. As a result, Diego was almost never home. He was always working, determined to climb the ladder at the hospital. No matter how well he was doing, it was never enough for him.

His over dedication to his work and her spending habits and inability to understand him led to a lot of resentment over the years. What he saw as proving his love to her, she saw as neglect. Neither one of them could have told you how Santi was conceived since they were living like two ships passing in the night. He always told himself tomorrow. When I…then I will take them on vacation. When I can…then we will… If I…then we can Except, tomorrow never came and then she died within minutes of Santi’s birth. Belen was a C-section, and Paula had felt “robbed” no matter how much Diego had reassured her that giving birth is giving birth and that a C-Section makes it no less miraculous. She insisted on a VBAC with Santi which should have been perfectly safe, except she was the one in a million. She suffered a uterine rupture and during the emergency surgery to try and save her life, she went into DIC.

After her death, Diego was devastated. Even more so after finding her journal and learning that she couldn’t take it anymore and was planning on leaving him after the baby was born. He does not have a good relationship with her parents. They resent him for making their daughter unhappy and even more so for finding love with Carina and starting a new family with their grandchildren across the country.

Diego, for his part, learned his lesson from the loss of his wife. He became determined to be the best, most loving and attentive, involved father he could be. He learned that the brass ring isn’t that great if it means not having someone to share it with him. The lessons he learned in his marriage to Paula translate to him being an amazing husband to Carina. Paula got the boy, Carina got the man. His past also makes him very empathetic to Maya. Once Carina and Maya learn to be friends again, he is very accepting. He comes to genuinely care for her to the point that when she requires a second ankle surgery not only is he not jealous when Carina drives her home from the hospital, but he encourages her to sleepover a couple of nights (Maya refuses) and takes it upon himself to help out. She comes home from the hospital and finds that her sink no longer leaks, her door no longer squeaks, the litterbox is clean, and a note where her step ladder should be saying that all smoke detectors have been checked and batteries changed…all courtesy of Diego.

[myrawjcsmicasereports]

Clinical Case Reports – 1970  by  P. Syamasundar Rao in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

In this paper five case reports were presented and include congenital pulmonary cyst, Wilson-Mikity syndrome, diaphragmatic eventration; foreign body in the bronchus, and cor pulmonale that developed after implantation of a ventriculo-atrial shunt with a Pudenz-Heyer valve for treatment of hydrocephalus. For each case report, clinical, chest x-ray, electrocardiogram and other pertinent findings were presented. This was followed by discussion of etiology, diagnosis, and treatment options, as appropriate.

Keywords: congenital pulmonary cyst; diaphragmatic eventration; Wilson-Mikity syndrome; foreign body in the bronchus; cor pulmonale

Introduction

During the academic clinical practice for over five decades, the author had the unique opportunity to observe and document many interesting clinical case scenarios. The purpose of this review is to revisit these interesting cases. Because of the voluminous amount of this material, the material may be divided into a five-part series. Each of these case reports, while rare and important clinical observations, do demonstrate a clinical point that is useful to the pediatricians, pediatric cardiologists and/or other physicians.

Congenital Pulmonary Cyst

Case Report

A female infant with a birth weight of  6 lb 7 oz, born after a full-term, normal pregnancy and delivery with an Apgar score of 9 presented at three weeks of age with a two-week history of tachypnea. There were no other symptoms and the infant’s physical examination was normal except for tachypnea (respiratory rate of 50 per minute) and mild inter-costal and sub costal retractions. A chest roentgenogram was obtained (Figure 1) which was interpreted as pulmonary cyst. The heart was pushed to the right by the cyst (dextroposition of the heart). At thoracotomy, a huge lung cyst, involving the lower lobe of the left lung, was found, and was resected and the patient made an uneventful recovery.

Discussion

Congenital pulmonary cysts in the neonate are uncommon and are considered as errors in embryological development. They are of several categories namely, bronchogenic cell, alveolar cell, and combined cell types, based on the cellular component of the cell wall of the cyst. The symptoms depend largely upon the size of the cyst. These patients may not be discovered until a chest x-ray is performed for other reasons or may present with symptoms of tachypnea, dyspnea, and cyanosis in the neonatal period secondary to compression of lung tissue. The findings depend upon the size and location of the cyst. Dextroposition of the heart or tracheal shift and hyper-resonance, diminished breath sounds, and rales may be detected on physical examination. The chest x-ray findings may demonstrate a cyst, as in our case (Figure 1) or may be misinterpreted as pneumothorax. Other conditions simulating the cyst are staphylococcal pneumonia, diaphragmatic hernia, congenital lobar emphysema, sequestrated lobe, and hydro-pneumothorax or pyo-pneumothorax. In symptomatic cases, cystectomy, segmentectomy, lobectomy, or pneumonectomy, depending upon the size and location of the cyst is suggested. Percutaneous aspiration of the cyst is not recommended except as an emergency measure to relieve the tension. Some authorities advocate no surgical intervention because of the possibility of spontaneous regression of the pulmonary cysts, but most authorities recommend surgical excision of the cysts [1].

Late Respiratory Distress in a Premature Infant

Case Report

A premature male infant was born at 25 weeks of gestation and weighed 2 lb 12 oz at birth. Abruptio placenta and prolapse of the umbilical cord complicated the delivery and required resuscitation with oxygen. The chest x-ray was normal at that time. The baby was placed in an incubator in 35 percent oxygen, which was discontinued within 24 hours. At the age of 31 days, tachypnea and recurrent apnea with cyanosis developed. Auscultation revealed bilateral rales in the chest, again necessitating resuscitation with O2, administered by bag and mask. Chest x-ray  revealed a diffuse parenchymal reticular pattern with multifocal areas of radiolucency. This roentgenographic pattern, along with the clinical findings, is essentially diagnostic of the Wilson-Mikity syndrome.

Figure 2: Chest x-ray in posterio-anterior view demonstrating a diffuse parenchymal reticular pattern with multifocal areas of radiolucency. This roentgenographic pattern, along with the clinical findings, is essentially diagnostic of the Wilson-Mikity syndrome. Reproduced from Rao PS. Chest 1970; 57:495-6.

Discussion

Wilson an Mikity originally described this condition in 1960, and is now called Wilson-Mikity syndrome.2 The etiology is not clearly understood but is considered to be due to pulmonary dysmaturity with uneven postnatal development of pulmonary alveoli in the premature infants.2 No consistent relationship with O2 therapy has been established. Bronchopulmonary dysplasia is another condition seen in the neonatal period and should be distinguished from Wilson-Mikity syndrome. The cystic appearance on the chest x-ray in the third stage of bronchopulmonary dysplasia resemble those of Wilson-Mikity syndrome; however, it follows treatment of severe hyaline membrane disease with high concentrations of O2 and artificial ventilation.2 The clinical presentation of Wilson-Mikity syndrome is characteristic in that the infant is premature with minimal or no respiratory distress at birth but, develops progressive respiratory distress, with dyspnea, tachypnea, cough, cyanosis, and rales in a few days to weeks. Diffuse reticular pattern of both lungs with areas of multifocal radiolucency are usually seen, similar to those seen in figure 2. Progressive pulmonary insufficiency with signs of right heart failure develop in patients with fatal outcome. But, about half of the patients eventually recover from their pulmonary disease. Pulmonary function studies are abnormal with decreased lung compliance, increased expiratory flow resistance, and increased breathing effort. Respiratory acidosis develops in spite of increased minute volume. Arterial O2 desaturation is thought to be secondary to intrapulmonary right-to-left shunting.2 The treatment is largely supportive [2].

Fever, Vomiting and Dome-Shaped Density in Right Thorax

Case Report

A four-month-old boy presented with a history of fever, poor feeding, vomiting, and slight cough for two days. Past history is essentially normal except for an Apgar score of 6 at birth. Breath sounds were diminished at the right base. Laboratory studies were normal. Chest x-ray (Figure 3) was performed which revealed a dome-shaped density in the right thorax which did not coincide with any pulmonary lobe or segment. The elevation of the inferior liver margin in the abdomen indicated that the abnormal shadow was liver. Based on these findings eventration of the right hemi-diaphragm was suspected. To confirm the diagnosis, a diagnostic pneumoperitonium was performed  which confirmed the diagnosis.

Discussion

Eventration of the diaphragm is classified into adult and infantile types [3]. It is generally thought to be the result of congenital mal-development of the diaphragmatic musculature. However, such an abnormality may occasionally be caused by phrenic nerve injury during birth. The true incidence of eventration is not known, but in mass x-ray surveys of adults, it was found to be one in 10,000 [3]. Total eventration is thought to be more common on the left side and partial eventration on the right [3].

Clinical findings largely depend on the extent of eventration. There may be no symptoms or the patient may present with dyspnea, tachypnea, and cyanosis in the newborn period, requiring immediate treatment. Seesaw cyclic motions of the epigastrium with respiration and Hoover's sign (uninhibited divergence of costal margin from midline on inspiration), if present, are helpful in making the diagnosis. Percussion on the affected side may be dull or tympanic depending on the organs migrated under the diaphragm.

Fluoroscopy and chest x-rays are generally useful in arriving at the diagnosis. In right-sided eventrations, the lesser amount of liver shadow in the abdomen, i.e., elevation of the inferior margin of the liver helps to distinguish eventration from the other conditions [3]. Diagnostic pneumoperitonium is likely to establish the diagnosis, but the current availability of ultrasound technology, diagnostic pneumoperitoneum may not be necessary at the present time.

Symptomatic newborns with diaphragmatic eventration should be treated surgically; plication of the eventrated diaphragm is successful in relieving the symptoms with good long-term results. Some authorities suggest that asymptomatic patients also should be addressed surgically [3].

Foreign Body (Peanut) in The Left Main Stem Bronchus

Case Report

A 13-month-old girl with a history of poor appetite, loss of weight, cough, and intermittent low grade fever was admitted to the hospital for evaluation and treatment. No history of choking episodes was elicited. History revealed that a relative who had active pulmonary tuberculosis lived with the infant's family for a short period of time four months prior to the current admission. Because of this reason, the local health department performed tuberculin skin test which was positive and treatment with isoniazid was initiated. On examination her weight and height were between the third and tenth percentile. Decreased breath sounds on auscultation and hyper tympanic note on percussion were noted over the left side of the chest.

Intermediate strength purified protein derivative (PPD) was positive. Chest roentgenograms were obtained . Based on the history, physical examination, and chest x-ray findings, a diagnosis of endobronchial tuberculosis was entertained. However, prior to beginning treatment, bronchoscopy was performed to appraise the extent of airway encroachment.

Discussion

Autoimmune encephalitis is a condition that can be easily missed as it is not commonly considered in the differential diagnosis of various medical presentations. However, such diagnosis should be always taken into consideration when a person, particularly a child, presents with a new onset of refractory status epilepticus (NORSE) and/or new behavioral or psychiatric conditions. An early diagnosis of AE is essential, as the treatment is different from other conditions. With correct timely interventions the outcome is frequently favorable.

Though SARS-Cov-2 virus rarely invades the nervous system, Covid-19 infection frequently causes neurological symptoms like headache, delirium, anosmia, and dysgeusia [14]. One of the mechanisms of indirect nervous system involvement is through inflammatory response and immune dysregulation. There are few recorded cases of indirect involvement of CNS by auto-antibodies that are directed against the surface and synaptic protein. This case is one of the rare cases of Anti NMDA antibody autoimmune encephalitis that is associated with Covid-19 infection [15]. It indicates that in the era of COVID-19, high vigilance is required as a possible association may increase AE incidence.

A recent systemic review that analyzed 16 studies, including a total of 161 patients with NORSE [16], showed that the most frequent cause was AE. In addition to the well-known association with teratoma and cancer, AE, and specifically Anti-NMDA receptor Ab encephalitis, could be associated with a SARS‑CoV‑2 infection, either concomitantly or as post-infection manifestation. In this reported case, immunotherapy, in addition to anti-seizure medication, showed to be effective.

The main limitation of this report is the relatively short follow-up period. Observation of the child is ongoing to detect possible medium- or long-term consequences.

Positive PPD in an infant with poor appetite, loss of weight, and fever is suggestive of primary tuberculosis. This is particularly so given the patient's exposure to a subject with active pulmonary tuberculosis. The x-rays show hyper aeration of the left lung with a shift of the heart and mediastinum to the right. The left leaf of the diaphragm is also flattened. While there are no areas of infiltration or consolidation were seen, prominent shadows suggesting enlarged lymph nodes were seen . Endobronchial tuberculosis with compression of the bronchus by adenopathy may produce changes seen figure 5.

Discussion

Even though there was no history of choking or aspiration, the possibility of foreign body aspiration should be considered in this age group. Consequently, bronchoscopy was performed which revealed a peanut in the left main stem bronchus and was extracted during bronchoscopy. The peanut and the adjacent edema of the bronchus caused partial bronchial obstruction and acted as a check valve, so the air entered the left lung but, unable to leave the left lung since the bronchus becomes smaller during expiration, producing the roentgenographic appearance shown in figure 5. The baby improved and the treatment with isoniazid was continued because of the positive PPD.

Cor Pulmonale as a Complication of Ventriculoatrial Shunts

Introduction

Cerebral ventricle-to-right atrial shunts with Pudenz-Heyer or Spitz-Holter valves were widely used to treat hydrocephalus in the 1960s. Development of pulmonary hypertension with chronic cor pulmonale is rare with these shunts. We reported a patient who developed such a complication along with description of specialized pulmonary function studies in the early detection of such complication [5].

Case Report

An 11-year-old white boy was hospitalized in April 1969 with a history of progressive weakness, dyspnea, and pedal edema. He was diagnosed to have hydrocephalus and had a ventriculo-atrial shunt with a Pudenz-Heyer valve implanted at the age of 6 months. The shunt was thought to be functioning well when he was evaluated at the age of 2 years. He was asymptomatic until he was 9.5 years old, when he developed signs of congestive heart failure (CHF) and was treated at another hospital with digitalis and diuretics with some improvement. Right heart catheterization at the same institution revealed a mean right atrial pressure of 35 mmHg and right atrial angiography revealed slow emptying of the contrast, filling defects on the right lateral atrial wall and in the right and left pulmonary arteries. The ventriculo-atrial shunt was removed shortly thereafter. The patient was referred to our group for further evaluation and management [5].

Pertinent findings on examination included height and weight below the third percentile, head circumference above the 97th percentile, pretibial edema, prominent “a” wave in the left side of the neck, no venous pulsations on the right side, palpable right ventricular heave, markedly accentuated single second heart sound, an audible fourth heart sound at left lower sternal border, a Grade I/VI ejection systolic murmur at the mid-left sternal border, liver edge palpable 5 cm below the right costal margin, clear lung fields on auscultation, and normal neurological examination.

Electrocardiogram (ECG) and the vectorcardiogram (not shown) revealed right atrial and ventricular hypertrophy. Chest roentgenogram  showed moderate cardiomegaly and prominent main pulmonary artery (PA) segment and clear lung fields. Lung scan with 131I-labeled macro-aggregated albumin was suggestive of multiple pulmonary emboli. Blood gas analysis showed pH 7.56; PaO2 80 mmHg, PaCO2 23 mmHg and bicarbonate 24 mEq/liter. Routine pulmonary function studies revealed restrictive lung disease. The ratio of wasted ventilatory volume (physiological dead space) to tidal volume (VD:VT) using Bohr's equation was 0.58 (normal 0.3 or less).

Vigorous treatment with digitalis and diuretics resulted in only temporary relief. During the next year, he continued to deteriorate and died of intractable right ventricular failure. Postmortem revealed right atrial thrombosis, severe right ventricular hypertrophy, multiple thrombo-emboli in the large and medium-sized pulmonary arteries, and intimal proliferation of the pulmonary arterioles.

Discussion

The case presented demonstrated development of cor pulmonale secondary to pulmonary thrombo-embolism which was produced by thrombi that arose following a ventriculo-atrial shunt with a Pudenz-Heyer valve for treatment of hydrocephalus. The causes of thrombo-embolic complications were not well understood, but the hypotheses, as reviewed by us [5], include infection, periarteritis due to autoimmune reaction of the pulmonary vessels to protein of cerebrospinal fluid, release of brain thromboplastin resulting in thrombosis at the point of contact with plasma coagulation factors, and simply the presence of a foreign body in the cardiovascular system for prolonged periods of time.

Early detection of pulmonary hypertension by periodic (every six months) evaluation by chest x-ray and ECG studies was suggested by some investigators, but early detection of pulmonary hypertension is of limited value since obstruction of 60% of the pulmonary vascular bed occurs by the time pulmonary hypertension develops [5]. Detection of multiple filling defects on radioisotope scanning in a child with a ventriculo-atrial shunt would be suggestive of pulmonary embolization and might be useful in early identification. Based on the observations of Nadel and associates [6] and those of ours [5], we suggested that specialized pulmonary function studies such as VD:VT, pulmonary diffusing capacity, pulmonary capillary blood volume, blood gas, and pH be performed periodically to detect obstruction of pulmonary vasculature prior to the development of pulmonary hypertension and cor pulmonale [5]. However, it should be noted that ventriculo-atrial shunts are no longer performed to treat hydrocephalus, but instead ventriculo-peritoneal shunts are used at the present time.

In summary, a rare case of pulmonary thrombo-embolism with resultant pulmonary hypertension and cor pulmonale following ventriculo-atrial shunt for hydrocephalus was presented with the recommendation to use of special pulmonary function studies for early detection and if found to be positive, immediate removal of the shunt system may eliminate further embolization into the lungs and prevent irreversible pulmonary vascular disease.

[anchorcare]

What could cause chest and back pain together?

Chest and back pain occurring together can be concerning and may have various underlying causes. Here are some potential reasons:

1. Musculoskeletal Issues

Muscle Strain: Overexertion or poor posture can strain muscles in the chest and back, leading to pain in both areas.

Rib Injury: Injuries to the ribs or inflammation of the costal cartilage (costochondritis) can cause pain that radiates from the chest to the back.

2. Nerve Compression

Herniated Disc: A herniated disc in the thoracic spine can compress nerves, causing pain that radiates from the chest to the back.

Thoracic Outlet Syndrome: Compression of nerves or blood vessels in the area between the collarbone and the first rib can lead to pain in both the chest and back.

3. Gastrointestinal Issues

Acid Reflux: Gastroesophageal reflux disease (GERD) can cause chest pain that may also be felt in the back.

Esophageal Spasms: Sudden contractions of the esophagus can lead to chest pain that radiates to the back.

4. Cardiovascular Conditions

Angina: Reduced blood flow to the heart can cause chest pain that may radiate to the back.

Heart Attack: In some cases, heart attacks can present with pain in the chest that also affects the back.

5. Respiratory Conditions

Pneumonia or Pleurisy: Inflammation of the lungs or the lining around the lungs can cause chest and back pain, often accompanied by other symptoms like coughing or shortness of breath.

6. Anxiety or Panic Attacks

Anxiety can manifest physically, leading to chest tightness and back pain as part of a panic attack or generalized anxiety.

7. Shingles

Reactivation of the varicella-zoster virus can cause pain in the chest and back, often accompanied by a rash.

Conclusion

If you experience chest and back pain together, especially if it’s severe, persistent, or accompanied by other symptoms (like shortness of breath, dizziness, or sweating), it’s important to seek medical attention immediately. A healthcare professional can conduct the necessary evaluations to determine the underlying cause and appropriate treatment.

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