Funtabulously Frivolous Friday Five 305

Severe Aortic Regurgitation

Landolfi sign (1909) is a rapidly alternating systolic constriction and diastolic dilation of the pupil occurring in severe aortic regurgitation. Believed to be an exaggeration of the physiologic circulatory hippus in the iridal vessels due to high pulse pressure and large stroke volume

Pupillary hippus is the spasmodic, cyclical and bilaterally in-phase fluctuations in pupil size in the absence of external influences such as luminance, mood and fixation. Its mechanism remains unclear but is hypothesised to be due to the continuous neurologic antagonism of the SNS and PSNS as well as respiratory and cardiac activity.

Landolfi examined twenty-four patients with grave aortic insufficiency, and found in one circulatory hippus. The patient suffered from arteriosclerosis with aortic insufficiency and hypertrophy of the left ventricle. A rapid alternate contraction and dilatation of pupil was observed. He was also able to produce this sign in three other patients after giving fifteen drops of tincture of digitalis a day for four days. He also observed the circulatory hippus in a dog with experimental aortic insufficiency after the administration of heart stimulants.

New York Medical Journal 1909

Video: Landolfi Sign: Rapid alternate constriction and dilation of the left pupil occurring synchronously with heartbeat [Saini et al. Am J Med. 2017]

7.5%

After tightening the necktie in a Windsor knot to the point of “slight discomfort”, CBF decreased by 7.5% (− 4.33 ± 3.34 ml/min/100 g) compared to baseline (p < 0.001). More worryingly there was still a drop of 5.7% (− 3.08 ± 1.52 ml/min/100 g; p < 0.001) after the necktie was taken off.

The control group showed a constant value of CBF with no statistically significant drops.

This study did not evaluate whether there was any clinical significance, but perhaps if there are still tie wearing doctors you could perform your own ‘before and after’ study to see if performance improved.

As a random aside (and no affiliation), for those of you still keen on the tie/bowtie or have a friend that owns everything sneak a peak at ‘Infectious Awareables’ which features ties ranging from biohazard symbols to gonorrhoea.

Reference:

• Lüddecke R et al. Should you stop wearing neckties? – wearing a tight necktie reduces cerebral blood flow. Neuroradiology 2018.

Haemophilia C (Factor XI deficiency)

Also known as Rosenthal syndrome who described two sisters in 1953 with abnormal bleeding after a tooth extraction and surgery to remove tonsils. Four more of the thirteen members of the same family over four generations were identified as having factor XI deficiency. Factor XI deficiency is an autosomal recessive disease that is most commonly reported in Askhenazic Jews. The incidence in the Ashkenazic population is 3 in 1000, compared with a rate of 1 in 1,000,000 in the general population.

Factor IX deficiency presents with a prolongation of the aPTT, with a normal PT. There is an incomplete correlation between the severity of factor deficiency and hemorrhagic symptoms. Bleeding typically occurs after trauma or surgery and is commonly seen in sites that have a high fibrinolytic rate, such as the genitourinary tract, and after circumcision. The most common form of treatment is FFP and for mild bleeding cyklokapron (tranexamic acid).

Reference:

• Canada Hemophilia Society – Hemophilia C

Glaukomflecken simply means glaucoma flecks. It is anterior subcapsular or capsular opacity of the lens associated with focal epithelial infarct from past acute angle closure glaucoma.

For something a little lighter you can see how it all started with Dr G being accused of being racist with an ophthalmoscope avatar – #GuGate – and if amused you check out the charity first descents he helps out.

Reference:

• EyeRounds.org – Glaukomflecken

It reflects transmission of heart vibrations through a motionless lung and was first described by Daniel Lichtenstein in 2003.

Possible causes include:

• Mainstem intubation
• Obstructive bronchial foreign body
• Temporary voluntary apnea
• Pharmacological paralysis.

Below is a rather dramatic video of a lung pulse . And then a still image of the lung pulse shown in ‘m-mode’ where it has been aptly named the ‘T wave’, some argue this is an easier method for spotting a lung pulse.

Reference:

• Lichtenstein DA et al. The “lung pulse”: an early ultrasound sign of complete atelectasis. Intensive Care Med 2003; 29(12): 2187-2192.
• Rippey J. COPD Case 1 Lung Pulse. 2019
• emDOCs.net – Unmasking the lung pulse
• Intensive Care network – lung ultrasound