Common diagnoses and factors associated with abnormal neuroimaging in headache patients in the emergency department.

OBJECTIVES: To determine causes of headaches in patients who presented to the emergency department (ED) and underwent neuroimaging, and to determine the clinical features associated with abnormal neuroimaging. METHODS: Patients were retrospectively selected from a database between June, 2015 and May, 2019. Patients were included if they had neuroimaging requested from the ED mainly for headache. Associations between clinical characteristics and abnormal neuroimaging were assessed. RESULTS: We included 329 patients (33.4% men, 66.6% women). The mean (SD) age was 39.7 (18.4) years. Neurological signs were reported in 43.8% of the patients, head-computed tomography was requested in 79.6%, magnetic resonance imaging in 77.5%, and both in 57.1%. Abnormal neuroimaging was reported in 31.9%. The most common reported diagnoses were secondary headache disorders (48.9%), followed by primary headache disorders (16.4%). The remainder were nonspecific-headaches (35%). Variables associated with abnormal neuroimaging were headache onset ≤1 month (OR 3.37, CI 1.47-7.70, p=0.004), and presence of an abnormal neurological sign (OR 3.60, CI 1.89-6.83, p<0.001). CONCLUSION: Secondary headache disorders are common in patients who undergo neuroimaging in the ED. Those who have a neurological sign and recent onset of headache are more likely to have abnormal neuroimaging.

Hidden in the Rash: A Sneddon Syndrome Case Report.

This clinical case report aims to highlight the unusual presentation of Sneddon syndrome with a possible association with paroxysmal hemicrania. A medical record review was performed at a tertiary hospital in Riyadh, Saudi Arabia. Data collected include clinical evaluations and laboratory and imaging results. Informed consent was obtained. Hereby, we present a 27-year-old female who presented with multiple stroke attacks, along with severe headaches involving right retro-orbital pain with an eight-year history of spotted skin lesions. Initial unenhanced computed tomography (UCT) brain in the emergency showed left insular cortex hypodensity, revealing acute ischemic insult. Subsequent magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) revealed acute ischemic infarct in the territory of the left middle cerebral artery (MCA) involving the insula and frontoparietal lobe. Further investigations were done, including cerebrospinal fluid (CSF) analysis and autoimmune and infectious workup, which were unrevealing. Skin biopsy of the lesions showed subcutaneous fat necrosis with nonspecific scattered fibrinogen positivity and was labeled as livedo reticularis vs. livedo racemosa. A Sneddon syndrome diagnosis can be very challenging, needing a high index of suspicion to direct the diagnostic investigations. Moreover, the presence of a severe headache is an unusual phenomenon that needs further study.

NR2F1 mediated down-regulation of osteoblast differentiation was rescued by bone morphogenetic protein-2 (BMP-2) in human MSC.

Endochondral ossification is the process by which long bones are formed; the process of long bone formation is regulated by numerous factors such as transcription factors, cytokines, and extracellular matrix molecules. Human hormone Nuclear receptors (hHNR) are a family of ligand-regulated transcription factors that are activated by steroid hormones, such as estrogen and progesterone, and various lipid-soluble signals, including retinoic acid, oxysterols, and thyroid hormone. Whole genome microarray data from our previous study revealed that most hHNR's are up-regulated during osteoblast differentiation in hMSCS. NR2F1 was among the highest expressed hHNR during osteogenesis, NR2F1 belongs to the steroid/thyroid hormone nuclear receptor superfamily. NR2F1 is designated as an orphan nuclear receptor because its ligands are unknown. NR2F1 plays a wide range of roles, including cell differentiation, cancer progression, and central and peripheral neurogenesis. Identifying signaling networks involved in osteoblast differentiation is important in orchestrating new therapeutic and clinical applications in bone biology. This study aimed to identify alterations in signaling networks mediated by NR2F1 in osteoblast differentiation. siRNA-mediated down-regulation of NR2F1 leads to impairment in the differentiation of hBMSC-TERT to osteoblast; gene-expression results confirmed the down-regulation of osteoblast markers such as RUNX2, ALPL, OSC, and BSP. Global whole gene expression analysis revealed that most down-regulated genes were associated with osteoblast differentiation (DDIT3, BMP2). Pathway analysis revealed prominent signaling pathways that were down-regulated, including the TGFß pathway and MAPK pathway. Functional studies on NR2F1 transfected cells, during osteoblast differentiation in combination with TGFß1 and BMP-2, showed that TGFß1 does not recover osteoblast differentiation, whereas BMP-2 rescues osteoblast differentiation in NR2F1 siRNA transfected cells. Thus, our results showed that BMP-2 could intervene in NR2F1 down-regulated signaling pathways to recover osteoblast differentiation.

Accuracy of seizure semiology obtained from first-time seizure witnesses.

BACKGROUND: Little is known of how accurately a first-time seizure witness can provide reliable details of a semiology. Our goal was to determine how accurately first-time seizure witnesses could identify key elements of an epileptic event that would aid the clinician in diagnosing a seizure. METHODS: A total of 172 participants over 17 years of age, with a mean (sd) of 33.12 (13.2) years and 49.4% female, composed of two groups of community dwelling volunteers, were shown two different seizure videos; one with a focal seizure that generalized (GSV), and the other with a partial seizure that did not generalize (PSV). Participants were first asked about what they thought was the event that had occurred. They then went through a history-taking scenario by an assessor using a battery of pre-determined questions about involvement of major regions: the head, eyes, mouth, upper limbs, lower limbs, or change in consciousness. Further details were then sought about direction of movement in the eyes, upper and lower limbs, the side of limb movements and the type of movements in the upper and lower limbs. Analysis was with descriptive statistics and logistic regression. RESULTS: One hundred twenty-two (71.4%) identified the events as seizure or epilepsy. The accuracy of identifying major areas of involvement ranged from 60 to 89.5%. Horizontal head movements were significantly more recognized in the PSV, while involvement of the eyes, lateralization of arm movement, type of left arm movement, leg involvement, and lateralization of leg movement were significantly more recognized in the GSV. Those shown the GSV were more likely to recognize the event as "seizure" or "epilepsy" than those shown the PSV; 78 (84.8%) vs 44 (55.7%), (OR 0.22, p < 0.0001). Younger age was also associated with correct recognition (OR 0.96, P 0.049). False positive responses ranged from 2.5 to 32.5%. CONCLUSION: First-time witnesses can identify important elements more than by chance alone, and are more likely to associate generalized semiologies with seizures or epilepsy than partial semiologies. However, clinicians still need to navigate the witness's account carefully for additional information since routine questioning could result in a misleading false positive answer.