Efficacy and Safety of High PEEP NIV in COVID-19 Patients.

OBJECTIVE: To investigate the efficacy and safety of non-invasive ventilation (NIV) with high PEEP levels application in patients with COVID-19-related acute respiratory distress syndrome (ARDS). METHODS: This is a retrospective cohort study with data collected from 95 patients who were administered NIV as part of their treatment in the COVID-19 intensive care unit (ICU) at University Hospital Centre Zagreb between October 2021 and February 2022. The definite outcome was NIV failure. RESULTS: High PEEP NIV was applied in all 95 patients; 54 (56.84%) patients could be kept solely on NIV, while 41 (43.16%) patients required intubation. ICU mortality of patients solely on NIV was 3.70%, while total ICU mortality was 35.79%. The most significant difference in the dynamic of respiratory parameters between 2 patient groups was visible on Day 3 of ICU stay: By that day, patients kept solely on NIV required significantly lower PEEP levels and had better improvement in PaO2, P/F ratio, and HACOR score. CONCLUSION: High PEEP applied by NIV was a safe option for the initial respiratory treatment of all patients, despite the severity of ARDS. For some patients, it was also shown to be the only necessary form of oxygen supplementation.

Case report: Rapid-onset parkinsonism after a hornet sting.

Neurological manifestations with basal ganglia involvement following Hymenoptera stings are rare and clinically ill-defined conditions. We present a patient with acute parkinsonism non-responsive to levodopa, who developed striatal lesions after a hornet sting. We report his response to immunomodulatory treatment and subsequent clinical and brain magnetic resonance imaging (MRI) follow-up. We also searched the literature for patients with acute extrapyramidal syndromes following an insect sting. Fourteen cases have been published; 12 of them are reviewed here. The majority of cases presented with symmetric akinetic syndrome with axial rigidity and/or gait impairment. Six patients were treated with levodopa and only two of these had a modest response to therapy. Brain MRI/computed tomography scan revealed lesions of the basal ganglia, which resulted in fatal outcome in four patients, whereas only one achieved complete recovery. Clinicians should be aware of this rare but devastating cause of acute-onset parkinsonism and specific clinical presentation of this condition, and should consider prompt and prolonged immunomodulatory treatment to prevent irreversible basal ganglia damage.

Association of intestinal inflammation and permeability markers with clinical manifestations of Parkinson's disease.

INTRODUCTION: Intestinal inflammation and gut microbiota dysbiosis can stimulate degeneration of dopaminergic neurons and development of Parkinson's disease (PD) via the gut-brain axis in certain patients. METHODS: In a case-control study, fecal markers of intestinal inflammation and permeability were measured using the ELISA method in PD patients and healthy controls. Motor and nonmotor symptoms were assessed using the Movement Disorder Society (MDS) Unified PD Rating Scale, Hoehn & Yahr scale, MDS Non-Motor Symptom Scale, Scales for Outcomes in PD - Autonomic Dysfunction, PD Sleep Scale - 2, Montreal Cognitive Assessment, Beck Anxiety Inventory, and Beck Depression Inventory-II. A correlation was established between the intestinal inflammation and permeability markers and PD symptoms. RESULTS: Higher levels of beta-defensin 2, zonulin and lactoferrin were recorded in PD patients compared to controls. Calprotectin and secretory immunoglobulin A showed no significant differences. Regression analysis indicated the roles of beta-defensin 2 and lactoferrin in predicting PD likelihood. Calprotectin yielded positive correlations with disease duration, depression, motor fluctuations, and gastrointestinal symptoms; beta defensin 2 with thermoregulation; and secretory immunoglobulin A with depression. Secretory immunoglobulin A showed negative correlation with age and age at disease onset, while zonulin showed negative correlation with the MDS Unified PD Rating Scale total score. CONCLUSIONS: Fecal markers differed in PD patients compared to controls and correlated with age, disease duration, and some nonmotor symptoms. Future studies should identify the subgroups of PD patients that are likely to develop intestinal inflammation.

Seborrheic Dermatitis Is Related to Motor Symptoms in Parkinson's Disease.

BACKGROUND AND PURPOSE: Parkinson's disease (PD) patients present with numerous motor and nonmotor symptoms. Seborrheic dermatitis (SD) is reported in 18.6%-59% of PD patients. However, the etiology of SD in PD patients remains unknown. The aim of this study was to determine how motor and nonmotor symptoms, age, sex, and levodopa-equivalent daily dose (LEDD) influence the appearance and severity of SD in PD patients, and then discuss about SD possible etiology based on the obtained results. METHODS: Motor symptoms were evaluated using the Unified Parkinson's Disease Rating Scale part III and nonmotor symptoms were evaluated using the Parkinson's Disease Sleep Scale, Scales for Outcomes in Parkinson's Disease-Autonomic Dysfunction, and Non-Motor Symptoms Questionnaire. LEDD was calculated and demographic data on age, sex, disease duration, and symptoms of SD prior to a PD diagnosis were collected. A dermatologist evaluated the skin for SD using the Seborrhea Area and Severity Index. RESULTS: SD was present in 36.1% of the PD patients. There were positive correlations between age, motor-symptoms severity, and SD. After adjusting for age, disease duration, and sex, there remained a positive correlation between the severity of motor symptoms and SD. Patients with moderate-to-severe motor symptoms had more-severe SD symptoms, and their risk of developing SD was 1.8-fold higher. There was no correlation between SD and autonomic dysfunction, sleep disturbances, or other nonmotor symptoms, and no sex difference. CONCLUSIONS: In PD, SD is related to motor symptoms.

Headache onset after vaccination against SARS-CoV-2: a systematic literature review and meta-analysis.

BACKGROUND: Vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are used to reduce the risk of developing Coronavirus Disease 2019 (COVID-19). Despite the significant benefits in terms of reduced risk of hospitalization and death, different adverse events may present after vaccination: among them, headache is one of the most common, but nowadays there is no summary presentation of its incidence and no description of its main features. METHODS: We searched PubMed and EMBASE covering the period between January 1st 2020 and August 6th, 2021, looking for record in English and with an abstract and using three main search terms (with specific variations): COVID-19/SARS-CoV-2; Vaccination; headache/adverse events. We selected manuscript including information on subjects developing headache after injection, and such information had to be derived from a structured form (i.e. no free reporting). Pooled estimates and 95% confidence intervals were calculated. Analyses were carried out by vaccine vs. placebo, by first vs. second dose, and by mRNA-based vs. "traditional" vaccines; finally, we addressed the impact of age and gender on post-vaccine headache onset. RESULTS: Out of 9338 records, 84 papers were included in the review, accounting for 1.57 million participants, 94% of whom received BNT162b2 or ChAdOx1. Headache was generally the third most common AE: it was detected in 22% (95% CI 18-27%) of subjects after the first dose of vaccine and in 29% (95% CI 23-35%) after the second, with an extreme heterogeneity. Those receiving placebo reported headache in 10-12% of cases. No differences were detected across different vaccines or by mRNA-based vs. "traditional" ones. None of the studies reported information on headache features. A lower prevalence of headache after the first injection of BNT162b2 among older participants was shown. CONCLUSIONS: Our results show that vaccines are associated to a two-fold risk of developing headache within 7 days from injection, and the lack of difference between vaccine types enable to hypothesize that headache is secondary to systemic immunological reaction than to a vaccine-type specific reaction. Some descriptions report onset within the first 24 h and that in around one-third of the cases, headache has migraine-like features with pulsating quality, phono and photophobia; in 40-60% of the cases aggravation with activity is observed. The majority of patients used some medication to treat headache, the one perceived as the most effective being acetylsalicylic acid.

Fatigue is related to depression in idiopathic dystonia.

INTRODUCTION: Dystonia is a movement disorder presented with involuntary muscle contraction causing abnormal posture, movement, or both. Besides motor symptoms, patients may also report non-motor symptoms such as pain, anxiety, apathy, depression, sleep problems, fatigue, and cognitive impairment. The etiology of fatigue in patients with dystonia is not yet well understood. AIM: To evaluate the presence of fatigue, depression, anxiety, sleep disorders, and daily sleepiness in patients with focal and segmental dystonia and to determine which of these non-motor symptoms influence the occurrence and severity of fatigue. PATIENTS AND METHODS: Patients were surveyed for symptoms of fatigue, depression, anxiety, night-time sleep problems, and daily sleepiness using the Fatigue Assessment Scale, Beck Depression Inventory II, Beck Anxiety Inventory, Pittsburgh Sleep Questionnaire Index, and Epworth Sleepiness Scale. Demographic data (sex, age, and disease duration) were collected from patient medical records. On statistical analysis, we used SPSS for Windows 10. The level of significance was set at p<0.05. RESULTS: Sixty patients (43 female and 17 male) with focal or segmental dystonia were evaluated. Fatigue was reported by 67.2% of patients. Fatigue (general, physical, and mental fatigue) was found to correlate with depression, anxiety, and sleep problems. Daily sleepiness correlated only with mental fatigue. Disease duration, age, and gender did not influence the symptoms of fatigue. Multiple regression analysis showed that depression mostly predicted symptoms of general, physical, and mental fatigue. CONCLUSION: Depression mostly predicted symptoms of general, physical, and mental fatigue in patients with focal and segmental dystonia.

Suicidality in Epilepsy: Does It Share Common Pathogenic Mechanisms with Epilepsy?

Suicidality presents a major global health concern and its association with epilepsy has been suggested. The body of evidence is growing due to targeted epidemiological studies, genetic findings, and neuroimaging data, use of specific neuropsychiatric inventories, neuropsychological tests, and metabolic and immunological studies.Suicide tendencies and psychiatric comorbidity such as depression are not uncommon in chronic diseases, especially in epilepsy. Suicide is an important cause of death in epilepsy, and is usually underestimated. Persons with epilepsy have higher risk for suicide than healthy controls. It appears that some epilepsy types have stronger tendencies for suicide, in particular temporal lobe epilepsy. The suicidal risk factors in persons with epilepsy include difficult to treat epilepsies, onset of epilepsy at an earlier age, and comorbid depression.This clinical evidence is mostly based on observational studies in which we found an increased risk of suicidal ideation, suicidal attempts, and completed suicides in persons with epilepsy. However, we lack prospective and longitudinal studies on suicide in epilepsy. In this chapter we will examine recent research in neurobiological mechanisms between suicidality and epilepsy, and comorbid depression.

Glycaemia, renal function and body mass in men and women with type 2 diabetes.

Aim To determine parameters of glycaemic control, renal function and anthropometric measurements in patients with type 2 diabetes in family medicine offices and to examine whether there is a difference in these parameters between genders. Methods This cross-sectional study included 136 patients of both genders diagnosed with type 2 diabetes, with an average age of 69.33±10.87. General and demographic data were collected, anthropometric measurements were taken, as well as data on fasting plasma glucose, HbA1 c and creatinine level from laboratory findings. Estimated glomerular filtration rate (eGFR) was calculated. Results The average results of fasting plasma glucose test were 8.43 mmol/L, of HbA1c 7.15%, and of creatinine 79.00 µmol/L. In 19.12% of patients eGFR was <60 mL/min/1.73m2 . 80.15% were overweight and 38.97% had a body mass index (BMI) of 30 kg/m2 or higher. Morbid obesity was recorded in 2.94% of patients. Females had a statistically significantly higher hip circumference (p=0.002) and BMI (p=0.019), while males had a statistically significantly higher waist-to-hip ratio (p=0.006) and BMI (p=0.007). Conclusion The patients did not reach the target value of fasting plasma glucose (<7mmol/L) and HbA1c was above recommended (<7%). Given that the patients were elderly, glucoregulation can be considered as adequate. The average eGFR classified the patients into G2 group (mildly decreased glomerular filtration). The mean BMI was not within the recommended values. It is important to educate patients on a healthy diet and physical activity, to control their weight, but also to choose medications that reduce weight in addition to glycaemic control.

Hyperhomocysteinemia influenced malnutrition in Parkinson's disease patients.

INTRODUCTION: Parkinson's disease (PD) is a neurodegenerative disease with many motor and non-motor symptoms. Hyperhomocysteinemia is reported in many PD patients. Homocysteine (Hcy) is reported to be a risk factor for some PD non-motor symptoms. AIM: The aim was to analyze Hcy level and its correlation with physical activity and motor and some non-motor symptoms (depression and cognition) in PD patients. PATIENTS AND METHODS: Patients were surveyed for physical activity and demographic data. Blood samples were obtained for Hcy, vitamin B12, and folic acid determination. The Mini Nutritional Assessment (MNA), Unified Parkinson's Disease Rating Scale (UPDRS) parts III and IV, Hoehn and Yahr (H&Y) Scale, Beck Depression Inventory (BDI), and Mini Mental State Examination (MMSE) were used to assess nutritional status, disease stage, and motor and some non-motor symptoms (depression and cognition) of PD in study patients. RESULTS: We analyzed 34 PD patients. Elevated Hcy level was found in 70.6% of these patients. Patients reporting regular exercise had lower Hcy level (p < 0.025). Hcy level yielded a statistically significant correlation with MNA score (rs = - 0.510; p < 0.003), UPDRS part III (rs = 0.372; p < 0.030), vitamin B12 (rs = - 0.519; p < 0.002), and folic acid (rs = - 0.502; p < 0.003) but not with cognition and depression. There were no statistically significant differences in Hcy level for disease stage either for dyskinesia or "off" periods. CONCLUSION: PD patients are at a risk of hyperhomocysteinemia. Regular physical activity decreases Hcy level, whereas poor motor function increases it. There is correlation between Hcy level and malnutrition in PD patients.

Orthostatic intolerance: postural orthostatic tachycardia syndrome with overlapping vasovagal syncope.

A 28-year-old female with a history of situational syncope and a new-onset right sided hemiparesis is described. Tilt-up table test revealed the postural orthostatic tachycardia syndrome followed by vasovagal syncope. Neurological and internal medicine tests showed no particular disorders. The patient underwent autonomic physical training and the tilt-up test performed three months later showed improvement of the autonomic system in terms of lower heart beat rate of the postural orthostatic tachycardia syndrome and longer duration of the test. This case report describes longstanding idiopathic dysautonomia that can be improved by nonpharmacological treatment, while reminding that this medical condition may also be the cause of syncope.