Endovascular Therapy in Large Core Ischemic Strokes: Real-World Indian Experience.

BACKGROUND: Large core acute ischemic strokes have predominantly been excluded from endovascular therapy (EVT) studies due to perceived higher risks of hemorrhage and poorer functional outcomes. However, recent randomized controlled trials (RCTs) indicate that EVT for large vessel occlusion (LVO) strokes improves functional outcomes compared to medical management alone, despite higher hemorrhagic transformation rates, with no corresponding increase in symptomatic intracerebral hemorrhage (sICH) rates. The real-world outcomes of this intervention in Indian patients remain underexplored. OBJECTIVES: To evaluate the real-world outcomes of EVT for large core acute ischemic strokes with LVO in an Indian population. METHODS: We conducted a single-center, retrospective observational study using a 7 years prospective database of EVT in anterior circulation stroke patients. Patients with Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 3-5 were included. Clinical and radiologic data were analyzed, with the primary endpoint being 90-day modified Rankin scale (mRS) scores. Safety outcomes included rates of sICH and mortality. Descriptive statistical analysis was done using Microsoft Excel. RESULTS: The study included 25 patients who met the inclusion criteria. Mean age of patients was 52.9 ± 14.3 years, and there were 13 (52%) males. Median ASPECTS was 5 (interquartile range 4-5). Successful recanalization, classified by modified Thrombolysis in Cerebral Infarction score, was 92%. Good functional recovery, that is, 90-day mRS 0-3, was achieved in nine (36%) patients. Safety outcomes: sICH was seen in four (16%) and mortality was reported in nine (36%) patients. CONCLUSIONS: Our results reaffirm findings from RCTs, provide updated real-world evidence, and suggest that EVT is a viable option to be considered in selected patients with large core ischemic infarcts.

Vagal nerve stimulation for headache.

PURPOSE OF REVIEW: Vagal nerve stimulation (VNS) is emerging as a probable therapeutic option for headache. Several questions remain on the mechanism of action, device parameters, efficacy, duration of treatment and long-term safety. This review aims at describing findings of recent literature pertaining to VNS for headache, to put these findings into the perspective of our current fund of knowledge and future scope of work on the topic. RECENT FINDINGS: Several studies on functional magnetic resonance imaging patterns following VNS in patients with headache have been published, revealing potential biomarkers of headache and possible treatment effects. A study on post-COVID-19 headache and its management with noninvasive cervical VNS adds to the body of original studies. Meta-analyses and systematic reviews outlining previous work have been published. The collection of these studies adds some data to mechanisms of VNS without adding much insight to differential effects of sub-types of VNS and possible device settings that could prove to be beneficial for headache management. SUMMARY: Well designed studies are needed to identify mechanisms of action, elicit differential effects of various stimulation parameters, and to demonstrate long-term therapeutic effects and safety of VNS in headache.

Comparison of STEMI Door-To-Device Time During the COVID-19 Crisis in a New Jersey Inner City Community Hospital.

As the novel COVID-19 pandemic was on the rise, its impact on the healthcare system was devastating. Patients became more reluctant to present to the hospital and elective procedures were being postponed for patient safety. We wanted to assess the effects of the COVID-19 pandemic on the door-to-device time in our small community hospital in the heart of Trenton, New Jersey. We created a retrospective study that evaluated all STEMI cases that presented to our institute from January 2018 until the end of May, 2021. Our primary outcome was the door-to-device time. Secondary outcomes were the length of hospital stay, ICU admission, length of ICU stay, cardiac arrest, and death during the hospitalization. We studied 114 patients that presented with STEMI to our emergency department, 77 of these patients presented pre-COVID-19, and 37 presented during the pandemic. Our median door-to-device for STEMI cases pre-COVID-19, and during the pandemic were 70 min (IQR 84-57) and 70 min (IQR 88-59) respectively with no significant difference found (P-value 0.55, Mann Whitney Test). It is, however, interesting to note that the number of STEMI admissions significantly decreased during the pandemic era. There are limitations to our study, most noticeably the number of STEMI cases at our small community hospital which limits its generalizability. Moreover, we did not assess other comorbidities which might have confounded our outcomes and we were also unable to follow patients post-discharge to assess the long-term sequela of their STEMI admission. Therefore, more dedicated studies of this clinical conundrum are required to further assess and implement guidelines for the future.

Prostate Cancer Presenting With an Unusual Presentation of Rectal Pain and Bleeding.

We report an atypical case of prostate cancer with rectal involvement presenting with gastrointestinal symptoms predominately and a rectal mass. A 51-year-old male patient came to the hospital with abdominal pain and rectal bleeding. Imaging revealed prostate enlargement, perirectal lymphadenopathy, and multiple hepatic and pulmonary nodules. The patient also had an elevated prostate-specific antigen (PSA) of 502 ng/mL (against normal range 0.6-0.7 ng/mL). Biopsies were performed on tissue samples taken from the rectum and prostate gland, which confirmed the diagnosis of prostate adenocarcinoma. The lack of urinary symptoms and close clinical similarity to colorectal cancer presented a diagnostic challenge for us. Familiarity with this specific presentation of prostate cancer is necessary to avoid misdiagnoses and guide correct treatment.

Delayed Diagnosis in a Rare Case of Pulmonary Sarcoidosis Presenting as Unilateral Hilar Lymphadenopathy and Fever of Unknown Origin.

In this report, we present a rare case of sarcoidosis presenting as fever of unknown origin with unilateral hilar lymphadenopathy, in contrast with the typical presentation of sarcoidosis. Sarcoidosis presenting with asymmetric or isolated unilateral lymphadenopathy is highly unusual. Sarcoidosis is also an uncommon cause of fever of unknown origin. This atypical presentation led to diagnostic delays in our case. This case report emphasizes the importance of considering sarcoidosis early in the differential diagnosis of fever of unknown origin with unilateral hilar lymphadenopathy.

A rare case of native mitral valve infective endocarditis presenting with complete heart block and intermittent atrial flutter.

Mitral valve infective endocarditis, without aortic involvement, is a rare cause of complete heart block. It is thought that infections placed close to the conductive system of the heart may drive a conduction block. We found six cases in the literature, via searching PubMed, of mitral valve infective endocarditis with complete heart block and no aortic involvement. We report a case of complete heart block with a junctional escape rhythm in a patient with a Staphylococcus Aureus vegetation on a native mitral valve only.

Traumatic brain injury (TBI): exploring degrees and causes of TBI in mental health impairment by comprising gender differences / Traumatismo cranioencefálico (TCE): explorando graus e causas do TCE e comprometimento da saúde mental por compreender gênero

ABSTRACT Objective: To exploring differences between degrees and causes of TBI in mental health impairment with comprising gender differences. Methods: The study was a cross-sectional observational study of TBI patients who bedded within 24 hours of presentation to the emergency department (ED), Khatam Hospital, located in Zahedan, Iran. Participants were randomized by a simple randomization technique. Information had been collected twice, first time screening patients by Glasgow Coma Scale score (GCS) and the second time was two months after discharging patients from the ED to estimate mental health impairment by using two separate clinical diagnostic tests. Results: The research considered 80 patients, with 66% being male and 34% female. The median age for both genders estimated 23.5 years. There was a statistically significant difference between degrees and causes of TBI on the total score of hospital anxiety and depression. In particular, degree and cause of TBI with depression in males (M = 14.54, SD = .22), and degrees of TBI on post-traumatic stress disorder in females (M = 87, SD = .7) were significant difference. Conclusion: The current investigation highlights the incidence of depression in male patients with severe levels of traumatic brain injury who injured by car accident multiple trauma; furthermore, this research found the remarkable rate of post-traumatic stress disorder in female patients with a mild degree of TBI. The researcher in traumatic brain injury should seriously deliberate and explore gender differences with the degree and cause of TBI in detail.

RESUMO Objetivo: Explorar diferenças entre graus e causas de traumatismo cranioencefálico (TCE) no comprometimento de saúde mental de acordo com o gênero. Métodos: Estudo observacional transversal de pacientes com TCE que se hospitalizaram dentro de 24 horas após a apresentação no pronto-socorro (PS) no Hospital Khatam, localizado em Zahedan, Irã. Os participantes foram randomizados e as informações foram coletadas duas vezes: na primeira vez, na triagem, os pacientes foram avaliados pela Escala de Coma de Glasgow (GCS); na segunda vez, dois meses depois da alta do PS, eles foram avaliados para estimar o comprometimento da saúde mental usando dois instrumentos de avaliação independentes. Resultados: A amostra foi constituída de 80 pacientes, 66% sendo do sexo masculino e 34% do sexo feminino. A idade mediana para ambos os sexos estimada foi de 23,5 anos. Houve uma diferença estatisticamente significativa entre graus e causas de TCE no escore total de ansiedade hospitalar e depressão. Em particular, o grau e a causa de TCE estiveram associados com depressão no sexo masculino (M = 14,54, DS = 0,22) e os graus de TCE, com transtorno de estresse pós-traumático em mulheres (M = 87, DS = 0,7). Conclusão: Este estudo destaca a incidência de depressão em pacientes do sexo masculino com níveis graves de lesão cerebral traumática e que se feriram por acidente de carro com trauma múltiplo; além disso, observamos uma notável taxa de transtorno de estresse pós-traumático em pacientes do sexo feminino com um grau leve de TCE. O pesquisador em lesão cerebral traumática deve explorar séria e detalhadamente as diferenças de gênero com o grau e a causa do TCE.

Telemedicine Across the Globe-Position Paper From the COVID-19 Pandemic Health System Resilience PROGRAM (REPROGRAM) International Consortium (Part 1).

Coronavirus disease 2019 (COVID-19) has accelerated the adoption of telemedicine globally. The current consortium critically examines the telemedicine frameworks, identifies gaps in its implementation and investigates the changes in telemedicine framework/s during COVID-19 across the globe. Streamlining of global public health preparedness framework that is interoperable and allow for collaboration and sharing of resources, in which telemedicine is an integral part of the public health response during outbreaks such as COVID-19, should be pursued. With adequate reinforcement, telemedicine has the potential to act as the "safety-net" of our public health response to an outbreak. Our focus on telemedicine must shift to the developing and under-developing nations, which carry a disproportionate burden of vulnerable communities who are at risk due to COVID-19.

Key Strategies for Clinical Management and Improvement of Healthcare Services for Cardiovascular Disease and Diabetes Patients in the Coronavirus (COVID-19) Settings: Recommendations From the REPROGRAM Consortium.

Patients with cardiovascular disease and diabetes are at potentially higher risk of infection and fatality due to COVID-19. Given the social and economic costs associated with disability due to these conditions, it is imperative that specific considerations for clinical management of these patients be observed. Moreover, the reorganization of health services around the pandemic response further exacerbates the growing crisis around limited access, treatment compliance, acute medical needs, and mental health of patients in this specific subgroup. Existing recommendations and guidelines emanating from respective bodies have addressed some of the pressure points; however, there are variations and limitations vis a vis patient with multiple comorbidities such as obesity. This article will pull together a comprehensive assessment of the association of cardiovascular disease, diabetes, obesity and COVID-19, its impact on the health systems and how best health systems can respond to mitigate current challenges and future needs. We anticipate that in the context of this pandemic, the cardiovascular disease and diabetes patients need a targeted strategy to ensure the harm to this group does not translate to huge costs to society and to the economy. Finally, we propose a triage and management protocol for patients with cardiovascular disease and diabetes in the COVID-19 settings to minimize harm to patients, health systems and healthcare workers alike.

Chronic Neurology in COVID-19 Era: Clinical Considerations and Recommendations From the REPROGRAM Consortium.

With the rapid pace and scale of the emerging coronavirus 2019 (COVID-19) pandemic, a growing body of evidence has shown a strong association of COVID-19 with pre- and post- neurological complications. This has necessitated the need to incorporate targeted neurological care for this subgroup of patients which warrants further reorganization of services, healthcare workforce, and ongoing management of chronic neurological cases. The social distancing and the shutdown imposed by several nations in the midst of COVID-19 have severely impacted the ongoing care, access and support of patients with chronic neurological conditions such as Multiple Sclerosis, Epilepsy, Neuromuscular Disorders, Migraine, Dementia, and Parkinson disease. There is a pressing need for governing bodies including national and international professional associations, health ministries and health institutions to harmonize policies, guidelines, and recommendations relating to the management of chronic neurological conditions. These harmonized guidelines should ensure patient continuity across the spectrum of hospital and community care including the well-being, safety, and mental health of the patients, their care partners and the health professionals involved. This article provides an in-depth analysis of the impact of COVID-19 on chronic neurological conditions and specific recommendations to minimize the potential harm to those at high risk.

Persistent extreme delta brush in anti-NMDA-receptor encephalitis: Does it portend a poor prognosis?

We describe an adolescent girl with non-paraneoplastic anti-NMDA-receptor encephalitis (ANMDARE), who despite persistence of the extreme delta brush (EDB) pattern for nearly 2 years in her serial EEGs, she exhibited a speedy and sustained response to immunotherapy. To the best of our knowledge, our patient had the longest persistence of the EDB pattern on EEG reported to date. Our patient illustrates that, although presence of EDB supports the diagnosis of ANMDARE, its presence and persistence may not be a reliable predictor of response to immunotherapy and overall clinical prognosis.