Association of Cannabis Use Disorder with Major Adverse Cardiac and Cerebrovascular Events in Older Non-Tobacco Users: A Population-Based Analysis.

BACKGROUND: Tobacco use disorder (TUD) adversely impacts older patients with established cardiovascular disease (CVD) risk. However, CVD risk in chronic habitual cannabis users without the confounding impact of TUD hasn't been explored. We aimed to determine the risk of major adverse cardiac and cerebrovascular events (MACCE) in older non-tobacco smokers with established CVD risk with vs. without cannabis use disorder (CUD). METHODS: We queried the 2019 National Inpatient Sample for hospitalized non-tobacco smokers with established traditional CVD risk factors aged ≥65 years. Relevant ICD-10 codes were used to identify patients with vs. without CUD. Using multivariable logistic regression, we evaluated the odds of MACCE in CUD cohorts compared to non-CUD cohorts. RESULTS: Prevalence of CUD in the sample was 0.3% (28,535/10,708,815, median age 69), predominantly male, black, and non-electively admitted from urban teaching hospitals. Of the older patients with CVD risk with CUD, 13.9% reported MACCE. The CUD cohort reported higher odds of MACCE (OR 1.20, 95% CI 1.11-1.29, p < 0.001) compared to the non-CUD cohort. Comorbidities such as hypertension (OR 1.9) and hyperlipidemia (OR 1.3) predicted a higher risk of MACCE in the CUD cohort. The CUD cohort also had higher unadjusted rates of acute myocardial infarction (7.6% vs. 6%) and stroke (5.2% vs. 4.8%). CONCLUSIONS: Among older non tobacco smokers with known CVD risk, chronic cannabis use had a 20% higher likelihood of MACCE compared to those who did not use cannabis.

Clinical utility of intraoperative direct wave monitoring in patients with pre-operative motor deficits: Case series.

INTRODUCTION AND IMPORTANCE: D-wave (Direct waves) are Motor Evoked Potentials (MEPs) generated by a single transcranial stimulation and captured by attaching an epidural recording electrode caudal to the vulnerable area. Intraoperative neurophysiologic monitoring (IONM) is widely used in neurosurgery to recognize important neurological structures but can be challenging in the pediatric population due to incomplete neural development. CASE PRESENTATION: Case 1: A 48-year-old female presented to the outpatient department with complaints of difficulty walking for the past six months, numbness and weakness in bilateral lower limbs with recurrent falls for the past 1 month. Case 2: A 12-year-old boy presented to the emergency room with a history of inability to use both upper and lower limbs on the right side with tremulousness. CLINICAL DISCUSSION: Magnetic resonance imaging (MRI) Spine in the first case revealed a D9-D10 calcified meningioma with significant spinal cord compression. In the second case, MRI Spine showed C1-C2 Intramedullary Space Occupying Lesion (SOL) and was planned for C1-C2 laminectomy with midline myelotomy. The first case was planned for microsurgical excision of the lesion under IONM guidance. The procedure went smoothly. Microsurgical gross total resection (GTR) of the intramedullary SOL under IONM Guidance was done for the second case. Postoperatively, the first patient showed no neurological compromise or complications. In the second case, following surgery, the child recovered gradually from surgery. CONCLUSION: This case series demonstrates the successful surgical management of two cases of spinal cord tumors through an IONM-guided surgery and the effective use of D waves in such challenging cases.

Pathological Manifestations of Gluten-Related Neuro-Psychiatric Disorders and the Impact of Gluten-Free Diet in a Pediatric Age Group: A Systematic Review.

Gluten, as a term, causes unease among a vast majority of the population. The reason is the body's inability to process gluten, causing various pathological manifestations. While celiac disease is predominantly a gastrointestinal disease, it also has various extra-intestinal manifestations. Many children receive diagnoses of idiopathic neuropsychiatric symptoms such as epilepsy, attention-deficit hyperactivity disorder (ADHD), restless leg syndrome (RLS), and peripheral neuropathy without ever finding the root cause. A majority of these cases may be associated with celiac disease if only their antibody titers and other appropriate investigations were conducted. The treatment of these manifestations may be eliminated or at least controllable with dietary modification to a gluten-free diet (GFD). In this paper, we will discuss the pathology of celiac disease and the impact of GFD on the neuropsychiatric aspects of this disease, which is of higher prevalence in the pediatric population. A comprehensive literature search was conducted in prominent databases, namely PubMed and Google Scholar, to include studies that provided individual-level data on the neuropathological manifestations and the impact of a GFD on extra-intestinal manifestations of celiac disease. The research protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) with the registration ID: CRD42023415100. Based on the inclusion and exclusion criteria, we included prospective studies, observational studies, and case reports on pediatric patients with biopsy-proven celiac disease, serologically positive celiac disease, celiac disease with neuropsychiatric manifestations, and studies reporting the impact of GFD. After a rigorous quality assessment to remove the risk of bias, we finally included 20 studies to be discussed.  In 6 (30%) studies, patients with neuropsychiatric manifestations had positive serology findings and a relatively higher grade of biopsy results. Seven studies discussed the positive impact of GFD. Five of these seven studies reported statistically significant results (p ≤ 0.001). Our study suggests that gluten plays a role in the severity of neuropsychiatric manifestations of celiac disease. Considering the results of our study, we can see that GFD does impact the prognosis of the disease. Neuropsychiatric findings without gastrointestinal manifestations are more common in the pediatric age group. We have clear evidence that several neurological conditions (neuropathy, ADHD, epilepsy, and RLS) have not only a significant association with gluten but can also potentially benefit from GFD. Thus, screening, with a combination of serological, biopsy, and imaging techniques, must be adapted into the guidelines for early detection and induction of GFD. Furthermore, studies should aim at introducing GFD in the pediatric population as a mode of primary prevention. In conclusion, our review underscores the importance of gluten while dealing with idiopathic neurological conditions in children and hopes to shed light on this commonly misdiagnosed and easily manageable disease.

A Hidden Complication of Poorly Managed Diabetic Control: A Case of Diabetic Myonecrosis.

Diabetic myonecrosis is an infrequently encountered complication of poorly managed type 2 diabetes. Despite its relative rarity, early detection and appropriate management can yield favorable outcomes. This case report details the presentation, diagnosis, and management of a 53-year-old male patient with a history of type 2 diabetes who presented with acute-onset pain, swelling of the muscles, and weakness. Following a battery of laboratory investigations, radiological imaging, and a muscle biopsy, the patient was diagnosed with diabetic myonecrosis. The patient was treated conservatively with analgesics, physiotherapy, and optimization of glycemic control, significantly improving muscle strength and function. This case highlights the necessity of considering diabetic myonecrosis as a potential differential diagnosis in diabetic patients who present with sudden muscle weakness and discomfort.

Cutaneous Coccidioidomycosis and Basal Cell Carcinoma: Case Report on a Diagnostic Dilemma.

In the world of medical diagnoses, a particularly intriguing scenario unfolds, wherein the cutaneous manifestation of a systemic fungal infection disguises itself as a Basal Cell Carcinoma (BCC), a skin cancer. Coccidioidomycosis is an endemic fungal infection caused by inhaling spores of the fungus Coccidioides immitis. It is primarily a pneumonic illness which, in a few cases, has the potential to cause severe systemic disease. In this article, we report a case of a 60-year-old female with a known history of infiltrating ductal carcinoma of left breast status post lumpectomy and adjunct chemotherapy presented with complaints of cough, fever, and easy fatigability that seemed to be attributable to her immunocompromised state. She also had a pseudo-vesicular plaque on her left upper arm for two years. As we delve into the case, it becomes clear that Coccidioidomycosis and other opportunistic infections are commonplace among immunocompromised patients. Prior awareness of this condition and a cautious yet open-minded approach prevented gross misdiagnosis in our case. Physicians should be vigilant in diagnosing Coccidioidomycosis, especially in immunocompromised patients presenting with mild constitutional symptoms in endemic regions. Early detection and management are crucial to prevent severe complications and increase patient survival rates.