Neuroanatomical Localization of the Vestibular Cortex: A Case Report.

Vertigo, a symptom of illusory movement, is caused by asymmetry of the vestibular system. The vestibular system consists of the vestibular labyrinth, cranial nerve VIII, brainstem vestibular nuclei, cerebellum, ocular motor nuclei, spinal cord, and less well-defined cerebral projections. In this day and age of artificial intelligence, machine learning, advanced imaging, and cutting-edge research in the field of neurology, the exact cortical control of vestibular function is still uncharted. A 45-year-old woman with a past medical history of labyrinthitis about 4.5 years ago (resolved) presented to hospital due to severe dizziness, emesis, and mild vertical diplopia for the past few days. Her symptom of dizziness i.e. room spinning was continuous without any postural component. MRI of the brain revealed a small stroke in the left hippocampal area, more specifically alveus of hippocampus. The patient was started on dual antiplatelet therapy and atorvastatin for secondary stroke prevention. Follow-up visit as an outpatient at one-month post hospital discharge was unremarkable without any recurrence of vertigo symptoms. We believe this may indicate that the limbic lobe has a much larger role in vestibular functioning than previously thought, and may control more vestibular operations than any other central nervous system area.

Endovascular Thrombectomy With or Without Intravenous Thrombolysis: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: We performed this meta-analysis of randomized clinical trials to compare the outcomes in patients treated with endovascular thrombectomy who receive prior intravenous thrombolysis with those who do not receive such treatment. Recently, one randomized trial reported outcomes to address this issue, so timely update of meta-analysis is needed to determine the value of administering intravenous thrombolysis before endovascular thrombectomy. MATERIALS AND METHODS: Four randomized clinical trials are included in our meta-analysis. We calculated pooled odds ratios and 95% CIs using random-effects models. The primary efficacy endpoint was a favorable outcome defined by a modified Rankin Scale score of 0 (no symptoms), 1 (no significant disability), or 2 (slight disability) at 90 days post-randomization. Secondary endpoints analyzed were any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality. RESULTS: Of the 1633 patients randomized, the proportion of patients who achieved a favorable outcome was similar between endovascular thrombectomy alone and combined approach with intravenous thrombolysis and endovascular thrombectomy (1631 patients analyzed; odds ratio 1.02; CI 0.84-1.25; p = 0.83). Risk of any intracerebral hemorrhage was significantly lower among those randomized to endovascular thrombectomy alone (1633 patients analyzed; odds ratio 0.75; CI 0.57-0.99; p = 0.04). Rates of symptomatic intracerebral hemorrhage (p = 0.36) and mortality (p = 0.62) were not significantly different between the two groups. CONCLUSIONS: Compared with endovascular thrombectomy preceded by intravenous thrombolysis, endovascular thrombectomy resulted in similar rates of favorable outcome with a lower rate of intracerebral hemorrhage. A large phase 3 trial is required to conclusively demonstrate equivalency of both approaches to guide future practice.

Onychotillomania in the Setting of Homelessness.

Onychotillomania is a psychodermatosis that involves repetitive, self-induced trauma to the nail and sometimes the periungual skin. It is generally seen as an overlapping psychiatric and dermatologic disorder, although there have not been any statistically significant associations with psychiatric illness. Some studies have noted an association with obsessive-compulsive disorder (OCD). Due to the relative lack of empirical data on this condition, treatments are often not evidence-based. As a result, there is no standardized method of treating onychotillomania, and patients suffering from this disease are susceptible to relapse. This report presents the case of a 32-year-old male experiencing homelessness and suffering from major depressive disorder and methamphetamine use disorder who developed onychotillomania two months after becoming homeless. He regularly used various instruments such as nail cutters, tweezers, and nail files to constantly pick at his nails, a few of which were noted to be bleeding with signs of infection. He was evaluated jointly by dermatology and psychiatry providers who confirmed the diagnosis. By thorough examination of the patient's history, he was provided tactile sensory equipment to reduce his repetitive picking behavior. A direct referral for substance use counseling was also provided. At follow-up, he was noted to have a subjective improvement in his picking symptoms, although there was no significant difference in the size of his nails. This case represents the twofold challenge of managing a difficult condition, onychotillomania, in the setting of the severe socio-personal stressor of homelessness.

Combined Pulmonary Fibrosis and Emphysema and Digital Clubbing.

Combined pulmonary fibrosis and emphysema (CPFE) is an underrecognized syndrome that involves simultaneous restrictive-obstructive lung disease. The prognosis is poor, and it frequently occurs with comorbidities. Heavy or former smoking is a major risk factor, and computed tomography (CT) typically shows lower zone fibrosis and upper zone emphysema. Chronic respiratory failure, pulmonary hypertension, and lung carcinoma are major causes of mortality. Diagnosis of CPFE should be combined with palliative care due to the high mortality of the condition, especially in the case of delayed diagnosis. We present the case of a 73-year-old male with a history of non-small cell lung cancer, 50 pack-year smoking, and cervical spine injury (CSI) with a late diagnosis of CPFE. After presenting to the emergency department for an acute exacerbation of dyspnea and hypoxia, he was initially treated with a congestive heart failure protocol. Further examination showed mixed pulmonary function tests as well as digital clubbing, and a CT scan showed changes indicative of advanced bullous emphysema diffusely throughout both lungs with an upper lobe predominance and basilar fibrosis. He was diagnosed with CPFE and immediately treated for both restrictive and obstructive lung diseases with supplemental oxygen, albuterol, ipratropium, corticosteroids, systemic antibiotics, as well as provided with palliative consultation. His previous history and CSI delayed diagnosis, as his lung restriction was likely assumed to be from impaired chest wall mobility rather than CPFE. This case highlights the presentation of a relatively rare disease that was confounded by comorbidities.

Cutaneous Fungal Infections in Patients Experiencing Homelessness and Treatment in Low-Resource Settings: A Scoping Review.

Patients experiencing homelessness (PEH) suffer from a high burden of cutaneous fungal infections. Preventative treatment is important as such infections can lead to harmful complications such as cellulitis and even osteomyelitis. There are sparse data regarding cutaneous fungal infections of homeless populations and management in low-resource settings. A MEDLINE search was conducted using the key terms "cutaneous," "fungal," "infections," "dermatophytes," and "homeless." The search included case-control, cohort, and randomized controlled trials published in the English language. This scoping review of studies yielded information with regard to practical treatment advice for providers in low-resource settings, including medical, hygiene, prevention, and treatment options for PEH with cutaneous fungal infections, the most common of which were tinea pedis (3-38%) and onychomycosis (1.6-15.5%). Few studies have been conducted on the differences between sheltered and unsheltered homeless patients, which can have treatment implications. Systemic antifungal therapy should be carefully considered for diffuse, refractory, or nail-based cutaneous fungal infections if there is a history of alcohol use disorder or liver disease. While PEH have a high risk of alcohol use disorder, this can make definitive treatment challenging.