Theta-burst stimulation as a therapeutic tool in neurological pathology: a systematic review.

TBS (theta-burst stimulation) is a novel therapeutic approach in a wide range of neurological diseases. The present systematic review aims to identify the various protocols used in the last years, to assess study quality and to offer a general overview of the current state of the literature. The systematic review was conducted according to the Preferred Reporting Item for Systematic Review and Meta-Analyses (PRISMA) guidelines. We applied the following inclusion criteria: (1) population over 18 years old with diagnosed neurological disorders, (2) patients treated with sessions of theta-burst stimulation, (3) randomized-controlled clinical trials, (4) articles in the English language, and (5) studies that report response and score reduction on a validated scale of the investigated disorder or remission rates. We included in the final analysis 56 randomized controlled trials focusing on different neurological pathologies (stroke, Parkinson`s disease, multiple sclerosis, tinnitus, dystonia, chronic pain, essential tremor and tic disorder), and we extracted data regarding study design, groups and comparators, sample sizes, type of coil, stimulation parameters (frequency, number of pulses, intensity, stimulation site etc.), number of sessions, follow-up, assessment through functional connectivity and neurological scales used. We observed a great interstudy heterogenicity that leads to a difficulty in drawing plain conclusions. TBS protocols have shown promising results in improving various symptoms in patients with neurological disorders, but larger and more coherent studies, using similar stimulation protocols and evaluation scales, are needed to establish guideline recommendations.

Therapeutic Efficacy and Outcomes of Remdesivir versus Remdesivir with Tocilizumab in Severe SARS-CoV-2 Infection.

The infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) generated many challenges to find an effective drug combination for hospitalized patients with severe forms of coronavirus disease 2019 (COVID-19) pneumonia. We conducted a retrospective cohort study, including 182 patients with severe COVID-19 pneumonia hospitalized between March and October 2021 in a Pneumology Hospital from Cluj-Napoca, Romania. Among patients treated with standard of care, 100 patients received remdesivir (R group) and 82 patients received the combination of remdesivir plus tocilizumab (RT group). We compared the clinical outcomes, the inflammatory markers, superinfections, oxygen requirement, intensive care unit (ICU) admission and mortality rate before drug administration and 7 days after in R group and RT group. Borg score and oxygen support showed an improvement in the R group (p < 0.005). Neutrophiles, C-reactive protein (CRP) and serum ferritin levels decreased significantly in RT group but with a higher rate of superinfection in this group. ICU admission and death did not differ significantly between groups. The combination of remdesivir plus tocilizumab led to a significantly improvement in the inflammatory markers and a decrease in the oxygen requirement. Although the superinfection rate was higher in RT group than in R group, no significant difference was found in the ICU admission and mortality rate between the groups.

Using checklists to improve care in the nonoperating room environment.

PURPOSE OF REVIEW: As the number and complexity of cases performed in the nonoperating room environment continue to increase to a higher share of all anesthetic procedures, checklists are needed to ensure staff and patient safety. RECENT FINDINGS: Providing anesthesia care in the nonoperating room environment poses specific challenges. Closed claims data base analysis shows a higher morbidity and mortality in this setting. This is driven by the location-related challenges, and critical patients undergoing minimally invasive procedures, as well as a higher percentage of emergency and after-hours procedures. Although adequate case preparation and maintaining the same standard of care as in the main operating room, establishing protocols and checklists for procedures in nonoperating room locations has emerged as a sound strategy in improving care and safety. SUMMARY: Anesthesia in the nonoperating room environment is becoming an increasing share of total anesthesia cases. Establishing protocols and implementing site-specific checklists is emerging as a strategy in improving care in the environment of nonoperating room. VIDEO ABSTRACT: http://links.lww.com/COAN/A89 .

Change in Neuroticism and Extraversion among Pre-University Education Employees during the COVID-19 Pandemic.

Background and objectives: Since the first reports of SARS-CoV-2 infection cases in China, the virus has rapidly spread to many countries, including Romania. In Romania, schools were closed in March 2020 to prevent the virus from spreading; since then, they have been sporadically opened, but only for a short time. Teachers had to adopt online education methods, experiencing real difficulties in their attempts to maintain high-quality teaching, as a result of social distancing from students and colleagues. The current study aimed to evaluate the burden on the neuroticism states of employees in the pre-university education system during the COVID-19 pandemic. Materials and Methods: A prospective study was conducted, in which personality trait data from 138 employees were collected via a questionnaire (EPI, Eysenck Personality Inventory), which measured extraversion-introversion and neuroticism scores before and during the COVID-19 pandemic. Initially, 150 subjects were invited to participate in the study, although 12 of them refused to participate. Based on the questionnaire not being fully filled in a further three subjects were excluded from the study, leaving a total of 135, of which 115 were woman and 20 were men. Results: The results demonstrate that the subjects included in the study expressed higher neuroticism during the COVID-19 pandemic than in the pre-pandemic period. This change could promote more stress and depression symptoms. Subjects with high school education had significantly lower neuroticism scores over time than those with university education (p = 0.006). Furthermore, we found extraversion scores to be statistically significant in our population (p = 0.022). Conclusion: The gender and living environment of the teachers were not significantly associated with the reduction in the extraversion score, but were more frequently found among older persons and in subjects without higher education. Subjects of Hungarian ethnicity had lower extraversion scores than those of Romanian ethnicity.

Anesthetic Considerations in a Patient With LVAD and COVID-19 Undergoing Video-Assisted Thoracic Surgery.

Increased survival with left ventricular assist devices (LVAD) has led to a large number of patients with LVADs presenting for noncardiac surgeries (NCS). With studies showing that a trained noncardiac anesthesiologist can safely manage these patients when they present for NCS, it is vital that all anesthesiologists understand the LVAD physiology and its implications in various surgeries. This is even more relevant during the current pandemic in which these complex cardiopulmonary interactions may be even more challenging in patients with coronavirus disease 2019 (COVID-19). The authors describe a case of a patient with COVID-19 with an LVAD who needed thoracoscopic decortication for recurrent complex pleural effusion and briefly discuss unique challenges presented and their management.

Electrophysiology Practice During COVID-19 Pandemic: A New York Tertiary Hospital Experience.

As hospitals became overwhelmed during the Covid-19 pandemic in March-May in New York, Cardiology and Electrophysiology (EP) departments rapidly developed protocols for case selection as well modifying the practice of managing the cases. Recommendations by the AHA/HRS as well as American Society of Anesthesiology (ASA) were considered in the multidisciplinary collaborative approach to patient care and personnel safety and the anesthesiology team had an integral role in developing protocols for workflow, care, recovery and transport during these challenging times.

The Management of Obstructive Sleep Apnea Patients during the COVID-19 Pandemic as a Public Health Problem-Interactions with Sleep Efficacy and Mental Health.

With the onset of the COVID-19 outbreak, it was stipulated that patients with obstructive sleep apnea (OSA) may have a greater risk of morbidity and mortality and may even experience changes in their mental health. The aim of the current study is to evaluate how patients managed their disease (sleep apnea) during the COVID-19 pandemic, to determine if continuous positive airway pressure (CPAP) usage changed after the beginning of the pandemic, to compare the stress level with the baseline, and to observe if any modifications are related to their individual characteristics. The present studies highlight the level of anxiety, which was high among patients with OSA during the COVID-19 pandemic (p < 0.05), with its influence on weight control (62.5% of patients with high levels of stress gained weight) and sleep schedule (82.6% reported a change in sleep schedule). Patients with severe OSA and high levels of stress increased their CPAP usage (354.5 min/night vs. 399.5 min/night during the pandemic, p < 0.05). To conclude, in OSA patients, the presence of the pandemic led to a greater level of anxiety, changes in sleep schedule and weight gain because of job loss, isolation, and emotional changes, influencing mental health. A possible solution, telemedicine, could become a cornerstone in the management of these patients.

Safety and Efficacy of a Novel Approach to Pulmonary Vein Isolation Using Prolonged Apneic Oxygenation.

BACKGROUND: Improved ablation catheter-tissue contact results in more effective ablation lesions. Respiratory motion causes catheter instability, which impacts durable pulmonary vein isolation (PVI). OBJECTIVES: This study sought to evaluate the safety and efficacy of a novel ablation strategy involving prolonged periods of apneic oxygenation during PVI. METHODS: We conducted a multicenter, prospective controlled study of 128 patients (mean age 63 ± 11 years; 37% women) with paroxysmal atrial fibrillation undergoing PVI. Patients underwent PVI under general anesthesia using serial 4-minute runs of apneic oxygenation (apnea group; n = 64) or using standard ventilation settings (control group; n = 64). Procedural data, arterial blood gas samples, catheter position coordinates, and ablation lesion characteristics were collected. RESULTS: Baseline characteristics between the 2 groups were similar. Catheter stability was significantly improved in the apnea group, as reflected by a decreased mean catheter displacement (1.55 ± 0.97 mm vs 2.25 ± 1.13 mm; P < 0.001) and contact force SD (4.9 ± 1.1 g vs 5.2 ± 1.5 g; P = 0.046). The percentage of lesions with a mean catheter displacement >2 mm was significantly lower in the apnea group (22% vs 44%; P < 0.001). Compared with the control group, the total ablation time to achieve PVI was reduced in the apnea group (18.8 ± 6.9 minutes vs 23.4 ± 7.8 minutes; P = 0.001). There were similar rates of first-pass PVI, acute PV reconnections and dormant PV reconnections between the two groups. CONCLUSIONS: A novel strategy of performing complete PVI during apneic oxygenation results in improved catheter stability and decreased ablation times without adverse events. (Radiofrequency Ablation of Atrial Fibrillation Under Apnea; NCT04170894).

First bioanthropological evidence for Yamnaya horsemanship.

The origins of horseback riding remain elusive. Scientific studies show that horses were kept for their milk ~3500 to 3000 BCE, widely accepted as indicating domestication. However, this does not confirm them to be ridden. Equipment used by early riders is rarely preserved, and the reliability of equine dental and mandibular pathologies remains contested. However, horsemanship has two interacting components: the horse as mount and the human as rider. Alterations associated with riding in human skeletons therefore possibly provide the best source of information. Here, we report five Yamnaya individuals well-dated to 3021 to 2501 calibrated BCE from kurgans in Romania, Bulgaria, and Hungary, displaying changes in bone morphology and distinct pathologies associated with horseback riding. These are the oldest humans identified as riders so far.

Titanium Dioxide: Structure, Impact, and Toxicity.

Titanium dioxide, first manufactured a century ago, is significant in industry due to its chemical inertness, low cost, and availability. The white mineral has a wide range of applications in photocatalysis, in the pharmaceutical industry, and in food processing sectors. Its practical uses stem from its dual feature to act as both a semiconductor and light scatterer. Optical performance is therefore of relevance in understanding how titanium dioxide impacts these industries. Recent breakthroughs are summarised herein, focusing on whether restructuring the surface properties of titanium dioxide either enhances or inhibits its reactivity, depending on the required application. Its recent exposure as a potential carcinogen to humans has been linked to controversies around titanium dioxide's toxicity; this is discussed by illustrating discrepancies between experimental protocols of toxicity assays and their results. In all, it is important to review the latest achievements in fast-growing industries where titanium dioxide prevails, while keeping in mind insights into its disputed toxicity.

Determining factors of participation and success rates in research funding competitions: Case study.

Research and innovation play a key role in generating smart and sustainable economic growth. By producing new knowledge, the research contributes to the development of new and innovative products, processes, and services, which in turn lead to increased productivity, industrial competitiveness, and, ultimately, the prosperity of the community as a whole. However, all research, development and innovation activities depend on the financial resources made available, as specific financing accelerates the production and dissemination of the best ideas and practices, as well as their role in meeting the challenges our society deals with nowadays. Our study aims to identify the determining factors for the researcher's participation and success rates in research funding competitions. The goal of the research is to understand how variables such as age, gender, main field, affiliation, and scientific rank can affect the access to funding opportunities available for research and innovation. The study relies on a questionnaire-based survey conducted with 243 early-career and senior researchers from many state universities across Romania. For an in-depth analysis of the factors that influence the success rate in research competitions, in the present approach, we used both graphical and econometric methods. A binary logistic regression modelling was performed in order to explain the relationships between variables. Among other considerations, our findings revealed that in all main research fields, scientific rank and gender are important features for raising the participation and success rate in research funding competitions.

Multivariate Analysis of the Predicted Probability of Smoking Behavior of Foster Care Minors: Results of a Study from Romania.

BACKGROUND: There are a multitude of factors that influence smoking status, and minors from the social protection system are a vulnerable category in terms of smoking. METHODS: The objective of this research was to assess the degree of smoking dependence and to identify potential predictors of smoking status in foster care teenagers. Smoker status was confirmed by dosing CO in the exhaled air, and the degree of dependence was assessed using the Fagerström score. We performed a multivariate logistic regression analysis. RESULTS: From the 275 foster care minors, 22.5% were current smokers. Exhaled CO was not influenced by general demographic factors, was associated with the frequency of smoking, and was positively correlated with the estimated number of cigarettes consumed daily and with the Fagerström score. The calculated probability of being a smoker was less than 20.4% in 75% of nonsmokers, whereas 75% of actual smokers had a predicted probability higher than 30.3%. CONCLUSIONS: In addition to age, gender, social environment, previous exposure to secondhand smoking, and residential type of foster care system, the expressed opinions regarding the health effects of tobacco use were associated with smoking in foster care teenagers.

NORA: Considerations during COVID 19 Pandemic-The New York Experience.

Hospitals rapidly developed new procedure and protocols and engaged in emergency construction projects to adapt their facilities and procedures to provide safe and effective patient care during the COVID- 19 pandemic surge in the New York metropolitan area. Physical and procedural revisions were necessary in the operating room to continue to care for emergent patients both with and without COVID. Similar adaptions in non operating room procedure suites, recognized commonly as Non-operating Room Anesthesiology (NORA), necessitated the engagement of multiple departments in order to develop protocols and to redesign procedural areas. This article describes in detail the collaborative planning, construction and preparation implemented in two academic medical centers with regard to their various NORA programs. In developing patient care, personal protective equipment training and repurposing of procedure suites, the multidisciplinary collaborative teams have taken into consideration the professional national societies governing Gastroenterology, Cardiology, and Interventional Radiology.

Polymorphism of the Serotonin Transporter Gene and the Peripheral 5-Hydroxytryptamine in Obstructive Sleep Apnea: What Do We Know and What are We Looking for? A Systematic Review of the Literature.

BACKGROUND: Obstructive sleep apnea (OSA) is a highly prevalent disease with substantial public health burden. In most of the cases, there is a genetic predisposition to OSA. Serotonin/T-HydroxyTriptamine (5-HT) plays a key role in ventilatory stimulation, while the polymorphism of the serotonin transporter gene (STG) leads to alterations in serotonin level, making it important in OSA. OBJECTIVE: To examine whether the 5-HydroxyTriptamine and the genetic predisposition influence the incidence and evolution of OSA, we reviewed randomized, controlled trials and observational studies on the selected topic. The secondary objective was to determine the metabolic effects of the circulating serotonin in other tissues (liver, pancreas, gut, brown adipose tissue, and white adipose tissue) and its role in the development of obesity. DATA SOURCES: A systematic review of English articles was performed based on PubMed and the Cochrane Library databases. Search filters included randomized controlled trial, controlled clinical trial, random allocation, double-blind method, and case-control studies and used the following keywords: Brain Serotonin OR Serotonin Transporter Gene Polymorphism OR Peripheral 5-HydroxyTryptamine AND Obstructive Sleep Apnea OR Sleep Disorder Breathing OR brain serotonin AND OSA OR serotonin transporter gene OR Peripheral 5-Hydroxytryptamine AND Sleep. STUDY ELIGIBILITY CRITERIA: The inclusion criteria for the current review were previous diagnosis of OSA, age above 18 years, and articles including quantitative data about serotonin transporter gene or peripheral serotonin. Language and time criteria were added - English articles published in the last 15 years. Studies that were not included were reviews and case reports. STUDY APPRAISAL AND SYNTHESIS METHODS: In order to study the serotonin function, a literature research was conducted in the databases Pubmed and Cochrane Library. The following search terms were used: serotonin, 5-hydroxytryptamine, serotonin transporter gene. A critical appraisal of the included studies was performed with the Newcastle-Ottawa scale (NOS) and Delphi list. RESULTS: The search yielded 1210 articles, from which 43 were included. The included studies suggest that the two polymorphisms of serotonin transporter gene (5HTT) - variable number of tandem repeats (VNTR) and linked polymorphic region (LPR) - are strong candidates in the pathogenesis of OSA. The allele 10 of 5HTTVNTR and the long/long (L/L) allele genotype were associated with a higher prevalence of OSA and the L allele with a higher apnea-hypopnea index and a longer time during sleep with oxygen desaturation. LIMITATIONS: The main limitation of the present study consists of heterogeneity of the information. Being a less studied subject, randomized trials are not widely available and most data were obtained from case-control trials. Moreover, the included material indirectly approached the subject by demonstrating the effects of serotoninergic system over the metabolism, the connection between serotonin and obesity, factors which are implied in the pathogenesis of OSA. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The two polymorphisms of serotonin gene can be considered important factors in the diagnosis and management of OSA.

A Prospective Study of CPAP Therapy in Relation to Cardiovascular Outcome in a Cohort of Romanian Obstructive Sleep Apnea Patients.

BACKGROUND: Despite efforts at treatment, obstructive sleep apnea (OSA) remains a major health problem, especially with increasing evidence showing an association with cardiovascular morbidity and mortality. The treatment of choice for OSA patients is Continuous Positive Airway Pressure (CPAP), which has been proven in randomized controlled trials to be an effective therapy for this condition. The impact of CPAP on the cardiovascular pathology associated with OSA remains, however, unclear. Although the effect of CPAP has been previously studied in relation to cardiovascular outcome, follow-up of the treatment impact on cardiovascular risk factors at one year of therapy is lacking in a Romanian population. Thus, we aimed to evaluate the one-year effect of CPAP therapy on lipid profile, inflammatory state, blood pressure and cardiac function, assessed by echocardiography, on a cohort of Romanian OSA patients. METHODS: We enrolled 163 participants and recorded their baseline demographic and clinical characteristics with a follow-up after 12 months. Inflammatory and cardiovascular risk factors were assessed at baseline and follow up. RESULTS: Our results show that CPAP therapy leads to attenuation of cardiovascular risk factors including echocardiographic parameters, while having no effect on inflammatory markers. CONCLUSION: Treatment of OSA with CPAP proved to have beneficial effects on some of the cardiovascular risk factors while others remained unchanged, raising new questions for research into the treatment and management of OSA patients.

Quality of life in stroke survivors after local intra-arterial thrombolysis.

BACKGROUND: We aimed to assess quality of life (QOL) and its predictors in stroke survivors after local intra-arterial thrombolysis (IAT) as well as to measure QOL according to the site of pretreatment vessel occlusion. METHODS: From January 2000 to April 2004, 175 consecutive patients underwent IAT for acute ischemic stroke. Clinical and radiological data were collected prospectively. We contacted 135 stroke survivors after a mean of 923 (+/-431) days, 132 responded. QOL, assessed with EuroQol (EQ-5D), and functional abilities, measured with the modified Rankin Scale (mRS) and the Barthel Index, were compared, and predictors of QOL were analyzed. RESULTS: Measured with EQ-5D, 56% of the patients reported a good QOL (EQ-5D Index >or=70). Low mRS and high Barthel Index scores at follow-up were associated with better overall QOL (Kendall's tau >0.5). Nevertheless, 25% of the functionally independent patients (mRS 0-2) indicated a markedly impaired QOL (EQ-5D Index <70) and 10% of disabled patients indicated good QOL. QOL was significantly lower in patients with occlusion of the internal carotid artery compared to patients with occlusion of the basilar artery or the M1, M2 or M3/4 segment of the middle cerebral artery (EQ-5D Index: p = 0.005). A high National Institute of Health Stroke Scale score on admission and occlusion of the internal carotid artery were independent predictors of impaired QOL (p < 0.05). CONCLUSION: More than half of the stroke survivors treated with IAT reported a good QOL, mostly survivors with mild disabilities. QOL assessment gives information that is not provided by traditional outcome scores. Our results support guidelines to measure QOL in stroke research.

Takotsubo syndrome induced by malignant pheochromocytoma in a patient with type 2 papillary renal cell carcinoma - a case report.

The clinical presentation of the Takotsubo syndrome mimics an acute coronary syndrome with chest pain, ischemia-like ECG changes, mild to moderate myocardial enzyme elevation, and apical ballooning on echocardiography and ventriculography. On coronary angiography, epicardial coronary arteries are either normal or exhibit minimal atherosclerotic changes. Primary Takotsubo syndrome usually occurs in postmenopausal women in whom symptoms are triggered by emotional or physical stress, associated with catecholamine surges. Secondary Takotsubo syndrome may have multiple causes, including an increased catecholamine release due to pheochromocytoma. We present the case of a 56-years-old woman with confirmed Takotsubo syndrome who was later diagnosed with pheochromocytoma and type 2 papillary renal cell carcinoma.

Aspectos anatómicos de la disposición y anastomosis de las ramas terminales del plexo braquial: (nervus mediano, ulnar, radial y musculocutáneo) / Anatomical aspects of the disposition and anastomosis of the braquial plexus: (median nerve urnal, radial and musclecutaneous)

En los tiempos modernos, los múltiples traumatismos que ocurren en el miembro superior, exigen de los profesionales de la salud conocimiento preciso de la disposición del pedículo y sus posibles variaciones. Se estudiaron 40 miembros superiores de cadáveres adultos previamente tratados con solución de formol al 5 por ciento, glicerina y fenos durante al menos tres meses en el Instituto Anatómico José Izquierdo de la Escuela Luis Razetti de la Facultad de Medicina de la Universidad Central de Venezuela. Los resultados fueron registrados en un protocolo, tras lo cual se obtuvo un 47,5 por ciento de variabilidad (19 variaciones), de las cuales el 35 por ciento correspondían al nervio mediano, 7,5 por ciento al nervio ulnar, y 5 por ciento al nervio musculocutáneo. Por otro lado se encontró mayor variabilidad en el miembro derecho (57,9 por ciento) y en el sexo masculino (84,2 por ciento)