A Comparative Review of Typical and Atypical Optic Neuritis: Advancements in Treatments, Diagnostics, and Prognosis.

Optic neuritis (ON) is a debilitating condition that through various mechanisms, including inflammation or demyelination of the optic nerve, can result in partial or total permanent vision loss if left untreated. Accurate diagnosis and promptly initiated treatment are imperative related to the potential of permanent loss of vision if left untreated, which can lead to a significant reduction in the quality of life in affected patients. ON is subtyped as "typical" or "atypical" based on underlying causative etiology. The etiology of ON can be differentiated when appropriate diagnostic testing is performed. Using history taking, neuroimaging, and visual testing to localize the underlying pathology of ON in a time-sensitive manner is critical in mitigating these unsatisfactory outcomes. Herein, we examine the differences in presentation, pathophysiology, and treatments of typical ON causes, like multiple sclerosis (MS), and atypical causes such as neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein (MOG)-immunoglobulin G (IgG) ON. The present investigation places focus on both neuroimaging and visual imaging in the differentiation of ON. Additionally, this review presents physicians with a better understanding of different presentations, treatments, and prognoses of ON.

1-Piece Versus 2-Piece Fronto-Temporo-Orbito-Zygomatic Craniotomy: A Narrative Overview of Evolution.

BACKGROUND: The fronto-temporo-orbito-zygomatic (FTOZ) craniotomy is a commonly utilized surgical approach for many complex skull base lesions, especially lesions traversing skull base compartments. This craniotomy has evolved over multiple stages, originating from the classic pterional craniotomy and many variations that have emerged over time. METHODS: Few clinical and anatomic studies have both shaped these craniotomies as well as provided immense information about instances in which they are most useful. We review the origin and history of the one-piece and two-piece fronto-temporo-orbito-zygomatic craniotomy and deliberate their advantages and disadvantages. RESULTS: The FTOZ craniotomy provides access to the orbit as well as to multiple compartments in the cranium (anterior, middle and upper third posterior cranial fossae); thus, offering a multi-corridor approach to complex skull base lesions. The one-piece and two-piece fronto-temporo-orbitozygomatic craniotomies are two particularly notable variations that have stood the test of time. Selection between the two variations is mostly surgeon preference and comfort with the technique; however, there are certain indications that specifically suit each approach. Additionally, a pictorial review has been crafted to clearly illustrate the cuts to be made in both methods. CONCLUSION: Understanding the evolution of this craniotomy and surgical approach provides an insight into accessing complex skull base pathologies with minimal brain retraction via safe and viable corridors.

Testosterone replacement therapy: clinical considerations.

INTRODUCTION: As an increasingly popular therapeutic option, testosterone replacement therapy (TRT) has gained significant notoriety for its health benefits in indicated populations, such as those suffering from hypogonadism. AREAS COVERED: Benefits such as improved libido, muscle mass, cognition, and quality of life have led to widened public interest in testosterone as a health supplement. No therapy exists without side effects; testosterone replacement therapy has been associated with side effects such as an increased risk of polycythemia, benign prostate hypertrophy (BPH), prostate cancer, gynecomastia, testicular atrophy, and infertility. Testosterone replacement therapy is often accompanied by several prophylactic co-therapies aimed at reducing the prevalence of these side effects. Literature searches for sections on the clinical benefits and risks associated with TRT were performed to include clinical trials, meta-analyses, and systematic reviews from the last 10 years. EXPERT OPINION: Data from clinical studies over the last decade suggest that the benefits of this therapy outweigh the risks and result in overall increased quality of life and remission of symptoms related to hypogonadism. With this in mind, the authors of this review suggest that carefully designed clinical trials are warranted for the investigation of TRT in symptomatic age-related hypogonadism.

Impulse control disorders in Parkinson's disease patients treated with pramipexole and ropinirole: a systematic review and meta-analysis.

BACKGROUND: This analysis is the first systematic review and meta-analysis assessing occurrences of ICD in PD patients treated with oral DAs: ropinirole (ROP) and pramipexole (PRX). This study compares the two oral DAs to a transdermal patch, rotigotine (RTG). METHODS: We performed an extensive systematic search for eligible studies from PubMed, Embase, Cochrane Library, and Google Scholar. The data was analyzed by various software, including EndNote, Rayyan, PRISM, and RevMan. Two studies incorporating 658 patients collectively were assessed. RESULTS: This meta-analysis shows a significant correlation between the usage of PRX (25.3%) or ROP (21.8%) and the development of ICD in PD patients. Compared to the transdermal patch, RTG, PRX was found to have a significant relative risk (P < 0.0001) of 3.46 (95% CI 2.07-5.76), and ROP was found to have a significant relative risk (P < 0.0001) of 2.98 (95% CI 1.77-5.02). The data collected shows RTG is approximately three times less likely to cause ICDs than oral PRX and ROP. CONCLUSION: The present investigation provides insight into ICD occurrences with PRX, ROP, and RTG to allow physicians to make more informed decisions on risk versus reward when deciding how to treat a PD patient with these drugs. However, related to various disclosed limitations, our conclusion cannot provide definitive practice protocols.

Experimental Analysis of the Efficiency and Usability of Tylke Versus Magill Forceps.

INTRODUCTION: The procedure of nasotracheal intubation (NI) has long been performed utilizing the Magill forceps as developed by Sir Ivan Magill in the 1920s. While used for nearly a century, several serious patient safety concerns remain including torn tube cuffs, vocal cord trauma, and inefficient tube placement. The Tylke forceps have been developed as a modification to the largely unchanged form of Magill forceps. METHODS: In the present investigation we compared the efficacy, number of clasps, and muscle activation involved in NI using the Tylke forceps versus the Magill forceps in previously untrained individuals. RESULTS: Tylke forceps showed faster successful NI over the standard Magill forceps at an average intubation time of 6.54s vs. 13.73s, respectively. Tylke forceps also had fewer clasps per intubation over the Magill. The trapezius, deltoid, and brachioradialis muscle activation was also compared in Tylke vs Magill forceps intubation trials. Tylke forceps required less lower muscle activation in the brachioradialis and trapezius over the Magill forceps with Tylke forceps resulting in higher deltoid muscle activation. CONCLUSION: Tylke forceps were more efficacious and reduced the number of clasps over the Magill forceps when used in successful NI with different muscle activation patterns.

A rare encounter: Comprehensive case review of myxoid meningiomas with a representative case.

Meningiomas are the most diagnosed primary central nervous system tumor. Currently, 15 different subtypes of meningioma exist with various characteristics. One extremely rare subtype is myxoid meningioma, which is a World Health Organization grade 1 benign meningioma. These specific meningiomas have only been reported 12 times in the literature. In this representative case, we present a 46-year-old female patient with a left frontal myxoid meningioma, describe the findings on imaging, and provide the histopathological features that are needed for diagnosis. Furthermore, this report discusses the other existing myxoid meningioma case reports found throughout the literature.

Infigratinib for the Treatment of Metastatic or Locally Advanced Cholangiocarcinoma With Known FGFR2 Gene Fusions or Rearrangements.

Cholangiocarcinoma (CCA) is an aggressive and diverse malignancy with a poor prognosis. Related to a typical indolent course of progression, most cases of CCA are metastatic or locally advanced at the time of presentation. For patients with nonresectable tumors or metastatic disease, the mainstay of treatment is comprehensive with combination chemotherapy. The first-line chemotherapeutic combination for the treatment of CCA are cisplatin and gemcitabine-based chemotherapies. However, many locally advanced and progressive CCA cases are refractory to first-line management. Within the past few years, the increase in the incidence of metastatic CCA and its poor prognosis has brought to light the need for novel therapeutic approaches to treatment. With advancements in next-generation genome sequencing, multiple molecular pathways have been identified in the pathogenesis of CCA and have shown great potential as alternative treatments in cases of CCA refractory to surgical resection. FGFR2 fusions or rearrangements have been identified in 10-16% of all intrahepatic CCA and are thought to serve as a pathway of resistance for a number of nonresectable and refractory cases of cholangiocarcinoma. A novel therapeutic agent that has been discussed is infigratinib, a selective, ATP-competitive inhibitor of fibroblast growth factor receptor 2 (FGFR2). In a phase 1 trial, infigratinib showed a safe profile and showed remarkable clinical efficacy in advanced CCA with FGFR2 fusions or rearrangements in phase II trials. As of May 2021, the Food and Drug Administration (FDA) approved infigratinib for CCA largely based on tumor response and duration of response. As of 2021, infigratinib, futibatinib, and pemigatinib, similar novel selective FGFR inhibitors, have been approved by the FDA for the treatment of locally advanced or metastatic CCA harboring FGFR2 gene mutations. The present investigation reviews the development of infigratinib in particular and its clinical efficacy compared to other available treatment options for cholangiocarcinoma. While the side effect profile of infigratinib is minimal, particularly GI side effects, when compared with futibatinib and pemigatinib, the overall response rate (ORR) and median overall survival (mOS) for infigratinib (ORR=23.1%, mOS=3.8 months) was significantly lower than futibatinib (ORR=35.8%, mOS=21.1 months) and pemigatinib (ORR=35.5%, mOS=21.1 months). While there is ample promise for the use of infigratinib as molecular-directed therapy in the treatment of CCA harboring FGFR2 mutations, there is an appropriate concern for patient-acquired resistance. The heterogeneous nature of FGFR mutations and the emergence of different resistance mechanisms emphasize a need for more agents to inhibit FGFR rearrangements effectively.

Lyme Disease and Post-treatment Lyme Disease Syndrome: Current and Developing Treatment Options.

Lyme disease and its treatment implications have become an ever-increasing area of concern within the United States related to the markedly increased prevalence of infection within the last two decades. The presentation, pathophysiology, and epidemiology of Lyme disease have been well studied, and thus treatments for this disease are widely available. While the treatment of its early and late stages is relatively simple with 10-14 day and four-week courses of doxycycline, respectively, the main problem rests in the understanding of the etiology and pathology of post-treatment Lyme disease syndrome (PTLDS). With the time of symptoms onsetting approximately six months after treatment and potentially lasting indefinitely, this syndrome's effect on patients' quality of life could be devastating. Searching on PubMed, Google Scholar, MEDLINE, and ScienceDirect using keywords including Lyme disease, PTLDS, doxycycline, erythema migrans, azlocillin, and treatment, the authors have tried to make clear the different aspects. The authors have reviewed and discussed clinical studies of Lyme disease and its treatments/potential therapeutics as well as PTLDS and its sparse treatments/potential therapeutics.

Association of Acetaminophen With Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Pharmacologic Considerations and Treatment Options.

Acetaminophen is an extremely common drug with many implications for its analgesic and antipyretic properties. It has a unique mechanism of action and downstream effects that separate it categorically from non-steroidal anti-inflammatory drugs. These differences come with potential adverse effects that range from mild drug reactions to severe life-threatening emergencies. While acetaminophen's toxic liver effects are well known, a lesser-known adverse effect of this drug is its association with the development of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). These dermatological emergencies involve similar pathological processes, including apoptosis of the epidermis and sloughing of the dermis and mucosa from the underlying layers with a positive Nikolsky sign. Currently, SJS and TEN are considered immune-mediated type IV hypersensitivity reactions predominantly involving CD8+ T lymphocytes. Other immune mediators, including regulatory T cells, natural killer cells, interleukins, and drug metabolites are speculated to be involved, but their mechanisms have not been entirely determined. These conditions are differentially diagnosed by the percentage of body area affected with SJS and TENS, involving <10% and >30%, respectively. Genomic variations in human leukocyte antigens (HLA) genes have been implicated in the susceptibility and severity of acetaminophen-induced SJS/TENS, however, details of these interactions remain unclear. Acetaminophen's widespread use and the morbidity of its associated skin pathologies SJS and TENS warrant an in-depth examination of the causative processes involved in their pathogenesis. It is critical that both physicians and patients be made aware that while acetaminophen is widely tolerated by most individuals, severe and potentially fatal interactions do occur, and further investigation is necessary to reduce these adverse effects.

Unusual Origin of the Posterior Circumflex Humeral Artery: A Case Report.

Prior knowledge of possible variations in human anatomy is essential for basic medical and clinical training. Many surgeons can avoid uncharacteristic situations by having sources and availability of resources that document potential irregularities in human anatomy. In this case, a human cadaver is identified as having an altered origin of the posterior circumflex humeral artery (PCHA). While it usually stems from the axillary artery, this cadaver had a left-sided PCHA originating from the subscapular artery (SSA) and continuing into the quadrangular space. This irregularity of the PCHA from the SSA is not commonly discussed in the literature. Physicians and anatomists need to be fully aware of this possibility and be prepared for any unexpected differences in anatomy during procedures.

Telemedicine, E-Health, and Multi-Agent Systems for Chronic Pain Management.

Telemedicine, telehealth, and E-health all offer significant benefits for pain management and healthcare services by fostering the physician-patient relationship in otherwise challenging circumstances. A critical component of these artificial-intelligence-based health systems is the "agent-based system", which is rapidly evolving as a means of resolving complicated or straightforward problems. Multi-Agent Systems (MAS) are well-established modeling and problem-solving modalities that model and solve real-world problems. MAS's core concept is to foster communication and cooperation among agents, which are broadly considered intelligent autonomous factors, to address diverse challenges. MAS are used in various telecommunications applications, including the internet, robotics, healthcare, and medicine. Furthermore, MAS and information technology are utilized to enhance patient-centered palliative care. While telemedicine, E-health, and MAS all play critical roles in managing chronic pain, the published research on their use in treating chronic pain is currently limited. This paper discusses why telemedicine, E-health, and MAS are the most critical novel technologies for providing healthcare and managing chronic pain. This review also provides context for identifying the advantages and disadvantages of each application's features, which may serve as a useful tool for researchers.

Tetracycline-, Doxycycline-, Minocycline-Induced Pseudotumor Cerebri and Esophageal Perforation.

Tetracyclines are a class of broad-spectrum bacteriostatic antibiotics used to treat many infections, including methicillin-resistant Staphylococcus aureus (MRSA), acne, pelvic inflammatory disease, chlamydial infections, and a host of zoonotic infections. These drugs work by inhibiting protein synthesis in bacterial ribosomes, specifically by disallowing aminoacyl-tRNA molecules from binding to the ribosomal acceptor sites. While rare, tetracycline antibiotics, particularly minocycline and doxycycline, are associated with an increased risk of developing esophageal perforation and pseudotumor cerebri (PTC, or idiopathic intracranial hypertension). Since tetracyclines are a commonly prescribed class of medications, especially in adolescents for acne treatment, it is important for clinicians to appreciate significant side effects that can result in morbidity and mortality. This paper aims to consolidate and to emphasize current research on the association between tetracycline antibiotics and the development of esophageal perforation, and PTC. PTC is a neurological syndrome consisting of increased intracranial pressure, headache, and vision changes without evidence of the contributing source, such as mass lesion, infection, stroke, or malignancy. Esophageal perforation, while rare, can be the result of pill esophagitis. Pill-induced injuries occur when caustic medicinal pills dissolve in the esophagus rather than in the stomach. Most patients experience only self-limited pain (retrosternal burning discomfort, heartburn, dysphagia, or odynophagia), but hemorrhage, stricture, and perforation may occur. Tetracycline use can lead to pill esophagitis. In summary, clinicians should appreciate the potential risks of tetracycline compounds in clinical practice.

Bromocriptine and Colesevelam Hydrochloride: Novel Therapies for Type II Diabetes Mellitus.

The increasing prevalence of type II diabetes mellitus (T2DM) is a worldwide healthcare concern. Over the years, our understanding of T2DM has grown considerably in uncovering the pathophysiology of the disease and, in turn, understanding how improved treatment methods can be used to slow disease progression. Some long-term complications that are responsible for most T2DM mortalities include cardiovascular disease, neurological decline, and renal failure. In treating T2DM, it is important that not only glycemic control be obtained but also control of associated complications. Bromocriptine and colesevelam hydrochloride have both been approved by the Food and Drug Administration (FDA) to treat T2DM but are not readily used in practice. These medications are known to treat glycemic dysregulation via unconventional mechanisms, which might contribute to their potential to provide protection against common diabetic complications such as cardiovascular disease. In order to ensure that these overlooked medications become more readily used, it is vital that more research be performed to further elucidate their efficacy in a clinical setting. Future studies should continue to provide clinicians a better understanding of the role these medications have on the treatment of T2DM such as their ability to be used in combination with other commonly used T2DM medications or as monotherapies.

Neuroprotective Potential of Melatonin: Evaluating Therapeutic Efficacy in Alzheimer's and Parkinson's Diseases.

Decreased melatonin levels have been linked to both Alzheimer's disease (AD) and Parkinson's disease (PD), which are the two most prevalent neurodegenerative disorders. The development of sleep disorders is widespread in patients diagnosed with AD or PD. In this regard, calcification of the pineal gland, typically seen in the third decade, has been associated with a reduction in melatonin production. Recent studies have suggested that exogenous melatonin application can be utilized to treat sleep disorders in patients with neurodegenerative diseases. Furthermore, research has shown that deficiencies in melatonin levels in patients with AD or PD begin before a diagnosis of either disease is made. These findings could encourage further research on melatonin as a potential biomarker for the diagnosis or a possible area for the early treatment of these diseases. Many clinical studies have also produced data denoting melatonin treatment as a method to reduce the detrimental neurocognitive effects of these diseases. Further research on the role of melatonin in neurodegenerative diseases could expand symptomatic and prophylactic treatment options for diseases such as AD and PD. This review investigates melatonin's physiological properties, its role in AD and PD, and current findings on its potential therapeutic benefits in AD and PD patients.