Comparative effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies and onabotulinumtoxinA in chronic migraine: A multicenter, real-world study in Taiwan.

OBJECTIVE: To compare the real-world effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) and onabotulinumtoxinA in chronic migraine (CM) patients. METHODS: This multicenter study involved retrospective analysis of prospectively collected data of CM patients treated with CGRP mAbs or onabotulinumtoxinA, including difficult-to-treat (DTT) patients (i.e., ≥3 preventive failures). Treatment outcomes were determined at 6 months based on prospective headache diaries and Migraine Disability Assessment (MIDAS). RESULTS: The study included 316 (55 M/261F, mean age 44.4 ± 13.5 years) and 333 (61 M/272F, mean age 47.9 ± 13.4 years) CM patients treated with CGRP mAbs or onabotulinbumtoxinA, respectively. At 6 months, CGRP mAb treatment was associated with a greater decrease in monthly migraine days (MMDs) (-13.0 vs. -8.7 days/month, p < 0.001) and a higher ≥50% responder rate (RR) (74.7% vs. 50.7%, p < 0.001) compared with onabotulinumtoxinA injections. The findings were consistent in DTT patients (-13.0 vs. -9.1 MMDs, p < 0.001; ≥50% RR: 73.9% vs. 50.3%, p < 0.001) or those with medication-overuse headache (MOH) (-13.3 vs. -9.0 MMDs, p < 0.001; ≥50% RR: 79.0% vs. 51.6%, p < 0.001). Besides, patients receiving CGRP mAbs had greater improvement (-42.2 vs. -11.8, p < 0.001) and a higher ≥50% RR (62.0% vs. 40.0%, p = 0.001) in MIDAS scores and a lower rate of adverse events (AEs) (6.0% vs. 21.0%, p < 0.001). However, none of the patients discontinued treatment due to AEs. CONCLUSIONS: In this multicenter, real-world study, CGRP mAbs were more effective than onabotulinumtoxinA in CM patients, even in DTT or MOH patients. All of these injectables were well tolerated. Further prospective studies are needed to verify these findings.

Portable ultrasonic humidifier exacerbates indoor bioaerosol risks by raising bacterial concentrations and fueling pathogenic genera.

Portable ultrasonic humidifiers are frequently used in heating rooms to ease air dryness. However, it has also posed serious health concerns such as "humidifier fever" because the bioaerosol concentration and community in the humidified space may alter quickly before the occupants could even notice. We compared the microbial proliferation rates in the humidifiers' reservoirs filled with three commonly used water types and investigated the impacts of the ultrasonic humidifiers on the temporal concentration, size distribution, and community variations of indoor bacterial and fungal aerosols during two-week humidification. The concentration of indoor bacterial aerosols increased exponentially, concentrating in the respiratory size ranges (≤1.1 µm), and was proportional to the humidification level, which soon exceeded 1000 CFU/m3 in one week (at RH = 70%), while the fungal concentration always remained low (≤177 CFU/m3 ). The indoor bioaerosol community, significantly associated with the humidifier water, was substantially distorted after humidification and dominated by the pathogenic Pseudomonas spp. (40.50%), Brevundimonas spp. (3.02%), Acinetobacter spp. (0.98%) and Legionella spp. (0.69%). Our results show that ultrasonic humidification contaminates indoor air by raising bacterial concentrations and fueling the pathogenic genera. To minimize the exposure risks, occupants should avoid long-term and excessive humidification (RH ≥ 70%) and clean the ultrasonic humidifier weekly.

Intravenous Thrombolysis in Acute Ischemic Stroke After Idarucizumab Reversal of Dabigatran Effect: Analysis of the Cases From Taiwan.

BACKGROUND: Asians with atrial fibrillation carry a higher risk of ischemic stroke than non-Asians even under treatment of nonvitamin K antagonist oral anticoagulants. The purpose of the study was to observe the feasibility of intravenous thrombolytic therapy after administering a reversal agent, idarucizumab, in dabigatran-treated patients with acute ischemic stroke in Taiwan. METHODS: Dabigatran-treated patients with acute ischemic stroke who received intravenous recombinant tissue plasminogen activator (rt-PA) after idarucizumab reversal were enrolled in the retrospective nationwide study. The clinical data, treatment course, and outcomes were recorded. Stroke severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) score. Any intracerebral hemorrhage (ICH) after rt-PA was detected by neuroimaging studies. RESULTS: Ten dabigatran-treated patients (6 men, mean age 71.10 ± 7.96 years) with acute ischemic stroke were included. Before stroke, the mean CHA2DS2-VASc score was 4.50 ± 1.57 and 8 patients (80%) received dabigatran 110 mg twice daily. All patients were treated with 5 g idarucizumab, following which the activated partial thromboplastin time normalized. Intravenous rt-PA (mean dose .78 mg/kg) was initiated a mean time of 11.11 minutes after idarucizumab infusion. The NIHSS score improved significantly after thrombolysis (16.0 ± 6.67 at admission to 9.38 ± 4.75 at discharge, P = .016). ICH developed in 3 patients (30%). Two of them were asymptomatic and 1 patient suffered from symptomatic ICH leading to mortality. CONCLUSION: Our data reconfirmed the feasibility of intravenous rt-PA for Asian stroke patients after reversal of dabigatran effect with idarucizumab.

Wernicke's Encephalopathy after Bariatric Surgery with Atypical Magnetic Resonance Imaging: A Case Report.

Wernicke's encephalopathy (WE) is a disease caused by thiamine deficiency related to alcoholism, hyperemesis, or thiamine malabsorption. The clinical manifestations of WE are mental change, ataxia, and ophthalmoplegia. The typical magnetic resonance imaging (MRI) findings of WE are symmetrical involvement of medial thalamus, periventricular region of the third ventricle, periaqueductal area, and mammillary body. The atypical MRI findings are more common in nonalcoholic WE. Since the increasing population of obesity and the preference of weight loss surgery, the risk of developing thiamine deficiencies associated with weight loss surgery has become a considerable etiology of WE. We herein reported a case reminds clinicians that WE can be a possible diagnosis in patient who developed acute altered mental status with atypical MRI lesion involving bilateral centrum semiovale and corona radiata after receiving bariatric surgery.

Association of vitamin D deficiency with post-exercise hypotension and arterial stiffness following prolonged endurance exercise in healthy young men.

BACKGROUND: Vitamin D is associated with vascular function; however, the impact of different vitamin D levels on vascular elasticity following prolonged exercise remains uncertain. The primary objective of this study was to investigate the association of vitamin D levels with changes in peripheral pulse wave velocity (pPWV) and the magnitude of acute post-exercise hypotension (PEH) following prolonged endurance exercise in healthy young men. METHODS: All the participants were divided into two groups: the 25-hydroxyvitamin D (25(OH)D) sufficiency group (25(OH)D ≧50 nmol/L) and the deficiency group (25(OH)D < 50 nmol/L). A cardiopulmonary exercise test for maximal oxygen uptake (V.O2max) was performed on the graded cycling. The prolonged exercise was set at 60% V.O2max for 120 min of continuous riding on a stationary bicycle. The pPWV and blood pressure were measured at baseline and 0, 15, 30, 45, 60 min after prolonged endurance exercise. RESULTS: Post hoc analysis revealed that the vitamin D sufficient group had a greater magnitude of PEH than the deficiency group at post-45 min. Multiple linear regression analyses showed a significant correlation between 25(OH)D and both pPWV (p = 0.036) and PEH (p = 0.007), after adjusting for V.O2max, weight, height, and physical activity. In addition, the 25(OH)D deficiency group also had higher pPWV at post-15 min (5.41 ± 0.93 vs 4.84 ± 0.75 m/s), post-30 min (5.30 ± 0.77 vs 4.87 ± 0.50 m/s), post-45 min (5.56 ± 0.93 vs 5.05 ± 0.68 m/s) than the sufficiency group. CONCLUSIONS: There was a positive correlation between 25(OH)D levels and systolic PEH following prolonged endurance exercise. Individuals with sufficient 25(OH)D status may have better vascular elasticity and more efficient blood pressure regulation during exercise.

Serial magnetic resonance imaging changes in hypoglycemic encephalopathy.

PURPOSE: Reports of serial magnetic resonance imaging (MRI) in hypoglycemic encephalopathy were limited because MRI is not routinely performed in these patients. Here we present one patient with a history of hypoglycemic encephalopathy and discuss sequential neuroimaging findings. CASE REPORT: A 53-year-old male mistakenly took oral hypoglycemic agents developed hypoglycemic encephalopathy. Immediate brain diffusion-weighted image (DWI) demonstrated extensive symmetrical hyperintensive lesions over bilateral subcortical white matter. 14 days later, new hyperintensive lesions involving bilateral cerebral cortex were found on DWI, while previous subcortical white matter lesions disappeared. On day 86, diffusion-weighted images abnormalities vanished and diffuse brain atrophy was noted. CONCLUSION: Although subcortical white matter involvement in hypoglycemic encephalopathy was occasionally reported in the literature, few report revealed similar serial MRI changes as our case. Although its mechanism is still unknown, it is important to follow sequential images in hypoglycemic encephalopathy. The brain tissue which was normal in early DWI may not necessarily guarantee undamaged.

Wernicke encephalopathy with atypical magnetic resonance imaging.

Wernicke encephalopathy (WE) is a medical emergency caused by thiamine (vitamin B1) deficiency. Typical clinical manifestations are mental change, ataxia, and ocular abnormalities. Wernicke encephalopathy is an important differential diagnosis in all patients with acute mental change. However, the disorder is greatly underdiagnosed. Clinical suspicion, detailed history taking, and neurologic evaluations are important for early diagnosis. Magnetic resonance imaging (MRI) is currently considered the diagnostic method of choice. Typical MRI findings of WE are symmetrical involvement of medial thalamus, mammillary body, and periaqueductal gray matter. Prompt thiamine supplement is important in avoiding unfavorable outcomes. Here, we report a case of alcoholic WE with typical clinical presentation but with atypical MRI. Axial fluid-attenuated inversion recovery images showing symmetrical hyperintensity lesions in dentate nuclei of cerebellum, olivary bodies, and dorsal pons. Although atypical MRI findings are more common in nonalcoholic WE, it can also occur in alcoholic WE. This article is aimed to highlight the potential pitfalls in diagnosing acute mental change, the importance of clinical suspicion, and early treatment in WE.

Cervical spinal epidural hematoma mimics acute ischemic stroke.

Spinal epidural hematoma is an accumulation of blood in the epidural space that can mechanically compress the spinal cord. It is an uncommon condition, and most cases occur spontaneously. Detailed evaluation of neurologic deficit and detailed history taking are important tools for early diagnosis, and magnetic resonance imaging is currently the diagnostic method of choice. Prompt surgical intervention is important in achieving positive clinical outcomes. Spinal epidural hematoma usually comes with acute, severe pain with radiation to the extremities and may be accompanied with severe neurologic deficit. Common neurologic signs include paraparesis and quadriparesis. Here, we report 2 cases of cervical spinal epidural hematoma with sudden onset of neck pain, followed by the development of unilateral limbs weakness and respiratory distress. Both patients were initially suspected to have acute ischemic stroke and were considered using intravenous thrombolytic therapy with recombinant tissue plasminogen activator as treatment. Cervical spinal epidural hematoma was confirmed after obtaining magnetic resonance imaging. Patients with this uncommon presentation must be carefully distinguished from acute stroke. This article aimed to highlight the potential pitfalls in diagnosing acute hemiparesis with no cranial nerves deficits and the importance of clinical suspicion.

Metronidazole-induced Encephalopathy: Case Report and Review Literature.

PURPOSE: Neurotoxicities resulting from various medications are under diagnosed; Metronidazole-induced encephalopathy is one of them. Here we present two patients with a history of metronidazole use and discuss neuroimaging findings. CASE REPORT: We report two patients suffering from acute neurological symptoms associated with metronidazole use. A 70-year-old female who received a cumulative dose of 41.25g of metronidazole within one month, developed seizure. Brain magnetic resonance imaging (MRI) showed T2 hyperintensity over bilateral dentate nuclei and dorsal midbrain. A 56-year-old female suffering from acute onset of central vertigo with metronidazole use, took a total dose of 24g. The brain MRI showed T2 hyperintensity over dorsal midbrain and dorsal medulla, which disappeared in the following neuroimaging 50 days later. Metronidazole-induced encephalopathy (MIE) was suspected in both patients. CONCLUSION: Metronidazole-induced encephalopathy is an uncommon but potentially reversible disease in patients with acute neurological deficits from the use of metronidazole. Nonalcoholic Wernicke's encephalopathy may share a similar metabolic pathway with MIE, resulting in difficulties in diagnosis.

Low Vitamin D Status Relates to the Poor Response of Peripheral Pulse Wave Velocity Following Acute Maximal Exercise in Healthy Young Men.

The primary objective of this study was to determine the effects of vitamin D levels on peripheral pulse wave velocity (pPWV) following acute maximal exercise in healthy young adults. Fifty male healthy adults from National Chung Cheng University participated in the study. Participants were divided into the 25-hydroxyvitamin D (25(OH)D) sufficiency group (n = 28, 25(OH)D ≥ 50 nmol/L) and deficiency group (n = 22, 25(OH)D < 50 nmol/L). The acute maximal exercise was performed using an incremental cycling test to exhaustion. Additionally, the pPWV and blood pressure were obtained at rest and 0, 15, 30, 45, 60 min after acute maximal exercise. The results show that 25(OH)D deficiency group had higher pPWV at post-exercise (5.34 ± 0.71 vs. 4.79 ± 0.81 m/s, p < 0.05), post-exercise 15 min (5.13 ± 0.53 vs. 4.48 ± 0.66 m/s, p < 0.05) and post-exercise 30 min (5.26 ± 0.84 vs. 4.78 ± 0.50 m/s, p < 0.05) than the sufficiency group. Furthermore, there was a significant inverse correlation between 25(OH)D levels and pPWV following acute maximal exercise. Our study demonstrated that low vitamin D status relates to the poor response of pPWV following maximal exercise in healthy young men. Vitamin D deficiency may increase the risk of incident cardiovascular events after acute exhaustive exercise, even in healthy and active adults.

Correlation of vocals and lyrics with left temporal musicogenic epilepsy.

Whether the cognitive processing of music and speech relies on shared or distinct neuronal mechanisms remains unclear. Music and language processing in the brain are right and left temporal functions, respectively. We studied patients with musicogenic epilepsy (ME) that was specifically triggered by popular songs to analyze brain hyperexcitability triggered by specific stimuli. The study included two men and one woman (all right-handed, aged 35-55 years). The patients had sound-triggered left temporal ME in response to popular songs with vocals, but not to instrumental, classical, or nonvocal piano solo versions of the same song. Sentimental lyrics, high-pitched singing, specificity/familiarity, and singing in the native language were the most significant triggering factors. We found that recognition of the human voice and analysis of lyrics are important causal factors in left temporal ME and provide observational evidence that sounds with speech structure are predominantly processed in the left temporal lobe. A literature review indicated that language-associated stimuli triggered ME in the left temporal epileptogenic zone at a nearly twofold higher rate compared with the right temporal region. Further research on ME may enhance understanding of the cognitive neuroscience of music.

Paraneoplastic cerebellar degeneration in a patient with ovarian cancer.

OBJECTIVE: Herein, we report a case of ovarian serous carcinoma with paraneoplastic cerebellar degeneration. CASE REPORT: A 44-year-old female presented to our hospital with dizziness, slurred speech, and ataxic gait. Brain magnetic resonance imaging was normal. A lumbar puncture revealed a normal cell count in the cerebrospinal fluid, but slightly elevated protein. Her serum cancer antigen -125 level was high (2126.4 U/mL), and abdominal computed tomography disclosed a pelvic mass measuring 11 cm in diameter. Exploratory laparotomy was then performed, and a frozen section of the tumor revealed serous carcinoma. CONCLUSION: According to the surgical findings and pathological report, The International Federation of Gynecology and Obstetrics (FIGO) Stage IIIC, Grade 3, serous-type ovarian cancer was diagnosed. Due to the abovementioned symptoms and signs, we performed a serial test to document the presence of anti-Yo antibody in this patient.

Stroke during pregnancy and puerperium: clinical perspectives.

Stroke is a rare but potentially devastating disease during pregnancy and puerperium. Pregnancy is well recognized as a risk factor for stroke. Accurate and timely identification of stroke is crucial for clinical practice. However, the optimal management of pregnant women with stroke remains a clinical challenge. Thus, identification of risk factors and modification of underlying pathophysiological mechanisms would be of great value for stroke prevention and management. In terms of pharmacological intervention, it is important to determine the safety of a drug for mothers, their fetuses, and nursing infants. Neurologists treat non-pregnant patients without those considerations. Based on the above issues, we have reviewed the current literature and summarized clinically relevant issues for obstetricians and neurologists in treating stroke during pregnancy and puerperium.

Direct UV observation and kinetic studies of a alpha-alkoxy benzyloxy radical.

A alpha-alkoxy benzyloxy radical 3 was generated by laser flash photolysis of peroxyacetal 2, and its UV spectrum, decomposition pattern, reactivity with PPh(3), O(2), and i-PrOH, and quantum yield were explored. It was found that the radical 3 is very unstable and highly reactive and performs beta-C-H scission much faster than beta-C-O scission and H-abstraction.