Understand My Language, to Understand My Pain: Challenges of Neurological Evaluation Among Refugees.

The increasing number of migrants and refugees entering Albania during the last decade has been a challenge to the medical service of the country. Many of the migrants arrive from remote areas of Middle East or other Asian regions, heading toward northern Europe, deprived from medical assistance during their tormenting journey. An exacerbation of previous m"unicodeedical conditions is expected and is related to the hardship of traveling conditions. The medical professionals working in migration medicine have little, if any, training on the field and need to familiarize themselves with a variety of previously unknown conditions. Empathy, necessary on an individual basis, may not be sufficient in itself; the burden of medically treating migrants needs a holistic and multidisciplinary approach.

The Role of TaqI DRD2 (rs1800497) and DRD4 VNTR Polymorphisms in Posttraumatic Stress Disorder (PTSD).

BACKGROUND: Posttraumatic stress disorder (PTSD) is a complex stress related disorder, that follows a severe traumatic experience, characterized with an intense sense of terror, fear, and helplessness. The aim of this study is to identify associations of genetic variations within candidate genes DRD2 and DRD4 with various PTSD related phenotypes. PTSD lifetime and PTSD current subjects were analyzed separately, each of them were analyzed in a Case/Control design, as well as regarding BSI and CAPS within cases only. SUBJECTS AND METHODS: 719 (487 male, 232 female) participants who had experienced war-related trauma between 1991 and 1999 in Bosnia and Hercegovina, Kosovo and Croatia were included in the study. Sociodemographic questionnaire, Clinician Administered PTSD Scale (CAPS) and the Brief Symptom Inventory (BSI) were used to collect clinical data. RESULTS: The DRD2 rs1800497 variant and a variable number tandem repeat (VNTR) located in exon three of DRD4 were investigated for association with PTSD. In case control analyses we did not identify any significant associations. Within the PTSD current patients, we identified an association of DRD2 rs1800497 with BSI in the genotypic and the recessive model with the T allele as the risk allele. CONCLUSION: Our findings suggest that rs1800497 of DRD2 gene is involved in pathogenesis of PTSD.

Forbidden insanity: the systematic denial of mental health issues from a state-run psychiatry.

The authors discuss the issue of psychiatric care and patients during the second half of XX century in Albania, when the country was under an absolute regime of communism. Completely isolated from the rest of the world, the territory remained a prohibited area for scholars, and local authors due to censorship or self-censorship, offered very scarce information. The general feeling of the public was that of a denial of psychic disorders in total, combined with the fear that this kind of disorders has ever since provoked. Nevertheless, insanity defence was a formulation encountered with a certain frequency in Albanian judicial procedures, although forensic psychiatry was a peripheral part of an already neglected medical specialty. The entire system of psychiatric care was mainly hospital based, and shock therapies (electroconvulsive therapy, pyretotherapy, insulin coma) were normal part of the therapeutic armamentarium along with antipsychotics and social isolation. Some recently unclassified documents and some archival papers, whose exhaustive consultation needs further study, might shed light to the problems of a psychiatry, that are not substantially different from the ones encountered in the Eastern communist Europe of the same period of time.

Imported malaria in Albania and the risk factors that could allow its reappearance.

Malaria is an infectious disease gradually becoming a serious concern for public health institutions, even in European countries where the eradication of the disease was previously taken for granted. Albania was listed as an endemic area from the beginning of the 20th Century, but the disease was gradually under control and some decades after the World War II it was merely considered a historical curiosity. Nevertheless, for many reasons, since 1994 and in increasing trend, Albanian health facilities have registered several cases of malaria. Tracing the remnants of the autochthonous disease and finding links with the actual situation seems difficult, due to the relatively long period separating the proclaimed eradication of malaria with the re-appearance of the infection. Among major factors leading to such re-appearance might be massive migratory movements, and environmental changes such as the flooding of areas close to river deltas that flow into the Adriatic and Ionian Seas. These factors, combined with the constant presence of several Anopheles species, have led to newly-diagnosed imported malaria cases in Albania. Although all reported cases are considered imported, measures have to be put in place, in order to prevent reappearance of autochthonous malaria cases, and to control disease spread.

The ill-fated triad: Roosevelt, Stalin and Churchill-Post-Yalta strokes and the impact on world leaders.

The Yalta Conference of 1945 brought together three of the most influential leaders of the 20th century: Franklin D. Roosevelt, Joseph Stalin and Winston Churchill. Surprisingly, all three leaders would go on to suffer strokes after the conference. This manuscript examines the health status of these leaders during and after the Yalta Conference, the factors that contributed to their strokes (including the role of hypertension), and other modifiable risk factors present in each one of them, and the impact of their declining health on their countries and the world. Roosevelt's demise, prior to the conclusion of the war, triggered a leadership transition during a critical moment in history, while Churchill and Stalin's passing shaped the early Cold War era. A veil of secrecy shrouded the health conditions of these pivotal leaders. "The Big Three" made considerable efforts to hide their health conditions from both the press and the public at large.

Herpes simplex virus encephalitis mimicking acute ischemic stroke.

Background: Infections of the central nervous system might present in an acute form such as to be similar with the clinical characteristics of a stroke. This situation will hamper a correct diagnosis and a prompt treatment that can otherwise be successful. Case Description: We present the case of a herpes virus encephalitis that came up in the emergency department with an admission diagnosis of ischemic cerebral accident. Being the symptomatology unclear, the findings of magnetic resonance of the brain oriented versus an infectious disorder. The lumbar tap confirmed the presence of herpes simplex virus (HSV) 1 virus and an antiviral therapy was administered, leading to resolution of the condition within the 3 weeks of hospitalization. Conclusion: HSV infections may mimic stroke and therefore should be included in the differential diagnosis of atypical acute nervous conditions. In neurological events of acute nature, especially in febrile patients whose brain imaging is suspicious or inconclusive, the eventuality of a herpetic encephalitis should be kept in mind. This will lead to a prompt antiviral therapy and to a favorable outcome.

A Theoretical Framework on the Biology of Prion Diseases.

Background: Prion diseases or TSE diseases are a group of neurodegenerative disorders that manifest in several forms in humans, such as Kuru disease, Creutzfeldt‒Jakob disease (CJD), Gerstmann-Sträussler-Scheinker syndrome (GSS) and fatal familial insomnia. Objective: In this study, we propose a multimodular hypothesis of prion diseases. According to this hypothesis, a prion disease manifests because of the interaction of two genetic modules, such as the PRNP gene module and that of the gene or genes responsible for one or more chaperones, with one or some chemical module on whose structure the products of the genes or genetic modules interact. Methods: This study presents the perspective that modular thinking can allow us to overcome conceptual obstacles in the understanding and interpretation of prion diseases. Results and Discussion: The structure of the chemical module or modules is directly responsible for the folding or misfolding of the PrPC protein. The etiology of acquired prion diseases is explained based on this hypothesis. Hence, it has been proposed that (g) CJD involves the PRNP gene mutant and one or more mutant genes for one or more chaperone genes. In contrast, sCJD has one or more mutant chaperone genes. When does iCJD occur? Healthy individuals manifest acquired prion disease through contamination when infected with one or more mutant chaperones. The mutant chaperones interact with the prion protein, and PrPC is converted to its isoform PrPSc. In a recent study, there was a case of an individual with CJD after COVID-19 infection. Conclusion: This case emphasizes the link between neuroinflammation and protein misfolding and provides proof that chemical module formation is a necessary condition for the manifestation of prion diseases.

Morgagni hernia presenting in a 68-year-old patient treated for pneumonia.

Key Clinical Message: We report an unusual case of an advanced congenital diaphragmatic hernia (Morgagni type) in an elderly patient, which was initially diagnosed and treated for pneumonia. Surgical repair through laparotomy is the method of choice in acute and complicated cases such as our patient. She was successfully treated surgically. Abstract: Morgagni hernia represents a congenital form of diaphragmatic hernia that due to its frequent complications is regularly diagnosed during late infancy or early adulthood. Described some centuries before, its pathogenesis is still a matter of controversy. Nevertheless, authors converge into the option of surgical repair that, as a rule, ensures a definite resolution of symptoms. We describe the case of a female patient aged 68 years old, which was being treated for pneumonia. Due to persistent vomiting, malaise, and lack of improvement, she underwent imaging procedures that initially suspected and thereafter confirmed the presence of a huge intrathoracic right Morgagni hernia, needing surgery.

Importance of methodological considerations in documenting psychological trauma.

The documentation of psychological trauma is obviously a challenge to clinicians while they are diving deep into remote events related to their clients or patients. The potential role of psychological trauma in the early developmental stages, and even the existence of adverse childhood experiences, is important to prove, yet it is difficult to do so. A diverse range of methods have been applied, all of which presumably benchmark a big therapeutic step; however, these enthusiastic methods frequently do not last for long. While hypnosis supporters, Freudian and Neo-Freudian disciples can be acute enough to enhance and uncover suppressed memories, modern psychiatry relies mostly on diversely structured interviews. Functional magnetic resonance and its related subtleties might help, but the questions that remain unanswered are numerous and confusing. Connecting early experiences with long-term memory while identifying psychological trauma its importance for the individual's growth trajectory; thus, it remains an intriguing issue.

Dementia in custody: A historical and forensic approach.

The constant ageing of the population extends to the population behind bars. We consider and summarise medical, ethical, legal and societal concerns raised when older adults with dementia are charged and put into custody.Dementia in custody is a relatively new concept in forensic science. When you take into account the adversarial nature of the judicial system and the hardship posed by correctional facilities, an older adult with severe cognitive problems will increases the complexity of the situation.The possibility of an octogenarian in cognitive decline being detained in police custody is less remote than it seemed half a century ago.

Multiple cerebral septic emboli sourcing from a ventricular assist device: a case report.

Background: Patients carrying portable cardiac devices are at high risk of serious infections, such as endocarditis and sepsis. The event of a neurological complication should be taken into account, despite the fact that this group of patients is as a rule, strictly anticoagulated and monitored duly. Case Description: We present the case of a patient of middle age with heart failure awaiting for organ transplantation, and meanwhile having a ventricular assist device (VAD) implanted. The suspicion of an infection was raised following a purulent drainage from the external lead of the device, as well as the clinical picture of malaise, fever and sweating. A right hemiparesis complicated the condition and the brain computerized tomography (CT) scan demonstrated the presence of several hemorrhagic lesions. The suspicion of septic emboli was proven following the result of hemoculture yielding Staphylococcus epidermidis. Conclusions: The patient was treated with antibiotics, anti-seizure drugs and with supportive therapy, with good recovery of the clinical picture. He was transferred to a cardiac surgery facility for a revision, or eventually for a replacement of the VAD. There is clearly a need for an increased awareness of probable neurological events among patients holding external heart devices. Available guidelines for their follow-up and monitoring should be strictly respected, in order to avoid complications, and eventually install a prompt and adequate treatment.

Avoiding parental distress when discussing about SUDEP: the Albanian experience.

INTRODUCTION: Pediatric SUDEP (Sudden Unexpected Death in Epilepsy) is an uncommon event, but its unpredictability has rendered the issue very important to be addressed, under all points of view: medical, moral and legal one. The death of a child has been always considered a dramatic event for the Albanian families, and when it overcomes unexpectedly the emotional reactions might even be more exaggerated. DISCUSSION: Debates about truth-telling on the prognosis, or even on the probability of a sudden death related to the main diagnosis (epilepsy) are old and controversial. Risk factors for SUDEP have been formulated and strategies to confront them have been put in place; however medical (pharmacological) compliance seems by large the most important protective factor. CONCLUSION: To our opinion, disclosing the risk of a sudden death to the family on a child suffering from epilepsy is a necessary act; timing and ways of disclosure are details that need to be refined case-by-case, in a situation where a general consensus or guidelines are lacking. A step-by-step approach and a gradual informing are helpful and psychologically acceptable from the parents or other relatives.

Psychiatric disorders and pain: The recurrence of a comorbidity.

Painful conditions are probably among the most frequent reasons for seeking medical advice and assistance. Although pain is a common complaint among psychiatric patients, clinicians generally separate its presence from the background mental disorder and downplay its importance, trying primarily to control the psychiatric symptomatology. As a sensory modality, the presence of pain and its importance account for an impressive body of scholarly research. Cartesian methodology considered sensations of all modalities in a mechanistic form, which actually sounds obsolete. However, authors have continuously been faced with the same dilemmas plaguing scholars for centuries. We assume that a large portion of the sensory inputs might be generators of distorted perceptions, which subsequently lead to psychopathology. Auditory and visual hallucinations are incontestable examples. Somaesthetic hallucinations also exist, but pain hardly deserves such a denomination. Nevertheless, chronic pain and psychiatric comorbidity is a reality that needs explanation. Painkillers are not effective in treating psychiatric disorders, and antipsychotics do very little, perhaps nothing, to relieve pain. The pharmacological approach opens one door on the horizon and closes many others, while clinicians continue to face a high prevalence of comorbid pain and mental health issues. However, attempts to correlate altered body schemata (as distorted as it may be, for example, in phantom limb pain) with somatic delusions can simplify all these dilemmas, and the basket of psychophysiology, in fact, might be bigger than presumed.

Professor Bajram Preza (1923-2007), a leading academic figure in the Albanian medicine.

Professor Bajram Preza was a career neurologist with a strong background in research both in neurology and psychiatry. After a period of study in Sarajevo in the immediate post-WWII period, he completed his studies in medicine and a fellowship in neuropsychiatry in Nizhny Novgorod (formerly Gorky). A highly prolific author, he holds the laurels of the first medical dissertation sustained in the University of Tirana (1958) as well as for publishing the first student's textbook on medicine (Semiotics of nervous diseases, 1964) in Albania. He led the Clinic of Neurology in Tirana for more than three decades, while relentlessly lecturing, publishing and editing a diversity of medical papers, translations and original works that have shaped the professional education of entire generations of future Albanian physicians.

Occultism and playing with the dead: When rituals go wrong.

There have been at least two deaths in Albania linked to ritualistic/satanic practices, which have provoked considerable public concern. Until the 1990s, Albania was strictly atheist. However, since then some religious sects have been establishing themselves. In fact, satanic killings and ritualistic deaths are rare in Albania. We describe two such cases that occurred in 2020 along with consideration of the psychological profiles of perpetrators and victims.The first case involved two deaths: a mother and daughter whose bodies were found near each other, with another daughter in attendance who was diagnosed as clearly psychotic, and legally did not face any charge thereafter. This daughter was witnessing the decomposition of her sister's mummified corpse. She said she was waiting for the "Messiah" to resurrect her. Apparently, while performing ritualistic ceremonies, the daughter and her mother refused food until the mother died from starvation. It was at that point that police broke into the house and discovered the situation.The second case involved a young woman who was found dead, apparently following a trivial infection. Her body (abdomen and dorsum) had written symbols on it, suggesting Satanism and the occult.A detailed analysis of the death scenes and crime scenes provide valuable data for further proceedings, but psychological evaluation of the perpetrators may prove more difficult, and more so where the victims have died.

Through-and-through gunshot wound to the head in a rare case of survival.

We describe the case of a 42-year old Caucasian male who presented for follow-up treatment of refractory epilepsy. He suffered a cranial trauma 13 years before when a bullet from a pistol, (presumably accidentally) entered the right frontal side of the cranial vault and exited contralateral, causing severe neurological damage.

Pneumoretroperitoneum, pneumomediastinum, and neck emphysema due to rectal diverticulosis.

Intestinal diverticulosis is a chronic disorder that might present with acute symptoms, due to colonic perforation. Pneumoperitoneum and air bubbles spreading in different anatomical locations can be seen. These complications need careful consideration and, when appropriate, surgery, for an otherwise chronic condition that can be successfully treated through conservative measures.

Pseudomonas aeruginosa nosocomial meningitis following spinal anesthesia - still a significant treatment dilemma.

Background: Infections of central nervous system after spinal anesthesia nowadays are a rarity; however, their presence might be of concern. Case Description: We report the case of lateral ventricular empyema treated unsuccessfully with parenteral antibiotic therapy, with the clinical signs of a persisting meningitis. After several lumbar taps suggesting an infection, Pseudomonas aeruginosa was isolated and a brain magnetic resonance imaging find out the collection in the left horn of the lateral ventricle. An intrathecal/intraventricular antibiotic therapy with colistin proved highly effective combined with an extra ventricular drainage to deal with the hydrocephaly. Conclusion: Clinicians should take into account even uncommon infectious agents while facing the picture of a meningitis otherwise nonresponsive to empiric or standard therapy.

Inapplicability of advance directives in a paternalistic setting: the case of a post-communist health system.

BACKGROUND: The Albanian medical system and Albanian health legislation have adopted a paternalistic position with regard to individual decision making. This reflects the practices of a not-so-remote past when state-run facilities and a totalitarian philosophy of medical care were politically imposed. Because of this history, advance directives concerning treatment refusal and do-not-resuscitate decisions are still extremely uncommon in Albania. Medical teams cannot abstain from intervening even when the patient explicitly and repeatedly solicits therapeutic abstinence. The Albanian law on health care has no provisions regarding limits or withdrawal of treatment. This restricts the individual's healthcare choices. DISCUSSION: The question of 'medically futile' interventions and pointless life-prolonging treatment has been discussed by several authors. Dutch physicians call such interventions 'medisch zinloos' (senseless), and the Netherlands, as one of the first states to legislate on end-of-life situations, actually regulates such issues through appropriate laws. In contrast, leaving an 'advance directive' is not a viable option for Albanian ailing individuals of advanced age. Verbal requests are provided during periods of mental competence, but unfortunately such instructions are rarely taken seriously, and none of them has ever been upheld in a legal or other official forum. SUMMARY: End-of-life decisions, treatment refusal and do-not-resuscitate policies are hazardous options in Albania, from the legal point of view. Complying with them involves significant risk on the part of the physician. Culturally, the application of such instructions is influenced from a mixture of religious beliefs, death coping-behaviors and an immense confusion concerning the role of proxies as decision-makers. Nevertheless, Albanian tradition is familiar with the notion of 'amanet', a sort of living will that mainly deals the property and inheritance issues. Such living wills, verbally transmitted, may in certain cases include advance directives regarding end-of-life decisions of the patient including refusal or termination of futile medical treatments. Since these living wills are never formally and legally validated, their application is impossible and treatment refusal remains still non practicable. Tricks to avoid institutional treatment under desperate conditions are used, aiming to provide legal coverage for medical teams and relatives that in extreme situations comply with the advice of withholding senseless treatment.

Eagle syndrome presenting as a neurological emergency: A case report.

BACKGROUND: Eagle syndrome, due to the elongation of the styloid process as well as the calcification of the stylohyoid ligament, rarely presents itself with a major neurological disorder such as a brain infarct. CASE DESCRIPTION: Authors describe the case report of a previously healthy 64-year-old Caucasian male that complained of inability to control his right upper and lower extremity of an acute nature. Imaging at the emergency department (magnetic resonance of the brain and computerized angiography) showed the presence of elongated styloid process bilaterally with clear predomination at the left side. The brain ischemia (left temporal brain infarct) was due to carotid artery dissection, and the left internal carotid artery was not visualized during the contrast-enhanced angiography. The patient was hospitalized at a neurological facility and thereafter referred to surgery for styloidectomy. CONCLUSION: The present case underscores the need for a prompt diagnosis and an enhanced awareness of this syndrome, especially among emergency department professionals.