Medicine by Alexandros G. Sfakianakis

Management of a Buccal Space Mass: A Clinical Case Report, Alexander Karatzanis, Stylianos Velegrakis, Georgia Liva, Dionysios Kyrmizakis, and Emmanuel Prokopakis
Volume 2020 (2020), Article ID 6828453, 6 pages

A Case of a Nonpetrous Cholesterol Granuloma Presenting as a Temporal Mass, Nathaniel Reeve, Jacob Kahane, and Matthew Ng
Volume 2020 (2020), Article ID 8872270, 3 pages

Middle Ear Neuroendocrine Adenoma: A Case Report and Literature Review, Luca Bruschini, Rachele Canelli, Christina Cambi, Giacomo Fiacchini, Stefano Berrettini, and Francesca Forli
Volume 2020 (2020), Article ID 8863188, 5 pages

Synchronous Ipsilateral Pleomorphic Adenomas of Parotid and Submandibular Glands: An Unusual Finding, Walter Colangeli, Aleksandr Kapitonov, Valerio Facchini, Marta Zappalà, and Evaristo Belli
Volume 2020 (2020), Article ID 8887867, 5 pages

Sudden Odynophagia and Globus—A Unique Presentation of a Nonsecreting Parathyroid Adenoma: A Case Report and Literature Review, Luxman Srikantha, Esmael H. Amjad, and Rafic Beydoun
Volume 2020 (2020), Article ID 6805805, 5 pages

Endoscopic Removal of an Uncommon Iatrogenic Foreign Body from the Maxillary Sinus: A Dental Burr, Nafil Arimbrathodi, Waqar Aslam, Abhishek Menon, and Ali Ahmad Al Saadi
Volume 2020 (2020), Article ID 8861701, 4 pages

Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Brain Circulation

Beyond reperfusion: Enhancing endogenous restorative functions after an ischemic stroke
Melissa Wills, Yuchuan Ding

Brain Circulation 2020 6(4):223-224

Neurocysticercosis and movement disorders: A literature review
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara, Ícaro Durante

Brain Circulation 2020 6(4):225-241

Neurocysticercosis (NCC) is a specific form of cysticercosis that affects the central nervous system. It is caused by the tapeworm Taenia solium, which is often found in pigs. NCC is considered one of the “great simulator/mimickers” of other diseases. In this context, movement disorders (MDs) can occur in a small percentage of individuals with NCC. This review aims to evaluate the clinicoepidemiological profile, pathological mechanisms, and historical features of NCC-associated MD. Relevant reports in six databases were identified and assessed by two reviewers without language restriction. A total of 71 reports containing 148 individuals who developed an MD related to NCC were identified. NCC-associated MD included parkinsonism (n = 47), ataxia (n = 32), chorea (n = 18), dystonia (n = 13), tremor (n = 8), myokymia (n = 6), myoclonus (n = 4), ballism (n = 1), tics (n = 1), and others (n = 18). The mean and median ages were 36.58 (standard deviation: 20.51) and 35 years (age range: 1–88 years), respectively. There was a slight predominance of female sex (52.17%). On follow-up, 58.90% of the individuals had a full recovery; two deaths were reported. We believe that the majority of cases reported were only diagnosed because patients had classical clinical manifestations generally investigated by neuroimaging, resulting in incidental findings suggestive of NCC, which were later supported by laboratory examinations. Therefore, the association between NCC and MD is probably underreported. Clinicians should be wary of this association, mainly in endemic areas for cysticercosis.

Mini review (Part I): An experimental concept on exercise and ischemic conditioning in stroke rehabilitation
Qingzhu Wang, Melissa Wills, Zhenzhen Han, Xiaokun Geng, Yuchuan Ding

Brain Circulation 2020 6(4):242-247

Stroke remains a leading cause of adult death and disability. Poststroke rehabilitation is vital for reducing the long-term sequelae of brain ischemia. Recently, physical exercise training has been well established as an effective rehabilitation tool, but its efficacy depends on exercise parameters and the patient's capacities, which are often altered following a major cerebrovascular event. Thus, ischemic conditioning as a rehabilitation intervention was considered an “exercise equivalent,” but the investigation is still in its relative infancy. In this mini-review, we discuss the potential for physical exercise or ischemic conditioning and its relation to angiogenesis, neurogenesis, and plasticity in stroke rehabilitation. This allows the readers to understand the context of the research and the application of ischemic conditioning in poststroke rehabilitation.

Clinical application of nitric oxide in ischemia and reperfusion injury: A literature review
Shangqian Jiang, Chaitu Dandu, Xiaokun Geng

Brain Circulation 2020 6(4):248-253

Ischemia–reperfusion injury (IRI) is a series of multifactorial cellular events that lead to increased cellular dysfunction after the restoration of oxygen delivery to hypoxic tissue, which can result in acute heart failure and cerebral dysfunction. This injury is severe and would lead to significant morbidity and mortality and poses an important therapeutic challenge for physicians. Nitric oxide (NO) minimizes the deleterious effects of IRI on cells. NO donors, such as organic nitrates and sodium nitroprusside, are used systematically to treat heart failure, angina, and pulmonary hypertension. Inhaled NO gas was approved by the FDA in 1999 to treat hypoxic newborns, and its beneficial ameliorations reach outside the realm of lung disease. This review will summarize the clinical application of NO in IRI.

How to remove those bloody collections: Nonsurgical treatment options for chronic subdural hematoma
Ho Jun Yun, Yuchuan Ding

Brain Circulation 2020 6(4):254-259

Chronic subdural hematoma (CSDH) is one of the most prevalent neurosurgical disorders. Patients with CSDH commonly present with altered mental status, focal neurological deficit, and/or headache. The first-line treatment for CSDH is surgical evacuation. Although the surgical procedures for CSDH have been considered relatively “straightforward,” they are not without any risk. The elderly are especially prone to show poor surgical outcomes. To make matters worse, many elderly patients are on anticoagulants and antiplatelet agents, increasing the risk of re-bleeding before and after surgery. These complications have led clinicians to search for nonsurgical alternatives. Dexamethasone should be used with caution for selected patients given its side effects. Tranexamic acid may be utilized as an adjunct therapy to surgery, but more randomized clinical trials are needed to evaluate its definitive efficacy. Interesting results of middle meningeal artery embolization (MMAE) have been reported from case studies. However, the risks associated with MMAE, including intracerebral hemorrhage, stroke, and vasospasm, have not been properly studied yet. The clinical benefits of atorvastatin and angiotensin-converting enzyme inhibitors are uncertain for CSDH. In conclusion, surgical intervention continues to be the first-line treatment while nonsurgical treatment options may be considered an adjunct therapy especially for recurrent hematoma or to reduce the volume of a hematoma.

Blocking pro-inflammatory platelet-activating factor receptors and activating cell survival pathways: A novel therapeutic strategy in experimental ischemic stroke
Ludmila Belayev, Andre Obenaus, Pranab K Mukherjee, Eric J Knott, Larissa Khoutorova, Madigan M Reid, Cassia R Roque, Lawrence Nguyen, Jeong Bin Lee, Nicos A Petasis, Reinaldo B Oria, Nicolas G Bazan

Brain Circulation 2020 6(4):260-268

OBJECTIVE: Acute ischemic stroke triggers complex neurovascular, neuroinflammatory, and synaptic alterations. This study explores whether blocking pro-inflammatory platelet-activating factor receptor (PAF-R) plus selected docosanoids after middle cerebral artery occlusion (MCAo) would lead to neurological recovery. The following small molecules were investigated: (a) LAU-0901, a PAF-R antagonist that blocks pro-inflammatory signaling; and (b) derivatives of docosahexaenoic acid (DHA), neuroprotectin D1 (NPD1), and aspirin-triggered NPD1 (AT-NPD1), which activates cell survival pathways and are exert potent anti-inflammatory activity in the brain. MATERIALS AND METHODS: Sprague-Dawley rats received 2 h MCAo and LAU-0901 (30 or 60 mg/kg, 2 h after stroke), NPD1, and AT-NPD1 (333 μg/kg), DHA (5 mg/kg), and their combination were administered intravenous at 3 h after stroke. Behavior testing and ex vivo magnetic resonance imaging were conducted on day 3 or 14 to assess lesion characteristics and lipidomic analysis on day 1. Series 1 (LAU-0901 + NPD1, 14d), Series 2 (LAU-0901 + AT-NPD1, 3d), and Series 3 (LAU-0901 + DHA, 1d). RESULTS: All combinatory groups improved behavior compared to NPD1, AT-NPD1, or DHA treatments alone. Total lesion volumes were reduced with LAU-0901 + NPD1 by 62% and LAU-0901 + AT-NPD1 by 90% treatments versus vehicle groups. LAU-0901 and LAU-0901 + DHA increased the production of vasoactive lipid mediators (prostaglandins: PGE2, PGF2-α, 6-keto-PGF1-α, and PGD2) as well an inflammatory regulating mediator hydroxyoctadecadienoic acid. In contrast, LAU-0901 and LAU-0901 + DHA decreased the production of 12-hydroxyeicosatetraenoic acid, a pro-inflammatory mediator. CONCLUSION: Combination therapy with LAU-0901 and selected docosanoids is more effective than the single therapy, affording synergistic neuroprotection, with restored pro-homeostatic lipid mediators and improved neurological recovery. Altogether, our findings support the combinatory therapy as the basis for future therapeutics for ischemic stroke.

Blood-transfusion-related posterior reversible encephalopathy syndrome - A description of a new case and review of the literature
Mukesh Dube, Rashi Rathore

Brain Circulation 2020 6(4):269-273

Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome associated with headache, altered mental status, seizures, and visual disturbances and characterized by white matter vasogenic edema affecting predominantly the posterior occipital and parietal lobes of the brain. Neurological complications of blood transfusion are uncommon, and blood-transfusion-related PRES is seldom reported. We report here one such case of PRES. A 61-year-old Asian woman with chronic anemia presented with a history of fall, causing fracture of the left femur neck. As her hemoglobin was 5 g per deciliter, she was transfused with four units of packed cells in three consecutive days. At the time of admission, she was alert, normotensive, and afebrile. Later, she developed mild headache and had a generalized tonic-clonic seizure. Her brain magnetic resonance (MR) imaging showed edema in bilateral frontal lobes and parieto-occipital lobes with normal MR venogram, consistent with PRES. We described her disorder as blood-transfusion-related PRES. Immunologic, as well as non-immunologic complications of blood transfusion, are known but, PRES is rare. Cumulative effects of blood transfusion on blood flow, blood viscosity, endothelial dysfunction leads to blood-brain barrier dysfunction, which culminates into vasogenic edema and vasoconstriction despite normal systemic blood pressure, leading to blood-transfusion-related PRES.

Rapid temporary coiling of the parent artery for the management of intraprocedural aneurysm rupture
Muhammad Waqas, Kunal Vakharia, Bennett R Levy, Steven B Housley, Rimal H Dossani, Andrew Gong, Justin Cappuzzo, Elad I Levy

Brain Circulation 2020 6(4):274-279

Intraprocedural rupture (IPR) of an intracranial aneurysm is the most feared complication of primary and stent-assisted coiling because it carries a high risk of morbidity and mortality. The endovascular strategy applied to control IPR depends on the cause of the rupture and stage of the procedure. Rupture during primary or stent-assisted coiling is traditionally managed with the use of continued packing, balloon microcatheter placement, or in rare cases, with parent artery sacrifice. In this technical note, we describe the use of temporary coiling of the parent artery to control IPR in three cases. Temporary parent artery coiling creates a subocclusive state, resulting in aneurysmal blood flow reduction without interruption of blood flow to the distal territory. Flow reduction combined with the thrombogenicity of the previously deployed coils results in hemostasis. In the cases presented here, IPR occurred during the late stage of coiling. In each case, parent artery coiling was performed along with heparin reversal. After confirmation of hemostasis, the coils were retrieved to restore normal blood flow. We demonstrate that the technique of temporary parent artery coiling may be a safe and effective option for the management of IPR during primary or stent-assisted coiling.

Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Clinical Pulmonary Medicine

Vaping-associated Lung Injury Successfully Treated With Pulse Dose Corticosteroids

Electronic cigarettes were developed for the inhalation of flavored nicotine, tetrahydrocannabinol and cannabidiol via cannabis oil. Recently, there has been an outbreak of vaping-induced lung injuries ranging in severity. We report 3 previously healthy male patients, who presented with acute respiratory failure with a recent history of electronic cigarette use, ultimately diagnosed with lipoid pneumonia. All 3 patients received intravenous high-dose, pulse corticosteroids for short duration with dramatic improvement.

Corticosteroids for COVID-19-Associated ARDS

Systemic corticosteroids have emerged as a possible therapy to mitigate lung injury in severe COVID-19 infection. Here, we provide historical context for corticosteroid administration in acute respiratory failure due to viral infection and review existing data for the use of systemic corticosteroids for SARS-CoV-2 infection. The results of these limited data consistently suggest a mortality benefit for patients with COVID-19-associated acute respiratory distress syndrome with no existing evidence to suggest harm.

The Complex Relationship Between Poor Sleep Quality and Chronic Obstructive Pulmonary Disease

Sleep-related symptoms are prevalent among patients with chronic obstructive pulmonary disease (COPD). The disease process often manifests with nocturnal respiratory symptoms. Long-acting antimuscarinic medications improve nocturnal COPD symptoms, though their effect on sleep quality requires further investigation. Those with COPD often suffer from comorbidities that negatively impact sleep, including obstructive sleep apnea (OSA) and mood disorders such as anxiety and depression. Sleep quality is also predictive of COPD exacerbations. Patients with concurrent COPD and OSA suffer from overlap syndrome (OVS), characterized by a synergistic effect on poor health outcomes. The intersection of COPD and OSA offers the clinical pulmonary audience a useful lens for ongoing basic, clinical, and translational research. Patients with OVS experience higher mortality compared with either COPD or OSA alone. This observation is attributable to the compound effect each condition has on adverse cardiovascular events. A complex interplay exists between COPD, sleep symptoms, and OSA. COPD appears to influence important nonanatomical contributors to OSA. The presence of underlying COPD makes the definitive diagnosis of OSA a challenge. Chronic noninvasive ventilation (NIV) is the backbone of therapy for OVS, OSA, and hypercarbic COPD. NIV is additionally a well-established treatment for acute COPD exacerbations and emerging research demonstrates that NIV decreases mortality and hospitalizations in patients with hypercarbic COPD. Clinicians often need to individualize therapeutic interventions for patients with COPD, OSA, and OVS, balancing the benefits and adverse effects of such interventions. NIV can have unwanted impact on the quality of life for some patients with COPD. Certain medications used for COPD, such as corticosteroids, have adverse effects on sleep quality. Future therapeutic approaches are needed to improve the sleep symptoms and health outcomes of patients suffering from COPD and OVS.

Excessive Dynamic Airway Collapse: A COPD/Asthma Mimic or a Treatment-emergent Consequence of Inhaled Corticosteroid Therapy: Case Series and Brief Literature Review

Excessive dynamic airway collapse (EDAC) is a clinical entity characterized by narrowing of larger airways during tidal breathing. Symptoms of EDAC can be similar to chronic obstructive airway disease (COPD)/asthma and EDAC can coexist with airway disease. More recently widespread use of inhaled corticosteroids (ICS) among patients with COPD/asthma has been implicated for the emergence of EDAC. In this report, we describe 6 adult patients presenting with chronic cough with a background diagnosis of either COPD or asthma on ICS, who were noted to have EDAC. We also made an attempt to briefly review the earlier published reports on EDAC. Our review suggested that EDAC is prevalent among patients with previous diagnosis of COPD/asthma and with ICS use. Female sex, older age, higher body mass index, and presence of gastroesophageal reflux disease (GORD), and chronic upper respiratory tract infections (URTI) may be a risk factor for EDAC. Chronic barking cough and shortness of breath are the common clinical presentation and acute presentation could be triggered by lower respiratory tract infection and episodic presentations can be related to chronic recurrent aspiration secondary to GORD or chronic URTI. Dynamic computed tomography of the chest and bronchoscopy are useful in the diagnosis. Pulmonary function tests could be variable, demonstrating normal, obstructive, or restrictive pattern. Management of EDAC with weight loss strategies, addressing GORD and URTI issues and antibiotics during acute lower respiratory tract infection may be helpful. Noninvasive positive pressure ventilation may be beneficial in some patients. ICS should be used wisely to prevent the emergence of EDAC among patients with chronic airway disease.

Immune checkpoint inhibitors (ICIs) are one of the major advances in cancer treatment. ICIs have shown significant benefit in treating several types of cancer. Currently there are 6 ICIs available in the United States and multiple ICIs in the pipeline. Immune checkpoint signaling leads to immune tolerance of cancer cells through downregulation of T-cell activation. The reversal in tumor-tolerance and self-tolerance effected by ICIs likely drives both T-cell–mediated toxicity and immune-related adverse effects (irAEs); however, the exact mechanism remains not completely understood. Pulmonary irAEs are among the most feared high-grade irAEs leading to discontinuation of ICIs and, not uncommonly, treatment-related death. Because of the high degree of morbidity and mortality associated with pulmonary irAEs and the exponential growth of ICI use, clinicians must increasingly be facile in diagnosing and managing these irAEs.

The Diagnosis of Hypersensitivity Pneumonitis and the Role of Lung Biopsy

Hypersensitivity pneumonitis (HP) refers to a collective noun of diffuse lung diseases encompassing some degree of bronchiolar and interstitial granulomatous inflammation that results from persistent inhalation exposure and consequent immune sensitization to a large potential diversity of (predominantly) organic antigens in predisposed individuals. In suspected cases of HP, forceps transbronchial lung biopsy (TBLB) has been traditionally performed on a case-by-case basis along with bronchoalveolar lavage. This option has been subject to some debate and its use is more restrained in the presence of a chronic fibrotic form of HP—where surgical lung biopsy is classically recommended in the face of the need for a more reliable differentiation from fibrotic idiopathic interstitial pneumonias. We intended to assess the diagnostic contribution of conventional TBLB in the combined multidisciplinary diagnosis of an HP patient cohort. A retrospective evaluation of all the diagnostic elements and level of confidence from all HP cases followed in an interstitial lung disease ILD outpatient clinic of a district hospital center (Centro Hospitalar do Baixo Vouga), from June 2015 to August 2019, and simultaneously evaluated in a multidisciplinary team discussion of the same hospital, comprising an interstitial lung disease dedicated lung physician, a chest radiologist, 2 rheumatologists, and a pathologist. We identified 78 patients (mean age: 70.5 y, interquartile range: 58.5 to 78.0) with a slight female predominance. Most of the patients (61.5%) had chronic/fibrotic HP. The most frequently identified inducing antigens were avian antigens in 59.0% of cases, followed by molds in 20.5%. Of the 72 patients who underwent bronchofibroscopy, 36.1% (n=26) conventional TBLB performed, predominantly in the segments of the right lower lobe with an average number of 3.9 biopsies (SD±1.4) accomplished per patient. In 50.0% of the cases submitted to TBLB, the biopsies showed representative material with histologic features (definite or supportive) which had some degree of contribution for the diagnostic discussion. Among the patients where TBLBs were not performed or whose results were found to be devoid of significant findings, 73.1% were still diagnosed as HP without the need for surgical video-assisted thoracoscopic lung biopsy/transbronchial lung cryobiopsy (VATS/TBLCB) on the grounds of other diagnostic elements; 15.4% of patients were diagnosed with HP after a VATS/TBLCB procedure. Lastly, around 11.5% of patients were considered to have an unacceptable risk for VATS/TBLCB but, on the basis of clinical, radiologic, and immunologic elements received a multidisciplinary provisional diagnosis still with a reasonable level of confidence. Regarding complications with TBLB, there were 2 cases of moderate bleeding (7.6%) and 1 pneumothorax (3.8%) that did not require drainage. Notwithstanding its limitations, TBLB can still have a role in the diagnostic workup of HP, namely in acute/inflammatory HP, adding definite or supportive histologic information for multidisciplinary discussion in up to 50% of cases. TBLB can augment diagnostic yield at the expense of only a minimal increase of risk, as it is a universally available technique that can be performed along with bronchoalveolar lavage. This has important implications, particularly in centers devoid of TBLCB, as a surgical biopsy can be avoided in approximately half of patients who are eventually diagnosed with HP.

Bronchoscopy in the COVID-19 Era

Bronchoscopy is an aerosol-generating procedure with important diagnostic and therapeutic indications. However, in the era of the coronavirus disease 2019 (COVID-19) pandemic, airway procedures can put health care providers at an increased risk of exposure and transmission of COVID-19. We have reviewed and summarized guidelines from various societies of respiratory medicine to stratify the indications for bronchoscopy and optimize preprocedural, procedural, and postprocedural preparation. Appropriate measures can help decrease exposure to health care workers when performing this aerosol-generating procedure.

Is a Trial of Observation Safer Than Intervention With Spontaneous Pneumothorax?
Synopsis: Modest evidence that a conservative approach to the treatment of primary spontaneous pneumothorax is noninferior to intervention.

Home, Hospice, or Hospital: Where Are Our Patients With Chronic Lung Disease Dying?
Synopsis: This cross-sectional study examined the differences in place of death among patients with chronic lung disease living in the United States from 2003 to 2017. Overall, there was a shift toward home and hospice deaths and away from hospital or nursing facility deaths. However, important differences in race, education, and socioeconomic status indicate the pressing need for further research into how to best care for all patients with chronic lung disease at the end of their lives.

Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Medicine by Alexandros G. Sfakianakis

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Τετάρτη 30 Δεκεμβρίου 2020

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