Managing Severe Acute Asthma Exacerbation in Pregnancy during the COVID-19 Pandemic: A Case Report from a Resource-limited Setting

BACKGROUND: One-third of pregnant women will experience worsening asthma requiring emergency hospitalization. However, no report comprehensively discussed the management of asthma attacks in pregnant women in impoverished settings. We attempt to illuminate what general practitioners can do to stabilize and improve the outcome of severe acute asthma exacerbations in primary care with resource limitations. CASE REPORT: A nulliparous 29-year-old woman in her 21st week of pregnancy presented severe acute asthma exacerbation in moderate persistent asthma with uncontrolled asthma status along with gestational hypertension, uncompensated metabolic acidosis with a high anion gap, anemia, respiratory infection, and asymptomatic bacteriuria, all of which influenced her exacerbations. This patient was admitted to our resource-limited subdistrict hospital in Indonesia during the COVID-19 pandemic for optimal stabilization. Crystalloid infusions, oxygen supplementation, nebulized beta-agonist with anticholinergic agents, inhaled corticosteroids, intravenous methylprednisolone, broad-spectrum antibiotics, subcutaneous terbutaline, mucolytics, magnesium sulphate, oral antihypertensives, and continuous positive airway pressure were used to treat her life-threatening asthma. After she was stabilized, we referred the patient to a higher-level hospital with more advanced pulmonary management under the supervision of a multidisciplinary team to anticipate the worst scenario of pregnancy termination. CONCLUSION(S): Limitations in primary care, including the lack of sophisticated intensive care units and laboratory panels, may complicate challenges in managing severe acute asthma exacerbation during pregnancy. To enhance maternal-fetal outcomes, all multidisciplinary team members should be well-informed about key asthma management strategies during pregnancy using evidence-based guidelines regarding the drug, rationale, and safety profile.Copyright © 2023 Muhammad Habiburrahman, Triya Damayanti, Mohammad Adya Firmansha Dilmy, Hariyono Winarto.

Higher levels of physical activity is associated with better walking ability and fall-related fitness of older adults during COVID-19 in China

This study analyzed the relationship of physical activity levels with walking ability and fall-related fitness in older adults in the Henan Provence, China. Physical activity levels of 288 older adults were assessed using the short form of the International Physical Activity Questionnaire. The participants were divided into low (LPAG, n = 81), moderate (MPAG, n = 106), and high physical activity groups (HPAG, n = 101). The 10-m walking test (10MWT), 3-m backward walking (3MBW), and Berg Balance Scale (BBS) were used to evaluate walking ability. Thirty seconds Sit to Stand Test (30SST), Time up and Go Test (TUGT), and figure-of-8 walk test (8WT) were evaluated for fall-related fitness. One-way ANOVA was used to detect between group differences, whilst Pearson's correlation was used to evaluate the relationship between total physical activity level and the measured variables. Logistic regression analyses were used to compute the odds ratios (ORs) of LPAG and MPAG relative to HPAG. There were significant differences between the groups for walking ability, 10MWT (p < 0.01), 3MBW, and BBS (p < 0.01), and also for variables of fall-related fitness, TUGT (p < 0.01), and 8WT (p < 0.01). Total physical activity levels had significant correlations with all variables except 30SST. In the walking ability, OR for 10MWT was 2.42 and 2.53 times for the LPAG compared to that for HPAG by model 1 and model 2. OR for BBS was 3.24 and 3.54 times for the LPAG and 9.31 and 9.65 times for the MPAG compared to for the HPAG by model 1 and model 2. In the fall-related fitness, OR for 8WT was 14.09 and 16.76 times for the LPAG compared to that for HPAG. High levels of physical activity are positively correlated with good walking ability and fall-related fitness. Increasing physical activity levels can reduce the risks associated with impaired walking ability and fall-related fitness.Copyright ©2023 The Author(s). Published by MRE Press.

Acute hemorrhagic leukoencephalitis after administration of the first dose of ChAdOx1 nCoV-19 SARS-CoV-2 (COVISHIELDTM) vaccine

Background: Many central and peripheral nervous system complications, following COVID-19 vaccination, have been described. We report an unusual case of central demyelinating disorder, following the administration of the ChAdOx1 nCoV-19 SARS-CoV-2 (COVISHIELDTM) vaccine. Case-report: The 28-year female developed sudden onset headache followed by weakness of the left upper and lower limbs, and gait ataxia. Neurological symptoms developed two weeks after administration of the first dose of the ChAdOx1 nCoV-19 SARS-CoV-2 (COVISHIELDTM) vaccine. Magnetic resonance imaging brain revealed T2/FLAIR hyperintense lesions involving bilateral subcortical white matter, splenium of the corpus callosum, and both cerebellar hemispheres. Few lesions showed blooming on gradient echo sequence suggestive of a hemorrhagic component. Post-contrast T1 images showed mild enhancement of demyelinating lesions. The patient was treated intravenously with methylprednisolone. After 12 weeks of follow-up, there was a substantial improvement in her symptoms. She became independent in all her activities of daily living. Conclusion(s): In conclusion, this is an unusual case of acute hemorrhagic leukoencephalitis following ChAdOx1 nCoV-19 SARS-CoV-2 (COVISHIELDTM) vaccination.Copyright © 2022 The Author(s)

A rare case of central post-stroke pain in a patient with migraine and lacunar infarcts in the medulla oblongata

Studies about headaches associated with acute ischemic stroke in patients suffering from migraine were limited, and therefore we present a clinical case of central post-stroke pain (CPSP) in a 47-year-old woman with migraine and lacunar infarcts in the medulla oblongata and also possible mechanisms of CPSP in patients with migraine. Magnetic resonance imaging of the brain revealed lacunar infarction in the medulla oblongata on the right (vertebral artery basin) and a single focus of gliosis in the parietal lobe on the right. Magnetic resonance angiography of cerebral vessels showed the fetal type of structure of both posterior cerebral arteries. This clinical case is a complex clinical situation of a combination of secondary headaches (post-stroke) in a patient with a primary headache (migraine), which was successfully treated by the combined administration of first-line drugs for the treatment of neuropathic pain in a patient with lacunar infarcts in the medulla oblongata. The treatment of CPSP is a difficult task due to the insufficiently unexplored mechanisms of development, the most effective approaches are those aimed at reducing the increased excitability of neurons.Copyright © 2023, Indian Association of Biomedical Scientists. All rights reserved.

Guillain-Barre syndrome associated with SARS-CoV-2 infection: A case series from 4 Colombian cities during the pandemic

SARS-CoV-2 infection has been associated with multiple neurological manifestations. One such manifestation, which has been described since the early stages of the COVID-19 pandemic and is relevant for current neurological practice, is Guillain-Barre syndrome (GBS). The literature describes neurotoxic mechanisms of the virus itself and the possible pathways by which it may affect the peripheral nerves in experimental studies;however, we still lack information on the mechanisms causing the immune response that gives rise to GBS in the context of SARS-CoV-2 infection. Colombia is one of the Latin American countries worst affected by the pandemic, with the third-highest number of cases in the region;thus, it is essential to recognise GBS, as this potential postinfectious complication may severely compromise the patient's functional status in the absence of timely diagnosis and treatment. We present a series of 12 cases of GBS associated with SARS-CoV-2 infection from hospitals in 4 different Colombian cities and describe the clinical presentation, laboratory and electrophysiological study findings, and treatment.Copyright © 2022 Sociedad Espanola de Neurologia

TRANSVERSE MYELITIS: A RARE BUT SERIOUS COMPLICATION OF COVID-19 VACCINATION

CASE: The patient is a 66-year-old male presenting with progressive ambulatory dysfunction and lower extremity weakness that began ten days ago. Notably, the patient was admitted to the hospital two months prior with similar complaints. At that time, he was diagnosed with transverse myelitis after MRI showed a spinal cord lesion concerning for demyelination at T3-T4. The patient was treated with IV steroids and discharged. Neurology impression at time of discharge was transverse myelitis possibly related to Covid vaccination two weeks prior to admission. The patient states he was doing fine after initial discharge before recurrence of his progressive weakness and difficulty walking that led to the current admission. He denies fever, chest pain, abdominal pain, and bladder/ bowel incontinence. The patient is a former smoker and denies current alcohol or drug use. Past medical history includes WPW status post ablation, stable thoracic aortic aneurysm, peripheral neuropathy secondary to past alcohol abuse, osteoarthritis, GERD, and anxiety. Family history is remarkable for cancer, coronary artery disease, and diabetes in his father. Medications include metoprolol, tamsulosin, pantoprazole, olanzapine, and venlafaxine. Neurological exam is positive for atrophy and decreased vibratory sensation in bilateral lower extremities. His gait is not assessed due to safety concerns, but the patient notes he has begun using a cane to assist with ambulation. Otherwise, physical exam is unremarkable. Imaging studies include MRI showing T3-T4 hyperintensity, as seen during previous admission two months prior. Labs including ANA, rheumatoid factor, SPEP, CSF studies, and AQP-4 were negative. After an unrevealing workup, the patient experienced symptomatic improvement with IV steroids and was discharged home. IMPACT/DISCUSSION: Our case illustrates a clinical picture of Covid-19 vaccine-related transverse myelitis, a rare but serious complication of the vaccine. The prolonged course of this patient's complications is concerning, although the benefit of receiving the vaccine remains unquestionable. Furthermore, although the timing of symptom onset and vaccination suggests a relation, there are other diagnoses that could explain the presentation and further research is needed regarding vaccine-related side effects. This case emphasizes the importance of maintaining a high index of suspicion for neurological issues of unclear etiology following recent Covid-19 vaccination despite their rare occurrence. CONCLUSION: Teaching points: Diagnostic criteria for transverse myelitis includes sensory, motor, or autonomic dysfunction attributable to spinal cord, no evidence of cord compression, bilateral symptoms with clear sensory level, and inflammation defined by CSF analysis, elevated IgG, or MRI enhancement. Neurological complications of the Covid vaccine include general symptoms such as headache, fever, and fatigue, Bell's palsy, encephalomyelitis, myelitis, and cerebral venous sinus thrombosis.

BRIDGING TECHNOLOGY AND HEALTH: A COMMUNITYBASED TELEHEALTH PROGRAM FOR LOW-INCOME OLDER ADULTS

STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic prompted a rapid shift to telemedicine as both a replacement and adjunct to usual in-person care, but in a recent estimate using 2018 data from the National Health and Aging Trends Study, 13 million, or roughly 38% of older adults in the US, are not ready to participate in video visits primarily due to inexperience with technology. DESCRIPTION OF PROGRAM/INTERVENTION: The purpose of this community-based partnered program between Denver Health and Denver Housing Authority (DHA) is to provide the supports needed to engage older adults in telehealth. DHA manages approximately 3900 subsidized housing units across Denver with buildings designated specifically for low-income older adults (65+) and persons with disabilities. Up to 467 of these individuals already receive primary care at Denver Health which offers a unique opportunity to establish targeted supports for the equitable delivery of virtual health. These supports may include technology and digital health education, equipment deployment, and facilitated telehealth appointments. We conducted a formative evaluation of DHA resident interest and capability to participate in video visits. MEASURES OF SUCCESS: Outcomes for the formative survey include interest in video visits, perceived barriers to in-person care, comfort levels with technology, barriers to use of technology, healthcare topics of interest, and selfreported health status. The results of the survey helped to shape the key interventions proposed: 1) digital health literacy workshops and 2) facilitated on-site video visits. FINDINGS TO DATE: Survey responses were compiled for all participants across six participating sites. 115 participants provided responses to program interest and baseline comfort levels with technology. Of participants surveyed, 89% have a mobile phone, 46% have had experience with videoconferencing, and 53% have someone to help them with technology. Challenges accessing healthcare included scheduling an appointment 20%, getting a ride to clinic 23%, and difficulty walking 15%. Of the 76 participants who indicated their learning interests, 51% were interested in learning how to use the online patient portal, 465 in participating in a video visit, and 59% in understanding and managing chronic medical conditions. KEY LESSONS FOR DISSEMINATION: At baseline there were both barriers to seeking in person medical care and interest in technology as a tool for health. The survey participants showed a strong interest in sessions about using the online patient portal, how to have a video visit, and understanding chronic medical conditions. Video visits and technology have become an increasingly common and useful part of the primary care system, yet a portion of the population is not equipped with the knowledge or resources to utilize this resource. Older adults may also find transportation and mobility in getting to the doctor's office a significant challenge. This program is designed to outreach those individuals and give them the skills and resources to utilize technology to reduce barriers to health.

Neurological Complications of COVID-19: Guillain-Barre Syndrome Following Pfizer COVID-19 Vaccine

Objective: The first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was reported in Wuhan, China, in December 2019. In December 2020, the FDA approved two vaccines for the prevention of COVID-19 infection. In the clinical trials of the vaccine, multiple side effects have been reported ranging from mild symptoms including injection site pain, myalgia, fatigue, and fever to more serious side effects including anaphylactic shock. However, Guillain-Barre Syndrome (GBS) after receiving COVID-19 vaccine was not been reported till (February 2, 2021) to the best of our knowledge. We reported the first case of GBS after receiving the first dose of Pfizer COVID-19 vaccine. Background: An 82-year-old highly functional female presented to the emergency department with generalized body aches, paresthesia, and difficulty walking. She received first dose of the Pfizer COVID vaccine two weeks prior to presentation. Physical examination demonstrated 5/5 strength in bilateral upper extremities in proximal and distal muscles, 4/5 in hip flexors and decrease sensation to light touch and pinprick in bilateral lower extremities up to the knees. Areflexia in both upper and lower extremities. Cerebrospinal fluid analysis showed albuminocytologic dissociation (protein of 88 and WBC of 4) suggestive of Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP). MRI lumbar spine demonstrated the enhancement of cauda equina nerve roots consistent with the diagnosis of GBS. The patient completed five days of IVIG with significant improvement and was discharged to acute rehabilitation facility. Design/Methods: NA Results: NA Conclusions: In this pandemic and with ongoing worldwide mass vaccination campaign, it is critically important for clinicians to rapidly recognize neurological complications associated with COVID-19 vaccination. We would like to highlight that the risk of neurological complications or any other adverse effect associated with COVID-19 vaccination is low and the benefits of the vaccination outweigh any potential risks or side effects, both at the individual and society levels.

Two Cases of Neurological Complications After mRNA Vaccination for COVID-19

Objective: We present two patients with neurological complications following COVID-19 mRNA vaccination. Background: Post-vaccinal myelitis and demyelination is well described. We investigated two patients presenting inflammatory demyelination following mRNA based vaccination against COVID-19. Design/Methods: Patients were referred to the treating neurologist for a second opinion as possible cases of multiple sclerosis. Clinical neurological evaluation, MRI imaging of brain and spine as well as serum and cerebrospinal fluid (CSF) analysis was performed. Results: In case 1, the patient developed left-side numbness and difficulty walking six weeks post-second dose of the Moderna mRNA COVID-19 vaccine. She was found to have an enhancing thoracic cord lesion on MRIs, and CSF ELISA studies showed highly elevated IgG levels against the spike protein receptor-binding domain (S1-RBD) of COVID 19. In case 2, the patient began to hiccup and vomit, developed diplopia, and right-side weakness and numbness around two days post-second dose of the Moderna vaccine. MRIs showed two lesions on her brain and a C4 enhancing lesion on her spinal cord. CSF showed oligoclonal bands. However, further analysis of her spinal fluid showed highly elevated IgG antibodies to the S1-RBD. Conclusions: Initially, case 1 was diagnosed with transverse myelitis and possible multiple sclerosis, and case 2 with multiple sclerosis. Both patients likely would have received long-term immunosuppressive therapy had vaccine complications not been suspected. The presence of CSF antibodies to the S1-RBD protein suggests an immune response to the mRNA COVID-19 vaccinations crossing over to the CNS as the likely cause of these neurological complications. In patients developing acute neurological complaints in the period following vaccination, even with the presence of oligoclonal bands, CSF should be analyzed for reactivity against the S1-RBD. Further investigation is required to explain the mechanism of this response and subsequent complications. Both patients are clinically improving and will continue to be managed by a neurologist.

Acute and Chronic Demyelinating Neuropathies following COVID-19 Vaccination: A Report of Four Cases

Objective: To report demyelinating neuropathies following COVID-19 vaccination. Background: Suspected COVID-19 vaccine-associated Guillain-Barre syndrome and other demyelinating conditions affecting the peripheral nervous system have been reported. The pathophysiologic basis of these associations, and that of vaccination-associated demyelinating neuropathies in general, has not been established. Design/Methods: Case report Results: Four cases of acute and chronic demyelinating neuropathies following COVID-19 vaccination were seen at the University of Nebraska Medical Center from May to September 2021. All were males, ages 26-83 years old. Two received the Pfizer-BioNTech vaccine, one Moderna, and one Johnson&Johnson. Onset ranged from 2-21 days after the final dose of vaccination. The time from symptom onset to neurological evaluation ranged from 3 weeks to 4 months, during which symptoms progressed. All cases presented with progressive numbness, weakness, and areflexia in all limbs;two had difficulty walking. Severe facial diplegia was seen in two cases and other bulbar symptoms in one other case. Three cases had electrophysiologic studies confirming demyelination while one case had findings of subacute polyradiculopathies. Cerebrospinal fluid protein was elevated in two cases and normal in the others. No cases had other co-morbidities or histories suggesting an alternate diagnosis. The diagnosis was acute inflammatory demyelinating polyneuropathy (AIDP) in one case, chronic demyelinating polyradiculoneuropathy (CIDP) in two, and subacute polyradiculopathies in one. The cases with AIDP and CIDP received treatment with intravenous immunoglobulin due to significant motor disability, while the case with subacute polyradiculopathies had spontaneous recovery within 8 weeks. Of the treated cases, two had significant improvement by outpatient follow-up at 2-4 weeks post-treatment and one has yet to follow up. Conclusions: Continued identification and reporting of demyelinating neuropathies following COVID-19 vaccination is essential to determine whether a causative association is present. Prompt evaluation for alternative etiologies is vital and early treatment is recommended.

Hiding from the drug screen: a case of extensive nitrous oxide misuse

Objective: To describe a case of extensive nitrous oxide (NO) misuse in a commercial airline pilot to specifically avoid detection on employer urine drug screens (UDS). Case report: A 48-year-old male commercial airline pilot was evaluated in a Medical Toxicology clinic for history of NO misuse. He started using NO and cannabis as a teenager. When he became an airline pilot, he stopped his cannabis use to ensure he passed frequent employer drug screens. He researched that NO was not detected on UDS and continued its use. During the COVID-19 pandemic, the patient's use grew to 1,200 eight gram NO canisters daily in an attempt to alleviate his stress. He described inhaling the gas until he passed-out. Upon waking, he, would use more until he again passed-out, repetitively cycling throughout the night. His developed paresthesias, progressive weakness in legs, and difficulty walking to the point where he had to crawl to the front door to receive his shipments of NO canisters. His cognition declined and he was brought to the hospital for help after being found in his home garage. Magnetic resonance imaging (MRI) imaging of the brain showed atrophy from chronic toxic metabolic encephalopathy. MRI of the spine did not show abnormalities. Upon referral to the Medical Toxicology clinic, he had not used NO for 3 months and had been taking vitamin B172. Symptoms had improved, but he still had extremity paresthesias, memory difficulties, and required a cane to walk. The patient's NO misuse had been reported to the Federal Aviation Administration (FAA) during his hospitalization and he was no longer allowed to pilot commercial airlines. Conclusion: Random drug testing of airline pilots is required by the FAA and the UDS test for D-9-tetrahydrocannabinol-9-carboxylic acid, benzoylecgonine, codeine, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, 6-acetylmorphine, phencyclidine, amphetamine, methamphetamine, methylenedioxymethamphetamine and methylenedioxyamphetamine [1]. Negative drug screens may give an employer a false sense of security that a pilot is not using/misusing substances but the UDS does not pick up numerous abused substances, including inhalants. This case illustrates the dangers in relying solely on the UDS to ensure pilots are clear from illicit substances. This patient was misusing nitrous oxide for decades which lead to permanent cognitive decline that negatively impacted his ability to safely fly.

BIOPHYTIS BIO101 IN SARCOPENIA: RESULTS OF THE PHASE 2 SARA-INT STUDY

Backgrounds: Sarcopenia is a geriatric condition characterized by a progressive loss of muscle mass and function, having high personal, social and economic burdens when untreated. Sarcopenia increases risk of falls and fractures;impairs ability to perform activities of daily living;is associated with cardiac and respiratory disease and cognitive impairment;leads to mobility disorders;and contributes to lowered quality of life, loss of independence or need for long-term care placement, and death. It is recognized as one of the five pillars of frailty. As of today, to our knowledge, only exercise and nutrition interventions seem somewhat effective interventions. Objectives: SARA-INT study is a Phase 2 study to develop a viable option to treat community-dwelling seniors suffering from age-related sarcopenia, including sarcopenic obesity. Methods: SARA-INT is a randomized double-blind three-arm study (BIO101 175 mg bid / BIO101 350 mg bid / placebo) with planned treatment duration of 6 Months;due to COVID-related measures, 49 patients continued up to 9 months of treatment. Main eligibility criteria for sarcopenia were meeting FNIH criteria and Short Physical Performance Battery (SPPB) score ≤ 8/12 in men and women aged ≥ 65 years. Primary analysis was the gait speed from the 400-meter walking test (400MWT) at month 6/9 in the FAS with secondary analyses at other timepoints, secondary endpoints were other physical activity assessments, muscle strength, muscle mass and Patient Reported Outcomes (PROs). Results: 233 participants were randomized in the study, 232 and 156 participants were included in the Full Analysis Set (FAS) and Per-Protocol (PP) populations, respectively. Due to COVID-19 pandemic, end-of-treatment assessments are missing for approximately half of the participants, impacting the treatment effect detection. In the primary analysis (at month 6/9 in the FAS population) of the primary parameter, the improvement in 400MWT compared to placebo was not statistically significant (0.0363 (0.03098) m/s and 0.0385 (0.02985) m/s in the BIO101 175 mg and 350 mg groups, p=0.2437 and p=0.2000, respectively). BIO101 350 mg bid treatment after 6 months showed a clinically relevant improvement in the 400MWT of 0.07 m/s in the FAS population (not significant) and of 0.09 m/s in the PP population (nominally statistically significant, p=0.008);this is close to the Minimal Clinically Important Difference (MCID) in sarcopenia (0.1 m/s). BIO101 350mg bid treatment effect on the 400MWT is confirmed in pre-defined sub-populations at higher risk of mobility disability such as slow walkers, obese and those with chair stand sub-score ≤2 from SPPB;trends were observed with other independent endpoints. BIO101 showed no difference in adverse events or safety laboratory parameters versus placebo (), and no severe adverse event associated with BIO101 treatment. Conclusions: After 6 to 9 months of treatment, BIO101 at 350 mg bid showed promising results with a clinically relevant improvement in the 400MWT gait speed, the primary endpoint of the study, confirmed in sub-populations at higher risk of mobility disability. BIO101 showed a very good safety profile at the doses of 175 and 350 mg bid. Biophytis is preparing to start a phase 3 program with BIO101 at 350 mg bid in 2022, targeting a similar patient population. Conflicts of interests: CT, WD, CM, RL, PD, RvM and SV are employees of Biophytis SA, AZ, and SA are employees of Biophytis Inc., JM is president of the Scientific Advisory Board of Biophytis, SDS is employee of BlueCompanion Ltd.

Living with Pompe disease in the UK: Characterizing the patient journey and burden on physical, emotional and social quality of life

Pompe disease is a rare, progressive, multisystemic disease with heterogenous presentation. We evaluated the burden, unmet needs and evolving management landscape for people living with late-onset Pompe disease (LOPD) based on their own experiences. The objective was to better understand the experiences of people living with LOPD in the UK, including their diagnostic and treatment journeys;the potential impact of LOPD on their quality of life;and the impact of COVID-19 on their lives, HCP interactions and the care they received. Following an invitation from a patient advocacy organization and completion of an eligibility questionnaire, in-depth qualitative interviews were conducted with 27 participants living with LOPD (male, n = 13 [48%];mean age, 56 years;mean age at diagnosis, 43 years;received ≥1 misdiagnosis, n = 9 [33%]). Participants' diagnostic journeys typically included the following phases: undetected symptoms;noticeable symptoms;HCP visits and misdiagnosis;diagnosis. The diagnostic process was typically long and distressing, with most participants emphasizing a desire for reduced times to diagnosis, referral to a specialist HCP and treatment initiation. The most frequent LOPD-associated symptoms mentioned by participants were walking difficulties (n = 27, 100%), fatigue (n = 26, 96.3%) and balance issues (n = 22, 81.5%);participants stated the most important symptoms to treat were walking difficulties (n = 15, 55.6%), fatigue (n = 10, 37.0%) and breathing problems (n = 10, 37.0%). For most participants, the COVID-19 pandemic has been a period of increased anxiety, low mood and physical deterioration. The results of these interviews provide a very full understanding of the emotional journey experienced by individuals living with LOPD in the UK and enabled the construction of a unique infographic visually representing an archetypal patient journey. Findings from this study further characterize challenges faced by people living with LOPD (e.g., delays in diagnosis and/or treatment initiation, treatment satisfaction) and the impact of these challenges on daily life. Supported by Amicus Therapeutics.

Endovascular Reperfusion of Acute Large Vessel Occlusion Stroke

Acute stroke treatment continues to evolve with optimization of systemic intravenous thrombolysis and endovascular mechanical thrombectomy (MT) for intracranial large vessel occlusion (LVO). Neurointerventional techniques to achieve reperfusion in acute LVO stroke initially involved local intra-arterial infusion of thrombolytic agents. The subsequent development of MT devices has resulted in more complete and faster arterial recanalization while maintaining patient safety. Today, MT is standard of care for LVO stroke up to 24 h from last known well. In this chapter, we discuss various endovascular recanalization techniques for LVO stroke with illustrative cases.

Chronic polyarthritis in an adolescent with cutaneous polyarteritis nodosa

Introduction: Polyarteritis nodosa (PAN) is a necrotizing vasculitis of medium/small arteries. It is a rare condition, especially in the pediatric age group. Cutaneous PAN (cPAN) is recognized as a separate entity. It is characterized by disease affecting the skin with no major organ system involvement. Objectives: Chronic polyarthritis is much less observed and can simulate juvenile idiopathic arthritis, which can delay diagnosis, as was the case with this patient. Methods: We report a 14-year-old boy, who presented to us with polyarthritis and myalgia as a first manifestation of cPAN. Results: This 14-year-old male adolescent presented with a history of arthritis in right shoulder, ankles, knees, elbows, fingers and toes, associated with myalgia, with partial improvement after the use of non-hormonal anti-inflammatory drugs. Two months later, he was diagnosed with juvenile idiopathic arthritis. Corticosteroids were prescribed in a dose of 20 mg/day, methotrexate 7.5 mg/week and folic acid. There was no clinical improvement. At this time, he start with fever and the appearance of a painful erythematous lesions in the lower limbs and arms, difficulty in walking, which were progressively getting worse, anorexia and weight loss during this period. He also had a history of oropharyngeal infection prior to beginning of these symptoms. At that time, he was treated with azithromycin for 5 days. As there was no improvement in his clinical condition, he sought the Emergency Room where he was admitted for investigation 3 months after the beginning of his symptoms. On physical examination, we found arthritis in the elbows, knees, ankles and joints of the hands, maculopapular rash in the ankles, muscle atrophy in the arms and legs, palpable and painful nodules on the right leg and right foot. Several laboratory tests were requested. Blood investigations showed anemia, leucocytosis, elevated CRP, ESR and ASLO titres, with normal liver and kidney functions, and normal urine 1. Syphilis, HIV, serology for Mycoplasma pneumoniae, leishmaniasis, Paracoccidioides brasiliensis, Epstein-Barr virus, cytomegalovirus, Zika and Chikungunya viruses, dengue, and parvovirus B19 were negative. HBsAg, hep c were negative. CRP and serology was negative for Coronavirus 19 (Covid-19). Chest Xray, echocardiogram, and ultrasound of the abdomen were normal. Lupus anticoagulant, and FR were negative. Other autoantibodies were negative. p-ANCA and c-ANCA were negative. Myelogram with normal immunophenotyping was found. A skin biopsy was suggestive of PAN showing perivascular lymphomononuclear inflammatory infiltrate, sometimes permeating the vascular wall. The presence of eosinophils and neutrophils with outbreaks of leukocytoclasia was noted, an absence of malignancy was also shown. With infectious, hematological and oncological causes aside, pulse therapy with methylprednisolone was started. After the first infusion, a significant improvement in myalgia and arthritis was observed, in addition to the disappearance of febrile peaks. Then, he started a monthly pulse therapy with cyclophosphamide and methylprednisolone. Four months after start this therapy, we observed improvement of skin lesions and in laboratory exams. Conclusion: Cutaneous PAN is a rare disease, especially in the pediatric age group. Its clinical manifestations are quite varied, making early diagnosis difficult. Joint involvement, when it occurs, is characterized by an acute and oligoarticular pattern in the knees and ankles. Chronic polyarthritis is much less observed and can simulate juvenile idiopathic arthritis, which can delay diagnosis, as was the case with this patient. We must consider the diagnosis of PAN in those patients with chronic polyarthritis, associated with cutaneous vasculitic manifestations and increased ASLO.

Self-rated resilience and mobility limitations as predictors of change in active aging during COVID-19 restrictions in Finland: a longitudinal study.

Social distancing during the COVID-19 pandemic decreased older people's opportunities to lead an active life. The purpose of this study was to investigate whether walking difficulties predict changes in leading an active life during the COVID-19 social distancing recommendation compared to 2 years before, and whether self-rated resilience moderates this association among older people. Data were collected during social distancing recommendation in May and June 2020 and 2 years before (2017-18) among community-living AGNES study participants initially aged 75, 80, or 85 years (n = 809). Leading an active life was assessed with the University of Jyväskylä Active Aging Scale (UJACAS; total score range 0-272) and resilience with the 10-item Connor-Davidson Resilience Scale (0-40). Self-reported walking difficulties over a 2 km distance were categorized into no difficulty, difficulty, and unable to walk. The total UJACAS score declined 24.9 points (SD 23.5) among those without walking difficulty, 27.0 (SD 25.0) among those reporting walking difficulty and 19.5 (SD 31.2) among those unable to walk 2 km. When adjusted for baseline UJACAS score, those unable to walk 2 km demonstrated the greatest decline. Baseline resilience moderated this association: Higher resilience was associated with less declines in UJACAS scores among persons with or without walking difficulty, and with more declines among persons unable to walk 2 km. When opportunities for leading an active life are compromised, those with less physical and psychological resources become particularly vulnerable to further declines in activity.