Intracranial atherosclerotic disease: current management strategies.

A stroke due to underlying intracranial large artery occlusion, which is atherosclerotic in nature, is known as intracranial atherosclerotic disease (ICAD). It is important to recognize that ischaemic stroke due to ICAD differs from extracranial disease and other stroke aetiologies and requires a nuanced approach. It is a significant cause of stroke worldwide, and severe symptomatic ICAD can present challenges from a therapeutic standpoint, including recurrent ischaemic stroke despite optimal management. Furthermore, exploring the underlying pathophysiological mechanisms responsible for the disease may be necessary while considering treatment options. This narrative review aims to provide an all-encompassing overview of this disease. Epidemiology and clinical pathophysiology will be explored in detail. The findings of large clinical trials will serve as a guide to finding the most optimized management strategies. Another critical question that arises is the treatment of acute ischaemic stroke due to large vessel occlusion with underlying intracranial atherosclerosis, is the treatment and clinical diagnosis the same as for other aetiologies of stroke (i.e. extracranial disease and nonvalvular atrial fibrillation)? Consequently, secondary prevention of patients with ischaemic stroke or transient ischaemic attack will be divided into medical therapy, risk factor control, and endovascular and surgical treatment options.

An Assessment of Risk Factors of Delayed Speech and Language in Children: A Cross-Sectional Study.

Introduction Communication is the exchange of information through speaking, writing, and other mediums. Speech is the expression of thoughts in spoken words. Language is the principal method that humans use for relaying information; consisting of words conveyed by speech, writing, or gestures. Language is the conceptual processing of communication. Problems in communication or oral motor function are called speech and language disorders. Developmental delay is diagnosed when a child does not attain normal developmental milestones at the expected age. Speech and/or language disorders are amongst the most common developmental difficulties in childhood. Such difficulties are termed 'primary' if they have no known etiology, and 'secondary' if they are caused by another condition such as hearing and neurological impairment, and developmental, behavioral, or emotional difficulties. Objectives The objective of our study was to observe the risk factors for speech and language delay in the children presenting to the speech therapy clinic of a tertiary care hospital in a large urban center. Methodology A cross-sectional study was conducted on 150 children presenting at the speech therapy clinic of Lahore General Hospital from July to August 2021. A well-designed questionnaire was used to collect data about the sociodemographic profile, and biological, developmental, and environmental risk factors of speech and language delay in children. SPSS, version 25 (IBM Corp., Armonk, NY) was used to enter and analyze the data. Results Parents or caretakers of a total of 98 male and 52 female children took part in this study aged 2-11 years. The average age of speech and language delay among the children was 5.65 years, 66.7% of which went to normal school while 31.3% went to special school; 66.7% were from urban areas. Around 60% had middle ear infections, and 34.7% were found to have oropharyngeal anomalies. A history of intrapartum complications was found in 68.4% of children; 46.7% of children had a history of use of a pacifier and 38% had a history of thumb sucking. Nearly 39% of children belonged to a multilingual family environment and 66.7% had a family history of screen viewing for more than two hours. Conclusion The major risk factors contributing to speech and language delay in children are family history of speech and language delay, prolonged sucking habits, male gender, oropharyngeal anomalies, hearing problems, and middle ear infections. Measures should be taken to educate people regarding risk factors, courses, and management of speech and language delay in children.

The Impact of COVID-19 on the Behaviors and Attitudes of Children and Adolescents: A Cross-Sectional Study.

Background and objective Over the past few decades, new infectious diseases have emerged, and these have played a key role in changing behavior and lifestyle in all age groups. More recently, with the emergence of the coronavirus disease 2019 (COVID-19) pandemic, governments around the world have made unprecedented efforts to contain the epidemic by implementing quarantine measures, social distancing, and isolating infected individuals. Social behavioral adaptations (e.g., social distancing, isolation, etc.) impact children's and adolescents' lifestyle activities and lead to increased incidence of psychosocial problems, worsening of preexisting mental illness, and fears of infection, uncertainty, isolation, and stress. In light of this, this study aimed to assess the impact of COVID-19 on the behaviors and lifestyles of the children and adolescent population of Pakistan. Methodology A cross-sectional study was conducted involving 323 children and adolescents by targeting parents of children and adolescents in the age group of 4-18 years living in Pakistan. The study was conducted from April 2021 to September 2021. A well-designed structured questionnaire was used to collect data about the sociodemographic profile, attitudes, and behavioral factors impacted by COVID-19 in children and adolescents. SPSS Statistics version 23 (IBM, Armonk, NY) was used to enter and analyze data. Results Parents or caregivers of a total of 189 male and 134 female children aged between four and 18 years took part in this study. During COVID-19, the consumption of fast food and fried foods by children and adolescents increased significantly. In this study, out of 323 participants, almost all (289, 89.5%) had increased their screen time significantly. Nearly half of the total individuals experienced the feeling of depression and loneliness during the pandemic. Additionally, some children and adolescents felt fearful when leaving home. COVID-19 lockdowns have led to many changes in children's and adolescents' lifestyle habits. They reduced physical contact with others due to the fear of transmission of COVID-19. Based on our findings, the pandemic and its containment strategies have adversely affected the behaviors, lifestyles, and attitudes of children and adolescents. Conclusion Governments around the world have imposed social distancing during the COVID-19 pandemic, leading to adverse short-term and long-term negative mental health issues such as unhappiness, fear, worry, irritability, depressive symptoms, anxiety, and post-traumatic stress disorder (PTSD). Interventions are needed to focus on building resilience in children and adolescents, addressing their fears and concerns through better communication, encouraging routine and physical activity, and taking measures to alleviate loneliness.

Impact of Vitamin D Supplementation on Multiple Sclerosis.

Multiple sclerosis (MS) is an autoimmune disease affecting a large number of people every year. The exact causal factor for this disease is unclear, but it commonly affects middle-aged women, with known triggers like stress, childbirth, infections, poor diet, lack of sleep, etc. Many epidemiological studies have indicated that various genetic abnormalities are also critical drivers of the onset of MS. The major risk factors of MS identified include hypovitaminosis D while environmental protective factors include allele HLA DRB1 1501, obesity, Epstein-Barr virus infection, sexual hormones, and smoking. Our article explores the correlation between the deficiency of vitamin D and the onset and progression of MS. The study uses a systematic review methodology by researching and reviewing scholarly articles exploring the topic. We conducted online searches of literature on Google Scholar and PubMed using the keywords "vitamin D deficiency" and "multiple sclerosis" and accessed the relevant secondary literature sources for review. The variables under study included vitamin D insufficiency as the dependent variable while MS was the independent variable. Causal variables included environmental, genetic, and protective factors. We hypothesized that there is indeed a correlation between vitamin D deficiency and MS. The findings from our review indicate a strong correlation between the insufficiency of vitamin D and the onset and progression of MS. These results are essential in devising interventions to accomplish primary and secondary prevention of MS, as well as integrating vitamin D supplementation in current treatment protocols for MS.

Intrathoracic gastric fistula after bariatric surgery: a systematic review and pooled analysis.

Even in the hands of highly experienced bariatric surgeons, perioperative complications are inevitable. Of these, leaks and fistulas are amongst the scariest complications. Intrathoracic gastric fistulas (ITGF) can be associated with serious morbidity, mostly when cases are misdiagnosed or detected with delay. This is a systematic review of the literature to investigate the clinical and surgical outcomes of morbidly obese adult patients with a confirmed diagnosis of ITGF following bariatric surgery. A pooled analysis of 25 articles, encompassing 76 patients with post-bariatric ITGF, showed that the clinical outcome depends on the initial presentation, timing of the diagnosis in relation to symptom onset, and prompt and effective treatment. Any septic or unstable patient must undergo urgent surgical intervention, while stable patients might tolerate a step-up approach and watchful waiting for nonsurgical treatment. Among those who undergo surgery, treatment failure and the mortality rate are substantially high. Contingent upon a prompt management strategy, patients with postbariatric ITGF can generally have a favorable outcome in the long term.

Pathogenesis of Ventricular Arrhythmias and Its Effect on Long-Term Prognosis in Patients With Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TTC), also known as broken heart syndrome, stress cardiomyopathy (SCM), or apical ballooning syndrome, is a non-ischemic cardiac disease with an initial clinical presentation that is very similar to acute coronary syndrome (ACS). Ventricular arrhythmias (VAs) contribute significantly to an increase in the rates of death in patients with TTC, especially during the acute phase, in which patients with TTC are more susceptible to develop life-threatening arrhythmias (LTA) such as ventricular tachycardia (VT), ventricular fibrillation (VF), torsades de pointes (TdP), and sudden cardiac death (SCD). However, the pathophysiology of TTC and how VA occurs are still a mystery. We aim to review previous literature and discuss the possible mechanisms of VA in TTC patients. VA usually complicates the acute phase of the disease and worsens the long-term prognosis. Alterations of repolarization (negative T wave, prolonged QTc) indicate a high risk of arrhythmic events (TdP, VT, VF, and SCD). Catecholamine effect on myocardial cells and myocardial edema can create a substrate for the development of VA. Some of the most commonly proposed mechanisms for the development of VA in patients with TTC are coronary vasospasm, myocardial stunning due to catecholamines, re-entry, and triggered activity. Further prospective studies, including a more significant number of patients, are required to understand the disease's pathophysiology better and improve LTA management in patients with TTC.

Effect of pre-existing left bundle branch block on post-procedural outcomes of transcatheter aortic valve replacement: a meta-analysis of comparative studies.

BACKGROUND: As an established procedure for patients with aortic valve stenosis and a high surgical risk profile, transcatheter aortic valve replacement (TAVR) can be associated with conductance abnormalities. However, data regarding the impact of pre-existing left bundle branch block (LBBB) on post-TAVR outcome is scarce. OBJECTIVES: We conducted this meta-analysis to pool available data in the literature on the impact of pre-existing LBBB on the clinical outcomes of patients undergoing TAVR. METHODS: We queried Medline/PubMed, Scopus, and Cochrane Library to identify comparative studies of patients with and without a pre-existing LBBB undergoing TAVR for aortic stenosis. Risk ratio (RR) and the corresponding 95% confidence interval (95% CI) were estimated to measure the effect of pre-existing LBBB on developing post-procedure stroke, permanent pacemaker implantation (PPM), or moderate/severe aortic regurgitation (AR). RESULTS: Data of three clinical trials encompassing 4,668 patients undergoing TAVR were included in this meta-analysis. Patients with pre-existing LBBB prior to TAVR had an increased risk of developing moderate/severe AR (RR = 1.04 [0.79-1.37]; P = 0.77), stroke (RR = 1.72 [0.61-4.85]; P = 0.31), and a need for PPM implantation (RR = 4.43 [0.43-45.64]; P = 0.21) following TAVR. CONCLUSION: Preexisting LBBB seems to increase the risk of developing stroke, aortic regurgitation, and the need for a permanent pacemaker implantation. However, due to scarcity of data and high heterogeneity among the current studies, further clinical trials are warranted.

The Future of Metformin in the Prevention of Diabetes-Related Osteoporosis.

As a worldwide aging population is on the rise, osteoporosis (OS) is becoming a global health burden. Therefore, many researchers and health authorities are looking into the potential prevention and treatment of OS. Although previously regarded as two separate pathological processes, diabetes (DM) and OS are now regarded as two conditions that can occur together. It is now believed that OS can develop as a complication of DM. This relationship is further evidenced through a reduction in bone mineral density in type-1 diabetes with a resulting increased risk of fracture. Although bone mineral density in type-2 diabetes mellitus is normal or increased, there is also increased fragility due to decreased bone quality. These abnormal bone qualities tend to occur through the production of reduced bone microvasculature and advanced glycation end product, AGE. Interestingly, one of the most common treatments for DM, metformin (MF), shows a promising result on the protection of diabetes and non-diabetes related bone turnover. It is believed that MF modulates its effect through the adenosine monophosphate-activated protein kinase (AMPK) pathway. Recent data regarded AMPK as a vital mediator of homeostasis. It is involved not only in glucose metabolism but also in osteogenesis. AMPK can directly influence the production of mature and good quality bone by decreasing osteoclasts, increasing osteoblast formation, and enhancing bone mineral deposition. As an activator of AMPK, MF also upregulates osteogenesis. Furthermore, MF can influence osteogenesis through a non-AMPK pathway, such as the fructose 1-6 phosphatase pathway, by reducing glucose levels. While already recognized as a safe and effective treatment for DM, this article discusses whether MF can be used for the prevention and treatment of OS.

Myasthenia Gravis and its Association With Thyroid Diseases.

Myasthenia gravis (MG) is a rare autoimmune neuromuscular junction disorder, and thyroid disorder is a disorder involving the thyroid receptor, of which Graves' disease (GD) is the most common autoimmune thyroid disorder, in which antibodies develop against thyroid receptors. Both may have similar clinical features. In myasthenia gravis, autoimmune antibodies develop against postsynaptic neuromuscular junction disrupting the neuromuscular transmission, resulting in fluctuating muscle weakness and fatigue. It is a disease of young women and older men. The two pathologies may coexist in a patient or can precede one another. Graves' disease (GD) among thyroid diseases is most often associated with MG.  Similarities in clinical features lead to difficulty in distinguishing MG and GD. Despite the standard treatment of myasthenia gravis, including steroids, acetylcholinesterases, rituximab, immunosuppressants, and thymectomy, there is still an increased number of relapses and myasthenia crisis. Eculizumab and plasmapheresis are the two new treatment options for MG, with supporting evidence of marked improvement in recent studies. Myasthenia gravis and Graves' disease have a see-saw relationship. Treating one pathology may worsen the other, so physicians should always consider MG as a differential in patients of hyperthyroidism presenting with new symptoms of fatigue or respiratory failure or neuromuscular weakness. In this comprehensive review article, we tried to establish an association between myasthenia gravis and Graves' disease (GD) by exploring currently available literature from PubMed. However, more studies need to be done to establish an association between pathologies.