Effect of Steroids on Patients With Fibromyalgia/Chromic Widespread Pain: An Observational Study.

OBJECTIVE: Fibromyalgia causes widespread chronic pain. Pain management and treating underlying conditions are of utmost importance. Recent studies found an association of thyroid autoimmunity with fibromyalgia. Pain management of patients with anti-thyroid peroxidase antibody (anti-TPO Ab) positive was studied sparsely. To determine the effect of steroid (deflazacort) on pain management using numerical rating scale (NRS) pain score at baseline and at 3-month follow-up. STUDY DESIGN: A retrospective observational study was undertaken, recruiting patients diagnosed with fibromyalgia as per 2010 American College of Rheumatology guidelines and treated with the steroid, deflazacort 12 mg. Patients with missing details were excluded. Patients were categorized into negative, positive, and strongly positive anti-TPO Ab groups. Baseline and follow-up (3 months) pain score was compared across the groups. Reduction in pain was considered as a primary outcome variable. RESULTS: The study included 128 participants with 98 (76.6%) females and 30 (23.4%) males. The age of the study population was 48±13.29 years. The proportion of hyper, hypo, and euthyroid was 10 (7.81%), 42 (32.81%), and 76 (59.38%), respectively. The proportion of participants with negative, positive, and strongly positive anti-TPO Ab levels was 41 (32.03)%, 50 (39.06%), and 37 (28.91%), respectively. Baseline pain score was 7.3±1.32 and 3-month follow-up was 4.7±2.46. Steroid response was found in 66 (51.6%). Negative and positive anti-TPO Ab had a 1-point reduction in pain score from baseline, p-value <0.001. The strongly positive group had 5 points reduction, p-value<0.05. CONCLUSION: Fibromyalgia patients with thyroid autoimmunity responded well to short courses of steroids. Greater pain relief was observed among those who are strongly positive anti-TPO Ab group.

The Covert Impact of Chiari Network and Eustachian Valves on Stroke: A Scoping Review and Meta-Analysis.

BACKGROUND: The role of Chiari network (CN) and Eustachian valves (EVs) in cardioembolic strokes is still unclear. There is inconsistency in the literature regarding clinical approach to these lesions to reduce stroke risk. We aimed to describe clinical presentation, neuroimaging and cardioimaging features, as well as management approaches for CN and EV in stroke context. REVIEW SUMMARY: A systemic search was carried out using PubMed and Web of Science following PRISMA guidelines, Supplemental Digital Content 1 (http://links.lww.com/NRL/A123). We retrieved 4 case-control studies, 2 cross sectional studies as well 8 case reports, with a total of 883 patients with a mean age of 44.6 years (±13.8). The combined prevalence of EV/CN in stroke-related patent foramen ovale (PFO) patients was 50% (95% CI: 31-68). With isolated prevalence for EV and CN of 43% (95% CI: 25-63), 18% (95% CI: 12-25), respectively. Patients with history of stroke had higher prevalence of EV/CN compared with controls odds ratio=2.45 (95% CI: 1.2-5, P<0.01). All case-control and cross-sectional studies defined EV/CN by transesophageal echocardiography or intracardiac cardiography. In the 8 case reports, 7 cases were diagnosed by transesophageal echocardiography, while only 1 case was diagnosed postmortem. CONCLUSION: EV/CN are relatively common findings in stroke patients with PFO. While it appears that presence of EV/CN with a PFO increases the risk of cardioembolic stroke, they remain underrecognized. EV/CN should be considered as high-risk PFO features. There is a scarcity of research emphasizing their role in clinical decision making, especially PFO closure and antithrombotic therapy choice.

Advances in Cardiac Workup for Transient Ischemic Attack: Improving Diagnostic Yield and Reducing Recurrent Stroke Risk.

Transient ischemic attack (TIA) is a warning sign for an impending stroke, with a 10-20% chance of a stroke occurring within 90 days of the initial event. Current clinical practice for cardiac workup in TIA includes cardiac enzymes, with 12-lead electrocardiogram, transthoracic echocardiography, and 24-hour Holter monitoring. However, the diagnostic yield of these investigations is variable, and there is a need for better diagnostic approaches to increase the detection of cardiac abnormalities in a cost-effective way. This review article examines the latest research on emerging diagnostic tools and strategies and discusses the potential benefits and challenges of using these advanced diagnostic approaches in clinical practice. Novel biomarkers, imaging techniques, and prolonged rhythm monitoring devices have shown great promise in enhancing the diagnostic yield of cardiac workup in TIA patients. Echocardiography, Transcranial Doppler ultrasound, cardiac MRI, and cardiac CT are among the promising diagnostic tools being studied. We conclude the article with a suggested diagnostic algorithm for cardiac workup in TIA. Further research is necessary to enhance their usefulness and to outline future directions for research and clinical practice in this field.

Scrub Typhus Meningoencephalitis: Review of Literature and Unique Diagnostic & Management Challenges in Resource-Limited Settings.

Scrub typhus is a zoonotic febrile illness caused by Orientia tsutsugamushi and transmitted by Leptotrombidium larvae. Scrub typhus often presents with nonspecific clinical features, and ranges in severity from mild illness to multiorgan failure and fatality. The disease is primarily found in the Asia-Pacific rim, including India, Pakistan, Thailand, Malaysia, Korea, and China. Due to frequent limitations in healthcare resources in many of these countries, the diagnosis and management of scrub typhus meningoencephalitis pose unique challenges. This review focuses on the epidemiology, clinical features, diagnostic testing, and management modalities in such resource-limited settings. Exercising a high index of clinical suspicion and timely diagnostic tests and management strategies are vital to prevent life-threatening complications of this treatable illness.

Pulmonary Embolism in Ischemic Stroke.

Silent pulmonary embolism (PE) may be associated with acute ischemic stroke (AIS). We identified 10 patients from 3,132 unique patients (3,431 CT scans). We retrospectively examined CT angiogram of patients with AIS to determine the frequency of concurrent PE in AIS. The period prevalence of PE was 0.32. Seven patients had concurrent PE, whereas three had PE diagnosed 2 days after their AIS presentation. We suspected paradoxical embolism via patent foramen ovale as the cause of stroke in three patients and thrombophilia in four patients. Seven patients had poor outcome including four deaths. CT angiogram stroke protocol images from aortic arch to vertex allows visualization of upper pulmonary arteries and PE detection in AIS.

Access to hyperacute stroke services across Canadian provinces: a geospatial analysis.

BACKGROUND: Canada's vast geography creates challenges for ensuring prompt transport to hospital of patients who have had a stroke. We sought to determine the proportion of people across various Canadian provinces for whom hyperacute stroke services are accessible within evidence-based time targets. METHODS: We calculated, for the 8 provinces with available data, drive-time polygons on a map of Canada that delineated the area around stroke centres and emergency medical services (EMS) base centres to which one can drive in 3.5-6 hours. We calculated the proportional area of each forward sortation area (first 3 digits of the postal code) contained within a drive-time polygon. We applied this ratio to the 2011 Canadian census population of the forward sortation area to estimate the population that can reach a stroke centre in a designated time. RESULTS: A total of 47.1%-96.4% of Canadians live within a 4.5-hour drive to a stroke centre via road EMS, and 53.3%-96.8% live within a 6-hour drive. Assuming a total travel time of 5 hours by EMS from base centre to patient and patient to hospital, 84.7%-99.8% of the population has access to a current or proposed endovascular thrombectomy site. INTERPRETATION: Most Canadians live within 6 hours' road access to a stroke centre. Geospatial mapping could be used to inform decisions for additional sites and identify gaps in service accessibility. Coordinated systems of care and ambulance bypass agreements must continue to evolve to ensure maximal access to time-sensitive emergency stroke services.

MR imaging of carotid webs.

PURPOSE: We propose a magnetic resonance (MR) imaging protocol for the characterization of carotid web morphology, composition, and vessel wall dynamics. The purpose of this case series was to determine the feasibility of imaging carotid webs with MR imaging. METHODS: Five patients diagnosed with carotid web on CT angiography were recruited to undergo a 30-min MR imaging session. MR angiography (MRA) images of the carotid artery bifurcation were acquired. Multi-contrast fast spin echo (FSE) images were acquired axially about the level of the carotid web. Two types of cardiac phase resolved sequences (cineFSE and cine phase contrast) were acquired to visualize the elasticity of the vessel wall affected by the web. RESULTS: Carotid webs were identified on MRA in 5/5 (100%) patients. Multi-contrast FSE revealed vessel wall thickening and cineFSE demonstrated regional changes in distensibility surrounding the webs in these patients. CONCLUSION: Our MR imaging protocol enables an in-depth evaluation of patients with carotid webs: morphology (by MRA), composition (by multi-contrast FSE), and wall dynamics (by cineFSE).

Imaging in acute stroke.

INTRODUCTION: Stroke is the third leading cause of death and disability in Canada. In the hyperacute stroke setting, the treating physician must make a time critical decision on the treatment of each patient. Recent advances in imaging help the treating physician identify the subgroup of patients eligible for acute treatment of ischaemic stroke. AREAS COVERED: In this review we will discuss Non-Contrast Computed Tomography (NCCT), CT-Angiography (CTA), and CT-Perfusion (CTP) in assessment of patients with acute ischaemic stroke and intracerebral haemorrhage. Intravenous tPA was the only proven therapy for acute ischaemic stroke presenting within 4.5 hours, until the five recent trials proved the efficacy of EVT for acute ischaemic stroke with proximal arterial occlusion. Imaging played a major role in patient selection in all five trials. Expert commentary: The challenge of rapid clinical assessment, review of imaging and timely treatment will continue to be made easier as the development and understanding of imaging progresses.

Essential thrombocythemia: Rare cause of chorea.

Essential thrombocythemia (ET) is a clonal myeloproliferative disorder (MPD), characterized predominantly by a markedly elevated platelet count without known cause. It is rare hematological disorder. In ET clinical picture is dominated by a predisposition to vascular occlusive events and hemorrhages. Headache, transient ischemic attack, stroke, visual disturbances and light headedness are some of the neurological manifestations of ET. Here, we describe a 55 year-old female who presented to us with generalized chorea. On evaluation, she was found to have thrombocytosis. After ruling out the secondary causes of thrombocytosis and other MPD we confirmed diagnosis of ET in her by bone marrow studies. Polycythemia vera (PV) another MPD closely related to ET may be present with generalized chorea. There are few case reports of PV presenting as chorea in the literature, but none with ET. We report the first case of ET presenting as generalized chorea.