Allergic Rhinitis Seasonality, Severity, and Disease Control Influence Anxiety and Depression.

OBJECTIVES: Allergic rhinitis (AR) has been associated with anxiety and depression. A possible influence of frequency and intensity of the AR symptoms has remained unclear. Therefore, we evaluated the association between AR, as well as its control, seasonality and severity, and the presence of anxiety and depression. METHODS: Participants were selected from a preexistent national database and consecutively contacted by phone. AR was classified according to Allergic Rhinitis and its Impact on Asthma. Presence of anxiety and depression was identified by Hospital Anxiety and Depression Scale (HADS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory-II (BDI-II). We built linear regression models assessing the association between any of the assessed anxiety or depression scores and the occurrence, degree of control, seasonality or severity of AR. RESULTS: We analyzed 115 participants with AR and 38 participants with no respiratory symptoms. Patients with AR presented higher scores of anxiety (HADS: 3.1; 95% confidence interval [CI] = 1.9; 4.3; p < 0.001) and depression (HADS: 3.8; 95% CI = 2.5; 5.0; p < 0.001). Poorer AR control was positively associated with higher prevalence and scores of anxiety (HADS: 3.0; 95% CI = 1.5; 4.5; p < 0.001) and depression (HADS: 1.8; 95% CI = 0.2; 3.4; p = 0.031). Similar results were obtained with BAI and BDI-II scales. A moderate/severe presentation of AR were also related with higher scores of anxiety (HADS: 1.7; 95% CI = 0.1; 3.2; p = 0.040) and depression (HADS: 1.7; 95% CI = 0.1; 3.3; p = 0.037). CONCLUSION: The presence of AR, a poorer control, and a moderate/severe presentation of the disease were significantly associated with higher scores of anxiety and depression. Thus, it is important to alert to this association to allow a quick diagnosis of AR-associated pathologies. Laryngoscope, 133:1321-1327, 2023.

The Surgical Vascular Anatomy of the Lower Lumbar Arteries and Its Implications in Minimally Invasive Spine Surgery: A Cadaveric Study.

BACKGROUND: Minimally invasive lateral lumbar interbody fusion is a technique that has become increasingly popular for the treatment of degenerative lumbar spine disease; however, the pertinent surgical vascular anatomy has not been examined in detail. The goal of this study is to examine the anatomy of the lower lumbar and median sacral arteries, which are important determinants of these surgical outcomes. METHODS: This is an observational, experimental study based on cadaveric models, including 20 embalmed adult human cadavers. The following measurements were made: length of the lumbar and median sacral arteries, vertical distance between the third and fourth lumbar arteries and the superior end plate of the corresponding vertebrae, anterior vertebral body height, and intervertebral disc height. RESULTS: Our sample showcased considerable variability regarding vascular anatomy around the lower lumbar spine. In 10% of specimens, the abdominal aorta bifurcated at the level of the L3-L4 intervertebral disc, and 20% showed variations in vena cava origin. Regarding the lumbar arteries, in 10% of the sample, the fourth lumbar artery was absent on the right side, and 10% presented a fifth lumbar artery. The median sacral artery was present in all cadavers; however, in 15% of specimens, it originated from a common trunk that also gave rise to the fourth pair of lumbar arteries. Anterior vertebral body height was smaller in L3 comparing with L5 (P = 0.003), and there was a significant cephalocaudal increase in the anterior intervertebral disc height in the analyzed levels (P < 0.001). Bilaterally, the distance between the fourth lumbar arteries and the superior end plate of the L4 vertebral body was shorter than this distance at the L3 vertebral body (P < 0.001 and P = 0.002 on the right and left, respectively). CONCLUSIONS AND CLINICAL RELEVANCE: These data may be useful in spine surgery planning and operative management. These anatomic variations should be identified beforehand to prevent difficulties during surgery and possible complications.

Palatine Tonsils Primary Presentation of Blastoid Variant of Mantle Cell Lymphoma: Case Report.

Head and neck lymphomas can present with a wide range of symptoms. Timely and accurate diagnosis is often challenging. The blastoid variant of mantle cell lymphoma (MCL) accounts for less than one-third of all MCL cases. Isolated primary presentation on the palatine tonsils is rare, and prognosis and outcome are seemingly unfavorable. An 81-year-old man presented with persistent odynophagia, dysphagia, and obstructive hypertrophic palatine tonsils with purulent exudate. The signs and symptoms were non-responsive to antibiotic therapy, and the tonsils were biopsied. The cellular morphology, immunophenotype, and genotype supported a diagnosis of the blastoid variant of MCL. After staging, the patient underwent chemotherapy with Rituximab-Bendamustine (R-Benda). The patient is in clinical remission more than two years after therapy. We report an exceedingly rare case of blastoid MCL that is prone to be misdiagnosed as tonsillitis. We review the literature and discuss treatment options of this uncommon malignancy.

Red Blood Cell Distribution Width as a 5-Year Prognostic Marker in Patients Submitted to Carotid Endarterectomy.

OBJECTIVE: Patients submitted to carotid artery endarterectomy (CEA) have a long-term risk of major adverse cardiovascular events (MACE) of 6-9% at 2 years. Hematological parameters have been shown to have a predictive function in atherosclerotic diseases, namely the red blood cell distribution width-coefficient of variation (RDW-CV). This parameter has been associated with worse outcomes such as myocardial infarction (MI), stroke, and all-cause mortality. This study aims to evaluate the potential role of preoperative hematologic parameters such as RDW-CV in predicting perioperative and long-term cardiovascular adverse events and mortality in patients submitted to CEA. METHODS: From January 2012 to January 2019, 180 patients who underwent CEA with regional anesthesia in a tertiary care and referral center were selected from a prospective cohort database. Blood samples were collected preoperatively 2 weeks before admission, including a full blood count. The primary outcome included long-term MACE. Secondary outcomes included all-cause mortality, stroke, MI, acute heart failure, and major adverse limb events (MALE). RESULTS: At baseline, 27.2% of patients had increased RDW-CV. Increased RDW-CV was independently associated with baseline hemoglobin (adjusted odds ratio [aOR] 0.715, 95% CI 0.588-0.869, p = 0.001) and atrial fibrillation (aOR 4.028, 95% CI 1.037-15.639, p = 0.001). After a median follow-up of 50 months, log-rank univariate analysis of RDW-CV demonstrated a significant association between increased RDW-CV and long-term all-cause mortality (log-rank <0.001), MACE (log-rank <0.001), and MI (log-rank = 0.017). After multivariate Cox regression analysis, increased RDW-CV was associated with increased long-term mortality (adjusted hazard ratio [aHR] 2.455, 95% CI 1.231-4.894, p = 0.011) and MACE (aHR 2.047, 95% CI 1.202-3.487, p = 0.008). A decreased hemoglobin to platelet ratio (aHR 2.650e-8, 95% CI 9.049e-15 to 0.078, p = 0.019) was also associated with all-cause mortality. CONCLUSION: RDW is a widely available and low-cost marker that independently predicts long-term mortality, MACE, and MI after CEA. This biomarker could prove useful in assessing which patients would likely benefit from CEA in the long term.

Efficacy of near-infrared spectroscopy cerebral oximetry on detection of critical cerebral perfusion during carotid endarterectomy under regional anesthesia.

Background: Patients undergoing carotid endarterectomy (CEA) may suffer from cerebral hypoperfusion during the carotid cross-clamping. Near-infrared spectroscopy cerebral oximetry (NIRS) is a non-invasive method of regional cerebral oxygen saturation measurement reflecting changes in cerebral blood flow during CEA. The main goal of the study was to evaluate the accuracy of the NIRS in detecting cerebral hypoperfusion during CEA under regional anesthesia (RA) and compare it with awake neurological testing. Patients and methods: A prospective observational study of 28 patients that underwent CEA in RA and manifested neurologic deficits, and 28 consecutive controls from a tertiary and referral center, was performed. All patients were monitored with NIRS cerebral oximetry and awake testing as the control technique. Subsequently, operating characteristic curve and Cohen's kappa coefficient were determined to evaluate the reliability of the monitoring test. Results: NIRS presented a sensitivity of 27.3% and a specificity of 89.3% in comparison to awake testing. Receiver operating characteristic (ROC) curve analysis demonstrated that a decrease of at least 20% in cerebral oxygen saturation is the best threshold to infer cerebral hypoperfusion. However, the respective area under the curve (AUROC) was 0.606 (95% CI: 0.456-0.756, P = 0.178) with a calculated Cohen's kappa of 0.179, P = 0.093. Regarding 30-days outcomes, only awake testing has shown significant associations with stroke and postoperative complications (P = 0.043 and P = 0.05), which were higher in patients with post-clamping neurologic deficits. Conclusions: NIRS demonstrated a reduced discriminative capacity for critical cerebral hypoperfusion, and does not seem to add substantial clinical benefits to the awake test.

Neurosurgical anatomy of the insular cortex.

OBJECTIVE: The purpose of this study was to clarify the morphology of the insular cortex focusing not only on the shape of the insula, but also on sulcal and gyral organization. PATIENTS AND METHODS: Sixty formalin-fixed adult brain hemispheres had their insula exposed and photographed. The dimensions of each gyrus and sulcus were measured using an image analysis software. The morphometric data obtained was statistically analysed. RESULTS: The insular cortex shape alternates between triangular and trapezoid, being the triangular shape the most common (75%). The angle between the posterior and inferior peri-insular sulcus in the trapezoid insulae had a mean range of 131.17° (SD = 12.277). A minimum of 3 and a maximum of 6 insular gyri were observed, being 5 the most common total number of gyri observed. The accessory gyrus was present in 66% of the insulae and well-developed in 38% of the cases. A statistical association between the number of gyri in the posterior lobe and the presence of a novel gyrus or a more developed accessory gyrus in the anterior lobe was found (P = 0.006). The posterior short gyrus was the longest of the short gyri (P <  0.001), followed by the anterior short gyrus (P < 0.001). The anterior long gyrus was the largest of the long gyri (P = 0.003). The contribution of each of the short gyri to the formation of the insular apex was inconstant. The most common observed apex arrangement was the combination of the anterior and of the middle short gyri. CONCLUSIONS: This study makes a strong contribution to the understanding of the insular cortex anatomy, allowing neurosurgeons to be more capable to decide the best approach to this cortical area.

Chronic stress leads to long-lasting deficits in olfactory-guided behaviors, and to neuroplastic changes in the nucleus of the lateral olfactory tract.

A recent study reported that the integrity of the nucleus of the lateral olfactory tract (nLOT) is required for normal olfaction and for the display of odor-driven behaviors that are critical for species survival and reproduction. In addition to being bi-directionally connected with a key element of the neural circuitry that mediates stress response, the basolateral nucleus of the amygdala, the nLOT is a potential target for glucocorticoids as its cells express glucocorticoid receptors. Herein, we have addressed this hypothesis by exploring, first, if chronic variable stress (CVS) disrupts odor detection and discrimination, and innate olfactory-driven behaviors, namely predator avoidance, sexual behavior and aggression in male rats. Next, we examined if CVS alters the nLOT structure and if such changes can be ascribed to stress-induced effects on the activity of the main output neurons, which are glutamatergic, and/or of local GABAergic interneurons. Finally, we analyzed if the stress-induced changes are transient or, conversely, persist after cessation of CVS exposure. Our data demonstrate that CVS leads to severe olfactory deficits with inability to detect and discriminate between odors and to innately avoid predator odors. No effects of CVS on sexual and aggressive behaviors were observed. Results also showed that CVS leads to somatic hypertrophy of pyramidal glutamatergic neurons, which likely results from neuronal disinhibition consequent to the loss of inhibitory inputs mediated by GABAergic interneurons. Most of the CVS-induced effects persist beyond a 4-week stress-free period, suggesting long-lasting effects of chronic stress on the structure and function of the olfactory system.

The integrity of the nucleus of the lateral olfactory tract is essential for the normal functioning of the olfactory system.

The nucleus of the lateral olfactory tract (nLOT) is a relatively small component of the cortical pallial amygdala, with peculiar neurogenic, neurochemical and connectivity patterns. Although it has been suggested that it might be involved in non-pheromonal olfactory-guided behaviors, particularly feeding, the functional implications of the nLOT have never been investigated. In view of this fact, we have tackled this subject by performing a series of behavioral tests and by quantifying biological and biochemical parameters in sexually naïve adult male rats that were submitted to bilateral excitotoxic lesions of the nLOT. nLOT-lesioned rats had severe olfactory deficits with inability to detect and discriminate between odors. Additionally, they did not display innate behavioral responses to biologically relevant chemosignals. Specifically, nLOT-lesioned rats did not show avoidance towards predator odors or aggressive behaviors towards intruders, and had severely impaired sexual behavior. In fact, nLOT lesions abolished preference for odors of receptive females, reduced chemoinvestigatory behavior and eliminated mounting behavior. nLOT-lesioned rats had normal circulating levels of testosterone, did not display anxiety- or depressive-like behaviors, and had unimpaired cognitive functions and fear acquisition and memory. Altogether, our results suggest that the nLOT integrity is required for the normal functioning of the olfactory system.

Age effects on the nucleus of the lateral olfactory tract of the rat.

The olfactory deficits that occur during aging influence the quality of life and have been regarded as a risk factor for malnutrition in the elderly. The nucleus of the lateral olfactory tract (nLOT) is a cortical nucleus of the pallial amygdala that has been implicated in feeding behavior. Here we present quantitative data on the anatomy of the nLOT in the adult rat and on the effects of age on its structure and neurochemistry. Total neuron numbers, neuronal volumes, and volumes of layers 1-3 of the nLOT were estimated in adult and old male rats using stereological techniques. We also estimated the total number of interneurons expressing neuropeptide Y (NPY) and vasoactive intestinal polypeptide (VIP), and the numerical density of the nLOT cholinergic varicosities. Our data show that aging is associated with a reduction of the total neuron numbers in the nLOT, due to cell loss in layers 2 and 3. There were no age-related variations in neuronal volumes. Similarly, the volume of the nLOT was unchanged in aged rats, except in layer 3 where it was reduced. The numerical density of cholinergic varicosities was also unchanged in aged rats. Conversely, the total numbers of NPY- and VIP-immunoreactive neurons were reduced by 55% and 30%, respectively, in aged rats. These findings include the nLOT in the list of cortical olfactory structures susceptible to aging and raise the possibility that the age-related changes that occur in the nLOT might contribute for the decline in olfactory functions reported in normal aging.