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Challenges and Opportunities in Headache

Challenges and Opportunities in Headache

Helin Gosalia
NIHR SLaM Clinical Research Facility @ King’s, SLaM Biomedical Research Centre, King’s College London, London, UK

Diana Y. Wei
NIHR SLaM Clinical Research Facility @ King’s, SLaM Biomedical Research Centre, King’s College London, London, UK; Department of Neurology, King’s College Hospital, London, UK

Peter J. Goadsby
NIHR SLaM Clinical Research Facility @ King’s, SLaM Biomedical Research Centre, King’s College London, London, UK; Department of Neurology, King’s College Hospital, London, UK; Department of Neurology, University of California, Los Angeles, CA, USA

Abstract

Cluster headache is a primary headache disorder and is the most prevalent of the trigeminal autonomic cephalalgias. Cluster headache significantly impacts those affected, necessitating early diagnosis and management. Despite unique clinical features, such as patients experiencing attacks in a circannual pattern and often with a circadian rhythm within bouts, cluster headache patients often are misdiagnosed, mismanaged and have a delay in diagnosis. Preclinical, neuroimaging and clinical studies have advanced our understanding of cluster headache pathophysiology. The trigeminovascular system, the trigeminal autonomic reflex, and the hypothalamus are all involved in the pathophysiology of cluster headache. As our understanding of the pathophysiology of cluster headaches has evolved, new therapeutic options, such as calcitonin gene-related peptide monoclonal antibodies, non-invasive vagal nerve stimulation and sphenopalatine ganglion stimulation, have proved to have efficacy in the treatment of cluster headache. Herein, we aim to review developments to aid readers in their understanding of this debilitating disorder. 

Ritwik Ghosh, MD
Department of General Medicine, Burdwan Medical College & Hospital, Burdwan, West Bengal, India

Dipayan Roy, MD
Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India; Indian Institute of Technology (IIT), Madras, Tamil Nadu, India

Adrija Ray, MBBS
Department of Medicine, RG Kar Medical College and Hospital, Kolkata, West Bengal, India

Shambaditya Das, MD, DM
Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India

Amrita Mandal, MBBS
Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India

Shambaditya Das, MD, DM
Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India

Shyamal Kanti Pal, MD
Department of General Medicine, Burdwan Medical College & Hospital, Burdwan, West Bengal, India

Julián Benito-León, MD, PhD
Department of Neurology, University Hospital “12 de Octubre”, Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain

Abstract

Background: Hemorrhagic cerebrovascular events, either due to aneurysmal rupture or spontaneous subarachnoid hemorrhage (SAH), are not rare in COVID-19. Several mechanisms such as coagulopathy, cytokine storm, viral endotheliopathy, hypertension, and immune modulation might play a role in the pathogenesis of SAH in COVID-19. This study aimed to report the first case of spontaneous non-aneurysmal SAH associated with SARS-CoV-2 from India. We briefly discussed the possible pathogenetic mechanisms underlying this process and succinctly reviewed the relevant literature.

Case report: We herein report a case of a non-comorbid young woman infected with SARS-CoV-2 presenting with thunderclap headache and eventually non-aneurysmal SAH,  who recovered with conservative management.

Conclusion: Headache, although a very common clinical feature of COVID-19 itself, must be investigated in detail to identify alternate causes that may be life-threatening. This case also incites further enquiry into the possible pathogenic mechanisms of neurovascular complications in COVID-19.

Dimitrios Panagopoulos
Consultant Pediatric Neurosurgeon, Neurosurgical Department, Pediatric Hospital of Athens, Agia

Maria Gavra 
Georgios Stranjalis 
Efstathios Boviatsis 
Stefanos Korfias 
Ploutarchos Karydakis 
Marios Tmemistocleous

Abstract

Introduction: Hydatid disease of the central nervous system, especially when there is no involvement of other organs, is a rare occurrence and it accounts for 2–3% of all the hydatid cyst cases that are recorded worldwide. Echinococcus is considered as an endemic disease, mainly encountered in sheep and cattle-raising regions, with a large proportion of patients living in Mediterranean countries, as well as Turkey and Syria. Pediatric neurosurgeons in nonendemic countries are facing a differential diagnostic challenge when a patient with hydatid cyst of the central nervous system is admitted to their department, mainly due to lack of awareness.

Materials and Methods: We report the case of an eleven years old patient, coming from a village, who was admitted to our hospital due to progressive hemiparesis, hemianopsia, headache and episodes of vomiting. A thorough laboratory and neuroimaging investigation was performed, which revealed the presence of a hydatid cyst at the right fronto-parietal region. An en-block total resection was performed and the patient neurological signs and symptoms were immediately relieved.

Conclusions: The clinical features related to hydatid cyst involving the central nervous system are largely nonspecific. Nevertheless, MRI has proved to be a very important diagnostic tool, significantly enhancing the diagnostic aid of neuroimaging and supporting our pre-operative diagnostic accuracy. Laboratory investigation with immunological tests may be indicative, but negative results should be interpreted with caution. En block removal of the cyst without interruption of its wall and avoidance of any spillage of content is our ultimate therapeutic goal. Infection with Echinococcus granulosus should be included in the differential diagnosis for non-specific neurologic symptoms such as progressive headache, especially in pediatric patients who are coming from regions which are considered as endemic for such parasitic diseases. In addition, the adjuvant therapy with albendazole is strongly indicated. The majority of misdiagnoses or delayed diagnoses may have resulted from confusing clinical features and atypical radiographic findings.

Rob Sillevis, PT, DPT, Ph.D., OCS, FAAOMPT
Florida Gulf Coast University, Fort Myers, FL USA

David Stockhausen, SPT
Florida Gulf Coast University, Fort Myers, FL USA

Nicole Gerdts, DPT
Florida Gulf Coast University, Fort Myers, FL USA

Anne Weller Hansen, BS, MBA
Florida Gulf Coast University, Fort Myers, FL USA

Abstract

Study design:  A quasi-experimental study design

Background: The motion of the suboccipital region is controlled by several groups of the smaller and larger muscle group, and these might play a role in the development of cervicogenic headache. Abnormal muscle tone can lead to abnormal movement patterns resulting in altered proprioceptive information from the mechanoreceptors in this region. Thus, abnormal muscle tone will contribute to cervical dysfunction and might result in pain, joint irritation, and poor functioning of the neck. At the same time , unilateral contraction of the suboccipital muscles could lead to rotation of the atlas. This could result in a significant translation of the spinal cord toward the side of rotation within the dural sack. This homolateral shift of the spinal cord could then lead to dural tension and possibly contribute to cervicogenic headaches.

Methods: A convenience sample of 25 healthy subjects were recruited for this study. Musculoskeletal ultrasound imaging was used to measure the diameter of the Obliquus Capitis Inferior and the Rectus Capitis Posterior Major immediately following an isometric contraction into head extension and rotation.

Outcomes: An isometric-induced contraction resulted in a significant change in the diameter of the obliquus capitis inferior and contralateral rectus capitis posterior major and, thus, could affect the position of atlas in the atlantoaxial joint.

Discussion: The effect of an isometric-induced contraction of the obliquus capitis inferior and contralateral rectus capitis posterior major in a subgroup of asymptomatic individuals was measured using musculoskeletal ultrasound imaging. The results of this study indicate that the diameter of both muscles significantly changed with the isometric contraction. This study’s findings support that suboccipital muscles can contract in isolation and, thus effect the position of atlas.

Oscar Cobar
Pharmacogenomics and Nutrigenomics Research Laboratory, School of Chemical Sciences and Pharmacy, University of San Carlos, Guatemala.

Stella Cobar
School of Chemical Sciences and Pharmacy, University of San Carlos, Guatemala.

Abstract

Background: HV.1 (EG.5.1.6.1) was the dominant strain in the U.S. as of the end of second week of December 2023, according to the U.S. Centers for Disease Control and Prevention (CDC). The strain is a descendant of EG.5 family that was identified in China in February 2023 and was first detected in the United States in April 2023. 44 mutations in S-protein, 2 in Membrane and Envelope viral structures, 5 mutations in the Nucleocapsid, 21 mutations in Orf1a, 1 mutation in Orf3a, Orf6, Orf10, and 2 mutations in Orf8 virus genome open reading frames are reported. The symptoms of HV.1 are similar that of other Omicron variants, these include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea, but congestion, sore throat and dry cough seem to be the three most prominent symptoms right now. Since HV.1 belongs to the same family as XBB, health experts assumethat updated vaccines are expected to be effective against this new dominant subvariant.The only way to distinguish (COVID-19) from RSV and flu, both of which are now gaining steam, is by testing.

Aim: The purpose of the manuscript is to present a systematic review on the prevalence, structural, genomic, and pathogenic characteristics of HV.1 from October 1, 2023, as of December 31, 2023, emphasizing on the variant genetic characteristics, contagiousness, and potential pathogenicity.

Material and Methods: Original scientific articles published in Medline, Pubmed, Science Direct, Web of Science, Scopus, EBSCO and BioMed Central databases, official health organizations electronic publications, and specialized media in the subject, were electronically searched to accomplish the aim of the study. Articles published in any language were included from October 2023 to present using a variety of keywords in combination. The studies relevant to our review were analysed and compared.

Results and Discussion: HV.1 showed significantly lower plasma neutralisation titers compared with their parental strains after acquiring L452R and A475V mutations, explaining their growth advantages. A475V mutation also resulted in decreased binding affinity, enhancing immune evasion compared to HK.3 (XBB.1.5+FLip). However, the L452R mutation of HV.1 did not affect binding affinity. 44 mutations in S-protein, 2 in Membrane and Envelope viral structures, 5 in the Nucleocapsid, 21 in Orf1a, 1 mutation in Orf3a, Orf6, Orf10, and 2 in Orf8 virus genome open reading frames mutations are reported. These mutations give to HV.1 improved ability to enter the human cell, although no greater pathogenicity or severity of the symptoms.

Conclusions: The latest data from US-CDC in 2023, shows HV.1 as the second prevalent SARS-CoV-2 variant in the United States. HV.1 (XBB.1.9.2.5.1.6.1 or EG.5.1.6.1) in October 2023, quickly increase its prevalence and surpassed other variants, includingEG.5 (Eris) to become the most prevalent strain in USA until week ending on December 9, 2023. HV.1 has a similar transmission rate, exhibits a greater evasive capacity of immune-generated antibodies than EG.5.1* family of SARS-CoV-2, produce similar symptoms that of other Omicron variants, are expected not to produce an increase in hospitalizations and mortality rate and the SARS-CoV-2 vaccines recently developed by Pfizer and Moderna, must be effective against this Omicron subvariant.For now HV.1 does not seem harmful in terms of creating a deadly disease but is still contagious enough to not be ignored.

Kaveer Greywal
Lewisgale Medical Center, Capital Division, HCA Healthcare, Salem, VA, USA

Nelson Greene
Lewisgale Medical Center, Capital Division, HCA Healthcare, Salem, VA, USA

Rahul Kashyap
TriStar Centennial Medical Center, TriStar Division, HCA Healthcare, Nashville, TN, USA; Anaesthesiology & Critical Care Medicine, Mayo Clinic, Rochester, MN, US

Salim Surani, MD, MPH, MSHM, FACP, FAASM, FCCP
Anaesthesiology & Critical Care Medicine, Mayo Clinic, Rochester, MN, US; Texas A&M University, College Station, Texas, US; Valley Coastal Bend VA, Corpus Christi, Texas, US

Abstract

Since the outbreak of the COVID-19 pandemic, there have been myriad signs and symptoms ascribed to this disease process. While some of the most notable features described since the initial months of the pandemic include cough, fever, myalgia, headache, dyspnea/hypoxia, anosmia, and multifocal pneumonia, the pandemic’s prolonged continuation has afforded ample opportunity to detect more subtle signs of the disease. Mediastinal adenopathy is one such sign that has been found in many patients with active COVID-19 infection, though the value of this finding in both prognostication and guiding treatment remains unknown. We did a timely brief review of mediastinal adenopathy in COVID-19 infection to shed more light on the potential implications of this finding. We conclude that Mediastinal Adenopathy in hospitalized COVID-19 patients has been associated with higher ICU admissions and higher mortality. Its non-specific nature and confounding etiology may prevent it from being a good marker for prognosticator of COVID-19 disease severity.

Adriano Focus Lubanga
Kamuzu University of Health Sciences, Department of Public Health, Blantyre, Malawi; Clinical Research, Education and Management Services (CREAMS), Lilongwe, Malawi; Ollie Health Magazine Organization, International Research Academy (OHMO), Istanbul, Turkey

Alfred Lipenga
Kamuzu University of Health Sciences, Department of Public Health, Blantyre, Malawi; Clinical Research, Education and Management Services (CREAMS), Lilongwe, Malawi

Victor Mwapasa
Kamuzu University of Health Sciences, Department of Public Health, Blantyre, Malawi

Gift Kanyinji
Kamuzu University of Health Sciences, Department of Public Health, Blantyre, Malawi; Clinical Research, Education and Management Services (CREAMS), Lilongwe, Malawi

Darlington Ndlovu
Kamuzu University of Health Sciences, Department of Public Health, Blantyre, Malawi; Clinical Research, Education and Management Services (CREAMS), Lilongwe, Malawi

Tuntufye Sichinga
Kamuzu University of Health Sciences, Department of Public Health, Blantyre, Malawi; Clinical Research, Education and Management Services (CREAMS), Lilongwe, Malawi

George Mwenye-Phiri
Lake Malawi Anglican University, Lilongwe Malawi

Louis Mnyema Ng’oma
Anglican Council of Malawi, Lilongwe, Malawi

Elled Mwenyekonde
Christian Health Association of Malawi, Lilongwe Malawi

Donghyun Jeon
Youth with Talents, Fairfax, VA 20030, USA

Seok Gyu Han
Youth with Talents, Fairfax, VA 20030, USA

Kaylin Choe
Youth with Talents, Fairfax, VA 20030, USA

Joanna HH Seung
Youth with Talents, Fairfax, VA 20030, USA

Justin Kong
Youth with Talents, Fairfax, VA 20030, USA

Thomas Nyirenda
Department of Global Health, Stellenbosch University, Cape Town, South Africa; Clinical Research, Education and Management Services (CREAMS), Lilongwe, Malawi; The European and Developing Countries Clinical Trials Partnership (EDCTP), Cape Town, South Africa.

Abstract

Background: The COVID-19 pandemic has caused devastating effects on the world since its discovery in the city of Wuhan in 2019. It has claimed millions of lives and has significantly affected the economies of the world. However, the characteristics of affected populations in poorest settings in Africa are not clearly known.

Aims and Objectives: The study was undertaken to evaluate common clinical presentations of patients diagnosed with COVID-19, asses the socio-economic and demographic profiles and analyze the clinical course, and comorbidities of COVID-19 positive patients at Likuni mission hospital, central region of Malawi.

Methods: This was a cross sectional study, however we looked at retrospective data from for all patients diagnosed from January 2021 to January 2022.

Results:  Patients were predominantly female (65%), less than 40 years, without any known comorbidity and had at least 3 symptoms before being diagnosed. The most common symptoms were fever, cough, chest pains, headache, shortness of breath, and general body weakness. A significantly higher population were from low social economic status (p<0.05). Over 95% of the population suffered minor ailment and did not need hospitalization and advanced life support. All patients that required hospitalization were above the age of 60 and the results were statistically significant (p<0.05). More than 90% of the cases were locally spread and did not have traceable positive contact.

Conclusion: The diversity of clinical and epidemiological characteristic of patients diagnosed with COVID-19 across gender, socio-economic status, age group and occupation is extremely important. Our results provides an understanding of the characteristics of patients in a poor setting like Malawi and will inform policy makers at local hospitals and district levels including researchers and the ministry of health.

Matteo Varini
Centro Puzzle, Turin, Italy, ; Department of Psychology, University of Turin, Turin, Italy

Marina Zettin
Centro Puzzle, Turin, Italy, Department of Psychology, University of Turin, Turin, Italy

Marta Gai
Centro Puzzle, Turin, Italy,

Danilo Dimitri
Centro Puzzle, Turin, Italy; Department of Psychology, University of Turin, Turin, Italy

Abstract

Background. One of the most used non-invasive brain stimulation (NIBS) techniques in aphasia rehabilitation is Anodal Transcranial Direct Current Stimulation (A-tDCS). Its application is supported by the fact that brain plasticity, when facilitated by language intervention, can be improved by non-invasive brain stimulation. The effects of neuromodulation combined with various language and communication therapies have led to promising results in the rehabilitation of patients presenting with acquired aphasia. An Action Observation Therapy such as IMITAF seems to contribute to improvements in language skills, mainly in naming. This experimental clinical protocol aims to investigate the rehabilitative potential of A-tDCS on perilesional areas, combined with computerized neuropsychological training.

Method. Participant: Mr. V., 66-year old right-handed male, Italian native speaker. The patient suffered an ischemic stroke due to left carotid artery dissection which resulted in right hemiparesis, mixed transcortical aphasia, characterized by non-fluent speech and dysarthric and disfluent speech. Treatment: The subject underwent unipolar montage stimulation, with anode placed in F5 and intra-cephalic reference on Fp2. For safety reasons, a stimulation intensity of 1.5 mA was applied for 20 minutes once a day in combination with IMITAF level I, which required the subject to repeat bisyllabic words.

Procedure: The stimulation protocol lasted a total of 4 weeks and was divided into 2 different modes. Clinical Training: 40-minute treatments (no.10 sessions) and involved the combined administration of a-tDCS (20-minute online mode) and 40-minute training. Home-Based Training: 40-minutes trainig carried out at the patient’s home, via PC (no. 8 sessions). Results. Mr. V. completed the protocol treatment sessions without reporting any adverse effects, such as scalp redness, tingling or headache. The results showed an improvement in the auditory/visual comprehension of words/sentences after A-tDCS and Action Observation Therapy, which has maintained one month after treatment.

Conclusions. Together with IMTAF neuropsychological training, the constant and repeated use of A-tDCS, on the perilesional areas, contributed to improvements in language skills thus promoting an overall recovery of communicative skills in an individual with chronic post-stroke non-fluent aphasia.

Rajendra Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, Nehru Nagar, Belagavi, Karnataka, India.

Sonali Bijjargi
Department of Paediatrics, JN Medical College, KLE Academy of Higher Education & Research (Deemed-to-be-University), JNMC Campus, Nehru Nagar, Belagavi, Karnataka, India.

Shridhar C. Ghagane
Department of Biotechnology, KAHER‟s Dr. Prabhakar Kore Basic Science Research Center, 3rd Floor, V. K. Institute of Dental Sciences Campus, Nehru Nagar, Belagavi, Karnataka, India.

Swapnil A. Pattanshetti
Department of Paediatric Surgery, JN Medical College, KLE Academy of Higher Education & Research (Deemed-to-be-University), JNMC Campus, Nehru Nagar, Belagavi, Karnataka, India.

Shadab Rangrez
Division of Paediatric Urology, JN Medical College, KLE Academy of Higher Education & Research (Deemed-to-be-University), JNMC Campus, Nehru Nagar, Belagavi, Karnataka, India.

Shreyas Rai
Division of Paediatric Urology, JN Medical College, KLE Academy of Higher Education & Research (Deemed-to-be-University), JNMC Campus, Nehru Nagar, Belagavi, Karnataka, India.

Abstract

Introduction: There is limited data available on the epidemiological features, clinical manifestations, and transmission patterns in children with COVID-19, although there has been widespread information available regarding COVID-19 in adults. The objective of our study was to report our experience in the management of children admitted with COVID-19 to our hospital.

Materials & Methods: We retrospectively reviewed the in-patient records of all children  18 years of age admitted to our COVID-19 facility during the period March 2020 till May 2021. Detailed information including demographic data, travel and contact history, living conditions and overcrowding, symptoms, and presence of co-morbid conditions were noted. The clinical symptoms, physical findings, laboratory readings and imaging data were similarly noted and analysed.

Results: During the study period a total of 67 children (30 males and 37 females) with a mean age of 11.88 4.35 years were admitted to the COVID-19 facility. The presenting symptoms were fever (71.64%), skin rashes (14.93%), breathlessness (7.46%), cough (31.34%), cold (2.99%), headache (8.96%), sore throat (25.37%), loose motions (26.87%) and vomiting (8.96%). The RT-PCR was positive in 60 (89.55%) children. Sixty-one (91.045%) children recovered over a period of 10-14 days and were discharged.  Six (8.955%) children died due to multisystem failure. When compared to the children who recovered, the children who died had a significantly raised serum ferritin, IL 6, C reactive proteins, D-Dimer levels, and Sr LDH.

Conclusions: COVID-19 has been affecting children, more so in the second wave, with increased hospitalizations and mortality.

Aynur Ozge, MD, PhD
Department of Neurology, Mersin University School of Medicine, Mersin, Türkiye

Reza Ghouri
Department of Neurology, Brain 360 Integrative Center, İstanbul, Türkiye

Derya Uludüz
Department of Neurology, Brain 360 Integrative Center, İstanbul, Türkiye; Department of Neurology, Cerrahpaşa University Medical Faculty, İstanbul, Türkiye

Abstract

This comprehensive review examines the impact of vascular risk factors on the phenotypic expression of migraine in the elderly population. Migraine, particularly migraine with aura, has been established as a risk factor for ischemic lesions of the brain, stroke, and other cardiovascular diseases. The association between migraine and specific vascular events, such as stroke, myocardial infarction, and angina pectoris, underscores the need for a comprehensive understanding of the interplay between migraine and cardiovascular diseases. The challenges in differentiating migraine from vascular insults, especially in the elderly population, highlight the need for improved diagnostic and treatment strategies to address the complexities of managing migraine in this demographic. Patient education and treatment of modifiable risk factors may decrease future vascular events, emphasizing the importance of addressing vascular risk factors in migraine management. The potential impact of prevention and treatment of unfavorable arterial hemodynamics on neurocognitive outcomes underscores the broader implications of addressing vascular risk factors in migraine management. The clinical and public health relevance of understanding the modifiability of vascular risk factors in elderly migraine patients extends to addressing challenges in cancer survivorship, radiological emergency response, and rational person behavior, emphasizing the diverse applications of addressing vascular risk factors in healthcare and public health. Ultimately, the clinical and public health relevance of understanding the impact of vascular risk factors on the phenotypic expression of elderly migraine underscores the need for continued research and clinical vigilance in addressing the complex interplay between migraine and vascular risk factors in the elderly population.

Russ Best

Abstract

Mint and to a lesser extent menthol have been used since antiquity for medicinal purposes. Key components of mint and menthol use such as composition and intake, safety and traditional uses are discussed prior to a review of clinical and human performance outcomes in the areas of digestive and respiratory health; antibacterial and anti-fungal properties, nocioception, migraine and headache and emerging evidence regarding COVID 19. Evidence suggests benefit for patients with irritable bowel syndrome and related digestive issues, with analgesic and respiratory effects also noted. Perceptual characteristics relating to thermal comfort and sensation, taste sensitivity and alertness are also considered; these effects are predominantly driven by stimulation of transient receptor potential melastatin 8 (TRPM8) activity resulting in sensations of cooling and freshness, with lesser influence on thirst. Finally, sport performance is considered as a domain that may further elucidate some of the aforementioned underpinning outcomes due to its systemic and dynamic nature, especially when performed in hot environmental conditions.

Patrícia Candido
Moriah Institute of Science and Education (MISE), Hospital Moriah, São Paulo, SP, BR, Laboratory of Medical Investigation (LIM55), Urology Department, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.

Luís Otávio Alves Mendonça
Universidade do Estado de Minas Gerais – UEMG, Passos, MG, Brazil.

Paulo Otávio Lopes Pereira
Universidade do Estado de Minas Gerais – UEMG, Passos, MG, Brazil.

Elisa de Oliveira Valente
Universidade do Estado de Minas Gerais – UEMG, Passos, MG, Brazil.

Camila Costa de Morais
Universidade do Estado de Minas Gerais – UEMG, Passos, MG, Brazil.

Michael Silva Miranda
Universidade do Estado de Minas Gerais – UEMG, Passos, MG, Brazil.

Samuel Câmara
Universidade do Estado de Minas Gerais – UEMG, Passos, MG, Brazil.

Poliana Romão
Laboratory of Medical Investigation (LIM55), Urology Department, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.

Eunice Higuchi
Moriah Institute of Science and Education (MISE), Hospital Moriah, São Paulo, SP, BR

João Pádua Manzano
Moriah Institute of Science and Education (MISE), Hospital Moriah, São Paulo, SP, BR

Katia Ramos Moreira Leite
Laboratory of Medical Investigation (LIM55), Urology Department, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.

Ruan Pimenta
Laboratory of Medical Investigation (LIM55), Urology Department, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil; D’Or Institute for Research and Education (ID’Or), São Paulo, SP, Brazil.

Victor Srougi

Sabrina Reis, MSc; Ph.D.
Moriah Institute of Science and Education (MISE), Hospital Moriah, São Paulo, SP, BR, Laboratory of Medical Investigation (LIM55), Urology Department, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.

Abstract

Background/aim: The clinical spectrum of COVID-19 infection ranges from asymptomatic infection to deadly and potentially lethal disease. Although some studies have been performed, data on the long-term effects and persistent symptoms after COVID-19 are limited. We aimed to evaluate the long-term effects in an adult population with SARS-CoV-2 infection treated in a patient clinic.

Materials and Methods: The study included a random sample of 231 adults (≥18 years) with a positive outpatient test result for SARS-CoV-2 who were not hospitalized. We adapted six quality of life questionnaires already validated. We performed an overall analysis of the frequency of responses and then statistically correlated the frequency of symptoms with gender, age, and presence of comorbidities. Results: The mean age was 40.25 years old, 62.8% were women, who had a higher frequency of various symptoms (p < 0.05). We found a higher frequency of symptoms associated with SARS-CoV-2 in patients under 40 years: Shortness of breath at rest (p = 0.004), Shortness of breath when walking at your own pace (p = 0.007), Shortness of breath when performing sexual activities (p = 0.047), Tired or low energy (p = 0.002), Difficulty in concentrating (p = 0.047), Heart change even without physical exertion (p = 0.005), Headache (p = 0.007) and Memory problems (p = 0.031).

Conclusion: Our study showed that individuals that required no hospitalization might have persistent quality of life symptoms after recovery from COVID-19 infection. Therefore, there is a need for long-term follow-up and rehabilitation strategies for patients should be developed.

George W. Kukurin
KCANN

Corissa D. Audren

Abstract

The number of literature reports suggesting that various types of electrical, optokinetic, caloric, and mechanical vestibular stimulation may enhance recovery of function in patients suffering from traumatic and degenerative brain disorders is growing. This case report describes the integration of vestibular stimulation techniques into a rehabilitation treatment plan of a traumatically brain injured 16-year-old patient who had failed to sustain recovery after a course of standard care. His intractable signs and symptoms included headache, brain fog/mild cognitive impairment and disequilibrium which made participation in his chosen sport, hockey, virtually impossible.   His symptoms developed following a concussion while playing hockey.  He was treated by the team’s designated sports specialist and eventually cleared to return to play, however he was rapidly re-concussed. At the time he presented for evaluation, a battery of tests was conducted and clearly supported the reoccurrence of his symptoms. His baseline scores were Graded Symptom Checklist symptom severity 46, Standard Assessment of Concussion 25/30, BESS Balance Score 14, Trails Test A 15.0, Trails Test B 27.4, Processing Speed Task 63, Reaction time simple 255 and Reaction time choice 469. Standard methods of rehabilitation including Gaze Stabilization Exercises and Progressive Balance Exercises were augmented with vestibular stimulation through the use of skull vibrations and optokinetic stimulation. After 18 treatments over approximately six weeks of rehabilitation augmented with vestibular stimulation, findings associated with mTBI normalized and he was able to resume his full participation in sporting activities.  His post treatment scores were. Graded Symptom Checklist symptom severity 1, Standard Assessment of Concussion 24/30, BESS Balance Score 5, Trails Test A 12.4, Trails Test B 34.0, Processing Speed Task 64, Reaction time simple 245 and Reaction time choice 385. He remained asymptomatic at 4 months follow-up post discharge and is participating fully in team hockey activities. This case report describes the integration of vestibular stimulation into neurorehabilitation protocols which appeared to be associated with sustained reduction in disability and improved treatment-refractory symptoms in a patient with traumatic brain injury. It adds to the growing knowledgebase supporting the role of vestibular stimulation as an adjunct modality in the rehabilitation of brain disorders.

Stella Bruce
Neuroscience Undergraduate Program, University of Southern California

Kimberly Cockerham
Private Practice, San Diego, CA

Abstract

Patients presenting with neuro-ophthalmic disorders pose a diagnostic challenge when they present to community hospital emergency departments (ED) where expertise in neuro-ophthalmology is often limited. Many have no ophthalmology coverage or have a call group composed of general ophthalmologists who are not comfortable managing neuro-ophthalmic disorders. The limited familiarity with neuro-ophthalmology and the lack of essential equipment, such as a fundus camera or optical coherence tomography (OCT), contribute to a substantial gap in accurate and timely diagnosis and treatment. This deficiency results in patients making multiple visits to the emergency department, where they receive limited or no treatment, and this overall increases the risk of disease progression and potentially blindness.

Advocating for standardized protocols and integrating technological advancements will aid non-ophthalmologist physicians and mid-level physician extenders in the initial assessment and management of patients with acute visual issues. Additionally, improving the accessibility of neuro-ophthalmological services through telehealth, and diagnostic aids (such as smartphone-based fundus cameras) in emergency department settings is essential to avoid overlooked or misdiagnosed neuro-ophthalmological disorders.

We describe two common scenarios that illustrate the diagnostic journey of patients. One is a young patient presenting with headache and vague visual symptoms and the other is an elderly patient with unilateral visual loss and vague headaches. We will focus on the crucial role of the fundus camera/OCT in identifying disc edema but also discuss the key questions that help guide diagnosis.

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