Evaluation of an Algorithm for the Diagnosis and Therapy of Lyme Neuroborreliosis: A Follow-up Study

Background: Although Lyme Neuroborreliosis (LNB) is often seen in paediatric practice, diagnostic criteria for LNB in children are not clearly defined. The guidelines for LNB in adults are based on a combination of clinical picture, CSF pleocytosis and the detection of specific antibodies against Borrelia burgdorferi in CSF and serum. Diagnostic procedure takes several days, thus it isn´t useful in deciding for the need of prompt antibiotic treatment. Aim of study was a retrospective evaluation of an algorithm for the diagnosis and therapy of lyme’s disease, which is used since 2005 at the paediatric department of Innsbruck. Patients and Methods: All patients presenting with acute peripheral facial palsy from January 2006 to December 2014 were reviewed. The patients were diagnosed according to the algorithm, based on the criteria of the German Society of Neurology. The focus lay on evaluation of diagnosis and therapy according to the algorithm and whether overtreatment and underdiagnosis could therefore be avoided. Results: 120 patients were enrolled with peripheral facial palsy. 65 (54%) were handled as bell´s palsy and 55 (46 %) as B. burgdorferi s.l. infection. 19 cases were classified as confirmed LNB, 10 as probable and 26 as possible LNB. A total of 69 patients (58 %) were treated correctly according to the algorithm, 16 (13%) were over treated and 14 (11%) under treated with antibiotics. 21 (18%) could not be classified, according to the algorithm, due to the lack of CSF results. Although receiving proper treatment, 3 cases had a persistent defect after recovery. Conclusions: The algorithm is an appropriate diagnostic tool for the diagnosis and therapy of LNB, particularly with regard to the necessity of a prompt antibiotic treatment, and therefore helpful to avoid underdiagnosis and overtreatment.

The Scope and Impact of a Novel, Urban, Rapid Patient Interhospital Transfer System to Improve Neuroemergent Care: The Design and Development of the Neuroemergency Transfer Program

Background: Access to neuroemergent care in the United States represents a significant public health concern, with limited neurosurgery and/ or neurocritical care coverage in both rural and urban settings. Inadequate access to neuroemergent providers, even in urban settings, may result in prolonged patient transfer time, associated neurological decline and translate into increased morbidity and mortality. Methods: A single center retrospective analysis of prospectively collected data of interhospital patient transfers to a neuroscience ICU between 2008-2018 was performed. Results: 9637 patients were included for analysis. A substantial increase in transfer requests were observed, 610 to 1221 from 2008 to 2018 respectively, with concurrent increase in the number and geographic distribution of referral centers. Ultimately, 7726 (80.2%) patients were discharged home or to outpatient or acute rehabilitation while 1820 (18.9%) were discharged to a long-term acute care facility (LTAC), hospice, or expired during the index admission. The leading diagnoses for transfer were: 1. intracerebral hemorrhage, 2. subarachnoid hemorrhage, 3. ischemic stroke, 4. subdural hematoma and 5. brain tumor. Transfer from an ED or ICU constituted 93.3% of requests. Mean total transfer time between 2012-2018 was < 155 minutes annually (range 128-155 minutes). In 2018, 91.5% of patients had health insurance with 68.7% covered by some form of Medicaid or Medicare. Conclusions: The ongoing evolution and overall success of the NTP draws chiefly from the designation of an easily accessible central operator to orchestrate transfer, establishing a network of community referral centers and optimization of regional patient transportation - all with the solitary goal of improving patient outcomes.

Clinical and Electrooculographical Finding in Patient with Essential Tremor

Background: Essential Tremor (ET) is the most common movement disorder, yet the location of the primary disease substrate continues to be a matter of debate. In this study, we aimed to evaluate ocular movement abnormalities with Electrooculography (EOG) in patients with ET to find a possible location of disease pathology. Methods: Electrooculographic evaluation including saccade, tracking, optokinetic, gaze and positional tests were performed to 36 ET patients and 36 healthy subjects. Patient age on the onset of the tremor, duration of the disease, characteristics and the location of the tremor were also investigated. Fahn- Tolosa-Marin tremor rating scale was used to determine the tremor severity. Differences of abnormal test results between patient and control groups were analysed with Pearson’s and Fisher’s Exact and correlation analyses of EOG tests and clinical data were performed with Spearman’s and Pearson’s correlation tests. Results: There was not any significant difference in EOG tests between the ET patients and controls. Significant correlation was only found between EOG abnormality and patient age in correlation analyses. Conclusions: Our results showed that ET patients may not have specific EOG test abnormalities. These tests would be used especially in the different diagnosis of other movement disorders.

Antepartum COVID-19 and Postpartum Autism

A little over a year ago, a new viral disease appeared worldwide. Much like earlier pathologic RNA viruses, Covid-19 can cause distinctive harmful effects on pregnant women and their offspring. Because of the coexistent fever associated with a rise in pro-inflammatory interleukins in the most severe cases, there is a serious concern about the baby’s neurologic development. Although not yet observed in many Covid-19 pregnancies, it is anticipated particularly that the onset of autism in the child may be realized in a year or more postpartum. Prior studies have reported that exclusive breast-feeding which provides a good source of IGF1 for the baby may well reduce the incidence of autism in such cases.

Brain Tumors Presumed Malignant without Biopsy-Evaluation and Treatment Problems

Patients with brain tumors may have the following issues: tumors are in deep or vital regions; they refuse the biopsy; the neurosurgeon does not reach the tumoral tissue and the biopsy is irrelevant; advanced cases, considered “outside the surgical and oncological therapeutic resources”. These patients cannot receive oncological treatment or radiotherapy because of the restrictive indications of the insurers (health insurance companies) or because of the risk of allegations of malpractice. Patients will not receive some social security rights (short term sick leave, disability pension) in the same way as cancer patients, but only as a patient with a common illness. Patients can receive palliative treatment, can be hospitalized in oncology departments. We propose to discuss a separate diagnostic and treatment protocol for this group of patients, based on laboratory (ctDNA) and imagistic criteria. Assistive technologies using Computer Vision Model combined with Convolutional Neural Network may help classificate and diagnose these tumors.

TLR2, SOCS1 and IL1R1 but not Legionella Play a Potential Role in the Pathogenesis of Bell’s Palsy Revealed by Competitive Endogenous RNA Network Study

Background: The present study aimed to identify the key long noncoding RNAs (lncRNAs) and determine their potential etiological factors of Bell’s palsy using RNA-Seq data based on bioinformatics tools. Methods: Serum from fifteen patients with Bell’s palsy and fifteen healthy individuals were collected. Differentially Expressed Genes (DEGs)-Differentially Expressed lncRNAs (DELs) in two groups were identified. The competing endogenous RNAs (ceRNAs) regulatory network was constructed by integrating lncRNA-mRNA pairs, miRNA-mRNA regulatory pairs, and miRNA-lncRNA pairs using Cytoscape. The Gene Ontology (GO) functions and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways analyses of key lncRNAs in the ceRNA network were evaluated to explore the effects of lncRNA during the occurrence of Bell’s palsy. Finally, pathogen culture, ELISA or q-PCR were applied to verify the presence of the pathogen and relevant cytokines or proteins. Results: In the present study, hub proteins such as TLR2 (degree=25), ITGAM (degree=14), SOCS1 (degree=13), IL1R1 (degree=11) were identified in PPI network based on DEGs. Subsequently, 2761 lncRNA-mRNA coexpression pairs including RP11-415J8.3-TLR2, 5629 miRNA-lncRNA interaction pairs, and 51 miRNA-mRNA interactions were obtained. Finally, 9 miRNAs, 5 DEGs, 6 DELs, and 9 miRNA-mRNA pairs, 10 miRNA-lncRNA pairs, and 7 mRNA-lncRNA co-expression pairs were including in ceRNA regulatory network. Meanwhile, RP11-415J8.3 were mainly enriched to legionellosis (pathway), cytokine receptor activity (GO: 0004896), and phospholipid binding (GO: 0005543). Subsequently, validation of neuroinflammation relevant TLR2, ITGAM, SOCS1, IL1R1 and legionella through another forty-five BP patients and thirty healthy individuals showed that TLR2, ITGAM, IL1R1 expressions were upregulated in the serum of patients with Bell’s palsy while SOCS1 was down-regulated, while legionella was not found among them. Conclusions: We hypothesized that the etiological factor of Bell’s palsy correlate to a complex miRNA-lncRNA-mRNA interacting network and IL1R1, SOCS1 and TLR2 may involve in the onset of Bell’s palsy rather than legionella.

Adult-onset Neurological Langerhans Cell histiocytosis and Response to Treatment

Introduction: Langerhans Cell Histiocytosis (LCH) is a rare form of cancer that mostly affects children and rarely adults. LCH involves an abnormal clonal proliferation of Langerhans cells in the bone marrow. These cells are capable of migrating from the skin to lymph nodes. Therefore, it is characterized as a multisystem disease. Neurological manifestations are not common, and often patients’ present with endocrine dysfunction with neuroimaging findings of hypothalamic and pituitary masses can mimic pituitary adenoma. Here, we discuss two instances of unusual adult-onset, primary neurological LCH in patients with a positive response to therapy-these two patients presented with mass lesion and neurodegenerative form of LCH, respectively. LCH can manifest features of mass lesions or neurodegeneration on brain Magnetic Resonance Imaging (MRI). Since it is rare in adults, it is crucial to identify this condition as timely treatment can have a better prognosis.

Spinal Modulation by Dexamethasone Sodium Phosphate, Cyclophosphamide and Miconazole Iontophoresis in Asymptomatic SARS-CoV-2 Patient with Extensive Myelitis

A very rare neurological complication of SARS-CoV-2 infection includes transverse myelitis. I assume a post-infectious etiology in terms of secondary immunogenic overreaction. Iontophoresis is the process of the permeation of ionic (charged) drugs into the body under the influence of electrical current. Besides increasing therapeutic efficiency by, by passing first pass metabolism there are less risks of systemic absorption and undesirable side effects. The study was conducted in a SARS-CoV-2 patient with transverse myelitis, by transdermal application of dexamethasone sodium phosphate, cyclophosphamide and miconazole by iontophoresis at corresponding vertebral levels to look for the neurological outcome who had been unresponsive to intravenous methylprednisolone. With Dexamethasone sodium phosphate and cyclophosphamide iontophoresis there was modulation of the activity of posterior grey column, fasiculus gracilis and corticospinal tracts, and with miconazole iontophoresis I was able to ameliorate the dyesthesias, fasiculations and muscle atrophy probably due to neuromodulation at substantia gelatinosa and lamina IX and remyelination effect. There were no systemic or localized side effects and no adverse effects occurred during the treatment period.

The Etiology and Secondary Prevention of a Stroke Patient after Successful Catheter Ablation

Ischemic Stroke (IS) is one of the leading diseases of mortality and disability worldwide. The rational administration of anticoagulant or antiplatelet drugs is of great importance to prevent stroke recurrence. Here we report an IS patient with a medical history of Catheter Ablation (CA) of Atrial Fibrillation (AF), who had a single vessel scattered lesions in the head Magnetic Resonance Imaging (MRI) scan, which indicated a remarkable correlation with morphology of atherosclerotic artery and artery embolism, while no AF recurrence was detected. At last, we focused on the possible criminal artery and found vulnerable plaques from apparent positive remodeling demonstrated by High-Resolution Vessel Wall MRI (HRVW-MRI). We provided a secondary prevention with the statin and antiplatelet therapy to reduce the risk of bleeding caused by anticoagulation and asked him to follow up Holter every three months. Along with this case report, we describe the imageology, review of literature and treatment outcomes in regard to CA of AF and discuss the prevention of IS.