Cardiac Sarcoidosis Presented With Hiccups: A Case Report and Literature Review

Sarcoidosis is a multisystem disorder of unknown etiology commonly associated with hilar lymphadenopathy and granulomas. Cardiac involvement is less common; however, sarcoidosis is a known cause of restrictive cardiomyopathy. It typically presents as new-onset arrhythmias or heart failure, although cases of sudden cardiac death have been reported. We present a case of a 56-year-old male with a known history of pulmonary sarcoidosis, not on active treatment, who presented to the emergency department with a week of continuous hiccups every few seconds associated with non-exertional dyspnea. An initial computed tomography (CT) scan of the chest showed multiple stellate-like ground-glass opacities and the progression of bronchiectasis. Troponins were negative. On the initial electrocardiogram (EKG), he was found to be in atrial flutter and was admitted to the medical floor. Cardiology was consulted for suspected cardiac sarcoidosis, and they recommended transfer to the tertiary care center for further evaluation. Upon arrival, the patient underwent catheter ablation for atrial flutter and returned to sinus rhythm after the procedure. The initial nuclear scan with gallium was not suggestive of cardiac sarcoidosis. However, subsequent cardiac magnetic resonance imaging (MRI) showed cardiac involvement. Due to the high risk of arrhythmias, the patient was scheduled for implantable cardioverter defibrillator placement before discharge. The patient was given oral prednisone. The patient was discharged in stable condition, and interrogation of the device found it well functioning, and no significant arrhythmias were noted. Presentation of cardiac sarcoidosis can be variable, and any should be considered in any patient with a known history of sarcoidosis who presents with atypical symptoms above the diaphragm, such as hiccups or with new-onset arrhythmias.

Hypophosphatemia in Patients With Multiple Myeloma

Hypophosphatemia is among the most common electrolyte abnormalities, especially among patients with underlying malignancies, and is frequently associated with adverse prognoses. Phosphorus levels are regulated through a number of mechanisms, including parathyroid hormone (PTH), fibroblast growth factor-23 (FGF-23), vitamin D, and other electrolyte levels themselves. Clinically, the findings are nonspecific, and the diagnosis is frequently delayed. This article is a narrative literature review. The PubMed database was searched for relevant articles pertaining to hypophosphatemia causes and consequences in patients suffering from multiple myeloma. We found a variety of causes of hypophosphatemia in patients with multiple myeloma. Tumor-induced osteopenia, although more common among patients with small squamous cell carcinomas, can occur with multiple myeloma as well. Additionally, both light chains themselves and medications can trigger Fanconi syndrome, which leads to phosphorus wasting by the kidney. Bisphosphonates, in addition to being a possible cause of Fanconi syndrome, lead to a decrease in calcium levels, which then stimulates parathyroid hormone (PTH) release, predisposing the patient to significant hypophosphatemia. Additionally, many of the more modern medications used to manage multiple myeloma have been associated with hypophosphatemia. A better understanding of those mechanisms may give clinicians a clearer idea of which patients may need more frequent screening as well as what the potential triggers in the individual patient may be.

Impact of erythropoietin therapy on cardiorenal syndrome: A systematic review with meta-analysis

BACKGROUND

Heart and kidney dysfunction frequently coexist in patients with acute heart failure due to the overlap between these two organ systems. Cardiorenal syndrome (CRS) results from pathology occurring in the heart and kidneys along with the consequences of dysfunction in one organ contributing to dysfunction in the other and vice versa.

AIM

To evaluate the use of erythropoietin (EPO) in patients with CRS and its effects on hemoglobin (Hb), major cardiovascular (CV) events, and hospitalization rates.

METHODS

On February 24, 2022, searches were conducted using PubMed, MEDLINE, and EMBASE, and 148 articles were identified. A total of nine studies were considered in this systematic review. We assessed the included articles based on the National Heart, Lung, and Blood Institute quality assessment tools for controlled intervention and observational cohort or cross-sectional studies. An assessment of bias risk was conducted on the chosen studies, and data relevant to our review was extracted.

RESULTS

The systematic review of these studies concluded that most existing literature indicates that EPO improves baseline Hb levels and decreases myocardial remodeling and left ventricular dysfunction without reducing CV mortality. In addition, the effect of EPO on the hospitalization rate of patients with CRS needs to be further studied since this relationship is unknown. Future studies, such as randomized controlled clinical trials and prospective cohort studies, should be conducted to enhance the literature on the potential of EPO therapy in patients with CRS.

CONCLUSION

Our systematic review suggests that EPO therapy may have a significant role in managing CRS. The review highlights the potential benefits of EPO in improving baseline Hb levels, reducing the risk of major CV events, improving cardiac remodeling, myocardial function, New York Heart Association class, and B-type natriuretic peptide levels. However, the effect of EPO treatment on hospitalization remains unclear and needs further exploration.

Torsades De Pointes in a 71-Year-Old Female With Normal Qt Interval After Azithromycin Use

A 71-year-old female visiting from Colombia presented to the emergency room with a productive cough, subjective fever, and chills for the past three days. Baseline EKG demonstrated a QT interval of 385 milliseconds with left ventricular hypertrophy and T wave inversions in leads V4, V5, and V6. Azithromycin was administered, and she was subsequently found to have torsades de pointes (TdP) on telemetry. In high-risk individuals, medications with reduced effects on cardiac conduction should be considered to avoid potentially lethal reactions. This case highlights the importance of clinical history prior to the administration of medications that have a propensity to cause abnormalities in cardiac conduction. Our patient had a grossly normal QT interval prior to the administration of azithromycin; however, she subsequently developed torsades de pointes. The patient was on telemetry monitoring, and cardiopulmonary resuscitation was quickly initiated as she was in a hospitalized setting; however, in an outpatient community setting, she likely would not have survived. By examining all the elements which contribute to QT prolongation, clinicians can have a deeper understanding of the complexities, particularly in individuals with multiple co-morbid conditions prior to the administration of medications that have a propensity to affect the QT interval.

Mortality rate of COVID-19 infection in end stage kidney disease patients on maintenance hemodialysis: A systematic review and meta-analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been the most talked-about disease of the past few years. Patients with significant comorbidities have been at particular risk of adverse outcomes. This study looked at the outcomes and risk factors for adverse outcomes among patients on chronic hemodialysis for end-stage renal disease, a group of patients known to be particularly susceptible to infectious complications.

AIM

To assess outcomes and risk factors for adverse outcomes of COVID-19 infection among patients on chronic hemodialysis.

METHODS

We searched PubMed/MEDLINE, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Web of Science databases for relevant terms and imported the results into the Covidence platform. From there, studies were assessed in two stages for relevance and quality, and data from studies that satisfied all the requirements were extracted into a spreadsheet. The data was then analyzed descriptively and statistically.

RESULTS

Of the 920 studies identified through the initial database search, only 17 were included in the final analysis. The studies included in the analysis were mostly carried out during the first wave. We found that COVID-19 incidence among patients on hemodialysis was significant, over 10% in some studies. Those who developed COVID-19 infection were most likely going to be hospitalized, and over 1 in 5 died from the infection. Intensive care unit admission rate was lower than the infection lethality rate. Biochemical abnormalities and dyspnea were generally reported to be associated with adverse outcomes.

CONCLUSION

This systematic review confirms that patients on chronic hemodialysis are very high-risk individuals for COVID-19 infections, and a significant proportion was infected during the first wave. Their prognosis is overall much worse than in the general population, and every effort needs to be made to decrease their exposure.

FDA-Approved Pharmacotherapy for Weight Loss Over the Last Decade

Obesity is a recently defined illness whose diagnosis and treatment continue to be stigmatized. Currently, due to lifestyle changes brought on by technological advancements and the wide availability and affordability of high-calorie foods, millions of people around the world suffer from obesity and/or its sequelae. Finding adequate prevention and treatment options would therefore lead to massive improvements in the duration and quality of life of affected individuals. In this review, we searched the PubMed database for studies exploring the safety and efficacy of the five medications currently approved by the FDA for the treatment of obesity. We included only studies pertaining to adult patients that have been published between 2012 and 2022. We found evidence that all the drugs analyzed such as orlistat, phentermine/topiramate, naltrexone/bupropion, liraglutide, and semaglutide appear to be effective in inducing weight loss, with the suggestion that semaglutide may have superior efficacy. However, a massive obstacle in developing treatment guidelines remains the lack of prolonged studies monitoring the long-term safety and efficacy of obesity medications. Nevertheless, in patients at risk of complications from obesity, the benefits of losing fat mass may outweigh the potential side effects associated with these medications and clinicians should prescribe whichever of the FDA-approved pharmacotherapy they deem most appropriate for the patient’s specific set of circumstances.

Role of Hydrogen Sulfide in the Treatment of Fibrosis

Hydrogen sulfide (H₂S) is a biological gas, the abnormal metabolism of which has associations with the pathogenesis of fibrosis. The purpose of this paper was to determine the potential of H₂S in the prevention and treatment of fibrosis. The data is obtained mainly from articles found in the PubMed database using the keywords “fibrosis” and “hydrogen sulfide,” limiting the results to those published within the last 10 years. Some additional resources have also been used, such as books and articles within journals. Evidence of decreased H₂S enzyme levels in animal models with fibrotic diseases has been found. The protective role of H₂S has been validated by the administration of exogenous H₂S donors in animal models with fibrosis. It is also evident that H₂S is involved in complex signaling pathways and ion channels that inhibit fibrosis development. These findings support the role of H₂S in the treatment of a variety of fibrotic diseases. A randomized controlled trial in fibrosis patients comparing the efficacy of exogenous H₂S and placebo in addition to standard of care can be implemented to validate this further.

Is Prophylaxis the Only Way Out for Cytokine Release Syndrome Associated With Chimeric Antigen T-cell Therapy?

Chimeric antigen receptor T-cell (CAR-T) therapy is a new advancement in hematology and oncology with its use in treating many refractory malignancies. Cytokine release syndrome (CRS) is CAR-T's clinically hazardous side effect, ranging from mild to life-threatening events. It was one of the first side effects detected with CAR-T. We conducted a literature review using PubMed (MeSH) to study CRS incidence after the administration of CAR-T to reflect its clinical importance. Nine studies are mentioned, with a total of 1357 patients enrolled for different types of refractory/relapsed cancers, and an average incidence of CRS of 64% is being noted. We have also stated numerous studies which mentioned the use and effectiveness of the commonly used drugs like tocilizumab, corticosteroids, and some new drugs. Although statistical data on CRS's conservative and supportive management is not available, the role of different supportive measures is evident. An overview of how it sets the framework of a peri-management approach has been considered. Through heightened incidence and relatively complex management of CRS, we would like to raise the question of the need for early prophylaxis against CRS when considering CAR-T. The need for more clinical trials in the future to prove the effectiveness of the latter is stated.

Clozapine-Related Thromboembolic Events

Clozapine is an atypical antipsychotic used for treatment-resistant schizophrenia. Venous thromboembolism (VTE) is a rare side effect of clozapine which can be fatal. This article summarizes current evidence regarding the risk of VTE associated with the use of clozapine. We performed a PubMed (MeSH) and Google Scholar search for the last two decades. Studies or case reports performed in humans were included in the review, of which 42 case reports of patients taking clozapine at VTE onset were included in the analysis of this review. According to the articles reviewed, the mean age was 42.9 years, with more males (71.43%) than females (28.57%). The average clozapine dose was 285.62 mg/day. VTE onset occurred within the first six months in 71.8% of the cases. Overall, 70.37% of the patients had comorbidities, and 87.5% had risk factors for VTE. In total, 68.57% were prescribed other medications at VTE onset, and 60% were being treated with another antipsychotic concomitantly. Finally, 32.5% of the patients died, while 67.5% survived. In 60% of the cases, clozapine was discontinued after VTE. In our literature review, we observed that among clozapine users, VTE occurred at a wide dose range, and most of the events occurred within the first six months. As many patients who are prescribed clozapine have risk factors for VTE, the risk should be considered at the time of prescribing. Further research should be conducted to elucidate the risk of VTE in clozapine users and the benefits of thromboprophylaxis.

Takayasu's Arteritis and Its Association With Mycobacterium Tuberculosis: A Systematic Review

Takayasu's arteritis (TAK) is a rare large vessel vasculitis of unknown etiology that chiefly targets the aorta and its branches. It predominantly affects females under 50 years of age. A relationship between TAK and Mycobacterium tuberculosis (TB) has been suggested for a long time, but only a few systematic studies have been done centering on this association. The present systematic review aimed to analyze the possible association between TAK and TB based on the studies conducted previously. A detailed search was conducted until April 2021 using three databases: PubMed, Cochrane Library, and MedlinePlus. PubMed search on the related topic identified 1053 articles, four on Cochrane Library, and three on MedlinePlus. Finally, 13 papers were pertinent for our review. The appropriate data was extracted from these articles, and the risk of bias assessment was done. The systematic review of these finalized articles found that the majority of the current studies supported the presence of TB in patients with TAK. Out of 13 final observational studies, only one study failed to detect a link between TAK and TB. However, data are still lacking that show a direct link between them. Future large-scale studies are needed to probe the exact role of Mycobacterium tuberculosis infection in the etiopathogenesis of TAK.

Influence of Microbiome and Antibiotics on the Efficacy of Immune Checkpoint Inhibitors

The human microbiome mainly consists of bacteria and interacts closely with the immune system. Immune checkpoint inhibitors (ICI) are used to treat several types of cancers. Recently, it has been identified that the gut microbiome plays a role in the effectiveness of immunotherapy. This study aims to analyze the effect of microbiome and antibiotics on the effectiveness of ICI in cancer patients and the measures to improve efficacy based on that. A detailed review was conducted on articles published in PubMed and Science Direct in the last five years i.e., 2016 to 2021. A total of 16 articles involving 1293 patients with cancer who were receiving immunotherapy, were deemed eligible to be included in the final review. Data were extracted from the eligible articles and were checked for quality appraisal. All 16 articles revealed the effect of either gut microbiome or antibiotics or both on ICI. Based on our findings, we found that the microbiome enriched in different microorganisms responded differently to the ICI and that antibiotics negatively impacted the effectiveness of ICI. The time at which patients receiving ICI were prescribed antibiotics influenced the effect of ICI. Antibiotics and different microbiome also affected progression-free survival (PFS) and overall survival (OS).

Systemic Sclerosis Associated Interstitial Lung Disease and Nintedanib: A Rare Disease and a Promising Drug

Systemic sclerosis-associated interstitial lung disease (SSc-ILD) is a rare disease with a progressive nature, eventually leading to lung fibrosis. Nintedanib, a tyrosine kinase inhibitor, is a widely accepted drug for treating idiopathic pulmonary fibrosis (IPF), a disease that shares some similarities with SSc-ILD regarding pathological disease processes. In this review, we aim to discuss the pathogenesis of SSc-ILD and the overall role of nintedanib in the management of SSc-ILD. SSc-ILD involves multiple pathological mediators contributing to various pathways that ultimately cause lung fibrosis. The pathogenesis of SSc-ILD is a complex phenomenon and still needs further study. Nintedanib has demonstrated its efficacy in the treatment of SSc-ILD by reducing the progression of the pathological process. It has also proven its clinical significance in the management of SSc-ILD. However, the currently available literature does not have any evidence to compare the effectiveness of nintedanib with the already available treatment modalities such as cyclophosphamide (CYC), mycophenolate mofetil (MMF), and azathioprine (AZT). The current literature also lacks information about nintedanib's long-term consequences on patients with SSc-ILD. Therefore, to create better evidence-based treatment guidelines, we recommend that researchers conduct randomized clinical trials comparing nintedanib to MMF, CYC, AZT, etc., and continue surveillance to explore the long-term consequences of nintedanib.

A Paradigm Shift in the Management of Atherosclerosis: Protective Role of Sirtuins in Atherosclerosis

 Facing the rise of an aging population and age-related pathologies such as atherosclerosis will continue to be some of the biggest challenges encountering health care. Regardless of considerable advancements in management and prevention to deal with atherosclerosis and other related pathologies. The current guidelines for preventing and managing atherosclerotic diseases are lifestyle changes, blood pressure control, blood glucose control, and lipid control. There has been an increase in pre-clinical studies regarding the effects of sirtuins on atherosclerosis and this review aims to highlight the benefits of sirtuins in atherosclerosis. We did an extensive search using the PubMed database with the medical subject headings (MeSH) keywords “sirtuin'' and “atherosclerosis.” The reviewed literature reported that sirtuins prevent and ameliorate atherosclerosis by halting inflammation, apoptosis, oxidative stress, and regulating low-density lipoprotein (LDL) cholesterol. Sirtuin 1 (SIRT1) and sirtuin 6 (SIRT6) inhibit the RELA component of NF-kB, thus suppressing inflammation, SIRT1 inhibits p53 by deacetylation, and the latter stabilize telomeres thus preventing apoptosis and cell death. Sirtuin 3 (SIRT3) inhibits oxidative stress by driving the production of reduced glutathione. Sirtuin 2 (SIRT2) regulates LDL cholesterol by inhibiting pcsk9, increasing LDL receptors on the cell surface of hepatocytes. A combination of these effects of sirtuins in the endothelial cells suggests sirtuins are anti-atherogenic and could revolutionize the standards for the management of atherosclerosis. This article also emphasizes the need for future research on human cells or subjects rather than animal subjects.

Association of G20210A Prothrombin Gene Mutation and Cerebral Ischemic Stroke in Young Patients

Ischemic stroke is an acute episode of neurological dysfunction resulting from the focal brain and spinal cord infarction. Many etiologies have been reported and vary significantly with the age of the patients. This study aims to show the association of G20210A prothrombin gene mutation and cerebral ischemic stroke in young patients. The prothrombin gene mutation is the second most common inherited thrombophilia after the factor V mutation. In this single missense mutation, guanine is substituted by adenine base pair in the nucleotide position 20210 of the 3'-untranslated region of the prothrombin gene, resulting in abnormal thrombin production predisposing to both arterial or venous thrombosis. Forty-seven relevant articles were selected after a thorough screening process using a regular keyword ‘G20210A Prothrombin’ and/or ‘Ischemic Stroke’ mostly from the PubMed database. We included the studies that are published in the last 22 years with patients age ≤57 years. This review article depicts the association of G20210A prothrombin gene mutation with ischemic stroke in young patients irrespective of ethnicity and zygosity status of their genotype. However, more multicenter prospective studies are needed to better understand the application of prothrombin gene mutation in predicting the associated risk of ischemic stroke in young patients and its importance in deciding the patients' treatment or prognosis.

Alzheimer's Gone Viral: Could Herpes Simplex Virus Type-1 Be Stealing Your Memories?

Alzheimer's disease (AD) is one of the principal causes of disability and morbidity. It is one of the most expensive illnesses. Despite this, there are no significant data regarding its etiology and optimal treatment. This review concentrates on the viral hypothesis of AD. After a comprehensive PubMed literature search, we analyzed the studies associating herpes simplex virus type-1 (HSV1) infection to AD from the previous 10 years. Molecular mechanisms whereby HSV1 induces AD-related pathophysiology, including neuronal production and accumulation of amyloid-beta (amyloid-β), abnormal phosphorylation of tau proteins, impaired calcium homeostasis, and autophagy, are addressed. The virus also imitates the disease in other ways, showing increased neuroinflammation, oxidative stress, synaptic dysfunction, and neuronal apoptosis. Serological studies correlate HSV1 infection with AD and cognitive impairment. A causal link between HSV1 and AD raises the concept of a simple, efficient, and preventive treatment alternative. Anti-viral agents impede brain degeneration by preventing HSV1 spread and its replication, decreasing hyperphosphorylated tau and amyloid-β; thus providing an efficacious treatment for AD. We also mention brown algae, intravenous immunoglobulin (IVIG), and a synthetic drug, BAY57-1293, with anti-viral properties, as options for treating AD. We want to recommend future researchers to look for more affordable, non-invasive, and swifter techniques to identify HSV1 in the brain and assist in the early detection and prevention of AD.

The Effects of Resveratrol on Telomeres and Post Myocardial Infarction Remodeling

Post myocardial infarction (MI) remodeling is the term used to define the changes in cardiac musculature after sustaining an ischemic injury. These changes decrease myocardial function and ultimately lead to heart failure. We review the contributing factors to post-MI remodeling, its association with telomere biology, as well as a myriad of other factors affecting aging and telomere length in relation to cardiovascular health. The main focus is on the effects of resveratrol in the cardiovascular system and its potential for therapeutic use in preventing long-term cardiovascular morbidity and mortality. We tried to answer important questions regarding the potential for resveratrol as a therapeutic drug to prevent adverse post-MI remodeling. In our search, we gathered 62 studies and narrowed our data down to 44 studies. The database used was PubMed, and the keywords used are "Resveratrol", "Telomere", "Post Myocardial Infarction". All the studies were carefully screened for relevant articles regarding our topic manually, Articles related to a positive association between resveratrol and its anti-aging, cardioprotective effects have been included in our study, as we could not find any articles in our search which showed a negative correlation. Our review concluded that resveratrol had pro-telomerase effects which could counter the development of adverse post-MI remodeling. Therefore resveratrol could be a useful therapeutic add-on drug to prevent cardiovascular disease. It is essential that further research including observational and large-scale clinical trials should be conducted to increase our understanding of the efficacy and viability of these novel therapeutic interventions.

The Role of the Gut Microbiota and the Immune System in the Development of Autism

Autism‌ ‌spectrum‌ ‌disorders‌ ‌(ASDs)‌ ‌are‌ ‌neurodevelopmental‌ ‌disorders‌ ‌that‌ ‌present‌ ‌with‌ ‌social‌ skills‌ ‌and‌ ‌communication‌ ‌challenges,‌ ‌restricted‌ ‌interest,‌ ‌and‌ ‌repetitive‌ ‌behavior.‌ ‌The‌ ‌specific‌ cause ‌of‌ ‌autism‌ ‌is‌ ‌not‌ ‌well‌ ‌understood‌ ‌yet.‌ ‌However,‌ ‌numerous‌ ‌studies‌ ‌indicated‌ ‌that‌ ‌environmental‌ ‌and‌ ‌genetic‌ ‌factors,‌ ‌dysregulated‌ ‌immune‌ ‌response,‌ ‌and‌ ‌alterations‌ ‌to‌ ‌the‌ ‌balance‌ ‌and‌ ‌content‌ ‌of‌ ‌the‌ ‌gut‌ ‌microbiota‌ ‌are‌ ‌implemented‌ ‌in‌ ‌the‌ ‌development‌ ‌of‌ ‌autism.‌ ‌Many‌ ‌non-pharmacological‌ ‌interventions‌ ‌are‌ ‌nominated‌ ‌to‌ ‌manage ‌autism,‌ ‌including‌ ‌family‌ ‌support‌ ‌services‌ ‌and‌ ‌psychoeducational‌ ‌methods‌. Moreover,‌ ‌different‌ ‌pharmacological‌ ‌therapy‌ ‌modalities‌ ‌are‌ ‌recommended‌ ‌for‌ ‌children‌ ‌with‌ ‌ASD.‌ ‌Learning‌ ‌more‌ ‌about‌ ‌the‌ ‌brain,‌ ‌immune‌ ‌system, ‌and‌ ‌gut‌ ‌connections‌ ‌could‌ ‌assist‌ ‌in early‌ ‌diagnosis‌ ‌and‌ ‌treatment‌ ‌of‌ ‌this‌ ‌devastating‌ ‌neurodevelopmental‌ ‌disorders‌ ‌as‌ ‌an‌ ‌early‌ ‌intervention‌ ‌in‌ ‌ASD‌ ‌could‌ ‌improve‌ ‌a‌ ‌child's‌ ‌overall‌ ‌development.‌ We‌ ‌gathered‌ ‌data‌ ‌from‌ ‌relevant‌ ‌previously‌ ‌published‌ ‌articles‌ ‌on‌ ‌PubMed‌ ‌to‌ ‌evaluate ‌the‌ ‌role‌ ‌of‌ ‌the‌ ‌gut‌ ‌microbiota‌ ‌and‌ ‌the‌ ‌immune‌ ‌system‌ ‌on‌ ‌the‌ ‌development‌ ‌of‌ ‌autism.‌.

Is Estrogen a Curse or a Blessing in Disguise? Role of Estrogen in Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD), a condition wherein there is reflux of stomach contents into the esophagus, causing heartburn and regurgitation with a sour and bitter taste in the mouth. It may or may not lead to mucosal injury. GERD symptoms can be troublesome and negatively impact the quality of life. Estrogen, the sex hormone in females, may play a role in the gender differences observed in GERD symptoms. This review article analyzes estrogen's mechanism in the causation of GERD symptoms and its complications. A better understanding of pathophysiology will help us guide early detection, treatment, and prevention of repeated reflux complications. We did a comprehensive PubMed database search and analyzed differences in GERD symptoms experienced by males and females and the role of estrogen in erosive and non-erosive GERD. GERD symptoms in association with hormonal replacement therapy (HRT) and pregnancy, the lower esophageal sphincter (LES) relaxant effects, and estrogens' protective effect on the esophagus from mucosal injury due to repeated reflux are discussed. Estrogen can cause GERD as an adverse effect and, at the same time, can be used to protect the mucosa from GERD induced injury and its complications like metaplasia and cancer. The mechanism is complex and requires further studies and trials. We recommend future researchers to look for possible estrogen use to treat erosive GERD and complication prevention.

Cardiovascular Involvement in Psoriasis, Diagnosing Subclinical Atherosclerosis, Effects of Biological and Non-Biological Therapy: A Literature Review

Psoriasis is a long-lasting, noncontagious chronic inflammatory disease of skin and joints. Previous epidemiological studies have demonstrated that psoriatic patients have a shorter life expectancy, mainly due to cardiovascular (CV) events with a higher prevalence of cardiovascular risk factors like dyslipidemia, diabetes mellitus, insulin resistance, obesity, and hypertension. Besides these risk factors, psoriasis likely plays an independent role in increasing CV events probably due to the chronic inflammatory state. This literature review aims to summarize the mechanism of atherosclerosis formation, CV risk factors, tools to diagnose subclinical atherosclerosis, and the effects of various therapies in psoriatic patients to prevent cardiovascular-related deaths in psoriasis. This review was performed by searching the relevant articles in PubMed and Google Scholar databases without including any exclusion criteria and time limitations. Our review documented that psoriatic patients are at increased risk of CV events due to chronic inflammatory profile and the associated CV risk factors. Also, anti-inflammatory therapies may prevent early subclinical atherosclerotic vascular changes reducing cardiovascular events. However, the available studies lack to establish the exact targets for CV risk factors, to assess the clinical importance of screening for subclinical vascular changes and the impact of anti-inflammatory therapies on CV risk profile in psoriatic patients. This heightened awareness about the CV involvement in psoriasis should encourage conducting large, well planned comprehensive studies to address these issues that can reduce cardiovascular morbidity and mortality.

Significance of Homocysteine Levels in the Management of Polycystic Ovarian Syndrome: A Literature Review

Polycystic ovarian syndrome (PCOS) is a complex disorder involving cardiovascular, metabolic, endocrine, and reproductive systems. Even though the exact etiology is not clear, many studies suggest genetic and environmental factors play a role. Homocysteine (Hcy) is considered to be an independent risk factor for atherogenic and thrombotic components of various systems. Many studies in the past have evaluated Hcy levels in the PCOS population. This article aims to elaborate on the importance of Hcy levels in the overall management of PCOS. We conducted a PubMed data search using combined keywords PCOS and homocysteine levels and manually screened relevant articles for the review while avoiding duplication of data. After the literature review, we analyzed the relationship between homocysteine levels and various components of PCOS. Most of the studies identified a statistically significant elevation in Hcy levels in PCOS women with insulin resistance, androgen excess, elevated markers of cardiovascular risk, recurrent pregnancy loss, and metformin treatment. We also examined studies that focused on treating hyperhomocysteinemia (Hhcy) in PCOS women. However, because of the limited sample sizes and various inclusion criteria used for subjects in the studies, their clinical implication is unclear in routine practice. Furthermore, we encourage clinicians to follow up on Hcy levels in PCOS women at high risk for any complications in their management course. We believe an observational study on a larger scale in a well-defined PCOS population would be useful to uncover the prevalence of elevated Hcy levels in PCOS women, which would help pave the way for establishing treatment guidelines on serum Hcy levels in PCOS management.

Diabetic Cardiomyopathy as a Clinical Entity: Is It a Myth?

Dilated cardiomyopathy (DCM) is a common form of cardiomyopathy that affects the cardiac muscle. It is a life-threatening condition that causes heart failure as it decreases the myocardial ability to pump sufficient blood throughout the body. Numerous causes trigger DCM without pathophysiology; however, the key concept is a decrease in the systolic function of either the left ventricle or of both the left and right ventricles. Long-term diabetes plays an important role in the pathogenesis of DCM in the form of diabetic cardiomyopathy. Diabetic cardiomyopathy is a non-ischemic form of DCM, which is associated with diabetes. It is unrelated to atherosclerosis and hypertension. The PubMed and Google Scholar databases were used to identify the relevant studies related to diabetes and DCM. We found that diabetes was associated with cardiac muscle injury by activating the renin-angiotensin-aldosterone system, myocardial inflammation, and fibrosis. Based on the available data, we concluded that there is strong evidence to support the interrelation of DCM and diabetes.

Role of Substance P in the Pathophysiology of Inflammatory Bowel Disease and Its Correlation With the Degree of Inflammation

Inflammatory bowel disease (IBD) is a multi-factorial, chronic inflammation of the gastrointestinal tract, containing ulcerative colitis (UC) and Crohn's disease (CD). In UC, inflammation and sores are confined morphologically and microscopically to the mucosa, the innermost surface of the colon and the rectum. Although, in CD, the infection is granulomatous and transmural, affecting the entire gastrointestinal tract from the mouth to the anus, with the skip area in-between. A Neuropeptide, substance P (SP), which acts as a neurotransmitter and as a neuromodulator, plays a vital role in the brain-gut axis under stress. Owing to the pro-inflammatory effects of SP, neuropeptide dysregulation induces inflammation in the intestine. There are variations in the distribution of substance P immunoreactive fibres in the various intestinal layers. The highest concentration of SP is in the mucosa and the lowest concentration in the lamina propria of the intestinal muscular membrane. Reduced vasoactive intestinal peptide (VIP) levels and elevated SP levels observed in the colonic mucosa of IBD by using immunohistochemistry and immunoassay. This literature review aims to find out the correlations between the level of substance P (SP) and disease activity. We conducted a literature review on IBD, SP, and we searched PubMed and Google Scholar for relevant articles in English. The result of the study supports a positive relationship between the level of substance P (SP) and disease activity, with increased concentration of substance p in the colon and rectum of CD and UC patients. It is concluded that patients with active CD, along with inflammatory changes, had elevated plasma SP levels and immunoreactivity of SP in the colon than those seen in control and inactive cases. These alterations are more prevalent in ulcerative colitis than Crohn's disease and are more prevalent in the moderately infected area than the least affected area of the intestine.

Minerals: An Untapped Remedy for Autoimmune Hypothyroidism?

For decades, the focus of managing autoimmune hypothyroidism has been on thyroxine replacement. Correcting lab parameters such as thyroid stimulating hormone (TSH) has been a primary goal. The increasing prevalence of Hashimoto’s thyroiditis (HT) continues to impact the quality of life in patients. We believe a holistic approach to this disease entity, considering its underlying complex etiopathogenesis, would benefit patients. Nutraceuticals are combinations of essential nutrients and are becoming a part of novel medical treatments despite the lack of regulation. This review aims to present a concise summary of recent developments regarding minerals such as zinc, selenium, magnesium, iron, and their potential clinical benefit as nutraceuticals in patients with HT. We have explored the potential benefits and associations of these minerals in HT and thyroid function. We reviewed relevant articles, metanalyses, and clinical trials in literature platforms such as PubMed, PubMed Central, and Google Scholar. Significant data found in the literature suggesting a potential health benefit of these minerals in HT though there were many studies to the contrary. Many trials demonstrated the restoration of residual symptoms, reversal of HT-associated thyroid morphological changes, and improvement in thyroid functions. Many of these trials lack statistical power due to the small sample sizes, and their external validity may be questionable due to unaccounted confounding factors. In our opinion, to support an evidence-based holistic clinical approach, further scientific evidence is needed. The association of these elements in thyroid function necessitates more large scale pragmatic trials to elucidate the benefits of nutraceuticals in HT.

Role of Low Molecular Weight Heparin in the Management of Unexplained Recurrent Pregnancy Loss: A Review of Literature

Recurrent pregnancy loss remains a significant challenge in gynecological practice, accounting for about 2%-4% of pregnancies. In some patients, the etiology is unknown. Unexplained recurrent pregnancy loss (URPL) refers to the spontaneous loss of three or more consecutive pregnancies without an identifiable risk factor, accounting for about 40%-50% of pregnancy losses. The review aims to understand the role of low molecular weight heparin (LMWH) in the treatment of URPL. Articles for this review have been found in the PubMed database, and studies published more than ten years before the review excluded. The articles were reviewed to determine the effect of LMWH on live birth rates, reduced late pregnancy complications, and adverse drug reactions following its use. Many studies show improved live birth rates in women treated with LMWH compared to the control, while some studies show no improvement. There was no statistically significant difference in reducing late pregnancy complications, such as preeclampsia, intrauterine growth restriction, preterm labor, and low birth weight, in either study and control groups. Adverse drug reaction was rare among women treated with LMWH and, if present, was mild and self-limiting, thus making it a safe therapy. More studies, preferably large multicenter randomized controlled trials, need to be conducted on the use of LMWH to establish a consensus guideline on the treatment of URPL.

Do Menopause and Aging Affect the Onset and Progression of Rheumatoid Arthritis and Systemic Lupus Erythematosus?

Rheumatoid arthritis and systemic lupus erythematosus (SLE) are autoimmune diseases that are commonly seen in the female population. Rheumatoid arthritis mainly consists of distal symmetrical deforming polyarthritis. SLE patients have immune complexes that damage the organs and systems of the body, and this can present with one or more symptoms including the characteristic malar rash, serositis, lupus nephritis, photosensitivity, and arthritis of large joints. The onset and progression of the diseases are affected by physiological processes that occur in the body such as menopause and aging. The studies used as evidence were found in the PubMed, ScienceDirect, ProQuest, Taylor & Francis Online, Wiley Online Library, Ovid, and Oxford Academic databases. By analyzing these studies, the effects of aging and menopause on rheumatoid arthritis and SLE were revealed. In relation to menopause and aging, it was found that there was a progression of disease in women who had rheumatoid arthritis. However, aging and menopause caused the progression of SLE to decrease in women. An earlier age of onset of menopause was correlated with an increased chance of developing rheumatoid arthritis and SLE. Furthermore, while some studies showed that a later onset of SLE caused an increase in the progression of the disease, other studies showed that a later onset of SLE led to a decrease in the progression of the disease. Due to the prevalence of rheumatoid arthritis and SLE in females, we believe that the effects of menopause, age, and other factors on these two diseases should be examined in future studies.

Unraveling the Mysteries of Restless Leg Syndrome

Restless leg syndrome (RLS) or Willis-Ekbom disease (WED) is an under-diagnosed, chronic, and progressive primary sensory-motor disorder. It is characterized by an uncontrollable urge to move the legs due to uncomfortable and sometimes painful sensations, with a diurnal variation. RLS can lead to severe sleep disturbances, a usual cause of consultation. The pathophysiology is known partially, and it is believed that there is an association between the different variants of genetic mutations combined with dopaminergic and brain iron dysregulation, which plays an important role. The data used for this study were extracted from the articles found in the PubMed database that discuss different gene variants, pathophysiology, and various methods of treatment. They also highlight the role of iron in the pathogenesis of RLS as it is required for the synthesis of tyrosine hydroxylase, which is the rate-limiting step for dopamine synthesis. This review article provides a clinically useful overview of RLS in terms of pathophysiological findings, its genetic associations, and therapeutic options by using the currently available literature. Because RLS presents with vague symptoms and shares similarities with many other diseases, it might be overlooked by many physicians resulting in underdiagnosis and under-treatment. While these discoveries provide a breakthrough in understanding the details of RLS, further studies are recommended as these studies are limited to animal models and provide a limited representation of the general population.

Can Nutritional Adequacy Help Evade Neurodegeneration in Older Age? A Review

There is an increase in susceptibility to chronic and debilitating diseases with aging. The reason for the underlying neuronal degeneration and normal aging of the brain remains elusive. Different research studies have been conducted to discover how the brain degenerates and the importance of vitamins' role in the neurocognitive decline. Comprehensive literature research was conducted using all relevant data available from PubMed and Google scholar for this article. There has been evidence linking the consumption of essential nutrients to preventing the disease conditions that result in cognitive decline. This article provides the latest scientific advances specific to how dietary nutrients and non-nutrient may affect cognitive aging. An adequate supply of nutrients like vitamin B2 (riboflavin), vitamin B12, vitamin E, essential fatty acid (omega-3 fatty acid), and flavonoids play a vital role in ensuring healthy aging, enhancing memory, and strengthening neuroprotection. These nutrients help in neurodegenerative diseases like Alzheimer's disease and Parkinson's. We recommend more research studies to determine the underlying mechanism of how these essential nutrients work in the prevention of cognitive decline. These studies will help provide the evidence needed for new dietary recommendations for combating these diseases that often affect aging patients.

Role of Vitamin D Supplementation in Heart Failure Patients With Vitamin D Deficiency and Its Effects on Clinical Outcomes: A Literature Review

Vitamin D deficiency has become a global pandemic affecting approximately one billion people worldwide. Much attention has been paid to the association of low serum 25-hydroxyvitamin D (25(OH)D) levels and various chronic diseases, especially heart failure (HF). A clear role of vitamin D deficiency has been established, with increased mortality and morbidity in heart failures. However, previous randomized control trials have failed to show improvement in clinical outcomes with calciferol supplementation in these patients. Therefore, it is still unclear whether calciferol therapy can be added to the standard care in congestive heart failure (CHF) patients with deficiency. Hence, to evaluate the role of vitamin D supplementation in CHF patients with low serum 25(OH)D, we conducted an extensive search in the PubMed and Google Scholar databases using various combinations of keywords. All potentially eligible studies that evaluated the effects of vitamin D supplementation on clinical outcomes in HF patients were retrieved and extensively studied. We also checked the references of all eligible studies to identify additional relevant publications. In this study, we reviewed various mechanisms of vitamin D affecting the cardiovascular system and examined the impact of deficiency on heart failures in terms of mortality and hospitalizations. In conclusion, vitamin D supplementation has failed to improve the clinical outcomes in HF patients. The possible long-term benefits of supplementation cannot be excluded. Therefore, for future clinical trials, we recommend considering large sample sizes, longer follow-up durations, along with optimal dosage and appropriate dosing frequency.

Long-term Opioids Linked to Hypogonadism and the Role of Testosterone Supplementation Therapy

Opioids play a pivotal role in managing chronic pain with increasing prescription rates over the last few years. Hence, it is crucial to focus on the adverse effects of narcotics, and one of the lesser-known side effects is hypogonadism. Opioids act on the hypothalamus, pituitary, and directly on the gonads affecting serum testosterone levels. Narcotic-induced androgen insufficiency contributes to sexual dysfunction, infertility, hyperalgesia, and involving various body functions overall, affecting the quality of life. Opioid-induced hypogonadism is very challenging to diagnose for the clinicians, as the patients often under-report the symptoms. There are no established guidelines to analyze androgen insufficiency and dealing with their manifestations successfully. We did a substantial search in PubMed and Google Scholar, using various combinations of keywords to collect data to evaluate the impacts of opioids on serum testosterone levels. This study aims to highlight the clinical significance of opioid-induced androgen deficiency and the diagnostic techniques to recognize and credible treatment alternatives, including testosterone replacement therapy. Health care providers should screen the patients routinely for the signs and symptoms and monitor them often for the hormonal changes to select the patients cautiously for testosterone replacement therapy.

Influence of Vitamin K on Bone Mineral Density and Osteoporosis

Vitamin K (VK) has an established biological function in blood coagulation and hemostasis and maintains general health and bone wellbeing. VK supplements have been promoted to treat and prevent many diseases, particularly for decreasing fracture risk in osteoporosis, a chronic condition described by weak bone tissue, and a high fracture risk following minor trauma. It affects older people from different races and ethnicity, mainly postmenopausal women. Many kinds of research emphasize the role of VK in improving bone health and preventing osteoporotic bone fracture, but the findings are mostly inconclusive. In this literature review, PubMed and Google Scholar databases were used as the primary sources to select the relevant studies and review the association between VK and bone health and also, to explore the impact of VK supplementation in osteoporosis management. A majority of studies reported that VK has an essential role in promoting bone health. Although some studies revealed that VK might increase bone mineral density and reduce fracture risk in people with osteoporosis, VK supplements' potential benefits were not sufficiently supported. Thus, more clinical studies are needed to determine the positive effects of VK supplementation in osteoporosis prevention and treatment.

A Review of the Impact of Bariatric Surgery in Women With Polycystic Ovary Syndrome

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in reproductive-age women that causes infertility. Obesity and insulin resistance are closely tied to the pathophysiology of PCOS. Current first-line treatments include lifestyle modifications, hormone modulators, and laparoscopic ovarian drilling, but little attention has been given to bariatric surgery as a viable option. A detailed review of the literature regarding the outcomes of obese women with PCOS after bariatric surgery is necessary. All studies were found in the PubMed database, limited to females and humans, and selected due to relevancy and quantitative data. Bariatric surgery promotes significant weight loss within one year, which is associated with amelioration of insulin resistance, hyperandrogenism, menstrual irregularity, and ovulatory dysfunction. Surgery successfully mediates the regression of PCOS and promotes successful pregnancy. Thus, we recommend the consideration of bariatric surgery as part of the main treatment considerations in obese patients with PCOS. However, more focused and comprehensive research with better study designs are still needed in the future to investigate PCOS and bariatric surgery.

Biologics Targeting in the Treatment of Inflammatory Bowel Disease: A Conundrum

Inflammatory bowel disease is a chronic, gastrointestinal disorder which is classified into Crohns’ disease and ulcerative colitis. It has a strong effect on the quality of life and is characterized by chronic periods of exacerbation and remission. It has an unknown etiology but is driven due to excessive immune response in the gut wall. The triggered immune response causes overproduction of proinflammatory cytokines and adhesion molecules. Biological therapies are the monoclonal antibodies that are created in the laboratory to stop certain proteins in the body causing inflammation. These biologics have dramatically changed the therapeutic approach to inflammatory bowel disease. Biologics has three classes: anti-tumor necrosis factor (TNF), anti-integrins, and anti-interleukin (IL) 12/23. This article offers a critical evaluation of the efficacy and safety of biological agents in the management of inflammatory bowel disease. We compared different studies that were available in the PubMed database. All the biologics showed a better clinical response and mucosal healing than placebo. Infliximab has the highest efficacy, but it can make antibodies to infliximab that causes loss of response; then golimumab is effective in these patients. Certolizumab is more effective if it is used as a first-line drug. If corticosteroid and immunomodulator therapy has failed then vedolizumab is effective. As steroid therapy causes major adverse effects and involves the whole body, biological therapy should take over. Still, we need more studies to make biological therapy as a first option in the treatment of inflammatory bowel disease. 

Is Hyperthyroidism a Possible Etiology of Early Onset Dementia?

Dementia, a disabling syndrome of the elderly characterized by the decline in memory and cognition, is increasing in incidence and affects not only the individual but also their family and close ones. Hyperthyroidism can mimic many other diseases and untreated hyperthyroidism can lead to adverse problems of various systems including the heart, bones, muscles, menstrual cycle, and fertility. In this article, we have tried to evaluate the association between hyperthyroidism and dementia, as well as the impact of hyperthyroidism management in the treatment and prevention of dementia. Studies available in the PubMed database have been used, excluding animal studies and including studies of adults above the age of 50. The analysis of studies reveals that thyroid dysfunction can lead to cognitive impairment. It has not been able to prove that hyperthyroidism can lead to an earlier onset of dementia. But subclinical hyperthyroidism, thyroid-stimulating hormone (TSH) levels below the normal range, and high free thyroxine (T4) levels increase the risk of dementia among the elderly. The possible mechanisms involved in this association have also been discussed. Thus, we concluded that it is essential to detect and manage hyperthyroidism at an earlier stage since hyperthyroidism increases the risk of dementia. The possibility of using antithyroid treatment in euthyroid dementia is yet to be studied extensively.

Have Our Attempts to Curb Obesity Done More Harm Than Good?

Dieting is a common method for weight loss, maintenance, and prevention of weight gain, but the harmful outcomes of dieting are understudied. Dieting is typically advised for obese patients for the sake of their health, though this does not account for the many complicated factors surrounding obesity. We conducted a search through the PubMed database on obesity, dieting, and eating disorders and did not limit the study by population or year. We found studies showing that although dieting may cause short-term weight loss, it is associated with weight gain in the long-term. We also found studies assessing the negative psychological and physical outcomes of dieting. Though there are many studies that emphasize the negative psychological impact of dieting, few studies have explored how dieting may contribute to the development of eating disorders in the obese. Studies on the physical impact of dieting were less conclusive but warrant further study. While it is difficult to draw any substantial conclusions from the data, our results showed that dieting may carry more risks than benefits as a means to lose weight.

Dialysis Patients With Restless Leg Syndrome: Can We Relieve Their Suffering?

Restless leg syndrome (RLS), also called Willis Ekbom disease, can be described as an unpleasant feeling that intensely urges the patients to move their lower limbs. RLS is classified into primary and secondary. It is one of the common complications in hemodialysis patients, and it impairs patients’ quality of life. Unfortunately, it is an underdiagnosed and undertreated disorder. In this review article, we performed a literature search using the PubMed database to compare different treatment modalities for RLS in patients with end-stage renal disease (ESRD) on regular hemodialysis. Many of the non-pharmacologic modalities of treatment are cost-effective and safer than pharmacologic therapy. Given the small sample size of the studies and short follow up duration, we should consider conducting studies on a larger number of patients and for longer periods of time to assess the efficacy and safety of different treatment patterns for RLS in hemodialysis patients. We hope to raise awareness about this neurologic condition in hemodialysis patients.

Romiplostim and Eltrombopag in Immune Thrombocytopenia as a Second-Line Treatment

Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by platelet count less than 100×10⁹/L and an increased risk of bleeding. The risk of bleeding increases in proportion with the degree of thrombocytopenia. Although several medications are used for primary thrombocytopenia treatment, refractoriness remains a concern. Romiplostim and eltrombopag, two relatively new drugs, have been shown to be successful in ITP treatment after standard treatment failure. The current guidelines recommend their use as a second-line treatment. In this article, we have tried to compare which of these two medications is the best option considering clinical effectiveness, cost-effectiveness, adverse effects, and the possibility of switching between them in case of ineffectiveness. The studies used in this article were found in the PubMed database. All the studies are limited to adults. Based on these studies, both medications seem to be a largely effective, safe option. Romiplostim appears to have slightly fewer adverse effects and higher costs. Switching between thrombopoietin receptor agonists (TRAs) is a successful way to overcome adverse effects and inadequacy according to the currently available literature. We believe that more detailed studies are needed to determine which of these drugs should be considered the first choice, to report long term efficacy and adverse effects, and to determine if treatment guidelines can change regarding the use of TRAs as first-line treatment.

Aortic Involvement in Antineutrophil Cytoplasmic Antibodies Vasculitis, a Coincidence or a Real Association?

Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a type of small-vessel vasculitis. It is unusual for ANCA to involve aorta. However, multiple cases have been found where ANCA involved large vessels, particularly the aorta. Among vasculitides, aortic vasculitis is a part of Takayasu arteritis (TAK). In this review article, we tried to find the mechanism behind the aortic involvement in AAV. PubMed was used as a primary search engine, and all the available cases of aortic, as well as large-vessel involvement in ANCA-associated vasculitis, were thoroughly reviewed. Very limited data was available that could provide the mechanism behind this involvement. It is observed that ANCA-associated aortitis is more common in immunocompromised people; however, cases in previously healthy individuals have also been found. Pathogenesis of ANCA-related aortitis is different from Takayasu arteritis and is more close to ANCA-associated small vasculitis. ANCA-related aortitis involves the aorta through the same mechanism as it uses to involve small vessels. This rare manifestation of ANCA-associated vasculitis could be life-threatening but has a good prognosis if timely diagnosed and treated. ANCA-associated vasculitis must be considered as a differential diagnosis while treating a case of aortitis. We believe that there is a need to revise the classification of different types of vasculitides, and physicians should be aware of the possible overlap between different forms of vasculitides.

Long-Term Cardiovascular Diseases of Heatstroke: A Delayed Pathophysiology Outcome

Heatstroke, defined as an elevated core body temperature above 40°C accompanied by altered mental status (e.g., confusion, disorientation, seizure and coma), is the most severe and life-threatening condition in the spectrum of heat-related illnesses. Heatstroke patients may present with multi-organ dysfunction, but with rapid cooling and organ failure management, a full recovery often occurs within weeks. Long-term impairment is rare, with neurological impairment occurring most frequently. Despite an abundance of research on the persistent neurological and hepatic impairments, our knowledge of the long-term cardiovascular events in patients with heatstroke history is poor. We wondered whether heatstroke leads to cardiovascular diseases long after full recovery. Using Pubmed, Web of Science and Scopus, we gathered cohort studies looking at cardiovascular disease incidence or mortality as an outcome, including heatstroke animal studies. Based on the available literature, we found that a history of heatstroke is associated with an increased risk of cardiovascular diseases, including ischemic heart disease, heart failure and atrial fibrillation. Delayed metabolic disturbances occurring in exertional heatstroke mice are linked to the formation of atherosclerosis and the development of heart failure. These processes provide potential pathophysiological pathways leading to ischemic heart disease and heart failure in heatstroke patients. Our findings may massively impact our understanding of heatstroke recovery and the follow up of heatstroke patients. Therefore larger, more adequately powered cohort studies with cardiovascular disease as an outcome, in tandem with animal studies examining the underlying pathophysiology, are required to confirm or reject these findings and answer the proposed questions.

Role of Smoking in the Pathogenesis of Multiple Sclerosis: A Review Article

Multiple sclerosis (MS) is a complex and unpredictable neurological condition. It is the most commonly seen autoimmune disorder. The incidence of disease and its prevalence are growing worldwide. Early identification of the disease and accurate diagnosis is important to prevent further complications and disability. The etiology remains unclear, and it is believed that complex gene-environment interactions play an essential role. Genetic predisposition only describes a portion of the disease risk, whereas lifestyle and environmental factors are significant contributors. Smoking was identified as an important risk factor for MS. The main objectives of this review were to examine the underlying mechanisms of immune dysregulation in the development of MS, explore the association between smoking and MS, and identify other genetic and environmental factors that alter the risk of developing the disease. We searched PubMed for articles relevant to the study topic published between 2000 and 2020 using the search terms “multiple sclerosis,” “cigarette smoking,” “risk factors,” and, “epigenetics.” Studies reveal a marked association between smoking and the risk of MS. Unlike genetic risk factors, many lifestyles and environmental factors can be adjusted, with potential for prevention, particularly for people at the highest risk, such as families of individuals with MS.

Survival of the Fittest: Addressing the Disparities in the Burden of Chronic Kidney Disease

The prevalence of chronic kidney disease (CKD) is increasingly becoming recognized as a global health concern as well as a critical determinant of poor health outcomes. Decreased access to health care and low socioeconomic status (SES) worsen the adverse effects of biologic or genetic predisposition to CKD. All the studies used were retrieved using the PubMed database. The literature suggests that in developing and developed countries, lower SES is inversely proportional to CKD. It shows an inconsistent relationship between CKD and race; that is, there may or may not be a relationship between these two variables. In the United States (US), the prevalence of the early stages of CKD is similar across different racial/ethnic groups. However, the preponderance of end-stage renal disease (ESRD) is higher for minorities than their non-Hispanic white counterparts.

Further investigation is required to understand the role of racial disparities and CKD as well as to understand the significant difference seen in the incidence when progressing from CKD to ESRD. It is necessary to recognize how lower SES and racial/ethnic disparity may result in the impediment of appropriate disease management. A possible approach is the use of the biopsychosocial model, which integrates biological, individual, and neighborhood factors. A practical method of providing appropriate care to these populations will require economically feasible prevention strategies as well as extending the scope of dialysis by the implementation of cheaper alternatives.

Anabolic Steroids and Cardiovascular Outcomes: The Controversy

Anabolic steroids (AS) are synthetic derivatives of the male sex hormone testosterone. The use of AS is not limited to bodybuilders and athletes, but non-athletes also use them. It is used to enhance athletic performance, induce muscle hypertrophy, and augment male sexual characteristics. AS use is associated with a wide range of side effects and potential cardiovascular complications. In this article, we have searched the available literature to investigate the association between AS use and cardiovascular disease (CVD). The results revealed that AS was linked to lipid metabolism derangements, hypertension, coagulation disorders, and cardiomyopathy. We concluded, based on the relevant data, that there was evidence that suggests an association with CVD, primarily myocardial infarction, fatal arrhythmias, and cardiomyopathy in AS users. The general population should be informed of the risk. Also, methods of primary and secondary prevention should be implemented to mitigate the risk of CVD secondary to AS.

Cannabis, More Than the Euphoria: Its Therapeutic Use in Drug-Resistant Epilepsy

A significant number of epilepsy patients are refractory to conventional antiepileptic drugs. These patients experience considerable neurocognitive impairments that impact their quality of life and ability to function independently. This need for alternative treatment has generated increased interest in cannabis use as a therapeutic option in these patients. This review seeks to analyze data presented on the pharmacology, safety, and efficacy of cannabis use in patients with drug-resistant epilepsy (DRE) and to propose any future recommendations regarding its use. PubMed was used to retrieve all published studies and articles which evaluated the use of cannabis in epilepsy. The two foremost phytocannabinoids of cannabis showing anticonvulsant properties are tetrahydrocannabinol (THC) and cannabidiol (CBD). Due to the psychoactive properties of THC, most studies focused on CBD use in these patients. The use of CBD as an adjunct resulted in decreased seizure frequency, and secondary benefits observed included improvement in mood, alertness and sleep. Adverse events (AEs) reported were drowsiness, diarrhea, increased transaminases and worsening of seizures. It can safely be concluded that there is a significant benefit in DRE patients using CBD as adjunctive therapy. However, further controlled and adequately powered studies are needed to assess the pharmacokinetics and impact of the long-term use of cannabis.

A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America

Racial/ethnic disparities in maternal care exist, even as medicine continues to progress on several aspects, medical care continues to fail countless women each year, particularly minority women and women of color. Black and American Indian/Alaska Native women experienced exponentially more pregnancy-related deaths. Recognizing factors that underlie disparities in pregnancy-related deaths and implementing preventive approaches to resolve them may mitigate racial/ethnic disparities in pregnancy-related mortality. Future research on these disparities should focus on strategies for reducing racial/ethnic inequalities in pregnancy-related deaths, including improving access to high-quality preconception, maternity, and postpartum care for minority women, multi-ethnic education for physicians and healthcare providers in a bid to eliminate implicit biases, adequate funding, and improvement of healthcare facilities in minority areas, education of healthcare providers on variation in the incidence of some certain conditions in different ethnic groups so that care is patient-centered and culturally appropriate. All of these can be enforced through the community, healthcare facility, patient, family, physician, and system-level collaboration.

Role of Antibiotic Prophylaxis in the Management of Antenatal Hydronephrosis, Vesicoureteral Reflux, and Ureterocele in Infants

Widespread prenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. Antenatal hydronephrosis (AHN) and vesicoureteral reflux (VUR) are among the most common congenital anomalies diagnosed in utero or after birth. Pediatric urologists frequently rely on continuous antibiotic prophylaxis (CAP) for managing AHN, VUR, and ureterocele, unless definitive treatment is performed. The main aim of antibiotic prophylaxis (ABP) is to prevent urinary tract infection and long-term complications. Nevertheless, the efficacy of ABP has been a source of considerable debate, and pediatricians have varied opinions on who would benefit from ABP. In this review article, we searched the currently available literature, for evidence of the role of ABP in the setting of AHN, VUR, and ureterocele. Most of our studies showed a limited benefit of ABP for HN and VUR. The data on the use of CAP in the management of ureterocele is scarce. However, due to the involvement of independent risk factors and other variables, a conclusion cannot be drawn from these studies alone. Pediatric urologists are urged to conduct randomized controlled trials to compare patients followed up with and without ABP. Given the lack of guidelines, an individualized approach should be used for the use of ABP, until precise guidelines and recommendations are developed.

SARS-CoV-2 (COVID 19) Infection in Hypertensive Patients and in Patients With Cardiac Disease

COVID 19, caused by the SARS-CoV-2 virus, a newly discovered coronavirus, has caused the global pandemic of early 2020. The first case was described in December 2019 in Wuhan, China, and by March 2020, most countries around the world have put in place some of the strictest restrictions seen in decades in order to slow down the spread of the disease. Patients with pre-existing hypertension and cardiovascular comorbidities were reported to be at an increased risk of serious infections caused by SARS-CoV-2. Considering that those are among the most common chronic medical conditions in the Western world, the potential impact of it is huge. The proposed mechanism behind those associations is the expression of angiotensin converting enzyme II (ACE II) in those patients. Furthermore, the association between ACE inhibitors/AR blockers, which are among the most frequently prescribed medications, and serious cases of COVID 19 has been studied with the same mechanism in mind. The reports on the association between hypertension and COVID 19 morbidity and mortality are less clear, and the International Society of Hypertension even claims that there is none. The reports on the association between heart failure or coronary disease and COVID 19 are more uniform, and all seem to point to a greater risk from serious infections faced by patients with those comorbidities. A significant effort will need to be invested by the scientific community into finding strategies for protecting those patients from contracting the virus in the first place and then, once infected, into developing management plans aimed at preserving cardiac function as much as possible.

Uncommon Presentations of Multiple Myeloma

Multiple myeloma is a rare malignancy that exhibits a wide range of possible clinical presentations. In recent years, with the advent of stem cell transplantation, the prognosis of patients with multiple myeloma has been increasing. We searched the literature for reports of atypical myeloma presentations to aid clinicians in formulating differential diagnoses and to increase the number of cases diagnosed early. There have been a number of reports of early ocular symptoms, including, but not limited to, proptosis, optic neuropathy, vision loss, retinal hemorrhage, and detachment. Neurological presentations included cranial nerve palsies, vertigo related to cerebellar involvement, and diabetes insipidus related to pituitary involvement. Among gastrointestinal manifestations, there are a number of reports of multiple myeloma presenting as acute and chronic pancreatitis. Mesenteric ischemia due to amyloidosis, acute abdomen, and hepatosplenomegaly were also among reported presentations. When it comes to renal involvement, while acute renal failure and proteinuria are typical, there are reports of patients presenting with both nephritic and nephrotic forms of glomerular disease, as well as end-stage renal disease requiring dialysis. We believe that it is essential for clinicians to keep reporting atypical multiple myeloma presentations and consider it as a possible diagnosis in a patient with serious, atypical symptoms.

Thyrotoxic Periodic Paralysis With Features of Andersen-Tawil Syndrome: A Case Report and Literature Review

Thyrotoxic periodic paralysis (TPP) is a rare manifestation of hyperthyroidism. The pathophysiology of hyperthyroidism causing periodic paralysis involves the Na+/K+ ATPase and potassium channels. We present a case of a 30-year-old male who presented to the ED with acute onset of upper and lower limb weakness. The patient was found to have bilateral weakness in the upper and lower limbs, orbital hypertelorism, and mandibular hypoplasia. He was also found to have hypokalemia, low thyroid-stimulating hormone (TSH), elevated thyroid peroxidase antibody, and elevated thyroid-stimulating immunoglobulins. The patient’s EKG was remarkable for a prolonged QTc interval. The patient regained his muscle strength after potassium replacement in less than 24 hours. He was started on methimazole and potassium supplements. Our case is unique because it shows the possibility of the presence of Andersen-Tawil syndrome (ATS) (long QT syndrome 7), diagnosed by the presence of periodic paralysis, long QT, and dysmorphic facial features with TPP. In conclusion, thyrotoxicosis can trigger ATS; also the two syndromes can co-exist owing to the similarity in their pathophysiology.

Coronavirus Disease 2019 (COVID-19) in Cancer Patients

The Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become the most talked-about clinical entity in early 2020. As an infection that spreads easily and has a significant mortality rate, it has caused global panic rarely seen before. Many of the measures taken by governments worldwide will have long-lasting impacts on the wellbeing of the population at large. It has been widely reported that the most vulnerable patients have been most negatively affected by SARS-CoV-2 (COVID-19). In this study, we have tried to search the currently available data on the outcomes of infected cancer patients. Most of the data points to the very challenging nature of treating such patients. Their overall outcomes seem to be worse than in the general population, and it may be difficult to differentiate which potential complications are a result of the primary oncologic disease versus the infection. Management presents its own set of challenges, including but not limited to, deciding whether postponing cancer treatment until the infection resolves is going to benefit the patient and how to organize all aspects of patient care when social contact is as limited as it is for patients newly diagnosed with COVID-19. We believe that as more data becomes available, it is going to be necessary to publish detailed guidelines on how to approach this unique clinical challenge.