Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options

Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.

Investigating the safety and efficacy of nerve stimulation for management of groin pain after surgical herniorrhaphy: a systematic review and meta-analysis

PURPOSE

Chronic post-operative inguinal pain (CPIP) following inguinal hernia repair has been a major sequela affecting 4000-48000 patients annually. Optimal management of CPIP has been a challenge, and pharmacological management particularly with opioids has shown unsatisfactory results. The main objective of this systematic review is to investigate the safety and efficacy of neuromodulation as an alternative intervention for the management of post-operative inguinal pain.

METHODS

A literature search was conducted by three reviewers to identify all relevant studies on the use of neuromodulatory interventions for treating post-operative inguinal pain. Data on study characteristics, neuromodulatory modalities, and patient's clinical data such as pre/post-interventional pain scores and analgesic requirements were extracted and reported.

RESULTS

A total of 389 patients with 357 (95.9%) males and 15 (4.1%) females were evaluated. The mean age of study participants was 47.9 ± 10.4 years. There were 187 (48.1%) and 202 (51.9%) patients allocated to the control and trial groups, respectively. The most common neuromodulation modality was TENS (4, 36.4%), followed by SCS (3, 27.3%), PNS (3, 27.3%), and acupuncture-assisted (2, 18.2%). The overall mean follow-up duration of the entire cohort was 3.8 months. The mean difference between pre-operative and post-operative VAS scores in the trial groups was 4.65 (95% Confidence Interval [CI], 2.97, 6.33), which was statistically significant (P value < 0.05). Patient-reported outcome measures showed significant responsiveness toward their treatments.

CONCLUSION

Nerve stimulation, in its many forms, is a safe and feasible option for the management of post-operative inguinal pain.

A ciliated hepatic foregut cyst mimicking hydatid cyst treated with laparoscopic surgery; a case-report and review of literature

INTRODUCTION AND IMPORTANCE

Congenital hepatic foregut cyst (CHFC) is a rare condition that is derived from an abnormal detachment of esophageal buds during foregut embryonic development. Early treatment is generally recommended due to the potential of malignant transformation. In this study, we are reporting our experience with laparoscopic resection of CHFC in a female patient.

CASE PRESENTATION

A 41-year-old female farmer presented with a 5-month history of right upper quadrant (RUQ) pain with a palpable mass. Abdominal examination revealed a visible subhepatic large mass with an estimated size of 10 cm, which was horizontally mobile. Abdominopelvic ultrasonography showed a 76 ∗ 87 ∗ 15 cm single subhepatic cyst with internal septations. The patient was scheduled to undergo laparoscopic surgical resection of the cyst with an initial diagnosis of a hepatic hydatid cyst. Histopathologic evaluations showed that the cyst wall was composed of four layers consistent with the diagnosis of CHFC.

CLINICAL DISCUSSION

Due to the disease's rarity there have been various recommendations regarding treatment of CHFC in literature including observation with serial imaging, aspiration, and surgical excision. However, surgical excision is considered the most reasonable option given the chance of malignant transfusion, particularly in patients with enlarging cysts with size of more than 4 cm, cyst wall abnormality, abnormal liver function tests, and symptomatic cases.

CONCLUSION

Surgical resection is a feasible option for resection of CHFC given that the cyst wall is thick enough to be excised from the hepatic parenchyma and the lesion is situated on the surface of the liver.

The significance of volume overload in the development of pulmonary arterial hypertension in continuous ambulatory peritoneal dialysis patients

INTRODUCTION

The underlying pathophysiology of pulmonary arterial hypertension (PAH) is multifactorial; however, the significance of chronic volume overload and its subsequent effects on cardiac function must be studied thoroughly. The main objective of this study was to determine the predictive parameters of PAH in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) using transthoracic echocardiography (TTE) and bioimpedance analysis (BIA).

METHODS

In this cross-sectional study, 43 eligible CAPD patients were chosen. The patients were examined by TTE and BIA before the morning dialysis session, and baseline patient characteristics, echocardiography, and BIA parameters were recorded.

RESULTS

Sixteen (37.2%) patients were diagnosed with PAH. Patients with PAH had significantly greater left atrial diameter (LAD), left ventricular mass index (LVMI), and higher grades of diastolic dysfunction (DDF). Systolic pulmonary artery pressure (sPAP) correlated with LAD (p < 0.001, r = 0.566), interventricular septal diameter (IVSD) (p = 0.004, r = 0.425), LVMI (p = 0.030, r = 0.323), and extracellular water/total body water (ECW/TBW) ratio (p = 0.002, r = 0.458).

CONCLUSION

Two volume status-related parameters including ECW/TBW ratio and inferior vena cava (IVC) expiratory diameter, and cardiac-related TTE findings such as LAD and DDF were predictors of sPAP in CAPD patients.

Outcomes in Severe COVID-19 Patients Following Percutaneous Versus Open Surgical Tracheostomy: An Analysis of Clinical and Prognostic Indicators

Background and objective Tracheostomy in coronavirus disease 2019 (COVID-19) patients can be performed in cases of prolonged intubation or in patients with a known difficult airway. Tracheostomy is usually performed by two main approaches: open surgery or percutaneous endoscopic insertion. However, few studies have compared these two techniques in severe COVID-19 patients. The objective of the present study was to compare the efficacy of the two main methods of tracheostomy among patients with severe COVID-19 infection. We also aimed to investigate the impact of various lab data and medications on patient outcomes. Materials and methods We included all symptomatic severe COVID-19 patients in need of prolonged mechanical ventilation. We examined the patients' past medical history, arterial blood gas (ABG) analysis, laboratory workups, and medication history. We calculated the PaO₂/FiO₂ ratio as an index to evaluate the severity of acute respiratory distress syndrome (ARDS). Results During the study period, 72 patients with severe COVID-19 underwent tracheostomy tube insertion. The average age of participants was 58.93 ±15.27 years; 44 (61.1%) were male and 28 (38.9%) were female. Of note, 54 (75.0%) patients passed away and only 18 (25.0%) survived. Among the survivors, 13 (29.5%) were men and five (17.9%) were women. The study showed a significantly higher mortality rate (23, 92.0%) among patients who underwent open surgery compared to those who received percutaneous surgery (31, 65.9%) (p=0.01). Conclusion Based on our findings, percutaneous endoscopic tracheostomy seems to be the superior approach compared to open tracheostomy. Other predictive factors associated with patient outcomes included levels of HCO₃, FiO₂, PaCO₂, and PaO₂/FiO₂ ratio.

Primary Closure of Pilonidal Sinus With Slide-Swing Skin Flap Compared With the Secondary Closure: A Single-Blinded Randomized Controlled Trial

INTRODUCTION

There are many surgical approaches for sacrococcygeal pilonidal sinus disease (PSD) therapy, ranging from wide excision repair to less morbid excisions with primary/flap closure. The off-midline flaps, which shift the incision line away from the midline natal cleft, have been associated with lower recurrence rates than the conventional mid-line closure techniques. This single-blinded randomized controlled trial aims to compare the short/long-term efficacy and outcome of the slide-swing flap technique with the conventional secondary wound closure.

METHOD AND MATERIALS

This study was a prospective randomized controlled trial conducted on patients with PSD. Patients were assigned into two groups: secondary closure (control) and slide-swing flap (trial). Patients were advised to visit the surgical clinic two times weekly for the two weeks after the operation for at least six months.

RESULTS

In this study, 100 patients were enrolled. They were assigned into two groups of control, and trial. The mean age of all participants was 29.15 ± 8.36 years old (age range: 18-62 years old). The mean operation time was 39.65 ± 12.63 for both groups, with the control group being 29.70 ± 7.71 and the swing flap group 46.90 ± 7.81. Patient visual analog scale (VAS) scores in both groups revealed that the trial group was associated with lower VAS scores compared with patients who underwent secondary closure (p-value = 0.006). Also, the trial group demonstrated a higher rate of healing, better cosmetic outcomes, and quicker recovery time compared with the controls.

CONCLUSION

Compared with secondary closure, the slide-swing flap was associated with excellent cosmetic outcomes, disease recurrence, and recovery time. Also, the post-operative complications were significantly lower compared with the traditional method.

Effects of neuromodulation on treatment of recurrent anal fissure: A systematic review

BACKGROUND

Anal fissure is a linear tear in the distal anoderm most frequently occurring in the posterior midline. Lateral internal sphincterotomy is considered the gold standard for the treatment of this condition. To this date, several pharmacological and neuromodulatory therapies have been tried out as alternative non-invasive treatments for anal fissures, however, the efficacy of some of these methods remains to be understood.

OBJECTIVE

the primary aim of this study was to review available literature on neuromodulatory treatments for recurrent anal fissure as a potentially effective cure for this condition.

DATA SOURCES

A search was conducted among five main online databases Embase, PubMed, Web of Science, Scopus, and Scholar.

STUDY SELECTION

All published human studies in English literature addressing neuromodulation for the treatment of recurrent anal fissure were selected.

INTERVENTION

neuromodulation for the treatment of anal fissure. We chose to include all articles in which the authors stated that the procedure they performed was via neuromodulation technique, or that the described technique used in their study resembled the technique.

RESULT

Among a total of 3487 evaluated studies, seven represented the effects of neuro modulation on treatment of recurrent anal fissure, among which two were randomized controlled trials and the rest were prospective studies. A total of 186 patient were evaluated in these studies. The mean age of the participants was 46.97 ± 8.2. The average VAS score before intervention was 7.77 ± 2.13, which decreased to 0.31 ± 1.13 after intervention.

LIMITATIONS

limitations of this study include the lack of related articles, and data regarding this subject.

CONCLUSION

Posterior tibial nerve stimulation (PTNS) provides rapid pain relief and fissure healing especially in short-to mid-terms with little to no complications, however, using this treatment, symptoms of anal fissure do not improve as well as LIS, especially in the long-term.

The effects of nebulized ketamine and intravenous magnesium sulfate on corticosteroid resistant asthma exacerbation; a randomized clinical trial

BACKGROUND AND AIMS

Asthma exacerbation is defined as an acute attack of shortness of breath with more than 25% decrease in morning peak flow compared to the baseline on 2 consecutive days, which requires immediate standard therapy. The majority of asthmatic patients are considered to be steroid-sensitive; however, corticosteroid-resistant asthma is a subset of asthma with poor response to corticosteroids and is responsible for frequent hospital admissions. In this study we aimed to compare the effects of two enhancing strategies, the nebulized ketamine and IV magnesium sulfate, in treatment of severe steroid resistant asthma.

MATERIALS AND METHODS

This double-blind randomized clinical trial was conducted on patients who presented to a referral clinic in Alborz, Iran. Using random allocation, patients were divided into two groups. The first group was treated with nebulized ketamine and the second group was treated with intravenous magnesium sulfate. Peak expiratory flow rates were assessed before the intervention, 30 and 60 min after the intervention and compared with the aid of SPSS software.

RESULTS

The Peak expiratory flow rates before the intervention, 30 min and 60 min after the intervention was statistically significantly different in both ketamine and magnesium sulfate groups. Peak expiratory flow rates change between 0 and 60 min were 29.4 and 15.2% in the ketamine and magnesium sulfate group respectively. Although the ketamine group showed much higher increase in mean PEFR compared to the MgSO4 groups, there was no statistically significant difference across both groups.

CONCLUSION

Our study concluded that combined with standard therapy, both ketamine and IV magnesium sulfate are effective agents in the improvement of PEFR in patients with acute severe asthma that failed to respond to traditional therapies. However, there were no statistically significant difference between the two groups.

Follicular Dendritic Cell Sarcoma of the Thyroid Gland in a Patient with Preexisting Hashimoto’s Thyroiditis: A Rare Case Report with a Literature Review

Thyroid follicular dendritic cell sarcoma (FDCS) is an extremely rare malignancy that originates from follicular dendritic cells of the thyroid germinal centers. To the best of our knowledge, there are only 4 reported cases of thyroid FDCS in the English literature. Herein, we present the fifth case of FDCS of the thyroid gland. A 63-year-old woman presented with a painless midline neck mass, enlarging for the last 4 months. Physical examination revealed a 6-cm nonmobile, firm, multinodular thyroid mass with palpable cervical lymphadenopathy. Due to high suspicion for thyroid malignancy, the patient underwent total thyroidectomy with bilateral modified radical neck dissection. Histologic evaluations revealed sheets of storiform eosinophilic tumoral cells with prominent nucleoli containing multinucleated giant cells, and subsequent immunohistochemistry showed immunoreactivity for CD4, CD21, CD35, CD45 (LCA), and CD68. The patient was started on 6 cycles of doxorubicin, ifosfamide, and radiotherapy. She has had monthly thyroid ultrasonography and contrast-enhanced thoracoabdominal CT scan every 3 months for detecting potential recurrence and/or metastasis screening. Fortunately, 8 months after the operation, the patient is alive without any signs of local or distant metastasis.

Two cases of primary leiomyosarcoma of sigmoid colon treated with laparoscopic surgery: A case report and a review of literature

INTRODUCTION AND IMPORTANCE

Leiomyosarcoma (LMS) of the colon is an extremely rare and highly invasive tumor arising from the muscularis propria of the gastrointestinal tract. After the introduction of oncogenic role of KIT by immunohistochemistry (IHC), the reported cases of gastrointestinal leiomyosarcoma were highly limited. True LMS of the colon is such a rare disorder that there isn't much description of its nature.

CASE PRESENTATION

We reported two very rare cases of primary leiomyosarcoma of sigmoid colon, which referred to our institution with symptoms of abdominal pain, lower GI bleeding and fatigue. After the initial investigations, both patients were diagnosed with primary LMS of sigmoid colon that underwent laparoscopic tumor resection.

CLINICAL DISCUSSION

The classical colonic LMS presents with a vast majority of non-specific symptoms including mild abdominal pain, fresh/obscure rectal bleeding, and weight loss. The most common location for colonic LMS is the sigmoid colon, and ascending colon. The prognostic factors for the disease outcome have not been established properly; however, patient age, tumor size/grade, and local/distant dissemination are of great importance.

CONCLUSION

Herein, we reported two rare cases of primary leiomyosarcoma of sigmoid colon that was treated with laparoscopic surgery.

Primary synovial sarcoma of thyroid gland: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Synovial cell sarcoma (SS) is an extremely rare mesenchymal malignancy, representing nearly 10% of all soft-tissue sarcomas. These high-grade soft tissue sarcomas commonly arise in the para-articular regions of lower extremities. However, 15% of Synovial sarcomas has been described at Unusual locations, including head, neck, and trunk. Herein, we describe the twelfth case of primary synovial cell sarcoma of thyroid with a literature review.

CASE PRESENTATION

A 43-year-old woman presented with complaint of a progressive neck mass for the last five-months. She developed with dysphagia and dyspnea nearly 2 months prior, without signs of hoarseness, and weight loss. Ultrasonography in which revealed a heterogeneous, hypervascularized thyroid mass. After total thyroidectomy immunohistochemistry was in favor of primary synovial cell sarcoma of thyroid. The diagnosis was confirmed via Molecular genetic analysis of the SYT-SSX fusion gene transcript using the RT- polymerase chain reaction method. Clinical Discussion: Primary thyroid SVS is an extremely rare malignancy with poor biological behavior. SVS has been known for its tendency to local and distal re-occurrence after a few years of treatment. SS can be classified into two subtypes of monophasic or biphasic based on the presence of mesenchymal and/or epithelial components. Accordingly, the most accurate diagnostic tool for SS is considered to be molecular genetic analysis for SYT/SSX fusion transcript.

CONCLUSION

Herein, we reported an extremely rare case of SVS of thyroid gland. These high-grade soft tissue sarcomas mainly present with an asymptomatic rapid growing neck mass. Unspecific clinical presentations and extreme rarity of this disorder, make the diagnosis of thyroid SVS very challenging. Due to paucity of data, there is not enough evidence to establish a reliable mortality rate. However, the prognosis of thyroid SVS seems unfavorable.