Background. Antibiotics are responsible for most dramatic improvement in medical therapy in history. These medications contributed significantly to the decreasing mortality and morbidity when prescribed based on evidence of microbial infection. Objective. The aim of this study was to determine the prevalence and predictors of self-prescription with antibiotics in Al Wazarat Health Center, Riyadh City, Kingdom of Saudi Arabia. Material and Methods. Cross-sectional study was conducted in Al Wazarat Health Center between February 2014 and November 2014. Respondents were randomly selected using a multistage clustered random sampling technique. Data was entered into SPSS version 21 and analyzed. Descriptive statistics and multiple logistic regression models were applied. Results. A total of 681 patients have participated in this study with a response rate of 92%. The prevalence of self-prescription with antibiotics in Al Wazarat Health Center was 78.7%. Amoxicillin was the most used self-prescribed antibiotic with prevalence of (22.3%). Friend advice on self-prescription of antibiotics use (p = 0.000) and pharmacy near to the participants (p = 0.002) were the most common predictors for self-prescription with antibiotics. Conclusion. The level of self-prescribing antibiotics is relatively high among participants. Health education on the appropriate use of antibiotics is highly recommended. The proper use of treatment guidelines for antibiotic therapy will significantly reduce self-prescription with antibiotics.

ImportanceThe Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE AF) trial found that approximately 1 in 8 patients with recent ischemic stroke attributed to large- or small-vessel disease had poststroke atrial fibrillation (AF) detected by an insertable cardiac monitor (ICM) at 12 months. Identifying predictors of AF could be useful when considering an ICM in routine poststroke clinical care.ObjectiveTo determine the association between commonly assessed risk factors and poststroke detection of new AF in the STROKE AF cohort monitored by ICM.Design, Setting, and ParticipantsThis was a prespecified analysis of a randomized (1:1) clinical trial that enrolled patients between April 1, 2016, and July 12, 2019, with primary follow-up through 2020 and mean (SD) duration of 11.0 (3.0) months. Eligible patients were selected from 33 clinical research sites in the US. Patients had an index stroke attributed to large- or small-vessel disease and were 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor. A total of 496 patients were enrolled, and 492 were randomly assigned to study groups (3 did not meet inclusion criteria, and 1 withdrew consent). Patients in the ICM group had the index stroke within 10 days before insertion. Data were analyzed from October 8, 2021, to January 28, 2022.InterventionsICM monitoring vs site-specific usual care (short-duration external cardiac monitoring).Main Outcomes and MeasuresThe ICM device automatically detects AF episodes 2 or more minutes in length; episodes were adjudicated by an expert committee. Cox regression multivariable modeling included all parameters identified in the univariate analysis having P values <.10. AF detection rates were calculated using Kaplan-Meier survival estimates.ResultsThe analysis included the 242 participants randomly assigned to the ICM group in the STROKE AF study. Among 242 patients monitored with ICM, 27 developed AF (mean [SD] age, 66.6 [9.3] years; 144 men [60.0%]; 96 [40.0%] women). Two patients had missing baseline data and exited the study early. Univariate predictors of AF detection included age (per 1-year increments: hazard ratio [HR], 1.05; 95% CI, 1.01-1.09; P = .02), CHA2DS2-VASc score (per point: HR, 1.54; 95% CI, 1.15-2.06; P = .004), chronic obstructive pulmonary disease (HR, 2.49; 95% CI, 0.86-7.20; P = .09), congestive heart failure (CHF; with preserved or reduced ejection fraction: HR, 6.64; 95% CI, 2.29-19.24; P < .001), left atrial enlargement (LAE; HR, 3.63; 95% CI, 1.55-8.47; P = .003), QRS duration (HR, 1.02; 95% CI, 1.00-1.04; P = .04), and kidney dysfunction (HR, 3.58; 95% CI, 1.35-9.46; P = .01). In multivariable modeling (n = 197), only CHF (HR, 5.06; 95% CI, 1.45-17.64; P = .05) and LAE (HR, 3.32; 1.34-8.19; P = .009) remained significant predictors of AF. At 12 months, patients with CHF and/or LAE (40 of 142 patients) had an AF detection rate of 23.4% vs 5.0% for patients with neither (HR, 5.1; 95% CI, 2.0-12.8; P < .001).Conclusions and RelevanceAmong patients with ischemic stroke attributed to large- or small-vessel disease, CHF and LAE were associated with a significantly increased risk of poststroke AF detection. These patients may benefit most from the use of ICMs as part of a secondary stroke prevention strategy. However, the study was not powered for clinical predictors of AF, and therefore, other clinical characteristics may not have reached statistical significance.Trial RegistrationClinicalTrials.gov Identifier: NCT02700945

Onychoptosis is the periodic shedding and falling of one or more nails, in whole or part. It can be seen after fever, trauma, adverse reaction to medications, and in systemic illnesses including syphilis (syphilitic onychia). We report a case of 38-year-old man presented with subacute bilateral retrobulbar optic neuritis. Physical examination revealed diffuse onychoptosis which lead into the diagnosis of neurosyphilis. Symptoms significantly improved with appropriate treatment with intravenous penicillin G for 14 days.

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Transverse myelitis (TM) is an inflammatory syndrome of the spinal cord that presents with acute-to-subacute neurological deficits. The differential for TM is broad and includes demyelinating, infectious, neoplastic and paraneoplastic, autoimmune, and metabolic/toxic etiologies. With the novel severe acute respiratory syndrome coronavirus pandemic, more commonly referred to as the coronavirus infectious disease of 2019 (COVID-19), there have been increasing reports of neurological complications. In this case report, we describe a novel case of longitudinally-extensive TM associated with the Moderna vaccination.

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INTRODUCTION: Seronegative Limbic encephalitis (SNLE) is a rare condition that presents with cognitive impairment, personality changes, memory loss, and seizures. It results from either an idiopathic or neoplasm mediated autoimmune processes leading to direct neuronal damage. We present a rare case of SNLE that significantly improved after early recognition and aggressive plasma exchange therapy. CASE PRESENTATION:A 75-year-old woman with history of systemic lupus erythematosus, CKD, hypertension, presented with 14 day history of new-onset progressively worsening behavioral changes manifested by irritability, psychosis, confusion, delirium and elevated blood pressures ranging from 200-250 mm Hg. On admission, patient was extremely delirious and was intubated for airway protection. Workup showed Hb 9.8, BUN 62, Cr 3.15, and ESR >145 . CT head was negative for abnormalities and MRI brain showed small vessel disease with old microhemorrhages but no acute pathology. Patient was started on antibiotics and acyclovir for suspicion of central nervous system infection, hypertension was managed with intravenous nicardipine. CSF revealed mildly elevated total protein of 59 mg/dL and white cell count of 3, otherwise normal. Blood cultures, CSF cultures, HSV I/II, West Nile, COVID-19 and prolonged video EEG remained unremarkable. Lupus cerebritis was ruled out by rheumatology given stable levels of C3/C4. Patient developed generalized hyperekplexia with repetitive clonus-like movements of all extremities that resolved spontaneously shortly after discontinuation of the external stimuli. Given her the clinical presentation, hyperekplexia on exam and negative work-up, limbic encephalitis was suspected. She was started on IV steroids and plasma exchange therapy with significant improvement in mental status. Paraneoplastic panel came negative. A CT scan of abdomen/pelvis showed an adrenal mass, however PET was negative for avid malignancy and adrenal gland was hypometabolic. She was discharged with complete neurologic recovery.DISCUSSION: SNLE comprises 10% of all autoimmune encephalitis diagnoses. In our patient due to reports of a previous adrenal mass, initial suspicion was of SNLE secondary to adrenal source was made but after extensive workup the diagnosis of exclusion of autoimmune SNLE was made. Corticosteroids and plasma exchange remain understudied in SNLE yet data suggests at least 50% of patients recover with these interventions. Due to concern of persistent autoimmune injury if SNLE is left untreated/undiagnosed, prompt empiric intervention and simultaneous workup to rule out an underlying occult malignancy may stagnate neurological impairment. CONCLUSIONS:We highly recommend keeping SNLE in the differential of ICU patients with persistent encephalopathy, especially in those with a history of autoimmune disorders.