Kleine–Levin syndrome (KLS) is characterized by episodes of hypersomnia. Additionally, these patients can present with hyperphagia, hypersexuality, abnormal behavior, and cognitive dysfunction. Functional neuroimaging studies such as fMRI-BOLD, Positron Emission Tomography (PET) or SPECT help us understand the neuropathological bases of different disorders. We conducted a systematic review to investigate the neuroimaging features of KLS patients and their clinical correlations. This systematic review was conducted by following the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) and PRISMA protocol reporting guidelines. We aim to investigate the clinical correlation with neuroimaging among patients with KLS. We included only studies written in the English language in the last 20 years, conducted on humans; 10 studies were included. We excluded systematic reviews, metanalysis, and case reports. We found that there are changes in functional imaging studies during the symptomatic and asymptomatic periods as well as in between episodes in patients with K.L.S. The areas most reported as affected were the hypothalamic and thalamic regions, which showed hypoperfusion and, in a few cases, hyperperfusion; areas such as the frontal, parietal, occipital and the prefrontal cortex all showed alterations in cerebral perfusion. These changes in cerebral blood flow and regions vary according to the imaging (SPECT, PET SCAN, or fMRI) and the task performed while imaging was performed. We encountered conflicting data between studies. Hyper insomnia, the main feature of this disease during the symptomatic periods, was associated with decreased thalamic activity. Other features of K.L.S., such as apathy, hypersexuality, and depersonalization, were also correlated with functional imaging changes. There were also findings that correlated with working memory deficits seen in this stage during the asymptomatic periods. Hyperactivity of the thalamus and hypothalamus were the main features shown during the asymptomatic period. Additionally, functional imaging tends to improve with a longer course of the disease, which suggests that K.L.S. patients outgrow the disease. These findings should caution physicians when analyzing and correlating neuroimaging findings with the disease.
COVID-19 mainly causes pulmonary manifestation; nonetheless, its systemic inflammatory response involves multiple organs, including the heart. We aimed to evaluate the prevalence, predictors, and outcomes of myocardial injury in hospitalized patients with SARS-CoV-2 infection. Methods and Results: We performed an observational retrospective analysis on patients hospitalized with COVID-19 in a moderate-sized community hospital system. Myocardial injury was defined as highly sensitive troponin T levels in the 99th percentile above the normal upper limit for the respective biological sex. Multivariable logistic regression models were fitted to assess the association between the myocardial-injury and the no-myocardial-injury groups for primary and secondary outcomes. A total of 1632 (49.3% male, 41.7% aged 60–79 years) patients with COVID-19 were included, out of which 312 (19.1%) had a myocardial injury. Patients with myocardial injury were older (36.9% > 80 years) and had higher cardiovascular-related comorbidities than those without. The prevalence of cardiovascular risk factors (78.5% vs. 52.0%) and cardiovascular diseases (78.2% vs. 56.1%) was much higher in the myocardial-injury group. Older age (50–64 years vs. <49 years; OR, 3.67 [1.99–6.74]), Angiotensin Receptor Blockers (ARBs) (OR, 1.44 [1.01–2.05]), Beta-blockers (OR, 2.37 [1.80–3.13]), and cardiovascular comorbidities (OR, 1.49 [1.09–2.05]) were strong predictors of cardiac injury after multivariable adjustment. Myocardial injury was strongly associated with ICU admission (adjusted OR, 1.68 [1.29–2.19]) and longer length of hospital stay (median days, 5 (3, 9) vs. 4 (2, 7)). The results do not show a significant difference in the use of mechanical ventilation (OR, 1.29 [0.87–1.89]) or in-hospital mortality (OR, 1.37 [0.98–1.91]) with respect to myocardial injury. Conclusion: This multicenter retrospective study of nearly 1600 patients revealed the following findings: Myocardial injury was observed in 1 out of 5 patients hospitalized with COVID-19 but was more often clinically insignificant. Patients of age > 65 had very high odds of having elevated troponin levels after adjusting for sex and other illnesses. Pre-existing cardiac diseases and risk factors were robust predictors of cardiac injury after adjusting for age and sex. In the adjusted model, myocardial injury was not associated with the requirement of mechanical ventilation or change in in-hospital mortality.
Introduction A higher prevalence of cardiovascular diseases among COVID-19 with positive troponin levels was initially observed in China beginning of the pandemic era. We are trying to add to the material available with demographics and prevalence of cardiovascular disease among COVID-19 positives. SARS-CoV-2 is mainly a respiratory disease, but it can involve a heart with direct virulence through ACE-2, exaggerated inflammatory reaction, micro thrombosis, and endothelial injury [1]. We conducted a retrospective analysis to determine cardiovascular disease prevalence among these populations stratified by troponin levels. Cardiovascular diseases led to an increase in the rate of morbidity and mortality among COVID-19 patients. The viral infection in severe cases causes cytokine storm and hypercoagulability that manifests in various acute cardiovascular events like myocardial infarction, heart failure, and myocarditis or thrombotic events like pulmonary embolism and DIC [2]. There is also a high incidence of arrhythmia observed in cases with COVID-19 likely because of viral infection, QT-prolonging medications including antibiotics and anti-viral. The overall burden of cardiovascular diseases, demographics, and co-morbidities in COVID-19 patients has been described in the literature but no causal relationship between them has been explored [3]. Also, there is little evidence regarding the characteristics of patients with myocardial injury [4]. Hence, further evidence on the subject can aid better evidence-based decisions on the prevention of acute cardiac events. A retrospective observational study was conducted of patients with a clinical diagnosis of COVID-19 from January 2020 to December 2021 in a large community health service. Patients were included if they had a laboratory or nasal swab confirmed SARS-CoV-2 infection. Myocardial injury was defined as high-sensitive troponin T levels 99th percentile above the upper limit of normal for respective biological sex (22ng/ml for female; 14ng/ml for male). The primary outcome was to find out prevalence of cardiovascular disease among COVID-19 patients stratified by troponin level. Descriptive analyses were performed by troponin level divided into positive and negative. We evaluated demographic, baseline characteristics, and medical history of cardiovascular diseases. The categorical variables are reported as total count and percentage with their p-value based on the chi-square test. A total of 13560 (45.3 % Male, 21.5 % aged >65 years) patients with COVID-19 were included, out of which 411 (3%) had a myocardial injury. Patients with myocardial injury were older (75.9% >65 years) and had higher cardiovascular-related comorbidities when compared with those without. The male and females were equally distributed (49.4% vs 45.2%, 50.6% vs 54.8%; Male and Female respectively). The population in this study was predominantly white (85.2% vs 86.4%) and non-Hispanics (92.2% vs 85.2%). The overall cardiovascular diseases and cardiovascular risk factors were markedly higher in the myocardial injury group. The overall prevalence of Hypertension, Diabetes, and Dyslipidemia were 34.8%, 38.8%, and 36.8% respectively among patients with COVID-19. Troponin positive group had higher dyslipidemia, myocardial infarction (MI), unstable angina, coronary artery disease, cardiomyopathy, heart failure, arrhythmias, stroke, and peripheral arterial disease (PAD). Hospitalization was higher in troponin-positive patients compared to those in troponin negative group (75.9% vs 10%). Length of stay and use of mechanical ventilation was higher in troponin-positive patients. The mortality among troponin-positive strata was 19.7 % versus 1.6 % in troponin-negative strata. In our study, we found the prevalence of cardiovascular diseases was much higher among Covid-19 patients with positive troponin levels. The main finding, confirming this study, is that the prevalence of cardiovascular diseases is significantly increased among patients with troponin positive and that this increase can be attributable to traditional risk factors. One previous study found 56.1 % of prevalence of myocardial injury among hospitalized COVID-19 patients [5]. Further research may be needed to understand the pathophysiology of Covid-19 affecting cardiovascular diseases.
Acquired tracheoesophageal fistula (TEF) is a rare complication of esophageal or lung cancer. A 57-year-old male presented with complaints of vomiting, cough, 20 lb weight loss, and progressive dysphagia. Early laryngoscopy and CT chest showed a normal pharynx with an irregular thickness of the thoracic esophagus. The upper gastrointestinal endoscopy (UGIE) and upper endoscopic ultrasound (EUS) revealed a hypoechoic mass evolving as complete obstruction. During the procedure, minimal CO2 was used for insufflation; however, when attempts were made to traverse the obstruction, capnography revealed an end-tidal CO2 (EtCO2) estimating 90 mmHg indicating possible TEF. This case depicts the use of capnography during UGIE in diagnosing an acquired TEF.
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