Initial Episode Research Articles

#2379 Acute kidney injury as a key predictor of major adverse cardiovascular events in chronic kidney disease patients

Abstract Background and Aims Chronic kidney disease (CKD) significantly raises cardiovascular event risks. The influence of acute-on-chronic kidney incidents is less understood. This study examines the link between acute kidney injury (AKI) episodes and subsequent Major Adverse Cardiovascular Events (MACE) in CKD patients. Method From 2013 to 2016, the CKD-REIN cohort enrolled 3033 adults with CKD stages 3-5 (average age 67; 66% male; mean eGFR 33 mL/min/1.73m²) from 40 French outpatient nephrology clinics, reflecting national geographic and legal diversity. During a 5-year follow-up, all AKI episodes, whether inpatient or outpatient, were identified, confirmed, and categorized per KDIGO-AKI standards by an expert panel. Cardiovascular events were evaluated using clinical trial Cardiovascular and Stroke Endpoint Definitions. MACE cumulative incidences (myocardial infarction, stroke, heart failure hospitalization, cardiovascular death) post-AKI were calculated using Aalen-Johansen methods, accounting for kidney failure and death risks. The impact of the first AKI episode on MACE risk was analyzed using a multivariable Cox model, treating AKI as a time-variable and stratifying by characteristics (in/outpatient status, AKI stage, pre-renal causes, renal recovery at discharge). Factors like demographics, cardiovascular risks, CKD severity, and treatments were considered. Interaction and sensitivity analyses were performed, excluding those with prior AKI or cardiovascular disease. Results During a median follow-up of 5.2 years, 530 patients experienced an incident AKI episode. The cumulative incidence of MACE at 1 year following this initial episode of AKI was 8.1% [95% confidence interval, 6.1; 10.8], with a median time to occurrence of 6.7 months after AKI. After adjustment for multiple confounders, we observed a substantial increased hazard of MACE associated with a first episode of AKI (HR = 5.99 [4.63; 7.76], p < 0.001), and this association remained significant for each MACE component (Fig. 1A). A dose-response relationship was observed, with higher risks in more severe AKI cases (KDIGO grades 2-3) and among hospitalized versus non-hospitalized patients (Fig. 1B). This association was also observed across all subgroups, without any interaction with age, sex, nor major comorbidities (diabetes, history of AKI, or cardiovascular events), as well as in various sensitivity analyses. Overall, we estimated an attributable risk fraction of 18.1% [13.6; 22.4] for MACE associated with AKI episodes within this population. Conclusion Our study highlights a strong dose-response relationship between incident AKI events and the risk of subsequent major cardiovascular events in CKD patients. These findings suggest that AKI may not only be a marker of increased cardiovascular risk but also a potential mediator of this risk. From a clinical perspective, these results underscore the importance of close monitoring and management of AKI in CKD patients to reduce the risk of MACE. This study improves our understanding of the interplay between renal and cardiovascular health, emphasizing the need for integrated care approaches in this high-risk population.

Characteristics of recurrence in area postrema-onset NMO spectrum disorder - a retrospective cohort study

BackgroundNeuromyelitis Optica Spectrum Disorder (NMOSD) is an inflammatory autoimmune disease with high risk of recurrence and disability, the treatment goal is a recurrence free state. Area postrema (AP) is one of the most common involved area of NMOSD, which may have a particular significance in the pathogenesis of NMOSD and clinical heterogeneity. Our study is to investigate the clinical and recurrent characteristics AP onset NMOSD patients.MethodsA retrospective study was done in a cohort of 166 AQP4-IgG seropositive NMOSD patients which were identified by the 2015 IPND criteria. The patients were divided into AP onset (APO-NMOSD) group and non-AP onset (NAPO-NMOSD) group based on the initial episode location. Clinical features and recurrence differences of two groups were compared.ResultsThe APO-NMOSD group and NAPO-NMOSD group had a population ratio of 24:142. APO-NMOSD patients were younger (34.6y VS 42.3y, P = 0.013), had lower EDSS at first episode (0.7 VS 4.2, p = 0.028) and last follow up (1.9 VS 3.3, p = 0.001), more likely to have multi-core lesions at the first attack (33.3% VS 9.2%, P = 0.001). Also, they had a higher annual recurrence rate (0.4 ± 0.28 VS 0.19 ± 0.25, P = 0.012). In natural course NMOSD patients without immunotherapy, APO-NMSOD had a shorter time of first relapse (P < 0.001) and higher annual recurrence rate (0.31 ± 0.22 VS 0.16 ± 0.26, P = 0.038) than NAPO-NMOSD. APO-NMOSD group also have a higher risk of having the first relapsing compared to optic neuritis onset-NMOSD (HR 2.641, 95% CI 1.427–4.887, p = 0.002) and myelitis onset-NMOSD group (HR 3.593, 95% CI 1.736–7.438, p = 0.001). Compared to NAPO-NMOSD, APO-NMOSD has a higher likelihood of brainstem recurrence (28.6% vs. 4.7%, p<0.001) during the first recurrence, while NAPO-NMOSD is more susceptible to optic nerve involvement (10.7% vs. 41.1%, p = 0.01).ConclusionAQP4-IgG seropositive NMOSD patients with AP onset are youngers and have higher risk of recurrence. Clinicians should pay attention to AP damage in NMOSD, as it indicates a potential risk of recurrence.Trial registrationRetrospectively registered.

CURRENT CHALLENGES OF HEPATITIS A IN UKRAINE DURING WARTIME: A LITERATURE REVIEW

Goal: to analyze the situation of the incidence of hepatitis A in Ukraine during wartime. Materials and methods. The literature review was carried out using search engines on the platforms PubMed and Google Scholar, abstract database of scientific literature Scopus. Articles in both English and Ukrainian languages were sought. Employing bibliographic and analytical methods, approximately 50 literary sources were scrutinized. These included review articles, randomized and cohort studies, as well as international recommendations for antiviral drug prescriptions, directives, Ukrainian and European protocols for managing hepatic infection. Results. Fulminant hepatitis is a rare occurrence, accounting for less than 1% of cases, although cholestatic forms and recurrent hepatitis have also been documented. Recurrent hepatitis typically manifests in about 3–20% of patients, usually occurring 3–12 weeks following the initial episode, with symptoms generally less severe than the initial presentation. Unlike other hepatitis viruses, HAV does not establish chronic infections. While extrahepatic manifestations of acute hepatitis A are uncommon, they may include neurological symptoms such as Guillain-Barré syndrome, rash, pancreatitis, arthritis, myocarditis, acute kidney injury, and hematologic disorders such as hemolysis and cryoglobulinemia. Numerous studies have indicated that disease severity and mortality associated with HAV infection are heightened among individuals with chronic liver disease, encompassing hepatitis B or C virus coinfection, alcoholic cirrhosis, and fatty liver disease. Chronic liver disease is prevalent in HIV patients due to factors such as coinfection with HBV or HCV, hepatotoxicity from antiviral medications, or alcoholic liver disease. This population may also face an elevated risk of acute or chronic liver failure. HAV infections represent the predominant cause of viral hepatitis globally. The epidemiology of HAV has undergone significant changes due to globalization and improved sanitation. Person-to-person transmission, particularly among high-risk populations such as men who have sex with men (MSM), individuals who use psychoactive substances, and those experiencing homelessness, predominates in high-income countries. Conclusion. However, outbreaks still occur despite the availability of safe, effective vaccines and long-term HGA vaccination recommendations for these individuals. Efforts should be made to develop resources aimed at raising awareness of HAV among high-risk populations and promoting vaccination. Additionally, the development of a specific antiviral treatment for HAV could be very helpful in preventing outbreaks of the virus.

Predictors and Clinical Characteristics of Relapses in LGI1-Antibody Encephalitis.

Relapses occur in 15%-25% of patients with leucine-rich glioma-inactivated 1 antibody (LGI1-Ab) autoimmune encephalitis and may cause additional disability. In this study, we clinically characterized the relapses and identified factors predicting their occurrence. This is a retrospective chart review of patients with LGI1-Ab encephalitis diagnosed at our center between 2005 and 2022. Relapse was defined as worsening of previous or appearance of new symptoms after at least 3 months of clinical stabilization. Among 210 patients, 30 (14%) experienced a total of 33 relapses. The median time to first relapse was 23.9 months (range: 4.9-110.1, interquartile range [IQR]: 17.8). The CSF was inflammatory in 11/25 (44%) relapses, while LGI1-Abs were found in the serum in 16/24 (67%) and in the CSF in 12/26 (46%); brain MRI was abnormal in 16/26 (62%) relapses. Compared with the initial episode, relapses manifested less frequently with 3 or more symptoms (4/30 patients, 13% vs 28/30, 93%; p < 0.001) and had lower maximal modified Rankin scale (mRS) score (median 3, range: 2-5, IQR: 1 vs 3, range: 2-5, IQR: 0; p = 0.001). The median mRS at last follow-up after relapse (2, range: 0-4, IQR: 2) was significantly higher than after the initial episode (1, range: 0-4, IQR: 1; p = 0.005). Relapsing patients did not differ in their initial clinical and diagnostic features from 85 patients without relapse. Nevertheless, residual cognitive dysfunction after the initial episode (hazard ratio:13.8, 95% confidence interval [1.5; 129.5]; p = 0.022) and no administration of corticosteroids at the initial episode (hazard ratio: 4.8, 95% confidence interval [1.1; 21.1]; p = 0.036) were significantly associated with an increased risk of relapse. Relapses may occur years after the initial encephalitis episode and are usually milder but cause additional disability. Corticosteroid treatment reduces the risk of future relapses, while patients with residual cognitive dysfunction after the initial episode have an increased relapse risk.

Primary nasopharyngeal carcinoma with Sjögren's syndrome and positive cerebrospinal fluid Epstein-Barr virus: a case report and literature review

The study presents an analysis of the diagnostic and treatment protocol for a patient with a first episode of nasopharyngeal carcinoma who also has Sjogren's syndrome and Epstein-Barr Virus (EBV) positive cerebrospinal fluid, as detected through metagenomic next-generation sequencing (mNGS). It reviews existing literature to examine the connections between EBV and various conditions including Sjogren's syndrome, encephalitis or meningitis, and nasopharyngeal carcinoma, emphasizing the importance of EBV positive cerebrospinal fluid. The study focuses on a case from the Eighth Medical Center of the General Hospital of the People's Liberation Army, where a patient was admitted with headaches as the primary symptom on March 3, 2021. This patient had a history of Sjogren's syndrome and was later diagnosed with nasopharyngeal carcinoma. The research involved reviewing both domestic and international databases for cases related to cerebrospinal fluid EBV positive encephalitis or meningitis, and nasopharyngeal carcinoma. It aimed to aggregate data on demographics, initial symptoms, treatment methods, and patient outcomes. Findings suggest that positive cerebrospinal fluid EBV is linked to autoimmune diseases, viral encephalitis or meningitis, and nasopharyngeal carcinoma, albeit infrequently in the context of Sjogren's syndrome. Notably, EBV positive cerebrospinal fluid is commonly associated with recurrent nasopharyngeal carcinoma rather than initial episodes. The study concludes that for patients with an immune condition, exhibiting symptoms like headaches or cranial nerve issues, or in cases where nasopharyngeal carcinoma is suspected, early testing through cerebrospinal fluid mNGS or EBV DNA is recommended. This approach facilitates risk assessment, prognosis determination, and the creation of individualized treatment plans.

Origin and modern microbial ecology of secondary mineral deposits in Lehman Caves, Great Basin National Park, NV, USA.

Lehman Caves is an extensively decorated high desert cave that represents one of the main tourist attractions in Great Basin National Park, Nevada. Although traditionally considered a water table cave, recent studies identified abundant speleogenetic features consistent with a hypogenic and, potentially, sulfuric acid origin. Here, we characterized white mineral deposits in the Gypsum Annex (GA) passage to determine whether these secondary deposits represent biogenic minerals formed during sulfuric acid corrosion and explored microbial communities associated with these and other mineral deposits throughout the cave. Powder X-ray diffraction (pXRD), scanning electron microscopy with electron dispersive spectroscopy (SEM-EDS), and electron microprobe analyses (EPMA) showed that, while most white mineral deposits from the GA contain gypsum, they also contain abundant calcite, silica, and other phases. Gypsum and carbonate-associated sulfate isotopic values of these deposits are variable, with δ34SV-CDT between +9.7‰ and +26.1‰, and do not reflect depleted values typically associated with replacement gypsum formed during sulfuric acid speleogenesis. Petrographic observations show that the sulfates likely co-precipitated with carbonate and SiO2 phases. Taken together, these data suggest that the deposits resulted from later-stage meteoric events and not during an initial episode of sulfuric acid speleogenesis. Most sedimentary and mineral deposits in Lehman Caves have very low microbial biomass, with the exception of select areas along the main tour route that have been impacted by tourist traffic. High-throughput 16S rRNA gene amplicon sequencing showed that microbial communities in GA sediments are distinct from those in other parts of the cave. The microbial communities that inhabit these oligotrophic secondary mineral deposits include OTUs related to known ammonia-oxidizing Nitrosococcales and Thaumarchaeota, as well as common soil taxa such as Acidobacteriota and Proteobacteria. This study reveals microbial and mineralogical diversity in a previously understudied cave and expands our understanding of the geomicrobiology of desert hypogene cave systems.

Comparison of fidaxomicin, metronidazole and vancomycin for initial episode and recurrence of Clostridioides difficile infection - An observational cohort study

ObjectivesThe main aim of this study was to compare the clinical outcomes of patients attended in our area with Clostridioides difficile infection (CDI) (sustained cure, recurrence or death) in relation to treatment to normal or hypervirulent C. difficile as a risk factor and to describe the resistance profile to metronidazole and vancomycin antibiotics in our hospital over a one-year period. MethodsA retrospective, cross-sectional and observational study was conducted between June 2022 and June 2023 to compare the clinical cure and/or recurrence of CDI in adult patients treated in a Spanish secondary Hospital depending on the prescribed antibiotic treatment. In addition, we performed an antimicrobial susceptibility study to vancomycin and metronidazole in all C. difficile isolated in bacterial culture. ResultsOut of 194 selected patients the treatments were as follow: 43.81 % vancomycin, 21.65 % metronidazole, 8.25 % a combination of both, 6.70 % fidaxomicin and 19.59 % were untreated. Vancomycin and fidaxomicin patients had higher odds ratio of prolonged hospitalization (p = 0.041 and p = 0.040, respectively). Fidaxomicin had increased odds of suffering another episode of C. difficile (p = 0.009) and it was inferior to metronidazole for recurrent CDI (rCDI) (p = 0.035).Resistance profile for C. difficile was 4.07 % for vancomycin and 3.49 % for metronidazole. Hypervirulent C. difficile was identified in 17 (8.76 %) patients with 29.41 % of mortality (5/17; p > 0.05). ConclusionFidaxomicin treated patients had statistically increased odds of rCDI. Compared to other treatments, fidaxomicin was inferior to metronidazole for rCDI in our cohort;Hypervirulent C. difficile was not associated with death.Vancomycin resistance of C. difficile statistically decreased, whereas metronidazole resistance did not vary during the studied period.

Circulating HMGB1 in acute ischemic stroke and its association with post-stroke cognitive impairment.

Ischemic stroke frequently leads to a condition known as post-stroke cognitive impairment (PSCI). Timely recognition of individuals susceptible to developing PSCI could facilitate the implementation of personalized strategies to mitigate cognitive deterioration. High mobility group box 1 (HMGB1) is a protein released by ischemic neurons and implicated in inflammation after stroke. Circulating levels of HMGB1 could potentially serve as a prognostic indicator for the onset of cognitive impairment following ischemic stroke. To investigate the predictive value of circulating HMGB1 concentrations in the acute phase of ischemic stroke for the development of cognitive dysfunction at the 3-month follow-up. A total of 192 individuals experiencing their initial episode of acute cerebral infarction were prospectively recruited for this longitudinal investigation. Concentrations of circulating HMGB1 were quantified using an enzyme-linked immunosorbent assay (ELISA) technique within the first 24 hours following hospital admission. Patients underwent neurological evaluation including NIHSS scoring. Neuropsychological evaluation was conducted at the 3-month follow-up after the cerebrovascular event, employing the Montreal Cognitive Assessment (MoCA) as the primary tool for assessing cognitive performance. Multivariable logistic regression models were employed to investigate the relationship between circulating HMGB1 concentrations and cognitive dysfunction following stroke, which was operationalized as a MoCA score below 26, while controlling for potential confounders including demographic characteristics, stroke severity, vascular risk factors, and laboratory parameters. Of 192 patients, 84 (44%) developed PSCI. Circulating HMGB1 concentrations were significantly elevated in individuals who developed cognitive dysfunction following stroke compared to those who maintained cognitive integrity (8.4 ±1.2 ng/mL vs 4.6 ±0.5 ng/mL, respectively; p<0.001). The prevalence of PSCI showed a dose-dependent increase with higher HMGB1 quartiles. After controlling for potential confounders such as demographic factors (age, gender, and education), stroke severity, vascular risk factors, and laboratory parameters in a multivariable logistic regression model, circulating HMGB1 concentrations emerged as a significant independent predictor of cognitive dysfunction following stroke (regression coefficient = 0.236, p<0.001). Circulating HMGB1 concentrations quantified within the first 24 hours following acute cerebral infarction are significantly and independently correlated with the likelihood of developing cognitive dysfunction at the 3-month follow-up, even after accounting for potential confounding factors. HMGB1 may be a novel biomarker to identify patients likely to develop post-stroke cognitive impairment for targeted preventive interventions.

CLINICAL AND IMMUNOLOGICAL FEATURES OF REACTIVATION OF CHRONIC LYME BORRELIOSIS AFTER A PREVIOUS INFECTION OF COVID-19

A clinical case of reactivation of chronic Lyme borreliosis after a COVID-19 infection has been described. The purpose of the study is to use the example of a clinical case of reactivation of chronic Lyme borreliosis to demonstrate the peculiarities of its course, and modern methods of diagnosis and treatment, as well as to confirm the potential impact of coronavirus disease on the possibility of reactivation of chronic infectious pathology, even with a mild course of the COVID-19 infection. Materials and Methods. A diagnosis of borreliosis polyarthritis and Lyme myocarditis has been established. Since the specific lesions occurred for no apparent reason, and the symptoms appeared in winter, this ruled out the possibility of re-infection with Lyme borreliosis. During the further search for a potential causative agent that led to the detected changes, the patient was tested for the detection of antibodies to Borrelia burgdorferi by immunoenzymatic analysis. Results and discussion. The obtained positive result in the detection of specific antibodies (IgM – 46.64 units/ml, IgG – 87.31 units/ml) indicated the reactivation of Lyme borreliosis. At the same time, the immunological changes were significantly deeper than during the initial episode of infection. Treatment was prescribed: doxycycline 100 mg twice a day for 28 days, anti-inflammatory therapy. After completion of the course of etiotropic therapy, there was clinical remission, as well as negative results of specific IgM after 3, 6, and 12 months. Even 3 months after achieving clinical remission, the patient had residual immunological changes. Conclusion. So, the clinical case shows the difficulties of establishing a diagnosis of reactivation of Lyme borreliosis, and the need for clinical vigilance of practical healthcare specialists regarding similar cases, even with a mild course of the COVID-19 infection, is emphasized.

Relapse in ocular tuberculosis: relapse rate, risk factors and clinical management in a non-endemic country

AimsTo assess the risk of uveitis relapse in ocular tuberculosis (OTB) following clinical inactivity, to analyse clinical factors associated with relapses and to describe the management strategies for relapses.MethodsA retrospective...

IL-1β, the first piece to the puzzle of sepsis-related cognitive impairment?

Sepsis is a leading cause of death resulting from an uncontrolled inflammatory response to an infectious agent. Multiple organ injuries, including brain injuries, are common in sepsis. The underlying mechanism of sepsis-associated encephalopathy (SAE), which is associated with neuroinflammation, is not yet fully understood. Recent studies suggest that the release of interleukin-1β (IL-1β) following activation of microglial cells plays a crucial role in the development of long-lasting neuroinflammation after the initial sepsis episode. This review provides a comprehensive analysis of the recent literature on the molecular signaling pathways involved in microglial cell activation and interleukin-1β release. It also explores the physiological and pathophysiological role of IL-1β in cognitive function, with a particular focus on its contribution to long-lasting neuroinflammation after sepsis. The findings from this review may assist healthcare providers in developing novel interventions against SAE.

Skin and Soft Tissue Actinomycosis in Children and Adolescents.

Pediatric actinomycosis studies are limited to case reports or small case series. In this retrospective cohort study, we aimed to describe characteristics of skin and soft tissue actinomycosis in adolescents and children. We conducted the study from January 2019 to December 2022, including patients ≤21 years of age with at least 1-year follow-up data. All clinical cultures obtained under sterile conditions with Actinomyces growth were included. One hundred four patients met inclusion criteria; median age 19 (interquartile range: 17-20) years, 68.3% female, 46.2% Black and 47.1% Hispanic. The median antibiotic treatment duration was 10 (7-10) days, and majority of patients received treatment with non-first-line Actinomyces antibiotics. Infectious disease consultation was requested for only 7 patients during their initial skin and soft tissue actinomycosis treatment. One-third of the patients with skin and soft tissue actinomycosis had documented recurrence within a median of 10 (interquartile range: 6-16) months of the initial episode. Monobacterial culture growth (85.7% vs. 63.8%, P = 0.02), patients with body mass index >25 (75% vs. 52.6%, P = 0.04) and patients with prior abscess in the same area (18.8% vs. 51.4%, P = 0.001) were significantly higher in patients with recurrent actinomycosis compared to the nonrecurrent group. In a univariate logistic regression model, they were found to be significantly associated with recurrence; monobacterial growth [odds ratio (OR): 3.4; 95% confidence interval (CI): 1.2-9.9], body mass index >25 (OR: 2.7; 95% CI, 1.1-7.0) and prior abscess (OR: 4.6; 95% CI: 1.9-11.2). Our study results highlight the importance of considering Actinomyces species in skin and soft tissue infections, especially in recurrent ones, and risk factors for recurrence. Suboptimal antibiotic utilization, very low numbers of consultations with infectious diseases and high recurrence rate suggest that providers should be informed and updated regarding this rare but hard-to-treat infection.

Prevalence, Predictors, and Prognosis of Serious Infections in Takayasu Arteritis: A Cohort Study.

To describe the incidence, risk factors, and outcomes associated with serious infections in patients with Takayasu arteritis (TA). Serious infections, defined as infections resulting in hospitalization or death or unusual infections like tuberculosis, were identified from a cohort of patients with TA. Corticosteroid and disease-modifying antirheumatic drug (DMARD) use at the time of serious infection was noted. Demographic characteristics, clinical presentation, angiography, and disease activity at presentation, and the use of DMARDs during follow-up were compared between patients with TA with or without serious infections. Mortality in patients with TA who developed serious infections was compared to those who did not using hazard ratios (HR; with 95% CI). Of 238 patients with TA, 38 (16%) had developed serious infections (50 episodes, multiple episodes in 8; 3 episodes resulted in death). Among the 38 initial episodes, 11/38 occurred in those not on corticosteroids and 14/38 in those not on DMARDs. Pneumonia (n = 19) was the most common infection, followed by tuberculosis (n = 12). Patients with TA who developed serious infections vs those who did not had higher disease activity at presentation (active disease 97.4% vs 69.5%, mean Indian Takayasu Arteritis Activity Score 2010 12.7 (SD 7.3) vs 10.2 (SD 7.0), mean Disease Extent Index in Takayasu Arteritis 11.2 (SD 6.1) vs 8.8 (SD 6.1) and were more frequently initiated on corticosteroids or DMARDs. HRs calculated using exponential parametric regression survival-time model revealed increased mortality rate in patients with TA who developed serious infections (HR 5.52, 95% CI 1.75-17.39). Serious infections, which occurred in the absence of immunosuppressive treatment in approximately one-fifth of patients with TA, were associated with increased mortality in patients with TA.

Development and chronology of the Late Jurassic shallow-water carbonate deposits of the Holy Cross Mountains area, central Poland

The Late Jurassic shallow-water carbonates with intervening clayey-marly deeper-water deposits in the Holy Cross Mts. area formed over large bank of the elevated part of the Northern Tethyan Shelf during about 12 myr. They comprise three main successions (I, II and III) deposited partly in different environmental conditions, controlled by tectonic and climatic factors, and still preserved in the north-eastern margin, the north-western margin and the south-western margin of the Holy Cross Mountains. The history of sedimentation is presented according to the concept of the large tectono-stratigraphic units COK, LUK and KVB, which owe their origin to variable rates of tectonic subsidence, as introduced by Kutek (1994) for the area of central Poland. The studied deposits of the COK megasequence corresponding to the Upper Oxfordian and the Lower Kimmeridgian up to the Hypselocyclum Zone consist of coral limestones, various grained (including oolitic) limestones, and micritic limestones formed over the gradually enlarging shallow-water carbonate platform of the Holy Cross Mts. This platform was subsequently subdivided into two elevated areas, separated by a depressed zone in the middle, bounded by the Nowe Miasto–Iłża–Bałtów Fault Zone in the north-east and the Holy Cross Fault System in the south. The younger megasequence LUK with it strongly transgressive character marks the successive stages of the marine transgression which entered the central, lowered part of the area of the Holy Cross Mts. from the west, where it appeared already in the early Hypselocyclum Chron. It successively spread across the Holy Cross Mts. area towards the north-east and south bringing everywhere the deposition of various oyster lumachelles and marls with ammonites at the end of the Hypselocyclum Chron and during the Divisum Chron of the Early Kimmeridgian to the Acanthicum/Mutabilis Chron of the earliest Late Kimmeridgian. The following megasequence KVB is represented by the detrital lumachelles and chalky limestones with nereineids of the Eudoxus Chron of the Late Kimmeridgian marking the development of still younger shallow-water carbonate platform in the uplifted areas in the north-eastern and possibly the south-western margins of the mountains, allegedly subdivided by a deeper area of sedimentation of marly deposits. The youngest Late Jurassic deposits of the Holy Cross Mts., are very fragmentarily preserved, mostly because of Early Cretaceous uplift and erosion. They suggest an initial episode of complete drowning of the carbonate platform which became covered by marly deposits during the Early Tithonian, and the subsequent restoration of shallow-water carbonate sedimentation at the end of the Early Tithonian.

Brain Abnormalities in Schizophrenia: A Comparative Imagistic Study.

Background and Objectives: Neuroimaging reveals a link between psychiatric conditions and brain structural-functional changes, prompting a paradigm shift in viewing schizophrenia as a neurodevelopmental disorder. This study aims to identify and compare structural brain changes found during the first schizophrenia episode with those found after more than 5 years of illness. Materials and Methods: This prospective study involved 149 participants enrolled between 1 January 2019 and 31 December 2021. The participants were categorized into three groups: the first comprises 51 individuals with an initial psychotic episode, the second consists of 49 patients diagnosed with schizophrenia for over 5 years, and a control group comprising 50 individuals without a diagnosis of schizophrenia or any other psychotic disorder. All participants underwent brain CT examinations. Results: The study examined all three groups: first-episode schizophrenia (FES), schizophrenia (SCZ), and the control group. The FES group had a mean age of 26.35 years and a mean duration of illness of 1.2 years. The SCZ group, with a mean age of 40.08 years, had been diagnosed with schizophrenia for an average of 15.12 years. The control group, with a mean age of 34.60 years, had no schizophrenia diagnosis. Structural measurements revealed widening of frontal horns and lateral ventricles in the SCZ group compared to FES and the FES group compared to the control group. Differences in the dimensions of the third ventricle were noted between SCZ and FES, while no distinction was observed between FES and the control group. The fourth ventricle had similar measurements in FES and SCZ groups, both exceeding those of the control group. Our results showed higher densities in the frontal lobe in schizophrenia patients compared to FES and the control group, with the control group consistently displaying the lowest densities. Conclusions: In summary, our comparative imaging analysis of schizophrenia patients, first-episode schizophrenia, and control patients revealed distinct ventricular patterns, with SCZ showing greater widening than FES and FES wider than the control group. Frontal lobe density, assessed via cerebral CT scans, indicated a higher density in the SCZ group in both anterior and posterior cortex portions compared to FES and the control group, while the left posterior cortex in FES had the highest density. These findings highlight unique neuroanatomical features across groups, shedding light on structural differences associated with different stages of schizophrenia.

Recurrent Intensive Care Episodes and Mortality Among Children With Severe Neurologic Impairment

Children requiring care in a pediatric intensive care unit (PICU) are known to have increased risk of subsequent mortality. Children with severe neurologic impairment (SNI)-who carry neurologic or genetic diagnoses with functional impairments and medical complexity-are frequently admitted to PICUs. Although recurrent PICU critical illness episodes (PICU-CIEs) are assumed to indicate a poor prognosis, the association between recurrent PICU-CIEs and mortality in this patient population is poorly understood. To assess the association between number of recent PICU-CIEs and survival among children with severe neurologic impairment. This population-based retrospective cohort study used health administrative data from April 1, 2002, to March 31, 2020, on 4774 children born between 2002 and 2019 with an SNI diagnosis code in an Ontario, Canada, hospital record before 16 years of age and a first PICU-CIE from 2002 to 2019. Data were analyzed from November 2021 to June 2023. Pediatric intensive care unit critical illness episodes (excluding brief postoperative PICU admissions). One-year survival conditioned on the number and severity (length of stay >15 days or use of invasive mechanical ventilation) of PICU-CIEs in the preceding year. In Ontario, 4774 children with SNI (mean [SD] age, 2.1 [3.6] months; 2636 [55.2%] <1 year of age; 2613 boys [54.7%]) were discharged alive between 2002 and 2019 after their first PICU-CIE. Ten-year survival after the initial episode was 81% (95% CI, 79%-82%) for children younger than 1 year of age and 84% (95% CI, 82%-86%) for children 1 year of age or older; the age-stratified curves converged by 15 years after the initial episode at 79% survival (95% CI, 78%-81% for children <1 year and 95% CI, 75%-84% for children ≥1 year). Adjusted for age category and demographic factors, the presence of nonneurologic complex chronic conditions (adjusted hazard ratio [AHR], 1.70 [95% CI, 1.43-2.02]) and medical technology assistance (AHR, 2.32 [95% CI, 1.92-2.81]) were associated with increased mortality. Conditional 1-year mortality was less than 20% regardless of number or severity of recent PICU-CIEs. Among children with high-risk PICU-CIEs, 1-year conditional survival decreased from 90% (95% CI, 89%-91%) after the first PICU-CIE to 81% (95% CI, 77%-86%) after the fourth PICU-CIE. This cohort study of children with SNI demonstrated a modest dose-dependent association between PICU-CIEs and short-term mortality. These data did not support the conventional wisdom that recurrent PICU admissions are associated with subsequent high mortality risk.

A case series of post-infectious chikungunya myeloradiculoneuropathy

Chikungunya fever is an arboviral illness caused by chikungunya virus (CHIKV) and transmitted by the bite of Aedes aegypti and Aedes albopictus. It is an RNA virus belonging to the genus Alphavirus and family Togaviridae. We present a case series of three patients with chikungunya illness developing para/post-infectious myeloradiculoneuropathy.These patients developed neurological symptoms in the form of bilateral lower limb weakness with sensory and bowel involvement after the recovery from the initial acute episode of chikungunya fever. Clinical examination findings suggested myeloradiculoneuropathy with normal Magnetic Resonance Imaging of the Spine, with the nerve conduction study showing sensorimotor axonal polyneuropathy. All the patients were treated with 1 g of methylprednisolone once a day for five days, and case 2 was given intravenous immunoglobulin also. In the follow-up, cases 1 and 2 showed complete recovery without recurrence, and case 3 did not show improvement at one month.

Concealed Long-QT Syndrome with Rare KCNQ1 Gene Mutation in an Elderly Female: A Case Report

Long QT syndrome (LQTS) is a hereditary disorder that can lead to recurrent syncope, convulsive episodes, and sudden death due to ventricular arrhythmia. In most instances, LQTS remains concealed and primarily presents as unexplained syncope despite have a normal electrocardiogram (ECG) during periods of rest. This characteristic can be highly deceptive and may result in severe and potentially fatal consequences if treated incorrectly. In this report, we present a case of concealed LQTS in an elderly female patient who experienced an initial episode of syncope at the age of 76. Upon admission, the surface ECG showed no abnormalities. However, during the bedside ECG examination, typical manifestations of LQTS were detected, indicating an early stage of the ictal process. Subsequent treatment with βblockers provided symptomatic relief. Genetic testing identified a rare mutation, p. Arg366Trp (with a c.1096C&gt;T variant), in the KCNQ1 gene, confirming the diagnosis of LQTS. Although congenital LQTS cases are more commonly found in young females, the potential for LQTS should not be overlooked in elderly patients who complain of unexplained syncope, even if their ECG normal. The use of an artificial intelligence (AI)-based diagnostic tool has the potential to offer a more precise means of identifying concealed LQTS in the future, but, until now, thorough examination and close observation during admission is necessary to avoid missed diagnoses of the concealed LQTS-syndrome.

Herpes Zoster Recurrence: A Narrative Review of the Literature.

Herpes zoster (HZ; shingles) is a painful, cutaneous disease caused by reactivation of the varicella zoster virus, which causes varicella (chickenpox) typically during childhood. The considerable healthcare burden of HZ is relatively well documented, with approximately one in three individuals experiencing at least one episode during their lifetime, debilitating symptoms including neuropathic pain, and complications such as post-herpetic neuralgia, vision loss, and rarely, stroke, and increased severity in immunocompromised individuals. However, we are not aware of a comprehensive review of literature specifically examining the burden of HZ recurrence. We conducted a PubMed search (1 January 2003-2 February 2023) to assess available literature on the incidence, risk factors, and clinical features of HZ recurrence. The incidence of HZ recurrence reported by the studies identified was wide ranging. Studies in general populations of immunocompetent or immunocompetent/immunosuppressed (mixed) populations with an initial HZ episode estimate that approximately 1.2-9.6% of individuals may experience HZ recurrence, with an incidence rate of 1.7-16.6 cases per 1000 person-years. HZ recurrence was reported in 0.0-18.2% of immunocompromised individuals with HZ, with an incidence rate of 17.0-55 cases per 1000 person-years. Incidence rates varied according to study design, follow-up, and study populations. Recognized risk factors for HZ recurrence include immunocompromised status, female sex, family history, and comorbidities such as diabetes. Other factors that may predispose individuals to recurrence include long-lasting pain after the initial HZ episode and the presence of herpes zoster ophthalmicus. Our review underlines that following an initial HZ episode, individuals remain at risk of HZ recurrence, adding to the disease burden in a population. As HZ is preventable by vaccination, national HZ vaccination recommendations should include the need for and timing of vaccination in both immunocompetent and immunocompromised individuals who have a history of HZ.

Maintenance Electroconvulsive Therapy in Catatonia: Clinical Profiles From a Case Series.

This study aims to conduct a descriptive analysis of the clinical features and treatment responses in 6 patients with catatonia who received maintenance electroconvulsive therapy (ECT). Our study included all patients who underwent maintenance ECT (mECT) at the Hospital Clínic de Barcelona between September 2020 and September 2022 following a catatonic episode. The study cohort comprised 5 patients with schizophrenia and 1 patient with major depressive disorder. Among patients with schizophrenia, the first catatonic episode occurred several years after their initial paranoid psychotic episode, whereas the patient with depression experienced a rapid progression from the first depressive episode to catatonia. After acute ECT, 4 patients achieved complete symptomatic remission, 1 patient exhibited a partial response, and another maintained a severe catatonic state. Maintenance ECT was indicated because of the high risk of severe relapses. The mean frequency of mECT sessions was 9.83 (SD, 5.60) days. Notably, 66.67% of the patients were concurrently receiving clozapine as part of their pharmacological treatment. Among patients with schizophrenia, mECT sessions could not be extended beyond 7 to 10 days, whereas the depressed patient could space ECT sessions up to 21 days without experiencing a relapse. Maintenance ECT proves to be a safe and well-tolerated strategy for preventing relapses in severe catatonic patients who have previously stabilized with acute ECT. Further research is needed to develop clinical guidelines that define optimal application strategies for mECT in catatonia.