Brain Imaging Modalities for Cavernous Sinus Pathology With Migraine Features: A Case Report

This case report delves into the unusual presentation of a 38-year-old female with a history of migraines, who initially presented with a severe right-sided headache and changes in vision in her right eye, which gradually improved. Although she had consulted with an eye specialist for these issues, she did not receive targeted treatment. This case underscores the necessity of vigilant evaluation and early intervention in a patient with seemingly benign symptoms, thereby highlighting the potential gravity of underlying conditions such as aneurysms. Our analysis and description of this case provide insights for clinicians to consider comprehensive assessment and to explore less common etiologies, resulting in improved patient outcomes.

LentiGlobin Administration to Sickle Cell Disease Patients: Effect on Serum Markers and Vaso-Occlusive Crisis

LentiGlobin, an innovative gene therapy, introduces a modified beta-globin gene that yields an anti-sickling hemoglobin variant. It boosts total hemoglobin levels, mitigates hemolysis, curtails inflammation, and addresses iron overload by reducing transfusion requirements. These changes, in turn, provide insights into disease mechanisms and treatment outcomes. Alterations in serum markers, such as hemoglobin levels and inflammatory biomarkers, can illuminate the therapeutic effectiveness of LentiGlobin and its impact on mitigating complications such as vaso-occlusive crises. Therefore, the purpose of this narrative review is to discuss the effects of LentiGlobin administration on diverse serum biomarkers and its correlation with vaso-occlusive crises in individuals with sickle cell disease (SCD).

A Case of Takayasu's Arteritis Presenting With Acute Middle Cerebral Artery Stroke Managed With Aortic-Common Carotid Artery (CCA) Bypass Surgery

Takayasu's arteritis (TA) is a rare inflammatory disorder that affects large arteries, particularly the aorta and its main branches. TA is also known as a pulseless disease because it diminishes blood flow to the limbs and organs. The patient was a 17-year-old female whose prior medical history included a diagnosis of TA. She had been experiencing multiple syncopal episodes up to three times daily, lasting 10 seconds each. She was being managed outpatient with immunologic therapy and warfarin. She initially presented to a children's hospital with abdominal pain and an asymmetrical smile and was found to have a ruptured ovarian cyst. This case demonstrated that life-threatening complications of TA can occur as a result of otherwise unrelated and common circumstances. The patient was managed medically and then proceeded to surgery. The case further highlights the multidisciplinary team approach between medical and surgical specialties and weighing the risks and benefits of complications for the patient's long-term care. Early diagnosis and prompt initiation of appropriate therapy are essential for better outcomes. Clinicians should be aware of the nonspecific symptoms of TA and consider it in the differential diagnosis of young patients presenting with systemic symptoms and arterial insufficiency. The initial presentation of middle cerebral artery stroke in young women has been documented in prior literature, but most published cases present the medical management of the disease. Our patient's case was unique because medical management was insufficient, with surgical management pursued due to persistent symptomatic hypotension. The inciting event of this case, an ovarian rupture with retroperitoneal hemorrhage, represents a unique burden to watershed infarctions in this patient group. Further research is needed to understand the pathogenesis of TA better and to develop more effective treatment strategies for this challenging disease.

Neuromyelitis Optica Spectrum Disorder

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune condition characterized by recurrent episodes of optic neuritis (ON) and transverse myelitis. This case report aims to highlight the importance of considering atypical presentations of NMOSD when confronted with MRI-detected Wernicke's encephalopathy. The primary target in NMOSD is the aquaporin-4 (AQP4) protein, predominantly located on astrocyte surfaces. Antibodies binding to AQP4 can lead to astrocyte dysfunction and damage, contributing to NMOSD's distinctive pathology. The associated immune response and inflammation can cause secondary harm to various components of the central nervous system, including oligodendrocytes and neuronal axons. This inflammatory process results in perivascular demyelination and axonal injury, further aggravating neurological deficits in NMOSD. In this case, we present a 39-year-old female with no prior medical or surgical history who sought medical attention due to a three-week history of progressive eyelid heaviness and somnolence. NMOSD is an autoimmune condition primarily targeting the AQP4 protein, resulting in recurrent ON and transverse myelitis. The patient was initially misdiagnosed with myasthenia gravis due to somnolence and ptosis. Due to concerns about myasthenia gravis due to diffuse fatigue and bilateral ptosis, the patient was initially treated with intravenous immunoglobulin (IVIG) and admitted to the neurology service. On the first day of her hospitalization, MRI with and without contrast revealed extensive, non-enhancing T2-weighted-fluid-attenuated inversion recovery (T2-FLAIR) hyperintensities surrounding the third ventricle and affecting the periaqueductal grey, medial thalami, and mammillary bodies. There was also an interval increase in T2-FLAIR hyperintensity within the right medial temporal lobe, extending more posteriorly and inferiorly, abutting the temporal horn. Subsequent CSF encephalitis panel results showed positive West Nile virus (WNV) IgG but negative WNV IgM, and AQP4 antibodies were positive. Given the high specificity of AQP4 antibodies, the patient was diagnosed with neuromyelitis optica (NMO) encephalitis. This case underscores the importance of considering atypical presentations of NMO when confronted with MRI-detected Wernicke's encephalopathy. Since our patient primarily displayed somnolence and eye-related symptoms, neither NMO nor Wernicke's encephalopathy were initially considered in the differential diagnosis. Furthermore, despite MRI findings suggestive of Wernicke's encephalopathy, it was considered less likely due to the absence of thiamine deficiency and consistent denials by family members regarding alcohol use, gastrointestinal issues, or inadequate oral intake. This case underscores the importance of considering NMOSD in patients with atypical symptoms, even when initial presentations suggest other conditions. Timely diagnosis is crucial to prevent mismanagement and improve patient outcomes. Clinicians should maintain a high level of suspicion for NMOSD, especially when MRI findings do not align with the initial diagnosis, as early recognition and treatment can significantly impact patient care and prognosis.

Comparative use of ultrasound and radiography for the detection of fractures: a systematic review and narrative synthesis

Background

Traditionally, X-rays have remained the standard modality for bone fracture diagnosis. However, other diagnostic modalities most notably ultrasound have emerged as a simple, radiation-safe, effective imaging tool to diagnose bone fractures. Despite the advantages, there is a prevalent scarcity of literature recognizing its significance in bone trauma management. This review investigates the effectiveness of ultrasound in the diagnosis of various bone fractures when compared to conventional radiography such as X-rays.

Methodology

Electronic databases such as PubMed/Medline, SCOPUS, and Web of Science (WOS) were reviewed for observational studies and review articles from the years 2017-2022 utilizing MESH terminology in a broad term search strategy. The search returned a total of 248 articles. After removal of duplicates, abstract, and full-text screening this systematic review ultimately utilized data from 31 articles. All searches were performed and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology and were conducted during August 2022. In accordance with the guidelines for assessing the quality of included systematic reviews, we used the AMSTAR 2020, Supplemental Digital Content 2, http://links.lww.com/MS9/A241 (A Measurement Tool to Assess Systematic Reviews) tool to evaluate the methodological quality of the included studies. A data extraction form based on the Cochrane Consumers and Communication Review group's extraction template for quality assessment and evidence synthesis was used for data extraction. The information extracted included details such as author information, database, journal details, type of study, etc. Studies included will be classified into long bones, short bones, pneumatic bones, irregular bones, ankle and knee, stress fractures, hip fractures, POCUS, and others. All included studies considered bias and ethical criteria and provided valuable evidence to answer the research question.

Results

The search returned a total of 248 articles, with 192 articles remaining after the removal of duplicates. Primary screening of the title and abstract articles from the database search and additional sources identified 68 relevant articles for full-text screening. This systematic review ultimately used data from 33 articles of the remaining articles we included all of them because they had more than 70% certainty, using the STROBE tool for observational articles, narrative reviews with the ENTREQ guide, and systematic reviews and meta-analyses with the PRISMA guide; however, two articles were excluded at the eligibility stage because of risk of bias.

Conclusion

This systematic review provides insightful evidence on safety and effectiveness of ultrasound in diagnosing fractures when compared to the conventional imaging modalities such as X-rays. This shall promote further large-scale, multi-centre research that can eventually guide clinic practice in diagnosing and managing various bone fractures.

Anticoagulation Options for Cranial Procedures: A Comparative Review of Aspirin, Plavix, and Aggrastat

Anticoagulation therapy is critical to avoiding thrombotic events in patients following cranial surgery. Although Aspirin, Plavix, and Aggrastat are used as anticoagulants for this purpose, there is no consensus on which agent is the most effective and safe. In this comparative study, we analyze the current evidence on the efficacy and safety of these three anticoagulants in the context of cranial surgeries. This review focuses on the advantages and disadvantages of each anticoagulant, such as its pharmacokinetics, indications, contraindications, and possible consequences. The outcomes of this study will help physicians choose the best anticoagulant for their patients based on individual patient characteristics and the kind of cranial procedure. Aggrastat's potential to be included as a recommended anticoagulant for cranial procedures warrants further study.

Recent Advancements in Epidural Etanercept for Pain Management in Radiculopathy: A Literature Review

The most common etiology of low back and neck pain is associated with spinal cord pathologies. Regardless of origin, low back and neck pain are some of the most common causes of disability worldwide. Mechanical compression due to spinal cord diseases, such as degenerative disc disorders, can lead to radiculopathy, which manifests as numbness or tingling and can progress to loss of muscle function. Conservative management, such as physical therapy, has not been proven effective in treating radiculopathy, and surgical treatments have more risks than benefits for most patients. Epidural disease-modifying medications, such as Etanercept, have been recently explored due to their minimal invasiveness and direct effects on inhibiting tumor necrosis factor-α (TNF-α). Therefore, this literature review aims to evaluate epidural Etanercept's effect on radiculopathy caused by degenerative disc diseases. Epidural Etanercept has been shown to improve radiculopathy in patients with lumbar disc degeneration, spinal stenosis, and sciatica. Further research is needed to compare the effectiveness of Etanercept with commonly used treatments such as steroids and analgesia.

The Potential Role of Etanercept in the Management of Post-stroke Pain: A Literature Review

Strokes are the second leading cause of death and disability worldwide. The brain injury resulting from stroke produces a persistent neuroinflammatory response in the brain, resulting in a spectrum of neurologic dysfunction affecting stroke survivors chronically, also known as post-stroke pain. Excess production of tumor necrosis factor alpha (TNF alpha) in the cerebrospinal fluid (CSF) of stroke survivors has been implicated in post-stroke pain. Therefore, this literature review aims to assess and review the role of perispinal etanercept in the management of post-stroke pain. Several studies have shown statistically significant evidence that etanercept, a TNF alpha inhibitor, can reduce symptoms present in post-stroke syndrome by targeting the excess TNF alpha produced in the CSF. Studies have also shown improvements in not only post-stroke pain but also in traumatic brain injury and dementia. Further research is needed to explore the effects of TNF alpha on stroke prognosis and determine the optimal frequency and duration of etanercept treatment for post-stroke pain.

The Role of Radiofrequency Ablation in the Treatment of Trigeminal Neuralgia: A Narrative Review

Trigeminal neuralgia (TN) is a chronic pain condition that affects the trigeminal nerve, the largest of the cranial nerves. It is characterized by severe, sudden, and recurrent facial pain, often triggered by light touch or a breeze. Treatment options for TN include medication, nerve blocks, and surgery, but radiofrequency ablation (RFA) has emerged as a promising alternative. RFA is a minimally invasive procedure that uses heat energy to destroy the small portion of the trigeminal nerve responsible for the pain. The procedure is performed under local anesthesia and can be done as an outpatient procedure. RFA has been shown to provide long-term pain relief for TN patients with a low complication rate. However, RFA is not suitable for all TN patients and may not be effective for those with multiple pain sites. Despite these limitations, RFA is a valuable option for TN patients who are not responding to other treatments. Furthermore, RFA is a good alternative for a patient unsuitable for surgery. Further research is needed to fully understand the long-term effectiveness of RFA and identify the best candidates for the procedure.

Snowed In: A Case Report on the Utilization of Ultrasound in the Diagnosis of Fractures

The standard convention for diagnosing bone fractures is through radiography. However, radiography can miss fractures depending on the type of injury or if human error is present. This may be due to improper patient positioning leading to superimposing bones being captured in the image, obscuring pathology. As of late, ultrasound has been gaining traction in terms of its utilization for diagnosing fractures, which radiography can miss at times. Here we present a case of a 59-year-old female who was diagnosed using ultrasound with an acute fracture that was initially missed on X-ray. We present a case of a 59-year-old female with a past medical history significant for osteoporosis who presented to an outpatient clinic for evaluation of acute left forearm pain. She reported sustaining a mechanical fall forward to the ground three weeks before bracing herself with her forearms, immediately developing left upper extremity pain lateralized to the forearm. Upon initial evaluation, forearm radiographs were obtained and showed no evidence of acute fractures. She then underwent a diagnostic ultrasound that showed an obvious fracture of the proximal radius, distal to the radial head. Upon reviewing initial radiograph films, it was evident that the proximal ulna was superimposed over the radius fracture as a proper neutral anteroposterior view of the forearm was not taken. The patient then underwent a computed tomography (CT) scan of her left upper extremity, which confirmed the presence of a healing fracture. We present a case in which ultrasound is an excellent adjunct when a fracture cannot be identified on plain film radiography. Its utilization should be well-known and considered more often in the outpatient setting.

Investigating Edaravone Use for Management of Amyotrophic Lateral Sclerosis (ALS): A Narrative Review

The use of Edaravone, given orally, for the treatment of amyotrophic lateral sclerosis (ALS) was officially approved by the Federal Drug Association (FDA) in 2017. ALS is a rare and progressive degenerative disease that worsens over time. It attacks and destroys the nerve cells that control voluntary muscles, thus leading to weakness, eventual paralysis, and, ultimately death. Edaravone was given initially intravenously, but recent evidence shows better results with oral suspension. This narrative review is aimed to investigate the benefit of Edaravone for the management of ALS, compare it to Riluzole, discuss its mechanism of action, route of use, and side effects, and ultimately discuss future implications of this pharmacotherapy.

Osteopathic Manipulative Treatment and the Management of Headaches: A Scoping Review

Headaches have been studied and treated since nearly 7,000 BC because of their significant global impact. Current headache treatment modalities are various and have a wide variety of targets, but medications are the most common. Since conventional medical treatments have several side effects, alternative remedies such as osteopathic manipulative treatment (OMT) should be considered. OMT can assist in the management of various health conditions, such as low back pain, neck pain, and headaches. The purpose of this scoping review is to evaluate recent findings regarding the efficacy of OMT modalities in the management of headaches such as tension-type headaches (TTH) and migraines. This study was designed as a scoping review to gather evidence on the efficacy of OMT modalities in the management of headaches. Following PRISMA guidelines, four databases were used to search for articles published between 2010 and 2022 that reported the use of OMT and manual therapy for TTH and migraines. Databases used include Embase, PubMed, Medline, and Web of Science. The following keywords were used: treatment, therapy, Headache, migraine, craniosacral, muscle energy, myofascial release, trigger point, osteopathic, and manipulation. The initial search yielded 473 unique articles after removing duplicates. After screening based on the inclusion and exclusion criteria, and after further analysis, 15 articles were selected. Data reports of OMT and manual therapy efficacy and/or effectiveness in treating TTH and migraine were analyzed. Articles included were randomized control studies (13 of 15, 86.6%), one pilot study (one of 15, 6.7%), and one case series (one of 15, 6.7%), which were divided into TTH (nine of 15, 60%) and Migraine Headaches (six of 15, 40%). All articles reported significant headache improvement in at least one measurement. Of all treatments analyzed, single technique interventions (seven of 15, 47%) and multiple technique interventions (eight of 15, 53%) were identified. Among the techniques used, Myofascial Release was the most common (nine of 15, 60%). The articles presented provide evidence of the significant benefits of manual therapy. Because of the limitations of traditional medicine, OMT can be used either as an alternative or adjuvant therapy for headaches. Evidence suggests the positive impact it can provide on headache management, but the number of randomized control trials and population samples should be increased to support its recommendation. This demonstrates how different osteopathic techniques can provide therapeutic effects on TTH, MH, and potentially other types of headaches. A preference for myofascial release was observed, which can be due to the fast relief from the physiologic effect on tissue movement. This review study demonstrates the benefits OMT has on decreasing headache frequency, intensity, and duration in TTH and migraines. OMT has shown to be beneficial, especially for patients seeking alternative non-pharmaceutical and non-invasive treatments. Further studies are needed to evaluate the effects of different OMT techniques, and different combinations of treatments, on other types of headaches.

Usefulness of Electoral Models for COVID-19 Vaccine Distribution

Purpose of Review

In response to the COVID-19 pandemic, there has been a remarkably accelerated development of vaccines worldwide. However, an effective distribution system is crucial for vaccination at a national level. Ecuador was one of the first Latin American countries to be most severely affected by the pandemic. It has been struggling to expand its vaccination drive and requires a strategy that provides an achievable vaccination rate and maintains its primary care services. This study aims to provide an efficient vaccination model to achieve herd immunity by utilizing the country’s existing infrastructure (the centralized electoral system) for mass vaccination.

Recent Findings

The national electoral data from 2017 and 2021 were used to create estimates for the proposed vaccination model. Two model variations, total personnel, needed, and the number of days needed to vaccinate 50%, 75%, and 100% of the population were considered. The numbers of vaccines needed, and vaccination sites were estimated based on the current number of registered voters and polling stations. The results from the proposed model show that 17,892,353 people can be vaccinated, at 40,093 polling stations, by 90,209 personnel if one vaccinator was available per polling station.

Summary

Based on this model, even a conservative estimate shows that 12.56 days are needed to achieve herd immunity, and 16.74 days are needed to vaccinate the entire population of Ecuador. Additionally, we propose that this vaccination model can be used as a blueprint for any country to address similar catastrophes in the future.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40475-022-00251-y.

Behavioral Problems in Fragile X Syndrome: A Review of Clinical Management

Fragile X syndrome (FXS) is noted to be the leading cause of inherited intellectual disabilities and is caused by expansive cytosine-guanine-guanine (CGG) trinucleotide repeats in the fragile X mental retardation 1 gene (FMR1). FXS can display a wide range of behavioral problems in addition to intellectual and developmental issues. Management of these problems includes both pharmacological and non-pharmacological options and research on these different management styles has been extensive in recent years. This narrative review aimed to collate recent evidence on the various management options of behavioral problems in FXS, including the pharmacological and non-pharmacological treatments, and also to provide a review of the newer avenues in the FXS treatment.

Bevacizumab and Sinus Venous Thrombosis: A Literature Review

Pediatric glioma treatment can be confounded by eloquent anatomical location and pathologic and genetic characteristics. Current literature suggests that the vascular endothelial growth factor (VEGF) inhibitor bevacizumab has been linked to enhancing disease control; however, its safety and effectiveness are unknown. Bevacizumab has been linked with an increased incidence of intratumoral hemorrhage as well as arterial and venous thromboembolism. A rare adverse effect of chemotherapeutic treatment with bevacizumab is sinus venous thrombosis (SVT), with only a few cases reported to date. This review highlights the pathophysiology of bevacizumab, its rare and life-threatening side effect of SVT, and future recommendations.

Rituximab in the Management of Refractory Myasthenia Gravis and Variability of Its Efficacy in Anti-MuSK Positive and Anti-AChR Positive Myasthenia Gravis

Myasthenia gravis affects the neuromuscular junction of the skeletal muscles. It results in muscle weakness involving skeletal muscles (diaphragm, extraocular muscles) and myasthenic crisis. Treatment options for myasthenia gravis management have expanded, including azathioprine, corticosteroids, plasma exchange, and tacrolimus. Unfortunately, a few cases of myasthenia gravis don't respond to conventional treatment modalities. Monoclonal antibodies, rituximab (RTX), are novel treatments that have garnered interest as of late due to their efficacy within the patient population presented with refractory form myasthenia gravis. This review aims to showcase how RTX is an effective treatment within different forms of myasthenia gravis. A limited review was performed using databases that include PubMed and Google Scholar. The following keywords were used: "myasthenia gravis," "rituximab," "monoclonal antibody," "anti-AChR antibody," and "refractory myasthenia." The review focused on case reports, human studies, or research surveys based on the inclusion criteria of human studies involving participants more than 18 years of age and published in English literature. Out of 69 articles, 14 were duplicates, and 29 were relevant and met the inclusion criteria. The findings from the study demonstrate that patients with refractory myasthenia gravis responded well to RTX treatment. Furthermore, RTX has been shown to decrease corticosteroid dependence, induce sustained remission, and have a favorable response to anti-MuSK antibody positive myasthenia gravis compared to anti-AChR antibody positive myasthenia gravis. This literature review suggests that patients with refractory myasthenia gravis can benefit from rituximab; however, it has a variable response in different forms of myasthenia gravis.

Glioma-Induced Seizure in a Neurofibromatosis Type 1 Patient: A Case Report

Neurofibromatosis type 1 (NF-1), also known as Von Recklinghausen's disease, is an autosomal-dominant disease that is characterized by high-frequency mutations leading to multiple benign tumors called neurofibromas and café au lait spots on the skin. Although NF-1 mainly affects the nervous system, it can have multisystem involvement as well, associated with the cardiovascular, orthopedic, gastrointestinal, and dermatologic systems. Psychiatric complications like anxiety, dysthymia, and depression have also been reported in patients with NF-1. The prevalence of this disorder is one in 3,000 births. NF-1 patients have a higher prevalence of seizures compared to the general population.

A 20-year-old male with a diagnosis of NF-1 at the age of three months presented to the emergency room (ER) of a local hospital for the evaluation of an unwitnessed seizure characterized by loss of consciousness and bladder control. MRI of the brain without contrast revealed hyperintensities in the mesial temporal lobe bilaterally, with a hyperintense FLAIR lesion in the splenium of the corpus callosum. The patient exhibited sudden aggression and combativeness while in the ER and also experienced a second seizure, which prompted immediate intubation. A second MRI with contrast confirmed the presence of the lesion. The patient also underwent electroencephalogram (EEG) monitoring later during his hospital stay, the results of which were unremarkable.

This case report discusses an adult male with NF-1 and a tumor of the splenium of the corpus callosum. The displayed imaging suggested a possible etiology for high seizure frequency in patients with NF-1 compared to the general population.

Updates on the Role of Spinal Cord Stimulation in the Management of Non-Surgical Chronic Lower Back Pain

Studies have shown that spinal cord stimulation (SCS) therapy is effective in the management of chronic low back pain. It plays a role by minimizing the intensity of chronic pain, improving the quality of life index, reducing the intake of narcotic analgesics, and increasing the functional improvement in the working environment. However, spinal cord stimulation therapy is not universal because of the complications in the procedure itself, the invasive nature of the treatment, and cost-effectiveness. Therefore, the proper selection of the patients is necessary to get the maximum benefit from the treatment. The study's main objective is to determine the role of spinal cord stimulation in treating non-surgical patients with chronic low back pain. The article will review the mechanism, outcomes, efficacy, predisposing factors in the success and failure of the treatment and indications, contraindications, and selection of patients undergoing spinal cord stimulation therapy. A manual search of the literature was done using databases like Google Scholar and PubMed using the keywords: spinal cord, stimulation, chronic, and low back pain. A total of 37 articles were included in the study after considering the inclusion and exclusion criteria. Spinal cord stimulation therapy effectively treats refractory lower back pain, considering the technology and mechanism of action. The authors conclude that spinal cord stimulation therapy can be used to manage chronic low back pain, other neuropathic pain, and ischemic pain when other standard treatment methods have failed and the pain persisted for more than six months.

Refractory Epilepsy in a Toddler With PPP2R1A Gene Mutation and Congenital Hydrocephalus

Protein phosphatase 2A (PP2A) is a serine-threonine phosphatase that controls a variety of cellular functions. The PPP2R1A gene is present on chromosome 19 (19q13.41). Its mutation can interrupt B56δ-dependent dephosphorylation where B56δ is greatly expressed in the neural tissues. We present a case of a 14-month-old boy with infantile spasms, developmental delay, obstructive sleep apnea, PPP2R1A gene mutation, congenital hydrocephalus, hypoplastic/absent corpus callosum, pontocerebellar hypoplasia, and medically refractory seizures. He underwent multiple surgical procedures that include endoscopic third ventriculostomy with choroid plexus cauterization, ventriculoperitoneal shunting, and external ventricular drain for progressive hydrocephalus with multiple antiepileptic regimes for refractory epilepsy with variable response.

Pediatric Chemotherapy Drugs Associated With Cardiotoxicity

Pediatric cancers are a common cause of childhood morbidity. As a result, chemotherapeutic regimens have been designed to target childhood cancers. These medications are necessary to treat pediatric cancers, however, oncology management options are accompanied by multiple negative and potentially fatal adverse effects. Although anthracyclines are the most commonly used chemotherapeutic agents associated with cardiotoxicity, we also explore other chemotherapeutic drugs used in children that can potentially affect the heart. Genetic variations resulting in single nucleotide polymorphism (SNP) have the propensity to modify the cardiotoxic effects of the chemotherapy drugs. The clinical presentation of the cardiac effects can vary from arrhythmias and heart failure to completely asymptomatic. A range of imaging studies and laboratory investigations can protect the heart from severe outcomes. The physiology of the heart and the effect of drugs in children vary vividly from adults; therefore, it is crucial to study the cardiotoxic effect of chemotherapy drugs in the pediatric population. This review highlights the potential contributing factors for cardiotoxicity in the pediatric population and discusses the identification and management options.

Medical Cannabis, Headaches, and Migraines: A Review of the Current Literature

Cannabis has been long used since ancient times for both medical and recreational use. Past research has shown that cannabis can be indicated for symptom management disorders, including cancer, chronic pain, headaches, migraines, and psychological disorders (anxiety, depression, and post-traumatic stress disorder). Active ingredients in cannabis that modulate patients' perceptions of their conditions include Δ⁹‐tetrahydrocannabinol (THC), cannabidiol (CBD), flavonoids, and terpenes. These compounds work to produce effects within the endocannabinoid system to decrease nociception and decrease symptom frequency. Research within the United States of America is limited to date due to cannabis being classified as a schedule one drug per the Drug Enforcement Agency. Few anecdotal studies have found a limited relationship between cannabis use and migraine frequency. The purpose of the review article is to document the validity of how medical cannabis can be utilized as an alternative therapy for migraine management. Thirty-four relevant articles were selected after a thorough screening process using PubMed and Google Scholar databases. The following keywords were used: "Cannabis," "Medical Marijuana," "Headache," "Cannabis and Migraine," "Cannabis and Headache." This literature study demonstrates that medical cannabis use decreases migraine duration and frequency and headaches of unknown origin. Patients suffering from migraines and related conditions may benefit from medical cannabis therapy due to its convenience and efficacy.

Hypoxic-Ischemic Encephalopathy-Induced Seizure in an 11-Year-Old Female

Hypoxic-ischemic encephalopathy (HIE) typically manifests in the neonatal period. The degree of hypoxia following intrapartum asphyxia determines the structural changes in the brain, which can cause functional deficits in the affected child leading to developmental deficits and recurrent seizures. Management requires physical therapy, occupational therapy, and anti-seizure medications. We present a rare case of an 11-year-old female with a past medical history of epilepsy and cerebral atrophy secondary to hypoxic injury at birth. The patient presented to the hospital following a witnessed seizure and loss of consciousness for one hour. Given the past medical history and clinical findings, it was determined that a mild-to-moderate encephalopathic process resulted in a lower seizure threshold. HIE can manifest beyond the neonate years mainly due to the structural changes within the brain. Therefore, it is essential to understand aspects of HIE beyond the neonate years to manage this condition for a better patient outcome.

Hyperammonemic Encephalopathy in an Adolescent Patient of Citrullinemia Type 1 With an Atypical Presentation

Citrullinemia refers to a family of autosomal recessive disorders involving the urea cycle. Three forms exist, which have different implications. Type I citrullinemia exists in both mild and severe forms. It arises due to mutations with argininosuccinate synthase leading to accumulation of ammonia and producing symptoms of lethargy, poor feeding, and seizures. Type II citrullinemia occurs due to citrin mutations involved in the urea cycle transport or during neonatal cholestasis. Management of both conditions requires low-protein diets along with arginine, sodium benzoate, and sodium phenylacetate. While traditional treatment shows improved outcomes, modifications may be necessary depending on a patient’s presentation.

We present a unique case of a 19-year-old wheelchair-bound female with a past medical history of heterozygous type I citrullinemia, seizures, and chronic encephalopathy presented to a local children’s hospital for evaluation of altered mental status with a lethargic mental state. She was initially found to have an ammonia level of 329 µmol/L and choledocholithiasis on admission. Dietary modification with intravenous dextrose and intralipids with oral lactulose saw improvement in her labs. However, her ammonia level increased to 381 µmol/L despite such interventions. Intensive care was required to normalize her serum ammonia level and clear her for a magnetic resonance cholangiopancreatography (MRCP).

We present a unique case of heterozygous type I citrullinemia with some overlap with type II citrullinemia features. Further studies are needed to understand better the observed unique presentation and long-term clinical implications associated with the disease.

Prednisolone plus albuterol versus albuterol alone in mild to moderate bronchiolitis

To evaluate combination therapy of mild to moderate bronchiolitis with bronchiodilators and corticosteroids, we treated 51 young children with first-time wheezing and symptoms of respiratory tract infection with albuterol plus either prednisolone or placebo for 5 days. Disease severity was scored on days 0, 2, 3, and 6. On day 2, prednisolone resulted in significantly lower scores (2.7 +/- 1.4 vs. 4.0 +/- 1.5 in all patients evaluated, p < 0.05) than placebo, whereas there was no detectable difference on day 6, suggesting that addition of prednisolone to albuterol transiently accelerates recovery from bronchiolitis. The clinical significance of this effect needs to be evaluated in further studies.