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Purpose: Syncope remains a common medical problem. Recently, the role of dedicated syncope units and implantable loop recorders has emerged in the investigation of unexplained syncope. This study aims to investigate the possibilities for a more rational and targeted use of various diagnostic tools. Methods: In this retrospective single-center study, 196 patients with unexplained syncope were included between March 2019 and February 2023. Various diagnostic tools were utilized during the investigation, according to clinical judgement. Patients were retrospectively allocated into Group A (including those who, among other tests, underwent loop recorder insertion) and Group B (including patients investigated without loop recorder implantation). Data were compared with Group C, including patients assessed prior to syncope unit establishment. Results: There was no difference between Group A (n = 133) and Group B (n = 63) in the diagnostic yield (74% vs. 76%, p = 0.22). There were significant differences between Groups A and B regarding age (67.3 ± 16.9 years vs. 48.3 ± 19.1 years, p < 0.001) and cause of syncope (cardiogenic in 69% of Group A, reflex syncope in 77% of Group B, p < 0.001). Electrocardiography-based diagnosis occurred in 55% and 19% of Groups A and B, respectively (p < 0.001). The time to diagnosis was 4.2 ± 2.7 months in Group A and 7.5 ± 5.6 months in Group B (p < 0.001). In Group C, the diagnostic yield was 57.9% and the electrocardiography-based diagnostic yield was 18.3%. Conclusions: A selective use of loop recorders according to clinical and electrocardiographic characteristics increases the effectiveness of the structured syncope unit approach and further preserves financial resources. [ABSTRACT FROM AUTHOR]

This document is a letter to the editors of the Journal of Neurology discussing a case of RFC1-related disorder presenting recurrent syncope. RFC1-related disorder is a neurodegenerative disorder characterized by cerebellar ataxia, sensory neuropathy, and bilateral vestibular dysfunction. The patient in this case was an 81-year-old man who experienced repeated episodes of syncope. The letter provides a detailed description of the patient's symptoms and medical history, as well as the diagnostic tests conducted. The authors conclude that RFC1-related disorder should be considered in cases of autonomic dysfunction and syncope. [Extracted from the article]

Deep neural networks (DNNs) have shown remarkable performance across a wide range of fields, including image recognition, natural language processing, and speech processing. However, recent studies indicate that DNNs are highly vulnerable to well-crafted adversarial samples, which can cause incorrect classifications and predictions. These samples are so similar to the original ones that they are nearly undetectable by human vision, posing a significant security risk to DNNs in the real world due to the impact of adversarial attacks. Currently, the most common adversarial attack methods explicitly add adversarial perturbations to image samples, often resulting in adversarial samples that are easier to distinguish by humans. To address this issue, we are motivated to develop more effective methods for generating adversarial samples that remain undetectable to human vision. This paper proposes a pixel-level adversarial attack method based on attention mechanism and high-frequency information separation, named DIPA. Specifically, our approach involves constructing an attention suppression loss function and utilizing gradient information to identify and perturb sensitive pixels. By suppressing the model's attention to the correct classes, the neural network is misled to focus on irrelevant classes, leading to incorrect judgments. Unlike previous studies, DIPA enhances the attack of adversarial samples by separating the imperceptible details in image samples to more effectively hide the adversarial perturbation while ensuring a higher attack success rate. Our experimental results demonstrate that under the extreme single-pixel attack scenario, DIPA achieves higher attack success rates for neural network models with various architectures. Furthermore, the visualization results and quantitative metrics illustrate that the DIPA can generate more imperceptible adversarial perturbation. [ABSTRACT FROM AUTHOR]

Debranching thoracic endovascular aortic repair may disturb the implantation of a cardiac implantable electronic device in the anterior thoracic region. In case 1, the bypass graft between the right axillary artery, left axillary artery, and left common carotid artery disturbed pacemaker implantation from the left anterior thoracic region. Therefore, right‐sided implantation was selected. By contrast, in case 2, the bypass graft between axillary arteries in the anterior thoracic region was visible on fluoroscopy, and we performed conventional left‐sided pacemaker implantation with extra‐thoracic puncture. The pacemaker implantations were successful in both cases. The implantation strategies were affected by the number of debranched arteries and visibility of the bypass graft. [ABSTRACT FROM AUTHOR]

This tutorial covers the use of absolute astrometry, in particular from the combination of the Hipparcos and Gaia missions, to identify faint companions to nearby stars and to measure the masses and orbits of those companions. Absolute astrometry has been used with increasing success to discover new planets and brown dwarfs and to measure masses and orbits for systems with periods as long as centuries. This tutorial summarizes the nature of the underlying astrometric data, the approach typically used to fit orbits, and the assumptions about that data implicit throughout the process. It attempts to provide intuition for the sensitivity of astrometry as a function of stellar and companion properties and how the available constraints depend on the character and quantity of data available. This tutorial is written for someone with some background in astronomy but with no more than a minimal acquaintance with astrometry or orbit fitting. [ABSTRACT FROM AUTHOR]

Differentiation between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) with aberrancy based on the 12‑lead ECG alone can be imprecise. Implantable cardiac defibrillators (ICD) may be inserted for presumed VT, particularly in patients with syncopal presentation or atypical aberrancy patterns. Accurate diagnosis of these patients facilitated by an electrophysiology study (EPS) may alter diagnosis and management. We present a prospective collection of cases across 3 cardiac centers of consecutive patients with WCT presumed to be VT who were referred for consideration of an ICD, and in whom further evaluation including an EPS ultimately demonstrated SVT with aberrancy as the culprit arrhythmia. 22 patients were identified (17 male, mean age 50±13 years. Available rhythm data at the time of referral was presumptively diagnosed as monomorphic VT in 16 patients and polymorphic VT in 6 patients. Underlying structural heart disease was present in 20 (91%). EPS resulted in a diagnosis of SVT with aberrancy in all cases: comprising AV nodal re-entry tachycardia (n=10), orthodromic reciprocating tachycardia (n=3), focal atrial tachycardia (n=3), AF/AFL (n=3) and 'double fire' tachycardia (n=2). 21 (95%) patients underwent successful ablation. All patients remained free of arrhythmia recurrence at a median of 3.4 years of follow-up. ICD insertion was obviated in 18 (82%) patients, with 1 patient proceeding to ICD extraction. SVT with atypical aberrancy may mimic monomorphic or polymorphic VT. Careful examination of all available rhythm data and consideration of an EPS can confirm SVT and obviate the need for ICD therapy. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Pulmonary embolisms (PEs) exhibit clinical features similar to those of acute coronary syndrome (ACS), including electrocardiographic abnormalities and elevated troponin levels, which frequently lead to misdiagnoses in emergency situations. Case presentation: Here, we report a case of PE coinciding with chronic coronary syndrome in which the patient's condition was obscured by symptoms mimicking ACS. A 68-year-old female with syncope presented to the hospital. Upon admission, she was found to have elevated troponin levels and an electrocardiogram showing ST-segment changes across multiple leads, which initially led to a diagnosis of ACS. Emergency coronary arteriography revealed occlusion of the posterior branches of the left ventricle of the right coronary artery, but based on the complexity of the intervention, the occlusion was considered chronic rather than acute. On the 3rd day after admission, the patient experienced recurrent chest tightness and shortness of breath, which was confirmed as acute PE by emergency computed tomography pulmonary angiography. Following standardized anticoagulation treatment, the patient improved and was subsequently discharged. Conclusions: This case report highlights the importance of recognizing the nonspecific features of PE. Clinicians should be vigilant when identifying other clinical features that are difficult to explain accompanying the expected disease, and it is necessary to carefully identify the causes to prevent missed diagnoses or misdiagnoses. [ABSTRACT FROM AUTHOR]

Background Bradycardia can have a number of different aetiologies, including as a side effect of medications. Brimonidine is a rare, but recognized, cause of bradycardia. Brimonidine is indicated in the treatment of facial erythema in rosacea when given as topical brimonidine gel (Mirvaso). It may also be administered as eye drops for raised intraocular pressure in open-angle glaucoma and ocular hypertension. Brimonidine is an alpha-2 agonist, which if systemically absorbed can present with bradycardia, hypotension, and dizziness. The authors are unaware of any other case reports regarding topical administration of Mirvaso in an adult and symptomatic bradycardia. Case summary We present the case of a 78-year-old man with a background of rosacea, benign prostatic hyperplasia, and hypertension who had two separate admissions with symptomatic bradycardia. Electrocardiograms showed sinus bradycardia with AV block first degree, with rate recorded as low as 31 b.p.m. during a syncopal episode. These episodes of symptomatic bradycardia were intermittent and had a temporal association with topical administration of Mirvaso. He had no further episodes of bradycardia on discontinuation of Mirvaso and has remained symptom free for over 6 months. Discussion The topical administration of Mirvaso should be avoided to broken or inflamed skin. This is owing to the increased risk of systemic absorption, which as in this case report, may present with bradycardia. This case reiterates the importance of completing a full medication history including all topical and parenteral medications in patients with arrhythmia. [ABSTRACT FROM AUTHOR]

Background Exercise-induced complete atrioventricular block (EIAVB) is a rare cardiac conduction abnormality presenting challenges in diagnosis due to non-specific symptoms such as exertional dyspnoea, dizziness, and syncope. Case summary We present a case of a 76-year-old female with recurrent exercise-associated syncope. Non-invasive exercise testing played a crucial role in diagnosing her condition, revealing EIAVB and underscoring its importance in patients with cardiovascular risk factors. Discussion This case provides insight into the pathophysiology of EIAVB, including altered atrioventricular nodal refractoriness and exercise-induced ischaemic imbalances. It highlights the need for heightened clinical vigilance in diagnosing exercise-related syncope, especially in pre-existing cardiovascular conditions. This case underscores the critical importance of non-invasive testing for diagnosing EIAVB, highlighting the necessity of thorough evaluation in patients presenting with ambiguous symptoms and cardiovascular risks. Consequently, it advocates for adherence to guidelines to enhance outcomes and reduce the need for unnecessary invasive procedures. [ABSTRACT FROM AUTHOR]

Background PTPN11 is ubiquitously expressed and has a variety of phenotypes even in a single heart. We examined LEOPARD syndrome (LS) in a patient with PTPN11 variants through pathological, electrophysiological, and anatomical studies. Case summary A 49-year-old man with no previous medical history was brought to our emergency department because of syncope. An electrocardiogram (ECG) revealed alternating bundle branch block, and echocardiography revealed hypertrophic cardiomyopathy-like morphology with systolic anterior motion of the posterior mitral valve. Atrioventricular block, left ventricular outflow tract (LVOT) obstruction, and ventricular tachycardia were considered the differential diagnoses; however, the treatment plan was difficult to determine. An electrophysiological study revealed the cause of the ECG abnormality to be accelerated idioventricular rhythm, and the programmed ventricular stimulation was negative. Genetic testing revealed LS with PTPN11 variant, which was speculated to be the cause of these various unique cardiac features. The cause of syncope was considered to be exacerbation of LVOT obstruction due to dehydration, and the patient was treated with oral beta-blockers. Implantable loop recorder observation for 1 year revealed no arrhythmia causing syncope, and an implantable cardioverter-defibrillator and pacemaker were deemed unnecessary for primary prevention of syncope. During 2.5 years of follow-up, the LVOT peak velocity fluctuated between 2.5 and 3.5 m/s, but the patient remained stable with no recurrent syncope. Conclusion We confirmed that LS is distinct from other cardiomyopathies using characterization, physiological, electrophysiological, and pathological examinations. Evidence supporting a specific treatment strategy for LS is limited, and understanding the pathogenesis may help establish effective treatment strategies. [ABSTRACT FROM AUTHOR]

As one of the most commonly used AIoT sensors, smart cameras and their supporting services, namely cloud video surveillance (CVS) systems, have brought great convenience to people's lives. Recent CVS providers use different machine learning techniques to improve their services (regarded as tasks) based on the uploaded video. However, uploading data to the CVS providers may cause severe privacy issues. Existing works that remove privacy information could not achieve a high tradeoff between data usability and privacy, because the importance of information varies with the task. In addition, it is challenging to design a real-time privacy protection mechanism, especially in resource-constrained smart cameras. In this work, we design a task-driven and efficient video privacy protection mechanism for a better tradeoff between privacy and data usability. We use Class Activation Mapping to protect privacy while preserving data usability. To improve the efficiency, we utilize the motion vector and residual matrix produced during video codec. Our work outperforms the region of interest–based methods in data protection while preserving data usability. The attack accuracy drops 70%, while the task accuracy is comparable to those without protection (within ± 4%). The average protection frame rate of the High Definition video can exceed 16 fps+ even on a CPU. [ABSTRACT FROM AUTHOR]

Background: Aortic stenosis (AS) remains one of the most commonly encountered valvular pathologies. Medical management does not alter the progression of the disease, making assessment of severity and timing of referral for valve replacement the most important aspects of caring for patients with AS. Objective: To review the contemporary management of AS, including signs and symptoms, echocardiography and decision making in management. Discussion: Severe symptomatic AS is frequently accompanied by dyspnoea, chest pain or syncope and a physical examination might reveal the presence of an ejection systolic murmur. Echocardiography is the first and most useful investigation to stratify risk and determine requirement for valve replacement by assessing valve gradients and left ventricular function. Surgical and transcatheter options now exist for treatment of AS and decision making is usually multidisciplinary and based on individual patient parameters. [ABSTRACT FROM AUTHOR]

Abstract: Uspanteko is an endangered Mayan language spoken in Guatemala. Unstressed vowels in Uspanteko often delete, though deletion is variable within and across speakers. Deletion appears to be phonological: it is sensitive to foot structure, morphology, and certain phonotactics, and it occurs in slow, careful speech. But deletion also has characteristics more typical of a phonetic process: it is intertwined with a pattern of gradient vowel reduction and is insensitive to most phonotactics. Electroglottography data shows that even 'deleted' vowels may contribute voicing to [inline-graphic 01] intervals when flanked by voiceless consonants. This suggests that 'deleted' vowels are represented in the input to speech production, even when they are acoustically masked by articulatory overlap with adjacent segments. We conclude that vowel deletion is grammatically controlled gestural overlap, consistent with the claim that phonological representations encode information about the relative timing and coordination of articulatory gestures (e.g. Browman & Goldstein 1986, Gafos 2002). At a minimum, language-specific phonetic processes must have access to more fine-grained, abstract grammatical information than is usually assumed.

Migraine is a cyclic condition with attacks consisting mainly of intense headaches, sensory intolerance, and nausea or vomiting. Loss of consciousness during attacks is often attributed exclusively to a neurally mediated reflex to pain, although it may also be due to migraine’s autonomic impairment, with cardiac conduction abnormalities, probably in relation to a degree of reduced sympathetic function. We report the case of a 51-year-old woman presenting episodes of syncope exclusively after vomiting during migraine attacks. A 24-hour Holter monitoring performed during a migraine attack disclosed an intermittent complete atrioventricular block coincident with an episode of syncope. The patient was implanted with a pacemaker without further syncopes on subsequent attacks. This case highlights the importance of clinical suspicion and investigation of syncope during migraine attacks. Recurrent syncope during migraine should not be attributed to pain to avoid misdiagnosis and ensure the treatment of other important causes of syncope.

Key Clinical Message Be aware of potential severe interactions between aged honey containing grayanotoxins and alcohol. Such combinations can exacerbate symptoms like syncope and hypotension, especially in elderly patients with pre‐existing conditions, necessitating careful evaluation and management.

Cardiac tamponade is a critical cardiovascular condition where timely diagnosis and treatment are crucial. The formation of an intrapericardial hematoma following acupuncture therapy is clinically rare. This paper reports a case of an elderly female patient who experienced severe chest pain and syncope during acupuncture therapy, subsequently diagnosed with traumatic hemopericardium and acute cardiac tamponade, complicated by cardiogenic shock. Under ultrasound guidance, pericardial puncture and drainage were successfully performed. The patient's symptoms were alleviated, her vital signs stabilized, and follow-up outcomes were favorable. This case provides valuable reference for understanding the pathogenesis, diagnosis, and treatment of pericardial hemorrhage following acupuncture therapy, integrating both clinical practice and literature review.

Vitamin C deficiency, otherwise known as scurvy, is one the oldest known diseases. Although its prevalence has substantially diminished, certain populations such as smokers, alcoholics, elderly, and those with malabsorptive syndromes remain at risk. Deficiency presents with perifollicular hemorrhage, corkscrew hairs, and petechiae that can evolve into ecchymoses and purpura. Diagnosis starts with clinical suspicion and is confirmed with plasma and leukocyte ascorbic acid levels. Early suspicion is key. Treatment with vitamin C offers an excellent prognosis and avoids unnecessary workup for differential diagnoses. In our case, a 45-year-old male alcoholic with progressively worsening symptoms was found to have scurvy. Treatment was initiated with vitamin C supplementation, and he had remarkable improvement in his symptoms within weeks. This case demonstrates that scurvy is not a disease of history and must be considered in modern medicine, especially as homelessness with concomitant poor nutrition continues to increase. [ABSTRACT FROM AUTHOR]

Four adolescent female athletes across four grades were diagnosed with either psychogenic nonepileptic seizures or conversion disorder. The females underwent thorough evaluations with their primary care providers and episode and symptom tracking by their athletic trainer. Through different applications of cognitive behavioral therapy and one-on-one counseling, the disorders resolved. Teaching athletes the importance of choosing healthy coping mechanisms to stress is vital to quality mental health. It is recommended that more research be done on psychogenic nonepileptic seizures and provide an understanding to those working with the adolescent population on triggers and treatments for psychogenic nonepileptic seizures. [ABSTRACT FROM AUTHOR]

The article focuses on a case of intermittent atrial capture loss following a cardiac defibrillator implantation. Topics include the mechanisms behind the loss of atrial capture, such as electrotonic facilitation and partial depolarization of the atrial membrane and their relationship to pacing rates; the potential causes of altered membrane excitability, like lead-tissue trauma or ischemia; and the management of the patient through adjusting the lower rate limit (LRL) for consistent capture.

Copyright of Practical Pharmacy & Clinical Remedies is the property of Editorial Department of Practical Pharmacy & Clinical Remedies and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Summa, Animali da Compagnia is the property of Point Veterinaire Italie s.r.l. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Steal syndrome is characterized by the disruption of blood flow from specific vascular territories due to perfusion via collateral vessels bypassing an obstructed artery segment. In the neurovascular setting, this can lead to entities such as subclavian steal syndrome or the less prevalent double steal phenomenon, primarily associated with atherosclerosis. We present a case of an early 80s patient with cerebrovascular insufficiency who exhibited neurological deficits during mastication. The angiographic evaluation showed occlusion at the origins of the left common carotid and of the brachiocephalic trunk. This configuration caused the left vertebral artery to be the only vessel filling anterograde. The flow in the right vertebral artery is retrograde, filling the subclavian and the right common carotid artery. Endovascular revascularization of the brachiocephalic trunk was successfully performed using a Gore Viabahn VBX Balloon Expandable Stent (W.L. Gore & Associates, Flagstaff, AZ, USA), leading to symptom resolution. [ABSTRACT FROM AUTHOR]

A 16‐year‐old female with dual‐chamber pacemaker (Medtronic Azure XT DR), due to symptomatic third‐degree congenital atrioventricular (AV) block, presented to our ambulatory with dizziness and presyncopal episodes preceded by prodromes, occurring over the last few months. The device was programmed in DDD mode with an upper rate of 150 bpm. A head‐up Tilt Test (HUTT) revealed the unexpected emergence of 2:1 electronic AV block at a sinus rate of 130 bpm. [ABSTRACT FROM AUTHOR]

Although vasovagal episodes are a common cause of syncope, vasovagal syncope can be cardioinhibitory in nature, resulting in a severe heart block or asystole. This case report focuses on a young man with a history of seizures and frequent syncopal episodes who required an extensive clinical workup and treatment for cardioinhibitory syncope. [ABSTRACT FROM AUTHOR]

A 49-year-old woman with a history of right breast cancer status post radiation therapy presented to our ED with increasing chest pain, exertional dyspnea, fatigue, and dizziness for several weeks. She denied syncope or near-syncope, and she had no personal or family history of cardiac disease. Her outpatient medications included tamoxifen and venlafaxine.

Atrial standstill is a rare arrhythmogenic condition characterized by the absence of electrical and mechanical activity in the atria. The therapeutic options for these patients described in the current literature, in which no reversible cause is detected, are permanent cardiac pacing, anticoagulant, and heart failure treatment when the latter exists. We present a case of a young male with no personal or family history of cardiovascular disease, diagnosed with atrial standstill after multiple syncopal episodes, in whom, because of the high expected ventricular pacing percentage, we opted for conduction system pacing with left bundle branch area pacing.

Abstract Background The reported prevalence of patent foramen ovale (PFO) in the general population is variable. It ranges between 8.6 and 42% according to the population studied and the imaging technique used. We aim to prospectively assess the prevalence and characteristics of PFO and interatrial septum (IAS) abnormalities as well as the related clinical manifestations in a sample of Egyptian population. Results This study comprised 1000 patients who were referred for CT coronary angiography (CTCA). Mean age was 52.5 ± 10.9 years. The prevalence of PFO among the studied population was 16.3%; closed PFO (grade I) 44.2%, open PFO (grade II) 50.9%, and open PFO with jet (grade III) 4.9%. Anatomical high-risk PFO features—defined as the presence of at least 2 or more of the following (diameter ≥ 2 mm, length ≥ 10 mm, septal aneurysm “ASA”, or redundant septum)—were found in 51.5% of PFOs’ population. Other IAS abnormalities as redundant septum (8.6%), ASA (5.3%), Bachmann’s bundle (4.5%), microaneurysm (2.6%), and atrial septal defect (ASD) (0.4%) were detected. There was a lower rate of coexistence of ASA with PFO (p = 0.031). Syncope was significantly higher in patients with PFO compared to those without PFO (6.7% vs. 1.6%, p = 0.001). Stroke, transient ischaemic attacks (TIA), and dizziness were similar in both groups. TIA, dizziness, and syncope were significantly higher in patients with IAS abnormalities including PFO compared to those without IAS abnormalities. Syncope was also significantly higher in PFO with high-risk anatomical features compared to those with non-high-risk PFO population (p = 0.02). Conclusion The prevalence of PFO in our study was approximately 16.3%, almost half of them showed anatomical high-risk features for stroke. Dizziness, syncope and TIA were significantly higher in patients with IAS abnormalities including PFO.

Abstract Background Pheochromocytoma is a rare catecholamine-producing tumour originating from adrenal chromaffin cells. Classic clinical presentation includes headache, diaphoresis and palpitation. Syncope is uncommon and may result from hypotension or arrhythmia. We report a case of neurally mediated syncope in pheochromocytoma associated with cardiac repolarization abnormalities, a unique presentation of the disease. Case presentation This case report presents a 28 year-old woman, describing recurrent syncope usually preceded by prodromes such as headache, visual blurring, heart palpitations and psychomotor agitation. Firstly she was diagnosed with anxiety and depression, but there was no improvement of symptoms with psychiatric treatment. Previous Holter revealed long QT interval. Echocardiogram showed normal dimensions, preserved left ventricular function and no valvopathies. The patient was referred for a Head-up tilt test (HUTT) in order to investigate reflex syncope. The electrocardiogram (ECG) exhibited normal sinus rhythm and diffuse cardiac repolarisation abnormalities. HUTT was positive for vasodepressor type neurally mediated syncope and ECG showed U waves after a syncope episode. This electrocardiographic finding motivated further clinical investigation. The patient also described abdominal pain, increased abdominal volume, weight loss and blood pressure instability. Based on clinical history and ventricular repolarisation abnormalities uncovered by HUTT, pheochromocytoma was suspected. Urinary test was positive for catecholamines and the abdominal imaging revelead expansive lesion. She underwent surgery to remove the pheochromocytoma, confirmed by immunohistochemistry. Conclusions After surgery she had no recurrency of symptoms, remaining asymptomatic after six years of follow-up, suggesting a cause-effect relationship between neurally mediated syncope and pheochromocytoma.

Cholinergic urticaria (CholU) is a rare condition characterized by itchy hives in the form of 1-4 mm small, raised wheals on skin, which are short-lived for duration of 15 to 20 minutes; they are caused by stimuli associated with sweating such as from physical exercise. CholU is also known as cholinergic angioedema urticaria. Hereby, we present a case report of a 42-year-old male with ChoIU who presented with systemic manifestation in the form of recurrent attacks of syncope. Diagnosis was made after a detailed history taking and all cardiac and neurological evaluations done that were normal, and widespread literature research was done to rule out other causes of syncope as systemic symptoms are rarely seen in ChoIU. His IgE antibodies levels were highly increased. He was managed with nonsedating antihistamines and health education regarding the rare condition.

Meniere's disease (MD) is a condition of the inner ear with symptoms affecting both vestibular and hearing functions. Some patients with MD experience vestibular drop attacks (VDAs), which are violent falls caused by spurious vestibular signals from the utricle and/or saccule. Recent surgical work has shown that patients who experience VDAs also show disrupted utricular otolithic membranes. The objective of this study is to determine if otolithic membrane damage alone is sufficient to induce spurious vestibular signals, thus potentially eliciting VDAs and the vestibular dysfunction seen in patients with MD. We use a previously developed numerical model to describe the nonlinear dynamics of an array of active, elastically coupled hair cells. We then reduce the coupling strength of a selected region of the membrane to model the effects of tissue damage. As we reduce the coupling strength, we observe large and abrupt spikes in hair bundle position. As bundle displacements from the equilibrium position have been shown to lead to depolarization of the hair-cell soma and hence trigger neural activity, this spontaneous activity could elicit false detection of a vestibular signal. The results of this numerical model suggest that otolithic membrane damage alone may be sufficient to induce VDAs and the vestibular dysfunction seen in patients with MD. Future experimental work is needed to confirm these results in vitro.

BackgroundLimbic-predominant age-related TDP-43 encephalopathy neuropathologic change (LATE-NC) is a clinicopathological construct proposed to facilitate studying TDP-43 pathology in older individuals.ObjectiveOur aim was to describe clinical and cognitive characteristics of LATE-NC without Alzheimer's disease neuropathologic change (ADNC) and Lewy body (LB) and to compare this with ADNC and primary age related tauopathy (PART).MethodsIn 364 autopsies of the oldest old of The 90+ Study, we identified those with LATE-NC without ADNC and LB. Control groups were participants with ADNC and PART.ResultsOf 31% of participants who had LATE-NC, only 5 (1.4%) had LATE-NC without ADNC and LB, all of whom had tau. These participants had a gradual and progressive cognitive decline. Four (80%) had dementia at death, a rate that was higher than ADNC (50%) and PART (21.7%). Mean duration of cognitive impairment was twice as long in LATE-NC without ADNC and LB (6.2 years) compared to ADNC (2.9 years) and PART (3 years). LATE-NC without ADNC and LB group had a higher prevalence of syncope, depression, and extrapyramidal signs than the ADNC and PART groups.ConclusionsDespite the high prevalence of LATE-NC, LATE-NC without ADNC and LB was rare in this large oldest-old cohort, highlighting the very high prevalence of multiple pathologic changes in the oldest old. Slowly progressive cognitive decline, ubiquitous memory impairment, history of syncope and depression, and extrapyramidal signs were prominent features among our LATE-NC without ADNC and LB group.

ABSTRACT:Audience: This simulation is intended for MS4 or PGY-1 learners.Introduction: Both headache and syncope are common chief complaints in the emergency department (ED); however, subarachnoid hemorrhage (SAH) is uncommon (accounting for 1-3% of all patients presenting to the ED with headache), with near 50% mortality.1-3 It is important to recognize the signs and symptoms that point to this specific diagnosis. Once subarachnoid hemorrhage is suspected, it is critical to understand the appropriate workup to diagnose SAH, depending on the timing of presentation. Once SAH is diagnosed, appropriately managing the patient’s glucose, blood pressure, and pain is important.Educational Objectives: By the end of this case, the participant will be able to: 1) construct a broad differential diagnosis for a patient presenting with syncope, 2) name the history and physical exam findings consistent with SAH, 3) identify SAH on computer tomography (CT) imaging, 4) identify the need for lumbar puncture (LP) to diagnose SAH when CT head is non-diagnostic > 6 hours after symptom onset, 5) correctly interpret cerebral fluid studies (CSF) to aid in the diagnosis of SAH, and 6) specify blood pressure goals in SAH and suggest appropriate medication management.Educational Methods: High-fidelity simulation was utilized since this modality forces learners to actively construct a differential for syncope, recognize the possibility of subarachnoid hemorrhage, recall the need for lumbar puncture, and talk through management considerations in real time as opposed to a more passive lecture format.Research Methods: Twenty emergency medicine residents and medical student learners completed the simulation activity. Each learner was asked to complete an eight question post-simulation survey. The survey addressed the utility and appropriate training level of the simulation activity while also including an open- ended prompt for suggestions for improvement.Results: Five PGY3, four PGY2, four PGY1, and seven medical students completed the survey. Ninety-five percent felt that the case was more helpful in a simulation format than in a lecture format. All learners felt that the simulation was an appropriate level of difficulty. Of the comments received, a few learners noted they preferred more complexity.Discussion: Overall, the educational content was effective in teaching about the SAH diagnostic algorithm, CSF interpretation, and blood pressure management in SAH. Overall, learners very much enjoyed the activity and felt it was appropriate for their level of training. The most common constructive feedback was to include more specific neurologic findings on physical examination to help guide the student to the diagnosis of SAH.Topics: Syncope, subarachnoid hemorrhage, cerebrospinal fluid interpretation, lumbar puncture, intracranial bleed, blood pressure goals and management.

Background: Abnormal uterine bleeding, formerly known as menometrorrhagia, is estimated to occur in up to one-third of women, commonly at menarche or perimenopause. Among many other causes, abnormal uterine bleeding is known to be caused by leiomyomas, and is itself a leading cause of severe iron deficiency and iron deficiency anemia in women. Rarely, abnormal uterine bleeding can lead to critically low hemoglobin values of less than 2 g/dL. We report here a case of a woman with abnormal uterine bleeding caused by leiomyomas presenting with severely low hemoglobin. Case presentation: We report the case of a 42-year-old Asian American woman who presented to the emergency department with chronic abnormal uterine bleeding and symptoms of anemia, including multiple syncopal episodes and abnormally pale skin but otherwise alert and oriented. Laboratory tests found a record-low hemoglobin of 1.6 g/dL and hematocrit of 6%. Transabdominal pelvic ultrasound revealed a lower uterine segment/cervical fibroid measuring 7.5 × 5 × 7.8 cm (length × depth × width). Patient was diagnosed with abnormal uterine bleeding–leiomyoma and received five units of packed red blood cells, one unit of fresh frozen plasma, Venofer infusions, tranexamic acid, and medroxyprogesterone. She was discharged from the hospital after 4 days. Conclusion: To date, only a handful of cases have been reported of female patient survival following severely low hemoglobin caused by abnormal uterine bleeding. This case adds to this literature, highlighting the remarkable degree of compensation that can lead to an alert, ambulatory, and oriented patient with abnormal uterine bleeding caused by leiomyoma. [ABSTRACT FROM AUTHOR]