Dysphagia as a Main Symptom of Myasthenia Gravis in a Middleaged Adult Male: A Case Report

Background: Myasthenia gravis (MG) is a rare neuromuscular disorder resulting from the destruction of acetylcholine receptors at the neuromuscular junction by IgG antibodies. Although dysphagia is a common symptom in generalized form of MG, it is rarely reported as a sole manifestation of the disease, specifically in younger patients. Herein, we report a middle-aged adult patient with dysphagia as the sole manifestation of MG.Case presentation: A 49-year-old male complaining of severe dysphagia underwent an extensive clinical and paraclinical examination. Oropharyngeal dysphagia was confirmed by an experienced speech-language pathologist using the water swallowing test. Unilateral right paresis of the soft palate and vocal fold was confirmed using laryngeal video stroboscopy. Chest computerized tomography (CT) scan, brain Magnetic resonance imaging (MRI), and routine blood, urine, and thyroid tests were normal. In electromyography, slow repetitive nerve stimulation (RNS) showed a decremental response in the right nasalis muscle. The diagnostic neostigmine test with 1.5 mg of intramuscular neostigmine led to significant recovery of laryngeal and pharyngeal motor dysfunction and dysphagia within 12 hours, so the MG diagnosis was confirmed. The patient was treated with plasmapheresis, pyridostigmine, and prednisolone, which followed an improving course and led to better swallowing of solid and liquid foods.Conclusion: MG should be considered as a diagnosis in middle-aged adults with complaints of dysphagia

A new delivery model to increase adherence to methadone maintenance treatment

Dear Editor, Today, a large number of Iranian addicts are treated in methadone maintenance treatment (MMT) centers (1). According to the current procedure, each patient has treatment record in only one clinic. So, each patient is able to get prescribed medications and other medical services of the center. Receiving drugs and center-based services has always faced serious challenges such as access (2). For example, some patients with mobility jobs, people with movement restrictions and physical conditions, and patients living in rural and remote areas are unable to refer to get the medication according to a regular timetable (3). The mentioned issues are a serious challenge for persistence and adherence to MMT. Under such circumstances, a significant proportion of patients abandoned treatment plan and they lost the ancillary services, including medical visits, psychological interventions, and physical and emotional support from a social worker. Ultimately, this situation led to an increased the risk of relapse and resume high risk behaviors related to substance abuse (4). Social damage and financial losses of the country's health system are only some of the negative consequences of this situation. Based on these considerations, presentation of the strategies and constructive recommendations in support of the related organizations is a necessity. Despite the several offers raised, it seems that the abolition of the system receiving drugs from the origin center and the use of digital identification systems can be useful and practical (5). In the form of drug delivery system, patients can receive their daily dosages in any of the center across the country. This project is done in such a manner that each patient first enrolls in an MMT center and fills out a medical record form. Then, the doctor will determine the types of medication and drug dose based on the patients’ medication history. In the first three months of treatment (i.e. until the stabilization of the dose), visits or appointments will be face to face. After the period and stabilized drug dose, the patient who receives medication is no longer confined to the origin center. This means that each patient is issued an entity identifier such as a smart card for medication. By issuing the smart card, the patient can receive quota set medication use in any part of the country. Definitely to prevent abuse of patients, it is recommended that the patient's identity be verified through the finger, eye, or facial recognition digital sensors (5). Meanwhile, bringing up an instruction can be useful based on a mandatory visit to the center of origin for medical examination and psychological services at least once a month. So far, few studies have been conducted to review and confirm the delivery format of pharmaceutical services (6, 7). However, previous studies show that the facial assessment via computer evaluation and photo anthropometric variations in facial features are standard references for personal identification in the field of health and forensic (8, 9). Thus, our offer could possibly be effective in increasing adherence to treatment and reducing problems caused by the access to origin MMT center. As a result, we recommend using this pilot model for at least a one-year period. Then, if the benefit of this model is in practice, this proposal could be implemented permanently

Safety and outcomes of intravenous thrombolytic therapy in ischemic stroke patients with COVID-19: CASCADE initiative

BACKGROUND: There is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19. METHODS: This multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes. RESULTS: A total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054). CONCLUSION: IV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19