Paradoxical herniation associated with hyperbaric oxygen therapy after decompressive craniectomy: A case report

BACKGROUND Whether hyperbaric oxygen therapy(HBOT)can cause paradoxical herniation is still unclear.CASE SUMMARY A 65-year-old patient who was comatose due to brain trauma underwent decompressive craniotomy and gradually regained consciousness after surgery.HBOT was administered 22 d after surgery due to speech impairment.Paradoxical herniation appeared on the second day after treatment,and the patient’s condition worsened after receiving mannitol treatment at the rehabilitation hospital.After timely skull repair,the paradoxical herniation was resolved,and the patient regained consciousness and had a good recovery as observed at the follow-up visit.CONCLUSION Paradoxical herniation is rare and may be caused by HBOT.However,the underlying mechanism is unknown,and the understanding of this phenomenon is insufficient.The use of mannitol may worsen this condition.Timely skull repair can treat paradoxical herniation and prevent serious complications.

Multiple paradoxical embolisms caused by central venous catheter thrombus passing through a patent foramen ovale: A case report

BACKGROUND To date,this is the first case of a paradoxical embolism(PDE)that concurrently manifested in the coronary and lower limb arteries and was secondary to a central venous catheter(CVC)thrombus via a patent foramen ovale(PFO).CASE SUMMARY Here,we report a case of simultaneous coronary and lower limb artery embolism in a PFO patient carrier of a CVC.The patient presented to the hospital with acute chest pain and lower limb fatigue.Doppler ultrasound showed a large thrombus in the right internal jugular vein,precisely at the tip of the CVC.Transthoracic and transesophageal echocardiography confirmed the existence of a PFO,with inducible right-to-left shunting by the Valsalva maneuver.The patient was administered an extended course of anticoagulation therapy,and then the CVC was successfully removed.Percutaneous PFO closure was not undertaken.There was no recurrence during follow-up.CONCLUSION Thus,CVC-associated thrombosis is a potential source for multiple PDE in PFO patients.

Paradoxical roles of inhibitory autapse and excitatory synapse in formation of counterintuitive anticipated synchronization

Different from the common delayed synchronization(DS)in which response appears after stimulation,anticipated synchronization(AS)in unidirectionally coupled neurons denotes a counterintuitive phenomenon in which response of the receiver neuron appears before stimulation of the sender neuron,showing an interesting function of brain to anticipate the future.The dynamical mechanism for the AS remains unclear due to complex dynamics of inhibitory and excitatory modulations.In this article,the paradoxical roles of excitatory synapse and inhibitory autapse in the formation of AS are acquired.Firstly,in addition to the common roles such that inhibitory modulation delays and excitatory modulation advances spike,paradoxical roles of excitatory stimulation to delay spike via type-II phase response and of inhibitory autapse to advance spike are obtained in suitable parameter regions,extending the dynamics and functions of the excitatory and inhibitory modulations.Secondly,AS is related to the paradoxical roles of the excitatory and inhibitory modulations,presenting deep understandings to the AS.Inhibitory autapse induces spike of the receiver neuron advanced to appear before that of the sender neuron at first,and then excitatory synapse plays a delay role to prevent the spike further advanced,resulting in the AS as the advance and delay effects realize a dynamic balance.Lastly,inhibitory autapse with strong advance,middle advance,and weak advance and delay effects induce phase drift(spike of the receiver neuron advances continuously),AS,and DS,respectively,presenting comprehensive relationships between AS and other behaviors.The results present potential measures to modulate AS related to brain function.

Paradoxical vocal fold motion masquerading as post-anesthetic respiratory distress:A case report

BACKGROUND Functional vocal cord disorders can be a differential diagnosis for postoperative upper airway obstruction requiring urgent intervention.However,this may be unfamiliar to anesthesiologists who would favor inappropriate airway intervention and increased morbidity.CASE SUMMARY A 61-year-old woman underwent cervical laminectomy,followed by laparoscopic cholecystectomy 10 mo later.Despite adequate reversal of neuromuscular blockade,the patient experienced repetitive respiratory difficulty with inspiratory stridor after extubation.After the second operation,the patient was diagnosed with paradoxical vocal fold motion(PVFM)by an otolaryngologist based on the clinical features and fiberoptic bronchoscopy results,and the patient was successfully treated.CONCLUSION PVFM should be considered a differential diagnosis if a patient presents with stridor after general anesthesia.

nfluence of paradoxical sleep deprivation and sleep recovery on testosterone level in rats of different ages

This study was performed to assess serum testosterone alterations induced by paradoxical sleep deprivation （PSD） and to verify their attenuation during sleep recovery （SR） based on different durations and ages. Wistar male rats aged 12 weeks for the younger group and 20 weeks for the elder group were randomly distributed into one of the following groups： a control group （cage and platform）, 3-day SD, 5-day SD, 7-day SD, 1-day SR, 3-day SR and 5-day SR groups. For PSD, the modified multiple platform method was used to specifically limit rapid eye movement （REM） sleep. Differences in the testosterone and luteinizing hormone levels between the younger group and the elder group according to duration of PSD and SR recovery were analysed. Testosterone continued to fall during the sleep deprivation period in a time-dependent manner in both the younger （P=-0.001, correlation coefficient r=-0.651） and elder groups （P=0.001, correlation coefficient r=-0.840）. The elder group showed a significantly lower level of testosterone compared with the younger group after PSD. Upon SR after 3 days of PSD, the testosterone level continued to rise for 5 days after sleep recovery in the younger group （P=0.013）, whereas testosterone concentrations failed to recover until day 5 in the elder group. PSD caused a more detrimental effect on serum testosterone in the elder group compared to the younger group with respect to decreases in luteinizing hormone （LH） levels. The replenishment of serum testosterone level was prohibited in the elder group suggesting that the effects of SD/SR may be age-dependent. The mechanism by which SD affects serum testosterone and how age may modify the process are still unclear.

Progressive paradoxical sleep deprivation impairs partial memory following learning tasks in rats

BACKGROUND： Complex learning tasks result in a greater number of paradoxical sleep phases, which can improve memory. The effect of paradoxical sleep deprivation, induced by ＂flower pot＂ technique, on spatial reference memory and working memory require further research. OBJECTIVE： To observe the effect of progressive paradoxical sleep deprivation in rats, subsequent to learning, on memory using the Morris Water Maze. DESIGN, TIME AND SETTING： Controlled observation experiment. The experiment was performed at the Laboratory of Neurobiology, Department of Anatomy, Histology and Embryology, School of Basic Medical Sciences, Lanzhou University from December 2006 to October 2007. MATERIALS： Twenty-eight, male, Wistar rats, 3-4 months old, were provided by the Experimental Animal Center of Lanzhou University. The Morris Water Maze and behavioral analyses system was purchased from Genheart Company, Beijing, China. METHODS： All animals, according to a random digits table, were randomly divided into paradoxical sleep deprivation, tank control, and home cage control groups. Paradoxical sleep deprivation was induced by the ＂flower pot＂ technique for 72 hours, housing the rats on small platforms over water. Rats in the ＂tank control＂ and ＂home cage control＂ groups were housed either in a tank with large platforms over the water or in normal cages without paradoxical sleep deprivation. MAIN OUTCOME MEASURES： Morris Water Maze was employed for task learning and spatial memory testing. Rats in all groups were placed at six random starting points each day for four consecutive days. Each placement was repeated for two trials; the first trial represented reference memory and the second working memory. Rats in the first trial were allowed to locate the submerged platform within 120 seconds. Data, including swimming distance, escape latency, swimming velocity, percentage of time in correct quarter, and memory scores were recorded and analyzed automatically by behavioral analyses systems for Morris Water Maze. RESULTS： Twenty-eight rats were included in the final analysis, without any loss. In the first trial, between day 2 and 4, escape latency and swimming distance increased significantly in the paradoxical sleep deprivation group compared to the home cage control and tank control groups （P 〈 0.01）; percentage of time in correct quarter and memory scores, however, decreased in the paradoxical sleep deprivation group compared to the home cage control and tank control groups （P 〈 0.01）. The escape latency, swimming distance, percentage of time in correct quarter, and memory scores in the second trial was not significantly different among the three groups （P 〉 0.05）. CONCLUSION： Paradoxical sleep deprivation inhibits spatial reference memory, but not working memory.

Paradoxical embolus straddling patent foramen ovale demonstrated by computed tomographic pulmonary angiography

An elderly gentleman presented to the emergency department with a recent history of dyspnoea, collapse and transient neurological symptoms. He was noted to be hypoxic with a significantly elevated D Dimer. A computer tomography pulmonary angiogram demonstrated a large embolus with a further filling defects within the left and the right atria, abutting the interatrial septum. Suspicion of a paradoxical pulmonary embolus was raised and the patient subsequently underwent echocardiography which confirmed a patent foramen ovale(PFO). He was commenced on warfarin therapy. In patients with elevated right heart pressure, a PFO can be unmasked and give rise to cerebral emboli. Clinical suspicion should be raised in patients with pulmonary emboli or deep venous thrombosis if there is a concomitant history of focal neurological symptoms.

Recalcitrant paradoxical pustular psoriasis induced by infliximab:Two case reports

BACKGROUND Paradoxical psoriasis induced by tumor necrosis factor alpha antagonists is a rare side effect of those drugs and has similarities with and differences from classical psoriasis in clinical and pathological characteristics.Treating severe paradoxical psoriasis is challenging because the reported cases are rare,with treatment experience being only anecdotal.CASE SUMMARY We report 2 cases of paradoxical psoriasis caused by infliximab.Both cases manifested with a significant number of pustular lesions and had protracted and complicated clinical courses.In case 1,secukinumab alone could not control the eruptions,but colchicine supplementation markedly decreased disease activity.In case 2 miscellaneous medications were administered,including the systemic drug acitretin,the immunosuppressive drug cyclosporine,and the biologic agent ustekinumab.However,multiple applications of those medications failed to prevent new lesions from occurring.Both cases showed moderate-to-high antinuclear antibody titers.CONCLUSION Based on these cases,moderate-to-high anti-nuclear antibody titer seems to be a risk factor for paradoxical psoriasis.In addition,extensive pustular presentation may be a negative prognostic indicator and may portend a protracted clinical course refractory to therapy.

Paradoxical herniation after decompressive craniectomy provoked by mannitol:A case report

BACKGROUND Paradoxical transtentorial herniation is a rare but life-threatening complication of cerebrospinal fluid drainage in patients with large decompressive craniectomy.However,paradoxical transtentorial herniation after rapid intravenous infusion of mannitol has not been reported yet.CASE SUMMARY A 48-year-old male suffered from a right temporal vascular malformation with hemorrhage.In a coma,the patient was given emergency vascular malformation resection,hematoma removal,and the right decompressive craniectomy.The patient woke up on the 1st d after the operation and was given 50 g of 20% mannitol intravenously every 8 h without cerebrospinal fluid drainage.On the morning of the 7th postoperative day,after 50 g of 20% mannitol infusion in the Fowler’s position,the neurological function of the patient continued to deteriorate,and the right pupils dilated to 4 mm and the left to 2 mm.Additionally,computed tomography revealed an increasing midline shift and transtentorial herniation.The patient was placed in a supine position and given 0.9% saline intravenously.A few hours later,the patient was fully awake with purposeful movements on his right side and normal communication.CONCLUSION Paradoxical herniation may occur,although rarely,after infusing high-dose mannitol intravenously in the Fowler’s position in the case of a large craniectomy defect.An attempt should be made to place the patient in the supine position because this simple maneuver may be life-saving.Do not use high-dose mannitol when the flap is severely sunken.

Ischemic Stroke Due to Paradoxical Embolism in a Patient with Patent Foramen Ovale, Bilateral Distal Deep Vein Thrombosis and Platypnea-Orthodeoxia Syndrome: A Case Report

Patent foramen ovale (PFO) is a common congenital cardiac defect. It is usually asymptomatic, but it can be associated with relevant clinical manifestations such as cryptogenic stroke and platypnea-orthodeoxia syndrome. We present the case of a patient with hemodynamically significant carotid artery stenosis who underwent endarterectomy for a transient ischemic attack (TIA). After surgery, the patient presented an ischemic stroke due to M2 occlusion treated with mechanical thrombectomy. During hospitalization, a distal bilateral deep vein thrombosis was found. The patient developed respiratory failure due to a massive right-to-left shunt through a large PFO (platypnea-orthodeoxia syndrome). These findings are consistent with the hypothesis that the TIA and the subsequential ischemic stroke were related to paradoxical embolism rather than atherothromboembolism. The aim of our case report is to raise awareness of the possible complications of such a common finding as PFO.

Large eustachian valve fostering paradoxical thromboembolism:passive bystander or serial partner in crime?

Catheter-based closure of patent foramen ovale(PFO)is more effective than medical therapy in the prevention of recurrent stroke[1].It is likely that a proportion of patients evaluated for potential transcatheter PFO closure has actually different anatomical variants particularly common in the right atrium such as eustachian valve,Chiari network,Thebesian valve and Crista Terminalis.Notably,the eustachian valve may represent an increased risk factor for left circulation thromboembolism beyond that associated with PFO size and shunting.Such patients may benefit the most from percutaneous closure procedure.

Acute inferior ST-segment elevation myocardial infarction cryptogenic stroke caused by a paradoxical embolism with pulmonary embolism and previous a concomitant

A 61-year-old woman was hospitalized for a chief complaint of sudden chest tightness with sweating for two hours. The chest tightness and sweating occurred suddenly and without remission after a morning stool. Electrocardiography showed a complete atrioventricular （AV） block and arc-like elevation of the ST-segment in leads Ⅱ, Ⅲ, AVF, V7-V9, and V3R-V5R, at about 0.05-0. 15 mV. After being administered 1 mg of atropine in the emergency room （ER）, the patient was admitted to the cardiology department. The patient had been found in a cyanotic state two years previously, but did not receive any treatment; she was diagnosed with a transient ischemic attack （TIA） 1.5 years previously because of limb dyskinesia accompanied by slurred speech.

The Contemporary Disintegration of Aesthetic Utopia and Its Paradoxical Form

With the advent of the era of aesthetic capitalism in the late 20th century, aesthetics and art exude enormous political potential. In contemporary aesthetic field, Utopia is breaking through the existing model and disintegrating into the paradoxical ＂Heterotopia＂ or ＂Dystopia （anti-utopia）＂ with its revolutionary and negative power. It engages in politics, society and life with its reflexivity and anew assesses and activates aesthetical language and perceptive experience, The popularity of the engagement of aesthetics and art is the new modeling road of Utopia aiter its contemporary disintegration.

Modeling and Characterization of Vegetation, Aquatic and Mineral Surfaces Using the Theory of Plausible and Paradoxical Reasoning from Satellite Images: Case of the Toumodi-Yamoussoukro-Tiébissou Zone in V Baoulé(Côte d’Ivoire)

In this paper, the theory of plausible and paradoxical reasoning of Dezert- Smarandache (DSmT) is used to take into account the paradoxical charac-ter through the intersections of vegetation, aquatic and mineral surfaces. In order to do this, we developed a classification model of pixels by aggregating information using the DSmT theory based on the PCR5 rule using the ∩NDVI, ∩MNDWI and ∩NDBaI spectral indices obtained from the ASTER satellite images. On the qualitative level, the model produced three simple classes for certain knowledge (E, V, M) and eight composite classes including two union classes characterizing partial ignorance ({E,V}, {M,V}) and six classes of intersection of which three classes of simple intersection (E∩V, M∩V, E∩M) and three classes of composite intersection (E∩{M,V}, M∩{E,V}, V∩{E,M}), which represent paradoxes. This model was validated with an average rate of 93.34% for the well-classified pixels and a compliance rate of the entities in the field of 96.37%. Thus, the model 1 retained provides 84.98% for the simple classes against 15.02% for the composite classes.

Pulmonary embolism and impending paradoxical embolism： a case report

A definitive diagnosis of paradoxical embolism is ,based on the evidence that a thrombus crosses through the right-to-left shunting. We report a case of impending paradoxical embolism in a patient with pulmonary embolism diagnosed by echocardiography and proved by operation later.

PARADOXICAL EFFECT OF A GnRH AGONIST ON STEROIDOGENESIS IN CULTURED MONKEY GRANULOSA CELLS

In this study we demonstrate: (i) The GnRH agonist exerts a direct dose-dependet stimulative effect on the aromatase activity and progesterone production in cultured monkey granulosa cells; (ii)the stimulative effect on steroidogenesis can be completely blocked by concomitant treatment with a GnRH antagonist, suggesting that the actions of GnRH are mediated through stringent stereospecific recongnition sites; (iii) in addition to the stimulative effect, the GnRH agonist in the presence of gonadotropins also exerts an inhibitory effect, even though the peptide by itself is more effective in the stimulation of steroidogenesis, and the stimulation of gonadotropin on steroidogenesis could be gradually restored by decreasing the concentration of the GnRH agonist in the culture; and (iv) paradoxical effect can also be observed in the presence of cAMP-inducing agents, suggesting that the inhibitory action of the peptide on gonadotropin-induced steroidogenesis is localized at a step distal to the stringent recognition sites.

Coexistent of paradoxical herniation and subdural hygroma: a case report

Background: Coexistent of paradoxical herniation and subdural hygroma (SDG) is very rare, confusing symptoms may mislead the therapies.Case presentation: We report a case of a 33-year-old man underwent decompressive craniectomy (DC),postoperatively, the patient developed progressive neurologic deterioration and midline shift opposite to the DC window, CT scan revealed a SDG beside the DC window, instead of attributing the midline shift to the SDG, we recognized the underlying paradoxical herniation according to the sunken skin flap and history of lumbar cistern drainage.Subsequently we treat him with intravenous fluid expansion therapy instead of draining from the SDG, the patient recovered in one day and no recurrence was found later.Conclusion: For patients underwent DC, we should pay attention to the occurrence of paradoxicalherniation, SDG following DC may be the consequence of paradoxical herniation caused by CSF reduce therapy in post-DC patient, intravenous fluid expansion therapy is recommended and would play a great role for the recovery of the patient rather than surgical management.

Dynamic foraging strategy adaptation to heterogeneous environments contributes to social aggregation in snub-nosed monkeys

The dynamics of animal social structures are heavily influenced by environmental patterns of competition and cooperation.In folivorous colobine primates,prevailing theories suggest that larger group sizes should be favored in rainforests with a year-round abundance of food,thereby reducing feeding competition.Yet,paradoxically,larger groups are frequently found in high-altitude or high-latitude montane ecosystems characterized by a seasonal scarcity of leaves.This contradiction is posited to arise from cooperative benefits in heterogeneous environments.To investigate this hypothesis,we carried out a six-year field study on two neighboring groups of golden snub-nosed monkey(Rhinopithecus roxellana),a species representing the northernmost distribution of colobine primates.Results showed that the groups adjusted their movement and habitat selection in response to fluctuating climates and spatiotemporal variability of resources,indicative of a dynamic foraging strategy.Notably,during the cold,resource-scarce conditions in winter,the large group occupied food-rich habitats but did not exhibit significantly longer daily travel distances than the smaller neighboring group.Subsequently,we compiled an eco-behavioral dataset of 52 colobine species to explore their evolutionary trajectories.Analysis of this dataset suggested that the increase in group size may have evolved via home range expansion in response to the cold and heterogeneous climates found at higher altitudes or latitudes.Hence,we developed a multi-benefits framework to interpret the formation of larger groups by integrating environmental heterogeneity.In cold and diverse environments,even smaller groups require larger home ranges to meet their dynamic survival needs.The spatiotemporal distribution of high-quality resources within these expanded home ranges facilitates more frequent interactions between groups,thereby encouraging social aggregation into larger groups.This process enhances the benefits of collaborative actions and reproductive opportunities,while simultaneously optimizing travel costs through a dynamic foraging strategy.

COVID-19 mortality paradox(United States vs Africa):Mass vaccination vs early treatment

The coronavirus disease 2019(COVID-19)mortality rate in 55 African countries is almost 4.5 times lower than in the coronavirus disease 2019(COVID-19)despite Africa having over 4.2 times more people.This mortality paradox is also evident when comparing Nigeria,a heavily populated,poorly vaccinated and weakly mandated country to Israel,a small,highly vaccinated and strictly mandated country.Nigeria has almost 4 times lower COVID mortality than Israel.In this Field of Vision perspective,I explain how this paradox has evolved drawing upon my academic,clinical and social experience.Since April 2020,I’ve developed and been using the Egyptian immune-modulatory Kelleni’s protocol to manage COVID-19 patients including pediatric,geriatric,pregnant,immune-compromised and other individuals suffering from multiple comorbidities.It’s unfortunate that severe acute respiratory syndrome coronavirus 2 is still evolving accompanied by more deaths.However in Africa,we’ve been able to live without anxiety or mandates throughout the pandemic because we trust science and adopted early treatment using safe,and effective repurposed drugs that have saved the majority of COVID-19 patients.This article represents an African and Egyptian tale of honor.

Variations in evaporation from water surfaces along the margins of the Badain Jaran Desert over nearly 60 years and influencing factors

Based on meteorological data collected over nearly 60 years(1960-2017)from four national meteorological stations along the margins of the Badain Jaran Desert,this study analyzed the spatiotemporal variations in evaporation from water surfaces and identified the dominant controlling factors.Methods used included linear trend analysis,linear tendency estimation,the departure method,the rank correlation coefficient-based method,and Multiple Linear Regression(MLR).Results indicate notable spatiotemporal differences in evaporation distribution and evolution.Spatially,average annual evaporation exhibited a pronounced altitude effect,decreasing at a rate of about 8.23 mm/m from east to west with increasing altitude.Temporally,annual evaporation showed significant upward trends after 1996 at the northeastern(Guaizi Lake)and western(Dingxin)margins,with rates of 132 mm/10a and 105 mm/10a,respectively.Conversely,along the northwestern(Ejina Banner)and southern(Alxa Right Banner)margins of the desert,an evaporation paradox was observed,with annual evaporation trending downward at rates of 162 mm/10a and 187 mm/10a,respectively,especially after 1987.The dominant factors controlling evaporation varied spatially:Average annual temperature and relative humidity influended the western margin(Dingxin),average annual temperature was the key factor for the northeastern margin(Guaizi Lake),and average wind speed was crucial for the northern(Ejina Banner)and southern(Alxa Right Banner)margins.