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these probiotics is essential in protecting these patients who are at risk and ensuring quality control and helping clinicians making the right choice.Moyamoya disease (MMD) is a cerebrovascular disease of unknown etiology characterized by stenotic and occlusive arterial changes of the anterior circulation, with subsequent proliferative development of arterial collateralization. In spite of there being limited understanding of the clear etiology of MMD, surgical revascularization for MMD is considered the standard treatment to prevent further stroke. While the use of surgical revascularization to prevent future hemorrhagic stroke in MMD is still controversial, it is considered effective in the case of ischemic stroke. This article presents a review of the current surgical management of MMD based on an analysis of the most recent data from peer-reviewed articles and opinion based on personal experience with surgical revascularization in the treatment of MMD.The SARS-CoV-2 virus has created an unprecedented impact on healthcare globally. Being a novel virus, several treatments have been explored against COVID-19. During the early stages of the disease, treatment is mainly supportive. While several studies have suggested different treatment modalities, there is still no definitive treatment against COVID-19. Re-purposing already established medications, with excellent safety profiles, is a possible approach for treating the disease in its early stage. Having a mode of transmission as a droplet mode, several studies have supported how the nose can contain the primary route of entry of SARS-CoV-2. Hence, we postulated that re-purposing a commercially available nasal spray containing xylitol and grapefruit seed extract (GSE), namely Xlear Nasal Spray® (Xlear, Inc., American Fork, USA) could be used as an adjunct treatment of COVID-19. With a well-established safety profile, the components of this nasal spray have been studied and have been shown to have potential efficacy against viral pathogens, including coronavirus, and may potentially regulate pathways important in the initial entry of infection, replication, and systemic response to SARS-CoV-2. We present a series of three mild-moderate risks, symptomatic, COVID-19 patients, treated with the intranasal combination, as an adjuvant to their ongoing treatment, with rapid clinical improvement and shorten time to negativization on repeat intranasal swab test via PCR. No safety issues were noted during the course of treatment. Xlear nasal spray, containing xylitol plus GSE, given its established safety profile and compelling clinical results described here, could be a potential adjunct treatment option in mild-moderate COVID-19 cases.A 35-year-old Hispanic male presented at an outside facility with chest pain a few days after a long road trip. The initial electrocardiogram (EKG) showed sinus tachycardia with no other abnormality. His D-dimer was positive but a subsequent computed tomography angiography (CTA) of the chest was negative for pulmonary embolism. An echocardiogram showed trace pericardial effusion with a normal ejection fraction (EF) of 70% and severe asymmetric septal hypertrophy. Satisfactory Doppler signals to assess the gradient across the left ventricle outflow tract (LVOT) could not be obtained on echocardiogram. The patient was diagnosed with acute pericarditis, which was treated medically with an improvement of his symptoms. Later, he presented to our facility for an outpatient cardiac magnetic resonance (CMR) with and without contrast, which showed severe asymmetric septal hypertrophy measuring 29 mm with substantial patchy myocardial delayed enhancement and systolic anterior motion of the mitral leaflet with flow dephasing of LVOT. These findings were diagnostic of hypertrophic obstructive cardiomyopathy. CMR also showed signs consistent with pericarditis. A Holter monitor was unremarkable for arrhythmia. A stress echocardiogram did not demonstrate any drop in blood pressure during exercise. His interventricular septum measured 29 mm on cardiac magnetic resonance imaging (MRI), which was very close to the 30 mm cut-off for an implantable cardioverter-defibrillator (ICD). In addition, he had a marked delayed enhancement in the hypertrophied septum due to gadolinium uptake, which is also considered a high-risk feature for sudden cardiac death. After discussions between the patient, cardiologist, cardiac imaging specialist, and electrophysiologist, a subcutaneous ICD was pursued, which was successfully implanted. He was started on medical treatment. He was followed closely in the clinic and has remained asymptomatic for the past two years.Takotsubo cardiomyopathy (TC), also recognized as stress-induced cardiomyopathy, is a transient condition of left ventricular (LV) dysfunction, which presents similarly to acute coronary syndrome (ACS) but with normal coronaries. Physical or emotional stressors usually precipitate TC. selleck products It is typically a benign condition, with a complete resolution once the triggering cause resolves. There have been a few cases of TC induced by diabetic ketoacidosis (DKA) that have been reported in the literature. A 50-year-old Caucasian female patient presented with lethargy, in addition to hypothermia and hypotension. Further investigation showed hyperglycemia with metabolic acidosis and ketonemia. Eventually, she was diagnosed with diabetic ketoacidosis (DKA). On Day 2 of the admission, the patient's condition further deteriorated despite appropriate treatment of DKA. An electrocardiogram (EKG) showed ST-segment elevation in inferior leads, and troponin levels were elevated. Cardiac catheterization showed non-obstructive coronary arteries but a severely reduced cardiac index. Echocardiography showed an ejection fraction (EF) of 25% with global hypokinetic LV. Eventually, the patient was diagnosed with TC or stress-induced cardiomyopathy. TC should always be suspected in any patient presenting with acute heart failure during DKA treatment. TC is a transient syndrome; however, it can result in dreadful complications, including cardiogenic shock, arrhythmias, or thromboembolic events. Early recognition and timely treatment are pivotal in such cases.