Chronic headaches and sleep disorders

BACKGROUND

Headaches and sleep problems are common complaints in the daily practice of the general practitioner. Since the relationship between headaches and sleep complaints is complex, clear models of interaction are needed for adequate diagnosis and treatment.

METHODS

All subjects, successively seen in a headache clinic during a defined period, were subdivided based on the time of onset of cephalalgia. Subjects who reported onset of headache on a long-term basis, during the nocturnal or early morning (before final awakening) period, were systematically studied by a headache clinic and a sleep disorders center. This subgroup represented 17% of the total headache group.

RESULTS

Although the results of the headache clinic study did not differentiate this subgroup from the other patients, the sleep disorders center's interviews and questionnaires demonstrated a significant impact of the sleep disorders on headache and daytime function. Nocturnal monitoring during sleep identified specific sleep disorders in 55% of the subjects with onset of headache during the nocturnal sleep period. Follow-up after treatment of the sleep disorder showed that all subjects with an identifiable sleep disorder reported either an improvement or absence of their headache. The subjects identified with periodic limb movement syndrome were mostly those who reported only an improvement in their sleep and still needed treatment for their headaches. The question of the interaction and association of sleep-related headache and periodic limb movement syndrome is unresolved.

CONCLUSION

Headaches occurring during the night or early morning are often related to a sleep disturbance.

[The factors triggering epileptic crises according to patients]

The authors were interested in knowing what epileptic patients think about seizure-inducing factors; whether they are convinced that their seizures are induced by any trigger factor and, if so, which factor it is. While mainly interested in the psychological reality of patients, data about objective factors could emerge from this study. An inquiry was made among the 1005 patients who attended the outpatient clinic for epilepsy of Santa Maria Hospital, Lisbon, during five months of 1994. Of the 308 that answered the inquiry, 147 could not recognise any inducing factor for their last seizure, while 144 mentioned such a factor (of the latter, some mentioned two or more factors acting together). Emotional factors were most often mentioned. Seventeen answers were discarded. In many instances, seizure-inducing factors are identified by the patients but difficult to objectivize by investigators, namely those of emotional type. Answers given by the patients might help doctors to provide patients with better care.

[Sepsis in the very low-birth-weight newborn infant]

Sepsis is a common pathology during the neonatal period. Low-birth weight is the most important isolated risk factor. With the purpose of determining the prevalence of nosocomial infection in newborns of very low birth weight (VLBW), finding the microbial flora and the mortality of these patients, the authors retrospectively analysed the clinical processes of the hospitalized VLBW in the Neonatal Intensive Care Unit (NICU) in S. João Hospital in 1993 and 1994. Of the 1091 newborns admitted to the hospital in these two years, 112 were VLBW (10%). Of these, 48 had sepsis-31 (28%) confirmed sepsis and 17 (15%) probable sepsis. The agents most commonly found were Staphylococcus epidermidis (44%) and Klebsiella pneumoniae (21%). Thirteen patients (27%) died, with infection as the cause of death in nine (19%). Our results confirm the importance of nosocomial neonatal infection, which should involve the strict observance of the asepsis norms and a proper policy of antibiotics.

Effect of mercuric chloride intoxication and dimercaprol treatment on delta-aminolevulinate dehydratase from brain, liver and kidney of adult mice

Dimercaprol is a compound used in the treatment of mercury intoxication, however with low therapeutic efficacy. It is assumed that dimercaprol acts by reactivating target sulfhydryl-containing proteins. In the present investigation we studied the inhibitory effect of mercuric chloride treatment (3 days with 2.3 or 4.6 mg/kg HgCl2, sc) in mice on cerebral, renal and hepatic delta-aminolevulinate dehydratase (ALA-D) activity, and a possible reversal of the effect of mercury by dimercaprol (0.25 mmol/kg, 24 hr after the last mercury injection). Mercuric chloride did not inhibit cerebral ALA-D at the doses injected. Dimercaprol treatment did not restore the normal enzyme activity of the liver after the 25% inhibition caused by 4.6 mg/kg HgCl2. In the kidney, dimercaprol enhanced the inhibitory effect of 4.6 mg/kg mercuric chloride (from 35% after mercury treatment alone to 65% after mercury plus dimercaprol treatment). Mercury content increased in kidney after exposure to 2.3 or 4.6 mg/kg and the levels attained were higher than in any other organ Mercury accumulated in liver only after exposure to 4.6 mg/kg HgCl2, and dimercaprol further increased mercury deposition. Dimercaprol treatment also increased the levels of mercury in brain of animals exposed to 4.6 mg/kg HgCl2 The enzymes from all sources presented similar sensitivity to the combined effect of HgCl2 and dimercaprol in vitro. In the absence of preincubation, 0-500 muM dimercaprol potentiated the inhibitory effect of HgCl2 on ALA-D activity. In the presence of preincubation, and 100 and 250 muM dimercaprol enhanced ALA-D sensitivity to mercury, whereas 500 muM dimercaprol partially protected the enzyme from mercury inhibition. Dimercaprol (500 muM) inhibited renal and hepatic ALA-D when preincubated with the enzymes. These data suggested that the dimercaprol-Hg complex may have a more toxic effect on ALA-D activity than Hg2+. Furthermore, the present data show that dimercaprol did not acts by reactivating mercury-inhibited sulfhydryl-containing ALA-D, and that indeed it may have an inhibitory effect per se depending on the tissue.

Reinforcing properties of the substance P C-fragment analog DiMe-C7 in Carassius auratus

The aim of the present study was to investigate whether two substance P (SP) fragments have reinforcing effects in Carassius auratus when the fish were tested in a place-preference experimental model. Fish were placed in a 3-compartment box in which one compartment gives access to two others that are not connected. The time spent in each compartment was recorded for 10 min in order to determine which one was preferred. Twenty-four hours later the fish were given one of the following ip treatments: 1) group VEH (N = 12), injected with teleost saline, 2) group DiMe-C7 (N = 12), injected with 33 micrograms/kg DiMe-C7, and 3) group SP1-7 (N = 12), injected with 167 micrograms/kg SP1-7. Immediately after treatment the fish were kept for 30 min in the compartment that was the least preferred on the day before and this procedure was repeated for 3 days. On the fifth day the fish were retested for 10 min to determine the time spent in each compartment. Two-way analysis of variance with treatments and testing as factors indicated a main effect (P < 0.0025) as well as a testing effect (P < 0.009). The post-hoc Scheffé multiple comparison test indicated that only the DiMe-C7 group presented an increase in the time spent in the paired compartment after treatment. We suggest that the C-terminal fragment of SP has reinforcing effects in Carassius auratus.

Effects of dental decompensation on the surgical treatment of mandibular prognathism

The dental compensation presented in patients with the Class III malocclusion, or mandibular prognathism, and its importance to the surgical-orthodontic treatment, was evaluated in this study. The study involved the cephalometric examination of two groups of patients, who were considered either adequately or inadequately treated during the presurgical orthodontic phase. The results showed that dental compensation is common in both the maxillary and mandibular arches. Such compensation is more frequently eliminated from the mandibular arch during presurgical orthodontic treatment. There was some correlation between decompensation and the amount of mandibular reduction during surgery and a strong correlation between cephalometric postsurgical mandibular excess and the lower anterior facial height.

The relationship between headaches and sleep disturbances

The relationship between headaches and sleep disturbances is complex and difficult to analyze. Both symptoms may have causal relations, or may be associated in the same patient with mutual reinforcements. We studied 25 patients presenting with morning or nocturnal headaches. Standard headache diagnosis and polysomnography were performed. After polysomnography, the diagnoses were reevaluated. The main headache entities were cluster, chronic paroxysmal hemicrania, migraine, tension, combined headache, and chronic substance abuse headache. For each group, headache, sleep data, and changes in diagnosis are discussed. The diagnosis was changed in 13 patients; the final diagnoses were periodic movements of sleep, fibromyalgia syndrome, and obstructive sleep apnea. The diagnoses of cluster headache and chronic paroxysmal hemicrania were not modified by polysomnography. The migraine and tension headache groups had a relative male preponderance, and the diagnosis was changed in approximately half of the patients. This was also observed in combined headaches. Patients who had chronic substance abuse headaches had mainly insomnia, which in some cases, was relieved by stopping medication. Data were also analyzed in terms of simple models linking headache and sleep disturbances. Such an approach allowed the identification of several modes of mutual interaction. In summary, morning or nocturnal headaches are frequent indicators of a sleep disturbance and their presence might justify polysomnography, and the use of simple clinical models may be useful for understanding the complex relationship between headache and sleep.

[Striato-pallido-dentate calcifications and acquired facial atrophy]

A family with two siblings presenting cerebral calcifications is reported. The sister was suffering from action tremor since the age of 10. The disease worsened by the age of 39. When aged 42, she was unable to walk and had severe rigidity and intellectual deterioration. She died at 43. The brother had mild debility. Action tremor started at the age of 14, without significant aggravation when seen at the age of 30. In both cases, brain CT scan showed calcifications of the dentate nuclei and cortical atrophy with ventricular enlargement. In addition, the sister had bilateral putaminal and pallidal calcifications. The other family members were unaffected and had normal CT scans. The nosology and the pathophysiology of this family report are discussed, particularly regarding the late occurrence of facial atrophy, reminiscent of the Cole-Engmann syndrome (Dyskeratosis Congenita).

Histologic and genetic assessment of explanted allograft valves

A possible way of analyzing the immune response triggered by the allograft and the cellular viability is to compare immunocompetent and immunosuppressed patients, such as those having valve replacement and heart transplantation, respectively. These groups differ in immunosuppression therapy, preparation methods, valve hemodynamics. In the present study, we investigated polymerase chain reaction-amplified DNA flanking hypervariable (CA)n regions obtained from valve leaflets taken from patients having valve replacement or heart transplantation and performed a histologic analyses of the cells. In addition, we assessed an autograft valve to compare the hemodynamic effects on the cellular composition of the valve leaflet. We conclude that leaflet cellularity of the heart transplantation and autograft patients is superior to that of the valve replacement patients. These differences were consistent with the occurrence of an immune response in the valve replacement group, which was prevented or abrogated by immunosuppressive therapy administered to the heart transplantation group. However, it cannot be excluded that preparation procedures have a long-term effect on the extracellular matrix, leading to deterioration of cell adhesion and homing conditions.

The allograft valve in heart transplantation and valve replacement. Genetic assessment of the origin of the cells by means of deoxyribonucleic acid profiles

Assessment of the cellular origin of allograft valves is essential in comprehending their biologic behavior and in improving preparation methods. In this study we retrospectively analyzed 10 allografts obtained from patients who underwent valve replacement or heart transplantation. Histologic evaluation and deoxyribonucleic acid amplification by polymerase chain reaction technology with fluorescence labeled primers was performed on different parts of the valve leaflets. Automated analyses of the obtained amplimers showed in the heart transplantation group the presence of receptor cells interspersed with native donor cells in three cases. Preliminary results for the valve replacement group are inconclusive as yet.

Genetic identification and nucleotide sequence of the DNA polymerase gene of African swine fever virus

The DNA polymerase gene of African swine fever virus (ASFV) was mapped by marker rescue experiments using a phosphonoacetic acid-resistant mutant and hybridization with an oligonucleotide probe designed from the most conserved motif of family B DNA polymerases. Viral DNA fragments mapping in this region were cloned and sequenced. An open reading frame coding for a 1244 amino acid long peptide with a molecular mass of 142.5 kDa was determined from the sequence. A unique feature of ASFV DNA polymerase is the presence of 13 tandem repeats of the sequence Ala-Gly-Asp-Pro near the carboxyl end of the molecule. Comparison with 30 sequences of alpha-like DNA polymerases of cellular and viral origin showed that ASFV DNA polymerase has all the conserved motifs of family B DNA polymerases. A 3.9 kb transcript was detected by Northern hybridization and the transcription initiation and termination sites were mapped by S1 analysis and primer extension. Late transcription was initiated at a site different from the early transcription initiation site. A 145 kDa protein, consistent with the size of the gene, was identified by an in situ enzyme assay after gel electrophoresis of infected cell extracts.

[Value of congenital hypertrophy of the retinal pigment epithelium as diagnostic marker in familial adenomatous polyposis]

Familial Adenomatous Polyposis (FAP) is a dominant autosomic disease characterized by the development of hundreds to thousands of colonic adenomatous polyps. Affected patients have a 100% risk of colon cancer development if they are not submitted to a prophylactic colectomy. Identification of carriers depends on the detection of colonic polyps, and endoscopic surveillance must be offered to all descendents, including healthy individuals. Congenital hypertrophy of the retinal pigment epithelium (CHRPE) has been suggested to have a correlation with FAP trait, even before colonic polyp development. The objective of this study is to evaluate CHRPE as a diagnostic marker in FAP patients and descendents. CHRPE was studied in 26 members of 7 FAP families, using direct and indirect ophthalmoscopy, biomicroscopy and retinography. It was found in 62.5% of patients and in 10% of the descendents at risk. Two families did not show signs of CHRPE. Affected members in the remaining families, had positive examinations in 83.3% (two affected members were negative). These results suggest that CHRPE is an important diagnostic tool to identify FAP patients in those families which express the marker. To those descendents who have negative examinations, whether they belong to positive or negative CHRPE families, identification of FAP trait depends on endoscopic surveillance in order to detect colonic polyps.

Further experience with the posterior interosseous flap

This paper describes and discusses some of the clinical applications of the posterior interosseous forearm flap in hand reconstruction, including the fact that larger areas of skin than previously reported can be used safely. It is based on a series of 21 patients, 50 anatomical dissections and 10 injection studies.

Ocular changes in familial amyloidotic polyneuropathy with dense vitreous opacities

Familial amyloid polyneuropathy (FAP) is a hereditary disease which eventually causes serious ocular problems. Seven eyes from patients with FAP 1 were vitrectomised, and the insoluble proteins from the vitreous were purified, the amyloid protein isolated, and the prealbumin characterised with a monoclonal antibody against amyloid fibril protein. Before surgery, visual acuity was very poor, due to abundant deposits in the vitreous, frequently attached to the posterior lens capsule. The pupil had peculiar indentations and the pupillary reflexes were abnormal. Intraocular pressure (IOP) was at the upper limit of normal. In the ocular fundus an intraretinal perifoveal gray ring was sometimes seen. Vitrectomy improved visual acuity, but the reappearance of vitreous deposits reduced it to 8.8/10 after 33.4 months, when treatment was needed for most of the eyes to control IOP. Amyloid and the mutant form of prealbumin characteristic of FAP 1, TTR Met 30, were shown to be present in the vitreous.

[Importance of magnetic resonance in Parkinson disease. An analytic study of the pars compacta]

The authors have studied by high field MR (Signa 1.5 T, GE) 11 patients with known Parkinson's disease and 19 normal controls. In all cases the widths of the pars compacta were measured by optical densitometry in T2-weighted images (gradient-echo TR 2600, TE 80). In Parkinson's patients the compactae of the nigra were found to be significantly thinned (p less than 0.01) which may be of importance for the discussion of the physicopathology and clinic of the extrapyramidal disease.

Education for professional socialization in nursing

The professional socialization of nursing students is seen as a developmental process occurring primarily during the period of formal education. As such, it cannot be left to chance but should be consciously considered in all generic nursing programs.

A distally based median plantar flap

The first metatarsophalangeal joint area is a very difficult one to reconstruct, needing skin that is thick, sensitive, and resistant to friction. Although the medial plantar island flap was initially described to resurface heel defects, we have used this flap as a cross-foot flap to recover the first metatarsophalangeal joint area. Its use has always required a second surgical procedure. To overcome this inconvenience, we describe the use of a flap based on the principle of reversing the direction of blood flow in a distal vascular pedicle to restore a defect of the anteromedial aspect of the foot. Good functional and aesthetic results were obtained.

Radiation-induced carcinoma of the rectum

Carcinomas and sarcomas are known to develop after radiation therapy. A complete review of the literature regarding appearance of carcinoma of the rectum following radiation therapy to the pelvis was undertaken. The average interval between irradiation and diagnosis of the rectal cancer was 15.2 years, the range being from one year, two months to 33 years. We present a case of carcinoma of the rectum arising as two separate primaries 46 years after irradiation for an epidermoid carcinoma of the cervix. There were many pathologic changes related to the radiation therapy.