Efficacy, Speed of Action and Tolerability of Almotriptan in the Acute Treatment of Migraine

A meta-analysis of pooled individual patient data from four randomized, placebo-controlled, double-blind trials comparing several doses of almotriptan ( n = 1908) with placebo ( n = 386) was used to investigate the efficacy, speed of onset and tolerability of almotriptan in the acute treatment of migraine. As early as 30 min after dosing, almotriptan 12.5 mg was significantly more effective than placebo for pain relief (14.9% vs. 8.2%; P < 0.05) and pain free (2.5% vs. 0.7%; P < 0.05). At 2 h, pain-relief rates were 56.0%, 63.7% and 66.0% for almotriptan 6.25, 12.5 and 25 mg, respectively, compared with 35% for placebo; 2-h pain-free rates were 26.7%, 36.4% and 43.4% compared with 13.9% for placebo. All almotriptan dosages were significantly more effective than placebo in eliminating migraine-associated symptoms ( P < 0.05) and in achieving sustained pain relief up to 24 h ( P < 0.05). The incidence of adverse events after almotriptan 6.25 mg and 12.5 mg was not significantly different from that of placebo. This meta- analysis confirms the findings of individual clinical trials, while demonstrating for the first time, significant pain-free efficacy at 30 min compared with placebo.

Relationship between serum levels of VIP, but not of CGRP, and cranial autonomic parasympathetic symptoms: A study in chronic migraine patients

Background

Cranial autonomic parasympathetic symptoms (CAPS) appear in at least half of migraine patients theoretically as a result of the release of peptides by the trigemino-vascular system (TVS). Cranial pain pathways become sensitised by repeated episodes of TVS activation, leading to migraine chronification.

Objective

The objective of this article is to correlate the presence of CAPS with serum levels of vasoactive intestinal peptides (VIP) and calcitonin gene-related peptide (CGRP).

Patients and methods

Patients with chronic migraine (CM) were asked about the presence – during migraine attacks – of five CAPS, which were scored from 0 to 10 by using a quantitative scale. Serum VIP and CGRP levels were determined by ELISA.

Results

We interviewed 87 CM patients (82 females; mean age 44.7 ± 10.6 years). Seventeen had no CAPS, while 70 reported at least one CAPS. VIP levels ranged from 20.8 to 668.2 pg/ml (mean 154.5 ± 123.2). There was a significant positive correlation between scores in the CAPS scale and VIP levels (Spearman correlation coefficient = 0.227; p = 0.035). VIP levels were significantly higher in CM patients by at least one point in the scale vs those with 0 points ( p = 0.002). Analysing symptoms individually, VIP levels were numerically higher in those patients with symptoms, though they were significantly higher only in those patients with lacrimation vs those without it ( p = 0.013). There was no significant correlation between CGRP levels and the score in the CAPS scale.

Conclusions

Serum VIP, but not CGRP, levels seem to reflect the rate of activation of the parasympathetic arm of the TVS in migraine.

European Headache Federation consensus on technical investigation for primary headache disorders

The diagnosis of primary headache disorders is clinical and based on the diagnostic criteria of the International Headache Society (ICHD-3-beta). However several brain conditions may mimic primary headache disorders and laboratory investigation may be needed. This necessity occurs when the treating physician doubts for the primary origin of headache. Features that represent a warning for a possible underlying disorder causing the headache are new onset headache, change in previously stable headache pattern, headache that abruptly reaches the peak level, headache that changes with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre, first onset of headache ≥50 years of age, neurological symptoms or signs, trauma, fever, seizures, history of malignancy, history of HIV or active infections, and prior history of stroke or intracranial bleeding. All national headache societies and the European Headache Alliance invited to review and comment the consensus before the final draft. The consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. Persistent aura without infarction and migrainous infarction require brain MRI, MRA and MRV. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all TACs. For primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required. Because there is little and no good evidence the committee constructed a consensus based on the opinion of experts, and should be treated as imperfect.

Circulating NK-cell subsets in renal allograft recipients with anti-HLA donor-specific antibodies

Detection of posttransplant donor-specific anti-HLA antibodies (DSA) constitutes a risk factor for kidney allograft loss. Together with complement activation, NK-cell antibody-dependent cell mediated cytotoxicity (ADCC) has been proposed to contribute to the microvascular damage associated to humoral rejection. In the present observational exploratory study, we have tried to find a relationship of circulating donor-specific and non donor-specific anti-HLA antibodies (DSA and HLA non-DSA) with peripheral blood NK-cell subsets and clinical features in 393 renal allograft recipients. Multivariate analysis indicated that retransplantation and pretransplant sensitization were associated with detection of posttransplant DSA. Recipient female gender, DR mismatch and acute rejection were significantly associated with posttransplant DSA compared to HLA non-DSA. In contrast with patients without detectable anti-HLA antibodies, DSA and HLA non-DSA patients displayed lower proportions of NK-cells, associated with increased CD56(bright) and NKG2A(+) subsets, the latter being more marked in DSA cases. These differences appeared unrelated to retransplantation, previous acute rejection or immunosuppressive therapy. Although preliminary and observational in nature, our results suggest that the assessment of the NK-cell immunophenotype may contribute to define signatures of alloreactive humoral responses in renal allograft recipients.

[How to convince the head of department and managing director of the importance of specialised headache clinics]

In spite that headache is, by far, the most frequent reason for neurological consultation and that the diagnosis and treatment of some patients with headache is difficult, the number of headache clinics is scarce in our country. In this paper the main arguments which should allow us, as neurologists, to defend the necessity of implementing headache clinics are reviewed. To get this aim we should first overcome our internal reluctances, which still make headache as scarcely appreciated within our specialty. The facts that more than a quarter of consultations to our Neurology Services are due to headache, that there are more than 200 different headaches, some of them actually invalidating, and the new therapeutic options for chronic patients, such as OnabotulinumtoxinA or neuromodulation techniques, oblige us to introduce specialised headache attendance in our current neurological offer. Even though there are no definite data, available results indicate that headache clinics are efficient in patients with chronic headaches, not only in terms of health benefit but also from an economical point of view.

Age may explain the association of an early dialysis initiation with poor survival

BACKGROUND

Some studies postulate that early dialysis initiation may increase mortality.

AIM

The aim of the present study was to assess to what extent this was due to confounding by age.

DESIGN

Observational retrospective cohort study.

METHODS

We studied all patients starting dialysis therapy between 1 January 1995 and 31 December 2009 in our center. The following variables at dialysis initiation in end-stage renal disease (ESRD) patients were analysed: estimated glomerular filtration rate (eGFR), age, gender, diabetes mellitus, serum albumin, hemoglobin, period of dialysis initiation, history of ischemic heart disease and stroke. Multivariate Cox model was used to calculate adjusted patient survival.

RESULTS

Over the last 15 years, 428 patients initiated dialysis therapy in our reference area. Median eGFR at dialysis initiation was 8.16 ml/min. In the univariate analysis, increased eGFR, age, dialysis initiation 1995-1999/2000-2004, diabetes and history of ischemic heart disease were associated (P < 0.05) with increased mortality in ESRD. Patients that started dialysis program with eGFR > 8.16 were older than those who did it with eGFR < 8.16 (66 vs. 61 years, P < 0.001). The association between mortality and eGFR in the crude multivarite Cox model was lost when the model was adjusted by age. In the multivariate Cox model, dialysis initiation period, serum albumin and history of ischemic heart disease were associated with mortality.

CONCLUSION

History of ischemic heart disease, serum albumin and dialysis start before 2005 were risk factors for mortality in ESRD patients. Older age is usually associated with early dialysis initiation, so age adjustment is needed to perform studies aimed to calculate the effect of eGFR at dialysis initiation on survival.

Spanish consensus document for acceptance and rejection of kidneys from expanded criteria donors

In the recent years, more than 60% of available deceased donors are either older than 50 yr or have significant vascular comorbidities. This makes the acceptance and rejection criteria of renal allografts very rigorous, especially in cases of younger recipients, and at the same time encourages live donations. In our country, there is a lack of homogeneity in the percentages of use of expanded criteria donor (ECD) allografts between the different autonomous communities. Furthermore, the criteria vary greatly, and in some cases, great importance is given to the biopsy while in others very little. In this study, we present a unified and homogenous criteria agreed upon by consensus of a 10-member Panel representing major scientific societies related to renal transplantation in Spain. The criteria are to be used in accepting and/or rejecting kidneys from the so-called ECDs. The goal was to standardize the use of these organs, to optimize the results, and most importantly to provide for the maximum well being of our patients. Finally, we believe that after taking into account the Panel's thorough review of specific scientific literature, this document will be adaptable to other national renal transplant programmes.

Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions

A consensus meeting was held in Vienna on September 8-9, 2013, to discuss diagnostic and therapeutic challenges surrounding development of diabetes mellitus after transplantation. The International Expert Panel comprised 24 transplant nephrologists, surgeons, diabetologists and clinical scientists, which met with the aim to review previous guidelines in light of emerging clinical data and research. Recommendations from the consensus discussions are provided in this article. Although the meeting was kidney-centric, reflecting the expertise present, these recommendations are likely to be relevant to other solid organ transplant recipients. Our recommendations include: terminology revision from new-onset diabetes after transplantation to posttransplantation diabetes mellitus (PTDM), exclusion of transient posttransplant hyperglycemia from PTDM diagnosis, expansion of screening strategies (incorporating postprandial glucose and HbA1c) and opinion-based guidance regarding pharmacological therapy in light of recent clinical evidence. Future research in the field was discussed with the aim of establishing collaborative working groups to address unresolved questions. These recommendations are opinion-based and intended to serve as a template for planned guidelines update, based on systematic and graded literature review, on the diagnosis and management of PTDM.