Determining of migraine prognosis using latent growth mixture models

BACKGROUND

This paper presents a retrospective study to classify patients into subtypes of the treatment according to baseline and longitudinally observed values considering heterogenity in migraine prognosis. In the classical prospective clinical studies, participants are classified with respect to baseline status and followed within a certain time period. However, latent growth mixture model is the most suitable method, which considers the population heterogenity and is not affected drop-outs if they are missing at random. Hence, we planned this comprehensive study to identify prognostic factors in migraine.

METHODS

The study data have been based on a 10-year computer-based follow-up data of Mersin University Headache Outpatient Department. The developmental trajectories within subgroups were described for the severity, frequency, and duration of headache separately and the probabilities of each subgroup were estimated by using latent growth mixture models. SAS PROC TRAJ procedures, semiparametric and group-based mixture modeling approach, were applied to define the developmental trajectories.

RESULTS

While the three-group model for the severity (mild, moderate, severe) and frequency (low, medium, high) of headache appeared to be appropriate, the four-group model for the duration (low, medium, high, extremely high) was more suitable. The severity of headache increased in the patients with nausea, vomiting, photophobia and phonophobia. The frequency of headache was especially related with increasing age and unilateral pain. Nausea and photophobia were also related with headache duration.

CONCLUSIONS

Nausea, vomiting and photophobia were the most significant factors to identify developmental trajectories. The remission time was not the same for the severity, frequency, and duration of headache.

Computerized detection and analysis of cancer chemotherapy-induced emesis in a small animal model, musk shrew

Vomiting is a common side effect of cancer chemotherapy and many drug treatments and diseases. In animal studies, the measurement of vomiting usually requires direct observation, which is time consuming and often lacks temporal precision. Musk shrews have been used to study the neurobiology of emesis and have a rapid emetic episode (∼1 s for a sequence of retching and expulsion). The aim of the current study was to develop a method to automatically detect and characterize emetic episodes induced by the cancer chemotherapy agent cisplatin. The body contour in each video frame was tracked and normalized to a parameterized shape basis. The tracked shape was projected to a feature space that maximized the shape variations in the consecutive frames during retching. The resulting one dimensional projection was sufficient to detect most emetic episodes in the acute (peak at 2h) and delayed (peak at 54 h) phases after cisplatin treatment. Emetic episodes were relatively invariant in the number of retches (∼6.2), duration (∼1.2s), inter-retch interval (∼198 ms), and amplitude during the 72 h after cisplatin treatment. This approach should open a new vista into emesis research to permit tracking and analysis of emesis in a small animal model and facilitate the development of new antiemetic therapies. These results also yield a better understanding of the brain's central pattern generator for emesis and indicate that the retching response in the musk shrew (at ∼5.4 Hz) is the fastest ever recorded in a free-moving animal.

Cyclical vomiting syndrome with bilateral epileptiform discharges

Cyclical vomiting syndrome is a paroxysmal, condition characterized by recurrent severe episodes of vomiting lasting for hours to days, with variable intervals of normal health in between with no apparent cause of the vomiting. We hereby report a 10 yr old girl with cyclical vomiting syndrome with multiple, bisynchronous occipitally predominant, bilateral epileptiform discharges representing a diagnostic confusion.

Boerhaave's syndrome - rapidly evolving pleural effusion; a radiographic clue

Boerhaave's syndrome is the rare and often fatal condition of spontaneous esophageal rupture. Meckler's triad of vomiting, pain and subcutaneous emphysema are characteristic features of Boerhaave's syndrome. When these symptoms are absent, diagnosis is frequently late and often occurs as the result of incidental investigation. This contributes to the observed high morbidity and mortality. Unless specifically considered in the differential diagnosis, this rare disease is frequently overlooked. The authors described the case of a patient in whom the diagnosis was made several days following presentation by observing that a large pleural effusion had evolved rapidly on chest radiographs. This uncommon radiological sign has relatively few causes and prompted a review of the history and diagnosis, followed by the initiation of additional investigations that confirmed Boerhaave's syndrome.

Cannabinoid hyperemesis

A 21-year-old woman presented with a 4-week history of sudden onset vomiting, nausea and anorexia. Questioning revealed that she had a 7-year history of heavy cannabis use (smoking). She did not describe abdominal pain, change in bowel habit, antibiotic use, foreign travel or contact with gastroenteritis. Biochemistry results demonstrated mild metabolic derangement with a low potassium and a low bicarbonate, and urine toxicology was positive for cannabinoids. Other investigations, including a full blood count, renal function tests, liver function tests, a coagulation sample, an ECG, urinary β-hCG and a CT head scan, were all normal. A diagnosis of cannabinoid hyperemesis was made and her symptoms resolved after treatment with intravenous fluids, antiemetics and abstinence from cannabis. Since her discharge and abstinence she has had several relapses, each related to cannabis use and each resolving with abstinence. The patient is now seeking cognitive behavioural therapy to achieve permanent abstinence.

Management of chemotherapy-induced nausea and vomiting

Chemotherapy-induced nausea and vomiting (CINV) remains one of the most disturbing side effects of cancer treatment. Research in anti-emetic therapy progressed gradually since the early eighties and the development of anti-emetic agents continues. This review focuses on the current management of CINV based on the most recent guidelines and adherence to the latter is examined more carefully. Setrons (5HT3 receptor antagonists), corticosteroids and NK-1 receptor antagonists are the cornerstones of anti-emetic therapy. The latest developed palonosetron and casopitant proved to be highly promising in clinical trials. Other types include benzodiazepines, cannabinoids and olanzapine. Various risk factors contribute to the overall risk of developing CINV, such as patient characteristics, emetogenic potency of the chemotherapeutic agents and correct prevention of CINV. Current guidelines determine which is the right preventive regimen for each cancer patient at risk for experiencing CINV. Adherence to this guidelines and implementation in daily practice seem to be below the optimal level. In Belgium, authorities use the guidelines as a base for reimbursement and this has increased the level of implementation.

The burden and cost of ambulatory cases of rotavirus gastroenteritis in central Israel

BACKGROUND

While the burden of rotavirus infection with regard to hospitalizations has been extensively investigated, there are sparse data on the cost and impact of this infection on the ambulatory part of the health system in Israel.

OBJECTIVES

To investigate the burden of rotavirus infection on the ambulatory system in Israel.

METHODS

Infants younger than 3 years examined for acute gastrointestinal symptoms in four pediatric clinics had their stool tested for rotavirus. The parents were contacted 7-10 days later and questioned about the symptoms of illness, medications given, use of diapers, consumption of formula, and any loss of parents' workdays.

RESULTS

Rotavirus was detected in 71 of the 145 stool samples tested (49%). A total of 54 parents responded to the telephonic survey. Patients' mean age was 15.4 months. Three patients were hospitalized due to the illness. The mean duration of fever was 1.7 days. Infants with rotavirus gastroenteritis had on average 2.25 days of vomiting and 7.5 days of diarrhea. The average number of workdays lost was 2.65 days per RVGE case. The cost of the average case of RVGE in Israel is 257 euros; 69.64% of this cost (179 euros) is due to parental work loss.

CONCLUSIONS

Our results indicate that the economic impact of the ambulatory cases in Israel is quite significant.

[Prevalence of delayed gastric emptying of solids in functional dyspepsia and its relationship to symptoms]

The relationship between functional dyspepsia and delayed gastric emptying of solids is still unclear. This study evaluated the prevalence of delayed gastric emptying of solids in functional dyspepsia patients and its relationship to dyspeptic symptoms.

MATERIAL AND METHOD

142 patients with functional dyspepsia were prospectively assessed, the solid gastric emptying was measured using 13C-acid octanoic breath test and the severity of six dyspeptic symptoms (postprandial fullness, early satiety, bloating, abdominal discomfort, nausea and vomiting) was scored.

RESULTS

Gastric emptying of solids was delayed in 45 (31.7%) dyspeptic patients. Multivariate analysis showed that the presence and severity of nausea and vomiting were associated with delayed solid gastric emptying (p < 0.05). Female gender was also associated with the risk of delayed gastric emptying (p < 0.05).

CONCLUSIONS

A subset of functional dyspepsia patients has delayed gastric emptying of solids. Female sex, the presence and severity of nausea and vomiting are independently associated with delayed gastric emptying of solids in these patients.

Opportunities for the replacement of animals in the study of nausea and vomiting

Nausea and vomiting are among the most common symptoms encountered in medicine as either symptoms of disease or side effects of treatments. Developing novel anti-emetics and identifying emetic liability in novel chemical entities rely on models that can recreate the complexity of these multi-system reflexes. Animal models (especially the ferret and dog) are the current gold standard; however, the selection of appropriate models is still a matter of debate, especially when studying the subjective human sensation of nausea. Furthermore, these studies are associated with animal suffering. Here, following a recent workshop held to review the utility of animal models in nausea and vomiting research, we discuss the limitations of some of the current models in the context of basic research, anti-emetic development and emetic liability detection. We provide suggestions for how these limitations may be overcome using non-animal alternatives, including greater use of human volunteers, in silico and in vitro techniques and lower organisms.

Natural evolution of regurgitation in healthy infants

OBJECTIVES

To determine the natural history of infant regurgitation during the first year of life.

METHODS

Parents recorded prospectively the frequency of regurgitation for 1 week before consultation during the first year of life. A sub-group analysis according to the method of feeding was planned.

RESULTS

A total of 130 infants of an original sample of 163 (80%) newborns were followed up for 1 year. Daily spilling was highest during the first month of life (73%) and decreased gradually to 50% during the fifth month of life. During the first 2 months of life, 20% of the infants regurgitated more than four times per day. After the age of 12 months, only 4% of the infants had daily regurgitations. Exclusively breastfed infants did regurgitate less than partially breastfed infants. Weight gain was influenced by the frequency of regurgitation, especially in partially breastfed infants.

CONCLUSION

Regurgitation in infancy is common, decreasing from birth, and tends to disappear by 12 months of age. Weight gain during the first 4 months of life is decreased in infants who regurgitate more than four times a day. Our data suggest that exclusively breastfed infants regurgitate less than partially breastfed babies.

Misdiagnosis due to gastrointestinal symptoms in an adolescent with probable autonomic status epilepticus and Panayiotopoulos syndrome

Panayiotopoulos syndrome is a common benign epilepsy affecting otherwise healthy children that present with autonomic seizures, in which nausea, retching, and vomiting are particularly common and prominent. Because of the unusual ictal symptoms and lengthy manifestations, misdiagnosis is a common major problem. We describe a young girl with intractable and lengthy vomiting attacks, several admissions to hospitals, and extensive gastroenterological workup for several years from early childhood. On all previous occasions the diagnosis varied from psychosomatic disease, to functional dyspepsia, to cyclic vomiting syndrome. The possibility of autonomic epileptic seizures and Panayiotopoulos syndrome, though likely, was not considered.

Cannabinoid hyperemesis presenting to a New Zealand hospital

Cannabis use is common among the general population in many areas of the world and cannibis is readily available in much of New Zealand. We report an unusual complication of chronic cannabis use which has recently been described overseas. Cannabinoid hyperemesis with abnormal bathing behaviour is a syndrome of episodic cyclic vomiting, often associated with relief being obtained by hot water bathing or showering. Underlying the disorder is the chronic use of cannabis. The proposed mechanism of the syndrome is accumulation of cannabis metabolites in the brain. Abstaining from cannabis use is likely to prevent ongoing recurrences. Although there have been limited reports in the medical literature, it is likely that the syndrome is commoner than previously recognised and the presentation could easily be confused with psychiatric illness or cyclic vomiting syndromes.

A higher meal frequency may be associated with diminished weight loss after bariatric surgery

OBJECTIVE

This study aimed to investigate the relationship between meal frequency, the occurrence of vomiting and weight loss among patients submitted to Roux-en-Y gastric bypass up to 9 months after surgery.

METHODS

Female patients (n = 80) were followed at 3-month intervals for 9 months. Weight, BMI, 24-hour dietary recall, drug consumption and vomiting episodes were recorded and compared with nutritional outcome.

RESULTS

The BMI values at 3, 6 and 9 months were 45.1 +/- 9.7, 39.9 +/- 7.6 and 35.4 +/- 8.2 kg/m(2), respectively. The corresponding choleric intakes were 535.6 +/- 295.7, 677.1 +/- 314.7 and 828.6 +/- 398.2 kcal/day, and the numbers of daily meals were 5.0 +/- 2.5, 4.7 +/- 1.8 and 4.9 +/- 1.0, respectively. The peak of vomiting episodes occurred within 6 months; however, patients tolerated this complication despite its high prevalence. A significant negative correlation between weight loss and diet fractioning, but not vomiting, was observed throughout the entire postoperative period (P = 0.001).

CONCLUSIONS

1) Frequent small meals were associated with a reduction in weight loss after gastric bypass and a decrease in vomiting episodes at 6 months, and 2) vomiting did not interfere with nutritional outcome. Unless required because of vomiting or other reasons, multiple small meals may not be advantageous after such intervention.

Patient and caregiver perspective on pediatric eosinophilic esophagitis and newly developed symptom questionnaires*

OBJECTIVE

Eosinophilic esophagitis (EE), a rare chronic inflammatory condition of the esophagus, is predominantly observed in children and is primarily manifested with feeding difficulties. To our knowledge, no self- or caregiver-reported questionnaires are available to assess pediatric EE symptoms and their impact as reported directly by children or their parents/caregivers. The objectives of this study were to characterize the symptoms and impact of EE among children as reported by patients and parents/caregivers and to assess the content validity of two newly developed pediatric eosinophilic esophagitis symptom questionnaires, one parent/caregiver-reported questionnaire for ages 2-7 years and one child-reported questionnaire for ages 8-17 years. The questionnaires were developed based on a review of the literature and clinical expert consultation.

RESEARCH DESIGN AND METHODS

This cross-sectional study involving one-on-one interviews with patients and caregivers was conducted at an American Partnership for Eosinophilic Disorders conference. Parents of patients aged 2-7 years (n = 12) and patients aged 8-17 years (n = 16) were first asked about symptoms and their impact on everyday life, using open-ended questions. Participants then completed the appropriate symptom questionnaire and were asked to provide feedback on the relevance, comprehensiveness, and clarity of each item and other questionnaire issues (time to complete, length, format, etc.). All reported symptoms were enumerated, and the feedback on the symptom questionnaires was analyzed qualitatively.

RESULTS

The majority of study participants were white (82%) and male (86%). The most frequently reported symptoms of 2-7-year olds were vomiting (92%), "reflux" (50%), dysphagia (25%), abdominal pain (25%), and trouble sleeping (25%). The 8-17-year group reported abdominal pain (56%), vomiting (31%), throat pain (25%), diarrhea (25%), and food getting stuck (25%). Symptoms and treatment were reported to have a major impact on daily life, particularly on school, after-school activities and social events, feeling frustrated regarding symptoms and treatment, and feeling "different". Overall, participants thought that the questionnaires were clear, relevant, and appropriate for symptom assessment.

LIMITATION

This study was based on a small and convenient sample of participants attending an EE conference and hence may not be representative of the general EE patient population.

CONCLUSIONS

EE is associated with a range of symptoms that vary in terms of the type, frequency and severity across and within patients. The results provide adequate support for the content validity of the self- and caregiver-reported versions of the symptom-specific questionnaires. Minor modifications were made based on the feedback obtained. A psychometric evaluation of the revised questionnaires is needed next to assess the construct validity, reliability, and responsiveness of the measures.

A phase I safety, pharmacological, and biological study of the farnesyl protein transferase inhibitor, lonafarnib (SCH 663366), in combination with cisplatin and gemcitabine in patients with advanced solid tumors

PURPOSE

This phase I study was conducted to evaluate the safety, tolerability, pharmacological properties and biological activity of the combination of the lonafarnib, a farnesylproteintransferase (FTPase) inhibitor, with gemcitabine and cisplatin in patients with advanced solid malignancies.

EXPERIMENTAL DESIGN

This was a single institution study to determine the maximal tolerated dose (MTD) of escalating lonafarnib (75-125 mg po BID) with gemcitabine (750-1,000 mg/m(2) on days 1, 8, 15) and fixed cisplatin (75 mg/m(2) day 1) every 28 days. Due to dose-limiting toxicities (DLTs) of neutropenia and thrombocytopenia in initial patients, these patients were considered "heavily pre-treated" and the protocol was amended to limit prior therapy and re-escalate lonafarnib in "less heavily pre-treated patients" on 28-day and 21-day schedules. Cycle 1 and 2 pharmacokinetics (PK), and farnesylation of the HDJ2 chaperone protein and FPTase activity were analyzed.

RESULTS

Twenty-two patients received 53 courses of therapy. Nausea, vomiting, and fatigue were frequent in all patients. Severe toxicities were observed in 91% of patients: neutropenia (41%), nausea (36%), thrombocytopenia (32%), anemia (23%) and vomiting (23%). Nine patients withdrew from the study due to toxicity. DLTs of neutropenia, febrile neutropenia, thrombocytopenia, and fatigue limited dose-escalation on the 28-day schedule. The MTD was established as lonafarnib 75 mg BID, gemcitabine 750 mg/m(2) days 1, 8, 15, and cisplatin 75 mg/m(2) in heavily pre-treated patients. The MTD in the less heavily pre-treated patients could not be established on the 28-day schedule as DLTs were observed at the lowest dose level, and dose escalation was not completed on the 21-day schedule due to early study termination by the Sponsor. No PK interactions were observed. FTPase inhibition was not observed at the MTD, however HDJ-2 gel shift was observed in one patient at the 100 mg BID lonafarnib dose. Anti-cancer activity was observed: four patients had stable disease lasting >2 cycles, one subject had a complete response, and another had a partial response, both with metastatic breast cancer.

CONCLUSION

Lonafarnib 75 mg BID, gemcitabine 750 mg/m(2) days 1, 8, 15, and cisplatin 75 mg/m(2) day 1 on a 28-day schedule was established as the MTD. Lonafarnib did not demonstrate FTPase inhibition at these doses. Despite the observed efficacy, substantial toxicity and questionable contribution of anti-tumor activity of lonafarnib to gemcitabine and cisplatin limits further exploration of this combination.

5-HT system in the gut: roles in the regulation of visceral sensitivity and motor functions

5-Hydroxytryptamine (5-HT) is a major transmitter molecule within the gastrointestinal tract. It is contained in enterochromaffin (EC) cells, which form part of the epithelial lining of the gut and in enteric neurones in the submucosal and myenteric plexuses. 5-HT is present in murine mucosal mast cells in the lamina propria and some studies have suggested that human mast cells may also contain 5-HT especially in conditions associated with mastocytosis. The strategic positioning of the enteric and extrinsic sensory innervation in close proximity to these sources of 5-HT, in conjunction with their demonstrated sensitivity to this mediator, suggests the involvement of 5-HT in the transduction of visceral stimuli and reflex responses affecting motor and secretory function. Under physiological conditions, the release of 5-HT from these storage sites may result in the orchestration of reflexes responsible for transit of material along the bowel at a rate that is appropriate for digestion and absorption of nutrients. However, in the pathophysiological state, 5-HT acting together with other inflammatory mediators may cause inappropriate intestinal secretomotor activity and/or initiate sensations such as nausea or discomfort/pain. Current evidence suggests that the bioavailability of 5-HT within the gut wall is altered in a number of post-inflammatory models of gut dysfunction with increased numbers of EC cells and mast cells with increased 5-HT content in proximity to sensory nerve endings, and decreased serotonin reuptake mechanisms. Changes may also occur in the sensory innervation or pathways within the central nervous system. These processes may contribute to pain mechanisms in the irritable bowel syndrome, in which visceral hypersensitivity is a predominant feature and may also contribute to motor dysfunction leading to altered bowel habit.