The association of timing of coronary artery bypass grafting for non-ST-elevation myocardial infarction and clinical outcomes in the contemporary United States

BACKGROUND

In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA.

METHODS

We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24 h, 24-72 h, 72-120 h, and >120 h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost.

RESULTS

A total of 147 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120 h and at >120 h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24 h from admission. In addition to these differences, CABG at >120 h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24 h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24 h.

CONCLUSION

CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.

Interest and Satisfaction of Telemedicine Use Among Ambulatory Neurology Patients in Western North Carolina During the COVID-19 Pandemic

Introduction: During the COVID-19 pandemic, care shifted from exclusively telemedicine to hybrid models with in-person, video, and telephone visits. We explored how patient satisfaction and visit preferences have changed by comparing in-person versus virtual visits (telephone and video) in an ambulatory neurology practice across three time points. Methods: Patients who completed a virtual visit in March 2020 (early-pandemic), May 2020 (mid-pandemic), and March 2021 (later-pandemic) were contacted. Patients were assessed for visit satisfaction and desire for future telemedicine. Univariate and multivariable logistic regression analysis was conducted to determine factors independently associated with video visit completion. Results: Four thousand seven hundred seventy-eight the number of ambulatory visits (n = 4,778) were performed (1,004 early; 1,265 mid; and 2,509 later); 1,724 patients (36%) assented to postvisit feedback; mean age 45.8 ± 24.4 years, 58% female, 79% white, and 56% with Medicare/Medicaid insurance. Patient satisfaction significantly increased (73% early, 79% mid, 81% later-pandemic, p = 0.008). Interest in telemedicine also increased for patients completing telephone visits (40% early, 50% mid, 59% later, p = 0.027) and video visits (52% early, 59% mid, 62% later, p = 0.035). Patients satisfied with telemedicine visits were younger (p < 0.001). White patients were more interested in future telemedicine (p = 0.037). Multivariable analysis showed that older patients (for each 1 year older), Black patients, and patients with Medicare/Medicaid were 2%, 45%, and 54% less likely to complete a video visit than telephone, respectively. Discussion: Patients, especially younger ones, have become more satisfied and more interested in hybrid care models during the COVID-19 pandemic. Barriers to conducting video visits persist for older, Black patients with Medicare or Medicaid insurance.

Effects of muscle quantity and bone mineral density on injury and outcomes in older adult motor vehicle crash occupants

Objectives: Quantify the independent and combined effects of abdominal muscle quantity and lumbar bone mineral density (BMD) on injury risk and in-hospital outcomes in severely injured motor vehicle crash (MVC) occupants ages 50 and older.Methods: Skeletal muscle area measurements of MVC occupants were obtained through semi-automated segmentation of an axial computed tomography (CT) slice at the L3 vertebra. An occupant height-normalized Skeletal Muscle Index (SMI) was calculated - a defining metric of sarcopenia and low muscle mass (sarcopenia thresholds: <38.5 cm2/m2 females; <52.4 cm2/m2 males). Lumbar BMD was obtained using a validated, phantomless CT calibration method (osteopenia threshold: <145 mg/cm3). SMI and BMD values were used to categorize occupants, and logistic regression was used to associate sarcopenia, osteopenia, and osteosarcopenia predictors to injury outcomes (e.g., Injury Severity Score (ISS), maximum Abbreviated Injury Scale (MAIS) score, fractures) and hospital outcomes (e.g., length of stay, ICU days).Results: Of the 336 occupants, 210 (63%) were female (mean ± SD: age 66.3 ± 10.6). SMI was 41.7 ± 8.0 cm2/m2 in females and 51.2 ± 10.8 cm2/m2 in males. Based on SMI, 40% of females and 55% of males were classified as sarcopenic. BMD was 163.2 ± 38.3 mg/cm3 in females and 164.1 ± 35.4 mg/cm3 in males, with 41% of females and 33% of males classified as osteopenic. Prevalence of both conditions (osteosarcopenia) was similar between females (21%) and males (22%). Incidence of low SMI and BMD increased with age. Sarcopenic individuals were less likely to sustain a MAIS 2+ thorax injury and had longer ICU stays. Osteopenic individuals were more likely to sustain upper extremity injuries and fractures, and were less likely to be discharged to a rehabilitation facility. Osteosarcopenic individuals were less likely to be ventilated or admitted to the ICU but tended to spend more time on the ventilator if placed on one.Conclusions: Osteosarcopenia was not associated with any injury outcomes, but sarcopenia was associated with thoracic injury and osteopenia was associated with upper extremity injury incidence. Sarcopenia was only associated with ICU length of stay, while osteopenia was only associated with discharge destination. Osteosarcopenia was associated with likelihood of being ventilated, being admitted to the ICU, and with increased length of ventilation.

A comparison of telemedicine and in-person neurology visits: what are the factors that patients consider when selecting future visit type?

Objective

To identify factors that patients consider when choosing between future in-person, video, or telephone visits.

Background

Telemedicine has been rapidly integrated into ambulatory neurology in response to the COVID-19 pandemic.

Methods

Ambulatory neurology patients at a single center were contacted via telephone to complete: (1) a survey quantifying likelihood of scheduling a future telemedicine visit, and (2) a semi-structured qualitative interview following their visit in March 2021. Data were processed using the principles of thematic analysis.

Results

Of 2493 visits, 39% assented to post-visit feedback; 74% were in-person visits and 13% video and telephone. Patients with in-person visits were less likely than those with video and telephone visits to “definitely” consider a future telemedicine visit (36 vs. 59 and 62%, respectively; p < 0.001). Patients considered five key factors when scheduling future visits: “Pros of Visit Type,” “Barriers to Telemedicine,” “Situational Context,” “Inherent Beliefs,” and “Extrinsic Variables.” Patients with telemedicine visits considered convenience as a pro, while those with in-person visits cited improved quality of care. Accessibility and user familiarity were considered barriers to telemedicine by patients with in-person and telephone visits, whereas system limitations were prevalent among patients with video visits. Patients agreed that stable conditions can be monitored via telemedicine, whereas physical examination warrants an in-person visit. Telemedicine was inherently considered equivalent to in-person care by patients with telephone visits. Awareness of telemedicine must be improved for patients with in-person visits.

Conclusion

Across visit types, patients agree that telemedicine is convenient and effective in many circumstances. Future care delivery models should incorporate the patient perspective to implement hybrid models where telemedicine is an adjunct to in-person visits in ambulatory neurology.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11149-0.

Patient Experiences With Ambulatory Telehealth in Neurology: Results of a Mixed-Methods Study

Objective

To assess patient experiences with rapid implementation of ambulatory telehealth during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

A mixed-methods study was performed to characterize the patients' experience with neurology telehealth visits during the first 8 weeks of the COVID-19 response. Consecutive patients who completed a telehealth visit were contacted by telephone. Assenting patients completed a survey quantifying satisfaction with the visit followed by a semistructured telephone interview. Qualitative data were analyzed using the principles of thematic analysis.

Results

A total of 2,280 telehealth visits were performed, and 753 patients (33%) were reached for postvisit feedback. Of these, 47% of visits were by video and 53% by telephone. Satisfaction was high, with 77% of patients reporting that all needs were met, although only 51% would consider telehealth in the future. Qualitative themes were constructed, suggesting that positive patient experiences were associated not only with the elimination of commute time and associated costs but also with a positive physician interaction. Negative patient experiences were associated with the inability to complete the neurologic examination. Overall, patients tended to view telehealth as a tool that should augment, and not replace, in-person visits.

Conclusion

In ambulatory telehealth, patients valued convenience, safety, and physician relationship. Barriers were observed but can be addressed.

Rapid Implementation of Outpatient Teleneurology in Rural Appalachia: Barriers and Disparities

Objective

To describe rapid implementation of telehealth during the COVID-19 pandemic and assess for disparities in video visit implementation in the Appalachian region of the United States.

Methods

A retrospective cohort of consecutive patients seen in the first 4 weeks of telehealth implementation was identified from the Neurology Ambulatory Practice at a large academic medical center. Telehealth visits defaulted to video, and when unable, phone-only visits were scheduled. Patients were divided into 2 groups based on the telehealth visit type: video or phone only. Clinical variables were collected from the electronic medical record including age, sex, race, insurance status, indication for visit, and rural-urban status. Barriers to scheduling video visits were collected at the time of scheduling. Patient satisfaction was obtained by structured postvisit telephone call.

Results

Of 1,011 telehealth patient visits, 44% were video and 56% phone only. Patients who completed a video visit were younger (39.7 vs 48.4 years, p < 0.001), more likely to be female (63% vs 55%, p < 0.007), be White or Caucasian (p = 0.024), and not have Medicare or Medicaid insurance (p < 0.001). The most common barrier to scheduling video visits was technology limitations (46%). Although patients from rural and urban communities were equally likely to be scheduled for video visits, patients from rural communities were more likely to consider future telehealth visits (55% vs 42%, p = 0.05).

Conclusion

Rapid implementation of ambulatory telemedicine defaulting to video visits successfully expanded video telehealth. Emerging disparities were revealed, as older, male, Black patients with Medicare or Medicaid insurance were less likely to complete video visits.

Sarcopenia and osteosarcopenia in seriously injured motor vehicle crash occupants

Objective: The objective of this study was to examine the prevalence of sarcopenia (low muscle mass) and osteosarcopenia (low bone density and muscle mass) in older motor vehicle crash (MVC) occupants and the relationship of these musculoskeletal conditions with age, sex, and injury.Methods: Sarcopenia and osteopenia was assessed from abdominal computed tomography (CT) scans of 61 seriously injured MVC occupants over age 50 in the Crash Injury Research and Engineering Network (CIREN) database.Results: The prevalence was 43% for sarcopenia, 25% for osteopenia, and 15% for osteosarcopenia in the CIREN occupants. The Injury Severity Score (ISS) was higher in those with only sarcopenia (mean ± SE = 22.4 ± 2.3), followed by those with osteosarcopenia (17.9 ± 2.4) and only osteopenia (12.8 ± 1.5). More total fractures were observed in occupants with sarcopenia alone (7.6 ± 1.5) or osteosarcopenia (7.0 ± 2.1) compared to nonsarcopenic occupants with osteopenia (4.0 ± 2.5).Conclusions: Sarcopenia and osteosarcopenia may be associated with more serious injuries and fractures in MVCs.

Interictal Abnormalities of Gamma Band Activity in Visual Evoked Responses in Migraine: An Indication of Thalamocortical Dysrhythmia?

Between attacks, migraineurs lack habituation in standard visual evoked potentials (VEPs). Visual stimuli also evoke high-frequency oscillations in the gamma band range (GBOs, 20–35 Hz) assumed to be generated both at subcortical (early GBOs) and cortical levels (late GBOs). The consecutive peaks of GBOs were analysed regarding amplitude and habituation in six successive blocks of 100 averaged pattern reversal (PR)-VEPs in healthy volunteers and interictally in migraine with (MA) or without aura patients. Amplitude of the two early GBO components in the first PR-VEP block was significantly increased in MA patients. There was a significant habituation deficit of the late GBO peaks in migraineurs. The increased amplitude of early GBOs could be related to the increased interictal visual discomfort reported by patients. We hypothesize that the hypo-functioning serotonergic pathways may cause, in line with the thalamocortical dysrhythmia theory, a functional disconnection of the thalamus leading to decreased intracortical lateral inhibition, which can induce dishabituation.

(68)Ga-DOTANOC PET/CT detection of multiple extracranial localizations in a patient with anaplastic meningioma

We report herein a case of a 65-year-old male with intracranial recurrence of atypical meningioma initially treated with a combination of surgical resection and gamma knife radiotherapy. Afterwards, he underwent a (68)Ga-DOTANOC PET/CT scan in order to evaluate the feasibility of peptide receptor radionuclide therapy (PRRT). The scan identified multiple pulmonary, pleural and lymph node localizations. Histological diagnosis was consistent with intracranial atypical meningioma with diffuse metastatic spread. In our case, we have shown that meningioma with extracranial locations may present high uptake of somatostatin receptor analogues. Among other radionuclides, we believe that (68)Ga-DOTANOC PET/CT may be particularly useful for staging, detection of recurrence, evaluation of disease extension and alternative therapeutic approaches.

Clostridium difficile-related pancolitis in lung-transplanted patients with cystic fibrosis

C. difficile (C. d.) is the main cause of antibiotic-associated diarrhea and colitis. It is shown in literature a high asymptomatic carriage rate of C. d. in patients with cystic fibrosis (CF), though C. d.-related colitis is an uncommon complication in these patients, despite the use of multiple high-dose antibiotic regimes and the frequency of hospital admissions. Lung transplantation with the associated immunosuppression and aggressive antibiotic therapy may increase the risk of the clinical manifestation of C. d. In this paper, we describe three cases of severe C. d. colitis in patients with CF following lung transplantation and illustrate our experience in the diagnosis and management of these patients.

Efficacy of an acidic vaginal gel on vaginal pH and interleukin-6 levels in low-risk pregnant women: a double-blind, randomized placebo-controlled trial

BACKGROUND

Increased interleukin-6 (IL-6) levels and a vaginal pH of > 4.7 are associated with obstetric complications such as preterm delivery and low birth weight. Topical treatments, able to maintain a physiological vaginal pH, could help in the prevention of vaginal infections.

STUDY AIM

In a randomized, double-blind, placebo-controlled trial, we evaluated the effects of an acidic buffering vaginal gel (Miphil) on vaginal pH and IL-6 levels in pregnant women.

PATIENTS AND METHODS

Seventy low-risk women pregnant with a singleton (second trimester) were enrolled in the trial. Thirty-five were randomized to the acidic gel, 2.5 g every 3 days for 12 weeks, and 35 to the corresponding placebo. Vaginal pH and vaginal IL-6 level were measured at baseline and after 12 weeks. Women were then followed until delivery. The main outcome measures were vaginal pH, vaginal pH normalization (pH < 4.5) and vaginal IL-6 levels.

RESULTS

Vaginal pH at baseline was 4.6 +/- 0.4 and 4.4 +/- 0.3 in the acidic gel and the placebo group, respectively. At baseline, a total of 40% (14/35) and 22% (8/35) of women in each group, respectively, had a vaginal pH of > or = 4.7. At week 12, the vaginal pH was 4.3 +/- 0.3 in the acidic gel group and 4.3 +/- 0.3 in the placebo group (NS). The acidic gel normalized the vaginal pH in ten out of 14 women (p = 0.04) in comparison with only one out of eight women in the placebo group (NS). The acidic gel induced a significant (p < 0.02) reduction of vaginal IL-6 from 12.0 +/- 7 to 8.9 +/- 5 pg/l (-36%). In the placebo group, IL-6 increased from 9.0 +/- 5 to 13.5 +/- 6.8 pg/l (+50%) (p = 0.05). Birth weight was 2978 +/- 700 g in the placebo group and 3241 +/- 477 g in the acidic gel group (p = 0.06).

CONCLUSIONS

The use of the acidic gel in low-risk pregnant women is able to maintain a physiological vaginal ecosystem and prevents the increases of vaginal pH and vaginal IL-6. Prospective and controlled trials are warranted to evaluate whether this acidic gel can reduce obstetric complications linked to vaginal inflammation during pregnancy.

Evaluation and proposal for optimalization of neurophysiological tests in migraine: part 1--electrophysiological tests

Neurophysiological testing has become a valuable tool for investigating brain excitability and nociceptive systems in headache disorders. Previous reviews have suggested that most neurophysiological tests have limited value for headache diagnosis, but a vast potential for exploring the pathophysiology of headaches, the central effects of certain pharmacological treatments and phenotype-genotype correlations. Many protocols, however, lack standardization. This meta-analytical review of neurophysiological methods in migraine was initiated by a task force within the EUROHEAD project (EU Strep LSHM-CT-2004-5044837-Workpackage 9). Most of the neurophysiological approaches that have been used in headache patients are reviewed, i.e. evoked potentials, nociception-specific blink reflex, single-fibre electromyography, neuroimaging methods (functional MRI, PET, and voxel-based morphometry) and the nitroglycerin attack-provoking test. For each of them, we summarize the results, analyse the methodological limitations and propose recommendations for improved methodology and standardization of research protocols. The first part is devoted to electrophysiological methods, the second to neuroimaging techniques and the NTG test.

A novel ATP1A2 mutation in a family with FHM type II

Familial hemiplegic migraine (FHM) is a rare subtype of migraine with aura with an autosomal dominant pattern of inheritance. Six FHM families underwent extensive clinical and genetic investigation. The authors identified a novel ATP1A2 mutation (E700K) in three patients from one family. In the patients, attacks were triggered by several factors including minor head trauma. In one subject a 3-day coma developed after a cerebral angiography. Overall, the phenotype of the patients closely resembles that of previously reported cases of FHM type II. The E700K variant might be regarded as the cause of the disease in this family, but this was not tested functionally.

Familial basilar migraine associated with a new mutation in the ATP1A2 gene

Basilar migraine (BM), familial hemiplegic migraine (FHM), and sporadic hemiplegic migraine (SHM) are phenotypically similar subtypes of migraine with aura, differentiated only by motor symptoms, which are absent in BM. Mutations in CACNA1A and ATP1A2 have been found in FHM. The authors detected a novel mutation in the ATP1A2 gene (R548H) in members of a family with BM, suggesting that BM and FHM may be allelic disorders.

Sertoli cell tumor: a rare case in an elderly patient

Sertoli-Leydig cell tumors constitute < 1% of ovarian tumors, mostly in young women with virilization; however, not all present endocrine manifestations. A 72-year-old female presented with an abdominal mass and no signs of virilization. Total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy and selective pelvic lymphadenectomy was performed. The pathologic diagnosis was poorly-differentiated sex cord-stromal tumor with Sertoli cells. No adjuvant chemotherapy or radiation was administered. At 12-month follow-up the patient showed no evidence of disease.

Human subtelomere structure and variation

Work towards completion of the human reference genome sequence has revealed a great deal of complexity and plasticity in human subtelomeric regions. The highly variable subtelomeric repeat regions are filled with recently shuffled genomic segments, many of which contain sequences matching transcripts and transcript fragments; the rapid duplication and combinatorial evolution of these regions has generated an extremely diverse set of subtelomeric alleles in the human species, the complexity and potential significance of which is only beginning to be understood. This review summarizes recent progress in analyzing human subtelomeric sequence assemblies and large-scale variation in human subtelomere regions.

On the importance of anandamide structural features for its interactions with DPPC bilayers: effects on PLA2 activity

The acylethanolamide anandamide (AEA) occurs in a variety of mammalian tissues and, as a result of its action on cannabinoid receptors, exhibits several cannabimimetic activities. Moreover, some of its effects are mediated through interaction with an ion channel-type vanilloid receptor. However, the chemical features of AEA suggest that some of its biological effects could be related to physical interactions with the lipidic part of the membrane. The present work studies the effect of AEA-induced structural modifications of the dipalmitoylphosphatidylcholine (DPPC) bilayer on phospholipase A2 (PLA2) activity, which is strictly dependent on lipid bilayer features. This study, performed by 2-dimethylamino-(6-lauroyl)-naphthalene fluorescence, demonstrates that the effect of AEA on PLA2 activity is concentration-dependent. In fact, at low AEA/DPPC molar ratios (from R = 0.001 to R = 0.04), there is an increase of the enzymatic activity, which is completely inhibited for R = 0.1. X-ray diffraction data indicate that the AEA affects DPPC membrane structural properties in a concentration-dependent manner. Because the biphasic effect of increasing AEA concentrations on PLA2 activity is related to the induced modifications of membrane bilayer structural properties, we suggest that AEA-phospholipid interactions may be important to produce, at least in part, some of the similarly biphasic responses of some physiological activities to increasing concentrations of AEA.

[Renal transplantation in the North Italy Transplant program (NITp): Organ allocation and results]

Renal transplantation is an effective therapeutic tool for patients with end-stage renal diseases (ESRDs). Data reported in this article summarize the results obtained from 30 years' activity in the North Italy Transplant program (NITp), the first transplant organization in Italy that implemented a donor procurement and organ transplantation network. In the NITp kidney allocation is governed by a computerized algorithm, NITK3, put in place in 1997, aimed at ensuring equity, transparency and traceability during the stages of the allocation decision-making process. The NITp working group has recognized the NITK3 criteria and they are periodically reviewed following the results of the analysis of patients' transplantation odds. The results obtained with the use of the NITK3 algorithm have been very satisfactory: after 6 yrs, a significantly higher percentage of patients at immunological risk (sensitized or waiting for re-transplant), of patients waiting for >3 yrs and of patients with 0-1 HLA A,B,DR mismatches have been transplanted. Moreover, a higher percentage of kidneys were used locally (in a hospital within the procurement area), and this is known to stimulate donor procurement. Finally, we performed a preliminary statistical analysis of transplants carried out from 1998-2002 in 5/16 centers of the NITp area, demonstrating the quality of the NITp program in terms of patient and graft survival, and that donor and recipient age are the variables significantly impacting on transplant results.

Adenosarcoma of the ovary. A case report

Adenosarcoma of the ovary is a rare condition. We report a case of a 32-year-old patient that has been treated in our Department. The diagnosis of ovarian adenosarcoma was carried out after laparoscopy with removal of an ovarian endometriotic cyst. Laparoscopic homolateral ovariectomy was then performed and conservative treatment was decided on considering the young age, low stage and low grade of the disease. Second-look laparoscopy, clinical evaluation and ultrasound were performed for four years of follow-up. No recurrence has been detected. Conservative treatment should be proposed in fertile age with low-grade ovarian adenosarcoma, but a strict follow-up is always necessary.

Cerebellar metabolite alterations detected in vivo by proton MR spectroscopy

The aim of our work was to evaluate the feasibility of in vivo single-voxel quantitative proton MR spectroscopy in order to identify possible alterations in the main metabolite concentrations due to some metabolic dysfunctions in the cerebellum of patients suffering from a particular form of migraine called "with aura." Measurements of metabolite levels in the cerebellum disclosed reduced choline values (normalized both to N-acetyl-aspartate and creatine) in the patient group with respect to the age-matched control group. Our interest in this pathology is motivated by the fact that there are no available specific biochemical markers for migraine characterization, and the current diagnostic only takes advantage of the medical history and the clinical examination.

Lack of habituation causes high intensity dependence of auditory evoked cortical potentials in migraine

Migraineurs are characterized interictally by lack of habituation, or even potentiation, of cortical evoked potentials during repetitive stimulation and by a strong intensity dependence of auditory evoked potentials (IDAP). To determine whether these two features of sensory processing are interrelated, we have studied them simultaneously on the same recordings of auditory evoked potentials (AEPs). AEPs were obtained at four different stimulation intensities in 14 patients suffering from migraine without aura (MO) and 14 healthy volunteers (HV). For each intensity, 120 trials were averaged off-line globally and over four sequential blocks of 30 trials. IDAP was expressed by the amplitude/stimulus intensity function (ASF slope) for global and block averages. Habituation was calculated as the percentage amplitude variation between the first and fourth blocks for each stimulus intensity. The IDAP slope for global averages was higher in MO (1.05 +/- 0.27 microV/10 dB) than in HV (0.64 +/- 0.45 microV/10 dB) (P = 0.008), but IDAP slopes for block averages were greater in MO only at the fourth block (P = 0.048). First block amplitudes tended to be lower in MO, except at 80 dB. There was a potentiation of AEP amplitudes at every stimulus intensity in MO, contrasting with habituation in HV. IDAP slopes were negatively correlated with mean habituation percentages in pooled data from patients and controls (r = -0.610; P = 0.0006). This study confirms that IDAP is higher in migraineurs than in healthy controls. It also shows that the AEP habituation is replaced by potentiation at all stimulus intensities. The negative correlation found between IDAP and habituation suggests that the latter is able to have a strong influence on the former and perhaps even lead to it. In migraine, the habituation deficit amplifies the IDAP and may thus be the causal functional abnormality. We propose that it is due to a decreased pre-activation level of sensory cortices, a hypothesis also supported in this study by the lower amplitude of first AEP blocks in patients.

Idiopathic infertility: susceptibility of spermatozoa to in-vitro capacitation, in the presence and the absence of palmitylethanolamide (a homologue of anandamide), is strongly correlated with membrane polarity studied by Laurdan fluorescence

Capacitation is a widely investigated process, which induces sperm plasma membrane changes resulting in its increased affinity for the zona pellucida. The fluorescent probe Laurdan, localized only within the plasma membrane of spermatozoa, is particularly useful to evaluate bilayer polarity in this part of the cell. According to a previous study, sperm membranes from oligozoospermic and some normozoospermic subjects (defined according to World Health Organization criteria), are characterized by low polarity (high Laurdan exGP(340)), while the spermatozoa from the remaining normozoospermic men show a larger polarity (low exGP(340)). In this paper, Laurdan was used to study membrane changes occurring during in-vitro capacitation, on sperm membranes from oligozoospermic and normozoospermic subjects. Results indicated that cells with high exGP(340) show a different susceptibility to Ca(2+)-induced capacitation in vitro, as compared with cells with low exGP(340). Palmitylethanolamide, physiologically present in human reproductive tracts, affects the time-course of in-vitro capacitation, increasing the rate of this process only in the cells with a lower membrane polarity.

Electrophysiological studies in migraine: a comprehensive review of their interest and limitations

Electrophysiological methods may help to unravel some of the pathophysiological mechanisms of migraine. Lack of habituation is the principal and most reproducible interictal abnormality in sensory processing in migraineurs. It is found in evoked potential (EP) studies for every stimulation modality including nociceptive stimuli, and it is likely to be responsible for the increased intensity dependence of EP. We have hypothesized that deficient EP habituation in migraine could be due to a reduced preactivation level of sensory cortices because of hypofunctioning subcortico-cortical aminergic pathways. This is not in keeping with simple hyperexcitability of the cortex, which has been suggested by some, but not all, studies of transcranial magnetic stimulation (TMS). A recent study of the effects of repetitive TMS on visual EP strongly supports the hypothesis that migraine is characterized by interictal cortical hypoexcitability. With regard to pain mechanisms in migraine, electrophysiological studies of trigeminal pathways using nociceptive blink and corneal reflexes have confirmed that sensitization of central trigeminal nociceptors occurs during migraine attacks.

Acetazolamide acts on neuromuscular transmission abnormalities found in some migraineurs

Mild subclinical impairment of neuromuscular transmission can be detected with single-fibre electromyography (SFEMG) in subgroups of patients suffering from migraine and could be due to dysfunctioning Ca2+-channels on motor axons controlling stimulation-induced acetylcholine release. Acetazolamide, which is thought to ameliorate ion channel function, was shown effective in familial hemiplegic migraine and episodic ataxia type 2, both of which are associated with mutations of the neuronal Ca2+-channel gene CACNA1A, as well as in aura status. We treated therefore in an open pilot study five non-hemiplegic migraineurs showing mild SFEMG abnormalities with acetazolamide for several weeks. This was followed by a normalization of SFEMG recordings in all patients and by clinical improvement in four. These results support the assumption that the subclinical impairment of neuromuscular transmission found in certain migraineurs might be due to dysfunctioning Ca2+-channels.

A neural network model of sensitization of evoked cortical responses in migraine

Migraine patients show abnormalities of cerebral electrophysiology that manifest themselves mainly during the attack interval. Cortical-evoked potentials of migraineurs fail to habituate to repetitive presentations of visual stimuli, and the amplitude of components of their auditory cortical-evoked potentials have a higher dependence on the stimulus intensities than in healthy subjects. A computer model of a neural hetwork has been developed that is able to reproduce both these neurophysiological dysfunctions. It predicts a positive correlation between the magnitudes of both these dysfunctions. The model also offers an explanation of why mutations in the same ion channel gene with opposite consequences on channel function, e.g. P/Q Ca2+ channels in migraine, may lead to similar electrophysiological abnormalities.

Neuromuscular transmission in migraine patients with prolonged aura

P/Q Ca2+ channels are genetically abnormal in most cases of familial hemiplegic migraine (FHM) and may be involved in other types of migraine. They are also found at the neuromuscular junctions, where they control stimulation-induced acetylcholine release. Prolonged aura is a very frequent clinical feature in FHM patients. The objective of this study was thus to explore neuromuscular transmission in migraine with typical and prolonged aura patients. We performed single fiber electromyography (SFEMG) in such patients and compared them to a group of healthy volunteers. Results were expressed as mean jitter (MCD) and percentage of single endplate abnormalities. Mean MCD was on average comparable in controls and migraineurs. By contrast, single endplate abnormalities were only found in patients (p < 0.01), especially in those with prolonged aura (p < 0.001). These results suggest subtle impairment of neuromuscular transmission in a subgroup of migraineurs characterized by prolonged aura, which might be due to dysfunctioning P/Q Ca(2+)-channels.

Laurdan fluorescence: a simple method to evaluate sperm plasma membrane alterations

OBJECTIVE

To determine, by a simple fluorescence method, sperm plasma membrane alterations related with changes of lipid bilayer that, together with routine semen analysis, could help to elucidate the causes of the unexplained male infertility problems.

DESIGN

Pilot study.

SETTING

Andrology laboratory and biochemistry institute, medical school.

PATIENT(S)

Men whose semen was studied for infertility problems.

INTERVENTIONS(S)

No therapeutic intervention was performed on patients.

MAIN OUTCOME MEASURE(S)

Presence of spermatozoa plasma membrane alterations evidenced by evaluation of Laurdan fluorescence Generalized Polarization (GP) and reported as a function of increasing cell concentration, spermatozoa total motility, linear speed, and vitality.

RESULT(S)

Reporting GP values as a function of increasing sperm cell concentration, it is evident that the samples are distributed in two distinct areas: at >32 x 10(6) cells per milliliter, mean GP value was 0.303 +/- 0.015, whereas for lower sperm cell concentrations, the mean GP was 0.365 +/- 0.026 (P<.001). These data indicate that the spermatozoa plasma membranes are characterized by liquid-crystalline phases with different ordering degree and polarity and that about 50% of samples with normal semen characteristics (> or =20 x 10(6) cells per milliliter) show high GP values.

CONCLUSION(S)

Laurdan fluorescence can be used as a simple method to evaluate spermatozoa plasma membrane alterations, particularly in a group of infertile men presenting normal semen parameters. In these samples, Laurdan could be used as a simple tool for infertility assessment. In fact, it is known that compositional and physicochemical alterations of bilayer features can be important for the fertilizing ability of spermatozoa because they are necessary for a proper physiological membrane activity.

Reduced gating of middle-latency auditory evoked potentials (P50) in migraine patients: another indication of abnormal sensory processing?

Habituation of cortical evoked responses to repetitive stimuli is reduced in migraine between attacks. To explore another aspect of information processing, we measured auditory sensory gating. The amplitude of the P50 response to the second of two homologous stimuli was significantly less reduced in migraineurs than in healthy volunteers. This lack of auditory sensory gating may be due to a hypofunction of monoaminergic subcortico-cortical pathways, which is also supposed to cause the interictal deficit of cortical habituation to repetitive stimuli.

Neuromuscular transmission in migraine: a single-fiber EMG study in clinical subgroups

OBJECTIVE

To search for impairment of neuromuscular transmission by single-fiber electromyography (SFEMG) in patients with common forms of migraine.

BACKGROUND

P/Q Ca(2+) channels are genetically abnormal in most cases of familial hemiplegic migraine (International Headache Society [IHS] code 1.2.3) and may be involved in other types of migraine. Besides in the brain, these channels are found in motor nerve endings, where they control stimulation-induced acetylcholine release. If they are functionally abnormal, the neuromuscular transmission might be impaired.

METHODS

Sixty-two migraineurs (18 without aura, IHS code 1.1; 19 with typical aura, IHS code 1.2.1; 10 with prolonged aura, IHS code 1.2.2; 15 with and without aura) and 16 healthy control subjects underwent stimulation SFEMG. Results were expressed as the mean value of consecutive differences (MCD) and percentage of single-fiber abnormalities (abnormal jitter or impulse blocking).

RESULTS

Average MCD was comparable in control subjects and migraineurs (17.1 +/- 2.6 versus 17.5 +/- 4.7 microsec). By contrast, single-fiber abnormalities were found in 17 patients but in none of the control subjects (p = 0.036). Most of these patients had unilateral sensorimotor symptoms and/or aphasia and/or loss of balance during the aura. SFEMG abnormalities were significantly correlated with the occurrence of these clinical features and with a diagnosis of migraine with prolonged aura.

CONCLUSIONS

Stimulation SFEMG shows mild abnormalities of neuromuscular transmission in a subgroup of migraineurs with aura, characterized by clinical features frequently found in human P/Q Ca(2+) channelopathies. These abnormalities might thus be due to genetically modified P/Q Ca(2+) channels.

Steady-state and time resolved fluorescence of albumins interacting with N-oleylethanolamine, a component of the endogenous N-acylethanolamines

The functions of N-acylethanolamines, minor constituents of mammalian cells, are poorly understood. It was suggested that NAEs might have some pharmacological actions and might serve as a cytoprotective response, whether mediated by physical interactions with membranes or enzymes or mediated by activation of cannabinoid receptors. Albumins are identified as the major transport proteins in blood plasma for many compounds including fatty acids, hormones, bilirubin, ions, and many drugs. Moreover, albumin has been used as a model protein in many areas, because of its multifunctional binding properties. Bovine (BSA) and human (HSA) serum albumin are similar in sequence and conformation, but differ for the number of tryptophan residues. This difference can be used to monitor unlike protein domains. Our data suggest that NOEA binds with high affinity to both albumins, modifying their conformational features. In both proteins, NOEA molecules are linked with higher affinity to hydrophobic sites near Trp-214 in HSA or Trp-212 in BSA. Moreover, fluorescence data support the hypothesis of the presence of other NOEA binding sites on BSA, likely affecting Trp-134 environment. The presence of similar binding sites is not measurable on HSA, because it lacks of the second Trp residue.

Apoptosis induced by 2-chloro-adenosine and 2-chloro-2'-deoxy-adenosine in a human astrocytoma cell line: differential mechanisms and possible clinical relevance

We have previously demonstrated that 2-chloro-adenosine (2-CA) can induce apoptosis of rat astroglial cells (Abbracchio et al. [1995] Biochem. Biophys. Res. Commun. 213:908-915). In the present study, we have characterized, for the first time, the effects induced on a human astrocytoma cell line (ADF cells) by both 2-CA and its related analog 2-chloro-2'-deoxy-adenosine (2-CdA, that is employed as anti-cancer agent in chronic lymphoid malignancies). Exposure of these cells to either adenosine analog resulted in time- and concentration-dependent apoptosis. Experiments with pharmacological agents known to interfere with adenosine receptors, its membrane transporter, and intracellular nucleoside kinases showed that: (i) cell death induced by either adenosine analog did not depend on extracellular adenosine receptors, but on a direct intracellular action; however, only in the case of 2-CA, was entry into cells mediated by the specific nitrobenzyl-tioinosine-sensitive transporter; (ii) for both adenosine analogs, induction of apoptosis required the phosphorylation/activation by specific intracellular nucleoside kinases, i.e., adenosine kinase for 2-CA, and deoxycytidine kinase for 2-CdA. In addition, only in the case of 2-CdA, was induction of apoptosis preceded by a block of cells at the G2/M phase of the cell cycle. Finally, at concentrations of either analog that killed about 80-90% of astrocytoma cells, a significantly lower effect on the viability of primary cortical neurons was observed. In conclusion, both adenosine analogs can trigger apoptosis of human astrocytoma cells, albeit with different mechanisms. This effect together with the relative sparing of neuronal cells, may have potential clinical implications for the therapy of tumors of glial origin.

cAMP cascade leads to Ras activation in cortical neurons

Monoaminergic G protein-coupled receptors (GPCRs) are highly expressed in the CNS at the cerebrocortical level, where they support a variety of behavioural responses. To elucidate possible intracellular signalling pathways coupled to these receptors, we have studied their ability to activate extracellular signal-regulated kinases (ERKs) in cultured cortical neurons. An increase in ERK activity was observed after stimulation of neurons with dopamine or serotonin, and with agonists selective for various GPCRs. In addition, ERK activation was also observed following treatment with phorbol dibutyrate (PdBu) and forskolin, activators of protein kinase C (PKC) and protein kinase A (PKA), respectively. Concomitant with ERK activation, all the monoaminergic agonists tested also increased the level of active Ras (Ras-GTP). Surprisingly, Ras activation was also observed after activation of cAMP pathway, and this effect was at least in part mediated by PKA. Ras activation by cAMP was unique for neurons, since in PC12 cells forskolin caused activation of ERK but did not increase Ras-GTP level. These results highlight the relevance of Ras as a target for multiple signalling cascades leading to activation of the ERK pathway in neurons.

Influence of colors on habituation of visual evoked potentials in patients with migraine with aura and in healthy volunteers

OBJECTIVE

To investigate whether colored glasses influence the habituation of visual evoked potentials.

BACKGROUND

We have previously shown that during pattern-reversal stimulations lasting 2 minutes the amplitude of the visual evoked potential increases in migraine with and without aura between attacks, whereas it decreases in healthy volunteers. Red light was found to increase visually evoked EEG fast activity only in children with migraine with aura. Wearing rose-tinted glasses for 4 months decreased attack frequency in parallel with a reduction of the visually evoked EEG fast activity.

METHODS

We compared the change in amplitude of the visual evoked potential using five different tinted glasses in 12 patients with migraine with aura and in 10 healthy volunteers. During continuous stimulation at 3.1 Hz, five blocks of 50 responses were sequentially averaged using red, yellow, green, blue, and grey glasses and without glasses in a random order and analyzed in terms of latencies and N1-P1 amplitudes. Amplitude changes were calculated for each block by comparison with the first block in every condition and analyzed statistically using Zerbe's method.

RESULTS

In healthy volunteers, the visual evoked potential amplitude increased with red glasses compared to without glasses (P = .05) or with green glasses (P = .03). In patients with migraine with aura, no significant difference was detected using colored glasses. Our findings in healthy volunteers are in line with earlier reports of increased excitability of the human visual cortex when exposed to red light. The lack of such a pattern in patients with migraine with aura suggests that the visual cortex is interictally hypoexcitable rather than hyperexcitable, which is consistent with studies of transcranial magnetic stimulation.