Real-life data in 115 chronic migraine patients treated with Onabotulinumtoxin A during more than one year

Background

OnabotulinumtoxinA (OnabotA) is effective in Chronic Migraine (CM) during first year of treatment and longer. In real clinical setting, CM patients with acute Medication Overuse (MO) or concurrently receiving oral preventatives are treated with OnabotA. We aim to assess evolution of CM patients beyond first year on OnabotA.

Methods

Data were retrospectively collected in three headache units. We analyzed cases who had received at least five sessions of OnabotA according to PREEMPT protocol. We continued OnabotA therapy when a reduction of number of headache days of at least 30% was achieved.

Results

We included 115 patients (98 females, 17 males) who completed 7.6 ± 2.3 (5–13) OnabotA procedures. Previously they had not responded to topiramate and, at least, one other preventative. Age at inclusion was 45.3 ± 12 (14–74) years, and latency between CM onset and OnabotA therapy was 43.1 ± 38.2 (6–166) months. At first OnabotA session 92 patients (80%) fulfilled MO criteria and 107 (93%) received a concurrent oral preventative. In 42 cases (36.5%) OnabotA dose was increased over 155 units. After first year in 57 out of 92 patients (61.9%) MO was discontinued. Among those receiving preventatives, in 52 out of 107 they were retired (48.6%). In 22 cases (19.1%) OnabotA administration was delayed to the fourth or fifth month and in 12 (10.4%) it was temporally stopped. Finally, in 18 patients (15.7%) OnabotA was discontinued due to lack of efficacy beyond first year of treatment.

Conclusion

Our results suggest that discontinuation of acute medication overuse and oral preventive therapies are achievable objectives in long-term using of OnabotA in CM patients.

Diagnostic accuracy of the faecal immunochemical test for colorectal cancer in symptomatic patients: comparison with NICE and SIGN referral criteria

AIM

The diagnostic accuracy of the faecal immunochemical test (FIT) at a 100 ng/ml threshold for colorectal cancer (CRC) was compared with National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) referral criteria.

METHOD

A multicentre, prospective, blind study of diagnostic tests was carried out in two Spanish health areas. In 787 symptomatic patients referred for a diagnostic colonoscopy, we determined whether patients met NICE and SIGN referral criteria. All patients performed one FIT determination (OCsensor(™) ). The sensitivity and specificity for CRC detection were determined with McNemar's test. The diagnostic odds ratio as well as the number needed to scope (NNS) to detect a CRC were calculated.

RESULTS

We detected CRC in 97 (12.3%) patients; 241 (30.6%) had an FIT ≥ 100 ng/ml and 300 (38.1%) and 473 (60.1%) met NICE and SIGN referral criteria. The FIT had a higher sensitivity for CRC detection than NICE criteria (87.6%, 61.9%; P < 0.001) and SIGN criteria (82.5%; P = 0.4). The specificity of FIT was also higher than NICE and SIGN criteria (77.4%, 65.2%, 42.7%; P < 0.001). The odds ratios of FIT, NICE and SIGN criteria for the diagnosis of CRC were 24.24 (95% CI 12.91-45.53), 3.04 (95% CI 1.96-4.71) and 3.51 (95% CI 2.03-6.06). The NNS to detect a CRC in individuals with an FIT ≥ 100 ng/ml was 2.83 (95% CI 2.4-3.41) and in individuals who met NICE and SIGN criteria it was 5 (95% CI 3.98-6.37) and 5.95 (95% CI 4.85-7.35).

CONCLUSION

Our study suggests that FIT is more accurate for the detection of CRC than the current NICE and SIGN referral criteria in symptomatic patients referred for colonoscopy.

Influence of APOE gene polymorphisms on interferon-beta treatment response in multiple sclerosis

OBJECTIVE

Clinical trials with interferon beta in relapsing remitting multiple sclerosis (RRMS) have demonstrated a reduction in the relapse rate. Nevertheless, not all patients respond to this treatment, although there is no consensus regarding the definition of response to therapy. The reasons for this failure are not known but genetic factors probably influence this, as has been previously shown with Interleukin 10 or Interferon gamma polymorphisms. The role of apolipoprotein E (APOE) gene in MS has been investigated and does not appear to increase risk for MS or influence disease severity. Interestingly APOE variation influences response to cholinesterase inhibitor treatment in Alzheimer disease or to statins in hypercholesterolemia. This might have future implications for MS.

MATERIAL AND METHODS

We retrospectively reviewed 38 RRMS patients (32 females and 6 males) treated with interferon beta (INFbeta) over at least two years. Criteria for treatment were uniform accordingly to an "Advisory Committee for the Treatment of Multiple Sclerosis". We collected data variables including age, age of onset, clinical type or disease duration. Patients were classified, two years after the start of treatment, as responders and non-responders based upon clinical criteria available in the literature, which rely on the presence of relapses, increase of disability, or both. APOE genotype was determined from blood samples using validated polymerase chain reaction methods. Correlation between patient responding status with allele E2 or E4 was tested.

RESULTS

A total of 20 patients (52.6%) received subcutaneous INFbeta1b (Betaferón(®)), 13 (34.2%) INFbeta1a intramuscular (Avonex(®)), and 5 (13.2%) subcutaneous INFbeta1a (Rebif(®)). We found 2 patients (5.2%) heterozygous for the E2 allele and 9 (23.7%) for the E4 allele. No patient was homozygous for E2 or E4. Comparison of patients with and without E2 or E4 allele showed no significant differences in any of the ten therapy response variables assessed.

CONCLUSION

Findings of a recent meta-analysis have not supported a role for APOE in MS susceptibility or severity. We have not found, in our data, any influence of this gene in the RRMS response to INFbeta. However, larger series would be required to validate these results.

[Multiple spontaneous cerebral haemorrhages. Description of a series and review of the literature]

INTRODUCTION

The simultaneous occurrence of intracerebral haemorraghes in different arterial territories is an clinical event that develops in 2% to 3% of hemorrhagic strokes. Multiple risk factors have been associated with multiple intracerebral haemorraghes, but none of them are clearly defined. We reported clinical features, radiological findings, and outcome of 7 patients admitted to our department during last nine years and the diverse etiologic factors are discussed.

PATIENTS AND METHODS

We retrospectively reviewed all patients with acute stroke admitted to our department during the period January 1998-February 2007. Patients with a history of traumatic brain injury or suspected hemorrhagic infarctions were excluded. We collected data concerning age, risk factors, clinical features, number and location of haematomas and outcome.

RESULTS

We studied 7 patients (5 males and 2 females) Mean age was 78. The most common clinical manifestations were decreased alertness and weakness. Total number of haematomas was 20, 19 (95%) supratentorial and 15 (75%) in lobar area. One patient haemorrhage extended into the ventricular system. Three patients (43%) had hipertensive history, and in only one case was associated with oral anticoagulant (14%) and one blood dyscrasia (14%). Three patients died (43%).

CONCLUSION

In our series of patients with multiple intracerebral haemorraghes, clinical and radiological findings and outcome were comparable to others previously described, but our patients were older. The advanced age and lobar localization suggest amyloid angiopathy is an important risk factor to multiple intracerebral haemorraghes.

Apolipoprotein E genotype does not associate with disease severity measured by Multiple Sclerosis Severity Score

OBJECTIVES

During the last years, the association between apolipoprotein E (APOE) polymorphism and disease severity in multiple sclerosis (MS) has been studied with conflicting results. As a result of a considerable individual variation in the clinical course of MS, there is no consensus method for measuring progression using single assessments of disability. Recently, Multiple Sclerosis Severity Score (MSSS) method has been proposed for comparing disease progression using single data. We evaluate in our population if there is any correlation between APOE genotype and severity according to MSSS.

METHODS

We studied 82 patients followed up in our Neurology Unit throughout the year 2005, diagnosed with MS, and with disease duration of at least 2 years. We collected data concerning demographic and clinical variables including age of onset, disease duration, Expanded Disability Status Scale (EDSS) score and the total number of relapses. When reached, we determined the latency to EDSS scores of 4.0 and 6.0. We calculated progression index (PI) and relapse rate (RR). We ascertained MSSS for our patients in the global MSSS table.

RESULTS

We found four patients heterozygous for the E2 allele and 16 for the E4 allele. No patient was homozygous for E2 or E4. RR (P = 0.017 with 95% CI: 0.005-0.57) and PI (P = 0.016 with 95% CI: 0.004-0.38) were significantly lower in E4 carriers. MSSS scores were not associated with carriership of E2 or E4.

CONCLUSION

Our results show no effect of the APOE genotype on the severity of MS measured by MSSS, as a recently published meta-analysis has noticed. So, our data do not support a role for APOE in MS severity, in spite of the seeming influence shown using other measures such as PI. MSSS is probably the best method to measure severity with a single measure of disability and should be used more frequently when performing genetic research.

Contaminación externa de viales de metotrexato detectada en un hospital argentino

OBJECTIVE

To quantify external contamination of methotrexate vials and alert about occupational health hazards.

METHOD

All 50 mg and 500 mg methotrexate vials were opened and cleaned with an alcohol wet white wipe in February 2005. The vials were divided in two groups according to visual external contamination or not. The air tightness of the vials was stated.

RESULTS

9.33% methotrexate vials were contaminated under visual inspection. Two of five manufacturers presented contaminated vials. The proportion of contaminated vials in the two former manufacturers was 18.8 and 21.43%.

CONCLUSIONS

External contamination would be due to manufacture processes. Cutaneous absorption is very important because of the contamination founded. It s strongly recommended that all personal involved in cytotoxic handling take protection measures.

Gammagrafía con 99mTc-ceftizoxima en ratas normales y en ratas con absceso inducido

This study aimed to investigate the biodistribution of the 99mTc-ceftizoxime in normal rats and in rats bearing septic and sterile induced abscess.

MATERIAL AND METHODS

Three groups of rats were studied. a) Six normal rats b) 15 rats with E. coli induced abscess and c) 15 rats with sterile zymosan induced abscess. Septic abscess was induced with 2 x 10(8) colony forming units of E. coli and sterile one with 0.1 mL of 5% sterile Zymosan. 24 h after the abscess induction, 12 MBq of 99mTc-CFT were injected iv. and whole body images were collected at 30 min, 1, 2, 4 and 6 h p.i. Areas of interest were drawn and lesion/background index was calculated. The 6 normal rats were scanned at the same times, killed at 6 h p.i and kidney, liver, spleen, lung, heart and muscle activity were measured. Each organ was weighed, cut and its activity measured. Parallelly, the biological activity of the labeled antibiotic and its binding to the E. coli and S. aureus bacteria were analyzed.

RESULTS

High biliary excretion was seen in all rats. Organ measurement showed the maximal uptake in kidney and very low uptake in muscles. Mean +/- s.d abscess/background ratio at 30 min, 1, 2, 4 and 6 h were 2.60 +/- 0.36, 2.67 +/- 0.66, 2.6 0 +/- 0.58, 2.78 +/- 0.84, 3.24 +/- 1.00 for septic abscess and 2.37 +/- 0.39, 2.10 +/- 0.38, 1.97 +/- 0.34, 1.82 +/- 0.25, 1.65 +/- 0.23 for aseptic abscess. The 99mTc-CFT uptake was significantly higher in the septic abscess than in sterile one (p < 0.05). The 99mTc-CFT uptake in the septic abscess remains stable or increases until along the 6 h. The 99mTc-CFT uptake in the aseptic abscess decreases along the time.

CONCLUSIONS

The scintigraphy with 99mTc-CFT seems able to differentiate sterile inflammation from infection. High biliary excretion limits its application in abdomen. Main application could be diagnosis of osteoarticular infection.

Transbronchial Needle Aspiration of Diseased Mediastinal Lymph Nodes: Predictors of Positive Findings

OBJECTIVE

To assess the factors that may determine the effectiveness of transbronchial needle aspiration through a flexible bronchoscope in the diagnosis of diseased mediastinal lymph nodes in patients with lung or extrapulmonary tumors.

METHODS

Prospective study carried out at 2 hospitals between 1998 and 2004 that included all transbronchial needle aspirations performed on patients who had diseased mediastinal lymph nodes larger than 10 mm and nonlymphoid neoplasms. Univariate and multivariate analysis of the diagnostic results of transbronchial needle aspiration were performed according to the type and location of the primary neoplasm and the lymph node station biopsied, the diameter of the affected node, endoscopic findings, and the results of other bronchoscopic techniques.

RESULTS

The study evaluated the transbronchial needle aspiration of 230 lymph node stations in 207 patients. Histologic examination revealed 151 cases (72.9%) of non-small cell lung cancer, 42 cases (20.3%) of small cell lung cancer, and 14 cases (6.8%) of extrapulmonary cancer. The best predictors of obtaining a diagnostic sample were a diameter of the diseased node greater than 20 mm in diameter (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.2-4.7; P=.01) and a histologic diagnosis of small cell lung cancer (OR, 2.7; 95% CI, 0.9-8.2; P=.07).

CONCLUSIONS

The size of the diseased node and the tumor type are the best predictors of obtaining a diagnostic sample with transbronchial needle aspiration of diseased mediastinal lymph nodes in patients with lung or extrapulmonary tumors.

Chemotaxis, viability, and labeling stability of leukocytes labeled with (99m)Tc-exametazime stabilized with methylene blue

The in vitro viability, chemotaxis, and labeling stability of leukocytes labeled using (99m)Tc-exametazime stabilized with methylene blue were evaluated and compared with those obtained using nonstabilized (99m)Tc-exametazime.

METHODS

Two identical leukocyte populations, from 30 healthy donors, were labeled simultaneously using freshly prepared and 2-h-old stabilized (99m)Tc-exametazime. The following quality control techniques were performed on each labeled leukocyte sample: eosin Y staining, chemotaxis radioassay, and labeling stability at 2 h after labeling.

RESULTS

Eosin Y staining showed a cell viability of at least 98% in all samples, without a significant statistical difference between the populations. Chemotactic indices obtained with leukocytes labeled with freshly prepared, unstabilized (99m)Tc-exametazime were statistically greater than those obtained using (99m)Tc-exametazime stabilized with methylene blue (z = 2.41; P<0.02). Labeling stability at 2 h after labeling was the same for both populations.

CONCLUSION

The use of (99m)Tc-exametazime stabilized with methylene blue for leukocyte radiolabeling does not affect either cell membrane integrity or labeling stability but can cause a decrease in the cell chemotactic capacity that discourages its clinical use.

[Labelling of ceftizoxime with 99mTc]

AIM OF THE STUDY

A new method to label antibiotics with 99mTc, using a third generation, wide spectrum cephalosporine (ceftizoxime), is presented.

MATERIAL AND METHODS

2.5 mg of ceftizoxime, 6.25 mg sodium dithionite in sodium bicarbonate buffer (pH=11.4) as a reductor agent, and 300 MBq of 99mTc were used. The final pH was adjusted to 8.4 with NaOH 0.1N. Radiochemical purity was assessed using ITLC-SG/MEK, ITLC-SG/0.9% NaCl and reverse phase HPLC. Biologic activity was assessed with the agar diffusion technique soaked with E. Coli in disks containing 10.5 microg labelled and non-labelled antibiotic. The maintenance of antibiotic activity was assessed by the diameter of the inhibition halos measured after 24 hours of incubation at 37 degrees C.

RESULTS

The labelling efficiency was 94.9 +/- 2.4% (n = 20) and the complex was stable up to 6 h post-labelling. The HPLC chromatography showed five peaks: two of them at 1.7-2.0 min, which corresponds to the ceftizoxime derived product (82%-83% of the absorbance and about 90% of the radioactivity) and a third one at 4.7 min which corresponds to the intact ceftizoxime (6% of absorbance). The remaining two peaks appeared at 3.8 and 6.7 min and represented about 7%-8% of the absorbance. The antibiotic activity of the ceftizoxime-derived compound (CDC) was 83% of the unlabelled one.

CONCLUSIONS

1) The labelling method of ceftizoxime described causes a modification in its structure. 2) The 99mTc binds to the newly formed compound with high labelling efficiency and an acceptable shelf life stability. 3) The 99mTc-CDC maintains 83% of the original antibiotic activity and could be used for the detection of in vivo infection.

Irreducible phalangeal fracture in a child due to flexor tendon entrapment

A 4-year-old girl sustained a longitudinal shaft fracture of the proximal phalanx of the ring finger. The fracture was irreducible by closed manipulation and required open reduction. The fragments were separated by both flexor tendons near the level of Camper's chiasma, which caused a "pinching" phenomenon when manipulative reduction was attempted. The case presented reveals that an irreducible fracture should be suspected in hyperextension injuries with severe angulation when rubbery resistance is noted at the time of closed manipulation.

[Effective renal plasma flow with I-131-hipuran: evaluation of a method with four extractions]

The aim of this work was to evaluate a method for the estimation of the effective renal plasma flow (ERPF) using sodium 131I-o-hippurate (OIH) by means the bicompartmental analysis of the radioactive concentration of 4 plasma samples, analyzing the error obtained respecting to the multi-sample method and comparing it with those obtained with other simplified methods. We calculated the ERPF from 62 patients using the multi-sample method as standard, the method based in a single sample at 44 minutes p.i., a method based in 2 samples from the first exponential, 4 methods based in 2 samples from the second exponential, one method based in 3 samples and 5 methods based in 4 samples (2 from the first exponential and 2 from the second exponential). Each simplified method was compared to the standard method and their absolute error (AE) and standard estimation error (SEE) were calculated. The method based in the 4 samples withdrawn at 4, 10, 30 and 60 minutes p.i. was the best of them with a correlation factor with the standard equal to 0.997, an EA that ranged from -63 ml/min to 49 ml/min (mean: -4 ml/min) and a SEE of 19.5 ml/min.

Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases

We analyzed our experience with cough, exertional, and vascular sexual headaches, evaluated the interrelationships among them, and examined the possible symptomatic cases. Seventy-two patients consulted us because of headaches precipitated by coughing (n = 30), physical exercise (n = 28), or sexual excitement (n = 14). Thirty (42%) were symptomatic. The 17 cases of symptomatic cough headache were secondary to Chiari type I malformation, while the majority of cases of symptomatic exertional headaches and the only case of symptomatic sexual headache were secondary to subarachnoid hemorrhage. Although the precipitant was the same, benign and symptomatic headaches differed in several clinical aspects, such as age at onset, associated clinical manifestations, or response to pharmacologic treatment. Although sharing some properties, such as male predominance, benign cough headache and benign exertional headache are clinically separate conditions. Benign cough headache began significantly later, 43 years on average, than benign exertional headache. By contrast, our findings suggest that there is a close relationship between benign exertional headache and benign vascular sexual headache. We conclude that benign and symptomatic cough headaches are different from both benign and symptomatic exertional and sexual headaches.

MRI in radiation-induced myelopathy and pharyngocutaneous fistula

A patient developed a cervical myelopathy 20 months after radiotherapy for a carcinoma of the larynx. MRI showed an intramedullary lesion at C7. Although radiation myelopathy was suspected, tumour recurrence could not be excluded. A radiation-induced pharyngocutaneous fistula, confirmed histologically, appeared a month later. The fistula lay just anterior to the level of the spinal cord lesion, a finding useful in supporting a diagnosis of simultaneous radiation myelopathy.

Conformations in crystals and solutions of d(CACGTG), d(CCGCGG) and d(GGCGCC) studied by vibrational spectroscopy

Crystals of self complementary DNA hexamers d(CACGTG), d(CCGCGG) and d(GGCGCC) were grown by vapour diffusion technique and studied by microRaman and microIR spectroscopies. The oligonucleotides were studied in parallel in solution by vibrational spectroscopy. A B- greater than Z transition was detected by Raman spectroscopy during the crystallization process for d(CACGTG). Vibrational spectroscopy shows that the d(GGCGCC) crystals adopt a B geometry. On the contrary the d(CCGCGG) sequence which is shown to be able to undergo in solution or in films quite easily the B- greater than Z transition, remains trapped in crystals in a geometry which may correspond to an intermediate conformation often proposed in models of the B- greater than Z transition. The crystals used in this study were characterized by X-ray diffraction. The unit cell and space group have been determined.