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Couch JR, Stewart KE. Persistence of headache and its relation to other major sequelae following traumatic brain injury at 2–8 years after deployment‐related traumatic brain injury in veterans of Afghanistan and Iraq wars. Headache 2022; 62:700-717. [DOI: 10.1111/head.14303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/27/2022]
Affiliation(s)
- James R. Couch
- Department of Neurology University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA
| | - Kenneth E. Stewart
- Department of Surgery University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA
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Hanas JS, Hocker JRS, Vannarath CA, Lerner MR, Blair SG, Lightfoot SA, Hanas RJ, Couch JR, Hershey LA. Distinguishing Alzheimer's Disease Patients and Biochemical Phenotype Analysis Using a Novel Serum Profiling Platform: Potential Involvement of the VWF/ADAMTS13 Axis. Brain Sci 2021; 11:brainsci11050583. [PMID: 33946285 PMCID: PMC8145311 DOI: 10.3390/brainsci11050583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022] Open
Abstract
It is important to develop minimally invasive biomarker platforms to help in the identification and monitoring of patients with Alzheimer's disease (AD). Assisting in the understanding of biochemical mechanisms as well as identifying potential novel biomarkers and therapeutic targets would be an added benefit of such platforms. This study utilizes a simplified and novel serum profiling platform, using mass spectrometry (MS), to help distinguish AD patient groups (mild and moderate) and controls, as well as to aid in understanding of biochemical phenotypes and possible disease development. A comparison of discriminating sera mass peaks between AD patients and control individuals was performed using leave one [serum sample] out cross validation (LOOCV) combined with a novel peak classification valuation (PCV) procedure. LOOCV/PCV was able to distinguish significant sera mass peak differences between a group of mild AD patients and control individuals with a p value of 10-13. This value became non-significant (p = 0.09) when the same sera samples were randomly allocated between the two groups and reanalyzed by LOOCV/PCV. This is indicative of physiological group differences in the original true-pathology binary group comparison. Similarities and differences between AD patients and traumatic brain injury (TBI) patients were also discernable using this novel LOOCV/PCV platform. MS/MS peptide analysis was performed on serum mass peaks comparing mild AD patients with control individuals. Bioinformatics analysis suggested that cell pathways/biochemical phenotypes affected in AD include those involving neuronal cell death, vasculature, neurogenesis, and AD/dementia/amyloidosis. Inflammation, autoimmunity, autophagy, and blood-brain barrier pathways also appear to be relevant to AD. An impaired VWF/ADAMTS13 vasculature axis with connections to F8 (factor VIII) and LRP1 and NOTCH1 was indicated and is proposed to be important in AD development.
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Affiliation(s)
- Jay S. Hanas
- Department of Biochemistry, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (J.R.S.H.); (C.A.V.); (R.J.H.)
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (M.R.L.); (S.G.B.)
- Veterans Administration Hospital, Oklahoma City, OK 73104, USA;
- Correspondence:
| | - James R. S. Hocker
- Department of Biochemistry, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (J.R.S.H.); (C.A.V.); (R.J.H.)
| | - Christian A. Vannarath
- Department of Biochemistry, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (J.R.S.H.); (C.A.V.); (R.J.H.)
| | - Megan R. Lerner
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (M.R.L.); (S.G.B.)
| | - Scott G. Blair
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (M.R.L.); (S.G.B.)
| | | | - Rushie J. Hanas
- Department of Biochemistry, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (J.R.S.H.); (C.A.V.); (R.J.H.)
| | - James R. Couch
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (J.R.C.); (L.A.H.)
| | - Linda A. Hershey
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (J.R.C.); (L.A.H.)
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Couch JR, Grimes GR, Green BJ, Wiegand DM, King B, Methner MM. Review of NIOSH Cannabis-Related Health Hazard Evaluations and Research. Ann Work Expo Health 2021; 64:693-704. [PMID: 32053725 DOI: 10.1093/annweh/wxaa013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 11/13/2022] Open
Abstract
Since 2004, the National Institute for Occupational Safety and Health (NIOSH) has received 10 cannabis-related health hazard evaluation (HHE) investigation requests from law enforcement agencies (n = 5), state-approved cannabis grow operations (n = 4), and a coroner's office (n = 1). Earlier requests concerned potential illicit drug exposures (including cannabis) during law enforcement activities and criminal investigations. Most recently HHE requests have involved state-approved grow operations with potential occupational exposures during commercial cannabis production for medicinal and non-medical (recreational) use. As of 2019, the United States Drug Enforcement Administration has banned cannabis as a Schedule I substance on the federal level. However, cannabis legalization at the state level has become more common in the USA. In two completed cannabis grow operation HHE investigations (two investigations are still ongoing as of 2019), potential dermal exposures were evaluated using two distinct surface wipe sample analytical methods. The first analyzed for delta-9-tetrahydrocannabinol (Δ9-THC) using a liquid chromatography and tandem mass spectrometry (LC-MS-MS) method with a limit of detection (LOD) of 4 nanograms (ng) per sample. A second method utilized high performance liquid chromatography with diode-array detection to analyze for four phytocannabinoids (Δ9-THC, Δ9-THC acid, cannabidiol, and cannabinol) with a LOD (2000 ng per sample) which, when comparing Δ9-THC limits, was orders of magnitude higher than the LC-MS-MS method. Surface wipe sampling results for both methods illustrated widespread contamination of all phytocannabinoids throughout the tested occupational environments, highlighting the need to consider THC form (Δ9-THC or Δ9-THC acid) as well as other biologically active phytocannabinoids in exposure assessments. In addition to potential cannabis-related dermal exposures, ergonomic stressors, and psychosocial issues, the studies found employees in cultivation, harvesting, and processing facilities could potentially be exposed to allergens and respiratory hazards through inhalation of organic dusts (including fungus, bacteria, and endotoxin) and volatile organic compounds (VOCs) such as diacetyl and 2,3-pentanedione. These hazards were most evident during the decarboxylation and grinding of dried cannabis material, where elevated job-specific concentrations of VOCs and endotoxin were generated. Additionally, utilization of contemporary gene sequencing methods in NIOSH HHEs provided a more comprehensive characterization of microbial communities sourced during cannabis cultivation and processing. Internal Transcribed Spacer region sequencing revealed over 200 fungal operational taxonomic units and breathing zone air samples were predominantly composed of Botrytis cinerea, a cannabis plant pathogen. B. cinerea, commonly known as gray mold within the industry, has been previously associated with hypersensitivity pneumonitis. This work elucidates new occupational hazards related to cannabis production and the evolving occupational safety and health landscape of an emerging industry, provides a summary of cannabis-related HHEs, and discusses critical lessons learned from these previous HHEs.
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Affiliation(s)
- James R Couch
- NIOSH, Division of Science Integration, Cincinnati, OH, USA
| | | | - Brett J Green
- NIOSH, Health Effects Laboratory Division, Morgantown, WV, USA
| | - Douglas M Wiegand
- NIOSH, Division of Field Studies and Engineering, Cincinnati, OH, USA
| | | | - Mark M Methner
- NIOSH, Division of Field Studies and Engineering, Cincinnati, OH, USA
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Couch JR, Grimes GR, Wiegand DM, Green BJ, Glassford EK, Zwack LM, Lemons AR, Jackson SR, Beezhold DH. Potential occupational and respiratory hazards in a Minnesota cannabis cultivation and processing facility. Am J Ind Med 2019; 62:874-882. [PMID: 31332812 DOI: 10.1002/ajim.23025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cannabis has been legalized in some form for much of the United States. The National Institute for Occupational Safety and Health (NIOSH) received a health hazard evaluation request from a Minnesota cannabis facility and their union to undertake an evaluation. METHODS NIOSH representatives visited the facility in August 2016 and April 2017. Surface wipe samples were collected for analysis of delta-9 tetrahydrocannabinol (Δ9-THC), delta-9 tetrahydrocannabinol acid (Δ9-THCA), cannabidiol, and cannabinol. Environmental air samples were collected for volatile organic compounds (VOCs), endotoxins (limulus amebocyte lysate assay), and fungal diversity (NIOSH two-stage BC251 bioaerosol sampler with internal transcribed spacer region sequencing analysis). RESULTS Surface wipe samples identified Δ9-THC throughout the facility. Diacetyl and 2,3-pentanedione were measured in initial VOC screening and subsequent sampling during tasks where heat transference was greatest, though levels were well below the NIOSH recommended exposure limits. Endotoxin concentrations were highest during processing activities, while internal transcribed spacer region sequencing revealed that the Basidiomycota genus, Wallemia, had the highest relative abundance. CONCLUSIONS To the authors' knowledge, this is the first published report of potential diacetyl and 2,3-pentanedione exposure in the cannabis industry, most notably during cannabis decarboxylation. Endotoxin exposure was elevated during grinding, indicating that this is a potentially high-risk task. The findings indicate that potential health hazards of significance are present during cannabis processing, and employers should be aware of potential exposures to VOCs, endotoxin, and fungi. Further research into the degree of respiratory and dermal hazards and resulting health effects in this industry is recommended.
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Affiliation(s)
- James R. Couch
- Division of Field Studies and Engineering, National Institute for Occupational Safety and HealthCenters for Disease Control and Prevention Cincinnati Ohio
| | - George R. Grimes
- Division of Field Studies and Engineering, National Institute for Occupational Safety and HealthCenters for Disease Control and Prevention Cincinnati Ohio
- Epidemic Intelligence Service, Center of Surveillance, Epidemiology, and Laboratory ServicesCenters for Disease Control and Prevention Cincinnati Ohio
| | - Douglas M. Wiegand
- Division of Field Studies and Engineering, National Institute for Occupational Safety and HealthCenters for Disease Control and Prevention Cincinnati Ohio
| | | | - Eric K. Glassford
- Division of Field Studies and Engineering, National Institute for Occupational Safety and HealthCenters for Disease Control and Prevention Cincinnati Ohio
| | - Leonard M. Zwack
- Division of Field Studies and Engineering, National Institute for Occupational Safety and HealthCenters for Disease Control and Prevention Cincinnati Ohio
| | - Angela R. Lemons
- Health Effects Laboratory Division, National Institute for Occupational Safety and HealthCenters for Disease Control and Prevention Morgantown West Virginia
| | - Stephen R. Jackson
- Health Effects Laboratory Division, National Institute for Occupational Safety and HealthCenters for Disease Control and Prevention Morgantown West Virginia
| | - Donald H. Beezhold
- Health Effects Laboratory Division, National Institute for Occupational Safety and HealthCenters for Disease Control and Prevention Morgantown West Virginia
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Hanas JS, Hocker JRS, Lerner MR, Couch JR. Distinguishing and phenotype monitoring of traumatic brain injury and post-concussion syndrome including chronic migraine in serum of Iraq and Afghanistan war veterans. PLoS One 2019; 14:e0215762. [PMID: 31026304 PMCID: PMC6485717 DOI: 10.1371/journal.pone.0215762] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/08/2019] [Indexed: 12/31/2022] Open
Abstract
Traumatic Brain Injury (TBI) and persistent post-concussion syndrome (PCS) including chronic migraine (CM) are major health issues for civilians and the military. It is important to understand underlying biochemical mechanisms of these conditions, and be able to monitor them in an accurate and minimally invasive manner. This study describes the initial use of a novel serum analytical platform to help distinguish TBI patients, including those with post-traumatic headache (PTH), and to help identify phenotypes at play in these disorders. The hypothesis is that physiological responses to disease states like TBI and PTH and related bodily stresses are reflected in biomolecules in the blood in disease-specific manner. Leave one out (serum sample) cross validations (LOOCV) and sample randomizations were utilized to distinguished serum samples from the following TBI patient groups: TBI +PTSD + CM + severe depression (TBI "most affected" group) vs healthy controls, TBI "most affected" vs TBI, TBI vs controls, TBI + CM vs controls, and TBI + CM vs TBI. Inter-group discriminatory p values were ≤ 10-10, and sample group randomizations resulted in p non-significant values. Peptide/protein identifications of discriminatory mass peaks from the TBI "most affected" vs controls and from the TBI plus vs TBI minus CM groups yielded information of the cellular/molecular effects of these disorders (immune responses, amyloidosis/Alzheimer's disease/dementia, neuronal development). More specific biochemical disease effects appear to involve blood brain barrier, depression, migraine headache, autoimmunity, and autophagy pathways. This study demonstrated the ability for the first time of a novel, accurate, biomarker platform to monitor these conditions in serum, and help identify biochemical relationships leading to better understanding of these disorders and to potential therapeutic approaches.
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Affiliation(s)
- Jay S. Hanas
- Department of Biochemistry, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, United States of America
- Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, United States of America
- Veterans Administration Hospital, Oklahoma City, Oklahoma, United States of America
- * E-mail:
| | - James R. S. Hocker
- Department of Biochemistry, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, United States of America
| | - Megan R. Lerner
- Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, United States of America
| | - James R. Couch
- Department of Neurology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, United States of America
- Department of Neurology, Veterans Administration Hospital, Oklahoma City, Oklahoma, United States of America
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Green BJ, Couch JR, Lemons AR, Burton NC, Victory KR, Nayak AP, Beezhold DH. Microbial hazards during harvesting and processing at an outdoor United States cannabis farm. J Occup Environ Hyg 2018; 15:430-440. [PMID: 29370578 PMCID: PMC6314012 DOI: 10.1080/15459624.2018.1432863] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Cannabis cultivation is an emerging industry within the United States. Organic dust derived in part from naturally occurring microorganisms is known to cause byssinosis in the hemp industry. In this pilot study, bacteria and fungi encountered by workers at an outdoor cannabis farm that utilized organic practices were elucidated by 16 S ribosomal RNA (rRNA) and Internal Transcribed Spacer (ITS) region sequencing, respectively. Area (n = 14) and personal air samples (n = 12) were collected during harvesting and processing activities. 16 S rRNA and ITS regions of extracted bacterial and fungal genomic DNA were amplified and sequenced using Sanger sequencing. Bacterial sequencing resolved 1,077 sequences that were clustered into 639 operational taxonomic units (OTUs) and predominantly placed in the phylum, Actinobacteria (46%). Personal air samples revealed higher bacterial and Actinobacteria diversity compared to outdoor area samples collected within the facility (p < 0.05). A high degree of dissimilarity between bacteria was identified within and between samples. Fungal sequences (n = 985) were identified and predominantly clustered in the phylum Ascomycota (53%). Of the 216 fungal OTUs elucidated, the cannabis plant pathogenic species, Botrytis cinerea, was the most prevalent and accounted for 34% of all fungal sequences. The relative abundance of B. cinerea was highest in personal air samples (59%) compared to area samples collected in the drying room (19%), greenhouse (18%), and outdoor environment (6%). There was 49% sample similarity between fungi identified within personal air samples, but higher dissimilarity coefficients were observed within and between greenhouse, drying room, and outdoor area air samples. The results of this pilot study suggest that the cannabis farm workers are potentially exposed to Actinobacteria as well as the cannabis plant pathogen, B. cinerea during harvesting, bud-stripping, and hand-trimming processes.
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Affiliation(s)
- Brett J. Green
- Allergy and Clinical Immunology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
- Corresponding author: Brett J. Green, Allergy and Clinical Immunology Branch, Health Effects Laboratory Branch, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, 1095 Willowdale Road, Morgantown, WV 26505,
| | - James R. Couch
- Hazard Evaluations and Technical Assistance Branch, Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, OH, USA
| | - Angela R. Lemons
- Allergy and Clinical Immunology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Nancy C. Burton
- Hazard Evaluations and Technical Assistance Branch, Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, OH, USA
| | - Kerton R. Victory
- Office of the Director, Emergency Preparedness and Response Office, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ajay P. Nayak
- Allergy and Clinical Immunology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Donald H. Beezhold
- Office of the Director, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
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Schubauer-Berigan MK, Couch JR, Deddens JA. Is beryllium-induced lung cancer caused only by soluble forms and high exposure levels? Occup Environ Med 2017; 74:601-603. [DOI: 10.1136/oemed-2016-104064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/21/2016] [Accepted: 01/09/2017] [Indexed: 11/03/2022]
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Couch JR, Stewart KE. Headache Prevalence at 4-11 Years After Deployment-Related Traumatic Brain Injury in Veterans of Iraq and Afghanistan Wars and Comparison to Controls: A Matched Case-Controlled Study. Headache 2016; 56:1004-21. [PMID: 27237921 DOI: 10.1111/head.12837] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 02/29/2016] [Accepted: 03/13/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Evaluate the extent and severity of headache following deployment-related TBI (D-TBI) in veterans of the Iraq (OIF) and Afghanistan (OEF) wars over a follow-up period of 4-11 years with comparison to age, sex, race, and time of deployment matched controls. BACKGROUND TBI has been recognized as the "signature Injury" of the OEF/OIF campaigns occurring in 14-20% of deployed soldiers. Currently, there are very few data on the longer term follow-up of soldiers with D-TBI. This study deals with prevalence and severity of headache and headache burden at 4-11 years following D-TBI for OEF/OIF veterans with comparison to controls without D-TBI. METHODS This is a matched case controlled-study. All subjects were recruited from Operation New Dawn (OND), a voluntary program for OEF/OIF Veterans at the Oklahoma VAMC designed to assist with re-integrating into civilian life. On entry into OND a medical questionnaire was administered that included a brief screen for D-TBI, and those with a possible D-TBI were referred to a TBI clinic, For this study, the first 500 TBI clinic patients who were found to have had a D-TBI (TBIS) were matched by age, sex, race, and time of deployment to control subjects (CS), drawn from the 4411 OND program members with no D-TBI, creating a pool of 500 TBIS/CS pairs. From this pool, 55 pairs (11%) were randomly selected for this study. Data were collected from both TBIS and CS by telephone interview with questionnaires regarding the DTBI, headache, depression, and PTSD. TBI severity was measured by duration of loss of consciousness (LOC) as: [a] Very Mild (VMTBI, dazed only, no LOC), [b] Mild (MTBI, LOC 1-30 minutes), and [c] Moderate-Severe (MSTBI, LOC > 30 minutes). Intensity for individual headaches was measured by disability produced by the headache as: [a] Disabling (must be in bed), [b] Severe (50-90% decrease in activity), or [c] Mild-Moderate (>50% of usual activity possible). Statistical analysis employed Fisher's exact test and odds ratio. RESULTS The 55 TBIS/CS pairs were segregated by severity of TBI for the TBIS. For the TBIS there were no significant differences among these three subgroups as to mechanism producing the TBI (blast injury or direct head trauma). Comparing TBIS vs CS for phenotypic classification of headaches, for TBIS - 89% had migraine, 2% probable migraine, 9% had tension, and 0% had no headaches, while for CS - 36% had migraine, 15% probable migraine, 27% tension, and 22% no headache (P < .0001). Migraine with aura occurred in 38% of TBIS and 6% of CS (P < .0001). As to headache frequency, for TBIS - chronic daily headache (CDH) occurred in 44%, frequent headache in 33%, and infrequent or no headache in 23%, while for CS - CDH occurred in 7%, frequent headache in 13%, and infrequent or no headache in 80% (P < .0001). For TBIS, 54% had severe or disabling headache ≥2 days/week as opposed to only 16% of CS (OR 6.13 [2.5-14.9]). As to onset of most severe and frequent headaches, this occurred shortly after TBI in 89% of TBIS while only 27% of CS reported most severe headaches starting during deployment. There was no correlation of severity of headache problem with severity of TBI. Comparing TBIS at 4-7 vs 8-11 years after injury, there was no difference in frequency or severity of headache between these groups. CONCLUSIONS At 4-11 years after D-TBI for TBIS, or after deployment for CS, the TBIS as compared to CS suffered much more frequent and severe headaches. For TBIS, there was no relation of headache intensity or phenotype to severity or cause of the TBI, and the Headache Burden has not improved over time up to 11 years after D-TBI. The process initiated by the D-TBI that relates to the headache has a prolonged effect up to and beyond 11 years.
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Affiliation(s)
- James R Couch
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kenneth E Stewart
- Department of Biostatistics and Epidemiology, School of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Abstract
OPINION STATEMENT Triptans should remain the first choice in migraine abortive treatment. They are not always effective or adequate for specific patients. Before declaring a triptan in appropriate for a given patient, the provider ought to be analytical about the rationale and especially the use of objective efficacy outcome measures and ensure that treatment is prescribed and used appropriately. Other ergot derivatives, especially dihydroergotamine, may on one hand share common contraindications of triptans but on the other hand can be quite effective where triptans failed. Non-steroids are simple, readily available, and overall safe, and evidence for their efficacy in migraine is plentiful. Opioid analgesics are blatantly overprescribed especially in non-complicated migraine patients. These should be used with great care and restraint and closely monitored. Frequent opioid usage often leads to tolerance, dependence, and medication overuse headache. Neurostimulation is gaining momentum in the armamentarium of migraine management but at the present time remains primarily focused on prophylaxis, yet abortive use is expected to grow.
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Affiliation(s)
- Elena H Page
- a U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health , Cincinnati , Ohio
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Abstract
OPINION STATEMENT Chronic daily headache (CDH), defined as a primary headache occurring at least 15 days per month, is a problem of worldwide scope, which is seen in 3% to 5% of the population. Though it has been recognized since ancient times, only recently have there been attempts to define and classify it. CDH usually consists of a mixture of migraine and tension-type headaches (TTH), with the more severe headaches having migraine features and the less severe headaches fitting the definition of TTH. Some patients have pure chronic TTH and no migrainous features, and others have only migraine, but most have a mixed migraine-TTH pattern. New daily persistent headache, a CDH pattern that comes on over a few days, constitutes 9% to 10% of this group and is otherwise indistinguishable from CDH. Hemicrania continua (1% of CDH) appears to be unique in being absolutely responsive to indomethacin. Accurate diagnosis of CDH is critical to management, as all organic etiologies of chronic headache must be ruled out. Problems often associated with CDH and complicating the diagnosis are head injury or medication overuse (rebound-withdrawal headache). These accompanying issues must be recognized and treated appropriately in the management plan. Finally, psychiatric problems (unipolar depression, bipolar disease, generalized anxiety disorder, and obsessive/compulsive disorder) often accompany CDH, as they are comorbid with migraine. These conditions must be recognized and treated along with the headache itself for treatment to succeed fully. Treatment of CDH is multimodal. The cornerstone of therapy is the use of prophylactic antimigraine medications to prevent or modulate the next headache. Amitriptyline, topiramate, valproic acid, and gabapentin have all had class I studies showing effectiveness in reducing headache occurrence. Recent studies with botulinum toxin have also shown effectiveness in reducing the headache burden. Recognition and treatment of medication overuse headache (MOH) must be carried out as part of the initial approach. Use of acute symptomatic treatments such as triptans or NSAIDs must be undertaken with care, as frequent use of these agents can lead to MOH. Educating the patient about the condition and reasonable expectations for therapy is essential to success. Recognition and appropriate treatment of psychiatric disorders is likewise essential. Adjunctive nondrug therapies and lifestyle changes round out the requirements for a management plan. The chances for long-term remission or significant improvement are up to 65%. The patient and physician must understand that CDH is a long-term process with relapses and remissions. A strong and trusting relationship between patient and physician is a major asset in managing this condition.
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Affiliation(s)
- James R Couch
- Professor of Neurology, Department of Neurology, University of Oklahoma Medical School, 711 Stanton L. Young Boulevard, Suite 215, Oklahoma City, OK, 73104, USA,
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Schubauer-Berigan MK, Deddens JA, Couch JR, Petersen MR. Risk of lung cancer associated with quantitative beryllium exposure metrics within an occupational cohort. Occup Environ Med 2010; 68:354-60. [PMID: 21084327 DOI: 10.1136/oem.2010.056515] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Beryllium has been identified as a human carcinogen on the basis of animal and epidemiological studies. The authors recently reported updated associations between lung cancer and beryllium exposure in a large, pooled occupational cohort. The authors conducted the present study to evaluate the shape of exposure-response associations between different exposure metrics and lung cancer in this cohort, considering potential confounders (race, plant, professional and short-term work status, and exposure to other lung carcinogens). METHODS The authors conducted Cox proportional hazards regression analyses of lung cancer risk with cumulative, mean and maximum 'daily weighted average' (DWA) exposure among 5436 workers, using age-based risk sets. Different exposure-response curves were fitted to the exposure metrics, including categorical, power, restricted cubic spline and piecewise log-linear fits. RESULTS The authors found significant positive associations between lung cancer and mean (p < 0.0001) and maximum (p < 0.0001) exposure, adjusting for age, birth cohort and plant, and for cumulative (p = 0.0017) beryllium exposure, adjusting for these factors plus short-term work status and exposure to asbestos. The best-fitting models were generally categorical or piecewise log-linear, with the steepest increase in lung cancer risk between 0 and 10 μg/m(3) for both mean and maximum DWA exposure and between 0 and 200 μg/m(3)-days for cumulative DWA exposure. The estimated mean DWA beryllium exposure associated with 10(-3) excess lifetime risk based on the piecewise log-linear model is 0.033 μg/m(3). CONCLUSION This study provides evidence that lung cancer risk is elevated at levels near the current US Occupational Safety and Health Administration beryllium exposure limit of 2.0 μg/m(3) DWA for workers.
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Affiliation(s)
- Mary K Schubauer-Berigan
- National Institute for Occupational Safety and Health, Division of Surveillance, Hazard Evaluations, and Field Studies, Cincinnati, Ohio 45226, USA.
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Abstract
OBJECTIVE AND BACKGROUND Amitriptyline is one of the most commonly used medications in migraine prophylaxis. There have been relatively few placebo-controlled studies of amitriptyline in migraine prophylaxis or in treatment of chronic daily headache (CDH). This report deals with a large placebo-controlled trial of amitriptyline vs placebo of 20 weeks duration that included subjects with intermittent migraine (IM) as well as CDH. The study was carried out between 1976 and 1979; however, results have never been fully reported. METHODS Patients with a history of migraine as defined by the 1962 Ad Hoc Committee report were recruited for this study. Subjects had at least 2 headaches per month, and no limit was placed on the number of headaches per month that could be experienced. The study format included a 4-week baseline period (Period A) in which all subjects received placebo in a dose of 2 pills per day for one week, 3 pills per day for one week and then 4 pills per day for 2 weeks. Subjects with at least 2 migraine headaches in this period were then entered into Period B and randomized into either amitriptyline or placebo tracks. Medication consisted of identical tablets containing either 25 mg amitriptyline or placebo. Period B was 4 weeks in duration with dose titration identical to Period A. The dose could be reduced if necessary to reduce side effects. The minimum dose was one pill per day. Period C was a 12-week maintenance or stabilization period in which the patient continued the dose established by week 8 with visits at weeks 12, 16, and 20. Patients kept a headache calendar that was used for data collection. Headache frequency (per month), severity, and duration (hours) were the primary measurement parameters employed for data analysis. RESULTS For the entire group, 391 subjects were entered into Period A, 338 were randomized into Period B, 317 (81%) subjects completed the first post-randomization visit (8 weeks), 255 (65%) completed week 12, 210 (54%) completed week 16, and 186 (48%) completed week 20. Using headache frequency and evaluating parameters of (a) improvement, (b) no change, or (c) worsening relative to baseline, there was a significant improvement in headache frequency for amitriptyline over placebo at 8 weeks (P = .018) but not at 12, 16, or 20 weeks. When amitriptyline and placebo patients were compared for headache frequency at 8, 12, 16, and 20 weeks to their own placebo stabilization period at 4 weeks, statistically significant improvement vs worsening was seen in headache frequency at each evaluation point for both amitriptyline and placebo groups (P ≤ .01) reaching 50% reporting a decrease in frequency in each group and approximately 10% reporting worsening by week 20. There were no significant differences in headache severity or duration between amitriptyline and placebo groups at anytime during the study. Within the study sample, there were 36 amitriptyline and 22 placebo subjects who had headaches ≥ 17 days/month that fit the current definition of CDH by the Silberstein-Lipton criteria. These were analyzed separately as a subgroup for comparison of amitriptyline vs placebo using a metric of (1) no change or worsening; (2) up to a 50% improvement; and (3) ≥ 50% improvement in headache frequency. Amitriptyline was superior to placebo in number with improvement in frequency of ≥ 50% at 8 weeks (25% vs 5% [P = .031]) and at 16 weeks (46% vs 9% [P = .043]). There was a trend for amitriptyline to be superior to placebo at 12 and 20 weeks but this did not reach significance. CONCLUSIONS In this study, using headache frequency as the primary metric, for the entire group, amitriptyline was superior to placebo in migraine prophylaxis at 8 weeks but, because of a robust placebo response, not at subsequent time points. For the subgroup with CDH, amitriptyline was statistically significantly superior to placebo at 8 weeks and 16 weeks with a similar but nonsignificant trend at 12 and 20 weeks. Compared with placebo amitriptyline is effective in CDH. Amitriptyline was also significantly effective in IM compared intragroup to its own baseline; however, placebo was equally effective in the same analysis. The reason for the robust placebo response in the IM group is not clear, but has been occasionally reported.
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Affiliation(s)
- James R Couch
- University of Oklahoma Medical School, Oklahoma City, OK 73104, USA
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15
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs), including naproxen and naproxen sodium, are effective yet nonspecific analgesic and anti-inflammatory drugs, which work for a variety of pain and inflammatory syndromes, including migraine. In migraine, their analgesic effect helps relieve the headache, while their anti-inflammatory effect decreases the neurogenic inflammation in the trigeminal ganglion. This is the hypothesized mechanism by which they prevent the development of central sensitization. Triptans, including sumatriptan, work early in the migraine process at the trigeminovascular unit as agonists of the serotonin receptors (5-HT receptors) 1B and 1D. They block vasoconstriction and block transmission of signals to the trigeminal nucleus and thus prevent peripheral sensitization. Therefore, combining these two drugs is an attractive modality for the abortive treatment of migraine. Sumatriptan-naproxen fixed combination tablet (Treximet [sumatriptan-naproxen]) proves to be an effective and well tolerated drug that combines these two mechanisms; yet is far from being the ultimate in migraine abortive therapy, and further research remains essential.
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Affiliation(s)
- Chaouki K Khoury
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA.
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Silberstein SD, Mannix LK, Goldstein J, Couch JR, Byrd SC, Ames MH, McDonald SA, Lener SE, Toso C. Multimechanistic (sumatriptan-naproxen) early intervention for the acute treatment of migraine. Neurology 2008; 71:114-21. [PMID: 18606965 DOI: 10.1212/01.wnl.0000316800.22949.20] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- S D Silberstein
- Jefferson Headache Center, 111 South 11th Street, Suite 8130, Philadelphia, PA 19107, USA.
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Affiliation(s)
- ME Lenaerts
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - KJ Oommen
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - JR Couch
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - V Skaggs
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Schubauer-Berigan MK, Daniels RD, Fleming DA, Markey AM, Couch JR, Ahrenholz SH, Burphy JS, Anderson JL, Tseng CY. Chronic lymphocytic leukaemia and radiation: findings among workers at five US nuclear facilities and a review of the recent literature. Br J Haematol 2007; 139:799-808. [DOI: 10.1111/j.1365-2141.2007.06843.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE To evaluate the extent to which head and neck injury (HANI) contributes to chronic daily headache (CDH). BACKGROUND In prospective studies, head injury is associated with headache (HA) that remains a problem at 12 to 24 months post-head injury in 20 to 30% of patients. Of these, up to 30 to 50% manifest CDH. The degree to which head injury contributes to CDH has not been evaluated in a non-clinical population. We evaluate the relationship between lifetime occurrence of HANI and CDH in a randomly chosen population sample. METHODS Study participants are from the Frequent Headache Epidemiology Study. Cases with CDH (> or =180 HA/year) and a comparison group with episodic headache (EH, 2 to 102 HA/year) were identified from the general population. Subjects were asked about lifetime occurrence of HANI. HANI were further classified as potentially precipitating injuries (PPI) if they occurred within 2 years of CDH onset for cases or in an equivalent 2-year period for EH controls. RESULTS Lifetime occurrence of HANI was more frequent in cases than controls for men (adjusted OR = 3.1 [1.3 to 7.2]), women (OR = 1.5 [0.97 to 2.3]), and overall (OR = 1.7 [1.1 to 2.4]). The attributable risk was 15% (36% men, 11% women). Results were similar for PPI. The odds of CDH increased with the number of lifetime HANI in all groups (p < 0.05 trend). CONCLUSIONS Results suggest that head and neck injury (HANI) accounts for approximately 15% of chronic daily headache (CDH) cases in this non-clinical population. The relationship between HANI and CDH was not limited to injuries proximate to CDH onset. The lifetime risk of CDH increases with increasing number of HANI.
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Affiliation(s)
- James R Couch
- Department of Neurology, University of Oklahoma Medical School, Oklahoma City, OK 73104, USA
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22
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Lenaerts ME, Couch JR. Medication overuse headache. Minerva Med 2007; 98:221-31. [PMID: 17592444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Medication overuse headache is a common feature underlying chronic headache, especially migraine. It also represents a major therapeutic challenge, especially in headache specialty clinics where it can represent the majority of patients. The syndrome remains under-diagnosed and the role of symptomatic medication overuse underestimated. Physicians should be properly educated in this area of pain, for prevention of this too often intractable syndrome could be improved. The basis of therapy is discontinuance of the abused medication. Additional treatment relies on a multifaceted approach that embraces management of psychiatric comorbidities and emphasizes patient education. Various pharmacological regimens, abortive and prophylactic, are available. Further scientific study is warranted to elucidate the ultimate mechanisms of this syndrome and define more effective treatments. This article gives detailed clinical description, tentative pathophysiologic explanation and therapeutic suggestions.
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Affiliation(s)
- M E Lenaerts
- Headache Section, Department of Neurology, Oklahoma University Health Sciences Center, Oklahoma City, OK 73104, USA.
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23
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Schubauer-Berigan MK, Daniels RD, Fleming DA, Markey AM, Couch JR, Ahrenholz SH, Burphy JS, Anderson JL, Tseng CY. Risk of Chronic Myeloid and Acute Leukemia Mortality after Exposure to Ionizing Radiation among Workers at Four U.S. Nuclear Weapons Facilities and a Nuclear Naval Shipyard. Radiat Res 2007; 167:222-32. [PMID: 17390730 DOI: 10.1667/rr0724.1] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A nested case-control study was conducted among workers at five U.S. nuclear facilities to evaluate leukemia mortality risk (excluding chronic lymphocytic) from ionizing radiation using worksite doses and adjusting for potential confounding. Conditional logistic regression was used to estimate the relative risk (RR) of exposed workers and the excess relative risk (ERR) per unit of radiation among 206 cases and 823 age-matched controls. Adjusting for sex and benzene, the RR of leukemia for workers receiving more than 10 mSv was higher compared to those receiving lower or no dose; however, the risk increase was attenuated in the highest dose group. The ERR per 10 mSv was 1.44% (95% CI: < -1.03%, 7.59%) but was higher for workers born after 1921 compared to workers born earlier or when excluding leukemias of uncertain type. Excluding the 7% who were high-dose workers (> 100 mSv), the sex- and benzene-adjusted ERR per 10 mSv was 6.82% (95% CI: -2.87%, 24.1%). The results suggest that risks among these nuclear workers are comparable to those observed in high-dose populations, although no evidence was observed of a positive quadratic dose-response term in this study. This large study is among the first to jointly evaluate benzene and ionizing radiation risk.
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MESH Headings
- Aged
- Benzene/toxicity
- Cohort Studies
- Female
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/etiology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/mortality
- Male
- Middle Aged
- Neoplasms, Radiation-Induced/mortality
- Nuclear Reactors
- Nuclear Warfare
- Radiation, Ionizing
- Regression Analysis
- Risk
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Affiliation(s)
- Mary K Schubauer-Berigan
- National Institute for Occupational Safety and Health, Division of Surveillance, Hazard Evaluations, and Field Studies, Cincinnati, Ohio 45213, USA.
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Couch JR. Can medication overuse headache be treated by abrupt withdrawal of the overused agent? ACTA ACUST UNITED AC 2006; 2:654-5. [PMID: 17117167 DOI: 10.1038/ncpneuro0350] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2006] [Accepted: 09/15/2006] [Indexed: 11/08/2022]
Affiliation(s)
- James R Couch
- Department of Neurology, University of Oklahoma Medical School, 711 Stanton L Young Boulevard, Suite 215, Oklahoma City, OK 73104, USA.
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25
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Abstract
Rebound-withdrawal headache (medication overuse headache) is a problem that affects 1% of the population or perhaps more. Work from many countries has shown this to be a worldwide problem. It appears that the rebound-withdrawal headache often occurs on the background of pre-existing migraine or tension headache and may assume the phenotype of chronic migraine or chronic tension-type headache. The key feature of this entity is that the patient initially uses a symptomatic treatment for headache with good result. Use of this medication may increase over time, but as the use increases to more than 10 to 15 days per month, headache frequency may also increase, reaching a point where metabolic processing of the medication and removal from the system triggers another headache. The patient then finds that as use of the medication increases, the frequency and intensity of the headaches also increases, and the overall headache worsens. Once this pattern is established, therapy requires removal of the medication in order for the rebounding process to be terminated. Preventative antimigraine medications will not work in the presence of the rebound phenomenon. Once the rebound-withdrawal headache is established, it is difficult to treat. After withdrawal of the medication, there is often a high relapse rate of using the medication again with redevelopment of the rebound-withdrawal headache. Even in patients who do not relapse to drug use, headache usually remains a major problem. Recognition and treatment of rebound headache are key factors in management of these patients. Perhaps more important in regard to this entity is recognizing its existence and preventing patients from entering a pattern of rebound withdrawal, which can be achieved by early attention to their use of analgesic narcotic or migraine-abortive medications. Overall, it is likely that this will continue to be an increasing worldwide problem in managing patients with headache.
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Affiliation(s)
- James R Couch
- Department of Neurology, Oklahoma University Health Sciences Center, 711 Stanton L. Young Boulevard, PO Box 29601, Suite 215, Oklahoma City, OK 73190, USA.
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Couch JR, Smith R, Bartleson JD, Lenaerts ME. Are the headache guidelines useful in therapeutic decisions for primary care physicians, general neurologists, and headache specialists? Curr Treat Options Neurol 2005; 8:33-41. [PMID: 16343359 DOI: 10.1007/s11940-996-0022-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The International Headache Society Classification of Headache Disorders has been widely accepted as the gold standard for classification of headache. Initially a research tool, this classification is now increasingly used in the daily practice of headache medicine. Accurate diagnosis is a prerequisite to planning a therapeutic approach. The three commentaries here discuss the use of this tool in the setting of primary care, general neurology, and subspecialty headache medicine. As the Section Editor, I hope these perspectives are helpful to the reader.
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Affiliation(s)
- James R Couch
- Department of Neurology, Oklahoma University Health Sciences Center, 711 Stanton L. Young Boulevard, PO Box 29601, Suite 215, Oklahoma City, OK 73190, USA.
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27
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Abstract
Tension-type headache (TTH) is a very common problem that usually causes only minimal to moderate discomfort and little disability. If episodic TTH evolves to chronic TTH, then the morbidity in terms of discomfort, disability, and use of medication escalates dramatically. There are no long-term studies, but inferences can be made from population surveys. These suggest that episodic TTH occurs in 15% to 75% of the population, but 30% to 40% is the most common estimate. There is a modest increase in prevalence between the ages of 30 and 50 years and a decrease to 25% to 35% prevalence after the age of 60 years. TTH appears to remain a problem for most sufferers throughout their lives.
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Affiliation(s)
- James R Couch
- University of Oklahoma Health Sciences Center, Department of Neurology, 711 Stanton L. Young Boulevard, #215, Oklahoma City, OK 73104, USA.
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Yiin JH, Schubauer-Berigan MK, Silver SR, Daniels RD, Kinnes GM, Zaebst DD, Couch JR, Kubale TL, Chen PH. Risk of Lung Cancer and Leukemia from Exposure to Ionizing Radiation and Potential Confounders among Workers at the Portsmouth Naval Shipyard. Radiat Res 2005; 163:603-13. [PMID: 15913392 DOI: 10.1667/rr3373] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Significantly elevated lung cancer deaths and statistically significantly positive linear trends between leukemia mortality and radiation exposure were reported in a previous analysis of Portsmouth Naval Shipyard workers. The purpose of this study was to conduct a modeling-based analysis that incorporates previously unanalyzed confounders in exploring the exposure-response relationship between cumulative external ionizing radiation exposure and mortality from these cancers among radiation-monitored workers in this cohort. The main analyses were carried out with Poisson regression fitted with maximum likelihood in linear excess relative risk models. Sensitivity analyses varying model components and using other regression models were conducted. The positive association between lung cancer risk and ionizing radiation observed previously was no longer present after adjusting for socioeconomic status (smoking surrogate) and welding fume and asbestos exposures. Excesses of leukemia were found to be positively, though not significantly, associated with external ionizing radiation, with or without including potential confounders. The estimated excess relative risk was 10.88% (95% CI -0.90%, 38.77%) per 10 mSv of radiation exposure, which was within the ranges of risk estimates in previous epidemiological studies (-4.1 to 19.0%). These results are limited by many factors and are subject to uncertainties of the exposure and confounder estimates.
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Affiliation(s)
- James H Yiin
- Division of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, Cincinnati, Ohio 45226, USA.
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29
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Abstract
Chronic daily headache (CDH) is an overarching term that includes multiple types of frequent primary headaches that are not trigeminal-autonomic cephalgias. The components of typical CDH can be divided into a more severe or "big" headache and a less severe or "little" headache. The big headaches tend to have features of migraine while the little headaches have features of tension-type headache (TTH). Whether this represents a spectrum or continuum or whether it is the superimposition of two unique headache entities is open to debate. For subjects with big and little headache, the concept that the TTH component is part of a spectrum seems likely. Subjects with only TTH and no migrainous component seem to represent a different entity, pure chronic TTH. These patients have a daily moderate headache that is poorly responsive to current therapies and appears to be a different TTH than the migraine tension type of CDH. The TTH component of CDH may represent multiple subdivisions of TTH.
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Affiliation(s)
- James R Couch
- University of Oklahoma Health Sciences Center, Department of Neurology, 711, Stanton L. Young Boulevard, #215, Oklahoma City, OK 73104, USA.
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30
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Abstract
Posttraumatic headache (PTH) is divided into acute and chronic groups whose management and prognosis are clearly different. Although IHS criteria stipulate that PTH should have an onset within 2 weeks of the trauma, it has been observed that a headache linked to the trauma can start later. PTH can be clinically divided into the following groups: migraine-like headache, tension-type-like headache, cluster-like headache, cervicogenic-like headache, and others. Based on these clinical distinctions, therapy can be administered accordingly. However, the distinction is relative and numerous clinical features may be common to all. There seems to be a weak inverse relationship between the severity of the head trauma and the occurrence of a PTH, especially chronic. A holistic approach is not only useful but it is necessary for a therapeutic success. Early and aggressive treatment and empathy are essential to the patient's improvement. Prompt recognition and treatment of laceration, peripheral nociceptive sources such as cervical joint displacement, vascular factors, may diminish chronicity. Neuromodulation of pain with prophylactic agents is recommended early. Although it is less necessary for the acute PTH, it will be crucial for the chronic form and should be initiated no later than 2 months cut-off time between acute and chronic PTH. Recognition and treatment of psychiatric factors such as depression and anxiety will lessen the risk of chronicity. Analgesic rebound-withdrawal headache commonly is seen in chronic PTH. This must be corrected rapidly because it can protract the headache and render other inappropriate therapeutic measures inefficient.
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Affiliation(s)
- Marc E Lenaerts
- Headache Section, Department of Neurology, Oklahoma University Health Sciences Center, 711 Stanton L. Young Boulevard, 215, Oklahoma City, OK 73104, USA.
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Silver SR, Daniels RD, Taulbee TD, Zaebst DD, Kinnes GM, Couch JR, Kubale TL, Yiin JH, Schubauer-Berigan MK, Chen PH. Differences in mortality by radiation monitoring status in an expanded cohort of Portsmouth Naval Shipyard workers. J Occup Environ Med 2004; 46:677-90. [PMID: 15247807 DOI: 10.1097/01.jom.0000128154.79025.2a] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Studies of leukemia and lung cancer mortality at the Portsmouth Naval Shipyard (PNS) have yielded conflicting results. In an expanded cohort of PNS workers employed between 1952 and 1992 and followed through 1996, the all-cause standardized mortality ratio (SMR) was 0.95 (95% confidence interval, 0.93-0.96). Employment duration SMRs were elevated with confidence intervals excluding 1.00 for lung cancer, esophageal cancer, and all cancers combined. Leukemia mortality was as expected overall, but standardized rate ratio analyses showed a significant positive linear trend with increasing external radiation dose. The role of solvent exposures could not be evaluated. Findings differed by radiation monitoring subcohort, with excess asbestosis deaths limited to radiation workers and several smoking-related causes of death higher among nonmonitored workers. At PNS, asbestos exposure and possibly smoking could be nonrandomly distributed with respect to radiation exposure, suggesting potential for confounding in internal analyses of an occupational cohort.
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Affiliation(s)
- Sharon R Silver
- Division of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA.
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Abstract
CONTEXT Small open-label and controlled trials suggest that the antiepileptic drug topiramate is effective for migraine prevention. OBJECTIVE To assess the efficacy and safety of topiramate for migraine prevention in a large controlled trial. DESIGN, SETTING, AND PATIENTS A 26-week, randomized, double-blind, placebo-controlled study was conducted during outpatient treatment at 52 North American clinical centers. Patients were aged 12 to 65 years and had a 6-month history of migraine (International Headache Society criteria) and 3 to 12 migraines a month but no more than 15 headache days a month during a 28-day prospective baseline phase. INTERVENTIONS After a washout period, patients meeting entry criteria were randomized to topiramate (50, 100, or 200 mg/d) or placebo. Topiramate was titrated by 25 mg/wk for 8 weeks to the assigned or maximum tolerated dose, whichever was less. Patients continued receiving that dose for 18 weeks. MAIN OUTCOME MEASURES The primary efficacy measure was change from baseline in mean monthly migraine frequency. Secondary efficacy measures included responder rate (proportion of patients with > or =50% reduction in monthly migraine frequency), reductions in mean number of monthly migraine days, severity, duration, and days a month requiring rescue medication, and adverse events. The month of onset of preventive treatment action was assessed. RESULTS Of 483 patients randomized, 468 provided at least 1 postbaseline efficacy assessment and comprised the intent-to-treat population. Mean monthly migraine frequency decreased significantly for patients receiving topiramate at 100 mg/d (-2.1, P =.008) and topiramate at 200 mg/d (-2.4, P<.001) vs placebo (-1.1). Statistically significant reductions (P<.05) occurred within the first month with topiramate at 100 and 200 mg/d. The responder rate was significantly greater with topiramate at 50 mg/d (39%, P =.01), 100 mg/d (49%, P<.001), and 200 mg/d (47%, P<.001) vs placebo (23%). Reductions in migraine days were significant for the 100-mg/d (P =.003) and 200-mg/d (P<.001) topiramate groups. Rescue medication use was reduced in the 100-mg/d (P =.01) and 200-mg/d (P =.005) topiramate groups. Adverse events resulting in discontinuation in the topiramate groups included paresthesia, fatigue, and nausea. CONCLUSION Topiramate showed significant efficacy in migraine prevention within the first month of treatment, an effect maintained for the duration of the double-blind phase.
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Abstract
The therapy of chronic daily headache (CDH) is complex and involves a combination of drugs, supportive psychotherapy, nondrug therapy, "tender-loving care," and "tough love." CDH is a chronic problem with exacerbations and remissions. Patients with CDH often manifest mood disorders, and recognition and treatment of these problems is a key component of success. The use of preventative antimigraine therapy is a major component of treatment of this condition. Patients with exacerbations may need judicious short courses of medications that can produce medication-overuse headache. Patients may switch to another physician to get opiates or other pain relief medications. The patient may later realize this mistake and return to the physician. Use of patient "contracts," in which the patient agrees not to take more than a prescribed amount of restricted medication or seek it elsewhere, may be helpful. In this area, there is no standard patient or standard therapeutic regimen. The treatment plan must be individualized for each patient. Taking a little extra time to talk with patients and discuss medications, procedures, and goals and objectives may pay bigger dividends in the therapeutic relationship later in the course of treatment.
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Affiliation(s)
- James R. Couch
- Department of Neurology, Oklahoma University Health Sciences Center, 711 SL Young Boulevard, PO Box 29601, Suite 215, Oklahoma City, OK 73190, USA.
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Abstract
Antidepressants, particularly tricyclic antidepressants, have been a mainstay in the prophylactic therapy of migraine. The tricyclic antidepressants amitriptyline, nortriptyline, and doxepin have been the major agents for prophylactic treatment of migraine. These cause significant side effects in some patients. The high-affinity selective serotonin reuptake inhibitors and other newer antidepressants have been disappointing and much less effective in the treatment of migraine. In patients who are depressed with severe migraine, a tricyclic antidepressant may treat both conditions; however, the addition of a newer atypical antidepressant may be needed.
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Affiliation(s)
- Nestor C Punay
- The University of Oklahoma Health Sciences Center, Department of Neurology, 711 S.L. Young Boulevard, Oklahoma City, OK 73104, USA.
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Oommen KJ, Gilson GE, Nelson JW, Couch JR. A study to determine the accuracy of a computerized algorithm for interpretation of EEGs. J Okla State Med Assoc 2001; 94:400-2. [PMID: 11577629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The main use of computerized EEG has been in sleep studies. A comprehensive system of interpreting routine EEGs by computers has not yet been developed and is technically difficult. We have tried to incorporate computers in the analysis and interpretation of EEGs by using information obtained from visual analysis of EEG in the present work. The purpose of this study was to determine the accuracy of such an algorithm. An electroencephalographer visually analyzed routine EEGs and the data was entered into an EEG Worksheet. The electroencephalographer then interpreted the data and a report was dictated and transcribed. Data from the EEG Worksheet was entered into a computer for interpretation, clinical correlation, and report preparation. Results indicate that the algorithm used with the EEG Worksheet can correctly interpret and clinically correlate visually-analyzed EEG data entered into a computer and reduce time for EEG report generation.
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Affiliation(s)
- K J Oommen
- University of Oklahoma College of Medicine, USA
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Gomez-Mancilla B, Cutler NR, Leibowitz MT, Spierings EL, Klapper JA, Diamond S, Goldstein J, Smith T, Couch JR, Fleishaker J, Azie N, Blunt DE. Safety and efficacy of PNU-142633, a selective 5-HT1D agonist, in patients with acute migraine. Cephalalgia 2001; 21:727-32. [PMID: 11595000 DOI: 10.1046/j.1468-2982.2001.00208.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In this randomized, double-blind, placebo-controlled, parallel-group study, patients received a single 50-mg oral dose of a 5-HT(1D) agonist, PNU-142633 (n = 34), or matching placebo (n = 35) during an acute migraine attack. No statistically significant treatment effects were observed at 1 and 2 h after dosing, even after stratifying by baseline headache intensity. At 1 and 2 h post-dose, 8.8% and 29.4% of the PNU-142633 group, respectively, and 8.6% and 40.0% of the placebo group, respectively, experienced headache relief; 2.9% and 8.8% of the PNU-142633 group and 0% and 5.7% of the placebo group were free of headache pain. Adverse events associated with PNU-142633 treatment included chest pain (two patients) and QTc prolongation (three patients). Results from this study suggest that anti-migraine efficacy is not mediated solely through the 5-HT(1D) receptor subtype, although this receptor may contribute, at least in part, to the adverse cardiovascular effects observed with 5-HT agonist medications.
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Abstract
OBJECTIVE To evaluate the occurrence of continued intermittent headache and chronic daily headache in patients with head injury and the relationship between severity of the headache problem and intensity of the head injury. BACKGROUND In the majority of patients with posttraumatic headache, the condition is self-limited, but a minority of patients may develop persistent headaches. The features of posttraumatic headache may vary, but the most distressing type is the chronic daily headache. This study evaluates occurrence of chronic daily headache in relation to the intensity of head injury. METHODS All patients with head injury who were seen by the senior author (J.R.C.) in the Southern Illinois University Medical School (SIUMS) Neurology Clinic between 1980 and 1991 were identified from the SIUMS headache registry. Data on headache status before and after head injury was obtained, and patients with more than one headache per week before head injury were excluded. Each patient's headache status at the time of the clinic visit was classified as chronic daily headache (headache occurring at least 5 of 7 days for 6 months), intermittent migraine, or no headache. Head injury severity was graded by duration of loss of consciousness or amnesia as minimal (less than 5 minutes), mild (5 to 60 minutes), moderate (1 to 24 hours), or severe (more than 24 hours). RESULTS There was an inverse relation between extent of head injury and occurrence of chronic daily headache. For minimal head injury (n = 54), 80% had chronic daily headache, and 11% had no headache, while for moderate/severe head injury (n = 23), only 27% had chronic daily headache, and 68% had no headache (P<.001, chi2). CONCLUSION This study suggests that the risk of developing posttraumatic chronic daily headache is greater for less severe head injury compared with moderate/severe head injury. The reason for this relation is unclear.
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Affiliation(s)
- J R Couch
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City 73190-3048, USA
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Abstract
BMS180048 is a 5HT agonist that was well-tolerated in early phase II trials. This study utilized a double-blind, parallel-group dose ranging format, comparing BMS180048 in doses of 25, 50, or 75 mg to placebo in effectiveness of treatment of a single migraine headache. To assess tolerability of BMS180048, patients received a test dose of the medication they would receive for a headache in the clinic under observation. If no significant side effects occurred, patients were allowed to treat a headache. Headaches were moderate or severe in intensity before treatment, and response at 2 hours was tabulated. Reduction to mild or no headache was the criteria for successful response. Response rates at 2 hours were as follows: placebo--19 of 53 subjects (35.8%); 25 mg--21 of 53 subjects (40.3%); 50 mg--34 of 53 subjects (64.2%); 75 mg--35 of 55 subjects (63.6%) The improvement for subjects treated with 50 or 75 mg of BMS180048 when compared to placebo was highly significant (P < .01). Nausea, photophobia, and phonophobia improved 35% to 50% for BMS180048-treated subjects and 20% to 24% in the placebo group. The improvement in these symptoms in comparison to placebo was statistically significant only for nausea in those treated with 75 mg of BMS180048 (P = .02). Side effects were mild for the most part, and no serious adverse events occurred. The study suggests BMS180048 is effective in acute symptomatic therapy of migraine.
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Affiliation(s)
- J R Couch
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City 73190-2048, USA
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Evans MS, Naritoku DK, Couch JR, Ghobrial MW. Onset of neurologic deficits after treatment with dihydroergotamine in a patient with sagittal sinus thrombosis. Clin Neuropharmacol 1996; 19:177-84. [PMID: 8777772 DOI: 10.1097/00002826-199619020-00007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A woman with a 7-year history of intermittent migraine had 3 months of gradually worsening headaches. Initial neurologic examination including fundus examination was normal, and initial head computerized tomographic (CT) scan and magnetic resonance imaging (MRI) were thought to be normal. The patient was given dihydroergotamine (DHE-45), 1.0 mg, intravenously for relief of headache. Five hours later, she complained of severe diffuse headache and nausea. Neurologic examination showed left arm weakness and sensory loss, blurring of the left optic disc, and bilateral Babinski signs. Cerebral arteriography demonstrated thrombosis of the sagittal sinus, which in retrospect was present on the initial contrast CT scan and MRI scan. The patient's deficits worsened, and she eventually died 20 days later as a result of cerebral infarctions and increased intracranial pressure, despite attempts at selective thrombolysis of the sagittal sinus. DHE has potent venoconstrictive effects. We suspect that DHE helped precipitate neurologic deterioration in this patient with sagittal sinus thrombosis.
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Affiliation(s)
- M S Evans
- Department of Neurology, Southern Illinois University School of Medicine, Springfield 62794-1316, USA
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40
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Abstract
We studied transnasal butorphanol (Stadol NS) for pain relief during acute migraine in a multicenter, randomized, double-blind, placebo controlled trial using ambulatory patients at 10 geographically diverse headache centers. Patients were volunteer adults diagnosed with migraine with or without aura by International Headache Society criteria. One hundred fifty-seven patients completed the study. We treated the pain of one headache in each patient with either transnasal butorphanol (n = 107) or transnasal placebo (n = 50). Pain relief, pain intensity, nausea, vomiting, and effect on function were measured periodically. Adverse experiences were documented. Global assessments were made at follow-up. With butorphanol, migraine pain was reduced from moderate, severe, or incapacitating to slight or absent for 35 patients (33%) within 30 minutes, for 50 patients (47%) within 1 hour, and for 76 (71%) within 6 hours, compared to 2 (4%), 8 (16%) and 15 (30%) respectively for placebo. Side effects were prominent, though confounded by the migraine. The most common side effects, compared to placebo, were dizziness (58% vs 4%), nausea and/or vomiting (38% vs 18%), and drowsiness (29% vs 0%). We conclude that transnasal butorphanol is a useful analgesic for the pain of acute migraine. Its prominent side effects and low self reinforcement rate may limit its usefulness in some patients, while increasing its appropriateness for others.
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Affiliation(s)
- M J Hoffert
- John R. Graham Headache Center, Faulkner Hospital, Boston, MA 02130, USA
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41
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Abstract
Aspirin and the new agent ticlopidine have been the most thoroughly evaluated of the platelet-antiaggregating drugs used for the prevention of stroke and other vascular events. Numerous trials have shown aspirin to be effective in reducing the risk of myocardial infarction (MI), recurrent transient ischemic attacks, stroke, and vascular death in men at high risk for these events. Primary prevention trials have shown that aspirin reduces the risk of MI in healthy men over 50 years of age but does not reduce the risk of stroke. Two large, multicenter trials have shown that ticlopidine is effective in reducing the risk of fatal and nonfatal stroke in both men and women. Ticlopidine may also be effective in reducing the risk of recurrent stroke in patients who have had a completed thromboembolic stroke.
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Affiliation(s)
- J R Couch
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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Abstract
The headache to worry about is one that is unique or different from headaches which the patient has suffered in the past. The association with the headache of meningismus or of focal neurologic symptoms of oculoparesis, other cranial nerve palsies, hemiparesis, or loss of consciousness are particularly worrisome, especially if onset is recent and acute. Headaches related to arteritis or vasculitis usually have a slower subacute course but may also produce focal neurologic deficits. For subjects over 50 years old, temporal arteritis is always a consideration and any new type of headache requires testing of the sedimentation rate to rule out this treatable but potentially devastating problem.
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Affiliation(s)
- J R Couch
- Department of Neurology, University of Oklahoma College of Medicine, Oklahoma City
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Abstract
A group of 350 migraineurs (87 male, 263 female) and 300 controls without migraine (104 male, 196 female) were questioned about occurrence, in parents, of the atherosclerosis-related diseases (ASRD) of diabetes mellitus (DM), hypertension (HBP), myocardial infarction (MI), and stroke as well as about recurrent severe headache (RSHA). Occurrence of DM, HBP, MI and stroke was compared for mothers and fathers of migraine vs. those of control subjects and no significant differences were found. The mothers and fathers were pooled and resegregated by presence or absence of RSHA and then occurrence of DM, HBP, MI and stroke again compared. For mothers there was increased occurrence of stroke and DM in the RSHA group but the differences were not significant. For RSHA fathers there was increased incidence of MI (p less than .10) and HBP (p less than .01). Aggregate occurrence of all ASRD was evaluated for RSHA vs. no-RSHA parents. ASRD occurred more frequently in the RSHA than in the no-RSHA parents (p less than .05). Breakdown by age showed that this occurred at all ages in men (p less than .05) but in women the difference was significant only under age 60 (p less than .05). This study suggests that RSHA, which is primarily migraine, may be a risk factor or a marker for occurrence of ASRD.
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Affiliation(s)
- J R Couch
- Department of Medicine, Southern Illinois University School of Medicine, Springfield 62794-9230
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Norfray JF, Couch JR, Elble RJ, Good DC, Manyam BV, Patrick JL. Visualization of brain iron by mid-field MR. AJNR Am J Neuroradiol 1988; 9:77-82. [PMID: 3124588 PMCID: PMC8331538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Brain iron was visualized on a mid-field (0.5 T) scanner using a spin-echo pulse sequence. Methemoglobin was hyperintense on T1- and T2-weighted images. Deoxyhemoglobin, hemosiderin, and ferritin were seen as decreased intensity on T2-weighted images. The spin-echo pulse sequences were improved for identification of deoxyhemoglobin, hemosiderin, and ferritin by prolonging the TR to 3000 msec and the TE to 80-120 msec. Phase-encoding artifacts at the level of the sylvian fissures caused increased noise, obscuring the brain iron in the lentiform nuclei with the TE of 120 msec. This artifact was substantially reduced or eliminated by lowering the TE to 80 msec, changing the phase-encoding gradient to the Y axis, or using additional pulsing in the slice and read gradients. Use of either the improved spin-echo or gradient-echo pulse sequences on a mid-field MR scanner provides improved evaluation of brain iron.
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Abstract
Migraine is a cyclical condition in which the cycles may occur or remit in an unpredictable fashion. The goal of prophylactic antimigraine therapy is to induce remission of an active cycle of migraine or to inhibit occurrence of individual headaches until the cycle remits for other reasons. The placebo effect probably takes advantage of these cycles. The placebo effect is significant and quite potent. The placebo effect may be divided into (1) the initial effect and (2) the continuing effect which is seen following a stabilization period. The initial placebo effect is dramatic with 62% of 188 subjects improving by 75% after 4 weeks of placebo. The continuing effect is demonstrated by occurrence of 75% further improvement in 28% of 282 subjects in 7 studies in which comparison of results after 4-12 weeks was made with a placebo stabilization period. The placebo effect is a very potent one and must be taken into account in designing and carrying out studies of migraine therapy.
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Affiliation(s)
- J R Couch
- Department of Medicine, Southern Illinois University School of Medicine, Springfield
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Abstract
Synaptic modulation refers to altered excitability of a synapse by a substance that does not produce a spike potential at the synapse. Available evidence points to the conclusion that beta-melanocyte stimulating hormone (beta-MSH) modulates synaptic transmission through monosynaptic pathways in the cat spinal cord. Earlier evidence is reviewed, and new data are presented. In the first experiments populations of cells contributing to a knee jerk were studied using the Lloyd preparation, and MSH was found to increase the monosynaptic reflex. With intracellular single unit recording techniques, beta-MSH was found to facilitate recovery from synaptic transmission. With extracellular single unit recording techniques and iontophoretic methods for drug application, beta-MSH has been found to increase the probability of generation of single spike potentials by alpha-motoneurons in response to orthodromic stimulation. Administration of beta-MSH did not cause spontaneous discharge of alpha-motoneurons. The physiological and pharmacological importance of synaptic modulation is discussed.
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Abstract
Thirteen patients with cervical spondylosis and high compressive myelopathy between C-3 and C-5 presented with a distinctive clinical syndrome of "numb, clumsy hands" and stereoanesthesia of the hands. Loss of position and vibration sense was much more severe in the hands than in the legs. Relative sparing of primary sensory modalities and motor and bladder functions were other features. Most patients were incorrectly diagnosed at first and cervical myelography was the critical diagnostic test. Pathology was confirmed surgically or at autopsy. Early recognition and treatment resulted in lessened disability. The syndrome is a distinctive and unusual manifestation of high cervical myelopathy, and it has seldom been reported associated with cervical spondylosis.
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Abstract
Statistical study of the correlation between 49 variables concerning characteristics of headache and of headache patients was carried out on 1,198 sequential patients complaining of severe or disabling headaches and attending a headache clinic. Factor analysis was the statistical method employed, 17 factors accounting for 64% of total variation emerged. The most prominent factor contained descriptors of neurological dysfunction associated with headache. Another factor contained variables of nausea and vomiting, only associated with inability to work. Other factors, contained separately, the following variables: (a) Time of headache, (b) time of week of headache, (c) unilateral nature of headache, (d) visual phenomena associated with headache. Relation of these findings to headache taxonomy is discussed.
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