Consensus recommendations on the role of nurses in headache care: A European e-Delphi study

BACKGROUND

Nurses work at headache centres throughout Europe, and their care for migraine patients is acknowledged. However, the specific roles and tasks of nursing vary, and a unified understanding is lacking, posing challenges to knowledge sharing and research.

OBJECTIVES

Using an e-Delphi study method, the objective is to obtain healthcare professional headache experts' opinions on nursing-specific roles and tasks and combine this into consensus statements for nurse recommendations for migraine treatment.

METHODS

A three-round questionnaire study was conducted with nurses and neurologists from 18 specialised headache centres in 10 countries. In round 1, statements were compiled from a systematic examination of existing literature and expert opinions. In rounds 2 and 3, the experts rated the importance of statements (from round 1) on a 5-point Likert scale. Statements were analysed using a content analysis method, and the consensus of pre-defined statements was evaluated with gradually increased predetermined criteria using descriptive statistics.

RESULTS

Twenty-one experts, representing all 10 countries, participated. The predetermined consensus of ≥70% agreement was reached for 42 out of the initial 63 statements. These statements formed the final recommendations within two themes: "The nurses' roles and tasks in the clinical setting" and "The nurses' roles and tasks in educating patients and colleagues." The consensus level of statements was strong, with 40% receiving unanimous agreement (100%) and 97% achieving relatively high agreement (>80%).

CONCLUSION

Nursing plays a vital role with diverse tasks in migraine care. This study offers practical recommendations and a framework for nurses, equipping them with a clinical tool to enhance care and promote a coordinated approach to migraine treatment.

Baseline demographics and disease characteristics of patients with episodic or chronic cluster headache: data from two phase 3 randomized clinical trials in Europe and North America

Objective

Two phase 3 galcanezumab trials were conducted in Europe and North America to analyze the reduction of weekly cluster headache (CH) attack frequency in populations with episodic and chronic CH. The current study aims to illustrate prospectively recorded baseline clinical data from these trials and to identify possible predictors of response.

Methods

Patients (aged 18-65 years) met The International Classification of Headache Disorders 3rd edition-beta criteria for CH. Attacks were evaluated using an electronic headache diary for 7-day (episodic) or 14-day (chronic) eligibility assessments before patients were randomized 1:1 to monthly subcutaneous galcanezumab 300 mg or placebo.

Results

Data were collected from 106 patients with episodic and 237 with chronic CH. Overall, the mean age [standard deviation] was 45.4 [11.0] years; patients were predominantly White (84.5%), male (75.8%), and European (77.6%). Patients with episodic CH reported 17.5 [10.0] attacks/week; patients with chronic CH reported 18.8 [10.2] attacks/week. The average pain severity score (range 0-4) was 2.5 [0.7] for episodic CH and 2.7 [0.7] for chronic CH. Higher attack frequency was a possible predictor of response to galcanezumab; potential negative predictors of response were greater attack severity and duration.

Conclusion

This large dataset of patients with CH provides reliable systematically and prospectively collected information on disease characteristics. The analysis in episodic CH underscores potential predictors of response worth considering for future CH trial design.

Clinical Trial Registration

ClinicalTrials.gov, identifiers: NCT02397473 and NCT02438826.

Consensus recommendations on the role of nurses in the care of headache patients: protocol for a european e-delphi study

BACKGROUND

Nurses play an important role in the treatment of headache patients at the specialized headache centers in Europe, however, a unified definition of nursing tasks and conduction of tasks is lacking. The objective of this e-Delphi study is twofold. Initially, to obtain healthcare professional headache experts' opinions on which tasks are associated with nurses' care in migraine treatment. Then, through an iterative multi-staged process, to combine the opinions into group consensus statements and develop evident European nursing recommendations for migraine treatment.

METHODS

In Delphi studies there are no unambiguous methodological guidelines and this protocol is being published to ensure transparency and quality in the study process. We invite nurses working in specialized headache centers and neurologists co-working with nurses in Finland, Denmark, Norway, Sweden, United Kingdom, Netherlands, Germany, Ireland, Estonia and Switzerland to participate anonymously in the expert panel. This e-Delphi study consists of three rounds of online questionnaires. We use Open-ended questions to capture the essentials of nurse tasks as understood by the expert panel members. Data are analyzed using content analysis. Predefined statements are applied for the experts to rate the importance of nurses' tasks synthesized from a systematic examination of the existing literature. Consensus is measured using descriptive statistics; median, Interquartile range (IQR) and percentage agreement. Measurement of agreement between participants will be analyzed using inferential statistics; Kendall's coefficient and stability between rounds; Wilcoxon rank-sum test. Statements, which receive consensus in the third round, are included in the final compilation of European recommendations for nurse care for migraine patients.

DISCUSSION

The e-Delphi study will provide European recommendations on nurse care in migraine treatment, which could not be created on the basis of the existing literature. The recommendations can open for the conduction of further research including measurement of efficacy of clinical implementation of the recommended tasks.

TRIAL REGISTRATION

The study is registered at The Region of Southern Denmark (21/52,885). According to The Regional Ethical Committee and Danish law, no additional approval is relevant (20212000-145). A written informed consent is obtained from all participants before inclusion in the study.

Pain sensitivity in relation to frequency of migraine and tension-type headache with or without coexistent neck pain: an exploratory secondary analysis of the population study

OBJECTIVES

We aimed to investigate whether coexistent self-reported neck pain influences cephalic and extracephalic pain sensitivity in individuals with migraine and tension-type headache (TTH) in relation to diagnosis and headache frequency.

METHODS

A population of 496 individuals completed a headache interview based on ICHD criteria, providing data collected by self-administered questionnaires, assessments of pericranial total tenderness score (TTS) and pressure pain thresholds (PPT). Stimulus-response (SR) functions for pressure vs. pain were recorded. Presence of neck pain in the past year was assessed by the self-administered questionnaire. We categorized participants by primary headache type. We also categorized participants into 3 groups by headache frequency: chronic (≥15) or episodic (<15 headache days/month) headache and controls. TTS, PPTs and the area under the SR curve were compared between subgroups using Generalized Linear Models with pairwise comparisons controlling for age and sex.

RESULTS

Individuals with chronic followed by episodic headache had higher TTS than controls (overall p≤0.001). The difference between chronic and episodic headache subgroups was significant in the group with neck pain (p≤0.001) but not in the group without neck pain. In individuals with neck pain, mean TTS was higher in coexistent headache (migraine and TTH), 23.2 ± 10.7, and pure TTH, 17.8 ± 10.3, compared to pure migraine, 15.9 ± 10.9 and no headache 11.0 ± 8.3 (overall p<0.001). Temporal and finger PPTs did not statistically differ among the chronic headache, the episodic headache and controls in individuals with and without neck pain. Temporalis and trapezius SR-functions showed that tenderness was increased in individuals with chronic headache to higher degree than in those with episodic headache, and more so in those with neck pain.

CONCLUSIONS

Coexistent neck pain is associated with greater pericranial tenderness in individuals with chronic headache and to a lesser degree in those with episodic headache. Sensitization may be a substrate or consequence of neck pain and primary headache, but a longitudinal study would be needed for further clarification.

Preclinical update on regulation of intracranial pressure in relation to idiopathic intracranial hypertension

Background

Elevated intracranial pressure (ICP) is observed in association with a range of brain disorders. One of these challenging disorders is idiopathic intracranial hypertension (IIH), characterized by raised ICP of unknown cause with significant morbidity and limited therapeutic options. In this review, special focus is put on the preclinical research performed in order to understand the pathophysiology behind ICP regulation and IIH. This includes cerebrospinal fluid dynamics, molecular mechanisms underlying disturbances in brain fluids leading to elevated ICP, role of obesity in IIH, development of an IIH model and ICP measurements in rodents. The review also discusses existing and new drug targets for IIH that have been evaluated in vivo.

Conclusions

ICP monitoring in rodents is challenging and different methods have been applied. Some of these methods are invasive, depend on use of anesthesia and only allow short-term monitoring. Long-term ICP recordings are needed to study IIH but existing methods are hampered by several limitations. As obesity is one of the most common risk factors for IIH, a rodent obese model has been developed that mimics some key aspects of IIH. The most commonly used drugs for IIH have been evaluated in vivo for their efficacy at lowering ICP in the existing animal models. These studies suggest these drugs, including acetazolamide, might have limited or no reducing effect on ICP. Two drug targets that can impact ICP in healthy rodents are topiramate and a glucagon-like peptide-1 receptor (GLP-1R) agonist. However, it remains to evaluate their effect in an IIH model with more precise and valid ICP monitoring system. Therefore, continued evaluation in the preclinical research with refined tools is of great importance to further understand the pathophysiology behind disorders with raised ICP and to explore new drug targets.

More precise phenotyping of cluster headache using prospective attack reports

BACKGROUND AND PURPOSE

The clinical characteristics of cluster headache (CH) are based mainly on retrospective attack descriptions of 'usual' attacks, but whether these reports are reliable is uncertain. The aim was to compare retrospective and prospective attack descriptions and describe the within- and between-patient variability of attacks.

METHOD

Fifty-seven CH patients underwent a semi-structured interview obtaining a retrospective account of usual CH attacks. Patients thereafter prospectively recorded the clinical characteristics of up to 10 attacks per patient in a headache diary. Four different attack characteristics were investigated: (i) severity, (ii) duration, (iii) number of autonomic symptoms and (iv) number of migrainous symptoms. Retrospective and prospective data were compared. Within- and between-patient variability of attacks was assessed.

RESULTS

Retrospective attack descriptions (n = 57) were significantly longer (P = 0.046) and more severe (P < 0.0001) for untreated attacks compared with prospective reports (n = 500). The number of autonomic symptoms was significantly higher in the retrospective reports compared to the prospective reports (P < 0.0001). Within-patient variability for attack duration, pain severity and number of autonomic and migrainous symptoms was low. Compared to men, more women reported longer (P = 0.026) and more severe (P = 0.028) attacks with more migrainous symptoms (P = 0.033).

CONCLUSIONS

Important differences were found between prospectively and retrospectively reported attacks with duration and severity of untreated attacks overestimated in retrospective attack descriptions. CH attacks display low within-patient variability, but the presentation of CH attacks varies between patients. The high prevalence of symptoms typically associated with migraine should raise more diagnostic awareness for CH, especially in women who are more often misdiagnosed as having migraine.

Contaminating viral sequences in high-throughput sequencing viromics: a linkage study of 700 sequencing libraries

OBJECTIVES

Sample preparation for high-throughput sequencing (HTS) includes treatment with various laboratory components, potentially carrying viral nucleic acids, the extent of which has not been thoroughly investigated. Our aim was to systematically examine a diverse repertoire of laboratory components used to prepare samples for HTS in order to identify contaminating viral sequences.

METHODS

A total of 322 samples of mainly human origin were analysed using eight protocols, applying a wide variety of laboratory components. Several samples (60% of human specimens) were processed using different protocols. In total, 712 sequencing libraries were investigated for viral sequence contamination.

RESULTS

Among sequences showing similarity to viruses, 493 were significantly associated with the use of laboratory components. Each of these viral sequences had sporadic appearance, only being identified in a subset of the samples treated with the linked laboratory component, and some were not identified in the non-template control samples. Remarkably, more than 65% of all viral sequences identified were within viral clusters linked to the use of laboratory components.

CONCLUSIONS

We show that high prevalence of contaminating viral sequences can be expected in HTS-based virome data and provide an extensive list of novel contaminating viral sequences that can be used for evaluation of viral findings in future virome and metagenome studies. Moreover, we show that detection can be problematic due to stochastic appearance and limited non-template controls. Although the exact origin of these viral sequences requires further research, our results support laboratory-component-linked viral sequence contamination of both biological and synthetic origin.

TM3-1 Idiopathic intracranial hypertension: consensus guidelines on investigation and management

Objectives

The aim was to capture interdisciplinary expertise from a large group of clinicians, reflecting practice from across the UK and further, to inform subsequent development of a national consensus guidance for optimal management of Idiopathic Intracranial Hypertension.

Design

Consensus guideline critically reviewed by the Association of British Neurologists, British Association for the Study of Headache, the Society of British Neurological Surgeons and the Royal College of Ophthalmologists.

Subjects

An initial UK survey of attitudes and practice in IIH was sent to a wide group of physicians and surgeons.

Methods

Between September 2015 and October 2017 a specialist interest group including neurology, neurosurgery, neuro-radiology, ophthalmology, nursing, primary care doctors, and patient representatives met. A comprehensive systematic literature review was performed to assemble the foundations of the statements.

Results

Over twenty questions were constructed: One based on the diagnostic principles for optimal investigation of papilloedema and twenty-one for the management of IIH. 3 main principles were identified:

to treat the underlying disease;

to protect the vision and

to minimise the headache morbidity.

Statements presented provide insight to uncertainties in IIH where research opportunities exist.

Conclusions

In collaboration with many different specialists, professions and patient representatives we have developed guidance statements for the investigation and management of adult IIH.

The DoloTest® in a specialized headache center among patients receiving psychological treatment. A pilot study

Background The DoloTest is a newer health-related quality of life (HRQoL) monitoring instrument for pain, not yet validated for headache. Aims To examine the usefulness of the DoloTest in a specialized headache center. Methods The sample consisted of patients referred to psychologists from the Danish Headache Center (DHC) for whom the test was carried out at start of, end of, and 6 months after treatment. Points on eight scales of the test were measured (values ranged from 0 to 100), then totaled (0 to 800). Scores were analyzed using Wilcoxon Signed Ranks test. The correlation between headache days and DoloTest scores were computed using linear regression adjusted for age. Qualitative feedback on usefulness of the test were gathered from psychologists. Results Of 135 patients included, 105 completed treatment. On average, headache days decreased from 22 days per month at start of treatment (SD 9.0, median 29) to 18 days at end of treatment (SD 10.8, median 19) (p<0.001). At end of treatment, DoloTest scores improved for pain (p=0.015) and reduced energy and strength (p=0.034). At 6 months' follow-up, total scores improved (p=0.034), as well as component scores for pain (p=0.010), problems with strenuous activity (p=0.045) and reduced energy and strength (p=0.012). Correlation between reduced headache days and improved DoloTest scores was 0.303 (p=0.028). Psychologists found the test useful in monitoring and evaluating patients. Conclusions The DoloTest was useful for psychoeducation and for monitoring the effect of headache treatment. Implications The DoloTest is a potential HRQoL monitoring instrument for headache patients. We recommend further validation studies.

Has aerobic exercise effect on pain perception in persons with migraine and coexisting tension-type headache and neck pain? A randomized, controlled, clinical trial

BACKGROUND

A large subset of persons with migraine suffers from coexisting tension-type headache and neck pain which may adversely affect the prognosis of migraine. Aerobic exercise has been shown to decrease migraine burden in these persons. Therefore, the aim of this study was to investigate whether the effect of aerobic exercise in persons with migraine and coexisting tension-type headache and neck pain can be explained by changes in pain perception.

METHOD

Seventy consecutively recruited persons with migraine and coexisting tension-type headache and neck pain were randomized into exercise group or control group. Aerobic exercise consisted of bike/cross-trainer/brisk walking for 45 min, three times/week for 3 months. Controls continued their usual daily activities. Pericranial tenderness, pain thresholds, supra-thresholds and temporal summation were assessed at baseline, after treatment and at follow-up (6 months from baseline).

RESULTS

Fifty-two persons with migraine and coexisting tension-type headache and neck pain completed the study. Aerobic exercise did not induce consistent changes in nociceptive pathways measured by pericranial tenderness, pressure pain thresholds and sensitivity to electrical stimulation.

CONCLUSION

The effect of aerobic exercise cannot be explained by measurable effects on the pain modulation system. Thus, the positive effect on migraine burden may rather be explained by positive alteration of avoidance behaviour. Aerobic exercise can be recommended as a safe and inexpensive migraine treatment strategy.

SIGNIFICANCE

This study adds further knowledge about the positive effect of aerobic exercise for persons with migraine and coexisting tension-type headache and neck pain. This effect cannot be measured by changes in pain modulation, but may rather be explained by positive alteration of avoidance behaviour.

The headache under-response to treatment (HURT) questionnaire, an outcome measure to guide follow-up in primary care: development, psychometric evaluation and assessment of utility

Background

Headache disorders are both common and burdensome but, given the many people affected, provision of health care to all is challenging. Structured headache services based in primary care are the most efficient, equitable and cost-effective solution but place responsibility for managing most patients on health-care providers with limited training in headache care. The development of practical management aids for primary care is therefore a purpose of the Global Campaign against Headache. This manuscript presents an outcome measure, the Headache Under-Response to Treatment (HURT) questionnaire, describing its purpose, development, psychometric evaluation and assessment for clinical utility. The objective was a simple-to-use instrument that would both assess outcome and provide guidance to improving outcome, having utility across the range of headache disorders, across clinical settings and across countries and cultures.

Methods

After literature review, an expert consensus group drawn from all six world regions formulated HURT through item development and item reduction using item-response theory. Using the American Migraine Prevalence and Prevention Study’s general-population respondent panel, two mailed surveys assessed the psychometric properties of HURT, comparing it with other instruments as external validators. Reliability was assessed in patients in two culturally-contrasting clinical settings: headache specialist centres in Europe (n = 159) and primary-care centres in Saudi Arabia (n = 40). Clinical utility was assessed in similar settings (Europe n = 201; Saudi Arabia n = 342).

Results

The final instrument, an 8-item self-administered questionnaire, addressed headache frequency, disability, medication use and effect, patients’ perceptions of headache “control” and their understanding of their diagnoses. Psychometric evaluation revealed a two-factor model (headache frequency, disability and medication use; and medication efficacy and headache control), with scale properties apparently stable across disorders and correlating well and in the expected directions with external validators. The literature review found few instruments linking assessment to clinical advice or suggested actions: HURT appeared to fill this gap. In European specialist care, it showed utility as an outcome measure across headache disorders. In Saudi Arabian primary care, HURT (translated into Arabic) was reliable and responsive to clinical change.

Conclusions

With demonstrated validity and clinical utility across disorders, cultures and settings, HURT is available for clinical and research purposes.

Electronic supplementary material

The online version of this article (10.1186/s10194-018-0842-6) contains supplementary material, which is available to authorized users.

Effect of resistance training on headache symptoms in adults: Secondary analysis of a RCT

BACKGROUND

While strength training for the neck and shoulder muscles may be effective in reducing headache, the optimal combination of exercise frequency and duration is unknown. This study investigates the effect of different time-wise combinations of one weekly hour of strength training for the neck and shoulder muscles on headache frequency, intensity, and use of analgesics.

METHODS

A total of 573 office workers were randomly allocated at the cluster-level to five groups; 3 × 20 min a week of minimally supervised (3MS), 1 × 60 (1WS), 3 × 20 (3WS) or 9 × 7 (9WS) min a week of supervised high-intensity strength training for 20 weeks, or to a reference group without training (REF). Headache frequency, intensity, and use of analgesics in relation to headache were determined by questionnaire at baseline and follow-up.

RESULTS

The intention-to-treat analysis showed reduced headache frequency and intensity of approximately 50% in all training groups compared with REF at 20-week follow-up (P < 0.001). Use of analgesics was lower in the supervised training groups (1WS, 3WS and 9WS), but not in the group with minimal training supervision (3MS), compared with REF at follow-up.

CONCLUSION

One hour of specific strength training - regardless of the distribution during the week - effectively reduced both headache frequency and intensity in office workers. Thus, a large time-wise flexibility exists when implementing specific strength training at the workplace. However, only supervised training led to a reduction in use of analgesics for headache.

Choroid plexus aquaporin 1 and intracranial pressure are increased in obese rats: towards an idiopathic intracranial hypertension model?

BACKGROUND/OBJECTIVES

Idiopathic intracranial hypertension (IIH) is a condition of increased intracranial pressure (ICP) without identifiable cause. The majority of IIH patients are obese, which suggests a connection between ICP and obesity. The aim of the study was to compare ICP in lean and obese rats. We also aimed to clarify if any ICP difference could be attributed to changes in some well-known ICP modulators; retinol and arterial partial pressure of CO₂ (pCO₂). Another potential explanation could be differences in water transport across the choroid plexus (CP) epithelia, and thus we furthermore investigated expression profiles of aquaporin 1 (AQP1) and Na/K ATPase.

METHODS

ICP was measured in obese and lean Zucker rats over a period of 28 days. Arterial pCO₂ and serum retinol were measured in serum samples. The CPs were isolated, and target messenger RNA (mRNA) and protein were analyzed by quantitative PCR and western blot, respectively.

RESULTS

Obese rats had elevated ICP compared to lean controls on all recording days except day 0 (P<0.001). Serum retinol (P=0.35) and arterial pCO₂ (P=0.16) did not differ between the two groups. Both AQP1 mRNA and protein levels were increased in the CP of the obese rats compared to lean rats (P=0.0422 and P=0.0281). There was no difference in Na/K ATPase mRNA or protein levels (P=0.2688 and P=0.1304).

CONCLUSION

Obese Zucker rats display intracranial hypertension and increased AQP1 expression in CP compared to lean controls. The mechanisms behind these changes are still unknown, but appear to be unrelated to altered pCO₂ levels or retinol metabolism. This indicates that the increase in ICP might be related to increased AQP1 levels in CP. Although further studies are warranted, obese Zucker rats could potentially model some aspects of the IIH pathophysiology.

Burden of Cluster Headache

The aim was to analyse the socioeconomic burden of cluster headache in patients from a tertiary headache centre. One hundred consecutive patients from the Danish Headache Centre were invited to an interview about the socioeconomic impact of cluster headache. Work absence and use of medical services were compared with a Danish population-based survey. Eighty-five patients participated; 78% reported restrictions in daily living and 13% also outside of cluster periods; 25% reported a major decrease in their ability to participate in social activities, family life and housework. The disease caused lifestyle changes for 96%, most frequently in sleeping habits and avoidance of alcohol. The absence rate among patients was 30%, which was significantly higher than 12% among the general population ( P < 0.001). Use of health services due to headache was also higher among the patients ( P < 0.001). Cluster headache, although periodic in most cases, has considerable impact on social functions, quality of life and use of healthcare.

Sleep in cluster headache - beyond a temporal rapid eye movement relationship?

BACKGROUND AND PURPOSE

Cluster headache (CH) is a primary headache disorder characterized by severe attacks of unilateral pain following a chronobiological pattern. There is a close connection with sleep as most attacks occur during sleep. Hypothalamic involvement and a particular association with rapid eye movement (REM) sleep have been suggested. Sleep in a large, well-characterized population of CH patients was investigated.

METHODS

Polysomnography (PSG) was performed on two nights in 40 CH patients during active bout and one night in 25 age, sex and body mass index matched controls in hospital. Macrostructure and other features of sleep were analyzed and related to phenotype. Clinical headache characterization was obtained by semi-structured interview.

RESULTS

Ninety-nine nights of PSG were analyzed. Findings included a reduced percentage of REM sleep (17.3% vs. 23.0%, P = 0.0037), longer REM latency (2.0 vs. 1.2 h, P = 0.0012) and fewer arousals (7.34 vs. 14.1, P = 0.003) in CH patients. There was no difference in prevalence of sleep apnea between patients (38%) and matched controls (32%, P = 0.64) although the apnea index in patients was numerically higher (mean apnea-hypopnea index 10.75 vs. 4.93). No temporal association between nocturnal attacks (n = 45) and particular sleep stages was observed.

CONCLUSIONS

To date, this is the largest study of sleep in CH. It is demonstrated that REM sleep is affected which is in line with our current understanding of CH and hypothalamic involvement in the regulation of this sleep stage. Further, fewer arousals were found in CH patients but no association between apnea events or specific sleep stages. The findings support a central role of the hypothalamus and arousal systems in CH.

The course of headache in idiopathic intracranial hypertension: a 12-month prospective follow-up study

BACKGROUND AND PURPOSE

Our aim was to prospectively describe the course of headache during the first year of idiopathic intracranial hypertension (IIH).

METHODS

Patients with newly diagnosed IIH were consecutively included from December 2010 to June 2013. Treatment according to standard guidelines was initiated. Headache history was obtained by headache diaries and standardized interviews performed at baseline and after 1, 2, 3 and 12 months. Parallel changes in papilledema were assessed by optical coherence tomography (OCT). All patients had comprehensive neuro-ophthalmological examinations including automated perimetry.

RESULTS

Forty-four patients were included. Thirty-five patients completed the 12-month follow-up. Dramatic improvement in headache occurred within the first weeks after diagnosis. After 1 year, 15 patients reported no or only infrequent headache. However, 15 of the remaining 20 patients reported sustained chronic headache. Early age of onset and high diagnostic intracranial pressure (ICP) were associated with better headache outcome (≤1 headache days/month) after a year. Papilledema decreased rapidly within the first 2 months of diagnosis. After 1 year, OCT measures had normalized. Visual outcome was excellent in most patients.

CONCLUSIONS

Although headache in 43% of patients responded well to ICP management, sustained long-term headache was seen in the remaining patients, despite resolution of papilledema. Headache in IIH may thus be attributed to more complex mechanisms than ICP elevation alone. High ICP and young age were associated with better headache outcome. Early treatment according to standard guidelines seems sufficient to ensure excellent visual outcome in the vast majority of patients.

A prospective survey of Aspergillus spp. in respiratory tract samples: prevalence, clinical impact and antifungal susceptibility

A three-month laboratory-based prospective survey was conducted at four major university hospitals covering one-third of the Danish population in order to determine the prevalence, significance, and susceptibility pattern of aspergilli in airway samples. Samples received in January-March 2007 for routine microbiologic investigation were examined for Aspergillus following routine procedures and with extended incubation (5 days). Identification was done by morphologic criteria and susceptibility testing using EUCAST method for azoles and amphotericin B E-test. Invasive aspergillosis (IA) was evaluated using modified EORTC/MSG criteria. A total of 11,368 airway samples were received. Growth of Aspergillus spp. was found in 129 and 151 patients using routine and extended incubation, respectively. Three patients had proven IA (2%), 11 probable (7%), four had allergic bronchopulmonary aspergillosis (ABPA) (3%), but the majority was colonised (88%). Underlying conditions were cystic fibrosis in 82 patients (55%), chronic obstructive pulmonary disease in 19 (13%) and haematological disorder in 11 (7%). Twenty-six patients (18%) were at intensive care unit and 69 (47%) received steroid treatment. Azole MICs were elevated for five isolates as follows (itraconazole, posaconazole, voriconazole MICs [mg/L]): two A. fumigatus isolates (>4; >4; 2 and >4; 0.125; 1), one A. lentulus isolate (2; 2; 0.5) and two A. terreus isolates (2; 2; 2 and 2; 0.125; 1). For four isolates the amphotericin B MIC was >1 μg/ml (3/112 A. fumigatus, 1/2 A. terreus). In conclusion, Aspergillus appears to be an important pathogen in Denmark. Elevated itraconazole MICs were detected in 4% of the isolates including a multi-azole resistant isolate.

Medication overuse as a cause of chronic headache in shunted hydrocephalus patients

PURPOSE

To highlight the group of hydrocephalus patients known to have a long history of shunt revisions and refractory chronic headache. When a shunt in perfect working order has no effect on headache, other causes of headache should be investigated. In this paper, patients with medication overuse headache are identified and the positive effect of medication withdrawal are described.

MATERIALS AND METHOD

Patients with hydrocephalus and shunt referred from the neurosurgical department to the Danish Headache Centre were identified. In all cases, over- and underdrainage was ruled out prior to referral. Six patients with medication overuse headache were documented and their charts were reviewed retrospectively with specific attention to: shunt revisions, inpatient and outpatient contacts, headache data and medication use before and after withdrawal of analgesic medication overuse.

RESULTS

A marked reduction in shunt revisions and inpatient contacts in five out of six patients was found and a reduction in outpatient contacts in four out of six patients. Furthermore, an improvement in headache intensity was found in three out of six patients and a reduction in duration was found in two out of six patients.

CONCLUSION

This study indicates that it is important to identify shunt patients with persistent chronic headache from causes other than shunt malfunction. By reducing their analgesic intake, it is possible to reduce headaches, the number of surgical interventions and hospital contacts. Hopefully this will raise awareness and lead to further research on the subject.

Assessment of D-dimer in plasma: diagnostic value in suspected deep venous thrombosis of the leg

D-dimer, a fibrin degradation product containing the gamma-gamma crosslink of fibrin, can now be assayed by the use of highly specific monoclonal antibodies. Such assays are not influenced by fibrinogenolysis and measurements can be performed on citrated plasma. The diagnostic values of four such assays--two based on ELISA technique and two on latex agglutination--were evaluated in 108 out of 118 consecutive patients admitted with suspected deep venous thrombosis of the leg. With cut-off limits defined by a pilot study and with venography as reference, a negative D-dimer test was confirmed in 45 of 46 patients (98%; 95% confidence limits: 88-99.9%) after ELISA-M, in 43 of 44 (98%; 88-99.9%) after ELISA-S, in 54 of 67 (81%; 69-89%) after Latex-M and in 40 of 44 (91%; 78-97%) after Latex-S. A positive D-dimer test was confirmed in 61% (48-73%), 59% (46-71%), 63% (47-78%), and 55% (42-67%) respectively. These data suggest the use of one of the ELISA assays for screening. A negative D-dimer test excludes deep venous thrombosis, whereas a positive D-dimer should be followed by venography. By this procedure a 40% reduction of venographic examinations can be expected.

Characterization of the TSU-PR1 cell line by chromosome painting and flow cytometry

TSU-PR1 was originally reported as a prostatic carcinoma cell line derived from a lymph node metastasis. Recently, however, this cell line was reported to be derived from T24 bladder carcinoma cells, and thus further definition of its origin is needed. Conventional cytogenetic study of TSU-PR1 showed aneuploidy, ranging from 65 to 86 chromosome with a modal number of 80, and with 10 marker chromosomes, thus conventional cytogenetics cannot be used to determine which chromosomes or regions of chromosomes are critical in cancer development and progression of this cell line. The present study was conducted to characterize genetic changes of the cell line using comparative genomic hybridization (CGH), fluorescence in situ hybridization (FISH), and flow cytometry. CGH results showed that green-to-red fluorescence ratios were within the range of 0.85-1.15, except for a few chromosomes, which reflected near tetraploidy in TSU-PR1. Flow cytometric analysis of TSU-PR1 revealed a DNA index of 3.46n, which is close to the 3.48n calculated from a modal number of 80. The copy numbers of chromosomes 4, 6, 7, 17, and 20 determined by the DNA index and the CGH analyses were 2.85 +/- 0.09, 3.22 +/- 0.77, 3.01 +/- 0.26, 4.05 +/- 0.44, and 4.99 +/- 0.48, respectively. These numbers are also in accordance with the chromosome copy numbers determined with FISH: 2.98 +/- 0.23, 2.91 +/- 0.44, 2.74 +/- 0.44, 3.93 +/- 0.38, and 5.05 +/- 0.78 for chromosomes 4, 6, 7, 17, and 20, respectively (P > 0.05).

The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia

This preliminary study indicates the proportion of patients with lateral epicondylalgia that demonstrate a favourable initial response to a manual therapy technique - the mobilization with movement (MWM) for tennis elbow. Twenty-five subjects with lateral epicondylalgia participated. In a one-group pretest - post-test design, we measured (1) pain with active motion, (2) pain-free grip strength and, (3) maximum grip strength before and after a single intervention of MWM. Results of the study indicate that MWM was effective in allowing 92% of subjects to perform previously painful movements pain-free, and improving grip strength immediately afterwards. Significant differences were found between the grip strength of the affected and unaffected limbs prior to the intervention. Both pain-free grip strength and maximum grip strength of the affected limb increased significantly following the intervention. Pain-free grip strength increased by a greater magnitude than maximum grip strength. It can be concluded that MWM is a promising intervention modality for the treatment of patients with Lateral Epicondylalgia. Pain-free grip strength is a more responsive measure of outcome than maximum grip strength for patients with Lateral Epicondylalgia. Further research is warranted to investigate the long-term effectiveness of MWM in the treatment of impairment and disability resulting from Lateral Epicondylalgia.

DNA copy number alterations in HIV-positive and HIV-negative patients with diffuse large-cell lymphomas

Individuals infected with HIV are at increased risk of developing aggressive non-Hodgkin's lymphoma with a worse prognosis than those similarly afflicted without HIV infection. The underlying genetic differences in tumor behavior between these two groups are not known. We explored the hypothesis that lymphomas from HIV-positive individuals have distinct somatic genetic changes that may provide clues to the genetic basis of disease progression and outcome. Genome-wide DNA copy number alterations (CNAs) in primary tumors from 14 HIV-positive and 11 HIV-negative patients with diffuse large B-cell lymphoma (DLCL) were quantified using comparative genomic hybridization (CGH). Tumors from HIV-positive patients displayed fewer regional DNA-CNAs than those from patients who did not have HIV. When CNAs were present, they occurred at lower frequency in HIV-positive patients. Gains at chromosomes 8q and Xp were the most frequent changes in the HIV-negative group, and gains on 2p and 12q were common in the combined HIV-positive and HIV-negative groups. No alteration was specific to AIDS-related DLCL. These data suggest that fewer somatic genomic changes are needed for progression to DLCL in HIV-immunocompromised hosts, and that other factors, such as reduced immune surveillance, may contribute to neoplastic progression.

Quantitative mRNA expression analysis from formalin-fixed, paraffin-embedded tissues using 5' nuclease quantitative reverse transcription-polymerase chain reaction

Analysis of gene expression and correlation with clinical parameters has the potential to become an important factor in therapeutic decision making. The ability to analyze gene expression in archived tissues, for which clinical followup is already available, will greatly facilitate research in this area. A major obstacle to this approach, however, has been the uncertainty about whether gene expression analyses from routinely archived tissues accurately reflect expression before fixation. In the present study we have optimized the RNA isolation and reverse transcription steps for quantitative reverse transcription-polymerase chain reaction (RT-PCR) on archival material. Using tissue taken directly from the operating room, mRNAs with half-lives from 10 minutes to >8 hours were isolated and reverse transcribed. Subsequent real-time quantitative PCR methodology (TaqMan) on these cDNAs gives a measurement of gene expression in the fixed tissues comparable to that in the fresh tissue. In addition, we simulated routine pathology handling and demonstrate that this method of mRNA quantitation is insensitive to pre-fixation times (time from excision to fixation) of up to 12 hours. Therefore, it should be feasible to analyze gene expression in archived tissues where tissue collection procedures are largely unknown.

Detection of genetic changes in anal intraepithelial neoplasia (AIN) of HIV-positive and HIV-negative men

Compared with HIV-negative individuals, HIV-positive individuals have a higher prevalence of anogenital human papillomavirus (HPV) infection, as well as a higher incidence of HPV-associated anal cancer. Little is currently known of chromosomal changes occurring in anal intraepithelial neoplasia (AIN), the probable precursor to anal cancer. Genetic changes in AIN were characterized by comparative genomic hybridization (CGH) in a study of samples obtained from 19 HIV-positive and 11 HIV-negative men. The proportion with genetic changes significantly increased with the severity of the histopathologic grade with none diagnosed as (0%) AIN 1; 5 of 17 (29%) as AIN 2; and 5 of 9 (56%) AIN 3 showing genetic changes (p = .02). This correlation was also found in study subjects who had multiple biopsies with different grades of pathology concurrently or serially over time. The most common regional DNA copy number change was gain mapped to chromosome arm 3q (12% of AIN 2 and 33% of AIN 3). This alteration was previously reported to be commonest alteration in cervical cancer, which suggests a common molecular pathway for these two HPV-associated anogenital neoplasias.

Measurement of DNA copy number at microsatellite loci using quantitative PCR analysis

This report describes the development and validation of quantitative microsatellite analysis (QuMA) for rapid measurement of relative DNA sequence copy number. In QuMA, the copy number of a test locus relative to a pooled reference is assessed using quantitative, real-time PCR amplification of loci carrying simple sequence repeats. Use of simple sequence repeats is advantageous because of the large numbers that are mapped precisely. In addition, all markers are informative because QuMA does not require that they be polymorphic. The utility of QuMA is demonstrated in assessment of the extent of deletions of chromosome 2 in leukemias arising in radiation-sensitive inbred SJL mice and in analysis of the association of increased copy number of the putative oncogene ZNF217 with reduced survival duration in ovarian cancer patients.

Genetic alterations in microdissected prostate cancer cells by comparative genomic hybridization

Molecular genetic abnormalities were assessed on 23 cases of prostate adenocarcinoma by performing microdissection on archived tumor tissue sections followed by degenerate oligonucleotide primed PCR (DOP-PCR) on extracted DNA, providing sufficient product to carry out comparative genomic hybridization (CGH). The results of CGH show a significant regional DNA copy number alteration in 100% of the cases. Copy number gains were detected most frequently in chromosome 8q (91.3%), followed by chromosome X (43.5%), and chromosomes 20, 7, 4, and 3 (8.7%). DNA copy number losses occurred most frequently in chromosome 18 (34.8%), followed by chromosome 20 (21.7%), chromosomes 16 and 22 (17.4%) and chromosomes 12, 17, and 19 (8.7%). Since tissue microdissection and DOP-PCR yields product for analysis that represents DNA from pure tumor cells. CGH shows high sensitivity in detecting copy number alterations. This method indicates regions of the genome that are likely to be driven to amplification or deletion by the presence of oncogenes or tumor suppressor genes, respectively. The most common alteration detected was a regional gain in copy number in chromosome 8 near 8q21, indicating an oncogene in this region may be key to development of prostate adenocarcinoma. Prostate Cancer and Prostatic Diseases (2000) 3, 110-114

Genetic instability and hematologic disease risk in Werner syndrome patients and heterozygotes

Werner syndrome (WRN) is an uncommon autosomal recessive disease in which progeroid features are associated with genetic instability and an elevated risk of neoplasia. We have used the glycophorin A (GPA) somatic cell mutation assay to analyze genetic instability in vivo in WRN patients and heterozygotes. GPA variant frequencies were determined for 11 WRN patients and for 10 heterozygous family members who collectively carry 10 different WRN mutations. Genetic instability as measured by GPA O/N allele loss variant frequency was significantly increased, and this increase was strongly age-dependent in WRN patients. GPA O/N allele loss variants were also significantly elevated in heterozygous family members, thus providing the first evidence for in vivo genetic instability in heterozygous carriers in an autosomal recessive genetic instability syndrome. Our results and comparable data on other human genetic instability syndromes allow an estimate of the level of genetic instability that increases the risk of human bone marrow dysfunction or neoplasia.

Whole genome amplification and molecular genetic analysis of DNA from paraffin-embedded prostate adenocarcinoma tumor tissue

PURPOSE

Often tissues obtained from prostate adenocarcinoma tumors embedded in paraffin are heterogeneous in cell type and must be carefully microdissected to acquire tissue fragments that provide homogeneous aliquots of tumor clones. Such tissue fragments rarely contain sufficient DNA to perform genomic characterization needed as an early step in localizing relevant oncogenes or tumor suppressor genes. We report that PCR using a degenerate oligonucleotide primer (DOP-PCR) can be applied to DNA samples from microdissected paraffin-embedded prostate adenocarcinomas, and this provides sufficient product for fluorescent allelic imbalance measurements or comparative genomic hybridization (CGH).

MATERIALS AND METHODS

Samples were selected to be representative of those routinely obtained during prostatectomies, based on typical tumor stages (T2 and T3) and Gleason grades (range 3 +3 to 4 +5). For DNA analysis without prior DOP-PCR, only large tumors were selected to be sectioned. More than 50 specimens were analyzed. Close comparison of data obtained from analysis of DOP-PCR with those from non-DOP DNA was obtained on a subset 8 samples. To compare the allelic balance of DOP-PCR amplified DNA with that measured for non-DOP DNA, we analyzed allelic ratios on DNA from 5 different tissue samples processed by both microdissection and conventional sectioning.

RESULTS

Systematic comparison of allelic imbalance results shows close similarity between DOP-PCR amplified product and non-DOP DNA, indicating that PCR product is a valid representation of the tumor genome. In addition, the difference between allelic balance and imbalance is more distinctive when microdissection followed by DOP-PCR is performed. Performing CGH on products of DOP-PCR also shows distinctive regional copy number alterations in DNA from microdissected tumor tissue.

CONCLUSION

Either of these procedures allows distinction between benign and malignant genomes, and also allows independent analysis of genomic alterations in different portions of tumors. They also may be applied clinically for genomic characterization of small foci that frequently appear in prostates of elderly men who are showing no obvious pathological symptoms of adenocarcinoma.

[Fiber optic tracheoscopy in percutaneous dilation tracheostomy]

Percutaneous dilatational tracheostomy (PDT) was performed on a 64 year-old female multitraumatised patient. Because of difficulties during the procedure, fiberoptic tracheoscopy was carried out and revealed perforation and dilatation of the endotracheal tube. The error was corrected with little loss of time, and no complications were observed after finishing the procedure. We recommend the use of routine fiberoptic tracheoscopy during and after percutaneous dilatational tracheostomy as suggested by Ciaglia et al (2).

Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy. A clinical randomised study

BACKGROUND

As no clinical randomised studies have previously been performed comparing complications with the Ciaglia Percutaneous Dilatational Tracheostomy Introducer Set (PDT) and conventional surgical tracheostomy (TR), we designed a study with the aim of comparing the efficacy and safety of the two techniques.

METHODS

Sixty patients selected for elective tracheostomy were randomised for either PDT (30 patients) or TR (30 patients). All patients had general anaesthesia and were ventilated with 100% oxygen. Furthermore, lidocaine with epinephrine 1% (3-5 ml) was used for local analgesia and to minimise bleeding during the procedure.

RESULTS

The median time for insertion of the tracheostomy tube was 11.5 min (range 7-24 min) in the PDT group and 15 min (range 5-47 min) in the TR group (P<0.01). Complications during the procedure were cuff puncture of the endotracheal tube in 5 cases in the PDT group. Minor bleeding was encountered in 6 cases in the PDT group as opposed to 24 cases in the TR group (P<0.01), major bleeding in none versus 2 cases, respectively. In 8 cases in the PDT group, increased resistance to insertion of the tracheostomy tube was met by further dilatation. During the post-tracheostomy period, complications occurred with minor bleeding in 2 cases in the PDT group as opposed to 9 cases in the TR group (P<0.05), and major bleeding was encountered in 1 case in each group. Minor infections were encountered in 3 cases in the PDT group as opposed to 11 cases in the TR group (P<0.01). Major infection was encountered in none versus 8 cases, respectively (P<0.01).

CONCLUSION

Our results indicate that the percutaneous dilatational tracheostomy technique performed with the Ciaglia Introducer Set is effective, safe and superior to conventional surgical tracheostomy as immediate complications as well as complications with the tracheostomy tube in situ are fewer and of less severity.

Radiobiological evaluation of immigrants from the vicinity of Chernobyl

Eighty individuals (55 adults and 25 children) who were residents of four cities (Kiev, Mozyr, Gomel and Bobrujsk) located 100-200 km from Chernobyl at the time of the accident in 1986 were tested after immigrating to the US from 1989-1991. A whole-body counter was employed to quantitate radiocesium content. In addition, two biological measures of radiation effects, namely, chromosomal integrity using the micronucleus assay and somatic mutation analysis of erythrocytes at the glycophorin A (GPA) locus, were applied to this group. Radiocesium activity in the body ranged from 0 to 56.8 Bq/kg with a mean and standard deviation of 5.0 +/- 8.2 and a median value of 2.0 Bq/kg. Mean radiocesium content by groups was highest in adult males (9.0 +/- 11.7; range 0.21-56.8 Bq/kg) followed by adult females (3.3 +/- 4.5; range 0-21.3 Bq/kg), male children (3.0 +/- 5.7; range 0-20.2 Bq/kg) and lowest in female children (1.6 +/- 3.5; range 0-12.7 Bq/kg). Individuals with the highest radiocesium content in each group belonged to one family that lived in Mozyr (100 km from Chernobyl) until emigrating in 1989. The frequency of lymphocyte micronuclei and erythrocyte GPA allele-loss (O/N) somatic mutations were both significantly correlated with radiocesium content (r=0.57, p=0.002; r=0.75, p=0.002, respectively). The micronucleus frequency also correlated with the estimated internal absorbed dose from radiocesium in a subset of 20 immigrants for whom this calculation was possible (r=0.71, p=0.0005). Altogether, the biomonitoring data indicate that some subjects had radiation doses sufficient to produce gene and chromosomal mutations in blood cells, although these effects cannot be attributed solely to radiocesium exposure.

Glycophorin A somatic cell mutation frequencies in residents of Tibet at high altitudes

Since cosmic radiation is absorbed by the atmosphere surrounding the Earth, people who live at high altitude receive significantly larger amounts of cosmic radiation exposure than do those who live at low altitude. The glycophorin A-based somatic mutation assay was performed on 36 blood samples from two populations of Tibet inhabitants to determine whether residents at high altitude (4,300 m) accumulate more somatic mutations than do those who live at low altitude (1,500-1,900 m). These two populations differ in estimated cumulative lifetime cosmic radiation dose, with high altitude residents having received a mean of 111 mSv while low altitude residents received a mean of 27 mSv. Results showed no significant difference in peripheral blood variant erythrocyte frequency between these two populations and no difference from results of a previous study on Finnish workers who live at very low altitude (<500 m).

Allelic imbalance mapping of chromosome 16 shows two regions of common deletion in prostate adenocarcinoma

Allelic imbalance (AI) has now been reported on the long arm of chromosome 16 in several cancers including breast, prostate, hepatocellular carcinoma, and Wilms tumor. Such nonrandom AI is commonly associated with the presence of a tumor suppressor gene (TSG) at or near the tested locus. Previous studies in our laboratory indicated that prostate cancer genomes frequently exhibit a region of allelic loss near the q terminus of chromosome 16. Here we report a detailed, PCR based, allelic imbalance study at ten polymorphic loci on 16q. The data indicate that there are two common regions of 16q AI in prostate cancer, one at 16q21-22 (50% of informative cases) and another at 16q24.2-qter (56% of informative cases). These are similar to regions of 16q previously shown to exhibit AI in breast cancer. Neither of these regions shows correlation of AI with the clinical parameters; Gleason grade, tumor stage, or metastases.

Biological dosimetry of radiation workers at the Sellafield nuclear facility

The British Nuclear Fuels plc facility at Sellafield performs a range of nuclear-related activities. The site has been in operation since 1950 and has, in general, employed a stable work force, many of whom have accumulated relatively high occupational exposures to ionizing radiation. This paper compares the physical dosimetry with two biological end points for evaluating radiation exposure: fluorescence in situ hybridization with whole-chromosome painting probes to quantify stable chromosome aberrations (translocations and insertions), and glycophorin A (GPA) analysis of variant erythrocytes. For the cytogenetic analyses, 81 workers were evaluated in five dose categories, including 23 with minimal radiation exposure (< or = 50 mSv) and 58 with exposures ranging from 173 to 1108 mSv, all but 3 being > 500 mSv. In a univariate analysis, the mean stable chromosome aberration frequencies showed a significant increase with dose category (P = 0.032), and with cumulative dose when dose is treated as a continuous variable (P = 0.015). The slope of the dose response for stable aberrations is 0.79 +/- 0.22 aberrations per 100 cells per sievert (adjusted for smoking status), which is less than that observed among atomic bomb survivors, and suggests a dose and dose-rate effectiveness factor for chronic exposure of about 6. Analyses of the data for GPA N/O and N/N variants from 36 workers revealed no correlation with dose. Neither was there a correlation between the frequencies of N/O GPA variants and stable aberrations, although a weak negative association was observed between N/N variant frequency and stable aberrations (r = -0.38, P = 0.05). These results provide clear evidence for the accumulation of stable aberrations under conditions of chronic occupational exposure to ionizing radiation and show that stable chromosome aberrations are a more sensitive indicator for chronic radiation exposure than GPA variants. In comparison with human studies of brief exposure, chronic low-dose exposures appear substantially less effective for producing somatic effects as reflected by stable chromosome aberrations.