bluuebunny/crossref_metadata_2025 huggingface dataset:
Ultrahigh‐pressure metamorphism in the forbidden zone: the Xugou garnet peridotite, Sulu terrane, eastern China
Authors: Zhang R. Y. , Liou J. G. , Yang J. S. , Ye K.
Published: July 2003

The Xugou garnet peridotite body of the southern Sulu ultrahigh‐pressure (UHP) terrane is enclosed in felsic gneiss, bounded by faults, and consists of harzburgite and lenses of garnet clinopyroxenite and eclogite. The peridotite is composed of variable amounts of olivine (Fo91), enstatite (En92−93), garnet (Alm20−23Prp53−58Knr6−9Grs12−18), diopside and rare chromite. The ultramafic protolith has a depleted residual mantle composition, indicated by a high‐Mg number, very low CaO, Al2O3 and total REE contents compared to primary mantle and other Sulu peridotites. Most garnet (Prp44−58) clinopyroxenites are foliated. Except for rare kyanite‐bearing eclogitic bands, most eclogites contain a simple assemblage of garnet (Alm29−34Prp32−50Grs15−39) + omphacite (Jd24−36) + minor rutile. Clinopyroxenite and eclogite exhibit LREE‐depleted and LREE‐enriched patterns, respectively, but both have flat HREE patterns. Normalized La, Sm and Yb contents indicate that both eclogite and garnet clinopyroxenite formed by high‐pressure crystal accumulation (+ variable trapped melt) from melts resulting from two‐stage partial melting of a mantle source.

Recrystallized textures and P–T estimates of 780–870 °C, 5–7 GPa and a metamorphic age of 231 ± 11 Ma indicate that both mafic and ultramafic protoliths experienced Triassic UHP metamorphism in the P–T forbidden zone with an extremely low thermal gradient (< 5 °C km−1), and multistage retrograde recrystallization during exhumation. Develop of prehnite veins in clinopyroxenite, eclogite, felsic blocks and country rock gneiss, and replacements of eclogitic minerals by prehnite, albite, white mica, and K‐feldspar indicate low‐temperature metasomatism.
SHRIMP U–Pb dating of coesite‐bearing zircon from the ultrahigh‐pressure metamorphic rocks, Sulu terrane, east China
Authors: Yang J. S. , Wooden J. L. , Wu C. L. , Liu F. L. , Xu Z. Q. , Shi R. D. , Katayama I. , Liou J. G. , Maruyama S.
Published: July 2003

This paper provides further evidence for the ongoing discussion as to whether the Dabie UHPM belt formed in Triassic or Palaeozoic time, and whether the Sulu UHPM belt formed in Triassic or Neoproterozoic time. Combined use of laser Raman spectrometer (LR), cathodoluminescence imaging (CL), and ion probe U–Pb in‐situ dating (SHRIMP) provided accurate ages of UHPM from rocks collected from Weihai, NE Sulu UHPM belt. LR was used to identify coesite and other UHP minerals as inclusions in zircon separates from an amphibolized peridotite and an eclogite. CL was used to examine the zoning structure of these zircon, and SHRIMP dating was performed on specific spots on zircon to obtain ages of different geological events. An age of 221 ± 12 Ma was obtained for coesite‐bearing zircon from the amphibolized peridotite; an age of 228 ± 29 Ma for eclogite was obtained from the lower intercept of a concordia plot. These ages are interpreted as the time of UHPM in the Weihai region. Ultramafic rocks to the east of Weihai yield a magmatic age at 581 ± 44 Ma. The zircon in the ultramafic rocks possibly also records a thermal event at c. 400 Ma, but no independent geological evidence for this event has been found. The eclogite protolith formed in the Middle Proterozoic (1821 ± 19 Ma), which is similar to the age of country rock gneisses of 1847–1744 Ma. The new geochronological data confirm that UHPM occurred in the Triassic in the Sulu area when subduction took the ultramafic body and the eclogite protolith, together with the adjacent supracrustal rocks, to mantle depths.
Remnants of premetamorphic fluid and oxygen isotopic signatures in eclogites and garnet clinopyroxenite from the Dabie‐Sulu terranes, eastern China
Authors: Fu B. , Touret J. L. R. , Zheng Y.‐F.
Published: July 2003

A combined oxygen‐isotope and fluid‐inclusion study has been carried out on high‐ and ultrahigh‐pressure metamorphic (HP/UHPM) eclogites and garnet clinopyroxenite from the Dabie‐Sulu terranes in eastern China. Coesite‐bearing eclogites/garnet clinopyroxenite and quartz eclogites have a wide range in whole‐rock δ18OVSMOW, from 0 to 11‰. The high‐T oxygen‐isotope fractionations preserved between quartz and garnet preclude significant retrograde isotope exchange during exhumation, and the wide range in whole‐rock oxygen‐isotope composition is thought to be a presubduction signature of the precursors. Aqueous fluids with variable salinities and gas species (N2‐, CO2‐, or CH4‐rich), are trapped as primary inclusions in garnet, omphacite and epidote, and in quartz blebs enclosed within eclogitic minerals. In high‐δ18O HP/UHPM rocks from Hujialin and Shima, high‐salinity brine and/or N2 inclusions occur in garnet porphyroblasts, which also contain inclusions of coesite, Cl‐rich blue amphibole and dolomite. In contrast, in low‐δ18O eclogites from Qinglongshan and Huangzhen, the Cl concentrations in amphibole are very low, < 0.2 wt.%, and low‐salinity aqueous inclusions occur in quartz inclusions in epidote porphyroblasts and in epidote cores. These low‐salinity fluid inclusions are believed to be remnants of meteoric water, although the fluid composition was modified during pre‐ and syn‐peak HP/UHPM. Eclogites at Houshuichegou and Hetang contain CH4‐rich fluid inclusions, coexisting with high‐salinity brine inclusions. Methane was probably formed under the influence of CO2‐rich aqueous fluids during serpentinisation of mantle‐derived peridotites prior to or during plate subduction. Remnants of premetamorphic low‐ to high‐salinity aqueous fluid with minor N2 and/or other gas species preserved in the Dabie‐Sulu HP/UHPM eclogites and garnet clinopyroxenite indicate a great diversity of initial fluid composition in the precursors, implying very limited fluid–rock interaction during syn‐ and post‐peak HP/UHPM.
Low δ18O eclogites from the Kokchetav massif, northern Kazakhstan
Authors: Masago H. , Rumble D. , Ernst W. G. , Parkinson C. D. , Maruyama S.
Published: July 2003

Oxygen isotopic compositions of silicates in eclogites and whiteschists from the Kokchetav massif were analyzed by whole‐grain CO2‐laser fluorination methods. Systematic analyses yield extremely low δ18O for eclogites, as low as −3.9‰ for garnet; these values are comparable with those reported for the Dabie‐Sulu UHP eclogites. Oxygen isotopic compositions are heterogeneous in samples of eclogite, even on an outcrop scale. Schists have rather uniform oxygen isotope values compared to eclogites, and low δ18O is not observed. Isotope thermometry indicates that both eclogites and schists achieved high‐temperature isotopic equilibration at 500–800 °C. This implies that retrograde metamorphic recrystallization barely modified the peak‐metamorphic oxygen isotopic signatures. A possible geological environment to account for the low‐δ18O basaltic protolith is a continental rift, most likely subjected to the conditions of a cold climate. After the basalt interacted with low δ18O meteoric water, it was tectonically inserted into the surrounding sedimentary units prior to, or during subduction and UHP metamorphism.
Timing of Himalayan ultrahigh‐pressure metamorphism: sinking rate and subduction angle of the Indian continental crust beneath Asia
Authors: Kaneko Y. , Katayama I. , Yamamoto H. , Misawa K. , Ishikawa M. , Rehman H. U. , Kausar A. B. , Shiraishi K.
Published: July 2003

Coesite relics were discovered as inclusions in clinopyroxene in eclogite and as inclusions in zircon in felsic and pelitic gneisses from Higher Himalayan Crystalline rocks in the upper Kaghan Valley, north‐west Himalaya. The metamorphic peak conditions of the coesite‐bearing eclogites are estimated to be 27–32 kbar and 700–770 °C, using garnet–pyroxene–phengite geobarometry and garnet–pyroxene geothermometry, respectively. Cathodoluminescence (CL) and backscattered electron (BSE) imaging distinguished three different domains in zircon: inner detrital core, widely spaced euhedral oscillatory zones, and thin, broadly zoned outermost rims. Each zircon domain contains a characteristic suite of micrometre‐sized mineral inclusions which were identified by in situ laser Raman microspectroscopy. Core and mantle domains contain quartz, apatite, plagioclase, muscovite and rutile. In contrast, the rim domains contain coesite and minor muscovite. Quartz inclusions were identified in all coesite‐bearing zircon grains, but not coexisting with coesite in the same growth domain (rim domain). 206Pb/238U zircon ages reveal that the quartz‐bearing mantle domains and the coesite‐bearing rim were formed at c. 50 Ma and 46.2 ± 0.7 Ma, respectively. These facts demonstrate that the continental materials were buried to 100 km within 7–9 Myr after initiation of the India–Asia collision (palaeomagnetic data from the Indian oceanic floor supports an initial India‐Asia contact at 55–53 Ma). Combination of the sinking rate of 1.1–1.4 cm year−1 with Indian plate velocity of 4.5 cm year−1 suggests that the Indian continent subducted to about 100 km depth at an average subduction angle of 14–19°.
The timing of stabilisation and the exhumation rate for ultra‐high pressure rocks in the Western Gneiss Region of Norway
Authors: Carswell D. A. , Brueckner H. K. , Cuthbert S. J. , Mehta K. , O'Brien P. J.
Published: July 2003

New petrographic evidence and a review of the latest radiometric age data are taken to indicate that formation of the ultra‐high pressure (UHP) eclogites within the Western Gneiss Region of Norway probably occurred within the 400–410 Ma time frame. Thus, this event took place significantly later than the previous, widely accepted age of c. 425 Ma for the timing of the high pressure metamorphism in this part of the Scandinavian Caledonides. Garnet growth under UHP (coesite‐stable) conditions is recognised as a discrete, younger event following on from earlier garnet formed under firstly amphibolite facies then quartz‐stable, eclogite facies conditions. Currently, the best constrained and most precise age, specifically for UHP mineral growth, is the 402 ± 2 Ma U–Pb age for metamorphic zircon (some of which retain coesite inclusions) from the Hareidland eclogite. Exhumation must have followed shortly thereafter and, based on synoptic pressure–temperature and depth–time curves, must have been very fast. Our data and those of others indicate an initial fast exhumation to about 35 km depth by about 395 Ma at a mean rate of about 10 mm a−1. This rapid exhumation rate may have been driven by the appreciable residual buoyancy of the deeply subducted continental crustal slab due to incomplete eclogitization of the dominant Proterozoic orthogneisses during the short‐lived UHP event. Subsequent exhumation to 8–10 km depth by about 375 Ma occurred at a much slower mean rate of about 1.3 mm a−1 with the late‐stage extensional collapse of the Caledonian orogen playing an increasingly important role, especially in the final unroofing of the Western Gneiss Region with some remarkably preserved UHP rocks.
Exhumation of high‐pressure rocks beneath the Solund Basin, Western Gneiss Region of Norway
Authors: Hacker B. R. , Andersen T. B. , Root D. B. , Mehl L. , Mattinson J. M. , Wooden J. L.
Published: July 2003

The Solund–Hyllestad–Lavik area affords an excellent opportunity to understand the ultrahigh‐pressure Scandian orogeny because it contains a near‐complete record of ophiolite emplacement, high‐pressure metamorphism and large‐scale extension. In this area, the Upper Allochthon was intruded by thec. 434 Ma Sogneskollen granodiorite and thrust eastward over the Middle/Lower Allochthon, probably in the Wenlockian. The Middle/Lower Allochthon was subducted to c. 50 km depth and the structurally lower Western Gneiss Complex was subducted to eclogite facies conditions at c. 80 km depth by c. 410–400 Ma. Within < 5–10 Myr, all these units were exhumed by the Nordfjord–Sogn detachment zone, producing shear strains > 100. Exhumation to upper crustal levels was complete by c. 403 Ma. The Solund fault produced the last few km of tectonic exhumation, bringing the near‐ultrahigh‐pressure rocks to within c. 3 km vertical distance from the low‐grade Solund Conglomerate.
Metamorphic evolution of the coesite‐bearing ultrahigh‐pressure terrane in the North Qaidam, Northern Tibet, NW China
Authors: Song S. G. , Yang J. S. , Xu Z. Q. , Liou J. G. , Shi R. D.
Published: July 2003

Widespread evidence for ultrahigh‐pressure (UHP) metamorphism is reported in the Dulan eclogite‐bearing terrane, the North Qaidam–Altun HP–UHP belt, northern Tibet. This includes: (1) coesite and associated UHP mineral inclusions in zircon separates from paragneiss and eclogite (identified by laser Raman spectroscopy); (2) inclusions of quartz pseudomorphs after coesite and polycrystalline K‐feldspar + quartz in eclogitic garnet and omphacite; and (3) densely oriented SiO2lamellae in omphacitic clinopyroxene. These lines of evidence demonstrate that the Dulan region is a UHP metamorphic terrane. In the North Dulan Belt (NDB), eclogites are characterized by the peak assemblage Grt + Omp + Rt + Phn + Coe (pseudomorph) and retrograde symplectites of Cpx + Ab and Hbl + Pl. The peak conditions of the NDB eclogites areP= 2.9–3.2 GPa, andT= 631–687 °C; the eclogite shows a near‐isothermal decompressionP–Tpath suggesting a fast exhumation. In the South Dulan Belt (SDB), three metamorphic stages are recognized in eclogites: (1) a peak eclogite facies stage with the assemblage Grt + Omp + Ky + Rt + Phn atP= 2.9–3.3 GPa andT= 729–746 °C; (2) a high‐pressure granulite facies stage with Grt + Cpx (Jd < 30) + Pl (An24–29) + Scp atP= 1.9–2.0 GPa,T= 873–948 °C; and (3) an amphibolite facies stage with the assemblage Hbl + Pl + Ep/Czo atP= 0.7–0.9 GPa andT= 660–695 °C. The clockwiseP–Tpath of the SDB eclogites is different from the near‐isothermal decompressionP–Tpath from the NDB eclogites, which suggests that the SDB was exhumed to a stable crustal depth at a slower rate. In essence these two sub‐belts formed in different tectonic settings; they both subducted to mantle depths of around 100 km, but were exhumed to the Earth's surface separately along different paths. This UHP terrane plays an important role in understanding continental collision in north‐western China.
2003 Wolff Award: Possible Parasympathetic Contributions to Peripheral and Central Sensitization During Migraine
Authors: Yarnitsky David , Goor‐Aryeh Itay , Bajwa Zahid H. , Ransil Bernard I. , Cutrer F. Michael , Sottile Anna , Burstein Rami
Published: July 2003

Background.—Neurologic signs of increased parasympathetic outflow to the head often accompany migraine attacks. Because increased parasympathetic outflow to the cranial cavity induces vasodilation of cerebral and meningeal blood vessels, it can enhance plasma protein extravasation and the release of proinflammatory mediators that activate perivascular nociceptors. We recently showed that activation of intracranial perivascular nociceptors induces peripheral and central sensitization along the trigeminovascular pathway and proposed that these sensitizations mediate the intracranial hypersensitivity and the cutaneous allodynia of migraine.

Methods.—The present study investigates possible parasympathetic contributions to the generation of peripheral and central sensitization during migraine by applying intranasal lidocaine to reduce cranial parasympathetic outflow through the sphenopalatine ganglion.

Results.—In the absence of migraine, patients were pain‐free, and their skin sensitivity was normal. Their mean baseline pain thresholds were less than 15°C for cold, more than 45°C for heat, and more than 100 g for mechanical pressure. Their mean pain score was 7.5 of 10 (standard deviation, 1.4) during untreated migraine and 3.5 of 10 (standard deviation, 2.4) after the nasal lidocaine‐induced sphenopalatine ganglion block (P < .0001). Most patients developed cutaneous allodynia during migraine, and their mean pain thresholds changed to more than 25°C for cold, less than 40°C for heat, and less than 10 g for mechanical pressure. Following the nasal lidocaine administration (sphenopalatine ganglion block), this allodynia remained unchanged in spite of the pain relief.

Conclusion.—These findings suggest that cranial parasympathetic outflow contributes to migraine pain by activating or sensitizing (or both) intracranial nociceptors, and that these events induce parasympathetically independent allodynia by sensitizing the central nociceptive neurons in the spinal trigeminal nucleus.
Headache Management Program Improves Outcome for Chronic Headache
Authors: Harpole Linda H. , Samsa Gregory P. , Jurgelski Annette E. , Shipley Janice L. , Bernstein Allan , Matchar David B.
Published: July 2003

Objective.—To determine the feasibility of developing a headache management program and to assess the outcomes of patients referred to the program for treatment of chronic headache.

Background.—Effective headache treatment requires that the patient receives the correct headache diagnosis; that appropriate acute and, if indicated, preventive medications be prescribed; and that the patient receives adequate education, including headache self‐management skills.

Design/Methods.—A headache management program was established at a northern California staff‐model health maintenance organization. Fifty‐four patients were enrolled in the program and followed for 6 months. Patients participated in a structured program of group and individual sessions with the program manager. Data collection at baseline and 6 months included the Migraine Disability Assessment (MIDAS), the Short Form‐36 Health Survey (SF‐36), a patient satisfaction survey, and 2 additional short surveys—one that assessed patient worries about their headaches and another that queried patients on their problems with headache management.

Results.—All enrolled patients participated in the initial group visit; 74% had at least one additional visit. All but one patient suffered from more than one headache type. Sixty‐one percent of patients suffered from migraine headache and 98% from tension‐type headache. At baseline, patients were severely disabled, with a mean MIDAS score of 41. At 6 months, MIDAS scores decreased an average of 21.2 points (P < .005). Patients reported 14.5 fewer days with headache over the preceding 3 months (P < .0001) and experienced clinically significant improvements in 6 of the SF‐36 subscales. Patients were significantly more satisfied with their headache care (P < .0001), reported less problems with their headache management (P < .0001), and were less worried about their headaches (P < .01). During the intervention, emergency department visits for headache decreased (P < .02).

Conclusions.—A headache management program was successfully established. Patients referred to the program experienced significant improvement in headache‐related disability and functional health status and reported greater satisfaction with care. Even so, these results were obtained at one site and in a small sample that was not randomized. We currently are conducting a randomized controlled trial to better evaluate the clinical and financial impact of a headache management program for patients with chronic headache.
Prevalence of Atrial Septal Aneurysm in Patients With Migraine: An Echocardiographic Study
Authors: Carerj S. , Narbone M. C. , Zito C. , Serra S. , Coglitore S. , Pugliatti P. , Luzza F. , Arrigo F. , Oreto G.
Published: July 2003

Objective.—To evaluate the prevalence of atrial septal aneurysm in patients with migraine.

Background.—Migraine has long been considered a risk factor for stroke. Atrial septal aneurysm is often observed in young patients with ischemic stroke and is frequently associated with other conditions potentially leading to embolism.

Methods.—We performed a transthoracic echocardiogram in 90 consecutive patients (65 women and 25 men; mean age, 35.3 years [standard deviation, 9]) with migraine but free from cerebral and cardiovascular disease and in 53 control subjects (37 women and 16 men; mean age, 34 years [standard deviation, 10]). The diagnosis of atrial septal aneurysm was performed according to Olivares‐Reyes criteria. A transesophageal echocardiogram also was performed in 75 patients with migraine (83.3%).

Results.—The prevalence of isolated atrial septal aneurysm was higher in patients with migraine with aura (28.5%) than in patients with migraine without aura (3.6%) (P < .005) or in control subjects (1.9%) (P < .005).

Conclusions.—Our data suggest a role of atrial septal aneurysm in the genesis of aura in patients with migraine.
Sumatriptan Plus Metoclopramide in Triptan‐Nonresponsive Migraineurs
Authors: Schulman Elliott A. , Dermott Kathleen F.
Published: July 2003

Objectives.—We evaluated the effectiveness of combination treatment using sumatriptan plus metoclopramide versus sumatriptan alone for the treatment of acute migraine. The patients who were treated had failed to respond to triptans in the past despite adequate doses on at least 2 separate trials of the same triptan or 2 trials involving different triptans.

Background.—There is limited evidence that dopaminergic antagonists may benefit the migraineur by relieving migraine pain and associated symptoms. The exact mechanism of action in migraine is unknown. The postulated action is the inhibition of dopaminergic overactivity. A dopaminergic antagonist, metoclopramide, may improve the efficacy of a 5‐HT1B/1D agonist, sumatriptan.

Methods.—In this double‐blind, randomized, crossover study, 16 adult migraineurs fulfilling International Headache Society (IHS) criteria for migraine with or without aura who had failed to receive adequate relief from triptans treated one migraine with each treatment: sumatriptan 50 mg plus metoclopramide 10 mg or sumatriptan 50 mg plus placebo to match metoclopramide. Patients treated their migraines when they were moderate or severe in intensity and recorded pain severity and symptoms prior to treatment and 30, 60, 90, and 120 minutes and 24 hours after treatment.

Results.—Thirteen women and 3 men (mean age, 40 years) completed the study; ie, treated 2 migraines (a total of 32 migraines), one attack with each treatment. Meaningful relief was attained in 10 (63%) of 16 migraines treated with the combination of sumatriptan 50 mg plus metoclopramide 10 mg compared with 5 (31%) of 16 migraines treated with sumatriptan 50 mg plus placebo. Headache response (moderate or severe to mild or no pain at 2 hours) was achieved in 7 (44%) of 16 migraines with the combination of sumatriptan 50 mg plus metoclopramide 10 mg compared with 5 (31%) of 16 migraines treated with sumatriptan 50 mg plus placebo. There did not appear to be a difference between treatment groups with respect to associated symptoms. The combination of sumatriptan 50 mg plus metoclopramide 10 mg was well tolerated.

Conclusions.—Combining sumatriptan with metoclopramide provided relief in some migraineurs who failed to achieve adequate relief with a triptan alone. It remains unknown whether initiating therapy when pain was mild or using a higher dose of sumatriptan (ie, 100 mg) would have provided additional benefit. Further studies are indicated.
Almotriptan Versus Rizatriptan in Patients With Migraine in Spain
Authors: Leira Rogelio , Dualde Elena , Del Barrio Horacio , Machuca Manuel , López‐Gil Arturo ,   Spanish Group for the Study of Triptan Consumption in Community Pharmacies
Published: July 2003

Objectives.—To compare patient‐reported use of rizatriptan 10 mg with that of almotriptan 12.5 mg per migraine attack (24 hours) in a Spanish population.

Methods.—One hundred twenty Spanish community pharmacies recruited patients with migraine to whom they had dispensed almotriptan and rizatriptan. No other selection criteria were used. Patients kept diaries for baseline pain intensity, the number of triptan tablets used, additional medication taken per attack, and their degree of satisfaction with the medication 2 hours after the initial dose. Patients recorded details for a maximum of 3 attacks. Analysis of variance or the Student t test and chi‐squared or Fisher exact tests were used for univariate comparisons. A generalized estimating equation method was used to correct for within‐subject variability. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results.—One hundred twenty‐six patients (85% women) recorded data for 318 migraine attacks. Rizatriptan was used to treat 122 attacks, almotriptan was used to treat 110 attacks, and a nontriptan medication was used in the initial treatment of 86 attacks. Triptan use (adjusted mean, 95% CI) per attack in this study was lower for rizatriptan (1.19 tablets; 95% CI, 1.06 to 1.32) than for almotriptan (1.43 tablets; 95% CI, 1.30 to 1.56; P= .003). The use of a triptan and additional medication per attack increased with baseline pain severity. Rizatriptan was used to treat more attacks with only one tablet (78%) than almotriptan (58%). Treatment of attacks with almotriptan was more than twice as likely to involve the use of more than one tablet per attack (24 hours) than those treated with rizatriptan (adjusted OR, 2.42; 95% CI, 1.37 to 4.30; P= .003). Patient satisfaction with treatment response at 2 hours was more than 2‐fold greater for rizatriptan (85%) than for almotriptan (68%) (adjusted OR, 2.55; 95% CI, 1.11 to 5.87; P= .03).

Conclusions.—In this prescription‐selected Spanish population, a significantly lower number of rizatriptan tablets were required to treat migraine attacks compared with almotriptan. Further, patients were more than twice as likely to use more than one tablet or additional medication (or both) for attacks treated with almotriptan than for those treated with rizatriptan. Although these data suggest that rizatriptan may be a more effective treatment for migraine than almotriptan, further randomized studies are required to confirm this conclusion.
Burden of Migraine in Brazil: Estimate of Cost of Migraine to the Public Health System and an Analytical Study of the Cost‐Effectiveness of a Stratified Model of Care
Authors: Bigal Marcelo E. , Rapoport Alan M. , Bordini Carlos A. , Tepper Stewart J. , Sheftell Fred D. , Speciali José G.
Published: July 2003

Background.—The search for rationality in health expenses in developing countries collides with the lack of effectively conducted epidemiologic studies.

Purpose.—To present an estimate of the impact and costs of migraine in the Brazilian public health system and to estimate the impact on these costs and the effectiveness of a model of stratified care in the management of migraine.

Methods.—An analytical model of utilization of the Brazilian public health system was constructed. Data refer to 1999 and were obtained in accordance with the following steps: (1) Brazilian demographic characteristics; (2) characteristics of the public health system related to its 3 hierarchical levels—primary, secondary, and tertiary care, the last being subdivided into emergency department and hospital care; and (3) estimation of the number of migraine consultations at each complexity level. In Brazil, migraineurs seen in the public health system are most often discharged with an acute treatment, usually a nonspecific medication. We compared this treatment with a proposed stratified care model that uses a triptan as an acute care medication.

We have made the following assumptions: (1) 15% of the patients would fall into the Migraine Disability Assessment (MIDAS) grade I category, 25% would fall into the MIDAS grade II category, 30% into the grade III category, and 30% into the MIDAS grade IV category; (2) the mean number of migraine attacks per year are: MIDAS I, 7.49; MIDAS II, 8.02; MIDAS III, 12.22; and MIDAS IV, 27.01. The annual costs of the treatment were calculated according to the following equation: AC = P × N × C + P × Cp + P × Cat × AMA, where P is the number of patients; N, the number of consultations per patient; C, the cost of consultation per level; Cp, the cost of preventive drugs; Cat, the cost of acute therapy drugs; and AMA is the number of migraine attacks per year.

Results.—The public health system resources included 55 735 ambulatory units (primary and secondary) and 6453 emergency department and public hospital units, with a corresponding budget of US $2 820 899 621.26. The estimated cost of a consultation on the primary care level was US $11.53; on the secondary care level, US $22.18; in the emergency department, $34.82; and for hospitalization, US $217.93. The total estimated public health system expenses for migraine were US $140 388 469.60. The proposed model would imply a cost reduction of 6.2% (US $7 514 604.40) with an improvement in the quality of the public health system from the actual 18.2% to an estimated 84.5%.

Conclusion.—Migraine seems to pose a huge burden on the Brazilian public health system. The implementation of a stratified care model of treatment that would include specific acute migraine therapies could result in a dramatic increase in the quality of migraine care and a significant reduction in cost.
Posttraumatic Headache: Biopsychosocial Comparisons With Multiple Control Groups
Authors: Tatrow Kristin , Blanchard Edward B. , Hickling Edward J. , Silverman Daniel J.
Published: July 2003

Objective.—This study examined somatic, psychological, and cognitive functioning of subjects with posttraumatic headache in comparison with multiple control groups.

Background.—Posttraumatic headache is not as widely studied as other forms of headache (eg, tension‐type, migraine). Previous research has suggested poor psychological functioning in patients with posttraumatic headache in comparison with other groups of patients with pain; however, this group has yet to be compared with a group of persons who have experienced trauma but are headache‐free.

Design and Methods.—Nineteen subjects with posttraumatic headache were studied, with full assessments available for 14 participants. Comparison groups, containing 16 participants each, included another headache group, a nonheadache group, and a trauma (motor vehicle accident) survivor nonheadache group. Participants completed several measures assessing somatic, psychological, and cognitive functioning.

Results.—Findings revealed that the posttraumatic headache group exhibited significantly poorer functioning than the comparison groups on several measures including the Psychosomatic Symptom Checklist, Postconcussion Syndrome Checklist, axis II psychiatric diagnoses, Minnesota Multiphasic Personality Inventory, and the Daily Hassles Scale (frequency and total). Additionally, they scored higher on the following: number of axis I psychiatric diagnoses, the Daily Hassles Scale (intensity), Beck Depression Inventory, State‐Trait Anxiety Inventory, and State‐Trait Anger Expression Inventory. The posttraumatic headache group was similar to the other trauma group on the Posttraumatic Stress Disorder Symptom Checklist and the Life‐Trauma Checklist.

Conclusions.—This study confirmed the distress seen in this understudied population of persons with headache and highlights areas of focus for proper assessment and treatment of those with headache and who have had an accident.
Use of the Migraine Disability Assessment Questionnaire in Children and Adolescents With Headache: An Italian Pilot Study
Authors: D'Amico D. , Grazzi L. , Usai S. , Andrasik F. , Leone M. , Rigamonti A. , Bussone G.
Published: July 2003

Objectives.—To determine the suitability of the Migraine Disability Assessment (MIDAS) Questionnaire for assessing disability in children and adolescents with headache and to obtain preliminary information about disability in different primary headaches.

Background.—During the last decade, researchers have begun to employ standardized methodologies to investigate the global impact of primary headaches. Disease‐specific instruments have been developed to measure headache‐related disability. The MIDAS Questionnaire, which is the most extensively studied of these instruments, was designed to assess the overall impact of headaches over the 3 months before compilation. The MIDAS Questionnaire is an optimal tool to assess headache‐related disability in adults.

Methods.—Ninety‐five patients aged 7 to 17 years with tension‐type headache, migraine, or both completed the validated Italian form of the MIDAS questionnaire on 2 occasions. Test‐retest reliability was assessed by the Spearman rank correlation test. The Cronbach α assessed internal consistency. The patients answered questions about the adequacy of the questionnaire.

Results.—The Cronbach α was .8. Correlation coefficients were generally high for the overall MIDAS score and for the items investigating disability in school and in family/leisure activities; they were lower for the items about housework. Most patients thought that the MIDAS Questionnaire was useful (98.9%) and that it captured the impact of their headaches (58.9%); 41% thought that questions about disability in housework were useless, 44.2% suggested adding questions regarding inability to do homework. All primary headaches had a considerable impact on daily activities, but patients with migraine tended to have lower headache frequencies and lower total disability time; those with tension‐type headache suffered more days in which activities, although performed, were substantially impaired.

Conclusions.—The MIDAS Questionnaire is useful for assessing disability in children and adolescents with different primary headaches. Minimal changes in the phrasing and content of the items would be sufficient to render the MIDAS specific for the younger population with headache.
Prevalence of Headache in Puerto Rico
Authors: Miranda Héctor , Ortiz Gilberto , Figueroa Sandra , Peña Diana , Guzmán Josué
Published: July 2003

Background.—Headache is one of the most frequently reported disorders in the general adult population. Despite the fact that this disorder is common, no official estimate of the prevalence of headache exists in Puerto Rico.

Purpose.—To examine the prevalence of headache and migraine, specifically, in Puerto Rico.

Methods.—A telephone survey of 1610 individuals was conducted. The telephone calls were distributed using the 1990 census adjusted to the population of Puerto Rico in 1998, and according to gender, geographical area, and age.

Results.—The prevalence of headache in Puerto Rico was 35.9% and migraine, in particular, 13.0%. When prevalence was fractionated by age, gender, and geographical areas, the prevalence of headache was similar for all ages, with females exhibiting a 2:1 preponderance over males. In the younger population (between 20 and 50 years of age), the female‐male ratio for migraine was 3:1, and the prevalence for migraine was lower in the Metropolitan area.

Conclusion.—This study, the first of its type in Puerto Rico, demonstrates that headache (and migraine specifically) is a common disorder in this country.
Aspects of Referral Care for Headache Associated With Improvement
Authors: Salvesen Rolf , Bekkelund Svein Ivar
Published: July 2003

Objective.—To assess which aspects of referral care for headache are associated with improvement of pain and subjective quality of life.

Background.—In managed care, referrals to a specialist are sometimes kept to a minimum. It has been questioned whether patients with headache do better after consultation with a specialist.

Methods.—We mailed a questionnaire to all patients referred for headache to a neurologic center in northern Norway during a 2‐year period (n = 1403). The questionnaire included items concerning diagnosis and treatment, along with simple visual analog scales to assess whether the patient's headache syndrome and self‐perceived quality of life had changed after seeing the specialist.

Results.—There were 1052 responders (75%). Headache generally decreased after consultation with a specialist; it decreased significantly more in the 527 patients who were assigned a diagnosis compared to the 344 patients who claimed they were not. Reduction of headache also was significantly more obvious in the 483 patients who had treatment prescribed, as compared to the 385 patients not receiving any therapeutic measure. Self‐perceived quality of life was generally improved, significantly more when the patient was given a diagnosis, and even when the diagnosis did not lead to treatment.

Conclusions.—Patients referred to a neurologic center for evaluation of headache generally experience a significantly greater improvement in their headache syndrome and quality of life. This appears particularly so when they receive a diagnosis, even if no treatment is prescribed.
Topiramate in the Prophylactic Treatment of Cluster Headache
Authors: Láinez Miguel J. A. , Pascual Julio , Pascual Ana M. , Santonja Jose M. , Ponz Alejandro , Salvador Antonio
Published: July 2003

Objective.—The role of topiramate in the prophylactic treatment of cluster headache is still unclear. The aim of this study was to evaluate the effectiveness of topiramate in a group of patients with refractory episodic or chronic cluster headache.

Background.—Proof of efficacy of preventive treatment of cluster headache is limited, especially for the chronic form of the disorder. There are very few randomized clinical trials on this condition with topiramate or other new anticonvulsant agents. Recent case reports and series involving topiramate have shown good results. The mechanism of action of topiramate is unknown, but is presumably mediated by γ‐aminobutyric acid.

Methods.—Twenty‐six patients with episodic (n = 12) or chronic (n = 14) cluster headache were studied prospectively. All patients had been treated with some preventive treatment, with poor or no response. Treatment with topiramate was initiated with 25 mg once a day, and the dose was titrated every 3 to 7 days to a maximum of 200 mg, according to clinical response and tolerability.

Results.—Topiramate rapidly induced cluster remission in 15 patients, reduced the number of attacks more than 50% in 6 patients, and reduced the cluster period duration in 12. The mean time to remission was 14 days (range, 1 to 27), but in 7 patients remission was obtained within the first days of treatment with very low doses (25 to 75 mg a day). Tolerability was good within the lower range of doses used. Six patients discontinued treatment due to side effects (all with daily doses over 100 mg) or lack of efficacy.

Conclusions.—Our results confirm that topiramate can be an effective option for the preventive treatment of episodic and chronic cluster headache.
Software Reuse Reference Model Approach in Developing an Automated Medical Information System (AMIS) for Improving Health Care Practice
Authors: Khatri Anil , Rine David C. , Khatri Sadhna
Published: July 2003

Objective.—To evaluate patient acceptance of an automated medical information system specific to headache.

Background.—Studies suggest that automated tools may help health care delivery systems to be efficient and effective, but patient satisfaction remains a major concern.

Methods.—We adapted our software reuse reference model and Unified Modeling Language to apply the domain model to the headache population. Patients with headache were tested both to validate the system and to evaluate patient satisfaction and headache management with an automated system.

Results.—The mean age of all study participants was 44 years. Over 95% of the participants were satisfied or strongly satisfied with the Automated Medical Information System.

Conclusions.—The results strongly suggest that patients are willing and able to use nontraditional sources, such as the Automated Medical Information System, to learn about their illnesses.
Dental Status and Oral Health of Patients with Epilepsy: An Epidemiologic Study
Authors: Károlyházy Katalin , Kovács Eszter , Kivovics Péter , Fejérdy Pál , Arányi Zsuzsanna
Published: July 2003

Summary:  Purpose: We performed a dental survey of epilepsy patients to examine their oral health by statistical means and to provide a guide for the dental treatment of these patients.

Methods: We first set up four “dental” subgroups of epilepsy patients, based on the types of seizures, seizure frequency, and mental state. One hundred one patients underwent a survey concerning their dental, medical, and epilepsy histories, followed by a dental examination. Indexes quantifying oral hygiene, the number and condition of the remaining teeth, periodontium, and the degree of prosthetic treatment were measured. An age‐matched control group of general (nonepilepsy) population underwent an identical dental examination. Statistical comparison was performed between the patient and the control groups and between subgroups of epilepsy patients.

Results: In almost all aspects of oral health and dental status, patients with epilepsy showed a significantly worse condition compared with the control group. Comparison of the subgroups of epilepsy patients revealed that the most severe findings concern patients who have poorly controlled epilepsy, especially those who have frequent generalized tonic–clonic seizures.

Conclusions: The observed difference probably results from a combination of factors such as the effect of the seizures themselves, socioeconomic conditions, and the negative attitude of dentists. We recommend that the planning of dental treatment of such patients should start with the assessment of their disease and determination of the “dental” subgroup to which they belong. For each subgroup, specific recommendations for interventions are given.
Confirmation of Nonconvulsive Limbic Status Epilepticus with the Sodium Amytal Test
Authors: Burneo Jorge G. , Knowlton Robert C. , Gomez Camilo , Martin Roy , Kuzniecky Ruben I.
Published: July 2003

Summary:  Is it a seizure? This question can be difficult for a clinician to answer, and it may be more critical if the possible seizure lasts >30 min. Long‐duration questionable seizure activity changes the question to, “Is it status epilepticus?”

Status epilepticus (SE) can be divided into convulsive and nonconvulsive types. Convulsive SE is the most easily recognized, whereas nonconvulsive SE is more clinically variable and controversial. The term nonconvulsive SE is more often applied to patients who are severely obtunded or comatose with minimal or no motor movements, or in a stupor of altered consciousness reflecting generalized ictal activity. Nonconvulsive SE also can be caused by focal seizure activity, sometimes restricted to deep small volumes of brain in which scalp EEG may not be diagnostic.

We present the case of a patient who had dominant limbic hippocampal SE, but in whom the diagnosis could not be confirmed until a modified novel use of the sodium amytal test was performed.
Outcome of Surgical Treatment in Familial Mesial Temporal Lobe Epilepsy
Authors: Kobayashi Eliane , D'Agostino Maria Daniela , Lopes‐Cendes Iscia , Andermann Eva , Dubeau François , Guerreiro Carlos A. M. , Schenka André A. , Queiroz Luciano S. , Olivier André , Cendes Fernando , Andermann Frederick
Published: July 2003

Summary:  Purpose: To describe postoperative outcome in patients with familial mesial temporal lobe epilepsy (FMTLE).

Methods: We studied FMTLE patients who underwent surgical treatment for refractory seizures. FMTLE was defined when at least two individuals in a family had a clinical EEG diagnosis of MTLE. Preoperative investigation included magnetic resonance imaging (MRI), interictal/ictal EEGs, and neuropsychological evaluation. We used Engel's classification for postoperative outcome.

Results: To date, 20 FMTLE patients have been operated on, with 1.6 to 9.8 years of follow‐up (mean, 5.5 years). Hippocampal atrophy (HA) and other signs of mesial temporal sclerosis (MTS) were present in 18 patients (15 unilateral). Seizures were recorded in 19 patients. Seventeen (85%) patients are in class I. Two patients had normal hippocampal volumes (HcV): one (5%) is in class II and the other (5%) in class IV (extratemporal seizures developed after surgery). One (5%) patient had bilateral HA and is in class III. Qualitative histopathology showed MTS with different degrees of severity.

Conclusions: Refractory FMTLE patients have good surgical outcome when unilateral or clearly asymmetric HA is identified. Preoperative investigation should be the same as that in patients with sporadic refractory MTLE.
Evidence for S284L Mutation of the CHRNA4 in a White Family with Autosomal Dominant Nocturnal Frontal Lobe Epilepsy
Authors: Rozycka Agata , Skorupska Elzbieta , Kostyrko Andrzej , Trzeciak Wieslaw H.
Published: July 2003

Summary:  Purpose: To identify mutations of the neuronal nicotinic acetylcholine receptor α4 subunit gene (CHRNA4) responsible for autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) in a group of white patients.

Methods: A group of 47 patients from 21 unrelated families with ADNFLE were screened for mutations in CHRNA4. Clinical features and EEG findings in the patients were consistent with those reported in the literature for other affected families. The entire gene was amplified from genomic DNA by polymerase chain reaction (PCR) followed by multitemperature single‐strand conformation polymorphism analysis (MSSCP) and sequencing.

Results: A c.851C>T transition in exon 5 of CHRNA4 was identified in three affected individuals from two generations of the same family, but not in the remaining patients or in 100 healthy volunteers. This mutation caused an S284L substitution in the transmembrane domain M2 segment of the α4 subunit of the neuronal nicotinic acetylcholine receptor. The same mutation had previously been detected in a single Japanese family with ADNFLE, and in an Australian woman with a sporadic form of NFLE.

Conclusions: This is the first report of an occurrence of c.851C>T transition in a white family with ADNFLE.
Expressed Emotion in the Relatives of People with Epileptic or Nonepileptic Seizures
Authors: Stanhope Nicola , Goldstein Laura H. , Kuipers Elizabeth
Published: July 2003

Summary:  Purpose: This study investigated Expressed Emotion (EE) in relatives of people with epileptic or nonepileptic seizures (NES).

Methods: In a cross‐sectional study, we used the Five‐Minute Speech Sample to explore EE in the key relative of people with epilepsy (n = 36) and those with NESs (n = 21), as well as levels of anxiety and depression and use of coping strategies.

Results: A significantly greater proportion of relatives of NES than epilepsy patients were rated as high EE. Hostility was evident in more high‐EE epilepsy than high‐EE NES relatives, whereas emotional overinvolvement and positive relationship ratings tended to be more common in high‐EE NES relatives. High‐ and low‐EE epilepsy relatives used problem‐focused as opposed to emotion‐focused coping strategies significantly more than half the time. High EE and seizure frequency were not associated. Age at onset of the disorder was higher in epilepsy patients with high‐ than with low‐EE relatives.

Conclusions: Irrespective of etiology, carers for people with seizure disorders may find it hard to adjust to the difficulties these disorders create. Interventions that encourage problem‐solving, reappraisals of “loss” and education regarding the causes of some of the patients' behavioral and mood problems seem likely to be beneficial.