bluuebunny/crossref_metadata_2025 huggingface dataset:
Implications for the Establishment of Accelerated Fatigue Test Protocols for Prosthetic Heart Valves
Authors: Iwasaki Kiyotaka , Umezu Mitsuo , Iijima Kazuo , Imachi Kou
Published: March 2003

Abstract: The goal of this research is to establish a reliable methodology for accelerated fatigue tests of prosthetic heart valves. A polymer valve was the subject, and the influence of various drive parameters on durability was investigated in three different machines. Valve lifetime was notably shortened by increasing the cyclic rate or stroke even though the maximum pressure difference at valve closure was maintained at 120 mm Hg. These results demonstrate that adjustment of the maximum transvalvular pressure is not sufficient to ensure tests are conducted under the same conditions and indicate that measurement of the dynamic load would be more efficacious. Moreover, the locations of tears sustained in the accelerated tests differed from those encountered in an animal experiment although in both cases the locations were entirely consistent with the areas of strain concentration revealed by finite element analysis. These findings should be discussed during a revision of ISO 5840.
Computational Fluid Dynamics and Vascular Access
Authors: Krueger Ulf , Zanow Juergen , Scholz Hans
Published: March 2003

Abstract: Anastomotic intimal hyperplasia caused by unphysiological hemodynamics is generally accepted as a reason for dialysis access graft occlusion. Optimizing the venous anastomosis can improve the patency rate of arteriovenous grafts. The purpose of this study was to examine, evaluate, and characterize the local hemodynamics and, in particular, the wall shear stresses in conventional venous end‐to‐side anastomosis and in patch form anastomosis (Venaflo) by three‐dimensional computational fluid dynamics (CFD). We investigated the conventional form of end‐to‐side anastomosis and a new patch form by numerical simulation of blood flow. The numerical simulation was done with a finite volume‐based algorithm. The anastomotic forms were constructed with usual size and fixed walls. Subdividing the flow domain into multiple control volumes solved the fundamental equations. The boundary conditions were identical for both forms. The velocity profile of the patch form is better than that for the conventional form. The region of high static pressure caused by flow stagnation is reduced on the vein floor. The anastomotic wall shear stress is decreased. The results of this study strongly support patch form use to reduce the incidence of intimal hyperplasia and venous anastomotic stenoses.
Computational Fluid Dynamics and Stent Design
Authors: Frank Andreas O. , Walsh Peter W. , Moore James E.
Published: March 2003

Abstracts: Stents are small, usually metallic tubes that are intended to prop open arteries blocked with atherosclerotic plaques. While stents have been used successfully in recent years, they still suffer from failure due to development of new tissue in stented segment (restenosis). Variations in the failure rates associated with different stent designs have led researchers to investigate the role of near‐wall flow patterns. While there is no direct evidence yet, the patterns of flow stagnation as the blood flows past the stent struts may affect the restenosis process. Computational fluid dynamics (CFD) approaches are well suited for obtaining detailed information on stent flow patterns. Many CFD simulations make use of a two‐dimensional model. The strong dependence of flow stagnation on stent strut spacing has been clearly demonstrated. These results have been employed to interpret the results of in vitro experiments designed to elucidate the mechanisms of restenosis.
Effects of Mild Hypothermic Cardiopulmonary Bypass on Blood Viscoelasticity in Coronary Artery Bypass Grafting Patients
Authors: Ündar Akif , Vaughn William K.
Published: March 2003

Abstract:The purpose of this study was to determine the changes in blood viscoelasticity during and after coronary artery bypass grafting (CABG) and to identify correlations between blood viscoelasticity and patients' age, duration of cardiopulmonary bypass (CPB), and cross‐clamp time. After Institutional Review Board approvals, patients (n = 10) who were subjected to mild hypothermic CPB were included in this study. Viscosity and elasticity were measured at strains of 0.2, 1, and 5 using a Vilastic‐3 Viscoelasticity Analyzer. Arterial blood samples were collected pre‐CPB, on normothermic CPB, hypothermic CPB, after rewarming, and after CPB. Viscosity and elasticity at strains of 0.2 and 1 were altered significantly during and after CPB compared to the pre‐CPB (p < 0.01). In particular, elasticity of blood was diminished during normothermic bypass and could not be recovered after CPB (p < 0.01). Although there were strong correlations between blood viscoelasticity, duration of CPB, and cross‐clamp time on normothermic CPB, only the patients' age showed a positive correlation between viscosity (r = 0.61, p = 0.05), and elasticity (r = 0.89, p < 0.001) after CPB. These results suggest that mild hypothermic CPB alters the blood viscoelasticity during and after CABG.
Centrifugal Pump Support for Distal Aortic Perfusion During Repair of Traumatic Thoracic Aortic Injury
Authors: Walls Joseph T. , Curtis Jack J. , McKenney‐Knox Charlotte A. , Schmaltz Richard A.
Published: March 2003

Abstract: Paraplegia from ischemic injury of the spinal cord and renal failure from inadequate perfusion of the kidneys may occur from aortic cross‐clamping during repair of traumatic thoracic aortic injuries. After Institutional Review Board approval, we retrospectively reviewed the charts of 26 patients surgically treated for traumatic transection of the descending thoracic aorta during a 14 year period (1987–2001), using centrifugal pump (Sarns) support for distal aortic perfusion. The study group comprised 19 males and 7 females, whose ages ranged from 15 to 69 years. For all but 1 patient, who fell from a flagpole, the injuries were incurred in motor vehicle accidents. Aortic cross‐clamp time lasted between 5 to 78 min (median = 40 min). Mean arterial pressure ranged from 50 to 80 mm Hg (median = 70 mm Hg). All patients survived operation without developing paraplegia or renal failure. Distal centrifugal pump perfusion during repair of traumatic injury of the descending thoracic aorta is a valuable adjunct during surgical treatment and aids in preservation of spinal cord and renal function.
Biodiversity Value, Status, and Strategies for Conservation of Sacred Groves of Meghalaya, India
Authors: Tiwari B.K. , Barik S.K. , Tripathi R.S.
Published: March 2003

ABSTRACT

The tribal communities of Meghalaya in northeast India—Khasis, Garos, and Jaintias—have a tradition of environmental conservation based on various religious beliefs which have been passed on from one generation to the other. Based on these beliefs, certain patches of forests are designated as sacred groves under customary law and are protected from any product extraction by the community. Such forests are very rich in biological diversity and harbor many endangered plant species including rare herbs and medicinal plants. Seventy‐nine sacred groves were located, denoted on a geographical map of Meghalaya, and studied for their biodiversity value, status, and vegetation characteristics. A baseline floristic survey revealed that at least 514 species representing 340 genera and 131 families were present in these sacred groves. The status of sacred groves was ascertained through canopy cover estimate. A little over 1.3% of total sacred grove area was undisturbed, 42.1% had relatively dense forest, 26.3% had sparse canopy cover, and 30.3% had open forest. The vegetation characteristics and species diversity of an undisturbed sacred grove were compared with that of an unprotected disturbed forest. The species diversity indices were higher for the sacred grove than for the disturbed forest. The species composition and community characteristics differed significantly between the two forests. Sociocultural aspects of sacred grove conservation were analyzed, and views of the local people were enlisted. Based on the findings, conservation strategies for sacred groves were suggested.
Beyond the Rhetoric of Premeditated Murder: Toward a Rational and Compassionate Environmentalist Perspective about the Ethics of Risk Assessment
Authors: Tal Alon
Published: March 2003

ABSTRACT

The philosophical basis for opposition and support of risk assessment by environmentalists is considered. Opponents’ perspective is dominated by “empathy” for individual victims, theoretical and identifiable, who suffer morbidity or mortality due to environmental pollution. Proponents’ perceive optimization of aggregate public health as the ethical imperative. Taken to their extreme, these positions lead to angry rhetoric in their mutual efforts to discredit the opposing view, without considering whether it is possible to integrate the legitimated impulses that lie behind the two perspectives. This essay presents one such synthesis that both accepts the inevitability of risk assessment (and in many cases its importance) as a decision analytic tool but also integrates many of the noble convictions that lie behind the critique when victims are clearly identifiable. As ecological risk assessment becomes an increasingly developed tool for decision‐making about managing ecosystem health, many of the same arguments are certain to be wielded. A balanced philosophical approach to this new discipline has the potential to expedite a more rational and ultimately protective public policy while conveying an important societal message about compassion and respect for the sanctity of life.
The Role of Surveillance in Interventions Directed Against Vector‐Borne Disease
Authors: Spielman Andrew
Published: March 2003

ABSTRACTTo analyze the contribution of epidemiological surveillance to the sustainability of public health interventions, programs designed to suppress prevalence of vector‐borne infections are contrasted with those aiming to contain outbreaks of such agents of disease. Suppression programs apply insecticides or drugs according to a predetermined plan, employing surveillance solely for evaluating progress. Containment programs, in contrast, react to epidemiological indicators. Although efforts to suppress prevalence should be time‐limited, reactive programs may be indefinitely sustainable. Alternative epidemiological bases for surveillance are described, including indicators for the basic reproduction number of infections, vectorial capacity, reservoir capacity, entomological inoculation rates (EIR), and transmission indices (TI) based on experience. Although risk of human infection is most reliably estimated as a function of the EIR, interventions are most frequently guided by TI estimates. Because they invest in surveillance rather than application of insecticides or drugs, containment efforts are more sustainable and more conducive to ecosystem health than are programs designed to suppress transmission.
Living with Great Lakes Chemicals: Complementary Strategies and Cross‐Paradigm Reconciliation *
Authors: Gilbertson Michael
Published: March 2003

ABSTRACTThe exposure of Great Lakes populations of fish, wildlife, and humans to persistent toxic substances has resulted in injury, particularly related to reproductive and developmental processes. TheGreat Lakes Water Quality Agreementof 1978 is a binational instrument designed by the governments of the United States and Canada to respond to this injury through the development and implementation of common water quality objectives, cooperative regulatory programs, and other measures. The implementation of theGreat Lakes Water Quality Agreementhas entered a critical phase because the ambiguously drafted purpose is interpreted differently by toxicologists and ecologists with consequent misunderstandings in preparing Remedial Action Plans and Lakewide Management Plans, selecting indicators of restoration, and selecting critical pollutants. With shrinking budgets, agencies cannot afford such misunderstandings when injury to health and property continues unabated.
Forest Health Monitoring in Australia: National and Regional Commitments and Operational Realities
Authors: Stone Christine , Old Ken , Kile Glen , Coopst Nicholas
Published: March 2003

This review examines national and regional approaches and challenges to forest health monitoring in Australia. Divergent management priorities for forests and plantations within Australia have resulted in differing interpretations of what is meant by forest health. This in turn has influenced the approaches taken to monitoring forest health. The commercial forest sector has taken a simplistic approach, focusing on the surveillance of tree condition and the extent of damaging agents that directly affect tree productivity. Resources for this task are generally restricted to high‐value plantations. In order to fulfil their obligations to sustainable forest management most State forestry agencies are committed to developing regional Sustainable Forest Management monitoring programs. At the federal level there is a commitment to complying with several international conservation agreement including the Montreal Process. Forest health in these programs tends to be poorly defined. Some States have established, or are planning monitoring programs based on intensive measurements in permanent sites or plots. While current forest health monitoring programs in Australia are state‐based, the need for coordination and compatibility of assessment and reporting systems is recognized. Several national and state fora exist, for example, the national Forest Health Committee and the state‐based Forest Health Advisory Committees. These groups have the potential to develop and coordinate the linkage from the regional‐based forest health monitoring programs up to the national level. A major driver of this process, however, will be individual State's priorities and available resources and funding.
The Consequences of Landscape Change on Ecological Resources: An Assessment of the United States Mid‐Atlantic Region, 1973‐1993
Authors: Jones K. Bruce , Neale Anne C. , Wade Timothy G. , Wickham James D. , Cross Chad L. , Edmonds Curtis M. , Loveland Thomas R. , Nash Maliha S. , Riitters Kurt H. , Smith Elizabeth R.
Published: March 2003

ABSTRACT Spatially explicit identification of changes in ecological conditions over large areas is key to targeting and prioritizing areas for environmental protection and restoration by managers at watershed, basin, and regional scales. A critical limitation to this point has been the development of methods to conduct such broad‐scale assessments. Field‐based methods have proven to be too costly and too inconsistent in their application to make estimates of ecological conditions over large areas. New spatial data derived from satellite imagery and other sources, the development of statistical models relating landscape composition and pattern to ecological endpoints, and geographic information systems (GIS) make it possible to evaluate ecological conditions at multiple scales over broad geographic regions. In this study, we demonstrate the application of spatially distributed models for bird habitat quality and nitrogen yield to streams to assess the consequences of landcover change across the mid‐Atlantic region between the 1970s and 1990s. Moreover, we present a way to evaluate spatial concordance between models related to different environmental endpoints. Results of this study should help environmental managers in the mid‐Atlantic region target those areas in need of conservation and protection.
Platelet Responsiveness in Migrainous Children During Headache‐Free Period
Authors: Tozzi E. , Tozzi‐Ciancarelli M.G. , Di Massimo C. , Mascioli A. , Angelini R. , de Matteis F.
Published: March 2003

Results of this study confirm the link between migrain and alterations of platelet responsiveness. Our data suggest that in migraineurs the perturbated platelet microviscosity analyzed by means of fluorescence polarization, appears responsible for the decrease of stimulation‐induced influx of external calcium through the platelet membrane. These findings suggest that platelet membrane microviscosity may be considered as a more significant platelet marker of migraine rather than the well‐known and nonspecific phenomenon of platale: hyperaggregation, evaluated by time‐transmittance variations induced by adenosine diphosphate and collagen.
Clusterlike Headache as a First Sign of Brain Metastases of Lung Cancer
Authors: Tajti J. , Sas K. , Szok D. , Vörös E. , Vécsei L.
Published: March 2003

We report on a patient with clusterlike headache and multiple brain metastases of lung cancer. Initially, cluster headache was suggested clinically by characteristic symptoms without any focal central nervous system signs. However, magnetic resonance imaging demonstrated multiple brain metastases. It is possible that tumor necrosis factor may have played a role in initiating the clusterlike headache.
Self‐reported Disability Due to Headache: A Comparison of Clinic Patients and Controls
Authors: Ziegler Dewey K. , Paolo Anthony M.
Published: March 2003

Objective.‐To compare the self‐reported disability of headache sufferers who seek medical assistance with those who do not seek such help and determine possible relationships between perceived disability and psychological factors.

Method.‐Subjects were 51 headache patients and 53 persons without medical assistance for their headache within the past 2 years. All subjects completed a structured interview that gathered headache data, a headache disability scale, and the Minnesota Multiphasic Personality Inventory‐Revised (MMPI‐2).

Design.‐A 2 x 2 ANCOVA design was employed. Subject group (patient vs control) was the first factor and headache type (migraine vs mixed) was the second. Covariates were headache intensity and five subscales of the MMPI‐2. Dependent variables were the seven subscales of the headache disability scale. Stepwise discriminant analysis was conducted to determine which factors best classified subjects as patients or controls.

Setting.‐University Medical Center headache clinic.

Results.‐Clinic patients reported significantly greater disability on their occupation than controls‐a difference emerging after controlling for level of headache pain and personality variables. Patients differed from controls, although not significantly, in the rank order of life activities most affected by headache. Discriminant analysis revealed that self‐reported disability for occupation and the Hysteria scale from the MMPI‐2 best differentiated the groups.
Practice and Economics Cost Considerations in Headache Treatment Part 2: Acute Migraine Treatment
Authors: Von Seggern Randal L. , Adelman James U.
Published: March 2003

Today's physician has many useful medication options available for acute migraine treatment. There is a wide cost range among these drugs and today’s health care environment demands that cost be factored into the decision process. Effective migraine abortive treatment decreases the costs of repeat dosing and disability. Early use of migraine abortive medication can increase its rapidity of action and effectiveness. Adjunctive medication such as metoclopramide ($0.10) is inexpensive and may improve the effectiveness of the primary abortive medication.

Over‐the‐counter medications such as aspirin ($0.02/325 mg), Excadrin· ($0.09/tablet), ibuprofen ($0.04/200 mg), or naproxen sodium ($0.09/220 mg) are inexpensive and effective. “Triple therapy” combining metoclopramide, a nonsteroidal ant‐inflammatory agent, and an ergotamine preparation may improve tolerance and effectiveness of the ergot. Locally compounded dihydroergotamine nasal spray is inexpensive ($0.78/1 mg spray). The cost of using oral sumatriptan can be almost halved by prescribing half of a 50‐mg tablet.

Emergency department services are expensive. Huge cost savings occur through self‐controlled administration of oral, rectal, or even intramuscular narcotic medications. Oral narcotic agents such as hydromorphone ($0.42/4 mg) and meperidine ($0.92/200 mg) are generally used in inadequate doses to be effective for severe migraine. Guidelines are given for more effective use of these agents.

Sophisticated comparative studies are needed to evaluate, not only the direct costs of medications, but all costs of treatment of an acute migraine attack, as well as Indirect costs to the patient, family, and society.
Enhanced Performance Feedback to Strengthen Biofeedback Treatment Outcome With Childhood Migraine
Authors: Allen Keith D. , Shriver Mark D.
Published: March 2003

Recent research has indicated that both the magnitude and frequency of performance feedback may be important variables in the biofeedback treatment of headaches. The purpose of this research was to determine whether the qualitative and/or quantitative enhancement of performance feedback could improve the efficacy of thermal biofeedback as a treatment for childhood migraine. In a time‐lagged control design, six children with migraine headaches were exposed to thermal biofeedback training and then provided performance feedback reflecting moderate and high success, and, if needed, increased feedback frequency. In four of six subjects, clinically significant reductions in headache activity corresponded directly with the addition of feedback suggesting marked improvement in handwarming relative to peers, even when no improvement in handwarming had actually occurred. In two other subjects, clinically significant changes in headache activity were reported only after performance feedback frequency was increased. The results support the importance of attending to both qualitative and quantitative parameters of feedback as well as skill acquisition during thermal biofeedback treatment of children with migraine.
The Stress Response in Headache Sufferers: Physiological and Psychological Reactivity
Authors: Holm Jeffrey E. , Lamberty Kerri , McSherry William C. , Davis Paul A.
Published: March 2003

When examining headache sufferers' reactivity to stress, few studies attend to differing characteristics of the environment. In this study, we evaluated the influence of the clarity/ambiguity and positive/negative valence of an event on subjects’ physiological and psychological reactivity. Migraine (n=30), tension (n=39) and control (n=35) subjects participated in a laboratory experience in which they had to practice and then deliver a news story to a videocamera (similar to a newscaster on television). During this experience, they received performance feedback and were instructed to try to use the information to improve their performance. In reality, this feedback was noncontingent, with subjects semirandomly assigned to either a positive, negative, or ambiguous feedback condition. Physiological and psychological measures were collected prior to this experience, during an anticipation or practice period prior to the newscast, and during a recovery period following the delivery of the news story. Results suggested that tension subjects might not attend to information from their environment when assessing, responding, or reevaluating potentially stressful events: relying instead on more global beliefs or attributions. Results also indicated that migraine might be associated with a prolonged cardiovascular response (ie, delayed recovery) following a stressful experience.
Repeated Doses of Combined Oral Lysine Acetylsalicylate and Metoclopramide in the Acute Treatment of Migraine
Authors: Hugues F.‐C. , Lacoste J.‐P. , Danchot J. , Joire J.‐E.
Published: March 2003

The combination of lysine acetylsalicylate and metoclopramide is effective in the treatment of migraine attacks. It was unknown whether repeated doses could improve efficacy.

The aim of this open trial was to evaluate the effects of a second, and eventually a third dose of lysine acetylsalicylate and metoclopramide when a first dose of the treatment was ineffective. Patients were asked to take a second dose 2 hours after a first dose when they thought that the first dose was ineffective. They were allowed to take a third dose or their rescue medication 2 hours after the second dose when they judged that the treatment remained ineffective.

Two hundred ninety‐two patients were included in the study; 262 of the 292 patients treated 517 attacks.

Headache relief (reduction in headache severity from grade 3 or 2 to grade 1 or 0) was observed in 54.8% of attacks after one dose, in 48.1% of attacks after a second dose, and in 40.3% of attacks after a third dose.

Complete headache relief without recurrence and without use of a rescue medication was reported in 37% of the total attacks.

The patients judged their treatment as good or excellent in 78% of attacks treated with one dose, in 41% of those treated with two doses, and in 19% of those treated with three doses.

Tolerance, as judged by the patients, was considered good in 92% of treated attacks. Minor side effects occurred in 6% of attacks after a first dose, in 4.5% of attacks after a second dose, in 1.5% of attacks after a third dose, in 2% after unspecified delay, and in 14% overall.

In conclusion, the efficacy of lysine acetylsalicylate and metoclopramide in the treatment of migraine attacks can be improved by repeated doses. It is well tolerated.
Headaches and Face Pains as a Manifestation of Munchausen Syndrome
Authors: Solomon Seymour , Lipton Richard B.
Published: March 2003

Virtually every psychological or physical symptom may be feigned in order to assume a sick role; the term Munchausen syndrome is applied when the physical features are predominant. Complaints of headache as a manifestation of this condition are rare. We report such a case and review the literature of similar cases.

A 34‐year‐old man consulted several headache specialists in different cities. Many different diagnoses were made, consistent with the various histories the patient related. It seems most unlikely that any one individual could experience 14 distinct headache disorders. Dozens of medications were prescribed, and a dozen or more were taken by the patient daily.

People with Munchausen syndrome consciously feign physical symptoms and signs because of the apparently senseless need to assume a sick role. This condition is distinguished from malingering in which the symptoms are consciously feigned for personal gain and from somatoform disorder in which development of symptoms for psychological purposes is unconscious.

Primary headache disorders, once thought to have a psychological basis, are now recognized as biological disorders. Though psychogenic mechanisms have been largely discredited, rarely, as illustrated by the present case, psychological mechanisms are predominant.
Headache in Patients With Neck‐Shoulder‐Arm Pain of Cervical Radicular Origin
Authors: Persson Liselott C.G. , Carlsson Jane Y.
Published: March 2003

In a series of 81 patients with chronic cervicobrachialgia, 54 (67%) reported that they also suffered from recurrent headache. Forty‐four (81%) of these patients were classified as having cervical headache, 5 as having migraine, 2 with tension‐type headache, and 3 patients were not classifiable according to the diagnostic system of the International Headache Society (IHS). Patients with headache presented significantly higher tenderness scores and pain intensity in the neck‐shoulder‐arm region than patients without headaches.

Twenty‐three (52%) of the 44 patients with cervical headache reported that their headache had improved after treatments directed towards their cervicobrachialgia.

The IHS classification system of cervical headache is discussed.
Precipitating Factors of Headache. A Prospective Study in a National Control‐Matched Survey in Migraineurs and Nonmigraineurs
Authors: Chabriat H. , Danchot J. , Michel P , Joire J.E. , Henry P
Published: March 2003

Prospective studies of precipitating factors in migraine are rare. Mig Access is a national control‐matched survey conducted to evaluate the access of migraineurs to health care in France. This study allowed us to screen prospectively some precipitating factors of headache in migraineurs and in nonmigraineurs.

Three hundred eighty‐five migraineurs (group 1) and 313 nonmigraineurs (group 2) kept a diary for a 3‐month period (a total of 35 805 days in group 1 and 29 109 days in group 2). Precipitating factors were reported for each headache period. Headache intensity was self‐assessed during each headache period using a visual analog scale of 0 to 100.

Headache was reported on 4274 days (12%) in group 1 and on 602 days (2%) in group 2. Headache intensity was greater in group 1 (39 ± 20 versus 32 ± 19, P<.05). The most frequent precipitating factors (reported at least once by more than 10% of subjects [range 18% to 80%] in both groups) were fatigue and/or sleep, stress, food and/or drinks, menstruation, heat/cold/weather, and infections in both groups. All these factors except infections were reported to cause headache more frequently in migraineurs than in nonmigraineurs. Mean intensity of headache related to fatigue and/or sleep, stress, food and/or drinks, hot/cold weather, and menstruation varied from 37 to 43 in migraineurs and from 29 to 35 in nonmigraineurs. Headache with the highest mean intensity was due to infections in the two groups (47 ± 20 in group 1,45 ± 23 in group 2).

Our results support that endogenous factors are the most frequent triggers of headache in migraineurs. The most frequent precipitating factors of headache appear identical in migraineurs and in nonmigraineurs. Our results suggest that similar triggers could precipitate headache of different type in these two populations.
Predictability of Exogenous Hormone Effect on Subgroups of Migraineurs
Authors: Mueller Loretta
Published: March 2003

Objective.–To evaluate whether self‐reported past migraine response to reproductive life events (menses, pregnancy, menopause) alters the likelihood of worsening of migraine with exogenous hormone use.

Methods.–A retrospective study was conducted on 451 female patients at the University Headache Center who had a diagnosis of migraine with or without aura.

Results.–The majority of migraineurs recalled no change in headaches with oral contraceptive use or hormone replacement therapy (67.2% and 77%, respectively). Worsening of migraines with oral contraceptive use was associated with a menstrual trigger, worsening during pregnancy, and a diagnosis of migraine without aura. Worsening with hormone replacement therapy was associated with worsening during prior oral contraceptive use, improvement during pregnancy, worsening during menopause, and a diagnosis of migraine without aura.

Conclusions.–Prospective studies are needed to confirm these associations.
Acute Headache in Children and Adolescents Presenting to the Emergency Department
Authors: Lewis Donald W. , Qureshi Faiqa
Published: March 2003

Objectives.–Our goals were (1) to investigate the causes of acute headache in childhood from the emergency department perspective and (2) to search for clinical clues that might distinguish headache associated with serious underlying disease.

Background.–The clinical presentation of headache in children and adolescents can be separated into 5 temporal patterns: acute, acute‐recurrent, chronic progressive, chronic nonprogressive, and mixed. Few data exist regarding acute headache in children.

Methods.–Consecutive children who presented to our emergency department with the abrupt onset of severe headache were prospectively evaluated. The headache character, location, severity, and associated symptoms, as well as underlying causes, were recorded using a standardized survey.

Results.–One hundred fifty children, aged from 2 to 18 years, 87 boys and 63 girls, were enrolled over a 10‐month period. Upper respiratory tract infection with fever (viral upper respiratory tract infection 39%, sinusitis 9%, streptococcal pharyngitis 9%) was the most frequently identified cause of acute headache (57%). Other causes included migraine (18%), viral meningitis (9%), posterior fossa tumors (2.6%), ventriculoperitoneal shunt malfunction (2%), epileptic seizure (postictal headache) (1.3%), concussion (postconcussive headache) (1.3%), intracranial hemorrhage (1.3%), and undetermined (7%). Two clinical features were found to have statistically significant associations with serious underlying disease: occipital location of headache and an inability of the patient to describe the quality of the head pain. All children with surgically remediable conditions had clear and objective neurological signs.

Conclusions.–In children and adolescents, the abrupt onset of severe headache is most frequently caused by upper respiratory tract infection with fever, sinusitis, or migraine. Special attention is warranted if the acute headache is occipital in location and if the affected patient is unable to describe the quality of the pain. Serious underlying processes such as brain tumor or intracranial hemorrhage are uncommon and, when present, are accompanied by multiple neurological signs (ataxia, hemiparesis, papilledema).
Recurrent Headache, Coping, and Quality of Life in Children: A Review
Authors: Bandell‐Hoekstra Inez , Abu‐Saad Huda Huijer , Passchier Jan , Knipschild Paul
Published: March 2003

Objectives.–To clarify the concepts of coping with pain and quality of life (QoL) and to present a literature review of the strategies that children with recurrent headaches use to cope with their pain, the impact of recurrent headaches on children's QoL, and the influence of personal and situational variables on headache, coping, and QoL in children.

Methods.–The literature search encompassed published articles that were found by means of a CD‐ROM search of MEDLINE (1966 to December 1998) and PsycLIT (1974 to December 1998) and the snowball method.

Results.–In pediatric headache research, only three studies have been found in which children report the use of various coping strategies, and only two studies considered QoL. Demographic factors and psychological variables such as depression, anger, and anxiety influence headache prevalence. The impact of headache‐related variables such as headache type, severity, perceived cause, and prior experience on QoL has only been studied in adults.

Conclusions.–More research on coping and QoL is needed in pediatric headache. The conceptual model that is presented in this article may serve as a guide.
Periaqueductal Gray Matter Dysfunction in Migraine: Cause or the Burden of Illness?
Authors: Welch K.M.A. , Nagesh Vijaya , Aurora Sheena K. , Gelman Neil
Published: March 2003

Objective.—The periaqueductal gray matter (PAG) is at the center of a powerful descending antinociceptive neuronal network. We studied iron homeostasis in the PAG as an indicator of function in patients with episodic migraine (EM) between attacks and patients with chronic daily headache (CDH) during headache. High‐resolution magnetic resonance techniques were used to map the transverse relaxation rates R2, R2*, and R2′ in the PAG, red nucleus (RN), and substantia nigra (SN). R2′ is a measure of non‐heme iron in tissues.

Methods.—Seventeen patients diagnosed with EM with and without aura, 17 patients diagnosed with CDH and medication overuse, and 17 normal adults (N) were imaged with a 3.0‐tesla magnetic resonance imaging system. For each subject, mean values of the relaxation rates, R2 (1/T2), R2* (1/T2*), and R2′ (R2* − R2) were obtained for the PAG, RN, and SN. R2, R2*, and R2′ values of the EM, CDH, and N groups were compared using analysis of variance, Student t test, and correlation analysis.

Results.—In the PAG, there was a significant increase in mean R2′ and R2* values in both the EM and CDH groups (P<.05) compared with the N group, but no significant difference in these values was demonstrated between the EM and CDH groups, or between those with migraine with or without aura in the EM group. Positive correlations were found for duration of illness with R2′ in the EM and CDH groups. A decrease in mean R2′ and R2* values also was observed in the RN and SN of the CDH group compared with the N and EM groups (P<.05), explained best by flow activation due to head pain.

Conclusions.—Iron homeostasis in the PAG was selectively, persistently, and progressively impaired in the EM and CDH groups, possibly caused by repeated migraine attacks. These results support and emphasize the role of the PAG as a possible “generator” of migraine attacks, potentially by dysfunctional control of the trigeminovascular nociceptive system.
The Role of Anger and Depression in Recurrent Headache
Authors: Venable Vanessa L. , Carlson Charles R. , Wilson John
Published: March 2003

Individuals with tension‐type headache report significant anger, depression, anxiety, and stressors. However, it is not clear to what extent these variables are interrelated. The objective of the present study was to explore the role of anger in headaches, and to examine its relationship to anxiety, depression, and daily life stressors. Participants were 65 young adult women who suffered from recurrent headaches. The sample was obtained in a large‐scale screening of young adult women using the Headache Symptoms List to identify those with recurrent headache. Those individuals reporting headaches completed a battery of assessment measures that included the State‐Trait Anger Expression Inventory, the Mood and Anxiety Symptoms Questionnaire, and the Hassles Scale. Results revealed a significant relationship between anger suppression and depression (r = 0.40, P<.01), as well as anger expression and anxiety (r = 0.41, P<.01) for those with headache. The use of the Mood and Anxiety Symptoms Questionnaire allowed for the separate analysis of general distress symptoms and symptoms more specific to anxiety and depression. Results indicated that those with headache experience more general, nonspecific distress rather than symptoms indicative of anxiety and depression (P<.01). In addition, the mixed headache group scored high on both general (mean, 28.96) and specific measures of depression (mean, 65.76) and on anger suppression (mean, 20.12), suggesting that they might experience more psychological distress than those with tension‐type headache. The present results indicate the need to distinguish the unique dimensions of anxiety and depression that should be assessed in the population with recurrent headache.
Differentiating the Efficacy of 5‐HT1B/1D Agonists
Authors: Sheftell Fred D. , Fox Anthony W. , Weeks Randall E. , Tepper Stewart J.
Published: March 2003

Objective.—To examine, for a set of published clinical trials of serotonin (5‐HT1B/1D) agonists as acute treatments for migraine, whether transformation of efficacy data into therapeutic gain (TG) or number needed to treat (NNT) is useful.

Background.—Pivotal clinical trials of 5‐HT1B/1D agonists in migraine use a primary end point of change in pain score from 3 or 2 to 1 or 0. Placebo response rates among such studies are variable. Meta‐analytic comparisons of 5‐HT1B/1D agonists often employ TG and NNT as efficacy measures.

Methods.—Data from US product labeling or published sources were converted into TG (TG = active response rate [%] − placebo response rate [%]) and NNT (NNT = 1/TG). Pivotal clinical trial data were compared before and after transformation.

Results.—Therapeutic gain ranged from 17.5% to 51%. The transformation of TG into NNT yielded no clinically significant difference in efficacy estimate for the range of 17.5% to 47% (N = 29 clinical trials). However, NNT and TG had a nonlinear relationship for some secondary end points. When the relationship between the standard primary and secondary end points was compared, the correlation of TG with clinical disability (Pearson coefficient R = 0.93) was stronger than for NNT. Placebo response rates correlated more strongly with NNT (R = 0.66) than active response rates (R = 0.42; N = 29 clinical trials), although both TG and NNT were sensitive to placebo response rate.

Conclusions.—Transforming efficacy rates into TG or NNT adds no new information to placebo‐controlled trials. The variables, TG and NNT, should not be used to compare members of this class of drugs. Migraine therapies can only be compared using well‐designed head‐to‐head studies and not by meta‐analysis. Broader measures of efficacy should be used to describe and compare 5‐HT1B/1D efficacy.
Headaches Associated With Refractive Errors: Myth or Reality?
Authors: Gil‐Gouveia R. , Martins I.P.
Published: March 2003

Introduction.—Headache and refractive errors are very common conditions in the general population, and those with headache often attribute their pain to a visual problem. The International Headache Society (IHS) criteria for the classification of headache includes an entity of headache associated with refractive errors (HARE), but indicates that its importance is widely overestimated.

Objectives.—To compare overall headache frequency and HARE frequency in healthy subjects with uncorrected or miscorrected refractive errors and a control group.

Methods.—We interviewed 105 individuals with uncorrected refractive errors and a control group of 71 subjects (with properly corrected or without refractive errors) regarding their headache history. We compared the occurrence of headache and its diagnosis in both groups and assessed its relation to their habits of visual effort and type of refractive errors.

Results.—Headache frequency was similar in both subjects and controls. Headache associated with refractive errors was the only headache type significantly more common in subjects with refractive errors than in controls (6.7% versus 0%). It was associated with hyperopia and was unrelated to visual effort or to the severity of visual error. With adequate correction, 72.5% of the subjects with headache and refractive error reported improvement in their headaches, and 38% had complete remission of headache. Regardless of the type of headache present, headache frequency was significantly reduced in these subjects (t = 2.34, P = .02).

Conclusions.—Headache associated with refractive errors was rarely identified in individuals with refractive errors. In those with chronic headache, proper correction of refractive errors significantly improved headache complaints and did so primarily by decreasing the frequency of headache episodes.
Intravenous Propofol in the Treatment of Refractory Headache
Authors: Mendes Paula M. , Silberstein Stephen D. , Young William B. , Rozen Todd D. , Paolone Mary F.
Published: March 2003

We analyzed the results of treating patients who had chronic daily headaches that were refractory to standard medications with repetitive low‐dose boluses of intravenous propofol (2,6‐diisopropylphenol).

Patients were treated over a 1‐year period at Thomas Jefferson University Hospital. A total of 18 patients were treated a total of 21 times. Over 90% of patients had at least some headache relief after treatment. The headache cycle was broken in eight patients. There were no complications. Intravenous propofol is safe and effective when used under monitored conditions and should be considered for patients who have refractory chronic daily headache and have failed other interventions.
A Review of Mechanisms of Response to Pain Therapy: Why Voodoo Works
Authors: Solomon Seymour
Published: March 2003

A person's response to pain treatment may be due to factors other than the direct effect of analgesics. Amelioration of pain is often associated with modalities that appear to make no scientific sense.

This review outlines the mechanisms of pain amelioration other than that by medication. These mechanisms help to explain why pain relief may follow the administration of allopathic modalities.

Pain is modulated, enhanced, or diminished by both cerebral and peripheral mechanisms. Cerebral factors include the placebo response, psychological phenomena, and conscious cognitive activation. In addition to evoking endogenous opioids, these central mechanisms activate antinociceptive pathways beginning in the limbic forebrain and relayed in the periaqueductal gray matter to primary afferent nociceptive sites in the spinal cord dorsal horn (and medullary nucleus caudalis). Obvious peripheral factors that may diminish pain perception are those that decrease afferent stimuli. Paradoxically, stimulation of afferent neurons may also ameliorate pain by activating spinal or supraspinal inhibitory mechanisms. Finally, improvement in pain or other symptoms is often falsely attributed to a therapy when remission occurs because the underlying illness has run its normal course.
Tripstar: A Comprehensive Patient‐Based Approach to Compare Triptans
Authors: Ferrari Michel D.
Published: March 2003

Several second‐generation triptans have been introduced that differ in their pharmacologic profiles relative to each other and to sumatriptan. As therapeutic options multiply, clinicians must be able to distinguish among these compounds. Recently, a meta‐analysis was conducted on data from 53 double‐blind, randomized, placebo‐ or active‐controlled trials involving over 24 000 patients receiving oral triptans. Results indicated that almotriptan 12.5 mg, rizatriptan 10 mg, and eletriptan 80 mg are generally superior to sumatriptan 100 mg based on individual treatment attributes, such as pain relief, sustained pain freedom, consistency of response, and tolerability. Meta‐analyses are limited, however, as the analysis can only be performed for individual end points, whereas patients and prescribers balance a variety of treatment attributes when assessing drug acceptability. A flexible overall scoring system (“Tripstar”) is proposed that compares triptans to a hypothetical “ideal” using meta‐analysis data combined with ratings of the relative importance of clinically relevant treatment criteria. An informal test of the Tripstar model indicated that sumatriptan is most similar to a hypothetical ideal for both mild and severe migraine, primarily due to its high worldwide clinical exposure. However, after exclusion of worldwide exposure as a contributing factor, almotriptan 12.5 mg is most similar to the ideal, principally because of its good tolerability. Further tests of the Tripstar model are planned that will gauge the relative importance of a broader range of attributes.
Dysphonia Associated with Carotidynia and Migraine Responding to Dihydroergotamine
Authors: White James R. , Bell William L.
Published: March 2003

Carotidynia is characterized by throbbing pain over the carotid artery and may be caused by migraine. We report a case of a 54‐year‐old woman with recurrent dysphonia associated with carotidynia and other features of atypical migraine that resolved after treatment with dihydroergotamine. To our knowledge, this is the first report of dysphonia associated with migraine.