α-[11C] methyl-L tryptophan-PET as a surrogate for interictal cerebral serotonin synthesis in migraine without aura.

BACKGROUND: Alteration in central serotonin biology has been implicated in migraine, and serotonin (5-HT) agonists have been available for more than a decade in the treatment of that condition. OBJECTIVES: To test this hypothesis, we studied in vivo using positron-emission tomography (PET) and α-[(11)C] methyl-L-tryptophan (α-[(11)C]MTrp) as a surrogate marker of cerebral 5-HT synthetic rate before and after administration of eletriptan in migraine and control subjects. METHODS: Six nonmenopausal female migraine subjects with migraine without aura (MoA) and six nonmenopausal age-matched female control subjects were scanned at baseline and after oral administration of 40 mg of eletriptan. Migraine subjects at the time of PET had to have been headache free for a minimum of three days. Images of (α-[(11)C]MTrp) brain trapping were colocalized with individual MRI images in three dimensions and analyzed. RESULTS: There was no difference in baseline cerebral global 5-HT synthesis between migraine and control subjects. After administration of eletriptan, there was a striking global reduction in cerebral 5-HT synthesis (K*) in the migraine group and in 22 regions of interest (ROIs). In control subjects, no significant changes were found in global cerebral 5-HT synthesis (K*) or in any of the ROIs. CONCLUSIONS: These findings suggest in migraine an interictal alteration in the regulation mechanisms of cerebral 5-HT synthesis.

Sumatriptan normalizes the migraine attack-related increase in brain serotonin synthesis.

BACKGROUND: Altered serotonin (5-HT) neurotransmission has been implicated in the pathophysiology of migraine headache. OBJECTIVES: To test this hypothesis in migraine patients in vivo using PET and alpha-[(11)C]methyl-l-tryptophan as a surrogate marker of brain 5-HT synthetic rate during different phases of their migraine attack and after acute antimigraine therapy with sumatriptan, and to compare them with normal controls. METHODS: Six patients were scanned 1) within 6 hours after the onset of a spontaneous migraine attack, 2) 2 hours after subcutaneous sumatriptan, and 3) interictally when migraine free for at least 3 days. Head pain was rated before each scan, and before and every 15 minutes after sumatriptan. RESULTS: Brain 5-HT synthesis was highest during attacks, lowest after sumatriptan, and intermediate when patients were migraine free. All states were statistically different from the others in virtually all brain regions examined. 5-HT synthetic rates in patients during migraine attacks did not differ from those of age- and sex-matched controls, whereas they were significantly lower after sumatriptan in a majority of regions. Interictally, global brain 5-HT synthetic rate was slightly, albeit not significantly, lower (-14%) in migraine patients than in controls, with specific cortical areas exhibiting proportionally more severe reductions (-28% to 31%). CONCLUSIONS: These findings point to a low cortical serotonergic tone in migraine patients interictally. Further, they demonstrate widespread increases in brain serotonin (5-HT) synthetic rate in migraine patients during attacks, and that triptans exert a negative feedback regulation of brain 5-HT synthesis concurrently with modulation of pain pathways.

[The daily public health nursing practice: the Montreal infectious diseases unit as an example]. / La pratique quotidienne des infirmières d'une direction de santé publique: l'exemple de l'unité maladies infectieuses à Montréal.

The health of urban populations depends on multiple factors, among them access to health and social services. The Montreal Public Health Department (PHD) is part of such services, where a number of nurses are working within a multidisciplinary team. It is through the description of the work accomplished by the team for infectious diseases control and prevention, and the vignettes of real life events related to the follow-up of syphilis, tuberculosis and hepatitis A cases, as well as quarantined individual exposed to SARS that the authors want to illustrate the work of the urban public health nurses. The examples are preceded by a description of the socio-demographic characteristics of the city of Montreal, that influence health problems, and therefore nurses' work.

Non-obstructive hydrocephalus associated with intracranial schwannomas: hyperproteinorrhachia as an etiopathological factor?

BACKGROUND: This series illustrates the association of communicating hydrocephalus with intracranial non-obstructive schwannomas. This association has commonly been observed, however it has only been reported once previously. Moreover, in all the patients we present, hyperproteinorrhachia was a common denominator. This finding may therefore be the underlying mechanism for hydrocephalus. METHOD AND FINDINGS: Seven patients presenting with intracranial schwannomas along with non-obstructive hydrocephalus and hyperproteinorrhachia are reported. Six had a vestibular schwannoma and presented with a unilateral deafness and various degrees of gait disturbance, urinary incontinence and neuropsychological impairment. Due to their advanced ages, these patients underwent a ventriculo-peritoneal shunt, and their symptoms related to hydrocephalus resolved. One patient that suffered from hemifacial dysesthesia and memory deficits presented with a non-obstructive trigeminal schwannoma. In this case the tumour was removed and the hydrocephalus was consequently reversed, and the CSF protein content normalized. INTERPRETATION: The constant finding of hyperproteinorrhachia in all these patients suggests that a high CSF protein content may be the underlying cause of hydrocephalus through a speculative mechanism of decreased CSF resorption.

Evaluation of a modified sanitary napkin as a sample self-collection device for the detection of genital chlamydial infection in women.

A modified sanitary napkin was compared with endocervical swab and urine specimens for the detection of urogenital Chlamydia trachomatis infection. Endocervical swabs and/or first-catch urine were collected from 510 women at medical or community settings in Quebec City. Participants were also asked to wear a modified sanitary napkin (Ezy-Detek) during 4 consecutive hours and to bring it back to the clinic or mail it to the laboratory. Endocervical and urine specimens were tested using the Cobas Amplicor CT/NG assay (Roche Diagnostic Systems) according to the manufacturer's instructions, as were specimens collected with the napkin after adequate preparation. If the PCR test result was positive on the endocervical sample or on any two samples, a woman was considered to be infected. PCR testing results on paired samples were identical for 493 (96.6%) of 510 women. According to the definition given above, 58 (11.3%; 95% confidence interval [CI], 8.7 to 14.5%) women were infected with C. trachomatis. The sensitivity and specificity of PCR testing on modified sanitary napkin specimens were, respectively, 93.1% (54 of 58; 95% CI, 83.3 to 98.1%) and 98.9% (447 of 452; 95% CI, 97.4 to 99.6%) compared to 81.0% (47 of 58; 95% CI, 68.6 to 90.1%) and 100% (451 of 451; 95% CI, 99.2 to 100%) for urine specimens. The positive and negative predictive values were, respectively, 91.5% (54 of 59) and 99.1% (447 of 451) for the sanitary napkin specimens compared to 100% (47 of 47) and 97.6% (451 of 462) for urine samples. These results suggest that a modified sanitary napkin represents an effective noninvasive device for self-collection of specimens to detect urogenital C. trachomatis infection.

Decreased expression of the decoy interleukin-1 receptor type II in human endometriosis.

Many of the biological changes occurring in the endometrium during the menstrual cycle bear a striking resemblance to those associated with inflammatory and reparative processes. Hence, it would not be surprising to find that cytokines known for their pro-inflammatory properties, such as interleukin-1 (IL-1), could play a key role in the physiology of this tissue and that their action would be tightly controlled by local mechanisms. In the present study, immunohistochemical and Western blot analyses show that in normal women (n = 39), the endometrial tissue expresses, in a cycle-dependent manner, the IL-1 receptor type II (IL-1RII), a molecule of which the only biological property known to date is that of capturing IL-1, inhibiting thereby its binding to the functional type I IL-1 receptor. IL-RII immunostaining was particularly intense within the lumen of the glands and at the apical side of surface epithelium. Interestingly, the intensity of staining was markedly less pronounced in the endometrium of women with endometriosis (n = 54), a disease believed to arise from the abnormal development of endometrial tissue outside the uterus, especially in the early stages of the disease (stages I and II). This study is the first to show the local expression in endometrial tissue of IL-1RII, a potent and specific down-regulator of IL-1 action and its decreased expression in women suffering from endometriosis.

Cervicofacial angioma and the Kasabach-Merritt syndrome.

We present a neonate with a cervicofacial haemangioma complicated by the Kasabach-Merritt syndrome, respiratory distress due to airway compression and high-output heart failure. This haemangioma and intravascular disseminated coagulation, treated initially by aspirin, ticlopidine and corticosteroids, required more invasive treatment with superselective embolisation and interferon alpha-2a. The clinical outcome was good.

Migraine in pregnancy.

Migraine does not increase the risk for complications of pregnancy for the mother or for the fetus: the incidences of toxemia, miscarriages, abnormal labour, congenital anomalies, and stillbirths are comparable to those of the general population. Several retrospective studies have shown a tendency for migraine to improve with pregnancy. Between 60 and 70% of women either go into remission or improve significantly, mainly during the second and third trimesters. Women with migraine onset at menarche and those with perimenstrual migraine are more likely to go into remission during pregnancy. The migraine type does not seem to be a significant prognostic factor for improvement. However, in the small number of women (4-8%) whose migraines worsen with pregnancy, migraine with aura appears to be overrepresented. In a small number of cases (1.3-16.5%), migraine appears to start with pregnancy, often in the first trimester; these headaches involve a higher proportion of migraine with aura. Management of migraine during pregnancy should first focus on avoiding potential triggers. Consideration should also be given to nonpharmacologic therapies. If pharmacologic treatment becomes necessary, acetaminophen and codeine can be used safely as abortive agents; ASA and NSAIDs (ibuprofen, naproxen) can be used as a second choice, but not for long periods of time, and they should be avoided during the last trimester. For treatment of severe attacks of migraine, chlorpromazine, dimenhydrinate, and diphenhydramine can be used; metoclopramide should be restricted to the third trimester. According to the United States FDA risk categories, meperidine and morphine show no evidence of risk in humans but should not be used at the end of the third trimester. In some refractory cases, dexamethasone or prednisone can be considered. Should prophylactic treatment become indicated, the beta-adrenergic receptor antagonists (e.g., propranolol) can be used.

MR of nonhemorrhagic postpartum pituitary apoplexy.

A 30-year-old woman had uterine bleeding and hypotension after delivery. Hyponatremic seizures and a mild headache prompted early neuroimaging, which disclosed an enlarged nonhemorrhagic pituitary gland with subsequent involution consistent with pituitary apoplexy (Sheehan syndrome). Endocrinologic investigation confirmed a partial pituitary insufficiency with subsequent improvement to almost normal status.

Migraine with vasospasm and delayed intracerebral hemorrhage.

Three women with well-documented migraine associated with intracerebral hemorrhage are described. In each case, migraine headaches began during adulthood. Unusually severe and protracted headache heralded the onset of fixed neurological deficits associated with lobar intracerebral hemorrhage. Striking carotid artery tenderness was characteristic. Except for a history of migraine, no cause for intracerebral hemorrhage could be established. In each case arteriography showed extensive spasm of the appropriate extracranial or intracranial artery. Surgical pathology following evacuation of two hematomata demonstrated signs of vessel wall necrosis associated with subacute inflammatory changes. Vasospasm associated with severe migraine attacks may result in ischemia of intracranial vessel walls, leading to necrosis and subsequent vessel rupture when perfusion pressure is restored.

Neuropathic arthropathy associated with chronic inflammatory demyelinating polyradiculoneuropathy.

We report a patient who developed acute neuropathic arthropathy secondary to chronic inflammatory demyelinating polyradiculoneuropathy. The association between these two conditions has not been previously reported. Their relationship is important to understand, as many other forms of inflammatory polyradiculoneuropathy share a similar pathology and are therefore susceptible to a similar complication.

Safety of outpatient angiography: a prospective study.

A prospective study of 100 consecutive outpatient angiograms with catheters on rapid changers was undertaken to ascertain the safety of this protocol. Ninety-four patients could be discharged after a 4 hr surveillance and were still well 1 week later; six patients had to be observed up to 24 hr for minor problems and one was hospitalized the night after his angiogram, for a renal complication. This approach to angiography, emphasizing the outpatient status, seems to be safe and should deserve widespread acceptance.

Manual dexterity test in relation to obesity and hyperostosis frontalis interna in elderly women.

A manual dexterity test was performed in a population of elderly women. Obese subjects with hyperostosis frontalis interna (HFI) had a poorer performance than subjects with either HFI alone or obesity alone. The combined effects of cerebral arteriosclerosis and HFI is suggested as a possible explanation for these findings.

Primary aberrant third nerve regeneration.

The clinical and neuroradiological features in 4 patients with the syndrome of aberrant regeneration of the third nerve are presented. In contrast to what is commonly seen, the syndrome was not preceded by third nerve palsy. A petrous apex-cavernous sinus meningioma was the underlying lesion in all 4 patients. Surgical and pathological confirmation of the diagnosis was obtained in 3. Regardless of whether the other ocular motor nerves are spared (as in our patients) or involved (as in other cases reported in the literature), primary aberrant regeneration of the oculomotor nerve appears to be characteristic of a cavernous sinus meningioma.

Human cysticercosis: a probable case of cerebral cysticercosis with generalized subcutaneous nodular lesions.

A case is reported in Montreal of human cysticercosis in a 44-year-old man who emigrated from Italy in 1956. Numerous subcutaneous nodules were found throughout his body. X-ray of his thighs and chest showed oblong calcific densities measuring 1 x 0.5 cm in size. Examination of an excised nodule from the right biceps revealed a cysticercus larva morphologically similar to Cysticercus cellulosae although the scolex lacked hooks. On the basis of the intensity of infection, focal and generalized epileptic seizures, changes in the CSF, and well demarcated lucencies observed in brain scan, cerebral cysticercosis was considered the most likely diagnosis.