Prospective real-world analysis of OnabotulinumtoxinA in chronic migraine post-National Institute for Health and Care Excellence UK technology appraisal.

BACKGROUND AND PURPOSE: The National Institute for Health and Care Excellence (NICE) in the UK recommends the use of OnabotulinumtoxinA (BoNTA, Botox® ) in the management of chronic migraine (CM) following specific guidelines within the National Health Service. In view of the lack of data on the efficacy of this therapy following implementation of these guidelines in clinical practice and on the evaluation of guidance compliance, we aimed to evaluate the effectiveness and safety of BoNTA in patients with CM following the NICE guidelines. METHODS: This was a prospective real-life audit study. RESULTS: After two treatments, 127 of 200 patients (63.5%) obtained at least a 30% reduction in headache days. Those who continued the treatment up to 3 years reported a stable beneficial effect compared with baseline. Amongst responders, 68 patients (53.5%) were reclassified as episodic migraineurs. A total of 57 of these patients (83.8%) converted to an episodic migraine pattern at 6-month follow-up. The majority of those whose migraine became episodic after BoNTA extended the treatment intervals beyond 3 months (range 4-8 months) before noticing any worsening of headache. We observed no significant differences in the efficacy measures in patients treated with 155 U BoNTA compared with those treated with >155 U BoNTA. CONCLUSIONS: When administered according to the NICE guidance, BoNTA produced a clinically meaningful effect in the long-term management of CM with and without medication overuse headache. Treatment discontinuation when CM becomes episodic may be useful in clinical practice to identify those who may benefit from extended treatment intervals. Our clinical experience indicates a lack of additional benefit from using the 'follow-the-pain' paradigm.

Development of a decision-support tool for identifying the most suitable approach to achieve nitrate source determination.

Numerous approaches have been suggested for differentiating point and diffuse sources of nitrate contamination, including nitrate stable isotopes, microbiological analyses, genetic markers and chemical markers. Each approach has its own strengths and limitations. As a result, the most appropriate approach to use largely depends upon the scenario and the context of the study. However, available data on nitrate source determination is highly fragmented and approach dependent, with very little if any interface between the different techniques. This makes it difficult for stakeholders to identify the most suitable approach to adopt in a specific scenario. Therefore, this paper examines the development and application of a decision-support tool to support environmental forensics studies for nitrate contamination. In particular, this tool can support policy makers, regulators and operators within the field in understanding the environmental hazards and processes resulting from nitrate contamination, and to implement appropriate actions for limiting the impacts that may arise from such contamination. The tool was developed using the IDEF0 modeling system, and evaluated by interviewing key stakeholders who suggested a number of important implications for practice.

The potential for a suite of isotope and chemical markers to differentiate sources of nitrate contamination: a review.

Nitrate is naturally found within the environment as part of the nitrogen cycle. However, anthropogenic inputs have greatly increased nitrate loads within ground and surface waters. This has had a severe impact on aquatic ecosystems and has given rise to health considerations in humans and livestock. Therefore, the identification of nitrate sources is important in preserving water quality and achieving sustainability of our water resources. Nitrate sources can be determined based on the nitrate nitrogen (N) and oxygen (O) isotopic compositions (δ(15)N, δ(18)O). However, sewage and manure have overlapping δ(15)N and δ(18)O values making their differentiation on this basis problematic. The specific differentiation between sources of faecal contamination is of particular importance, because the risk to humans is usually considered higher from human faecal contamination (sewage) than from animal faecal contamination. This review summarises the current state of knowledge in using isotope tracers to differentiate various nitrate sources and identifies potential chemical tracers for differentiating sewage and manure. In particular, an in depth review of the current state of knowledge regarding the necessary considerations in using chemical markers, such as pharmaceuticals and food additives, to differentiate sewage and manure sources of nitrate contamination will be given, through an understanding of their use, occurrence and fate, in order to identify the most suitable potential chemical markers.

Membrane currents in cultured human intestinal smooth muscle cells.

Using whole-cell patch-clamp recording techniques, we have examined voltage-gated ion currents in a cultured human intestinal smooth muscle cell line (HISM). Experiments were performed at room temperature on cells after passages 16 and 17. Two major components of the whole-cell current were a tetraethylammonium-sensitive (IC50 = 9 mM), iberiotoxin-resistant, delayed rectifier K+ current and a Na+ current inhibited by tetrodotoxin (IC50 A 100 nM). No measurable inward current via voltage-gated Ca2+ channels could be detected in these cells even with 10 mM Ca2+ or Ba2+ in the external solution. No current attributable to calcium-activated K+ channels was found and no cationic current in response to muscarinic receptor activation was present. In divalent cation-free external solution two additional currents were activated: an inwardly rectifying hyperpolarization-activated current, I(HA), and a depolarization-activated current, I(DA) x I(HA) and I(DA) could be carried by several monovalent cations; the sizes of currents in descending order were: K+ > Cs+ > Na+ for I(HA) and Na+ > K+ >> Cs+ for I(DA). I(HA) was activated and deactivated instantaneously and showed no inactivation whereas I(DA) was activated, inactivated and deactivated within tens of milliseconds. These currents were inhibited by external calcium with an IC50 of 0.3 microM for I(DA) and an IC50 of 20 microM for I(HA). Cyclopiazonic acid (CPA) induced an outward, but not an inward current. SK&F 96365, a blocker of store-operated Ca2+ channels, suppressed I(DA) with a half-maximal inhibitory concentration of 9 microM but was ineffective in inhibiting I(HA) at concentrations up to 100 microM. Gd3+ and La3+ strongly suppressed I(DA) at 1 and 10 microM, respectively and were less effective in blocking I(HA) (complete inhibition required a concentration of 100 microM for both). Carbachol at 10-100 microM evoked about a 3-fold increase in I(HA) amplitude and completely abolished I(DA). We conclude that I(HA) and I(DA) are Ca2+-blockable cationic currents with different ion selectivity profiles that are carried by different channels. I(DA) shows novel voltage-dependent properties for a cationic current.

A cellular solid criterion for predicting the axial-shear failure properties of bovine trabecular bone.

In a long-term effort to develop a complete multi-axial failure criterion for human trabecular bone, the overall goal of this study was to compare the ability of a simple cellular solid mechanistic criterion versus the Tsai-Wu, Principal Strain, and von Mises phenomenological criteria--all normalized to minimize effects of interspecimen heterogeneity of strength--to predict the on-axis axial-shear failure properties of bovine trabecular bone. The Cellular Solid criterion that was developed here assumed that vertical trabeculae failed due to a linear superposition of axial compression/tension and bending stresses, induced by the apparent level axial and shear loading, respectively. Twenty-seven bovine tibial trabecular bone specimens were destructively tested on-axis without end artifacts, loaded either in combined tension-torsion (n = 10), compression-torsion (n = 11), or uniaxially (n = 6). For compression-shear, the mean (+/- S.D.) percentage errors between measured values and criterion predictions were 7.7 +/- 12.6 percent, 19.7 +/- 23.2 percent, 22.8 +/- 18.9 percent, and 82.4 +/- 64.5 percent for the Cellular Solid, Tsai-Wu, Principal Strain, and von Mises criteria, respectively; corresponding mean errors for tension-shear were -5.2 +/- 11.8 percent, 14.3 +/- 12.5 percent, 6.9 +/- 7.6 percent, and 57.7 +/- 46.3 percent. Statistical analysis indicated that the Cellular Solid criterion was the best performer for compression-shear, and performed as well as the Principal Strain criterion for tension-shear. These data should substantially improve the ability to predict axial-shear failure of dense trabecular bone. More importantly, the results firmly establish the importance of cellular solid analysis for understanding and predicting the multiaxial failure behavior of trabecular bone.

The senegalese cholera epidemic of 1995 to 1996, an example of the geographic approach to health studies

There have been many cholera outbreaks in Senegal since 1971. The last outbreak began in the Dakar region in August 1995. It spread to the Diourbel, Fatick, Saint-Louis and Thies regions. In January 1996, the outbreak hit the Niakhar study area in the Fatick region. A team from ORSTOM (the French Institute of Scientific Research for Development in Cooperation) has been recording demographic events in this area for almost 15 years. The geographic approach is based on the automated mapping of cholera in hamlets and villages. Such studies investigate the factors determining the spread of diseases, within the context of land use. Three sets of data were used: demographic data that had been routinely collected and were available from a database, digitized maps and epidemiological data from a surveillance system set up to monitor the outbreak. A series of incidence maps, over time and on various scales, were generated using specialized software. The maps were analyzed and the outbreak was found to be heterogeneous over time. There were two waves of the outbreak and differences according to age and gender. The degree of heterogeneity depended on the place of residence. Heterogeneity was probably determined by village size, roads and the concentration of inhabitants within hamlets, which is roughly equivalent to the number of people per bore hole. These preliminary results suggest that further research is necessary, looking at different geographical scales (e.g. households, districts and regions). Qualitative studies of water use and the organization of the water supply are also required.

[Cholera epidemic in Senegal in 1995-1996: an example of geographic approach to health]. / L'épidémie de choléra de 1995-1996 au Sénégal: un exemple de démarche de géographie de la santé.

There have been many cholera outbreaks in Senegal since 1971. The last outbreak began in the Dakar region in August 1995. It spread to the Diourbel, Fatick, Saint-Louis and Thies regions. In January 1996, the outbreak hit the Niakhar study area in the Fatick region. A team from ORSTOM (the French Institute of Scientific Research for Development in Cooperation) has been recording demographic events in this area for almost 15 years. The geographic approach is based on the automated mapping of cholera in hamlets and villages. Such studies investigate the factors determining the spread of diseases, within the context of land use. Three sets of data were used: demographic data that had been routinely collected and were available from a database, digitized maps and epidemiological data from a surveillance system set up to monitor the outbreak. A series of incidence maps, over time and on various scales, were generated using specialized software. The maps were analyzed and the outbreak was found to be heterogeneous over time. There were two waves of the outbreak and differences according to age and gender. The degree of heterogeneity depended on the place of residence. Heterogeneity was probably determined by village size, roads and the concentration of inhabitants within hamlets, which is roughly equivalent to the number of people per bore hole. These preliminary results suggest that further research is necessary, looking at different geographical scales (e.g. households, districts and regions). Qualitative studies of water use and the organization of the water supply are also required.

Voltage-activated proton current in eosinophils from human blood.

1. The resting membrane potential of freshly purified normodense human eosinophils bathed in and dialysed with quasi-physiological solutions was -63 +/- 2 mV (n = 100). 2. In voltage-clamp mode with quasi-physiological internal and external solutions, voltage steps from the holding potential of -60 mV to levels positive to +20 mV resulted in development of a quasi-instantaneous outward current and a slowly developing outward current. The instantaneous current was absent when the cells were bathed in and dialysed with K(+)-free solution. 3. The slow outward current persisted following simultaneous replacement of K+, Na+ and most of the Cl- with largely impermeant ions (tetraethylammonium, N-methyl-D-glucamine and methanesulphonate) and was augmented when the cell was dialysed with a solution of increased buffering capacity for protons. The observed reversal potential of the current closely followed the hydrogen equilibrium potential over a wide range of internal-external pH combinations, indicating that the conductance underlying the slow outward current was highly selective for H+ ions. 4. Acidification of the pipette solution (increasing [H+]i) augmented the outward H+ current and shifted its activation range negatively, whilst acidification of the external solution had the opposite effect. The voltage dependence of the current is modulated by the transmembrane pH gradient so the only outward current could be activated. However, when the outward current was activated by a voltage step, rapid acidification of external solution produced an inward H+ current which rapidly deactivated. 5. The proton current was reversibly inhibited in a voltage-dependent manner by extracellular application of Zn2+. The apparent dissociation constants were 8 nM (at +40 mV), 36 nM (at +70 mV) and 200 nM (at +100 mV). 6. The proton current was augmented by exposure to 10 microM arachidonic acid. This augmentation consisted of a shift of the voltage dependence of activation to more negative potentials and enhancement of maximum conductance (gH,max). The proton current recorded in eosinophils was significantly augmented under conditions of elevated cytosolic free calcium concentration ([Ca2+]i). The threshold level of [Ca2+]i associated with this effect lay between 0.1 and 1 microM and was not measurably affected by cytosolic acidification. 7. Eosinophils from human blood possess a voltage-dependent H+ conductance (gH) which normally allows protons to move outwards only; raising [Ca2+]i was associated with augmentation of gH and intracellular acidification or arachidonate shifted its activation range negatively towards physiological potentials.

Chloride current activated by hypotonicity in cultured human astrocytoma cells.

Cultured astrocytoma cells were voltage clamped with pipettes where [Ca2+] in the pipette was buffered to 10(-7) M with 10 mM 1,2-bis(O-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid (BAPTA) and membrane currents recorded. In isotonic solution predominantly K+ currents were evoked by depolarizing or hyperpolarizing commands and 4,4'-diisothiocyanatostilbene-2,2'-disulphonic acid (DIDS; 1 mM) had little effect on inward and outward currents evoked by voltage steps to negative and positive potentials. If the osmolarity of the bathing solution was reduced from 280 to 200 mosmol l-1, a large current developed, which rectified outwardly and reversed close to the equilibrium potential for chloride ions, ECl. Upon stepping to potentials positive to about +30 mV in hypotonic solution, this outward current inactivated over 2-3 s; this decline was greater with N-methyl-D-glucamine chloride (NMDG-Cl) in the pipette than when KCl or sodium glutamate was present. Holding at various positive potentials inactivated the current, with half-inactivation occurring around +50 mV. The current reactivated over 2-3 s at potentials negative to about +30 mV. The current evoked by hypotonic solution was inhibited by various putative chloride channel blockers with the order of potency DIDS > SITS (4-acetamido-4'-isothiocyanatostilbene-2,2'-disulphonic acid) approximately NPPB (5-nitro-2-(3-phenylpropylamino)-benzoic acid) > niflumic acid > 9-AC (anthracene 9-carboxylic acid). The currents inhibited by these compounds reversed close to the calculated ECl. It is concluded that hypotonic solution evokes a large anionic current in these cultured astrocytoma cells largely carried by chloride ions. This current is absent in isotonic solution, when currents are carried mainly by potassium ions. It is likely that the current elicited by hypotonic solution is part of the mechanisms regulating astrocyte volume in vivo.