Triggers of migraine: where do we stand?

PURPOSE OF REVIEW: In this review, we illustrate and discuss the recent findings regarding the epidemiology and pathophysiology of migraine triggers and their implications in clinical practice. RECENT FINDINGS: Data from the literature suggest that individual triggers fail to provoke migraine attack in experimental settings. It is therefore possible that more triggers acting in combination are needed to induce an attack by promoting some degree of brain dysfunction and thus increasing the vulnerability to migraine. Caution is however needed, because some of the factors rated as triggers by the patients may actually be a component of the clinical picture of migraine attacks. SUMMARY: Trigger factors of migraine are endogenous or exogenous elements associated with an increased likelihood of an attack in a short period of time and are reported by up to 75.9% of patients. Triggers must be differentiated from premonitory symptoms that precede the headache phase but do not have a causative role in attack provocation, being rather the very first manifestations of the attack. Identification of real triggers is an important step in the management of migraine. Vice versa, promoting an active avoiding behaviour toward factors whose role as triggers is not certain would be ineffective and even frustrating for patients.

Pain distraction during awake low anterior resection and Cuddle Delivery initiative for inpatient: frugal procedural options to support surgery in the COVID-19 era.

OBJECTIVE: Since minimally invasive surgery and general anesthesia are both aerosol-generating procedures, their use became controversial during the outbreak of coronavirus disease 2019 (COVID-19). Moreover, social distancing resulted in serious psychological consequences for inpatients. This case report investigates pain distraction during awake laparotomy, as well as new possibilities for emotional postoperative support to inpatients. PATIENTS AND METHODS: A 72-year-old man affected by middle rectal adenocarcinoma underwent lower anterior resection plus total mesorectal excision under combined spinal-epidural anesthesia. A 3D mobile theatre (3DMT) was intraoperatively used for pain distraction. A postoperative "Cuddle delivery" service was instituted: video-messages from relatives and close friends were delivered daily to the patient through the 3DMT. Emotional correlations were investigated through a clinical interview by the psychologist of our Hospital. RESULTS: Intraoperative, as well as postoperative pain, resulted well-controlled: visual analogue scale (VAS) ≤3. Conversion to general anesthesia and postoperative intensive support/monitoring were unnecessary. The "Cuddle delivery" initiative positively fed our patient's mood and attitude, strengthening his bond to life. CONCLUSIONS: During pandemic, awake laparotomy under loco-regional anesthesia may be a crucial option in delivering acute care surgery to selected patients when intensive care beds are unavailable. Our procedure introduces potential ways to optimize this approach.

Anodal transcranial direct current stimulation in chronic migraine and medication overuse headache: A pilot double-blind randomized sham-controlled trial.

OBJECTIVES: Little evidence is available on the role of transcranial direct current stimulation (tDCS) in patients affected by chronic migraine (CM) and medication overuse headache (MOH). We aim to investigate the effects of tDCS in patients with CM and MOH as well as its role on brain activity. METHODS: Twenty patients with CM and MOH were hospitalized for a 7-day detoxification treatment. Upon admission, patients were randomly assigned to anodal tDCS or sham stimulation delivered over the primary motor cortex contralateral to the prevalent migraine pain side every day for 5 days. Clinical data were recorded at baseline (T0), after 1 month (T2) and 6 months (T3). EEG recording was performed at T0, at the end of the tDCS/Sham treatment, and at T2. RESULTS: At T2 and T3, we found a significant reduction in monthly migraine days (p = 0.001), which were more pronounced in the tDCS group when compared to the sham group (p = 0.016). At T2, we found a significant increase of alpha rhythm in occipital leads, which was significantly higher in tDCS group when compared to sham group. CONCLUSIONS: tDCS showed adjuvant effects to detoxification in the management of patients with CM and MOH. The EEG recording showed a significant potentiation of alpha rhythm, which may represent a correlate of the underlying changes in cortico-thalamic connections. SIGNIFICANCE: This study suggests a possible role for tDCS in the treatment of CM and MOH. The observed clinical improvement is coupled with a potentiation of EEG alpha rhythm.

Awake laparotomy: is locoregional anesthesia a functional option for major abdominal surgeries in the COVID-19 era?

OBJECTIVE: Over the ongoing pandemic of coronavirus disease 2019 (COVID-19), the demand for critical care beds among medical services has rapidly exceeded its supply. Elective surgery has comprehensively been drastically limited and allocating intensive care beds to emergency cases or to high risk scheduled elective cases has become an even more difficult task. Here we present our experience which could help to handle undelayable surgical procedures during this emergency. PATIENTS AND METHODS: In 2019, eight patients (4 men, 4 women) with a mean age of 88 years, needing emergency abdominal surgery underwent awake open surgery at our Department of Surgery. All of them were identified as fragile patients at preoperative evaluation by the anesthesiologist. In all cases, locoregional anesthesia (spinal, epidural or combined spinal-epidural anesthesia) was performed. Intraoperative and postoperative pain has been monitored and regularly assessed. RESULTS: None of the patients was intubated. Mean operative time was 80 minutes (minimum 30 minutes, maximum 130 minutes). Intraoperative and postoperative pain were both well controlled. None of them required postoperative intensive care support. No perioperative complications were observed. CONCLUSIONS: Based on our preliminary case series, awake open surgery has resulted feasible and safe. This approach has allowed to perform undelayable major abdominal surgeries on fragile patients when intensive care beds were not available. Surely, it represents a helpful alternative in the COVID-19 era. A streamlining of workflows would fast-track both fragile patients management, as well as healthcare workers' tasks and activity.

Ectopic parotid: case report.

A recent case led the authors to re-examine the clinical characteristics of the cervical ectopia of the major salivary glands. These glands develop in the embryo between the sixth and seventh week, starting with the formation of endodermal invaginations of the branchial section of the floor of the primitive mouth. These cell cords, initially solid, proliferate in the underlying mesenchyme, starting from the opening of the future excretory duct, and subsequently branch and canalize. During embryogenesis, the endodermal invaginations become closely interconnected with the adjacent lymphatic tissue. It is thus possible for lymphoid tissue to migrate into the parotid or the other major salivary glands, or conversely, for salivary tissue to become included in the cervical lymph nodes. Very rarely, ectopic salivary gland tissue can also be found in other unusual locations, including the neck region, as a result of a developmental abnormality of the branchial apparatus. The base of the neck is the most common location, while ectopia of the mid third of the neck is quite rare. The authors discuss the clinical details and diagnostic procedure leading to preoperative diagnosis. This congenital anomaly can, albeit rarely, degenerate into cancer, and surgical excision is thus imperative.

[Retained rectal foreign bodies by trans-anal introduction. Case report]. / Corpi estranei endorettali introdotti per via anale. Case report.

The Authors refer about two cases of retained rectal foreign bodies by trans-anal introduction as consequence of anal eroticism: a deodorant aerosol-can cap and a sizeable phallic object. These reports represent an occasion to talk about the etiology (the wide variety of foreign bodies) and the motivations (eroticism or sadism, clumsy diagnostic and therapeutic procedures, true or presume accidents) responsible for this pathological condition and to consider every therapeutic options employed during the past years, without forgetting that, despite difficulties, non-surgical extraction is to prefer, if possible, because of the negative prognostic implications often related to the surgical treatment. The Authors finally confirm, because of the severity of this pathological condition - with negative outcomes especially in that cases with complete or incomplete perforative complications (produced during introduction through the anus or during several attempts of extraction of the object or caused by its long staying in the rectum because of the patient's denial of medical care) - the surgeons can't put aside possible indication for surgical treatment.

[Management of perforations as adverse events of ERCP plus ES. Personal experience]. / Trattamento degli eventi perforativi post-colangiopancreatografia retrograda con sfinterotomia endoscopica. Esperienza personale.

UNLABELLED: INTRODUCTION. ERCP has brought real progress in the study and treatment of pancreatic and biliary diseases, because of its ambivalence as diagnostic and therapeutic procedure. Among its complications, perforations occur in fewer than 1% of patients, but are associated with a mortality rate of 16% -18%. CASE REPORTS: CASE 1- F, 89 years old with obstructive jaundice by choledocholithiasis submitted to ERCP plus ES, during which occurs type II lesion; the partial removing of stones from choledochus during the procedure allow us to opt for a conservative treatment, with resolution on post-ERCP day 12. CASE 2- F, 53 years old with recurring cholangitis and post-cholecystectomy stenosis of choledochus already treated by stenting; for the occurrence of type I lesion during ERCP, the patient undergoes surgery in emergency with healing in postoperative day 23. CASE 3- M, 84 years old with lithiasic cholecystitis, obstructive jaundice, lung emphysema and ischemic heart disease; after percutaneous cholecystostomy in emergency, we attempt to ERCP with evidence of type I lesion. Because of comorbility, we opt for a conservative treatment, not resolving, and then proceed to surgery. Exitus for cardio-respiratory complications. CASE 4- M, 89 years old with obstructive jaundice; ERCP is suspended for respiratory complications and then a PTC is perform; during it we note a type IV lesion, which is treated conservatively with resignation in day 12. CASE 5- F, 68 years old with cholecystitis and choledocholithiasis; during ERCP plus SE a type II lesion occurs with worsening signs of acute abdomen. Because of clinical conditions and the impossibility of carrying out stones from choledochus by endoscopy, we opt for a surgical treatment in emergency. Exitus for respiratory complications. DISCUSSION: Because of the controversy exists on what should be the management of perforations as adverse events of ERCP plus ES (immediate surgery or conservative therapy), we can only hope an eclectic approach based on the anatomical and clinical peculiarity of each case.

[Relations between allergic rhinitis and otitis media with effusion. The role of the Eustachian tube]. / Rapporti tra rinite allergica ed otite media con effusione. Il ruolo della tuba di eustachio.

It was recently observed that otitis media with perfusion (OME) occurs in 35-50% of children suffering from allergic rhinitis. The main pathogenetic mechanism was identified as the dysfunction of the eustachian tube (ET) following its impairment during nose allergy infection. As a result of this dysfunction, the tympanic cavity is affected by: accumulated secretion, proliferation of germs and changes of the hypersecretion of the lining mucous. The long-term persistence of these secretions may damage the normal functions of the ossicular chain and thus the transmission of sounds, leading to the onset of hypoacusis which may interfere negatively with the child's mental-physical development.

[An assessment of middle ear involvement in children with allergic rhinitis: a comparison with chronic hypertrophic adenoiditis]. / Valutazione della compromissione dell'orecchio medio in bambini affetti da rinite allergica: confronto con adenoidite cronica ipertrofica.

The allergic inflammation may contribute to the development of otitis media with effusion (OME). For this reason we have examined two groups of children: the first (group A) formed by 12 children with allergic rhinitis, the second (group B) by 15 children with hypertrophic adenoids. We have found respectively: pathologic otoscopy in 75% and 93% of cases; pathologic tympanometry in 83% and in 90%; pathologic audiometry in 60% and in 83%. This values are not significant according to a statistic analysis. Instead, the degree of compromission has been significant: in fact 16% of the children belonging to group A had a retracted and atelectatic eardrum in comparison with 33% of the children belonging to group B. Also tympanometry has confirmed this aspect: in fact 33% of group A showed type C and B tympanograms in comparison with 77% of group B. Besides, audiometry has confirmed the presence of hearing loss in the subjects with tympanometry of type C and B, belonging to both groups. For this reason the allergic rhinitis, because it may cause OME, must be treated in order to limit the negative effects of allergic nasal obstruction on the functionality of the middle ear.