Efficacy and tolerability of diclofenac potassium sachets in migraine: a randomized, double-blind, cross-over study in comparison with diclofenac potassium tablets and placebo.

A randomized, controlled, cross-over trial compared single doses of 50 mg diclofenac potassium sachets and tablets with placebo in 328 patients with migraine pain, treating 888 attacks. For the primary endpoint 24.7% of the patients were pain free at 2 h postdose with sachets, 18.5% for tablets and 11.7% for placebo. Treatment differences were significant for sachets vs. placebo (P<0.0001), tablets vs. placebo (P=0.0040) and for sachets vs. tablets (P=0.0035). The numbers needed to treat compared with placebo to achieve pain free at 2 h were 7.75 [95% confidence interval (CI) 5.46, 13.35] for sachets and 15.83 (95% CI 8.63, 96.20) for tablets. Sachets were also statistically superior to tablets for sustained headache response, sustained pain free and reduction in headache intensity within the first 2 h postdose measured on a visual analogue scale (P<0.05). Onset of analgesic effect was 15 min for sachets and 60 min for tablets. Fewer patients needed rescue medication, and there were marked improvements in accompanying symptoms and working ability with both sachets and tablets vs. placebo. No safety issues were identified. This study demonstrates that sachets offer patients suffering from migraine pain a more effective treatment with a faster onset of analgesia when compared with tablets.

Dimensional complexity of the EEG in subcortical stroke--a case study.

The conventional electrophysiological methods used for the analysis of the functional characteristics of the nervous system are not able to grasp its non-linear and random features. Of the methods based on the application of chaos-theory the correlation dimension analysis can be used to quantify the complexity of the analyzed signal, such as the electroencephalogram (EEG). The new version (point-correlation dimension, PD2) was used in this study, which is more accurate than the other, currently used algorithms. The purpose of the present investigation was to compare the sensitivity of the methods based on chaos-theory with the traditional electrophysiological ones in a case when no apparent abnormality was present as judged on the basis of this latter methodology. The PD2 was calculated from the EEG recorded in 13 healthy control subjects and in a patient who suffered a small subcortical stroke 2 years prior to the investigation and who was free of neurological symptoms at the time of recording. Compared to that seen in the control group, in the Z-score maps of the scalp distribution of the PD2, a marked asymmetry was seen and the absolute PD2 values showed a low-dimensional area in the parietal region, ipsilateral to the stroke. A relative decrease of the gamma band was found in the frequency power spectra in the same area. It is suggested that the additional information extracted from the EEG by non-linear analysis may increase the sensitivity of electrophysiological methods for detecting brain pathology.

[Hyperimmunoglobulinemia E (Job) syndrome]. / Hyperimmunoglobulinaemia E (Jób) szindróma.

A patient with hyperimmunoglobulin E (Job's) syndrome is presented. The authors review the clinical and immunological characteristics of the disease and sum up the different explanations for the pathogenesis of the syndrome.

The effect of socio-economic conditions on the time of diagnosis and compliance during treatment in growth hormone deficiency.

In 78 patients with idiopathic growth hormone (GH) deficiency the effect of the fathers' educational level on the age and the extent of growth retardation at diagnosis was studied. There was a tendency for an increase of the age and the degree of growth retardation with the decrease of the fathers' completed grades. The occurrence of height SD scores less than -4.5 was conversely related to the number of grades completed by the father (chi 2 = 19.2 p less than 0.001). Eighteen of the 70 patients treated with growth hormone discontinued treatment after 0.3 to 6 years. Compliance was closely related to the grades completed by the father (chi 2 = 24.7 p less than 0.001). Six out of 7 patients with a height SDS less than -4.5 at diagnosis and with a father of low level of education (less than 8 grades) became non compliant. It is concluded that the degree of growth retardation at diagnosis and compliance at treatment in GH deficiency is related to the educational level of the father.

Blood-spot 17-hydroxyprogesterone daily profiles in infants with congenital adrenal hyperplasia.

To define the optimum blood levels of 17-hydroxyprogesterone, the hormonal effects of glucocorticoid treatment were studied during the neonatal period and infancy in 20 patients with 21-hydroxylase deficiency. Repeated daily profiles of blood spot 17-hydroxyprogesterone were used to monitor therapy and these data were related to serum concentrations of testosterone. A wide fluctuation of blood 17-hydroxyprogesterone levels was observed in patients with a mean daily value higher than 150 nmol/l indicating poor control. Serum testosterone levels decreased into normal range in female patients with blood-spot 17-hydroxy-progesterone levels between 50 and 150 nmol/l. Daily profiles with mean values less than 50 nmol/l showed low magnitude of circadian variation suggesting overtreatment. We conclude that the daily profile of blood-spot 17-hydroxyprogesterone is a practical alternative in hormonal monitoring of infants treated for congenital adrenal hyperplasia.

[Final body height and puberty in idiopathic hypopituitarism]. / Végsö testmagasság és serdülés idiopathiás hypopituitarismusban.

Twenty four children with hypopituitarism were treated with growth hormone from 6-15 years of age until cessation of growth. The height deficit decreased from -4.2SD to -2.2SD. Final height was above the 3rd percentile in half of the patients. There was no difference in final height between patients with and without additional gonadotropin deficiency. Spontaneous puberty started late but at a normal bone age and its course was normal. In girls with gonadotropin deficiency low dose oestrogen given at unchanged growth hormone doses did not accelerate growth. Final height was closely correlated with the degree of growth retardation at the beginning of treatment (r = 0.73, p less than 0.001). In 17 of the 79 patients treated with growth hormone compliance was bad. The main cause of bad compliance was the low educational level of the parents. It is concluded that final height in growth hormone deficiency can be increased with earlier diagnosis and improved compliance.

Perinatal factors in the aetiology of hypopituitarism.

The possible aetiological factors were studied in 73 children with idiopathic growth hormone deficiency. The following perinatal abnormalities were found to be more frequent than expected: breech presentation (32.9%) and asphyxia (15.0%). Parallel with an increased application of caesarean section there was a significant reduction in the incidence of breech birth among the hypopituitary patients. On the basis of TSH levels measured during TRH tests, most of the patients with breech delivery had a hypothalamic damage, while at vertex position the pituitary damage was more frequent. Of the two pairs of siblings with hypopituitarism both members of the first had breech birth and of the second high birth weight. It is concluded that perinatal abnormalities are important aetiological factors in hypopituitarism and that the occurrence of this disease can be reduced with improved obstetrical practice and perinatal care.

Effect of growth hormone on serum lipoproteins in growth hormone deficiency.

The effect of growth hormone treatment on the plasma lipoproteins was studied in 13 growth hormone deficient children. The pretreatment total cholesterol level was moderately (p less than 0.05) higher in growth hormone deficiency and it decreased significantly under the effect of growth hormone administration. This decrease was due to the reduction of HDL-cholesterol in the first week and to the decrease of LDL-cholesterol after one month of treatment. The level of LDL-cholesterol returned to normal at one month. The plasma triglyceride level increased significantly under the effect of growth hormone in the first week and returned to normal after one month. This change was due to the increase of VLDL-triglyceride level. There was no difference in the cholesterol and triglyceride concentrations of growth hormone deficient children with normal or subnormal plasma thyroxine concentrations.

Detection of late-onset adrenal hyperplasia in girls with peripubertal virilization.

We investigated the value of serum levels of adrenal steroids (dehydroepiandrosterone sulphate, testosterone, 17-hydroxyprogesterone, cortisol) in the identification in peripubertal females with late-onset congenital adrenal hyperplasia owing to 21-hydroxylase deficiency. Among 68 females (age 3-18 years) with virilization in childhood, peripubertally or postpubertally, we selected 21 girls for an ACTH test by measurement of basal blood-spot or serum 17-hydroxyprogesterone (17-OHP) levels. Eight of 21 patients had supranormal post-ACTH serum 17-OHP concentration (57-153 nmol/l) with low normal cortisol concentration. All of them had supranormal basal and post-ACTH 17-OHP to cortisol ratios. These data show a relatively high incidence (about 12%) of mild 21-hydroxylase deficiency among prepubertal and adolescent girls with virilization. It is concluded that the first step in the investigation of peripubertally virilized girls should be the determination of serum 17-OHP and cortisol. Patients with basal morning 17-OHP concentration and 17-OHP to cortisol ratio above reference range should be given an ACTH test.

The effect of age and body size on the urinary excretion of C-peptide from birth to 14 years of age.

The daily excretion of C-peptide in the urine was measured in 105 healthy infants and children from birth to 14 years of age. For technical reasons no studies were performed from 1-3 years of age. The excretion of C-peptide showed a close positive correlation with age and weight. The relationship with weight was already apparent in the 1st days of life. The C-peptide/weight and the C-peptide/creatinine ratios were constant throughout most of childhood with the exception of the age range of 1 month-1 year when the C-peptide/creatinine was significantly higher. In obese children the C-peptide/weight and C-peptide/creatinine ratios were similar to those found in children with normal weight. In growth hormone deficiency these ratios were low and increased during the 1st week of growth hormone therapy. It is concluded that urinary C-peptide is a reliable indicator of integrated insulin production and gives new information about insulin secretion in various conditions.

Occurrence and mechanisms of occlusion of the anterior cerebral artery.

Occlusion of the anterior cerebral artery is a rare condition. A review of CT scans from 413 patients with ischemic infarction confirmed this low relative incidence: only 3% of CT scans evidencing infarction involved the territory of the anterior cerebral artery. Four major mechanisms of anterior cerebral artery occlusion have been identified in this series: Emboli in unusual hemodynamic circumstances such as patients presumed to have increased flow through the anterior communicating artery because of unilateral internal carotid artery occlusion. Propagation of thrombotic material from an occluded internal artery into the intracranial branches. Spasm, emboli or propagating thrombosis associated with anterior communicating aneurysm.

CT visualization of intracranial arterial thromboembolism.

Eight cases of presumed acute occlusion of intracranial arteries, 7 middle cerebral and 1 posterior cerebral, demonstrated the occluded artery as an abnormal high density structure on non-enhanced computed tomography. Three cases underwent subsequent angiography which confirmed the diagnosis. CT scanning is therefore able to visualize acute thromboembolism in the intracranial arteries. In the appropriate clinical setting of acute stroke, an artery visualized on non-contrast CT scan as diffuse high density and higher in density than other visualized vessels should be suspected as acutely occluded by clot.

Late effects of therapy in children previously treated for leukaemia or malignant tumour.

The late sequelae of leukaemia and tumour therapy are discussed. The most important and/or the most frequent are neuro-psychologic disturbances, deformities of the bones, the decreased reproduction capacity and the second tumours. Because of the rapidly growing number of cured patients a better knowledge of the occurrence, aetiology, prophylaxis and rehabilitation of these changes is needed.

Peripheral aneurysms of the cerebellar arteries. Review of 16 cases.

True congenital peripheral aneurysms of the cerebral arteries are rare and may constitute a special group. The authors report on 16 cases of peripheral aneurysms of the cerebellar arteries; six of them arising from vessels feeding arteriovenous malformations (AVM's). The possible causative role of increased blood flow versus developmental factors in the frequent occurrence in cases of AVM of this otherwise rare type of aneurysm is discussed. In five of the six cases with AVM's (one dural and five parenchymal), the aneurysm rather than the AVM proved to be the source of the hemorrhage. The occurrence of spasm was in inverse proportion to the distance of the aneurysm from the main arteries. The surgical result was good in 11 cases. One patient with associated AVM died, and four patients had residual symptoms.