Episodes of flushing, dyspnea and hypertension after carotid stenting for severe carotid stenosis.

INTRODUCTION: Carotid angioplasty and stenting (CAS) is a treatment option for carotid stenosis in high surgical risk patients. As it implies instrumentation of the carotid bulb, baroreceptors dysfunction may be provoked with consequent hemodynamic instability. REPORT: An 83-year-old woman treated by CAS presented with episodes of flushing, dyspnea and palpitations accompanied by transitory desaturation, hypertension, agitation and anxiety. Symptoms started 12h after the procedure. Each episode lasted 10 min. Five episodes in 3 days were observed. DISCUSSION: A dysfunction of the carotid baroreceptors and chemoreceptors was hypothesized.

Osmophobia in allodynic migraineurs: cause or consequence of central sensitization?

Migraine is a primary headache characterized by recurrent attacks of head pain associated with nausea or vomit, photophobia, phonophobia and osmophobia. The presence of osmophobia during migraine attacks seems to be a very specific complaint. Cutaneous allodynia (CA) is very common in migraineurs, and it is the most evident clinical manifestation of central sensitization, a mechanism involved in migraine chronification. This study was aimed at identifying the possible correlation between osmophobia and CA in migraineurs. 673 migraineurs were studied (492 episodic, 181 chronic). The prevalence of both CA and osmophobia was higher in chronic than in episodic migraineurs. The association between these two symptoms was significant in chronic migraineurs at Chi square test. The highlighted relationship between CA and osmophobia may be interpreted in different ways: central sensitization induced by recurrent pain stimulation may in parallel induce a distortion of both cutaneous sensitivity (CA) and olfaction (osmophobia); alternatively, the recurrent olfactory stimulation in subjects with a hypersensitivity to olfactory stimuli may co-work with repetitive pain stimulation to induce the central sensitization process.

Negative emotions in migraineurs dreams: the increased prevalence of oneiric fear and anguish, unrelated to mood disorders.

BACKGROUND: Migraineurs brain has shown some functional peculiarities that reflect not only in phonophobia, and photophobia, but also in mood and sleep. Dreaming is a universal mental state characterized by hallucinatory features in which imagery, emotion, motor skills, and memory are created de novo. We evaluated dream contents and associated emotions in migraineurs. MATERIALS AND METHODS: 412 subjects: 219 controls; and 148 migraineurs (66 with aura, MA; 82 without aura, MO), and 45 tension type headache patients (TTH). A semistructured retrospective self-reported questionnaire was used to evaluate dreams. The Generalized Anxiety Disorder Questionnaire (GAD-7), and the Patient Health Questionnaire (PHQ-9) were administered to evaluate anxiety and depression. RESULTS: Migraineurs showed increased levels of anxiety (P = 0.0002 for MA versus controls, P = 0.004 for MO versus controls). Fear and anguish during dreaming were more frequently reported by migraine patients compared to controls, independently by anxiety and depression scores. DISCUSSION: The brain of migraineurs seems to dream with some peculiar features, all with a negative connotation, as fear and anguish. It may be due to the recorded negative sensations induced by recurrent migraine pain, but it may just reflect a peculiar attitude of the mesolimbic structures of migraineurs brain, activated in both dreaming and migraine attacks.

Is the brain of migraineurs "different" even in dreams?

Migraineurs brain is hyper-excitable and hypo-metabolic. Dreaming is a mental state characterized by hallucinatory features in which imagery, emotion, motor skills and memory are created de novo. To evaluate dreams in different kinds of headache. We included 219 controls; 148 migraineurs (66 with aura-MA, 82 without aura-MO); 45 tension type headache (TTH) patients. ICHD-II diagnostic criteria were used. Ad hoc questionnaire was used to evaluate oneiric activity. The Generalized Anxiety Disorder Questionnaire, and the Patient Health Questionnaire were administered to evaluate anxiety and mood. The prevalence of dreamers was similar in different groups. Frequency of visual and auditory dreams was not different between groups. Migraineurs, particularly MA, had an increased frequency of taste dreams (present in 19.6 % of controls, 40.9 % of MA, 23.2 % of MO, 11.1 % of TTH, p < 0.01), and of olfactory dreams (present in 20 % of controls, 36 % of MA, 35 % of MO and 20 % of TTH, p < 0.01). Anxiety and mood did not influence these results. The increased frequency of taste and olfactory dreams among migraineurs seems to be specific, possibly reflecting a particular sensitivity of gustative and olfactory brain structures, as suggested by osmofobia and nausea, typical of migraine. This may suggest the role of some cerebral structures, such as amygdala and hypothalamus, which are known to be involved in migraine mechanisms as well in the biology of sleep and dreaming.

Blood pressure during nocturnal sleep in headache.

AIM: Interactions between blood pressure control, sleep and headache have been largely studied, although not well understood. We designed a study trying to simultaneously evaluate all three aspects in the same subjects. We particularly concentrated on the observation of physiological blood pressure circadian rhythm, and the presence of cutaneous allodynia correlated to headache. Objective of the study was to investigate blood pressure during nocturnal sleep in patients that underwent a blood pressure 24 hours monitoring, and at the same time the presence of headache and of sleep behavioural alterations. METHODS: Blood pressure 24 hours monitoring was performed by an ambulatory blood pressure (ABP) monitor (Space Labs) with its ad hoc software. Headache diagnosis was made according to ICHD-II criteria. Presence of allodynia and sleep behavior were evaluated through semi-structured ad hoc questionnaires. RESULTS: A total of 195 subjects were included, of which 122 without headache (mean age 60.4±11.6 years, 78 men and 44 women) and 73 with history of headache, (mean age 54.2±12.5 years, 18 men and 55 women). Fifty-one headache patients had migraine (mean age 52.6±11.7 years, 11 men and 40 women) and 22 tension type headache (TTH - mean age 58.0±13.5 years, 7 men and 15 women). Allodynia was found in 30 out of 73 headache patients: 23 out of 51 in the migraine group and in 7 out of 22 in the tension-type one. The physiological reduction of blood pressure during night (dipping) was more conserved among headache patients (34 dippers out of 73 subjects, 46,6%) with respect to subjects without headache (40 dippers out of 122, 32,8%) and that this border-line difference was more strongly significant comparing allodynic subjects (19 dippers out of 30, 63.3%) with both non-headache (40 dippers out of 122, 32.8%, P<0.001) and non-allodynic (15 out of 43, 34.9%, P<0.05) ones. No significant difference was observed between headache patients and subjects without headache in terms of mean systolic and diastolic pressure, neither between migraine and TTH. CONCLUSION: Allodynic headache patients seem to maintain a more physiologic pressure circadian rhythm. While considering the possibility of selection bias, the hypothesis of an allostatic function of headache and allodynia in patients with unbalanced blood pressure could be made.

Central sensitization in photophobic and non-photophobic migraineurs: possible role of retino nuclear way in the central sensitization process.

The aim of the present study was to investigate the possible relationships between the presence of headache-related photophobia and migraine-associated allodynia--a hallmark of central sensitization--among patients with different migraine types. A sample of 456 migraineurs was studied. Our results showed that photophobia was present in a high proportion of patients, with similar figures in patients with episodic migraine or CM, and confirmed that the prevalence of allodynia was higher among CM patients than in those with episodic migraine. We found a clear association between migraine-related allodynia and photophobia only in CM patients. Overall, these findings suggest that light stimulation may contribute to central sensitization of pain pathways in migraineurs, possibly contributing to progression into chronic forms. The possible connections underlying this type of sensitization is offered by the recently published data on a non-image-forming visual retino-thalamo-cortical pathway which may allow photic signals to converge on a thalamic region which is selectively activated during migraine headache.

Possible correlations between blood pressure, primary headaches and cutaneous allodynia.

Following an allostatic perspective, episodic migraine (M) may be considered as an adaptive behavioural response to endogenous or exogenous stressors, while its progression to a daily or nearly daily form (chronic migraine) may represent the failure of adaptive strategies. Multiple factors may enhance the progression/chronification of M, and among these the presence of cutaneous allodynia (CA) as well as alterations in blood pressure and in sleep. The working hypothesis of the study was that subjects with M, and particularly those with CA, could show a tendency towards high blood pressure levels and/or to alterations in the circadian rhythm of blood pressure. We studied 235 subjects consecutively attending a centre for blood pressure control for a blood pressure 24 h monitoring. Headache diagnosis was made according to the ICHD-II criteria. The presence of CA was evaluated through a semi-structured ad hoc questionnaire. Blood pressure 24 h monitoring was performed by an ambulatory blood pressure monitor (Space Labs) with its ad hoc software. Seventy-eight subjects had a history of headache (mean age 54.0 ± 12.4 years, 18 men and 60 women); 56 of them had M, 22 had tension-type headache; among them, CA was found in 24/56 subjects with M, and in 6/22 with tension-type headache; 157 subjects did not suffer from headache (mean age 60.5 ± 11.5 years, 99 men and 58 women). No significant difference was observed between headache subjects and subjects without headache in terms of mean systolic and diastolic pressure, neither in the M nor in tension-type subgroups. With regard to the circadian rhythm of blood pressure, the physiological reduction during night (dipping) was more evident among headache subjects than in subjects without headache; this border-line difference was more strongly significant in subjects with CA than both non-headache (p = 0.003) and non-CA (p = 0.05) ones. The difference between allodynic and non-allodynic subjects was present also in the M sub-group (7 dippers out of 32 non-allodynic migraineurs vs. 12 dippers out of 24 allodynic migraineurs, p = 0.03) notwithstanding the reduction of the sample size. Despite the initial hypothesis, subjects with primary headaches did not show differences in terms of mean blood pressure values and they showed a more physiologic blood pressure daily rhythm than those without headaches. Also the presence of CA, a marker of progression to chronic headache forms, was associated neither with hypertension nor with increased frequency of loss of dipping. M, particularly when associated with allodynia, may improve breathing during nocturnal sleep and consequently counteract possible blood pressure alterations, suggesting an allostatic function of allodynic headache.

Possible relationships between headache-allodynia and nocturnal sleep breathing.

Sleep and headache are linked in a bidirectional way. Breathing quality during sleep may be a possible link between them. The objective of this study were to evaluate the prevalence of headache--and of allodynia--in a population of subjects who underwent cardiopulmonary monitoring during sleep for presumed respiratory problems; to evaluate the possible relationships between the presence of headaches--and of allodynia--and respiratory parameters. We studied 181 subjects, 112 without headache (mean age 59.4 ± 13.1 years, 97 men and 15 women); 69 with history of headache (42 men and 27 women; 41 migraineurs and 28 with tension type headache). Headache diagnosis was made according to ICHD-II criteria. A semi-structured ad hoc questionnaire was used to evaluate the presence of allodynia. Full cardiopulmonary monitoring was performed by SOMNO check(®) effort (WEINMANN) with SaO(2), T90 and AHI determination. Headache and headache-associated allodynia were particularly frequent in this population, suggesting a positive correlation between breathing problems during sleep and head pain, and allodynia. The observation that better respiratory parameters were found among headache sufferers with respect to those without headache, even in allodynic subjects, seems to reverse this point of view: headache and allodynia may possibly have an allostatic function preventing deep sleep and, in turn, avoiding prolonged apneas.

Efficacy of HT 7 point acupressure stimulation in the treatment of insomnia in cancer patients and in patients suffering from disorders other than cancer.

AIM: The induction of sleep would depend on interaction between gabaergic system and the pineal gland through its main hormone melatonin. Until few years ago benzodiazepines were the only drugs effective in the treatment of insomnia. Recently, however, both melatonin and acupressure have appear to be active in sleep disorders. The aim of study was to evaluate the efficacy of HT 7 point acupressure in insomnia. METHODS: The study enrolled 25 patients affected by sleep disorders, 14 of whom had a neoplastic disease. They were treated by HT 7 stimulation for al least two consecutive weeks using a medical device named H7 Insomnia Control. RESULTS: An improvement in the quality of sleep was achieved in 15/25 (60%) patients, with a more evident efficacy in cancer patients (11/14 [79%]). CONCLUSION: This study confirms previous clinical data showing the efficacy of acupressure in the treatment of sleep disorders, particularly in cancer-related insomnia.

A progress study of 100 cancer patients treated by acupressure for chemotherapy-induced vomiting after failure with the pharmacological approach.

AIM: The recent rediscovery of the natural traditional medical sciences has contributed to improve the treatment of the human diseases and, in particular, it has been shown that the pharmacological approach is not the only possible strategy in the treatment of nausea and vomiting, since bioenergetic approaches, such as acupressure and acupuncture, may also counteract the onset of vomiting due to different causes. Previous preliminary clinical studies had already suggested a possible efficacy of acupressure also in the treatment of chemotherapy-induced vomiting resistant to the classical antiemetic drugs. The aim of this study was to confirm these preliminary data. METHODS: The study was performed in 100 consecutive metastatic solid tumour patients, who underwent chemotherapy for their advanced neoplastic disease, and who had no benefit from the standard antiemetic agents, including corticosteroids, antidopaminergics and 5-HT 3R-antagonists. Acupressure was made by a stimulation of PC6 acupoint. RESULTS: The emetic symptomatology was reduced by acupressure in 68/100 (68%) patients, without significant differences in relation to tumour histotype. The lowest efficacy was observed in patients treated by anthracycline-containing regimens, without, however, statistically significant differences with respect to the other chemotherapeutic combinations. CONCLUSION: This study confirms previous preliminary clinical results, which had already suggested the potential efficacy of acupressure in the treatment of vomiting due to cancer chemotherapy. Therefore, acupressure may be successfully included within the therapeutic strategies of cancer chemotherapy-induced vomiting.

A case-control study of Panicum Miliaceum in the treatment of cancer chemotherapy-induced alopecia.

AIM: Alopecia still remains one of the most untreatable side-effects induced by cancer chemotherapy. According to the phytotherapeutic tradition, Panicum Miliaceum has been proven to be effective in the prevention of hair loss for different reasons. At present, however, there are no data about its possible efficacy in the treatment of cancer chemotherapy-induce alopecia. The aim of this study was to analyze the efficacy of Panicum Miliaceum in cancer patients treated with the most potent chemotherapeutic drugs in terms of hair loss, consisting of cisplatin (CDDP) and anthracyclines. METHODS: This case-control study included 28 cancer patients concomitantly treated with Panicum Miliaceum and 56 patients receiving the same combinations of chemotherapy alone as a control group. Panicum Miliaceum was given orally at 300 mg (daily dose) 3 times per day, every day until the end of chemotherapy. The grade of hair loss was assessed by World Health Organization (WHO) criteria. RESULTS: The percentage of alopecia of third grade observed in patients concomitantly treated with Panicum Miliaceum in association with CDDP-containing regimens was significantly lower than that found in those who received the chemotherapy only. The percentage was also lower under anthracycline-containing schedules, without, however, statistically significant differences. Panicum Miliaceum therapy was substantially well tolerated in all patients. RESULTS: This preliminary study would suggest that the concomitant treatment with Panicum Miliaceum may be effective in preventing hair loss induced by CDDP-containing chemotherapies, whereas the benefit was lower in patients treated with anthracyclines. Future randomized studies will be necessary to confirm these preliminary

Effect of acupressure on nausea and vomiting induced by chemotherapy in cancer patients.

AIM: Corticosteroids, antidopaminergig agents and 5-HT3 antagonists are the most commonly used drugs in the treatment of chemotherapy-induced vomiting. Acupuncture and acupressure have also appeared to exert antiemetic effects. The aim of this study was to evaluate the efficacy of acupressure in the treatment of chemotherapy-induced vomiting resistant to the standard antiemetic therapies. METHODS: The study included 40 consecutive advanced cancer patients with untreatable chemotherapy-induced vomiting. Colorectal cancer, lung cancer and breast cancer were the neoplasm most frequent in our patients. According to tumour histotype, patients received chemotherapeutic regimens containing the main emetic cytotoxic agents, including cisplatin and athracyclines. Acupressure was made by PC6 point stimulation for at least 6 h/day at the onset of chemotherapy. RESULTS: The therapeutic approach was well accepted by the overall patients. An evident improvement in the emetic symptomatology was achieved in 28/40 (70%) patients, without significant differences in relation to neither tumor histotype, nor type of chemotherapeutic agent. CONCLUSIONS: This preliminary study seems to suggest that a bioenergetic approach by acupressure on PC6 point may be effective in the treatment of chemotherapy-induced vomiting resistant to the conventional pharmacological strategies, as previously demonstrated for vomiting occurring during pregnancy.

Comparison between intravenous iloprost and vasoactive drugs in limb ischemia IIB severe. A retrospective analysis.

AIM: Peripheral arterial vascular disease is caused by atherosclerosis. The severity of peripheral arterial disease is closely associated with the risk of myocardial infarction, ischemic stroke, and death from vascular causes. Approximately 1/3 of patients with peripheral disease have typical claudication. The goals of treatment for patients with claudication are to relieve their exertional symptoms, increase walking capacity, and globally improve their quality of life. In the peripheral arterial disease IIB stage, with claudication < 100 meters, no useful medical therapy is available. Aim of this investigation is to analyse, in a retrospective way, two groups of patients treated with vasodilator drugs or iloprost. METHODS: Data from 99 patients were registered: 79 patients were treated regularly with iloprost, administered for 10 days, 4 times a year. The 2nd group of 20 patients was treated with buflomedil 600 mg/die or pentoxifilline 1200 mg/die. The end point was the pain-free walking distance (PFWD) evaluated with treadmill test at basal conditions and at 3, 6, 12, 18 months. RESULTS: Treatment groups showed no difference as for occurrence of by-pass surgery or endovascular procedures during follow-up. Improvement in PFWD was significantly more evident in patients treated with iloprost as compared with the control (P = 0.02). Even considering the PFWD variations at any follow-up step vs basal value, we always observed a statistically significant difference with iloprost, P < 0.0001. CONCLUSIONS: The study suggests that iloprost may be effective in improving walking distance in severe IIB stage peripheral arterial vascular disease.

Increase in peripheral benzodiazepine receptors on monocytes in fibromyalgia.

OBJECTIVE: The aim of this study is to evaluate the expression of Peripheral Benzodiazepine Receptors (PBRs) on leukocytes in patients affected by primary fibromyalgia and to argue their possible role in pain perception and in modulation of immunologic process. METHODS: The expression of PBRs has been evaluated by flow cytometry on monocytes, on lymphocytes and on granulocytes in twenty patients with primary fibromyalgia, with indirect immunofluorescence methods. RESULTS: Upregulation of leukocyte PBRs expression has been demonstrated in fibromyalgia. A statistically significant difference has been documented only in monocytes. The monocyte PBRs expression was 26.74 +/- 14.84 MIF in fibromyalgia versus 17.45 +/- 8.54 MIF in controls (P < 0.023). Upregulation of PBRs expression, although not statistically significant, was also observed in lymphocytes and granulocytes. CONCLUSIONS: The monocyte PBRs overincrease in fibromyalgia may be due to abnormalities in the regulation of pain or to inflammation. It might perhaps explicate the possible mechanisms of therapeutic response to benzodiazepine in fibromyalgia.

Efficacy of cancer chemotherapy in relation to the pretreatment number of lymphocytes in patients with metastatic solid tumors.

The evidence of lymphocytopenia has been demonstrated to predict a poor prognosis in terms of survival in advanced cancer patients. This finding is not surprising because of the fundamental role of lymphocytes in mediating tumor cell destruction. Despite the importance of lymphocytes in the pathogenesis of cancer, there are only few data about the profile and the function of lymphocytes during the various antitumor therapies, and in particular the relation between lymphocyte pretreatment number and response to chemotherapy remains to be established. The present study was performed to evaluate whether the evidence of lymphocytopenia before the onset of treatment may influence the efficacy of chemotherapy in metastatic cancer patients affected by the most frequent tumor types. The study included 183 patients (lung cancer: 89; colorectal cancer: 63; breast cancer: 31), 95 of whom had been previously treated with chemotherapy. The chemotherapeutic regimens consisted of oxaliplatin plus 5-fluorouracil and folates in untreated colorectal cancer, weekly irinotecan in pretreated colorectal cancer, cisplatin plus gemcitabine or etoposide in untreated lung cancer, weekly vinorelbine in pretreated lung cancer, and taxotere in breast cancer patients who had been previously treated with anthracyclines. Lymphocyte count was considered to be abnormally low for values below 1500/mm3. Lymphocytopenia was found in 79/183 (43%) patients, without any significant differences in relation to tumor histology. A complete response (CR) was achieved in 6/104 patients with a normal lymphocyte count and in none of the 79 lymphocytopenic patients. A partial response (PR) was obtained in 39 patients with a normal lymphocyte count and in only eight patients with a low lymphocyte count prior to therapy. Therefore, irrespective of the type of chemotherapy, the objective tumor response rate (CR + PR) in lymphocytopenic patients was significantly lower than in patients with normal pretreatment lymphocyte counts (8/79 vs 45/104; p < 0.001). This study shows that the evidence of lymphocytopenia prior to chemotherapy is associated with a lower efficacy of treatment in terms of objective tumor regression rates in patients with metastatic solid tumors, and suggests that the action of chemotherapy may depend at least in part on an interaction with the antitumor immunity. Pretreatment lymphocyte count may represent a new, simple biological marker to be taken into consideration by oncologists in the chemotherapeutic treatment of metastatic cancer.

Ten-year survival results in metastatic renal cell cancer patients treated with monoimmunotherapy with subcutaneous low-dose interleukin-2.

After more than ten years of clinical investigations, IL-2 immunotherapy appears to constitute the most effective treatment metastatic renal cell carcinoma (RCC),at least in terms of survival time. Moreover, it has been shown that comparable results may be achieved with different schedules of treatment, including intravenous high-dose or subcutaneous (SC) low-dose IL-2. Finally, it has been demonstrated that the association with interferon-alpha does not increase the efficacy of IL-2. Therefore, SC low-dose IL-2 alone may be considered as an adequate therapy for metastatic RCC. In fact, our previous studies with SC low-dose IL-2 alone have shown a 5-year survival time similar to that described with higher and more toxic doses of IL-2. This study was performed to analyze the 10-year survival results with SC low-dose IL-2 in metastatic RCC The study included 44 consecutive metastatic RCC patients, with a minimum follow-up of 120 months. One comlete immunotherapeutic cycle consisted of IL-2 at 3 million IU twice/day SC, 5 days/week for 6 consecutive weeks. In non-progressing patients, a second cycle was planned after a 21-day rest period. Complete response (CR) was achieved in only 2 out of 44 (4%) patients, while partial response (PR) was obtained in 8 out of /44 (18%) patients. Therefore, the response rate (CR + PR) was 10 out of 44 (22%), with a median response duration of 12 months. Stable disease (SD) occurred in 21 out of 44 (48%) patients,whereas the remaining 13 out of 44 (30%) patients had a progressive disease (PD). A 10-year survival was achieved in 2 out of 44 (5%) and the percent of survival at 10 years was significantly higher in patients with response or SD than in those with PD. This study confirms at 10 years the results previously referred to by other authors and by ourselves, in showing that the efficacy of IL-2 immunotherapy in terms of control of cancer growth is associated with a clear prolongation of the overall survival time in metastatic RCC.

Blanket development in a malting wastewater anerobic treatment.

A 3 m3 pilot UASB reactor was operated with malting wastewater. In order to find the aggregation characteristics, the sludge concentration profile was determined throughout time. Reactor behaviour concerning the physical properties of the sludge can be evaluated using this procedure. Moreover, organic load per VSS can be calculated from this profile. The organic load based per VSS is more accurate as a design parameter than the volumetric load. Under the study conditions imposed the COD removal efficiencies achieved were about 85%. Organic loads of 0.6-0.7 kg COD/(kgVSS.d) were reached. After operating at 30 degrees C, temperatures of 28 degrees C and 15 degrees C were tested, showing no decrease in COD removal efficiency. At week 15 the presence of granules was verified, and after that, sludge concentrations of 30-35 kg VSS/m3 were measured at the bottom of the reactor. The SVI of the granular sludge decreased to values below 20 mL/gVSS. The settlement velocity was 10 m/h, which is much greater than the recommended values for the settlement zone; therefore, no problems are to be expected in the settler regarding the sludge sedimentation. The biomass yield coefficient obtained was 0.10 gVSS/gCOD in agreement with literature values for brewering effluent.