Migraine and risk of ischaemic heart disease: a systematic review and meta-analysis of observational studies.

BACKGROUND AND PURPOSE: Several studies have assessed the risk of ischaemic heart diseases in migraineurs, drawing different conclusions. To define and update the issue, a systematic review and meta-analysis of the available observational studies was performed. METHODS: PubMed and EMBASE were systematically searched up to April 2014 for observational studies dealing with the risk of any form of ischaemic heart disease in migraineurs. Studies assessing migraine as exposure and several types of ischaemic heart disease as outcomes were included in the analysis. A random effects model was used to pool the effect sizes. RESULTS: Out of 3348 records, 15 studies (one case-control, one cross-sectional and 13 cohort studies) were identified and were included in the meta-analysis. The pooled analysis indicated an increased risk of myocardial infarction (pooled adjusted effect estimate 1.33, 95% confidence interval 1.08-1.64; P = 0.007) and of angina (pooled adjusted effect estimate 1.29, 95% confidence interval 1.17-1.43; P < 0.0001) in migraineurs compared to non-migraineurs. CONCLUSIONS: Based on our data indicating an association of migraine with myocardial infarction and angina and on previous data showing an association of migraine, and particularly migraine with aura, with an increased risk for stroke, migraine can be appropriately considered an overall risk factor for cardiovascular diseases.

Insulin resistance in migraineurs: results from a case-control study.

OBJECTIVES: Several studies have suggested an association between migraine and insulin resistance (IR) without adequately addressing the issue according to migraine type. We assessed IR in subjects with migraine with aura (MwA) and migraine without aura (MwoA) to estimate the consistency of the possible association. METHODS: In a case-control study we included case subjects with MwA and MwoA, who were consecutively selected from those referred to our Regional Headache Center from September 2011 to February 2013, and age-matched control subjects selected using general practitioners' databases. IR was calculated by means of the homeostatic model assessment of IR (HOMA-IR), ß-cell function (HOMA-B), and the quantitative insulin sensitivity check index (QUICKI) measuring glucose and insulin values in a blood sample collected in the morning after overnight fasting. Data regarding anthropometric measures, comorbidity risk factors, and migraine characteristics were also recorded. RESULTS: We recruited 50 case subjects with MwA (38 women) and 50 with MwoA (40 women) and 50 control subjects (40 women). Proportions of arterial hypertension, cigarette smoking, hypercholesterolemia, use of oral contraceptives, and mean values of the body mass index (BMI) were similar in the three groups. We found significantly different glucose values among and within groups considering case subjects with MwA and MwoA and control subjects (4.9 ± 0.6 vs 4.7 ± 0.5 vs 4.6 ± 0.5 mmol/l; P = 0.018) in the absence of any difference in insulin (53.1 ± 24.0 vs 56.7 ± 34.4 vs 53.8 ± 24.4 pmol/l; P = 0.811), HOMA-IR (1.6 ± 0.8 vs 1.7 ± 1.0 vs 1.6 ± 0.7; P = 0.765), HOMA-B (121.4 ± 71.1 vs 149.2 ± 93.8 vs 162.8 ± 109.7; P = 0.107), and QUICKI (0.36 ± 0.03 vs 0.37 ± 0.03 vs 0.37 ± 0.03; P = 0.877) values. The logistic regression model showed increased odds of MwA in subjects exposed to the highest tertile of glucose values. This association was confirmed in the adjusted model, in which case subjects with MwA were compared with those with MwoA but not with control subjects. CONCLUSIONS: In contrast to what has been shown by the majority of the available studies, the results of our study do not support the association of migraine with IR. As our study was not population-based and several patients had low disease activity, these findings need further confirmation.

The use of complementary and alternative medicine in children admitted to Angau Memorial Hospital, Lae, Papua New Guinea.

There is considerable overlap between traditional medicine (TM) and complementary and alternative medicine (CAM). Although the use of CAM, often regarded as TM, is recognized to be widespread in Papua New Guinea (PNG) there are few if any studies of its use in children. This study assessed the use of CAM in 300 children admitted to the children's wards of Angau Memorial Hospital between April and July in 2010 and the same time period in 2011. 54% of the children had been treated with some form of CAM. The use of CAM did not appear to depend on socioeconomic indices. Children with chronic illness were twice as likely to have received CAM as those with acute illness. 116 (72% of the 161 children who had received CAM and 39% of the total sample) had received alternative medicine prior to commencing conventional treatment. Of these, 72 (62%) used plant-derived medication, 29 (25%) sought spiritual/religious help, 12 (10%) admitted to having accessed the help of sorcerers and 3 had used minerals. 43 (37%) were using some form of CAM whilst in hospital. The commonest reasons for using alternative medicine were previous use with perceived good effect (50, 43%), belief that it was a cure for the disease or symptom (28, 24%) and belief that the disease was due to a nonmedical or spiritual cause (14, 12%). Belief in spiritual or nonmedical causation of illness was strongly associated with delay in accessing conventional treatment. When CAM was used only in the outpatient setting plant-based treatment was more commonly used than mind-body medicine, whereas mind-body medicine--mainly religious activity--was used more commonly in the inpatient setting. CAM was given to 12 of the 35 outpatient user only group because of a perception that conventional treatment was not working whilst 13 carers gave it to assist in healing. The large majority of CAM treatments were free but in two cases (one the use of purported electromagnetic field with Biodisc and one religious activity) the cost had been more than 100 kina. The study demonstrates that the use of CAM for the treatment of childhood illness is common in PNG. Whilst most forms of CAM were in themselves not harmful, potential for harm exists, particularly when its use results in significant delay in accessing conventional treatment.

The aetiology, clinical presentations and outcome of febrile encephalopathy in children in Papua New Guinea.

BACKGROUND: Febrile encephalopathy, defined as fever, seizures and/or altered consciousness, is a common presentation in children in tropical developing countries. Outcomes range from complete recovery through varying degrees of neurological disability which slowly resolve or remain permanent to death from either the acute illness or complications. Whilst bacterial meningitis accounts for a proportion of children affected, the aetiology in many remains unclear but includes malaria and probably viral encephalitis. AIM: To understand the aetiology, presentation and outcome of febrile encephalopathy in children in Papua New Guinea. METHODS: Children aged between 1 month and 12 years presenting to Port Moresby General Hospital with febrile encephalopathy were studied prospectively. A detailed history and examination and the following laboratory investigations were undertaken as appropriate: cerebrospinal fluid (CSF) microscopy and bacterial culture, gram stain, measurement of protein and glucose and latex agglutination testing for Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitides; Ziehl-Neelsen staining and india ink examination on selected samples; IgM for Japanese encephalitis, dengue, rubella and measles; PCR testing and mycobacterial culture for Mycobacterium tuberculosis. Blood was tested for flavivirus, measles and rubella IgM and IgG. RESULTS: 149 children were enrolled in the study. 129 had a lumbar puncture and CSF examination; 66 had a normal CSF white cell count. A clinical or laboratory-based diagnosis was possible for 140 children, but a definite pathogen was identifiable for only 55 (37%). The diagnoses included bacterial meningitis in 33 (S. pneumonia 16, H. influenza 13 and N. meningitides 4), tuberculous meningitis (5), probable tuberculous meningitis (18), malaria (10), cryptococcal meningitis (1), flavivirus encephalitis (5), rubella encephalitis (1), hepatic encephalopathy (1) and HIV encephalopathy (1). There were 28 cases of meningitis of unspecified aetiology. Of the five children with IgM-confirmed flavivirus encephalitis, one had dengue serotype 1 and two had Japanese encephalitis. Twenty-five children (including three of the five children with CSF flavivirus IgM) had serological IgG evidence of previous flavivirus infection. A history of multiple convulsions, the presence of neck stiffness and use of the Glasgow coma score (GCS) and TB score chart helped to identify children with bacterial meningitis and an adverse outcome and those with febrile convulsions. CONCLUSION: The study confirms the importance of S. pneumonia and H. influenza as major causes of febrile encephalopathy in children in Papua New Guinea. Flaviviruses including Japanese encephalitis are a cause of the febrile encephalopathy syndrome, as is Mycobacterium tuberculosis. All children with febrile encephalopathy should have their GCS and TB scores recorded and should be examined for neck stiffness, and a history of the frequency of convulsions should be recorded. These basic clinical data can help to discriminate aetiology, to guide treatment and monitoring and to identify the children at highest risk of adverse outcome.

Comparison of the use of liquid crystal thermometers with glass mercury thermometers in febrile children in a children's ward at Port Moresby General Hospital, Papua New Guinea.

We compared the temperatures recorded, in febrile children admitted to a children's ward at Port Moresby General Hospital, by a doctor and by a group of nurses using glass mercury thermometers (GMT) and liquid crystal thermometers (LCT, Nextemp and Traxit. The mean difference (with 95% confidence intervals) in temperatures between GMT and Nextemp were -0.12 degrees C (-0.16 degrees C to -0.08 degrees C) for the doctor and 0.12 degrees C (0.04-0.20 degrees C) for nurses. The mean difference in temperatures between GMT and Traxit were -0.05 degrees C (-0.09 degrees C to -0.01 degrees C) for the doctor and 0.19 degrees C (0.10-0.28 degrees C) for the nurses. A similar result was obtained when one of the Nextemp thermometers used in the initial study was compared with GMT on a small sample of patients by the doctor 8 months later. Limited evaluation showed nursing staff were in favour of using the LCTs. Nextemp and Traxit thermometers can be used interchangeably with GMT in this setting.

Knowledge and attitudes about infant feeding among nulliparous and parous women in Port Moresby: a comparative study.

Knowledge of the advantages of breastfeeding, the disadvantages of bottle feeding and the Papua New Guinean legislation to protect breastfeeding was determined in a comparative study of nulliparous and parous women attending the Antenatal Clinic of Port Moresby General Hospital. A high proportion (40%) of both groups had had experience of bottle feeding. Whilst the large majority (94%) of the women indicated that breastfeeding was the best way to feed babies, knowledge of the reasons for its superiority over bottle feeding and of the dangers of bottle feeding was poor in both groups. Knowledge of the legislation to protect breastfeeding was also poor and was the only area in which there was a significant difference between the groups, nulliparous women having poorer knowledge (p = 0.015). The level of education did not appear to be associated with knowledge about feeding. There is an urgent need to review the legislation, to find ways of enforcing it, and to improve the education of young people on issues of infant feeding.

Migraine and epilepsy: clinical and pathophysiological relations.

Migraine and epilepsy are both chronic disorders characterised by recurrent neurological attacks, with a partial clinical and therapeutic overlap and frequently occurring together. Although still incompletely clarified, the possible existence of a link between migraine and epilepsy has long been debated. In this paper the epidemiologic evidence of migraine and epilepsy comorbidity, the possible occurrence of both disturbances in close temporal association, possible shared physiopathologic mechanisms and the rationale for antiepileptic drug use in migraine prophylaxis will be discussed.

Validation of AIDA Cefalee, a computer-assisted diagnosis database for the management of headache patients.

AIDA Cefalee is a database for the management of headache patients developed on behalf of the Italian Neurological Association for Headache Research (ANIRCEF). The system integrates a diagnostic expert system able to suggest the correct ICHD-II diagnosis once all clinical characteristics of a patient's headache have been collected. The software has undergone a multicentre validation study to assess: its diagnostic accuracy; the impact of using the software on visit duration; the userfriendliness degree of the software interface; and patients' acceptability of computer-assisted interview. Five Italian headache centres participated in the study. The results of this study validate AIDA Cefalee as a reliable diagnostic tool for primary headaches that can improve diagnostic accuracy with respect to the standard clinical method without increasing the time length of visits even when used by operators with basic computer experience.

Urinary tract infection in infants and young children presenting with fever without a focus in Port Moresby.

A prospective study was undertaken to document the importance of urinary tract infection (UTI) as a cause of fever without a focus (FWF) in children less than 3 years of age presenting to the Children's Outpatients Department (COPD) of Port Moresby General Hospital (PMGH). 98 children, 55 males and 43 females, with a median age of 17 months and an interquartile range of 5-31.25 months, were recruited. In addition to a history and physical examination each child had a full blood count, a malaria parasite smear, and a urine sample (obtained by clean catch or midstream methods) for dipstick testing, microscopy and culture. Blood culture was performed where practicable. Lumbar puncture and cerebrospinal fluid (CSF) examination were done only if clinically indicated. UTI was diagnosed on urine culture in 9 of the 98 children. Both urinary nitrite and leukocyte esterase tests were sensitive (89%) and specific (96%). Other causes of FWF were classified as non-specific viral infection (31 children), lower respiratory tract infection (11), malaria (7), meningitis (4), bacteraemia (1 neonate) and other or unknown causes. The finding of UTI in 9% of the children is consistent with data from other tropical countries. Checking for urinary tract infection, which can be done using noninvasive methods of urine collection, is an important part of the investigation of infants and children with FWF.

A clinical comparison of trigeminal neuralgic pain in patients with and without underlying multiple sclerosis.

Despite clinical similitude, there is a tendency to consider trigeminal pain in multiple sclerosis (MS) as a distinct condition. To evaluate clinical differences in trigeminal pain presentation in patients with and without underlying MS, we compared clinical characteristics of facial pain found in 15 consecutive MS patients with those reported by 13 consecutive subjects diagnosed with classical trigeminal neuralgia. The only significant difference between MS and non-MS neuralgic patients was the age of onset of pain (43.4+/-10.5 in MS vs. 59.6+/-11.50 in non-MS patients, p=0.000629, unpaired Student's t-test). No differences were observed for side, duration and quality of pain, trigeminal branches involved, presence of trigger areas or factors, pain refractive period, remitting-relapsing or chronic course. There was only a trend without statistical significance in interval pain and trigeminal hypoesthesia, more frequent in MS population. Only one patient in the MS group presented with long-lasting episodes (45-60 min) of atypical odontalgia. Our findings support the view of a common pathogenetic mechanism underlying TN in the two groups, possibly related to demyelination of the trigeminal entry root in the pons. Typical TN in MS patients should be considered as "symptomatic trigeminal neuralgia".

A comparison of booked and unbooked mothers delivering at the Port Moresby General Hospital: a case-control study.

A case-control study of unbooked mothers delivering at the maternity unit of the Port Moresby General Hospital was undertaken over a period of 7 months. 48 mothers who had no antenatal attendances during pregnancy were recruited with 96 booked controls. Reasons for non-attendance, understanding of the importance of antenatal clinics and socioeconomic and demographic factors were recorded to assess likely risk factors for non-attendance. Almost half the mothers cited financial difficulties as the reason for non-attendance at antenatal clinics despite most of them knowing that it was important to have antenatal care during pregnancy. The two most important risk factors for being unbooked were mothers having no education (p <0.001) and the type of employment of their spouse (p <0.01). Unbooked mothers were more likely to have preterm babies (OR 16.1; 95%CI 3.4-75.7) and all 6 perinatal deaths occurred in babies born to unbooked mothers. Remedial approaches would need to take into account maternal education, education of partners and the fact that despite free antenatal services in urban clinics financial difficulties in terms of other costs involved still remain an obstacle to overcome.

Sterol conjugates of two phenotypically different calli of Beta vulgaris.

Steryl glycosides are the predominant form of sterol at 88% of the total sterol in non-betalain producing calli of Beta vulgaris. The total sterol decreases and sterol form shifts from steryl glycosides to 97% free sterol upon the transition of non-betalain to betalain producing calli. A substantial decrease in stigmasterol (24α--ethylcholesta-5,22E-dien-3ß-ol) and sitosterol (24α-ethylcholest-5-en-3ß-ol) levels is observed during this transition, and alters the ratio of Δ(7):Δ(5) sterols. Spinasterol (24α- ethyl-5α-cholesta-7,22E-dien-3ß-ol) is the dominant sterol at 43% and 95% of the total sterol in non-betalain producing and betalain producing calli. The level of 22-dihydrospinasterol (24α-ethyl-5α-cholest-7-en-3ß-ol) is reduced in both calli to ≤ 3% from 25% in leaves. Lanosterol (4,4,14α-trimethyl-cholesta-8(9),24-dien-3ß-ol) and cycloartenol (9ß,19-cyclopropyl-4,4,14α-trimethyl-cholest-24-en-3ß-ol) were identified in betalain and nonbetalain producing callus respectively.