Ophthalmoplegic migraine: Still a diagnostic dilemma?

The term ophthalmoplegic migraine (OM) was first coined by Charcot in 1890. This condition was included as a migraine variant in the first Headache Classification of the International Headache Society in 1988. Based on postcontrast enhancement seen on MRI in some patients who were diagnosed with OM, there was a suggestion that this could be an inflammatory/demyelinating disorder; therefore, it was moved out of the “migraine” group and repositioned as a “neuralgia” in the revised 2004 classification. However, there have been subsequent reports in the literature in which there was no enhancement on postcontrast MRI. Based on a survey of literature on OM in the post-imaging era, this article highlights the fact that enhancement on magnetic resonance is not a sine qua non for the diagnosis of OM. Some diagnostic dilemmas are discussed, and a protocol is included for documentation of clinical findings in future case reports on a prospective basis. Hopefully, this will help in modification of the criteria, better understanding the etiology, correct diagnosis, and determining appropriate treatment for OM.     

Still a man's world,but why?

Women are generally under-represented in many academic medical settings. Through a brief commentary on this issue, the present article discusses possible explanations for this under-representation as well as potential solutions. Issues examined include women in leadership positions, attrition out of academic medicine, salary imbalance between men and women, potential bias among both genders, and the need for cultural change. We believe this is an extremely important issue of which we all need to be aware and hope that articles such as this will aid in starting a crucial conversation about gender issues in academic medicine.In the present issue of Critical Care Dr Metaxa asks whether this is (still) a man''s world [1]. In academic medicine, the answer is a disappointing ''yes''. Even in pediatrics and in obstetrics and gynecology, where women represent at least one-half of the faculty in US medical schools, the percentage of female full professors is less than 30% of the total professoriate. In all specialties combined, women comprise only 22% of permanent division or section chiefs and associate or vice chairs, and only 14% of permanent department chairs [2].The bigger questions are why this is this true, and what can be done to increase the number of women in academic medicine and in leadership positions. The imbalance is clearly not due to a pipeline effect. In the 2011/12 academic year, 48% of US medical school graduates were women, and 44% of new recruits to academic positions were women. The imbalance is also not due to excess attrition of women out of academic institutions, as less than one-half (40%) of faculty members who left their academic positions in 2011/12 were women, representing 7% of the total female faculty [2].According to a survey of former female and minority faculty at Virginia Commonwealth School of Medicine, the three most common reasons for leaving academic positions were career/professional advancement (30%), salary (26%), and leadership issues (22%) [3]. A similar survey of former Stanford University Medical School faculty who left the institution between 1999 and 2009 found that the major reasons why women leave academic positions are similar to the reasons why men leave: better professional opportunities, higher salary, personal/family reasons, lack of support (recognition, appreciation, and so forth), advancement or promotion-related concerns, and lack of critical resources for research (Sabine Girod, personal communication). Of the 74 survey respondents (a 56% response rate), 22 were women. Interestingly, women more often left for a higher salary or because of a lack of support or critical resources for research, and men more often left for better opportunities or for family reasons. The percentages of men and women at Stanford who left for reasons related to advancement or promotion were approximately equal.In addition to under-representation of women in academic medical positions, the literature suggests that there is also an imbalance in salary. A recent study found that salaries for 2000-2003 National Institutes of Health K08 and K23 recipients are almost $33,000 lower for women than for men, even after adjustment for confounders such as age, race, academic rank, institution, publications, grant funding, and work hours [4]. Furthermore, US data also suggest that women are not promoted at the same rate as men [5,6].These data raise concerns that bias on the part of employers and school leadership could play a major role in the under-representation of women in academic medicine, and this bias may exist among leaders of both sexes. A recent investigation of full-time faculty at 26 nationally representative US medical colleges reported inequalities in letters of recommendation, promotion and tenure, and opportunities of leadership for women, as well as feelings of isolation among women [7]. Another study found subtle biases from both male and female science faculty at research-intensive universities in favor of male students, and demonstrated that these biases would result in a higher likelihood of being hired into a laboratory manager position, higher salaries, and more mentorship for male students [8].Clearly there is a need for culture change in all areas of academic medicine, among both men and women. Educational programs to inform school leadership about biases, both subtle and overt, and concrete ways to avoid them are needed to improve mentorship, salary, and support for academic endeavors for women. Developing flexible working environments and timelines to promotion and tenure is important, but the perception of women that they are isolated and the reality of inequalities in advancement demonstrate that these efforts are inadequate. Programs to mentor women to help them write grants, prioritize goals, develop a complete and representative CV, and be appropriately self-promoting will help female faculty advance in their careers.Women''s organizations are important to allow women to discuss issues that may be unique to women and engender a sense of community among women, but these organizations may actually unintentionally make women feel more isolated and less a part of a bigger academic community. There must be efforts on the part of departmental and school leadership to make women feel they are valued members of the academic community and to encourage and support their advancement. Finally, women who have achieved promotion and leadership roles must take active and inclusive roles as role-models, advisors, mentors, and advocates for junior women in academic medicine. Women early in their careers need proof that there is light at the end of the academic tunnel.     

Unanswered Questions in Headache: How Does a Migraine Attack Stop?

Much research in migraine focuses on understanding its initiation. But as migraine is typically self‐limited, its offset may be as important as its onset. We pose the question “how does migraine stop?” to three investigators with different backgrounds. The consensus is that the termination of a migraine attack, rather than being the passive loss of a trigger, must itself be an active biologic process.     

Migraine in the emergency department: a psychometric study of a migraine “repeaters” sample

To evaluate the influence of psychometric variables on the “repeater” phenomenon in an emergency department, 15 “repeaters” and 27 outpatient migraineurs were recruited. All patients were submitted to the Beck Depression Inventory (BDI), State and Trait Anxiety Inventory, Toronto Alexithymia Scale–20 (TAS–20), Tridimensional Personality Questionnaire and Migraine DIsability Assessment Scale (MIDAS). The “repeater” group showed higher MIDAS total scores (p=0.02) and higher scores in TAS–20 (p=0.02) than the outpatients. A higher frequency of alexithymic trait (p=0.02) and higher BDI scores (p=0.07) have also been observed in the “repeater” group than the outpatients. Alexithymia and depressive mood associated with high disability may be a specific psychosocial pattern of “repeater” migraineurs. The psychometric evaluation of this population may be important to explain the “repeaters” phenomenon.     

Shine: Still a glittering moment,or now a little bit tarnished?

The representation of mental illness in the cinema has a long and varied history. Each film emerges from a cultural context and understanding of psychopathology and some landmark films have made a profound impact on the way in which psychiatric disorders are regarded by the general public. One prime example is Shine, produced in 1996 and based on the life of David Helfgott, a child musical prodigy who later developed a severe mental illness. However, although the film garnered numerous awards and public acclaim, its premises have been questioned and the explanatory model of mental illness that it promotes has been criticized. This paper examines the cultural forces that shape cinematic representations and the example of Shine in particular.     

Migraine,Brain Glucose Metabolism and the “Neuroenergetic” Hypothesis: A Scoping Review

Increasing evidence suggests that migraine may be the result of an impaired brain glucose metabolism. Several studies have reported brain mitochondrial dysfunction, impaired brain glucose metabolism and gray matter volume reduction in specific brain areas of migraineurs. Furthermore, peripheral insulin resistance, a condition demonstrated in several studies, may extend to the brain, leading to brain insulin resistance. This condition has been proven to downregulate insulin receptors, both in astrocytes and neurons, triggering a reduction in glucose uptake and glycogen synthesis, mainly during high metabolic demand. This scoping review examines the clinical, epidemiologic and pathophysiologic data supporting the hypothesis that abnormalities in brain glucose metabolism may generate a mismatch between the brain's energy reserve and metabolic expenditure, triggering migraine attacks. Moreover, alteration in glucose homeostasis could generate a chronic brain energy deficit promoting migraine chronification. Lastly, insulin resistance may link migraine with its comorbidities, like obesity, depression, cognitive impairment and cerebrovascular diseases.PerspectiveAlthough additional experimental studies are needed to support this novel “neuroenergetic” hypothesis, brain insulin resistance in migraineurs may unravel the pathophysiological mechanisms of the disease, explaining the migraine chronification and connecting migraine with comorbidities. Therefore, this hypothesis could elucidate novel potential approaches for migraine treatment.     

Concordance: a widely used term, but what does it mean?

The term concordance was first used by the Medicines Partnership to describe a new way of consulting with patients in order to gain the most effective use of medicines (Royal Pharmaceutical Society of Great Britain 1997). Over recent years, the term has become associated with many different health care interventions. The aim of concordance is to improve satisfaction with the process of health care consultations, having the ultimate goal to reduce wastage of health care resources. Concordance has evolved from terms such as non-compliance and non-adherence and reflects a shift in the culture of health care interventions, aiming to empower patients. Suggestions to the content of concordant consultations are outlined in this article and will be further developed in the second article.     

Validating clinical reasoning: a question of perspective,but whose perspective?

This paper explores the notion of validity from different perspectives and addresses its integration with clinical reasoning. Whilst valuing the evidence-based practice (EBP) perspective in our quest for validation of practice, the authors posit that other perspectives may provide added value through their potential for offering validity in differing circumstances. The reality of the EBP aspiration is discussed and nuances within the evolved term 'research-enhanced practice' are shared. Validity theory applied through different perspectives may, it is argued help to get to grips with the balancing act of validating manual therapy practice.     

Headache attributed to airplane travel (“airplane headache”: first italian case

A new form of headache, whose attacks seem to be stereotyped, has been recently reported; because of the peculiarity of its onset, strictly related to airplane travel, the name of “Airplane headache” was proposed. A total of 7 cases have been published. Here we present the first Italian one. Furthermore the revision of the clinical characteristics of each patient leads us to propose provisional diagnostic criteria.     

Headache during airplane travel (“airplane headache”): first case in Greece

Headache related to airplane flights is rare. We describe a 37-year-old female patient with multiple intense, jabbing headache episodes over the last 3 years that occur exclusively during airplane flights. The pain manifests during take-off and landing, and is located always in the left retro-orbital and frontotemporal area. It is occasionally accompanied by dizziness, but no additional symptoms occur. Pain intensity diminishes and disappears after 15–20 min. Apart from occasional dizziness, no other symptoms occur. The patient has a history of tension-type headache and polycystic ovaries. Blood tests and imaging revealed no abnormalities. Here, we present the first case in Greece. We review the current literature on this rare syndrome and discuss on possible pathophysiology and the investigation of possible co-factors such as anxiety and depression.     

Use of the Internet by patients: not a threat to nursing, but an opportunity?

The Internet poses numerous challenges for health care professionals. A significant one is the way in which patients, clients and carers now have access to large amounts of unfiltered, specialized health information, much of which was, hitherto, solely the province of the professionals. The specific problems that this poses, in terms of the effect that it might have on the therapeutic relationship, are discussed, along with some of the proposed solutions, such as the National Electronic Library for Health initiative and NHS Direct Online. Since this change is inevitable, it is recommended that nurses should seek to build on their role as educators of patients and carers. One of the ways in which they can do this is by guiding patients' and carers' use of the Internet, and helping them to evaluate the information that they find.     

“Our Teachers … Don’t Give Us No Help,No Nothin’”: Juvenile Offenders’ Perceptions of Academic Support

This qualitative study investigated the educational experiences that shaped juvenile offenders’ perceptions of the academic support they received in juvenile justice (JJ) settings and their public schools. We conducted interviews with students and JJ school personnel, two focus groups, classroom observations, and student surveys. Juvenile offenders characterized their teachers as supportive or unsupportive based on whether they made proactive efforts to help students learn. Disconnection with school occurred when students perceived teachers did not care and when there were difficulties in earning or transferring credits. Findings suggest that juvenile offenders demonstrate academic resiliency and a continued desire to pursue education.