Botulinum toxin A in the prophylactic treatment of migraine--a randomized, double-blind, placebo-controlled study

Botulinum toxin A has been suggested to be effective in the prophylactic treatment of migraine. However, only very few randomized, double-blind, placebo-controlled studies are available. We designed such a study with a specific focus on different injection sites. Sixty patients with a migraine according to the criteria of the International Headache Society were randomly assigned to receive either placebo in the frontal and neck muscles, or to receive 16 U botulinum toxin A in the frontal muscles and placebo in the neck muscles, or to receive in total 100 U botulinum toxin A in the frontal and neck muscles. The observation period was 3 months. In both treatment groups, 30% of patients showed a reduction of migraine frequency in month 3 by at least 50% compared with baseline, in the placebo group 25% of the patients showed such a reduction (P = 0.921). There were no significant differences between the three study groups with respect to reduction of migraine frequency, number of days with migraine, and the number of total single doses to treat a migraine attack. In the post hoc analysis, the reduction of all accompanying symptoms was significantly higher in the 16 U treatment group compared with the placebo group. In the 100 U treatment group significantly more adverse events occurred compared with the placebo group. All adverse events were mild and transient. Our study did not show any efficacy of botulinum toxin A in the prophylactic treatment of migraine. Only accompanying symptoms were significantly reduced in the 16 U but not in the 100 U treatment group. Future studies should focus on the efficacy of botulinum toxin A in specific subgroups of patients, on the efficacy of repetitive injections, and on other injection sites.     

Sleepiness and sleep quality in patients with HIV infection

ObjectivesPatients with HIV infection frequently complain of sleep disturbances and daytime sleepiness. Only few data on these problems evaluated by standardized measures is available.MethodsA sample of 180 consecutive patients with HIV infection referred to the internal and to the neurological HIV clinics at the University of Münster was enrolled in this study. The data were compared to a sample of 120 age- and sex-matched control subjects. We used the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), and the Beck's Depression Inventory (BDI). In addition, the clinical and immunological data of the patients were registered.ResultsAll scores of the ESS, the PSQI, and the BDI were significantly increased in the HIV infected patients as compared to the control group. There were no significant correlations between any of the immune parameters and the scores. Only a higher BDI score was correlated with both the ESS score and the PSQI score.ConclusionsPatients with HIV infection and not using evavirenz show an increased daytime sleepiness and a decreased quality of sleep. These findings could not be related to the immunological state of the patients. The only specific factor influencing daytime sleepiness in HIV infected patients is probably treatment with HAART. The most important factor determining sleepiness and sleep quality in HIV infected patients is depression which was found to be independent from the immunological state and HAART of the patients.     

The impact of different antimigraine compounds on platelet and erythrocyte aggregation

Clinical and experimental data suggest that ergotamine compounds and triptans may contribute to vascular events such as myocardial infarction and stroke. The role of blood cell aggregation in this context is, however, not clarified. We aimed to evaluate the impact of different acute antimigraine compounds on platelet and erythrocyte aggregation in a human ex vivo experimental design. In 20 healthy subjects without migraine and in 20 healthy subjects with migraine without aura, platelet and erythrocyte aggregation were measured before and after intake of placebo, acetylsalicylic acid, ergotamine tartrate, zolmitriptan and sumatriptan. Platelet aggregation was measured by the so-called platelet reactivity index. Erythrocyte aggregation was measured by photometric assessment in an aggregometer. Ergotamine tartrate induced a significant increase of platelet aggregation, whereas acetylsalicylic acid induced a significant decrease in both subject groups. After placebo, after sumatriptan and after zolmitriptan, no significant changes of platelet aggregation were noted. Erythrocyte aggregation was affected by neither compound. We can conclude that platelet aggregation, but not erythrocyte aggregation, is increased after intake of ergotamine tartrate. This may in part contribute to vascular side-effects of this compound. Acetylsalicylic acid and the triptans appeared to be safe with respect to platelet and erythrocyte aggregation.     

Bacterial contamination of enteral feeds

Enteral nutrition is increasingly used to provide nutritional support for children in hospital and at home. No suitable formula is available for preschool children, however, and until recently a modular feed has been prepared. The hypotheses were examined that the use of a modular feed is associated with increased bacterial contamination, and that contamination is more common in the home than in hospital. Thirty five children receiving enteral nutrition initially in hospital and subsequently at home were allocated randomly to receive either a modular feed or a newly available sterile ready to use paediatric feed. Samples of feed were taken from the nutrient container immediately after filling and at the end of feeding. The results show that feed contamination is common in hospital and at home, but significantly more so at home. The data indicate the importance of hygiene training for parents and the desirability of a ready to use formula.     

Paired stimulation and functional change of the sural nerve during beta blocker therapy

29 patients were examined during a therapy with beta blockers. The medication was applied over 12 weeks, 16 patients received propranolol 120 mg/day, 13 patients metoprolol 200 mg/day. Two patients showed side-effects. Neurophysiological examinations, i.e. sural nerve conduction velocity and paired stimulation of the sural nerve, revealed a slight decrease of nerve conduction velocity and a significant increase of the latency prolongation of the second nerve action potential when the medication was finished. These functional changes in the sural nerve may result from the interaction of metoprolol and propranolol with beta-receptors of the peripheral nerve.     

Is there a relation between an increase in IgM in the newborn infant and the course of pregnancy and labor?

In order to check the significance of the serum IgM concentration in newborns the IgM levels in the placental blood of 263 randomly selected neonates were determined; in 105 of these children the IgM concentration was again determined on the 6th day of life. The maternal IgM concentrations were also determined for the purpose of comparison. All of the newborns were allocated to infection risk categories on the basis of history and clinical data. The findings were evaluated on the basis of the mean values with simple standard deviation, single-case analysis and arrangement of the medium values in sequence. Significantly elevated IgM concentrations were found in newborns with the risk factor asphyxia on the 6th day of life. There was a certain tendency to elevated IgM concentrations - established on the basis of the mean values and the median value grouping - in the groups with maternal infection, premature rupture, frequent vaginal examination, and post-term birth of the child. The investigation shows that the majority of elevated IgM concentrations in neonates in whom no infection can be found are not closely correlated to a certain risk factor. An elevated IgM concentration in a newborn appears to be a factor of low specificity with regard to infection. However, in the diagnosis of neonatal infections it provides additional information in the overall context of the clinical examination.     

Brainstem Auditory Evoked Potentials in Migraine-Evidence of Increased Side Differences During the Pain-Free Interval

Brainstem auditory evoked potentials (BAEPs) were recorded in 38 unselected patients (6 m./32 f.; age 18-54 yrs.) with various forms of migraine, during the pain-free interval. The values were compared to those of 50 control persons (18 m./32 f.; age 17-75 yrs.). Peak latencies (PL I-VI), interpeak latencies (IPL I-III, III-V, I-V) and side differences of all peaks (delta I-VI) were calculated. In contrast to PL's of migraine patients, all PL's of control persons were normally distributed. In 6 migraine patients (2 with basilar migraine) PL's were pathologically delayed. Statistical analysis did not show any significant difference in regard to PL's and IPL's between migraine patients and controls. However, side differences of all peaks (except peak IV,VI) were significantly increased in migraine patients as compared to controls. Our results indicate a slight but permanent impairment of brainstem function in migraine.     

Headache Caused by a Sphenoid Mucocele but Presenting as an Ergotamine-Induced Headache

In a 65-year-old woman, symptomatic headache caused by a mucocele of the sphenoid sinus led to ergotamine abuse and subsequent ergotamine-induced headache. Since there were no neurological symptoms initially and the patient previously suffered from migraine, the mucocele was not recognized. Only after unsuccessful drug withdrawal therapy and an MRI, was the correct diagnosis made. Surgical removal of the mucocele led to complete relief of headache within 3 weeks. We conclude that ergotamine-induced headache can develop on the basis of symptomatic headache. In spite of the effectiveness of ergotamine tartrate, an MRI should be performed if focal neurological symptoms occur.