Airplane headaches--two new cases and a review of the literature

We present two new cases of airplane headache and compare them with 13 cases described so far. The two new cases refer to a man and a woman, one each. The woman suffered from headache during the take off and throughout the flight, which is rarely encountered. The man had a typical airplane headache with accompanying symptoms, with the feeling of pressure in the left side of the head. Diagnostic treatment revealed no pathomorphological substrate of the condition. The etiology and pathophysiology of this type of headache have not yet been fully clarified. We presume that this type of headache may be connected with changes in the nasal mucous membrane with deviation of the nasal septum, as well as in ethmoidal sinuses and other paranasal cavities. The rise of atmospheric pressure in the airplane and barotrauma from activation of the trigeminovascular system certainly play a major role in the occurrence of this headache.     

Prolonged mean reaction time in posterior cerebral artery during visual stimulation in patients with severe carotid stenosis

While the mean increase in flow velocities in posterior cerebral artery (PCA) as a response to visual stimuli is well documented, the data on the reaction time as a measurement of the vasomotor response of the posterior part of the circle of Willis are still sparse. The aim was to assess the visual evoked response in PCA during white light stimulation by means of functional transcranial doppler in patients with severe internal carotid artery (ICA) stenosis, to introduce a real‐time haemodynamic changes as a measurement of the effect of severe carotid disease on the posterior circulation. The measurements were taken in 49 right‐handed patients with severe ICA stenosis or occlusion and 30 healthy volunteers, simultaneously in left and right PCA using 2‐MHz probes, successively in the dark and during the white light stimulation, during three consecutive repetitive periods of 1 min each. Mean values of mean blood flow velocities (MBFV) and mean reaction time (MRT) with and without visual stimuli were analysed. Linear regression analysis showed no statistically significant correlation between the age, MBFV and a degree of left and right carotid stenosis, and MRT in left and right PCA either in the group of healthy subjects or in the group of patients with severe carotid stenosis, in both test conditions. MRT could be an indicator of compromised cerebral circulation in the presence of haemodynamic significant carotid stenosis as well as an additional and independent haemodynamic parameter of the cerebral visual evoked response.     

Emergency care of patients with upper gastrointestinal bleeding in regional hospitals in Catalonia

Objective

To evaluate the resources available in Catalan regional hospitals for the emergency care of upper gastrointestinal hemorrhage.

Methods

We analyzed a survey sent to 32 hospitals on the availability, composition and resources of a duty endoscopy service for the year 2009.

Results

Responses were obtained from 24 centers, covering 3,954,000 inhabitants. Duty endoscopists were available in 12 hospitals. A total of 1,483,000 inhabitants were unable to access a duty endoscopist in the referral center. Centers with duty endoscopists had more beds and had a larger catchment area. Duty services were composed of 4.5 endoscopists (range 2-11), covering 82.1 (33.2-182.5) duty shifts/year. Seventeen centers reported 1,571 episodes (51%, range: 3-280, 39.68/100,000 inhabitants). Centers with a duty service reported a greater number of cases (76 vs. 43, p = 0.047). Centers without this service referred a greater number of patients (147 vs. 17, p = 0.001). Patients in the emergency department were under the care of the internal medicine department in four centers, the surgery department in 14 centers and under the care of both departments in six. Admitted patients were under the care of the gastroenterology department in only six hospitals. The most widely used procedures were ligation of varicose bleeding and injection therapies in non-varicose bleeding. Twenty-one percent of centers did not perform combined treatment.

Conclusions

A significant proportion of the population does not have access to a duty endoscopist in referral centers. Duty shifts represent significant workload in regional hospitals. Coordination among health professionals and centers would allow the efficient application of therapeutic resources and a duty endoscopy service to be established in centers lacking this resource.     

Co-localisation of kisspeptin with galanin or neurokinin B in afferents to mouse GnRH neurones

The gonadotrophin-releasing hormone (GnRH) secreting neurones, which form the final common pathway for the central regulation of reproduction, are directly targeted by kisspeptin (KP) via the G protein-coupled receptor, GPR54. In these multiple labelling studies, we used ovariectomised mice treated with 17β-oestradiol (OVX + E(2)) or vehicle (OVX + oil) to determine: (i) the ultrastructural characteristics of KP-immunoreactive (IR) afferents to GnRH neurones; (ii) their galanin or neurokinin B (NKB) content; and (iii) the co-expression of galanin or NKB with KP in the two major subpopulations of KP neurones located in the rostral periventricular area of the third ventricle (RP3V) and the arcuate nucleus (Arc). Electron microscopic investigation of the neuronal juxtapositions revealed axosomatic and axodendritic synapses; these showed symmetrical or asymmetrical characteristics, suggesting a phenotypic diversity of KP afferents. Heterogeneity of afferents was also demonstrated by differential co-expression of neuropeptides; in OVX + E(2) mice, KP afferents to GnRH neurones showed galanin-immunoreactivity with an incidence of 22.50 ± 2.41% and NKB-immunoreactivity with an incidence of 5.61 ± 2.57%. In OVX + oil animals, galanin-immunoreactivity in the KP afferents showed a major reduction, appearing in only 5.78 ± 1.57%. Analysis for co-localisation of galanin or NKB with KP was extended to the perikaryal level in animal models, which showed the highest KP incidence; these were OVX + E(2) females for the RP3V and OVX + oil females for the ARC. In the RP3V of colchicine-treated OVX + E(2) animals, 87.84 ± 2.65% of KP-IR neurones were galanin positive. In the Arc of the colchicine-treated OVX + oil animals, galanin immunoreactivity was detected in only 12.50 ± 1.92% of the KP expressing neurones. By contrast, the incidence of co-localisation with NKB in the Arc of those animals was 98.09 ± 1.30%. In situ hybridisation histochemistry of sections from OVX + E(2) animals identified galanin message in more than a third of the KP neurones in the RP3V (38.67 ± 11.57%) and in the Arc (42.50 ± 12.52%). These data suggest that GnRH neurones are innervated by chemically heterogeneous KP cell populations, with a small proportion deriving from the Arc group. The presence of galanin within KP axons innervating GnRH neurones and the oestrogen-dependent regulation of that presence add a new dimension to the roles played by galanin in the central regulation of reproduction.     

Overexpression of cannabinoid CB2 receptor in the brain induces hyperglycaemia and a lean phenotype in adult mice

It is well known that the endocannabinoid system, through cannabinoid CB1 receptor activation, has an important role in the main aspects of energy balance (i.e. food intake, energy expenditure and glucose and fat metabolism), orchestrating all the machinery involved in body weight control and energy homeostasis. A number of studies have revealed a crucial role of brain CB1 receptors in these processes. However, functional cannabinoid CB2 receptors have also been described in the brain, with no studies addressing their putative role in body weight control and glucose homeostasis. We have tested this hypothesis by analysing fasting-induced feeding, body weight, some hypothalamic neuropeptides, glucose tolerance and plasma hormones in an animal model specifically overexpressing CB2 receptors in the central nervous system. We found that specific overexpression of CB2 receptors in the brain promoted higher basal glucose levels, decreased fasting-induced feeding and, eventually, led to a lean phenotype and glucose intolerance. These findings could not be attributed to decreased locomotor activity, increased anxiety or depressive-like behaviours. The expression of relevant neuropeptides such as pro-opiomelanocortin and galanin in the arcuate nucleus of the hypothalamus was altered but not those of the CB1 receptor. Indeed, no changes in CB1 expression were found in the liver, skeletal muscle and adipose tissue. However, cannabinoid CB1 and CB2 receptor expression in the endocrine pancreas and glucagon plasma levels were decreased. No changes in plasma adiponectin, leptin, insulin and somatostatin were found. Taken together, these results suggest a role for central cannabinoid CB2 receptors in body weight control and glucose homeostasis.     

Pathogenesis of Lyme neuroborreliosis: Borrelia burgdorferi lipoproteins induce both proliferation and apoptosis in rhesus monkey astrocytes

Brain invasion by Borrelia burgdorferi, the agent of Lyme disease, results in an inflammatory and neurodegenerative disorder called neuroborreliosis. In humans, neuroborreliosis has been correlated with enhanced concentration of glial fibrillary acidic protein in the cerebrospinal fluid, a sign of astrogliosis. Rhesus monkeys infected by us with B. burgdorferi showed evidence of astrogliosis, namely astrocyte proliferation and apoptosis. We formulated the hypothesis that astrogliosis could be caused by spirochetal lipoproteins. We established primary cultures of rhesus monkey astrocytes and stimulated the cells with recombinant lipidated outer surface protein A (L-OspA), a model B. burgdorferi lipoprotein, and tripalmitoyl-S-glyceryl-Cys-Ser-Lys(4)-OH (Pam(3)Cys), a synthetic lipopeptide that mimics the structure of the lipoprotein lipid moiety. L-OspA elicited not only astrocyte proliferation but also apoptosis, two features observed during astrogliosis. Astrocytes produced both IL-6 and TNF-alpha in response to L-OspA and Pam(3)Cys. Proliferation induced by L-OspA was diminished in the presence of an excess of anti-IL-6 antibody, and apoptosis induced by this lipoprotein was completely suppressed with anti-TNF-alpha antibody. Hence, IL-6 contributes to, and TNF-alpha determines, astrocyte proliferation and apoptosis, respectively, as elicited by lipoproteins. Our results provide proof of the principle that spirochetal lipoproteins could be key virulence factors in Lyme neuroborreliosis, and that astrogliosis might contribute to neuroborreliosis pathogenesis.     

Understanding Factors Associated with Postpartum Visit Attendance and Contraception Choices: Listening to Low-Income Postpartum Women and Health Care Providers

Background While there is considerable variability with respect to attendance at the postpartum visit, not much is known about women’s preferences with respect to postpartum care. Likewise, there is also limited information on providers’ practices regarding the postpartum visit and care including the delivery of contraception. To understand and address deficits in the delivery and utilization of postpartum care, we examined the perceptions of low-income postpartum women with respect to barriers to and preferences for the timing and location of the postpartum visit and receipt of contraception. We also examined providers’ current prenatal and postnatal care practices for promoting the use of postpartum care and their attitudes toward alternative approaches for delivering contraceptive services in the postpartum period. Methods Qualitative face-to-face interviews were completed with 20 postpartum women and in-depth qualitative phone interviews were completed with 12 health care providers who had regular contact with postpartum women. Interviews were coded using Atlas.ti software and themes were identified. Results Women believed that receiving care during the postpartum period was an important resource for monitoring physical and mental health and also strongly supported the provision of contraception earlier than the 6-week postpartum visit. Providers reported barriers to women’s use of postpartum care on the patient, provider, and system levels. However, providers were receptive to exploring new clinical practices that may widen the reach of postpartum care and increase access to postpartum contraception. Conclusion Approaches that increase the flexibility and convenience of postpartum care and the delivery of postpartum contraception may increase the likelihood that women will take advantage of essential postpartum services.