Efficacy of Adding a Distal Level Block to a C2 Level Greater Occipital Nerve Block under Ultrasound Guidance in Chronic Migraine.

Objective: To investigate the benefit of adding a distal level greater occipital nerve (GON) block to the proximal level GON block under ultrasound guidance in patients with chronic migraine (CM) with cutaneous allodynia (CA). Methods: Seventy-eight patients with CM were included. A single US-guided GON block was performed at proximal and distal levels in patients with CM with CA and only at the proximal level in patients with CM without CA. Thirty (38.5%) patients with bilateral pain received bilateral GON blocks, and 48 (61.5%) with unilateral pain received unilateral GON blocks. The patients were evaluated using Numeric Rating Scale (NRS) scores before treatment and 1 and 4 weeks after treatment and through Headache Impact Test-6 (HIT-6) scores before treatment and 4 weeks after treatment. Results: The NRS scores significantly decreased at first and fourth weeks, and the HIT-6 scores significantly decreased at fourth week (p < 0.001) compared with preintervention scores in all groups. No significant difference was found between the groups regarding the postinterventional first and fourth week when the decreases of NRS and HIT-6 scores were compared (p = 0.599). There were no significant differences in the effectiveness of unilateral and bilateral GON blocks (p > 0.001). Conclusion: A single US-guided GON block is an effective and safe treatment option in patients with CM, providing a positive effect on pain and quality of life for 4 weeks. The addition of a distal level GON block to the proximal level GON block provides no extra benefit to patients with CM with CA.

Autonomic Neuropathy and Endothelial Dysfunction in Patients With Impaired Glucose Tolerance or Type 2 Diabetes Mellitus.

Autonomic neuropathy is one of the most common complications of diabetes mellitus (DM). The etiology of autonomic impairment is not well-understood, yet. There is need for studies to investigate the cause-effect relationships of inflammation and/or endothelial dysfunction and diabetic autonomic neuropathy. Only a few reports have mentioned autonomic neuropathy in individuals with impaired glucose tolerance (IGT), previously. Furthermore, the association between the plasma markers of endothelial dysfunction (von Willebrand factor (vWF), soluble E-selectin) and autonomic neuropathy in patients with IGT or DM has not been studied before. In this study, we aimed to investigate the correlation between plasma markers of endothelial dysfunction and autonomic neuropathy in patients with IGT or type 2 DM (T2DM).In this case-control study, 25 IGT patients, 25 T2DM patients with autonomic symptoms, and 30 controls were included. Demographical data, HbA1c, vWF, and soluble E-selectin (sE-selectin) levels were analyzed. Sympathetic skin response (SSR) and heart rate variability (HRV) were used as the indicator of autonomic activity.Plasma levels of HbA1c, vWF, and sE-selectin were higher in patients with IGT than the controls; patients with T2DM had higher levels than both the controls and the patients with IGT. SSR measures were similar among the groups. However, higher number of T2DM patients had absent plantar SSR than controls. HRV analysis at rest revealed lower standard deviation of R-R interval, coefficient of variation of R-R interval, low-frequency (LF) power and total power in patients with IGT and T2DM than the controls. In addition, HRV analysis at deep breathing showed lower high-frequency (HF) power in IGT group. LF:HF ratio was lower in both patient groups at rest. No strong correlation was found between the levels of HbA1c, vWF, sE-selectin, HRV, and SSR measures.Our results support that endothelial dysfunction is evident in individuals with IGT or T2DM and HRV is impaired in early stages in the course of T2DM. However, increased levels of biomarkers of endothelial damage do not correlate with HRV or SSR. More studies are needed to clarify the disease pathogenesis and its clinical correlates. Impaired HRV in T2DM could be due to mechanisms other than endothelial dysfunction.

Association between the Levels of IL-6, sE-Selectin and Distal Sensory Nerve Conduction Studies in Patients with Prediabetes.

AIM: To determine the association between interleukin-6 (IL-6) and soluble E-selectin (sE-selectin) levels with the electrodiagnostic abnormalities in patients with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). METHODS: Serum HbA1c, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, IL-6 and sE-selectin levels were analyzed in 25 IFG patients, 22 IGT patients and 41 controls. Nerve conduction studies (NCS) of sural, dorsal sural (DS), medial dorsal cutaneous and medial plantar sensory nerves were conducted. RESULTS: HbA1c and IL-6 levels were significantly higher in IFG and IGT patients than the controls. IGT patients had higher sE-selectin levels compared to controls and IFG patients. IL-6 levels were significantly correlated with levels of CRP, fibrinogen, ESR and sE-selectin in patients with prediabetes. Both IFG and IGT patients had substantial impairments in very distal sensory NCS. IL-6 levels were positively correlated with HbA1c and negatively correlated with DS NCS in prediabetic patients. CONCLUSIONS: Inflammation and endothelial dysfunction might be important in patients with IFG or IGT. Furthermore, our findings strengthen the idea that inflammation (increased levels of IL-6) might be associated with early electrophysiological impairments in patients with prediabetes. NCS of the most distal sensory nerves significantly enhanced the diagnosis of subclinical neuropathy in patients with prediabetes. Subclinical peripheral sensory neuropathy should be investigated in prediabetes to lower the number of future outcomes they are associated with.

Interleukin-6, interleukin-1 beta and interleukin-1 receptor antagonist levels in epileptic seizures.

PURPOSE: Data are accumulating to support the involvement of inflammatory mechanisms in the pathogenesis and course of epilepsy. METHODS: The aim of this study was to examine seizure-induced changes in plasma concentrations of interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1Ra), and interleukin-1 beta (IL-1ß) in 23 patients with epilepsy undergoing a video-electroencephalography (EEG) study. Patients were divided into groups based on epilepsy type as follows: temporal lobe epilepsy (TLE) (n=6), extra-temporal lobe epilepsy (XLE) (n=8) and idiopathic generalised epilepsy (IGE) (n=9). Serum levels of IL-1ß, IL-1Ra and IL-6 were measured at baseline, immediately after the epileptic seizure, and at 3h, 6h, 12h and 24h after the seizure. RESULTS: We demonstrated a significant increase in plasma levels of IL-6 and IL-1Ra that peaked at 12h into the post-ictal period (p<0.05). IL-1ß levels did not differ from the baseline levels. We did not observe any differences in post-ictal cytokine release patterns between the TLE, XLE and IGE groups. CONCLUSION: The present study confirms the findings that epileptic seizures induce the production of IL-6 and IL-1Ra.

Surgical repair of a post-traumatic arteriovenous fistula complicated by stent-graft misplacement.

An arteriovenous fistula (AVF) is an abnormal connection between an artery and a vein which may result from a traumatic injury or occur as a congenital abnormality. It may be asymptomatic or may present with a variety of symptoms. Surgical or endovascular treatment can be preferred. We present a case of unsuccessful percutaneous treatment of a femoral AVF due to misplacement of the stent-grafts, necessitating surgical correction.