Headache in school age.

Headache, especially migraine and tension-type headache, is one of the most frequently reported somatic complaints by children and adolescents. Different population-based studies have been conducted to study the correlation between headache and lifestyles in pediatric age, nevertheless, the obtained results are often controversial and these relationship still remain unclear. Likewise, is still strongly debated the burden of headache during school age, its impact on school performances and on quality of life of children and their families. Consequently, larger studies are necessary to evaluate the degree of disability due to pediatric headache. We summarize the ongoing knowledge about these concepts, with the intent to provide useful data to neurologists but also to primary care providers, to further improve the management of pediatric headaches by preventing the headache progression, the disabling effects associated and improving the long-term outcome.

Switching on the deep brain stimulation: effects on cardiovascular regulation and respiration.

BACKGROUND: Objective of this study was to evaluate the acute cardiovascular and respiratory effects of switching on the deep brain stimulation in the follow up of nine Parkinson's disease patients with subthalamic nucleus stimulation and six cluster headache patients with posterior hypothalamic area stimulation. METHODS: Systolic and diastolic blood pressure, heart rate, and respiratory rate were monitored continuously during supine rest in both groups. Each patient was assessed in two conditions: resting supine with stimulator off and with stimulator on. RESULTS: In supine resting condition switching on the DBS induced no significant changes (p>0.05) in systolic and diastolic blood pressure as well as in heart rate and respiratory rate, in both groups of patients, either taking 1 min or 10 heartbeats as a sample for analysis. CONCLUSIONS: Switching on the DBS does not modify heart rate, blood pressure nor respiratory rate in both Parkinson and cluster headache patients under resting conditions.

Spectral analysis of heart rate variability reveals an enhanced sympathetic activity in narcolepsy with cataplexy.

OBJECTIVE: To test the autonomic control of cardiovascular reflexes and heart rate variability (HRV) at rest and during orthostatic stress in narcolepsy with cataplexy (NC). METHODS: Ten NC patients with a hypocretin deficit and 18 control subjects underwent head-up tilt test (HUTT), Valsalva manoeuvre, deep breathing and cold face under controlled laboratory conditions. Heart rate variability (HRV) was analysed during supine rest and HUTT considering the normalized unit of LF and HF power (LFnu; HFnu), using autoregressive (AR) and fast Fourier transform (FFT) algorithms. RESULTS: Cardiovascular changes during HUTT, Valsalva manoeuvre, deep breathing, isometric handgrip and cold face were normal and comparable in the two groups. AR and FFT analysis showed an increased LF/HF ratio in NC patients during supine rest. As expected, LFnu increased and HFnu decreased in the control group during HUTT, but did not change in narcoleptics being comparable to values in the supine condition. CONCLUSIONS: NC patients showed an increased sympathetic drive on heart rate (HR) in the supine condition that did not further increase during HUTT. SIGNIFICANCE: These results suggest the proper functioning of cardiovascular reflexes in NC but support an impairment of HR modulation at rest in favour of an enhanced sympathetic activity.

Evidence of a selective nociceptive impairment in systemic sclerosis.

OBJECTIVE: To test for the autonomic neuropathy in systemic sclerosis (SSc) using cardiovascular reflex evaluation including the "cold face test", which elicits forehead cold receptors (C-fibres). These tests examine the induced bradycardia-hypertensive response and the integrity of nociceptive afferent and parasympathetic-sympathetic efferent pathways. METHODS: Twelve SSc patients were studied; including 5 with the limited cutaneous (lcSSc) involvement, and 7 with diffuse cutaneous involvement (dcSSc). All patients were matched with healthy controls. We performed cardiovascular autonomic tests (tilt-test, Valsalva manoeuver, deep breathing, sustained handgrip and cold face) with continuous monitoring of beat-to-beat blood pressure (BP) and heart rate (HR). Baroreceptor sensitivity index (BRSI) and power spectral analysis (PSA) of heart rate variability (HRV) were also evaluated. RESULTS: SSc patients showed a statistically significant higher HR at rest (p<0.01), a lower increase of diastolic BP during tilt test (p<0.01). They had suboptimal hypertensive and bradycardic response to the cold face test (Systolic BP: p<0.05; Diastolic BP: p<0.01; HR: p=0.08). The Valsalva manoeuver, deep breathing, isometric handgrip, BRSI and PSA of HRV results were within normal limits in the majority of SSc patients. CONCLUSION: In this group of SSc patients cardiovascular reflexes were normal, whereas the cold face test which acts through cutaneous nociceptive sensory fibres was abnormal in almost all patients. These results suggest that insufficiency of epidermal small fibres (C-fibres) is involved in SSc.

Design of an accelerator-based neutron source for neutron capture therapy.

The boron neutron capture therapy is mainly suited in the treatment of some tumor kinds which revealed ineffective to the traditional radiotherapy. In order to take advantage of such a therapeutic modality in hospital environments, neutron beams of suitable energy and flux levels provided by compact size facilities are needed. The advantages and drawbacks of several neutron beams are here analysed in terms of therapeutic gains. In detail the GEANT-3/MICAP simulations show that high tumor control probability, with sub-lethal dose at healthy tissues, can be achieved by using neutron beams of few keV energy having a flux of about 10(9) neutrons/(cm(2)s). To produce such a neutron beam, the feasibility of a proton accelerator is investigated. In particular an appropriate choice of the radiofrequency parameters (modulation, efficiency of acceleration, phase shift, etc.) allows the development of relatively compact accelerators, having a proton beam current of 30 mA and an energy of 2 MeV, which could eventually lead to setting up of hospital-based neutron facilities.

Phenylketonuria: white-matter changes assessed by 3.0-T magnetic resonance (MR) imaging, MR spectroscopy and MR diffusion.

PURPOSE: This study evaluated the sensitivity of a 3.0-Tesla (T) magnetic resonance imaging (MRI) in measuring cerebral phenylalanine using proton magnetic resonance spectroscopy and in assessing MR-documented white-matter changes by means of diffusion studies (diffusion-weighted imaging, apparent diffusion coefficient map; diffusion tensor imaging) in patients with phenylketonuria. MATERIALS AND METHODS: Thirty-two patients with the classical clinical and biochemical deficits of phenylketonuria underwent biochemical (blood phenylalanine), genotypic (phenylalanine hydroxylase gene) and radiological investigation by means of MRI, proton magnetic resonance spectroscopy and diffusion magnetic resonance imaging with a 3.0-T scanner. RESULTS: Periventricular and subcortical white-matter changes were detected on all MR scans. In 29/32 patients, proton magnetic resonance spectroscopy easily documented abnormal signal elevation at 7.36 ppm, corresponding to phenylalanine, despite its low concentration. Phenylalanine signal amplitude relative to the creatine/phosphocreatine signal increased linearly with blood phenylalanine values (r 0.7067; p<0.001). Diffusion MRI demonstrated hyperintensity in the areas exhibiting MRI changes as well as decreased apparent diffusion coefficient values, but fractional anisotropy indices were normal. CONCLUSIONS: The high signal, together with better spectral, spatial, contrast and temporal resolution, makes the 3.0-T MR the most suitable technique in the study of the phenylketonuria. In particular, the multimodal approach with MRI, proton magnetic resonance spectroscopy and diffusion magnetic resonance imaging can provide more information than previous studies performed with low-field systems.

[Clinical cases, trials, and the problem of the colored socks. Or the problem of induction in medicine]. / Casi clinici, trial ed il problema delle calze colorate. Ovvero il problema dell'induzione in medicina.

The medical prevision is based on the induction, that is the logical procedure trying to get a general truth starting from pooling and analysis of single cases. A first type of induction is defined complete or mathematical, since it allows a switch from a finished to a wider and endless set of cases. The mathematical induction is a logical procedure, completely consequential and that's why the derived demonstration is always true. Instead the knowledge in medicine is founded upon empirical induction, inferred from the observation of a sufficiently wide number of real cases. But the conclusions which are induced empirically introduce an inevitable degree of uncertainty, because they cannot be deduced logically. Statistics is the tool employed for "weighing" somehow the degree of confidence in a conclusion induced from the observation of numerous single cases. But it presents the limit of quantifying global behaviors, so the generalization derived from statistical inference reflects only the final mean effects that occurred under some specific conditions. Here are presented the problems that arise when switching from conclusions induced by the observations of a wide sample to the management of the single patient. On the other side the limits, but also the complementary value of case reports, are presented.

Noninvasive risk stratification in women with uncomplicated acute myocardial infarction.

The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 89 female patients. Our data show that stress echocardiography has independent predictive value in a female patient population recovering from uncomplicated acute myocardial infarction.

Evidence of walk-through phenomenon during echocardiographic dipyridamole stress test.

This case report deals with induced regional wall motion abnormalities that spontaneously disappeared during an echocardiographic stress test with dipyridamole. A patient underwent this test because of atypical chest discomfort and a positive result of exercise stress test. Transient septal, apical and anterior akinesia were observed after the first dose of dipyridamole, but they were short-lasting and did not return during the continuation of the test. Coronary angiography showed a critical stenosis of the left coronary artery. A mechanism similar to that responsible for the walk-through phenomenon might explain the observed findings. Thus stress echo with dipyridamole needs careful continuous monitoring, because transient wall motion abnormalities can otherwise be missed resulting in a false negative test.

Dipyridamole stress echocardiography and exercise testing for risk stratification after uncomplicated myocardial infarction.

BACKGROUND: Risk stratification for subsequent cardiac events after an acute infarction can be obtained by exercise testing or dipyridamole stress echocardiography. It remains to be determined whether these modalities are equivalent and provide incremental information on top of clinical evaluation. The aim of our study was to compare the prognostic information obtained early after an acute uncomplicated myocardial infarction of high dose dipyridamole coupled with echocardiography (stress echo) or maximal symptom-limited exercise testing. METHODS AND RESULTS: Ninety patients underwent dipyridamole stress echo and exercise testing at a mean +/- SD of 9 +/- 4 days after admission for acute uncomplicated first myocardial infarction. All patients were prospectively followed for 22 +/- 16 months. There were 9 hard events (3 cardiac deaths and 6 acute myocardial infarctions) and 12 soft events due to post MI angina (6 angioplasty and 6 bypass surgery procedures). Univariate predictor of hard events was rest-stress wall motion score index variation (p = 0.009); univariate predictors of all events (hard + soft) were: positive exercise testing (p = 0.001), positive stress echo (p = 0.001), rest-stress wall motion score index variation (p = 0.002), extent of ischemia at echo (p = 0.008). Multivariate analysis by Cox selected a non-Q wave infarction and rest-stress wall motion score index variation as predictors of death or reinfarction (overall chi-square for the model 12.2, p = 0.0022). CONCLUSIONS: Stress echo is superior to ergometric variables for predicting events after uncomplicated myocardial infarction.

Exercise technetium 99m sestamibi single-photon emission computed tomography late after coronary artery bypass surgery: long-term follow-up.

BACKGROUND AND HYPOTHESIS: The prognostic value of exercise technetium 99m sestamibi single-photon emission computed tomography (SPECT) imaging in patients with previous bypass surgery is unknown. The aim of our study was to assess the prognostic information obtained with exercise scintigraphy performed for routine follow-up or reappearance of symptoms. METHODS: We studied 75 patients referred to our Center at a mean of 38 +/- 53 months from the revascularization procedure and prospectively followed them for 38 +/- 24 months. RESULTS: Fifteen patients (20%) had events at follow-up: there were 4 cardiac deaths, 3 nonfatal acute myocardial infarctions, 8 late revascularization procedures (4 percutaneous transluminal angioplasty and 4 repeat bypass surgery). Univariate analysis identified a history of typical angina (p = 0.001), a clinically positive ergometric test (p = 0.009), peak exercise heart rate (p = 0.0003), percentage of maximal predicted heart rate (p = 0.0001), peak exercise double product (p = 0.048), therapy during exercise (p = 0.003), scintigraphic summed reversibility score (i.e., the summation of the segmental differences between stress and rest) (p = 0.014), as significant predictors of events. Three multivariate models were built, with clinical variables (Model 1, chi square 15.97), ergometric variables (Model 2, chi square 19.66), and with scintigraphic variables added to clinical/ergometric variables (Model 3, chi square 31.13). The scintigraphic variable selected in the model as significant predictor of events was the summed reversibility score (p = 0.008). CONCLUSIONS: Exercise sestamibi SPECT scintigraphy provides optimal prognostic information after clinical and ergometric parameters in patients with previous bypass surgery.

[Echocardiography or stress scintigraphy with dipyridamole for the stratification of risk after acute myocardial infarction?]. / Ecocardiografia o scintigrafia da stress con dipiridamolo per la stratificazione del rischio dopo infarto miocardico acuto?

UNLABELLED: Increased risk of subsequent cardiac events after an acute infarction can be identified through dipyridamole infusion. It remains to be determined whether echocardiographic or scintigraphic imaging modes are equivalent. The aim of our study was to compare the prognostic information obtained early after an acute uncomplicated myocardial infarction through high-dose dipyridamole coupled with echocardiography or scintigraphy via Tc 99m sestamibi SPECT imaging. METHODS AND RESULTS: Fifty-one patients underwent simultaneous dipyridamole stress echocardiography and scintigraphy at a mean +/- SD of 12 +/- 3 days after admission for acute uncomplicated myocardial infarction. A subgroup of 44 patients performed exercise testing according to maximal symptom limited protocol. All patients were followed prospectively for 346 +/- 273 days (range 11-959). Cardiac events occurred in 20 patients (39%), and 1 death, 2 myocardial reinfarctions and 17 cases of unstable angina were recorded. Univariate predictors of cardiac events were: positive dipyridamole echo (p < 0.001), ischemia in the infarct zone or in remote zones by echo (p < 0.001), ejection fraction < 40% (p = 0.042) and positive exercise testing (p = 0.003). Risk was best predicted by multivariate Cox analysis on the basis of 1) ischemia in remote zones by dipyridamole echo (p < 0.001) and 2) ischemia in the infarct zone by dipyridamole echo (p = 0.003), blood pressure at peak exercise < 150 mmHg (p = 0.010) and non-Q wave infarction (p = 0.003). CONCLUSIONS: Echocardiographic imaging during dipyridamole infusion is superior to sestamibi scintigraphy for predicting events after uncomplicated myocardial infarction.

[Combined use of bicycle ergometry test and echo-dipyridamole in stratification of risk after thrombolysed myocardial infarct]. / Uso combinato di test al cicloergometro ed eco-dipiridamolo per la stratificazione del rischio dopo infarto miocardico trombolisato.

AIM: Verify the value of the combined use of Dipyridamole Stress Echocardiography (DSE) and Exercise Testing (ET) for predicting cardiac events after Thrombolysed Myocardial Infarction (TMI). STUDY DESIGN: Prospective, with a medium follow-up of 221 days (range 30-446). CLINICAL SETTINGS: Coronary Care Unit with Cardiology Service. PATIENTS: 32 consecutive patients, 24 men and 8 women, mean age 61 years (range 39-72) with acute myocardial infarction. INTERVENTIONS: Systemic thrombolysis with PTPA. DSE and ET in therapeutic wash out 12 +/- 3 days after admission to the Coronary Care Unit. RESULTS: 9 patients had positive ET, 18 patients had negative ET, 5 patients did not perform ET. 19 patients had positive DSE, 13 patients had negative DSE. Patients with positive DSE had in 6 cases (group 1) WMA remote from the infarction area (WMAR), in 13 cases (group 2) WMA appeared in the infarct related area. Cardiac events occurred in 15 patients: 1 cardiovascular death, 1 myocardial re-infarction, 13 cases of unstable angina. 2 patients with negative DSE had cardiac events. All patients in group 1 had events, 1 patient with a previous positive ET, 3 patients with previous negative ET. 2 patients in this group didn't perform ET. 7 patients in group 2 had cardiac events, in all cases with a previous positive ET. 1 single patient in this group with negative ET had events. CONCLUSIONS: 1) Patients without WMA at DSE are at low risk for cardiac events after thrombolysed myocardial infarction. 2) Presence of WMAR appears to be associated with a higher risk, whatever the result of ET may be. 3) Patients without WMAR can be further stratified by ET in therapeutic wash out. High risk patients seem to be those with positive DSE and positive ET. 4) Combined use of DSE and ET seem to allow optimal risk stratification after thrombolysed myocardial infarction.

HCV in a group of chronic hemodialysis patients.

Since HCV appears to be the major cause of post-transfusion non-A, non-B hepatitis in Italy, this study determines the presence of anti-HCV in a risk group. Among 26 patients, 9 were anti-HCV in a risk group. Among 26 patients, 9 were anti-HCV positive with the ELISA test and all of them were confirmed with the RIBA test of 2nd generation. Only 1 had a poussés movement of ALT levels. Hemodialyzed patients are reactive for HCV probably for the transfusional therapy.

[A case of idiopathic Bence-Jones proteinuria]. / Su di un caso di proteinuria di Bence-Jones "idiopatica".

A case of idiopathic Bence-Jones proteinuria with a follow-up of nine years without evidence of lymphoproliferative disorder is discussed.