Stress, anxiety, depression and migraine.

This study investigated the intensity of stress, anxiety and depression in a sample of 141 migraineurs compared with a control group of 109 non-migraine workers matched for age and sex. Stress was measured using the Perceived Stress Questionnaire, and anxiety and depression using the Hospital Anxiety and Depression Scale. Results indicated that stress and anxiety were higher in the migraine group than in the control group and above the clinical level. Depression scores remained low in both groups, under clinical relevance. Stress is a primordial factor in the triggering and perpetuation of migraine attacks. The high score of the items 'morning fatigue', 'intrusive thoughts about work', 'feeling under pressure', 'impatience', and 'irritability' of the stress questionnaire in the migraineurs is particularly significant in the intensive stress response. It seems necessary to manage stress to improve the daily life of migraineurs and to study the link between stress, anxiety and migraine.

[Churg-Strauss syndrome. Retrospective study of 20 cases]. / Le syndrome de Churg et Strauss. Etude rétrospective de vingt observations.

Churg-Strauss syndrome (CSS) is a disorder characterised by hypereosinophilia and systemic vasculitis complicating a preexisting asthma. Twenty cases have been studied. Mean duration of asthma before CSS was 8 years, the peripheral-blood eosinophilia, always > 1,700/microL, went above 5,000/microL in 17 cases. The clinical manifestations were the following: 20 impairements of general state with fever, 13 peripheral neuropathies, 15 cutaneous injuries, 10 pericardial or myocardial attacks, 10 digestive impairements, 9 muscular and articular diseases, 7 renal diseases--all of them linked with the vasculitis--and 9 upper respiratory tract involvements. Pleuropulmonary or cardiac anomalies have been discovered at the chest X-ray in 14 cases. The diagnosis has been histologicaly confirmed in 15 cases. No clinical or biological or evolutive distinction was noticed between the 15 positive biopsy patients and the 5 negative ones. During 8.4 (+/- 7.9 years) the evolution was caracterised by relapses which have always been announced by increasing eosinophilia. Eighteen patients have been successfully treated with corticoids alone or associated with cyclophosphamid in 9. Survival at 5 years was 85%. Five deaths occured because of CSS (2 because of an unadapted treatment). We have to focus the need for an emergency treatment of CSS. The diagnosis can be done by clinical investigation only, before any anatomopathologic results.

[Pneumopathies caused by inhalation of hydrocarbons: apropos of 3 cases]. / Les pneumopathies par inhalation d'hydrocarbures. A propos de trois observations.

We report three personal cases of hydrocarbide aspiration pneumonia. High-viscosity non-volatile hydrocarbides (paraffin oil, for instance) cause often pseudotumoral exogenous fat-aspiration lung disease. Low-viscosity volatile hydrocarbides (petroleum, gasoline, white spirit, for instance) cause acute pseudo-infectious lung disease with dyspnea and fever which usually resolves within a few weeks but which may also be life-threatening. Purely symptomatic treatment has greatly progressed with advances in intensive ventilatory assistance. Gastric emptying with emetic agents or lavage procedures is dangerous and must be avoided except for exceptional cases. When required, the airways must be protected with tracheal intubation. Volatile hydrocarbides should be stored in protected areas in containers with safety stoppers which children cannot open.

[Paroxetine withdrawal syndrome]. / Syndrome de sevrage à la paroxétine.

Withdrawal syndrome after discontinuing serotonin re-uptake inhibitors, especially paroxetine, is largely unknown to most physicians. Variable incidence has been reported. Our aim was to stress the main clinical features of this syndrome. Serotonin re-uptake inhibitor withdrawal syndrome generally begins within 24 to 48 hours after discontinuing the drug. Signs reach their maximum on day 5 and usually resolve within 2 to 3 weeks. Withdrawal syndrome is more common with short half-life drugs (paroxetine, fluvoxamine). The intensity of the clinical signs depends on the daily dose and how long the drug has been given. The main signs are dizziness, vertigo, headache, nausea, and flu-like symptoms as well as anxiety, confusion, irritability, excessive dreaming and insomnia. Risk factors usually stressed are poor treatment compliance, previous withdrawal syndrome with another drug, concomitant medication and alcohol consumption. The syndrome can be prevented by tapering off the dose and patient education. When a withdrawal syndrome is present, it is advisable to reintroduce the drug then withdraw gradually.

[Drug-induced gynecomastia]. / Les gynécomasties médicamenteuses.

Drugs are a very common cause of gynecomastia and should always be entertained as the possible causal agent of such a condition. This drug side-effect is due to an impaired balance in the serum estrogen/serum androgen ratio, whatever the mechanism, or a rise in prolactin level. Sex hormones, antiandrogens, are frequently involved as well as spironolactone, cimetidine, verapamil and cancer chemotherapy (especially alkylating agents). Diazepam, tricyclic antidepressants, neuroleptics, calcium channel blockers, captopril, digitalis glycosides, omeprazole, some antibiotics and growth hormone are all possibly, but less often, the responsible agent. Criteria of the French method for determining drug causality are discussed.

[Nicorandil-induced giant lingual aphthosis in a patient with Behcet's disease]. / Aphtose linguale géante induite par le nicorandil chez un patient atteint d'une maladie de Behçet.

BACKGROUND: Even in patients with Behçet's disease, disease, the development of severe aphthosis should suggest the possibility of a drug reaction. CASE REPORT: We observed a case of giant lingual aphthosis that developed four months after adding microrandil to the regimen of a patient with Behçet's disease who had been treated with colchicine for 16 years. The aphthosis healed after withdrawal of nicorandil. DISCUSSION: There have been 21 cases of nicorandil-induced buccal aphthosis reported in the literature. All healed at drug withdrawal. He delay between initiation of treatment of the stomatitis in most patients, the development of the aphthosis after increasing he nicorandil dose in two patients, its regression after reducing the dose in one and pathology date from biopsied cases suggest a dose-dependent toxic mechanism rather than an immunoallergic process is involved. To our knowledge, our case is the first reported with Behçet's disease. In our opinion, nicorandil should not be given to patients with Behçet's disease.

Short-term variability of blood pressure and heart rate in hyperthyroidism.

The effect of hyperthyroidism on the short-term memory variability of blood pressure and heart rate was evaluated in 12 untreated hyperthyroid patients during thyrotoxicosis and after a 6 1/2 month treatment designed to achieve a stable euthyroid state. Beat-by-beat finger blood pressure was measured with a Finapres device. The pulse interval, from which pulse rate was derived, was obtained from the blood pressure signal. Due to the significant change in heart rhythm associated with thyrotoxicosis, both pulse interval (taken as a surrogate of heart period) and pulse rate (taken as a surrogate of heart rate) were computed. Power spectral analysis showed a reduction in the overall heart period variability in the supine position in the hyperthyroid compared to the euthyroid state. This effect was observed in the low-frequency (0.005-0.068 Hz), mid-frequency (0.068-0.127 Hz) and high-frequency (respiratory) domains as well, with a significant reduction of the modulus of these bands of 31%, 35% and 47%, respectively. The heart rate spectral modulus also exhibited a reduction of the high-frequency component (31%) in the supine position in the hyperthyroid subjects. These changes in heart rhythmicity corroborate a vagal deficit in hyperthyroidism. In addition, blood pressure spectral power exhibited a significant deficit in the orthostatism-induced mid-frequency systolic blood pressure rise in the hyperthyroid state (64%) compared with the euthyroid state. This observation may reflect a reduced vascular sympathetic activation with standing. The resulting vasodilatation could well contribute to normalize blood pressure in thyrotoxicosis in which cardiac output is increased.

Repeated doses of combined oral lysine acetylsalicylate and metoclopramide in the acute treatment of migraine.

The combination of lysine acetylsalicylate and metoclopramide is effective in the treatment of migraine attacks. It was unknown whether repeated doses could improve efficacy. The aim of this open trial was to evaluate the effects of a second, and eventually a third dose of lysine acetylsalicylate and metoclopramide when a first dose of the treatment was ineffective. Patients were asked to take a second dose 2 hours after a first dose when they thought that the first dose was ineffective. They were allowed to take a third dose or their rescue medication 2 hours after the second dose when they judged that the treatment remained ineffective. Two hundred ninety-two patients were included in the study; 262 of the 292 patients treated 517 attacks. Headache relief (reduction in headache severity from grade 3 or 2 to grade 1 or 0) was observed in 54.8% of attacks after one dose, in 48.1% of attacks after a second dose, and in 40.3% of attacks after a third dose. Complete headache relief without recurrence and without use of a rescue medication was reported in 37% of the total attacks. The patients judged their treatment as good or excellent in 78% of attacks treated with one dose, in 41% of those treated with two doses, and in 19% of those treated with three doses. Tolerance, as judged by the patients, was considered good in 92% of treated attacks. Minor side effects occurred in 6% of attacks after a first dose, in 4.5% of attacks after a second dose, in 1.5% of attacks after a third dose, in 2% after unspecified delay, and in 14% overall. In conclusion, the efficacy of lysine acetylsalicylate and metoclopramide in the treatment of migraine attacks can be improved by repeated doses. It is well tolerated.

[Homonymy of drugs: a cause of prescription and dispensing errors]. / L'homonymie des médicaments: une cause d'erreur de prescription et de dispensation.

There have been recently a prescription error and a dispensing error in our department due to drug names which look or sound alike. Errors of this type have frequently been quoted in the Anglo-Saxon literature. The method of choosing a drug trade name is recalled, and a table of French drug names which can involve errors of prescription and dispensing errors is provided.

[Drug interactions and the elderly]. / Interactions médicamenteuses et personnes agées.

Elderly people are particularly at risk for drug interactions, for several reasons. They are the part of the population who consume the most drugs: over 75 years the mean number of drugs on a prescription is 5.6. As they suffer from various associated diseases, they see several medical specialists, each of them adding a new prescription to the others. Self-prescriptions complicate the problem because they are rarely mentioned. Changes in pharmacokinetics in the elderly tend to increase blood concentrations of drugs. Elderly people suffer from altered homeostatic mechanisms to compensate for adverse drug effects. As a whole, such individuals are more exposed to the side effects of drugs. The drugs most often involved in these interactions are diuretics, non-steroidal anti-inflammatory drugs, benzodiazepines, antiarrhythmics, cardiac glycosides, antihypertensive drugs, oral antidiabetics and antalgics. The clinical accidents most often occurring with these drug interactions are: malaise, orthostatic hypotension, loss of conciousness, amnesia, confusion, renal insufficiency, digestive problems. Since elderly people are less likely to recover easily, this problem of drug interaction should be looked for systematically.

[Evaluation of the gastrotoxicity of anti-inflammatory drugs: contribution of general registries of digestive endoscopy]. / Evaluation de la gastrotoxicité des anti-inflammatoires: apport des registres généraux d'endoscopie digestive.

The evaluation of the rate of gastroduodenal toxicity of anti inflammatory drugs is a difficult problem. We tried to analyse that question by studying the general endoscopic registers of the Gastro-Enterologic department of the hospital. This retrospective study concerns 2,945 endoscopies performed during the year 1988 and 1992 randomly chosen among the last 5 years. 992 results show injuries suggestive of non steroidal anti inflammatory drugs (NSAID) toxicity, however only in 65 cases the potential role of an anti inflammatory drug is mentioned: 36 men and 29 women, mean age: 50.6 +/- 19.6 years. Concerning the drugs, only the pharmacological classes they belong to are mentioned except for Aspirin. Acetyl salicylate acid 7 cases, NSAIDS 36 and Steroids 22. In the drug group 63% of injuries are located to the stomach (ulcers 13%, gastritis 50%), 37% to the duodenum (19% ulcers, 18% duodenitis). Compared to the groups with the same kind of injuries, but without any mention of drugs, there are no statistical difference in the proportion of ulcers. Aging and sex are not influent in our results on the genesis of drug induced ulcers. These results must be discussed because a lot of datas are missing in the registers and so the number of patients taking drugs is probably underestimated. This means that unless a prospective study is held with someone enquiring for all the risk factors, the study of the general endoscopic registers is not a good way to estimate gastrointestinal damages due to drugs.

Systemic and local tolerability of ophthalmic drug formulations. An update.

All eye drops raise problems of local tolerance, but with variable frequencies. They can induce pain on instillation, allergic reactions, delayed healing, punctate keratitis, disturbances of lacrimal secretion, disturbances of accommodation (especially the parasympathomimetics) and local pigmentation after prolonged use. Corticosteroids are associated with 2 major risks: chronic glaucoma and cataract, initially reversible if treatment is stopped. There is still a major risk of corneal herpes with corticosteroids. It is important to be aware of these local problems as they are responsible for poor patient compliance. The systemic effects essentially concern the agonists and antagonists of the autonomic nervous system. beta-Blocker eye drops can cause bronchospasm, heart failure, syncope and psychiatric disorders, especially at high doses and with nonselective beta-blockers. These consequences are usually related to failure to comply with the prescribing precautions. alpha-Adrenergic agonists, which exert dose-dependent effects, can induce hypertensive crises or angina attacks. Apart from patients at risk (children under the age of 30 months and the elderly), parasympathomimetics cause few systemic adverse effects; anticholinesterases, which have curare-like properties, are contraindicated for 6 weeks before general anesthesia. In the very young and the very old, atropinic eye drops carry a risk of cardiovascular collapse and neuropsychiatric disturbances. Problems may also occur with other classes of drugs such as anti-infectives, antispectics, anti-inflammatories and contact lens products. Nevertheless, it is clear that this form of treatment is generally very well tolerated in relation to the volume of eye drops prescribed by ophthalmologists each day.

[Phlebitis of the upper limbs on pacemaker electrodes. 4 cases and review of the literature]. / Phlébite du membre supérieur sur sonde de pace-maker. Quatre observations et revue de la littérature.

We report four cases of deep venous thrombosis of the upper extremity, which occurred in two women and two men (mean age 79 years) in whom a pacemaker electrode had been inserted 4 years on averages previously. In three of these four cases phlebitis developed after immobilization of the limb containing the electrode. Deep venous thrombosis of the upper extremity is rare, but 28% of catheterizations are responsible for phlebitis. One to 3% of patients fitted with a pacemaker have symptomatic phlebitis, but these figures rise to 28-65% when phlebography is systematically performed in subjects wearing a pacemaker. The clinical signs are the same as those of the classical forms, and the diagnosis is made by doppler-ultrasonography and by phlebography which informs on the collateral circulation. Cure is obtained with efficient anticoagulant therapy. These cases prompt us to prescribe a preventive subcutaneous heparin therapy in those pacemaker-fitted subjects whose arm is immobilized. The heparin dosage remains to be determined precisely.

[Malaise and its cost: the cost effectiveness of complementary tests]. / Le malaise et son coût: rentabilité des examens complémentaires.

A study of 200 patients hospitalized in the Internal Medicine ward for malaise enabled us to specify several clinical features and to estimate the cost of this disorder. Clinical data from our investigation showed that the mean age of patients was 60 +/- 1.7 years, the women were older than the men, and age is an important parameter for orienting examinations which affects the length of hospitalization and increases with it. Among the etiological diagnoses of malaise, the systematic search for orthostatic hypotension is extremely important: it was responsible for 22 of the malaises of which only half were diagnosed in the emergency room. In addition, 12% of our series of malaises were medication-associated. The 200 patients represent 1,300 hospital-days at a total cost of 2,273,000 FF (congruent to US$454,600), and an average cost of 11,660 FF (congruent to US$2330) per malaise, of which 730 FF (congruent to US$145) was paid for complementary examinations. Thus it appears that the "hotel accommodations" part of the bill is the major element. All the complementary examinations ordered during the etiological search do not provide the same information and cost-benefit analysis showed that several simple tests, i.e., ECG, blood-sugar level, blood electropherogram and dosage of toxic substances, led to approximately 75% of the diagnoses; more sophisticated tests, e.g., cerebral computed-tomography scanning, Holter ECG or echocardiography, did not concern more than 25% of the malaises studied.(ABSTRACT TRUNCATED AT 250 WORDS)