Consensus statement: the development of a national Canadian Migraine Strategy.

BACKGROUND: Migraine is a significant cause of suffering and disability in the Canadian population, and imposes a major cost on Canadian Society. Based on current medical science, much more could be done to provide better comprehensive medical care to the millions of individuals with migraine in Canada. OBJECTIVE: To propose and design a national Canadian Migraine Strategy which could be implemented to reduce migraine related disability in Canada. METHODS: A multidisciplinary task force of the Canadian Headache Society met for a Canadian Migraine Summit Meeting in Halifax, Nova Scotia in June, 2009. Pertinent literature was reviewed and a consensus document was produced based upon the round table discussion at the meeting. RESULTS: The outline of a national Canadian Migraine Strategy was created. This strategy is based on the chronic disease management model, and would include: an outline of what constitutes appropriate migraine care for Canadians, educational programs (for health care professionals, individuals with migraine, and the general public), research programs, and the development of the necessary organizations and partnerships to develop further and implement the Canadian Migraine Strategy. CONCLUSIONS: Based upon the medical literature and expert discussion at the meeting, a national Canadian Migraine Strategy with a patient self-management focus has the potential to improve patient care and reduce headache related disability in Canada.

Respiratory viral infection in lower airways of asymptomatic children.

AIM: The aim of this study was to determine if asthmatic children have viruses more commonly detected in lower airways during asymptomatic periods than normal children. METHODS: Fifty-five asymptomatic children attending elective surgical procedures (14 with stable asthma, 41 normal controls) underwent non-bronchoscopic bronchoalveolar lavage. Differential cell count and PCR for 13 common viruses were performed. RESULTS: Nineteen (35%) children were positive for at least one virus, with adenovirus being most common. No differences in the proportion of viruses detected were seen between asthmatic and normal 'control' children. Viruses other than adenovirus were associated with higher neutrophil counts, suggesting that they caused an inflammatory response in both asthmatics and controls (median BAL neutrophil count, 6.9% for virus detected vs. 1.5% for virus not detected, p = 0.03). CONCLUSIONS: Over one-third of asymptomatic children have a detectable virus (most commonly adenovirus) in the lower airway; however, this was not more common in asthmatics. Viruses other than adenovirus were associated with elevated neutrophils suggesting that viral infection can be present during relatively asymptomatic periods in asthmatic children.

High levels of Epstein-Barr virus in COPD.

Latent viral infection has been implicated in the pathophysiology of chronic obstructive pulmonary disease (COPD). Epstein-Barr virus (EBV) is known to be important in pulmonary fibrosis. The current authors hypothesised that EBV is associated with the pathogenesis of COPD. Sputum samples were collected from patients both during exacerbations of COPD and when stable. A control group of smokers who did not have airways obstruction also had their sputum examined. The presence of EBV DNA was established and quantified using a real-time nucleic acid amplification assay. A total of 136 patients with COPD were recruited during an acute exacerbation and a total of 68 when stable. EBV was detected in 65 (48%) exacerbation cases and 31 (46%) stable patients. In the comparison group of 16 nonobstructed smokers, EBV was demonstrated in only one (6%) case. Risk of COPD in patients with EBV and who are smokers confers an odds ratio of 12.6. Epstein-Barr virus DNA is more frequently identified in the respiratory tract of chronic obstructive pulmonary disease patients in comparison with unaffected smokers. It is present both during exacerbation and when stable, suggesting that infection is persistent. Smokers who do not develop chronic obstructive pulmonary disease rarely have Epstein-Barr virus in their sputum. This finding may be of importance in the pathogenesis of chronic obstructive pulmonary disease.

Effect of faecal consistency on virological diagnosis.

A study was set up to investigate the effect of consistency of routine faecal specimens on the diagnostic yield by electron microscopy (EM) and virus isolation. A total of 3078 specimens were characterized as solid, semisolid, or liquid. Of 2568 specimens processed by EM a virus was demonstrated in 8.6% of liquid, 19.9% of semisolid and 25.2% of solid specimens (Chi-squared for linear trend, P value <0.0001). This observation was valid for both adenovirus (2.4%, 5.0% and 6.6%) and rotavirus (5.2%, 13.6% and 16.6%). Virus isolation was positive in 3.6% of liquid, 17.4% of semisolid and 18.1% of solid specimens. (Chi-squared for linear trend, P value <0.0001). We suggest that solid faecal specimens at the end of an episode of diarrhoea will have a higher diagnostic yield than liquid specimens at the peak of symptoms. Our findings repudiate the commonly held dogma that viruses of gastroenteritis are more likely to be found in liquid than in solid faecal specimens. This finding has important implications for those establishing diagnostic algorithms for the investigation of viral gastroenteritis.

Clinical features and pharmacological treatment of migraine patients referred to headache specialists in Canada.

We set out to examine selected clinical characteristics of migraine patients referred to neurologists specializing in headache in Canada, and to document their pharmacological therapy both before and after consultation with the neurologist. Demographic, clinical and pharmacotherapy data were collected at the time of consultation for 606 patients referred to five headache clinics and who were given a migraine diagnosis by the neurologist. Data were analysed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The mean age of the migraine patients was 39.7 years; and 82.5% were female. The majority of patients suffered severe impact from their headaches. Prior to consultation, 48.7% were taking a triptan; after consultation, 97.2% were on a triptan. Before consultation, 30.9% were on a prophylactic drug; after consultation, 70.4% were. 20.8% of patients were medication overusers. Of these medication overusers, 42.4% were overusing an opiate, usually in combination with other analgesics; 21.6% were overusing a triptan. Medication changes made by the neurologists at consultation included a large increase in the use of both triptans and prophylactic medications. Medication overuse, particularly opiate overuse, remains a significant problem in patients with migraine in Canada.

Children with stable asthma have reduced airway matrix metalloproteinase-9 and matrix metalloproteinase-9/tissue inhibitor of metalloproteinase-1 ratio.

BACKGROUND: Childhood asthma is characterized by inflammation of the airways. Structural changes of the airway wall may also be seen in some children early in the course of the disease. Matrix metalloproteinases (MMPs) are key mediators in the metabolism of the extracellular matrix (ECM). OBJECTIVE: To investigate the balance of MMP-8, MMP-9 and tissue inhibitor of metalloproteinases (TIMP)-1 in the airways of children with asthma. METHODS: One hundred and twenty-four children undergoing elective surgical procedures also underwent non-bronchoscopic bronchoalveolar lavage (BAL). MMP-8, MMP-9 and TIMP-1 were measured by ELISA. RESULTS: There was a significant reduction in MMP-9 in atopic asthmatic children (n=31) compared with normal children (n=30) [median difference: 0.57 ng/mL (95% confidence interval: 0.18-1.1 ng/mL)]. The ratio of MMP-9 to TIMP-1 was also reduced in asthmatic children. Levels of all three proteins were significantly correlated to each other and to the relative proportions of particular inflammatory cells in BAL fluid (BALF). Both MMP-8 and MMP-9 were moderately strongly correlated to the percentage neutrophil count (r=0.40 and 0.47, respectively, P<0.001). CONCLUSIONS: An imbalance of MMPs and their inhibitors occurs in children with well-controlled asthma, which may indicate early derangement of the metabolism of the ECM.

Fast, short-column separation and fluorometric determination of monosodium glutamate in foods.

In a simple and fast procedure, monosodium glutamate in food products is first separated by a short ion exchange column and subsequently determined fluorometrically with fluorescamine. An average recovery of 90.8% with a standard deviation of plus or minus 6.67% was obtained for added monosodium glutamate in a series of 8 products. As little as 0.05% monosodium glutamate can be determined. The method is faster than the official method and saves 5 hr/determination.

Recrudescent herpes simplex infection mimicking primary herpetic gingivostomatitis.

We report six cases of recrudescent intraoral herpes simplex infection clinically indistinguishable from primary herpetic gingivostomatitis. All infections occurred in healthy children or young adults. Serological analysis demonstrated herpes simplex virus (HSV)-specific IgG at initial presentation, indicating that the infection was not a primary infection. Convalescent sera exhibited HSV-specific IgM and a rising HSV-specific IgG titre. These findings demonstrate that the initial clinical diagnosis of primary herpetic gingivostomatitis was erroneous and that what was actually being observed was widespread recrudescent intraoral herpes simplex infection.

Non-bronchoscopic sampling and culture of bronchial epithelial cells in children.

BACKGROUND: The bronchial epithelium is likely to play a vital role in airway diseases in children, such as asthma and viral-associated wheeze. In adults, studies with primary bronchial epithelial cells cultured from samples obtained by fibre-optic bronchoscopy have provided key insights into the role of the epithelial cell. However, it is difficult to justify bronchoscopy in children to obtain epithelial cells for research purposes. OBJECTIVE: To examine the possibility of retrieving and culturing viable epithelial cells using a blind non-bronchoscopic method from children undergoing elective surgery. METHODS: Subjects were children undergoing elective surgery under general anaesthesia. Following intubation, non-bronchoscopic bronchoalveolar lavage and non-bronchoscopic bronchial brushing were performed. A sheathed bronchial cytology brush was advanced through the endotracheal tube, wedged and then withdrawn 2-3 cm before gentle sampling was used to collect bronchial epithelial cells. Initial samples were used to characterize the number, type and viability of epithelial cells recovered compared to a control group of adults undergoing standard bronchoscopic sampling. Subsequent samples were used to establish primary bronchial epithelial cell cultures in children both with and without wheezing illness. RESULTS: A total of 63 children underwent bronchial brushing [38 male; median age 7.1 years (1.0-14.2 years]. Initial samples (n=30) showed recovery of viable epithelial cells comparable to that from a single brush obtained via a bronchoscope in an adult control group (n=11). In 27 (82%) of the subsequent 33 samples obtained non-bronchoscopically from children, primary bronchial epithelial cell cultures were successfully established. There were no adverse effects attributable to sampling. CONCLUSION: We have shown that non-bronchoscopic bronchial brushing is a safe and effective technique for recovering viable bronchial epithelial cells that consistently yield primary cultures. This method will facilitate examination of the role of the epithelium in paediatric disease.