Cluster headache in Greece: an observational clinical and demographic study of 302 patients.

BackgroundCluster headache (CH) is considered the most excruciating primary headache syndrome; although much less prevalent than migraine, it is not rare as it affects more than 1/1000 people. While its clinical presentation is considered stereotypic, atypical features are often encountered. Internationally, cluster headache is often misdiagnosed, undertreated and mistreated.MethodsWe prospectively studied 302 CH patients, all examined by the same headache specialist. The aim of our study was to describe the demographic and clinical characteristics of CH patients in Greece and draw attention to under-management, under-treatment and mis-treatment often encountered in clinical practice; our purpose is to improve recognition and successful treatment of cluster patients by Greek neurologists and other physicians.ResultsIn the present cohort, clinical characteristics of CH are similar to those described in other populations. Beyond the standard clinical characteristics, features like side shifts (12.6 %), location of maximal pain intensity outside the first trigeminal branch division (10.2 %), lack of autonomic features (7 %), presence of associated features of migraine and aggravation by physical activity (10 %) were encountered. Four out of five patients had consulted a physician prior to diagnosis. The median number of physicians seen prior to diagnosis was 3 and the median time to diagnosis was 5 years, though it improved for patients with recent onset. Chronic cluster headache, side shifts, pain location in the face or the back of the head and aggravation by physical activity were found, among others, to be statistically significantly related to delayed diagnosis or more physicians seen prior to diagnosis. Even properly diagnosed patients were often undertreated or mistreated.ConclusionsCluster headache, in a large cohort of Greek patients, has the same phenotypic characteristics as described internationally. Uncommon clinical features do exist and physicians should be aware of those, since they may eventuate in diagnostic problems. Most CH patients in Greece remain misdiagnosed or undiagnosed for rather lengthy periods of time, but time to diagnosis has improved recently. Even after diagnosis, treatment received was suboptimal

EEG correlated functional MRI and postoperative outcome in focal epilepsy

Background: The main challenge in assessing patients with epilepsy for resective surgery is localising seizure onset. Frequently, identification of the irritative and seizure onset zones requires invasive EEG. EEG correlated functional MRI (EEG-fMRI) is a novel imaging technique which may provide localising information with regard to these regions. In patients with focal epilepsy, interictal epileptiform discharge (IED) correlated blood oxygen dependent level (BOLD) signal changes were observed in approximately 50% of patients in whom IEDs are recorded. In 70%, these are concordant with expected seizure onset defined by non-invasive electroclinical information. Assessment of clinical validity requires post-surgical outcome studies which have, to date, been limited to case reports of correlation with intracranial EEG. The value of EEG-fMRI was assessed in patients with focal epilepsy who subsequently underwent epilepsy surgery, and IED correlated fMRI signal changes were related to the resection area and clinical outcome. Methods: Simultaneous EEG-fMRI was recorded in 76 patients undergoing presurgical evaluation and the locations of IED correlated preoperative BOLD signal change were compared with the resected area and postoperative outcome. Results: 21 patients had activations with epileptic activity on EEG-fMRI and 10 underwent surgical resection. Seven of 10 patients were seizure free following surgery and the area of maximal BOLD signal change was concordant with resection in six of seven patients. In the remaining three patients, with reduced seizure frequency post-surgically, areas of significant IED correlated BOLD signal change lay outside the resection. 42 of 55 patients who had no IED related activation underwent resection. Conclusion: These results show the potential value of EEG-fMRI in presurgical evaluation

Management of incidentally detected heart murmurs in dogs and cats

A dog or a cat has an incidentally detected heart murmur if the murmur is an unexpected discovery during a veterinary consultation that was not initially focused on the cardiovascular system. This document presents approaches for managing dogs and cats that have incidentally-detected heart murmurs, with an emphasis on murmur characteristics, signalment profiling, and multifactorial decision-making to choose an optimal course for a given patient

Stage T4B head and neck cancer survival outcome comparisons based on treatment modality: is surgery a viable treatment option?

IMPORTANCE: Advanced stage head and neck cancers are often deemed unresectable due to the aggressive nature of the cancer. In evaluating survival patterns of patients with stage IVb tumors, it is valuable to determine whether patients who undergo oncological surgery have favorable outcomes in order to deem surgery as a viable treatment option and demonstrate that these patients can survive with adequate treatment. OBJECTIVE: To determine whether patients with stage IVb cancers who undergo oncological surgery have favorable survival outcomes. MATERIALS AND METHODS: Of 320 cases reviewed of patients treated for head and neck cancer at Boston Medical Center between June 2009 and October 2014, 18 patients with stage IVb tumors were identified. Information regarding date of initial diagnosis, date and type of treatment, and date of death were extrapolated from medical records. Mean survival rates were calculated to compare survival outcomes of those who received and those who did not receive surgical intervention. RESULTS: The mean survival rate for patients who underwent surgical intervention was found to be 29.5 months while those who did not receive surgical intervention had a mean survival of 20.83 months. CONCLUSION: Cancers of the head and neck are associated with poor prognoses and are often deemed unresectable. Patients should be offered definitive treatment despite recommended palliative treatment, as, with adequate treatment, favorable survival outcomes are attainable

An update on the diagnosis and treatment of early Lyme Disease: Focusing on the bull\u27s eye, you may miss the mark

To confidently diagnose and treat Lyme disease, the clinician must first understand the natural history of this disease, especially its protean early manifestations. Emergency physicians, primary care physicians, and other providers need to be vigilant in terms of the timely recognition of erythema migrans (EM), the unique marker of early localized stage 1 disease. The classic EM, originally described as a slowly expanding bull\u27s eye lesion, is now recognized to be present in only the minority of cases (9%); the dominant morphologic lesion of EM is now recognized to be the diffusely homogenous red plaque or patch, which occurs in over 50% of cases. This update will define the current morphologic features of early Lyme disease, the indication for serologic studies, and the most recent treatment guidelines, including therapeutic pitfalls

Multicentric validation of proteomic biomarkers in urine specific for diabetic nephropathy

Background: Urine proteome analysis is rapidly emerging as a tool for diagnosis and prognosis in disease states. For diagnosis of diabetic nephropathy (DN), urinary proteome analysis was successfully applied in a pilot study. The validity of the previously established proteomic biomarkers with respect to the diagnostic and prognostic potential was assessed on a separate set of patients recruited at three different European centers. In this case-control study of 148 Caucasian patients with diabetes mellitus type 2 and duration >= 5 years, cases of DN were defined as albuminuria >300 mg/d and diabetic retinopathy (n = 66). Controls were matched for gender and diabetes duration (n = 82). Methodology/Principal Findings: Proteome analysis was performed blinded using high-resolution capillary electrophoresis coupled with mass spectrometry (CE-MS). Data were evaluated employing the previously developed model for DN. Upon unblinding, the model for DN showed 93.8% sensitivity and 91.4% specificity, with an AUC of 0.948 (95% CI 0.898-0.978). Of 65 previously identified peptides, 60 were significantly different between cases and controls of this study. In <10% of cases and controls classification by proteome analysis not entirely resulted in the expected clinical outcome. Analysis of patient's subsequent clinical course revealed later progression to DN in some of the false positive classified DN control patients. Conclusions: These data provide the first independent confirmation that profiling of the urinary proteome by CE-MS can adequately identify subjects with DN, supporting the generalizability of this approach. The data further establish urinary collagen fragments as biomarkers for diabetes-induced renal damage that may serve as earlier and more specific biomarkers than the currently used urinary albumin

An Essay towards an Epistemology of Responsibility: A Probabilistic Approach

This paper tries to develop an epistemological analysis on the notion of responsibility. After pointing out a peculiar kind of uncertainties concerning the notion of responsibility, I focus upon the issue of criminal responsibility, taking the case of mentally disordered offenders into account, and propose the distinction of the phases between sentence and practice with applying Slobogin's idea of integrationism. Finally, I propose a probabilistic approach to the problem of responsibility through considering the idea of relevance ratio, leading to my final proposal concerning the concept of the degrees of responsibility

Sex-related differences in respiratory symptoms: results from the BOLD Study

For both males and females, the pathway to diagnosis and treatment of lung disease often begins with the reporting of respiratory symptoms to their physician. Males and females with impaired lung function may experience the same symptoms but perceive and/or report them differently