Impact of biological agents on postsurgical complications in inflammatory bowel disease: A multicentre study of Geteccu

Background: The impact of biologics on the risk of postoperative complications (PC) in inflammatory bowel disease (IBD) is still an ongoing debate. This lack of evidence is more relevant for ustekinumab and vedolizumab. Aims: To evaluate the impact of biologics on the risk of PC. Methods: A retrospective study was performed in 37 centres. Patients treated with biologics within 12 weeks before surgery were considered “exposed”. The impact of the exposure on the risk of 30-day PC and the risk of infections was assessed by logistic regression and propensity score-matched analysis. Results: A total of 1535 surgeries were performed on 1370 patients. Of them, 711 surgeries were conducted in the exposed cohort (584 anti-TNF, 58 vedolizumab and 69 ustekinumab). In the multivariate analysis, male gender (OR: 1.5; 95% CI: 1.2–2.0), urgent surgery (OR: 1.6; 95% CI: 1.2–2.2), laparotomy approach (OR: 1.5; 95% CI: 1.1–1.9) and severe anaemia (OR: 1.8; 95% CI: 1.3–2.6) had higher risk of PC, while academic hospitals had significantly lower risk. Exposure to biologics (either anti-TNF, vedolizumab or ustekinumab) did not increase the risk of PC (OR: 1.2; 95% CI: 0.97–1.58), although it could be a risk factor for postoperative infections (OR 1.5; 95% CI: 1.03–2.27). Conclusions: Preoperative administration of biologics does not seem to be a risk factor for overall PC, although it may be so for postoperative infections

Chronic migraine plus medication overuse headache: two entities or not?

Chronic migraine (CM) represents migraine natural evolution from its episodic form. It is realized through a chronicization phase that may require months or years and varies from patient to patient. The transition to more frequent attacks pattern is influenced by lifestyle, life events, comorbid conditions and personal genetic terrain, and it often leads to acute drugs overuse. Medication overuse headache (MOH) may complicate every type of headache and all the drugs employed for headache treatment can cause MOH. The first step in the management of CM complicated by medication overuse must be the withdrawal of the overused drugs and a detoxification treatment. The goal is not only to detoxify the patient and stop the chronic headache but also to improve responsiveness to acute or prophylactic drugs. Different methods have been suggested: gradual or abrupt withdrawal; home treatment, hospitalization, or a day-hospital setting; re-prophylaxes performed immediately or at the end of the wash-out period. Up to now, only topiramate and local injection of onabotulinumtoxinA have shown efficacy as therapeutic agents for re-prophylaxis after detoxification in patients with CM with and without medication overuse. Although the two treatments showed similar efficacy, onabotulinumtoxinA is associated with a better adverse events profile. Recently, the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program proved that patients with CM, even those with MOH, are the ones most likely to benefit from onabotulinumtoxinA treatment. Furthermore, it provided an injection paradigm that can be used as a guide for a correct administration of onabotulinumtoxinA

Clinical Predictors of Hyperperfusion Syndrome Following Carotid Stenting: Results From a National Prospective Multicenter Study

[Objectives] The aim of the HISPANIAS (HyperperfusIon Syndrome Post-carotid ANgIoplasty And Stenting) study was to define CHS rates and develop a clinical predictive model for cerebral hyperperfusion syndrome (CHS) after carotid artery stenting (CAS).[Background] CHS is a severe complication following CAS. The presence of clinical manifestations is estimated on the basis of retrospective reviews and is still uncertain.[Methods] The HISPANIAS study was a national prospective multicenter study with 14 recruiting hospitals. CHS was classified as mild (headache only) and moderate-severe (seizure, impaired level of consciousness, or development of focal neurological signs).[Results] A total of 757 CAS procedures were performed. CHS occurred in 22 (2.9%) patients, in which 16 (2.1%) had moderate-severe CHS and 6 (0.8%) had mild CHS (only headache). The rate of hemorrhages was 0.7% and was associated with high mortality (20%). Pre-operative predictors of moderate-severe CHS in multivariate analysis were female sex (odds ratio [OR]: 3.24; 95% confidence interval [CI]: 1.11 to 9.47; p = 0.03), older patients (OR: 1.09; 95% CI: 1.01 to 1.17; p = 0.02), left carotid artery treated (OR: 4.13; 95% CI: 1.11 to 15.40; p = 0.03), and chronic renal failure (OR: 6.29; 95% CI: 1.75 to 22.57; p = 0.005). The area under the curve of this clinical and radiological model was 0.86 (95% CI: 0.81 to 0.92; p = 0.001).[Conclusions] The rate of CHS in the HISPANIAS study was 2.9%, with moderate-severe CHS of 2.1%. CHS was independently associated with female sex, older age, history of chronic kidney disease, and a treated left carotid artery. Although further investigations are needed, the authors propose a model to identify high-risk patients and develop strategies to decrease CHS morbidity and mortality in the future.This study was supported by a Spanish grant from the Instituto de Salud Carlos III (ISCIII-FIS IP14/00971, 2014–2017). The ITRIBIS project has the registration number REGPOT-2013-1. Cooperative Cerebrovascular Disease Research Network (INVICTUS+) (RD16/0019/0015). Dr. Mancha is supported by a Río Hortega contract (CM16/00015). Abbott and Grifols have partial financial supported the conduction of the HISPANIAS project but had no role in the design of the study, interpretation of the data, or manuscript approval.Peer reviewe

Risk factors of migraine-related brain white matter hyperintensities: an investigation of 186 patients

Brain white matter hyperintensities are more prevalent in migraine patients than in the general population, but the pathogenesis and the risk factors of these hyperintensities are not fully elucidated. The authors analyzed the routine clinical data of 186 migraine patients who were referred to the Outpatient Headache Department of the Department of Neurology, Medical School, University of Pécs, Hungary between 2007 and 2009: 58 patients with white matter hyperintensities and 128 patients without white matter hyperintensities on 3 T MRI. Significant associations between the presence of white matter hyperintensities and longer disease duration (14.4 vs. 19.9 years, p = 0.004), higher headache frequency (4.1 vs. 5.5 attacks/month, p = 0.017), hyperhomocysteinemia (incidence of hyperintensity is 9/9 = 100%, p = 0.009) and thyroid gland dysfunction (incidence of hyperintensity is 8/14 = 57.1%, p = 0.038) were found. These data support the theory that both the disease duration and the attack frequency have a key role in the formation of migraine-related brain white matter hyperintensities, but the effects of comorbid diseases may also contribute to the development of the hyperintensities

Familial hemiplegic migraine with severe attacks: a new report with ATP1A2 mutation

[Introduction]: Familial hemiplegic migraine (FHM) is a rare disorder characterized by migraine attacks with motor weakness during the aura phase. Mutations in CACNA1A, ATP1A2, SCN1A, and PRRT2 genes have been described. [Methods]: To describe a mutation in ATP1A2 gene in a FHM case with especially severe and prolonged symptomatology. [Results]: 22-year-old woman was admitted due to migraine-type headache and sudden onset of right-sided weakness and aphasia; she had similar episodes in her childhood. Her mother was diagnosed with hemiplegic migraine without genetic confirmation. She presented with fever, decreased consciousness, left gaze preference, mixed aphasia, right facial palsy, right hemiplegia, and left crural paresis. Computed tomography (CT) showed no lesion and CT perfusion study evidenced oligohemia in left hemisphere. A normal brain magnetic resonance (MR) was obtained. Impaired consciousness and dysphasia began to improve three days after admission and mild dysphasia and right hemiparesis lasted for 10 days. No recurrences were reported during a follow-up of two years. We identified a variant in heterozygous state in ATP1A2 gene (p.Thr364Met), pathogenic according to different prediction algorithms (SIFT, PolyPhen2, MutationTaster, and Condel). [Conclusion]: Prolonged and severe attacks with diffuse hypoperfusion in a FHM seemed to be specially related to ATP1A2 mutations, and p.T364M should be considered.Peer Reviewe

Familial Hemiplegic Migraine with Severe Attacks: A New Report with ATP1A2 Mutation

Introduction. Familial hemiplegic migraine (FHM) is a rare disorder characterized by migraine attacks with motor weakness during the aura phase. Mutations in CACNA1A, ATP1A2, SCN1A, and PRRT2 genes have been described. Methods. To describe a mutation in ATP1A2 gene in a FHM case with especially severe and prolonged symptomatology. Results. 22-year-old woman was admitted due to migraine-type headache and sudden onset of right-sided weakness and aphasia; she had similar episodes in her childhood. Her mother was diagnosed with hemiplegic migraine without genetic confirmation. She presented with fever, decreased consciousness, left gaze preference, mixed aphasia, right facial palsy, right hemiplegia, and left crural paresis. Computed tomography (CT) showed no lesion and CT perfusion study evidenced oligohemia in left hemisphere. A normal brain magnetic resonance (MR) was obtained. Impaired consciousness and dysphasia began to improve three days after admission and mild dysphasia and right hemiparesis lasted for 10 days. No recurrences were reported during a follow-up of two years. We identified a variant in heterozygous state in ATP1A2 gene (p.Thr364Met), pathogenic according to different prediction algorithms (SIFT, PolyPhen2, MutationTaster, and Condel). Conclusion. Prolonged and severe attacks with diffuse hypoperfusion in a FHM seemed to be specially related to ATP1A2 mutations, and p.T364M should be considered

Pericranial nerve blockade as a preventive treatment for migraine: Experience in 60 patients

Introduction: Anaesthetic blockade of pericranial nerves is frequently used to treat headache disorders. There is no evidence on indication of this treatment for migraine. We aim to evaluate its effectiveness as a preventive treatment for migraine using specific indication criteria. Methods: Between January 2009 and May 2013 we offered pericranial nerve blockade to migraine patients with a history of preventive drug intolerance or failure. We selected patients with tenderness to palpation of at least one greater occipital nerve (GON) or supraorbital nerve (SON). Responses at 3 months were categorised as complete response (no pain), partial response (reduction of at least 50% in severity or frequency of headache episodes), or no response. Results: Anaesthetic blockade was performed in 60 patients (52 females, 8 males; mean age 40.6 ± 12.4 years, range 19-76). The most common procedure was blockade of GON and SON on both sides. Complete response lasting at least 2 weeks was recorded in 23 patients (38.3%), with partial response in 24 patients (40%), and no response in 13 (21.7%). In the group presenting complete response, age and length of history of migraine were significantly lower. No severe side effects were detected. Response time ranged from 2 weeks to 3 months. Conclusions: Pericranial nerves blockade using tenderness to palpation as an inclusion criterion is safe and potentially effective as prophylactic treatment for migraine. The best responses in our series were observed in younger patients with shorter histories of migraine. Resumen: Introducción: El bloqueo anestésico de nervios pericraneales es utilizado con frecuencia en el tratamiento de diferentes cefaleas. No hay evidencia acerca de su indicación en pacientes migrañosos. Pretendemos evaluar su eficacia como tratamiento preventivo de migraña con criterios determinados. Métodos: Entre enero del 2009 y mayo del 2013 se ofreció este tratamiento a migrañosos con fracaso o intolerancia de fármacos preventivos. Seleccionamos a aquellos con sensibilidad a la palpación en al menos un nervio supraorbitario u occipital mayor. A los 3 meses, consideramos la respuesta completa (sin dolor), parcial (reducción al menos de un 50% en severidad y/o frecuencia de episodios) o ausente. Resultados: Se practicó un bloqueo anestésico en 60 pacientes (52 mujeres, 8 varones, edad media ± desviación estándar: 40,6 ± 12,4 años, rango 19-76). El procedimiento más habitual fue el bloqueo de ambos nervios occipitales y supraorbitarios. Hubo respuesta completa de al menos 2 semanas en 23 (38,3%), parcial en 24 (40%) y ausente en 13 (21,7%). En el grupo con respuesta completa, la edad y el tiempo de evolución de la migraña eran significativamente inferiores. Sin efectos adversos significativos. Tiempo de respuesta entre 2 semanas y 3 meses. Conclusiones: El bloqueo anestésico de nervios pericraneales utilizando la sensibilidad a la palpación como criterio de selección es un procedimiento seguro y potencialmente eficaz como tratamiento preventivo de migraña. Las mayores respuestas en nuestra serie se observan en pacientes jóvenes con menos tiempo de evolución de la migraña. Keywords: Anaesthetic blockade, Migraine, Chronic migraine, Great occipital nerve, Supraorbital nerve, Preventive therapy, Palabras clave: Bloqueo anestésico, Migraña, Migraña crónica, Nervio occipital mayor, Nervio supraorbitario, Tratamiento preventiv

Bloqueo anestésico de nervios pericraneales como tratamiento preventivo de migraña: experiencia en una serie de 60 pacientes

Resumen: Introducción: El bloqueo anestésico de nervios pericraneales es utilizado con frecuencia en el tratamiento de diferentes cefaleas. No hay evidencia acerca de su indicación en pacientes migrañosos. Pretendemos evaluar su eficacia como tratamiento preventivo de migraña con criterios determinados. Métodos: Entre enero del 2009 y mayo del 2013 se ofreció este tratamiento a migrañosos con fracaso o intolerancia de fármacos preventivos. Seleccionamos a aquellos con sensibilidad a la palpación en al menos un nervio supraorbitario u occipital mayor. A los 3 meses, consideramos la respuesta completa (sin dolor), parcial (reducción al menos de un 50% en severidad y/o frecuencia de episodios) o ausente. Resultados: Se practicó un bloqueo anestésico en 60 pacientes (52 mujeres, 8 varones, edad media ± desviación estándar: 40,6 ± 12,4 años, rango 19-76). El procedimiento más habitual fue el bloqueo de ambos nervios occipitales y supraorbitarios. Hubo respuesta completa de al menos 2 semanas en 23 (38,3%), parcial en 24 (40%) y ausente en 13 (21,7%). En el grupo con respuesta completa, la edad y el tiempo de evolución de la migraña eran significativamente inferiores. Sin efectos adversos significativos. Tiempo de respuesta entre 2 semanas y 3 meses. Conclusiones: El bloqueo anestésico de nervios pericraneales utilizando la sensibilidad a la palpación como criterio de selección es un procedimiento seguro y potencialmente eficaz como tratamiento preventivo de migraña. Las mayores respuestas en nuestra serie se observan en pacientes jóvenes con menos tiempo de evolución de la migraña. Abstract: Introduction: Anaesthetic blockade of pericranial nerves is frequently used to treat headache disorders. There is no evidence on indication of this treatment for migraine. We aim to evaluate its effectiveness as a preventive treatment for migraine using specific indication criteria. Methods: Between January 2009 and May 2013 we offered pericranial nerve blockade to migraine patients with a history of preventive drug intolerance or failure. We selected patients with tenderness to palpation of at least one greater occipital nerve (GON) or supraorbital nerve (SON). Responses at 3 months were categorised as complete response (no pain), partial response (reduction of at least 50% in severity or frequency of headache episodes), or no response. Results: Anaesthetic blockade was performed in 60 patients (52 females, 8 males; mean age 40.6 ± 12.4 years, range 19-76). The most common procedure was blockade of GON and SON on both sides. Complete response lasting at least 2 weeks was recorded in 23 patients (38.3%), with partial response in 24 patients (40%), and no response in 13 (21.7%). In the group presenting complete response, age and length of history of migraine were significantly lower. No severe side effects were detected. Response time ranged from 2 weeks to 3 months. Conclusions: Pericranial nerves blockade using tenderness to palpation as an inclusion criterion is safe and potentially effective as prophylactic treatment for migraine. The best responses in our series were observed in younger patients with shorter histories of migraine. Palabras clave: Bloqueo anestésico, Migraña, Migraña crónica, Nervio occipital mayor, Nervio supraorbitario, Tratamiento preventivo, Keywords: Anaesthetic blockade, Migraine, Chronic migraine, Great occipital nerve, Supraorbital nerve, Preventive therap