Relationship of migraine and other forms of chronic pain

The disability of migraine, a highly prevalent condition, is worsened by a second comorbid chronic pain condition. There is evidence of a relationship between migraine and several visceral pain conditions including irritable bowel syndrome, endometriosis, and dysmenorrhoea, as well as nonvisceral conditions including temporomandibular dysfunction, fibromyalgia, and lower back pain. While the mechanisms linking these conditions are inadequately surmised, a two-way relationship between migraine and these comorbidities likely exists. The progression and chronification of migraine is associated with peripheral and central sensitization, which may predispose to other conditions. Conversely, aspects of the mechanism of each comorbid condition may promote further migraine attacks. This chapter introduces each comorbidity, briefly summarizes the existing evidence, and discusses implications for treatment.

Interventional treatments

In migraine, when patients have failed medication management or are unable to be treated with systemic medications, minimally invasive interventions can be options used to provide pain relief. The type of intervention depends on the pain location, associated clinical features, clinical context, medical comorbidities, and response to prior injections. Interventions can vary from bedside peripheral nerve blocks to fluoroscopically guided interventions. Growing evidence is supporting the use of interventions in migraine, and judicious use can improve clinical outcomes.

Quantitative analysis of MR T2 relaxation times in neck muscles

T2 relaxation times (T2 times) are different between resting and exercised muscles and between muscles of healthy subjects and subjects with muscle pathology. However, studies specifically focusing on neck muscles are lacking. Furthermore, normative neck muscle T2 times are not well defined and methodology used to analyse T2 times in neck muscles is not robust. We analysed T2 times in key neck muscles and explored factors affecting variability between muscles. 20 healthy subjects were recruited. Two circular regions of interest (ROIs) were drawn in two mutually exclusive regions within neck muscles on T2 weighted images and values averaged. ROI measurements were performed by a co-investigator, supervised by a neuro-radiologist. For the first ten subjects, measurements were done from C1-T1. For the remaining subjects, ROIs were drawn at two pre-determined levels. Two MRIs were repeated at 31 degrees acquisition to evaluate the effect of muscle fibre orientation. ROI values were translated into T2 times. Results showed semispinalis capitis had the longest T2 times (range 46.88-51.42 ms), followed by splenius capitis (range 47.37-48.33 ms), trapezius (range 45.27-47.46 ms), levator scapulae (range 43.17-45.63 ms) and sternocleidomastoid (range 38.45-42.91 ms). T2 times did not vary along length of muscles and were unaffected by muscle fibre orientation (P > 0.05). T2 times of splenius capitis correlated significantly with age at C2/C3 and C5/C6 levels and trapezius at C7/T1 level. Gender did not influence relaxation times (P > 0.05). In conclusion, results of normative neck muscle T2 time values and factors influencing the T2 times could serve as a reference for future MR analysis of neck muscles. The methodology used may also be useful for related studies of neck muscles.

Association of plasma neurofilament light chain with disease activity in chronic inflammatory demyelinating polyradiculoneuropathy

BACKGROUND AND PURPOSE

This study was undertaken to explore associations between plasma neurofilament light chain (pNfL) concentration (pg/ml) and disease activity in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and examine the usefulness of pNfL concentrations in determining disease remission.

METHODS

We examined pNfL concentrations in treatment-naïve CIDP patients (n = 10) before and after intravenous immunoglobulin (IVIg) induction treatment, in pNfL concentrations in patients on maintenance IVIg treatment who had stable (n = 15) versus unstable disease (n = 9), and in clinically stable IVIg-treated patients (n = 10) in whom we suspended IVIg to determine disease activity and ongoing need for maintenance IVIg. pNfL concentrations in an age-matched healthy control group were measured for comparison.

RESULTS

Among treatment-naïve patients, pNfL concentration was higher in patients before IVIg treatment than healthy controls and subsequently reduced to be comparable to control group values after IVIg induction. Among CIDP patients on IVIg treatment, pNfL concentration was significantly higher in unstable patients than stable patients. A pNFL concentration > 16.6 pg/ml distinguished unstable treated CIDP from stable treated CIDP (sensitivity = 86.7%, specificity = 66.7%, area under receiver operating characteristic curve = 0.73). Among the treatment withdrawal group, there was a statistically significant correlation between pNfL concentration at time of IVIg withdrawal and the likelihood of relapse (r = 0.72, p < 0.05), suggesting an association of higher pNfL concentration with active disease.

CONCLUSIONS

pNfL concentrations may be a sensitive, clinically useful biomarker in assessing subclinical disease activity.

Intravenous Lidocaine and Ketamine Infusions for Headache Disorders: A Retrospective Cohort Study

Introduction

The use of lidocaine (lignocaine) and ketamine infusion in the inpatient treatment of patients with headache disorders is supported by small case series. We undertook a retrospective cohort study in order to assess the efficacy, duration and safety of lidocaine and ketamine infusions.

Methods

Patients admitted between 01/01/2018 and 31/07/2021 were identified by ICD code and electronic prescription. Efficacy of infusion was determined by reduction in visual analog score (VAS), and patient demographics were collected from review of the hospital electronic medical record.

Results

Through the study period, 83 infusions (50 lidocaine, 33 ketamine) were initiated for a headache disorder (77 migraine, three NDPH, two SUNCT, one cluster headache). In migraine, lidocaine infusion achieved a ≥50% reduction in pain in 51.1% over a mean 6.2 days (SD 2.4). Ketamine infusion was associated with a ≥50% reduction in pain in 34.4% over a mean 5.1 days (SD 1.5). Side effects were observed in 32 and 42.4% respectively. Infusion for medication overuse headache (MOH) led to successful withdrawal of analgesia in 61.1% of lidocaine, and 41.7% of ketamine infusions.

Conclusion

Lidocaine and ketamine infusions are an efficacious inpatient treatment for headache disorders, however associated with prolonged length-of-stay and possible side-effects.

The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy - analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

OBJECTIVE

To examine the association between pre-eclampsia definition and pregnancy outcome.

DESIGN

Secondary analysis of Control of Hypertension in Pregnancy Study (CHIPS) trial data.

SETTING

International multicentre randomised controlled trial (RCT).

POPULATION

In all, 987 women with non-severe non-proteinuric pregnancy hypertension.

METHODS

We evaluated the association between pre-eclampsia definitions and adverse pregnancy outcomes, stratified by hypertension type and blood pressure control.

MAIN OUTCOME MEASURES

Main CHIPS trial outcomes: primary (perinatal loss or high-level neonatal care for >48 hours), secondary (serious maternal complications), birthweight <10th centile, severe maternal hypertension, delivery at <34 or <37 weeks, and maternal hospitalisation before birth.

RESULTS

Of 979/987 women with informative data, 280 (28.6%) progressed to pre-eclampsia defined restrictively by new proteinuria, and 471 (48.1%) to pre-eclampsia defined broadly as proteinuria or one/more maternal symptoms, signs or abnormal laboratory tests. The broad (versus restrictive) definition had significantly higher sensitivities (range 62-79% versus 36-50%), lower specificities (range 53-65% versus 72-82%), and similar or higher diagnostic odds ratios and 'true-positive' to 'false-positive' ratios. Stratified analyses showed similar results. Addition of available fetoplacental manifestations (stillbirth or birthweight <10th centile) to the broad pre-eclampsia definition improved sensitivity (74-87%).

CONCLUSIONS

A broad (versus restrictive) pre-eclampsia definition better identifies women who develop adverse pregnancy outcomes. These findings should be replicated in a prospective study within routine healthcare to ensure that the anticipated increase in surveillance and intervention in a larger number of women with pre-eclampsia is associated with improved outcomes, reasonable costs and congruence with women's values.

TWEETABLE ABSTRACT

A broad (versus restrictive) pre-eclampsia definition better identifies the risk of adverse pregnancy outcomes.

Neurological implications of COVID-19: a review of the science and clinical guidance

COVID-19 is a significant global health burden. The pulmonary morbidity and mortality of COVID-19 is well described, however, there is mounting evidence of neurological manifestations of SARS-CoV-2, which may be of prognostic significance. This paper summarises the available evidence in order to provide clinicians with a concise summary of the peripheral and central neurological manifestations of COVID-19, discusses specific issues regarding the management of chronic neurological disease in the context of the pandemic, and provides a summary of the thrombotic implications of the disease for the neurologist.

Erenumab in Chronic Migraine: An Australian Experience

OBJECTIVE

To determine the effectiveness and safety of erenumab in patients with chronic migraine in the real-world setting of 3 headache centers in Australia.

METHODS

Patients with migraine were prescribed erenumab (70 or 140 mg) in the setting of either a product familiarization program or paid access to the medication in 3 headache centers in Australia. We obtained baseline and monthly prospective data on monthly headache days, monthly migraine days, monthly triptan use days, monthly codeine use days, Headache Impact Test-6 scores, and adverse reactions. In this paper, we present our data at 3 and 6 months in our subgroup of patients with chronic migraine with and without medication overuse.

RESULTS

A total of 170 patients with chronic migraine were prescribed erenumab in the 3 headache centers. At 3 months, 100/170 (58.8%) had 50% or greater reduction in monthly migraine days. At 6 months, 79/170 (46.5%) had 50% or greater reduction in monthly migraine days. At 6 months, there was a mean reduction in monthly headache days of 9.2 days, a mean reduction in monthly migraine days of 10.2 days. There were few adverse events reported.

CONCLUSION

This is the first report from 3 Australian headache centers about erenumab in the real world. Our analysis has supported erenumab as an effective and well-tolerated migraine preventative therapy for patients with chronic migraine who have failed many preventative therapies.

074 Early australian experience with erenumab for chronic migraine

Introduction

Erenumab is available in Australia since October 2018. We review the effectiveness and safety in 2 Australian headache centres.

Methods

Erenumab (70 mg or 140 mg) was prescribed. We monitored headache days, migraine days, analgesic use, adverse reactions, Headache Impact Test-6 (HIT6) score and Migraine Disability Assessment (MiDAS) score, at baseline and at 3 months. Primary outcomes were reduction in headache and migraine days, and adverse effects. Secondary outcomes were improvement in functional scores and analgesic use.

Results

65 patients (ages 18–73; mean 44 years) commencing Erenumab were assessed before and after 3 monthly treatments. The duration of chronic migraine (CM) ranged from 1 to 40 years, with 3 to 16 previous failed prophylactic treatments.

There was a >50% response in overall headache days and migraine days in 29% (19/65) and 46% (27/59), respectively. There was a modest (10–49%) response in overall headache days and migraine days in 29% (19/65) and 27% (18/59), respectively. There was no improvement in headache days and migraines in 42% (27/65) and 27% (14/59), respectively.

At onset, the mean HIT-6 and MiDAS scores were 66 and 65, decreasing after 3 treatments to 59 and 32, respectively. The mean monthly days taking triptan and codeine medications reduced from 9 and 6 days, to 5 and 3 days, respectively.

There were few reported side effects.

Conclusion

This Australian cohort in tertiary referral refractory migraine patients achieved a significant rate of reduced headache and migraine days with good safety and tolerability.

027 Will refractory patients respond to erenumab in the real world?

Introduction

Erenumab has been studied in Randomised Controlled Trials (RCT), with stricter exclusion criteria than real world populations.

Methods

65 patients from two Australian headache centres on Erenumab had primary outcomes of ≥ 50% response in monthly migraine days (MMD) and monthly headache days (MHD), compared to their demographics, frequency, duration of Chronic Migraine (CM), failed prophylactic medications, severity scores and medication overuse headache (MOH).

Results

35% (23/65) had daily headaches, with ≥ 50% MHD and MMD reduction in this subgroup of 17% (4/23) and 65% (13/20), respectively. Duration of CM was >10 years in 48% (29/61), with ≥ 50% MHD and MMD reduction in 28% (8/29) and 48% (13/27), respectively. 100% (64/64) had failed > 3 prophylactic medications with ≥50% MHD and MMD reduction in 30% (19/64) and 47% (27/58), respectively, with reducing rates of ≥ 50%MMD reduction if >5 (29%; 17/58) and >10 (22%;2/9). 95% had high severity scores (HIT-6 score >60), with a ≥ 50% MMD reduction in 43% (23/54). MOH occurred in 41% (24/58) for triptan and 29% (17/58) for codeine medications, with a ≥ 50% MMD reduction in 71% (17/24) and 41% (7/17), respectively (all groups p>0.05).

Conclusion

This real world cohort treated with Erenumab included patients that would be excluded from RCT analysis- including more chronic, frequent, severe and refractory migraine. Despite this, there were still ≥50% responders in more severe subgroups, particularly daily headache, high severity scores and triptan MOH. Measuring MMD may be more sensitive for assessing improvement than MHD.

061 Training in headache in australia, new zealand and asia

Introduction

Migraine is the leading cause of age-adjusted neurological disability in Australia, but little is known about headache training in our region. We aimed to assess the quantity of teaching in headache subjects during undergraduate and postgraduate years.

Method

This is a cross-sectional survey study where questionnaires were sent to 137 delegates from Australia, New Zealand and Asia, prior to the Headache Master School in Sydney in August 2018. The Main outcome measured are recalled number of hours of teaching in undergraduate year and postgraduate years in: 1) Migraine; 2) Trigeminal autonomic cephalalgias (TACs); 3) Asthma; 4) Myasthenia gravis (MG).

Results

The questionnaire response rate was 73% (100 of 137), of which 29 delegates were within 10 years of completing their undergraduate degree and 98 were neurologists. In undergraduate training, there was much greater quantity of teaching in asthma than migraine (Z=5.007, p<0.000) despite both being high-prevalent (asthma 11%, migraine 15–20%) conditions. Similarly, for diseases of medium-to-low prevalence, there was less training in TACs (1/1000), compared to MG (1.2/10,000) (Z=6.196, p<0.000). These major differences in training were also seen in postgraduate years even though overall headache teaching was greater in postgraduate than undergraduate training (p<0.000).

Conclusions

Despite the high prevalence and morbidity of headache disorders, they receive less attention in training than conditions with similar prevalence. We propose that headache training opportunities should be improved in our region, particularly in the undergraduate course and preceptorships or fellowships in postgraduate years.

122 ‘My migraine voice: burden of migraine and it’s management in an australian cohort’

Introduction

Migraine is the greatest cause of disability under the age of 50. It impairs ability to function, work and maintain relationships. This survey aimed to assess the impact of migraine and its management.

Methods

A questionnaire was sent to patients >18 years old who had taken at least one preventive treatment for migraine in the past. We report here the Australian results.

Results

68% were women, mean age 41 years. 53% were in paid employment whilst 13% received a disability allowance due to migraine. All patients (n=320) in the Australian survey had ≥ 4 migraine days each month. 90% had taken at least one preventive (274), with 80% (194) needing to change the preventive treatments previously. Common comorbidities were depression (41%), anxiety (40%), chronic pain (29%), sleep disorder (25%) and overweight (24%).

Diagnosis rate on initial GP visit was 57%, with 26% receiving a diagnosis in <1 month and 55% by 6 months.

There was greater retention of use (60%) and satisfaction (60%) with acute therapies, compared with use (43%) and satisfaction (53%) with preventives. Dissatisfaction with preventives included lack of efficacy (54%) and too many side effects (36%). Most (>60%) patients reported fear of the next attack, feeling hopeless and difficulty thinking clearly during attacks. Employers were often (69%) aware of the migraines, but only 24% offered any support. Migraine had negative impacts on relationships.

Conclusion

The Migraine Voice Survey highlights the true burden of migraine in Australia and limitations of current management options.

077 Recurrent guillain-barre syndrome

Introduction

Recurrent Guillain-Barre syndrome (GBS) is very rare. It occurs in 2% to 5% of GBS patients. It is unclear as to why some patients have a recurrence and whether this occurs more frequently in a distinct group of patients. We report a case of a 75 year old man who had five discreet attacks of GBS in 30 years. He had an excellent response to intravenous immunoglobulin (IVIG) and achieved full clinical recovery after each attack.

Case

A 75 year old man presented to the hospital with progressive ascending pattern of numbness and weakness in upper and lower limbs. This was in the setting of 10 days history of upper respiratory tract infective (URTI) symptoms. Neurological examination revealed distal sensory loss and distal weakness in upper and lower limbs. Deep tendon reflexes were absent. Nerve conduction studies showed features in keeping with GBS. He was treated with 5 days of intravenous immunoglobulin (IVIG) with significant improvement. Interestingly, this was on the background of having had 4 previous attacks of GBS in 1986 (preceded by acute gout), 1997 (preceded by the flu), 2010 (preceded by small bowel obstruction) and 2016 (preceded by viral gastroenteritis). He responded to IVIG each time and returned to his premorbid level function promptly after each attack.

Conclusion

Recurrent GBS is rare. It is important for clinician to be able to distinguish between recurrent GBS, treatment related fluctuations (GBS-TRF) and chronic inflammatory demyelinating polyneuropathy as the treatment and outcomes are different for each of these conditions.

References

. Kuitwaard K, Van Koningsveld R, Ruts L, Jacobs B, Van Doorn P. Recurrent Guillain Barre Syndrome. J Neurol Neurosurg Psychiatry2009;80:56–59.

. Pyun SY, Jeong JH, Bae JS. Recurrent Guillain-Barré syndrome presenting stereotypic manifestations, positive antiganglioside antibodies, and rapid recovery. Clin Neurol Neurosurg2015Dec;139:230–3.

. Mossberg N, Nordin M, Movitz C, Nilsson S, Hellstrand K, Bergström T, Andersson B, Andersen O. The recurrent Guillain-Barré syndrome: A long-term population-based study. Acta Neurol Scand2012Sep;126(3):154–61.

A study into the effectiveness of a postural care training programme aimed at improving knowledge, understanding and confidence in parents and school staff

BACKGROUND

Parents and school staff lack knowledge and confidence when providing postural care to physically disabled children. This can act as a barrier to the successful implementation of therapy. To address this problem, we developed a novel training programme to improve knowledge and confidence in providing postural care and evaluate the impact of the training programme in parents and school staff.

METHODS

The postural care training programme included three elements: a 2-h interactive workshop facilitated by physiotherapists and occupational therapists, a follow-up home/school visit and a follow-up telephone call. The Understanding, Knowledge and Confidence in Providing Postural Care for Children with Disabilities questionnaire was utilized to evaluate the impact and includes subscales assessing knowledge and understanding, concerns and confidence in providing postural care. The Understanding, Knowledge and Confidence in Providing Postural Care for Children with Disabilities questionnaire was completed at baseline and 6 weeks later. The training programme was delivered to N = 75 parents and school staff. Of these, N = 65 completed both baseline and follow-up measures and were used in the data analysis. Participants and therapists were also invited to provide further feedback on the overall training programme via interviews and focus groups.

RESULTS

Paired samples t-tests were used to determine statistically significant differences between baseline and follow-up scores for each of the three subscales. Mean levels of understanding and knowledge and confidence improved (P < 0.001), while concerns decreased (P < 0.001). Qualitative data were collected via interviews and group discussions providing an in-depth perspective on how participants experienced change.

DISCUSSION

Results suggest improvement in knowledge, understanding and confidence in parents and school staff that care for children with significant physical postural care impairments.

Development of a reliable, valid measure to assess parents' and teachers' understanding of postural care for children with physical disabilities: the (UKC PostCarD) questionnaire

BACKGROUND

Previous research has highlighted lack of knowledge, understanding and confidence among parents and teachers responsible for the postural care of children with physical disability. Interventions designed to improve these qualities require a reliable and validated tool to assess pre- and post-intervention levels. Currently, however, no validated measure of postural care confidence (i.e. self-efficacy) exists. Hence, the aim of this research was to develop a reliable and valid questionnaire to assess parents' and teachers' confidence, alongside knowledge and understanding of postural care - the Understanding Knowledge and Confidence in providing POSTural CARe for children with Disabilities (UKC PostCarD) questionnaire.

METHODS

Items were developed by a multidisciplinary team and designed to map onto the content of 'An A-to-Z of Postural Care'. Parents, teachers and therapists assessed items for face validity. Scale reliability was then assessed using Cronbach's alpha and known-group validity was assessed by comparing scores of an 'expert' group (physiotherapists and occupational therapists) with those of a 'non-expert' group (with no formal training in postural care).

RESULTS

The total scale and all three subscales (understanding and knowledge, confidence and concerns) demonstrated adequate reliability (α > 0.83) and subscale correlations formed a logical pattern (understanding and knowledge correlated positively with confidence and negatively with concerns). Experts' (n = 111) scores were higher than non-experts' (n = 79) for the total scale and all subscales (P < 0.001).

CONCLUSION

Findings support the reliability and validity of the UKC PostCarD questionnaire as a measure of understanding, knowledge and confidence in providing postural care for children with disabilities.

A pilot study of proximal strength training in Charcot-Marie-Tooth disease

Gait analysis of people with Charcot-Marie-Tooth (CMT) disease revealed proximal adaptive gait strategies to compensate for foot drop. We previously demonstrated that hip flexor muscle fatigue can limit walking endurance. This pilot study used a single-blinded cross over design to investigate the effect of a 16-week home-based programme of resistance training on hip flexor muscle strength. Measures of walking endurance, gait speed, exertion, fatigue, and general activity were also recorded. The exercise protocol was based on American College of Sports Medicine recommendations. A mixed effects model was used for analysis. Twenty-six people finished the study, with average reported exercise participation of 93%. No negative effects of exercise were observed. Significant increase in hip flexor muscle strength was observed on the left, but not the right. No changes were observed in walking speed and endurance measures. This pilot study of home-based resistance training showed a modest improvement in hip strength but only on one side. The lack of a more significant improvement and no improvement in walking measures suggests that this training protocol may not be optimal for people with CMT and that patients may need to stratified differently for training studies in CMT.

Do labetalol and methyldopa have different effects on pregnancy outcome? Analysis of data from the Control of Hypertension In Pregnancy Study (CHIPS) trial

OBJECTIVE

To compare pregnancy outcomes, accounting for allocated group, between methyldopa-treated and labetalol-treated women in the CHIPS Trial (ISRCTN 71416914) of 'less tight' versus 'tight' control of pregnancy hypertension.

DESIGN

Secondary analysis of CHIPS Trial cohort.

SETTING

International randomised controlled trial (94 sites, 15 countries).

POPULATION OR SAMPLE

Of 987 CHIPS recruits, 481/566 (85.0%) women treated with antihypertensive therapy at randomisation. Of 981 (99.4%) women followed to delivery, 656/745 (88.1%) treated postrandomisation.

METHODS

Logistic regression to compare outcomes among women who took methyldopa or labetalol, adjusted for the influence of baseline factors.

MAIN OUTCOME MEASURES

CHIPS primary (perinatal loss or high level neonatal care for >48 hours) and secondary (serious maternal complications) outcomes, birthweight <10th centile, severe maternal hypertension, pre-eclampsia and delivery at <34 or <37 weeks.

RESULTS

Methyldopa and labetalol were used commonly at randomisation (243/987, 24.6% and 238/987, 24.6%, respectively) and post-randomisation (224/981, 22.8% and 433/981, 44.1%, respectively). Following adjusted analyses, methyldopa (versus labetalol) at randomisation was associated with fewer babies with birthweight <10th centile [adjusted odds ratio (aOR) 0.48; 95% CI 0.20-0.87]. Methyldopa (versus labetalol) postrandomisation was associated with fewer CHIPS primary outcomes (aOR 0.64; 95% CI 0.40-1.00), birthweight <10th centile (aOR 0.54; 95% CI 0.32-0.92), severe hypertension (aOR 0.51; 95% CI 0.31-0.83), pre-eclampsia (aOR 0.55; 95% CI 0.36-0.85), and delivery at <34 weeks (aOR 0.53; 95% CI 0.29-0.96) or <37 weeks (aOR 0.55; 95% CI 0.35-0.85).

CONCLUSION

These nonrandomised comparisons are subject to residual confounding, but women treated with methyldopa (versus labetalol), particularly those with pre-existing hypertension, may have had better outcomes.

TWEETABLE ABSTRACT

There was no evidence that women treated with methyldopa versus labetalol had worse outcomes.

Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials

OBJECTIVES

To critically evaluate any benefit or harm for the mother and her baby of Valsalva pushing versus spontaneous pushing in the second stage of labour.

SEARCH STRATEGY

Electronic databases from MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were systematically searched (last search May 2010). The reference lists of retrieved studies were searched by hand and an internet hand search of master theses and dissertations was performed. No date or language restriction was used.

SELECTION CRITERIA

Randomised controlled trials that compared instructed pushing with spontaneous pushing in the second stage of labour were considered. Studies were evaluated independently for methodological quality and appropriateness for inclusion by two authors (MP and JB).

DATA COLLECTION AND ANALYSIS

The primary outcome was instrumental/operative delivery. Other outcomes were length of labour, any perineal repair, bladder function, maternal satisfaction. Infant outcomes included low Apgar score < 7 after 5 minutes, umbilical arterial pH <7.2, admission to neonatal intensive care unit and serious neonatal morbidity or perinatal death.

MAIN RESULTS

Three randomised controlled studies covering 425 primiparous women met the inclusion criteria. Women who used epidural analgesia were excluded in all three studies. No statistical difference was identified in the number of instrumental/operative deliveries (three studies; 425 women; relative risk 0.70; 95% CI 0.34-1.43), perineal repair, postpartum haemorrhage. Length of labour was significantly shorter in women who used the Valsalva pushing technique (three studies; 425 women; mean difference 18.59 minutes; 95% CI 0.46-36.73 minutes). Neonatal outcomes did not differ significantly. Urodynamic factors measured 3 months postpartum were negatively affected by Valsalva pushing. Measures of first urge to void and bladder capacity were decreased (one study; 128 women; mean difference respectively 41.50 ml, 95% CI 8.40-74.60, and 54.60 ml, 95% CI 13.31-95.89).

AUTHORS' CONCLUSION

The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour. The Valsalva pushing method has a negative effect on urodynamic factors according to one study. The duration of the second stage of labour is shorter with Valsalva pushing but the clinical significance of this finding is uncertain. The primary studies are sparse, diverse and some flawed. Further research seems warranted. In the mean time supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.

Extra-amniotic prostaglandin for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of extra-amniotic prostaglandin for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Date of last search: December 2000.

SELECTION CRITERIA

(1) clinical trials comparing extra-amniotic prostaglandin used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This has involved a two-stage method of data extraction. The initial data were extracted centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology.

MAIN RESULTS

Oxytocin was used to initiate or augment labour significantly less frequently with extra-amniotic prostaglandins when compared to placebo (relative risk 0.50, 95% confidence interval 0.38-0.66). No other findings were significant in the comparisons that were made for this review including when extra-amniotic prostaglandins were compared with other methods of cervical ripening or induction of labour. Although this could suggest that extra-amniotic prostaglandins are as effective as other agents, the findings are difficult to interpret because they are based on very small numbers and may lack the power to show a real difference.

REVIEWER'S CONCLUSIONS

The studies in this review are limited by their small sample sizes which are in many cases further divided into multiple comparison groups. The analyses resulted in most comparisons showing no significant differences, with wide confidence intervals. Although extra-amniotic prostaglandins may be as effective as other modalities in initiating labour, there is little conclusive information from this review to guide clinical practice. An adequately powered randomised controlled trial would be useful to determine if the use of extra-amniotic prostaglandins would lower the rate of caesarean section. However, in the time since these studies were undertaken the use of extra-amniotic prostaglandins has largely been replaced by other modes of prostaglandin administration.

Functional differences between keratins of stratified and simple epithelia

Dividing populations of stratified and simple epithelial tissues express keratins 5 and 14, and keratins 8 and 18, respectively. It has been suggested that these keratins form a mechanical framework important to cellular integrity, since their absence gives rise to a blistering skin disorder in neonatal epidermis, and hemorrhaging within the embryonic liver. An unresolved fundamental issue is whether different keratins perform unique functions in epithelia. We now address this question using transgenic technology to express a K16-14 hybrid epidermal keratin transgene and a K18 simple epithelial keratin transgene in the epidermis of mice null for K14. Under conditions where the hybrid epidermal keratin restored a wild-type phenotype to newborn epidermis, K18 partially but not fully rescued. The explanation does not appear to reside in an inability of K18 to form 10-nm filaments with K5, which it does in vitro and in vivo. Rather, it appears that the keratin network formed between K5 and K18 is deficient in withstanding mechanical stress, leading to perturbations in the keratin network in regions of the skin that are subjected either to natural or to mechanically induced trauma. Taken together, these findings suggest that the loss of a type I epidermal keratin cannot be fully compensated by its counterpart of simple epithelial cells, and that in vivo, all keratins are not equivalent.

The genetic basis of epidermolysis bullosa simplex with mottled pigmentation

Epidermolysis bullosa simplex (EBS) is a group of autosomal dominant skin diseases characterized by blistering, due to mechanical stress-induced degeneration of basal epidermal cells. It is now well-established that the three major subtypes of EBS are genetic disorders of the basal epidermal keratins, keratin 5 (K5) and keratin 14 (K14). Here we show that a rare subtype, referred to as EBS with mottled pigmentation (MP), is also a disorder of these keratins. Affected members of two seemingly unrelated families with EBS-MP had a C to T point mutation in the second base position of codon 24 of one of two K5 alleles, leading to a Pro: Leu mutation. This mutation was not present in unaffected members nor in 100 alleles from normal individuals. Linkage analyses mapped the defect to this type II keratin gene (peak logarithm of odds score at phi = 0 of 3.9), which is located on chromosome 12q11-q13. This provides strong evidence that this mutation is responsible for the EBS-MP phenotype. Only conserved between K5 and K6, and not among any of the other type II keratins, Pro-24 is in the nonhelical head domain of K5, and only mildly perturbs the length of 10-nm keratin filaments assembled in vitro. However, this part of the K5 head domain is likely to protrude on the filament surface, perhaps leading to additional aberrations in intermediate filament architecture and/or in melanosome distribution that are seen ultrastructurally in patients with the mutation.

The basal keratin network of stratified squamous epithelia: defining K15 function in the absence of K14

Keratin 5 and keratin 14 have been touted as the hallmarks of the basal keratin networks of all stratified squamous epithelia. Absence of K14 gives rise to epidermolysis bullosa simplex, a human blistering skin disorder involving cytolysis in the basal layer of epidermis. To address the puzzling question of why this disease is primarily manifested in skin rather than other stratified squamous epithelia, we ablated the K14 gene in mice and examined various tissues expressing this gene. We show that a key factor is the presence of another keratin, K15, which was hitherto unappreciated as a basal cell component. We show that the levels of K15 relative to K14 vary dramatically among stratified squamous epithelial tissues, and with neonatal development. In the absence of K14, K15 makes a bona fide, but ultrastructurally distinct, keratin filament network with K5. In the epidermis of neonatal mutant mice, K15 levels are low and do not compensate for the loss of K14. In contrast, the esophagus is unaffected in the neonatal mutant mice, but does appear to be fragile in the adult. Parallel to this phenomenon is that esophageal K14 is expressed at extremely low levels in the neonate, but rises in postnatal development. Finally, despite previous conclusions that the formation of suprabasal keratin filaments might depend upon K5/K14, we find that a wide variety of suprabasal networks composed of different keratins can form in the absence of K14 in the basal layer.

Genetic and clinical mosaicism in a type of epidermal nevus

BACKGROUND

Many skin disorders are characterized by a mosaic pattern, often with alternating stripes of affected and unaffected skin that follow the lines of Blaschko. These nonrandom patterns may be caused by a postzygotic mutation during embryogenesis. We studied the genetic basis of one such disorder, epidermal nevus of the epidermolytic hyperkeratotic type. Epidermolytic hyperkeratosis is an autosomal dominant blistering skin disease arising from mutations in the genes for keratin (K) 1 and 10. The offspring of patients with epidermal nevi may have generalized epidermolytic hyperkeratosis.

METHODS

We studied the K1 and K10 genes in blood and in the keratinocytes and fibroblasts of lesional and nonlesional skin from three patients with epidermal nevi and four of their offspring with epidermolytic hyperkeratosis.

RESULTS

In the patients with epidermal nevi, point mutations in 50 percent of the K10 alleles of epidermal cells were found in keratinocytes from lesional skin; no mutations were detected in normal skin. This mutation was absent or underrepresented in blood and skin fibroblasts. In the offspring with epidermolytic hyperkeratosis, the same mutations as those in the parents were found in 50 percent of the K10 alleles from all cell types examined.

CONCLUSIONS

Epidermal nevus of the epidermolytic hyperkeratotic type is a mosaic genetic disorder of suprabasal keratin. The correlation of mutations in the K10 gene with lesional skin and the correlation of the normal gene with normal skin provide evidence that genetic mosaicism can cause clinical mosaicism.

Making a connection: direct binding between keratin intermediate filaments and desmosomal proteins

In epidermal cells, keratin intermediate filaments connect with desmosomes to form extensive cadherin-mediated cytoskeletal architectures. Desmoplakin (DPI), a desmosomal component lacking a transmembrane domain, has been implicated in this interaction, although most studies have been conducted with cells that contain few or no desmosomes, and efforts to demonstrate direct interactions between desmoplakin and intermediate filaments have not been successful. In this report, we explore the biochemical nature of the connections between keratin filaments and desmosomes in epidermal keratinocytes. We show that the carboxy terminal "tail" of DPI associates directly with the amino terminal "head" of type II epidermal keratins, including K1, K2, K5, and K6. We have engineered and purified recombinant K5 head and DPI tail, and we demonstrate direct interaction in vitro by solution-binding assays and by ligand blot assays. This marked association is not seen with simple epithelial type II keratins, vimentin, or with type I keratins, providing a possible explanation for the greater stability of the epidermal keratin filament architecture over that of other cell types. We have identified an 18-amino acid residue stretch in the K5 head that is conserved only among type II epidermal keratins and that appears to play some role in DPI tail binding. This finding might have important implications for understanding a recent point mutation found within this binding site in a family with a blistering skin disorder.

Genetic bases of epidermolysis bullosa simplex and epidermolytic hyperkeratosis

Keratins are the major structural proteins of the epidermis. Analyzing keratin gene sequences, appreciating the switch in keratin gene expression that takes place as epidermal cells commit to terminally differentiate, and elucidating how keratins assemble into 10-nm filaments have provided the foundation that has led to the discoveries of the genetic bases of two major classes of human skin diseases. In this report, we review the cell biology and human genetics of these diseases, epidermolysis bullosa simplex and epidermolytic hyperkeratosis. Both of these diseases are epidermal disorders of keratin, typified by cell fragility as a consequence of defects in the mechanical strength of basal epidermolysis bullosa simplex or suprabasal epidermolytic hyperkeratosis cells.

Disease severity correlates with position of keratin point mutations in patients with epidermolysis bullosa simplex

Keratins are the major structural proteins of the epidermis. Recently, it was discovered that point mutations in the epidermal keratins can lead to the blistering skin diseases epidermolysis bullosa simplex (EBS) and epidermolytic hyperkeratosis (EH), involving epidermal cell fragility and rupture upon mechanical stress. In this study, we demonstrate a correlation between disease severity, location of point mutations within the keratin polypeptides, and degree to which these mutations perturb keratin filament structure. Interestingly, of the 11 EBS or EH mutations thus far identified, 6 affect a single highly evolutionarily conserved arginine residue, which, when mutated, markedly perturbs keratin filament structure and keratin network formation. This site also appears to be a hot spot for mutation by CpG methylation and deamination. In the four epidermal keratins, there are several other CpG dinucleotides that exist at codons within the highly conserved ends of the keratin rod. To elucidate why mutations at these sites have not been detected in severe cases of EBS, we engineered 7 of these C-->T transitions in K14 and tested their ability to perturb keratin network formation and keratin filament assembly in vitro. The effects of these mutants on keratin filament network formation were significantly less severe than the EBS/EH arginine mutation, suggesting that the high incidence of mutations of the residue in EBS and EH patients is a result of both a special sensitivity of filament structure to perturbations in this residue and its susceptibility to mutagenesis.

Applying the new concepts of the Neuman Systems Model

The latest version of the Neuman Systems Model contains new terminology--"spiritual variable" and "created environment"--and an emphasis on the concepts of primary prevention and wellness. A case study of a client who has tested positive for HIV explores the new terms and demonstrates the expanded concepts of primary prevention and wellness. Nurses can utilize this framework and the concept of wellness with terminally ill or healthy individuals. Nursing frameworks can be practical and useful to nurses and not just words in a theory book.