Occurrence of postdural puncture headache-A randomized controlled trial comparing 22G Sprotte and Quincke

OBJECTIVE

To assess the incidence of postdural puncture headache (PDPH) using 22-gauge atraumatic needle (Sprotte, 22GS) compared with 22-gauge traumatic needle (Quincke, 22GQ).

BACKGROUND

Diagnostic lumbar puncture (dLP) is commonly complicated by PDPH. Despite evidence to support the use of 22GS, European neurologists seem to keep using 22GQ.

METHODS

This was a randomized, double-blind study. Adults (age: 18-60 years) scheduled for dLP were included. dLP and CSF acquisition were performed in accordance with highly standardized procedures. Patients were followed up on days 2 and 7.

RESULTS

In total, 172 patients were randomized and lumbar punctured, and 21 were excluded due to wrong inclusion (n = 11), needle switch (n = 7), failed dLP (n = 1), withdrawal (n = 1), and missed follow-up (n = 1). Among the remaining 151 patients (mean age: 40.7 ± 12.4 years), 77 had dLP using 22GQ and 74 using 22GS. Incidence of PDPH among patients punctured with 22GS (18%) was significantly lower (p = .004) than among patients punctured with 22GQ (39%). Relative risk was 0.45, 95% CI 0.26-0.80. Patients with PDPH had significantly lower weight (p = .035), and there was no significant difference related to age (p = .064), sex (p = .239), height (p = .857), premorbid episodic migraine (p = .829), opening pressure (p = .117), operators (p = .148), amount of CSF removed (p = .205), or number of attempts (p = .623).

CONCLUSIONS

The use of 22GS halves the risk of PDPH compared with 22GQ. This study provides strong support to make a change in practice where traumatic needles are still in regular use.

Posterior reversible encephalopathy syndrome, a clinically diverse and challenging disorder

The characterizing features of Posterior reversible encephalopathy syndrome (PRES) are broad and diverse, making early recognition and diagnosis challenging tasks. To illustrate the heterogeneous nature of PRES, we present three cases and discuss their clinical and radiological presentation.

Group-Based Individualized Comprehensive Core Stability Intervention Improves Balance in Persons With Multiple Sclerosis: A Randomized Controlled Trial

BACKGROUND

Balance and trunk control are often impaired in individuals with multiple sclerosis (MS). Interventions addressing these issues are needed.

OBJECTIVE

The objective of this study was to compare the immediate and long-term effects of a 6-week individualized, group-based, comprehensive core stability intervention (GroupCoreDIST) with standard care on balance and trunk control in individuals with MS.

DESIGN

This study was a prospective, assessor-masked, randomized controlled trial.

SETTING

The GroupCoreDIST intervention was conducted by 6 physical therapists in 6 municipalities in Norway. Standard care included the usual care for individuals with MS in the same municipalities. Assessments at all time points took place at a Norwegian hospital.

PARTICIPANTS

Eighty people with Expanded Disability Status scores of 1 to 6.5 participated in this trial.

INTERVENTION

Randomized, concealed allocation was used to assign the participants to the GroupCoreDIST intervention (n = 40) or to standard care (n = 40). The GroupCoreDIST intervention was conducted with groups of 3 participants (1 group had 4 participants), for 60 minutes 3 times per week.

MEASUREMENTS

Assessments were undertaken at baseline and at weeks 7, 18, and 30. Outcomes were measured with the Trunk Impairment Scale-Norwegian Version, Mini Balance Evaluation Systems Test, and Patient Global Impression of Change-Balance. Repeated-measures mixed models were used for statistical analysis.

RESULTS

One individual missed all postintervention tests, leaving 79 participants in the intention-to-treat analysis. GroupCoreDIST produced significant between-group effects on the mean difference in the following scores at 7, 18, and 30 weeks: for Trunk Impairment Scale-Norwegian Version, 2.63 points (95% confidence interval [CI] = 1.89-3.38), 1.57 points (95% CI = 0.81-2.33), and 0.95 point (95% CI = 0.19-1.71), respectively; for Mini Balance Evaluation Systems Test, 1.91 points (95% CI = 1.07-2.76), 1.28 points (95% CI = 0.42-2.15), and 0.91 points (95% CI = 0.04-1.77), respectively; and for Patient Global Impression of Change-Balance, 1.21 points (95% CI = 1.66-0.77), 1.02 points (95% CI = 1.48-0.57), and 0.91 points (95% CI = 1.36-0.46), respectively.

LIMITATIONS

Groups were not matched for volume of physical therapy.

CONCLUSIONS

Six weeks of GroupCoreDIST improved balance and trunk control in the short and long terms compared with standard care in individuals who were ambulant and had MS. The intervention is an effective contribution to physical therapy for this population.

A man in his 50s with neurological symptoms during cancer treatment

Posterior reversible encephalopathy syndrome (PRES) is a rare clinicoradiographic disorder characterized by acute neurological symptoms with typical neuroimaging findings of vasogenic edema in posterior regions of the brain. This complication is linked to a number of medical conditions, and is increasingly being documented as a side effect associated with a number of therapeutic agents. We present a case of PRES as a result of treatment with the vascular endothelial growth factor (VEGF) multikinase inhibitor, regorafenib. A man in his 50’s with known metastatic colorectal cancer presented with headache, vomiting, altered mental state, reduced hand coordination and dexterity, and a homonymous inferior quadrantanopia. Symptoms developed soon after completion of the 3rd regorafenib therapy cycle. Cerebral MRI demonstrated signs indicative of PRES with bilateral vasogenic edema in the occipitotemporal regions. Regorafenib was subsequently discontinued and the patient’s condition improved gradually, with normalization of his neurological symptoms within a month. Albeit rare, PRES has been linked to VEGF treatments, particularly sorafenib, sunitinib and pazopanib, however this is the second reported case linking regorafenib with PRES. PRES is usually associated with good prognosis. However, delayed diagnosis and treatment may lead to permanent neurological symptoms, higher morbidity and in rare cases mortality. Therefore increased awareness of this condition is vital.

Preparation, characterization and antiproliferative activity of thymoquinone-beta-cyclodextrin self assembling nanoparticles

Thymoquinone (TQ) was complexed with beta-cyclodextrin (CD) to form nanosized aggregates. Various TQ:CD ratios were tested and it was found that the ratio of (1:0.25) TQ:CD formed distinguishable nanoparticles with minimum toxicity towards normal cells. These nanoparticles had an average size of 445 +/- 100 nm with a charge 21.8 mV using Zeta-sizer. Particle size measurement using scanning electron microscopy (SEM) showed an average size of 400 nm and it also revealed the presence of smaller structures, with an average size of 50 nm. The in vitro antiproliferative activity on MCF7 cells was determined using MTT assay and an IC50 of 4.70 +/- 0.60 microM for TQ-CD nanoparticles in comparison to 24.09 +/- 2.35 microM of free TQ solution after 72 h of incubation. Simultaneously, TQ-CD nanoparticles showed lesser toxicity than TQ solution using human periodontal fibroblasts as a model for normal cells. It could be concluded from the results that TQ loaded cyclodextrin nanoparticles might serve as a potential nanocarrier to improve TQ solubility as well as its antiproliferative activity with little toxicity to normal tissues.

Post-lumbar puncture headache

BACKGROUND

Headache is a complication of lumbar puncture that has been known for more than a hundred years. The aim of this paper is to provide an overview of the incidence and symptoms of, the risk factors for and the treatment of this type of headache.

METHOD

The article is based on a literature search in PubMed for studies on headache after lumbar puncture followed by discretionary selection of publications.

RESULTS

Post-dural puncture headache (PDPH) is characterised by the occurrence of a headache with a significant orthostatic component within 5 days of a lumbar puncture. The incidence depends on a number of factors. Younger women with a previous history of headaches appear to be at highest risk. The incidence can be significantly reduced by using a thin lumbar puncture needle with an atraumatic tip. The condition is self-limiting and harmless, but leads to significant morbidity. Caffeine alleviates the symptoms and reduces the course of the illness. When bed rest and caffeine prove ineffective, an epidural blood patch works well for the majority, but there is no consensus on when such treatment should be offered.

INTERPRETATION

Headache frequently occurs after lumbar puncture. There is substantial evidence for recommending the use of a thin, atraumatic needle to reduce the incidence. For practical reasons, a needle thinner than 22 G is not suitable for diagnostic lumbar puncture.

Expression mapping of tetracycline-responsive prion protein promoter: digital atlasing for generating cell-specific disease models

We present a digital atlas system that allows mapping of molecular expression patterns at cellular resolution through large series of histological sections. Using this system, we have mapped the distribution of a distinct marker, encoded by the LacZ reporter gene driven by the tetracycline-responsive prion protein promoter in double transgenic mice. The purpose is to evaluate the suitability of this promoter mouse line for targeting genes of interest to specific brain regions, essential for construction of inducible transgenic disease models. Following processing to visualize the promoter expression, sections were counterstained to simultaneously display cytoarchitectonics. High-resolution mosaic images covering entire coronal sections were collected through the mouse brain at intervals of 200 microm. A web-based application provides access to a customized virtual microscopy tool for viewing and navigation within and across the section images. For each section image, the nearest section in a standard atlas is defined, and annotations of key structures and regions inserted. Putative categorization of labeled cells was performed with use of distribution patterns, followed by cell size and shape, as parameters that were compared to legacy data. Among the ensuing results were expression of this promoter in putative glial cells in the cerebellum (and not in Purkinje cells), in putative glial cells in the substantia nigra, in pallidal glial cells or interneurons, and in distinct cell layers and regions of the hippocampus. The study serves as a precursor for a database resource allowing evaluation of the suitability of different promoter mouse lines for generating disease models.

Pontine maps linking somatosensory and cerebellar cortices are in register with climbing fiber somatotopy

The cerebropontocerebellar mossy fiber system is a major CNS sensorimotor pathway. We used a double-retrograde axonal tracing technique (red and green beads) to chart in rats the pontocerebellar projection to different electrophysiologically defined climbing fiber zones in the posterior lobe (face-receiving A2 zone and forelimb- and hindlimb-receiving parts of the C1 zone in the paramedian lobule and copula pyramidis, respectively). Individual cortical injection sites were verified as located in a given zone by mapping the pattern of cell labeling in the inferior olive, whereas labeled cells in the pontine nuclei were mapped using computer-aided three-dimensional reconstruction techniques. A number of topographical differences were found for the pontine projection to the individual zones. Projections to the A2 zone were bilateral, whereas to both parts of the C1 zone, the inputs were mainly contralateral. Furthermore, the A2 (face), C1 (forelimb), and C1 (hindlimb) zone projections were centered in progressively more caudal parts of the pontine nuclei with little or no overlap between them. The areas occupied by cell labeling for each zone corresponded closely to territories in the pontine nuclei shown previously to receive projections from somatotopically equivalent regions of the somatosensory cortex. This precise cerebropontocerebellar topography, defined by climbing fiber somatotopy, is a new principle of organization for linking somatosensory and cerebellar cortices. The convergence of direct and indirect sensory projections is likely to have important implications for cerebellar cortical processing.

Database and tools for analysis of topographic organization and map transformations in major projection systems of the brain

Integration of dispersed and complicated information collected from the brain is needed to build new knowledge. But integration may be hampered by rigid presentation formats, diversity of data formats among laboratories, and lack of access to lower level data. We have addressed some of the fundamental issues related to this challenge at the level of anatomical data, by producing a coordinate based digital atlas and database application for a major projection system in the rat brain: the cerebro-ponto-cerebellar system. This application, Functional Anatomy of the Cerebro-Cerebellar System in rat (FACCS), is available via the Rodent Brain WorkBench (http://www.rbwb.org). The data included are x,y,z-coordinate lists describing exact distributions of tissue elements (axonal terminal fields of axons, or cell bodies) that are labeled with axonal tracing techniques. All data are translated to a common local coordinate system to facilitate across animal comparison. A search capability allows queries based on, e.g. location of tracer injection sites, tracer category, size of the injection sites, and contributing author. A graphic search tool allows the user to move a volume cursor inside a coordinate system to detect particular injection sites having connections to a specific tissue volume at chosen density levels. Tools for visualization and analysis of selected data are included, as well as an option to download individual data sets for further analysis. With this application, data and metadata from different experiments are mapped into the same information structure and made available for re-use and re-analysis in novel combinations. The application is prepared for future handling of data from other projection systems as well as other data categories.

Neurons with distinctive firing patterns, morphology and distribution in laminae V-VII of the neonatal rat lumbar spinal cord

It is generally accepted that neurons in the ventral spinal grey matter, a substantial proportion of which can be regarded as constituents of the spinal motor apparatus, receive and integrate synaptic inputs arising from various peripheral, spinal and supraspinal sources. Thus, a profound knowledge concerning the integrative properties of interneurons in the spinal ventral grey matter appears to be essential for a fair understanding of operational principles of spinal motor neural assemblies. Using the whole cell patch clamp configuration in a correlative physiological and morphological experimental approach, here we demonstrate that the intrinsic membrane properties of neurons vary widely in laminae V-VII of the ventral grey matter of the neonatal rat lumbar spinal cord. Based on their firing patterns in response to depolarizing current steps, we have classified the recorded neurons into four categories: 'phasic', 'repetitive', 'single' and 'slow'. Neurons with firing properties characteristic of the 'phasic', 'repetitive' and 'single' cells have previously been reported also in the superficial and deep spinal dorsal horn, but this is the first account in the literature in which 'slow' neurons have been recovered and described in the spinal cord. The physiological heterogeneity in conjunction with the morphological correlation and distribution of neurons argues that different components of motor neural assemblies in the spinal ventral grey matter possess different signal processing characteristics.

Heterogeneous synaptic inputs from the ventrolateral periaqueductal gray matter to neurons responding to somatosensory stimuli in the rostral ventromedial medulla of rats

The ventrolateral cell column of the midbrain periaqueductal gray matter (vl-PAG) plays a major role in the attenuation of pain behaviour. It is established that this effect is exerted via modulation of neuronal activities in the rostral ventromedial medulla (RVM). Until recently it has been generally accepted that the vl-PAG exerts its modulatory effects upon RVM neurons through a direct monosynaptic pathway. However, recent data suggest that an additional indirect, di- or polysynaptic pathway may also exist. Using in vivo intracellular recordings we tested this hypothesis, by studying synaptic responses of somatosensory receptive RVM neurons evoked by electric stimulation of the vl-PAG in rats. RVM neurons were regarded as somatosensory receptive if they responded to electrical stimulation of the sciatic nerve. Most of the recorded RVM cells were excited by vl-PAG stimulation. Some of them responded with a short onset latency (3.6+/-0.9 ms) corresponding to monosynaptic excitation. All of these neurons were also excited by sciatic nerve stimulation at nociceptive intensities. In contrast to this, another proportion of the recorded RVM neurons responded with a four times longer (14.8+/-3 ms) onset latency to the vl-PAG stimulation, corresponding to polysynaptic modulation. All of these neurons were inhibited by sciatic nerve stimulation. The findings show that RVM neurons receive heterogeneous monosynaptic and polysynaptic inputs from the vl-PAG. The results also suggest that the monosynaptic and polysynaptic pathways modulate the activity of functionally distinct groups of RVM neurons.

The projections of the midbrain periaqueductal grey to the pons and medulla oblongata in rats

It is now established that stimulation of the ventrolateral midbrain periaqueductal grey (PAG) evokes inhibition of nociceptive spinal neurons, which results in analgesia and a powerful attenuation of pain behaviour. It is postulated that the PAG exerts this inhibitory effect on spinal nociceptive functions through the activation of descending serotonergic and noradrenergic pathways that arise from the rostral ventromedial medulla (RVM) and pontine noradrenergic nuclei. To investigate the neuroanatomical substrate of this functional link between the PAG and RVM, as well as the pontine noradrenergic nuclei in the rat, we labelled axons that project from the ventrolateral PAG to various regions of the pons and medulla oblongata using the anterograde tracing substance, Phaseolus vulgaris leucoagglutinin. We demonstrated that some of PAG efferents really do terminate in the RVM and pontine noradrenergic nuclei, but a substantial proportion of them project to the intermediate subdivision of the pontobulbar reticular formation. Combining the axonal tracing with serotonin- and tyrosine-hydroxylase-immunohistochemistry, we also found that, in contrast to previous results, PAG efferents make relatively few appositions with serotonin- and tyrosine-hydroxylase-immunoreactive neurons in the RVM and pontine noradrenergic nuclei; most of them terminate in nonimmunoreactive territories. The results suggest that the ventrolateral PAG may activate a complex pontobulbar neuronal assembly including neurons in the intermediate subdivision of the pontobulbar reticular formation, serotonin- and tyrosine-hydroxylase-immunoreactive and nonimmunoreactive neurons in the RVM and pontine noradrenergic nuclei. This pontobulbar neural circuitry, then, may mediate the PAG-evoked activities towards the spinal dorsal horn resulting in the inhibition of spinal nociceptive functions.

[Pathogenesis and prognosis of pyoderma gangrenosum (dermatitis ulcerosa) (author's transl)]

The diagnosis of p. g. is based on clinical appearance. P. g. is frequently associated with systemic disease. This paper presents 23 cases of p. g. associated with other sufferings and a review of the Literature in which pathogenesis, prognosis, age and sex of this cutaneous disorder are standing in foreground for a discussion.

[Sweet syndrome in systemic diseases (authors transl)]

Two patients with Sweet syndrome, in one patient - a 78 years old women - a chronic myeloid leukemia was found in addition. In the other case, a 69 years old man suffered from rheumatism. In the infiltrate giant cells of the epitheloid type were found.

Pyoderma gangrenosum with Koebner effect and Mondor's disease in the same patient

Case description: a 34-year-old female with the constellation of bullous pyoderma gangrenosum, Mondor’s disease, Koebner phenomenon and pleuropneumonia. Steroid therapy was successful.