Cross-sectional, hospital-based analysis of headache types using ICHD-3 criteria in the Middle East, Asia, and Africa: the Head-MENAA study

BACKGROUND

Headaches are frequent neurological disorders that are yet to be unveiled and treated comprehensively worldwide. Bearing in mind that the distribution of headache subtypes in neurology clinics (NC) is essential for planning appropriate diagnostic and therapeutic approaches, the primary goals of this multi-centric study are to carry out inter-regional comparisons by using current diagnostic criteria with evaluations of neurologists to delineate headache burden.

METHODS

A cross-sectional study between April 1 and May 16, 2022 was conducted with the participation of 13 countries from the Middle East, Asia, and Africa. Patients were included in the study on a specific day each week during five consecutive weeks. All volunteers over the age of 18 and whose primary cause for admission was headache were examined. The patients admitted to NC or referred from emergency services/other services were evaluated by neurologists by means of the International Classification of Headache Disorders (ICHD-3) criteria.

RESULTS

Among the 13,794 patients encountered in NC, headache was the primary complaint in 30.04%. The headache patients' mean age was 42.85 ± 14.89 (18-95 years), and 74.3% were female. According to the ICHD-3 criteria, 86.7% of the main group had primary headache disorders, 33.5% had secondary headaches, 4% had painful cranial neuropathies along with other facial and headaches, and 5.2% had headaches included in the appendix part showing some overlapping conditions. While the most common primary headache was migraine without aura (36.8%), the most common secondary headache was medication-overuse headache (MOH) (9.8%). Headaches attributed to COVID-19, its secondary complications, or vaccines continue to occur at rates of 1.2%-3.5% in current neurology practice. Pain severity was significantly lower in Ivory Coast and Sudan than in Türkiye, Turkish Republic of Northern Cyprus, Iran, Egypt, Senegal, Tatarstan, and Azerbaijan (p < 0.001).

CONCLUSIONS

The study showed that migraine is still the most common motive for admissions to NC in different regions. Furthermore, MOH, an avoidable disorder, is the most common secondary headache type and appears to be a significant problem in all regions. Remarkably, pain perception differs between regions, and pain intensity is lower in Africa than in other regions.

Microvesicular steatosis: a missed item in the management of nonalcoholic fatty liver disease?

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is among the most common causes of chronic liver disease and cirrhosis. In NAFLD, histological course of steatosis is usually macrovesicular (MacroS), but it may be accompanied by varying degrees of microvesicular steatosis (MicroS). Thus, in this study, we aimed to evaluate the prevalence and significance of MicroS in subjects with NAFLD.

METHODS

A retrospective analysis of clinical and laboratory data of patients with histologically proven NAFLD was performed. The liver biopsy specimens which stained with hematoxylin eosin, reticulin, and Masson's Trichrome stains were evaluated by single expert liver pathologist. Scoring and semiquantitative assessment of steatosis and NAFLD severity was done according to Kleiner scale known as NAFLD activity score (NAS). Grading for steatosis, steatosis type, zonal distribution of steatosis and other histological findings were also determined.

RESULTS

The prevalence of MicroS among the study population (n= 191) was 30.4%. There was no difference regarding the demographic and biochemical parameters between patients with or without MicroS. On the other hand, the prevalence of ballooning injury and megamitochondria were higher in patients with MicroS (p= 0.019 and p= 0.036, respectively). There was a significant association of MicroS with ballooning injury (OR 2.65, 95% CI= 1.26-5.55 ; p= 0.005) and the presence of megamitochondria (OR 3.72, 95% CI= 1.00-13.72 ; p= 0.037).

CONCLUSION

MicroS is common in patients with NAFLD and is associated with early histological findings in this clinically relevant condition. Further longitudinal studies are needed to characterize the role of MicroS in the natural history of NAFLD.

Plasma pentraxin-3 is associated with endothelial dysfunction in non-alcoholic fatty liver disease

OBJECTIVE

Pentraxin-3 (PTX-3) is an acute-phase protein belonging to the PTX family. It has been reported that PTX-3 is significantly associated with obesity, metabolic syndrome, and cardiovascular diseases (CVD). Non-alcoholic fatty liver disease (NAFLD) is strongly associated with atherosclerosis and CVD. In this study, we aimed to investigate the relationship of PTX-3 with circulating markers of endothelial dysfunction and atherosclerosis in patients with NAFLD.

PATIENTS AND METHODS

Seventy patients with biopsy-proven NAFLD and seventy healthy controls were enrolled in the study. Plasma asymmetric dimethylarginine (ADMA), adiponectin, and PTX-3 levels were determined using enzyme-linked immunosorbent assay (ELISA). High-sensitivity C-reactive protein (hsCRP) serum levels were measured with the immunoturbidimetric assay. Insulin resistance was estimated using the HOMA-IR index.

RESULTS

PTX-3 and hsCRP levels were higher and adiponectin levels were lower in the NAFLD group compared to the healthy controls (p < 0.001 for all). In correlation analysis, a significant association was observed between PTX-3 and ADMA levels (r = 0.423, p < 0.001).

CONCLUSIONS

Our study demonstrated for the first time that increased circulating PTX-3 is strongly associated with endothelial dysfunction in subjects with NAFLD. However, large prospective studies are needed to establish the independent predictive value of PTX-3 for CVD endpoints in this clinically relevant condition.

Effects of varying mandibular protrusion and degrees of vertical opening on upper airway dimensions in apneic dentate subjects

INTRODUCTION

Despite numerous studies investigating the dimensional and therapeutic effects of mandibular advancement splints (MASs), data regarding the effects of differently designed individual and non-adjustable MASs on the upper airway in fully dentate apneic subjects in the sagittal plane including comparison of these effects with a placebo device are sparse. The present study aimed to determine the dimensional changes in the sagittal plane created by differently designed MASs in the upper airway in fully dentate apneic subjects and to compare these changes with the effects of a placebo device.

MATERIALS AND METHODS

Magnetic resonance (MR) images of 9 dentate apneic subjects with 5 differently designed MASs and without a MAS were obtained. We measured the area of the entire pharynx (velopharynx, oropharynx, hypopharynx) on these MR images and compared the dimensional changes.

RESULTS

The dimensional changes triggered by two specific MASs (75% of the maximum mandibular protrusion with 5 mm vertical opening, and 75% of the maximum mandibular protrusion with 10 mm of vertical opening) in the entire pharynx in the sagittal plane were statistically significant compared to the other MASs (p < 0.05). The MAS effecting 75% of the maximum mandibular protrusion and 10 mm of vertical opening created a significant dimensional increase only in the velopharyngeal area among the three pharyngeal sites (p ≤ 0.003).

CONCLUSION

While the degree of mandibular protrusion created by the MAS affects the dimensions of the upper airway, the degree of the vertical opening exerts no significant dimensional effect in the sagittal plane in fully dentate apneic patients. The mandibular protrusion effect is comparatively larger in the velopharyngeal region.

Use of the Berlin Questionnaire to screen at-risk patients for obstructive sleep apnea

OBJECTIVE

To investigate the value of the Berlin Questionnaire (BQ) for screening at-risk patients for obstructive sleep apnea (OSA).

MATERIALS AND METHODS

This study included 217 subjects who were referred to a Department of Otolaryngology, Head and Neck Surgery for evaluation of suspected OSA. The subjects were classified as being at high or low risk of OSA according to their BQ score. The apnea hypopnea index (AHI), body mass index (BMI), Epworth sleepiness score, and BQ results were compared in the two risk groups, and the correlation of BQ with AHI was analyzed. The predictive accuracy of risk grouping was assessed for AHI > 5 and AHI > 15.

RESULTS

The BQ identified 82.03% of the subjects as being at high risk of sleep apnea and 17.9% as being at low risk. Using a cut-off point of AHI > 5, the sensitivity was 83.4% and the specificity was 22.2%; the positive predictive value was 76.4% and the negative predictive value was 30.8%. Using a cut-off point of AHI > 15, the sensitivity was 89.3% and the specificity was 22.6%; the positive predictive value was 42.1% and the negative predictive value was 76.9%.

CONCLUSIONS

These findings indicate that BQ is a poor predictor of OSA in patients who are at high risk of OSA. The BQ does not appear to be an appropriate screening tool for determining the risk of sleep apnea in this population.

Alpha fetoprotein levels and its relationship with histopathological findings in patients with non-alcoholic fatty liver disease

BACKGROUND

Non alcoholic fatty liver disease (NAFLD) encompasses a wide spectrum of liver disorders ranging from simple steatosis (SS) to cirrhosis. In addition, increasing evidence indicates that hepatocellular carcinoma (HCC) may represent a late complication of NAFLD. Alpha-fetoprotein (AFP) serum levels can rise in adults with HCC.

AIM

In the present study, we aimed to investigate circulating AFP concentrations in subjects with histologically proven NAFLD. In addition, the relationship of AFP with liver histology was also searched.

PATIENTS AND METHODS

One hundred and three male NAFLD patients and 57 healthy male controls were enrolled in the study. In addition, patients with NAFLD grouped as nonalcoholic steatohepatitis (NASH) (n = 72) and SS (n = 31). AFP serum levels were measured in duplicate by the chemiluminescence's method.

RESULTS

Age and gender were similar in subjects with NAFLD and controls. AFP serum levels were not different between two groups. In subgroup analysis, AFP levels were also found to be similar in patients with NASH and SS. Moreover, no significant relationship was found between AFP and histopathological findings in patients with NAFLD.

CONCLUSIONS

The results of this preliminary study suggest that AFP is not involved in the pathogenesis of NAFLD.

Serum lipid hydroperoxide levels and paraoxonase activity in patients with lung, breast, and colorectal cancer

OBJECTIVES

The objectives of this article are to investigate the serum lipid hydroperoxide (LOOH) levels and paraoxonase-1 (PON1) and arylesterase (ARE) activity in patients with lung, breast, and colorectal cancer.

DESIGN AND METHODS

Serum PON1 and ARE activities and LOOH levels were measured in 110 patients with cancer and same number of age- and sex-matched controls.

RESULTS

Serum LOOH levels were found to be increased while serum PON1 and ARE activities were found to be decreased in patients compared to controls. PON1 activity was found to be lower in patients with breast cancer than in patients with lung and colorectal cancer. There were positive correlations between the serum PON1 and ARE activities in patients with colorectal cancer.

CONCLUSION

We concluded that decreased PON1 and ARE activities and increased LOOH levels might have a connection to carcinogenesis. PON1 activity is decreased in all patients but it does not seem to be related to metastase status except for colorectal cancer.

Membranous structures affecting the success of endoscopic third ventriculostomy in adult aqueductus sylvii stenosis

BACKGROUND

The purpose of the present study was to observe Liliequist's membrane (LM) and membranous structures located in the prepontine cistern via 3-Tesla magnetic resonance imaging (MRI) with 3D driven equilibrium radio frequency reset pulse (DRIVE) sequence and multiplanar reformat (MPR) images and to evaluate the success of endoscopic third ventriculostomy (ETV) by assessing these membranes in adult aqueduct stenosis.

PATIENTS

29 patients (17 female, 12 male) with primary aqueductus sylvii stenosis were included in the study. 19 patients were diagnosed as long-standing overt ventriculomegaly in adults (LOVA) and patients had severe ventriculomegaly, macrocephalus, and aqueduct stenosis on MR imaging. 10 patients were diagnosed as aqueduct stenosis presented with acute onset of hydrocephalus with symptoms of raised ICP. All patients in the study group were analyzed with conventional and cine MRI before and after treatment. We performed 3D DRIVE sequence and MPR at 3-T MR equipment to determine the membranous structures in 3 dimensions. We correlated the success of the procedure considering the preoperative, postoperative MRI and intraoperative images.

RESULTS

5 patients (26.3%) with LOVA and 2 patients (20%) with aqueduct stenosis, in total 7 patients (24.1%), did not respond to ETV. Cerebrospinal fluid (CSF) flow was blocked by membranous structures located in the prepontine cistern in 4 of 8 patients. In 2 patients, CSF through the stoma was blocked either by the LM or closed tuber cinerum. In 1 patient insufficient CSF flow was observed through the stoma and the LM accompanying prepontine membranes.Totally closed membranes were observed in the prepontine cistern in 5 patients (17.24%) according to the postoperative MRI. LM was verified in all patients intraoperatively that were also demonstrated in the preoperative MRI.

CONCLUSION

3D sequences with MPR may help to observe not only the LM but also other membranes located through the prepontine cistern, which may be the reason of failed ETV.

Hydatid cyst in abdominal incisional hernia

Recurrence of hydatid cyst is one of the important complications of primary hydatid surgery. Here we present a very rare case of recurrent hydatid cyst inside an incisional hernial sac. A 50-year old male operated on for hydatid disease of the liver twice in 1998 and 2001 was admitted to our hospital for an abdominal mass formed under the old median incisional scar. On physical examination, a painless mass of 15 cm in diameter, stretched, hard and well bordered was palpated. There was also a fascial defect inferior to the mass. A herniated hydatid cyst was imaged with both of ultrasonography (US) and abdominal computed tomography (CT). As a surgical treatment hydatid cyst was excised totally together with primary repair of the fascial defect. The patient received preoperative Albendazole therapy, administered at a dose of 10 mg/kg body weight per day from 3 weeks before surgery to 6 months postoperatively. He had no problems in the 1-year follow up (Fig. 2, Ref. 19).

Minimally invasive focused parathyroidectomy without using intraoperative parathyroid hormone monitoring or gamma probe

BACKGROUND

Minimally invasive parathyroidectomy (MIP) is widely used worldwide for the treatment of primary hyperparathyroidism (pHPT). It is usually combined with a perioperative adjunct for high success rate.

AIM

To demonstrate that MIP can be successfully performed in a selected group of patients with presumabally solitary adenoma as the cause of pHPT without using any perioperative adjuncts.

SETTINGS AND DESIGN

A prospective data analysis of two surgeons' series from a teaching hospital in Turkey.

MATERIALS AND METHODS

Of the 47 patients referred with a diagnosis of pHPT during January 2004-May 2008, 30(63%) patients with sporadic pHPT with presumed solitary adenoma were included for analysis. These patients underwent MIP via focused lateral (n=24) or anterior (n=6) approach. Preoperative localization was done using 99 mTc-labelled sestamibi scan and ultrasonography. Only patients with concordant tests for single adenoma were selected for MIP. Serum parathyroid hormone and calcium levels were measured postoperatively and at follow-up visits.

STATISTICAL ANALYSIS

Parametric data presented were analyzed with Excel XP (Microsoft, Redmond, WA, USA).

RESULTS

Barring one patient, all other patients were initially biochemically cured by MIP. One patient remained hypercalcemic, who was found to have a second adenoma at the second operation. During a mean follow-up of 16 (3-55) months, all patients were normocalcemic with a mean serum calcium level of 9.4 (8.9-10.2) mg/dl. Parathormone levels were persistantly elevated only in one patient (3.4%). No postoperative permanent complication was encountered.

CONCLUSION

The results of MIP achieved in high-volume endocrine surgery centers can be replicated in low-volume center without any intraoperative adjuncts, in patients with overt clinical pHPT and concordant results of sestamibi and ultrasound.

Levels of paraoxonase, an index of antioxidant defense, in patients with active sarcoidosis

OBJECTIVE

Oxidative mechanisms are currently discussed as playing a crucial role in the genesis of inflammatory lung diseases. We aimed to evaluate the oxidant-antioxidant balance in the pathogenesis and activity of sarcoidosis and to search if the change in the level of PON can be taken as an activity marker.

METHODS

26 active sarcoidosis subjects aged 41.3+/-12.9 years, 37 inactive subjects aged 39.6+/-11.7 years and 48 control subjects aged 48.9+/-2.5 years were recruited in our study. Malondialdehyde (MDA), paraoxonase1 (PON1) and oxidized low density lipoprotein (oxLDL) levels in serum were analyzed by spectrophotometric, kinetic, and ELISA methods, respectively.

RESULTS

PON1 levels were significantly lower in the active disease state than both the inactive form and control groups. MDA levels were significantly higher in active sarcoidosis than both the inactive disease and control groups, and oxLDL levels were significantly higher in the active disease group than the inactive group and control group. The level of PON1 in the inactive disease group is not significantly different from the control group while the oxLDL and MDA levels of inactive group is significantly higher than the control group (p<0.001). There was a negative correlation between the PON1 activities and MDA values in both active and inactive groups (p=0.008).

CONCLUSION

Oxidative stress increases in sarcoidosis might be due to both increase in lipid peroxidation and decrease in antioxidant status (PON1) and the relationship between oxidative status and the activation of the disease should be discussed by comparing the previously known activation criteria.

The plasma levels of soluble P-selectin in subjects with prediabetes

Prediabetes has been associated with an increased risk of cardiovascular disease and mortality. Soluble P-selectin (sP-selectin) is an index of platelet activation and also a risk factor for future vascular events. sP-selectin levels were investigated in prediabetic subjects who had no confounding factors such as hypertension, obesity or dyslipidaemia. sP-selectin, hsCRP levels and HOMA-IR indexes were measured in 40 prediabetic subjects (n = 24 for IFG and n = 16 for IGT) and age-, sex- and BMI-matched 40 healthy controls. sP-selectin levels in prediabetic subjects were not significantly different compared with those in controls (p = 0.12). Prediabetic group had similar hsCRP (p = 0.29), higher HOMA-IR indexes (p < 0.001) and lower HDL cholesterol levels (p = 0.001) when compared with healthy controls. The power of the study was 0.93 for sP-selectin, 0.7 for hsCRP and 1.0 for HOMA. Our data suggest that sP-selectin may not contribute to the prothrombotic state as well as the accelerated atherogenesis associated with prediabetes.

An adult adrenal neuroblastoma: a case report

Neuroblastoma of the adrenal gland is an extremely rare tumour in adulthood although it is one of the most common malignancies in childhood. In this report, we present a 52-year-old man who had a left adrenal mass on preoperative imaging. On laboratory, slightly elevated catecholamine metabolites were detected in the urine that was collected over 24 hours. He was operated and the mass was resected in en-block manner along with the regional lymph nodes. The histopathological examination of the specimen revealed the diagnosis of neuroblastoma. He had no metastatic disease at the time of diagnosis and received chemotherapy after the operation. However, the prognosis was poor and he died 10 months after the operation. Although neuroblastoma of adrenal gland is rare in adulthood, it should be considered in the differential diagnosis for patients with adrenal masses.

Relation between hallux valgus deformity and lumbar and lower extremity biomechanics

Hallux valgus (HV) is a static subluxation of the first metatarsophalangeal joint with lateral deviation of the great toe and medial deviation of the first metatarsal. Our aim was to evaluate the interference of HV deformity with changes in lumbar lordosis and some foot deformities. Twenty HV patients and 20 healthy subjects were selected for the study. Hallux valgus angle, metatarsus primus varus (MPV), metatarsus omnis varus (MOV), first intermetatarsal (1.IMT), second metatarsal (2. MT) and hallux interphalangeal (HIP) angles were estimated from the anteroposterior foot X-rays. Lumbosacral (LSA) and sacrohorizontal angles (SHA) were measured from lateral lumbar x-rays and pes planus was detected from lateral and anteroposterior ankle and foot radiographs. There was a significant difference between HV angle mean values of two groups. MPV, MOV, 1.IMT, 2. MT and HIP angles did not show significant difference between groups. HV angle was found to be correlated with MPV. HIP angle was found to be correlated with LSA and SHA, indicating a relation with lordosis. HV and pes planus were correlated with each other. HV also showed weak correlation with hyperlordosis. Transmission of variations in body mechanics through pelvis and lower extremity plays an important role for certain foot deformities. Some factors affecting HV development are correctable; early diagnosis and treatment of MPV and pes planus, suggesting healthy rather than fashionable footwear and preventing obesity may lower HV incidence.

Radiological abnormalities of the lumbosacral spine in young male individuals

The purpose of this study was to determine the overall incidence and distribution of lumbosacral congenital abnormalities in healthy and active young male individuals. The study population consisted of 503 healthy young male candidates for sports training. Lumbosacral transitional vertebral (LSTV) abnormalities were found in 37 (7.4%) of subjects and were unilateral in 14 (2.8%) subjects (lumbarization/sacralization). Lumbar rotoscoliosis (LRS) was present in 14 (2.8%) subjects and facet asymmetry in one subject. LSTV and LRS together were present in 3 subjects. Spina Bifida Occulta (SBO) was present in 107 of 503 candidates (21.4%). The distribution of SBO throughout vertebra levels was as follows: 86 only in S1, 11 in S1+S2, 9 in L5, 1 in L5+S1. SBO and LSTV were present together in 8 subjects. SBO and LRS were present together in three subjects. 356 (70.4%) subjects had normal lumbosacral radiographs. Our study results support the notion that SBO is a common lumbosacral abnormality especially in young male healthy individuals.

Progress on strain differentiation of Citrus tristeza virus and its application to the epidemiology of citrus tristeza disease

Citrus tristeza virus (CTV) occurs in most citrus producing regions of the world, and it is the most serious viral pathogen of citrus. With the recent establishment of the brown citrus aphid, Toxoptera citricida, its most efficient vector, on Madeira Island (Portugal) and in Florida (USA) and the countries of the Caribbean Basin, the impact of CTV is likely to increase in these regions. Since there are many strains of CTV and CTV infections frequently occur as mixtures of several strains, it is necessary to be able to distinguish the strains for regulatory purposes, disease management and epidemiology. We describe the evolution of techniques developed to detect CTV and to differentiate the individual strains, and present the results of tests using these latest methods on CTV isolates from mainland Portugal, Madeira Island and Florida. Mild and decline-inducing strains of CTV were detected in mainland Portugal and mild, decline-inducing and severe stem pitting strains on Madeira Island. In Florida we demonstrated the presence of infections that reacted with probes made against stem pitting strains not previously detected there. It is concluded that CTV presents a significant threat to citrus production in mainland Portugal, on Madeira Island and in the neighbouring countries of the Mediterranean Basin, as well as in Florida, elsewhere in the USA and throughout the Caribbean Basin, especially following the widespread establishment of T. citricida throughout the region.

A triterpenoid saponin from Cyclamen coum

A new triterpenoid saponin, coumoside A, has been isolated from the whole plant of Cyclamen coum and the structure of this novel saponin (C58H92O27) has been deduced by NMR methods based on 1H, 13C, DEPT, 1H-1H COSY, HETCOR, NOESY-NMR experiments and the FAB-mass spectrum. It has the structure 3 beta-O-[beta-D-glucopyranosyl-(1-6)-[alpha-L-arabinopyranosyl- (1-2)]-beta-D-glucopyranosyl-(1-4)-[beta-D-glucopyranosyl-(1-2)]-alpha-L -arabinopyranosyl]-16 alpha-hydroxy-30,28 beta-lactone-olean-12-ene and is called coumoside.