Development of a Self-Report Measure of Prediction in Daily Life: The Prediction-Related Experiences Questionnaire

PURPOSE

Predictions are complex, multisensory, and dynamic processes involving real-time adjustments based on environmental inputs. Disruptions to prediction abilities have been proposed to underlie characteristics associated with autism. While there is substantial empirical literature related to prediction, the field lacks a self-assessment measure of prediction skills related to daily tasks. Such a measure would be useful to better understand the nature of day-to-day prediction-related activities and characterize these abilities in individuals who struggle with prediction.

METHODS

An interdisciplinary mixed-methods approach was utilized to develop and validate a self-report questionnaire of prediction skills for adults, the Prediction-Related Experiences Questionnaire (PRE-Q). Two rounds of online field testing were completed in samples of autistic and neurotypical (NT) adults. Qualitative feedback from a subset of these participants regarding question content and quality was integrated and Rasch modeling of the item responses was applied.

RESULTS

The final PRE-Q includes 19 items across 3 domains (Sensory, Motor, Social), with evidence supporting the validity of the measure's 4-point response categories, internal structure, and relationship to other outcome measures associated with prediction. Consistent with models of prediction challenges in autism, autistic participants indicated more prediction-related difficulties than the NT group.

CONCLUSIONS

This study provides evidence for the validity of a novel self-report questionnaire designed to measure the day-to-day prediction skills of autistic and non-autistic adults. Future research should focus on characterizing the relationship between the PRE-Q and lab-based measures of prediction, and understanding how the PRE-Q may be used to identify potential areas for clinical supports for individuals with prediction-related challenges.

Rhythmic and interval-based temporal orienting in autism

Individuals with autism spectrum disorder (ASD) may show secondary sensory and cognitive characteristics, including differences in auditory processing, attention, and, according to a prominent hypothesis, the formulation and utilization of predictions. We explored the overlap of audition, attention, and prediction with an online auditory "temporal orienting" task in which participants utilized predictive timing cues (both rhythmic and interval-based) to improve their detection of faint sounds. We compared an autistic (n = 78) with a nonautistic (n = 83) group, controlling for nonverbal IQ, and used signal detection measures and reaction times to evaluate the effect of valid temporally predictive cues. We hypothesized that temporal orienting would be compromised in autism, but this was not supported by the data: the boost in performance induced by predictability was practically identical for the two groups, except for the small subset of the ASD group with co-occurring attention deficit hyperactivity disorder, who received less benefit from interval-based cueing. However, we found that the presence of a rhythm induced a significantly stronger bias toward reporting target detections in the ASD group at large, suggesting weakened response inhibition during rhythmic entrainment.

Prenatal auditory experience and its sequelae

Towards the end of the second trimester of gestation, a human fetus is able to register environmental sounds. This in utero auditory experience is characterized by comprising strongly low-pass-filtered versions of sounds from the external world. Here, we present computational tests of the hypothesis that this early exposure to severely degraded auditory inputs serves an adaptive purpose-it may induce the neural development of extended temporal integration. Such integration can facilitate the detection of information carried by low-frequency variations in the auditory signal, including emotional or other prosodic content. To test this prediction, we characterized the impact of several training regimens, biomimetic and otherwise, on a computational model system trained and tested on the task of emotion recognition. We find that training with an auditory trajectory recapitulating that of a neurotypical infant in the pre-to-postnatal period results in temporally extended receptive field structures and yields the best subsequent accuracy and generalization performance on the task of emotion recognition. This strongly suggests that the progression from low-pass-filtered to full-frequency inputs is likely to be an adaptive feature of our development, conferring significant benefits to later auditory processing abilities relying on temporally extended analyses. Additionally, this finding can help explain some of the auditory impairments associated with preterm births, suggests guidelines for the design of auditory environments in neonatal care units, and points to enhanced training procedures for computational models.

Microwave Susceptibility Observation of Interacting Many-Body Andreev States

Electrostatic charging affects the many-body spectrum of Andreev states, yet its influence on their microwave properties has not been elucidated. We developed a circuit quantum electrodynamics probe that, in addition to transition spectroscopy, measures the microwave susceptibility of different states of a semiconductor nanowire weak link with a single dominant (spin-degenerate) Andreev level. We found that the microwave susceptibility does not exhibit a particle-hole symmetry, which we qualitatively explain as an influence of Coulomb interaction. Moreover, our state-selective measurement reveals a large, π-phase shifted contribution to the response common to all many-body states which can be interpreted as arising from a phase-dependent continuum in the superconducting density of states.

Coherent manipulation of an Andreev spin qubit

Two promising architectures for solid-state quantum information processing are based on electron spins electrostatically confined in semiconductor quantum dots and the collective electrodynamic modes of superconducting circuits. Superconducting electrodynamic qubits involve macroscopic numbers of electrons and offer the advantage of larger coupling, whereas semiconductor spin qubits involve individual electrons trapped in microscopic volumes but are more difficult to link. We combined beneficial aspects of both platforms in the Andreev spin qubit: the spin degree of freedom of an electronic quasiparticle trapped in the supercurrent-carrying Andreev levels of a Josephson semiconductor nanowire. We performed coherent spin manipulation by combining single-shot circuit-quantum-electrodynamics readout and spin-flipping Raman transitions and found a spin-flip time T _S = 17 microseconds and a spin coherence time T _2E = 52 nanoseconds. These results herald a regime of supercurrent-mediated coherent spin-photon coupling at the single-quantum level.

Oral health knowledge and practices in the Kaski District of Nepal

INTRODUCTION

Oral disease is a widespread problem in Nepal. However, up-to-date information on oral health is limited and oral health initiatives may be shaped by assumptions about insufficient oral health knowledge. Furthermore, the influence of socio-demographic factors on oral health in Nepal remains unclear. This study aims to explore the relationship between demographic background and oral health knowledge, attitudes and behaviors in rural Nepal.

METHODS

Secondary analysis of data from a community-based survey on oral health knowledge, beliefs, practices, and access to care among residents ages 12 and above across 4 rural villages in Nepal's Kaski District (Total number = 3,243). Chi-square tests were performed to examine associations among oral health knowledge, attitudes and behaviors and demographic characteristics.

RESULTS

Participants reported a baseline knowledge of oral health; 92.4% knew about the recommended tooth-brushing regimen. Participants with higher education and younger age demonstrated better oral health knowledge. Misconceptions about dental treatment causing blindness (23.1%), deafness (11.6%), and mental health problems (14.9%) were reported across all groups.

CONCLUSION

Numerous factors besides knowledge likely determine individual oral health behavior. Future interventions should consider community-based outreach programs and dental care delivery through community Health Posts to build trust in dental care, build on existing knowledge and community experiences, and improve access to preventative care. Up-to-date understanding of oral health knowledge and practices and sociocultural influences on oral health behavior will better focus interventions and policy decisions.

Hot Nonequilibrium Quasiparticles in Transmon Qubits

Nonequilibrium quasiparticle excitations degrade the performance of a variety of superconducting circuits. Understanding the energy distribution of these quasiparticles will yield insight into their generation mechanisms, the limitations they impose on superconducting devices, and how to efficiently mitigate quasiparticle-induced qubit decoherence. To probe this energy distribution, we systematically correlate qubit relaxation and excitation with charge-parity switches in an offset-charge-sensitive transmon qubit, and find that quasiparticle-induced excitation events are the dominant mechanism behind the residual excited-state population in our samples. By itself, the observed quasiparticle distribution would limit T_{1} to ≈200  μs, which indicates that quasiparticle loss in our devices is on equal footing with all other loss mechanisms. Furthermore, the measured rate of quasiparticle-induced excitation events is greater than that of relaxation events, which signifies that the quasiparticles are more energetic than would be predicted from a thermal distribution describing their apparent density.

Probable Migraine in the United States: Results Of The American Migraine Prevalence and Prevention (AMPP) Study

Probable migraine (PM) is a prevalent migraine subtype fulfilling all but one criterion for migraine with or without aura. The aims of this study were: (i) to describe the epidemiology, medical recognition and patterns of treatment for PM in the USA; (ii) to compare the patterns of preventive PM treatment in the population with expert panel guidelines for preventive treatment. A validated self-administered headache questionnaire was mailed to a random sample of 120 000 US households. Subjects were classified as PM according to the second edition of the International Classification of Headache Disorders (ICHD-2). The questionnaire also assessed patterns of migraine treatment. Guidelines for preventive medication use were developed by a panel of headache experts, who used headache frequency and impairment to assess the need for preventive therapy and the gap between current and ideal use. Our sample consisted of 162 576 individuals aged ≥12 years. The 1-year period prevalence of PM was 4.5% (3.9% in men and 5.1% in women). In women and men, prevalence was higher in middle life, between the ages of 30 and 59 years. The prevalence of PM was significantly higher in African-Americans than in Whites (female 7.4% vs. 4.8%; male 4.8% vs. 3.7%) and inversely related to household income. During their headaches, most (48.2%) had at least some impairment, while 22.1% were severely disabled. The vast majority (97%) of PM sufferers used acute treatments, although 71% usually treated with over-the-counter medication. Most PM sufferers (52.8%) never used a migraine-preventive treatment and only 7.9% were currently using preventive medication. According to the expert panel guidelines, prevention should be offered (16.9%) or considered (11.5%) for 28.4% of the PM sufferers in the survey. We conclude that PM is a frequent, undertreated, sometimes disabling disorder. It has an epidemiological profile similar to migraine. In contrast to migraine, which is less prevalent in African-Americans than in Whites, PM is more prevalent in African-Americans than in Whites. In the USA, many with PM do not receive adequate treatment.

Hydration Reactions in Cement Pastes Incorporating Fly Ash and Other Pozzolanic Materials

A model for reactions that occur in hydrating portland cement is now generally well developed. Incorporation of various by-products to form blended cements modifies both the hydration reactions and the physical properties of the resulting pastes. A review of recent progress in understanding the effects of blending agents on these reactions is presented. The blending agents considered are low-calcium (Class F) fly ash, high calcium (Class C) fly ash, blast furnace slag, silica fume, biosilica and natural pozzolans. Effects of the blending agents on physical properties such as rheology are also considered. Particular attention is given to the essential role of alkalies in pore solutions and the beneficial reactions that occur with high silica content blending agents.

Cement Paste Microstructure in Concrete

An understanding of the microstructure of cement paste in actual field concrete is considered to be the primary objective of cement microstructural studies. Cement paste in concrete is shown to consist of narrow ribbons of the order of 80 to 150 μm separating sand and coarse aggregate grains, and interrupted by frequent air voids. Individual cement grains form shells around themselves early in the hydration process. In subsequent hydration they either deposit dense layers of internal hydration product or empty out in a hollow-shell mode and precipitate hydration products in the empty spaces between nearby shells. Analogous shells are similarly formed around fly ash particles, which then react by progressive etching from within the shells. Interfacial zones around aggregates are pictured as having a complex characteristic structure including at least four different forms of calcium hydroxide particles with various preferred orientations. It is suggested that the conventional picture of the “aureole de transition” derived from successive x-ray diffraction measurements may have been misinterpreted.

Characterization of Fly Ash and its Reactions in Concrete

Fly ashes are currently being produced that are much more widely different from each other in composition and other characteristics than had been previously experienced, owing to the widespread use of low rank subbituminous and lignitic coals. The current ASTM classifications into Class F and Class C pozzolan categories are not adequate to describe all their important properties. Current characterization methods are reviewed, including physical characterization by particle size distribution, shape, apparent specific gravity, content of hollow grains and of residual coal fragments, etc., chemical procedures of various kinds, and SEM, EDXA, XRD, and other methods for the determination of mineralogical content and glass character. Etching and chemical dissolution procedures are particularly important. The state of these various methods, current results of their use in rly ash characterizations, and the relations of these to reactivity and performance of fly ashes in cement and concrete are discussed.

Evidence for Minimal Pozzolanic Reaction in a Fly Ash Cement during the Period of Major Strength Development

Strengths developed in fly ash concretes usually equal or exceed that of similar plain concrete after a few months, with much of the response usually attributed to “pozzolanic” reaction between ash and secondary calcium hydroxide (CH). The CH contents of pastes made with five different fly ashes were determined by DTA for periods up to six months. The CH contents found did not decrease notably over the period, and were substantially identical to that expected for plain cement pastes diluted with the same amount of inert material as the amount of fly ash used. Scanning electron microscope examination of the pastes showed only minimal evidence of reaction even up to 1 year of age, although many fly ash grains were in intimate contact with CH. Non-evaporable water contents of the fly ash pastes were substantially higher than expected at each age, suggesting that the fly ash promoted more complete cement hydration or that the hydration products formed bound substantially greater amounts of water than plain cement paste ordinarily does.

An Approach to Quantitative Image Analysis for Cement Pastes

Cement paste microstructure as revealed in backscatter SEM presents a number of inherent difficulties that interfere with implementing quantitative image analysis. An approach to overcoming these difficulties is presented, involving gray scale segmentation coupled with application of a hole filling algorithm. Using this approach it is possible to isolate the unhydrated and hydrated portions of phenograins separately, and to combine them for analysis of combined phenograins. Pores and coarse calcium hydroxide masses may also be isolated for feature analysis. Results are reported on mature cement pastes prepared at two water:cement ratios (w:c 0.45 and w:c 0.30) and with and without superplasticizer. It was found that superplasticizer greatly reduced the content and the average size of “visible pores” and increased the content and the average size of coarse CH particles compared to corresponding plain pastes. The area per hydrated phenograin was much smaller in the lower w:c ratio pastes and higher in superplasticized pastes. Among the solid features measured, unhydrated cement particles had the smallest circularity values (at about 2.7) and were the most circular features; Hydrated phenograins had the largest circularity values (at 3.5) and were the most elongated features.

A Re-Evaluation of Hardened Cement Paste Microstructure Based on Backscatter Sem Investigations

Backscattered electron imaging of polished cement paste specimens permits a re-evaluation of structural details of hydrated cement paste at the gim level. The primarily microstructural units comprise a highly porous groundmass and large distinct grains (“phenograins”) set in it. The groundmass is composed of several kinds of fine particles, with a significant content of easily detected gross pores. Phenograins are primarily large clinker grains hydrating in-situ, but may be distinct deposits of CH, or may be mineral admixture grains. Detailed EDS analyses indicated that hydrating cement in phenograins has a highly consistent composition, interpreted as C-S-H with a small but regular incorporation of sub-jim CH and calcium monosulfoaluminate. Groundmass particles are highly variable in composition, but appear to consist of C-S-H with variable and occasionally major contents of other hydration products on a sub-μm scale. Incorporation of fly ash does not appear to change the basic microstructure, but silica fume incorporated with superplasticizer drastically modifies the character of the groundmass. Some attempts at quantification of these features by application of image analysis are briefly described.

Pore Size Distributions in Hardened Cement Paste by Sem Image Analysis

Technical requirements for determining the size distribution of capillary pores in hardened cement paste by SEM image analysis are discussed. Results of such measurements are reported for a set of hardened cement pastes of w:c ratio 0.40 and 0.25, and of ages ranging from 1 to 28 days. Pore size distributions based on conventional mercury intrusion porisimetry are presented for the same pastes. Estimates of pore diameters by mercury intrusion are two orders of magnitude smaller than the sizes revealed by the image analysis. Diameters of air voids are even more drastically underestimated by mercury intrusion. Typical micrographs are provided to illustrate the physical reality of the image analysis results, and the technical reasons underlying the conventional misinterpretation of MIP results for hydrated cements are reviewed.

Evidence for Minimal Pozzolanic Reaction in a Fly Ash Cement During the Period of Major Strength Development

Strengths developed in fly ash concretes usually equal or exceed that of similar plain concrete after a few months, with much of the response usually attributed to “pozzolanic” reaction between ash and secondary calcium hydroxide (CH). The CH contents of pastes made with five different fly ashes were determined by DTA for periods up to six months. The CH contents found did not decrease notably over the period, and were substantially identical to that expected for plain cement pastes diluted with the same amount of inert material as the amount of fly ash used. Scanning electron microscope examination of the pastes showed only minimal evidence of reaction even up to 1 year of age, although many fly ash grains were in intimate contact with CH. Non-evaporable water contents of the fly ash pastes were substantially higher than expected at each age, suggesting that the fly ash promoted more complete cement hydration or that the hydration products formed bound substantially greater amounts of water than plain cement paste ordinarily does.

Migraine in adolescents: association with socioeconomic status and family history

OBJECTIVE

The influence of socioeconomic status on the prevalence of migraine is unknown in adolescents. Accordingly, we investigated the prevalence of migraine in a large sample of adolescents by sociodemographic features.

METHODS

A validated headache questionnaire was mailed to 120,000 households representative of the US population. All individuals in the household were interviewed (probands and their parents). We calculated sex-specific prevalence estimates of migraine in adolescents derived by age, race, urban vs rural residence, household income, region of the country, and parental status of migraine, using log-linear models.

RESULTS

A total of 32,015 adolescents were identified. Surveys were returned by 18,714 of them (58.4% response rate). The 1-year prevalence of migraine was 6.3% (5.0% in boys and 7.7% in girls). The prevalence was higher in girls than in boys older than 12 and in whites than African Americans. In families with an annual income lower than $22,500, the adjusted prevalence of migraine in adolescents without a parental history of migraine was 4.4%; in families earning $90,000 or more, it was 2.9% (OR = 0.49, 95% CI 0.38 to 0.63). In adolescents with a parental history of migraine, the prevalence in the lower vs the higher income group was 8.6% vs 8.4% (OR = 0.97, 0.81 to 1.15).

CONCLUSIONS

In adolescents with family history of migraine, household income does not have a significant effect, probably because of the higher biologic predisposition. In those without a strong predisposition, household income is associated with prevalence. This suggests social causation rather than social selection, highlighting the need for exploration of environmental risk factors related to low income and migraine and the search for specific comorbidities and stressors in this group.

DPC 681 and DPC 684: potent, selective inhibitors of human immunodeficiency virus protease active against clinically relevant mutant variants

Human immunodeficiency virus (HIV) protease inhibitors (PIs) are important components of many highly active antiretroviral therapy regimens. However, development of phenotypic and/or genotypic resistance can occur, including cross-resistance to other PIs. Development of resistance takes place because trough levels of free drug are inadequate to suppress preexisting resistant mutant variants and/or to inhibit de novo-generated resistant mutant variants. There is thus a need for new PIs, which are more potent against mutant variants of HIV and show higher levels of free drug at the trough. We have optimized a series of substituted sulfonamides and evaluated the inhibitors against laboratory strains and clinical isolates of HIV type 1 (HIV-1), including viruses with mutations in the protease gene. In addition, serum protein binding was determined to estimate total drug requirements for 90% suppression of virus replication (plasma IC(90)). Two compounds resulting from our studies, designated DPC 681 and DPC 684, are potent and selective inhibitors of HIV protease with IC(90)s for wild-type HIV-1 of 4 to 40 nM. DPC 681 and DPC 684 showed no loss in potency toward recombinant mutant HIVs with the D30N mutation and a fivefold or smaller loss in potency toward mutant variants with three to five amino acid substitutions. A panel of chimeric viruses constructed from clinical samples from patients who failed PI-containing regimens and containing 5 to 11 mutations, including positions 10, 32, 46, 47, 50, 54, 63, 71, 82, 84, and 90 had mean IC(50) values of <20 nM for DPC 681 and DPC 681, respectively. In contrast, marketed PIs had mean IC(50) values ranging from 200 nM (amprenavir) to >900 nM (nelfinavir).

The role of psychometric testing and psychological treatment in tension-type headache

Tension-type headaches are a common occurrence for many people. Psychological issues such as stress, depression, and anxiety have been shown to coexist with tension-type headaches. The relationship between psychological factors and headaches is supported by literature, and treatments that combine a pharmacologic and psychological approach address the needs of the whole person. In this article, the role of psychometric testing and the application of psychological interventions for use on patients with tension-type headaches are reviewed. Recommendations are made about approaches that are designed to improve physical and psychological health.

The use of ibuprofen plus caffeine to treat tension-type headache

Simple analgesics such as ibuprofen, aspirin, and acetaminophen have long been used in the treatment of tension-type headache. Studies of combination agents of aspirin with caffeine or acetaminophen with caffeine have also demonstrated efficacy as analgesic agents. Other evidence also suggests that caffeine may have an analgesic effect unto itself in the relief of pain. We undertook the direction of a multicenter, double-blind, placebo-controlled, parallel trial to assess the efficacy and safety of ibuprofen combined with caffeine in the treatment of tension-type headache. The study was designed to also verify the analgesic efficacy of caffeine and further assess the role of tension-type headache as a model for the study of pain.

4,1-Benzoxazepinone analogues of efavirenz (Sustiva) as HIV-1 reverse transcriptase inhibitors

A series of 4,1-benzoxazepinone analogues of efavirenz (Sustiva) as potent NNRTIs has been discovered. The cis-3-alkylbenzoxazepinones are more potent then the trans isomers and can be synthesized preferentially by a novel stereoselective cyclization. The best compounds are potent orally bioavailable inhibitors of both wild-type HIV-1 and its clinically relevant K103N mutant virus, but are highly protein-bound in human plasma.

Safety and efficacy of PNU-142633, a selective 5-HT1D agonist, in patients with acute migraine

In this randomized, double-blind, placebo-controlled, parallel-group study, patients received a single 50-mg oral dose of a 5-HT(1D) agonist, PNU-142633 (n = 34), or matching placebo (n = 35) during an acute migraine attack. No statistically significant treatment effects were observed at 1 and 2 h after dosing, even after stratifying by baseline headache intensity. At 1 and 2 h post-dose, 8.8% and 29.4% of the PNU-142633 group, respectively, and 8.6% and 40.0% of the placebo group, respectively, experienced headache relief; 2.9% and 8.8% of the PNU-142633 group and 0% and 5.7% of the placebo group were free of headache pain. Adverse events associated with PNU-142633 treatment included chest pain (two patients) and QTc prolongation (three patients). Results from this study suggest that anti-migraine efficacy is not mediated solely through the 5-HT(1D) receptor subtype, although this receptor may contribute, at least in part, to the adverse cardiovascular effects observed with 5-HT agonist medications.

Prevalence and burden of migraine in the United States: data from the American Migraine Study II

OBJECTIVE

To describe the prevalence, sociodemographic profile, and the burden of migraine in the United States in 1999 and to compare results with the original American Migraine Study, a 1989 population-based study employing identical methods.

METHODS

A validated, self-administered questionnaire was mailed to a sample of 20 000 households in the United States. Each household member with severe headache was asked to respond to questions about symptoms, frequency, and severity of headaches and about headache-related disability. Diagnostic criteria for migraine were based on those of the International Headache Society. This report is restricted to individuals 12 years and older.

RESULTS

Of the 43 527 age-eligible individuals, 29 727 responded to the questionnaire for a 68.3% response rate. The prevalence of migraine was 18.2% among females and 6.5% among males. Approximately 23% of households contained at least one member suffering from migraine. Migraine prevalence was higher in whites than in blacks and was inversely related to household income. Prevalence increased from aged 12 years to about aged 40 years and declined thereafter in both sexes. Fifty-three percent of respondents reported that their severe headaches caused substantial impairment in activities or required bed rest. Approximately 31% missed at least 1 day of work or school in the previous 3 months because of migraine; 51% reported that work or school productivity was reduced by at least 50%.

CONCLUSIONS

Two methodologically identical national surveys in the United States conducted 10 years apart show that the prevalence and distribution of migraine have remained stable over the last decade. Migraine-associated disability remains substantial and pervasive. The number of migraineurs has increased from 23.6 million in 1989 to 27.9 million in 1999 commensurate with the growth of the population. Migraine is an important target for public health interventions because it is highly prevalent and disabling.

Migraine diagnosis and treatment: results from the American Migraine Study II

OBJECTIVE

A population-based survey was conducted in 1999 to describe the patterns of migraine diagnosis and medication use in a representative sample of the US population and to compare results with a methodologically identical study conducted 10 years earlier.

METHODS

A survey mailed to a panel of 20 000 US households identified 3577 individuals with severe headache meeting a case definition for migraine based on the International Headache Society (IHS) criteria. Those with severe headache answered questions regarding physician diagnosis and use of medications for headache as well as headache-related disability.

RESULTS

A physician diagnosis of migraine was reported by 48% of survey participants who met IHS criteria for migraine in 1999, compared with 38% in 1989. A total of 41% of IHS-defined migraineurs used prescription drugs for headaches in 1999, compared with 37% in 1989. The proportion of IHS-defined migraineurs using only over-the-counter medications to treat their headaches was 57% in 1999, compared with 59% in 1989. In 1999, 37% of diagnosed and 21% of undiagnosed migraineurs reported 1 to 2 days of activity restriction per episode (P<.001); 38% of diagnosed and 24% of undiagnosed migraineurs missed at least 1 day of work or school in the previous 3 months (P<.001); 57% of diagnosed and 45% of undiagnosed migraineurs experienced at least a 50% reduction in work/school productivity (P<.001).

CONCLUSIONS

Diagnosis of migraine has increased over the past decade. Nonetheless, approximately half of migraineurs remain undiagnosed, and the increased rates of diagnosis of migraine have been accompanied by only a modest increase in the proportion using prescription medicines. Migraine continues to cause significant disability whether or not there has been a physician diagnosis. Given the availability of effective treatments, public health initiatives to improve patterns of care are warranted.

Divalproex in the long-term treatment of chronic daily headache

OBJECTIVE

The purpose of this study was to assess the safety and efficacy of divalproex sodium in the long-term treatment of chronic daily headache. Correlations between treatment variables were assessed.

BACKGROUND

Controlled and open-label trials of divalproex sodium have previously demonstrated its efficacy and safety in the treatment of migraine and chronic daily headaches. These data were primarily short-term and did not examine interaction between treatment variables.

METHODS

Retrospective chart review with data extraction was conducted from headache diaries of 642 current patients under treatment with divalproex sodium for chronic daily headaches. One hundred thirty-eight of the patients were treated with only divalproex sodium. Demographic variables including age, sex, initial and final body weights, adverse events, dose of divalproex sodium, duration of treatment, and the ability to differentiate their chronic daily headache into its migraine and tension-type headache components were analyzed. Baseline and end of study headache frequency indices were obtained.

RESULTS

The mean improvement was 47%, with an improvement in migraine of about 65%. At least a 50% reduction in headache frequency was reported by 93 of the 138 patients receiving treatment with only divalproex sodium. No correlation between response and age, sex, duration of treatment, and the prescribed dose of divalproex sodium was demonstrated. Adverse events occurred in approximately 35% of the patients. None were severe. Women were more likely to experience adverse effects than men. Weight gain, however, occurred less commonly in women (mean, 1.9 lbs) than in men (mean, 7 lbs). Initial body weight and age did not correlate with the weight change.

CONCLUSIONS

Divalproex sodium can be used for a prolonged period as a sole agent for the successful treatment of chronic daily headache. Nearly 75% of the patients had at least a 50% reduction in headache frequency, and adverse effects occurred in approximately one third. Weight gain was negligible and hepatotoxicity did not occur during treatment periods of up to 6 years.

Migraine's impact today. Burden of illness, patterns of care

Migraine is a common disorder that causes severe headaches and associated nausea, photophobia, phonophobia, and temporary disability. Though the pain and other symptoms of migraine can be effectively managed, the condition remains underdiagnosed and undertreated. In this article, Drs Lipton, Stewart, Reed, and Diamond consider the scope and distribution of the migraine problem and the current patterns of care in the United States.

A fresh look at migraine therapy. New treatments promise improved management

Successful management of migraine headaches involves identifying and avoiding headache triggers and using appropriate abortive therapy once a headache is recognized. Pain relief measures include over-the-counter analgesics, parenteral NSAID therapy when needed, and use of antiemetics and cold packs. Narcotic analgesics are best used only as a "last resort" measure. Prophylactic therapy should be considered for patients who have more than two acute migraine attacks each month or whose daily activities are seriously compromised by headaches. For the patient in whom status migrainosus threatens well-being, hospitalization and more intensive therapy may be needed.

Mass spectrometric and NMR characterization of metabolites of roxifiban, a potent and selective antagonist of the platelet glycoprotein IIb/IIIa receptor

1. The methyl ester prodrug roxifiban is an orally active, potent and selective antagonist of the platelet glycoprotein GPIIb/IIIa receptor and is being developed for the prevention and treatment of arterial thrombosis. 2. Roxifiban was rapidly hydrolyzed to the zwitterion XV459 in vivo and by liver slices from the rat, mouse and human and by intestinal cores from dog. XV459 was metabolized to only a small extent in vitro and in vivo. 3. Studies with rat and dog given radiolabelled roxifiban showed limited oral absorption with the majority of the radiolabel being excreted in faeces. After i.v. doses of 14C-roxifiban, most of the radioactivity was recovered in the urine of rat whereas the dog excreted significant amounts of radioactivity in bile and urine. 4. XV459 could be metabolized extrahepatically by dog gut flora to produce an isoxazoline ring-opened metabolite. In vitro hepatic metabolism of XV459 was mainly by hydroxylation at the prochiral and chiral centres of the isoxazoline ring. These hydroxylated metabolites were not detected in the urine and plasma of human volunteers administered roxifiban. 5. Initial LC/MS identification of metabolites was achieved by dosing the rat with an equimolar mixture of d0:d4 roxifiban and detecting isotopic clusters of pseudomolecular ions. Unequivocal characterization of these metabolites was achieved by LC/MS, LC/NMR and high-field NMR techniques using synthetic standards of the metabolites. 6. The synthesis of one hydroxylated metabolite enabled the assignment of the correct stereochemistry of the substituted hydroxyl group on the isoxazoline ring.

Ibuprofen plus caffeine in the treatment of tension-type headache

BACKGROUND

The effectiveness of caffeine as an adjuvant to ibuprofen has been documented in investigations of acute pain. Our objectives were to assess this agent in the treatment of tension-type headache and to establish clinical trial methods capable of assessing this agent in comparison with various tension headache treatments. Stopwatch technology was used for measurement techniques.

METHODS

A randomized, double-blind, parallel, multicenter, single-dose, placebo- and active-controlled study included 301 subjects diagnosed with tension-type headache. Treatment groups included ibuprofen and caffeine, ibuprofen alone, caffeine alone, or placebo. Subjects measured onset of relief (both time to first perceptible relief and time to meaningful relief) after taking a single oral dose of their assigned medication. Pain intensity and pain relief were rated over a 6-hour study period. Overall evaluation was made on completion of all other ratings.

RESULTS

Ibuprofen and caffeine administered together provided significantly greater analgesic activity than ibuprofen alone, caffeine alone, and placebo. Ibuprofen and caffeine administered together demonstrated significantly shorter times to meaningful improvement in headache relief than ibuprofen or placebo; significantly greater total analgesia than ibuprofen alone, caffeine alone, or placebo; and significantly greater peak relief than ibuprofen alone, caffeine alone, or placebo. Significantly more subjects obtained meaningful headache relief with ibuprofen and caffeine administered together than with ibuprofen alone or placebo. More patients reported complete headache relief with ibuprofen and caffeine administered together than with ibuprofen alone, caffeine alone, or placebo. Ibuprofen and caffeine administered together was rated significantly better by patients than either ibuprofen alone, caffeine alone, or placebo. No subjects ended participation in the study early because of adverse events.

CONCLUSIONS

Sensitive methods have been introduced to assess differences in analgesia among over-the-counter analgesic agents in relieving tension-type headache pain. A double-blind study with this method suggests that ibuprofen and caffeine administered together provides greater analgesic effectiveness than either component alone.

Intranasal civamide for the acute treatment of migraine headache

The objective of this study was to investigate the safety and efficacy of intranasal civamide for the acute treatment of migraine headache with or without aura. Civamide is a vanilloid receptor agonist and neuronal calcium channel blocker that inhibits the neuronal release of excitatory neurotransmitters (e.g. calcitonin gene-related peptide (CGRP) and substance P (SP)) and depletes the neurones of the trigeminal plexus of their neurotransmitter content. Applied intranasally, the release of neurotransmitters to meningeal and dural blood vessels should be decreased, along with the resultant vasodilatation, plasma extravasation, and histamine/serotonin release. Subsequent migraine headache pain may also be diminished. Thirty-four patients were enrolled into a double-blind study of intranasal civamide, and randomized to receive a single dose of either 20 microg or 150 microg of civamide, for the treatment of a single migraine headache, with or without aura, of moderate to severe pain. At 2 h post-dose, 55.6% of patients treated with either dose had a decrease in pain severity, with 22.2% of patients being pain-free. At 4 h post-dose, 72.7% of patients treated with either dose had a decrease in pain severity, with 33.0% of patients being pain-free. Adverse events were similar for both dosages, with 91.2% of patients experiencing nasal burning and 44.1% of patients experiencing lacrimation. No systemic side-effects were observed. Based upon the results of this study, intranasal civamide may be effective in the acute treatment of migraine headache. Given civamide's proposed mechanism of action, intranasal civamide should be substantially more effective for prophylaxis than acute treatment of migraine. A study evaluating its efficacy in prophylaxis of migraine is currently planned.

Inhibition of clinically relevant mutant variants of HIV-1 by quinazolinone non-nucleoside reverse transcriptase inhibitors

A series of 4-alkenyl and 4-alkynyl-3, 4-dihydro-4-(trifluoromethyl)-2-(1H)-quinazolinones were found to be potent non-nucleoside reverse transcriptase inhibitors (NNRTIs) of human immunodeficiency virus type-1 (HIV-1). The 4-alkenyl-3, 4-dihydro-4-(trifluoromethyl)-2-(1H)-quinazolinones DPC 082 and DPC 083 and the 4-alkynyl-3, 4-dihydro-4-(trifluoromethyl)-2-(1H)-quinazolinones DPC 961 and DPC 963 were found to exhibit low nanomolar potency toward wild-type RF virus (IC(90) = 2.0, 2.1, 2.0, and 1.3 nM, respectively) and various single and many multiple amino acid substituted HIV-1 mutant viruses. The increased potency is combined with favorable plasma serum protein binding as demonstrated by improvements in the percent free drug in human plasma when compared to efavirenz: 3.0%, 2.0%, 1.5%, 2. 8%, and 0.2-0.5% for DPC 082, DPC 083, DPC 961, DPC 963, and efavirenz, respectively.

Degradation kinetics of leucine5-enkephalin by plasma samples from healthy controls and various patient populations: in vitro drug effects

Incubation of [3H]tyrosine leucine5-enkephalin with platelet-poor human plasma (final concentration 1 x 10(-8) M; 1:9 ratio to Trizma base buffer, pH 7.4) resulted in rapid and complete peptide degradation in each of the subjects studied, with more than 95% of the initial labeled tyrosine consistently recovered as the free amino acid (< or =30 minutes). Essentially, and irrespective of the incubation time (1-180 minutes), tyrosine was the only Leu metabolite formed; we were unable to identify significant amounts (> or =3%) of any other possible labeled or nonlabeled Leu degradation fragments. Neither gender (64 men and 20 women; samples tested individually), age (men, 23-70; women, 25-65 years), nor the subjects' medical condition appeared to make a significant difference in either the t1/2 of Leu elimination, the initial velocity of this reaction (x +/- SD, median, minimum and maximum of 12.0 +/- 0.9, 12.0, and 10.6-13.7 minutes; 1.2 +/- 0.3, 1.1, and 0.6-2.0 pg/min, respectively), or in the Km and Vmax values for aminopeptidase Leu degradation (x +/- SD; 0.81 +/- 0.01 mM and 14.30 +/- 1.17 micromol/L/min, respectively). Subjects were diagnosed as chronic schizophrenics (n = 15), polydrug abusers including alcohol (n = 9) and polydrug abusers excluding alcohol (n = 8), chronic alcoholics (n = 12), and migraineurs (n = 10) during or outside an acute migraine episode; for comparison we used a group of gender-matched (20 men and 10 women), age-comparable, drug-free, healthy volunteers. Differences in plasma storage time or repeated sample freezing and thawing failed to alter significantly any of these kinetic parameters of Leu metabolism or to change the identity and/or relative ratio of the products formed. The Leu degradation rate was pH and temperature dependent (optimum, 7.4 and 37 degrees C, respectively). Leu degradation was strongly and similarly inhibited by puromycin, bacitracin, and bestatin (IC50 [+/- SD] of 1.4 +/- 0.2 micromol/L) and to a lesser extent by various L-tyrosine-containing Leu fragments. The kinetics of this reaction was not significantly affected by either thiorphan, N-carboxyphenylmethyl leucine, or any other of a number of monoamine neurotransmitters, substances of abuse, nonsteroidal anti-inflammatory agents, and miscellaneous compounds tested (concentration up to 10(-4) mol/L).

The effect of ablation sequence and duration on lesion shape using rapidly pulsed radiofrequency energy through multiple electrodes

Sequences of energy application to multiple electrodes and a study of ablation duration with distal tip and multi-electrode ablations were explored with a radiofrequency controller that distributes energy from a generator to up to 4 electrodes with various duty cycles. In vitro ablations were performed on bovine left ventricle in circulating blood and lesions in goats were performed to verify the in vitro results. All of the ablation sequences with simultaneous electrode activation of contiguous electrodes resulted in deeper lesions than those created in sequence. There was also no scalloping of the lesion if contiguous electrodes were activated simultaneously. During all distal tip ablations, lesion volume and depth was greater after 3 minutes of energy delivery than after 1 minute, but did not increase from 3 minutes to 5 minutes. There was a significant increase in multi-electrode ablation lesion depth with each additional minute in the ablation cycle. The in vivo ablations verified these results at 120 and 300 second ablations. Pulsed energy distal tip ablations resulted in deeper lesions than continuous only if power amplitudes over 50 W were employed. In conclusion, contiguous electrodes in simultaneous use create lesions that resemble one large lesion rather than two lesions positioned next to each other. Multi-electrode ablation lesions continue to grow at ablation durations of up to 5 minutes compared to distal tip lesions which reach steady-state between 1 and 3 minutes. Pulsed energy delivery to distal tips may result in deeper lesions than conventional if high powers are employed.

Tension-type headache

Tension-type headaches, the most prevalent form of headache, are differentiated as being either episodic or chronic. The episodic form is a physiologic response to stress, anxiety, depression, emotional conflicts, fatigue, or repressed hostility. Treatment focuses on the use of over-the-counter or prescribed simple analgesics for pain relief. Successful treatment of the chronic form depends on recognition of depression or persistent anxiety states. Primary care physicians can effectively manage most of these patients with nonhabituating anxiolytic or antidepressant medications; however, referrals for psychotherapy may be required in some cases. When tension-type headaches occur in children and adolescents, the physician must explore the patient's family and social relationships as well as school performance. In addition to nonhabituating drug therapies, family counseling and biofeedback may be helpful. In coexisting migraine and tension-type headaches, nonhabituating analgesics may be used for the relief of acute pain; the use of ergotamine and triptans should be restricted to relief of the hard or sick headache. Tricyclic antidepressants or monoamine oxidase inhibitors are the gold standards for prophylaxis, although the selective serotonin reuptake inhibitors may be indicated in less severe cases. Several forms of biofeedback have also proved effective. Nonetheless, some patients with this form of headache may require psychiatric treatment for severe depression.

The chemistry and biological activity of herbs used in Flor-Essence herbal tonic and Essiac

The herbal mixtures, Essiac and Flor-Essence, are sold as nutritional supplements and used by patients to treat chronic conditions, particularly cancer. Evidence of anticancer activity for the herbal teas is limited to anecdotal reports recorded for some 40 years in Canada. Individual case reports suggest that the tea improves quality of life, alleviates pain, and in some cases, impacts cancer progression among cancer patients. Experimental studies with individual herbs have shown evidence of biological activity including antioxidant, antioestrogenic, immunostimulant, antitumour, and antiocholeretic actions. However, research that demonstrates these positive effects in the experimental setting has not been translated to the clinical arena. Currently, no clinical studies of Essiac or Flor-essence are published, but a clinical study is being planned at the British Columbia Cancer Agency by the University of Texas-Center for Alternative Medicine (UT-CAM) and Tzu-Chi Institute for Complementary and Alternative Medicine.