Macit Selekler

Correlations between alexithymia and pain severity, depression, and anxiety among patients with chronic and episodic migraine.

Aims:  Some studies have found elevated alexithymia among patients with chronic pain, but the correlations between alexithymia and the severity of pain, depression, and anxiety among migraine patients are unclear. The aims of the present study were to investigate whether individuals suffering from episodic migraine (EM) differ from those with chronic migraine (CM) in regards to depression, anxiety, and alexithymia measures and to investigate the association of alexithymia with the results of depression and anxiety test inventories and illness characteristics.

Silent cerebral infarction in chronic heart failure: Ischemic and nonischemic dilated cardiomyopathy

Objectives Patients with dilated cardiomyopathy (DCM) may have a high incidence of clinically asymptomatic silent cerebral infarction (SCI). Prevalence of SCI and its risk factors may differ between ischemic and nonischemic DCM. The purpose of this study was to evaluate prevalence and related parameters of silent cerebral infarction in patients with ischemic and nonischemic DCM. Methods Patients with ischemic and nonischemic DCM (53 male, 19 female, aged 62 ± 12 years) were included in the study. Etiology of DCM was ischemic in 46 and nonischemic in 26 patients. Fifty-six age- and gender-matched healthy volunteers served as a control group for comparison of SCI prevalence. Results Prevalence of SCI was 39%, 27%, and 3.6% in ischemic, nonischemic DCM, and control group, respectively (ischemic DCM vs control group, p < 0.001, nonischemic DCM vs control group, p = 002). In patients with nonischemic DCM, the mean age of the subjects with SCI was significantly higher than that of subjects without lesions (67 ± 5 years vs 53 ± 13, p < 0.001), whereas in ischemic DCM NHYA Functional Class was statistically higher in patients with SCI than without SCI (p = 0.03). In both groups, patients with SCI had lower systolic functions than patients with normal MRI findings. In multivariable logistic regression analysis, restrictive type of diastolic filling pattern was found as an independent factor for SCI occurrence on the whole patient population (OR: 16.5, 95% CI: 4.4–61.8, p < 0.001). Conclusion SCI is common in patients with both ischemic and nonischemic DCM. In univariate analysis, both groups have similar systolic and diastolic characteristics in the occurrence of SCI. Logistic regression analysis revealed that restrictive diastolic filling pattern is an independent risk factor in the occurrence of SCI for the whole patient population.

Orgasmic Headache Responsive to Greater Occipital Nerve Blockade

We present a male with headache related to sexual activity. An injection of steroid and local anesthetic combination was applied to the greater occipital nerve of the symptomatic site. The orgasmic headache stopped after the procedure.

Extracephalic Stabbing Pain Temporally Related to Cephalic Ones

A 23‐year‐old woman consulted with the complaint of short‐lasting, severe stabbing headaches and mild‐to‐moderate degree near‐daily migrainous headaches. Further questioning revealed that she also had stabbing pain on both ipsilateral hand and calf. Stabs on the hand were time‐locked to cephalic ones and stabs in the calf were alternating with the ones in the hand. Dizziness and scotomas were accompanying symptoms to cephalic ones and paresthesia was the accompanying symptom in the hand. Patients cephalic and extracephalic stabbing pains responded to indomethacine and daily headaches responded to prophylactic sodium valproate therapy. The stabs were felt in the head; hand and calf are considered as the parts of a whole. Along with its accompanying symptoms, stabbing pain may be the result of complex interactions in central nervous system.

Cyclic alternating pattern analysis in REM sleep behavior disorder

ObjectiveRapid eye movement (REM) sleep behavior disorder (RBD) is a type of REM parasomnia characterized by complex motor activity during REM sleep. In this study, cyclic alternating pattern (CAP) in patients with idiopathic RBD was analyzed to evaluate the expression of arousal instability of NREM sleep.MethodsA total of 31 idiopathic RBD patients and age- and gender-matched 21 control subjects were consecutively recruited. Conventional sleep polysomnographic recording parameters and CAP parameters were compared between RBD and the control group.ResultsThe number of CAP cycles (120.13 ± 113.56, p = 0.007), CAP sequences (20.9 ± 18.15, p < 0.001), CAP index (25.14 ± 24.44, p = 0.017), and CAP rate (24.07 ± 13.22, p = 0.016) were all significantly higher in RBD patients compared to the control group. The increase in CAP sequences was observed in phase A2 and A3 subtypes while phase A1 subtype was significantly lower in RBD patients. A significant positive correlation was observed between disease duration with total CAP time (r = 0.289, p = 0.042) and A3 index (r = 0.32, p = 0.024). There was a negative correlation between the age and A1 index (r = −0.4491, p = 0.0001).ConclusionTo our knowledge this is the first polysomnographic clinical study which evaluated CAP parameters in RBD. Increased CAP rate found may be considered as a sign showing that NREM sleep may also be affected in RBD patients. Therefore, CAP analysis may be important to enlighten the pathogenesis of parasomnias.

Tremor in idiopathic distal acquired demyelinating symmetric neuropathy.

Recently, the journal Movement Disorders published a study1 that suggested pathological lesions in essential tremor might be distributed similarly in each cerebellar cortex and two case reports that included important suggestions that the successful treatment strategies in tremor associated with paraproteinemic neuropathy might act to modify the abnormal activation patterns in the cerebellar functional system.2,3 We report on a 71-year-old man with distal acquired demyelinating symmetric (DADS) neuropathy who had complaints of gradually increased weakness and clumsiness in his extremities symmetrically for 5 years. A disabling tremor had been seen in his right hand 4 years ago and in the left hand after 6 months. He had not received any medical treatment for these complaints. No history of a central nervous system (CNS) disorder, familial neuropathy, or essential tremor were present. Neurological examination revealed mild distal muscle weakness, areflexia, severe sensory loss in glove and stocking distribution, imbalance, and sensorial ataxia. Postural and action tremors were observed predominantly in the distal muscle of upper extremities. He had no significant leg tremor or any sign of Parkinson’s disease. Findings in electrophysiological studies were consistent with mixed motor–sensory but predominantly sensory demyelinating axonal polyneuropathy. Slowing in conduction velocity of median (48 m/sec in right), ulnar (40.2 m/sec in right), and posterior tibial (26.4 m/sec in right) motor nerves was detected. Sensory nerve action potentials of sural, superficial peroneal, ulnar, and median nerves, and motor nerve action potential of peroneal nerve were absent. Sural nerve biopsy demonstrated a mild decrease in the number of myelinated nerve fibers and severe axonal involvement. Surface electromyogram recordings revealed a rhythmic and synchronous activity of the wrist extensor and flexor muscles (frequency, 6.5 Hz in right hand) during antigravity posture maintenance. Routine laboratory findings, bone marrow examination, and computed tomography scan of the brain were completely normal. Protein concentration was elevated in the cerebrospinal fluid (46 mg/dl). Serum protein and immunofixation electrophoresis were normal. The level of antibodies reactive to myelin-associated glycoprotein (anti-MAG Ab) examined with thin-layer chromatography, enzyme-linked immunosorbent assay, and Western blot analysis (titer, 1:1,600) was also normal. Prednisone was given at an initial dose of 1 mg/kg per day and gradually tapered to 0.5 mg/kg per day after 4 months. But electrophysiological studies did not show any improvement in neuropathy at 6 months. Primidone was started at an initial dose of 125 mg/day and then gradually increased to 500 mg/day. Tremor assessment was quantified using the Fahn–Tolosa– Marin Rating Scale, administered before initiating primidone therapy, on the 15th day, and at the end of the 6th month. A 5-point scale was used, and the maximum possible score was 156 points. The total score was 58 at baseline, 36 at 15 days, and 16 at 6 months. A relevant decrease in tremor amplitude and frequency (4.5 Hz in right hand), and improved skills in assessed tasks (such as pouring and writing) were noticed. He reported significant improvement in activities of daily living without any side effect. Primidone was discontinued at the end of 6 months to evaluate treatment efficacy. Interruption caused a worsening in tremor (score, 52). Treatment was then restarted and resulted in marked improvement (score, 16). DADS neuropathy is an acquired demyelinating polyneuropathy present with distal, symmetric, predominantly sensory or sensorimotor involvement. Nearly two thirds of the patients have an M-protein, usually immunoglobulin M (IgM) kappa monoclonal protein (DADS-M). The remaining one third does not have it, and the condition is referred to as idiopathic DADS neuropathy (DADS-I).4,5 These patients also were categorized on the basis of antibodies reactive to anti-MAG Ab.6 An action or postural tremor prominent in distal muscles of upper extremities is one of the manifestations of peripheral neuropathies.7,8 It may improve with propranolol hydrochloride in dysgammaglobulinemic polyneuropathy, supporting the hypothesis that tremor is due to enhancement of physiologic tremor.7–9 However, most patients reveal relatively higher amplitude, lower frequency, irregular, and asymmetric tremor that improves as the neuropathy responds to immunosuppressive therapy, which is characteristic of neurogenic tremor.9–11 According to neurogenic theory, dispersed and distorted muscle spindle input due to slow peripheral conduction are central to the generation of tremor in demyelinating neuropathies. These inputs subsequently cause a confusion in the CNS generator that is structurally intact but misled into producing tremor. Activation studies using positron emission tomography have also indicated that cerebellar hemispheres appear to be overactive in patients with tremor associated with IgM paraproteinemic neuropathy.12,13 Even though a few publications about the characteristics and treatment of the tremor seen in dysgammaglobulinemic polyneuropathy are present in the literature, only a very limited amount of data is present about the tremor seen in DADS-I neuropathy. In an early study, patients with demyelinating polyneuropathy without anti-MAG Ab were reported to exhibit tremor having the same characteristics with exaggerated physiologic tremor (EPT).9 Our patient exhibited an asymmetric tremor with relatively higher amplitude and lower frequency (4.5–6.5 Hz) than seen in EPT (8–12 Hz).13 Findings in our case and in a previous report on a patient having tremor associated with nonparaproteinemic demyelinating polyneuropathy support the neurogenic mechanism in generation of Published online 19 August 2005 in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/mds.20693 Movement Disorders Vol. 20, No. 11, 2005, pp. 1529–1530

Gender differences in older adults with chronic migraine in Turkey

Chronic migraine is a growing and disabling subtype of migraine with different risk factors and clinical features, even in older adults. We sought to define and differentiate clinical features of chronic migraine in older adults. We also aimed to compare major clinical features of chronic migraine in older adults with those in younger people of both sexes.

Comparison of different matching methods in observational studies and sensitivity analysis: The relation between depression and STAI-2 scores

In researches where two or more groups are desired to be compared, observational and randomized experiments are very frequently used. As the subjects are randomly assigned to the groups in randomized experiments, balance is provided in observed/unobserved covariates of subjects in different groups. As the subjects cannot be randomly distributed into groups in observational studies, balance of observed/unobserved covariates between groups is not provided. This situation causes a biased estimate of the treatment effect. In this research, it is focused on different matching methods in observational studies and elimination of observed covariate effects confounding in the group effect, and these methods are examined comparatively. For this purpose, the effect of depression in 300 migraine patients, obtained from an observational study, on State continuous anxiety scale scores is taken and compared with the five different matching methods. Sensitivity of results is examined and it is researched whether the effect of treatment contains any bias. When results are examined, it is seen that matching methods produce similar results due to the overlap of propensity distribution in groups, high and balanced number of subjects in groups and covariates being not so many in number. The effects of unobserved covariates do not change the effect of treatment significantly. In conclusion, it is seen that, in the estimation of group effect in observational studies, it is possible to eliminate the effects of observed covariates using matching methods and matching quality of matching methods based on the propensity score is high.

Major depressive disorder in chronic heart failure patients: Does silent cerebral infarction cause major depressive disorder in this patient population?

OBJECTIVE Depression frequently occurs in patients with heart failure as similar pathophysiological mechanisms present in both these diseases. Patients with dilated cardiomyopathy (DCM) have a high incidence of clinically asymptomatic silent cerebral infarction (SCI). This study aimed to evaluate the relation between SCI and major depressive disorder (MDD), and between MDD and clinical and biochemical parameters in DCM patients. METHODS Patients with ischemic and non-ischemic DCM who had chronic heart failure (CHF) (39 male, 10 female, age 60±10 years) were included in the study. Mean patient ejection fraction (EF) was 34±10%. Patients had no localized neurological symptoms or stroke history. The etiology of DCM was ischemic in 40 and non-ischemic in 9 patients. Twenty-five age-matched healthy volunteers served as a control group for comparison of SCI and MDD prevalence. RESULTS Patients had mild to severe CHF symptoms. Prevalence of SCI and MDD was significantly higher in patients with DCM than in the control group; 63% vs 8%; p<0.001, and 52% vs 20%; p<0.001 respectively. Patients with SCI had a higher prevalence of MDD than patients without SCI in DCM (61% vs 27%, p=0.02). CONCLUSION CHF patients have an increased prevalence of SCI and MDD. Patients with SCI have a higher prevalence of MDD compared to patients without SCI in CHF.

EHMTI-0246. Lost productive time attributed to headache in a heavy-manufacturing workforce in Turkey

Results We obtained usable data from 5,916 employees (92.7% male, 7.3% female; mean age 32.5 ± 5.4 years) among whom 1-month headache prevalence was 45.4%, with 896 (16.4% of the workforce) reporting headache-attributed productivity loss. Presenteeism greatly outweighed absenteeism (3,036 [94%] vs 190 mean total days/month). The nature of an employee’s work, from office and managerial through paint-house to heavy manufacturing (welder, assembler, press-metal worker), had insignificant impact on the probability of reporting productivity losses (range 15.2-18.8%) or on the mean loss per individual (range 2.8-3.6 days/month). Discussion The lost productive time recorded was about 2.3% of all available time – a substantial penalty. It was surprising that the nature of work had so little influence, but it may be that the country’s economic state and unemployment rate, and the related social issues, were dominant factors. Supporting this was the finding that 94% of lost productivity was accounted for by presenteeism – largely hidden from the employer. No conflict of interest.