Perspectives in the Therapeutic Treatment of Migraine

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Migraine is a disabling disease which affects around 10% of the global population. It is characterized by a strong unilateral and pulsatile headache which is sometimes accompanied by nausea, vomiting, photophobia, phonophobia and other neurological symptoms. During migraine, alterations in the metabolism of serotonin (5-hydroxytryptamine; 5-HT) and in the dynamics of calcitonin gene-related peptide (CGRP) result in vasodilatation of meningeal blood vessels and in facilitation of trigeminal pain integration. The above conditions play a role in the painful phase of migraine. Regarding therapeutic alternatives, classical antimigraine drugs, such as the ergots (e.g. ergotamine and dihydroergotamine), produce cranial vasoconstriction, inhibit trigeminal vasodilatation and inhibit trigeminal pain integration, but some undesirable hypertensive mechanisms induced by systemic vasoconstriction are favoured. These problems led to the development of more selective antimigraine agents like the triptans (serotonin 5 HT1B/1D/1F receptor agonists), which represent the current mainstay of acute antimigraine treatment. However, the triptans: (i) may produce vasoconstriction of coronary blood vessels; (ii) are effective in less than 50% of migraine patients; (iii) are clearly contraindicated in patients with cerebro- and cardiovascular disease; and (iv) do not seem to be useful as prophylactic agents. Hence, more recent antimigraine alternatives include the development of CGRP receptor antagonists (e.g. olcegepant, telcagepant) and human monoclonal antibodies towards CGRP and the CGRP receptor. These antibodies are currently in clinical trials for the treatment of both episodic and chronic migraine with promising results. In short, the inhibition of the CGRPergic system (devoid of triptans-related vasoconstriction) is therapeutically similar to the antimigraine efficacy of the triptans, but hypothetically with fewer side effects. However, chronic blockade of CGRP receptors may represent a potential cardiovascular risk. Meanwhile, the triptans are currently considered the best therapeutic option to abort migraine attacks. The lack of a preventive drug is a persistent necessity for migraine therapeutics.

Migraine is a highly disabling disease characterized by a strong and pulsatile unilateral headache which affects 10% of the world population according with the world health organization. The “Headache Classification Committee of the International Headache Society”  describes several and complex neurological signs and symptoms which may occur before and during migraine. Before migraine attacks, premonitory symptoms such as yawning and scintillating scotoma (aura) may occur. Migraine attacks are sometimes accompanied by allodynia, hyperalgesia, photophobia, phonophobia, anorexia, nausea, vomiting, etc. Pain during migraine is restricted to the head, which suggests the main role of the trigeminal system. All these features dramatically affect the quality of life, not only of the patients, but also of their close family members as well as their social and professional activities.

One interesting aspect of migraine is its higher prevalence in female patients; the ratio is almost 3:1 during the adult life. The origin of this difference seems to be related with hormonal changes in view that the prevalence of migraine: (i) is quite similar in girls and boys under age 10; and (ii) decreases after menopause. On the other hand, there is a correlation between migraine and several psychiatric disorders (e.g., depression) which increase the risk to develop migraine from acute attacks to a chronic problem and consequently to increase the risk for impairing the psychiatric condition. A patient with chronic migraine may develop more than 15 attacks per month, which may represent the potential loss of school, job and/or spouse.

Regenerative Therapy in Autosomal Recessive Polycystic Kidney Disease

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Sodium-potassium adenosine tri-phosphatase (Na+ /K+ ATPase) is an enzyme that present in the plasma membrane of all mammalian cells and works to pump Na+ out and K+ in against their concentration gradients, obtaining the required energy through the hydrolysis of ATP [1]. The transmembrane protein complex is composed of an α and a β subunit. The α subunit is the channel with ATPase activity, while β subunit has a regulatory function. Naturally occurring isoforms for every subunit include α1 & α2 and β1 & β2. 

While in action, the pump binds an ATP molecule and 3 intracellular Na+ ions. As the ATP is hydrolyzed, phosphorylation of the pump at a highly conserved aspartate residue occurs and subsequently ADP is released. This is followed by a conformational change that exposes the Na+ ions to the cellular outside. As the phosphorylated form of the pump has a low affinity for Na+ ions, this allows the extracellular Na+ release.

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Afterwards, the pump binds 2 extracellular K+ ions, which facilitates the de-phosphorylation of the pump, reverting it to its original conformational state, transporting the K+ ions to the cell interior. As the de-phosphorylated form of the pump has a low affinity for K+ ions, this allows the intracellular K+ release.

Na+ /K+ ATPase helps to maintain the resting membrane potential and effective transport across the cell membrane, and accordingly, regulates the cellular volume.

Resting Potential: In order to maintain the physiological cell membrane potential, the intracellular concentrations of Na+ and K+ are kept under a physiological balance, where a low concentration of Na+ and high levels of K+ are favored. As the Na+ /K+ ATPase moves 3 Na+ out and 2 K+ in, thus, in total, removing one positive charge from the intracellular space, this creates a differential resting membrane potential between the cell membrane interior and exterior. Disturbance of this physiological balance, through the intracellular flow of Na+ , results in cell membrane depolarization

A Novel Aspect in Keloid Treatment: Short Term Effects of Kinesio® Taping

33 years old female patient diagnosed with keloid located in chest area was treated. The patient was referred to our clinic due to pain and aesthetic complaints. Written and verbal informed consent was obtained from the patient. The patient’s demographic details and family pedigree were recorded due to genetic factors may plat role in disease. The case has had the keloid since 1998, only a small acne on the chest that has become such a wide dimensions in 6 years time. The case explained the acne became a wound after scratching frequently and afterwards became a keloid. Our patient received crotherapy treatment for four sessions with each of the sessions have three week intervals in 2004. 

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This therapy repeated in 2006 also and had no gain in reduction of the size in keloid. Steroid injection was given once every five weeks into the keloids and a reduction height and volume in was observed but the colour became redder after this treatment procedure. Because of this reason our patient did not want to seek this treatment again even though the keloid was not healed. Before our treatment began, our patient had been using another taping method named Haelan Tape including an I band over keloid. This tape is a tight and firm tape covering keloid and has an impermeable tissue

On observational clinical examination, researchers measured keloid’s dimensions by using a standard tape measure. The case has a keloid on the chest in the localisation medio-lateral 7,4 cm and supero-inferior 5,1cm dimensions (Figure 1). The keloid was stiff; there was an increase in pain with palpation. The colour of keloid varied between pink to red that causes an aesthetic problem for our case. The intensity of pain felt during activity and rest was measured by Visual Analogue scale (VAS). Pain intensity was marked on a 100-mm horizontal line, in which 0 expresses no pain and 100 mm expresses maximum pain the patient felt. Her pain was found out to be as high as 5/10 (where 0 indicates no pain and 10 is the worst pain imaginable). The pain was evident especially when a pressure was implemented on to keloid area and did not change with activity.

The patient was decided to treat with Kinesio-taping method on the keloid area (Figure 2). Before the application was performed, the case was questioned for any allergenic reactions, then fully informed about all adversed invents including itching, sting, any other types of sensations giving discomfort and also erythema or increase in pain was set an exclution criteria for implemetation. The keloid was covered with I band with % 50 tension, taping technique. Two pieces of I bant were used, one vertically-upright, the other one was applied in horizontal direction. After the taping was completed, the area was rubbed to activate the kinesio-tape. Taping was renewed per 4 days, the tape was removed 1 hours before a new application was performed, to observe any allergic reactions. The case seek treatment for 3 months. Pain and the size of scar tissue was assesed before and after 3 months treatment.

A Multidisciplinary Collaboration

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Takayasu arteritis is defined as an inflammatory vasculitis that primarily affects the large vessels. Based on the criteria copublished by the Paediatric Rheumatology European Society (PRES), European League against Rheumatism (EULAR) and the Paediatric Rheumatology International Trials Organization (PRINTO), Takayasu Arteritis (TA) requires evidence of abnormalities within the aorta and/or its main branches. Major criteria can be visualized via angiography, Computerized Tomography (CT), or Magnetic Resonance Imaging (MRI) and consist of aneurysms, narrowing/occlusions, dilatations, or wall thickening. These have 100% sensitivity and 99.9% specificity when present. In addition to the major criteria, 1 of 5 minor criteria must be present including: 

1) pulse deficits or claudication, 

2) four limb blood pressure discrepancy > 10mmHg, 

3) bruits or a palpable thrill, 

4) hypertension > 95 percentile for age, gender, and height percentile 

5) elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) above normal. 

Takayasu Arteritis rarely occurs in the pediatric population, and often the diagnosis is delayed due to non-specific initial symptoms caused by systemic inflammation. Although the etiology of the disease is unknown, the pathophysiology includes chronic, autoimmune inflammation causing granulomatous changes to the great arteries. This ultimately results in the pathognomonic findings of aneurysms, vascular stenosis, and/or dilatation. The condition is predominantly described in Asian populations, however no ethnicity is spared, and overall females are affected at a rate of 2:1 over males (though it has been reported as high as 8.5:1). Patients classically present between the 2nd and 4th decade of life. The incidence of Takayasu arteritis in the pediatric population is not known, however it is estimated that annually there may be as many as 2.6 cases per million in North America and 1 case per million in Europe.

The patient is a three month old Hispanic female who was referred to a community hospital emergency room by her primary care physician with three days of cough, congestion, rhinorrhea, decreased oral intake and urine output, non-bloody/ bilious emesis, fatigue, tachypnea and persistent fever (TMax 39.7° C). Parents described development of a new rash that waxed and waned with each fever. A full sepsis screen was performed including blood, urine and cerebrospinal fluid (CSF) studies; and empiric ceftriaxone and gentamicin were initiated. She was briefly admitted to this hospital for concern of a systemic infectious process and dehydration; however required transfer to a tertiary care center pediatric intensive care unit (PICU) for progressive respiratory distress.

Medical history includes premature birth at 34 weeks via caesarean-section, complicated by maternal pre-eclampsia and gestational diabetes. She had a nine day neonatal intensive care unit (NICU) admission for feeding intolerance and hyperbilirubinemia requiring brief phototherapy. Upon discharge she was thriving, growing and developing well. The patient lives with her parents and two healthy siblings. She did not have sick contacts, had not travelled, had no pets, no unusual diet, and no exposure to farm animals or environmental water sources. Her family is Spanish-speaking only, and their history was only significant for a maternal 3rd trimester still-birth of unknown cause.

Nonketotic Diabetic Hemichorea-Hemiballismus in the Emergency Department

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_{We present a case of a 59-year old diabetic Jamaican male who presented to the emergency department with hemichorea-hemiballismus (HC-HB). HC-HB is a rare presentation of nonketotic hyperglycemia. While previously described in radiology, neurology and endocrinology literature, reports of this hyperkinetic movement caused by hyperglycemia are rare in the emergency medicine literature. Various conditions may cause hemichorea-hemiballismus. We highlight a case that illustrates the important distinguishing features of nonketotic hyperglycemic hemichorea-hemiballismus diagnosed in the emergency department.}

_{Hemichorea-hemiballismus (HC-HB) is a rare presentation of nonketotic hyperglycemia. Chorea is characterized by involuntary, poorly patterned, short lasting jerky movements. Ballismus, on the other hand, is described as large amplitude flailing movements. While previously described in journals of radiology, neurology and endocrinology literature, reports of this hyperkinetic movement caused by hyperglycemia are rare in the emergency medicine literature. While various conditions may cause hemichorea-hemiballismus, we present a case that illustrates the important distinguishing features of nonketotic hyperglycemic hemichorea-hemiballismus.}

_{A 59-year-old Jamaican male presented to the emergency department (ED) with complaints of involuntary movements of his left upper and left lower extremities that started one day prior to arrival. The patient’s family also reported an episode of transient slurred speech at the onset of the patient’s symptoms which resolved prior to arrival to the ED. The patient denied any other neurological complaints. The patient had no history of seizures and denied any history of drug or alcohol use. He had no recent travel, trauma, illness or hospitalization. His only medical history was diabetes.}

_{He admitted that he had not taken his prescribed metformin and glyburide for several weeks. He did not have health insurance coverage and stated that he had not been able to afford his medications and glucose test strips. The patient’s physical exam showed a very lean man in no acute distress. There were no cranial nerve deficits and no facial asymmetry. He had no visual field cuts. His extremities were noted to have normal strength and sensation. His gait was steady and no ataxia was observed. He was noted to have irregular, short-lasting, involuntary movements of his left upper and left lower extremities during the exam.}

Glucan Therapy

                                                         
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Giant condyloma acuminatum or Buschke-Löwenstein tumor (BTL) is a slow-growing, locally aggressive and disfiguring cauliflower-like tumor that typically affects the anogenital and perianal regions. BTL is a rare HPV-induced squamous cell carcinoma. It was first described in 1925 by Buschke and Löwenstein as a benign carcinoma-like condyloma acuminatum. Despite being histologically classified as a non-malignant tumor, malignant transformation can occur in 40-60% of cases and the recurrence rate after treatment can be as high as 67% . We report the case of a 31-year-old female patient with a history of  vulvar lesio

                                                            A 31-year-old woman, two previous cesarean sections, first

coitus at age 14 and 5 sexual partners during lifetime with non-compliance of condom use and no sexual partner at the time of the investigation presented with a giant condyloma acuminatum with concomitant bacterial infection. Physical examination showed exophytic tumor on the mons pubis, labia majora, labia minora, vaginal introitus, perineum and anus. The patient reported a small warty lesion in the vulvar region one year ago associated with difficulty in defecation and sexual intercourse. She did not report weight loss and she was afebrile and hemodynamically stable. The patient was screened for HIV, syphilis and hepatitis B and C infections and the results were nonreactive. Clinical and cytological evaluations of the cervix and vagina could not be performed by the time of admittance because of mechanical obstruction.

Since most of the exophytic lesions have a pedicled base, surgical excision of the condyloma was performed by fusiform incision with a safety margin of 0.5 cm. The wound was sutured by approximation of wound margins and the perineum was healed by second intention. During the surgery a pap smear was sampled and clinical evaluation was performed. There were no macroscopic lesions in the cervix or vagina.

Postoperatively, the patient developed dehiscence of the skin suture with secondary bacterial infection. Intravenous antibiotic therapy administered included cefalotin, metronidazole and garamycin, along with local application of potassium permanganate and four daily bandages embedded with DersaneSince most of the exophytic lesions have a pedicled base, surgical excision of the condyloma was performed by fusiform incision with a safety margin of 0.5 cm. The wound was sutured by approximation of wound margins and the perineum was healed by second intention. During the surgery a pap smear was sampled and clinical evaluation was performed. There were no macroscopic lesions in the cervix or vagina.

Postoperatively, the patient developed dehiscence of the skin suture with secondary bacterial infection. Intravenous antibiotic therapy administered included cefalotin, metronidazole and garamycin, along with local application of potassium permanganate and four daily bandages embedded with Dersane

Learning Together: Improving Women’s Health

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The health of women has a direct effect on the health of the future generation, their families, and communities. In other words, healthy women means health family, healthy society and healthy nations. Women’s health is affected by many factors such as culture, society and religion but pregnancy and childbirth have a huge impact on their health. According to World Health Organization about 830 women died everyday due to complications of pregnancy and child birth in 2015. The primary causes of maternal death are haemorrhage, hypertension, infections, and indirect causes, and indirect causes, mostly due to interaction between pre-existing medical conditions and pregnancy. Almost all of these deaths occurred in developing countries because of limited resources and shortage of qualified health care professionals, and most could have been prevented. In order to prevent maternal deaths, health care professionals including doctors, nurses, midwives have a pivotal role and responsibilities as well as policy makers. It is expected that every health care professionals must be well prepared and competent to give quality and safe health care services. Educational institutions has unique role to prepare these health care professionals for real life practices.

It is known that educational institutions use variety teaching strategies and methods to develop student’s cognitive, affective and psychomotor skills. Interprofessional education has become an effective teaching strategy since it brings health professional students together to give holistic health care services. WHO also recognizes interprofessional collaboration in education and practice as an innovative strategy to promote patient safety, maximize limited health resources, move care from acute to primary care settings or encourage greater integrated working. It also increases health worker job satisfaction or provides greater role clarity for health workers when working in teams.

Simulation is seen as an effective educational strategy that may provide an effective way to teach interprofessional collaboration for students and health care professionals. Simulation helps to increase patient safety, decrease the incidence of error and improve clinical judgment when working as a team. Simulated learning activities provides learners an opportunity to build their confidence, apply their knowledge, enhance technical, critical thinking and crisis management skills in “no-risk” environment. This also affords educators the opportunity to verify the competence of health professionals in a safe, interactive environment, before they enter the clinical setting. Therefore, health educators should be encouraged to use interprofessional education to develop students’ competencies to give effective women health services. Hence, policy makers and managers should support them to implement this innovative strategy in health care curricula and settings.

We hope that Mathews Journal of Gynecology & Obstetrics will contribute to women’s health around the world with high-quality publications of the authors. We are looking forward to receiving your valuable experiences to share with our extended reader population.