Warning Symptoms Research Articles

New approaches to the treatment and prevention of neurally mediated reflex (neurocardiogenic) syncope.

Neurally mediated reflex syncope (sometimes referred to as neurocardiogenic syncope), encompasses a group of disorders of which the best known and most frequently occurring forms are the vasovagal (or common) faint, and carotid sinus syndrome. Postmicturition syncope, defecation syncope, cough syncope, and other situational reflex faints are also included among these conditions. With the exception of carotid sinus syndrome in which cardiac pacing is effective, treatment of most neurally mediated reflex faints is shifting from reliance on various drugs to greater emphasis on education and nonpharmacologic therapy. Initial management should include counseling of patients regarding recognition of early warning symptoms, and avoidance of precipitating factors. Volume expansion with salt tablets or electrolyte-containing beverages and patient education on how to perform isometric arm contractions and/or leg crossing in order to abort impending syncope are also important. Thereafter, tilt-training has demonstrated benefit in several clinical studies. When symptoms remain despite the above-noted interventions, pharmacologic therapy with midodrine or a nonselective b-blocker can be considered. In the case of most neurally mediated reflex faints, permanent cardiac pacing should be reserved only for those older patients with significant bradycardia or asystole at time of syncope when all other interventions have failed.

New Challenges for Health Informatics

Abstract:In March 2001, the International Medical Informatics Association organized a workshop entitled “Challenges in Medical Informatics” in Madrid, Spain. It invited twenty members of the medical* informatics community to discuss current issues relating to the academic standing of the field. The broad objectives of the workshop were (a) to review the relevance of medical informatics as an academic discipline in today’s setting and (b) to examine its impact by the new world economy. One of the issues discussed was to find an appropriate response to the growing emergence of bioinformatics in the age of genomic discovery and molecular medicine. With the exciting discoveries in molecular medicine coming hot on the heels of the first draft of the mapping of the human genome and the availability of high-throughput measurement of gene expressions using microarray techniques, bioinformatics has, in recent years, gained prominence in life sciences research and development. As the next phase of research will see the applications of genomic and proteomic data in the clinical management and treatment of patients, it is inevitable that bioinformatics and health informatics will converge, presenting an exciting new challenge for our field. The terms “biomedical informatics” and “clinical bioinformatics” have been used to describe this convergence.Another exciting challenge for health informatics comes from the spectre of global bioterrorism. Following the September 11, 2001 terrorist attacks in the USA and the spate of anthrax outbreaks there and elsewhere, there has been an urgent need to review current methods of disease surveillance. Current research in “preventive bioterrorism” focuses on the use of prodromal (warning) symptoms to predict serious infectious disease outbreaks. The health informatics challenge, in this case, is to develop a wide area network of health information systems to achieve real-time reporting of prodromal symptoms from sentinel stations and to deploy datamining and decision analytical techniques for the outbreak predictions.The third challenge to be covered in this presentation relates to the deployment of networked virtual reality for remote tele-rehabilitation of patients with cognitive and physical impairments. While the benefits of deploying telemedicinal principles for remote medical rehabilitation of patients are clear, the costs and use of virtual reality pose a real challenge. Some solutions are proposed in this paper.

Does the percutaneous closure of patent foramen ovale help the migraine sufferer?

### What is a migraine? A migraine is a chronic episodic headache condition associated with other symptoms such as nausea/vomiting and sound/light sensitivity. Migraines can be classified into two types: with aura and without aura. An aura is a neurological warning symptom that precedes the headache. More information about migraine headache can be found on the next page. ### What is a patent foramen ovale (PFO)? The heart’s right side receives blood that does not contain much oxygen and pumps the blood into the lungs to get oxygen. Then the blood goes through the heart’s left side to get to the brain and other organs of the body. A patent foramen ovale (PFO) is a persistent hole in the heart’s right/left wall boundary that did not close after birth. This opening can cause blood in the right side of the heart to move into the left side of the heart before it has had a chance to get oxygen from the lungs. When this happens, the rest of the body does not get as much oxygen as it should. It is possible that blood clots can pass through this hole and lead to stroke. The figure shows what this looks like. Figure. Diagram of patent foramen ovale (the hole in the “atrial septum”). ### How is a PFO related to migraine? Research has shown that patients who have a PFO also have migraine …

Women's early warning symptoms of acute myocardial infarction.

Data remain sparse on women's prodromal symptoms before acute myocardial infarction (AMI). This study describes prodromal and AMI symptoms in women. Participants were 515 women diagnosed with AMI from 5 sites. Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, we surveyed them 4 to 6 months after discharge, asking about symptoms, comorbidities, and demographic characteristics. Women were predominantly white (93%), high school educated (54.8%), and older (mean age, 66+/-12), with 95% (n=489) reporting prodromal symptoms. The most frequent prodromal symptoms experienced more than 1 month before AMI were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of breath (42.1%). Only 29.7% reported chest discomfort, a hallmark symptom in men. The most frequent acute symptoms were shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Women had more acute (mean, 7.3+/-4.8; range, 0 to 29) than prodromal (mean, 5.71+/-4.36; range, 0 to 25) symptoms. The average prodromal score, symptom weighted by frequency and intensity, was 58.5+/-52.7, whereas the average acute score, symptom weighted by intensity, was 16.5+/-12.1. These 2 scores were correlated (r=0.61, P<0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology. Most women have prodromal symptoms before AMI. It remains unknown whether prodromal symptoms are predictive of future events.

Response

Response

Plasma lidocaine levels during local anaesthesia of the airway

We report a combined technique of direct application, nebulisation and spray-as-you-go local anaesthesia for airway endoscopy and intubation. Topical lidocaine in a dose of 9 mg.kg−1 appears to be safe for fibreoptic bronchoscopy [1]; however, when nebulised, most of the drug is lost [2]. This study assesses the acceptability of this combined method of airway anaesthesia and measures the plasma lidocaine concentrations achieved in 18 subjects attending a training course. Local Research and Ethics Committee approval was obtained and informed consent given by all delegates volunteering for the study. Following 3 μg.kg−1 intravenous glycopyrronium and xylometazoline 0.1% intranasally, 200 mg lidocaine 4% was nebulised. Lidocaine 5% and 10% was sprayed into the nose and oropharynx respectively. Further doses of lidocaine 4% were administered to the larynx via a fibrescope. A nasotracheal tube was passed once the vocal cords were unreactive. Lidocaine administration was limited to 9 mg.kg−1. For the purpose of dose calculation we estimated that less than 25% of the nebulised lidocaine reached its site of action [2]. Therefore only 50 mg of the 200 mg nebulised was included in our calculation of the dose administered. Heart rate, non-invasive blood pressure and oxygen saturation were recorded automatically at 5-min intervals. After a baseline blood sample, further samples were taken at 10-min intervals until 60 min after the last dose of local anaesthetic. These were assayed for lidocaine using high performance liquid chromatography with UV detection. Delegates graded levels of anxiety, pain and coughing using written and visual analogue scales; in addition, subjects recorded any local anaesthetic side-effects they experienced. We studied 18 volunteers. In all cases, conditions for fibreoptic endoscopy and intubation were good. Eleven subjects received the maximum calculated lidocaine dose of 9 mg.kg−1. The average dose used was 8.7 mg.kg−1. All plasma lidocaine concentrations assayed were below the toxic level of 5 mg.l−1 [3]. Three volunteers reported feeling light-headed following the procedure, despite normal blood pressures. Of these, two had the highest plasma lidocaine concentrations recorded in this study: 3.5 and 4.5 mg.l−1. Sixteen of the 18 subjects found endoscopy and intubation acceptable, two found it enjoyable and no subject rated it as distressing. This method of airway anaesthesia was acceptable to this small group of unsedated subjects. It produced good conditions for fibreoptic intubation. A maximum calculated lidocaine dose of 9 mg.kg−1 failed to produce toxic plasma concentrations of lidocaine in a series of 18 subjects. Those with highest blood levels experienced useful warning symptoms.

Evolution of information on women and heart disease 1957-2000: A review of archival records and secular literature

This project explores the evolution of public information on cardiac disease in women, focusing on warning signs and symptoms. Historical documents available from the American Heart Association of Wisconsin and selected professional and secular literature were reviewed. Analysis revealed little information specific to women's symptoms until the 1980s. During the 1960s, articles and programs focused on how women could take care of their husbands' hearts. The 1980s brought a dramatic surge in literature on women's health, specifically on women's risk for heart disease. The evolution of information about women has mirrored the evolution of women's social roles. Despite the growing body of literature, more information and educational programs are needed to increase public awareness of cardiac warning signs and symptoms in women. (Heart Lung® 2002;31:253-61.)

A review of symptoms of coronary artery disease in women

Research on heart disease has increasingly included information on women's experiences. A number of recent studies present frequencies and comparisons of symptoms between men and women and there appears to be some variability in the symptoms especially among women. Even with acute myocardial infarction (AMI) where anticipated symptoms are more clear-cut, women can have vague or nonclassic symptoms. Selected medical and nursing research on cardiac symptoms is examined for information on the cardiac warning symptom experiences unique to women. A search of the literature between 1995 and 2000 was done using CINAHL and MEDLINE. Terms used for the search included: cardiac symptoms, women's symptoms and symptom perception. The findings from this review are used to suggest implications for clinical practice. Women experiencing AMI present with a variety of symptoms including chest pain. Less obvious symptoms include; fatigue, shortness of breath, back pain, oedema, and transient non-specific chest discomfort. These less dramatic and non-specific symptoms do not necessarily prompt further assessment for coronary disease in women. Cardiac screening of women who present with cardiac risk factors and careful attention to less anticipated symptoms are critical factors that can improve the rapid identification of coronary disease in women. The unique physiological and sociological differences between women and men make further study of women's symptom experiences and perceptions important for health care providers. Further study of gender and ethnic differences in symptom patterns and recognition will help to improve screening and earlier identification of cardiac problems in women patients especially those without chest pain as a prodromal symptom.

Diagnosis and treatment of neurally mediated syncope.

Syncope is caused by a severe but reversible reduction in blood flow to the brain stem neurons responsible for supporting consciousness (reticular activating system). Neurally mediated syncope, also referred to as vasovagal or reflex syncope, is the most frequent cause of loss of consciousness in apparently normal subjects. Neurally mediated syncope is believed to be a reflex response with afferent, central, and efferent pathways. Characteristic autonomic changes in neurally mediated syncope are an increase in parasympathetic efferent activity causing bradycardia and a reduction in sympathetic vasoconstrictor outflow causing vasodilatation. Premonitory symptoms, such as nausea, diaphoresis, abdominal discomfort, and blurred vision, are caused by autonomic activation and are distinguishing features of neurally mediated syncope. Neurally mediated syncope frequently has a characteristic trigger, although this may not be apparent. Testing orthostatic tolerance during passive head-up tilt is the best available diagnostic procedure to evaluate patients with syncope in whom a cardiac cause has been excluded. In many cases, once the diagnosis of neurally mediated syncope is confirmed, it may suffice to reassure the patient and teach him to avoid known triggers and to recognize and act upon early warning symptoms. Because subjects with neurally mediated syncope may potentially be sodium depleted, increasing salt intake can be beneficial in improving their orthostatic intolerance. Neurally mediated syncope is the most common form of syncope in healthy adults. The best diagnostic tools are the clinical history and passive head-up tilt. The best treatment strategies are the avoidance of triggering factors as well as intravascular volume expansion.

医薬品市販後に追加される重大な副作用の現状

When a novel additional adverse effect is reported for a marketed medicine, the medical information leaflet has to be revised to inform physicians and pharmacists of this. Pharmacists are responsible for informing patients of early warning symptoms to avoid the subsequent appearance of severe adverse effects. However, at present, patients may suffer from severe adverse events because such symptoms may remain unrecognized until the medicine is on the market. As a result, investigations to predict and prevent novel additional adverse effects of medicines are required. In this study, we investigated a novel additional adverse effect classified as a pharmacological effect based on the drug safety update (DSU). As a result, skin disorders including toxic epidermal necrolysis and Stevens Johnson syndrome, and pseudomembranous colitis have become evident as additional adverse effects of antibiotics, with a high incidence. In addition, neuroleptic malignant syndrome and aplastic anemia have also been reported as adverse effects of central nervous system agents.Therefore, it is important to provide patients with information about the early warning symptoms related to such adverse effects, even though such adverse effects are not contained in the patient information leaflet.

Current diagnosis and treatment modalities for ovarian cancer.

Ovarian cancer is the major pelvic cancer health hazard for women. In 2000, the American Cancer Society estimates that 23,100 new ovarian cancer cases will be diagnosed and 14,000 women will have died of ovarian cancer (1). It is the fifth most common cancer in American women but the fourth most common cause of cancer death (1). The high mortality rate is due in part to a lack of obvious early warning symptoms, unavailability of sensitive early detection techniques and therapy of limited effectiveness. Despite improvements in management of women with epithelial ovarian cancer, the overall survival for this disease has been unchanged for at least the last 20 years (2). This chapter will concentrate on advances in the diagnosis and management of epithelial ovarian cancers, the form of ovarian cancer that represents at least 90% of all ovarian malignancies.

The role of early warning symptoms in the detection and prevention of relapse in schizophrenia.

The capacity of most clinical programs to detect early signs of relapse in schizophrenia and to implement strategies to prevent clinical progression remains unevaluated. The aim of this paper is to review the literature on the detection of relapse in schizophrenia and to draw conclusions that may be of use in the implementation of clinical programs. The relevant literature identified by standard search methods is explored and analysed. Few studies have the capacity to directly address the question as to whether it is possible to predict relapse with a high degree of predictive power. Recently, the implementation of a multifactorial approach to relapse prediction appears to have offered substantial benefits. The prediction of episodes of psychotic relapse is a realistic goal. Evidence indicates that interventions based upon programs of early detection can reduce rates of illness relapse. Prediction of relapse is most successful when implemented in a multifactorial way that involves specific and non-specific symptoms, structured ratings, clinical judgement, families, patients and clinicians.

Asthma self-management: the perspective of children

This qualitative study explored the knowledge, perceptions, and autonomy of 7- and 12-year-old children relative to the management of their asthma. A total of 32 children with moderate to severe asthma were interviewed using an open-ended drawing interview and a semi-structured interview. The triangulation of results from these two methods revealed developmental differences. Younger children identified medicines by shape, color, or lay terms, relied on adults to manage their asthma, and did not recognize warning symptoms of an attack. Older children mastered biomedical terminology and used medicines independently, although they sometimes asked for the assistance of an adult. All children perceived benefits and non-monetary costs of asthma medicines. However, they lacked understanding of the categories and role of asthma medicines. This study suggests that long-term control and quick-relief metered dose inhalers should be identifiable by consistent color-coding, and that professionals should tailor asthma education and information to children’s stages of cognitive development.

GENDER AND RACE DIFFERENCES IN CORONARY ARTERY DISEASE - ANGINA WARNING SYSTEM

Limited data exist about possible gender and race differences in symptom presentation at angina onset; thus the impetus for this study. Structured interviews and chart audits were used to assess differences in angina presentation between male (M) (n = 319; age = 60.0 ± 11.3; EF = 51.1 ± 11.9%) and female (F) (n = 131; age = 60.9 ± 12.4; EF = 53.5 ± 13.0%) patients enrolling in a comprehensive cardiac rehabilitation program (CRP). There were no significant gender differences in primary admission diagnosis [M v. F, respectively: CAD (11.8 v. 10.9%), stable angina (22.0 v.30.5%), MI (20.7 v.23.4%), CABG (45.5 v.35.2%)]. There were no significant gender differences in angina description [chest pain (44.4 v. 44.4%), pressure (16.8 v. 23.8%), tightness (16.5% v. 18.3%), burning (7.6 v. 3.2%), angina equivalent (4.6 v. 2.4%), silent (10.1 v. 7.9%)], location origin [chest (80.8 v. 82.1%), neck/jaw (4.7 v. 5.1%), back (0.4 v. 3.4%), shoulder/arm/hand (8.3 v. 6.8%), other (5.8 v. 2.6)], or in the precipitating factors [exertion (67.2 v. 58.3%), rest (22.6 v. 29.6%), mental/emotional stress (1.8 v. 4.6%), eating (2.6 v. 1.9%), other (5.8 v. 5.6%)]. White males (WM) were twice as likely as BM to report chest pain (46.0 v. 23.5%) and black females (BF) and BM were 4.6 and 2.5 times, respectively, more likely not to experience any angina warning symptoms than WF (26.7 v. 5.8%) and WM (23.5 v. 9.6%) (p < 0.05). These data indicate: (1) more than 90% of CAD patients enrolling in CRP have a history of angina; (2) approximately one-half (55.6%) of CAD patients with angina history deny chest pain; (3) no gender difference exist in angina presentation; and (4) African Americans are more likely than whites not to have an angina warning system. The development of an individualized angina warning system should improve the patient's ability to detect the onset of a subsequent cardiac episode, seek medical treatment in a more timely manner, and consequently, recover quicker and improve odds for survival.

Irritable bowel syndrome

PREVIEWIrritable bowel syndrome (IBS) is a functional disorder that may exhibit alarming warning symptoms of serious organic disease. But features of IBS, as described in two diagnostic models, are usually present in clusters. Application of the criteria and limited laboratory and clinical testing usually allow for a conclusive diagnosis. Dr Licht offers treatment options, including patient education, counseling, and agents for symptomatic relief.

Ethnicity and childhood mortality in The Netherlands

Background: This paper describes the rates and the causes of differences in childhood mortality between Turkish, Moroccan and native Dutch children in The Netherlands. Methods: Retrospective analysis of all routinely collected death certificates of 0-15 year old children who died between 1979 and 1993. In total 20,211 death certificates of which 1,764 of Turkish and Moroccan children were analysed. Childhood mortality was divided into four age periods, analysed according to ICD-9 codes and measured over three five-year periods. Results: Compared to native Dutch children, the relative mortality risk (RR) for Turkish and Moroccan infants and children is twice as high. It did diminish from 3.2 in the first five- year period (1979-1983) to 2.2 in the second (1984-1988). After 1988 no further decline In relative mortality risk was noticed (RR: 2.1). Minor differences were found between the Turkish and Moroccan groups in the four different age categories. The relative risk for Turkish and Moroccan children to die from different diagnostic categories is as follows: Infectious diseases: RR 2.2 (95% Cl: 1.83-2.68), hereditary (metabolic) disorders: RR 2.0 (Cl: 1.78-2.20), accidents and drowning RR 1.9 (Cl: 1.64-2.21). There was a decline In all cause specific mortality ratios over time except for hereditary disorders and (traffic) accidents and drowning. One quarter of the Turkish and Moroccan children died while on holiday in their country of origin. The only significant difference between the Turkish and Moroccan group was found in Sudden Infant Death Syndrome. While the actual number of SIDS cases declined drastically over the last five year period, the SIDS rate for Turkish infants remained twice as high as for Dutch Infants and four times higher than for Moroccan infants. Conclusion: Differences in mortality between Turkish, Moroccan and Dutch children are significant and have hardly changed during the last 10 years. Apart from apparent socio-economic differences, socio-cultural and life-style factors may play an important role as well. Preventive measures such as health and safety education concerning the (yearly) holiday trip to the country of origin, genetic counselling in consanguinity, better knowledge of early warning symptoms of serious infectious diseases, road safety education and early swimming-lessons are possible. The high SIDS differences have to be investigated further.

Conocimientos, creencias y actitudes de la población femenina de Mallorca respecto al cáncer

BACKGROUND: To analyze the knowledge of the facts on the part of the female population of Mallorca with regard to the causes of cancer, the beliefs regarding diagnosis and treatment and their attitude toward prevention. METHODS: A descriptive cross-section study of a random population sample (n=124) of women within the 40-69 age range. The questionnaire includes socio-demographic variables, risk factors, early warning symptoms and beliefs regarding diagnosis and treatment and attitudes toward prevention. RESULTS: Cigarette smoking (92.7%;CI:88.1-97.3) and drinking alcoholic (85.7%; CI:79.4-92.0) are the most well-identified causes. Also the presence of a lump in the breast (92.6%;CI:87.9-97.2) and changes in a mole or wart on the skin (89.7% ; CI:84.2-95.2%). The underestimate the role of the diet (44.4%; CI:35.1-53.8) and overestimate the environmental factors. The knowledge and use of self-examination procedures on the breast are associated directly with the degree of education (p<0.05). Most believe that early diagnosis improves the prognosis (98.4%; CI:94.2-99.5) and that treatment is beneficial (85.2%; CI:78.5-91.9). They consider surgery to be the most highly effective method, and in the event of any doubt they would first see their primary care physician (41.9%; CI:33.2-50.6). It is mainly older women having a low level of completed schooling who get their information regarding cancer above all from the television (43.5%; CI:34.8-52.3). Worthy of special mention is the very small impact of health care personal as a source of information (6.5%; CI:2.1-10.8). CONCLUSIONS: A major knowledge of the facts exists regarding the causes and warning signs, although some misconceptions do exist. In view of future prevention campaigns, educational measures addressed mainly to older women having a low level of completed schooling should be carried out.

Reduced beta-adrenergic sensitivity in patients with type 1 diabetes and hypoglycemia unawareness.

We tested the hypothesis that impaired tissue sensitivity to catecholamines contributes to hypoglycemia unawareness in subjects with type 1 diabetes. A total of 21 subjects with type 1 diabetes underwent a standardized insulin infusion protocol to produce a stepwise decrease in plasma glucose to 45-min plateaus of 4.3, 3.6, 3.0, and 2.3 mmol/l. Glycemic thresholds, maximum responses for adrenergic and neuroglycopenic symptoms, and counterregulatory hormones were determined. Patients were classified as hypoglycemia unaware if the initiation of adrenergic symptoms occurred at a plasma glucose level 2 SD below that of nondiabetic volunteers. beta-Adrenergic sensitivity was measured as the dose of isoproterenol required to produce an increment in heart rate of 25 beats per minute above baseline (I25) in resting subjects. Subjects with type 1 diabetes and hypoglycemia unawareness experienced the onset of adrenergic symptoms at a lower plasma glucose level than did those with awareness (2.5+/-0.1 vs. 3.7+/-0.1 mmol/l, P < 0.001), whereas neuroglycopenic symptoms occurred at similar glucose levels (2.7+/-0.2 vs. 2.8+/- 0.1 mmol/l). The plasma glucose levels for counterregulatory hormone secretion (epinephrine 2.9+/-0.2 vs. 4.1+/-0.2 mmol/l; norepinephrine 2.7+/-0.1 vs. 3.2+/-0.2 mmol/l; cortisol 2.5+/-0.2 vs. 3.3+/-0.2 mmol/l, P < 0.01) were also lower in subjects with unawareness. The maximal epinephrine (1,954+/-486 vs. 5,332+/- 1,059 pmol/l, P < 0.01), norepinephrine (0.73 +/- 0.14 vs. 1.47+/-0.21 nmol/l, P = 0.04), and cortisol (276+/-110 vs. 579+/-83 nmol/l, P < 0.01) responses were reduced in the unaware group. I25 was greater in unaware subjects than in subjects without unawareness (1.5+/-0.3 vs. 0.8+/-0.2 microg), where I25 was not different from that of controls (0.8 +/-0.2 microg). We conclude that subjects with type 1 diabetes and hypoglycemia unawareness have reduced beta-adrenergic sensitivity, which may contribute to their impaired adrenergic warning symptoms during hypoglycemia.

Improved glucose counterregulation and autonomic symptoms after intraportal islet transplants alone in patients with long-standing type I diabetes mellitus.

Defective glucose counterregulation and hypoglycemia unawareness are both well-recognized risk factors for recurrent episodes of severe hypoglycemia in patients with type I diabetes. At present, no conventional therapy is available to routinely overcome these acquired impairments in long-standing diabetes. To test the hypothesis that successful intraportal islet transplantation could improve this syndrome, hormonal counterregulatory responses and symptoms were studied during stepped hypoglycemic clamp tests before and after intraportal islet transplantation in three patients with type I diabetes who were prone to severe hypoglycemia. As compared with matched nondiabetic control subjects, before islet transplantation, glucagon responses were absent while epinephrine and cortisol responses were either markedly decreased or absent in all diabetic subjects. One patient also had decreased norepinephrine and growth hormone responses. Autonomic warning symptoms were absent in all patients during hypoglycemia. One month after successful islet transplantation, there was no improvement in the glucagon response. However, glycemic thresholds and/or peak incremental responses of epinephrine, norepinephrine, and cortisol improved in all patients. Moreover, all patients had developed autonomic warning symptoms so that glycemic thresholds were detectable within the examined range. We conclude that intraportal islet transplantation does not restore hypoglycemia-induced glucagon secretion, but it improves the responses of most counterregulatory hormones and hypoglycemic warning symptoms even in long-standing type I diabetes.

Premonitory and prodromal symptoms in cluster headache.

Warning symptoms in 150 cluster headache patients were studied by focusing on attacks occurring during waking hours. Warnings were divided into prodromes that started minutes before the pain of individual attacks (122 patients) and premonitory symptoms preceding the onset of cluster periods by days to weeks (12 patients). Pathogenetic and therapeutic implications are discussed.