Article

Members of the United States military who served in Vietnam between 1961 and 1971 risked exposure to the weaponized chemical defoliant known as Agent Orange. Among the components of Agent Orange, benzene and tetrachlorodibenzo-p-dioxin (TCDD) are known carcinogens linked to several cancers. They include multiple myeloma, Hodgkin and non-Hodgkin lymphoma, as well as bladder, prostate, and lung cancer. 

In this ReCAP, Dr Timothy O'Brien, section chief of hematology at the Louis Stokes Cleveland VA Medical Center, examines the evidence that suggests a link between service-related Agent Orange exposure and acute myeloid leukemia (AML). He discusses preclinical models that show a relationship between benzene and TCDD exposure and the development of AML. 

Dr O'Brien also explains the factors that have limited researchers' ability to positively connect Agent Orange and AML. For example, there is a dwindling cohort of affected patients to study because dioxins can lie latent in fat cells for more than a decade, delaying the development of AML. During that time, many veterans will have died from unrelated causes. 

More research is needed for veterans to receive service-connected benefits for AML diagnoses. However, as Dr O'Brien notes, the PACT Act provides coverage for veterans who developed AML after exposure to benzene-contaminated water at Camp Lejeune. 

--

Timothy O'Brien, MD, Associate Professor, Case Western Reserve University School of Medicine; Chief of Hematology, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio  

Timothy O'Brien, MD, has disclosed no relevant financial relationships. 

Members of the United States military who served in Vietnam between 1961 and 1971 risked exposure to the weaponized chemical defoliant known as Agent Orange. Among the components of Agent Orange, benzene and tetrachlorodibenzo-p-dioxin (TCDD) are known carcinogens linked to several cancers. They include multiple myeloma, Hodgkin and non-Hodgkin lymphoma, as well as bladder, prostate, and lung cancer. 

In this ReCAP, Dr Timothy O'Brien, section chief of hematology at the Louis Stokes Cleveland VA Medical Center, examines the evidence that suggests a link between service-related Agent Orange exposure and acute myeloid leukemia (AML). He discusses preclinical models that show a relationship between benzene and TCDD exposure and the development of AML. 

Dr O'Brien also explains the factors that have limited researchers' ability to positively connect Agent Orange and AML. For example, there is a dwindling cohort of affected patients to study because dioxins can lie latent in fat cells for more than a decade, delaying the development of AML. During that time, many veterans will have died from unrelated causes. 

More research is needed for veterans to receive service-connected benefits for AML diagnoses. However, as Dr O'Brien notes, the PACT Act provides coverage for veterans who developed AML after exposure to benzene-contaminated water at Camp Lejeune. 

--

Timothy O'Brien, MD, Associate Professor, Case Western Reserve University School of Medicine; Chief of Hematology, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio  

Timothy O'Brien, MD, has disclosed no relevant financial relationships. 

Members of the United States military who served in Vietnam between 1961 and 1971 risked exposure to the weaponized chemical defoliant known as Agent Orange. Among the components of Agent Orange, benzene and tetrachlorodibenzo-p-dioxin (TCDD) are known carcinogens linked to several cancers. They include multiple myeloma, Hodgkin and non-Hodgkin lymphoma, as well as bladder, prostate, and lung cancer. 

In this ReCAP, Dr Timothy O'Brien, section chief of hematology at the Louis Stokes Cleveland VA Medical Center, examines the evidence that suggests a link between service-related Agent Orange exposure and acute myeloid leukemia (AML). He discusses preclinical models that show a relationship between benzene and TCDD exposure and the development of AML. 

Dr O'Brien also explains the factors that have limited researchers' ability to positively connect Agent Orange and AML. For example, there is a dwindling cohort of affected patients to study because dioxins can lie latent in fat cells for more than a decade, delaying the development of AML. During that time, many veterans will have died from unrelated causes. 

More research is needed for veterans to receive service-connected benefits for AML diagnoses. However, as Dr O'Brien notes, the PACT Act provides coverage for veterans who developed AML after exposure to benzene-contaminated water at Camp Lejeune. 

--

Timothy O'Brien, MD, Associate Professor, Case Western Reserve University School of Medicine; Chief of Hematology, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio  

Timothy O'Brien, MD, has disclosed no relevant financial relationships. 

Vacuum-assisted closure (VAC) of wounds has become a foundational tool in the armamentarium of wound care specialists. Using a system consisting of a sponge, semi-occlusive barrier, and fluid collection device, VAC systems apply constant negative pressure resulting in macro and micro deformation to a wound, stabilization of the wound environment, and removal of inflammatory factors in wound fluid.¹ These conditions allow for the removal of drainage and fluid from a wound bed, reduced edema and inflammation, reduced bacterial load, recruitment of healing factors, approximation of wound edges, and increased blood flow to the wound.²

In complex, infected wounds, a variation of negative pressure wound therapy (NPWT) via the instillation of topical antibiotics (instillation VAC) has been used.³ This variation has been advantageous even in soft tissue fungal infections. Early and aggressive treatment of such infections is critical to prevent dissemination, particularly in aggressive infections, such as mucormycosis.⁴ We present a case of a patient with a mucormycosis infection of his left Achilles tendon and overlying skin who was successfully treated with surgical debridement and wound care with instillation NPWT with topical amphotericin B.

Case Presentation

A 53-year-old man underwent left Achilles tendon reconstruction with allograft after a complete tear during exercise. He had no relevant medical history and was otherwise healthy, which he attributed to working out daily. About a week after the operation, he began having incisional breakdown, prompting presentation to an emergency department. There, he received IV antibiotics along with multiple debridements. After the wound failed to improve and intra-operative cultures grew mucormycosis, he was transferred to our facility for a higher level of care. On admission, he was immediately given IV amphotericin B and scheduled for repeat debridement.

After 1 prior debridement and 10 total days of IV amphotericin, a repeat debridement was performed. After the debridement, the installation VAC was applied to the patient’s left lower extremity wound with an instilling fluid of amphotericin B and the settings as follows: smart phase instill volume, 110 mL; soak time, 3.5 hours; target pressure, 125 mm Hg; intensity, low; and VAC therapy mode, continuous. After 5 days, the wound bed appeared clean without overt signs of infection. However, due to some toxicity to healthy surrounding soft tissue, the instillation VAC was discontinued and standard NPWT was started. The patient underwent 2 additional rounds of debridement with partial delayed closure. Four weeks after discontinuation of the instillation VAC, the wound appeared healthy and granulated so the patient underwent split-thickness skin grafting to the left posterior ankle. He subsequently completed a course of oral antifungal medication as an outpatient.

The patient was seen in the outpatient clinic for 14 months from the initial mucormycosis infection (Figure).

Discussion

Mucormycosis is an infection caused by fungi in the class Zygomycetes and of the order Mucorales that typically occurs in immunocompromised patients, especially those with diabetic ketoacidosis and neutropenia. Given that this patient had no relevant medical history and was otherwise healthy, he was at extremely low risk of this type of infection. In this patient’s case, the spores of this nonseptate hyphae wide-branching species were most likely introduced at the time of left Achilles tendon repair. Mucormycosis is progressive and can be fatal unless treated, with a mortality rate approaching 70%.⁵ The rarity and heterogeneity of mucormycosis make treatment variable.⁶ No prospective or randomized clinical trials exist in plastic surgery literature.

The use of wound VAC in combination with the instillation of amphotericin B to treat cutaneous mucormycosis is not well documented. Mucormycosis infections are traditionally addressed with surgical debridement and antifungal therapy, specifically IV amphotericin B.^7,8 As previously noted, NPWT has become the gold standard in treating complex wounds.³ Additionally, wound VAC therapy with instillation has been noted in the literature as a reliable method to treat bacteria-infected wounds, providing a shorter treatment period and earlier wound closure.⁹ Instillation VAC therapy has proven particularly useful in complex, infected wounds, such as aggressive fungal infections.

Mucormycosis treatment is challenging particularly in the extremities as management must balance both mortality and limb salvage. In this case, the use of NPWT with wound VAC and intervals of instilling amphotericin B facilitated infection control in this lower extremity mucormycosis infection. The significant adverse effect profile of amphotericin B, particularly the nephrotoxicity, should be seriously considered when deciding the treatment regimen for patients affected by mucormycosis. Locally, topical amphotericin B has been reported to cause blistering, itchiness, redness, peeling, and dryness. However, topical preparations of amphotericin B are nontoxic unlike their IV counterpart, able to cross the physiological barriers of the skin while simultaneously targeting macrophages in the dermis and epidermis.¹⁰

Conclusions

Although the mainstay of treatment for systemic mucormycosis is radical debridement and IV amphotericin B, a more localized infection may benefit from an adjunct like an instillation wound VAC with topical amphotericin B, as presented in this case study. Swift treatment with wound VAC was beneficial in the overall recovery and tissue healing of this patient and may be beneficial in similar cases.

Vacuum-assisted closure (VAC) of wounds has become a foundational tool in the armamentarium of wound care specialists. Using a system consisting of a sponge, semi-occlusive barrier, and fluid collection device, VAC systems apply constant negative pressure resulting in macro and micro deformation to a wound, stabilization of the wound environment, and removal of inflammatory factors in wound fluid.¹ These conditions allow for the removal of drainage and fluid from a wound bed, reduced edema and inflammation, reduced bacterial load, recruitment of healing factors, approximation of wound edges, and increased blood flow to the wound.²

In complex, infected wounds, a variation of negative pressure wound therapy (NPWT) via the instillation of topical antibiotics (instillation VAC) has been used.³ This variation has been advantageous even in soft tissue fungal infections. Early and aggressive treatment of such infections is critical to prevent dissemination, particularly in aggressive infections, such as mucormycosis.⁴ We present a case of a patient with a mucormycosis infection of his left Achilles tendon and overlying skin who was successfully treated with surgical debridement and wound care with instillation NPWT with topical amphotericin B.

Case Presentation

A 53-year-old man underwent left Achilles tendon reconstruction with allograft after a complete tear during exercise. He had no relevant medical history and was otherwise healthy, which he attributed to working out daily. About a week after the operation, he began having incisional breakdown, prompting presentation to an emergency department. There, he received IV antibiotics along with multiple debridements. After the wound failed to improve and intra-operative cultures grew mucormycosis, he was transferred to our facility for a higher level of care. On admission, he was immediately given IV amphotericin B and scheduled for repeat debridement.

After 1 prior debridement and 10 total days of IV amphotericin, a repeat debridement was performed. After the debridement, the installation VAC was applied to the patient’s left lower extremity wound with an instilling fluid of amphotericin B and the settings as follows: smart phase instill volume, 110 mL; soak time, 3.5 hours; target pressure, 125 mm Hg; intensity, low; and VAC therapy mode, continuous. After 5 days, the wound bed appeared clean without overt signs of infection. However, due to some toxicity to healthy surrounding soft tissue, the instillation VAC was discontinued and standard NPWT was started. The patient underwent 2 additional rounds of debridement with partial delayed closure. Four weeks after discontinuation of the instillation VAC, the wound appeared healthy and granulated so the patient underwent split-thickness skin grafting to the left posterior ankle. He subsequently completed a course of oral antifungal medication as an outpatient.

The patient was seen in the outpatient clinic for 14 months from the initial mucormycosis infection (Figure).

Discussion

Mucormycosis is an infection caused by fungi in the class Zygomycetes and of the order Mucorales that typically occurs in immunocompromised patients, especially those with diabetic ketoacidosis and neutropenia. Given that this patient had no relevant medical history and was otherwise healthy, he was at extremely low risk of this type of infection. In this patient’s case, the spores of this nonseptate hyphae wide-branching species were most likely introduced at the time of left Achilles tendon repair. Mucormycosis is progressive and can be fatal unless treated, with a mortality rate approaching 70%.⁵ The rarity and heterogeneity of mucormycosis make treatment variable.⁶ No prospective or randomized clinical trials exist in plastic surgery literature.

The use of wound VAC in combination with the instillation of amphotericin B to treat cutaneous mucormycosis is not well documented. Mucormycosis infections are traditionally addressed with surgical debridement and antifungal therapy, specifically IV amphotericin B.^7,8 As previously noted, NPWT has become the gold standard in treating complex wounds.³ Additionally, wound VAC therapy with instillation has been noted in the literature as a reliable method to treat bacteria-infected wounds, providing a shorter treatment period and earlier wound closure.⁹ Instillation VAC therapy has proven particularly useful in complex, infected wounds, such as aggressive fungal infections.

Mucormycosis treatment is challenging particularly in the extremities as management must balance both mortality and limb salvage. In this case, the use of NPWT with wound VAC and intervals of instilling amphotericin B facilitated infection control in this lower extremity mucormycosis infection. The significant adverse effect profile of amphotericin B, particularly the nephrotoxicity, should be seriously considered when deciding the treatment regimen for patients affected by mucormycosis. Locally, topical amphotericin B has been reported to cause blistering, itchiness, redness, peeling, and dryness. However, topical preparations of amphotericin B are nontoxic unlike their IV counterpart, able to cross the physiological barriers of the skin while simultaneously targeting macrophages in the dermis and epidermis.¹⁰

Conclusions

Although the mainstay of treatment for systemic mucormycosis is radical debridement and IV amphotericin B, a more localized infection may benefit from an adjunct like an instillation wound VAC with topical amphotericin B, as presented in this case study. Swift treatment with wound VAC was beneficial in the overall recovery and tissue healing of this patient and may be beneficial in similar cases.

Vacuum-assisted closure (VAC) of wounds has become a foundational tool in the armamentarium of wound care specialists. Using a system consisting of a sponge, semi-occlusive barrier, and fluid collection device, VAC systems apply constant negative pressure resulting in macro and micro deformation to a wound, stabilization of the wound environment, and removal of inflammatory factors in wound fluid.¹ These conditions allow for the removal of drainage and fluid from a wound bed, reduced edema and inflammation, reduced bacterial load, recruitment of healing factors, approximation of wound edges, and increased blood flow to the wound.²

In complex, infected wounds, a variation of negative pressure wound therapy (NPWT) via the instillation of topical antibiotics (instillation VAC) has been used.³ This variation has been advantageous even in soft tissue fungal infections. Early and aggressive treatment of such infections is critical to prevent dissemination, particularly in aggressive infections, such as mucormycosis.⁴ We present a case of a patient with a mucormycosis infection of his left Achilles tendon and overlying skin who was successfully treated with surgical debridement and wound care with instillation NPWT with topical amphotericin B.

Case Presentation

A 53-year-old man underwent left Achilles tendon reconstruction with allograft after a complete tear during exercise. He had no relevant medical history and was otherwise healthy, which he attributed to working out daily. About a week after the operation, he began having incisional breakdown, prompting presentation to an emergency department. There, he received IV antibiotics along with multiple debridements. After the wound failed to improve and intra-operative cultures grew mucormycosis, he was transferred to our facility for a higher level of care. On admission, he was immediately given IV amphotericin B and scheduled for repeat debridement.

After 1 prior debridement and 10 total days of IV amphotericin, a repeat debridement was performed. After the debridement, the installation VAC was applied to the patient’s left lower extremity wound with an instilling fluid of amphotericin B and the settings as follows: smart phase instill volume, 110 mL; soak time, 3.5 hours; target pressure, 125 mm Hg; intensity, low; and VAC therapy mode, continuous. After 5 days, the wound bed appeared clean without overt signs of infection. However, due to some toxicity to healthy surrounding soft tissue, the instillation VAC was discontinued and standard NPWT was started. The patient underwent 2 additional rounds of debridement with partial delayed closure. Four weeks after discontinuation of the instillation VAC, the wound appeared healthy and granulated so the patient underwent split-thickness skin grafting to the left posterior ankle. He subsequently completed a course of oral antifungal medication as an outpatient.

The patient was seen in the outpatient clinic for 14 months from the initial mucormycosis infection (Figure).

Discussion

Mucormycosis is an infection caused by fungi in the class Zygomycetes and of the order Mucorales that typically occurs in immunocompromised patients, especially those with diabetic ketoacidosis and neutropenia. Given that this patient had no relevant medical history and was otherwise healthy, he was at extremely low risk of this type of infection. In this patient’s case, the spores of this nonseptate hyphae wide-branching species were most likely introduced at the time of left Achilles tendon repair. Mucormycosis is progressive and can be fatal unless treated, with a mortality rate approaching 70%.⁵ The rarity and heterogeneity of mucormycosis make treatment variable.⁶ No prospective or randomized clinical trials exist in plastic surgery literature.

The use of wound VAC in combination with the instillation of amphotericin B to treat cutaneous mucormycosis is not well documented. Mucormycosis infections are traditionally addressed with surgical debridement and antifungal therapy, specifically IV amphotericin B.^7,8 As previously noted, NPWT has become the gold standard in treating complex wounds.³ Additionally, wound VAC therapy with instillation has been noted in the literature as a reliable method to treat bacteria-infected wounds, providing a shorter treatment period and earlier wound closure.⁹ Instillation VAC therapy has proven particularly useful in complex, infected wounds, such as aggressive fungal infections.

Mucormycosis treatment is challenging particularly in the extremities as management must balance both mortality and limb salvage. In this case, the use of NPWT with wound VAC and intervals of instilling amphotericin B facilitated infection control in this lower extremity mucormycosis infection. The significant adverse effect profile of amphotericin B, particularly the nephrotoxicity, should be seriously considered when deciding the treatment regimen for patients affected by mucormycosis. Locally, topical amphotericin B has been reported to cause blistering, itchiness, redness, peeling, and dryness. However, topical preparations of amphotericin B are nontoxic unlike their IV counterpart, able to cross the physiological barriers of the skin while simultaneously targeting macrophages in the dermis and epidermis.¹⁰

Conclusions

Although the mainstay of treatment for systemic mucormycosis is radical debridement and IV amphotericin B, a more localized infection may benefit from an adjunct like an instillation wound VAC with topical amphotericin B, as presented in this case study. Swift treatment with wound VAC was beneficial in the overall recovery and tissue healing of this patient and may be beneficial in similar cases.

In the article, “Nonsurgical treatments for patients with urinary incontinence” (OBG Manag. September 2022;34:36- 42.), the authors, Ashley J. Murillo, MD, and Halina M. Zyczynski, MD, discuss the successful nonsurgical management of urge urinary incontinence, stress urinary incontinence, and mixed urinary incontinence, presenting the case of a 39-year-old woman with urine leakage during exercise. As a follow-up for readers, OBG Management posted a quiz question asking, “Which of the following is a nonsurgical treatment for stress urinary incontinence?”

In the article, “Nonsurgical treatments for patients with urinary incontinence” (OBG Manag. September 2022;34:36- 42.), the authors, Ashley J. Murillo, MD, and Halina M. Zyczynski, MD, discuss the successful nonsurgical management of urge urinary incontinence, stress urinary incontinence, and mixed urinary incontinence, presenting the case of a 39-year-old woman with urine leakage during exercise. As a follow-up for readers, OBG Management posted a quiz question asking, “Which of the following is a nonsurgical treatment for stress urinary incontinence?”

In the article, “Nonsurgical treatments for patients with urinary incontinence” (OBG Manag. September 2022;34:36- 42.), the authors, Ashley J. Murillo, MD, and Halina M. Zyczynski, MD, discuss the successful nonsurgical management of urge urinary incontinence, stress urinary incontinence, and mixed urinary incontinence, presenting the case of a 39-year-old woman with urine leakage during exercise. As a follow-up for readers, OBG Management posted a quiz question asking, “Which of the following is a nonsurgical treatment for stress urinary incontinence?”

Key clinical point: Increased intake of dietary fiber seemed protective against migraine or severe headache in a large population of US adults.

Major finding: Risk for migraine or severe headache was 26% lower among patients in the highest (22.10-95.50 g/day) vs lowest (0.0-7.79 g/day) quintile of dietary fiber intake (adjusted odds ratio 0.74; P  =  .0029).

Study details: This cross-sectional study included 12,710 participants from the US National Health and Nutrition Examination Survey, of which 2527 experienced migraine or severe headache.

Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.

Source: Huang H and He K. The association between dietary fiber intake and severe headaches or migraine in US adults. Front Nutr. 2023;9:1044066  (Jan 4). Doi: 10.3389/fnut.2022.1044066

Key clinical point: Increased intake of dietary fiber seemed protective against migraine or severe headache in a large population of US adults.

Major finding: Risk for migraine or severe headache was 26% lower among patients in the highest (22.10-95.50 g/day) vs lowest (0.0-7.79 g/day) quintile of dietary fiber intake (adjusted odds ratio 0.74; P  =  .0029).

Study details: This cross-sectional study included 12,710 participants from the US National Health and Nutrition Examination Survey, of which 2527 experienced migraine or severe headache.

Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.

Source: Huang H and He K. The association between dietary fiber intake and severe headaches or migraine in US adults. Front Nutr. 2023;9:1044066  (Jan 4). Doi: 10.3389/fnut.2022.1044066

Key clinical point: Increased intake of dietary fiber seemed protective against migraine or severe headache in a large population of US adults.

Major finding: Risk for migraine or severe headache was 26% lower among patients in the highest (22.10-95.50 g/day) vs lowest (0.0-7.79 g/day) quintile of dietary fiber intake (adjusted odds ratio 0.74; P  =  .0029).

Study details: This cross-sectional study included 12,710 participants from the US National Health and Nutrition Examination Survey, of which 2527 experienced migraine or severe headache.

Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.

Source: Huang H and He K. The association between dietary fiber intake and severe headaches or migraine in US adults. Front Nutr. 2023;9:1044066  (Jan 4). Doi: 10.3389/fnut.2022.1044066

Key clinical point: Index vein served as a good biomarker for migraine aura with a high diagnostic specificity and sensitivity in the emergency setting in patients with acute neurological deficit.

Major finding: Prevalence of index vein was more frequent in patients with migraine aura (17%) vs those with stroke (2%)/epileptic seizure (4%) or control participants (1%; P < .001). Index vein was highly specific to migraine aura (specificity 97%; 95% CI 95%-99%), with an ability to diagnose migraine aura with 94% sensitivity (95% CI 87.4%-97.8%) and 73.5% specificity (95% CI 66.8%-79.5%) at a cut-off of 4 points.

Study details: This retrospective case-control study included 400 patients who presented to the emergency department with an acute neurological deficit, underwent brain magnetic resonance imaging, and were discharged with a diagnosis of migraine aura/ischemic stroke/epileptic seizure or none of these (control participants).

Disclosures: This study did not receive any specific funding. Two authors declared serving as part-time employees at Zynnon or as a consultant, speaker, or advisory board member for various sources.

Source: Scutelnic A et al. The “index vein” as a sign for migraine aura in the emergency setting. Cephalalgia. 2023 (Jan 9). Doi: 10.1177/033310242211320

Key clinical point: Index vein served as a good biomarker for migraine aura with a high diagnostic specificity and sensitivity in the emergency setting in patients with acute neurological deficit.

Major finding: Prevalence of index vein was more frequent in patients with migraine aura (17%) vs those with stroke (2%)/epileptic seizure (4%) or control participants (1%; P < .001). Index vein was highly specific to migraine aura (specificity 97%; 95% CI 95%-99%), with an ability to diagnose migraine aura with 94% sensitivity (95% CI 87.4%-97.8%) and 73.5% specificity (95% CI 66.8%-79.5%) at a cut-off of 4 points.

Study details: This retrospective case-control study included 400 patients who presented to the emergency department with an acute neurological deficit, underwent brain magnetic resonance imaging, and were discharged with a diagnosis of migraine aura/ischemic stroke/epileptic seizure or none of these (control participants).

Disclosures: This study did not receive any specific funding. Two authors declared serving as part-time employees at Zynnon or as a consultant, speaker, or advisory board member for various sources.

Source: Scutelnic A et al. The “index vein” as a sign for migraine aura in the emergency setting. Cephalalgia. 2023 (Jan 9). Doi: 10.1177/033310242211320

Key clinical point: Index vein served as a good biomarker for migraine aura with a high diagnostic specificity and sensitivity in the emergency setting in patients with acute neurological deficit.

Major finding: Prevalence of index vein was more frequent in patients with migraine aura (17%) vs those with stroke (2%)/epileptic seizure (4%) or control participants (1%; P < .001). Index vein was highly specific to migraine aura (specificity 97%; 95% CI 95%-99%), with an ability to diagnose migraine aura with 94% sensitivity (95% CI 87.4%-97.8%) and 73.5% specificity (95% CI 66.8%-79.5%) at a cut-off of 4 points.

Study details: This retrospective case-control study included 400 patients who presented to the emergency department with an acute neurological deficit, underwent brain magnetic resonance imaging, and were discharged with a diagnosis of migraine aura/ischemic stroke/epileptic seizure or none of these (control participants).

Disclosures: This study did not receive any specific funding. Two authors declared serving as part-time employees at Zynnon or as a consultant, speaker, or advisory board member for various sources.

Source: Scutelnic A et al. The “index vein” as a sign for migraine aura in the emergency setting. Cephalalgia. 2023 (Jan 9). Doi: 10.1177/033310242211320

Key clinical point: American adults with higher dietary zinc intake were at a lower risk for migraine, demonstrating an inverse association between dietary zinc intake and migraine.

Major finding: The risk for migraine was significantly lower among participants in the highest (≥15.8 mg/day) vs lowest (≤5.9 mg/day) quintile of dietary zinc intake (adjusted odds ratio [aOR] 0.70; P  =  .029) and remained low among participants with dietary zinc intake of at least 6.0-8.4 mg/day (aOR 0.73; P  =  .004).

Study details: This cross-sectional study included 11,088 adults with or without migraine from the US National Health and Nutrition Examination Survey (1999-2004).

Disclosures: This study was supported by grants from the National Natural Science Foundation of China. The authors declared no conflicts of interest.

Source: Liu H et al. Dietary zinc intake and migraine in adults: A cross-sectional analysis of the National Health and Nutrition Examination Survey 1999-2004. Headache. 2023 (Jan 1). Doi: 10.1111/head.14431

Key clinical point: American adults with higher dietary zinc intake were at a lower risk for migraine, demonstrating an inverse association between dietary zinc intake and migraine.

Major finding: The risk for migraine was significantly lower among participants in the highest (≥15.8 mg/day) vs lowest (≤5.9 mg/day) quintile of dietary zinc intake (adjusted odds ratio [aOR] 0.70; P  =  .029) and remained low among participants with dietary zinc intake of at least 6.0-8.4 mg/day (aOR 0.73; P  =  .004).

Study details: This cross-sectional study included 11,088 adults with or without migraine from the US National Health and Nutrition Examination Survey (1999-2004).

Disclosures: This study was supported by grants from the National Natural Science Foundation of China. The authors declared no conflicts of interest.

Source: Liu H et al. Dietary zinc intake and migraine in adults: A cross-sectional analysis of the National Health and Nutrition Examination Survey 1999-2004. Headache. 2023 (Jan 1). Doi: 10.1111/head.14431

Key clinical point: American adults with higher dietary zinc intake were at a lower risk for migraine, demonstrating an inverse association between dietary zinc intake and migraine.

Major finding: The risk for migraine was significantly lower among participants in the highest (≥15.8 mg/day) vs lowest (≤5.9 mg/day) quintile of dietary zinc intake (adjusted odds ratio [aOR] 0.70; P  =  .029) and remained low among participants with dietary zinc intake of at least 6.0-8.4 mg/day (aOR 0.73; P  =  .004).

Study details: This cross-sectional study included 11,088 adults with or without migraine from the US National Health and Nutrition Examination Survey (1999-2004).

Disclosures: This study was supported by grants from the National Natural Science Foundation of China. The authors declared no conflicts of interest.

Source: Liu H et al. Dietary zinc intake and migraine in adults: A cross-sectional analysis of the National Health and Nutrition Examination Survey 1999-2004. Headache. 2023 (Jan 1). Doi: 10.1111/head.14431

Key clinical point: Eptinezumab vs placebo demonstrated significantly greater and sustained improvements in patient-reported overall health, quality of life, and most bothersome symptoms in patients with migraine and 2-4 preventive treatment failures.

Major finding: At week 12, 100 and 300 mg eptinezumab vs placebo led to significantly greater improvements in EQ-5D-5L visual analog scale scores (difference from placebo [Δ] 5.1; P < .001, and Δ 7.5; P < .0001, respectively), 6-item Headache Impact Test total scores (Δ −3.8 and −5.4, respectively; both P < .0001), Migraine-Specific Quality of Life Questionnaire scores (both P < .0001), and patient-identified most bothersome symptoms (both P < .0001), with effects sustained until week 24.

Study details: Findings are from the phase 3b DELIVER trial including 890 adults with episodic/chronic migraine and 2-4 prior preventive treatment failures who were randomly assigned to receive eptinezumab (100/300 mg) or placebo.

Disclosures: The clinical trial and publication was funded by H. Lundbeck A/S. Five authors declared being employees of H. Lundbeck A/S. Three authors reported ties with various sources.

Source: Goadsby PJ et al. Eptinezumab improved patient-reported outcomes and quality of life in patients with migraine and prior preventive treatment failures. Eur J Neurol. 2022 (Dec 30). Doi: 10.1111/ene.15670

Key clinical point: Eptinezumab vs placebo demonstrated significantly greater and sustained improvements in patient-reported overall health, quality of life, and most bothersome symptoms in patients with migraine and 2-4 preventive treatment failures.

Major finding: At week 12, 100 and 300 mg eptinezumab vs placebo led to significantly greater improvements in EQ-5D-5L visual analog scale scores (difference from placebo [Δ] 5.1; P < .001, and Δ 7.5; P < .0001, respectively), 6-item Headache Impact Test total scores (Δ −3.8 and −5.4, respectively; both P < .0001), Migraine-Specific Quality of Life Questionnaire scores (both P < .0001), and patient-identified most bothersome symptoms (both P < .0001), with effects sustained until week 24.

Study details: Findings are from the phase 3b DELIVER trial including 890 adults with episodic/chronic migraine and 2-4 prior preventive treatment failures who were randomly assigned to receive eptinezumab (100/300 mg) or placebo.

Disclosures: The clinical trial and publication was funded by H. Lundbeck A/S. Five authors declared being employees of H. Lundbeck A/S. Three authors reported ties with various sources.

Source: Goadsby PJ et al. Eptinezumab improved patient-reported outcomes and quality of life in patients with migraine and prior preventive treatment failures. Eur J Neurol. 2022 (Dec 30). Doi: 10.1111/ene.15670

Key clinical point: Eptinezumab vs placebo demonstrated significantly greater and sustained improvements in patient-reported overall health, quality of life, and most bothersome symptoms in patients with migraine and 2-4 preventive treatment failures.

Major finding: At week 12, 100 and 300 mg eptinezumab vs placebo led to significantly greater improvements in EQ-5D-5L visual analog scale scores (difference from placebo [Δ] 5.1; P < .001, and Δ 7.5; P < .0001, respectively), 6-item Headache Impact Test total scores (Δ −3.8 and −5.4, respectively; both P < .0001), Migraine-Specific Quality of Life Questionnaire scores (both P < .0001), and patient-identified most bothersome symptoms (both P < .0001), with effects sustained until week 24.

Study details: Findings are from the phase 3b DELIVER trial including 890 adults with episodic/chronic migraine and 2-4 prior preventive treatment failures who were randomly assigned to receive eptinezumab (100/300 mg) or placebo.

Disclosures: The clinical trial and publication was funded by H. Lundbeck A/S. Five authors declared being employees of H. Lundbeck A/S. Three authors reported ties with various sources.

Source: Goadsby PJ et al. Eptinezumab improved patient-reported outcomes and quality of life in patients with migraine and prior preventive treatment failures. Eur J Neurol. 2022 (Dec 30). Doi: 10.1111/ene.15670

Key clinical point: Single session of onabotulinumtoxinA effectively reduced neck and migraine-related disability and pain intensity over 3 months in patients with chronic migraine.

Major finding: OnabotulinumtoxinA significantly reduced Neck Disability Index scores (median −16.5 points; P < .001) and Migraine Disability Assessment scores (median −28 points; P < .001) after 4 weeks. The neck pain intensity and migraine headache intensity reduced by almost half (both P < .001) and the median number of monthly headache days reduced from 20 to 6 days (P < .001) after 3 months of onabotulinumtoxinA treatment.

Study details: This retrospective study included 134 patients with chronic migraine who received one session of onabotulinumtoxinA treatment.

Disclosures: This study did not receive any external funding. The authors declared no conflicts of interest.

Source: Onan D et al. OnabotulinumtoxinA treatment in chronic migraine: Investigation of its effects on disability, headache and neck pain intensity. Toxins (Basel). 2022;15(1):29 (Dec 30). Doi: 10.3390/toxins15010029

Key clinical point: Single session of onabotulinumtoxinA effectively reduced neck and migraine-related disability and pain intensity over 3 months in patients with chronic migraine.

Major finding: OnabotulinumtoxinA significantly reduced Neck Disability Index scores (median −16.5 points; P < .001) and Migraine Disability Assessment scores (median −28 points; P < .001) after 4 weeks. The neck pain intensity and migraine headache intensity reduced by almost half (both P < .001) and the median number of monthly headache days reduced from 20 to 6 days (P < .001) after 3 months of onabotulinumtoxinA treatment.

Study details: This retrospective study included 134 patients with chronic migraine who received one session of onabotulinumtoxinA treatment.

Disclosures: This study did not receive any external funding. The authors declared no conflicts of interest.

Source: Onan D et al. OnabotulinumtoxinA treatment in chronic migraine: Investigation of its effects on disability, headache and neck pain intensity. Toxins (Basel). 2022;15(1):29 (Dec 30). Doi: 10.3390/toxins15010029

Key clinical point: Single session of onabotulinumtoxinA effectively reduced neck and migraine-related disability and pain intensity over 3 months in patients with chronic migraine.

Major finding: OnabotulinumtoxinA significantly reduced Neck Disability Index scores (median −16.5 points; P < .001) and Migraine Disability Assessment scores (median −28 points; P < .001) after 4 weeks. The neck pain intensity and migraine headache intensity reduced by almost half (both P < .001) and the median number of monthly headache days reduced from 20 to 6 days (P < .001) after 3 months of onabotulinumtoxinA treatment.

Study details: This retrospective study included 134 patients with chronic migraine who received one session of onabotulinumtoxinA treatment.

Disclosures: This study did not receive any external funding. The authors declared no conflicts of interest.

Source: Onan D et al. OnabotulinumtoxinA treatment in chronic migraine: Investigation of its effects on disability, headache and neck pain intensity. Toxins (Basel). 2022;15(1):29 (Dec 30). Doi: 10.3390/toxins15010029

Key clinical point: The safety and tolerability of once-daily atogepant observed over 40 weeks in this extension trial aligns with profiles from the pivotal phase 3 trials with no new safety signals identified in patients with episodic migraine.

Major finding: Nearly 63% of patients reported treatment-emergent adverse events, most being mild or moderate, with upper respiratory tract infection (5.5%) and urinary tract infection (5.3%) being most frequent. Treatment discontinuation rates due to lack of efficacy (0.6%) or adverse events (3.6%) were low. No deaths were reported.

Study details: Findings are from the 309-OLEX trial, an open-label extension of phase 3 ADVANCE trial, including 685 patients with episodic migraine with or without aura who received 60 mg atogepant once daily for 40 weeks.

Disclosures: This study was supported by AbbVie Inc. (formerly Allergan). Five authors declared being full-time or former employees of or holding stock or stock options in AbbVie. Several authors reported ties with various sources, including AbbVie.

Source: Klein BC et al. Safety and tolerability results of atogepant for the preventive treatment of episodic migraine from a 40-week, open-label multicenter extension of the phase 3 ADVANCE trial. Cephalalgia. 2023 (Jan 9). Doi: 10.1177/03331024221128250

Key clinical point: The safety and tolerability of once-daily atogepant observed over 40 weeks in this extension trial aligns with profiles from the pivotal phase 3 trials with no new safety signals identified in patients with episodic migraine.

Major finding: Nearly 63% of patients reported treatment-emergent adverse events, most being mild or moderate, with upper respiratory tract infection (5.5%) and urinary tract infection (5.3%) being most frequent. Treatment discontinuation rates due to lack of efficacy (0.6%) or adverse events (3.6%) were low. No deaths were reported.

Study details: Findings are from the 309-OLEX trial, an open-label extension of phase 3 ADVANCE trial, including 685 patients with episodic migraine with or without aura who received 60 mg atogepant once daily for 40 weeks.

Disclosures: This study was supported by AbbVie Inc. (formerly Allergan). Five authors declared being full-time or former employees of or holding stock or stock options in AbbVie. Several authors reported ties with various sources, including AbbVie.

Source: Klein BC et al. Safety and tolerability results of atogepant for the preventive treatment of episodic migraine from a 40-week, open-label multicenter extension of the phase 3 ADVANCE trial. Cephalalgia. 2023 (Jan 9). Doi: 10.1177/03331024221128250

Key clinical point: The safety and tolerability of once-daily atogepant observed over 40 weeks in this extension trial aligns with profiles from the pivotal phase 3 trials with no new safety signals identified in patients with episodic migraine.

Major finding: Nearly 63% of patients reported treatment-emergent adverse events, most being mild or moderate, with upper respiratory tract infection (5.5%) and urinary tract infection (5.3%) being most frequent. Treatment discontinuation rates due to lack of efficacy (0.6%) or adverse events (3.6%) were low. No deaths were reported.

Study details: Findings are from the 309-OLEX trial, an open-label extension of phase 3 ADVANCE trial, including 685 patients with episodic migraine with or without aura who received 60 mg atogepant once daily for 40 weeks.

Disclosures: This study was supported by AbbVie Inc. (formerly Allergan). Five authors declared being full-time or former employees of or holding stock or stock options in AbbVie. Several authors reported ties with various sources, including AbbVie.

Source: Klein BC et al. Safety and tolerability results of atogepant for the preventive treatment of episodic migraine from a 40-week, open-label multicenter extension of the phase 3 ADVANCE trial. Cephalalgia. 2023 (Jan 9). Doi: 10.1177/03331024221128250

Key clinical point: A preconception history of migraine showed no significant association with the risk for spontaneous abortion (SAB); however, routine use of medication, suggesting more severe migraine, may confer a greater SAB risk.

Major finding: Preconception migraine history did not increase the risk for SAB (adjusted hazard ratio [aHR] 1.03; 95% CI 0.91-1.16), but daily migraine medication use (aHR 1.38; 95% CI 0.81-2.35), use of prescription migraine prophylaxis medication (aHR 1.43; 95% CI 0.72-2.84), or analgesic/caffeine medication use (aHR 1.42; 95% CI 0.99-2.04) showed a modest but non-significant association with SAB risk.

Study details: This study evaluated 7890 participants from an ongoing prospective study who conceived during follow-up and had or did not have a preconception diagnosis of migraine or migraine medication use, of which 1537 experienced SAB.

Disclosures: This study was funded by the National Institute of Child Health and Human Development, US National Institutes of Health. The authors declared no conflicts of interest.

Source: Crowe HM et al. Pre‑pregnancy migraine diagnosis, medication use, and spontaneous abortion: A prospective cohort study. J Headache Pain. 2022;23:162 (Dec 20). Doi: 10.1186/s10194-022-01533-6

Key clinical point: A preconception history of migraine showed no significant association with the risk for spontaneous abortion (SAB); however, routine use of medication, suggesting more severe migraine, may confer a greater SAB risk.

Major finding: Preconception migraine history did not increase the risk for SAB (adjusted hazard ratio [aHR] 1.03; 95% CI 0.91-1.16), but daily migraine medication use (aHR 1.38; 95% CI 0.81-2.35), use of prescription migraine prophylaxis medication (aHR 1.43; 95% CI 0.72-2.84), or analgesic/caffeine medication use (aHR 1.42; 95% CI 0.99-2.04) showed a modest but non-significant association with SAB risk.

Study details: This study evaluated 7890 participants from an ongoing prospective study who conceived during follow-up and had or did not have a preconception diagnosis of migraine or migraine medication use, of which 1537 experienced SAB.

Disclosures: This study was funded by the National Institute of Child Health and Human Development, US National Institutes of Health. The authors declared no conflicts of interest.

Source: Crowe HM et al. Pre‑pregnancy migraine diagnosis, medication use, and spontaneous abortion: A prospective cohort study. J Headache Pain. 2022;23:162 (Dec 20). Doi: 10.1186/s10194-022-01533-6

Key clinical point: A preconception history of migraine showed no significant association with the risk for spontaneous abortion (SAB); however, routine use of medication, suggesting more severe migraine, may confer a greater SAB risk.

Major finding: Preconception migraine history did not increase the risk for SAB (adjusted hazard ratio [aHR] 1.03; 95% CI 0.91-1.16), but daily migraine medication use (aHR 1.38; 95% CI 0.81-2.35), use of prescription migraine prophylaxis medication (aHR 1.43; 95% CI 0.72-2.84), or analgesic/caffeine medication use (aHR 1.42; 95% CI 0.99-2.04) showed a modest but non-significant association with SAB risk.

Study details: This study evaluated 7890 participants from an ongoing prospective study who conceived during follow-up and had or did not have a preconception diagnosis of migraine or migraine medication use, of which 1537 experienced SAB.

Disclosures: This study was funded by the National Institute of Child Health and Human Development, US National Institutes of Health. The authors declared no conflicts of interest.

Source: Crowe HM et al. Pre‑pregnancy migraine diagnosis, medication use, and spontaneous abortion: A prospective cohort study. J Headache Pain. 2022;23:162 (Dec 20). Doi: 10.1186/s10194-022-01533-6