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Therapy of : Cephalgia
Merck Online Lab
Diagnosis < Therapy > Rehabilitation Imaging Clinical Laboratory
What do we know about chronic tension-type headache?
Author(s): Fern; ández-de-Las-Peñas, C
Journal: Discov Med 2009 Dec 31; Vol. 8, Issue 43; Page(s) 232-6
[Medline ID - 20040276]

In the past few years there has been an increasing body of knowledge about etiological mechanisms of chronic tension type headache (CTTH), permitting a better understanding of this syndrome. It seems that CTTH diagnostic criteria should be modified to improve its differential diagnosis against migraine, since CTTH is a syndrome of "featureless" headaches characterized by nothing but pain in the head. It has been demonstrated that pressure pain hypersensitivity and pericranial muscle tenderness are both consequence and not causative factors of CTTH. An updated pain model has suggested that CTTH can be explained by referred pain from trigger points (TrPs) in the cranio-cervical muscles, mediated through the spinal cord and the trigeminal nerve nucleus caudalis. Different therapeutic strategies (pharmacological and non-pharmacological) are generally used for the management of these patients. CTTH is generally treated with non-steroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, and physical therapy, although the therapeutic efficacy of these approaches is controversial.

Resolution of Menstrually Related Migraine Following Aggressive Treatment for Breast Cancer.
Author(s): Smitherman, TA; Kolivas, ED
Journal: Headache 2009 Dec 31
[Medline ID - 20039954]

(Headache 2009;**:**-**) Hormonal influences associated with the female menstrual cycle play strong roles in both migraine and particular types of breast cancer, but there is limited literature on the effects of breast cancer treatment regimens in women with migraine. The present case describes resolution of menstrually related migraine following aggressive treatment for infiltrating ductal carcinoma (neoadjuvant chemotherapy, single radical mastectomy, and locoregional radiation therapy) that was maintained with supplemental treatment using tamoxifen, an anti-estrogenic agent. This novel case is presented to stimulate further research into the hormonal mechanisms underlying migraine.

Triptan Use as a Function of Cardiovascular Risk. A Population-Based Study.
Author(s): Bigal, ME; Golden, W; Buse, D; Chen, YT; Lipton, RB
Journal: Headache 2009 Dec 31
[Medline ID - 20039953]

(Headache 2009;**:**-**) Aim.- To estimate the proportion of individuals with migraine using triptan therapy as a function of their cardiovascular (CV) profile and disease severity. Methods.- As a part of the American Migraine Prevalence and Prevention study, we identified migraineurs representative of the U.S. adult population. Triptan use was estimated as a function of presence of CV disease (CVD), of CV risk factors, and by level of migraine-related disability. Results.- Our sample consists of 6102 individuals with migraine. Compared with migraineurs without risk factors for CVD, triptans were significantly less likely to be used in individuals with diabetes (11.5% vs 18.3%, OR = 0.6, 95% CI = 0.5-0.7), hypertension (14.8%, OR = 0.8, 0.7-0.9) and by smokers (12.9%, OR = 0.7, 0.6-0.8). Similar findings were seen for individuals with established CVD. As contrasted to individuals without CVD, those with myocardial infarct (8.5% vs 18.5%, OR = 0.4, 0.3-0.7), stroke (7%, OR = 0.6, 0.3-0.9) and heart surgery (9.3%, OR = 0.5, 0.4-0.7) were less likely to use triptans. Use of triptan increased as a function of disability regardless of CVD status or presence of CV risk factors. Conclusion.- Triptan use is lower in those with vs without CV risk, suggesting that doctors and/or patients fear using triptans in individuals at risk to CVD. Furthermore, triptan use in those with established CVD increases with headache-related disability, suggesting that patients and providers balance risks and benefits. Additional and analytical data are needed on the safety of triptans in the setting of CVD risk. This study has not assessed adequacy of care.

A novel type of influenza vaccine: safety and immunogenicity of replication-deficient influenza virus created by deletion of the interferon antagonist NS1.
Author(s): Wacheck, V; Egorov, A; Groiss, F; Pfeiffer, A; Fuereder, T; Hoeflmayer, D; Kundi, M; Popow-Kraupp, T; Redlberger-Fritz, M; Mueller, CA; Cinatl, J; Michaelis, M; Geiler, J; Bergmann, M; Romanova, J; Roethl, E; Morokutti, A; Wolschek, M; Ferko, B; Seipelt, J; Dick-Gudenus, R; Muster, T
Journal: J Infect Dis 2010 Jan 28; Vol. 201, Issue 3; Page(s) 354-62
[Medline ID - 20039806]

BACKGROUND. The nonstructural protein NS1 of influenza virus counteracts the interferon-mediated immune response of the host. By deleting the open reading frame of NS1, we have generated a novel type of influenza vaccine. We studied the safety and immunogenicity of an influenza strain lacking the NS1 gene (DeltaNS1-H1N1) in healthy volunteers. METHODS. Healthy seronegative adult volunteers were randomized to receive either a single intranasal dose of the DeltaNS1-H1N1 A/New Caledonia vaccine at 1 of 5 dose levels (6.4, 6.7, 7.0, 7.4, and 7.7 log(10) median tissue culture infective dose) ([Formula: see text] recipients) or placebo ([Formula: see text] recipients). RESULTS. Intranasal vaccination with the replication-deficient DeltaNS1-H1N1 vaccine was well tolerated. Rhinitis-like symptoms and headache were the most common adverse events identified during the 28-day observation period. Adverse events were similarly distributed between the treatment and placebo groups. Vaccine-specific local and serum antibodies were induced in a dose-dependent manner. In the highest dose group, vaccine-specific antibodies were detected in 10 of 12 volunteers. Importantly, the vaccine also induced neutralizing antibodies against heterologous drift variants. CONCLUSIONS. We show that vaccination with an influenza virus strain lacking the viral interferon antagonist NS1 induces statistically significant levels of strain-specific and cross-neutralizing antibodies despite the highly attenuated replication-deficient phenotype. Further studies are warranted to determine whether these results translate into protection from influenza virus infection. TRIAL REGISTRATION. ClinicalTrials.gov identifier: NCT00724997 .

A phase I study of dacetuzumab (SGN-40, a humanized anti-CD40 monoclonal antibody) in patients with chronic lymphocytic leukemia.
Author(s): Furman, RR; Forero-Torres, A; Shustov, A; Drachman, JG
Journal: Leuk Lymphoma 2009 Dec 30; Vol. 51, Issue 2; Page(s) 228-35
[Medline ID - 20038235]

Despite advances in therapy, chronic lymphocytic leukemia remains an incurable disease and novel, effective therapies are needed. In this open-label, dose-escalation, phase I study, dacetuzumab (IgG1 humanized monoclonal antibody) was administered to 12 adults, all of whom had received several prior systemic therapies (median, 4; range, 2-11). Intrapatient dose escalation (maximum weekly doses of 3-8 mg/kg) was used to diminish first-dose-related inflammatory symptoms. No dose-limiting toxicities or dose-dependent trends in adverse events (AEs) were observed. The most common AEs (in > /=2 patients) were fatigue, headache, anorexia, conjunctivitis, hyperhidrosis, and night sweats, all of which were mild or moderate. No deaths, serious AEs, or discontinuations due to AEs occurred. Although no patient achieved an objective response, five patients demonstrated stable disease after 1 cycle of therapy, with no discernable correlation between dacetuzumab dose and outcome. This modest single-agent activity may warrant further testing of dacetuzumab in combination with other chronic lymphocytic leukemia therapies.

[A case of a 14-month survival patient on advanced esophageal cancer with uncontrolled brain metastasis completely responding to nedaplatin, adriamycin, plus 5-FU (NAF) therapy]
Author(s): Iijima, S; Makari, Y; Kato, T; Ooshima, S; Hoshi, M; Doi, T; Miyake, Y; Sakamoto, T; Kato, A; Miyo, M; Kurokawa, E; Kikkawa, N
Journal: Gan To Kagaku Ryoho 2009 Dec 29; Vol. 36, Issue 12; Page(s) 2052-4
[Medline ID - 20037320]

This case was a male patient, about 50 years old. He received a curative operation for advanced esophageal carcinoma [poorly differentiated squamous cell carcinoma type, Lt, pT3 (pAd) pN3, pstage III] in March 2005. He also received adjuvant chemotherapy of 5-FU plus cisplatin (CDDP). Fourteen months later (May 2006) from surgery, metastases to the left lung and left subclavian lymph nodes were diagnosed, so he received first-line triplet combination chemotherapy (NAF regimen; nedaplatin 60 mg/m2: day 1, adriamycin 50 mg/m2: day 1, 5-FU 700 mg/m2: day 1-5). According to the 9 courses of treatment of this regimen, complete response for these metastases was observed and first-line chemotherapy was finished. However, a severe headache appeared 3 months later, and he had a diagnosis of solitary 5 cm brain metastasis by MRI. Excision of the metastasis was performed with sequential whole-brain radiation therapy (30 Gy). Five months later, diffuse and multiple brain metastases relapsed, and second-line chemotherapy did not respond well, and finally he was died 3 months after palliative care. But, completely controlled metastases (lung and lymph node) by first-line chemotherapy did not relapse again in all his clinical period. If an anticancer therapy goes in complete response in an advanced esophageal carcinoma patient, we should consider about a rare brain metastasis in order to find out as small and solitary state.

Adult-onset of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (melas) syndrome presenting as acute meningoencephalitis: a case report.
Author(s): Hsu, YC; Yang, FC; Perng, CL; Tso, AC; Wong, LJ; Hsu, CH
Journal: J Emerg Med 2009 Dec 29
[Medline ID - 20036095]

Background: Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is a rare mitochondrial disorder with a wide range of multisystemic symptoms. Epileptic seizures are common features of both MELAS and meningoencephalitis and are typically treated with anticonvulsants. Objectives: To provide the reader with a better understanding of MELAS and the adverse effects of valproic acid. Case Report: A 47-year-old man with a history of diabetes, hearing loss, sinusitis, and otitis media was brought to our emergency department due to acute onset of fever, headache, generalized seizure, and agitation. Because acute meningoencephalitis was suspected, the patient was treated with antibiotics on an empirical basis. The seizure activity was aggravated by valproic acid and abated after its discontinuation. MELAS was suspected and the diagnosis was confirmed by the presence of a nucleotide 3243 A-- > G mutation in the mitochondrial DNA. Conclusion: Detailed history-taking and systematic review help emergency physicians differentiate MELAS from meningoencephalitis in patients with the common presentation of epileptic seizures. Use of valproic acid to treat epilepsy in patients suspected of having mitochondrial disease should be avoided. Underlying mitochondrial disease should be suspected if seizure activity worsens with valproic acid therapy.

[Endocrine ophthalmopathy: surgical treatment]
Author(s): Olivari, N
Journal: HNO 2009 Dec 25; Vol. 58, Issue 1; Page(s) 8-10, 12-4
[Medline ID - 20033121]

Since the transpalpebral decompression of the orbit by removal of intraorbital fat was introduced in 1985, this technique has become the state of the art in surgical therapy for Graves' ophthalmopathy at the authors' institution. Our experience with a series of 3,210 orbital decompressions in 1,635 patients with endocrine ophthalmopathy represents the largest collective of such patients that has been published yet to our knowledge. Over time the technique has proved to be reliable, effective, safe, and easily performed by a trained and experienced oculoplastic surgeon with long-lasting results, leading to improvement not only in visual function but also in well-being and in patients' social life, with a high benefit to low risk ratio. The promising and satisfying results demonstrated earliest in 1988 have been confirmed in further evaluation at our clinic and others. In summary, this technique, which is associated with very low morbidity, is our method of choice in moderate to severe cases of exophthalmos and even in functionally asymptomatic patients with mild to moderate aesthetic impairment. However, it has to be emphasized that this complex and multifactorial disorder often requires a broad range of long-term medical attendance. Postoperatively the majority of patients showed significant improvements of ocular protrusion, diplopia, visual acuity, swelling of eyelids, headache and retrobulbar "burn". In very rare instances, the surgical technique can be performed as a one-stage procedure. In severe cases (proptosis > 28 or extreme muscle hypertrophy), lipectomy can be combined with expansion of the bony orbital cavity ( < 1% patients).

Sudden sensorineural hearing loss associated with vardenafil.
Author(s): Snodgrass, AJ; Campbell, HM; Mace, DL; Faria, VL; Swanson, KM; Holodniy, M
Journal: Pharmacotherapy 2009 Dec 25; Vol. 30, Issue 1; Page(s) 112
[Medline ID - 20030481]

The phosphodiesterase type 5 (PDE-5) inhibitors-sildenafil, vardenafil, and tadalafil-are used primarily in erectile dysfunction, but sildenafil is also indicated for pulmonary hypertension. Common adverse effects of vardenafil include headache, flushing, nasal congestion, dyspepsia, and nausea. Recently, PDE-5 inhibitors have been associated with adverse vision effects, and emerging evidence now indicates that they may also be responsible for hearing changes and hearing loss. We describe a patient who developed unilateral sudden sensorineural hearing loss possibly related to the use of vardenafil for erectile dysfunction. To our knowledge, only one other case of hearing loss related to this drug class has been published. Our patient was a 57-year-old man who came to the emergency department with right-sided mild-to-moderate hearing loss in the 500-3000-Hz range, confirmed by audiogram, that occurred after ingestion of vardenafil. The patient was hospitalized 2 days later for administration of intravenous dexamethasone, followed by oral prednisone. He reported that his hearing had improved o n the fourth hospital day and was discharged 3 days later, continuing to taper the prednisone on an outpatient basis. A repeat audiogram after 10 days of corticosteroid therapy confirmed that his hearing in the 500-3000-Hz range was within normal limits. Use of the Naranjo adverse drug reaction probability scale indicated a possible (score of 3) adverse reaction of sudden sensorineural hearing loss associated with vardenafil consumption. We also performed an analysis of hearing loss cases related to PDE-5 inhibitors in the United States Food and Drug Administration's Adverse Event Reporting System database to compare the characteristics of our patient with those of other reported adverse event cases. Based on the temporal relation of the sudden sensorineural hearing loss to this patient's drug consumption, we propose that the vardenafil is a likely cause of the hearing loss. This case provides further evidence that PDE-5 inhibitor consumption should be considered as a possible cause in patients presenting with sudden sensorineural hearing loss.

Ferumoxytol: a new intravenous iron preparation for the treatment of iron deficiency anemia in patients with chronic kidney disease.
Author(s): Schwenk, MH
Journal: Pharmacotherapy 2009 Dec 25; Vol. 30, Issue 1; Page(s) 70-9
[Medline ID - 20030475]

Ferumoxytol is an intravenous iron preparation for treatment of the anemia of chronic kidney disease (CKD). It is a carbohydrate-coated, superparamagnetic iron oxide nanoparticle. Because little free iron is present in the preparation, doses of 510 mg have been administered safely in as little as 17 seconds. Two prospective, randomized studies compared two doses of ferumoxytol 510 mg given in 5 +/- 3 days with 3 weeks of oral iron 200 mg/day (as ferrous fumarate) in anemic patients with CKD. One study enrolled 304 patients with stages 1-5 CKD (predialysis), and the other study enrolled 230 patients with stage 5D CKD (undergoing hemodialysis). In both studies, a greater increase in hemoglobin level from baseline to end of study (day 35) was noted in patients who received ferumoxytol compared with those who received oral iron (mean +/- SD 0.82 +/- 1.24 vs 0.16 +/- 1.02 g/dl in patients with stages 1-5 CKD and 1.02 +/- 1.13 vs 0.46 +/- 1.06 g/dl in patients with stage 5D CKD, p < 0.001). A greater proportion of both predialysis and hemodialysis patients who received ferumoxytol had hemoglobin level increases from baseline of 1 g/dl or more compared with those who received oral iron (p < 0.001). In a prospective, double-blind, crossover study of more than 700 patients with CKD stages 1-5D that compared the safety of ferumoxytol with normal saline injection, the rates of treatment-related adverse events were 5.2% and 4.5%, respectively. Serious treatment-related adverse events were seen in one patient in each treatment group. The most common adverse events with ferumoxytol occurred at the injection site (bruising, pain, swelling, erythema). Dizziness, nausea, pruritus, headache, and fatigue occurred in less than 2% of patients receiving ferumoxytol, with a similar frequency noted after administration of normal saline. In short-term studies, intravenous ferumoxytol was safely and rapidly administered, and was more effective than oral iron therapy in increasing hemoglobin levels in anemic patients with CKD. Long-term clinical trials with clinical outcomes and studies comparing ferumoxytol with other parenteral iron agents will help define the role of ferumoxytol in treating the anemia of CKD.
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