Cleveland Clinic journal of medicine
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Complex partial seizures originating in the temporal lobe are one of the most common types of seizures in patients with epilepsy. They are frequently intractable to medical treatment and are increasingly considered for surgical therapy. ⋯ Much research is being undertaken to better understand this disorder and to develop more effective approaches to diagnosis and treatment. Experimental work in animals has contributed to the understanding of epileptogenesis, the interictal state, and the homeostatic mechanisms that limit seizure activity.
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According to widely accepted theory, migraine is a self-limited neurogenic sterile inflammation characterized by initial cerebral vasoconstriction, subsequent extracranial and intracranial vasodilation, sterile inflammation, and secondary muscle contraction. It is characterized by recurrent attacks of headache, usually unilateral and accompanied by nausea, vomiting, and, often, other symptoms. Frequency, duration, and intensity of attacks are widely variable. ⋯ Precipitating factors include foods, alcohol, medications, visual stimuli, changes in routine, and stress. The first-line agent for abortive therapy is ergotamine; corticosteroids are indicated for prolonged headache. Propranolol is recommended for daily prophylactic therapy, and alternatives include calcium channel blockers, nonsteroidal anti-inflammatory agents, and tricyclic antidepressants.
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Mortality from asthma is increasing, raising questions about the goals and adequacy of treatment. It is important to understand the pathophysiology of asthma and the rationale and options for treatment. ⋯ Appropriate medical therapy includes treatment with compounds that specifically suppress airway inflammation. The best approach to treatment may be an anti-inflammatory agent--preferably by inhalation--along with an inhaled direct bronchodilator, with objective measures of airflow limitation to assess disease severity.
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Valve repair is the best operation currently available for patients with mitral valve disease. However, repair is technically more difficult than valve replacement and has a risk of early and late failure. ⋯ Preoperative echocardiography, including Doppler color flow mapping to evaluate intracardiac flow, is used to assess the feasibility of repair. Intraoperatively, epicardial and transesophageal echocardiography are used to monitor surgical results immediately after repair, ensuring successful outcome of surgery.
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Advances in chemotherapy and surgery have significantly improved the outcome of infective endocarditis, but the disease remains a therapeutic challenge with an overall mortality of 20%. More cases of infective endocarditis seen today are associated with prosthetic heart valves, intravenous drug abuse, or complications of medical and surgical technology. Prosthetic valve endocarditis occurs in 1% to 4% of patients with prosthetic valves. ⋯ The principal indication for urgent surgical intervention is acute valvular dysfunction. Other considerations for surgery include evidence of myocardial invasion, infection by antibiotic-resistant organisms, and large vegetations. For patients at risk of infective endocarditis, antibiotic prophylaxis during invasive procedures is an accepted practice.