Continuum : lifelong learning in neurology
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Continuum (Minneap Minn) · Aug 2012
Review Case ReportsNonmedication, alternative, and complementary treatments for migraine.
The efficacy of some nonpharmacologic therapies appears to approach that of most drugs used for the prevention of migraine and tension-type headaches. These therapies often carry a very low risk of serious side effects and frequently are much less expensive than pharmacologic therapies. Considering this combination of efficacy, minimal side effects, and cost savings, medications should generally not be prescribed alone but rather in combination with nonpharmacologic therapies. ⋯ Therapies proven (to various degrees) to be effective for migraine include aerobic exercise; biofeedback; other forms of relaxation training; cognitive therapies; acupuncture; and supplementation with magnesium, CoQ10, riboflavin, butterbur, feverfew, and cyanocobalamin with folate and pyridoxine.
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Continuum (Minneap Minn) · Jun 2012
Review Comparative StudyOsmotherapy for intracranial hypertension: mannitol versus hypertonic saline.
Hyperosmolar therapy is one of the core medical treatments for brain edema and intracranial hypertension, but controversy exists regarding the use of the most common agents, mannitol, and hypertonic saline. This article describes the relative merits and adverse effects of these agents using the best available clinical evidence. ⋯ Both mannitol and hypertonic saline are effective and have an acceptable risk profile for use in the treatment of elevated intracranial pressure secondary to brain edema.
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The Uniform Determination of Death Act indicates that "an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead," with brain death being determined based on "accepted medical standards." The AAN has published practice guidelines providing medical standards for the determination of brain death. The most recent AAN guideline update notes that "because of the deficiencies in the evidence base, clinicians must exercise considerable judgment when applying the criteria in specific circumstances" and that "ancillary tests can be used when uncertainty exists about the reliability of parts of the neurologic examination or when the apnea test cannot be performed. This article presents two cases commonly encountered in clinical practice in which the findings of the guideline-specified clinical neurologic assessment may be difficult to interpret, hampering the clinical determination of brain death. In these circumstances, ancillary testing specifically assessing for cerebral circulatory arrest may be helpful.
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Continuum (Minneap Minn) · Jun 2012
ReviewPrognosis of coma after cardiac arrest in the era of hypothermia.
Outcome prediction is more difficult in comatose survivors of cardiac arrest who are treated with hypothermia than in those who are kept normothermic. This article compares prognostication measures in these two groups of patients. ⋯ This article compares and contrasts prognostication before and after the introduction of hypothermia in an attempt to provide new guidance on predicting outcomes.