Mayo Clinic proceedings
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Many neurologic disorders, such as eclampsia, pseudotumor cerebri, stroke, obstetric nerve palsies, subarachnoid hemorrhage, pituitary tumors, and choriocarcinoma, can develop in the pregnant patient. Maternal mortality from eclampsia, which ranges from 0 to 14%, can be due to intracerebral hemorrhage, pulmonary edema, disseminated intravascular coagulation, abruptio placentae, or failure of the liver or kidneys. Associated fetal mortality ranges from 10 to 28% and is directly related to decreased placental perfusion. ⋯ This malignant tumor has a high rate of cerebral metastatic lesions. In addition to these disorders that develop during pregnancy, the pregnant state can affect numerous preexisting neurologic conditions, including epilepsy, headaches, multiple sclerosis, myasthenia gravis, spinal cord injury, and brain tumors. We discuss advice for patients with such conditions who wish to become pregnant, recommendations for medical and surgical management, and surgical considerations for neurologic complications during pregnancy.
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Obstructive sleep apnea syndrome is the most common cause of hypersomnolence in patients referred to sleep disorders centers. This type of sleep apnea is characterized by loud snoring, nocturnal oxyhemoglobin desaturation, and disrupted sleep that leads to daytime hypersomnolence. The anatomic configuration of the pharynx and the physiologic responses to occlusion of the upper airway play a major role in the pathogenesis of this disorder. ⋯ Nasally applied continuous positive airway pressure is an extremely effective modality for treating moderate and severe obstructive sleep apnea. Surgical correction of obvious anatomic defects has a role in diminishing obstructive sleep apnea, but the exact role of surgical intervention in patients without obvious anatomic defects remains unknown. The choice of therapy should be tailored to the individual patient with sleep apnea, and careful follow-up is essential to ensure a positive response to therapy.
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Because sleep needs vary from person to person, insomnia is defined as the chronic inability to obtain the amount of sleep needed for optimal functioning and well-being. Insomnia, which is a symptom rather than a disease, can be classified into three main etiologic groups: insomnias related to other mental disorders (for example, depression and anxiety), insomnias related to known organic factors (for example, sleep apnea and "nonrestorative" sleep), and primary insomnia (for example, learned psychophysiologic insomnias and insomnia complaints without objective findings). The treatment for insomnia often involves a combination of pharmacotherapy, behavioral and short-term psychotherapy, and sleep hygiene guidelines. Sleep disorders centers can provide specialized knowledge and techniques for patients with severe chronic insomnia.
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Mayo Clinic proceedings · Apr 1990
ReviewManagement of postoperative pain: review of current techniques and methods.
Pain is a common problem in the early postoperative period. Techniques that provide perioperative analgesia to alleviate pain may have a significant effect on postoperative events, such as earlier ambulation and earlier dismissal from the hospital with use of epidural analgesia than with systemic analgesia. Spinal opioids, which can be administered epidurally or intrathecally, provide analgesia that is superior to that achieved with systemically administered narcotics. ⋯ Intercostal nerve block, a valuable but underutilized procedure appropriate for unilateral upper abdominal or flank operations or for thoracotomy, has been shown to reduce postoperative narcotic requirements and pulmonary complications. A patient-controlled analgesia device, consisting of an electronically controlled infusion pump with a timing device that can be triggered by the patient for intravenous administration of a narcotic when pain is experienced, avoids the vast fluctuations in analgesia that accompany parenteral administration of drugs. In most patients, postoperative pain can be prevented or diminished, and clinicians should be aware of the available techniques for achieving this goal.
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The therapeutic goals for the patient with angina pectoris are to minimize the frequency and severity of angina and to improve functional capacity at a reasonable cost and with as few side effects as possible. An integrated approach necessitates attention to conditions that might be aggravating angina, such as anemia or hypertension. ⋯ Certain concomitant diseases, such as chronic obstructive pulmonary disease, may influence the selection of drug therapy. Nitrates, beta-adrenergic blockers, and calcium entry blockers are the major classes of drugs that can be used alone or in combination in a program that is designed for the individual patient.