Der Nervenarzt
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Drug prevention of migraine is recommended if more than three attacks occur per month, acute drug treatment is insufficient, or very severe attacks with aura are the main problem. Besides beta blockers, a variety of substances have proved efficacious in migraine prevention. Thus individualised treatment of migraine patients is possible. ⋯ Drugs of first choice, besides beta blockers, are flunarizine, valproic acid, and topiramate. Second-choice drugs with lower efficacy or less well published evidence include amitriptyline, venlafaxine, gabapentin, naproxen, acetylsalicylic acid, butterbur root, vitamin B2, and magnesium. Flunarizine or propranolol are recommended for children.
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At the moment atypical Parkinson syndromes have unfavorable prognoses and show little response to dopaminergic medication. Early differential diagnosis of these disorders from idiopathic Parkinson syndrome is of pivotal clinical relevance. ⋯ Additional electrophysiological, imaging, and nuclear medical investigations may support the clinical diagnosis. During disease progression clinical signs indicative of an atypical Parkinson syndrome should always warrant reevaluation of the diagnosis.
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The review deals with present problems of protecting mentally ill patients who are incompetent to give informed consent to participating in clinical research, and of assessment of the capacity to consent. 1. Clinical trials of drugs on efficacy and safety in incompetent patients are ethically justified and legally admissible if the investigational drug can be expected to exert a direct potential individual benefit and if such trials will be performed under defined criteria to protect these vulnerable patients. In Germany it is questionable how far these prescriptions of the German Drug Law (AMG) are transferable to other than drug research. 2. ⋯ However, the application of these criteria must be improved by practicable procedures. This is valid particularly for the assessment of the basic criterion whether a patient is capable of consenting or not. 5. Open Questions are formulated as need of research.
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Pain evoked potentials offer a possibility for the evaluation of nociceptive pathways. Contact heat evoked potentials (CHEPS) represent a novel technique allowing to investigate peripheral pain pathways represented by small-diameter nerve fibers (A-delta and C fibers) and to study the spinothalamic tract. In contrast to more time-consuming methods such as quantitative sensory testing, CHEPS enables an objective investigation of pain pathways. This article reviews and discusses the technique, possible indications, and pitfalls in the context of clinical cases.
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In modern medicine, decisions about the kind of treatment at life's end are often inevitable. According to German law, powers of attorney and advance directives can be of help in these decisions. When a patient in a state of competence has issued a lasting power of attorney, there is no need for courts to appoint a proxy, and physicians immediately have a legally empowered decision-maker they can address. ⋯ They are, however, more powerful when issued after consultation with a physician. If treatment at life's end no longer complies with the patient's will or loses its medical indication, the goal of treatment should be redirected towards palliation. This implies that life-sustaining treatment may be withdrawn or withheld, which is best accomplished with sensitivity to the needs of patients, relatives, and health care professionals.