Neurology
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Sixty patients with trigeminal neuralgia who did not have a response to pharmacologic treatment (including 22 who had no response to conventional surgical treatment) underwent stereotactic radiosurgical treatment with the Leksell Gamma Knife. A radiosurgical maximum dose of 70 Gy was delivered to the trigeminal nerve root adjacent to the pons via a 4-mm collimator helmet in 51 patients who presented with trigeminal neuralgia unrelated to tumors. In these patients, the root was localized by stereotactic MRI. ⋯ Only one patient with pre-existing facial sensory loss due to a tumor had a mild increase in facial numbness. No other patient experienced either loss of facial sensation or any other complication. Gamma Knife radiosurgery appears to be a minimally invasive, safe, and effective therapy of trigeminal neuralgia.
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Review Comparative Study
Evolution of the measurement of quality of life in migraine.
Although headache is among the most common pain complaints seen by physicians, the measurement of health-related quality of life (HRQoL) in headache patients is in its earliest stages. Two types of questionnaire have been used to measure HRQoL in headache sufferers: general and disease-specific instruments. General quality-of-life (QoL) instruments use scales to assess QoL with respect to a number of activities within physical, social, psychological, and behavioral life domains. ⋯ Generic QoL instruments, such as the SF-20 or SF-36, may be more useful to define populations being studied than to measure changes in the population over time. The publication of headache-specific QoL instruments, which have been widely used in clinical trials and have been validated, is awaited. Until such time, the SF-36 will remain the standard measure of QoL in headache.
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Migraine imposes an enormous health burden on individual headache sufferers and on society. The condition affects about 18% of women and about 6% of men across their lifespan. Because prevalence peaks during the most productive years, between the ages of 25 and 55, migraine is an important cause of lost work time. ⋯ Add to this the indirect costs, in the form of absenteeism and reduced productivity at work, and the overall burden of migraine becomes apparent. Work loss is not uniformly distributed, with the most disabled half of migraineurs accounting for more than 80% of all work loss. Although improvements in health care delivery for migraine may increase direct cost (i.e., drug or medical care), this may be offset by savings in indirect costs (i.e., reduced and lost productivity).
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Clinical Trial Controlled Clinical Trial
Intraepidermal nerve fiber density in patients with painful sensory neuropathy.
Despite prominent symptoms of neuropathic pain, patients with small-fiber sensory neuropathies have few objective abnormalities on clinical examination and routine electrodiagnostic studies. We quantified intraepidermal nerve fiber (IENF) density in sections of skin obtained by punch skin biopsy, and found it to be significantly reduced in patients with painful sensory neuropathies compared with age-matched control subjects. In addition, IENF density correlated with clinical estimates of neuropathy severity, as judged by the extent of clinically identifiable sensory abnormalities. IENF density at the calf was lower than that obtained from skin at more proximal sites, indicating the length dependency of small-fiber loss in these neuropathies.
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We report an extraordinary event of a lightning strike to the head of a helmeted bicyclist that occurred under fair weather conditions with a cloudless sky. The patient sustained a cardiac arrest and hypoxic encephalopathy with residual neurologic impairment. With the availability of highly developed meteorologic equipment, we were able to determine that the lightning "bolt from the blue" probably originated in a thunderstorm that was about 16 km away and obscured by the mountains.