Articles: outcome.
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To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment. ⋯ Migraine recurrence is common after "successful" ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.
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Intrathecal drug delivery improves pain relief, reduces suffering, and enhances quality of life in the small proportion of patients who do not respond well to oral analgesics, including oral morphine. Although morphine is the "gold standard," and the only drug approved for intrathecal pain therapy in the United States, off-label use of alternative agents appears promising, particularly in patients with neuropathic pain. Careful patient selection and management are significant determinants of successful treatment outcomes. ⋯ In addition, all patients (those with cancer or nonmalignant pain) must exhibit a positive response to an epidural or intrathecal screening test. A multidisciplinary team approach, involving psychologists, nurses, physical therapists, social workers, and spiritual leaders should be used to manage patients. Current practices for patient selection and management, screening tests, and dosing guidelines for intrathecal drug delivery systems are discussed.
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Intrathecal drug delivery is effective for the treatment of cancer and nonmalignant pain in patients who do not respond well to oral opioids, in patients who cannot tolerate the side effects associated with opioids, or in patients who show a large, permanent increase in dosage. Although intrathecal drug delivery is associated with pharmacological side effects and complications, its benefits far outweigh its risks. There are three main categories of potential adverse events associated with intrathecal drug delivery: pharmacologic side effects, surgical complications, and device-related complications. ⋯ Many adverse events either resolve on their own or can be managed with dosage or device adjustment. More serious complications may require surgical intervention or discontinuation of therapy. This paper will provide an overview of adverse events and complications, their origins, detection, manifestations, and management.
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Angioneurotic oedema is a rare disease caused by Cl esterase inhibitor deficiency. Hereditary angioneurotic oedema includes type I (quantitative and functional) deficiency and type 11 (functional) deficiency. Its prophylactic treatment during pregnancy, based on danazol therapy if the fetus is male, may avoid acute attacks of generalized or laryngeal oedema. ⋯ Regional analgesia is indicated for labour or caesarean section to prevent pain and stress and to avoid the difficulties associated with laryngeal oedema and tracheal intubation. In the treatment of an acute attack, Cl esterase inhibitor concentrates (1500 units) may be given i.v. We present two cases, one of hereditary and one of acquired angioneurotic oedema, both presenting during pregnancy and both delivered vaginally under epidural analgesia with successful outcome.
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To consider the evidence for the beneficial effects of the current management guidelines in traumatic brain injury, and to highlight the important issues. ⋯ The impact of management guidelines in traumatic brain injury on patient outcome has been difficult to determine. However, there is a large body of uncontrolled evidence that suggests secondary global cerebral ischaemia-hypoxic insults are the major determinants in influencing outcome and that therapeutic interventions that maintain and defend cerebral perfusion pressures may improve outcome.