Retinal Migraine: Evaluation and Management.

PURPOSE OF REVIEW: This review aims to summarize the last 15 years of literature and case reports detailing retinal migraine-an uncommon and somewhat poorly understood migraine variant. RECENT FINDINGS: In the last 15 years, only 12 cases of retinal migraine have been outlined. Similar to other migraine statistics, retinal migraine appears to affect women more so than men and presents with unilateral headache which tends to be ipsilateral to the side of vision loss. The pathophysiology may relate to vasoconstriction of retinal vessels, as evidenced by ictal fundus photography in the past few years. Retinal migraine is a rare entity, with a paucity of described cases in the literature. Retinal migraine is a diagnosis of exclusion, as monocular vision loss might be ascribed to several concerning disorders requiring urgent diagnosis and treatment, and any patient presenting as such should be thoroughly investigated. Patients suffering from retinal migraine appear to respond to typical migraine abortive therapies including NSAIDs and migraine prophylactic medications.

An Approach to Identifying Headache Patients That Require Neuroimaging.

Headache is one of the most common clinical scenarios faced by a neurologist or neurologist in training. However, the decision process on when to complete neuroimaging can be difficult in clinical practice. This article focuses on a well-organized and evidence-based approach to identify patients with headache that require neuroimaging and will lend confidence to the clinician faced with these scenarios in clinical practice. The approach includes neuroimaging in episodic migraine, chronic migraine, identifying secondary headache disorders in clinic and the emergency department, and discusses pitfalls to over imaging. The article concludes with a flowchart to summarize an overall clinical approach.

Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management.

PURPOSE OF REVIEW: Occipital neuralgia (ON) and cervicogenic headache (CGH) are secondary headache disorders with occipital pain as a key feature. Due to significant phenotypic overlap, differentiating ON and CGH from primary headache disorders such as migraine or tension-type headache, or other secondary headache disorders, can be clinically challenging. This article reviews the anatomy, clinical features, unique diagnostic considerations, and management approaches relating to ON and CGH. RECENT FINDINGS: Conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. ON and CGH represent an ongoing diagnostic challenge. Further studies are required to consolidate efficacy regarding the comprehensive management of ON and CGH.

Treatment of Cluster Headache.

Cluster headache (CH) is a debilitating primary headache disorder. Although uncommon, affecting only 0.1% of population, it is one of the most painful conditions known to humankind. Three strategies are employed for effective treatment of CH, namely, abortive therapy, transitional therapy, and preventive therapy. Being an uncommon condition, there is a paucity of large-scale controlled trials and evidence of various therapies are based on smaller studies. This review primarily focuses on therapies with highest quality of evidence and also on the emerging therapies for CH.

Exercise Headache: a Review.

PURPOSE OF REVIEW: Exercise headache refers to headache that is triggered by exercise or exertion. Although secondary causes must be excluded, most cases of exercise headache are benign, idiopathic, and self-limited. This article reviews the revised diagnostic criteria for primary exercise headache (PEH) and discusses recent research into the clinical presentation, epidemiology, pathophysiology, suggested workup, and treatment of this condition. RECENT FINDINGS: Recent studies estimate that PEH affects from 1 to 26% of the adult population. A secondary cause is thought to be present infrequently, but should be explored in all patients with a first or atypical presentation of exercise headache. Red flags for potential secondary causes may include older age at onset and more prolonged headache duration. There is inadequate evidence to include gender as a red flag. No recent trials have been conducted, but experts suggest that avoidance of triggers coupled with short-term NSAID and/or beta-blocker treatment may be effective for patients diagnosed with PEH. Larger studies are needed to provide high-quality evidence regarding the pathophysiology and treatment of PEH. However, recent work has shed light on the characteristics of this condition, and the ICHD-3 has provided important updates to the diagnostic criteria for this relatively common and potentially treatable condition.

LASH: A Review of the Current Literature.

PURPOSE OF REVIEW: The purpose of this review is to evaluate and explain our current understanding of a very rare disorder, long-lasting autonomic symptoms with associated hemicranias (LASH). RECENT FINDINGS: At present, there are four known cases in the literature of LASH. Its characteristics and reported response to indomethacin link it most closely to the trigeminal autonomic cephalalgias (TACs). Its pathophysiology and epidemiology remain unclear. Variance in the pain and autonomic symptom relationship in the existing TAC literature along with the reports of TAC sine headache suggests that LASH may represent a far end of the spectrum of TACs, with most similarities to paroxysmal hemicrania (PH) and hemicrania continua (HC).

The Relationship Between Headaches with Epileptic and Non-epileptic Seizures: a Narrative Review.

PURPOSE OF REVIEW: The purpose of this review is to examine the relationship between headaches and epilepsy as well as headaches and psychogenic non-epileptic seizures (PNES). Emphasis was placed on clinical characteristics, pathophysiology, and treatment. RECENT FINDINGS: Epilepsy and headaches are common disorders that co-occur more often than would be expected by chance. There are some overlapping clinical features between migraine and epilepsy as well as evidence for shared underlying mechanisms. Proposed theories for a shared etiology include ion channel dysfunction, glutamatergic mechanisms, and mitochondrial dysfunction. Some, but not all, recent diagnostic classification systems have recognized the relationship between headaches and epilepsy. Ictal headaches are rare and should raise suspicion for PNES. Headaches in patients with epilepsy are undertreated despite evidence for efficacy of abortive headache medications. Comorbid headaches and epilepsy are relatively common in the population presenting to a neurologist. Patients who have headaches and epilepsy and/or PNES should receive appropriate treatment that often includes mutually beneficial preventative therapy and includes abortive headache treatment.

Physician-assisted death: A Canada-wide survey of ALS health care providers.

OBJECTIVE: To survey amyotrophic lateral sclerosis (ALS) health care providers to determine attitudes regarding physician-assisted death (PAD) after the Supreme Court of Canada (SCC) invalidated the Criminal Code provisions that prohibit PAD in February 2015. METHODS: We conducted a Canada-wide survey of physicians and allied health professionals (AHP) involved in the care of patients with ALS on their opinions regarding (1) the SCC ruling, (2) their willingness to participate in PAD, and (3) the PAD implementation process for patients with ALS. RESULTS: We received 231 responses from ALS health care providers representing all 15 academic ALS centers in Canada, with an overall response rate for invited participants of 74%. The majority of physicians and AHP agreed with the SCC ruling and believed that patients with moderate and severe stage ALS should have access to PAD; however, most physicians would not provide a lethal prescription or injection to an eligible patient. They preferred the patient obtain a second opinion to confirm eligibility, have a psychiatric assessment, and then be referred to a third party to administer PAD. The majority of respondents felt unprepared for the initiation of this program and favored the development of PAD training modules and guidelines. CONCLUSIONS: ALS health care providers support the SCC decision and the majority believe PAD should be available to patients with moderate to severe ALS with physical or emotional suffering. However, few clinicians are willing to directly provide PAD and additional training and guidelines are required before implementation in Canada.

Analyzing the true cost of delivering medications.

Reimbursement to providers for delivering medications in the dialysis field is a subject of current concern, with some payors limiting payment to an amount equaling the provider's acquisition cost. At the same time, some providers arbitrarily mark up medications by a large factor. For dialysis, as well as for the general medical field, an objective approach is required for both providers and payors to fairly set prices and reimbursement levels. This analysis evaluated all cost elements involved in the delivery of medications and determined that an increase over the acquisition cost is appropriate for pricing and reimbursement. The increase has 2 parts: a fixed cost associated with resources required for a medication irrespective of its cost and a markup on the acquisition price. The conclusion of this analysis is that an increase over acquisition cost in reimbursement of providers for delivering medications is required to fairly compensate them for their actual costs and avoid compelling them to either incur a loss or cost shift by overcharging some payors to compensate for underpayment by others. Planned adjustments in Medicare reimbursement for dialysis may not recognize this reality.

Streptomycin, Schatz v. Waksman, and the balance of credit for discovery.

A recent article in Nature, arguing that "the misallocation of credit is endemic in science," used Selman Waksman as an illustration, claiming that the true discoverer of streptomycin was one of his graduate students. The article received wide publicity and seriously damaged Waksman's great reputation. What actually happened was that the success of penicillin stimulated Merck to fund research by Waksman, a soil scientist, into the collection of actinomycetes that he had assembled over thirty years. He applied the systematic, uncreative testing techniques that had made the German pharmaceutical industry so successful to these, and streptomycin was discovered within a matter of months. Work in the Mayo Institute then showed that it was marvelously effective against tuberculosis, and Waksman received the Nobel Prize for it in 1952. The test that turned out to be the crucial one could have been carried out by any of several students, but the lucky one was Albert Schatz. He then sued the university for a share of the royalties payable by Merck and also petitioned the Nobel committee to include him in the award. Although he obtained a very substantial out-of-court settlement, this probably damaged his subsequent academic career, and he has never ceased to argue his case for recognition, of which the Nature article is a reflection. To claim that Waksman took credit properly due to Schatz is to fail to understand that once pharmaceutical research had become primarily a matter of large-scale, routine testing, little individual creativity was left in this work. Credit for any successful results must therefore be given to whoever is the originator or director of a particular program. Nature refused to publish evidence that this case could not be used as an example of misallocation of credit for discovery. This in itself illustrates that editors of scientific journals should be every bit as mindful of scientists' reputations as they are of scientific facts.

Enterobactérias detectadas em primatas capturados na regiäo amazônica do Brasil / Enterobacteriaceae detected in primates captured in the Amazon Region of Brazil

A partir da implantaçäo do Centro Nacional de Primatas (CENP), em Belém, Pará, Brasil, proporcionou o estudo da microflora intestinal de 77 símios (38, C.apella; 14, S.sciureus; 20, C.a.argentata e 5, A.trivirgatus), através de coprocultivos realizados imediatamente após a captura desses animais na floresta amazônica brasileira e depois de 6 meses em cativeiro. Proteus mirabilis, Escherichia coli, Proteus morganii, Proteus vulgaris, Klebsiella pneumoniae, Proteus rettgeri, Enterobacter cloacae, Citrobacter freundii, Enterobacter aerogenes e Edwaedsiella tarda foram isolados dos primeiros coprocultivos procedidos logo após a captura dos símios. Salmonella worthington foi isolada de um exemplar de C.a.argentata em cativeiro