Real-world approaches to outpatient treatment of status migrainosus: A survey study.

OBJECTIVES: Identify how the American Headache Society (AHS) membership manages status migrainosus (SM) among outpatients. BACKGROUND: SM is defined as a debilitating migraine attack lasting more than 72 h. There is no standard of care for SM, including whether a 72-h duration is required before the attack can be treated as SM. METHODS: The Refractory Headache Special Interest Group from AHS developed a four-question survey distributed to AHS members enquiring (1) whether they treat severe refractory migraine attacks the same as SM regardless of duration, (2) what their first step in SM management is, (3) what the top three medications they use for SM are, and (4) whether they are United Council for Neurologic Subspecialties (UCNS) certified. The survey was conducted in January 2022. Descriptive statistical analyses were performed. RESULTS: Responses were received from 196 of 1859 (10.5%) AHS members; 64.3% were UCNS certified in headache management. Respondents treated 69.4% (136/196) of patients with a severe refractory migraine attack as SM before the 72-h period had elapsed. Most (76.0%, 149/196) chose "treat remotely using outpatient medications at home" as the first step, 11.2% (22/196) preferred procedures, 6.1% (12/196) favored an infusion center, 6.1% (12/196) sent patients to the emergency department (ED) or urgent care, and 0.5% (1/196) preferred direct hospital admission. The top five preferred medications were as follows: (1) corticosteroids (71.4%, 140/196), (2) nonsteroidal anti-inflammatory drugs (NSAIDs) (50.1%, 99/196), (3) neuroleptics (46.9%, 92/196), (4) triptans (30.6%, 60/196), and (5) dihydroergotamine (DHE) (21.4%, 42/196). CONCLUSIONS: Healthcare professionals with expertise in headache medicine typically treated severe migraine attacks early and did not wait 72 h to fulfill the diagnostic criteria for SM. Outpatient management with one or more medications for home use was preferred by most respondents; few opted for ED referrals. Finally, corticosteroids, NSAIDs, neuroleptics, triptans, and DHE were the top five preferred treatments for home SM management.

An Investigation on the Acetone and Ethanol Vapor-Sensing Behavior of Sol-Gel Electrospun ZnO Nanofibers Using an Indigenous Setup.

The calibration is essential for accuracy, repeatability, and continuous trouble-free operation of gas sensors with safety. Most gas sensors are fabricated using metal oxide nanomaterials in different structures such as films, coating, or nanofibers. Therefore, a device in the sensor manufacturing industry is necessary to test, calibrate, and optimize metal oxide structures. In this point of view, a simple device is developed to test and estimate the sensing response, response time, and recovery time of nanostructures. The sol-gel method was used to produce nanofibers through electrospinning. An average fiber diameter of 245 nm was obtained after pyrolysis at 600 °C. The structure and composition of ZnO nanofibers are confirmed by X-ray diffraction, scanning electron microscopy, and Brunauer-Emmett-Teller. The trials were taken using ZnO nanofibers in the presence of acetone and ethanol vapor, and the results were reported. High response (31.74), rapid response (40 s), and recovery (30 s) times have been achieved for ethanol gas to 50 ppm concentration test gas at an optimal temperature of 260 °C. The results obtained from the trials are compared with the literature results, which are in line with the values presented by the various researchers. Due to the low cost, easy maintenance, and accuracy, this device is recommended in metal oxide sensor development industries and laboratories.

The role of urgent care centers in headache management: a quality improvement project.

BACKGROUND: Patients with headache often seek urgent medical care to treat pain and associated symptoms that do not respond to therapeutic options at home. Urgent Cares (UCs) may be suitable for the evaluation and treatment of such patients but there is little data on how headache is evaluated in UC settings and what types of treatments are available. We conducted a study to evaluate the types of care available for patients with headache presenting to UCs. DESIGN: Cross-Sectional. METHODS: Headache specialists across the United States contacted UCs to collect data on a questionnaire. Questions asked about UC staffing (e.g. number and backgrounds of staff, hours of operation), average length of UC visits for headache, treatments and tests available for patients presenting with headache, and disposition including to the ED. RESULTS: Data from 10 UC programs comprised of 61 individual UC sites revealed: The vast majority (8/10; 80%) had diagnostic testing onsite for headache evaluation. A small majority (6/10; 60%) had the American Headache Society recommended intravenous medications for acute migraine available. Half (5/10) had a headache protocol in place. The majority (6/10; 60%) had no follow up policy after UC discharge. CONCLUSIONS: UCs have the potential to provide expedited care for patients presenting for evaluation and treatment of headache. However, considerable variability exists amongst UCs in their abilities to manage headaches. This study reveals many opportunities for future research including the development of protocols and professional partnerships to help guide the evaluation, triage, and treatment of patients with headache in UC settings.

A case of anti-VGKC antibody encephalitis and prolonged encephalopathy despite spontaneous resolution of imaging abnormalities.

Anti-voltage-gated potassium channel (anti-VGKC) antibody encephalitis is a common form of autoimmune encephalitis (AE). AE is usually associated with autoimmune diseases or paraneoplastic phenomena such as seen in small cell lung cancer. Clinical presentation can include memory impairment, seizures, and psychiatric symptoms. We report a case of a 72-year-old male with non-small lung cancer in remission who presented with erosive gastritis and acute severe encephalopathy. Anti-VGKC antibody limbic encephalitis was diagnosed. Spontaneous resolution of encephalitis-associated changes on brain Magnetic Resonance (MR) with concomitant decreased circulating antibody levels were observed despite lack of overall cognitive improvement. ABBREVIATIONS: AE: autoimmune encephalitis; AMPAR: antibody limbic encephalitis - anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor encephalitis; Anti-VGKC encephalitis: anti-Voltage-gated potassium channel antibody encephalitis; CRP: c-reactive protein; CT: computed tomography; EEG: electroencephalography; ESR: erythrocyte sedimentation rate; GCS: Glasgow Coma Scale; MRImaging: Magnetic resonance imaging; NMDA-R encephalitis: Anti-N-methyl D-aspartate receptor encephalitis; PCR: polymerase chain reaction.

Behavioral Problems and Intelligence Quotient Changes in Pediatric Epilepsy: A Case-Control Study.

BACKGROUND: Epilepsy is the most common chronic neurological disease and has neurological impairment as an important comorbidity. OBJECTIVE: To find behavioral problems and intelligence quotient (IQ) changes associated with epilepsy and to know the association of variables such as frequency, type of seizures, and duration of disease with cognitive impairment. MATERIALS AND METHODS: A descriptive cross sectional study, consisting of 50 cases (patients of epilepsy) and 50 controls (other patients of same socioeconomic status) was conducted at S.P. Medical College, Bikaner. The patients were subjected to detailed clinical history, thorough examination, Pediatric Symptom Checklist, and Bhatia's Battery of Performance intelligence Test. Data analysis was carried out with the help of SPSS 22 software. RESULTS: The prevalence of behavioral problems in generalized and partial seizure group was high (42% and 53.8%) as compared to control group (9%). Low IQ was present more in the patients (44%) of generalized and partial seizure group as compared with the control group, and results were statistically significant. Furthermore, behavioral problems were more in patients who were having more number of seizures (≥3 per year) with significant P values (χ2 = 5.067, P = 0.024). CONCLUSION: We conclusively found that behavioral problems and cognitive factors, apart from control of seizures, must be kept in mind to determine how well a child with epilepsy progresses toward independence.

Mechanisms of hypoxemia.

Oxygen is an essential element for life and without oxygen humans can survive for few minutes only. There should be a balance between oxygen demand and delivery in order to maintain homeostasis within the body. The two main organ systems responsible for oxygen delivery in the body and maintaining homeostasis are respiratory and cardiovascular system. Abnormal function of any of these two would lead to the development of hypoxemia and its detrimental consequences. There are various mechanisms of hypoxemia but ventilation/perfusion mismatch is the most common underlying mechanism of hypoxemia. The present review will focus on definition, various causes, mechanisms, and approach of hypoxemia in human.

Comparative evaluation of apically extruded debris with V-Taper, ProTaper Next, and the Self-adjusting File systems.

BACKGROUND: Complete cleaning of the root canal is the goal for ensuring success in endodontics. Removal of debris plays an important role in achieving this goal. In spite of advancements in instrument design, apical extrusion of debris remains a source of inflammation in the periradicular region. AIM: To comparatively evaluate the amount of apically extruded debris with V-Taper, ProTaper Next, and the self-adjusting File (SAF) system. MATERIALS AND METHODS: Sixty-four extracted human mandibular teeth with straight root canals were taken. Access openings were done and working length determined. The samples were randomly divided into three groups: Group I - V-Taper files (n = 20), Group II - ProTaper Next (n = 20), Group III - SAF (n = 20). Biomechanical preparation was completed and the debris collected in vials to be quantitatively determined. The data obtained was statistically analyzed using ANOVA and post hoc Tukey's test. RESULTS: All the specimens showed apical debris extrusion. SAF showed significantly less debris extrusion compared to V-Taper and ProTaper Next (P < 0.001). Among Groups I and II, ProTaper Next showed lesser debris extrusion as compared to V-Taper, but it was not significant (P = 0.124). CONCLUSION: The SAF showed least amount of apical debris extrusion when compared to newer rotary endodontic instruments. This indicates that the incidence of inter-treatment flare-ups due to debris extrusion would be less with the SAF.

Single C-shaped canal in mandibular first molar: A case report.

The variability of root canal system morphology presents a continuous challenge to endodontic diagnosis and therapeutics. There have been reports of teeth with multiple roots and canals as also those with lesser number of root and root canals. Variations of root canal systems need not always be in the form of extra canals. Clinicians should be aware that there is a possibility of existence of fewer numbers of roots and root canals than normal, which presents varied canal anatomy and poses a challenge to the clinician's expertise. This case report deals with the management of an unusual case of C-shaped canal in mandibular molar with two buccally fused roots. Cone-beam computed tomography (CBCT) was employed to confirm the extension of the unusual anatomy. The Self Adjusting File (SAF) system was used to ensure complete cleaning of the canal system. One-year follow-up of the case showed good healing. The clinician should expect to encounter unusual features when performing endodontic treatment. Use of diagnostic aids like CBCT, improved magnification with dental operating microscope, and the use of novel file systems like SAF ensure success.

Sleep-related headache and its management.

OPINION STATEMENT: Sleep and headache have both generated curiosity within the human mind for centuries. The relationship between headache and sleep disorders is very complex. While Lieving in 1873 first observed that headaches were linked to sleep, Dexter and Weitzman in 1970 described the relationship between headache and sleep stages. Though our understanding of sleep and headache relationship has improved over the years with expanding knowledge in both fields and assessment tools such as polysomnography, it is still poorly understood. Headache and sleep have an interdependent relationship. Headache may be intrinsically related to sleep (migraine with and without aura, cluster headache, hypnic headache, and paroxysmal hemicrania), may cause sleep disturbance (chronic migraine, chronic tension-type headache, and medication overuse headache) or a manifestation of a sleep disorder like obstructive sleep apnea. Headache and sleep disorder may be a common manifestation of systemic dysfunction-like anemia and hypoxemia. Headaches may occur during sleep, after sleep, and in relation to different sleep stages. Lack of sleep and excessive sleep are both considered triggers for migraine. Insomnia is more common among chronic headache patients. Experimental data suggest that there is a common anatomic and physiologic substrate. There is overwhelming evidence that cluster headache and hypnic headaches are chronobiological disorders with strong association with sleep and involvement of hypothalamus. Cluster headache shows a circadian and circannual rhythmicity while hypnic headache shows an alarm clock pattern. There is also a preferential occurrence of cluster headache, hypnic headache, and paroxysmal hemicrania during REM sleep. Silencing of anti-nociceptive network of periaqueductal grey (PAG), locus ceruleus and dorsal raphe nucleus doing REM sleep may explain the preferential pattern. Sleep related headaches can be classified into (1) headaches with high association with obstructive sleep apnea, which includes cluster headache, hypnic headache, and headache related to obstructive sleep apnea; and (2) headaches with high prevalence of insomnia, medication overuse, and psychiatric comorbidity including chronic migraine and chronic tension-type headache. The initial step in the management of sleep related headache is proper diagnosis with exclusion of secondary headaches. Screening for sleep disorders with the use of proper tests including polysomnography and referral to sleep clinic, when appropriate is very helpful. Control of individual episode in less than 2 hours should be the initial goal using measures to abort and prevent a relapse. Cluster headache responds very well to injectable Imitrex and oxygen. Verapamil, steroids and lithium are used for preventive treatment of cluster headache. Intractable cluster headache patients have responded to hypothalamic deep brain stimulation. Hypnic headache patients respond to nightly caffeine, indomethacin, and lithium. Paroxysmal hemicrania responds very well to indomethacin. Early morning headaches associated with obstructive sleep apnea respond to CPAP or BiPAP with complete resolution of headache within a month. Patient education and lifestyle modification play a significant role in overall success of the treatment. Chronic tension-type headache and chronic migraine have high prevalence of insomnia and comorbid psychiatric disorders, which require behavioral insomnia treatment and medication if needed along with psychiatric evaluation. Apart from the abortive treatment tailored to the headache types, - such as triptans and DHE 45 for migraine and nonsteroidal anti-inflammatory medication for chronic tension-type headache, preventive treatment with different class of medications including antiepileptics (Topamax and Depakote), calcium channel blockers (verapamil), beta blockers (propranolol), antidepressants (amitriptyline), and Botox may be used depending upon the comorbid conditions.

Cannabis-related stroke: case series and review of literature.

Marijuana, or cannabis, is one of the most commonly used illicit drugs worldwide. Although there are some case reports of stroke associated with cannabis use, there is no information on a causal role of cannabis in stroke. We identified 14 patients admitted to St Louis University Hospital between January 2004 and July 2007 with ischemic stroke who had documented clear exposure to cannabis during or before symptom onset and a positive urine screen for cannabis. We report this series, along with 3 cases previously reported by our group, for a total of 17 patients (13 men and 4 women), with a mean age of 41 years (range, 15-63 years). Nine patients were under age 45 years, 4 had a history of hypertension, and 10 sustained stroke in the posterior circulation. Headache, dysarthria, and ataxia were the most common presenting symptoms. Five patients had recurrent stroke with reexposure to cannabis. No patient had a prothrombotic state or cardiac source of embolism. Autopsy performed in 2 patients revealed hemorrhagic infarct with no evidence of vasculitis or embolus. The absence of other vascular risk factors in most of our patients, the temporal relation of symptom onset to cannabis exposure, and the recurrence of symptoms in a few patients with reexposure suggest a causal role of cannabis in these cases of ischemic stroke. However, this causal association cannot be definitely ascertained, given the descriptive nature of our series. More research is needed to explore this possible causal association.

Pontine warning syndrome: case series and review of literature.

Crescendo transient ischemic attacks (TIAs) are defined as repeated frequent short-lasting episodes of focal neurologic deficit due to cerebral ischemia. The capsular warning syndrome, a subset of crescendo TIA, consists of repetitive episodes of motor dysfunction due to ischemia in the region of internal capsule. It is not clear that patients with ischemia in the pons can have a similar clinical presentation and course. We report 11 cases presenting with crescendo TIA in the form of pure motor hemiparesis or ataxic hemiparesis that later proved to have a paramedian pontine infarct. The presumed mechanism of these infarcts is penetrating basilar artery branch occlusion at their origin, also called basilar branch disease.

Levetiracetam-induced thrombocytopenia among inpatients: a retrospective study.

Lately, few case reports have brought forth limited cases of levetiracetam (LEV)-induced thrombocytopenia. To estimate the burden of LEV-induced thrombocytopenia, we reviewed medical records of 758 patients aged 18 years or older who received LEV during their stay at the University Hospital from June 2005 to December 2008. In patients identified with thrombocytopenia, records were reviewed to establish a cause of thrombocytopenia and possible causal role of LEV. Of 758 patients, 29 patients were identified with thrombocytopenia while on LEV therapy. For 23 patients, an alternative cause for thrombocytopenia was established; 4 patients had preexisting thrombocytopenia without any appreciable change in platelet count after addition of LEV. One patient had limited data for identifying the cause of thrombocytopenia. A single patient had clear temporal co-relation and association of thrombocytopenia with LEV therapy. LEV-induced thrombocytopenia is a rare but reversible complication of LEV therapy. The mechanism remains unknown.

Vascularised Achilles tendon graft reconstruction--by the tendon for the tendon.

The management of posterior heel defects whether the result of trauma or post-operative that result in a loss of the Achilles tendon and overlying skin is complex and challenging. Various techniques have been employed to reconstruct these compound defects often comprising of a free tissue transfer combined with a fascial tendon reconstruction. We present a single-stage method of Achilles tendon reconstruction based upon a local vascularised tendon graft combined with a free antero-lateral thigh flap transfer and a review of the current literature.

Ondansetron and seizures.

Experimental studies suggest that 5-hydroxytryptamine (5-HT) receptors play a role in epileptogenesis and seizure propagation. Ondansetron, a 5-HT(3) receptor antagonist, has been reported to have proconvulsant and anticonvulsant effects in animals. We describe three patients who developed seizures after receiving ondansetron. There were two females and one male. Ages ranged from 38-56 years. None had a previous or family history of seizures. Four milligrams (mg) of ondansetron was given intravenously for severe nausea and vomiting in association with migraine, gastritis, and diabetic ketoacidosis. A generalized tonic-clonic seizure occurred in each patient--12, 15, and 22 min after injection. Brain magnetic resonance imaging (MRI) and electroencephalography (EEG) were normal in all patients. Although no antiepileptic drugs were given, none had seizure recurrence subsequently. The temporal relationship between ondansetron administration and seizures, lack of EEG or MRI abnormalities, and absence of seizure recurrence suggest that the seizures were causally related to ondansetron in our patients.