Guideline for primary care management of headache in adults

Objective

To increase the use of evidence-informed approaches to diagnosis, investigation, and treatment of headache for patients in primary care.

Quality of evidence

A comprehensive search was conducted for relevant guidelines and systematic reviews published between January 2000 and May 2011. The guidelines were critically appraised using the AGREE (Appraisal of Guidelines for Research and Evaluation) tool, and the 6 highest-quality guidelines were used as seed guidelines for the guideline adaptation process.

Main message

A multidisciplinary guideline development group of primary care providers and other specialists crafted 91 specific recommendations using a consensus process. The recommendations cover diagnosis, investigation, and management of migraine, tension-type, medication-overuse, and cluster headache.

Conclusion

A clinical practice guideline for the Canadian health care context was created using a guideline adaptation process to assist multidisciplinary primary care practitioners in providing evidence-informed care for patients with headache.Headache is one of the most common reasons patients seek help from family physicians. The estimated lifetime prevalence of headache is 66%: 14% to 16% for migraine, 46% to 78% for tension-type headache, and 0.1% to 0.3% for cluster headache.^1–3 In Canada, at least 2.6 million adult women and nearly 1 million men experience migraine.⁴ About 90% of migraine sufferers report moderate to severe pain, with 75% reporting impaired function and 33% requiring bed rest during an attack.⁵ The economic effects of headache are also substantial. It is estimated that headache accounts for 20% of work absences.⁶Vast quantities of over-the-counter medications are taken for headache disorders, and treatment is often suboptimal.^1,7 Although most migraine sufferers use acute treatment to relieve their headaches, a substantial number of people who might benefit from prophylactic therapy do not receive it—more than 1 in 4 migraineurs are candidates for preventive therapy.^5,8Better information and education for patients and health professionals is essential to improving management of headache in primary care, which should lead to prompt diagnosis and more effective treatment.⁹ To help address this, a consortium of organizations and clinicians from Alberta developed the Guideline for Primary Care Management of Headache in Adults.¹⁰     

第52例--关于脓毒症及脓毒性休克治疗的几个观点(Internet网上专题讨论)

冯丽洁医生 :急救快车网站编辑、主治医师 (fenglj@em12 0 .com)2 0 0 2年 10月 ,欧洲危重病协会(ESICM)、危重病协会 (SCCM)和国际脓毒症论坛提出了《巴塞罗那宣言》,共同呼吁采取措施减少世界最古老、最具杀伤力的疾病——脓毒症 ,争取在今后5 a内将脓毒症的死亡率降低 2 5 %。ES-ICM主席 Graham Ram say教授指出 ,临床医生一直在寻求最好的脓毒症治疗方法 ,但是各国政府没有以足够的资金和教育来支持 ,医生的努力受到限制 ,《巴塞罗那宣言》将促进政府和医学管理部门提高对脓毒症社会危害的认识和干预。对于医学界和学术界而言 ,…     

The management of neuropathic pain with a focus upon older adults

By the year 2030, it is projected that the US population over the age of 65 years will be 70 million (one-fifth of the US population). Pain of various etiologies initiates about 50% of yearly physician visits and is the most frequent reason for health care consultation in the United States identified commonly by the older patient. The negative impact on the patient coupled with less than optimal treatments often presented to the patient elicit patient and prescriber frustration with inadequate outcomes. This article is focused at pharmacotherapeutic selections to be utilized in a polymodal fashion for the older adult presenting with neuropathic pain. The pharmacotherapies are to be titrated in a patient-specific patient centered-patient focused-personalized pharmacotherapeutic care. The classes of agents discussed include antidepressants, mood stabilizers/antiseizure agents, opioids, anesthetics, and miscellaneous agents.     

Sternoclavicular joint septic arthritis following paraspinal muscle abscess and septic lumbar spondylodiscitis with epidural abscess in a patient with diabetes: a case report

Background

Septic arthritis of the sternoclavicular joint (SCJ) is extremely rare, and usually appears to result from hematogenous spread. Predisposing factors include immunocompromising diseases such as diabetes.

Case presentation

A 61-year-old man with poorly controlled diabetes mellitus presented to our emergency department with low back pain, high fever, and a painful mass over his left SCJ. He had received two epidural blocks over the past 2?weeks for severe back and leg pain secondary to lumbar disc herniation. He did not complain of weakness or sensory changes of his lower limbs, and his bladder and bowel function were normal. He had no history of shoulder injection, subclavian vein catheterization, intravenous drug abuse, or focal infection including tooth decay. CT showed an abscess of the left SCJ, with extension into the mediastinum and sternocleidomastoid muscle, and left paraspinal muscle swelling at the level of L2. MRI showed spondylodiscitis of L3-L4 with a contiguous extradural abscess. Staphylococcus aureus was isolated from cultures of aspirated pus from his SCJ, and from his urine and blood. The SCJ abscess was incised and drained, and appropriate intravenous antibiotic therapy was administered. Two weeks after admission, the purulent discharge from the left SCJ had completely stopped, and the wound showed improvement. He was transferred to another ward for treatment of the ongoing back pain.

Conclusion

Diabetic patients with S. aureus bacteremia may be at risk of severe musculoskeletal infections via hematogenous spread.     

Surgical treatment of the elbow joint in rheumaid arthritis, with particular attention to resection arthroplasty

Elbow involvement in rheumatoid arthritis begins at a later stage in the development of the disease and proceeds slowly. Depending upon the degree of intensity and the involvement of neighboring joints (shoulder, wrist, hand), pathological changes in the elbow may be the cause of serious limitations in the performance of basic daily life activities. This article presents methods of surgical treatment of the elbow joint in rheumatoid arthritis. Synovectomy and debridement, which given the proper indications are performed with simultaneous resection of the radial head, can significantly reduce pain and improve joint function. In cases where considerably reduced range of motion or ankylosis is preventing the performance of daily life activities, one of the surgical treatment methods in use is resection arthroplasty using the Hass-Vainio technique. The author presents his whom (42 elbows) were followed up post-operatively over a period of 3-30 years (mean 18 years). The favourable outcome obtained in a large majority of these cases indicates that resection arthroplasty is still a valuable method for the surgical treatment of rheumatoid arthritis, despite progress in prosthesis replacement.     

Daily needle aspiration versus surgical lavage for the treatment of bacterial septic arthritis in adults

Septic arthritis is a substantial public health problem, accounting for 0.2-0.7% of hospital admissions. However, despite the availability of effective antibiotics, the appropriate approach to adjunctive therapy remains controversial. Although early drainage is essential to minimize the risks of permanent loss of articular function, it is unclear whether the optimal approach involves arthroscopic lavage or daily arthrocentesis; surgeons appear to prefer surgical lavage because their training routinely considers septic arthritis to be a closed-space infection comparable to an abscess, whereas rheumatologists appear to prefer daily arthrocentesis because of its ease and non-invasive nature. There is a paucity of prospective data comparing the two approaches, and the literature is largely retrospective. Herein, we review the available literature concerning drainage of bacterially infected joints, and conclude that in the absence of prospective randomized clinical trials, the best evidence suggests that there is no compelling reason to recommend surgical lavage for the initial management of uncomplicated septic arthritis.     

Unilateral septic arthritis of a lumbar facet joint secondary to acupuncture treatment--a case report

This report describes a case of septic arthritis of the lumbar facet joint probably as a result of acupuncture treatment. A 48 year old man with a long history of back pain presented with a two week history of increasing pain following a third session of acupuncture. Examination revealed tenderness in the right lumbosacral area and laboratory investigations revealed raised inflammatory markers with negative blood cultures. A bone scan and MRI scan showed evidence of septic arthritis of the right L5/S1 facet joint. An x ray computed tomography guided biopsy was carried out which isolated staphylococcus aureus. The patient was initially treated with intravenous antibiotics. A repeat MRI scan demonstrated persistent septic arthritis with adjacent early abscess formation. Surgical debridement of the facet joint was therefore performed. The patient had resolution of his symptoms and the inflammatory markers returned to normal. He regained a full range of movement of the lumbar spine. Very few cases have been reported of lumbar facet joint septic arthritis and this condition is rare in association with acupuncture treatment. A high index of suspicion needs to be maintained and if conservative management fails then debridement can result in an acceptable outcome.     

Lithium carbonate therapy for granulocytopenia in a patient with myelofibrosis and septic arthritis

We report a patient with myelofibrosis, granulocytopenia, and septic arthritis, in whom lithium carbonate induced a more appropriate granulocyte count. Further evaluation of the use of lithium carbonate in granulocytopenic states seems warranted.     

Current and emerging therapies for rheumatoid arthritis, with a focus on infliximab: clinical impact on joint damage and cost of care in canada.

BACKGROUND: Rheumatoid arthritis (RA) is a physically debilitating disease that places an enormous burden not only on individuals and their families but also on the economy. Affecting -1% of the Canadian population, RA is characterized by pain and swelling of joints. Without effective treatment, RA results in joint destruction that often requires surgery. OBJECTIVE: This review summarizes the effect of current and new RA treatments on joint damage, with a focus on infliximab. The health-economic repercussions and potential impact of arresting the joint destruction of RA are discussed. METHODS: Information for inclusion in this review was identified through searches of the MEDLINE and HealthStar databases from 1995 to 2000. Search terms included rheumatoid arthritis, treatment guidelines, economics, and individual drug names. RESULTS: Standard initial RA drug therapy has been aimed at reducing pain and inflammation, whereas use of the more potent disease-modifying antirheumatic drugs (DMARDs) has been reserved for later stages of disease. More aggressive RA treatment involves introducing DMARDs at the earliest stage. The largest single direct cost of RA involves hospital admissions for the correction of joint deformities. Among newer therapies, the anti-tumor necrosis factor-alpha agent infliximab has been shown to arrest radiographic measures of disease progression. CONCLUSIONS: With early and aggressive treatment involving new drugs and drug combinations, it may be possible to ameliorate the physical, social, and economic effects of RA.     

Graduate foundation scheme with a focus on dignity and older adults

The care experiences of older people in Wales and the rest of the UK have risen to the top of the political agenda recently, and it is the role of nurse managers to find ways to meet the dignity agenda. A review by the Older People's Commissioner for Wales (Marks 2011) recommends that 'better knowledge of the needs of older people with dementia is needed, together with improved communication, training, support and standards of care'. In an effort to meet this recommendation, one healthcare organisation, Cwm Taf Health Board, has developed a graduate foundation programme that focuses on the dignity of older patients in various hospital settings. This article describes the development and implementation of the programme.     

Guideline for the management of acute sore throat

The European Society for Clinical Microbiology and Infectious Diseases established the Sore Throat Guideline Group to write an updated guideline to diagnose and treat patients with acute sore throat. In diagnosis, Centor clinical scoring system or rapid antigen test can be helpful in targeting antibiotic use. The Centor scoring system can help to identify those patients who have higher likelihood of group A streptococcal infection. In patients with high likelihood of streptococcal infections (e.g. 3-4 Centor criteria) physicians can consider the use of rapid antigen test (RAT). If RAT is performed, throat culture is not necessary after a negative RAT for the diagnosis of group A streptococci. To treat sore throat, either ibuprofen or paracetamol are recommended for relief of acute sore throat symptoms. Zinc gluconate is not recommended to be used in sore throat. There is inconsistent evidence of herbal treatments and acupuncture as treatments for sore throat. Antibiotics should not be used in patients with less severe presentation of sore throat, e.g. 0-2 Centor criteria to relieve symptoms. Modest benefits of antibiotics, which have been observed in patients with 3-4 Centor criteria, have to be weighed against side effects, the effect of antibiotics on microbiota, increased antibacterial resistance, medicalisation and costs. The prevention of suppurative complications is not a specific indication for antibiotic therapy in sore throat. If antibiotics are indicated, penicillin V, twice or three times daily for 10 days is recommended. At the present, there is no evidence enough that indicates shorter treatment length.     

Health check up and health care advice with a particular focus on the metabolic syndrome--background and overview

Along with the socio-economic development, the Japanese disease structure has changed form the acute diseases dominant to the lifestyle-related chronic diseases dominant pattern. Lifestyle-related diseases are defined as the group of diseases in which such lifestyle as the habits of eating, exercise, rest, smoking and drinking contribute to their outbreak and development. Today the lifestyle-related diseases account for two third of death, one third of health expenditures in Japan. According to the Health Care Reform 2006, health check up and health care advice with a particular focus on the Metabolic syndrome will be introduced from April, 2008. All citizens between 40 and 74 years old have to participate to this program. In this article, the author explains the background and overview of this new program.     

Streptococcus pneumoniae septic arthritis complicating hip osteonecrosis in adults: case report and review of the literature

A 42-year-old patient presented acutely with bacteremic pneumococcal pneumonia along with metastatic pneumococcal infection of the hip joint. Diagnostic evaluation revealed evidence of a pre-existing bilateral hip osteonecrosis. The osteonecrotic changes were attributed to chronic alcohol abuse and/or an old motor vehicle accident. Appropriate therapy was promptly instituted and the septic arthritis responded well, necessitating hip aspiration only once. A few months later, the patient had no permanent sequelae of the infection.