High-Dose Versus Low-Dose Valproic Acid as a Prophylactic Medication

Valproic acid has been shown to be effective in migraine prophylaxis. Its method of action is believed to be the inhibition of gamma-aminobutyric acid transaminase. The therapeutic dose needed to prevent migraine headaches has been examined in several studies, yet the optimum dose has not been found. In this case report, valproic acid was given to a 24-year-old woman with chronic headaches at 1000 mg per day. Her headaches resolved for 2 months. She tapered herself off of the medication, and her headaches returned. She was restarted at 500 mg per day of valproic acid and again, her headaches resolved. She preferred being on the lower dose which she found as effective as the higher dose. Her case makes two interesting points. The first is that lower dosages of valproic acid may be as effective as higher ones in headache prophylaxis. The second is that more studies looking at dose ranges are needed to correlate effectiveness with daily requirements.     

糖尿病患者低血糖反应时手臂毛细血管血糖值的可靠性研究

目的研究低血糖反应时手臂毛细血管血糖（CGA）、指尖毛细血管血糖（CGF）及自动生化血糖仪测定静脉血浆血糖（VG）的关系。方法选择2006年7-11月住院强化治疗的糖尿病患者中出现低血糖反应者34例,发生低血糖反应即刻和口服50%葡萄糖后20 min,由操作熟练的2名护士,1名护士抽取静脉血由实验室用全自动生化仪测定VG,另1名护士即刻用Free Style利舒坦快速血糖仪同时测定CGA与CGF。结果低血糖反应时CGA（4.04±0.68）mmol/L,明显高于CGF（2.85±0.22）mmol/L与VG（2.64±0.21）mmol/L（P〈0.001）;口服50%葡萄糖后20 min CGA（7.03±1.20）mmol/L,明显低于CGF（9.15±1.69）mmol/L与VG（9.27±1.70）mmol/L（P〈0.001）;CGF与VG在低血糖反应时及口服50%葡萄糖后20 min相关分析r值分别为0.616、0.983,P〈0.001。结论低血糖反应时测量手臂毛细血管血糖要慎重,应该测量指尖血糖或静脉血糖为宜。     

The Traditions and Risks of Fasting for Lipid Profiles in Patients with Diabetes

Abstract

Fasting overnight has been traditionally recommended by clinicians when ordering laboratory tests for lipid profiles for the purposes of health screening or monitoring of the effects of lipid-lowering medications. Patients with diabetes are tested for lipid profiles at least annually. This deeply rooted tradition of fasting for lipid testing has recently been challenged. Several studies have shown little benefit obtained by testing lipids in fasting compared with postprandial states. Furthermore, recent studies have shown the importance of postprandial lipid spikes in the pathogenesis of cardiovascular disease. At the same time, recent reports have alerted the medical community to the risk of hypoglycemia in patients with diabetes on antidiabetic medications (particularly insulin and sulfonylureas) who are asked to fast for lab tests. This article reviews the literature on these emerging issues in lipid testing in patients with diabetes, and offers recommendations for lipid testing in these patients in view of these emerging discussions.     

Hypoglycemia secondary to insulinoma masking the onset of type 1 diabetes in an adolescent

Type 1 diabetes and insulinoma can co‐occur in pediatric patients and may present with episodes of hypo‐ and hyperglycemia, significant glycemic variability, and weight gain. Surgical resection leads to development of fulminant diabetes.     

Migraine Mimics

The symptoms of migraine are non‐specific and can be present in many other primary and secondary headache disorders, which are reviewed. Even experienced headache specialists may be challenged at times when diagnosing what appears to be first or worst, new type, migraine status, and chronic migraine.     

Efficacy and tolerability of intravenous valproic acid in acute adolescent migraine

OBJECTIVE: To describe the efficacy and tolerability of rapid intravenous valproic acid (VPA) infusions in children with severe migraine headache. BACKGROUND: Intravenous VPA is an emerging treatment option for acute migraine headache. Adult data suggests both efficacy and tolerability of rapid VPA infusions as abortive therapy, but little data exist in children. METHODS: We conducted a retrospective chart review of all children who received intravenous VPA at The Children's Hospital Headache Clinic during an 18--month study period. Baseline intensity of headache pain, time at which maximum relief was attained, pain reduction following therapy, dose and duration of VPA infusion(s), patient's pulse, blood pressure, respiratory rate, and pulse oximetry were collected. Adverse events were also recorded. RESULTS: Thirty-one children (age=15+/- 2 years; 81% female) requiring 58 clinic visits and 71 VPA infusions were included. Most visits (n=45; 78%) resulted in only one dose of VPA (976+/- 85 mg infused over 12+/- 4 minutes) for desired pain relief. Percent pain reduction in those children was 39.8%, with time to maximum relief of 63+/- 31 minutes. Some children required a second dose of 500 mg (n=13 visits; 22%), that was infused over 14+/- 6 minutes and produced a 57% reduction in pain intensity from baseline. VPA infusions were well tolerated. Adverse events described included cold sensation (1), dizziness (3), nausea (1), possible absence seizure (1), paraesthesia (2), and tachycardia (2). CONCLUSIONS: Rapid infusion of intravenous VPA is generally well tolerated and may play a role in the management of children with acute migraine headache. Prospective, controlled trials to further investigate this treatment in children are warranted.     

社区老年2型糖尿病患者低血糖反应及生存质量现状研究

目的：调查社区老年2型糖尿病患者自我感知的低血糖反应发生频率和生存质量现状。方法：采用自行设计的问卷调查上海市某一社区203例老年2型糖尿病患者过去一年内和过去一个月内发生低血糖反应的情况;采用中文版糖尿病患者生存质量特异性量表（DSQL）对患者进行生存质量测评。结果：有22.2%的患者在过去一年内出现过至少1次的低血糖反应,有12.8%的患者在过去一个月内出现过至少1次的低血糖反应;患者生存质量评价得分为（41.9±8.6）分。结论：城市社区老年2型糖尿病患者生存质量水平处于中等水平,尚有提升的空间;应减少患者低血糖反应发生的频率,提高其生存质量。     

25例胰岛素治疗患者酗酒后致严重低血糖的因为分析与护理

分析总结25例糖尿病胰岛素治疗患者酗酒后致严重低血糖的原因及护理对策。空腹酗酒、酗酒后酒精使胰岛素分泌及作用增强、酗酒后肝功能损害、老年糖尿病患者是酗酒导致严重低血糖的原因。认为迅速判断、紧急处理以防止低血糖所致脑功能进一步损害,是成功抢救酗酒致胰岛素治疗患者严重低血糖反应的关键。针对酗酒致低血糖原因,适时进行个体化低血糖防范知识教育,帮助患者认识酗酒导致严重低血糖的危害;根据病情、生活方式等指导患者配合积极戒酒或为其制定个体化饮酒方案;积极随访,控制诱因;强化自我管理知识和技能,指导患者家属积极监督,促使患者行为改变,避免酗酒行为复萌,可以预防严重低血糖事件再次发生。本组25例胰岛素治疗患者酗酒后致严重低血糖反应病例中,24例抢救成功,未遗留各种脑功能障碍后遗症及诱发心脑血管事件,血糖控制平稳出院,随访1～3年,均无严重低血糖事件再次发生。     

Hypoglycemia in Diabetes: Challenges and Opportunities in Care

Optimal glycemic control, an A1c < 7% for most patients, is necessary to reduce the risk for diabetes complications. However, tight glucose control carries a risk for hypoglycemia. Hypoglycemia can be a frightening aspect of living with diabetes, causing harmful effects to the cardiovascular system and a decrease in quality of life. This article reviews the important aspects of hypoglycemia management from both the patient and provider perspective. Nurse practitioners (NPs) should understand the physiology behind glucose homeostasis and lead evidence-based discussions regarding medication timing and dose, physical activity/exercise, alcohol consumption, symptom management, treatment, and prevention of low blood glucoses. The management of special populations such as older adults, those with renal impairment, and pregnant women is included. In light of mounting evidence that hypoglycemia is harmful and should be avoided at all costs, NPs are well positioned to assist patients in identifying, managing, and preventing hypoglycemia.     

Migraine,Migraine Features,and Cardiovascular Disease

(Headache 2010;50:1031‐1040) Background.— Many studies support an association between migraine and cardiovascular disease (CVD). This association appears particularly in migraine with aura and is also modified by additional factors. Objective.— We sought to investigate whether the association between migraine and CVD in addition to aura status is affected by certain migraine features. Methods.— Cohort study among 27,840 women, participating in the Women's Health Study. We had detailed self‐reported information on migraine and migraine features among women with active migraine (migraine during the year prior to baseline). Incident CVD events were confirmed after medical record review. We used Cox proportional hazards models to evaluate the association between migraine and incident CVD. The results have been presented in part before. We ran additional analyses according to migraine features. Results.— At baseline, 5125 (18.4%) women reported history of migraine; 39.7% of the 3610 women with active migraine indicated aura. During a mean of 11.9 years of follow‐up, 708 CVD events occurred. Migraine with aura doubled the risk for CVD, ischemic stroke, and myocardial infarction. With regard to ischemic stroke, this association seemed stronger in the absence than in the presence of migraine features. This was most pronounced in the absence (hazard ratio = 3.27; 95% CI = 1.93‐5.51; P < .0001) than in the presence of nausea/vomiting (hazard ratio = 0.91; 95% CI = 0.43‐1.93; P = .80). In contrast, the association with myocardial infarction did not reveal a certain pattern. Conclusions.— These data suggest that the association between migraine with aura and ischemic stroke may differ by absence or presence of migraine features.     

Menstrual Migraine in Adolescents

Objective.— To characterize menstrually associated headaches and migraine in adolescent girls and identify any developmental and pubertal changes. Background.— Headache and migraine is a common problem in adolescents with a transition to adult patterns. One pattern of adult migraine is the menstrual association in a significant number of women. Methods.— A retrospective analysis was performed of characteristics of adolescent's headaches including association with menstrual pattern. A detailed analysis of the patient‐ and parent‐reported headache characteristics and patterns of longitudinal change with development and puberty was reviewed, including timing of headache with age and menstrual period and progression of these events over the adolescence. Results.— Of the 896 girls between 9 and 18 years old reviewed at initial evaluation, 331 (50.3% of menarchal girls and 36.9% of all girls) report experiencing headaches with their menstrual period. Of those reporting a menstrual pattern, 63.6% reported migraines starting between day ?2 and +3 of their menstrual period start. Girls with menstrual migraine reported increased associated symptoms compared with girls without menstrual migraine. There was no difference in disability between girls with a menstrual pattern and those without a menstrual pattern (t = 1.64; P = .10). Additionally, 160 girls reported a monthly pattern to their headaches prior to beginning menstruation, suggestive of a menstrually related migraine pattern prior to menstruation. Conclusions.— The pattern of menstrual association begins to become apparent during adolescence. Once the menstrual pattern has developed, this association is stable. Early identification of this pattern has potential long‐term benefit for improved lifelong outcome.     

Migraine with prolonged aura

We present the case of a 29-year-old man with a long history of migraine with aura, in whom migraine with prolonged aura was induced after the sudden withdrawal of prophylactic therapy.     

Hypoglycemia Worsened by Glucose Administration: A Case of Hypoglycemia Years After Gastric Surgery

BackgroundNoninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a rare syndrome characterized by postprandial hypoglycemia with neuroglycopenic symptoms occurring 1 to 3 h after a meal. Diagnosis can be elusive, as the vast majority of patients have normal fasting blood glucose levels, and onset of hypoglycemic episodes can be a late complication of gastric surgery.Case ReportWe report the case of a 45-year-old woman presenting to the Emergency Department (ED) with new-onset seizures and hypoglycemia worsened by glucose administration. Surgical history is pertinent for a Roux-en-Y gastric bypass approximately 10 years prior to presentation.Why Should an Emergency Physician Be Aware of This?Although rare, it is important for emergency physicians to be vigilant of this disease process as a traditional treatment approach for hypoglycemia may be detrimental. Although cases of NIPHS have been documented in literature, its presence in emergency medicine-specific literature is seemingly nonexistent. Noninvasive imaging techniques will be normal, and diagnosis is dependent on awareness of this disease entity coupled with a detailed history.     

Divalproex Sodium in Headache: Literature Review and Clinical Guidelines

Divalproex sodium is an anticonvulsant agent approved for use either alone or in combination with other antiepileptic drugs for simple and complex absence seizures and mania. Four double-blind placebo-controlled studies have confirmed that divalproex sodium/valproate is an effective migraine treatment. In all of the clinical studies, whether open, retrospective, or placebo-controlled and double-blind, valproate was an effective preventive treatment for migraine. There was a reduction in the number of migraine attacks, and migraine duration and intensity were also reduced in some instances. It is equally as effective in patients with severe frequent migraines as in those with less severe migraines. In clinical trials, the most frequent adverse events reported by patients treated with divalproex sodium were nausea, asthenia, dyspepsia, dizziness, somnolence, and diarrhea, with most adverse events being mild to moderate in severity.     

Complicated Retinal Migraine

SYNOPSIS
Retinal migraine is not uncommon, but permanent sequelae are rare. We describe the case of a 23-year-old woman who had suffered from retinal migraine for five years. After a typical migraine attack a left nasal quadranopsia persisted. Fluorescein angiography showed a branch retinal arterial occlusion. Other causes were ruled out by appropriate laboratory techniques. Her visual field defect has persisted for eleven months.     

Hypoglycemia Manifested by Sinus Bradycardia: A Report of Three Cases

Three cases are reported of hypoglycemia manifested by profound sinus bradycardia and fatigue, which responded to IV dextrose with prompt normalization of the cardiac rhythm. The cases involved 3 different patients and disease processes: a young female who had anorexia nervosa and profound malnutrition; an elderly, nondiabetic male who subsequently experienced a transient ischemic attack; and a patient who had diabetes mellitus managed with chronic, subcutaneous insulin administration. It is vitally important that the emergency physician recognize unusual clinical manifestations of hypoglycemia and fully evaluate such scenarios when hypoglycemia may occur. Untreated, hypoglycemia may result in significant chronic morbidity, and rarely, in death. Bradyarrhythmias–particularly sinus bradycardia–should be added to the list of potential clinical manifestations of hypoglycemia.     

Crying Migraine

Eighty-five percent of migraineurs report triggers which include a diverse array of internal and external factors. Crying as a trigger has been reported in two women, without details, in only one prior study. In the present report, the clinical history of two women (aged 38 and 41 years, respectively) with migraines triggered by crying are detailed. In both women, the migraines were triggered by crying associated with sadness or emotional upset. Crying when happy or due to cutting onions was not a trigger. Only in the second patient was crying during a sad movie or theatrical production also a trigger. Crying may be a common underrecognized migraine trigger.     

低血糖对糖尿病患者生活质量的影响及护理干预

目的调查糖尿病患者治疗过程中低血糖发生对其生活质量的影响,探讨护理干预对预防患者低血糖发生及提高患者生活质量的作用。方法采用糖尿病普适性生活质量量表(SF-36)评价102例糖尿病患者入院时及低血糖发生后的生活质量,并在对他们进行系统护理干预和药物调整1个月后作第3次评价。比较患者入院时、低血糖发生后及系统护理干预后生活质量的变化。结果糖尿病患者发生低血糖后生活质量降低,与发生前比较差异有统计学意义(P0.05或P0.01);系统护理干预后,患者的生活质量提高,除精力、躯体功能、社会功能以外的各维度与干预前相比差异有统计学意义(P0.01)。结论糖尿病患者低血糖发生后生活质量降低,通过护理干预能够提高患者生活质量。