Words intrude my mind , swinging between dream and reality, i need to write them down , i ought to save these perplexing evocations . Many wills unfulfilled ,corroded in time finally deplorably denied.
Pedram May 30 2011
Pic : R. Gatward
Monday, May 30, 2011
Time Grinds
Words intrude my mind , swinging between dream and reality, i need to write them down , i ought to save these perplexing evocations . Many wills unfulfilled ,corroded in time finally deplorably denied.
Pedram May 30 2011
Pic : R. Gatward
Sunday, May 29, 2011
My Author of The Month (April)
well, it's not fair to make a judgement in an unstable mood and that's definitely the case when i finished Nabokov's "The Defense" about 6-7 years ago. I really couldn't apporoach the novel,could't get close to the core of the story,and that's exactly an opposite impression i found when i reread the novel last month.that's an interesting outcome , in that specific period,an extreme bafflement and thought disorder, a very predictable result is the aforementioned near zero uptake .It's the outshining fact that oppressed mind does have a tendency to keep its calm by not entering the difficult process of reasoning.Now what seems necessary is to overlook some thaught materials and reread some of my essential books and notes shadowed by unclarity. The ordeal of rediscovering some masked pieces of value in literature is an amazing experience raising the question of how far silent wizening ages affected my logic and deduction powerhouse and drove it to apathetic status .
"The Defense " experience will count as an outstanding experience and a prelude to some vastly illuminating alliance.
Pedram May 29 ,2011
Monday, May 23, 2011
عصر یکشنبه ی من با استیگ دگرمن
خسته از کار و سایش های روزمره به خانه برگشتم . باز همان حالت خستگی ...باز همان حس خالی شدن ...همان نا امیدی همیشگی...کتاب استیگ دگرمن را از کنار تخت بر می دارم و بدون هدف ورق می زنم. حس عجیبی من را ترغیب می کند که بخوانم.داستان کوتاهی را شروع می کنم. "کودکی کشته می شود " من را به سال ها پیش می برد ،فضایش شدیدا برایم آشناست. گویا بخشی از دغدغه های من بیان شده است. گویا کلامی آشنا بعد از این همه پیام های نا مفهوم مغزم را ناگهان از جمود در می اورد. پیامی که ارزش توجه کردن را دارد.احسا س تنهایی رخت بر می بندد، انسانها یی که ذهنمم را درگیر کرده بودند یک به یک به نقاط بسیار کوچکی تبدیل می شوند.دیگر احساس خستگی نمی کنم .کتاب را می بندم.
Saturday, May 21, 2011
What Patients Need To Know About Osteoporosis
Osteoporosis is a condition that is sure to become increasingly diagnosed as our population ages.
Osteoporosis is significant because it is associated with an increased risk of bone fracture, including fracture of the hip and vertebra, which are the cause of significant morbidity, mortality, loss of independence and medical expense in the elderly. In current clinical practice, osteoporosis is diagnosed on the basis of either the occurrence of a low-impact or fragility fracture, or on the basis of measured low bone mineral density (BMD). A low-impact fracture is one that occurs after a fall from standing height or less; a fragility fracture occurs spontaneously or with no trauma (cough, sneeze, sudden movement).
Bone strength is determined by bone density, bone “quality,” and bone microarchitecture. Of these features, bone density, or mass, is what we are able to measure. Osteoporosis is defined by World Health Organization criteria based on a person’s bone density by dual energy x-ray absorptiometry (DXA). Osteoporosis occurs when bone density is below 2.5 standard deviations from the mean for non-Hispanic white women between ages 20 and 29 (T score < -2.5). Osteopenia is defined by bone density of between 1 and 2.5 standard deviations below the mean for non-Hispanic white women in their twenties (T score of -1 to -2.5).
In recent years a variety of effective medications have been developed and approved for treatment of low bone density. Nonetheless, there are still significant gaps in our knowledge. Recently, the FDA issued a warning about an increased risk of “atypical fractures” that has been observed amongst women who take bisphosphonates, the most commonly prescribed drugs for osteoporosis. A few years ago these drugs were also linked to another rare problem, osteonecrosis of the jaw. This was primarily described in cancer patients and those on cancer medications, but the finding got patients, dentists, and oral surgeons quite worked up over the potential risks.
In clinical practice there is significant variation in the practice of screening for and treating osteoporosis and its precursor, osteopenia. According to national epidemiological data from NHANES III over 56% of women over age 50 have reduced bone density, of these 16% have osteoporosis. In their 80s 87% of women have reduced bone density and 44% of have osteoporosis. The key to prevention and treatment is trying to figure out who and when to treat aggressively to best prevent fractures. Current guidelines by the US Preventive Services Task Force support screening women at age 65. However, many post-menopausal women under age 65 are also at risk and the conservative evidence-based USPSTF guidelines do not comment on which of these women should also be screened. Other professional guidelines, such as those issued by the National Osteoporosis Foundation, support screening younger women who are post-menopausal and who have risk factors.
A variety of clinical tools exist to help women quantify their osteoporosis risk.
Osteoporosis risk factors include:
• Low body weight (<57 kg)
• Asian or Caucasian ethnicity
• Personal history of fragility fracture
• Family history of osteoporosis
• Smoking
• Drinking > 2 glasses of alcohol per day
• Excessive caffeine intake
• Certain medications (glucocorticoids)
• Sedentary lifestyle
• Amenorrhea (lapses in menstruation prior to menopause)
• Eating disorders
• Marathon running
• Dietary deficiencies of calcium and vitamin D
• Chronic health conditions (chronic liver and kidney disease, rheumatoid arthritis)
Many women fall into these increased risk categories and thus are screened before age 65 leaving them with a diagnosis of osteopenia or osteoporosis and creating the conundrum of what to do for the remainder of a woman’s life.
In general, most women with osteopenia should not receive pharmacologic therapy unless they are higher risk, or have already suffered a fracture. Instead, they should be counseled to institute behavioral measures, such as increased weight-bearing exercise and increases in calcium and vitamin D supplementation. When these women should be rescreened is not clear, but probably no more often than every two years. Tracking the rate of bone density decline may help identify women who subsequently should receive drug therapy.
Effective pharmacologic treatments for osteoporosis are available and are, in general, well tolerated. Medication options include the bisphosphonates: alendronate, residronate, ibandronate and zoledronic acid, hormonal treatments (estrogen and selective estrogen receptor modulators), and recombinant parathyroid hormone (teriparatide). Of these options, the oral bisphosphonates, alendronate (Fosamax) and residronate (Actonel), have the most evidence supporting their efficacy in fracture prevention, and are considered first line. These drugs, however, can be somewhat inconvenient to administer because of their poor bioavailability that requires them to be taken on an empty stomach for best absorption. In addition, they are associated with gastrointestinal side effects—specifically esophagitis, and for this reason are contraindicated in patients with precancerous changes of the espophagus, “Barrett’s Esophagus.” For patients who experience gastrointestinal side effects the intravenous bisphosphonate, zoledronic acid may be administered every one to two years.
Hormonal therapies, such as estrogen, are effective treatment for low bone density. However, as indicated by the results of the Women’s Health Initiate, their use has been associated with an increased risk of breast cancer and cardiovascular disease. Raloxifene, a selective estrogen receptor modulator (SERM), is approved for both prevention and treatment of osteoporosis. Its use, while associated with a reduction in breast cancer risk, is also associated with an increased risk of thomboembolism. Its effect on cardiovascular disease appears to be neutral.
The appropriate duration of therapy and frequency of monitoring patients who are on pharmaceutical treatment are areas that remain ill-defined. Studies have indicated that 5 years of alendronate may be adequate for many average risk women. However, my experience in clinical practice is that many women are left on these drugs for years and years. Some have advocated drug “holidays” after five years of therapy. The largest randomized controlled trial looking at alendronate use and fracture outcomes was 10 years in duration, which in my view calls into question the safety of prolonged use.
Many questions remain about how to approach the treatment of aging bones to prevent the debilitating outcome of bone fracture. Seasoned clinicians have seen the problems that may occur in some cases with treating large populations of well patients for normal life processes (postmenopausal estrogen replacement therapy). Let’s hope that future research will address the question of when to treat with medication and for how long with further precision. Until then let’s use appropriate caution when prescribing medicine for normal senior bones.
by : Juliet K. Mavromatis
Osteoporosis is significant because it is associated with an increased risk of bone fracture, including fracture of the hip and vertebra, which are the cause of significant morbidity, mortality, loss of independence and medical expense in the elderly. In current clinical practice, osteoporosis is diagnosed on the basis of either the occurrence of a low-impact or fragility fracture, or on the basis of measured low bone mineral density (BMD). A low-impact fracture is one that occurs after a fall from standing height or less; a fragility fracture occurs spontaneously or with no trauma (cough, sneeze, sudden movement).
Bone strength is determined by bone density, bone “quality,” and bone microarchitecture. Of these features, bone density, or mass, is what we are able to measure. Osteoporosis is defined by World Health Organization criteria based on a person’s bone density by dual energy x-ray absorptiometry (DXA). Osteoporosis occurs when bone density is below 2.5 standard deviations from the mean for non-Hispanic white women between ages 20 and 29 (T score < -2.5). Osteopenia is defined by bone density of between 1 and 2.5 standard deviations below the mean for non-Hispanic white women in their twenties (T score of -1 to -2.5).
In recent years a variety of effective medications have been developed and approved for treatment of low bone density. Nonetheless, there are still significant gaps in our knowledge. Recently, the FDA issued a warning about an increased risk of “atypical fractures” that has been observed amongst women who take bisphosphonates, the most commonly prescribed drugs for osteoporosis. A few years ago these drugs were also linked to another rare problem, osteonecrosis of the jaw. This was primarily described in cancer patients and those on cancer medications, but the finding got patients, dentists, and oral surgeons quite worked up over the potential risks.
In clinical practice there is significant variation in the practice of screening for and treating osteoporosis and its precursor, osteopenia. According to national epidemiological data from NHANES III over 56% of women over age 50 have reduced bone density, of these 16% have osteoporosis. In their 80s 87% of women have reduced bone density and 44% of have osteoporosis. The key to prevention and treatment is trying to figure out who and when to treat aggressively to best prevent fractures. Current guidelines by the US Preventive Services Task Force support screening women at age 65. However, many post-menopausal women under age 65 are also at risk and the conservative evidence-based USPSTF guidelines do not comment on which of these women should also be screened. Other professional guidelines, such as those issued by the National Osteoporosis Foundation, support screening younger women who are post-menopausal and who have risk factors.
A variety of clinical tools exist to help women quantify their osteoporosis risk.
Osteoporosis risk factors include:
• Low body weight (<57 kg)
• Asian or Caucasian ethnicity
• Personal history of fragility fracture
• Family history of osteoporosis
• Smoking
• Drinking > 2 glasses of alcohol per day
• Excessive caffeine intake
• Certain medications (glucocorticoids)
• Sedentary lifestyle
• Amenorrhea (lapses in menstruation prior to menopause)
• Eating disorders
• Marathon running
• Dietary deficiencies of calcium and vitamin D
• Chronic health conditions (chronic liver and kidney disease, rheumatoid arthritis)
Many women fall into these increased risk categories and thus are screened before age 65 leaving them with a diagnosis of osteopenia or osteoporosis and creating the conundrum of what to do for the remainder of a woman’s life.
In general, most women with osteopenia should not receive pharmacologic therapy unless they are higher risk, or have already suffered a fracture. Instead, they should be counseled to institute behavioral measures, such as increased weight-bearing exercise and increases in calcium and vitamin D supplementation. When these women should be rescreened is not clear, but probably no more often than every two years. Tracking the rate of bone density decline may help identify women who subsequently should receive drug therapy.
Effective pharmacologic treatments for osteoporosis are available and are, in general, well tolerated. Medication options include the bisphosphonates: alendronate, residronate, ibandronate and zoledronic acid, hormonal treatments (estrogen and selective estrogen receptor modulators), and recombinant parathyroid hormone (teriparatide). Of these options, the oral bisphosphonates, alendronate (Fosamax) and residronate (Actonel), have the most evidence supporting their efficacy in fracture prevention, and are considered first line. These drugs, however, can be somewhat inconvenient to administer because of their poor bioavailability that requires them to be taken on an empty stomach for best absorption. In addition, they are associated with gastrointestinal side effects—specifically esophagitis, and for this reason are contraindicated in patients with precancerous changes of the espophagus, “Barrett’s Esophagus.” For patients who experience gastrointestinal side effects the intravenous bisphosphonate, zoledronic acid may be administered every one to two years.
Hormonal therapies, such as estrogen, are effective treatment for low bone density. However, as indicated by the results of the Women’s Health Initiate, their use has been associated with an increased risk of breast cancer and cardiovascular disease. Raloxifene, a selective estrogen receptor modulator (SERM), is approved for both prevention and treatment of osteoporosis. Its use, while associated with a reduction in breast cancer risk, is also associated with an increased risk of thomboembolism. Its effect on cardiovascular disease appears to be neutral.
The appropriate duration of therapy and frequency of monitoring patients who are on pharmaceutical treatment are areas that remain ill-defined. Studies have indicated that 5 years of alendronate may be adequate for many average risk women. However, my experience in clinical practice is that many women are left on these drugs for years and years. Some have advocated drug “holidays” after five years of therapy. The largest randomized controlled trial looking at alendronate use and fracture outcomes was 10 years in duration, which in my view calls into question the safety of prolonged use.
Many questions remain about how to approach the treatment of aging bones to prevent the debilitating outcome of bone fracture. Seasoned clinicians have seen the problems that may occur in some cases with treating large populations of well patients for normal life processes (postmenopausal estrogen replacement therapy). Let’s hope that future research will address the question of when to treat with medication and for how long with further precision. Until then let’s use appropriate caution when prescribing medicine for normal senior bones.
by : Juliet K. Mavromatis
Thursday, May 19, 2011
Monday, May 16, 2011
Phyllodes Tumor
 |
| Findings: Mammogram shows a lobular hyper dense mass with partially circumscribed and partially obscured margins. No calcifications visible |
Key point: Large rapidly growing circumscribed mass without calcifications
Mammography :Phyllodes tumors appear as a dense, round or oval masses with circumscribed or lobulated borders on mammography. Indistinct margins favor malignant transformation. Calcifications are rare but when present are coarse.
Ultrasonography: demonstrates an oval, round, or lobulated hypoechoic mass. Cystic spaces favor malignancy. Increased vascularity can be common .
T1W1/T2W1 :Phyllodes tumors appear heterogeneously hypointense on T1WI with slit like areas of increased T2WI representing fluid. Enhancement is typically rapid and suspicious kinetics can be observed in approximately 33% of cases.
Differential Diagnosis:
Typically occurring in younger women, fibroadenomas also appear as oval or lobulated mass but have dense, coarse calcifications, homogeneous echogenicity, and more moderate enhancement characteristics.
While there is some overlap with phyllodes tumors demonstrating malignant transformation, breast carcinoma is more likely to demonstrate indistinct margins. Pleomorphic calcifications also favor carcinoma.
Primary sarcoma of the breast is distinguished from phyllodes tumors by the absence of epithelial components. The clinical course of primary sarcoma of the breast is similar to malignant phyllodes tumors.
 |
| Ultrasound shows an irregularly shaped mass with heterogeneous echogenicity and ill-defined borders. |
Treatment: is by surgical excision with greater than 1 cm margins. Mastectomy may be required for large tumors. Axillary node dissection is usually unnecessary. With respect to adjuvant therapy, radiation reduces local recurrence. Chemotherapy has demonstrated no benefit.
Wednesday, May 11, 2011
US Braced For Fights With Pakistanis
President Obama insisted that the assault force hunting down Osama bin Laden last week be large enough to fight its way out of Pakistan if confronted by hostile local police officers and troops, senior administration and military officials said Monday.
In revealing additional details about planning for the mission, senior officials also said that two teams of specialists were on standby: One to bury Bin Laden if he was killed, and a second composed of lawyers, interrogators and translators in case he was captured alive. That team was set to meet aboard a Navy ship, most likely the aircraft carrier Carl Vinson in the North Arabian Sea.
Mr. Obama’s decision to increase the size of the force sent into Pakistan shows that he was willing to risk a military confrontation with a close ally in order to capture or kill the leader of Al Qaeda.
Such a fight would have set off an even larger breach with the Pakistanis than has taken place since officials in Islamabad learned that helicopters filled with members of a Navy Seals team had flown undetected into one of their cities, and burst into a compound where Bin Laden was hiding.
One senior Obama administration official, pressed on the rules of engagement for one of the riskiest clandestine operations attempted by the C.I.A. and the military’s Joint Special Operations Command in many years, said: “Their instructions were to avoid any confrontation if at all possible. But if they had to return fire to get out, they were authorized to do it.”
The planning also illustrates how little the administration trusted the Pakistanis as they set up their operation. They also rejected a proposal to bring the Pakistanis in on the mission.
Under the original plan, two assault helicopters were going to stay on the Afghanistan side of the border waiting for a call if they were needed. But the aircraft would have been about 90 minutes away from the Bin Laden compound.
About 10 days before the raid, Mr. Obama reviewed the plans and pressed his commanders as to whether they were taking along enough forces to fight their way out if the Pakistanis arrived on the scene and tried to interfere with the operation.
That resulted in the decision to send two more helicopters carrying additional troops. These followed the two lead Black Hawk helicopters that carried the actual assault team. While there was no confrontation with the Pakistanis, one of those backup helicopters was ultimately brought in to the scene of the raid when a Black Hawk was damaged while making a hard landing.
“Some people may have assumed we could talk our way out of a jam, but given our difficult relationship with Pakistan right now, the president did not want to leave anything to chance,” said one senior administration official, who like others would not be quoted by name describing details of the secret mission. “He wanted extra forces if they were necessary.”
With tensions between the United States and Pakistan escalating since the raid, American officials on Monday sought to tamp down the divisions and pointed to some encouraging developments.
A United States official said that American investigators would soon be allowed to interview Bin Laden’s three widows, now being held by Pakistani authorities, a demand that Mr. Obama’s national security adviser, Thomas E. Donilon, made on television talk shows on Sunday.
American officials say the widows, as well as a review of the trove of documents and other data the Seals team collected from the raid, could reveal important details, not only about Bin Laden’s life and activities since he fled into Pakistan from Afghanistan in 2001, but also information about Qaeda plots, personnel and planning.
“We believe that it is very important to maintain the cooperative relationship with Pakistan precisely because it’s in our national security interest to do so,” said the White House spokesman, Jay Carney.
In an effort to help mend the latest rupture in relations, the C.I.A. director, Leon E. Panetta, will talk soon with his counterpart, Lt. Gen. Ahmad Shuja Pasha, head of the Inter-Services Intelligence Directorate, or ISI, “to discuss the way forward in the common fight against Al Qaeda,” an American official said.
On Sunday, Adm. Mike Mullen, the chairman of the Joint Chiefs of Staff, called the Pakistani Army chief, Gen. Ashfaq Parvez Kayani. “Mullen just wanted to check in with him,” said an American military official. “The conversation was civil, but sober, given the pressure that the general is under right now.”
In describing the mission, the officials said that American surveillance and reconnaissance aircraft were watching and listening to how Pakistan’s police forces and military responded to the raid. That determined how long the commandos could safely remain on the ground going through the compound collecting computer hard drives, thumb drives and documents.
American forces were under strict orders to avoid engaging with any Pakistani forces that responded to the commotion at the Bin Laden compound, senior administration officials said.
If a confrontation appeared imminent, there were contingency plans for senior American officials, including Admiral Mullen, to call their Pakistani counterparts to avert an armed clash.
But when he reviewed the plans, Mr. Obama voiced concern that this was not enough to protect the troops on the mission, administration officials said.
In planning for the possible capture of Bin Laden, officials decided they would take him aboard a Navy ship to preclude battles over jurisdiction.
The plan, officials said, was to do an initial interrogation for any information that might prevent a pending attack or identify the location of other Qaeda leaders.
“There was a heck of a lot of planning that went into this for almost any and all contingencies, including capture,” one senior administration official said.
In the end, the team organized to handle his death was called into duty. They did a quick forensics study of the body, washed it, and buried it at sea.
But the officials acknowledged that the mission always was weighted toward killing, given the possibility that Bin Laden would be armed or wearing an explosive vest.
In revealing additional details about planning for the mission, senior officials also said that two teams of specialists were on standby: One to bury Bin Laden if he was killed, and a second composed of lawyers, interrogators and translators in case he was captured alive. That team was set to meet aboard a Navy ship, most likely the aircraft carrier Carl Vinson in the North Arabian Sea.
Mr. Obama’s decision to increase the size of the force sent into Pakistan shows that he was willing to risk a military confrontation with a close ally in order to capture or kill the leader of Al Qaeda.
Such a fight would have set off an even larger breach with the Pakistanis than has taken place since officials in Islamabad learned that helicopters filled with members of a Navy Seals team had flown undetected into one of their cities, and burst into a compound where Bin Laden was hiding.
One senior Obama administration official, pressed on the rules of engagement for one of the riskiest clandestine operations attempted by the C.I.A. and the military’s Joint Special Operations Command in many years, said: “Their instructions were to avoid any confrontation if at all possible. But if they had to return fire to get out, they were authorized to do it.”
The planning also illustrates how little the administration trusted the Pakistanis as they set up their operation. They also rejected a proposal to bring the Pakistanis in on the mission.
Under the original plan, two assault helicopters were going to stay on the Afghanistan side of the border waiting for a call if they were needed. But the aircraft would have been about 90 minutes away from the Bin Laden compound.
About 10 days before the raid, Mr. Obama reviewed the plans and pressed his commanders as to whether they were taking along enough forces to fight their way out if the Pakistanis arrived on the scene and tried to interfere with the operation.
That resulted in the decision to send two more helicopters carrying additional troops. These followed the two lead Black Hawk helicopters that carried the actual assault team. While there was no confrontation with the Pakistanis, one of those backup helicopters was ultimately brought in to the scene of the raid when a Black Hawk was damaged while making a hard landing.
“Some people may have assumed we could talk our way out of a jam, but given our difficult relationship with Pakistan right now, the president did not want to leave anything to chance,” said one senior administration official, who like others would not be quoted by name describing details of the secret mission. “He wanted extra forces if they were necessary.”
With tensions between the United States and Pakistan escalating since the raid, American officials on Monday sought to tamp down the divisions and pointed to some encouraging developments.
A United States official said that American investigators would soon be allowed to interview Bin Laden’s three widows, now being held by Pakistani authorities, a demand that Mr. Obama’s national security adviser, Thomas E. Donilon, made on television talk shows on Sunday.
American officials say the widows, as well as a review of the trove of documents and other data the Seals team collected from the raid, could reveal important details, not only about Bin Laden’s life and activities since he fled into Pakistan from Afghanistan in 2001, but also information about Qaeda plots, personnel and planning.
“We believe that it is very important to maintain the cooperative relationship with Pakistan precisely because it’s in our national security interest to do so,” said the White House spokesman, Jay Carney.
In an effort to help mend the latest rupture in relations, the C.I.A. director, Leon E. Panetta, will talk soon with his counterpart, Lt. Gen. Ahmad Shuja Pasha, head of the Inter-Services Intelligence Directorate, or ISI, “to discuss the way forward in the common fight against Al Qaeda,” an American official said.
On Sunday, Adm. Mike Mullen, the chairman of the Joint Chiefs of Staff, called the Pakistani Army chief, Gen. Ashfaq Parvez Kayani. “Mullen just wanted to check in with him,” said an American military official. “The conversation was civil, but sober, given the pressure that the general is under right now.”
In describing the mission, the officials said that American surveillance and reconnaissance aircraft were watching and listening to how Pakistan’s police forces and military responded to the raid. That determined how long the commandos could safely remain on the ground going through the compound collecting computer hard drives, thumb drives and documents.
American forces were under strict orders to avoid engaging with any Pakistani forces that responded to the commotion at the Bin Laden compound, senior administration officials said.
If a confrontation appeared imminent, there were contingency plans for senior American officials, including Admiral Mullen, to call their Pakistani counterparts to avert an armed clash.
But when he reviewed the plans, Mr. Obama voiced concern that this was not enough to protect the troops on the mission, administration officials said.
In planning for the possible capture of Bin Laden, officials decided they would take him aboard a Navy ship to preclude battles over jurisdiction.
The plan, officials said, was to do an initial interrogation for any information that might prevent a pending attack or identify the location of other Qaeda leaders.
“There was a heck of a lot of planning that went into this for almost any and all contingencies, including capture,” one senior administration official said.
In the end, the team organized to handle his death was called into duty. They did a quick forensics study of the body, washed it, and buried it at sea.
But the officials acknowledged that the mission always was weighted toward killing, given the possibility that Bin Laden would be armed or wearing an explosive vest.
By ERIC SCHMITT, THOM SHANKER and DAVID E. SANGER
@ NYTimes
Tuesday, May 10, 2011
Migraine : Update on New Therapies
Drugs with a better efficacy or side–effect profile than triptans may soon become available for acute treatment. The future may also look brighter for some of the very disabled chronic migraineurs thanks to novel drug and neuromodulation therapies.
•The oral calcitonine gene–related peptide antagonist Telcagepant is efficacious in acute treatment.
•Triptans, as other drugs, are more efficient if taken early but nonsteroidal anti–inflammatory drugs and analgesics remain useful for acute treatment, according to several meta–analyses.
•Single–pulse transcranial magnetic stimulation during the aura rendered more patients pain–free (39%) than sham stimulation (22%) in one study.
•Topiramate could be effective for migrainous vertigo, but it did not prevent transformation to chronic migraine in patients with high attack frequency.
•Onabotulinumtoxin A was effective for chronic migraine and well tolerated, but the therapeutic gain over placebo was modest; the clinical profile of responders remains to be determined before widespread use.
•Occipital nerve stimulation was effective in intractable chronic migraine with 39% of responders compared to 6% after sham stimulation. This and other neuromodulation techniques, such as sphenopalatine ganglion stimulation, are promising treatments for medically refractory patients but large controlled trials are necessary.
•One study suggests that outcome of patent foramen ovale closure in migraine might depend on anatomic and functional characteristics.
study by : Magis D et al
@Current Opinion in Neurology
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