Fulminant Herpes Simplex Virus Type I Encephalitis Despite Maximal Medical Therapy.

Herpes simplex-1 virus encephalitis (HSE) is the most commonly recognized cause of sporadic encephalitis in the United States. Historically HSE has been considered extremely detrimental given the associated relentless neurological deterioration secondary to cerebral edema and status epilepticus. With recent advances in antiviral therapeutics in past decades, the majority of complications can be managed effectively although the associated morbidity and mortality still remains high. The key modifiable factor determining recovery is the rapid initiation of antiviral therapy. We discuss the case of a 19-year-old female with HSE who received standard acyclovir therapy. Despite using recommended dosage and duration of acyclovir, her clinical condition worsened significantly and subsequently required multiple antiviral therapeutics and steroid therapy.

Corrigendum: Matrix Metalloproteinases and Blood-Brain Barrier Disruption in Acute Ischemic Stroke.

[This corrects the article on p. 32 in vol. 4, PMID: 23565108.].

Prescribing Oxygen for Cluster Headache: A Guide for the Provider.

BACKGROUND: Oxygen is the standard of care for acute treatment of cluster headache. CMS, the US Centers for Medicaid and Medicare Services, has made the indefensible decision to not cover oxygen for cluster headache for patients with Medicaid and Medicare insurance, despite the evidence and professional guidelines. Commercial insurance generally covers oxygen for cluster headache. OBJECTIVE: This is a "how-to" guide for successfully prescribing oxygen in the US. SUMMARY: Prescription information is provided that can be incorporated as dot phrases, smart sets, or other standard templates for prescribing oxygen for cluster patients. In many states, oxygen is affordable and can be prescribed for Medicaid and Medicare patients who wish to pay cash. Welding or nonmedical grade industrial oxygen is almost the same cost as medical oxygen. However, it is less pure, lacks the same inspection of tanks, and is delivered without regulators to provide appropriate flow rates. Patients who pay cash should be strongly encouraged to buy medical oxygen.

Economics of Inhaled Oxygen Use as an Acute Therapy for Cluster Headache in the United States of America.

BACKGROUND: Cluster headache (CH) is a primary headache disorder associated with low levels of diagnosis and high unmet medical need. The pain attacks, associated anxiety, and fear in anticipation of the attacks are extremely debilitating to a patient with CH. For acute therapy, treatment guidelines recommend inhalation of high flow oxygen during the period of an attack. However, the use of oxygen for treatment of CH remains largely underutilized. OBJECTIVES: The objectives of the study, which covered each of the US states, were to map the current market landscape of medical grade oxygen for use in CH and to develop a cost simulator based on a patient's needs and geography. METHODS: Desk research was undertaken to obtain price lists and product catalogs from wholesale and retail suppliers of medical grade oxygen across all US states. Base case scenarios for chronic and episodic forms of CH were assumed. A cost simulator was used to calculate the cost of oxygen use using inputs including the state in USA, tank size and price, exacerbations per year, duration of exacerbation, attacks per day, flow rate and duration of flow. Information was also collected to determine if healthcare insurers covered the costs of home oxygen use for CH. RESULTS: Out of the 42 US states where pricing information of medical grade oxygen was available from suppliers, in 38 states the annual cost of high-flow oxygen for a patient with episodic CH was estimated to be <$1000. In 39 states, the annual cost of high-flow oxygen for a patient with chronic CH was estimated to be <$5000. Most of the home oxygen suppliers were familiar with CH and stocked the special non-rebreather masks and regulators necessary for this condition. It was found that many of the private commercial healthcare insurance providers reimbursed the cost of oxygen use for CH. However, the US Centers for Medicare and Medicaid Services (CMS) maintains there is insufficient evidence for coverage and continues to deny coverage for US Medicare and Medicaid patients. CONCLUSIONS: Results from our study showed that the current costs for oxygen use as an acute therapy in CH are not prohibitively expensive for patients and healthcare insurance providers. Apart from CMS, many insurers do reimburse the cost of oxygen use for CH. Our study suggests that further research is needed to determine if a lack of physician awareness about treatments and ways to prescribe are barriers for patients to access the high-flow oxygen treatment.

A Prospective Cohort Study of Outpatient Interdisciplinary Rehabilitation of Chronic Headache Patients.

OBJECTIVE: To evaluate the efficacy of an intensive outpatient program designed to improve functioning and reduce psychological impairment in chronic headache patients. BACKGROUND: Chronic headaches, occurring 15 or more days per month, for three or more months, may arise from multiple International Classification of Headache Disorders diagnoses: Chronic Migraine, Chronic Tension Type Headache, New Daily Persistent Headache, Chronic Post Traumatic Headaches, and Medication Overuse Headache. Several interdisciplinary programs that treat patients with chronic headaches have reported decreases in headache frequency. This study sought to evaluate the effect of a 3 week interdisciplinary treatment program for patients with chronic headache disorders on headache severity, functional status, and psychological impairment. METHODS: Subjects were 379 patients admitted to an outpatient chronic headache treatment program. Assessments of headache severity, psychological status, and functional impairment were completed by 371 (97.8%) of these at the time of admission. At discharge, 340 subjects (89.7%) provided assessment data, and 152 (40.1%) provided data at 1-year follow-up. RESULTS: Subjects' mean ratings on a 0-10 scale for their headache pain in the prior week declined, and these improvements were maintained at follow-up. (Estimated marginal means on a 0-10 scale for Average pain: admission 6.1, discharge 3.5, follow-up 3.3; for Least pain: admission 3.2; discharge 1.5; follow-up 1.3; for Worst pain: admission 8.2; discharge 6.4; follow-up 5.7), and similar results were found for current pain (admission 4.7; discharge 2.8; follow-up 2.4): Measures of functional impairment also improved following treatment, and these gains were maintained at 12 month follow up (Estimated marginal mean Headache Impact Test-6 score: admission 66.1, discharge 55.4, follow-up 51.9; Estimated marginal mean Pain Disability Index score: admission 36.2, discharge 14.1, follow-up 11.6). As measured by the Depression, Anxiety and Stress Scale, anxiety and reactivity to stress decreased following treatment, and remained improved at follow-up (Estimated marginal mean score for Anxiety: admission 8.7, discharge 5.2, follow-up 4.4; Estimated marginal mean score for stress: admission 14.9, discharge 7.2, follow-up 7.6). Depression decreased with treatment, but while 1-year follow-up depression scores remained significantly lower than at admission, they were also significantly higher than at discharge (Estimated marginal means: admission 13.3, discharge 4.1, follow-up 6.6). CONCLUSIONS: The study supports the efficacy of the treatment model. Limitations of the study and suggestions for future research are also discussed.

Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies.

OBJECTIVE: To provide evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medication in an emergency department (ED). We addressed two clinically relevant questions: (1) Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED? METHODS: The American Headache Society convened an expert panel of authors who defined a search strategy and then performed a search of Medline, Embase, the Cochrane database and clinical trial registries from inception through 2015. Identified articles were rated using the American Academy of Neurology's risk of bias tool. For each medication, the expert panel determined likelihood of efficacy. Recommendations were created accounting for efficacy, adverse events, availability of alternate therapies, and principles of medication action. RESULTS/CONCLUSIONS: The search identified 68 unique randomized controlled trials utilizing 28 injectable medications. Of these, 19 were rated class 1 (low risk of bias), 21 were rated class 2 (higher risk of bias), and 28 were rated class 3 (highest risk of bias). Metoclopramide, prochlorperazine, and sumatriptan each had multiple class 1 studies supporting acute efficacy, as did dexamethasone for prevention of headache recurrence. All other medications had lower levels of evidence. RECOMMENDATIONS: Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer-Level B). Dexamethasone should be offered to these patients to prevent recurrence of headache (Should offer-Level B). Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid-Level C).

The Effectiveness of Aromatherapy in Reducing Pain: A Systematic Review and Meta-Analysis.

Background. Aromatherapy refers to the medicinal or therapeutic use of essential oils absorbed through the skin or olfactory system. Recent literature has examined the effectiveness of aromatherapy in treating pain. Methods. 12 studies examining the use of aromatherapy for pain management were identified through an electronic database search. A meta-analysis was performed to determine the effects of aromatherapy on pain. Results. There is a significant positive effect of aromatherapy (compared to placebo or treatments as usual controls) in reducing pain reported on a visual analog scale (SMD = -1.18, 95% CI: -1.33, -1.03; p < 0.0001). Secondary analyses found that aromatherapy is more consistent for treating nociceptive (SMD = -1.57, 95% CI: -1.76, -1.39, p < 0.0001) and acute pain (SMD = -1.58, 95% CI: -1.75, -1.40, p < 0.0001) than inflammatory (SMD = -0.53, 95% CI: -0.77, -0.29, p < 0.0001) and chronic pain (SMD = -0.22, 95% CI: -0.49, 0.05, p = 0.001), respectively. Based on the available research, aromatherapy is most effective in treating postoperative pain (SMD = -1.79, 95% CI: -2.08, -1.51, p < 0.0001) and obstetrical and gynecological pain (SMD = -1.14, 95% CI: -2.10, -0.19, p < 0.0001). Conclusion. The findings of this study indicate that aromatherapy can successfully treat pain when combined with conventional treatments.