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Women with many medical conditions need to plan their families with special care. For such women, the risk of complications with particular contraceptive methods is increased. Women with severe hypertension, a previous myocardial infarction or venous thromboembolism, or cerebrovascular stroke have a significant risk of problems in pregnancy, and should avoid the combined pill. The combined pill may increase the risk of cardiovascular disease in patients with diabetes mellitus and may worsen the severity of migrainous headaches in susceptible patients. Women with active hepatitis should wait for liver function tests to normalise before becoming pregnant or starting the combined pill or injectable progestogen. Control of epilepsy may deteriorate with use of the combined pill; this is probably because of the risk of drug interactions. Similarly, contraceptive control may also fail in women receiving rifampicin (rifampin) concurrently with contraceptive steroids. Intrauterine contraceptive devices should not be used in women who have experienced previous episodes of pelvic inflammatory disease, or with previous malignancy of the genital tract until complete cure is likely. Other conditions which may appear, become more common or worsen when the combined pill is prescribed include hepatic adenoma, gall bladder disease, ulcerative colitis, alopecia, hirsutism and acne. Some of these conditions are potentially hazardous to the woman's health, in which case combined pill use should be stopped. If the condition is unchanged then the combined pill may sometimes be reintroduced with caution.
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PMID:Contraceptive choice for women with 'risk factors'. 848 Dec 14

The US Food and Drug Administration finally approved the injectable contraceptive Depo-Provera (DMPA) in October 1992, 25 years after its introduction. Women return to a health facility every 90 days for an intramuscular injection of 150 mg DMPA, which provides them 99% effective contraception. Menstrual changes and spotting are the leading reasons for DMPA discontinuation. Eventually, more than 50% of DMPA users develop amenorrhea. During the first year, women gain about 2 kg and weight increases as time passes. Weight gain is the second leading reason for DMPA discontinuation. DMPA may adversely affect glucose tolerance in women at risk for diabetes, but it does not affect cardiovascular or metabolic functions. It may increase the risk of osteoporosis. A rare side effect is convulsions. 1-10% of DMPA users have other central nervous system effects, such as headaches, dizziness, and depression. Itching and rashes may develop. Fertility returns within 1 year after discontinuation. DMPA is linked to low birth weight. It apparently does not harm breast-fed infants or hinder lactation. A World Health Organization study shows that DMPA users less than 35 years old experience a slight increase in breast cancer but a reduced incidence of endometrial cancer. Nurses are instrumental in guiding women as they choose DMPA and in informing them about its potential side effects, including breast cancer risk. They must screen women for pregnancy and evaluate their risk of breast cancer. They must determine whether women are able to return every 3 months for DMPA injections. Women who select DMPA must use other contraception, e.g., barrier protection, within the first 24 hours after initial injection. Nurses should counsel them about the likely menstrual changes to reduce the likelihood of dissatisfaction. They should recommend a daily dose of 1200 mg of elemental calcium and daily exercise of long bones to minimize the risk of developing osteoporosis.
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PMID:Depo-Provera. 849 47

The autopsy report of Ludwig van Beethoven written by Dr Johann Wagner in 1827 reveals that he had renal calculi that had not been diagnosed during his lifetime, together with perirenal fibrosis. The most comprehensive interpretation of this autopsy finding is that the regular calcareous deposits in every one of his renal calices represented calcified necrotic papillae. Severe urinary obstruction or diabetes as possible causes of papillary necrosis were not present. Analgesic abuse because of headaches, back pain, and attacks of rheumatism or gout may be presumed on the basis of Beethoven's uncontrolled way of taking medication. Salicin, a commonly used analgesic substance of that time (dried and powdered willow bark), is able to cause papillary necrosis. Perirenal fibrosis may be due to chronic infection or drug intake. Beethoven's other well-known diseases are deafness caused by otosclerosis of the inner ear, relapsing attacks of diarrhea as the symptoms of irritable bowel syndrome, and liver cirrhosis following viral hepatitis and chronic alcohol consumption. Liver cirrhosis also may cause papillary necrosis. In Beethoven's case, renal papillary necrosis was most probably the consequence of analgesic abuse together with decompensated liver cirrhosis. The autopsy report of Beethoven is the first case of papillary necrosis recorded in the literature.
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PMID:Beethoven's renal disease based on his autopsy: a case of papillary necrosis. 850 20

A forty-six year-old premenopausal woman developed headache, nausea and vomiting, left hemiparesis and seizure two days after parenteral use of progesterone and estradiol. Diabetes mellitus (DM) was found during admission. Computed tomography showed a hemorrhagic infarct in the right frontal lobe and increased density in the superior sagittal sinus (SSS). Left carotid angiography found occlusion of the left internal carotid artery (ICA). Right carotid angiograms failed to show the SSS and inferior sagittal sinus, suggestive of venous sinus thrombosis. Coexistence of the cerebral artery and the venous sinus occlusion has been described infrequently. In this case, the authors postulate that the use of estradiol and progesterone and the underlying DM increased vascular thrombogenicity, which provided a common denominator for thrombosis of both the ICA and the venous sinus.
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PMID:Coexistence of cerebral venous sinus and internal carotid artery thrombosis associated with exogenous sex hormones. A case report. 863 76

Eleven cases of cryptococcal meningitis were diagnosed and biotyped from September 1991 to August 1992 in Papua New Guinea (PNG). Seven isolates were Cryptococcus neoformans var. gattii from paediatric and adult patients, one with diabetes mellitus and 4 were C. neoformans var. neoformans from adults, of whom 2 had human immunodeficiency virus type 1 (HIV-1) infection, and one each had tuberculosis and Plasmodium vivax malaria. Significant clinical findings were headache, fever, meningism, vomiting, photophobia, papilloedema and cranial nerve lesions. Five patients (45.5%) died; 3 of these were adults with var. gattii and 2 were men with both var. neoformans and HIV-1 infections. This prospective tropical study documents the emergence of C. neoformans var. neoformans in patients with HIV-1 infection in a country where previously var. gattii had predominated in the immunocompetent. There has been no earlier report of cryptococcosis in an HIV-1 seropositive patient in PNG. Despite presumed exposure to both varieties of C. neoformans, var. gattii infections had been most frequent. As HIV-1 spreads, the proportion of hosts infected with var. neoformans may rise. The course of meningitis caused by the 2 varieties of C. neoformans may differ, with mortality in the tropics remaining particularly high. In PNG the environmental source of C. neoformans remains elusive.
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PMID:Meningitis caused by Cryptococcus neoformans var. gattii and var. neoformans in Papua New Guinea. 873 Mar 14

A 34-year-old man with hypertension and diabetes mellitus developed dizziness and visited our institute. He had history of headache with numbness of the right hand since age 15 years and left occipital lobe infarction at age 28 years. The cerebral angiogram showed several changes peculiar to advanced stage of moyamoya disease (spontaneous occlusion of the circle of Willis), i.e. segmental stenoses or occlusions of bilateral internal carotid arteries, left vertebral artery and left posterior cerebral artery with abnormal vascular networks at the bilateral basal ganglia. He was also diagnosed to have asymptomatic ischemic heart disease. The coronary angiogram showed diffuse sclerotic lesions of left anterior descending and right coronary arteries without significant stenosis, which suggested the presence of microvascular lesion as a cause of myocardial ischemia. Coronary disease has been rarely reported as a complication of moyamoya disease, and microvascular coronary artery disease has never been described. Moyamoya disease should be regarded as a part of systemic vascular disorders, and the evaluation of extracerebral cardiovascular system is necessary to clarify pathophysiology of this disease.
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PMID:[Systemic vascular change associated with moyamoya-like cerebrovascular disease and microvascular coronary artery disease]. 875 87

Medical treatment of stroke is dependent on a narrow therapeutic time window. We prospectively analyzed the influence of demographic, medical, and pathophysiologic factors on admission delay in 1,197 unselected, acute stroke patients. Twenty five percent were admitted within 3 1/2 hours, 35% within 6 hours, 50% within 14 hours, and 68% within 24 hours after stroke onset. Living alone (odds ratio [OR] 1.75, 95% CI 1.3 to 2.3) and retired working status (OR 1.61, 95% CI 1.01 to 2.54) delayed admission. A well-working social network thus seems important to early admission. The milder the stroke, the higher was the risk of delayed admission (OR 1.25 per 10 points decrease in stroke severity [Scandinavian Neurological Stroke Scale score on admission], 95% CI 1.14 to 1.36). A history of TIA increased the relative chance of early admission by odds 1.64 (95% CI 1.06 to 2.54). Other factors such as age, sex, diabetes, hypertension, ischemic heart disease, other comorbidity, previous stroke, headache, aphasia, apraxia, anosognosia, neglect, lowered consciousness, mental status (Mini-Mental State Examination) and type of stroke (hemorrhage/infarct) had no independent influence on admission time. Admission was markedly delayed in most patients. This represents a major barrier to medical treatment. Patients with the most severe strokes are admitted early, but patients with milder symptoms should also be encouraged to seek immediate admission. The observation that a history of TIA reduced admission time indicates that an increase in public awareness and knowledge may reduce delay and save precious time.
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PMID:Factors delaying hospital admission in acute stroke: the Copenhagen Stroke Study. 875 8

Although headache is among the most common pain complaints seen by physicians, the measurement of health-related quality of life (HRQoL) in headache patients is in its earliest stages. Two types of questionnaire have been used to measure HRQoL in headache sufferers: general and disease-specific instruments. General quality-of-life (QoL) instruments use scales to assess QoL with respect to a number of activities within physical, social, psychological, and behavioral life domains. Disease-specific instruments reflect particular limitations or restrictions associated with specific disease states. These instruments are designed to be most sensitive in determining the effects of treatment or the longitudinal course of disease. Data from the Medical Outcomes Study Short Form (SF)-20 and SF-36 generic QoL instruments demonstrated that chronic headache disorders were associated with significant limitations in all eight health domains of patient wellbeing and functioning. The SF-20 outcomes profiles for each of the common benign headache disorders (migraine, tension-type headache, mixed headache, and cluster headache) appear to be unique for the specific headache diagnosis. The SF-20 and SF-36 were also used to compare headache disorders with other chronic illnesses. Chronic headache disorders, including migraine, were found to cause significantly more impairment of function than diabetes, hypertension, osteoarthritis, and low back pain. Preliminary studies of QoL during pharmacologic therapy have suggested that disease specific instruments may be more sensitive than generic instruments for evaluating the longitudinal impact of treatment. Generic QoL instruments, such as the SF-20 or SF-36, may be more useful to define populations being studied than to measure changes in the population over time. The publication of headache-specific QoL instruments, which have been widely used in clinical trials and have been validated, is awaited. Until such time, the SF-36 will remain the standard measure of QoL in headache.
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PMID:Evolution of the measurement of quality of life in migraine. 907 Dec 64

The aims of this ancillary study to the Italian Longitudinal Study of Aging were: (1) to provide reliable prevalence data on headache in an elderly population, (2) to classify the subtypes of headache according to International Headache Society criteria, and (3) to identify possible risk factors and associated pathologies in the elderly. A total of 312 subjects were examined, 148 women and 164 men, with a mean age of 73 years (SD 5.5). For 236 subjects (75.7%), 141 men (85.9%) and 95 women (64.2%), headache had never been a problem; 57 subjects (18.3%), 21 men (12.8%) and 36 women (24.3%), reported troublesome headache only in the past. Nineteen subjects (6%), 6 men (3.6%) and 13 women (8.8%), reported current headache: in this group tension-type headache was the most prevalent, accounting for 2.6%; secondary headaches ranked second, accounting for 2.2%; and only 1% had current migraine. Our data indicate female sex and younger age as risk factors for headache, and associate migraine and secondary headaches with hypertension, tension-type headaches and secondary headaches with diabetes, and tension-type headaches with myocardial ischemia.
Headache 1997 Feb
PMID:Headache in a population-based elderly cohort. An ancillary study to the Italian Longitudinal Study of Aging (ILSA). 907 91

Vascular headaches are a relatively common phenomenon. Increasing numbers of patients with headache are being considered for treatment with the selective serotonin-receptor agonist sumatriptan succinate because of its potential for pronounced therapeutic efficacy in selected patients. Sumatriptan-associated myocardial infarction occurred in a 50-year-old woman with a history of migraine headaches. Cardiac risk factors that must be considered in all patients with migraine before initiation of therapy include concomitant ergotamine use, postmenopausal state, male gender older than 40 years, family history of heart disease, cigarette smoking, hypertension, diabetes mellitus, as reviewed in this report.
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PMID:Sumatriptan-associated myocardial infarction: report of case with attention to potential risk factors. 910 27


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