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2014;5:63–70. 28. Eisenberger ma, blumenstein ba, crawford ed, et al. Bilateral orchiectomy with or without flutamide for metastatic prostate cancer. N engl j med. 1998;339:1036–1042. 29. Weckermann d, harzmann r. Hormone therapy in prostate cancer. Gnrh antagonists versus gnrh analogues. Eur urol. 2004;46:279–283. Discussion 83–84.

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Are primary headaches c mm n x in the c mmunity?. T e li etime prevalence o headache in the general population is extremely high, approaching ubiquity. 411 most people have experienced a headache even i in the context o a hangover or sleep deprivation. One o the pit alls o taking a headache history rom a patient relating to both them and their immediate amily is underreporting o what the patient has come to accept as “normal headache.” primary relatives o migraineurs o en su er rom occasional headaches that patients are unaware o —the symptom is never discussed, as “it is just a headache.” across the globe in both wealthy and impoverished countries, over 10% o people have been disabled by migraine at some point, and 3% o people have migraine on most days.2 migraine is the third most common disorder in the world behind dental caries and tension-type headache. It ranks seventh amongst global causes o disability, likely an underestimate. Migraine is the leading cause o disability worldwide amongst neurological disorders.2,3 migraine 1-year period prevalence is 6% in men and 18% in women in the usa, and is similar in most countries in the world where it has been studied.2 t e li etime incidence is 18 and 43%, respectively, or episodic migraine.4 other primary headaches are less common. Cluster headache, the most common ac, occurs in one in a thousand people with a ratio o three males or every emale. Is headache a c mm n presentati n x t the h spital?. In one study o american national data, 5% o presentations to the emergency department (ed) were due to headache. Migraine accounted or most o these.5 in a single-institution series two thirds o patients presenting to the ed with headache had a nal diagnosis o a primary headache disorder.6 what is status migrain sis?. X a debilitating migraine attack that goes or longer than 72 hours and less than 3 months.1 patients may present to the ed. T ey may require admission i initial treatment is unsuccess ul. What causes sec ndary headache x that tend t present with a gradual nset may be seen in an inpatient setting 1 ?. In ection (see chapter 7) viral viral meningitis is a common cause o the symptom complex o meningism—nuchal rigidity, photophobia, and nausea may accompany headache. Examples include the herpes amily epstein-barr virus (ebv) where symptoms may complicate a 412 chapt er 27 bout o “glandular ever,” or enteroviruses such as echovirus and coxsackievirus. Encephalomeningitis, where ocal neurological signs and altered conscious state may accompany meningism, can be caused by a wide variety o agents such as herpes simplex. Bacterial pneumococcal or meningococcal meningitis causes orid meningism with systemic signs, and can be rapidly progressive, while listeria can cause a more indolent syndrome in at-risk populations such as patients with chronic kidney disease. Borreliaburgdorferi may cause meningitis and acial nerve palsy. Abscess mycobacterial uberculosis may rarely present with a tuberculoma in the cns causing ocal signs. It may also cause basal meningitis. Fungal a number o presentations are possible, rom ulminant cryptococcus gattii in ection in an immunocompetent host with accompanying raised intracranial pressure, to an invasive mucormycosis in a drug addict. Rickettsial trauma or injury to the head or neck head injury with or without loss o consciousness may occur (see chapter 15). T is may involve overt brain injury such as an intracerebral, extradural, subdural, and subarachnoid hemorrhage (sah). Di use axonal injury may accompany acceleration– deacceleration injuries and not be readily apparent on a c brain. Headache may be part o a concussion syndrome in this context. Ongoing headache in patents with concussion is more common i patients have a history or amily history o migraine. Whiplash injury. In this context, structural damage such as vertebral and carotid artery dissection and bony racture must be excluded. Craniotomy stroke headache occurs in around 50% o patients with intracranial hemorrhage and 25% o patients with ischemic stroke (see chapter 13). T e size o the stroke does not in uence the likelihood o headache.

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2 l/min/m2, pcwp cheap viagra online fast delivery less than 18 mm hg (2. 4 kpa) •• patients are inadequately perfused and not congested •• hypoperfusion leads to increased mortality, elevating death rates fourfold compared with those who are adequately perfused •• treatment focuses on increasing co with positive inotropic agents and/or replacing intravascular fluids •• fluid replacement must be performed cautiously because patients can rapidly become congested subset iv (cool and wet) •• ci less than 2. 2 l/min/m2, pcwp greater than 18 mm hg (2. 4 kpa) •• patients are inadequately perfused and congested •• classified as the most complicated clinical presentation of ahf with the worst prognosis •• most challenging to treat. Therapy targets alleviating signs and symptoms of congestion by increasing ci as well as reducing pcwp while maintaining adequate mean arterial pressure •• treatment involves a delicate balance between diuretics, vasodilators, and inotropic agents •• use of vasopressors is sometimes necessary to maintain bp should be obtained 2 hours after the end of a nesiritide infusion, or alternatively the nt-probnp assay should be utilized. Other diagnostic tests should also be obtained to rule out precipitating factors (chest radiograph) and to evaluate cardiac function (ecg). Invasive hemodynamic monitoring in patients with hf entails placement of a right heart or pulmonary artery catheter (pac).

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Delayed reactions cheap viagra online fast delivery with these agents occur in 1% to 3% of patients. 30 although reactions are occasionally severe, most are mild and manifest as maculopapular rashes, fixed eruptions, erythema multiforme, and urticarial eruptions. Opiates opiates (morphine, meperidine, codeine, hydrocodone, and others) stimulate mast cell release directly, resulting in pruritus and urticaria with occasional mild wheezing. Though these reactions are not allergic, many patients state they are “allergic” to one or more of the opiates. Pretreatment with an antihistamine may reduce these pseudoallergic reactions which are rarely, if ever, life-threatening. 6 avoiding other mast cell degranulating medications while patients require opiates also reduces the chances of frightening and uncomfortable reactions. Patients may state they are allergic if they have experienced gastrointestinal upset, a common side effect to opiates, with previous exposures.