Therapy In Acute Care Research Articles

Thrombolytic Therapy in Acute Care: A Comprehensive Overview of Therapeutic Approaches and Clinical Outcomes

Thrombolytic therapy is a vital component in the treatment of acute illnesses such as myocardial infarction, ischemic stroke, and pulmonary embolism. Its purpose is to minimize tissue damage and restore perfusion. With an emphasis on the use of tissue plasminogen activator (tPA) and other drugs, the timing of administration, and the related clinical results, this study thoroughly analyses the therapeutic approaches to thrombolysis. Research shows that by lowering death and morbidity, early administration—ideally, during the first few hours after symptom onset—significantly improves outcomes. Treatment options have increased, especially for patients who are not good candidates for systemic thrombolysis, because to developments in thrombolytic drugs and delivery systems, such as catheter-directed thrombolysis and ultrasound-enhanced thrombolysis. It is important to carefully choose and monitor patients receiving thrombolytic treatment since, despite its advantages, it has some contraindications, including the possibility of haemorrhagic consequences. A customized treatment plan is essential to optimize effectiveness while avoiding side effects, as demonstrated by the outcomes of several clinical trials. In Result it should be noted that research is still being done to determine the best ways to employ thrombolytic treatment to enhance patient outcomes in acute care settings.

A Multidisciplinary Pathway for Patients Post–Brain Mass Resection: A Pilot Study

Abstract Date Presented 03/21/24 This study describes the utilization of the AM-PAC short forms to develop a hospital pathway for rehabilitation of patients after brain mass resection (BMR). These data were used to develop a guideline for acute care therapy to establish frequency and standardize care. Primary Author and Speaker: Chelsea Shade Contributing Authors: Natalie Dispoto, Caitlin Costanzo, Zachariah Garcia, Tory Laubach, Mollie Johnston, Nicole Moyer, Aubrey Schmidt, Milagros Uviles-Montalvo

Hemiplegic Shoulder Pain Prevention: A Collaborative Approach with Nursing and Occupational Therapy in Acute Care

Hemiplegic Shoulder Pain Prevention: A Collaborative Approach with Nursing and Occupational Therapy in Acute Care

Effect of oxygen therapy duration on cognitive impairment 12 months after hospitalization for SARS-COV-2 infection.

To identify predictors of persistent cognitive impairment at 12 months after hospitalization due to COVID-19 (SARS-CoV-2) infection. Retrospective, single-centre study. All consecutive patients assessed in physical and rehabilitation medicine consultations at 3 months with a neuropsychiatric testing (NPT) at 6 months. A Mini Mental State Examination (MMSE) was performed at 3 months and NPT at 6 and 12 months, exploring global cognitive efficiency, attention and processing speed, short-term memory and executive function. Logistic regression and receiver operating characteristic curves were used to identify predictors of persistent cognitive impairment. Among 56 patients, 64.3% and 53.6% had 1 or more impaired cognitive functions at 6 and 12 months, respectively, attention and processing speed being the most represented (41.1% at 12 month). Duration of oxygen therapy (odds ratio 0.926 [0.871-0.985], p = 0.015) and MMSE score at 3 months (odds ratio 0.464 [0.276-0.783], p = 0.004) were associated with cognitive impairment at 12 months by multivariable analysis (R² 0.372-0.497). Half of patients have cognitive impairment 12 months after acute SARS-CoV-2 infection requiring hospitalization. The duration of oxygen therapy in acute care could be a protective parameter. Systematic evaluation with the MMSE at 3 months after infection might be an effective tool to detect risk.

Initiating Occupational and Physical Therapy in the Hospital After Birth: Access, Reimbursement, and Outcomes

Acute care therapists routinely screen body systems, activity tolerance, safe mobility, activities of daily living/instrumental activities of daily living performance, cognition, caregiver support, home environment, and risk factors for hospital readmission. Despite most elective procedures, such as joint replacement and spine surgery, which receive automatic orders for acute care therapy, individuals who elect to give birth in a hospital are typically not offered rehabilitation services to optimize their recovery. Across hospitals in the United States, individuals receiving obstetric care have limited access to acute care therapy despite increasing postpartum readmission rates, severe maternal morbidity, and disproportionate levels of maternal mortality. Cardiovascular conditions, infection, and hemorrhage remain the leading causes of death in the obstetric population during the first 6 weeks postpartum. However, individuals are frequently discharged from the hospital after birth without a formal assessment by an acute care occupational or physical therapist. Extensive education to maternal care providers on obstetric rehabilitation is needed to improve outcomes after hospital birth with inpatient occupational and physical therapy. Supplemental video abstract available at https://www.youtube.com/watch?v=zfdU-1DuQiM.

65 THE IMPACT OF SOCIAL ISOLATION DURING COVID-19 ON COGNITION IN OLDER ADULTS

Abstract Background A correlation between social isolation and poorer cognitive function in later life has been increasingly implied in literature. Research indicates that maintaining a socially active lifestyle can enhance cognitive reserve and benefit cognitive function. Whereas social exclusion has been significantly associated with higher risks of cognitive impairment (Evans, et al., 2019). Recent studies reviewed the consequences of restrictive living conditions during COVID-19, finding poorer cognitive performance (Ingram, et al., 2021). However, few services have investigated this. This study intended to explore the impact of social isolation on cognitive function of hospitalised older adults. Methods Quantitative measures were used. A retrospective review of cognitive results of individuals open to occupational therapy in an acute Care of the Older Person’s service in May 2018 (n = 23) were compared to cognitive results of individuals open to occupational therapy in the same acute Care of the Older Person’s service in May 2021 (n = 62). Results For the purpose of this study, cognitive results were compared by means of assessment results which indicated a mild, moderate or significant cognitive impairment. Of the patients seen in May 2021 (n = 62), 9.68% (n = 6) had a mild cognitive impairment, 25.81% (n = 16) had a moderate cognitive impairment and 32.26% (n = 20) presented with a significant cognitive impairment. Comparatively in May 2018 (n = 23), 30.43% (n = 7) had a mild cognitive impairment, 43.38% (n = 10) had a moderate cognitive impairment and just 4.35% (n = 1) presented with a significant cognitive impairment. Conclusion A substantial increase in the number of inpatients presenting with a significant cognitive impairment in an acute Care of the Older Person’s service was found between May 2018 (4.35%) and May 2021 (32.26%). This suggests that COVID-19 had a severe impact on cognitive functioning of older adults and implies that this cohort are at a high risk of cognitive decline caused by social isolation. These findings are preliminary and further research is recommended.

Oxygen in the acute care of adults : Short version of the German S3 guideline

HintergrundSauerstoff (O2) ist ein Arzneimittel mit spezifischen Eigenschaften, einem definierten Dosis-Wirkungs-Bereich und O2 hat unerwünschte Wirkungen. Im Jahr 2015 wurden 14 % einer Stichprobe von britischen Krankenhauspatienten mit Sauerstoff behandelt, davon hatten nur 42 % eine Verordnung. Gesundheitspersonal ist häufig unsicher über die Relevanz einer Hypoxämie und es besteht ein eingeschränktes Bewusstsein für die Risiken einer Hyperoxämie. In den letzten Jahren wurden zahlreiche randomisierte, kontrollierte Studien zur Sauerstofftherapie veröffentlicht.MethodenIm Rahmen des Leitlinienprogramms der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) wurde unter Beteiligung von 10 Fachgesellschaften diese S3-Leitlinie auf Basis einer Literaturrecherche bis zum 01.02.2021 entwickelt. Zur Literaturbewertung wurde das System des Oxford Centre for Evidence-Based Medicine (CEBM; „The Oxford 2011 Levels of Evidence“) verwendet. Die Bewertung der Evidenzqualität erfolgte anhand des Grading of Recommendations Assessment, Development and Evaluation (GRADE) und die Leitlinienempfehlungen wurden formal konsentiert.ErgebnisseDie Leitlinie enthält 34 evidenzbasierte Empfehlungen zu Indikation, Verordnung, Überwachung und Abbruch der Sauerstofftherapie in der Akutversorgung. Die Indikation für Sauerstoff ist hauptsächlich die Hypoxämie. Hypoxämie und Hyperoxämie sollten aufgrund der Assoziation mit einer erhöhten Sterblichkeit vermieden werden. Die Leitlinie empfiehlt Zielbereiche der Sauerstoffsättigung für die Sauerstoff-Akuttherapie ohne Differenzierung zwischen verschiedenen Diagnosen. Zielbereiche sind abhängig vom Hyperkapnierisiko und Beatmungsstatus. Die Leitlinie bietet einen Überblick über verfügbare Sauerstoffzufuhrsysteme und enthält Empfehlungen für deren Auswahl basierend auf Patientensicherheit und -komfort.FazitDies ist die erste nationale Leitlinie zum Einsatz von Sauerstoff in der Akutmedizin. Sie richtet sich an medizinisches Fachpersonal, das Sauerstoff außerklinisch und stationär anwendet, und ist bis zum 30.06.2024 gültig.

German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients

Oxygen (O2) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.

Understanding Clinicians' Perceived Barriers and Facilitators to Optimal Use of Acute Oxygen Therapy in Adults.

BackgroundSupplemental oxygen is commonly administered to patients in acute care. It may cause harm when used inappropriately. Guidelines recommend prescription of acute oxygen, yet adherence is poor. We aimed to identify barriers and facilitators to practicing in accordance with the evidence-based Thoracic Society of Australia and New Zealand (TSANZ) oxygen guideline, and to determine the beliefs and attitudes relating to acute oxygen therapy.MethodsA national cross-sectional survey was conducted. The survey consisted of 3 sections: (1) introduction and participant characteristics; (2) opinion/beliefs, knowledge and actions about oxygen therapy and other drugs; and (3) barriers and facilitators to use of the TSANZ guideline. Convenience sampling was employed. A paper-based survey was distributed at the TSANZ Annual Scientific Meeting. An online survey was emailed to the TSANZ membership and to John Hunter Hospital's clinical staff.ResultsResponses were received from 133 clinicians: 52.6% nurses, 30.1% doctors, and 17.3% other clinicians. Over a third (37.7%) were unaware/unsure of the oxygen guideline’s existence. Most (79.8%) believe that oxygen is a drug and should be treated as one. Most (92.4%) stated they only administered it based on clinical need. For four hypothetical cases, there was only one where the majority of participants identified the optimal oxygen saturation. A number of barriers and facilitators were identified when asked about practicing in accordance with the TSANZ guideline. Lack of oxygen equipment, getting doctors to prescribe oxygen and oxygen being treated differently to other drugs were seen as barriers. The guideline itself and multiple clinician characteristics were considered facilitators.ConclusionThere is discordance between clinicians’ beliefs and actions regarding the administration of oxygen therapy and knowledge gaps about optimal oxygen therapy in acute care. Identified barriers and facilitators should be considered when developing evidence-based guidelines to improve dissemination and knowledge exchange.

Applying Telehealth Technologies and Strategies to Provide Acute Care Consultation and Treatment of Patients With Confirmed or Possible COVID-19.

Background and PurposeThe COVID-19 pandemic continues to grow, with 19% of total confirmed patients classified as severe or critical experiencing complications such as dyspnea, hypoxia, acute respiratory distress syndrome, or multiorgan failure. These complications require rehabilitative care. Considering the contagious nature of COVID-19 and the necessity to decrease the volume of health care professionals entering confirmed COVID-19 patient rooms and becoming a potential disease vector, can audiovisual technologies employed by telehealth and telerehabilitation help?Case Description:This case discusses the Baylor Scott and White Institute for Rehab (BSWIR) Physical Medicine and Rehabilitation (PMR) department COVID-19 acute care therapy team's creation of a telehealth strategy to provide early rehabilitative intervention without increasing the odds of disease transmission.Outcomes:The COVID-19 therapy team created a simple process for identifying and triaging care for patients with possible or confirmed COVID-19. These patients were evaluated and treated by the dedicated team using telehealth strategies. A structured risk-benefit analysis was used to determine when in-room care was indicated.Discussion:Acute care physical therapy, occupational therapy, and speech-language pathology telehealth strategies can add value by mitigating COVID-19–related harm and influencing recovery, while not unnecessarily becoming additional disease vectors consuming personal protective equipment. COVID-19 is not only an aggressive respiratory illness similar to acute respiratory distress syndrome but also highly contagious and a risk for health care providers. Telehealth strategies allow therapists to intervene early, opening the possibility to maximize recovery and prevent harm or decompensation. Telehealth strategies can be more prevention-focused while the patient is experiencing relatively good health with goals to maximize strength and endurance before the disease process evolves to critical illness. As COVID-19 progresses, therapy can help mitigate potential complications associated with prolonged intensive care unit stay and ventilator management.

Postoperative Delirium Prevention as Standard Practice in Occupational Therapy in Acute Care

Postoperative delirium (POD) is common, especially among older adults, and can significantly impact health and rehabilitation outcomes. Research evidence suggests that a multicomponent intervention is most effective for delirium prevention. Given that this intervention includes diverse components, interdisciplinary collaboration among members of the healthcare team is essential. This paper presents how occupational therapists, as part of the interdisciplinary acute care team, contribute to preventing POD and embed their unique value, skills, and strengths in each component of the collaborative intervention. This paper also argues that POD preventive care should be standard practice for occupational therapy in the acute care setting.

Patients With Greater Stroke Severity and Premorbid Disability Are Less Likely to Receive Therapist Consultations and Intervention During Acute Care Hospitalization.

A substantial number of patients with stroke never receive acute care therapy services, despite the fact that therapy after stroke reduces the odds of death and disability and improves patients' functioning. The aim of this study was to estimate the proportion of and factors associated with receipt of therapist consultations and interventions during acute care hospitalization following ischemic and hemorrhagic stroke. This was a single-center longitudinal observational study. Adults with a diagnosis of ischemic or hemorrhagic stroke (N=1366) were enrolled during their hospitalization in an acute stroke center in a large metropolitan area. The main outcomes were receipt of therapist consultations, interventions, or both. Participants with acute hemorrhagic stroke (intracerebral: odds ratio [OR]=0.34 [95% CI=0.19-0.60]; subarachnoid: OR=0.52 [95% CI=0.28-0.99]) and with greater stroke severity by National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score of > 15: OR=0.34 [95% CI=0.23-0.51]) were less likely to receive therapist consultations. Participants with moderate stroke severity (NIHSS score of 6-15: OR=1.43 [95% CI=1.01-2.33]) were more likely to receive therapy interventions. Those who were able to ambulate before admission were more than 5 times as likely to receive therapy interventions (OR=5.08 [95% CI=1.91-13.52]). Also, participants with longer lengths of stay (ie, more intensive care unit and non-intensive care unit days) were more likely to receive therapist consultations and interventions. Tests or procedures were the most common reasons for unsuccessful attempts to complete therapist consultations. Lack of operational and qualitative data prohibited detailed explorations of barriers to delivery of therapist consultations and interventions. Approximately 1 in 4 participants with acute stroke received neither a consultation nor an intervention. Efforts to improve the delivery of acute care therapy services are needed to optimize care for these people.

Policy and Payment Changes Create New Opportunities for Occupational Therapy in Acute Care.

Changes in health care policy and payment over the past decade have resulted in a greater emphasis on cost effectiveness, quality outcomes, and the health care consumer's experience. Payers' response to the new policies and their expectations have created expanded opportunities for occupational therapy practitioners in health care overall but particularly in acute care hospitals. The objective of this article is to empower occupational therapy directors, practitioners, educators, and students to be proactive in a rapidly changing acute care setting. Research on policy and payment changes since the passage of the Patient Protection and Affordable Care Act (Pub. L. 111-148) was synthesized with evidence related to occupational therapy practice and education. Occupational therapy practitioners in acute care environments are experiencing expanded roles in optimizing patient readiness for safe community discharge, decreasing lengths of stay, and protecting them from hospital-acquired conditions. Policy and payment initiatives reward health care organizations for the added value occupational therapy practitioners bring to acute care teams. This article details how occupational therapy practitioners can advance consumer satisfaction, outcomes, and efficiency in acute care, which can lead to increased recognition of the vital role that occupational therapy can play, thus leading to expanded opportunities.

OP137 Translating Results From Clinical Audit Studies To Local Context

IntroductionDespite widespread use of oxygen (O2) therapy, there is relatively little available information on routine O2 administration and monitoring; this is an issue particularly when considering the potential risks associated with inappropriate O2 utilization. A rapid health technology assessment (HTA) was conducted to inform the Respiratory Health Strategic Clinical Network Oxygen Summit in Alberta on aspects related to current practice in the use of O2 therapy in acute care, including administration, safety and quality, and inappropriate practice. Clinical audit is a tool used to determine deviations in practice and to identify opportunities for improvement. The objective of this presentation is to describe the experience and lessons learned from including clinical audit studies in the rapid HTA.MethodsA standardized rapid review approach was used to identify, select, and synthesize evidence from studies published in English from 2005 to 2016. A supplementary literature search conducted in 2018 provided additional background information on the value, applicability, and limitation of using results from clinical audit studies to inform questions of good practice.ResultsTwenty-four clinical audit studies on O2 therapy were identified; the majority were conducted in the United Kingdom. The studies varied in design, methodology, and data and outcomes reporting. Ten studies investigated the appropriateness of O2 therapy prescription pre- and post-implementation of local initiatives and interventions, which helped pinpoint major gaps in current practice, and identified general recommendations for improvement of practice. A list of reporting criteria is proposed for improving the reporting of clinical audit studies results.ConclusionsConducting clinical audit studies is resource-intensive. In the absence of other research evidence and local practice data, translating results from clinical audit studies conducted in other jurisdictions, while challenging, can help address appropriateness questions. However, inferences from these studies may be suitable only for certain topics or an operating context.

RecoverNow: A patient perspective on the delivery of mobile tablet-based stroke rehabilitation in the acute care setting.

We previously reported the feasibility of RecoverNow (a mobile tablet-based post-stroke communication therapy in acute care). RecoverNow has since expanded to include fine motor and cognitive therapies. Our objectives were to gain a better understanding of patient experiences and recovery goals using mobile tablets. Speech-language pathologists or occupational therapists identified patients with stroke and communication, fine motor, or cognitive/perceptual deficits. Patients were provided with iPads individually programmed with applications based on assessment results, and instructed to use it at least 1 h/day. At discharge, patients completed a 19-question quantitative and open-ended engagement survey addressing intervention timing, mobile device/apps, recovery goals, and therapy duration. Over a six-month period, we enrolled 33 participants (three did not complete the survey). Median time from stroke to initiation of tablet-based therapy was six days. Patients engaged in therapy on average 59.6 min/day and preferred communication and hand function therapies. Most patients (63.3%) agreed that therapy was commenced at a reasonable time, although half expressed an interest in starting sooner, 66.7% reported that using the device 1 h/day was enough, 64.3% would use it after discharge, and 60.7% would use it for eight weeks. Sixty-seven percent of patients expressed a need for family/friend/caregiver to help them use it. Our results suggest that stroke patients are interested in mobile tablet-based therapy in acute care. Patients in the acute setting prefer to focus on communication and hand therapies, are willing to begin within days of their stroke and may require assistance with the tablets.

Functional Outcomes of a Patient With Acute Paraplegia After Open Heart Surgery: A Case Report

Introduction: Paraplegia is a complication that may occur after open heart surgery. Minimal published research exists regarding functional outcomes for this patient population. The purpose of this case report is to describe the physical therapy management, including functional outcomes, as defined by the FIM instrument, before and after rehabilitation for a patient who developed paraplegia after open heart surgery. Case Presentation: A 69-year-old man with a past lumbar fusion presented with acute paraplegia immediately after a coronary artery bypass graft and aortic valve replacement surgery. Two months postoperatively, a neurologist determined the probable etiology to be a lumbar disc herniation. The medical charts were reviewed retrospectively. He spent 92 days in the hospital undergoing physical and occupational therapy in acute care and inpatient rehabilitation. He did not regain function in his lower extremities, and a power wheelchair became his primary mode of mobility. The patient was discharged home with his spouse as the primary caregiver. Conclusion: The patient demonstrated functional gains as evidenced by an increase of FIM total score, FIM efficacy, and FIM efficiency after multidisciplinary inpatient rehabilitation. This case report could assist health care professionals in the comprehensive rehabilitation management of this patient population regardless of etiology.

Acute oxygen therapy: a review of prescribing and delivery practices.

Oxygen is a commonly used drug in the clinical setting and like other drugs its use must be considered carefully. This is particularly true for those patients who are at risk of type II respiratory failure in whom the risk of hypercapnia is well established. In recent times, several international bodies have advocated for the prescription of oxygen therapy in an attempt to reduce this risk in vulnerable patient groups. Despite this guidance, published data have demonstrated that there has been poor uptake of these recommendations. Multiple interventions have been tested to improve concordance, and while some of these interventions show promise, the sustainability of these interventions are less convincing. In this review, we summarize data that have been published on the prevalence of oxygen prescription and the accurate and appropriate administration of this drug therapy. We also identify strategies that have shown promise in facilitating changes to oxygen prescription and delivery practice. There is a clear need to investigate the barriers, facilitators, and attitudes of clinicians in relation to the prescription of oxygen therapy in acute care. Interventions based on these findings then need to be designed and tested to facilitate the application of evidence-based guidelines to support sustained changes in practice, and ultimately improve patient care.

Changing the Culture of a Large Multihospital Acute Care Therapy System to Value-Added Through Best Practice Guidelines

Background and Purpose:As hospitals focus on adding value to patient care and operations, providers must ensure that evaluations and interventions shown to improve short- and long-term patient and hospital outcomes are consistently used. Acute care therapists can help hospitals lead the way to value

Acute respiratory failure following ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is a serious and potentially life-threatening physiological complication that may be encountered in patients who undergo controlled ovarian hyperstimulation cycles. The syndrome is typically associated with regimes of exogenous gonadotropins, but it can be seen, albeit rarely, when clomiphene is administered during the induction phase. Although this syndrome is widely described in scientific literature and is well known by obstetricians, the knowledge of this pathological and potentially life-threatening condition is generally less than satisfactory among physicians. The dramatic increase in therapeutic strategies to treat infertility has pushed this condition into the realm of acute care therapy. The potential complications of this syndrome, including pulmonary involvement, should be considered and identified so as to allow a more appropriate diagnosis and management. We describe a case of a woman with an extremely severe (Stage 6) ovarian hyperstimulation syndrome who presented ascites, bilateral pleural effusion and severe respiratory failure treated with non-invasive ventilation. The patient was admitted to the intensive care unit because of severe respiratory failure, ascites, and bilateral pleural effusion due to ovarian hyperstimulation syndrome. Treatment included non-invasive ventilation and three thoracentesis procedures, plus the administration of albumin, colloid solutions and high-dose furosemid. Severe form of ovarian hyperstimulation syndrome is observed in 0.5-5% of the women treated, and intensive care may be required for management of thromboembolic complications, renal failure and severe respiratory failure. Pulmonary intensive care may involve thoracentesis, oxygen supplementation and, in more severe cases, assisted ventilation. To our knowledge, there have been only two studies in English language medical literature that describe severe respiratory failure treated with non-invasive ventilation.

The therapeutic future in headache

There are many categories and individual types of headache and most have a variety of treatment protocols, while a few are best treated by just one medication. This paper will concentrate on acute care medications for migraine and discuss some new and future acute care treatments. There is not much to discuss about prevention, except that onabotulinumtoxinA has been approved for prevention of chronic migraine. Cluster headache will also be discussed, as there are some future treatments for acute care and prevention being studied at present. For the acute care of migraine in the US, we have seven triptans by tablet plus other routes and one non steroidal anti-inflammatory medication approved by the FDA that is currently available (Cambia brand of buffered diclofenac potassium for oral solution). There are several other acute care medications in various stages of development and there are three new methods of administering a triptan and others under investigation. The optimal acute care therapy for migraine should be faster, easier to use and more efficient with fewer adverse events than what is currently available. What follows is a brief review of the status in development for five of the many new acute care medications being investigated: the CGRP antagonist tablet telcagepant, the sumatriptan iontophoretic patch Zelrix, sumatriptan powder for use in the OptiNose apparatus, dihydroergotamine for oral inhalation (Levadex), civamide nasal solution for prevention of episodic cluster headache (Civanex) and sphenopalatine ganglion stimulation for acute cluster attacks in chronic cluster headaches. Other future treatments that will not be discussed include transcranial magnetic stimulation, a 5-HT(1F) agonist named alniditan, large conductance calcium-activated potassium channel openers, glial modulators or other medications and devices in early stages of development.