ObjectiveTo compare the effectiveness and side effects of migraine prophylactic medications.DesignWe performed a network meta-analysis. Data were extracted independently in duplicate and quality was assessed using both the JADAD and Cochrane Risk of Bias instruments. Data were pooled and network meta-analysis performed using random effects models.Data SourcesPUBMED, EMBASE, Cochrane Trial Registry, bibliography of retrieved articles through 18 May 2014.Eligibility Criteria for Selecting StudiesWe included randomized controlled trials of adults with migraine headaches of at least 4 weeks in duration.ResultsPlacebo controlled trials included alpha blockers (n = 9), angiotensin converting enzyme inhibitors (n = 3), angiotensin receptor blockers (n = 3), anticonvulsants (n = 32), beta-blockers (n = 39), calcium channel blockers (n = 12), flunarizine (n = 7), serotonin reuptake inhibitors (n = 6), serotonin norepinephrine reuptake inhibitors (n = 1) serotonin agonists (n = 9) and tricyclic antidepressants (n = 11). In addition there were 53 trials comparing different drugs. Drugs with at least 3 trials that were more effective than placebo for episodic migraines included amitriptyline (SMD: -1.2, 95% CI: -1.7 to -0.82), -flunarizine (-1.1 headaches/month (ha/month), 95% CI: -1.6 to -0.67), fluoxetine (SMD: -0.57, 95% CI: -0.97 to -0.17), metoprolol (-0.94 ha/month, 95% CI: -1.4 to -0.46), pizotifen (-0.43 ha/month, 95% CI: -0.6 to -0.21), propranolol (-1.3 ha/month, 95% CI: -2.0 to -0.62), topiramate (-1.1 ha/month, 95% CI: -1.9 to -0.73) and valproate (-1.5 ha/month, 95% CI: -2.1 to -0.8). Several effective drugs with less than 3 trials included: 3 ace inhibitors (enalapril, lisinopril, captopril), two angiotensin receptor blockers (candesartan, telmisartan), two anticonvulsants (lamotrigine, levetiracetam), and several beta-blockers (atenolol, bisoprolol, timolol). Network meta-analysis found amitriptyline to be better than several other medications including candesartan, fluoxetine, propranolol, topiramate and valproate and no different than atenolol, flunarizine, clomipramine or metoprolol.ConclusionSeveral drugs good evidence supporting efficacy. There is weak evidence supporting amitriptyline’s superiority over some drugs. Selection of prophylactic medication should be tailored according to patient preferences, characteristics and side effect profiles.

Background Ventra hernias are increasing in prevalence and many recur despite attempted repair. To date, much of the literature is underpowered and divergent. As a result there is limited high quality evidence to inform surgeons succinctly which perioperative variables influence postoperative recurrence. This systematic review aimed to identify predictors of ventral hernia recurrence. Methods PubMed was searched for studies reporting prognostic data of ventral hernia recurrence between 1 January 1995 and 1 January 2018. Extracted data described hernia type (primary/incisional), definitions of recurrence, methods used to detect recurrence, duration of follow-up, and co-morbidity. Data were extracted for all potential predictors, estimates and thresholds described. Random-effects meta-analysis was used. Bias was assessed with a modified PROBAST (Prediction model Risk Of Bias ASsessment Tool). Results Screening of 18 214 abstracts yielded 274 individual studies for inclusion. Hernia recurrence was defined in 66 studies (24.1 per cent), using 41 different unstandardized definitions. Three patient variables (female sex, age 65 years or less, and BMI greater than 25, 30, 35 or 40 kg/m2), five patient co-morbidities (smoking, diabetes, chronic obstructive pulmonary disease, ASA grade III–IV, steroid use), two hernia-related variables (incisional/primary, recurrent/primary), six intraoperative variables (biological mesh, bridged repair, open versus laparoscopic surgery, suture versus mesh repair, onlay/retrorectus, intraperitoneal/retrorectus), and six postoperative variables (any complication, surgical-site occurrence, wound infection, seroma, haematoma, wound dehiscence) were identified as significant prognostic factors for hernia recurrence. Conclusion This study summarized the current evidence base for predicting ventral hernia recurrence. Results should inform best practice and future research.

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of blood from the father ha(l no effect. On two occasions 10 c.cnI. of blood from the father was injected intramuscularly, and the first of these injectioins w as follow-ed by a temperature of 105°and rigor oIn three successive days.Then the temperature fell to 100°, and remained at 1000 to 1020, as it had averaged throughout the illness. Although the chil(d was extremely ill during the five weeks, death vas more sudden than wras expected. No post-mortem examination.}3ut for the discovery of a septic thrombus at a higher level than usuial, the case w ould hav,e been regarded as a primary aural bacteriaemia." CASE IV Peter WV., aged 11, had pain in both ears, followed two days later by discharge of pus, which ceased after a -week.Thein he complained of acute pain in the back of the neck, which continue(d for four weeks, and became more acute. He wvas then admitted to hospital, when it was noticed that the back of the neck was swollen anid verv tender on the left side. The swelling was well behind the mastoid region. Both tympaiiic membranes were of normal appearance. Temperat-ure 100°. The only abnormality of the nervous system was double optic neuritis. Mr. Dott determined to explore the cerebellum. A large absc&s 'was discovered among the suboccipital muscles. Streptococci were cultivated from the pus.There was no lesi6o of the cerebellum, but on exposing the laterall sinus from the p)osterior aspect it 'was found to be dilated and of yellow colour, though the outer dural surface was srmlooth. A needle 'was introduced, anda some thin pus w%Nas w-ithdra r,. The sinus wx-as then opened and the pus evacuated. The abscess was found to extend within the sinus for a distrance of 1ll inches, but the limiting clot at either end was not disturh)ed, as there had been no symptom indicative of sinus infection. A