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Background: There is a growing body of recent literature regarding the occurrence of pseudotumors associated with modular junctions and various bearing surfaces after total hip arthroplasty (THA). Revision surgery is often technically challenging and high complication rates have been reported. The optimal management of these patients and outcomes after operative treatment remain poorly understood. Methods: We report the case of a 77-year-old male with progressive unilateral lower extremity swelling, pain, and neuropathy 9 years after revision THA for polyethylene liner wear. Imaging and biopsy confirmed a massive intrapelvic pseudotumor exerting compressive effects. Radiographs demonstrated extensive femoral and pelvic osteolysis without evidence of component loosening. Debulking of the intrapelvic portion of the pseudotumor was performed via the lateral window of the ilioinguinal approach with component retention. Results: Debulking of the intrapelvic mass resulted in resolution of symptoms. One year postoperatively the patient reported pain free ambulation using a walker and no recurrence of symptoms. Radiographs demonstrated stable THA components in comparison with preoperative films. Discussion and Conclusion: This case demonstrates a rare finding of intrapelvic pseudotumor causing neurovascular compression after revision THA. Clinicians should be aware of intrapelvic pseudotumor as a possible cause of limb swelling and neuropathy, and that debulking of the mass is a potential treatment option in the setting of well-fixed implants.

Objective: Describe primary pharmacokinetic/pharmacodynamic (PK/PD) parameters of vancomycin and meropenem in pediatric patients undergoing ECMO and analyze utilized dosing to reach PK/PD target.Design: Prospective, multicentric, population PK analysis.Setting: Two hospitals with pediatric intensive care unit.Patients: Pediatric patients (1 month - 15 years old) receiving vancomycin and meropenem for empiric or definitive infection treatment while ECMO support.Measurements and Main Results: Four serum concentration were obtained for patients receiving vancomycin (n = 9) and three for meropenem (n = 9). The PK/PD target for vancomycin was a ratio of the area under the curve to the minimal inhibitory concentration (AUC/MIC) of >400, and for meropenem was 4 times above MIC for 50% of the dosing interval (fT50% > 4xMIC). Pharmacokinetic modeling was performed using PMetrics 1.5.0. We included nine patients, with 11 PK profiles for each antimicrobial. The median age of patients was 4 years old (2 months - 13 years) and 45% were male. Creatinine clearance (CL) was 183 (30–550) ml/min/1.73 m2. The median dose was 13.6 (range 10–15) mg/kg every 6–12 h and 40 mg/kg every 8–12 h for vancomycin and meropenem, respectively. Two compartment models were fitted. Weight was included as a covariate on volume of the central compartment (Vc) for meropenem. Weight was included as a covariate on both Vc and clearance (CL) and serum creatinine was also included as a covariate on CL for vancomycin. The pharmacokinetic parameters CL and Vc were 0.139 ± 0.102 L/h/kg and 0.289 ± 0.295 L/kg for meropenem and 0.060 ± 0.055 L/h/kg and 0.419 ± 0.280 L/kg for vancomycin, respectively. Across each dosing interval 91% of patients achieved the PK/PD targets for adequate exposure for meropenem and 63.6% for vancomycin.Conclusion: Pharmacokinetic/pharmacodynamic objectives for vancomycin were achieved partially with conventional doses and higher dosing with extended infusion were needed in the case of meropenem.

In patients undergoing emergent operation for trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure. DC surgery (abbreviated initial surgery followed by planned reoperation after a period of resuscitation in the intensive care unit) has been suggested to most benefit patients more likely to succumb from the “vicious cycle” of hypothermia, acidosis, and coagulopathy and/or postoperative abdominal compartment syndrome (ACS) than the failure to complete organ repairs. However, there currently exists no unbiased evidence to support that DC surgery benefits injured patients. Further, the procedure is associated with substantial morbidity, long lengths of intensive care unit and hospital stay, increased healthcare resource utilization, and possibly a reduced quality of life among survivors. Therefore, it is important to ensure that DC laparotomy is only utilized in situations where the expected procedural benefits are expected to outweigh the expected procedural harms. In this manuscript, we review the comparative effectiveness and safety of DC surgery when used for different procedural indications. We also review recent studies suggesting variation in use of DC surgery between trauma centers and the potential harms associated with overuse of the procedure. We also review published consensus indications for the appropriate use of DC surgery and specific abdominal, pelvic, and vascular DC interventions in civilian trauma patients. We conclude by providing recommendations as to how the above list of published appropriateness indications may be used to guide medical and surgical education, quality improvement, and surgical practice.

Non-compressible torso haemorrhage (NCTH) (i.e., bleeding from anatomical locations not amenable to control by direct pressure or tourniquet application) is a leading cause of potentially preventable death after injury. In select trauma patients with infra-diaphragmatic NCTH-related hemorrhagic shock or traumatic circulatory arrest, occlusion of the aorta proximal to the site of hemorrhage may sustain or restore spontaneous circulation. While the traditional method of achieving proximal aortic occlusion included Emergency Department thoracotomy (EDT) with descending thoracic aortic cross-clamping, resuscitative endovascular balloon occlusion of the aorta (REBOA) affords a less invasive option when thoracotomy is not required for other indications. In this manuscript, we review the innovation, pathophysiologic effects, indications for, and technique of EDT and partial, intermittent, and complete REBOA in injured patients, including recommended methods for reversing aortic occlusion. We also discuss advantages and disadvantages of each of these methods of proximal aortic occlusion and review studies comparing their effectiveness and safety for managing post-injury NCTH. We conclude the above by providing recommendations as to when each of these methods may be best when indicated to manage injured patients with NCTH.

Optical biosensing is being actively investigated for minimally-invasive monitoring of key biomarkers both $in~ vitro$ and $in~ vivo$ . However, typical benchtop instruments are not portable and are not well suited to high-throughput, real-time analysis. This paper presents a versatile multichannel instrument for measurement of emission intensity and lifetime values arising from luminescent biosensor materials. A detailed design description of the opto-electronic hardware as well as the control software is provided, elaborating a flexible, user-configurable system that may be customized or duplicated for a wide range of applications. This article presents experimental measurements that prove the $in~ vitro$ and $in ~vivo$ functionality of the system. Such tools may be adopted for many research and development purposes, including evaluation of new biosensor materials, and may also serve as prototypes for future miniaturized handheld or wearable devices.

Upper extremity pathology is uncommon and generally involves the brachial artery in about 12% of the cases. Of chronic upper limb ischemia, trauma, fibromuscular dysplasia, giant cell arteritis, and atherosclerosis are among the most reported cases. After a thorough review of the literature, there is agreement with duplex ultrasound sensitivity and specificity for predicting >70% stenosis in the subclavian arteries with a sensitivity of >82% and specificity of >90%. This article not only correlates the relationship between duplex ultrasound and severe peripheral arterial disease, but it also proves with 100% accuracy the ability to detect latent and abnormal pathology of the upper extremities post endovascular intervention.

Augmented renal clearance (ARC) is known to influence β-lactam antibiotic pharmacokinetics. This substudy of the BLING-II trial aimed to explore the association between ARC and patient outcomes in a large randomised clinical trial. BLING-II enrolled 432 participants with severe sepsis randomised to receive β-lactam therapy by continuous or intermittent infusion. An 8-h creatinine clearance (CLCr) measured on Day 1 was used to identify ARC, defined as CLCr ≥ 130 mL/min. Patients receiving any form of renal replacement therapy were excluded. Primary outcome was alive ICU-free days at Day 28. Secondary outcomes included 90-day mortality and clinical cure at 14 days following antibiotic cessation. A total of 254 patients were included, among which 45 (17.7%) manifested ARC [median (IQR) CLCr 165 (144–198) mL/min]. ARC patients were younger (P

OBJECTIVES This proposed systematic review will identify the existing evidence on medication-overuse headache in children and adolescents. BACKGROUND A number of medications have been shown to be effective for acute treatment of migraine in children and adolescents. However, patients may find they need to use their acute medications more frequently when migraine frequency is high. This has led to concern about their potential to develop medication-overuse headache. METHODS We will search PubMed, Embase, Web of Science, PsycINFO, and Cochrane databases from their inception to present time. We will also search conference proceedings of the last 4 scientific meetings of relevant societies and scan the reference lists of studies identified through the search. Study designs will include case series, cross-sectional, cohort, case-control, and interventional studies. Participants will include children and adolescents under 18 years of age with primary headache disorders. We aim to determine whether frequency of acute medication use is associated with headache frequency in children and adolescents. Outcomes of interest include: (1) headache frequency; (2) change in headache frequency, with time and in relationship to use of acute medications; and (3) headache-related disability. We will also review data addressing treatment/management of medication overuse or medication-overuse headache in children and adolescents. Relevant comparators will be withdrawal vs reduction of acute medication, initiation of preventive therapy vs no initiation with or without withdrawal of acute medication, and initiation of preventive therapy early vs late. Outcomes of interest include (1) days of acute medication use; (2) headache frequency; (3) change in headache frequency; and (4) headache-related disability. After screening for inclusion, 2 team members will independently review and extract relevant data, and any discrepancies will be resolved through discussion and arbitration. We will assess risk of bias using appropriate tools (Cochrane Risk of Bias for randomized controlled trials (RCT) and Newcastle-Ottawa Score for observational studies). Data will be summarized descriptively in text and tables. RESULTS This systematic review will provide an overview of the available evidence on medication-overuse headache in children and adolescents. CONCLUSIONS Findings from this review will aid clinicians by clarifying for them the current state of the evidence base, and will inform design of future research on this topic.

Introduction Chronic containment of a ruptured abdominal aortic aneurysm (AAA) is a rare clinical phenomenon that is often accompanied by abstract symptomatology, delayed diagnosis, and treatment. We describe a case of chronic contained rupture (CCR) in a hemodynamically stable and asymptomatic patient detected by duplex ultrasound (DU). Patient Description A 71-year-old white male presented to our medical facility to establish cardiac care for newly diagnosed pleural effusion and bilateral lower extremity edema. Physical examination revealed prominent abdominal aortic pulsations. An abdominal DU was ordered to evaluate for an AAA. Methods An abdominal DU examination was performed utilizing a Philips iU22 xMATRIX Ultrasound System equipped with a C5–1 MHz PureWave transducer. The aorta, common iliac and external iliac arteries were evaluated with gray scale, color, and spectral Doppler applications. Imaging Results The DU confirmed the presence of a 5.6 cm × 5.7 cm infrarenal AAA. The lumen was noted to have irregularities and multiple avascular hypoechoic lesions that were reproducible in multiple imaging planes. Computed tomography (CT) confirmed the presence of the 4.8-cm aneurysm accompanied by a 5.6 cm × 4.0 cm multi-lobular fluid collection extending into the mesentery. Active extravasations were not visualized during contrast administration; nevertheless, the appearance of the irregularity was suspicious of aneurysm leak resulting in evolving hematoma. The CCR was treated with a bifurcated intraluminal stent graft. Conclusion This case describes an extremely rare rupture complication that may be present during routine evaluation of the abdominal aorta. Because of its rarity in case presentation, standardized protocol for detection and sonographic presentation remain undocumented.

Case: A 19-year-old woman sustained a traumatic hip injury with dislocation and fractures of the femoral head and neck. A modified Gibson approach with trochanteric flip osteotomy was performed. We describe the management technique used to reduce and stabilize the femoral head and neck fractures during surgical hip dislocation. The stabilization of the femoral head to the femoral neck was performed primarily in a retrograde manner. Conclusion: Retrograde fixation of combined femoral head and neck fractures can be safely performed during surgical hip dislocation with satisfactory results.

Case: A 36-year-old bicyclist sustained an open anterior hip dislocation through the scrotum after being struck by 2 motor vehicles. There was no osseous injury present. The hip was irreducible by closed means and required open reduction via a Smith-Petersen approach. Postoperatively, the patient did not develop osteonecrosis of the femoral head but did have signs of mild osteoarthritis and heterotopic ossification. Conclusion: Open anterior hip dislocation into the scrotum is an exceedingly rare injury. Closed reduction can be attempted, but open intervention is often required. A Smith-Petersen approach allows visualization for reduction and does not violate the vascularity to the femoral head.

Traditionally, the time-to-fill metric is used as a scorecard for past performance. An organization may use time to fill to assess the performance of its internal recruiting team, or as a way to set service level agreements with outsourced recruiting partners. By first developing a set of quantifiable job features and then applying survival analysis to historical time-to-fill data, we build a predictor to assess the probability a job will remain open beyond its target time-to-fill date, enabling us to commit additional resources to high risk jobs at the beginning of the recruiting process.

Background Torso bleeding remains the most preventable cause of post-traumatic death worldwide. Remote damage control resuscitation (RDCR) endeavours to rescue the most catastrophically injured, but has not focused on prehospital surgical torso hemorrhage control (HC). We examined the logistics and metrics of intraperitoneal packing in weightlessness in Parabolic flight (0g) compared to terrestrial gravity (1g) as an extreme example of surgical RDCR. Methods A surgical simulator was customized with high-fidelity intraperitoneal anatomy, a "blood" pump and flowmeter. A standardized HC task was to explore the simulator, identify "bleeding" from a previously unknown liver injury perfused at 80 mm Hg, and pack to gain hemostasis. Ten surgeons performed RDCR laparotomies onboard a research aircraft, first in 1g followed by 0g. The standardized laparotomy was sectioned into 20-second segments to conduct and facilitate parabolic flight comparisons, with "blood" pumped only during these time segments. A maximum of 12 segments permitted for each laparotomy. Results All 10 surgeons successfully performed HC in both 1g and 0g. There was no difference in blood loss between 1g and 0g (p = 0.161) or during observation following HC (p = 0.944). Compared to 1g, identification of bleeding in 0g incurred less "blood" loss (p = 0.032). Overall surgeons rated their personal performance and relative difficulty of surgery in 0g as "harder" (median Likert, 2/5). However, conducting all phases of HC were rated equivalent between 1g and 0g (median Likert, 3/5), except for instrument control (rated slightly harder, 2.75/5). Conclusion Performing laparotomies with packing of a simulated torso hemorrhage in a high-fidelity surgical simulator was feasible onboard a research aircraft in both normal and weightless conditions. Despite being subjectively "harder," most phases of operative intervention were rated equivalently, with no statistical difference in "blood" loss in weightlessness. Direct operative control of torso hemorrhage is theoretically possible in extreme environments if logistics are provided.

Objective: Osseointegrated hearing implants have been readily available and extensively used in developed countries for over twenty years. Despite a great need for this technology, use of these implants in developing countries has been limited due to the prohibitive cost of the surgical implant system as well as the implant devices themselves. To address this problem we have developed a drill and implant system that mimics the currently available instrumentation using materials that are readily available at a fraction of the cost. Study Design: Proof of Concept. Methods: The construction of the drill and implant system will be described. Testing of the system so that it adhered to Cochlear’sTM Bone anchored hearing aid system specifications including the drill speed and torque settings were measured. Temperature readings were also recorded during procedures performed on human cadaveric temporal bones. Results: The speed of the drill with the guide drill and countersink drill bits ranged from 1400 revolutions per minute (rpm) to 2300 rpm’s. The temperature change of the room temperature temporal bones varied from 0 degrees to +0.2 degrees Fahrenheit during the drilling process with both drill bits. All five implants were stable in the cadaver bone after being checked for initial stability. Conclusion: This low cost implant system may make the BAHA technology more easily available to developing countries pending future studies with animal models.

Background Calcaneal fractures are commonly seen and treated in the emergency department. There are subsets of calcaneal fractures that pose a high risk to the adjacent soft tissue of the heel and can result in full-thickness tissue necrosis. Objective To identify which calcaneal fractures need to be managed within hours and triaged to the orthopedic team and which can be temporized in a neutral or plantarflexed ankle splint and seen in an outpatient setting. Discussion Tongue-type calcaneal fractures and tuberosity fractures must be triaged appropriately within the first few hours of presentation to prevent skin compromise. This requires the emergency physician to understand the radiographic morphology of the fracture as well as the clinical signs of skin compromise. Communication with the orthopedic surgery service is essential and splinting in a specific manner is important to stabilize the soft tissue envelope. Conclusion Recognizing the calcaneal injury pattern and implementing the correct treatment strategy is paramount to having successful patient outcomes. A delay or error in treatment can turn a closed fracture into an open fracture.

This book provides an up to date review on antimicrobials dosing in obese patients, including practice recommendations for clinical use. The book is written by a group of doctors and pharmacists working in infectious diseases practice and research. The introductory chapter outlines the important physiological changes in obesity including factors affecting the dosing of antimicrobials in obese patients. The introductory chapter is followed by ten chapters covering the major classes of antibiotics, antifungals, and antivirals. Each chapter briefly discusses the pharmacokinetics changes related to obesity and a summary of the relevant up-to-date literature. Specific dosing recommendations are provided for each class supplemented by real-life examples as clinical cases that are included as an appendix to the book. The book is a useful resource for clinicians, students and researchers needing up-to-date information on antimicrobial dosing in obese patients. Doctors, pharmacists, nurses working in hospital settings, and students of health courses (medical, pharmacy and nursing students) will find this book particularly useful.

Catheter-based methods for multichannel intraluminal impedance-pH monitoring are invasive and uncomfortable. The current alternative is a wireless system that clips to the esophageal mucosa, but which only measures pH. A shorter two-site wireless sensor that detects impedance and pH, and can be clipped to the esophagus, would be desirable. This study compares sensor positions and separations to determine the optimal configuration of a two-site wireless sensor. Records of 20 patients (10 on and 10 off proton pump inhibitor) who had ambulatory reflux testing with a multichannel intraluminal impedance-pH system (Sandhill Scientific Inc., Highlands Ranch, CO, USA) with six impedance and two pH sensors were reviewed. An investigator was blinded to four combinations of impedance channels plus pH. He read a 3-hour postprandial section from each of the combinations (total of 80 studies) and marked reflux episodes. Results were compared with his own interpretation of the full tracing. Two hundred and two total reflux episodes were analyzed, 113 acid (pH 4). Mean and median numbers of total reflux episodes were calculated. In the full study, the interpreter detected a mean of 10 reflux episodes per study. In the 5 cm and 7 cm, 3 cm and 7 cm, and 3 cm and 5 cm studies, the interpreter found a mean of 8.1, 11.1, and 9.8 reflux episodes per study, respectively. One-way analysis of variance yielded a P-value of 0.43. The trend of these preliminary findings suggests that the 3 cm and 5 cm site is the most sensitive and the 5 cm and 7 cm is the least, with the 3 cm and 7 cm site perhaps as the preferred location. The lack of a significant difference, at the very least, suggests that any of the 'mini' locations could be used. The small number of observations could have resulted in a Type II statistical error.

Nurses often function as capsule endoscopy "pre-readers" to save physicians' time and potentially increase diagnostic yield. Training pre-readers is time consuming, not standardized, and may not be feasible during regular business hours. A way to evaluate the progress and accuracy of pre-readers is needed to ensure competency. The aim of this study was to introduce a feedback and progress assessment tool for training novice capsule endoscopy pre-readers. We created a 1-page form with listings of potential findings for each segment of the examination. Findings could be circled or written in. The trainee reviewed capsule studies and filled out the form on each of 220 patients. The physician reviewers subsequently critiqued the data forms, providing feedback regarding missed lesions, overcalls, and overall agreement. Our trainee achieved consistent agreement with the physician reviewers, after reading 80 studies. In conclusion, a simple, 1-page standardized data sheet can be used to facilitate training of novice capsule pre-readers without significant time commitment from the supervising physician. Future studies may validate this resource-efficient instrument as a training and assessment tool for nurses, physicians, and other practitioners learning capsule endoscopy.

BACKGROUND Intramedullary nail (IMN) perforation through the cortex of the distal femur is a risk of intramedullary stabilization of proximal femur fractures. This study was performed to identify information that is available before operation that can pick out patients at risk for this complication. METHODS A retrospective review of records and roentgenograms of 150 patients treated with intramedullary stabilization of a proximal femur fracture during a 4-year period at a Level I trauma center was performed. The position of the tip of the IMN in the distal femur was measured on postoperative lateral roentgenograms and grouped into anterior, middle, or posterior one third positions. Patients in whom the tip of the nail contacted or penetrated through the anterior cortex were designated as having cortical impingement. RESULTS Nail tip position was in the anterior one third of the distal femur in 71 (47%) of 150 patients, and 38 (25%) of these patients fit the definition for cortical impingement. The radiographic femoral angle of incidence strongly correlated with an anterior nail tip position (p < 0.0001) and cortical impingement (p < 0.0001). Shorter patients were also more likely to have cortical impingement (p < 0.005), and patients less than 160 cm in height had a 49% likelihood of impingement. A starting point in the posterior one third of the greater trochanter increased the likelihood of having an anterior nail tip position as well (p < 0.007). CONCLUSION Of the 150 patients in whom an IMN was used for stabilization of a proximal femur fracture, 71 (47%) had the distal part of their nail positioned in the anterior one third of the distal femur. Patients who are shorter and/or had an increased femoral bow as measured on a lateral roentgenogram are more likely to have an anterior nail tip position or cortical impingement. Posterior starting points should be avoided to prevent this complication. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Distal oesophageal spasm is a rare and under-investigated motility abnormality. Recent studies indicate effective bolus transit in varying percentages of distal oesophageal spasm patients.Explore functional aspects including contraction onset velocity and contraction amplitude cut-off values for simultaneous contractions to predict complete bolus transit.We re-examined data from 107 impedance-manometry recordings with a diagnosis of distal oesophageal spasm. Receiver operating characteristic analysis was conducted, regarding effects of onset velocity on bolus transit taking into account distal oesophageal amplitude and correcting for intra-individual repeated measures.Mean area under the receiver operating characteristic curve for saline and viscous swallows were 0.84±0.05 and 0.84±0.04, respectively. Velocity criteria of30 cm/s when distal oesophageal amplitude100 mmHg and 8 cm/s when distal oesophageal amplitude100 mmHg for saline and 32cm/s when distal oesophageal amplitude100 mmHg and7 cm/s when distal oesophageal amplitude100 mmHg for viscous had a sensitivity of 75% and specificity of 80% to identify complete bolus transit. Using these criteria, final diagnosis changed in 44.9% of patients. Abnormal bolus transit was observed in 50.9% of newly diagnosed distal oesophageal spasm patients versus 7.5% of patients classified as normal. Distal oesophageal spasm patients with distal oesophageal amplitude100 mmHg suffered twice as often from chest pain than those with distal oesophageal amplitude100 mmHg.The proposed velocity cut-offs for diagnosing distal oesophageal spasm improve the ability to identify patients with spasm and abnormal bolus transit.

Extraesophageal (EE) symptoms such as cough and throat clearing are common in patients referred for reflux testing, but are less commonly associated with gastroesophageal reflux disease (GERD). Patients with reflux associated EE symptoms often lack typical GERD symptoms of heartburn and regurgitation. Our aim was to compare the frequency of proximal esophageal reflux between esophageal (typical) symptoms and EE (atypical) symptoms. Combined multichannel intraluminal impedance-pH (MII-pH) tracings were blinded by an investigator so that symptom markers were relabeled with a number without disclosure of symptom type. We selected 40 patients with at least five reflux-related symptom events for one of four symptoms (heartburn, regurgitation, cough, or throat clearing). A blinded investigator analyzed all 200 reflux episodes, reporting the proximal esophageal extent of the reflux for all symptoms. The percentage of symptom-related reflux extending proximally to 17 cm above the LES was similar among all four symptom types. At least 50% of all symptoms were associated with proximal esophageal reflux to 17 cm, with regurgitation having the highest frequency at 60%. Our data indicate that EE symptoms are not more frequently associated with proximal esophageal reflux than typical esophageal symptoms.

Medical language has implications for both public perception of and institutional responses to illness. A consensus panel of physicians, academics, advocates, and patients with diverse experiences and knowledge about migraine considered 3 questions: (1) What is migraine: an illness, disease, syndrome, condition, disorder, or susceptibility? (2) What ought we call someone with migraine? (3) What should we not call someone with migraine? Although consensus was not reached, the responses were summarized and analyzed quantitatively and qualitatively. Panelists participated in writing and editing the paper. The panelists agreed that "migraine," not "migraine headache," was generally preferable, that migraine met the dictionary definition for each candidate moniker, terms with psychiatric valence should be avoided, and "sufferer" should be avoided except in very limited circumstances. Overall, while there was no consensus, "disease" was the preferred term in the most situations, and illness the least preferred. Panelists disagreed strongly whether one ought to use the term "migraineur" at all or if "person with migraine" was preferable. Panelists drew upon a variety of principles when considering language choices, including the extent to which candidate monikers could be defended using biomedical evidence, the cultural meaning of the proposed term, and the context within which the term would be used. Panelists strove to balance the need for terms to describe the best science on migraine, with the desire to choose language that would emphasize the credibility of migraine. The wide range of symptoms of migraine and its diverse effects may require considerable elasticity of language.