We thank Maria Bond for technical assistance with manuscript preparation. Additional Supporting Information may be found in the online version of this article. “
“Systemic inflammation and susceptibility to developing sepsis is common in acute liver failure (ALF) resulting in tissue damage and MAPK inhibitor organ failure. This study characterized the function of circulating neutrophils in 25 patients with ALF and subacute liver failure (SALF). ALF (n = 15) / SALF (n = 10) patients were prospectively studied and compared with 11 healthy (HC) and 6 septic controls (SC). Neutrophils were isolated on admission to intensive care

and every 3-4 days until death / liver transplantation / recovery. Neutrophil phenotype was determined using fluorochrome-labeled antibodies to CD16 and CD11b and assessed by flow cytometry. Neutrophil phagocytic activity (NPA) was determined using fluorescein isothiocyanate-labeled opsonized Escherichia coli and oxidative burst (OB) was determined by the percentage of neutrophils producing reactive oxygen species (ROS) at rest and after stimulation with opsonized E. coli. Physiological variables, biochemistry, arterial ammonia, microbiology, and outcomes were collected. Plasma pro- and antiinflammatory find more cytokine profiles were performed by enzyme-linked immunosorbent assay. Neutrophil

expression of CD16 which recognizes the FcγRIII region of immunoglobulin G was significantly reduced in the ALF cohort (P < 0.001) on day 1 compared to HC. click here NPA was significantly impaired in the SALF cohort compared to HC (P < 0.01). Impaired NPA in the ALF and SALF cohorts on admission predicted nonsurvival without liver transplantation (P = 0.01). Spontaneous neutrophil production of ROS was not significantly increased in any of the cohorts. E. coli-stimulated OB was preserved in ALF/SALF cohorts but was significantly impaired in the SC group (P < 0.05). Conclusion: Circulating neutrophils in ALF/SALF have impaired bacteriocidal function similar

to that seen in severe sepsis. Neutrophil function indices are important biomarkers in ALF and may be implicated in the development of organ dysfunction and the increased susceptibility to developing sepsis. (HEPATOLOGY 2013) Acute liver failure (ALF) is a rare but frequently catastrophic consequence of an acute primary hepatic injury arising from a wide variety of insults. It is characterized by coagulopathy and encephalopathy, with a variable dynamic of progression to multiple organ dysfunction syndrome (MODS) and death.1 Liver transplantation (LT) remains the only curative option for advanced ALF with poor prognostic criteria and contributes to ∼10% of LT in the Western world.2 Neutrophils are a major innate immune cell subset involved in the first line of defense against infection.

046) and a single cluster consisting of all isolates. Gene flow among populations was estimated to be high (10 per generation). This study shows that the pathogen population of Ethiopia is characterized by a high genetic diversity within each population and absence of segregation among populations. Information obtained from this study

may serve as a basis to develop better strategies for deployment of resistance genes, e.g. using marker-assisted combination of resistance alleles to achieve better control of wheat stem rust in Ethiopia. this website “
“Globodera pallida and G. rostochiensis are two cyst-forming nematodes known to infest potato crops, causing severe economic losses worldwide. In this study,

a real-time TaqMan PCR assay was developed and optimized for the simultaneous detection of G. pallida and G. rostochiensis. The assay’s analytical MI-503 datasheet and diagnostic sensitivity and specificity were evaluated using reference isolates. Four different DNA extraction methods and one rapid crude template-preparation procedure were compared in terms of extraction purity, efficiency for PCR applications, utility and cost. Extraction methods A and B included two commercially available kits that utilize silica columns and magnetic beads, respectively. Method C was based on DNA isolation using Chelex resin, and method D was a standard chemistry in-house protocol. Procedure E included the direct use of crude mixture composed of disrupted cysts in Tris–EDTA buffer. The multiplex TaqMan PCR assay successfully discriminated the two nematode species from all reference cyst samples and its recorded diagnostic sensitivity

(Dse) and specificity (Dsp) was 100%. On the contrary, in conventional (Co) PCR tests, the overall Dsp and Dse were lower and estimated at 94 and 87% for G. pallida, and 97 and 88% for G. rostochiensis, respectively. Spectrophotometric results showed that DNA extraction methods A, B and C yielded the purest DNA and selleckchem gave the lowest mean Ct values as well as the most consistent results in Co PCR. Alternative crude preparation method E resulted in statistically similar and Ct values consistent with those obtained with methods A to C when tested by TaqMan PCR. The developed assay, using crude template-preparation E, allows the simple, accurate and cost-effective testing of a large number of cyst samples and can be applied in surveys and certification schemes. “
“Angelica dahurica is an important Chinese herbal medicine plant, and its rhizome is of high medicinal value. In recent years, a severe decline in yield has been observed in Bozhou City (China’s largest A. dahurica producing area), Anhui province, China. It showed symptoms of decline, stunting, yellowing and many galls in the roots, which was the characterization of infestation by root-knot nematodes.

In contrast, rifaximin has not been shown to have a significant side-effect profile,16 certainly when compared to other previously utilized antibiotics, although long-term data are not yet available. Some of the adverse effects of lactulose can be minimized with the use of lactitol (an analog of lactulose);17 however, this is not available worldwide. Overtreatment of lactulose can lead to the more serious side-effects of marked dehydration, hyponatremia, and worsening of hepatic encephalopathy.5 The dosing regime of rifaximin can Pexidartinib manufacturer be either fixed daily or cyclical,15 whereas lactulose does rely on some degree of patient adjustment to ensure approximately two to three semiformed

stools daily. Costing considerations are

not straightforward. While the direct cost of rifaximin compared to lactulose is marked, approximately $US1120 as opposed to $150 per month in the USA,15 the total annual costing of rifaximin has been reported to be less than lactulose when hospital admissions are taken into account.18 The role of rifaximin in the prevention or treatment of hepatic encephalopathy following an acute variceal bleed remains to be elucidated. Even if no further conclusive studies confirming the beneficial effect of lactulose occur, it is difficult to conceive of it being substituted as first-line therapy for hepatic encephalopathy. Its routine prophylactic use in the setting of an acute variceal bleed find more (post-initial stabilization and endoscopic

control of bleeding) seems intuitive. Perhaps prophylactic lactulose therapy should be considered for incorporation into acute variceal bleed practice guidelines as the “standard of care. “
“Hereditary hemochromatosis (HH) is an autosomal recessive disease caused by mutations in the HFE gene leading to increased iron absorption and deposition of iron in various organs, including the liver. It is the most common hereditary disorder in White people with a prevalence as high as one in 140 although phenotypic expression is much less common. It typically presents as asymptomatic elevation in iron studies selleck inhibitor but can present with abnormal liver enzymes and hepatomegaly. Arthralgias, loss of libido, diabetes and heart failure can occur due to iron deposition in other organs. The diagnosis relies on demonstration of a high iron saturation and ferritin. Testing for HFE gene mutations and liver biopsy can also be helpful. Treatment is based on depletion of iron through phlebotomy and improves survival. “
“A woman, aged 76, was admitted to hospital with abdominal pain that had persisted for 24 hours. On examination, she had a smooth mass in the right upper quadrant of her abdomen. Seventeen years previously, she had been diagnosed with two hepatic cysts; one had been treated by percutaneous sclerotherapy while the other had been left untreated.

In contrast, rifaximin has not been shown to have a significant side-effect profile,16 certainly when compared to other previously utilized antibiotics, although long-term data are not yet available. Some of the adverse effects of lactulose can be minimized with the use of lactitol (an analog of lactulose);17 however, this is not available worldwide. Overtreatment of lactulose can lead to the more serious side-effects of marked dehydration, hyponatremia, and worsening of hepatic encephalopathy.5 The dosing regime of rifaximin can selleck kinase inhibitor be either fixed daily or cyclical,15 whereas lactulose does rely on some degree of patient adjustment to ensure approximately two to three semiformed

stools daily. Costing considerations are

not straightforward. While the direct cost of rifaximin compared to lactulose is marked, approximately $US1120 as opposed to $150 per month in the USA,15 the total annual costing of rifaximin has been reported to be less than lactulose when hospital admissions are taken into account.18 The role of rifaximin in the prevention or treatment of hepatic encephalopathy following an acute variceal bleed remains to be elucidated. Even if no further conclusive studies confirming the beneficial effect of lactulose occur, it is difficult to conceive of it being substituted as first-line therapy for hepatic encephalopathy. Its routine prophylactic use in the setting of an acute variceal bleed GDC-0449 nmr (post-initial stabilization and endoscopic

control of bleeding) seems intuitive. Perhaps prophylactic lactulose therapy should be considered for incorporation into acute variceal bleed practice guidelines as the “standard of care. “
“Hereditary hemochromatosis (HH) is an autosomal recessive disease caused by mutations in the HFE gene leading to increased iron absorption and deposition of iron in various organs, including the liver. It is the most common hereditary disorder in White people with a prevalence as high as one in 140 although phenotypic expression is much less common. It typically presents as asymptomatic elevation in iron studies this website but can present with abnormal liver enzymes and hepatomegaly. Arthralgias, loss of libido, diabetes and heart failure can occur due to iron deposition in other organs. The diagnosis relies on demonstration of a high iron saturation and ferritin. Testing for HFE gene mutations and liver biopsy can also be helpful. Treatment is based on depletion of iron through phlebotomy and improves survival. “
“A woman, aged 76, was admitted to hospital with abdominal pain that had persisted for 24 hours. On examination, she had a smooth mass in the right upper quadrant of her abdomen. Seventeen years previously, she had been diagnosed with two hepatic cysts; one had been treated by percutaneous sclerotherapy while the other had been left untreated.

02% of the total IgG memory B cells. Therefore, a further improvement in the detection limit of the method might be necessary. Summarizing our data, we conclude that FVIII-specific memory B cells are an important target for the development of new strategies to induce FVIII-specific immune tolerance in patients with haemophilia A and FVIII inhibitors. Therefore, future efforts should focus on studying the regulation of these cells both in preclinical animal models and in patients. However, the eradication of memory B cells can only be a first step in the induction of immune tolerance in patients with FVIII inhibitors. A second step will

most likely be necessary to keep a stable VX-770 mw immune tolerance and prevent the re-induction of anti-FVIII antibodies. The authors are grateful to all team members within Global Preclinical R&D of Baxter BioScience who have supported us in our studies. The author would also like to thank Elise Langdon-Neuner for editing this manuscript. B. M. Reipert, P. Allacher, I. click here Lang, J. Ilas, E. M. Muchitsch and H. P. Schwarz are employees of Baxter Innovations GmbH. A. G. Pordes’ PhD research is funded by

Baxter Innovations GmbH. The other authors stated that they had no interests which might be perceived as posing a conflict or bias. “
“Summary.  Factor VIII (FVIII) levels show a considerable variability in female carriers of haemophilia A. Presently, the reasons for this are poorly understood. The aim of the study was to elucidate the influence of genetic and non-genetic parameters on FVIII plasma levels in carriers (n = 42). Results were compared with age-matched healthy women without carriership of haemophilia A (n = 42). Each carrier was tested for the family-specific mutation, ABO blood group, FVIII level, von Willebrand factor (VWF) antigen and activity and C-reactive protein (CRP). FVIII levels were lower in carriers compared to non-carriers [74% (51–103) vs. 142% (109–169), P < 0.001]. No statistically significant selleck inhibitor differences were observed between the two

groups with respect to VWF activity, prothrombin–time, hs-CRP, fibrinogen, body mass index (BMI), age and smoking status as well as the distribution of ABO blood groups. In non-carriers, FVIII was statistically significantly correlated with BMI, activated partial thromboplastin time (APTT), VWF antigen, hs-CRP and fibrinogen. In carriers, significant correlations between FVIII and APTT, VWF antigen and activity were found, whereas BMI, hs-CRP or fibrinogen did not correlate with FVIII. In non-carriers, the association of FVIII with ABO blood groups was statistically significant (P = 0.006), but not in carriers of haemophilia A (P = 0.234). The type of FVIII gene mutation did not influence FVIII levels. Carrier status is the major determinant of a carrier`s FVIII plasma level. Factors known to influence FVIII levels in the general population do not significantly affect FVIII activity in carriers, neither does the type of mutation influence FVIII levels. “
“Summary.

927, P < 0.05). Compared with group B2, the expressions of SMA and FN protein in group C1 also decreased statistically at the end of 10 weeks (F = 77.421, 118.262, P < 0.05), and more significantly decreased in group H-FZHc C2 (P = 0.002, 0.013) proved by immunohistochemistry staining. At the same time the expressions of Nrf2 and Nqo1 protein were all increased statistically in groups L-FZHc C1 and

H-FZHc C2 at the end of 10 weeks demonstrated by immunohistochemistry staining (F = 182.537, 75.615, P < 0.05) and western-blotting (F = 45.664, 127.673, P < 0.05) comparing with group B2, and more notabally in group H-FZHc C2 (P = 0.000, 0.014; 0.005, 0.014). And also proved the amount of Nrf2 nuclear selleck chemicals transportion and Nrf2 mRNA expression were increased higher in group C1 and C2 than group B2, and more significantly in group H-FZHc C2 (P = 0.044, 0.001). Conclusion: Fuzheng huayu compound can ameliorate the injury of hepatocytes in hepatic fibrosis in mice by exerting an anti-hepatic fibrosis effect via increase Nrf2

mRNA and protein expression and induce Nrf2 transport into nuclear, following by increasing the expression of target gene Nqo1, suppressing the activity of HSCs and decreasing the deposition of FN. Key Word(s): 1. Nrf2; 2. Fuzhenghuayu; 3. Liver fibrosis; 4. Nqo1; Presenting Author: PRAVEEN SHARMA Additional Authors: VARONICA ARORA, RINKESH BANSAL, ABDUL RAUF, PANKAJ TYAGI, NARESH BANSAL, VIKAS SINGLA, ASHISH KUMAR, ANIL ARORA Corresponding Author: PRAVEEN SHARMA Affiliations: SGRH Objective: Alcoholic MAPK inhibitor hepatitis is associated with significant morbidity and mortality. Traditionally, Maddrey discriminant function (DF) score, Child-Turcott-Pugh (CTP) score and model for end-stage liver disease (MELD) score have been

used for stratifying the this website prognosis of alcoholic hepatitis. Liver stiffness measurement (LSM) value is influenced by changes in aminotransferases and serum bilirubin in patients with acute hepatitis and chronic liver disease. We aimed to evaluate and compare the predictive performances of LSM by Fibroscan with CTP, MELD and DF in predicting in hospital mortality. Methods: All consecutive patients with severe alcoholic hepatitis (DF > 32) were enrolled. Their CTP score, MELD score, DF score and LSM was done at baseline and at day 7. A change at day 7 was calculated (Δ change). Area under curve was calculated for predicting mortality of the patients. Results: Fifty two consecutive patients (age 43 ± 10 yr, M : F 52 : 0) were enrolled. Their baseline CTP score (9.4 ± 1.5), MELD score (23.2 ± 6.9), DF score (69 ± 28), LSM (64.1 ± 14.3 kPa), median bilirubin (12.5,5.3–32 mg%), median AST (120,40–340 U/l) and median ALT was (102,42–158 U/l). In hospital mortality was 15 (29%). There was significant difference (p < 0.01) at baseline between patients who got discharged versus those who died in CTP score (8.9 ± 1.1 vs 10.7 ± 1.8), MELD (22.1 ± 4.6 vs 27.0 ± 5.6), DF (59.8 ± 18.7 vs 91.0 ± 33.5) and LSM (61.3 ± 13.

927, P < 0.05). Compared with group B2, the expressions of SMA and FN protein in group C1 also decreased statistically at the end of 10 weeks (F = 77.421, 118.262, P < 0.05), and more significantly decreased in group H-FZHc C2 (P = 0.002, 0.013) proved by immunohistochemistry staining. At the same time the expressions of Nrf2 and Nqo1 protein were all increased statistically in groups L-FZHc C1 and

H-FZHc C2 at the end of 10 weeks demonstrated by immunohistochemistry staining (F = 182.537, 75.615, P < 0.05) and western-blotting (F = 45.664, 127.673, P < 0.05) comparing with group B2, and more notabally in group H-FZHc C2 (P = 0.000, 0.014; 0.005, 0.014). And also proved the amount of Nrf2 nuclear learn more transportion and Nrf2 mRNA expression were increased higher in group C1 and C2 than group B2, and more significantly in group H-FZHc C2 (P = 0.044, 0.001). Conclusion: Fuzheng huayu compound can ameliorate the injury of hepatocytes in hepatic fibrosis in mice by exerting an anti-hepatic fibrosis effect via increase Nrf2

mRNA and protein expression and induce Nrf2 transport into nuclear, following by increasing the expression of target gene Nqo1, suppressing the activity of HSCs and decreasing the deposition of FN. Key Word(s): 1. Nrf2; 2. Fuzhenghuayu; 3. Liver fibrosis; 4. Nqo1; Presenting Author: PRAVEEN SHARMA Additional Authors: VARONICA ARORA, RINKESH BANSAL, ABDUL RAUF, PANKAJ TYAGI, NARESH BANSAL, VIKAS SINGLA, ASHISH KUMAR, ANIL ARORA Corresponding Author: PRAVEEN SHARMA Affiliations: SGRH Objective: Alcoholic see more hepatitis is associated with significant morbidity and mortality. Traditionally, Maddrey discriminant function (DF) score, Child-Turcott-Pugh (CTP) score and model for end-stage liver disease (MELD) score have been

used for stratifying the click here prognosis of alcoholic hepatitis. Liver stiffness measurement (LSM) value is influenced by changes in aminotransferases and serum bilirubin in patients with acute hepatitis and chronic liver disease. We aimed to evaluate and compare the predictive performances of LSM by Fibroscan with CTP, MELD and DF in predicting in hospital mortality. Methods: All consecutive patients with severe alcoholic hepatitis (DF > 32) were enrolled. Their CTP score, MELD score, DF score and LSM was done at baseline and at day 7. A change at day 7 was calculated (Δ change). Area under curve was calculated for predicting mortality of the patients. Results: Fifty two consecutive patients (age 43 ± 10 yr, M : F 52 : 0) were enrolled. Their baseline CTP score (9.4 ± 1.5), MELD score (23.2 ± 6.9), DF score (69 ± 28), LSM (64.1 ± 14.3 kPa), median bilirubin (12.5,5.3–32 mg%), median AST (120,40–340 U/l) and median ALT was (102,42–158 U/l). In hospital mortality was 15 (29%). There was significant difference (p < 0.01) at baseline between patients who got discharged versus those who died in CTP score (8.9 ± 1.1 vs 10.7 ± 1.8), MELD (22.1 ± 4.6 vs 27.0 ± 5.6), DF (59.8 ± 18.7 vs 91.0 ± 33.5) and LSM (61.3 ± 13.

580 for CC versus TT). There was no statistically significant difference in overall graft survival according

to recipient IL28B polymorphism (overall 5-year graft survival [n = 118]: 91% versus 76% versus 84% for CC versus CT versus BAY 73-4506 purchase TT genotypes [P = 0.2168]). There was also no significant effect of donor IL28B genotype on overall graft survival (5-year graft survival [n = 124]: 79% versus 84% versus 81% for CC versus CT versus TT genotype [P = 0.6977]). Neither recipient nor donor liver IL28B genotype was found to be significantly associated with liver-related mortality at 5 years (P = 0.3956 and P = 0.2418, respectively) (Fig. 2). An analysis was also performed of the association of IL28B genotype with BGJ398 price the frequency of a composite endpoint consisting

of: histological evidence of cirrhosis, liver-related death/retransplantation and fibrosis stage ≥2. The analysis was censored for antiviral therapy. This clinical composite endpoint was significantly associated with recipient and donor, IL28B genotype (P = 0.047 and 0.040 for recipient and donor CC versus TT genotypes, respectively) (Fig. 3). This study reports the association between IL28B genotype and virological treatment response and clinical outcome in HCV-infected patients following OLT. This unique cohort allowed interrogation of the respective roles of the IL28B genotype of hepatocytes (donor) and nonparenchymal cells of extrahepatic origin (recipient). We identified important roles for both donor and recipient IL28B genotype in determining treatment outcome. The data also suggest that recipient selleck compound IL28B genotype may determine the severity of histological recurrence of hepatitis C as indicated by progressive fibrosis. These findings have potentially important implications for the management of HCV following liver transplantation. The frequency of the CC variant in the transplant recipients was significantly lower than that in the non–HCV-infected donor livers. This is consistent with a role for the CC variant in spontaneous clearance of HCV, with enrichment for the non-CC variants in the chronic

hepatitis C population. Indeed, a role for the CC variant in promoting natural clearance has recently been established.6, 7 Patients with the non-CC genotypes are also more likely to be prior nonresponders to IFN-based therapies before proceeding to liver failure and transplantation. IL28B polymorphism, previously associated with treatment response in the nontransplant setting,4, 5, 7, 9, 10 strongly predicted for increased rate of SVR in the current cohort. Recipient and donor IL28B genotype were both independently associated with higher rates of SVR. Compared to the patients with matched recipient:donor non-CC variants, SVR rate was higher in patients with either a donor or recipient CC variant, and highest in patients with matched donor and recipient CC variants.

Likewise, the 4 procedures that

have been referred to collectively as migraine headache trigger site deactivation surgery may be effective interventions for different selleck chemicals llc types of head and face pain, but the decision to generalize these procedures as a treatment for a complex disorder such as migraine may have been presumptive. In the case of the intranasal trigger zone, the associated procedure may be useful for the treatment of contact point headache.[21, 22] It is important to note that in a systematic literature review, it was found that most patients with contact points do not have headache or facial pain. In this review, surgical treatment of contact points was found to be inconsistently effective for the treatment of contact point headache.[31] Although it is speculated that relief of the contact point against the nasal wall may lead to direct improvement of the BTK inhibitor pain, septoplasty and turbinectomy may also reduce upper airway resistance. This reduction in upper airway resistance may lead to improvement of sleep quality, and poor sleep is a well-known migraine trigger.[4] In the case of the frontal trigger zone, the associated procedure may be useful for the treatment of supraorbital neuralgia. It has been established in the literature that some cases of supraorbital neuralgia may be due to nerve

entrapment, which can be visualized with ultrasound imaging.[24] Subsequent decompression of the nerve has yielded some positive results.[32] By the same logic, future studies may demonstrate that the occipital trigger zone procedure could potentially be useful for the treatment of occipital neuralgia. In the case of the temporal trigger zone, the procedure should be modified to decompress a potentially entrapped nerve rather than performing nerve avulsions, as nerve destructive techniques are more likely to have complications.[8, 9] It is possible that some of the positive results in the surgical literature may have actually been treating one of these other headache

disorders in patients who also have migraines. Some of the mixed results may have treated the additional headache disorder, but the selleck chemical surgery exacerbated the subject’s migraines. For example, an occipital procedure may alleviate occipital neuralgia, but the trauma of the surgery may worsen the patient’s migraines. It is clear that more rigorous studies need to be conducted in order to evaluate the potential efficacy of each procedure. Future studies should look at each procedure individually rather than lumping the data together in order to report efficacy for any type of migraine. As such, subjects should not be receiving multiple procedures simultaneously. Presurgical evaluations should include objective testing to look for clear surgical targets, which may be suggestive of a headache disorder that exists in the presence or absence of migraine.

Likewise, the 4 procedures that

have been referred to collectively as migraine headache trigger site deactivation surgery may be effective interventions for different Navitoclax supplier types of head and face pain, but the decision to generalize these procedures as a treatment for a complex disorder such as migraine may have been presumptive. In the case of the intranasal trigger zone, the associated procedure may be useful for the treatment of contact point headache.[21, 22] It is important to note that in a systematic literature review, it was found that most patients with contact points do not have headache or facial pain. In this review, surgical treatment of contact points was found to be inconsistently effective for the treatment of contact point headache.[31] Although it is speculated that relief of the contact point against the nasal wall may lead to direct improvement of the Selleckchem Ivacaftor pain, septoplasty and turbinectomy may also reduce upper airway resistance. This reduction in upper airway resistance may lead to improvement of sleep quality, and poor sleep is a well-known migraine trigger.[4] In the case of the frontal trigger zone, the associated procedure may be useful for the treatment of supraorbital neuralgia. It has been established in the literature that some cases of supraorbital neuralgia may be due to nerve

entrapment, which can be visualized with ultrasound imaging.[24] Subsequent decompression of the nerve has yielded some positive results.[32] By the same logic, future studies may demonstrate that the occipital trigger zone procedure could potentially be useful for the treatment of occipital neuralgia. In the case of the temporal trigger zone, the procedure should be modified to decompress a potentially entrapped nerve rather than performing nerve avulsions, as nerve destructive techniques are more likely to have complications.[8, 9] It is possible that some of the positive results in the surgical literature may have actually been treating one of these other headache

disorders in patients who also have migraines. Some of the mixed results may have treated the additional headache disorder, but the see more surgery exacerbated the subject’s migraines. For example, an occipital procedure may alleviate occipital neuralgia, but the trauma of the surgery may worsen the patient’s migraines. It is clear that more rigorous studies need to be conducted in order to evaluate the potential efficacy of each procedure. Future studies should look at each procedure individually rather than lumping the data together in order to report efficacy for any type of migraine. As such, subjects should not be receiving multiple procedures simultaneously. Presurgical evaluations should include objective testing to look for clear surgical targets, which may be suggestive of a headache disorder that exists in the presence or absence of migraine.