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Caloric density may be Good Start Supreme (Nestle Clinical Nutrition) has increased gradually in 2–4kcaloz−1 increments buy discount noroxin online infection 68, and Table 9 generic noroxin 400mg amex virus replication cycle. To optimize digestibility discount noroxin 400 mg otc virus software, similar proportions of should be performed based on anticipated amino acid fat, protein, and carbohydrate as in the base formula losses and dextrose absorption from dialysis thera- should be provided. Electrolyte composition should be acid and small peptide losses may challenge the abil- guided by regular assessment of the patient’s labora- ity to supply adequate protein enterally. The underlying ill- ness and need for vasoactive medications may com- Optimal nutritional management of critically ill chil- promise gastrointestinal perfusion and function. An dren is challenging and becomes more complex should additional concern in the setting of chronic or acute there be an acute or chronic disturbance in renal func- renal failure is the potential detrimental effect of ure- tion. The provision of both adequate and appropriate mia on gastrointestinal motility, though this has been nutrition support should be viewed as a critical ele- studied primarily in patients on chronic dialysis [8, 28, ment in the therapeutic effort. Contraindications to enteral feeds include intesti- repeated evaluations of renal function, metabolic bal- nal obstruction, severe or protracted ileus, gastrointes- ance, volume status, and energy expenditure should be tinal ischemia, and hemodynamic instability. Chapter 9 Nutrition for the Critically Ill Pediatric Patient with Renal Dysfunction 135 continuous arteriovenous hemofiltration and total parenteral Take Home Pearls nutrition. Nutrition 13:45S–51S critical illness is to blunt the tendency towards negative 13. Nephrol Dial Transplant 22:2970–2977 parallels the severity of the underlying illness. American ing malnutrition in acute renal failure: A prospective cohort Society of Parenteral and Enteral Nutrition, Silver Spring, study. Kidney Int tive study of reducing the extracellular potassium concen- 65:999–1008 tration in red blood cells by washing and by reduction of 25. Nephrol Dial Transplant renal failure on continuous ambulatory peritoneal dialy- 9:287–290 sis using 99mTc-solid meal. Kidney Int following induction of systemic inflammatory response in 46:830–837 patients with severe sepsis or major blunt trauma. In: Byham-Gray L, amino acid balance during total parenteral nutrition and Wiesen K (eds) A clinical guide to nutrition care in kidney continuous arteriovenous hemofiltration in critically ill disease. Nutrition 18:445–446 ease as efficiently as calcium carbonate without increasing 40. Marin A, Hardy G (2001) Practical implications of nutri- serum calcium levels during therapy with active vitamin D tional support during continuous renal replacement therapy. Encephalopathy in childhood secondary to aluminum tox- Ann Surg 216:172–183 icity. Chapter 9 Nutrition for the Critically Ill Pediatric Patient with Renal Dysfunction 137 Postabsorptive rates and responses to epinephrine. J Clin ventilated, critically ill children during the early postinjury Invest 96:2528–2533 period. Clin Nutr agreement between indirect calorimetry and prediction equa- 26:677–690 tions using the Bland-Altman method. J Ren Nutr expenditure by continuous, online indirect calorimetry in 6:203–206 Tools for the Diagnosis 10 of Renal Disease K. This will provide strong clues to scores the importance of careful attention to ongoing the etiology of presenting renal and electrolyte abnormali- fluid, electrolyte, and biochemical balance. Predisposing existing medical with objective scientific measures or tools, which can be conditions, chronic medications, and knowledge reliably used to make a diagnosis and guide therapy. Clinical history and physical examination with While some provide anatomic information, e. As such, awareness of the limitations may otherwise remain unappreciated [27, 38, 39]. Effective cir- culating volume, that portion of the body water actually perfusing the tissues and accomplishing homeostasis, 10. At the same time, urine samples urinary osmolality (>500mOsm kg−1) suggest volume can be obtained for biochemical, microscopic, and depletion and are the most common urinary assess- microbiological analysis. Serum organic acids (lactic acid, pyruvic acid), Changes in serum calcium during intensive care serum ammonia levels, and urinary amino and organic treatments demonstrate distinct response patterns for acid screening is helpful in differentiation of potential survivors vs. The magnitude of increase metabolic abnormalities, particularly in the neonatal in the serum calcium after fluid resuscitation is a period. Examples include aminoacidopathies such as marker correlating with the patient’s ability to with- maple syrup urine disease, tyrosinemia, urea cycle stand physiologic stress, especially after major trauma. Certain serum patterns of chemistries can also pro- vide clues as to underlying etiology, for example, (1) 10. In rare hyperparathyroidism, while (3) hypocalcemia, hyper- circumstances, a 24-h urine collection for creatinine 142 K. It is extremely This measures sodium excreted in the urine as a important to be sure to discard the first bladder urine at percentage of sodium filtered at the glomerulus. It time zero, measure the time accurately, and obtain the may be used in assessment of either volume status or total urine volume for optimal results. In the setting of acute kidney injury, necessary to allow for medication dosage adjustments. U /P is also helpful in dis- Osm Osm tinguishing between the various causes of acute renal These values, calculated from direct chemical meas- failure (Table 10. There are no absolute normal values and there is a By providing a ratio of tubular fluid potassium to wide range in normal expected responses depending plasma potassium corrected for water reabsorp- on dietary intake, fluid balance, and intercurrent med- tion, this tool provides an indication of adequacy of ications. It is best to compare values obtained in any tubular handling of potassium and the driving force patient with expected values under similar clinical for its excretion in the distal tubule. However, this and plasma, thus adjusting for reabsorption of water along the whole nephron. There is good evidence that this correlates well with 24- h protein excretion [29, 31]. This may be used as a surrogate for urinary ammonium and therefore, hydrogen ion excretion. It may be used to dif- or another unmeasured anion is present in the urine), ferentiate between gastrointestinal and renal bicarbo- rendering calculation of urinary ammonium concen- nate losses as a cause of metabolic acidosis (see Sect. Measurement of creatinine clearance using a timed microscopic examination of the urinary sediment. However, the positive heme test on dipstick is due to hemoglob- under certain circumstances, for instance in individu- inuria or myoglobinuria, while the presence of a signif- als with exceptional dietary intake (vegetarian or vegan icant number of red blood cells confirms hematuria. Measurement of the respective heme pigment in the urine also helps differentiate between these entities. Furthermore, technical limitations may arise when posi- Myoglobin, a small protein (16,700Da), is readily tioning for the procedure in a critically ill patient who may filtered, whereas the larger hemoglobin (approximately be intubated with multiple intravenous lines. Acutely, simply examining a sample of sedation or anesthesia, and careful control of the airway the patient’s serum can differentiate between the two must all be coordinated. Preliminary treatment with conditions: the plasma will be red in hemoglobinuria, steroids, cyclophosphamide, or plasmapheresis may be but clear in myoglobinuria. In rare patients, the most often derived from food coloring or drugs such clinical circumstances may preclude immediate biopsy, as pyridium or rifampin. Polymorphonuclear leucocytes in the urine imply Renal and bladder ultrasound is a noninvasive and inflammation from infection or interstitial nephritis.

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They may fear that they have a chronic or dangerous illness—a belief that is reinforced by the symptoms of anxiety buy noroxin 400mg line antibiotic 3 pills. Inability to relax may lead to difficulty in getting to sleep and constant waking in the night buy noroxin without prescription antibiotic resistance the need for global solutions. Panic Attacks Severe anxiety will often produce what are known as “panic attacks”—intense feelings of fear discount noroxin generic infection quizlet. Panic attacks may occur independently of anxiety but are most often associated with generalized anxiety or agoraphobia. Causes Clinical anxiety, including panic attacks, can be produced by psychological problems as well as by biochemical factors such as caffeine, certain other drugs, and the infusion of lactate into the blood. The fact that these compounds can produce anxiety and panic attacks can be put to good use in understanding the underlying biochemical features of anxiety. Perhaps the most significant biochemical disturbance noted in people with anxiety and panic attacks is an elevated blood lactic acid level and an increased ratio of lactic acid to pyruvic acid. Lactate (the soluble form of lactic acid) is the final product in the breakdown of blood sugar (glucose) when there is a lack of oxygen. To illustrate how lactic acid is produced, let’s take the classic example of the exercising muscle. Muscles prefer to use fat as their energy source, but when you exercise vigorously there isn’t enough oxygen, so the muscle must burn glucose. Without oxygen, there is a buildup of lactic acid within the muscle; this is what causes muscle fatigue and soreness after exercise. Lactic Acid Conversion to Pyruvic Acid or Glucose The first few steps of normal glucose breakdown can occur without oxygen, until pyruvic acid is produced. The next steps require oxygen and end in the complete breakdown of pyruvic acid to carbon dioxide and water. Because the exercising muscle needs energy, the muscle cells continue to convert glucose to pyruvic acid in a process referred to as anaerobic metabolism. With good circulation, the lactic acid is removed from the muscle and transported to the liver, where it can be turned back into pyruvic acid or even glucose if needed. All of this biochemistry plays a role in anxiety, because individuals with anxiety have elevated blood levels of lactate and a higher ratio of lactic acid to pyruvic acid when compared with normal controls. Furthermore, if people who get panic attacks are injected with lactate, severe panic attacks are produced. Reducing the level of lactate is a critical goal in the treatment of anxiety and panic attacks. Therapeutic Considerations The natural approach to anxiety builds upon the recommendations given for stress in the chapter “Stress Management. If you suffer from mild anxiety, follow all of the recommendations given in that chapter for diet, exercise, nutritional supplementation, calming the mind and body, and taking an adrenal adaptogen. If you suffer from moderate to severe anxiety, follow all of the recommendations in that chapter as well as those discussed below; substitute kava for the adrenal adaptogen. Lactate Levels As pointed out previously, increased lactic acid levels may be an underlying factor in panic attacks and anxiety. The goal is to prevent the conversion of pyruvic acid to lactic acid and to improve the conversion of lactic acid back to pyruvic acid. There are at least six nutritional factors that may be responsible for elevated lactate levels or ratios of lactic acid to pyruvic acid:1 1. Food allergens By avoiding alcohol, caffeine, sugar, and food allergens, people with anxiety can go a long way toward relieving their symptoms. This recommendation may seem too simple to be valid, but substantial clinical evidence indicates that in many cases it is all that is necessary. For example, one study dealt with four men and two women who had generalized anxiety or panic disorder. Follow-up exams 6 to 18 months afterward indicated that five out of the six patients were completely without symptoms; the sixth patient became asymptomatic with a very low dose of Valium. By following the guidelines in the chapter “A Health-Promoting Diet,” as well as the recommendations for nutritional supplementation given in the chapter “Supplementary Measures,” you will provide your body with the kind of nutritional support it needs to counteract the biochemical derangements found in patients with anxiety and panic attacks. Nutritional Supplements Omega-3 Fatty Acids Anxiety and depression appear to be linked to lower levels of omega-3 fatty acids. A high intake of omega-6 fatty acids (found in corn-fed animal products, dairy products, and common vegetable oils such as corn, soy, safflower, and sunflower) and a low intake of omega-3 fatty acids (found in fish, fish oils, and flaxseed oil) can lead to an amplification in the production of these cytokines. So increasing the intake of omega-3 fatty acids and lowering the intake of omega-6 fatty acids may help to reduce anxiety and depression. The positive results seen with fish oil supplements in clinical depression are well documented. In regard to anxiety, one clinical study showed that fish oil supplementation decreased feelings of anger and anxiety in substance abusers. In one study, three out of four patients with a history of agoraphobia for 10 or more years improved within two to three months after taking flaxseed oil at a dosage of 2 to 6 tbsp per day, in divided doses depending upon response. Kava The area of Oceania—the island communities of the Pacific, including Micronesia, Melanesia, and Polynesia—is one of the few geographic areas in the world that did not have alcoholic beverages before European contact in the 18th century. However, these islanders did possess a magical drink that was used in ceremonies and celebrations because of its calming effect and ability to promote sociability. The drink, called kava, is still used today in this region, where the people are often referred to as the happiest and friendliest in the world. Preparations of kava root (Piper methysticum) gained popularity in Europe and the United States up until 2001, when safety concerns (discussed below) derailed their popularity. Several clinical trials utilized a special kava extract standardized to contain 70% kavalactones. However, this high percentage of kavalactones may be sacrificing some of the other constituents that may contribute to the pharmacology of kava. More important than the actual percentage of kavalactones is the total dosage of the kavalactones and the assurance that the full range of kavalactones is present. In one of the first double-blind studies, a 70% kavalactone extract was shown to exhibit significant therapeutic benefit in patients suffering from anxiety. Therapeutic effectiveness was evaluated using several standard psychological assessments, including the Hamilton Anxiety Scale. The results of this four-week study indicated that individuals who took kava extract had a statistically significant reduction in symptoms of anxiety, including feelings of nervousness and somatic complaints such as heart palpitations, chest pains, headache, dizziness, and feelings of gastric irritation. Studies have also compared the effects of a kava extract with antianxiety drugs such as buspirone and opipramol. In one double-blind study, 129 patients with generalized anxiety disorder were given either 400 mg kava (30% kavalactones), 10 mg buspirone, or 100 mg opipramol per day for eight weeks. Detailed analysis showed that no significant differences could be observed in terms of efficacy and safety. About 75% of patients were classified as responders (at least a 50% reduction of the anxiety score) in each treatment group, and about 60% achieved full remission. The group receiving the kava extract demonstrated significant improvement at the end of the very first week of treatment. In addition to symptoms of stress and anxiety, a number of other symptoms also improved.

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All of these components are interrelated discount 400mg noroxin mastercard antibiotics for comedonal acne, creating a situation in which no single component is more important than the others purchase noroxin master card infection 4 weeks after wisdom teeth extraction. Improvement in one facet may be enough to result in some positive changes purchase noroxin without prescription treatment for dogs back legs, but incorporating all components yields the greatest results. Literally hundreds of diets and diet programs claim to be the answer to the problem of obesity. In order for an individual to lose weight, energy intake must be less than energy expenditure. This goal can be achieved by decreasing caloric intake or by increasing the rate at which calories are metabolized; the best results are achieved by doing both. To lose 1 pound, a person must consume 3,500 fewer calories than he or she expends. The loss of 1 lb each week requires a negative caloric balance of 500 calories a day. This can be achieved by decreasing the amount of calories ingested or by increasing exercise. Reducing a person’s caloric intake by 500 calories is often difficult, as is increasing metabolism by an additional 500 calories a day through exercise (accomplished by a 45-minute jog, playing tennis for an hour, or a brisk walk for 1. The most sensible approach to weight loss is to both decrease caloric intake and increase energy expenditure through exercise. Most individuals begin to lose weight if they decrease their caloric intake below 1,500 calories a day and exercise for 15 to 20 minutes three to four times per week. Starvation and crash diets usually result in rapid weight loss (largely of muscle and water) but cause rebound weight gain. The most successful approach to long-term, sustainable weight loss is gradual weight reduction (0. Exercise is critical to maintaining muscle mass and bone mineral density and to preventing the accumulation of abdominal fat, both during active weight loss and after weight loss has been achieved. For example, a 5 to 10% reduction in weight is accompanied by clinically meaningful improvements in cholesterol, blood pressure, and blood glucose levels. Behavioral Therapy Although clinical studies indicate that behavioral approaches to the management of obesity are often successful in achieving clinically significant weight loss, the lost weight is generally regained. The great majority of patients return to their pretreatment weight within three years. In order to provide the best insights on effective interventions, it is important to examine the psychological characteristics of people who have lost significant amounts of weight and experienced only minimal weight regain. For example, most obese patients who see a doctor about weight loss want to lose 20 to 30% of their body weight. Because most people lose only modest amounts of weight, many quickly lose the motivation and determination to keep the weight off. However, if people feel a significant boost to self-esteem and self-confidence, as well as have the experience of improving their appearance, feeling more attractive, and being able to wear more fashionable clothing, it can provide tremendous impetus for continued weight loss until goals are achieved. Remember that the majority of people want to lose weight for the changes in their physical appearance, not the health benefits. Although there is widespread awareness that being overweight is associated with increased health risks, relatively few patients give this as their reason for seeking treatment. Identifying patients’ primary goals for losing weight is a key step in helping them achieve success. Diet The dietary strategy that we recommend for obesity is the one given in the chapter “A Health- Promoting Diet. We recommend 2 g protein daily per kg of body weight unless a person is showing signs of kidney failure. The importance of higher protein consumption was demonstrated in the Diogenes Study (Diogenes is an acronym for “Diet, Obesity, and Genes”). The five-year program involved 29 world- class centers in diet and health studies, epidemiology, dietary genomics, and food technology across Europe. More than 700 overweight adults from eight European countries who had lost at least 8% of their initial body weight with an 800-calorie diet (mean initial weight loss was 24. The participants were to stay on the diet for 26 weeks, and the amount they could eat was not controlled. Fewer participants dropped out in the high-protein/high glycemic and high-protein/low-glycemic groups than in the low-protein/high-glycemic group (26. Among participants who completed the study, only the low- protein/high-glycemic diet was associated with subsequent significant weight regain (3. The groups did not differ significantly with respect to diet- related adverse events. This high-protein, high-fat, low-carbohydrate diet was developed by Robert Atkins, M. Atkins brought his diet back into the nutrition spotlight with the publication of his best-selling book Dr. An estimated 50 million people worldwide have tried the Atkins Diet, which emphasizes the consumption of protein and fat. Individuals following the Atkins Diet are permitted to eat unlimited amounts of all meats, poultry, fish, and eggs, plus most cheeses. The Atkins Diet is divided into four phases: induction, ongoing weight loss, pre-maintenance, and maintenance. During the induction phase (the first 14 days of the diet), carbohydrate intake is limited to no more than 20 g per day. No fruit, bread, grains, starchy vegetables, or dairy products except cheese, cream, and butter are allowed during this phase. During the ongoing weight loss phase, dieters experiment with various levels of carbohydrate consumption until they determine the most liberal level of carbohydrate intake that allows them to continue to lose weight. Dieters are encouraged to maintain this level of carbohydrate intake until their weight loss goals are met. Then, during the pre-maintenance and maintenance phases, dieters determine the level of carbohydrate consumption that allows them to maintain their weight. To prevent regaining weight, dieters must stick to this level of carbohydrate consumption, perhaps for the rest of their lives. Although we agree with the underlying principle of the Atkins Diet, that diets high in sugar and refined carbohydrates cause weight gain and ultimately lead to obesity, we disagree with several aspects of the solution. One of the big reasons why the Atkins Diet is so attractive to dieters who have tried unsuccessfully to lose weight on low-fat, low-calorie diets is that while on the Atkins Diet, they can eat as many calories as desired from protein and fat, as long as carbohydrate consumption is restricted. As a result, many Atkins dieters are spared the feelings of hunger and deprivation that accompany other weight loss regimens. However, we simply do not agree that such a diet is conducive to long-term health. Despite its enormous popularity, the Atkins program was not evaluated in a proper clinical trial until 2003. In this initial study, although people following the Atkins Diet did experience initial weight loss (probably as a result of water loss rather than true fat loss), in the long run they gained it all back plus more. In the study, 63 obese men and women were randomly assigned to the Atkins Diet or a low-calorie, high-carbohydrate, low-fat diet. Although at 6 months subjects on the Atkins Diet had lost more weight than subjects on the conventional diet, the difference at 12 months was not significant.

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Vitamin B6 supplementation (usually 1 mg/kg) has been shown to improve histamine tolerance generic noroxin 400mg fast delivery antimicrobial wound cream, presumably by increasing diamine oxidase activity 400mg noroxin amex antibiotic 93 1174. Interestingly order noroxin 400mg mastercard antibiotic 2 hours late, the level of diamine oxidase in a woman increases by more than 500 times during pregnancy. Miscellaneous Diet-Related Triggers Hypoglycemia can be a trigger for migraine headaches. Making such a dietary change can reduce platelet aggregation and the formation of inflammatory mediators and may play a role in preventing migraine headaches. However, the adolescents responded equally well to olive oil supplements, the placebo chosen for this study. Although a number of drugs have been shown to be useful in the prevention of migraine headache, all of the currently used drugs carry with them a risk of significant adverse effects. Although some studies have employed a dosage of 600 mg per day, equally impressive results have been achieved at a dosage as low as 200 mg per day. In fact, five patients in the methysergide group had to withdraw during the trial because of side effects. Riboflavin (Vitamin B2) Migraine headaches may be the result of a deficit in the production of energy by the mitochondria, the energy-producing compartments of the cell. A double-blind study demonstrated that a dose of 400 mg riboflavin per day was superior to a placebo in preventing migraine attacks. Magnesium The high frequency of magnesium deficiency seen in migraine sufferers is well established in research. Magnesium levels are depleted by a multitude of common factors, including stress, excessive alcohol intake, high estrogen levels, low progesterone, certain drugs, hyperthyroidism, and hyperparathyroidism. Substantial documentation linking low magnesium levels to both migraine and tension headaches exists in the medical literature. Low brain and tissue magnesium concentrations have been found in patients with migraines, indicating a need for supplementation. Positive results with magnesium supplementation have been shown in preventing migraines, specifically in people with low levels of magnesium. Because most of the body’s magnesium is intracellular, serum levels are unreliable indicators. More sensitive tests of magnesium status include red blood cell magnesium levels and ionized magnesium, the most physiologically active form. The hypothesis that patients with an acute migraine episode and low serum levels (less than 0. Pain reduction of 50% or more, as measured on a headache intensity verbal scale of 1 to 10, occurred within 15 minutes of infusion in 35 patients. In 21 patients, at least this degree of improvement or complete relief persisted for 24 hours or more. Pain relief lasted at least 24 hours in 18 of 21 patients (86%) with serum ionized magnesium levels below 0. The average ionized magnesium level in patients who had relief lasting for at least 24 hours was significantly lower than that in patients who experienced no relief or only fleeting relief. Another possible benefit of magnesium supplementation in preventing migraines may be its ability to prevent mitral valve prolapse. Mitral valve prolapse is linked to migraines because it leads to damage to blood platelets, causing them to release vasoactive substances such as histamine, platelet- activating factor, and serotonin. Since research has shown that 85% of patients with mitral valve prolapse have chronic magnesium deficiency, magnesium supplementation is indicated. Magnesium bound to citrate, malate, or aspartate is better absorbed and better tolerated than inorganic forms such as magnesium sulfate, hydroxide, or oxide, which tend to produce a laxative effect. Also, it is a good idea to take at least 50 mg vitamin B6 per day, as this B vitamin has been shown to increase the intracellular accumulation of magnesium. Scientific interest in feverfew began when a 1983 survey found that 70% of 270 migraine sufferers who had taken feverfew daily for prolonged periods reported that the herb decreased the frequency or intensity of their attacks. This survey prompted several clinical investigations that support the therapeutic and preventive effects of feverfew in the treatment of migraine frequency and intensity. Two patients in the placebo group, who had been in complete remission during self-treatment with feverfew, developed recurrence of incapacitating migraine and had to withdraw from the study; when those two patients resumed self-treatment with feverfew, their symptoms abated. The second double-blind study, performed at the University of Nottingham, demonstrated that feverfew was effective in reducing the number and severity of migraine attacks. Rather, migraines are the end result of a diverse range of physiological dysfunctions. While conventional drugs often focus on relief of symptoms, most natural therapies address the cause—which for migraines can be quite diverse. If the natural therapy does not match the physiological dysfunction, then it is not going to work. The reason the early feverfew studies were so uniformly successful is that the patients had through trial and error preselected themselves: they had a physiological dysfunction that matched up well with the effects of feverfew. Butterbur There is significant documentation of the efficacy of butterbur (Petasides hybridus) in preventing migraines, and its recorded use for this purpose and others dates back at least 900 years. Butterbur has been shown to reduce the spasm of blood vessels as well as the formation of inflammatory compounds. Petadolex is a standardized extract from the butterbur plant that has been shown in several double-blind studies to produce excellent results in preventing migraine headaches without side effects. In one study, 60 patients suffering from headaches randomly received 50 mg Petadolex twice per day for 12 weeks. Compared with the beginning of the trial, Petadolex reduced the frequency of attacks by 46% after 4 weeks, 60% after 8 weeks, and 50% after 12 weeks of treatment (the figures for the placebo group were 24%, 17%, and 10%, respectively). It is important to use Petadolex or similarly prepared products that have had the liver-damaging and cancer-causing substances in butterbur (pyrrolizidine alkaloids) removed. No drug interactions have been identified, but its safety during pregnancy or lactation has not been determined, so it should not be used in these instances. Ginger may be commonly used in clinical practice for migraine treatment, but little clinical investigation has been performed to date. The most active anti-inflammatory components of ginger are found in fresh preparations and the oil. Acupuncture Sufficient evidence exists to support the use of acupuncture to relieve migraine pain. Biofeedback and Relaxation Therapy The most widely used nondrug therapies for migraine headaches are thermal biofeedback and relaxation training. Thermal biofeedback uses a feedback gauge to monitor the temperature of the hands. The patient is then taught how to raise (or lower) the temperature of the hands, while the device provides feedback regarding temperature measurements. Relaxation training involves teaching patients techniques designed to produce the relaxation response—a physiological state that opposes the stress response (see the chapter “A Positive Mental Attitude” for more information).