Volume 107, Issue 7

Context : A substantial proportion of the patient population with migraine headache should be considered for preventive treatment based on the frequency and disability associated with this disorder. Use of the anticonvulsant topiramate was previously examined in two large, double-blind, randomized, placebo-controlled clinical trials of a subset of patients who have 3 to 12 migraine episodes per month. Objective : To better characterize the efficacy of topiramate for prevention of migraine, with or without aura, by pooling and analyzing data from the two large clinical trials. Methods : The pooled intent-to-treat population included 937 patients receiving topiramate at one of three dosages (50 mg/d, 100 mg/d, 200 mg/d) or placebo. Outcome measures included change in mean monthly migraine frequency and categorical responder rate throughout the 26-week doubleblind phase. Results : At daily doses of 100 and 200 mg, topiramate was associated with significant reductions in mean monthly migraine frequency throughout the double-blind phase compared with placebo ( P <.001). Significantly more patients treated with these topiramate doses exhibited high-percentage reductions in monthly migraine frequency (≥50% [ P <.001], ≥75% [ P <.001], 100% [ P =.049]) versus placebo. The most common adverse events included anorexia, cognitive deficits, diarrhea, fatigue, nausea, and paresthesia. Topiramate (100 mg/d, 200 mg/d) was associated with significant and sustained reductions in mean monthly migraine frequency beginning as early as 1 week into therapy. Conclusion : Pooled efficacy data from two large, similarly designed, placebo-controlled migraine-prevention trials demonstrated that a statistically significant proportion of patients using topiramate met or exceeded two main outcome guidelines recommended by the International Headache Society (≥50% and ≥75% reduction in frequency of monthly attacks). Based on efficacy and tolerability, topiramate at a dosage of 100 mg per day (50 mg twice daily) should be the target dosage for most patients with migraine.

Type 2 diabetes mellitus is on the rise, yet glycemic control continues to elude patients—and their physicians. During the past decade, the use of insulin monotherapy has decreased while the use of oral antidiabetic agents (either alone or in combination with insulin injections) has increased. The continued prevalence of the disorder, changes in prescribing patterns, and recent data indicating that only one third of patients with type 2 diabetes mellitus achieve glycemic control underscore the need for physicians to reevaluate the clinical management of this now common disorder. Insulin analogs provide flexibility in the delivery of insulin therapy for this population. Although potential barriers and complications to initiation exist, patients should understand that achieving and maintaining glycemic control reduces the risk of long-term complications as a result of type 2 diabetes mellitus. Physicians are encouraged to actively identify and address patient concerns about this treatment modality.

As the healthcare needs of the United States change, some leaders at colleges of osteopathic medicine and osteopathic graduate medical education programs have embraced one very important and timeless goal: to prepare future physicians to meet society's health needs. These medical educators have made significant strides toward moving “beyond the barriers” to effect curricular reform and quality improvement at their institutions. Some of the barriers to osteopathic medical education reform are addressed in this article, which recommends allowing curricular evolution and faculty development; expanding clinical learning and teaching; breaking down departmental walls; integrating osteopathic principles and practice; reevaluating admission requirements of colleges of osteopathic medicine; and eradicating the unspoken and, ironically, often detrimental culture of medicine, which can be contrary to compassionate patient care and healing.