The effect of regional transmural agreements on the information transfer of frail older patients.

INTRODUCTION: Frail older patients are at risk for many complications when admitted to the hospital. Multidisciplinary regional transmural agreements (RTA) in which guidelines were set concerning the information transfer of frail older patients might improve outcomes. We aim to investigate the effect of implementation of the RTA on the completeness of the information transfer of frail older patients when admitted to and discharged from the hospital. METHODS: This is a retrospective cohort study in which we collected data from 400 randomly selected hospitalized frail older patients (70+) before the implementation of the RTA, January through March 2021, and after, October through December 2021. The cohort was split up into four groups, which determined what correspondence would be checked (referral letter by General Practitioner (GP) and three groups of 'hospital letters': ED letter upon admittance, clinical discharge letter to the elderly care physician and clinical discharge letter to the GP. We assessed for mention of frailty, a medication list and mention of resuscitation orders. RESULTS: In the period before implementation the mean age of patients was 82.6 years (SD 7.4) and 101 were female (50.5%), after implementation mean age was 82.3 (SD 6.9) and 112 were female (56.0%). Frailty was mentioned in hospital letters in 12.7% before and 15.3% after implementation (p = 0.09). More GP referral letters were present after implementation (32.0% vs. 54.0%, p = 0.03), however frailty was mentioned only in 12.5% before and 7.4% after (p = 0.58). There was a good handover of medication lists from the hospital (89.3% before, 94% after, p = 0.20) and even better from the GP (93.8% before, 100% after, p = 0.19). Resuscitation orders were mentioned in 59.3% of letters from the hospital before implementation and 57.3% after (p = 0.77), which is higher than in the referral letters (18.8% before and 22.2% after (p = 0.91). DISCUSSION: The implementation of RTA improved the number of GP referral letters present; however, it did not lead to other significant improvements in communication between the hospital and the GP's. Frailty and resuscitation orders are still frequently not mentioned in the reports. After a successful reimplementation, the improvements of outcomes could be investigated.

[Relaxation techniques and behavioural therapy for the treatment of migraine : Guidelines from the German Migraine and Headache Society]. / Entspannungsverfahren und verhaltenstherapeutische Interventionen zur Behandlung der Migräne : Leitlinie der Deutschen Migräne- und Kopfschmerzgesellschaft.

Besides pharmacological and interventional possibilities nonpharmacological options, deriving from behavioural approaches may be helpful in the treatment of migraine. Already consulting a patient reduces frequency of attacks. Relaxation (especially progressive muscle relaxation), endurance sports, and biofeedback as well as cognitive behavioural therapy are effective in treatment of migraine. The combination of these treatment options also with pharmacological treatment increase the positive effects.

[Psychological therapy of migraine: systematic review]. / Psychologische Therapie der Migräne: Systematische Übersicht.

This review summarizes the various forms of behavioral treatment of migraine which could demonstrate empirical efficacy. The main unimodal kinds of treatment are thermal and electromyography (EMG) biofeedback training and progressive muscle relaxation. The various relaxation techniques do not differ in their efficacy in treating migraine. On average a reduction in migraine frequency of 35-45 % is achieved. The mean effect sizes (ES) of various biofeedback techniques are between 0.4 and 0.6. Cognitive-behavioral treatment is applied as a multimodal treatment and on average achieves an improvement in migraine activity by 39 % and an ES of 0.54. All behavioral procedures can be used in combination or as an alternative to drug prophylaxis with comparable success. A combination of pharmacological and behavioral treatment can achieve additional success. There is strong evidence for the clinically significant efficacy of all forms of behavioral treatment in childhood and adolescence. There are no signs of differential indications.

Prevalence of primary headaches in Germany: results of the German Headache Consortium Study.

We investigated the prevalence of migraine (MIG), tension-type headache (TTH), and chronic headache in a population-based sample in Germany. A total of 18,000 subjects aged between 18 and 65 years were screened from 2003 until 2005 using a validated questionnaire. Overall 9,944 participants (55.2%) responded (mean age 43 ± 13.1 years, 52.7% women). Headache frequency <15 days/month was reported by 5,350 (55.5%) subjects of whom 1,601 (16.6%, [95% confidence interval (95% CI): 15.9-17.4]) reported episodic MIG, 1,202 (12.5%, 95% CI 11.8-13.1) episodic TTH, and 1,150 (11.9%, [11.3-12.6]) episodic MIG + episodic TTH, 1,396 (14.5%, [13.8-15.2]) unclassifiable headache. In women, episodic MIG peaked between 36 and 40 years, episodic MIG + TTH between 18 and 35 years and episodic TTH between 56 and 66 years. In men, episodic MIG was predominant between 36 and 45 years, episodic MIG + TTH between 26 and 35 years and episodic TTH showed comparable frequency between 36 and 66 years. Headache ≥15 days/month was reported by 2.6% (n = 255, [95% CI 2.3-3]). Chronic MIG was reported by 1.1% (n = 108, [0.91-1.33]), chronic TTH (n = 50, [95% CI 0.4-0.7]), chronic MIG + TTH 0.8% (n = 74, 95% CI 0.6-0.9) and unclassifiable headache 0.2% (n = 23, [95% CI 0.1-0.3]). Chronic headache was more frequent in women compared to men with the highest prevalence between 46 and 65 years. It is of note that the number of subjects with chronic headache is small in all age groups. The results of our large, population-based study provide reliable, age- and sex-specific estimates of the prevalence of primary headache disorders in Germany. The prevalence with respect to episodic and chronic primary headache disorders in Germany is comparable to other European countries and the USA.

Clinical aspects of 2009 pandemic influenza A (H1N1) virus infection in Austria.

PURPOSE: To describe the clinical features, risk factors for severe disease and effectiveness of oseltamivir in patients with 2009 pandemic influenza A (H1N1) virus infection. METHODS: In a prospective, cross-sectional, multicentre study, data on 540 patients with confirmed 2009 H1N1 infection from seven Austrian hospitals were collected using a standardised online case-history form. RESULTS: The median age of the patients was 19.3 years (range 26 days-90.8 years); point-of-care testing yielded false-negative results in 60.2% of the 176 cases tested. The most common symptoms were fever, cough, fatigue and headache. Overall, 343 patients (63.5%) were hospitalised, 49 (9.1%) were admitted to an intensive care unit (ICU) and 14 (4.1%) died. Case fatality rates were highest (9.1%) in those aged 65 years or older. Factors significantly associated with a higher risk for ICU admission included age, neurological disease, adipositas, and both interstitial pathology and lobular pathology on chest X-ray. No association with pregnancy, malignancy or immunosuppressive therapy was detected. Antiviral treatment significantly reduced the duration of fever by 0.66 days and lowered the risk of ICU admission, but had no significant benefit on survival. CONCLUSIONS: During the 2009 H1N1 influenza pandemic, elderly or obese patients and those with neurological disease had an increased risk for severe H1N1 infection in Austria. Pregnancy was not associated with a higher risk for severe disease in the later phase of the 2009 H1N1 pandemic. Antiviral treatment provided a minimal effect on the symptoms of influenza but reduced the risk of admission to an ICU.

Population-based validation of a German-language self-administered headache questionnaire.

We validated a German-language self-administered headache questionnaire for migraine (M), tension-type headache (TTH) and trigeminal autonomic cephalalgia (TAC) in a general population sample of people with headache. Randomly selected subjects (n = 240) diagnosed by the questionnaire as M (n = 60), TTH (n = 60), a combination of M and TTH (M+TTH, n = 60) and TAC (n = 60) were invited for examination by headache specialists. One hundred and ninety-three subjects (80%) were studied. Sensitivity and specificity for M were 0.85 and 0.85, for TTH 0.6 and 0.88, for M+TTH 0.82 and 0.87, respectively. Cohen's kappa was 0.6 (95% confidence interval 0.50, 0.71). Of 45 patients with TAC according to the questionnaire, physicians diagnosed cluster headache in two patients only. We conclude: (i) the questionnaire can be used to diagnose M, TTH and M+TTH, but not TAC; (ii) screening questionnaires for epidemiological research should be validated in a general population sample but not in a tertiary headache clinic.

Vascular damage induced by type 2 diabetes mellitus as a risk factor for benign prostatic hyperplasia.

AIMS/HYPOTHESIS: The aim of this study was to evaluate the relationship between benign prostatic hyperplasia (BPH) and arteriosclerosis shown in a model of type 2 diabetes in a trans-sectional population study using contrast-enhanced colour Doppler ultrasound for exact assessment of prostatic blood flow. METHODS: Contrast-enhanced transrectal colour Doppler ultrasound was performed using a microbubble-based ultrasound enhancer SonoVue for evaluating prostate vascularity (transitional zone [TZ] and peripheral zone [PZ]) in diabetic BPH patients, non-diabetic BPH patients and healthy subjects. Computer-assisted quantification of colour pixel intensity (CPI) was used to objectively evaluate the prostate vascularity. Resistive index measurements were obtained in the TZ and the PZ. Findings were compared between these three groups. RESULTS: TZ-CPI was significantly lower in diabetic patients than in non-diabetic BPH men (p=0.001), whereas the CPI of the PZ showed no difference between these two groups (p=0.978). TZ-CPI of patients with diabetic and non-diabetic BPH were significantly lower than in controls (p<0.001), but no difference was found between diabetic and healthy patients in the PZ (p=0.022) and borderline significance was seen when comparing patients of the BPH group with the control patients (p=0.019). Resistive index values of the TZ in diabetic patients showed significantly higher values (p<0.001) than the BPH and control groups. CONCLUSIONS/INTERPRETATION: The significantly lower CPI and higher resistive index values of the TZ in diabetic patients compared with patients with non-diabetic BPH and healthy subjects indicate considerable vascular damage in the TZ of these patients. Diabetic vascular damage may cause hypoxia and may contribute to the pathogenesis of BPH.

Medication overuse headache: rates and predictors for relapse in a 4-year prospective study.

We present a prospective 4-year follow-up study of 96 patients with medication overuse headache following withdrawal. Complete datasets were available from 85 patients (89%) 6 months, from 79 patients (82%) 1 year and from 75 patients (78%) 4 years after withdrawal. Twenty-six patients (31%) relapsed within the first 6 months after withdrawal. The number of relapses increased to 32 (41%) 1 year and to 34 (45%) 4 years after withdrawal. The 4-year relapse rate was lower in migraine than in tension-type headache (32% vs. 91%, P

[Gordian knot: medication overuse headache]. / Der gordische Knoten: medikamenteninduzierte Kopfschmerzen.

Overuse of any kind of headache drugs may lead to the development of the medication overuse headache (MOH). Clinical features of MOH depend on the substance class that has been overused. Overuse of analgesics leads to a chronic tension-type like headache, the overuse of triptans to daily migraine-like headache or to the increase of migraine frequency. The delay between the drug overuse and onset of daily headache is shortest for triptans (1.7 years), longer for ergots (2.7 years) and longest for analgesics (4.8 years). Treatment includes withdrawal followed by structured acute therapy and initiation of specific prophylactic treatment for the underlying primary headache. The relapse rate after a successful withdrawal is about 30%. Predictors for relapse are tension-type headache and the overuse of analgesics in combination with codeine, caffeine or opioids.

Large-vessel arteritis and myelodysplastic syndrome: report of two cases.

Myelodysplastic syndrome (MDS) is frequently associated with autoimmune diseases such as polymyalgia, arthritis, and rarely, with systemic vasculitis. The pathogenesis of these autoimmune complications remains unknown, but there is increasing evidence of profound immune dysregulation in MDS. In the few cases reported so far, vasculitides associated with MDS affected mainly cutaneous vessels. Here we describe two cases of acute large-vessel vasculitis in association with MDS. The first patient is a 67-yr-old male presenting with a massive large-vessel arteritis as primary manifestation of refractory anemia with excess of blasts type 1 (RAEB-1). The second patient is a 60-yr-old male, who presented with acute thoracic aortitis after a 2-yr history of refractory anemia with ringed sideroblasts (RARS). Both patients received immunosuppressive treatment with steroids, leading to rapid improvement of systemic inflammatory symptoms, vessel wall injury and peripheral blood counts. Whereas the first patient displayed sustained favorable hematologic responses under long-term steroid therapy, there was a rapid transformation into secondary acute myeloid leukemia in the second patient. We conclude that large-vessel vasculitis should be added to the list of potential autoimmune complications in MDS. In this clinical setting, steroid therapy may alleviate inflammatory symptoms and result in beneficial hematologic responses.

Incidence and predictors for chronicity of headache in patients with episodic migraine.

The authors followed 532 consecutive patients with episodic migraine (<15 days/month) for 1 year. Sixty-four patients (14%) developed chronic headache (>/=15 days/month). The odds ratios for developing CH were 20.1 (95% CI 5.7 to 71.5) comparing patients with a "critical" (10 to 14 days/month) vs "low" (0 to 4 days/month) and 6.2 (95% CI 1.7 to 26.6) in patients with an "intermediate" (6 to 9 days/month) vs "low" headache frequency and 19.4 (95% CI 8.7 to 43.2) comparing patients with and without medication overuse.

Rates and predictors for relapse in medication overuse headache: a 1-year prospective study.

The authors prospectively studied 98 patients with medication overuse headache. The 1-year relapse rate was 38% but was lower for patients with migraine compared with tension-type headache (22% vs 73%, p < or = 0.002) and combination of migraine and tension-type headache (22% vs 77%, p < or = 0.0001). The rate was also lower for patients overusing triptans than ergots (19% vs 20%, NS) and analgesics (19% vs 58%, p < or = 0.001). The long-term success of withdrawal depends on the type of primary headache and the type of overused medication.

The management of chronic tinnitus: comparison of an outpatient cognitive-behavioral group training to minimal-contact interventions.

OBJECTIVE: Using a randomized group design, the efficacy of an outpatient cognitive-behavioral Tinnitus Coping Training (TCT) was compared to two minimal-contact (MC) interventions. METHODS: TCT was conducted in a group format with 11 sessions (total n=43). One MC [MC-E (education), n=16] consisted of two group sessions in which education on tinnitus was presented and self-help strategies were introduced. The second MC [MC-R (relaxation), n=16] comprised four sessions. Besides education, music-supported relaxation was suggested as self-help strategy and audiotapes with relaxing music were provided. Furthermore, a waiting-list control group was installed (WC, n=20). Data were assessed at baseline (pretherapy) and at posttherapy period. Only TCT was additionally evaluated at a 6-month and a 12-month follow-up. Several outcome variables (e.g., awareness of tinnitus) were recorded in a tinnitus diary. Tinnitus coping and disability due to tinnitus were assessed by questionnaires. Subjective ratings of improvement were also requested from the patients. Furthermore, inventories of psychopathology were given to the patients. RESULTS: Findings reveal highly significant improvements in TCT in comparison to the control group (WC). MC interventions do not differ significantly from each other, but are superior to WC in a few domains of outcome. Outcome in TCT is somewhat superior to combined MC interventions in two domains of data, but not regarding disability reduction. Effect sizes, nevertheless, indicate distinct differences in degree of improvement, with TCT achieving the best results. CONCLUSIONS: A sequential scheme for the treatment of chronic tinnitus is discussed on the basis of cost-effectiveness considerations.

Features of medication overuse headache following overuse of different acute headache drugs.

OBJECTIVE: To investigate pharmacologic features such as mean critical duration until onset of medication-overuse headache (MOH) (MCDO), mean critical monthly intake frequencies (MCMIF), and mean critical monthly dosages (MCMD) as well as specific clinical features of MOH after overuse of different acute headache drugs, with a focus on newly approved triptans. METHODS: In a prospective study 98 patients with MOH according to International Headache Society (IHS) criteria underwent standardized inpatient withdrawal from their medication. Patient diaries and structured interviews were used to calculate the MCDO, MCMIF, and MCMD for each substance group. RESULTS: The MCDO was shortest for triptans (1.7 years), longer for ergots (2.7 years), and longest for analgesics (4.8 years). The MCMIF was lowest for triptans (18 single doses per month), higher for ergots (37), and highest for analgesics (114). Although patients overusing ergots and analgesics typically had a daily tension-type headache, patients with triptan-induced MOH were more likely to describe a (daily) migraine-like headache or an increase in migraine frequency. CONCLUSION: Overuse of triptans leads to MOH faster and with lower dosages compared with ergots and analgesics. Clinical features of MOH depend on the type of overused headache medication. Pharmacologic and clinical characteristics of triptan-induced MOH call for the renewal of the current IHS classification.

Clinical features of withdrawal headache following overuse of triptans and other headache drugs.

BACKGROUND: Complete withdrawal from headache medication is the treatment of choice for medication-overuse headache. Discontinuation of the overused headache medication, however, results in the development of withdrawal headache, often associated with nausea, vomiting, and sleep disturbances. METHOD: In a prospective study of 95 patients, the authors investigated the duration and severity of withdrawal headache after overuse of various headache drugs, including single and combination analgesics, ergots, and triptans. All patients underwent standard inpatient withdrawal therapy for 14 days. RESULTS: The duration of withdrawal headache was shorter in patients overusing triptans (4.1 days) than in patients overusing ergots (6.7 days) or analgesics (9.5 days; p < 0.002). The mean headache intensity on the first day of withdrawal did not differ between the groups (p = 0.821). By day 14, however, it was lower in patients overusing triptans (0.08) than in patients overusing ergots (0.4) or analgesics (0.9; p < 0.005). Rescue medication was requested less by patients undergoing triptan withdrawal (0.25 requests) than by patients undergoing ergot withdrawal (1.25) or analgesic withdrawal (1.85; p < 0.05). Similar to findings in the entire patient population, withdrawal headache was shorter and less severe in migraineurs overusing triptans than in those overusing ergots or analgesics. Because only patients with migraine, but no patient with tension-type headache, overused triptans, withdrawal headache was shorter in the group of patients with migraine alone (6.7 days versus 9.6 days for patients with tension-type headache and 8.5 days for patients with combination headache, p < 0.02). CONCLUSION: The duration and severity of withdrawal clearly depend on the type of overused headache drug only.

Drug-induced headache: long-term follow-up of withdrawal therapy and persistence of drug misuse.

Patients suffering from migraine, tension-type headache (TTH), or combined headache (CH) are at risk of developing drug-induced headache (DIH) due to regular use of analgesics, ergot alkaloids, and triptans. The aim of our study was to determine (1) the clinical features of DIH, (2) the outcome of withdrawal therapy using high methodological standards, and (3) predictors which could explain the high relapse rate (more than 40%) after a previously successful withdrawal therapy. We retrospectively reviewed 103 patients with migraine or TTH who underwent withdrawal therapy between 1994 and 1998. The long-term follow-up (2-4 years after therapy) was conducted by phone and by specially trained psychologists using a structured interview which enclosed characteristics of headache and medication behavior as well as patients global assessment of success. Complete sets of data were available from 83 patients (38 migraine, 26 TTH, 19 CH). The most frequently abused drugs were caffeine-combined analgesics (24%), followed by caffeine-combined ergotamines (19%), pure ergot alkaloids (17%), and monoanalgesics (17%). 48.5% of the patients suffered an abuse relapse within 4 years and developed the complete features of DIH again. Analgesic and ergot alkaloid combinations with caffeine lead significantly more often to a relapse. A long-term successful therapy is connected with a significant reduction of the frequency of headache attacks. Under relapse conditions, the patients reached their former headache frequency level. The data show a higher relapse rate than previously assumed and that certain substance groups bear a higher relapse risk.

Regulatory interactions between iron and nitric oxide metabolism for immune defense against Plasmodium falciparum infection.

Iron chelation therapy of Plasmodium falciparum infection alleviates the clinical course of cerebral malaria in children. This study assessed the underlying mechanisms of this therapy. Cytokine stimulation of human (intestinal cell line DLD-1) or murine cells (murine macrophage cell line RAW 264.7) resulted in increased nitric oxide (NO) formation and decreased survival of plasmodia within cocultured human erythrocytes. The addition of desferrioxamine (DFO) before cytokine treatment increased both NO formation and parasite killing but had no effect in the presence of the inhibitor of NO formation, L-N6-(1-iminoethyl)-lysine. Moreover, peroxynitrite, which is formed after chemical reaction of NO with superoxide, appears to be the principal effector molecule for macrophage-mediated cytotoxicity toward P. falciparum, and interferon-gamma is a major regulatory cytokine for this process. The effect of DFO on the clearance of plasmodia appears to be due to enhanced generation of NO, rather than to limitation of iron availability to the parasite.

[Psychological descriptors of excessive use of analgesic medication]. / Psychologische Deskriptoren des Schmerzmittelabusus und des medikamenteninduzierten Kopfschmerzes.

INTRODUCTION: Patients suffering from migraine and tension-type-headache are at risk of misusing analgesics and therefore developing chronic drug-induced headache. The present study compares migraine patients with and without abuse to identify psychological descriptors promoting drug abuse. METHODS: We examined 21 in-patients with migraine and drug-abuse and 21 out-patients with migraine and no drug-abuse who were comparable regarding age and diverse pain variables (intensity, frequency, duration, etc. ). Psychometric questionnaires measured the constructs "pain-", "depression", "self-efficacy" and "pain-coping". Using a standardized interview we investigated the external (environment) and internal (mental factors) conditions of all patients during medication intake. RESULTS: Migraineurs who misused medications showed significantly greater disability, greater helplessness and anxiety due to pain and a tendency towards more marked general depression than non-abusers. The extent of the helpless and depressive coping with pain was best suited for distinguishing the patients with and without drug abuse, followed by the fact that those with abuse receive drugs from several doctors at the same time and demand that the drugs free them of all complaints. CONCLUSIONS: These findings suggest that migraine patients with drug abuse often take analgesics not according to their headache, but rather depending on certain other factors.