Providing systematic detailed information on medication upon hospital discharge as an important step towards improved transitional care.

WHAT IS KNOWN AND OBJECTIVE: Good communication between hospital and primary care physicians (PCPs) is important for the continuity of patient care in the transition phase following hospital treatment. Drug-related problems and medication errors may occur at that interface. Discharge letters often lack a structured medication report at the end and therefore may not provide the reasons for medication changes, resulting in low adherence rates. The objectives were to develop a structured medication report as part of the discharge letter, to evaluate the impact of the medication report in ischaemic stroke patients and to identify the most important issues in the transitional care process of stroke patients. METHODS: First, a structured medication report was developed. Thereafter, the impact of this new medication report on clinical practice was evaluated with an open, prospective, interventional two-phase study conducted at the Klinikum Fulda gAG (Germany), which included patients with ischaemic stroke and >2 drugs in the discharge medication. In the control group (CG), the neurologist included the current medication in the discharge letter. In the intervention group (IG), the clinical pharmacist added the detailed information to a medication report. To evaluate adherence to discharge medication, the PCP was interviewed 3 months after hospital discharge about the medication. Adherence was measured with respect to the entire medication regimen, antithrombotic and cholesterol-lowering drugs and discontinued medication. The most important issues in the transitional care for patients with ischaemic stroke were identified on the basis of the secondary stroke prevention and cardiovascular risk factors. RESULTS AND DISCUSSION: Overall, 312 patients were enrolled in the study with 156 patients in each group. By providing detailed information in the newly developed discharge letter, adherence increased significantly from 83·3% (CG) to 90·9% (IG; P = 0·01). Significant differences between the CG and IG were found with regard to adherence to both antithrombotic drugs [83·8% CG vs. 91·9% IG (P = 0·033)] and statin therapy [69·8% CG vs. 87·7% IG (P < 0·001)]. WHAT IS NEW AND CONCLUSION: The use of a structured medication report as part of the discharge letter leads to improved adherence to hospital discharge medication.

[Cerebral venous thrombosis and subdural haematoma: complications of spontaneous intracranial hypotension]. / Sinus-/Hirnvenenthrombose und Subduralhämatome als Komplikationen eines spontanen Liquorunterdrucksyndroms.

We report on the case of a spontaneous intracranial hypotension with subdural hygroma, as well as cerebral venous thrombosis (CVT), both known complications of intracranial hypotension. The 45-year-old patient was subsequently treated - according to current guidelines for CVT - with anticoagulation, but developed subdural haematoma (SDH), which required neurosurgical treatment. Our case highlights the complex pathophysiological sequelae of intracranial hypotension, as well as the occasionally difficult treatment decisions. Subdural hygroma probably predisposes patients to SDH during anticoagulation. Thus, the potential benefit of anticoagulation needs to be weighed against the risk of SDH on an individual basis.

Development of a classification system for drug-related problems in the hospital setting (APS-Doc) and assessment of the inter-rater reliability.

WHAT IS KNOWN AND OBJECTIVE: Identifying, preventing and resolving drug-related problems (DRP) is an important issue in the pharmaceutical care process. Because DRPs have been detected in a more systematic way, the need for a classification system to document, classify and evaluate the collected data has become necessary. The objective was to develop a classification system for DRPs within the hospital setting, to evaluate the practicality and to assess the inter-rater reliability. METHODS: All DRPs defined in PI-Doc and PCNE, which are relevant in the hospital setting, were included. Further relevant DRPs identified in other projects in a hospital setting as well as DRPs from the daily work on the ward were collected, and a short description of each DRP was written. A prospective study was conducted at Klinikum Fulda, Germany, in both a non-surgical and a surgical setting to explore whether the new classification system is suitable to classify DRPs in clinics with different specifications. For assessing the inter-rater reliability, 24 standardized case reports were provided. All participants classified them independently. The inter-rater reliability was analysed using Kappa coefficient. RESULTS AND DISCUSSION: A classification system for DRPs in the hospital setting (APS-Doc) was established with 10 main categories and 48 subcategories. Practicality was assessed in 250 patients in a non-surgical ward as well as in 100 patients in a surgical ward. The inter-rater agreement was 0·68 (95% CI, 0·66-0·69) for main categories, which comprises substantial agreement. Moderate agreement (κ = 0·58; 95% CI, 0·58-0·59) was demonstrated for the subcategories. WHAT IS NEW AND CONCLUSION: A new hierarchical classification system for DRPs in the hospital setting has been developed. APS-Doc seems suitable for various parts of the medication process such as medication reconciliation and drug therapy within both non-surgical and surgical wards. Inter-rater reliability was found to be substantial in the main categories and moderate in the subcategories.

[Celebral vasculitis and autoimmune thyreoiditis]. / Zerebrale Vaskulitis bei Autoimmunthyreoiditis.

Hashimoto's encephalopathy- or steroid responsive encephalopathy with autoimmune thyreoiditis (SREAT) - is a disease that can show multiple neurologic manifestations. So far, the pathogenesis of Hashimoto's encephalopathy is not clear. We report on a 47-year-old male patient suffering from a cerebral infarction of the right posterior cerebral artery within the framework of an angiographic confirmed cerebral vasculitis and an autoimmune thyreoiditis. The clinical presentation of the disease could hardly be distinguished from the symptoms of Hashimoto's encephalopathy. The concurrence of the present results supports the view of a possible vasculitic origin of Hashimoto encephalopathy.

[Headache in the elderly]. / Alter Patient mit neu aufgetretenem Kopfschmerz. Stellen Sie keine Diagnose ohne Labor und CT!

Although the elderly generally suffer less often from headache, symptomatic headache and concomitant diseases are more frequent. For the diagnostic work-up of newly occurring headaches in old age, imaging examinations of the head (CT or MRI), together with laboratory investigations are necessary. The treatment of symptomatic headache is oriented to the underlying disease, and should be applied promptly, with the aim of preventing serious complications. When considering the management strategy, account must be taken of possible changes in pharmacokinetics, pharmacodynamics and the therapeutic response in the elderly. Numerous medications often cause headache or other side effects in patients of advanced age. Most antiheadache drugs have not been adequately been investigated in the group of over 65-year-olds. This means that drug treatment for headache is often applied in accordance with the principle: start low, go slow.

[Recurrent cerebral ischemias due to cerebral vasculitis within the framework of incomplete POEMS syndrome with Castleman disease]. / Rezidivierende zerebrale Ischämien bei zerebraler Vaskulitis im Rahmen eines inkompletten POEMS-Syndroms mit M. Castleman.

The POEMS syndrome is a multisystem disorder characterised by polyneuropathy, organomegaly, endocrinopathy, plasma cell dyscrasia and skin changes. A coincidence with angiofollicular lymphoid hyperplasia (Castleman's disease) exists in about 60% of all cases. The POEMS syndrome may be associated with macroangiopathy and acute vascular obliterations. Most case reports refer to involvement of the coronary and lower limb arteries. There are only few reports dealing with cerebral strokes and POEMS syndrome. We report on a 32-year-old female with an incomplete form of POEMS syndrome with Castleman's disease and associated cerebral vasculitis. After sufficient treatment of the plasma cell dyscrasia, recurrent cerebral ischemias occurred. A stable state was finally reached after primary treatment of the vasculitis with cyclophosphamide.

[Virus encephalitis with symptomatic Parkinson syndrome, diabetes insipidus and panhypopituitarism]. / Virusenzephalitis mit symptomatischem Parkinsonsyndrome Diabetes insipidus und Panhypopituitarismus.

Virusencephalitis is characterised by clinical symptoms of a parenchymatous inflammation. In addition, early mental status changes often occur as a result of virusencephalitis, beside focal neurological deficiencies, epileptic seizures, cerebral compression, even coma. Other pathological manifestations of virusencephalitis are disturbances of the neurohumoral and the endocrine system, which are often recognised and treated too late. This case report describes symptoms, treatment, and complications of a 76 year old female in-patient, who was diagnosed with virusencephalitis. The number of lymphocytes in the cerebrospinal fluid was increased to 30 cells per microliter, liquor albumin was 1705 mg/l, liquor sugar was 53 mg/dl and liquor lactat was 1.9 mmol/l. IgM antibodies against herpes viruses were found in the cerebrospinal fluid and distinct contrasting foci were found near the mammillary bodies, hypothalamus, tractus opticus, hypophyseal stalk and right parahippocampal in the magnetic resonance imaging of the head, indicating a focal herpes simplex encephalitis. Within seven days, the following symptoms developed: akinetic parkinsonian syndrome, central diabetes insipidus with hypernatremia and polyuria (6 l/die), hypothyreosis, adrenal insufficiency with adynamia, sopor, hypotension and even hypophyseal coma. Panhypopituitarism was diagnosed after measuring the basal hormone levels (ACTH, TSH, FT3, FT4, Cortisol, Prolactin, LH, FSH, ADH) and conducting the pituitary stimulation test. The severeness of all symptoms was slightly improved after substitution with antidiuretic hormone at 0.4 microgram/die and administration of hydrocortisone at 50 mg/die. Administration of amantadine sulphate at 0.6 g/die and L-dopa at 187.5 mg/die for 14 days resulted in a complete regression of the parkinsonism. After administration of aciclovir at 2.25 g/die for 21 days a complete regression of the clinical symptoms could be reached in connection with a decrease of 90% in number and size of cerebral contrasting foci in the magnetic resonance imaging of the head. Three month after therapy, clinical examination and blood serum analysis revealed persistent panhypopituitarism. The present case report is the first description of a viral infection on of the central nervous system (CNS) in combination with parkinsonism, diabetes insipidus, persistent panhypopituitarism and hyperprolactinemia. Early treatment of viral infections of the brain can improve a patient's prognosis dramatically. Early determination and early treatment of a patient's neurohumoral parameters is therefore critical to prevent or reverse early mental status changes like attention disturbances, alterations of personality and behavior, apathy, and slowed cognition.

[Headache caused by polycythemia vera. Classification of a headache under the heading of metabolic disturbances]. / Kopfschmerz bei Polycythaemia vera. Klassifikation eines Kopfschmerzes bei Stoffwechselstörungen.

UNLABELLED: As polycythemia vera is a myeloproliferative syndrome, it is based on an autonomic increase in the proliferation of all hematopoetic cells--mostly of erythropoesis. An increase in blood viscosity induces disturbed microcirculation, resulting in headaches with clinical symptoms. So far, the headache in polycythemia vera has not been classified. METHODS: We would like to demonstrate a case of a female patient aged 58 years who had been complaining of persistent hemicranial right-sided headaches for the last 16 days, alternating between throbbing and stabbing pain as well as a retrobulbar feeling of pressure. Blood chemistry demonstrated pronounced changes: hemoglobin, 20,1 g/dl; hematocrit, 58%; erythrocytes, 6,8 T/l (6,800,000/microl) leucocytes, 14,400/microl; thrombocytes, 543,000/microl A punch biopsy from the pelvic rim showed cell-rich bone marrow, demonstrating a myeloproliferative syndrome suggestive of polycytemia vera. RESULTS: Following hemodilution, the headache disappeared within 3 days following normalization of blood chemistry: hemoglobin, 14.9 g/dl; hematocrit, 44%; erythrocytes, 5.2 T/l (5,200,000/microl; leucocytes, 13,100/microl. Further diagnosis of the headache by means of MRI of the head, extra and transcranial doppler sonography as well as MRI of the cervical spine did not produce findings with the exception of retrospondylophyth at C5-6. The patient was therefore managed on aspirin 300 mg daily and was given weekly isovolemic bleeding. The headaches did not recur. CONCLUSION: We diagnosed a headache caused by polycythemia vera and recommend classification of this headache under the heading of metabolic disturbances, because this classification meets the diagnostic criteria of the international headache classification.

[The value of clinical and chemical laboratory follow-up parameters in neuroborreliosis]. / Wertigkeit klinischer und laborchemischer Verlaufsparameter bei Neuroborreliose.

Whereas the diagnosis of acute neuroborreliosis by considering clinical and cerebrospinal fluid parameters is very reliable chronic neuroborreliosis is an excluding diagnosis. The clinical symptoms are uncharacteristic, and there is no reliable laboratory test permitting a safe diagnosis. Serological evidence of antibodies is no sign of activity of disease. Development of chronic infection after adequate treatment of acute neuroborreliosis seems to be very rare. We reinvestigated 15 patients half a year after antibiotic therapy of acute neuroborreliosis with regard to clinical and laboratory parameters. Most patients had a continuous intrathecal IgG antibody production against Borrelia burgdorferi, whereas no clinical signs of chronic neuroborreliosis existed. The antibody production against Borrelia burgdorferi must not be regarded as a sign of chronic infection.

[Unilateral caudal cranial nerve paralysis in extracranial carotid dissection]. / Einseitige kaudale Hirnnervenlähmungen bei extrakraniellen Karotisdissektionen.

Focal cerebral ischemic symptoms, Horner's syndrome and mostly ipsilateral headache are the characteristic clinical triad of extracranial carotid artery dissection. Lower cranial nerve palsies seem to be uncommon and rare. By means of two cases with identical clinical symptoms and of a literature review we make clear, that ipsilateral lower cranial nerve palsies, especially a hypoglossal nerve palsy, are not uncommon. Without focal cerebral ischemic symptoms they can be the only sign of extracranial carotid artery dissection. Computed tomography of the skull base with regard to the high cervical internal carotid artery is as an usually quickly available examination an alternative to magnetic resonance imaging.

Topographic EEG mapping methods.

After almost 40 years of research on EEG computer analysis, present clinical applications of this method remain limited. At the present time, EEG mapping is suited primarily for research. Despite the pitfalls of an uncritical application of EEG mapping, progress in clinical research made possible by EEG mapping techniques has been considerable. Some problems of data acquisition, display and statistical analysis are discussed in this paper. For headache research examination of the activated EEG, especially with photic stimulation, has greater diagnostic importance than mapping under resting conditions.

[Analysis of diadochokinetic movement. Electronic data processing-aided diadochometry--a contribution to developmental neurologic diagnosis]. / Analyse der diadochokinetischen Bewegung. EDV-gestützte Diadochometrie--Ein Beitrag zur entwicklungsneurologischen Diagnostik.

A method of objective registration and analysis of diadochokinetic arm movement was tested in normal children and those with signs of minimal cerebral dysfunction (MCD). 44 children aged 4-10 yrs. (9 with the diagnosis of MCD, 31 controls) were investigated. By means of a special device 270 deg. twisting of the forearms were transduced linearly by foam-cushioned clamps at the wrists and a potentiometer into a direct current of 0-2,7 V, respectively. The analog DC signal was digitalized by 0.7 kHz and stored in a calculator, the identification of the first and last sectors were performed on monitor. After removing artificial currents by a special filtering program, the remaining sinus-like curves could be analyzed by a special program (BEWESI). Mathematical analysis was performed by 11 factors respecting right and left arm, unilateral or bilateral twisting. Statistical analysis showed significant differences in some parameters between normal and MCD-children. In addition, a significant difference between the velocity of pronation and supination was evident. The fact that a clear age relation of parameters was found, proves the practicability of this diagnostical method in developmental neurology.