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Background Patients with multimorbidity (here defined as three or more chronic conditions) require constant treatment and care. Furthermore, they have to manage their health and diseases in daily life. Offering support to patients’ medical self-management is an important task of primary care. The aim of this study was to explore, what further support is needed from the perspective of patients’ and primary care practitioners. Methods A qualitative study using individual semi-structed interviews with 17 patients with multimorbidity and 7 practitioners (4 primary care physicians and 3 practice assistants) was conducted in Germany. Data were audio-recorded, pseudonymised and transcribed verbatim. Data analysis was performed using qualitative content analysis to structure data into themes and subthemes. All data were managed and organised in MAXQDA. Results The three broad themes: current status, challenges and further support emerged. Patients reported on unfulfilled needs regarding role or emotional management, like coping with loneliness, loss of independence and, changing habits. The importance of social contact was highlighted by patients and practitioners. Patients articulated further support from their primary care practitioners on coping with the disease. Practitioners’ wished for further support in aspects of social participation, public transport, and community resources. Conclusion Challenges regarding self-management of elderly patients with multimorbidity may be addressed by harnessing social support and community initiatives.

Background Primary care is a relevant pillar in managing not only individual, but also societal medical crises. The COVID-19 pandemic has demanded a rapid response from primary care with interventions in the health care system. The aim of this paper was to explore the responses of primary care practitioners (PCP) during the early COVID-19 pandemic and to analyze these with a view on the resilience of the primary health care system from the PCPs perspective. Methods Shortly after the first COVID-19 wave (July—October 2020) n = 39, semi-structured telephone interviews were conducted with PCP in practices and at Corona contact points (CCP) in Baden-Wuerttemberg (Germany). Qualitative content analysis was applied, and the evolved categories were related to in a framework for resilience. Results Primary care had an overall strong ability to adapt and show resilience, albeit with wide variance in speed and scope of the responses. When coping with uncertainty, the reasons given by PCPs in favor of opening a CCP mainly involved intrinsic motivation and self-initiative; the reasons against doing so were i.e. the lack of personal protective equipment, problems with space, and worries about organizational burden. A strong association existed between the establishment of a CCP and the use of resources (i.e. existing networks, personal protective equipment, exercising an office of professional political function). Our study predominantly found adaptive aspects for measures taken at medical practices and transformative aspects for setting up outpatient infection centers. PCPs played an important role in the coordination process (i.e. actively transferring knowledge, integration in crisis management teams, inclusion in regional strategic efforts) reaching a high level in the dimensions knowledge and legitimacy. The dimension interdependence repeatedly came into focus (i.e. working with stakeholders to open CCP, interacting among different types of primary care facilities, intersectoral interfaces). A need for regional capacity planning was visible at the time of the interviews. Conclusions The results can be used for practical and research-based institutional and capacity planning, for developing resilience in primary care and for augmentation by perspectives from other stakeholders in the primary health care system.

The aim of this study was to give an early snapshot of primary care strategies that were implemented to cope with the early period of the COVID-19 pandemic in Baden-Wuerttemberg (Germany).In June 2020, all 271 outpatient SARS-CoV-2 contact points, established by the National Association of Statutory Health Insurance Physicians (16 centers for testing, 204 specialized family practices, 51 Outpatients Corona Centers), and a randomly generated sample of 400 primary care practices of Baden-Wuerttemberg were invited to take part in a paper-based questionnaire. The data were gathered anonymously and analysed descriptively.Out of those invited, n=63 (15.8%) primary care practices and n=92 (33.9%) SARS-CoV-2 contact points participated; 78.7% of the primary care practices cooperated with SARS-CoV-2 contact points (n=48). In all, 92.1% had implemented a compulsory registration by phone for patients with (suspected) COVID-19 (n=58) and 81% offered consultation exclusively by phone or video in case of a mild courses (n=51). The new outpatient SARS-CoV-2 contact points were established in collaboration with several stakeholders, mainly led by primary care physicians (n=76, 82.6%) and almost 50% of these were established in March 2020 (n=42, 48.3%). The most commonly reported method of registration was regulated mainly by primary care practices (n=88, 95.7%) and public health departments (n=74, 80.4%). In 92.4% (n=85) of cases, it was possible to register by phone. The consultation response was most commonly given in the form of oral information to the patient (n=65, 77.4%). Less then 50% of the SARS-CoV-2 contact points used standardized sheets for registration, documentation and consultation. The assessment of future primary care structures for (suspected) COVID-19 patients were heterogeneous.Effort, improvisation and collaboration were required for a successful and rapid implementation of measures for primary care during the initial period of the COVID-19 pandemic. Impulses for ongoing development of primary care strategies during a pandemic can be derived out of these results.Das Ziel der Arbeit war eine deskriptive frühzeitige Momentaufnahme von Einleitung und Umsetzung ambulanter Strategien im primärärztlichen Setting zur Bewältigung der frühen Phase der COVID-19- Pandemie in Baden-Württemberg (Deutschland).Im Juni 2020 erhielten alle 271 Corona-Anlaufstellen unter Trägerschaft der Kassenärztlichen Vereinigung (16 Abstrichstellen, 204 Corona-Schwerpunktpraxen, 51 Zentrale Fieberambulanzen) sowie eine zufällig generierte Stichprobe von 400 Hausarztpraxen aus Baden-Württemberg einen papierbasierten Fragebogen. Die Daten wurden anonym erhoben und deskriptiv ausgewertet.Insgesamt nahmen n=63 (15,8%) Hausarztpraxen und n=92 (33,9%) Corona-Anlaufstellen teil. 78,7% der Hausarztpraxen nutzten Corona-Anlaufstellen (n=48). 92,1% hatten eine verpflichtende telefonische Anmeldung für PatientInnen mit (vermuteter) COVID-19-Erkrankung (n=58) implementiert. 81% boten bei leichtem Verlauf eine rein telefonische oder videokonsultatorische Versorgung an (n=51). Parallel dazu wurden die neuen ambulanten Corona-Anlaufstellen vorwiegend unter hausärztlicher Leitung (n=76, 82,6%) in Zusammenarbeit mit weiteren Akteuren, in fast der Hälfte der Fälle bereits im März aufgebaut (n=42, 48,3%). Die am häufigsten genannten Anmeldepfade waren gesteuert und konnten vorwiegend über HausärztInnen (n=88, 95,7%) und Gesundheitsamt (n=74, 80,4%), aber auch durch weitere Akteure erfolgen. In 92,4% (n=85) konnte eine telefonische Anmeldung erfolgen. Die mündliche Rückmeldung an die PatientInnen (n=65, 77,4%) war der am häufigsten genannte Rückmeldeweg. In weniger als der Hälfte der Corona-Anlaufstellen lagen standardisierte Anmelde-, Dokumentations- und Rückmeldebögen vor. Die Einschätzung der zukünftigen Versorgungsstrukturen von PatientInnen mit (vermuteter) COVID-19-Erkrankung waren heterogen.In einem gemeinsamen Kraftakt, mit Improvisation und Zusammenarbeit gelang eine rasche Implementierung von Maßnahmen zur Patientenversorgung während der Anfangsphase der Pandemie im primärärztlichen Setting. Aus den Ergebnissen können Impulse für die primärärztliche Versorgung in einer Pandemie abgeleitet werden.

Background Patients with multiple long-term conditions often face a variety of challenges arising from the requirements of their health care. Knowledge of perceived treatment burden is crucial for optimizing treatment. In this study, we aimed to create a German version of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and to evaluate its validity. Methods The steps to translate the MTBQ included forward/back translation, cognitive interviews (n = 6) and a pilot test (n = 7). Psychometric properties of the scale were assessed in a cross-sectional survey with primary care patients aged 65 and older with at least 3 long-term conditions (n = 344). We examined the distribution of responses, dimensionality, internal reliability and construct validity. Results Cognitive interviewing and piloting led to minor modifications and showed overall good face validity and acceptability. As expected, we observed a positively skewed response distribution for all items. Reliability was acceptable with McDonald’s omega = 0.71. Factor analysis suggested one common factor while model fit indices were inconclusive. Predefined hypotheses regarding the construct validity were supported by negative associations between treatment burden and health-related quality of life, self-rated health, social support, patient activation and medication adherence, and positive associations between treatment burden and number of comorbidities. Treatment burden was found to be higher in female participants (Mdn1 = 6.82, Mdn2 = 4.55; U = 11,729, p = 0.001) and participants with mental health diagnoses (Mdn1 = 9.10, Mdn2 = 4.55; U = 3172, p = 0.024). Conclusions The German MTBQ exhibited good psychometric properties and can be used to assess the perceived treatment burden of patients with multimorbidity.

Chronic pain in the USA has presented with higher prevalence rates among women, older adults, those unemployed, living in poverty, living in rural environments, and adults with public health insurance. The COVID-19 pandemic has heavily played into the biopsychosocial model of pain. Consequently, greater impacts have affected patients with mood disorders, opioid abuse, and chronic pain. Concurrently, telemedicine has become a popular vehicle during the COVID-19 pandemic in continuing to provide quality patient care. The purpose of this article is to review the benefits and challenges related to the delivery of telemedicine for patients with chronic pain.The benefits of telemedicine have been examined from patient psychosocial and convenience factors as well in relation to medical practice efficiency. Within chronic pain management, one of telemedicine's most effective utilization is seen via post-injection follow-up and assessment of further necessary interventions. Challenges also exist in this framework, from lack of physical examination and convenient close therapeutic monitoring and drug screening, to technological and resource cost capabilities of older and disadvantaged chronic pain patients, to barriers in establishing patient-provider rapport. During the COVID-19 pandemic, telehealth services were covered at rates comparable to in-person visits. Health insurance coverage and payment were major barriers for implementation of telemedicine prior to the pandemic. It is difficult to predict ongoing coverage and payment of telehealth services, although the benefits in terms of access and patient satisfaction have clearly been demonstrated. While telemedicine has proven to be a very useful tool with a wealth of advantages, the delivery of virtual healthcare for chronic pain poses a set of challenges that will need to be met to ensure the quality and standard of care continue to be upheld.

ObjectivesThis study aimed to explore the association between patient activation and patients’ experience of care among an elderly multimorbid population in Germany.DesignCross-sectional study.SettingPrimary care practices in two German settings.Participants346 patients with 3 or more chronic conditions aged 65 years and over from 36 primary care practices.Outcome measuresPatient activation was measured with the patient activation measure (PAM). To assess patient experiences with primary care, a set of questions concerning domains of primary care were included. Multilevel regression analyses were performed to examine which domains of care were associated with patient activation.ResultsOut of 1243 invited patients, a total of 346 took part in the study (participation rate 27.8 %). Mean PAM score was 76.1. Across all patients, 3.8% achieved PAM level 1, 7.5% level 2, 27.2% level 3% and 60.7% level 4. PAM scores suggest a highly activated patient group. In the regression analysis, three out ten domains of patients’ experiences showed an association with patient activation. The domains ‘being involved in decision as much as desired’ (B=−8.56, p=0.012) and ‘receiving a self-management plan’ (B=6.51, p=0.051) were associated with higher patient activation scores. Patients with an up-to-date medication plan had lower patient activation scores (B=−12.01, p=0.041).ConclusionSpecific domains of primary care were found to be associated with patient activation. To enhance patient activation, primary care physicians may increase involvement of patients in decisions. Future research should examine the causality of these associations.Trial registration numberDRKS00015718.

Background and Objectives Providing health care for older adults with multimorbidity is often complex, challenging, and prone to fragmentation. Although clinical decision making should take into account treatment interactions, individual burden, and resources, current approaches to assessing quality of care mostly rely on indicators for single conditions. The aim of this project was to develop a set of generic quality indicators for the management of patients aged 65 and older with multimorbidity that can be used in both health care research and clinical practice. Research Design and Methods Based on the findings of a systematic literature review and eight focus groups with patients with multimorbidity and their family members, we developed candidate indicators. Identified aspects of quality were mapped to core domains of health care to obtain a guiding framework for quality-of-care assessment. Using nominal group technique, indicators were rated by a multidisciplinary expert panel (n = 23) following standardized criteria. Results We derived 47 candidate quality indicators from the literature and 4 additional indicators from the results of the focus groups. The expert panel selected a set of 25 indicators, which can be assigned to the levels of patient factors, patient–provider communication, and context and organizational structures of the conceptual framework. Discussion and Implications We developed a comprehensive indicator set for the management of multimorbidity that can help to highlight areas with potential for improving the quality of care and support application of multimorbidity guidelines. Furthermore, this study may serve as a blueprint for participatory designs in the development of quality indicators.

BackgroundPrevalence of people with multimorbidity rises. Multimorbidity constitutes a challenge to the healthcare system, and treatment of patients with multimorbidity is prone to high-quality variations. Currently, no set of quality indicators (QIs) exists to assess quality of care, let alone incorporating the patient perspective. We therefore aim to identify aspects of quality of care relevant to the patients’ perspective and match them to a literature-based set of QIs.MethodsWe conducted eight focus groups with patients with multimorbidity and three focus groups with patients’ relatives using a semistructured guide. Data were analysed using Kuckartz’s qualitative content analysis. We derived deductive categories from the literature, added inductive categories (new quality aspects) and translated them into QI.ResultsWe created four new QIs based on the quality aspects relevant to patients/relatives. Two QIs (patient education/self-management, regular updates of medication plans) were consented by an expert panel, while two others were not (periodical check-ups, general practitioner-coordinated care). Half of the literature-based QIs, for example, assessment of biopsychosocial support needs, were supported by participants’ accounts, while more technical domains regarding assessment and treatment regimens were not addressed in the focus groups.ConclusionWe show that focus groups with patients and relatives adding relevant aspects in QI development should be incorporated by default in QI development processes and constitute a reasonable addition to traditional QI development. Our QI set constitutes a framework for assessing the quality of care in the German healthcare system. It will facilitate implementation of treatment standards and increase the use of existing guidelines, hereby helping to reduce overuse, underuse and misuse of healthcare resources in the treatment of patients with multimorbidity.Trial registration numberGerman clinical trials registry (DRKS00015718), Pre-Results.

Background During the first wave of the COVID-19 pandemic various ambulatory health care models (SARS-CoV-2 contact points: Subspecialised Primary Care Practices, Fever Clinics, and Special Places for Corona-Testing) were organised in a short period in Baden-Wuerttemberg, a region in Southern Germany. The aim of these SARS-CoV-2 contact points was to ensure medical treatment for patients with (suspected) and without SARS-CoV-2 infection. The present study aimed to assess the beliefs and practices of primary care physicians who either led a Subspecialised Primary Care Practice or a Primary Care Practice providing care as usual in Baden-Wuerttemberg during the first wave of the COVID-19 pandemic. Methods This cross-sectional study was based on a paper-based questionnaire in primary care physicians during the first wave of the pandemic. Participants were identified via the web page of the Association of Statutory Health Insurance Physicians Baden-Wuerttemberg. The questionnaire was distributed in June and July 2020. It measured knowledge, practices, self-efficacy and fears towards SARS-CoV-2, using newly developed questions. Data was descriptively analysed. Results One hundred fifty-five participants (92 leads of SARS-CoV-2 contact points/ 63 leads of primary care practices) completed the questionnaire. Out of 92 leads of SARS-CoV-2 contact points 74 stated to lead n Subspecialised Primary Care Practices. About half participants of both groups did not fear an own infection with the novel virus (between 50.8% and 62.2%), however about 75% feared financial loss. Knowledge was gained using various sources; main sources were the Association of Statutory Health Insurance Physicians (between 82.5% and 83.8%) and the German Society for Hygiene and Microbiology (RKI) (between 88.9% and 95.9%). Leads of Subspecialised Primary Care Practice felt more confident to perform anamnestic/diagnostic procedures (p p p Conclusion The results of this study suggest that the Subspecialised Primary Care Practice that were implemented during the first wave of the SARS-CoV-2 pandemic contributed containment of the pandemic. Leads of Subspecialised Primary Care Practice indicated that physical separation of patients with potential SARS-CoV-2 infection was easier compared to those who continued working in their own practice. Additionally, leads of Subspecialised Primary Care Practice felt more confident in dealing with patients with SARS-CoV-2 infection. Trial registration The study has been prospectively registered at the German Clinical Trial Register (DRKS00022224).

Background Inadequate assessment of the severity and urgency of health problems is one of the factors contributing to unnecessary emergency department visits. A software-based instrument for standardized initial assessment (SmED) aims to support healthcare professionals and steer patients to the appropriate source of care. The aim of this study was to evaluate the implementation process of SmED based on the point of view of users in order to facilitate sustainable implementation. Methods A quantitative process evaluation on the basis of a paper-based questionnaire was carried out alongside the implementation of SmED in 26 outpatient emergency care services within 11 federal states in Germany. Healthcare professionals who worked with SmED either at the joint contact points of the outpatient emergency care service and the emergency departments of hospitals ("Joint Counter", German “Gemeinsamer Tresen”) or at the initial telephone contact points of the outpatient emergency care service (116117) were invited to participate in the survey. Results 200 users of SmED completed the questionnaire comprising the five scales: Intervention effectiveness/efficacy, Interprofessional context/occupational Interest, Individual Context, Organisational Framework Conditions, and Medical Context. Several individual characteristics were related to the implementation process of SmED. Female and younger healthcare professionals and participants with less than five years of professional experience tended to evaluate the implementation process as more positive. Factors related to the Individual Context and to the Medical Context were associated with the reported use of SmED (p = 0.004 and 0.041, respectively). Conclusion The involvement of healthcare professionals, particularly more experienced professionals, in the implementation of SmED may help to facilitate sustainable implementation. In addition, training of potential user prior and during the implementation process and the adaption of Organisational Context factors are crucial. Trial registration The study was registered at the German Clinical Trials Register prior to the start of the study (DRKS00017014).

The on-call service (emergency service) has been reachable under 116117 in Germany since 2012. Nevertheless, this number is almost unknown to most Germans. A literature review of emergency service has shown that information which can be found is often incomplete and unclear. Thus, the aim of this study was to cover the status quo regarding 116117 at the federal level in Germany.In February 2019 all physicians working with a statutory health insurance were asked to fill in an online survey. The survey was based on a literature review regarding emergency service and on-call service at the federal level in Germany. The questionnaire covered different areas. In this paper only results regarding 116117 will be reported. Data were analyzed descriptively.The organization and range of services as well as the qualifications of the staff are structured differently at the federal level. Services provided by 116117 are arrangements for home visits, out-of-hours service appointments, consulting, and forwarding to 112. Staff includes physician assistants, nurses, and physicians.Standardized regulations at the federal level might improve transparency. The planned extension of 116117 to include a standardized initial medical assessment as well as 24/7 accessibility could facilitate patient access to adequate medical treatment.Der ärztliche Bereitschaftsdienst (ÄBD) ist seit 2012 unter der bundeseinheitlichen Rufnummer 116117 erreichbar. Die Rufnummer ist dennoch in Deutschland noch nicht weitreichend bekannt. Eine Literaturrecherche zum Themengebiet der ambulanten Notfallversorgung hat gezeigt, dass Informationen lückenhaft und teilweise unübersichtlich sind. Ziel dieser Arbeit ist es den Status Quo der Strukturen der 116117 auf Länderebene zu erfassen.Im Februar 2019 wurden alle 17 KV-Bezirke schriftlich zur Beantwortung einer Online-Befragung eingeladen. Der Online-Fragebogen basiert auf einer ausgedehnten Literaturrecherche zum Themengebiet ambulante Notfallversorgung und ÄBD auf Länderebene innerhalb Deutschlands. Der Fragebogen umfasst mehrere Bereiche, hier wird auf die Rufnummer 116117 eingegangen. Die Daten wurden deskriptiv ausgewertet.Die Organisation und das Leistungsspektrum sowie die Qualifikationen der Mitarbeiter der 116117 sind in den Bundesländern unterschiedlich strukturiert. Leistungen der 116117 umfassen die Vermittlung von Hausbesuchen, sowie an eine Bereitschaftsdienstpraxis, Beratung und die Weiterleitung an die 112. Das eingesetzte Personal reicht von MFAs über Pflegepersonal und Rettungsdienstpersonal bis hinzu Ärzten.Einheitliche Regelungen des Leistungsangebots und der eingesetzten Mitarbeiter können die Transparenz der 116117 auf Seiten der Patienten verbessern. Die geplante Erweiterung der 116117 um eine standardisierte medizinische Ersteinschätzung und die 24/7 Erreichbarkeit kann den Patienten die Zugangswege zu einer adäquaten medizinischen Versorgung erleichtern.

INTRODUCTION: Researchers in perinatal health, as well as other areas, may be interested in linking existing datasets to vital records data when the existence or timing of births is unknown. METHODS: 5914 women who participated in the Bogalusa Heart Study (1973–2009), a long-running study of cardiovascular health in childhood, adolescence, and adulthood, were linked to vital statistics birth data from Louisiana, Mississippi, and Texas (1982–2010). Deterministic and probabilistic linkages based on social security number, race, maternal date of birth, first name, last name, and Soundex codes for name were conducted. Characteristics of the linked and unlinked women were compared using t-tests, chi-square tests, and multiple regression with adjustment for age and year of examinations. RESULTS: The Louisiana linkage linked 4876 births for 2770 women; Mississippi linked 791 births to 487 women; Texas linked 223 births to 153 women; After removal of duplicates and implausible dates, this left a total of 5922 births to 3260 women. This represents a successful linkage of 55% of all women ever seen in the larger study, and an estimated 65% of all women expected to have given birth. Those linked had more study visits, were more likely to be black, and had statistically lower BMIs than unlinked participants. CONCLUSIONS: Linking unrelated study data to vital records data was feasible to a degree. The linked group had a somewhat more favorable health profile and was less mobile than the overall study population.

Objective:The Developmental Origins of Disease hypothesis has spurred increased interest in how prenatal exposures affect lifelong health, while mechanisms such as epigenetics may explain the multigenerational influences on health. Such factors are not well captured within conventional epidemiologic study designs. We explored the feasibility of collecting information on the offspring and grand-offspring of participants in a long-running study.Design:The Bogalusa Heart Study is a study, begun in 1973, of life-course cardiovascular health in a semirural population (65% white and 35% black).Main measures:Female participants who had previously provided information on their pregnancies were contacted to obtain contact information for their daughters aged 12 and older. Daughters were then contacted to obtain reproductive histories, and invited for a clinic or lab visit to measure cardiovascular risk factors.Results:Two hundred seventy-four daughters of 208 mothers were recruited; 81% (223) had a full clinic visit and 19% (51) a phone interview only. Forty-five percent of the daughters were black, and 55% white. Mean and median age at interview was 27, with 15% under the age of 18. The strongest predictors of participation were black race, recent maternal participation in the parent study, and living in or near Bogalusa. Simple correlations for cardiovascular risk factors across generations were between r = 0.19 (systolic blood pressure) and r = 0.39 (BMI, LDL).Conclusion:It is feasible to contact the children of study participants even when participants are adults, and initial information on the grandchildren can also be determined in this manner.

Background To examine the consistency and likely degree of bias in a study of cardiovascular health, linked with reproductive data over 40 years. Methods Linkage of vital statistics data of births to female Bogalusa Heart Study participants was compared to interviewing of female participants. The characteristics of participants, the agreement, and demographic, study-related, and medical predictors of discrepancy were analyzed, using kappa statistics, mean and median differences, and logistic regression. Results Overall, 3944 (66.7%) of participants were located by one or both sources. The strongest predictor of either linkage or interview was recent and/or frequent participation in the parent study. Agreement between the two sources was generally good (kappa > 0.9 for birthweight and 0.8 for gestational age). Black race, older age, and time since pregnancy were associated with greater discrepancy in reporting of outcomes, but cardiovascular risk factors generally were not. Conclusions Combining information from multiple sources to increase sample size and outcome ascertainment may be valid, which will increase population health sciences’ ability to leverage the many existing, large-scale sources to answer previously unexplored questions, even those that the data were not initially collected to answer. Electronic supplementary material The online version of this article (10.1186/s12874-019-0758-0) contains supplementary material, which is available to authorized users.

The assembly of integral membrane protein complexes is frequently supported by transmembrane domain (TMD) interactions. Here, we present the BLaTM assay that measures homotypic as well as heterotypic TMD-TMD interactions in a bacterial membrane. The system is based on complementation of β-lactamase fragments genetically fused to interacting TMDs, which confers ampicillin resistance to expressing cells. We validated BLaTM by showing that the assay faithfully reports known sequence-specific interactions of both types. In a practical application, we used BLaTM to screen a focussed combinatorial library for heterotypic interactions driven by electrostatic forces. The results reveal novel patterns of ionizable amino acids within the isolated TMD pairs. Those patterns indicate that formation of heterotypic TMD pairs is most efficiently supported by closely spaced ionizable residues of opposite charge. In addition, TMD heteromerization can apparently be driven by hydrogen bonding between basic or between acidic residues.

Neurogenic inflammation is considered as an animal model of human migraine attacks. Using flow cytometry, we examined T-cell subsets and their integrin expression in the peripheral blood of 32 migraine patients in order to evaluate a possible inflammatory process in humans, as postulated in the migraine animal model. Our results show that migraine patients have a significant increased proportion of T-helper (47.4 ± 6.3% vs 43.2 ± 5.8%; p< 0.01) and T-helper memory cells (23.6 ± 5.9 vs 20.3 ± 6.5%; p< 0.01). Moreover, the 22 migraine patients without aura also exhibited an increase of LFA-1 expression of T-helper cells (34.7 ± 11.5%) compared to the 35 controls (27.5 ± 12.0%; p< 0.01). These preliminary results support the hypothesis that immunological mechanisms (such as an enhanced lymphocyte endothelium interaction) could be part of the migraine pathophysiology in humans.

Computed tomographic (CT) scanning has mostly replaced x-rays as an imaging modality, but concerns exist because of excess radiation, missed injuries, and whether it is the definitive procedure for intubated patients. The purpose of this study was to characterize missed cervical spine injuries (CSIs).All pediatric (18) trauma patients from 2004 to 2006 were analyzed. Age, sex, Injury Severity Score (ISS), mechanism, time, and missed injuries were reviewed. Flexion/extension views were used in patients with prolonged intubation. Descriptive statistics, chi(2), Student's t test, and bivariate correlation were used.There were 1307 pediatric trauma patients admitted with 318 imaged for potential CSI. Computed tomography was the sole imaging study in 200, x-rays in 64, and both in 54. Time to C-spine clearance was similar for all modalities (P.05). For CT, 34 (10.7%) were initially positive for CSI with 7 false-positives (FPs) and no false-negative (FN). There were 18 patients with CSI identified by x-ray, with 5 FPs and 5 FNs (missed injuries). The 5 FNs missed by x-ray were all positive by CT scan and required no intervention. None of the flexion/extension views revealed an additional injury. Sex, intubated patients, ISS, age, type, and injury location were not predictive of a missed injury (P.05).The sensitivity of CT scan was 1.0, specificity was 0.976, and the positive predictive value was 79.4%. The sensitivity of plain x-ray was 61.5%, the specificity was 1.6%, and the positive predictive value was 61.5%.Our data suggest that CT scans should be the primary modality to image a CSI. Flexion/extension views did not add to the decision making for C-spine clearance after CT evaluation.

Excitatory and inhibitory neurotransmitters and biogenic amines are important signaling molecules stored by and released from endocrine cells. They are either synthesized or taken up by endocrine cells and subsequently stored in secretory vesicles. Analysis of these storage mechanisms and of the receptors of these paracrine signaling molecules revealed important cross-talk within endocrine glands which add to storage and release of peptide hormones. Components of the exocytosis apparatus are shared by the release of transmitters and hormones. They, as other classical markers, can serve as broad spectrum markers for neuroendocrine tumors. Novel specific markers arise from studies of the synthesis, uptake, and targets of transmitters identified as an additional paracrine signaling system in endocrine systems.

Sodium-lithium countertransport and blood pressure responses, maximal elevated plasma norepinephrine concentrations induced by acute physical work load and the carbohydrate metabolic state were analyzed in 40 children suffering from insulin-dependent diabetes mellitus (IDDM). Patients were selected according to the duration of the disease to get a horizontal insight into the progression of the diabetes. Sixteen healthy children served as controls. Sodium-lithium countertransport (Na-Li CT) was 281 +/- 64 mumol/l red blood cells (RBC) per hour in the control group. Na-Li CT was elevated in all diabetic groups (newly diagnosed: 455 +/- 48; diabetics for 5-7 years: 495 +/- 48; diabetics for 10-13 years: 470 +/- 36). Plasma norepinephrine concentration increased during physical exercise, the elevation was more pronounced in diabetic children being 13.5 +/- 10.4, 10.1 +/- 5.0 and 12.3 +/- 5.4 nmol/l in the three diabetic groups, respectively, which differed significantly from that of controls (7.94 +/- 2.9; P0.01). Systolic blood pressure increased significantly during physical exercise in each group. However, maximal elevated systolic blood pressure was higher in children who had diabetes for more than 10 years than in controls (158 +/- 11 vs. 137 +/- 9.7 mmHg; P0.001). Na-Li CT correlated positively with the maximal systolic blood pressure measured during physical exercise in those diabetic children who suffered from diabetes for more than 5 years. High activity of Na-Li CT in combination with elevated blood pressure and high plasma concentration of norepinephrine induced by acute physical exercise may represent a risk of renal/vascular complications in patients suffering from IDDM.