Migraine in the Emergency Department: A Prospective Multinational Study of Patient Characteristics, Management, and Outcomes

<b><i>Background and Aim:</i></b> Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. <b><i>Methods:</i></b> This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. <b><i>Results:</i></b> The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. <b><i>Conclusions:</i></b> This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required.

Optimal measures for primary care physician encounters after stroke and association with survival: a data linkage study

Background and Purpose: Primary care physicians provide ongoing management after stroke. However, little is known about how best to measure physician encounters with reference to longer term outcomes. We aimed to compare methods for measuring regularity and continuity of primary care physician encounters, based on survival following stroke using linked healthcare data. Methods: Data from the Australian Stroke Clinical Registry (2010-2014) were linked with Australian Medicare claims from 2009 2016. Physician encounters were ascertained within 18 months of discharge for stroke. We calculated three separate measures of continuity of encounters (consistency of visits with primary physician) and three for regularity of encounters (distribution of service utilization over time). Indices were compared based on 1-year survival using multivariable Cox regression models. The best performing measures of regularity and continuity, based on model fit, were combined into a composite ‘optimal care’ variable. Results: Among 10,728 registrants (43% female, 69% aged ≥65 years), the median number of encounters was 17. The measures most associated with survival (hazard ratio [95% confidence interval], Akaike information criterion [AIC], Bayesian information criterion [BIC]) were the: Continuity of Care Index (COCI, as a measure of continuity; 0.88 [0.76 1.02], p=0.099, AIC=13746, BIC=13855) and our persistence measure of regularity (encounter at least every 6 months; 0.80 [0.67 0.95], p=0.011, AIC=13742, BIC=13852). Our composite measure, persistent plus COCI ≥80% (24% of registrants; 0.80 [0.68 0.94], p=0.008, AIC=13742, BIC=13851), performed marginally better than our persistence measure alone. Conclusions: Our persistence measure of regularity or composite measure may be useful when measuring physician encounters following stroke.

Evaluation of the Completeness of ALS Case Ascertainment in the U.S. National ALS Registry: Application of the Capture-Recapture Method

Introduction: The Centers for Disease Control and Prevention (CDC) National Amyotrophic Lateral Sclerosis (ALS) Registry is the first national registry for a chronic neurologic disease in the U.S. and uses a combination of case-finding methods including administrative healthcare data and patient self-registration. Methods: We applied capture-recapture methodology to estimate the completeness of the Registry for ascertaining patients with ALS for the first full year and the fourth years of the Registry (2011, 2014). The Registry uses the combination of two national administrative claims databases (Medicare and Veterans Affairs) with a self-register option at the registry portal. We conducted descriptive analyses of the demographic and clinical characteristics of the ALS cases identified by each of the sources and estimated the completeness of case ascertainment for each of the three ALS Registry sources individually, pairwise, and in all combinations. Results: Case-finding completeness was 54% in 2011 and improved to 56% in 2014. A smaller proportion of ALS patients under age 65 were ascertained than those 65 or older and ascertainment was also lower for non-White than White patients. The uncorrected ALS prevalence was 4.3/100,000 in 2011 (in 2014 5.0/100,000), but after correction for under-ascertainment, annual prevalence in 2011 was 7.9/100,000 (95% CI 7.6-8.2) (in 2014 was 8.9/100,000 (95% CI 8.7-9.2)). Discussion/Conclusion: Our findings indicate that administrative healthcare databases are a very efficient method for identifying the majority of ALS prevalent cases in the National ALS Registry and that the inclusion of a web registry portal for patients to self-register is important to ensure a more representative population for estimating ALS prevalence. Nonetheless, more than 40% of ALS cases were not ascertained by the Registry, with individuals younger than age 65 and people of color underrepresented. Recommendations are provided for additional methods that can be considered to improve the completeness of case ascertainment.

Waterpipe Tobacco Smoking and Other Multiple Sclerosis Environmental Risk Factors

Introduction There are a number of well-established risk factors for multiple sclerosis (MS). Other factors however, showed conflicting or non-consistent results. Here we examine some factors that are unique to or more practiced in Saudi Arabia (SA) and the Arab region such as waterpipe tobacco smoking (WTS), face veiling, raw milk (RM), and camel milk (CM) consumption, tuberculosis (TB) infection in addition to other traditional factors. Methods This is a sex and age matched case-control study in which we used a structured questionnaire to examine the relation between a number of factors and exposures and the risk of MS. Three hundred MS patients and 601 controls were included. Data was analyzed across different statistical models using logistic regression adjusting for age, sex, marital status, duration of breastfeeding, age first joining school, coffee consumption, and face exposure. Results Cigarette smoking [OR = 1.79, (95% CI 1.01-3.17), P =0.047)], WTS [OR = 2.25, (95% CI 1.21-4.15), P =0.010)], and CM consumption [OR = 2.50, (95% CI 1.20-5.21), P =0.014)] increased the risk of MS. While performing hajj [OR = 0.47, (95% CI 0.34-0.67), P =0.001)], TB infection [OR = 0.29, (95% CI 0.11-0.78), P =0.015)], face veiling [OR = 0.32, (95% CI 0.23-0.47), P =0.001)] and coffee consumption [OR =0.67, (95% CI 0.49-0.89), P =0.008)], appeared to be associated with decreased risk. No association was found between fast food, processed meat, soft drinks, animal milk (other than camel) or RM consumption and the risk of MS. Conclusion The results of this case-control study confirm that different means of tobacco smoking are associated with increased risk of MS. It also sheds more light on the complex association between infections and MS.

A Multicentre Study Comparing Cerebrovascular Disease Profiles in Pacific Islander and Caucasian Populations Presenting with Stroke and Transient Ischaemic Attack

<b><i>Introduction:</i></b> In a multicentre study, we contrasted cerebrovascular disease profiles in Pacific Island (PI)-born patients (Indigenous Polynesian [IP] or Indo-Fijian [IF]) presenting with transient ischaemic attack (TIA), ischaemic stroke (IS) or intracerebral haemorrhage (ICH) with those of Caucasians (CSs). <b><i>Methods:</i></b> Using a retrospective case-control design, we compared PI-born patients with age- and gender-matched CS controls. Consecutive patients were admitted to 3 centres in South Western Sydney (July 2013–June 2020). Demographic and clinical data studied included vascular risk factors, stroke subtypes, and imaging characteristics. <b><i>Results:</i></b> There were 340 CS, 183 (27%) IP, and 157 (23%) IF patients; mean age 65 years; and 302 (44.4%) female. Of these, 587 and patients presented with TIA/IS and 93 (13.6%) had ICH. Both IP and IF patients were significantly more likely to present &#x3e;24 h from symptom onset (odds ratios [ORs] vs. CS 1.87 and 2.23). IP patients more commonly had body mass indexes &#x3e;30 (OR 1.94). Current smoking and excess alcohol intake were higher in CS. Hypertension, diabetes, and chronic kidney disease were significantly higher in both IP and IF groups in comparison to CS. IP patients had higher rates of AF and those with known AF were more commonly undertreated than both IF and CS patients (OR 2.24, <i>p</i> = 0.007). ICH was more common in IP patients (OR 2.32, <i>p</i> = 0.005), while more IF patients had intracranial arterial disease (OR 5.10, <i>p</i> &#x3c; 0.001). <b><i>Discussion/Conclusion:</i></b> Distinct cerebrovascular disease profiles are identifiable in PI-born patients who present with TIA or stroke symptoms in Australia. These may be used in the future to direct targeted approaches to stroke prevention and care in culturally and linguistically diverse populations.

Traumatic Brain Injury and Risk of Dementia and Alzheimer’s Disease: A Systematic Review and Meta-Analysis

Introduction: Previous studies have investigated the potential role of traumatic brain injury (TBI) in subsequent development of dementia and Alzheimer’s disease (AD) but reported inconsistent results. We aim to determine the association between TBI and subsequent occurrence of dementia and AD. Methods: We performed a systematic search in PubMed and Web of Science for studies that quantitatively investigated the association between TBI and risk of dementia and AD and were published on or before September 21, 2021. A random-effect model was used to combine the estimates. Results: Twenty-five eligible articles were included in this meta-analysis. The results suggested that TBI was associated with an increased risk of dementia (pooled odds ratio [OR] = 1.81, 95% confidence interval [CI] = 1.53 - 2.14). However, no association was observed between TBI and Alzheimer’s disease (pooled OR = 1.02, 95% CI = 0.91 - 1.15). In the subgroup analysis, TBI with loss of consciousness was not associated with risk of dementia (pooled OR = 0.96, 95% CI = 0.84 - 1.09). Besides, Asian ethnicity, male gender, and mean age of the participants less than 65 were associated with a higher risk of dementia. Conclusion: Our study suggests an increased risk of dementia among individuals with TBI, highlighting the need for more intensive medical monitoring and health education in individuals with TBI. Biological mechanisms linking TBI and the development of dementia are needed in future studies.

Creutzfeldt - Jakob Disease in South West Sydney 2014-2020: An Unusually High Incidence of a Rare Disease

Introduction Creutzfeldt - Jakob Disease (CJD), a spongiform encephalopathy, caused by a transmissible misfolded cellular prion protein is a rapidly progressive, debilitating neuro-degenerative disorder with no effective treatment. The estimated global incidence is at 1/ million inhabitants. This retrospective study examined the incidence of CJD in South Western Sydney Local Health District (SWSLHD) from 2014 to 2020. Background SWSLHD had an estimated population of 1,038,534 in 2020, with CJD data being limited. Methods New South Wealth (NSW) Health-Information-Exchange (HIE) database, for all admissions with CJD diagnoses in SWSLHD, between 2014–2020, was reviewed according to World Health Organization (WHO) diagnostic criteria, consistent with the Australian national CJD registry. Only probable CJD cases were included. Incidence was calculated based on the projected SWSLHD population. Results 35 patients, diagnosed with CJD, were identified. Each was evaluated by two independent investigators, including clinical presentation; MRI; EEGs; 14-3-3; and RT-QUIC results, before assigning CJD-probable status. Four failed the CJD criteria and were excluded. Of the 31 CJD-probable cases, most (59%) were male and older (37% range 61-70 years). The incidence rate peaked at 9/million in 2017 and was above 2/million, throughout the seven years, with an average of 4.859/million/year. Conclusions The incidence of CJD, in SWSLHD, exceeds the national average of 1/million. Cost-effective, adequate diagnostic and screening tools, implementable over a large population, will become increasingly essential.

Prevalence of Parkinson’s disease in China: a multicenter population-based survey

ABSTRACT Objective: Few data are available on the current prevalence of Parkinson's disease in China. The aim of this study was to determine the prevalence of Parkinson's disease in Chinese individuals aged 65 years and older and to analyze associated risk factors. Methods: We performed a population-based cross-sectional survey with a multistage cluster sampling design. Residents aged 65 and over were drawn from 11 urban districts and 10 rural counties across China. Data were entered into spreadsheets, and imported and analyzed using Statistical Package SPSS 24. Results: We identified 151 patients with Parkinson's disease among 8124 residents aged 65 and over, including 75 men (49.67%) and 76 women (50.33%). The overall prevalence of PD in the study population was 1.86% (95% confidence interval [CI]: 1.6%–2.2%), and the standardized prevalence of PD was 1.60%. The crude prevalence in men (2.12%) was higher than in women (1.66%), and standardized prevalence in urban areas (1.98%) was higher than in rural areas (1.48%). Logistic regression analysis showed that independent risk factors for PD were older age, heavy metal or pesticide exposure (odds ratio [OR]=3.83; 95% CI: 2.021–7.256), urban residence (OR=1.307; 95% CI: 1.041–1.642), rapid eye movement sleep behavior disorder (OR=1.450; 95% CI: 1.021–2.059), and heart disease (OR=2.431; 95% CI: 1.481–4.990). Conclusion：The prevalence of Parkinson's disease in individuals aged 65 and older in China has not increased significantly in recent years. The prevalence of Parkinson's disease is higher in men than in women and higher in urban areas than in rural areas.