Use Of Prophylactic Medications Research Articles

Prevention of postoperative atrial fibrillation in cardiac surgery: a quality improvement project

PurposePostoperative atrial fibrillation (POAF) has an incidence of 20–60% in cardiac surgery. The Society of Cardiovascular Anesthesiologists and the European Association of Cardiothoracic Anaesthesiology Practice Advisory have recommended postoperative beta blockers and amiodarone for the prevention of POAF. By employing quality improvement (QI) strategies, we sought to increase the use of these agents and to reduce the incidence of POAF among our patients undergoing cardiac surgery.MethodsThis single-centre QI initiative followed the traditional Plan, Do, Study, Act (PDSA) cycle scientific methodology. A POAF risk score was developed to categorize all patients undergoing cardiac surgery as either normal or elevated risk. Risk stratification was incorporated into a preprinted prescribing guide, which recommended postoperative beta blockade for all patients and a postoperative amiodarone protocol for patients with elevated risk starting on postoperative day one (POD1). A longitudinal audit of all patients undergoing cardiac surgery was conducted over 11 months to track the use of prophylactic medications and the incidence of POAF.ResultsFive hundred and sixty patients undergoing surgery were included in the QI initiative from 1 December 2020 to 1 November 2021. The baseline rate of POAF across all surgical subtypes was 39% (198/560). The use of prophylactic amiodarone in high-risk patients increased from 13% (1/8) at the start of the project to 41% (48/116) at the end of the audit period. The percentage of patients receiving a beta blocker on POD1 did fluctuate, but remained essentially unchanged throughout the audit (34.8% in December 2020 vs 46.7% in October 2021). After 11 months, the overall incidence of POAF was 29% (24.9% relative reduction). Notable reductions in the incidence of POAF were observed in more complex surgical subtypes by the end of the audit, including multiple valve replacement (89% vs 56%), aortic repair (50% vs 33%), and mitral valve surgery (45% vs 33%).ConclusionsThis single-centre QI intervention increased the use of prophylactic amiodarone by 28% for patients at elevated risk of POAF, with no change in the early postoperative initiation of beta blockers (46.7% of patients by POD1). There was a notable reduction in the incidence of POAF in patients at elevated risk undergoing surgery.

Treatment-Related Clinical and Humanistic Unmet Needs in Hemophilia A without Inhibitors

Introduction: Patients with hemophilia still experience significant burden of disease despite the growing availability of efficacious treatment options. Presented here are the final patient-reported data from a non-interventional study of treatment and disease burden in US patients with hemophilia A without inhibitors (HAwoI). Methods: Patients with HAwol were recruited to the PicnicHealth research platform using digital marketing, referrals and community partnerships. PicnicHealth collects and extracts medical records on behalf of the patient, provides them with their records and invites them to participate in recurring patient-reported outcome surveys. Hemophilia severity reported here was based on baseline factor values and medical records. Two validated questionnaires, Hemophilia Treatment Experience Measure (Hemo-TEM)(Brod, M. et al., J Patient Rep Outcomes. 2023) and Patient-Reported Outcomes Measurement Information System (PROMIS)-29 Profile v2.0 (Hays, R.D., et al., Qual Life Res. 2018)were used to collect data on treatment and disease burden. Patients were also asked about their prophylactic medication, if any, as well as two independent questions on anxiety and/or worry concerning bleed protection with current treatment. All surveys were administered between April 2022 and April 2023, with the most recent survey included in this analysis for patients who completed multiple surveys during the study period. Hemo-TEM domain scores were transformed onto a 0 to 100-point scale with higher scores indicating greater burden. PROMIS-29 scores were transformed into T-scores, based on a reference sample with a mean of 50 and standard deviation of 10, except for the pain intensity score, which was rated 0-10. The directionality of impact was specific for each domain (Hays, R.D., et al., Qual Life Res. 2018). Results are presented as proportions, median and interquartile range (IQR, Q1-Q3). Informed consent was obtained. Results: Out of 230 patients with HAwol (91% male; median age: 33.3 years; IQR: 23.9-41.7), 147 (64%) had severe, 41 (18%) had moderate and 42 (18%) had mild hemophilia. Use of prophylactic FVIII was reported by 74 (50%), 16 (39%) and 13 (31%) patients with severe, moderate and mild hemophilia, respectively, while prophylactic non-factor replacement therapy use was reported by 64 (44%), 8 (20%) and 5 (12%) patients, respectively (treatment classes are not mutually exclusive). Treatment class was unspecified (includes patients who did not report prophylactic medication use) for 58 (25%) patients. Treatment burden was observed through Hemo-TEM scores across all subgroups of disease severity and treatment class (n=223), with the strongest drivers being physical impact (median: 25 [IQR: 12-38]), treatment bother (21 [9-32]) and emotional impact (21 [6-38]) domains (Table 1). The PROMIS-29 scores and its directionality shown in Figure 1 demonstrated comparable disease burden in all domains regardless of disease severity or treatment class (n=228). Patients with severe disease on prophylactic FVIII/prophylactic non-factor replacement therapy reported scores of 42 (37-50)/46 (39-57) in physical functioning and 51 (49-61)/49 (46-55), 57 (52-64)/56 (42-60) and 52 (48-56)/52 (46-56) in domains of fatigue, pain interference and sleep disturbance, respectively. Impact on mental well-being for these patients were shown by scores of 56 (49-61)/54 (41-59) and 58 (51-63)/56 (51-61) in domains of depression and anxiety, respectively. Pain intensity for all patients with severe disease was 4 (2-6) out of 10. In response to two independent survey questions, patients with severe HAwol reported feeling anxious (42%) and/or worried (39%) at least sometimes that their current treatment might not adequately protect them from bleed. Conclusion: Patients with HAwoI continue to experience treatment and disease burden, across treatment class and disease severity subgroup. Despite improved outcomes with current treatment strategies, there remains a need to continue to address disease burden. Greater understanding is required of the driving factors behind similar treatment and disease burden between the subgroups to facilitate individualized care.

Effect of randomized prophylactic nitroglycerin on radial artery spasm during transradial catheterization: An analysis based on operator experience.

One limitation to transradial access (TRA) is the occurrence of spasms (RAS), for which the use of prophylactic medications is recommended. Improvement in TRA material combined with the increase in operators' expertise, might mitigate this benefit. We assess the effect of preventive nitroglycerin on RAS during TRA, evaluating the role of the operator's experience. Patients received 500 μg nitroglycerin or placebo. The operator's expertise was classified as: inexperienced (I), intermediate (M), and experienced (E). 2040 patients were included. Prophylactic use of nitroglycerin did not reduce RAS (10.8% vs. 13.4% (placebo), p = 0.07). RAS incidence was 14.5% in I, 12.5% in M, and 9.7% in E (p = 0.01). In group I, nitroglycerin reduced RAS (17.4% vs. 11.1%, p = 0.04), which was not observed in other groups. Overall, nitroglycerin does not prevent RAS, which is more common among inexperienced operators. More experienced operators could abolish preventive nitroglycerin use.

Influence of sleep and physical exercise in migraine patients

IntroductionThe prevalence of headache and sleep disorders is quite high in the general population. Both are chronic pathologies considered factors of daily disability which often coexists in migraine patients. A cause-and-effect relationship between migraine attacks and sleepless nights has not been confirmed yet, but it is already recognized that they have in common neuropeptides and functional anatomy in their pathogenesis. Because of this high prevalence, there are several studies on treatment options and prophylactic measures for migraine. The regular practice of physical exercises is identified as an important prevention factor for migraine attacks. However, daily intense physical activities are identified as triggers for these attacks. ObjectivesTo investigate the correlation between sleep time and frequency of physical activity with headache days per month, migraine disability, allodynia, hyperacusis, anxiety and depression. MethodsCross-sectional study composed of 466 individuals of both sexes diagnosed with migraine. Patient data such as age, sex, race, body mass index (BMI), waist circumference, presence of hypertension and diabetes were analyzed. It was obtained information about the type of migraine (episodic or chronic; with or without aura), age of symptoms onset, duration of illness, use of prophylactic medication and excessive use of analgesics, as well as hours of sleep per night and frequency of practice of physical activity. Patients answered questionnaires to evaluate disability (Migraine Disability Assessment - MIDAS) and the impact of migraine (HIT-6), as well as questionnaires for anxiety (STAI Y1 and STAI Y2), depression (Beck Depression Scale), allodynia (ASC-12) and hyperacusis. Spearman's correlation test was performed and a statistical difference was considered when p ≤ 0.05. (To see the complete abstract, please, check out the PDF).

Using Prophylactic Antihemorrhagic Medications in Second-Trimester Surgical Abortions.

We aimed to estimate the association of prophylactic antihemorrhagic medication use during dilation and evacuation (D&E) with operative hemorrhage and estimated blood loss (EBL). Records for all pregnant patients between 14 and less than 22 weeks of gestation who had a D&E procedure from January 2012 to December 2019 were retrospectively reviewed. Prophylactic antihemorrhagic medication use was defined as receiving vasoconstrictors, uterotonics, or both before identification of hemorrhage during a D&E procedure. Overall, 147 D&E procedures were completed at a mean of 16.4 (±2.2) weeks of gestation. Prophylactic medications were used in 72.1% (n=106) of D&E procedures. Prophylactic medication use was associated with lower operative hemorrhage (21.7% vs 51.2%, P <.01) and lower EBL (336.9 mL vs 551.3 mL, P <.01).

Global perceptions of the current and future impacts of COVID-19 on hereditary angioedema management.

Background: The coronavirus disease 2019 (COVID-19) pandemic has greatly affected health-care provision across the globe. Management of chronic ailments has become challenging because of the strained health-care resources and social distancing measures that prevent on-site clinical visits and treatments. Hereditary angioedema (HAE) is a debilitating, chronic disease characterized by unpredictable swelling attacks in various parts of the body. Controlling HAE symptoms often requires long-term prophylactic medication use and regular medical care; however, limited scientific information has been published about HAE medical care during the COVID-19 pandemic. Objective: To gather patient and health-care professional (HCP) perspectives on the global impact that COVID-19 has had, and the future impact it will have on HAE medical care and to identify differences in perceptions across economic and geographic boundaries. Methods: We conducted two independent but similar online global surveys to capture patient and HCP perspectives on the impact that COVID-19 has had, and the future impact it will have on HAE medical care. Results: Both patients and HCPs globally reported that the pandemic has limited the availability of HAE medical care, and they expect the restrictions to continue far beyond the pandemic. In addition, the results of our study suggested that telehealth use has increased across the globe but has been more successfully implemented in high-income countries. Conclusion: Patients and HCPs expect that HAE-related care will be negatively impacted by the pandemic for many years. Disparities in medical care and technologic infrastructure may exacerbate these challenges in non-high-income countries. Supportive tools and global infrastructure should be established to provide aid to non-high-income countries throughout the pandemic and several years after.

Prospective cohort study of routine exercise and headache outcomes among adults with episodic migraine.

To evaluate the association of routine exercise with headache frequency, intensity, and duration among adults with episodic migraine (EM). A comprehensive management plan for EM must aim at reducing disability and cost of care; to do so requires optimizing acute and preventive medications, and behavior changes. Prophylactic medication use is associated with adverse events and contraindications with comorbidities. Aerobic exercise is reported to decrease migraine frequency. However, no study has evaluated a potential synergistic relation between regular exercise and preventive medication use among patients with EM. This was a secondary analysis of data from a prospective cohort study of adults with EMs. In that study, adults with EM (using International Classification of Headache Disorders-3 criteria confirmed by study physicians) were recruited from three academic medical centers in Boston, MA. At baseline, participants provided information on exercise, clinical and demographic characteristics, and lifestyle behaviors. We prospectively collected daily information on headaches and health behavior over at least 6weeks using electronic questionnaires from 94 participants. We assessed the association between baseline self-reported moderate-vigorous exercise at least three times per week, at baseline, and prospectively recorded headache frequency, intensity, and duration. We further assessed whether these associations differed by the prevalent use of prophylactic migraine medication. Data from 94 of 98 eligible participants were used in the analysis as 4 participants had missing data on routine exercise frequency or intensity at baseline. On average, patients who reported moderate-vigorous exercise at least three times per week at enrollment had 1.5 fewer headache days per month (-1.5 headache days/month; 95% confidence interval [CI] -3.1 to 0.1) compared to less exercise; this was not statistically significant (p=0.066). The association between exercise and headache days per month varied by baseline use of migraine prophylaxis (p-value of interaction=0.009). Among those who reported regular use of migraine prophylaxis, a report of moderate-vigorous exercise at least three times per week was associated with 5.1 fewer headache days (-5.1: 95% CI -8.2 to -2.0; p=0.001) compared to those who reported lower levels of exercise. However, among those not using migraine prophylaxis, we observed only 0.4 fewer headache days per month (-0.4: 95% CI -2.2 to 1.3; p=0.636) associated with moderate-vigorous exercise at least three times/week, a result that was not statistically significant. There was no association of self-reported moderate-vigorous exercise at least three times a week with headache intensity or duration. In patients with EM, those who reported moderate-vigorous exercise at least three times per week had fewer headache days per month, though not statistically significant. This association was significantly stronger in those who used prophylactic medication for migraines. Exercise appeared not to be associated with the severity or duration of headaches. Routine moderate-vigorous exercise may be an important adjunctive strategy for improving headache burden in patients eligible for migraine prophylaxis.

PND55 IMPACT OF BAROMETRIC PRESSURE CHANGES AND PROPHYLACTIC MIGRAINE MEDICATION USE ON THE OCCURRENCE OF SEVERE MIGRAINES: A CASE-CROSSOVER STUDY USING LINKED WEATHER AND CLAIMS DATA

Severe migraine patients may use prophylactic medications to reduce the number or severity of their headaches. Patients often experience a migraine after a meteorological change, and the association between these events and occurrence of severe migraines for patients with and without prophylactic use was examined. A case-crossover design was implemented utilizing the IBM® MarketScan Weather Database, which links weather data with administrative claims data using metropolitan statistical area (MSA)-specific daily weather data and the patients’ MSA from administrative claims. Patients with ≥1 severe migraine (a migraine-related inpatient or emergency room visit) between 2015 and 2017 were selected. The date of the first severe migraine was the ‘case date.’ Patients were stratified by whether or not they had a pharmacy claim for medication commonly used for migraine prophylaxis between 180 days before and 7 days after the case date. Three control dates were selected for comparison: 7 days before, 28 days before, and 7 days after the case date. Weather conditions on the case date versus control dates were compared via conditional logistic regression model to determine if weather conditions were predictive of a severe migraine for patients with or without prophylactic. The study included 34,776 patients who met the inclusion criteria. Of these, 17,508 patients used a prophylactic, while 17,268 did not. The conditional logistic regression model revealed that for each 1 inHg increase in daily maximum barometric pressure, the odds of severe migraine increased by 9% (OR: 1.09; p=0.025) for patients with prophylactic, and by 56% (OR: 1.56; p<0.001) for those without, controlling for other weather conditions. This study utilized a novel linked weather and administrative claims database to provide real-world evidence of the impact of prophylactic medication use on severe migraine events after changes in barometric pressure.

Medication overuse headache in 787 patients admitted for inpatient treatment over a period of 32 years.

Definitions of medication overuse headache have changed over time. To evaluate the clinical characteristics of medication overuse headache patients admitted for inpatient withdrawal therapy over a period of 32 years. We included all patients with medication overuse headache treated from 1 January 1984 to 31 December 2015. We obtained all data from the medical reports and defined three periods, P1 (1984-1993), P2 (1994-2003), and P3 (2004-2015). The p-value adjusted for multiple comparisons was set to 0.005. Within 32 years, a total of 787 patients accounted for 904 admissions for MOH. From P1 to P3, the proportion of patients with preexisting migraine increased from 44.3% to 53.3% (chi2 = 9.0, p = 0.01) and that with preexisting tension-type headache decreased from 47.9% to 34.6% (chi2 = 9.3, p < 0.01). The median time since onset of headache and medication overuse headache decreased from 20 to 15 years (p < 0.001) and from 3 to 2 years (p < 0.001). The median cumulative number of single doses decreased from 120 to 90 per month (p = 0.002). Overuse of triptans, non-opioid analgesics, and opioids increased, whereas overuse of ergotamines decreased over time (p < 0.001 for all tests). The use of prophylactic medication before admission increased from 8.3% to 29.9% (chi2 = 89.5, p < 0.001). This retrospective study in a large number of patients with medication overuse headache admitted for inpatient withdrawal therapy over a period of 32 years shows a trend towards changes in the preexisting headache type, a decrease in the time since onset of headache and medication overuse headache, a decrease in the number of drug doses used per month, changes in the type of drugs overused, and an increase in, but still low rate, of prophylactic medication prior to admission.

Efficacy, safety, and tolerability of rimegepant orally disintegrating tablet for the acute treatment of migraine: a randomised, phase 3, double-blind, placebo-controlled trial

Rimegepant, a small molecule calcitonin gene-related peptide receptor antagonist, has shown efficacy in the acute treatment of migraine using a standard tablet formulation. The objective of this trial was to compare the efficacy, safety, and tolerability of a novel orally disintegrating tablet formulation of rimegepant at 75 mg with placebo in the acute treatment of migraine. In this double-blind, randomised, placebo-controlled, multicentre phase 3 trial, adults aged 18 years or older with history of migraine of at least 1 year were recruited to 69 study centres in the USA. Participants were randomly assigned to receive rimegepant (75 mg orally disintegrating tablet) or placebo and instructed to treat a single migraine attack of moderate or severe pain intensity. The randomisation was stratified by the use of prophylactic medication (yes or no), and was carried out using an interactive web response system that was accessed by each clinical site. All participants, investigators, and the sponsor were masked to treatment group assignment. The coprimary endpoints were freedom from pain and freedom from the most bothersome symptom at 2 h postdose. The efficacy analyses used the modified intention-to-treat population, which included all patients who were randomly assigned, had a migraine attack with pain of moderate or severe intensity, took a dose of rimegepant or placebo, and had at least one efficacy assessment after administration of the dose. The safety analyses included all randomly assigned participants who received at least one dose of study medication. This study is registered with ClinicalTrials.gov, number NCT03461757, and is closed to accrual. Between Feb 27 and Aug 28, 2018, 1811 participants were recruited and assessed for eligibility. 1466 participants were randomly assigned to the rimegepant (n=732) or placebo (n=734) groups, of whom 1375 received treatment with rimegepant (n=682) or placebo (n=693), and 1351 were evaluated for efficacy (rimegepant n=669, placebo n=682). At 2 h postdose, rimegepant orally disintegrating tablet was superior to placebo for freedom from pain (21% vs 11%, p<0·0001; risk difference 10, 95% CI 6-14) and freedom from the most bothersome symptom (35% vs 27%, p=0·0009; risk difference 8, 95% CI 3-13). The most common adverse events were nausea (rimegepant n=11 [2%]; placebo n=3 [<1%]) and urinary tract infection (rimegepant n=10 [1%]; placebo n=4 [1%]). One participant in each treatment group had a transaminase concentration of more than 3 × the upper limit of normal; neither was related to study medication, and no elevations in bilirubin greater than 2 × the upper limit of normal were reported. Treated participants reported no serious adverse events. In the acute treatment of migraine, a single 75 mg dose of rimegepant in an orally disintegrating tablet formulation was more effective than placebo. Tolerability was similar to placebo, with no safety concerns. Biohaven Pharmaceuticals.

Treatment patterns in patients using triptan and prophylactic medication: an analysis of clinical practice prior to the introduction of CGRP antagonists.

PurposeThe newly developed calcitonin gene-related peptide (CGRP) antagonists were recently launched on the US and European market, with Switzerland as the second country worldwide. To enable forthcoming comparisons with established migraine therapy, the aim of this study was to provide a comprehensive picture of migraine (prophylactic) treatment patterns. Recent data in daily clinical practice are lacking.Patients and methodsThis population-based cohort study included enrollees from a Swiss Healthcare Insurance Database with at least one triptan prescription in 2015. Treatment patterns were defined by assessing subsequent triptan and prophylactic medication use (after index prescription for triptan) within the following year, divided into four quarters.ResultsTriptans were used by 10,090 patients (1.3%) in 2015. Most of them used triptan only (82.6%), 12.9% changed the treatment between triptan and prophylactics, and 4.5% received both in combination within 1year. Among triptan users with ≥1 prophylactic prescription in the first quarter, 48.6% used beta-blockers (BB), 40.7% “other prophylactics than BB (eg, topiramate)”, and 10.7% “a combination of both”. Most patients who received both BB and other prophylactics in the first quarter used this drug combination continuously over all four quarters.ConclusionThis study provides comprehensive data on treatment patterns prior to the introduction of a new drug class in migraine therapy. The majority of triptan users had no prophylactic medication therapy; however, a small, but relevant group used BB and other prophylactics concurrently in all quarters. Findings quantify the population in potential need for optimized migraine therapy, ie, the potential target population of the novel CGRP-targeted drugs.

Variables Associated With the Use of Prophylactic Amitriptyline Treatment in Patients With Tension-type Headache.

The objective of this study was to investigate differences in clinical, psychological, and psychophysical outcomes according to use of prophylactic medication (amitriptyline) in tension-type headache (TTH). In total, 173 individuals with TTH participated. Headache features and symptomatic medication intake were collected with a 4-weeks headache diary at baseline and at 6-months. Burden of headache (Headache Disability Inventory-HDI), sleep quality (Pittsburgh Sleep Quality Index-PSQI), anxiety/depression (Hospital Anxiety and Depression Scale-HADS), and trait/state anxiety levels (State-Trait Anxiety Inventory-STAI) were also assessed at baseline. Pressure pain thresholds (PPT) were assessed over the temporalis, C5-C6 joint, second metacarpal, and tibialis anterior at baseline. Differences between participants taking or not taking prophylactic medication based on self-perceived effectiveness of the medication on headache characteristics were assessed. In total, 49 (28%) reported taking prophylactic medication for the headaches (amitriptyline: 100%). From these, 11 (23%) reported no effect, 25 (51%) reported moderate effect, and 13 (26%) reported positive effect with medication. Patients taking prophylactic medication had longer headache history, higher frequency of headaches (61% CTTH), higher headache burden, worse quality of sleep, and higher depression than those not taking medication. Prophylactic medication was less effective in patients with generalized pressure pain hyperalgesia. No other significant differences were found. Prophylactic medication is used by TTH patients with higher headache frequency, higher headache burden, worse sleep quality, and higher depression. Lower effectiveness of prophylactic amitriptyline was associated with widespread pain hyperalgesia.

Patterns of initial migraine treatment in Denmark: A population-based study.

Population-based data are sparse on utilization of prophylactic versus acute therapies for newly diagnosed migraine. We examined initial migraine treatment patterns and associated patient characteristics in Denmark. We used population-based health databases to assemble a nationwide cohort of adult migraine patients in 2005 to 2013. Migraine was defined as a first hospital diagnosis of migraine or a second redeemed outpatient prescription for triptans, ergots, pizotifen, or flunarizine. We classified the initial migraine treatment received after migraine onset as "no treatment," "acute only," "prophylactic only," and "both acute and prophylactic" and described distributions of sex, age, comorbidities, and comedications. Among 97431 migraine patients (78% women, median age of 41y [interquartile range of 32-50y]), the initial migraine treatments received were "acute only" (88.2%), "prophylactic only" (1.9%), and "both acute and prophylactic" (5.2%) whereas 4.6% had no record of treatment. Initiators of prophylactic treatment-with or without acute treatment-were less likely than initiators of acute treatment to be women (71% and 77% versus 79%), were older (median ages: 45 and 44y versus 41y), and had more comorbidities (including hypertension [31% and 24% versus 7%] and diabetes [6% and 5% versus 3%]). Nonpersistence with initial prophylactic treatment was common: within the first year, 35% of initiators stopped therapy fully, 50% stopped and restarted, and 15% switched drugs. For 88% of patients with incident migraine, the initial migraine treatment was acute treatment only. Use of prophylactic medication as initial treatment was low and correlated with higher age and comorbidity.

The burden of migraine in Belgium: results from the My Migraine Voice Survey.

The burden of migraine in Belgium: results from the My Migraine Voice Survey.

A Study on the Leptospirosis Outbreak Among US Marine Trainees in Okinawa, Japan.

The US Marines operate the Jungle Warfare Training Center (JWTC) in Northern Okinawa, where leptospirosis is endemic. The JWTC endurance course involves prolonged fresh and stagnant water exposures in a simulated jungle warfare environment. Since a leptospirosis outbreak in 1987, JWTC has required prophylactic use of doxycycline at 200 mg weekly during exposure to the endurance course. This policy is based on a 1982 study in a similar environment in Panama. In August and September of 2014, an outbreak of leptospirosis occurred among 81 Marines training at JWTC. We analyzed data from the largest reported outbreak of leptospirosis among US military members. Two hundred and thirty nine US Marines who completed the endurance course were interviewed by trained personnel regarding their exposures and use of prophylactic medication utilizing a standardized questionnaire. All available personnel who went through the course during the outbreak period were interviewed regardless of whether or not they became ill. The Armed Forces Health Surveillance Branch's case definition was used to identify cases. Eighty-one cases in 239 personnel were identified (attack rate = 33.9%). Exposures linked to being a case were swallowing water in the stagnant pond (attack rate ratio [ARR] = 2.3, 95% confidence interval [CI] = 1.4-3.7), cuts on the body (ARR = 1.5, 95% CI = 1.01-2.11), and insect bites (ARR = 2.0, 95% CI = 1.2-3.4). Exposures not linked to being a case were taking doxycycline before the exposure (ARR = 3.2, 95% CI = 0.5-22.2), taking doxycycline after the exposure (ARR = 0.9, 95% CI = 0.6-1.3), and swallowing water in the natural stream (ARR = 1.3, 95% CI = 0.9-1.9). Attack rate data indicate that whether or not personnel took pre- or post-exposure doxycycline made no difference statistically. Increased internal exposure (via swallowing water or through broken skin) increased risk of symptomatic disease. This new study combined with a growing body of literature should prompt researchers to re-examine recommendations for those with significant water exposure in areas with high leptospirosis levels.

Cluster headache - clinical pattern and a new severity scale in a Swedish cohort.

Background The aim of this study was to investigate clinical features of a cluster headache cohort in Sweden and to construct and test a new scale for grading severity. Methods Subjects were identified by screening medical records for the ICD 10 code G44.0, that is, cluster headache. Five hundred participating research subjects filled in a questionnaire including personal, demographic and medical aspects. We constructed a novel scale for grading cluster headache in this cohort: The Cluster Headache Severity Scale, which included number of attacks per day, attack and period duration. The lowest total score was three and the highest 12, and we used the Cluster Headache Severity Scale to grade subjects suffering from cluster headache. We further implemented the scale by defining a cluster headache maximum severity subgroup with a high Cluster Headache Severity Scale score ≥ 9. Results A majority (66.7%) of the patients reported that attacks appear at certain time intervals. In addition, cluster headache patients who were current tobacco users or had a history of tobacco consumption had a later age of disease onset (31.7 years) compared to non-tobacco users (28.5 years). The Cluster Headache Severity Scale score was higher in the patient group reporting sporadic or no alcohol intake than in the groups reporting an alcohol consumption of three to four standard units per week or more. Maximum severity cluster headache patients were characterised by higher age at disease onset, greater use of prophylactic medication, reduced hours of sleep, and lower alcohol consumption compared to the non-cluster headache maximum severity group. Conclusion There was a wide variation of severity grade among cluster headache patients, with a very marked impact on daily living for the most profoundly affected.

P110: Acute mountain sickness in the Himalayas: preliminary report

Introduction: Acute Mountain Sickness (AMS) is a high-altitude medical emergency that requires prompt treatment. If left untreated AMS can progress to high-altitude cerebral edema or pulmonary edema, both of which can be fatal. As the popularity of high altitude trekking increases in the Himalayas we were interested in determining what rates of AMS are on popular routes in this region. Methods: AMS was diagnosed using a standardized Lake Louise Symptom Score (LLSS) where scores 3-5 denoted mild AMS and &amp;gt;5 denoted severe AMS. Forms were distributed to trekkers prior to departure and symptoms scores were determined daily. Data on medical history and patient demographics were also collected. All data are expressed as mean ±SEM. Results: Preliminary results are reported from N=17 (4 female) participants. Mean age was 43.7±3.9y. Most subjects, 68.8%, had trekked above 2500 m in the past. Only 6.25% reported having no knowledge of AMS, with the others having limited or expert knowledge. 25% of subjects had previously suffered from AMS. Most subjects, 82.4%, took prophylactic AMS medication, acetazolamide; at a dose of 250 mg/d. Subjects trekked at a mean altitude of 3650±85 m and ascended to a maximum altitude of 5012±103 m. The mean LLSS was 1.48±0.31 with a maximal LLSS of 4.76±0.75. Within our sample, 70.86% suffered from AMS at some point during their trek. Of those who suffered from AMS, the mean number of days affected was 3.17±0.61, and of those with severe AMS, mean number of days affected was 2.14±0.7. Conclusion: Over 70% of trekkers to the Himalayas experience AMS for an average of 3d, despite the use of prophylactic medication that most participants take. Almost 95% of trekkers have working knowledge of AMS and most have prior experience trekking at high-altitude. Given the dangers of high altitude trekking, pre-departure education for patients, especially those with chronic diseases, alongside prophylactic medication for AMS may help mitigate the risk.

Pharmacists' impact on opportunistic infection prophylaxis in patients with HIV/AIDS

Pharmacists have demonstrated a positive impact on the care of patients with human immunodeficiency virus/acquired immunodeficiency syndrome through enhancing patient outcomes associated with antiretroviral therapy. This pre- and postintervention study assessed the impact of pharmacist intervention on improving the use of prophylactic medications for opportunistic infections (OI). Of the 139 patients screened, 42 patients were included in the prospective intervention group. A total of 27 interventions were made on 15 patients, and 24 recommendations (89%) were accepted by providers. Compared with the retrospective control group, prescribing of OI prophylaxis increased from 58% to 93% (P<0.001) with the addition of pharmacist intervention.

Outcome and Cost of Inpatient Hospitalization for Intravenous Dihydroergotamine Treatment of Refractory Pediatric Headache

BackgroundTo determine the cost and efficacy of admitting patients for intravenous dihydroergotamine treatment and to identify factors associated with a higher likelihood of response to treatment. MethodsWe performed a retrospective review of all pediatric hospitalizations from 2001 to 2010 for intravenous dihydroergotamine therapy for headache. Data were collected using the REDcap database and consisted of multiple variables, including preadmission demographics, headache duration, use of prophylactic medications, inpatient therapies including dihydroergotamine dosing, procedures, consultations, total hospital cost, and headache severity at discharge and at follow-up. ResultsSeventy-four percent of the 145 individuals who were hospitalized were female. Mean age was 14.9 years. Headache was described as chronic or daily in almost all patients and 28 (19%) had status migrainosus. Sixty-six percent had a first-degree relative with migraine. The average length of stay was 3.7 days, and the average cost was $7569 per hospitalization. Patients received an average of eight doses of dihydroergotamine. At the time of discharge, 63% of patients reported improvement. Follow-up information was available for 68% of the cohort at a median of 42 days after discharge, and 21 of 99 patients (21%) experienced sustained relief of headache. Response to dihydroergotamine was correlated with a lower rate of comorbid diagnoses, lumbar puncture, and outpatient neuroimaging. Response also correlated to less expensive hospitalizations with an average cost of $5379 per hospitalization versus $7105 per hospitalization without positive response. Response was also correlated with a patient receiving more doses of intravenous dihydroergotamine. ConclusionsAlthough intravenous dihydroergotamine is an effective abortive medication for intractable migraine, it may provide only short-term headache relief in many pediatric patients. Hospitalization is relatively costly with only modest long-term benefit, especially in patients with chronic migraine or chronic daily headache.

Caffeine discontinuation improves acute migraine treatment: a prospective clinic-based study.

BackgroundCaffeine has both excitatory and vasoconstrictive effects on central nervous system. Caffeine use might be associated with development and chronification of migraine. We aimed to evaluate the effect of caffeine cessation on the acute treatment of migraine.MethodsWe prospectively recruited migraine patients who consumed caffeine drinks daily and instructed them to discontinue their caffeine intake. Triptans were prescribed for acute treatment. Patients were followed up after at least two weeks after screening and evaluated the efficacy of acute treatment with the migraine assessment of current therapy (Migraine-ACT) questionnaire. Excellent efficacy was defined as Migraine-ACT score of 4. Chronic migraine, body mass index, allodynia, depression, anxiety, antiemetic use, and use of prophylactic medication were included in the multivariate analysis if the univariate p < 0.2.FindingsAmong 108 patients included, 36 completely discontinued their caffeine intake (abstinence group). The efficacy of acute treatment was assessed at median 34.5 days (interquartile range, 28–89) after the screening. Twenty-six patients (72.2 %) in the abstinence group and 29 (40.3 %) in the non-abstinence group reported an excellent efficacy (p = 0.002). The abstinence group also showed a trend toward greater reduction of headache impact test-6 (HIT-6) scores (p = 0.085). Caffeine abstinence was independently associated with an excellent efficacy of acute treatment (multivariate odds ratio, 3.2; 95 % confidence interval, 1.2–8.4; p = 0.018) after controlling for covariates.ConclusionsCaffeine abstinence is associated with better efficacy of acute migraine treatment. Our uncontrolled study results encourage a further confirmatory study on this issue.