Successful long-term management of spasticity in people with multiple sclerosis using a software application: Results from a randomized, controlled, multicenter study.

BACKGROUND AND PURPOSE: Successful long-term treatment of spasticity in people with multiple sclerosis (pwMS) is challenging. We investigated the effects of multidisciplinary inpatient rehabilitation (MIR) and an individualized self-training program delivered by an app on spasticity in pwMS. METHODS: First, we assessed the efficacy of 4-week MIR in ambulatory pwMS (Expanded Disability Status Scale < 7.0) with moderate to severe lower limb spasticity (defined by ≥4 points on the Numeric Rating Scale for spasticity [NRSs]) in a cohort of 115 pwMS at seven rehabilitation centers in Austria. In the case of a clinically relevant improvement in spasticity of ≥20% on the NRSs following MIR (n = 94), pwMS were randomly allocated in a 1:1 ratio to either the newly designed MS-Spasticity App or to a paper-based self-training program for 12 weeks. The primary outcome was change in NRSs (German Clinical Trials Registry DRKS00023960). RESULTS: MIR led to a significant reduction of 2.0 points on the NRSs (95% confidence interval [CI] = 2.5-2.0, p < 0.000). MIR was further associated with a statistically significant improvement in spasticity on the Modified Ashworth Scale, strength, and all mobility outcomes. Following MIR, self-training with the MS-Spasticity App was associated with a sustained positive effect on the NRSs, whereas paper-based self-training led to a worsening in spasticity (median NRSs difference = 1.0, 95% CI = 1.7-0.3, p = 0.009). The MS-Spasticity App was also associated with a significantly better adherence to self-training (95% vs. 72% completion rate, p < 0.001). CONCLUSIONS: In pwMS, MIR is able to significantly improve lower limb spasticity, strength, and mobility. Following MIR, an individually tailored antispasticity program delivered by an app leads to sustained positive long-term management.

Proton beam radiation for iris melanoma: case series and review of literature.

OBJECTIVE: Purpose of this study is to analyse the visual outcomes, the complication and eye retention rate as well as tumour control data of patients treated with proton beam radiation therapy (PBRT) for iris melanoma. METHODS: Retrospective case series and review based on patients' records. All tumours were categorised according to the American Joint Committee of Cancer staging criteria for primary iris melanoma und underwent either sectorial or whole anterior segment PBRT. RESULTS: Thirteen cases were identified of which five received PBRT of the whole anterior segment and eight received sectorial PBRT. Local tumour control after a mean follow-up of 25 months was 92%. Complications after PBRT included cataract (46%), secondary glaucoma (31%), superficial keratitis (15%) and madarosis (8%). Complications were more common in patients necessitating irradiation of the entire anterior segment than in patients which received sectorial irradiation. Eye retention was achieved in all cases. No statistically significant difference in the mean best corrected visual acuity (BCVA) and intraocular pressure (IOP) was found before and after treatment. Comparison of mean BCVA and IOP between different treatment groups (complete anterior segment vs sectorial irradiation) at the last follow-up visit were also not significantly different. No patient developed metastatic disease during follow-up. CONCLUSION: PBRT is a safe and vision preserving therapeutic modality for iris melanoma. Complete irradiation of the anterior segment is associated with higher complication rates.

Impaired lipid profile and insulin resistance in a cohort of Austrian HIV patients.

INTRODUCTION: Traditional risk factors for cardiovascular diseases have been shown to have an even higher impact in the HIV infected population. Cardiovascular risk factors amongst people living with HIV treated in doctor's offices in Austria have not been documented before. Our study aimed to close this gap, focusing on dyslipidemia, diabetes mellitus and diabetes risk. PATIENTS AND METHODS: After ethics approval, consecutive patients who visited their treating physicians for routine checks were enrolled. The lipid profile was assessed by measuring total cholesterol, triglycerides, HDL and apolipoprotein B and calculating LDL and non-HDL-cholesterol. The diabetes risk was calculated by measuring insulin and blood glucose levels and assessing insulin resistance and beta cell function using the HOMA-IR model. RESULTS: 522 patients were included in the analysis. 90.2% of the participants were on antiretroviral therapy. Two third had an impaired lipid profile, but dyslipidemia had been diagnosed only in 46.3% of the patients. There was a clear correlation between protease inhibitor use and pathologic blood lipids. Of the persons with dyslipidemia, 18.4% received lipid lowering drugs. 8 persons (1.6%) fulfilled the criteria for diabetes mellitus. Of those, 4 patients already had a diagnosed diabetes mellitus. 50.1% of the study participants showed an increased insulin resistance. Patients on nucleoside reverse transcriptase inhibitors had significantly higher markers for impaired glucose metabolism. DISCUSSION: We found a high percentage of increased insulin resistance, of impaired lipid profile and in contrast to this a low treatment rate with lipid lowering drugs in this cohort of people living with HIV.

Medication adherence in patients with dementia: an Austrian cohort study.

Sustained treatment with effective doses of cholinesterase inhibitors or memantine is crucial to transfer treatment effects in dementia. Numerous studies, with often small samples sizes, describe low adherence rates. The purpose of current study was to examine the medical adherence of antidementia therapy in Austria. We analyzed the data of 10 Austrian Health Insurance Funds, including treatment-naive dementia patients. Study outcome measures were discontinuation, switching, number of days on therapy, Medication-Possession-Ratio, and compliance. A total of 15,809 patients (mean age: 79.9 y, female: 67.3%) met the study's inclusion criteria. After stratification by index medication there were 40.3% on donepezil (n=6371); 26.6% on rivastigmine (n=4206); 15.3% on galantamine (n=2424); and 17.8% on memantine (n=2808). After 6 and 12 months on therapy, 5376 (34.0%) and 9243 (58.5%) patients stopped the initially prescribed antidementia therapy; after 12 months the highest discontinuation rate was seen for patients taking rivastigmine (67.3%), whereas patients on memantine (45.0%) had the lowest. After 12 months, a total of 1874 (11.9%) patients switched from their index medication to another cholinesterase inhibitor or memantine. A total of 6163 patients (39.0%) were compliant (Medication-Possession-Ratio >80%) during the first 6 months and 5366 patients (33.9%) during 12 months of the study. Our study shows that memantine-treated patients adhere significantly better to treatment. Specifically, after 12 months, 45.0% discontinued medication, 7.9% switched, and 50.8% of patients on therapy were compliant.

Neurological disorders.

Neurological conditions during pregnancy can be pregnancy related or can be caused by exacerbation of pre-existing neurological disorders. Knowledge of pre-existing epilepsy or myasthenia gravis in women of childbearing age requires preconception counselling by neurologist and planned pregnancy. Possible adverse effects of medication on the foetus should be balanced with the risk of uncontrolled symptoms. Interdisciplinary management before, during and after pregnancy is recommended. New acute neurological symptoms in pregnant or postpartum women should lead to an urgent neurological review. Patients need a thorough diagnostic evaluation that targets a range of serious pathological conditions that are either unique to (e.g. eclampsia) or arise more frequently (e.g. cerebral venous thrombosis) in this population. Most of these conditions are infrequent and require a specialized and multidisciplinary management. Treatment is challenging due to risks to the unborn child.

Long-term efficacy of Boswellia serrata in four patients with chronic cluster headache.

BACKGROUND: Cluster headache is an extremely severe and debilitating trigemino-autonomic pain syndrome. About 10% of patients with cluster headache manifest a chronic form (CCH).The present case series study aims to evaluate the long-term efficacy of Boswellia serrata (Sallaki H15) on headaches and disturbed sleep in patients with CCH. CASE RESULTS: In an open-label study, four patients with CCH and disturbed sleep received oral B. serrata. CONCLUSION: The results provide Class IV evidence that oral B. serrata reduces the intensity and frequency of headaches in patients with CCH.

Driving cessation and dementia: results of the prospective registry on dementia in Austria (PRODEM).

OBJECTIVE: To assess the influence of cognitive, functional and behavioral factors, co-morbidities as well as caregiver characteristics on driving cessation in dementia patients. METHODS: The study cohort consists of those 240 dementia cases of the ongoing prospective registry on dementia in Austria (PRODEM) who were former or current car-drivers (mean age 74.2 (±8.8) years, 39.6% females, 80.8% Alzheimer's disease). Reasons for driving cessation were assessed with the patients' caregivers. Standardized questionnaires were used to evaluate patient- and caregiver characteristics. Cognitive functioning was determined by Mini-Mental State Examination (MMSE), the CERAD neuropsychological test battery and Clinical Dementia Rating (CDR), activities of daily living (ADL) by the Disability Assessment for Dementia, behavior by the Neuropsychiatric Inventory (NPI) and caregiver burden by the Zarit burden scale. RESULTS: Among subjects who had ceased driving, 136 (93.8%) did so because of "Unacceptable risk" according to caregiver's judgment. Car accidents and revocation of the driving license were responsible in 8 (5.5%) and 1(0.7%) participant, respectively. Female gender (OR 5.057; 95%CI 1.803-14.180; p = 0.002), constructional abilities (OR 0.611; 95%CI 0.445-0.839; p = 0.002) and impairment in Activities of Daily Living (OR 0.941; 95%CI 0.911-0.973; p<0.001) were the only significant and independent associates of driving cessation. In multivariate analysis none of the currently proposed screening tools for assessment of fitness to drive in elderly subjects including the MMSE and CDR were significantly associated with driving cessation. CONCLUSION: The risk-estimate of caregivers, but not car accidents or revocation of the driving license determines if dementia patients cease driving. Female gender and increasing impairment in constructional abilities and ADL raise the probability for driving cessation. If any of these factors also relates to undesired traffic situations needs to be determined before recommendations for their inclusion into practice parameters for the assessment of driving abilities in the elderly can be derived from our data.

Pregabalin as mono- or add-on therapy for patients with refractory chronic neuropathic pain: a post-marketing prescription-event monitoring study.

This observational study examined the outcome of two different therapeutic strategies in the treatment of chronic neuropathic pain by including pregabalin (PGB) as mono- or add-on therapy in one of two treatment options. Patients with a pain score of > or =4, refractory to usual care for neuropathic pain for at least 6 months, were allocated consecutively to one of two treatment strategies according to the decision of the physician: complete switch to a flexible-dosage, monotherapeutic or add-on therapy with pregabalin (PGB group), or change established doses and combinations of pre-existing mono- or combination therapy without pregabalin (non-PGB group). After 4 weeks (primary endpoint) a significant improvement in pain reduction was documented in both intention-to treat (ITT) analysis (PGB group, n = 85: mean pain score reduction of 3.53, SD 2.03, p < 0.001; non-PGB group, n = 102; mean pain score reduction of 2.83, SD 2.23, p < 0.001) and per-protocol (PP) analysis (PGB group, n = 79: mean pain score reduction 3.53 vs. 2.83, p < 0.05; non-PGB group, n = 81; 3.5 vs. 2.9, p < 0.05) compared to baseline. Comparison of the results observed in the two groups shows that patients in the PGB group achieved significantly greater pain reduction. These results demonstrate that PGB administered twice daily is superior to treatment regimes without PGB in reducing pain and pain-related interference in quality of life.

[Dementia and pain]. / Demenz und Schmerz.

Dementia has been associated with disturbed pain processing and an impaired ability to provide self-reported ratings on pain. Patients with cognitive impairment have been shown to receive pain treatment less frequently than cognitively unimpaired individuals. Comorbidity is common in patients with dementia and a major factor contributing to pain. This demonstrates that a structured evaluation and categorisation of pain is mandatory for the treatment of older patients and that care should be taken to note indirect signs of pain. The appropriate scales are available and we propagate their application. Multimodal pain therapy is superior to one-dimensional approaches. A discussion of the effects and interactions of the analgesics presently available for geriatric care forms an integral part of this review.