[Telemedicine in stroke-pertinent to stroke care in Germany]. / Telemedizin in der Schlaganfallversorgung ­ versorgungsrelevant für Deutschland.

BACKGROUND AND OBJECTIVE: Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution. METHODS: The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks. RESULTS: Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states. CONCLUSION: Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

Methionine metabolism and phenotypic variability in X-linked adrenoleukodystrophy.

A combined genotype of polymorphisms of methionine metabolism has been associated with CNS demyelination in methotrexate-treated patients. Within a sample of 86 patients with X-linked adrenoleukodystrophy, this genotype was overrepresented in a subgroup of 15 patients with adrenomyeloneuropathy (AMN) with CNS demyelination (adrenoleukomyeloneuropathy) in comparison to 49 AMN patients without CNS demyelination ("pure" AMN; p = 0.002), suggesting that methionine metabolism might contribute to the phenotypic variability in adrenoleukodystrophy.

An X-linked gene involved in androgenetic alopecia: a lesson to be learned from adrenoleukodystrophy.

BACKGROUND: Adrenoleukodystrophy (ALD), including its adult variant adrenomyeloneuropathy (AMN), is an X-linked recessive trait characterized by progressive demyelinization of the nervous system. The gene defect involves a peroxisomal transporter protein, resulting in accumulation of very-long-chain fatty acids in the brain and other organs such as the adrenal glands. Affected men show various endocrine disorders. Moreover, disturbances of hair growth are frequently mentioned in reports on ALD/AMN. OBJECTIVE: This study was performed to delineate further the hair status and type of hair loss in men with AMN. METHODS: We examined and documented the status of hair growth in 16 men suffering from AMN. A meticulous history with particular regard to hair changes was taken from all patients and their family members. RESULTS: The age of the patients varied between 27 and 62 years, their mean age was 39.8 years. Twelve men showed male-pattern androgenetic alopecia (AGA), Hamilton grades IV-VIII, 3 men had a female-pattern AGA (Ludwig grade I or II). Ten of the patients with male-pattern AGA had reached Hamilton stage VII or VIII. The remaining scalp hair was unusually scarce and thin in 11 cases, regardless of the grade of AGA. Moreover, in 10 of 16 patients the eyelids showed pronounced madarosis. The remaining body hair was found to be normal. If present, endocrine manifestations had started prior to the onset of alopecia, and in 11 of 12 patients hair loss was apparent before neurological symptoms were noted. CONCLUSION: ALD/AMN gives rise to two different types of hair loss. Firstly, affected men show diffuse hair loss involving the entire scalp and the eyelashes. Secondly, they tend to develop AGA more frequently and earlier and in a severer form. Paradoxically, pronounced AGA is present although the patients may simultaneously show some degree of hypogonadism. Hence, the X-linked ALD mutation can be taken as a well-defined gene within the polygenic spectrum of genes responsible for AGA. This may be of theoretical importance for the elucidation of the pathogenetic pathways of AGA.

X-linked adrenomyeloneuropathy associated with 14 novel ALD-gene mutations: no correlation between type of mutation and age of onset.

Adrenomyeloneuropathy (AMN) represents a milder form of X-linked adrenoleukodystrophy (ALD), the most frequent peroxisomal disorder. The disease is characterised by an abnormal accumulation of saturated, very long chain, fatty acids, because of altered peroxisomal beta-oxidation that concomitantly leads to demyelination in the central and peripheral nervous systems. ALD shows a highly variable phenotypic expression and extensive mutation analysis in ALD patients has failed to establish a genotype-phenotype correlation, even in the presence of the same ALD-gene defect. Therefore, we have looked for a relationship between the molecular lesion and the age of onset in 19 patients with a well-classified clinical course of AMN. The nearly complete novel spectrum of ALD gene mutations identified has revealed no obvious correlation between the type of mutation and age of AMN onset in this small series. However, intrafamiliar concordance could be observed with respect to the occurrence of adrenocortical insufficiency. This supports the idea of one (or more) additional gene(s) contributing to the phenotypic expression of ALD.

[Ultrasound studies of blood flow velocity in main cranial arteries in idiopathic headaches]. / Badania ultrasonograficzne szybkosci przeplywu w duzych naczyniach mózgowych w samoistnych bólach glowy.

The published results of transcranial Doppler (TCD) studies of main cerebral arteries, performed in the patients with idiopathic headaches, especially with migraine, are controversial. Some authors could not find any changes, others observed increased blood flow. These results were, however, based on single examination, and the comparison on mean velocities calculated for the whole groups. In the present study the authors decided to perform a series of TCD studies in each patient and to analyse the individual cases. It was found that blood flow velocity in the main cerebral arteries in chronic tension-type headache (8 cases) and cluster headache (7 cases) showed normal values, established for 35 healthy subjects. In migraine without aura (20 cases) and with aura (11 cases) a considerable increase (above 30%) in cerebral blood flow was found in some studies. In around 50% of the cases increased blood flow in anterior and middle cerebral arteries was found unilaterally. The authors believe that the above findings might be specific for migraine and reflect transient vasoconstriction of the vessels that, on the other head, may be the premonitory laboratory sign of the attack.

[Automatic regulation of sinus rhythm in patients with migraine]. / Automatyczna regulacja rytmu zatokowego serca u chorych z migrena.

The clinical symptoms of migraine point to autonomic disturbances, especially to disrupted regulation of the circulatory system and autonomic balance. Searching for more accurate autonomic system studies we turned to the spectral analysis of cardiac rhythm changes, that allows to estimate the autonomic balance in sinus node. 44 patients with migraine were studied and the results were compared with those obtained in 74 healthy subjects. The reduced influence of both sympathetic and parasympathetic part of autonomic system on the sinus rhythm in migraine patients was found. The autonomic balance is shifted to the parasympathetic innervation side in patients with migraine.

[Current views on pathophysiology of migraine. Part II: Further development and current status of the vascular theory. Migraine and allergy]. / Wspólczesne poglady na patogeneze migreny. Czesc II: Dalszy rozwój i stan obecny teorii naczyniowej. Migrena i alergia.

In this part further arguments advocating the vascular theory are discussed, among others: the influence of drugs (ergotamine, sumatriptan), so called "migrainous stroke", and the results of the last neuroimaging studies on the migraine. The authors state in summary that vascular disturbances do take place in migraine attack, but they should be regarded in connection with biochemical and central neuronal disorders. In the end the authors discusse the current views on the impact of allergy in the pathophysiology of migraine.

[Capsaicin in pain therapy]. / Kapsaicyna w terapii bólu.

In the paper the possibilities of therapeutic use of capsaicin are presented. This drug seems to be very effective in neuralgia after zoster, and less effective in painful diabetic neuropathy. Attempts are also undertaken at its use in cluster headache, trigeminal neuralgia and arthralgia. Confirmation of the effectiveness of the discussed drug in these pain syndromes requires further studies.

[Studies of heart rhythm variability in migraine. Preliminary communication]. / Badanie zmiennosci rytmu serca w migrenie. Doniesienie wstepne.

Spectral analysis of hart rhythm variability makes possible assessment of the state (power) of autonomic innervation of the heart. The reported study was carried out in 40 patients (22 women) with migraine. The studies were done in times between migraine attacks. The control group comprised 62 clinically healthy subjects. In most patients (over 61%) the sympathetic and parasympathetic innervation of the heart was weaker than in healthy subjects and the index of automatic equilibrium in the sinus node was lower than in controls.

Peer review organization payment denials: comparative analysis of emergency department and non-emergency-department admissions.

The Health Care Financing Administration has contracted with regional peer review organizations to review Medicare admissions and to deny payment for hospital admissions that fail to meet peer review organization criteria. The purpose of this study was to compare emergency department admissions with non-emergency-department admissions with respect to rates of peer review organization denial and the reasons for those denials. All hospital Medicare admissions between January 1984 and April 1987 were retrospectively reviewed. Patients were excluded if they received peer review organization pre-authorization prior to admission. The rest were classified by 1) source of admission (emergency department or non-emergency department), 2) peer review organization decision, 3) reason for peer review organization denial, 4) whether the denial was appealed, 5) the results of appeal. Chi-square or Fisher's Exact Test analysis was performed, and P less than 0.05 was considered to be significant. During the 40-month study period, there were 19,847 emergency department Medicare admissions and 19,752 non-emergency-department Medicare admissions. Of the non-emergency-department admissions, 7887 received pre-authorization. None of the emergency department admissions received pre-authorization. Of the 19,847 emergency department admissions, 433 (2.23%) were denied. Of these denials, 269 (60.7%) were appealed by the hospital; 136 (50.5%) successfully. Of the 11,865 non-emergency department, non-pre-authorized admissions, 333 (2.81%) were denied. Of these denials, 174 (52.2%) were appealed, 76 (43.6%) successfully. Overall, emergency department admissions were significantly less likely to receive peer review organization denial than non-emergency-department, non-pre-authorized admissions (P less than 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)