Effectiveness and safety of menopause treatments: pitfalls of available evidence and future research need.

By 2050 more than 1.6 billion women worldwide will be of post-reproductive age, with >75% reporting severe menopausal symptoms. The last few years saw a gradual uplift in public awareness reaffirming the health needs of women with menopause. Still, effective translation of available evidence on menopause treatments is hindered by several methodological limitations and poor research conduct. We argue that a paradigm shift is required in menopause research to address the remaining knowledge gap and guide safe evidence-based care provision. A critical misconception across studies on menopause is the assumption that women represent a homogeneous group who respond similarly to a particular therapy irrespective of their exposure and individual risk factors. We highlight potential solutions to optimize the quality of future research in menopause including adopting robust trial methodology, standardize outcome reporting to capture quality-of-life measures, and improve lay patient and public involvement in future research.

Distal fusion level, complications, and reoperations in individuals with cerebral palsy undergoing surgery for scoliosis.

PURPOSE: To compare radiological outcome, complications and reoperations in individuals with cerebral palsy and scoliosis fused to the fifth lumbar vertebra (L5), the sacrum, or the ilia. METHODS: 208 individuals were identified in the national quality registry Swespine. Lowest level of fusion was L5 in 58, the sacrum in 92, and the ilia in 58 individuals. A subanalysis on 58 matched pairs operated to L5 or the pelvis (sacrum = 42, ilia = 16) with similar pelvic obliquity (± 5°) was performed. RESULTS: The median (interquartile range) follow-up for the last radiograph was 1.7 (1.7) years and for reoperations 6.0 (5.9) years. Preoperatively, median Cobb angle of the major curve was 65° (23°) in the L5 group, 68° (28°) in the sacrum group, and 78° (25°) in the ilia group (p = 0.006). Preoperative median pelvic obliquity according to Maloney was 16° (19°), 21° (13°), and 27° (28°), respectively (p = 0.004). Immediate postoperative Cobb angles were 28° (18°), 28° (16°), and 32° (25°), respectively (p = 0.11). Immediate postoperative pelvic obliquity was 7° (10°), 7° (8°), and 8° (10°), respectively (p = 0.28). The median change in pelvic obliquity from the first to the last postoperative radiograph was - 5° (7°), - 3° (6°), - 3° (6°), respectively (p = 0.55). 7 (12%), 11 (12%), and 7 (12%) patients required at least one reoperation (p = 1.0), respectively. In the matched analysis, no significant differences in the radiological outcomes were found (all p ≥ 0.38). CONCLUSIONS: Maintained curve and pelvic obliquity correction with no significant difference in complication and reoperation rates were found irrespective of distal fusion level.

Predictors of receiving a diagnosis, referral and treatment of depression in people on antiretroviral therapy in South African primary care: a secondary analysis of data from a randomised trial.

OBJECTIVE: To describe the receipt of a diagnosis, referral and treatment for depression in people receiving antiretroviral therapy (ART), with depressive symptoms and attending primary care clinics in South Africa, and investigate factors associated with receiving these components of care. METHODS: This is a secondary analysis of data from a randomised controlled trial of an intervention intended to improve detection and treatment of depression in primary care patients receiving ART. In this analysis, we combined cross-sectional and longitudinal data from the intervention and control arms. Using regression models and adjusting for intra-cluster correlation of outcomes, we investigated associations between socioeconomic characteristics, depressive symptoms, stress, disability and stigma, and receipt of a diagnosis, referral and treatment for depression. RESULTS: Of 2002 participants enrolled, 18% reported a previous diagnosis of depression by a healthcare worker and 10% reported having received counselling from a specialist mental health worker. Diagnosis, referral and counselling during the follow-up period were appropriately targeted, being independently more frequent in participants with higher enrolment scores for depressive symptoms, stress or disability. Participants with higher stigma scores at enrolment were independently less likely to receive counselling. Severe socio-economic deprivation was common but was not associated with treatment. CONCLUSION: While the receipt of a diagnosis, referral and treatment for depression were uncommon, they seemed to be appropriately targeted. Socio-economic deprivation was not associated with treatment.

OBJECTIF: Décrire la réception d'un diagnostic, de l'orientation et du traitement pour la dépression chez les personnes recevant un traitement antirétroviral (ART), présentant des symptômes dépressifs et fréquentant des cliniques de soins primaires en Afrique du Sud, et étudier les facteurs associés à la réception de ces éléments de soins. MÉTHODES: Il s'agit ici d'une analyse secondaire des données d'un essai contrôlé randomisé d'une intervention destinée à améliorer la détection et le traitement de la dépression chez les patients sous ART dans les soins primaires. Dans cette analyse, nous avons combiné les données transversales et longitudinales des bras d'intervention et témoin. En utilisant des modèles de régression et en ajustant la corrélation intra-grappes des résultats, nous avons étudié les associations entre les caractéristiques sociodémographiques, les symptômes dépressifs, le stress, l'invalidité et la stigmatisation, et la réception d'un diagnostic, d'une orientation et d'un traitement pour la dépression. RÉSULTATS: Sur 2.002 participants inscrits, 18% ont déclaré un diagnostic antérieur de dépression par un agent de santé et 10% ont déclaré avoir reçu des conseils d'un agent spécialisé pour la santé mentale. Le diagnostic, l'orientation et le conseil pendant la période de suivi ont été ciblés de manière appropriée, étant indépendamment plus fréquents chez les participants ayant des scores d'inscription plus élevés pour les symptômes dépressifs, le stress ou l'invalidité. Les participants ayant des scores de stigmatisation plus élevés à l'inscription étaient indépendamment moins susceptibles de recevoir des conseils. La privation socioéconomique sévère était courante mais n'était pas associée au traitement. CONCLUSION: Bien que la réception d'un diagnostic, l'orientation et le traitement de la dépression soient rares, ils semblaient bien ciblés. La privation socioéconomique n'était pas associée au traitement.

Risk of venous thromboembolism among users of different anti-osteoporosis drugs: a population-based cohort analysis including over 200,000 participants from Spain and the UK.

The venous thromboembolism risk among anti-osteoporotics is unknown. In this primary care study, the risk with other bisphosphonates [1.05 (0.94-1.18) and 0.96 (0.78-1.18)], strontium [0.90 (0.61-1.34) and 1.19 (0.82-1.74)], in the UK and Spain respectively, and denosumab [1.77 (0.25-12.66)] and teriparatide [1.27 (0.59-2.71)] in Spain, did not differ versus alendronate. INTRODUCTION: Most of the known adverse drug reactions described for anti-osteoporosis medication (AOM) have been described in studies comparing AOM users to non-users. We aimed to compare the risk of venous thromboembolism (VTE) among incident users of different AOM compared to alendronate (first line therapy). METHODS: Two cohort studies were performed using data from the UK (CPRD) and Spain (BIFAP) primary care records separately. All patients aged ≥ 50 years with at least 1 year of data available and a new prescription or dispensation of AOM (date for therapy initiation) during 2000-2014 (CPRD) or 2001-2013 (BIFAP) were included. Users of raloxifene/bazedoxifene were excluded from both databases. Five exposure cohorts were identified according to first treatment: (1) alendronate, (2) other bisphosphonates, (3) strontium ranelate, (4) denosumab, and (5) teriparatide. Participants were followed from the day after therapy initiation to the earliest of a treated VTE (cases), end of AOM treatment (defined by a refill gap of 180 days), switching to an alternative AOM, drop-out, death, or end of study period. Incidence rates of VTE were estimated by cohort. Adjusted hazard ratios (HR 95%CI) were estimated according to drug used. RESULTS: Overall, 2035/159,209 (1.28%) in CPRD and 401/83,334 (0.48%) in BIFAP had VTE. Compared to alendronate, adjusted HR of VTE were 1.05 (0.94-1.18) and 0.96 (0.78-1.18) for other bisphosphonates, and 0.90 (0.61-1.34) and 1.19 (0.82-1.74) for strontium in CPRD and BIFAP, respectively; 1.77 (0.25-12.66) for denosumab and 1.27 (0.59-2.71) for teriparatide in BIFAP. CONCLUSIONS: VTE risk during AO therapy did not differ by AOM drug use. Our data does not support an increased risk of VTE associated with strontium ranelate use in the community.

Incident microalbuminuria and complement factor mannan-binding lectin-associated protein 19 in people with newly diagnosed type 1 diabetes.

BACKGROUND: Evidence links the lectin pathway of complement activation to diabetic kidney disease. Upon carbohydrate-recognition by pattern-recognition molecules, eg, mannan-binding lectin (MBL), the MBL-associated serine protease (MASP-2) is activated and initiates the complement cascade. The MASP2 gene encodes MASP-2 and the alternative splice product MBL-associated protein 19 (MAp19). Both MAp19 and MASP-2 circulate in complex with MBL. We tested the hypothesis that MAp19 and MASP-2 concentrations predict the risk of incident microalbuminuria. METHODS: Baseline MAp19 and MASP-2 were measured in 270 persons with newly diagnosed type 1 diabetes tracked for incidence of persistent microalbuminuria in a prospective observational 18-year-follow-up study. RESULTS: Seventy-five participants (28%) developed microalbuminuria during follow-up. MBL-associated protein 19 concentrations were higher in participants that later progressed to microalbuminuria as compared with those with persistent normoalbuminuria (268 ng/mL [95% CI, 243-293] vs 236 ng/mL [95% CI, 223-250], P = .02). Participants with MAp19 concentration within the highest quartile of the cohort had an increased risk of microalbuminuria as compared with participants with MAp19 concentration within the combined lower 3 quartiles in unadjusted Cox analysis, hazard ratio 1.86 ([95% CI, 1.17-2.96], P = .009). This remained significant in adjusted models, eg, adjusting for age, sex, HbA1c , systolic blood pressure, urinary albumin excretion, smoking, serum creatinine, and serum cholesterol. MBL-associated serine protease concentration was not associated with incidence of microalbuminuria. CONCLUSIONS: In conclusion, the results show an association between baseline MAp19 concentration and the incidence of microalbuminuria in an 18-year-follow-up study on persons with newly diagnosed type 1 diabetes.

Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK.

AIMS: To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age. METHODS: We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes. RESULTS: Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness. CONCLUSIONS: The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

18F-Labelling of electron rich iodonium ylides: application to the radiosynthesis of potential 5-HT2A receptor PET ligands.

18F-Labelling of aromatic moieties was limited to electron deficient aromatic systems for many years but recent developments have provided access to the direct labelling of electron rich aromatic systems. Herein we report the synthesis and 18F-labelling of iodonium ylide precursors in the pursuit of 18F-labelled 5-HT2A receptor agonist PET-ligands. Subsequent evaluation in pigs showed high brain uptake of the PET ligands but a blocking dose of ketanserin did not significantly reduce the signal in relevant brain regions - indicating that the ligands do not interact specifically with the 5-HT2A receptor in vivo.

Predicting dementia risk in primary care: development and validation of the Dementia Risk Score using routinely collected data.

BACKGROUND: Existing dementia risk scores require collection of additional data from patients, limiting their use in practice. Routinely collected healthcare data have the potential to assess dementia risk without the need to collect further information. Our objective was to develop and validate a 5-year dementia risk score derived from primary healthcare data. METHODS: We used data from general practices in The Health Improvement Network (THIN) database from across the UK, randomly selecting 377 practices for a development cohort and identifying 930,395 patients aged 60-95 years without a recording of dementia, cognitive impairment or memory symptoms at baseline. We developed risk algorithm models for two age groups (60-79 and 80-95 years). An external validation was conducted by validating the model on a separate cohort of 264,224 patients from 95 randomly chosen THIN practices that did not contribute to the development cohort. Our main outcome was 5-year risk of first recorded dementia diagnosis. Potential predictors included sociodemographic, cardiovascular, lifestyle and mental health variables. RESULTS: Dementia incidence was 1.88 (95% CI, 1.83-1.93) and 16.53 (95% CI, 16.15-16.92) per 1000 PYAR for those aged 60-79 (n = 6017) and 80-95 years (n = 7104), respectively. Predictors for those aged 60-79 included age, sex, social deprivation, smoking, BMI, heavy alcohol use, anti-hypertensive drugs, diabetes, stroke/TIA, atrial fibrillation, aspirin, depression. The discrimination and calibration of the risk algorithm were good for the 60-79 years model; D statistic 2.03 (95% CI, 1.95-2.11), C index 0.84 (95% CI, 0.81-0.87), and calibration slope 0.98 (95% CI, 0.93-1.02). The algorithm had a high negative predictive value, but lower positive predictive value at most risk thresholds. Discrimination and calibration were poor for the 80-95 years model. CONCLUSIONS: Routinely collected data predicts 5-year risk of recorded diagnosis of dementia for those aged 60-79, but not those aged 80+. This algorithm can identify higher risk populations for dementia in primary care. The risk score has a high negative predictive value and may be most helpful in 'ruling out' those at very low risk from further testing or intensive preventative activities.

Prescribing of neuraminidase inhibitors for influenza in UK primary care since the 2009 pandemic.

We determined prescribing rates of neuraminidase inhibitors (NIs) for influenza in UK primary care since 2009 in relation to national prescribing guidelines. All NI prescriptions issued during the influenza seasons between October 2010 and May 2013 were extracted from The Health Improvement Network (THIN), a large UK primary-care database. We calculated NI prescribing rates per 100,000 person-weeks (pw) by age group, sex, deprivation level, influenza season and presence of chronic conditions with 95% confidence intervals (CIs), and used negative binomial regression models to determine the independent association between these variables and NI prescribing. NI prescribing was rare. The prescribing rate was 1·7/100,000 pw (95% CI 1·7-1·8) during influenza-active periods, and 0·1/100,000 (95% CI 0·1-0·1) during non-active periods. Prescribing rates were highest in 25- to 44-year-olds in 2010/2011 and in persons aged ⩾85 years in 2011/2012 and 2012/2013. Individuals with chronic conditions had significantly higher prescribing rates than persons without (rate ratio 2·62, 95% CI 2·27-3·03). GPs are more likely to prescribe NIs to high-risk individuals and during influenza active periods, as per national guidelines. We could not assess the proportion of patients with influenza-like illness who were prescribed an NI.

[Grading of soft tissue and bone sarcomas]. / Grading von Weichgewebe- und Knochensarkomen.

Malignancy grading is an essential element in the classification of sarcomas. It correlates with the prognosis of the disease and the risk of metastasis. This article presents the grading schemes for soft tissue, bone and pediatric sarcomas. It summarizes the histological criteria of the Federation Nationale des Centres de Lutte Contre le Cancer (FNCLCC) system and the Pediatric Oncology Group as well as the grading of bone tumors by the College of American Pathologists (CAP). Furthermore, the potential relevance of gene expression signatures, the complexity index in sarcoma (CINSARC) and single genetic alterations (p53, MDM2, p16, SWI/SNF, EWSR1 fusions and PAX3/PAX7-FOXO1 fusions) for the prognosis of sarcomas are discussed.

Evidence for increasing severity of community-onset boils and abscesses in UK General Practice.

In England, hospital admissions for severe staphylococcal boils and abscesses trebled between 1989 and 2004. We investigated this trend using routine data from primary and secondary care. We used The Health Improvement Network (THIN), a large primary-care database and national data on hospital admissions from Hospital Episode Statistics (HES). Time trends in the incidence of primary-care consultations for boils and abscesses were estimated for 1995-2010. HES data were used to calculate age-standardized hospital admission rates for boils, abscesses and cellulitis. The incidence of boil or abscess was 450 [95% confidence interval (CI) 447-452] per 100 000 person-years and increased slightly over the study period (incidence rate ratio 1·005, 95% CI 1·004-1·007). The rate of repeat consultation for a boil or abscess increased from 66 (95% CI 59-73) per 100 000 person-years in 1995 to peak at 97 (95% CI 94-101) per 100 000 person-years in 2006, remaining stable thereafter. Hospital admissions for abscesses, carbuncles, furuncles and cellulitis almost doubled, from 123 admissions per 100 000 in 1998/1999 to 236 admissions per 100 000 in 2010/2011. Rising hospitalization and recurrence rates set against a background of stable community incidence suggests increased disease severity. Patients may be experiencing more severe and recurrent staphylococcal skin disease with limited treatment options.

Monitoring meticillin resistant Staphylococcus aureus and its spread in Copenhagen, Denmark, 2013, through routine whole genome sequencing.

Typing of meticillin resistant Staphylococcus aureus (MRSA) by whole genome sequencing (WGS) is performed routinely in Copenhagen since January 2013. We describe the relatedness, based on WGS data and epidemiological data, of 341 MRSA isolates. These comprised all MRSA (n = 300) identified in Copenhagen in the first five months of 2013. Moreover, because MRSA of staphylococcal protein A (spa)-type 304 (t304), sequence type (ST) 6 had been associated with a continuous neonatal ward outbreak in Copenhagen starting in 2011, 41 t304 isolates collected in the city between 2010 and 2012 were also included. Isolates from 2013 found to be of t304, ST6 (n=14) were compared to the 41 earlier isolates. In the study, isolates of clonal complex (CC) 22 were examined in detail, as this CC has been shown to include the hospital-acquired epidemic MRSA (EMRSA-15) clone. Finally, all MRSA ST80 were also further analysed, as representatives of an important community-acquired MRSA in Europe. Overall the analysis identified 85 spa-types and 35 STs from 17 CCs. WGS confirmed the relatedness of epidemiologically linked t304 neonatal outbreak isolates. Several non-outbreak related patients had isolates closely related to the neonatal isolates suggesting unrecognised community chains of transmission and insufficient epidemiological data. Only four CC22 isolates were related to EMRSA-15. No community spread was observed among the 13 ST80 isolates. WGS successfully replaced conventional typing and added information to epidemiological surveillance. Creation of a MRSA database allows clustering of isolates based on single nucleotide polymorphism (SNP) calling and has improved our understanding of MRSA transmission.

Promotion of mental health and prevention of mental disorders: priorities for implementation.

There is compelling evidence from high-quality studies that mental health promotion and primary prevention interventions can reduce the risk of mental disorders, enhance protective factors for good mental and physical health, and lead to lasting positive effects on a range of social and economic outcomes. This paper reviews the available evidence in order to guide the implementation of mental health promotion and prevention interventions in the Eastern Mediterranean Region. The paper identifies a number of priority areas that can generate clear health and social gains in the population and be implemented and sustained at a reasonable cost. The interventions cover population groups across the lifespan from infancy to adulthood and include actions delivered across different settings and delivery platforms. "Best practices" were identified as interventions for which there is evidence not only of their effectiveness but also of their feasibility within resource constraints. The implications of the findings for capacity development are considered.

Family strain and its relation to psychosocial dysfunction in children and adolescents after liver transplantation.

Parental functioning is essential to children's development. Therefore, this cross-sectional single-center study examined the prevalence of family strain in 181 parents and its associations to psychosocial functioning in their children after LT. Median age at LT was one yr. Mean time elapsed since LT was 5.8 yr. The IFS, and the SDQ were applied to parents. Family strain in the present sample was comparable to that in the German normative group of families with a chronically ill or disabled child, but families of LT recipients showed a significantly higher financial impact, impact on coping, and impact on siblings (p < 0.001). Younger age of patients at survey, a more severe clinical course, child's restrictions, and financial losses following LT were determined as significant predictors of family strain (R(2)  = 0.42). Parents reported less family strain after living-related compared with deceased donation. Family strain was significantly correlated to psychosocial dysfunction in children post-LT. Present findings demonstrate a risk of maladjustment to the post-LT condition in families. They emphasize the importance of psychological assessment of parents and patients during transplant and follow-up to ensure the best achievable long-term outcome of patients.

[Classification and therapy of medication-overuse headache: impact of the third edition of the International Classification of Headache Disorders]. / Klassifikation und Therapie des Medikamenten-Übergebrauch-Kopfschmerzes (MÜK) : Auswirkungen der 3. Auflage der internationalen Kopfschmerzklassifikation auf die Praxis.

The diagnosis of medication-overuse headache (MOH) is of central importance because this secondary headache disorder can be treated very effectively and patients do not usually respond to headache prophylaxis as long as MOH persists. The article describes important changes in the diagnostic criteria of different MOH subtypes after publication of the International Classification of Headache Disorders (ICHD-3beta) in 2013. The new classification has a crucial and direct impact on prevention and treatment of MOH. In addition interactions exist with the new criteria of chronic migraine. With a controlled medication intake scheme according to the 10-20 rule and using a medication break, MOH usually remits in most patients. If patient education and advice does not lead to remission of MOH, a specialized managed medication break or withdrawal treatment becomes necessary. This can be done on an outpatient, day clinic or inpatient basis. In uncomplicated cases, the results of these three treatment settings do not differ. From a cost-effectiveness standpoint, the outpatient treatment should be given priority. In complicated cases, a fully inpatient withdrawal treatment using a multimodal treatment concept is significantly superior.

[Lung cancer. Developments, concepts and preview of the new WHO classification]. / Karzinome der Lunge. Entwicklungen, Konzepte und Ausblick auf die neue WHO-Klassifikation.

The diagnostics of pulmonary neoplasms has considerably changed in recent years. Based on large-scale molecular characterization studies and the development of targeted therapies, precise morphological, immunohistochemical and molecular pathological tumor subtyping is now of utmost importance for evidence-based treatment decisions. This review highlights recent developments in morphological and immunohistochemical subtyping of pulmonary neoplasms, concepts of tumor progression and provides a preview of relevant changes of the forthcoming new WHO classification, which is expected to be published in 2015. It becomes apparent that a 3-step diagnostic procedure based on morphology, immunohistochemistry and molecular pathology is important to meet the requirements of an increasingly more complex, interdisciplinary care of lung cancer patients and to allow reliable, clinically meaningful tumor diagnosis.

[Impact of implementation strategies on adherence rates to colorectal cancer (CRC) guidelines after polypectomy in a university hospital]. / Einfluss von Weiterbildungsmaßnahmen auf die leitliniengerechten Nachsorgeempfehlungen nach Polypektomie aus dem Dickdarm in einem Universitätsklinikum.

BACKGROUND: Colorectal cancer (CRC) is the second most common malignancy in Germany. Screening colonoscopies with polypectomy have been demonstrated to reduce the incidence of CRC. Detailed recommendations on scheduling screening and follow-up colonoscopies have therefore been included into national guidelines. Knowledge about CRC guidelines and adherence to guideline recommendations varies greatly among physicians. METHODS: We combined different implementation strategies (training courses, case discussion, handouts, wall charts) to improve adherence of recommendations for scheduling follow-up colonoscopy. To assess adherence, written recommendations given at discharge after inpatient treatment for polypectomy were analysed before (n = 111) and after (n = 83) the implementation of the above-mentioned implementation measures. Additional factors possibly influencing the recommendations of physicians were collected (histology, polyp size). RESULTS: The adherence to the CRC guideline before implementation of the above-mentioned measures was moderate. After intervention, there was a non-significant increase from 47 % to 53 %. Senior physician review and editing of the discharge summaries improved guideline adherence of recommendations to 69 %. Neither the education level of residents nor their affiliation to a certain department had an impact on the quality of the recommendations. Histology and in particular information on the resection status of the polyps in the pathology report (complete versus incomplete resection) had an influence of the recommended schedule. Furthermore, size of the polyps, but not the number, had a statistically significant influence on the quality of the recommendations. CONCLUSIONS: The inadequate improvement of guideline adherence can possibly be explained by the insufficient interactive and repetitive character of interventions. As the histology reports seem to have an influence on the recommendations in regards to the interval to the next colonoscopy, interdisciplinary teaching is necessary to improve guideline concurrent care.

[Integrated headache care network. Kiel Migraine and Headache Center and German National Headache Treatment Network]. / Sektorenübergreifende schmerzmedizinische Versorgung. Schmerzklinik Kiel und bundesweites Kopfschmerzbehandlungsnetz.

Migraine and other headaches affect 54 million people in Germany. They rank among the ten most severely disabling complaints and the three most expensive neurological disorders. Nevertheless, they are not adequately recognized in the healthcare system with sketchy diagnoses and inadequate treatment. This inadequate care is not primarily due to a lack of medical and scientific knowledge on the development and treatment of headaches but is predominantly due to organizational deficits in the healthcare system and in the implementation of current knowledge. To overcome the organizational barriers the national headache treatment network was initiated in Germany. For the first time it allows national cross-sectoral and multidisciplinary links between inpatient and outpatient care. A hand in hand treatment programme, better education, better information exchange between all partners and combined efforts using clearly defined treatment pathways and goals are the basis for state of the art and efficient treatment results. The treatment network is geared towards the specialized treatment of severely affected patients with chronic headache disorders. A national network of outpatient and inpatient pain therapists in both practices and hospitals works hand in hand to optimally alleviate pain in a comprehensive cross-sectoral and multidisciplinary manner. For therapy refractive disorders, a high-intensive supraregional fully inpatient treatment can be arranged. This concept offers for the first time a nationwide coordinated treatment without limitation by specialization and bureaucratic remuneration sectors.