Migraine-related healthcare resource use in the emergency department setting: a panel-based chart review in France, Germany, Italy, and Spain

Objective: Migraine is a common, disabling condition typically characterized by severe headache, nausea, and/or light and sound sensitivity. This study assessed migraine-related health resource utilization (HRU) occurring in the emergency room/accident & emergency department (ER/A&E) setting among European patients with 4 or more migraine days per month. Methods: Patient-level clinical and HRU data were collected via chart extraction by ER/A&E physicians in France, Germany, Italy, and Spain. Eligible patients had 4 or more migraine days in the month prior to a migraine-related ER/A&E visit and a history of migraine, among other criteria. The index date for each patient was defined as the date of an ER/A&E visit for migraine on or after January 1, 2013. Physician and ER/A&E characteristics, patient and disease characteristics, treatment history, migraine-medication used, and migraine-related HRU (i.e. procedures) during the ER/A&E visit were assessed. Descriptive analyses were conducted in the pooled population, and a sensitivity analysis was performed by country. Results: A total of 467 eligible patient's charts (120 in France, 120 in Germany, 107 in Italy, and 120 in Spain) were provided by 136 physicians (36 in France, 36 in Germany, 28 in Italy, and 36 in Spain). On average, patients spent nearly 8 hours in the ER/A&E. Approximately 82% of patients received a blood test, 62% received an electrocardiography, and 46% received a cranial computerized tomography scan. Despite the majority of patients already using acute or prophylactic treatment upon visiting the ER/A&E, almost all patients were administered or prescribed migraine treatment during the visit. Approximately 21% of patients were admitted to the hospital, and over half of patients were referred to a neurologist or headache specialist. Conclusions: European patients who had four or more migraine days in the month prior to a migraine-related ER/A&E visit had high HRU associated with the visit.

Real-world healthcare resource utilization related to migraine treatment failure: a panel-based chart review in France, Germany, Italy, and Spain

Aims: This retrospective chart review examined the six-month migraine-related healthcare resource use (HRU) among European patients who had ≥4 migraine days per month and previously failed at least two prophylactic migraine treatments. Methods: Neurologists, headache specialists, and pain specialists in France, Germany, Italy, and Spain who treated ≥10 patients with migraine in 2017 were recruited (April-June 2018) to extract anonymized patient-level data. Eligible physicians randomly selected charts of up to five adult patients with clinically-confirmed migraine, ≥4 migraine days in the month prior to the index date, and had previously failed at least two prophylactic migraine treatments. Treatment failure was defined as discontinuation due to lack of efficacy and/or tolerability. Demographic and disease characteristics as of the index date, and migraine-related HRU incurred during the 6-month study period, were recorded. Results: A total of 104 physicians contributed 168 charts for patients (63% female). On average, patients were 38 years old and failed 2.3 prophylactic treatments as of the index date. During the study period, 83% of patients had ≥1 outpatient visit for migraine in the physician's office, and 27% went to the ER/A&E. Approximately 5% of patients were hospitalized for migraine, with an average of one hospitalization and an average length of stay of 3 days. Approximately 39% of patients had ≥1 blood test, 22% had ≥1 magnetic resonance imaging, 17% had ≥1 electroencephalogram, and 13% had ≥1 computerized tomography scan. Visits to other healthcare providers were common. Limitations: This study is subject to the limitations of chart review studies, such as errors in data entry. Conclusions: Across four European countries, the HRU burden of migraine among patients who previously failed at least two prophylactic treatments was high, indicating a need for more effective prophylactic treatments to appropriately manage migraine and reduce the HRU burden attributable to this common disorder.

Migraine burden and costs in France: a nationwide claims database analysis of triptan users

Objectives: To estimate the burden of migraine in the population of French patients identified as specific migraine acute treatment users compared to a control group. Methods: A cross-sectional retrospective analysis was performed on the Echantillon Généraliste des Bénéficiaires claims database, a 1/97 random sample of the French public insurance database. A representative sample of all adults with at least one delivery of triptans, ergot derivatives or acetylsalicylic acid/metoclopramide (all drugs with a specific label in migraine acute treatment - SMAT) in 2014 was selected with a control group matched on age, gender and geographic region. Among triptan users, a sub-group of over-users was defined according to their level of triptan uptake expressed in defined daily doses (DDD - a standard daily dose of treatment of acute migraine) per month over 3 months and more, was also compared with controls. The cost analysis was performed in a societal perspective for direct costs. Sick leave indirect costs were estimated using the human capital approach. Results: In total 8639 SMAT users (mean age: 44.6 years; 78.7% women) were selected representing a crude prevalence rate of 1.7%. The annual per capita total healthcare expenditures were higher by €280 in this group compared to controls (€2463 vs. €2183). Triptans contributed 47.8% to this extra cost. They used significantly (p < .0001) more frequently than controls antidepressants (20.8% vs. 11.0%), anxiolytics (29.4% vs. 18.8%) and analgesics (53.8% vs. 35.8%). The per capita annual productivity loss associated with sick leave was higher by €295 (€1712 vs. €1417). Among triptan users, there were 2.9% over-users. This last group was characterized by substantially higher per capita annual extra direct (+ €1805) and indirect costs (productivity loss +€706) compared to controls. Conclusions: Due to its high prevalence, migraine costs generate a significant societal burden. The group of over-users concentrates high per capita direct and indirect costs.

What does normal tendon structure look like? New insights into tissue characterization in the Achilles tendon

Recently, ultrasound tissue characterization (UTC) was introduced as a reliable method for quantification of tendon structure. Despite increasing publications on the use of UTC, it is striking that there is a lack of normative data in active adolescents. Therefore, the aim of this study was to provide normative values of the Achilles tendon as quantified by UTC. Seventy physiotherapy students (26 male and 44 female students) with no history of Achilles tendon injuries were recruited. The Achilles tendons were scanned with UTC to characterize tendon structure. This study demonstrated that Achilles tendons of active, healthy adolescents contained 54.6% echo type I, 42.8% echo type II, 2.2% echo type III, and 0.3% echo type IV at midportion. The comparison between insertion and midportion of the tendon showed more echo type II at insertion (P < 0.001). Furthermore, female tendons contained significantly more echo type II, in both insertion and midportion compared with male tendons (P = 0.004 and P = 0.003, respectively). The results of this study, with respect to the MDC (minimum detectable change), highlight differences in the UTC echopattern in the normal population (sex and regional location), which are important considerations for future studies.

Assessment of chemical and biochemical stabilization of organic C in soils from the long-term experiments at Rothamsted (UK)

Biological and chemical stabilization of organic C was assessed in soils sampled from the long-term experiments at Rothamsted (UK), representing a wide range of carbon inputs and managements by extracting labile, non-humified organic matter (NH) and humic substances (HS). Four sequentially extracted humic substances fractions of soil organic matter (SOM) were extracted and characterized before and after a 215-day laboratory incubation at 25 degrees C from two arable soils, a woodland soil and an occasionally stubbed soil. The fractions corresponded to biochemically stabilised SOM extracted in 0.5M NaOH (free fulvic acids (FA) and humic acids (HA)) and chemically plus biochemically stabilised SOM extracted from the residue with 0.1M Na4P2O7 plus 0.1M NaOH (bound FA and HA). Our aim was to investigate the effects of chemical and biochemical stabilization on carbon sequestration. The non-humic to humic (NH/H) C ratio separated the soils into two distinct groups: arable soils (unless fertilised with farmyard manure) had an NH/H C ratio between 1.05 and 0.71, about twice that of the other soils (0.51-0.26). During incubation a slow, but detectable, decrease in the NH/H C ratio occurred in soils of C input equivalent or lower to 4Mgha(-1)y(-1), whereas the ratio remained practically constant in the other soils. Before incubation the free to bound humic C ratio increased linearly (R2=0.91) with C inputs in the soils from the Broadbalk experiment and decreased during incubation, showing that biochemical stabilization is less effective than chemical stabilization in preserving humic C. Changes in delta13C and delta15N after incubation were confined to the free FA fractions. The delta13C of free FA increased by 1.48 and 0.80 per thousand, respectively, in the stubbed and woodland soils, indicating a progressive biological transformation. On the contrary, a decrease was observed for the bound FA of both soils. Concomitantly, a Deltadelta15N of up to +3.52 per thousand was measured after incubation in the free FA fraction and a -2.58 Deltadelta15N in the bound FA. These changes, which occurred during soil incubation in the absence of C inputs, indicate that free FA fractions were utilised by soil microorganisms, and bound FA were decomposed and replaced, in part, by newly synthesized FA. The 13CPMAS-TOSS NMR spectra of free HA extracted before and after 215 days of incubation were mostly unchanged. In contrast, changes were evident in bound HA and showed an increase in aromatic C after incubation.

The role of stretching in tendon injuries

The function of tendons can be classified into two categories: tensile force transmission, and storage and release of elastic energy during locomotion. The action of tendons in storing and releasing energy is mainly seen in sports activities with stretch-shortening cycles (SSCs). The more intense the SSC movements are (jumping-like activities), the more frequently tendon problems are observed. High SSC movements impose high loads on tendons. Consequently, tendons that frequently deal with high SSC motion require a high energy-absorbing capacity to store and release this large amount of elastic energy. As the elasticity of tendon structures is a leading factor in the amount of stored energy, prevention and rehabilitation programmes for tendon injuries should focus on increasing this tendon elasticity in athletes performing high SSC movements. Recently, it has been shown that ballistic stretching can significantly increase tendon elasticity. These findings have important clinical implications for treatment and prevention of tendon injuries.

Mechanisms of phosphorus solubilisation in a limed soil as a function of pH

Phosphorus (P) quantity-intensity relationships are central to the solubility and release of P from soil to water. Relationships between P extractable by 0.5 M NaHCO extractable P (Olsen P; quantity, Q) and P extractable by 0.01 M CaCl(2) (CaCl(2)-P; possible predictor of soil solution or drainage water P; intensity, I) are curvilinear: above a certain Olsen P concentration, CaCl(2)-P becomes much more soluble than when below it. Aluminium-, Fe- and Ca-P forms (extractable by Olsen's reagent) are thought to control P solubility. Thus, our objectives were to identify P forms in equilibrium with CaCl(2)-P via solubility equilibrium experiments, and the behaviour of CaCl(2)-P in relation to Al, Fe and Ca associated P, determined with 31P high power decoupling magic angle spinning nuclear magnetic resonance spectroscopy (31P HPDec/MAS NMR). Results indicated that two Q-I relationships occurred, one for soils above pH 5.8, and the other for soils below pH 5.8. Above pH 5.8, soils were saturated with respect to hydroxyapatite (Ca(5)(PO(4))(3)OH) and undersaturated with respect to beta-tricalcium phosphate (beta-Ca(3)(PO(4))(2)), while log ion-activity products showed that all soils and pHs were either saturated or in equilibrium with variscite (AlPO(4).2H(2)O) or its amorphous analogue. Using 31P HPDec/MAS NMR, Ca-P was best correlated with CaCl(2)-P in soils above pH 5.8, and with Al-P in soils below this pH. This study demonstrates the value of solid-state NMR in conjunction with wet chemical techniques for the study of labile P and P loss from pasture soils with a wide range of managements.

Analysis of potentially mobile phosphorus in arable soils using solid state nuclear magnetic resonance

In many intensive agroecosystems continued inputs of phosphorus (P) over many years can significantly increase soil P concentrations and the risk of P loss to surface waters. For this study we used solid-state 31P nuclear magnetic resonance (NMR) spectroscopy, high-power decoupling with magic angle spinning (HPDec-MAS) NMR, and cross polarization with magic angle spinning (CP-MAS) NMR to determine the chemical nature of potentially mobile P associated with aluminum (Al) and calcium (Ca) in selected arable soils. Three soils with a range of bicarbonate-extractable Olsen P concentrations (40-102 mg P kg(-1)) were obtained from a long-term field experiment on continuous root crops at Rothamsted, UK, established in 1843 (sampled 1958). This soil has a threshold or change point at 59 mg Olsen P kg(-1), above which potentially mobile P (as determined by extraction with water or 0.01 M CaCl2) increases much more per unit increase in Olsen P than below this point. Results showed that CaCl2 and water preferentially extracted Al-P and Ca-P forms, respectively, from the soils. Comparison among the different soils also indicated that potentially mobile P above the threshold was largely present as a combination of soluble and loosely adsorbed (protonated-cross polarized) P forms largely associated with Ca, such as monetite (CaHPO4) and dicalcium phosphate dihydrate (CaHPO4-2H2O), and some Al-associated P as wavellite. The findings of this study demonstrate that solid-state NMR has the potential to provide accurate information on the chemical nature of soil P species and their potential mobility.

Multinuclear magnetic resonance analysis of two humic acid fractions from lowland rice soils

To determine the effects of intensive cropping of tropical lowland rice (Oryza sativa L.) and the associated long-term soil submergence on chemical properties of soil organic matter, we used solid-state 13C and 15N and solution 31P nuclear magnetic resonance (NMR) spectroscopy to analyze the labile mobile humic acid (MHA) and the more recalcitrant calcium humate (CaHA) fractions extracted from a series of soils supporting several long-term field experiments in the Philippines. The soils varied mainly in degree of submergence and cropping intensity, ranging from a rainfed rice field without soil submergence to irrigated double- and triple-cropped fields in which soil remains submerged almost all year long. As reported previously, all analyses associated increasing intensity of rice cropping with larger proportions of less humified material in the MHA and CaHA, such as diester phosphorus (P), amide nitrogen (N), and phenolic carbon (C). We established significant correlations between proportions of various spectral areas as well as between some spectral areas and other humic acid (HA) properties such as visible light absorption and free radical concentration (positive indices of humification) and hydrogen (H) concentration (negative index of humification). For example, spectral proportions of heterocyclic N were positively, and proportions of amide N and phenolic C negatively, correlated with visible light absorption and free radical concentration, and each of these spectral proportions had an opposite sign when correlated with H concentration. The correlations of N-alkyl C proportions were the strongest with these properties and with other functional group proportions.