To assess efficacy and tolerability of simvastatin plus vitamin D for migraine prevention in adults with episodic migraine.
We performed a randomized, double-blind, placebo-controlled trial with a 12-week baseline period and 24-week intervention period in 57 adults with episodic migraine. Participants were randomly assigned to simvastatin 20 mg tablets twice daily plus vitamin D3 1000 international units capsules twice daily or matching placebo tablets and capsules.
Compared to placebo,
participants using simvastatin plus vitamin D3 demonstrated a greater decrease:
in number ofmigrainedays from the baseline period to intervention weeks 1-12: a change of -8.0 (IQR: -15.0 to -2.0) days in the active treatment group versus +1.0 (IQR: 1.0 to +6.0) days in the placebo group, P<0 .001="" and="" nbsp="" span="">0>
to intervention weeks 13-24: a change of -9.0 (IQR: -13 to -5) days in the active group versus +3.0 (IQR: -1.0 to +5.0) days in the placebo group, P<0 .001.="" abstracttext="" nbsp="">0>
In the active treatment group, 8 patients (25%) experienced 50% reduction in the number of migrainedays at 12 weeks and 9 (29%) at 24 weeks post randomization.
In comparison, only 1 patient (3%) in the placebo group (p=0.03) experienced such reduction. Adverse events were similar in both active treatment and placebo groups.
The results demonstrate that simvastatin plus vitamin D is effective for prevention of headache in adults with episodic migraine. Given statins ability to repair endothelial dysfunction, this economical approach may also reduce the increased risk for vascular diseases among migraineurs. This article is protected by copyright. All rights reserved.
Our previous study in patients with cerebellar ataxias of different causes showed significant benefit of riluzole after 8 weeks. We aimed to confirm these results in patients with spinocerebellar ataxia or Friedreich's ataxia in a 1-year trial.
Patients with spinocerebellar ataxia or Friedreich's ataxia (2:1 ratio) from three Italian neurogenetic units were enrolled in this multicentre, double-blind, placebo-controlled trial, and randomly assigned to riluzole (50 mg orally, twice daily) or placebo for 12 months. The randomisation list was computer-generated and a centralised randomisation system was implemented. Participants and assessing neurologists were masked to treatment allocation. The primary endpoint was the proportion of patients with improved Scale for the Assessment and Rating of Ataxia (SARA) score (a drop of at least one point) at 12 months. An intention-to-treat analysis was done. This trial is registered at ClinicalTrials.gov, number NCT01104649.
Between May 22, 2010, and Feb 25, 2013, 60 patients were enrolled. Two patients in the riluzole group and three in the placebo group withdrew their consent before receiving treatment, so the intention-to-treat analysis was done on 55 patients (19 with spinocerebellar ataxia and nine with Friedreich's ataxia in the riluzole group, and 19 with spinocerebellar ataxia and eight with Friedreich's ataxia in the placebo group). The proportion with decreased SARA score was 14 (50%) of 28 patients in the riluzole group versus three (11%) of 27 in the placebo group (OR 8·00, 95% CI 1·95–32·83; p=0·002). No severe adverse events were recorded. In the riluzole group, two patients had an increase in liver enzymes (less than two times above normal limits). In two participants in the riluzole group and two participants in the placebo group, sporadic mild adverse events were reported.
Our findings lend support to the idea that riluzole could be a treatment for cerebellar ataxia. Longer studies and disease-specific trials are needed to confirm whether these findings can be applied in clinical practice.
•Epileptic seizures are associated with frequent use of emergency department (ED).
•Little is known about the specific use by known epileptic patients (KEPs).
•One year descriptive case series report on KEPs admitted prospectively in ED.
•Proportion of KEPs using ED is high (9.0%), half of them concerned usual seizures.
•Data crucial to optimize the KEPs ED care pathway.
Background and purpose
Seizure is a frequent reason of admission in emergency department (ED) but little is known about the proportion and the characteristics of known epileptic patients (KEPs) who used emergency services.
Over a 12-month period, we prospectively recruited adults admitted for seizure to a tertiary hospital ED. For KEPs, clinical epilepsy features and characteristics of the admission were collected.
Of the 60,578 ED admissions, 990 were related to seizure; 580 of these admissions concerned 448 different KEPs (257 males; median age: 44); 339 were residents in the health district. Epilepsy was structural/metabolic in 268 (59.8%) patients, genetic in 44 (9.8%) and unknown/undetermined in 136 (30.3%); 218 (48.7%) patients were under a single antiepileptic drug and 135 (30.1%) were followed by an epileptologist. Of the 580 KEP admissions, 440 (75.8%) concerned patients who had called the emergency medical assistance number, 252 (43.4%) with a discharge diagnosis of usual seizure and 43 (7.4%) of a status epilepticus. Half the KEPs were discharged without hospitalization. We estimated that 9.0% of KEPs residing in the district had used the ED during the period.
Proportion of KEPs using ED is high. Most of the admissions concerned usual seizures suggesting that staff training and educational programmes for patients and for their relatives need to be improved. The organization of the prehospital and of the emergency medical services should also be adjusted to this specific need. Further research should be conducted to optimize the seizure care pathway for KEPs.
Hooray for the Sleep and Language Pathologists for looking at the data linking sleep and language delay! JR
The Evidence-Based Decision
There is consistent evidence that children with sleep disorders are at higher risk for language problems than healthy sleepers.
With the exception of expressive phonology (in a single study), these problems are subtle.
Effect sizes were typically small and the low scores earned on standardized tests of language were still within normal limits. Although it is clear that sleep disorders do increase the risk of at least subclinical language problems, the risk is not limited to language. Children with sleep disorders also presented with poor behavior, attention, and executive function.
The SLP should consider this evidence when taking case histories and making appropriate referrals.
If parents report that their child consistently exhibits limited sleep, poor quality sleep, snoring, or excessive daytime sleepiness, a referral to a physician is warranted. The child who presents with mild or subclinical deficits in language, along with problematic attention, executive function, or behavior, might be more accurately diagnosed with a sleep disorder than a language learning deficit. That said, given the current evidence, it is not clear that treatment for the child’s sleep disorder will remediate subclinical language problems.
Are people with sleep disorders at higher risk for language learning deficits than healthy sleepers?
PubMed, Google Scholar, Trip Database, ClinicalTrials.gov.
sleep disorders AND language AND learning; sleep disorders language learning -deprivation -epilepsy; sleep disorders AND verballearning.
NUMBER OF INCLUDED STUDIES:
Children and adults with sleep disorders were at a higher risk for language problems than healthy sleepers. The language problems typically co-occurred with problems of attention and executive function (in children and adults), behavior (in children), and visual-spatial processing (in adults). Effects were typically small. Language problems seldom rose to a level of clinical concern but there were exceptions involving phonological deficits in children with sleep-disordered breathing and verbal memory deficits among adults with sleep-disordered breathing or idiopathic REM sleep behavior disorder.
Case history interviews should include questions about limited sleep, poor-quality sleep, snoring, and excessive daytime sleepiness. Medical referrals for clients with suspected sleep disorders are prudent.
Why check an exome in children with autism and other neurologic illnesses?
This study reports molecular diagnostic yield from chromosomal microarray analysis and whole-exome sequencing performed for a population-based sample of 258 children diagnosed with autism spectrum disorder.
The combined molecular diagnostic yield was
6.3% (95% CI, 1.7%-15.2%) in the essential group (4/64 children), 28.6% (95% CI, 3.7%-71.0%) in the equivocal group (2/7 children), and 37.5% (95% CI, 18.8%-59.4%) in the complex group (9/24 children; 3-group comparison, P = .001).
The combined yield was significantly higher in the complex group when compared with the essential group (pairwise comparison, P = .002).
What is going on in pediatric specialty care? High Deductible Plans? Narrow Network health Plans? HMO? Learn more below. - JR
Risk that 'nobody will have access to pediatric specialty care'
By Modern Healthcare | July 18, 2015
Since 1999, Christopher Dawes has served as president and CEO of Lucile Packard Children's Hospital at Stanford, a 300-bed hospital in Palo Alto, Calif., affiliated with Stanford University that has 47 outpatient sites throughout the Greater San Francisco Bay Area....
Modern Healthcare: Has California's Medicaid expansion increased the number of patients at Lucile Packard and Stanford Children's Health who are on Medi-Cal?
Christopher Dawes: The number has not increased very much. About 42% of the patients we see are covered by Medi-Cal. The big issue for us and other children's hospitals in California is that, according to a recent Kaiser Family Foundation report, providers treating Medi-Cal patients are only paid about 53% of Medicare rates. California ranks 48th among the states in terms of what it pays for Medi-Cal recipients. So our challenge is that we're not paid by the state the full cost of providing care to these children. We have a significant deficit on that population, and we have to make up that deficit through our commercial patients, which represent about 55% of our patients.
This is a very big issue in California because over the next few years, they're estimating that about 50% of kids will be covered by Medi-Cal, and access becomes an increasing issue. We accept anybody regardless of their ability to pay, but that's not true across the whole state.
MH: Has your organization had problems with narrow-network health plans excluding your children's hospital?
Dawes: The trouble with narrow networks is that they're basically built around price and a limited number of providers. For routine adult care, that may or may not work. But when you're looking at kids with cancers and prematurity and so forth, it's a huge issue. If we simply have networks defined by low price and a thin cohort of providers, virtually nobody will have access to pediatric specialty care.
MH: Have there been any networks that Stanford has been excluded from?
Dawes: We have not been excluded yet. We have been put in different tiers. We negotiate pretty hard with payers to ensure that we're always in tier 1. That hasn't always happened. What that means is that kids whose parents are covered by a particular insurance product may be denied access to us. We follow up on those vigorously. But as of today, there hasn't been a narrow network created that we've been excluded from. Still, we're anticipating that to be the case over the next few months or years, because narrow networks are picking up some popularity.
We're kind of in a unique spot because we're in Silicon Valley, and the high-tech firms are trying to attract and retain a limited resource of engineers. So they have a tendency to offer more robust benefit packages than you would find in other industries. They are very interested in offering benefit plans that include us. If you look at other children's hospitals in California and other states, it's become a much bigger issue for them.
MH: What are you and other children's hospitals doing about this narrow-network issue?
Dawes: The California Children's Hospital Association has legislation pending, both at the state level and federal level, to create geographically based networks of care for kids with complex and chronic illnesses. The children's hospital would be a key component of that, but in addition, you'd have rehab and other services that these kids with special needs require. The networks would go at risk for managing a population of kids with special-care needs. We would have within that network all the resources required to care for these kids. On the federal level, we would accept a rate of increase on an annual basis that will be lower than the current rate of increase for Medicaid. So the government would save money, the kids would be better served, and the providers would have assurance that they would receive a sufficient revenue stream to support the needs of these kids.
MH: Have you noticed any pickup in high-deductible plans?
Dawes: We're seeing a lot more benefit plans that have much higher deductibles. It's making the consumer much more aware of costs. From a macro perspective, I think that's a good thing. A lot of the population we serve is fairly sophisticated, and many of the companies are providing tools to their employees to help them determine quality and cost for various providers.
We're seeing consumers get a lot more sophisticated in making their choices. They're getting a lot pickier, they're asking more questions, and that is definitely impacting us, and we're responding. We're looking carefully at our prices, particularly for ancillary services, so we can be more competitive.
One of the issues is we're an academic medical center, and we price our services based on our cost structure, which is quite extensive given that we're doing training and research and delivering services to very complex patients.
"You chose a managed care organization (MCO) because your primary doctor is in the plan's
network, but later you learn that you don't have access to your longstanding specialists, who
may be more important to your health care - Before selecting a plan, look at the MCO's network
Consider whether the MCO offers you access to your specialists (such as
psychiatrists or rehabilitation specialists) as well as your PCP.
For people with disabilities,
access to a specialist can be more important than access to their regular doctor. If you ask for a
list of specialists, the MCO is required to give it to you."
It appears that we are going through a cycle where families may experience difficulty with specialty access. Please learn the language health care insurance and review your rights.
Your primary care, employer (or even the health plan) may not be aware of the difficulties that you face with access. Let them know. They can help.
Cook Childrens' in Fort Worth compiled an excellent review. Read More Here
make covered health care services available within a certain distance of your home or workplace
allow referrals to out-of-network doctors and hospitals when medically necessary services aren't available within the network
allow members to change a PCP up to four times a year
allow members with chronic, disabling, or life-threatening illnesses to use specialists as their PCPs under certain circumstances
allow members with terminal illness, disability, life-threatening condition, or pregnancy to temporarily continue seeing doctors no longer with the network if the doctor agrees to continue treatment at the HMO's contracted rate
pay for emergency care if not getting immediate medical care could place your health - or the health of your unborn child if you're pregnant - in serious jeopardy. If you get emergency treatment at a hospital outside the HMO's network, you may be transferred to a network doctor or hospital after your condition is stabilized.
Referrals for Specialty Care - Its your primary care providers' responsibility for managing your care.
Q. How does an HMO deliver care? A. An HMO delivers care by providing or arranging for health care services directly or indirectly through contracts and subcontracts with physicians, providers, and/or other HMOs.
Q. What determines whether an HMO has an adequate health care delivery system? A. All covered health care services that are offered by the HMO shall be sufficient in number and location to be readily available and accessible within the geographical service area to all enrollees. The HMO must have a sufficient number of primary care physicians and specialists with hospital admitting privileges at participating facilities who are available and accessible 24 hours per day, seven days per week, within the HMO's geographical service area. Additionally, an HMO shall make emergency care available and accessible 24 hours per day, seven days per week, without restrictions as to where the services are rendered.
Q. What are the accessibility and availability requirements for an HMO? A. An HMO is required to provide an adequate network which would consist of contracted physicians and providers for its entire geographical service area.* All covered health care services must be accessible and available to enrollees within certain travel distances. The distance from any point in the HMOs service area to a point of service can be no greater than:
30 miles for primary care and general hospital care; and
75 miles for specialty care, specialty hospitals, and single healthcare service plan physicians or providers.
An HMO must arrange and make available urgent care within:
24 hours for medical and dental conditions; and
24 hours for behavioral health conditions.
An HMO must arrange and make available routine care within:
3 weeks for medical conditions;
8 weeks for non-emergent dental conditions; and
2 weeks for behavioral health conditions
An HMO must arrange and make available preventive care within:
2 months for a child;
3 months for an adult; and
4 months for dental services.
*Geographic Service Area is defined as a geographic area within which direct service benefits are available and accessible to HMO enrollees who live, reside, or work within that geographic area.