Organizational changes aiming to reduce iv tPA door-to-needle time.

OBJECTIVES: To assess time trends in intravenous thrombolytic (iv tPA) treatment in a general local hospital during a period with organizational changes, especially how movement of treatment start from the emergency room (ER) to the CT laboratory, and changing method of administration of acute antihypertensive medication influenced on door-to-needle time (DNT). MATERIALS AND METHODS: All stroke patients treated with iv tPA have been prospectively enrolled in the Safe Implementation of Treatments in Stroke (SITS) registry. Data from 2007 to 2011 were reviewed. Safety was evaluated by the incidence of symptomatic intracerebral hemorrhage (SICH). Predictors of DNT were assessed by multivariable regression. RESULTS: Two hundred and forty-three patients were treated with iv tPA. The annual treatment rate reached 21.9% of patients with ischemic strokes admitted to the hospital. Median DNT decreased from 36 to 28 min (P ≤ 0.001). The incidence of SICH remained low and was throughout the period 2.5%. Treatment start in the CT laboratory vs in the ER was associated with a reduction in median DNT (P = 0.007). Acute antihypertensive treatment and treatment with warfarin were associated with increased DNT (P = 0.024 and P = 0.003, respectively). Age, gender, baseline NIHSS, onset-to-door time, comorbidity, and method of administration of acute antihypertensive treatment did not influence DNT significantly. CONCLUSIONS: Streamlining of iv tPA logistics can reduce median DNT to <30 min in a general local hospital. Moving treatment start from the ER to the CT laboratory contributed to reduce DNT. Our organizational model was resistant to influence on DNT by patient age, gender, stroke severity, and time to hospital arrival. The incidence of SICH remained low.

Chronic daily headache with medication overuse: predictors of outcome 1 year after withdrawal therapy.

BACKGROUND AND PURPOSE: We examined prospectively the results of withdrawal therapy in 80 patients with probable medication overuse headache. The aim was to identify baseline patient characteristics that might predict outcome after 1 year (end of study). METHODS: We classified patients according to results of withdrawal therapy measured as the improvement of headache days (HD) from baseline to end of study. RESULTS: Thirty-six per cent (29/80) had at least 50% improvement. Sixty-four per cent (51/80) had <50% improvement, and among these, 30% (24/80) had <10% improvement. The following baseline characteristics were associated with poor outcome of withdrawal therapy: use of codeine-containing drugs, low self-reported sleep quality, and high self-reported bodily pain as measured by the quality of life tool SF-36. CONCLUSION: Before suggesting withdrawal therapy, one should probably pay more close attention to sleep problems.

Chronic daily headache with medication overuse: a randomized follow-up by neurologist or PCP.

Several studies have shown the benefit of withdrawal therapy when medication overuse headache (MOH) is suspected. Our aim was to compare the effect of withdrawal therapy in patients followed by a neurologist (group A, n = 42) and a primary care physician (PCP) (group B, n = 38). Patients were randomized to A or B, and follow-up was at 3, 6 and 12 months. Calculated mean headache (MH at 6 months + MH at 12 months)/2 (primary end-point) was similar; A 1.04 (0.87, 1.21) and B 1.02 (0.82, 1.21) (P = 0.87). The number of patients with 50% improvement of headache days was also similar; 14/42 in group A vs. 12/34 in B (P = 0.86) at 3 months, 15/42 vs. 11/33 (P = 0.83) at 6 months and 15/42 vs. 14/38 (P = 0.92) at 12 months. Days without headache during the last 9 months of follow-up were 123 (96, 150) in group A and 137 (112, 161) in B (P = 0.62). After 3 months one-third were classified as MOH. Patients with MOH improved similarly in group A and B, and so did patients without MOH. Within 1 year 7/42 in A and 9/38 in B had recurrent medication overuse (P = 0.43). In summary, there were no significant differences in follow-up results between the two groups.

[Transformed migraine--chronic daily headache]. / Transformert migrene--kronisk daglig hodepine.

Transformed migraine is probably a common cause of chronic daily headache. The International Headache Society system of diagnostic classification of headache classifies headaches, not patients, and pays no attention to the long-term evolution of the patient's headache. We support the suggestion made by Silberstein et al. that transformed migraine should be used as a diagnostic label in patients suffering from chronic daily headache with "migrainous features" and a history of migraine. Since 1994, intravenous treatment with dihydroergotamine (DHE) has been used for these patients. Among 16 patients suffering from chronic daily headache which were treated with this drug in 1996, 10 patients reported complete relief of headache at discharge from the hospital, but only four patients experienced complete relief from headache for more than two weeks. We think that the most important treatment for these patients are medicament withdrawal, information, help and support so that patients may cope with their headache. Dihydroergotamine can help patients going through a withdrawal regime.