Barriers to and facilitators for making emergency calls - a qualitative interview study of stroke patients and witnesses.

BACKGROUND AND OBJECTIVES: Early access to hospital for diagnosis and treatment is strongly recommended for patients with acute stroke. Unfortunately, prehospital delay frequently occurs. The aim of the current study was to gain in-depth insight into patient experience and behavior in the prehospital phase of a stroke. METHODS: We conducted qualitative interviews with a purposive sample of 11 patients and six witnesses within four weeks post stroke. The interviews were audio recorded, transcribed, and analyzed utilizing Systematic Text Condensation. RESULTS: The material was classified according to two main categories each containing three subgroups. The first category contained the diversity of sudden changes that all participants noticed. The subgroups were confusing functional changes, distinct bodily changes and witnesses' observations of abnormal behavior or signs. The second category was delaying and facilitating factors. To trivialize or deny stroke symptoms, or having a high threshold for contacting emergency services, led to time delay. Factors facilitating early contact were severe stroke symptoms, awareness of the consequences of stroke or a witness standing by when the stroke occurred. CONCLUSIONS: Prehospital delays involved interrelated elements: (1) Difficulties in recognition of a stroke when symptoms were mild, odd and/or puzzling; (2) Recognition of a stroke or need for medical assistance were facilitated by interaction/communication; (3) High threshold for calling emergency medical services, except when symptoms were severe. The findings may be helpful in planning future public stroke campaigns and in education and training programs for health personnel.

A pragmatic approach to sonothrombolysis in acute ischaemic stroke: the Norwegian randomised controlled sonothrombolysis in acute stroke study (NOR-SASS).

BACKGROUND: Ultrasound accelerates thrombolysis with tPA (sonothrombolysis). Ultrasound in the absence of tPA also accelerates clot break-up (sonolysis). Adding intravenous gaseous microbubbles may potentiate the effect of ultrasound in both sonothrombolysis and sonolysis. The Norwegian Sonothrombolysis in Acute Stroke Study aims in a pragmatic approach to assess the effect and safety of contrast enhanced ultrasound treatment in unselected acute ischaemic stroke patients. METHODS/DESIGN: Acute ischaemic stroke patients ≥ 18 years, with or without visible arterial occlusion on computed tomography angiography (CTA) and treatable ≤ 4(½) hours after symptom onset, are included in NOR-SASS. NOR-SASS is superimposed on a separate trial randomising patients with acute ischemic stroke to either tenecteplase or alteplase (The Norwegian Tenecteplase Stroke Trial NOR-TEST). The NOR-SASS trial has two arms: 1) the thrombolysis-arms (NOR-SASS A and B) includes patients given intravenous thrombolysis (tenecteplase or alteplase), and 2) the no-thrombolysis-arm (NOR-SASS C) includes patients with contraindications to thrombolysis. First step randomisation of NOR-SASS A is embedded in NOR-TEST as a 1:1 randomisation to either tenecteplase or alteplase. Second step NOR-SASS randomisation is 1:1 to either contrast enhanced sonothrombolysis (CEST) or sham CEST. Randomisation in NOR-SASS B (routine alteplase group) is 1:1 to either CEST or sham CEST. Randomisation of NOR-SASS C is 1:1 to either contrast enhanced sonolysis (CES) or sham CES. Ultrasound is given for one hour using a 2-MHz pulsed-wave diagnostic ultrasound probe. Microbubble contrast (SonoVue®) is given as a continuous infusion for ~30 min. Recanalisation is assessed at 60 min after start of CEST/CES. Magnetic resonance imaging and angiography is performed after 24 h of stroke onset. Primary study endpoints are 1) major neurological improvement measured with NIHSS score at 24 h and 2) favourable functional outcome defined as mRS 0-1 at 90 days. DISCUSSION: NOR-SASS is the first randomised controlled trial designed to test the superiority of contrast enhanced ultrasound treatment given ≤ 4(½) hours after stroke onset in an unselected acute ischaemic stroke population eligible or not eligible for intravenous thrombolysis, with or without a defined arterial occlusion on CTA. If a positive effect and safety can be proven, contrast enhanced ultrasound treatment will be an option for all acute ischaemic stroke patients. EudraCT No 201200032341; www.clinicaltrials.gov NCT01949961.

A qualitative description of telemedicine for acute stroke care in Norway: technology is not the issue.

BACKGROUND: To assist small hospitals in providing advanced stroke treatment, the Norwegian Directorate of Health has recommended telemedicine services. Telestroke enables specialists to examine patients via videoconferencing supplemented by teleradiology and to provide decision support to local health care personnel. There is evidence that telestroke increases thrombolysis rates. In Norway, telemedicine has mainly been used in non-critical situations. The first telestroke trials took place in 2008. The aim of this paper is to present an overview of telestroke trials and today's status with telestroke in Norway. Based on the divergent experience from two health regions in Norway, the paper discusses crucial factors for the integration of telestroke in clinical practice. METHODS: This is a descriptive study based on multiple methods to obtain an overview of the practice and experience with telestroke in Norway. A Web and literature search for 'telestroke in Norway' was performed and compared with a survey of telemedicine services at the country's largest hospitals. These findings were supplemented by interviews with key personnel involved in telestroke in two of four health regions, as well as hospital field observations and log data of telestroke transmissions from five of the hospitals involved. RESULTS: In Norway, experience in telemedicine for acute stroke care is limited. At the beginning of 2014, three of four regional health authorities were working with telestroke projects and services. Integration of the service in practice is challenging, with varying experience. The problems are not attributed to the technology in itself, but to organization (availability of staff on duty 24/7 and surveillance of the systems), motivation of staff, logistics (patient delay), and characteristics of the buildings (lack of space). CONCLUSIONS: Prerequisites for successful integration of telestroke in clinical practice include realization of the collaboration potential in the technology with consistent procedures for training and triage, availability of the equipment, and providing advice beyond questions concerning thrombolysis.

The Norwegian tenecteplase stroke trial (NOR-TEST): randomised controlled trial of tenecteplase vs. alteplase in acute ischaemic stroke.

BACKGROUND: Alteplase is the only approved thrombolytic agent for acute ischaemic stroke. The overall benefit from alteplase is substantial, but some evidence indicates that alteplase also has negative effects on the ischaemic brain. Tenecteplase may be more effective and less harmfull than alteplase, but large randomised controlled phase 3 trials are lacking. The Norwegian Tenecteplase Stroke Trial (NOR-TEST) aims to compare efficacy and safety of tenecteplase vs. alteplase. METHODS/DESIGN: NOR-TEST is a multi-centre PROBE (prospective randomised, open-label, blinded endpoint) trial designed to establish superiority of tenecteplase 0.4 mg/kg (single bolus) as compared with alteplase 0.9 mg/kg (10% bolus + 90% infusion/60 minutes) for consecutively admitted patients with acute ischaemic stroke eligible for thrombolytic therapy, i.e. patients a) admitted <4½ hours after symptoms onset; b) admitted <4½ hours after awakening with stroke symptoms c) receiving bridging therapy before embolectomy.Randomisation tenecteplase:alteplase is 1:1. The primary study endpoint is favourable functional outcome defined as modified Rankin Scale 0-1 at 90 days. Secondary study endpoints are: 1) haemorrhagic transformation (haemorrhagic infarct/haematoma); 2) symptomatic cerebral haemorrhage on CT 24-48 hours; 3) major neurological improvement at 24 hours; 4) recanalisation at 24-36 hours; 5) death. DISCUSSION: NOR-TEST may establish a novel approach to acute ischaemic stroke treatment. A positive result will lead to a more effective, safer and easier treatment for all acute ischaemic stroke pasients.NOR-TEST is reviewed and approved by the Regional Committee for Medical and Health Research Ethics (2011/2435), and The Norwegian Medicines Agency (12/01402). NOR-TEST is registered with EudraCT No 2011-005793-33 and in ClinicalTrials.gov (NCT01949948).

Clinical guidance of community physiotherapists regarding people with MS: professional development and continuity of care.

BACKGROUND AND PURPOSE: Clinical guidance to community physiotherapists (cPTs) is an integral part of physiotherapy service offered in hospital outpatient (OP) clinics for people with multiple sclerosis (PwMS). There is currently a lack of knowledge on the significance of such guidance. The aims of this study were 1) to identify the features that cPTs perceive to be significant in clinical guidance and 2) how this guidance may affect the cPTs' subsequent treatment of PwMS. METHODS: A phenomenological-hermeneutical framework was selected, and qualitative research interviews were performed and complemented with non-participating observations of a strategic sample of nine cPTs who received clinical guidance for their patients. The interviews were recorded and transcribed, and content analysis was conducted by using systematic text condensation, using theories of practice knowledge as analytic perspectives. RESULTS: The results indicate that cPTs identify participation in authentic movement analysis of a familiar patient as significant for professional development. Vital features are evaluation of the interplay between body parts, exploration of improvement of movement embedded in the OP clinic physiotherapist's explanations, followed by discussion. These elements provide access to dynamic elements in practice knowledge that are available only through first-hand experience and promote clinical reasoning through enhanced reflection during action as well as following action. Such guidance suggests direction for subsequent treatment and may enhance the continuity of care, particularly if the cPTs are experienced. Mutual information flow implementing the cPTs' perspective is requested, as are the use of plain language and supervision of the cPTs handling skills. Professional guidance for cPTs in OP clinics for PwMS should be considered when programmes aiming to develop competency in neurological physiotherapy are designed and when continuity of care for PwMS is discussed. More research regarding potential long-term impact of professional guidance in these clinics is requested.

Treatment of cerebral infarction at the stroke unit in Bodø 2011-12.

BACKGROUND: The regional health enterprises wish to increase the proportion of cerebral infarction patients who receive intravenous thrombolytic therapy. We have identified the reasons why only very few patients received such treatment during 2011-12. We also wished to assess the benefits of ECG telemetry in the examination of the patients. MATERIAL AND METHOD: With permission from the enterprise's own data protection officer, we analysed data for all patients discharged from the stroke unit at the Department of Neurology, Nordland Hospital, after a cerebral infarction (diagnostic code I63) in the period from 1 January 2011 to 30 April 2012. RESULTS: Of a total of 180 patients admitted directly to the stroke unit, only 12 (6.7%) received intravenous thrombolytic therapy. The main reasons why such treatment was not provided include late arrival at the hospital (n = 91: 50%) and an unknown time of symptom onset (n = 60: 33%). ECG telemetry detected atrial fibrillation in 27 of the 112 patients examined (24%), which meant that anticoagulation treatment was provided to 22 patients who otherwise would have received platelet inhibitors. INTERPRETATION: Half of all patients with cerebral infarction arrived in the hospital too late for provision of intravenous thrombolytic therapy, and in one-third the time of onset could not be determined. In many patients, ECG telemetry led to changes in the choice of secondary prophylaxis.

Randomised trial on episodic cluster headache with an angiotensin II receptor blocker.

OBJECTIVES: The aim of this study was to evaluate the angiotensin II receptor antagonist candesartan as prophylactic medication in patients with episodic cluster headache. METHODS: This study comprised a prospective, placebo-controlled, double-blind, parallel-designed trial performed in seven centres in Scandinavia. Forty (40) patients with episodic cluster headache (ICHD-2) were recruited and randomised over a five-year period to placebo or 16 mg candesartan in the first week, and placebo or 32 mg candesartan in the second and third week. RESULTS: The number of cluster headache attacks (primary efficacy variable) during the three-week treatment period was reduced from 14.3 ± 9.2 attacks in week 1 to 5.6 ± 7.0 attacks in week 3 (-61%) in the candesartan group and from 16.8 ± 14.1 attacks in week 1 to 10.5 ± 11.3 attacks in week 3 (-38%) in the placebo group. The difference between the candesartan and placebo group was not significant with the pre-planned non-parametric ranking test, but a post-hoc exact Poisson test, which takes into account the temporal properties of the data, revealed a significant result ( P < 0.0001). CONCLUSIONS: This was a negative trial. Post-hoc statistics suitable to describe the temporal changes in cluster headache indicate that conduction of future larger studies may be justified.

Contextualized perceptions of movement as a source of expanded insight: People with multiple sclerosis' experience with physiotherapy.

The hospitals' outpatient clinics for people with multiple sclerosis (PwMS) are important in the health care. Research regarding physiotherapy in such clinics is limited. The purpose was to investigate how PwMS perceive movement during single sessions of physiotherapy in a hospital's outpatient clinic, and what do these experiences mean for the patient's insight into their movement disturbances? Qualitative research interviews were performed with a purposive sample of 12 PwMS and supplemented with seven videotaped sessions. Content analysis was performed. The results indicate that contextualized perceptions of movement appear to be an essential source for PwMS to gain expanded insight with regard to their individual movement disturbances regardless of their ambulatory status. The contextualization implies that perceptions of movement are integrated with the physiotherapist's explanations regarding optimizing gait and balance or other activities of daily life. Perceptions of improvement in body part movement and/or functional activities are vital to enhancing their understanding of their individual movement disorders, and they may provide expanded insight regarding future possibilities and limitations involving everyday tasks. The implementation of movements, which transforms the perceived improvement into self-assisted exercises, appeared to be meaningful. Contextualized perceptions of improvements in movement may strengthen the person's sense of ownership and sense of agency and thus promote autonomy and self-encouragement. The findings underpin the importance of contextualized perceptions of movement based on exploration of potential for change, as an integrated part of information and communication in the health care for PwMS. Further investigations are necessary to deepen our knowledge.

Post-lumbar puncture headache.

BACKGROUND: Headache is a complication of lumbar puncture that has been known for more than a hundred years. The aim of this paper is to provide an overview of the incidence and symptoms of, the risk factors for and the treatment of this type of headache. METHOD: The article is based on a literature search in PubMed for studies on headache after lumbar puncture followed by discretionary selection of publications. RESULTS: Post-dural puncture headache (PDPH) is characterised by the occurrence of a headache with a significant orthostatic component within 5 days of a lumbar puncture. The incidence depends on a number of factors. Younger women with a previous history of headaches appear to be at highest risk. The incidence can be significantly reduced by using a thin lumbar puncture needle with an atraumatic tip. The condition is self-limiting and harmless, but leads to significant morbidity. Caffeine alleviates the symptoms and reduces the course of the illness. When bed rest and caffeine prove ineffective, an epidural blood patch works well for the majority, but there is no consensus on when such treatment should be offered. INTERPRETATION: Headache frequently occurs after lumbar puncture. There is substantial evidence for recommending the use of a thin, atraumatic needle to reduce the incidence. For practical reasons, a needle thinner than 22 G is not suitable for diagnostic lumbar puncture.

Patient satisfaction and perception of change following single physiotherapy consultations in a hospital's outpatient clinic for people with multiple sclerosis.

The aim of this study was to investigate satisfaction with physiotherapy and perception of change following single physiotherapy consultations in a hospital's outpatient service for people with multiple sclerosis (MS) (PwMS). The consultation included assessment, exploration of treatment, information, and instruction in self-assisted exercises based on the British guidelines for PwMS. Seventy-two PwMS were consecutively included, 54 women and 18 men with a mean age 45 (range 26-80). The Outpatient Experience Questionnaire (OPEQ) was used to record satisfaction; the Patient Global Impression of Change (PGIC) and the Borg's Rating Scale of Perceived Exertion (BRSPE) were used to investigate perceived changes in standing up, sitting down, and walking following the consultation. Sixty-four patients (89%) returned the OPEQ. The results showed strong satisfaction with physiotherapy regarding both interpersonal and clinical skills (mean 9.4, SD 1.0, best score 10) and no significant differences regarding the level of ambulatory independence, gender, or age. The PGIC indicated perceived short-term improvement for 35 (57%) patients, with no patients reporting deterioration. The BRSPE showed a significantly lower perception of exertion during walking after the consultation (Wilcoxon signed-rank test, Z-2.58, p = 0.010). The study indicates a high level of satisfaction regarding interpersonal and clinical skills, information, and instruction in self-assisted exercises and indicates that perceptions of short-term improvement may occur after single consultations. The study suggests an important role for physiotherapy in hospital outpatient services for PwMS, but further studies are necessary to deepen our understanding.

A 4-year follow-up of patients with medication-overuse headache previously included in a randomized multicentre study.

The aim of this study was to evaluate the long-term outcome in 61 patients with medication-overuse headache (MOH) who 4 years previously had been included in a randomized open-label prospective multicentre study. Sixty patients still alive after 4 years were invited to a follow-up investigation. Fifty patients (83%) participated. Sixteen visited a neurologist, 22 were interviewed through telephone, 2 gave response by a letter, and 10 were evaluated through hospital records. The influence of baseline characteristics on outcome 4 years later was evaluated by non-parametric tests. p values below 0.01 were considered significant. At follow-up, the 50 persons had a mean reduction of 6.5 headache days/month (p < 0.001) and 9.5 acute headache medication days/month (p < 0.001) compared to baseline. Headache index/month was reduced from 449 to 321 (p < 0.001). Sixteen persons (32%) were considered as responders due to a ≥50% reduction in headache frequency from baseline, whereas 17 (34%) persons met the criteria for MOH. None of the baseline characteristics consistently influenced all five outcome measures. Total Hospital Anxiety and Depression Scale (HADS) score at baseline was predictors (p < 0.005) for being a responder after 4 years. At 4 years' follow-up, one-third of the 50 MOH patients had ≥50% reduction in headache frequency from baseline. A low total HADS score at baseline was associated with the most favorable outcome.

Prophylaxis of migraine with melatonin: a randomized controlled trial.

BACKGROUND: A previous open-label study of melatonin, a key substance in the circadian system, has shown effects on migraine that warrant a placebo-controlled study. METHOD: A randomized, double-blind, placebo-controlled crossover study was carried out in 2 centers. Men and women, aged 18-65 years, with migraine but otherwise healthy, experiencing 2-7 attacks per month, were recruited from the general population. After a 4-week run-in phase, 48 subjects were randomized to receive either placebo or extended-release melatonin (Circadin®, Neurim Pharmaceuticals Ltd., Tel Aviv, Israel) at a dose of 2 mg 1 hour before bedtime for 8 weeks. After a 6-week washout treatment was switched. The primary outcome was migraine attack frequency (AF). A secondary endpoint was sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI). RESULTS: Forty-six subjects completed the study (96%). During the run-in phase, the average AF was 4.2 (±1.2) per month and during melatonin treatment the AF was 2.8 (±1.6). However, the reduction in AF during placebo was almost equal (p = 0.497). Absolute risk reduction was 3% (95% confidence interval -15 to 21, number needed to treat = 33). A highly significant time effect was found. The mean global PSQI score did not improve during treatment (p = 0.09). CONCLUSION: This study provides Class I evidence that prolonged-release melatonin (2 mg 1 hour before bedtime) does not provide any significant effect over placebo as migraine prophylaxis. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that 2 mg of prolonged release melatonin given 1 hour before bedtime for a duration of 8 weeks did not result in a reduction in migraine frequency compared with placebo (p = 0.497).

24-hour distribution of migraine attacks.

BACKGROUND: It is a widespread opinion that migraine attacks arise more frequently in the morning and that circadian rhythms may be responsible for the temporal pattern in migraine. However, only one small prospective study has previously been published on this topic. OBJECTIVE: To investigate circadian variation in migraine. METHOD: Eighty-nine females in fertile age who had participated in a previous questionnaire-based study volunteered to prospectively record in detail every migraine attack for 12 consecutive months. We reviewed all diary entries covering the period from March 2004 through April 2005, and did time-series analysis. RESULTS: Fifty-eight patients had complete recordings over the 12 months and 26 completed the diaries for 1-11 months. Three patients were excluded due to missing data and 2 patients were excluded due to chronic migraine or medication-overuse headache. A total of 2314 attacks were experienced, in average 27.5 per patient (range 1-75). By fitting a sine curve to the data there was a harmonic trend with a peak around 13.40 and the peak/low ratio was 25.6 (95% CI: 8.3-78.6). CONCLUSION: The main finding in our study is that migraine attacks tend to recur in a harmonic 24-hour cyclic manner with a peak around the middle of the day and that there is no difference between migraine with aura and migraine without aura regarding this.

[Migraine--mechanisms and consequences for treatment]. / Migrenesmerte--mekanismer og konsekvenser for behandling.

BACKGROUND: Migraine is a common headache syndrome. The understanding of processes in the brain during a migraine attack has increased significantly during recent years. MATERIAL AND METHODS: The article is based on literature retrieved from PubMed, and on own knowledge of older and more recent migraine literature. RESULTS AND INTERPRETATION: Patients with migraine probably have increased cortical excitability. Attacks may be initiated by the neurophysiological phenomenon "cortical spreading depression". This may again lead to meningeal inflammation and irritation of pain-sensitive fibres in the trigeminal nerve. There is compelling evidence that an episodic dysfunction of the brain stem plays an important role, either as a primary generator of or a secondary contributor to, migraine attacks. Patients often report allodynia as an expression for central sensitization. Activity in pain-modulating mechanisms is disturbed, and serotonin agonists efficiently stop attacks. The tendency to have repetitive migraine attacks is probably due to a genetic predisposition.

Insomnia and circadian variation of attacks in episodic migraine.

OBJECTIVES: To assess the influence of insomnia on the 24-hour temporal pattern of migraine. BACKGROUND: Migraine attacks have been reported to occur in a harmonic (monophasic) or a biphasic 24-hour cyclic manner, and in some studies to have preponderance in the morning hours. The influence of insomnia on the circadian pattern has not been evaluated. METHOD: Based on a previous study of the circadian variation in migraine, an explorative data analysis was made to compare the circadian pattern of insomnia-related migraine attacks to the circadian pattern of migraine attacks not related to insomnia. If the patients reported difficulties in falling asleep and/or maintaining sleep the night prior to the reported attack or the night the attack occurred, the attack was defined as insomnia-related. Relapses were not counted as distinctive attacks. RESULTS: Sixty-eight female migraineurs (mean +/- SD age: 35.5 +/- 7.0) prospectively recorded 1869 migraine attacks. Five hundred-and-thirty-three attacks (29%) were insomnia-related. Insomnia-related attacks had a biphasic temporal pattern with one peak in the morning hours and one peak after noon. They had a preponderance in the morning hours compared to attacks not related to insomnia (t= 3.27, df = 62, P= .002). In 79% of attacks insomnia was experienced prior to the headache. CONCLUSIONS: Episodic morning migraine is associated with insomnia. The cause and consequences of insomnia in migraine is not clarified, but sleep obviously protects against attacks rather than provokes them.

Prednisolone does not reduce withdrawal headache: a randomized, double-blind study.

INTRODUCTION: Medication overuse headache is a condition where abrupt drug withdrawal is considered the treatment of choice. OBJECTIVE: To study whether prednisolone given orally the first 6 days after medication withdrawal reduces headache intensity during the same period. METHODS: From August 2003 through November 2005, we included patients aged 18 to 70 years with probable medication overuse headache. The study was randomized, double-blind, and placebo controlled. The patients were hospitalized for 3 days to start medication withdrawal. They were randomly assigned to receive prednisolone 60 mg on days 1 and 2, 40 mg on days 3 and 4, and 20 mg on days 5 and 6 (Group A) or placebo tablets for 6 days (Group B). Headache intensity was recorded in a diary for a month before withdrawal (baseline) and throughout the study period of 28 days. The primary endpoint was a calculated mean headache (MH), based on number of days with headache and mean intensity the first 6 days after withdrawal. RESULTS: We included 26 men and 74 women. Sixty-five had migraine, 13 had tension-type headache, and 22 had both migraine and tension-type headache. Baseline headache days were 25.4 (CI 24.3 to 26.4). Baseline MH was 1.6 (CI 1.41 to 1.69). Fifty-one received Regimen A, and 49 received Regimen B. Baseline features were similar. During the first 6 days after withdrawal, headache was similar in Groups A and B (MH 1.48 [CI 1.28 to 1.68] vs 1.61 [CI 1.41 to 1.82], p = 0.34). CONCLUSION: Prednisolone has no effect on withdrawal headache in unselected patients with chronic daily headache and medication overuse.