Headache patients' satisfaction with telemedicine: a 12-month follow-up randomized non-inferiority trial.

BACKGROUND AND PURPOSE: We investigated non-acute headache patients' long-term satisfaction with a telemedicine consultation and consultation preferences in northern Norway. We hypothesized that patients were not less satisfied with telemedicine than traditional consultations. We also examined the influence of gender, age and education on satisfaction. METHODS: For 2.5 years, patients were consecutively screened, recruited and randomly assigned to telemedicine or traditional visits with a consultation at a neurological outpatient department. The primary endpoint was frequency of satisfied patients at 3 and 12 months. Secondary endpoints were satisfaction with consultation, communication, information, diagnosis, advice and prescriptions, and preferred visit form at 12 months. RESULTS: Of 402 participants, 279 (69.4%) answered questionnaires at both 3 and 12 month, and 291 (72.4%) responded at 12 months. The long-term satisfaction of telemedicine patients was 124/145 (85.5%) compared with 118/134 (88.1%) in the traditional group (P = 0.653). The groups did not differ with respect to secondary endpoints, but females were more satisfied with telemedicine communication (P = 0.027). In the telemedicine group, 99/147 (67.3%) were indifferent to the type of consultation. Age and education did not alter the primary results. CONCLUSIONS: At 1 year after a specialist evaluation for headache, telemedicine patients did not express less satisfaction than those with traditional consultation. Telemedicine specialist consultations may be a good alternative for headache patients in secondary care.

Lack of seasonal variation in menstrually-related migraine.

The aim of the study was to study seasonal variation in migraine headache in a group of women with menstrually-related migraine (MRM) compared with non-menstrual migraine. Via newspaper advertisement, women with migraine living in North Norway were invited. The patients were included by questionnaire and telephone interview. We prospectively recorded migraine attacks from a 12-month headache diary performed by a group of 62 women with a mean age of 36.0 years (range 16-46 years), who fulfilled the criteria of migraine without aura. Of these, 29 had MRM and 33 non-menstrual migraine. Mean ratio between number of attacks in the light arctic season (May-June-July) divided with total number of migraine attacks during 12 months was 0.24 (9.4/38.4) in the group of MRM compared with 0.25 (5.6/22.1) in others (confidence interval -4.2, 6.3, P = 0.84). Nor were there more migraine attacks in the dark season in an arctic area (November-December-January) in any group. We found a higher migraine attack rate in those with MRM, but no indication of more or less frequency of attacks during the bright arctic season. These findings support the assumption that MRM and seasonal variation of migraine are due to different mechanisms.

Is uncertain diagnosis a more frequent reason for referring migraine patients to neurologist than other headache syndromes?

The objective was to assess whether the physician's uncertainty of diagnosis was a more frequent motivation for referring migraine patients than other headache patients to a neurologist. In this population based survey we included 846 consecutive patients referred to and examined at a specialist centre for headache during a period of 2 years. As primary outcome we compared cross-sectionally frequency of referring patients with migraine and other headaches to neurologist. According to the patients, uncertainty of diagnosis was the main reason for referral to a neurological specialist consultation, i.e. in 51% of cases. Thirty-nine per cent of patients classified as having migraine were referred because of an uncertain diagnosis, compared with 62% in patient with other headaches (95 CI 0.13-0.33), (P < 0.0001). Headache subtypes other than migraine and younger age were associated to more uncertainty of diagnosis. We conclude that diagnostic uncertainty was an important factor amongst half the headache patients seen by neurologists and uncertain diagnoses as reason for referral was more important amongst patients with non-migrainous headache.

Quantitative cerebral MR in rheumatoid arthritis.

PURPOSE: To determine the presence of hyperintense white matter lesions and atrophy reflecting cerebral vasculitis in rheumatoid arthritis. METHODS: Thirty-three patients with rheumatoid arthritis and 48 control subjects were examined with MR. Mean age was 45.1 years (range, 26 to 55 years) for the patients and 42.2 years (range, 25 to 55 years) in the control group. To determine atrophy we measured the area of corpus callosum, the cerebrum, and the cerebellum on midline sagittal sections. On transverse images, the ventricle-to-brain ratio, the bifrontal ratio, and the bicaudate ratio were selected as atrophy parameters. Area and signal intensity were measured for the biggest and the smallest lesions in both groups. RESULTS: Nine patients (27%) had hyperintense lesions compared with 15 (31%) of the control subjects. Mean numbers of hyperintense lesions were 1.3 in patients and 2.1 in control subjects. Mean area of the largest lesion in each patient was 27.4 mm2 for the patients and 29.8 mm2 in the control group. In patients with long disease duration (> 15 years) the mean ventricle-to-brain ratio was 0.09 compared with 0.08 in the control subjects. The midsagittal area of the cerebellum was 1349.8 mm2 in the patients with long disease duration and 1573.3 mm2 in the control group. No difference in number of hyperintense white matter lesions was detected between patients with long disease duration and the control subjects. Comparing the total group of patients with the control subjects, no significant differences in atrophy parameters or hyperintense white matter lesions were found. Also, there were no significant differences in relative signal intensity of the hyperintense lesions and corpus callosum between the two groups. We were not able to detect differences between treated versus untreated patients. CONCLUSION: This study indicates a tendency of more cerebral and cerebellar atrophy in patients with severe rheumatoid arthritis. The number and size of the white matter lesions were not significantly different in the two groups and do not support a higher frequency of even clinically silent infarcts caused by vasculitis in the patients with rheumatoid arthritis compared with control subjects.

Quality of life in rheumatoid arthritis: a case-control study in patients living in northern Norway.

OBJECTIVE: To study quality of life parameters in patients with rheumatoid arthritis and the possible association of these parameters with disease activity. METHODS: Fifty-two women with rheumatoid arthritis and 52 controls completed two self reporting psychiatric screening tests: the General Health Questionnaire (GHQ - 30) and the Cantril Ladder scale. The number of psychiatric cases detected was not significantly higher for either group using the GHQ score S+ as the criterion. RESULTS: Comparing the GHQ scores, patients showed a higher score compared with the controls (p = 0.02). The patients scored significantly higher on feelings of incompetance (p = 0.004), but not on the other subgroups of psychiatric factors. The patients reported lower life satisfaction on the Cantril self anchoring ladder (p = 0.0001). The functional capacity score was positively associated with the GHQ score. No association was detected between disease duration or the other disease activity parameters and either the GHQ score or the life satisfaction score. CONCLUSION: This inconsistant relationship between clinical parameters and quality of life scores may be due to the fact that RA patients suffer from a chronic disease, or it may reflect an impaired psychosocial status in the patients. This study demonstrates that the increased psychological disturbances in women with RA is mainly explained by feelings of incompetance.

Unrecognized dementia in elderly patients admitted to hospital with psychiatric symptoms.

In this study, we hypothesized that elderly patients with first admission to a psychiatric hospital commonly suffer from dementia but did not have such a diagnosis on admission. Over a period of 5 years, we surveyed all medical journals from patients treated for the first time at the Department of Psychogeriatrics. By selecting all inpatients treated at the only regional psychiatric hospital within a defined geographic area, the selected patients became representative of this geographic area. After a diagnostic work-up at the hospital, 72 of 239 patients satisfied clinical criteria of dementia. Of these patients, 7 had Alzheimer's disease and 7 had evidence of vascular dementia. We identified 51 of 72 patients (71%) with an endpoint diagnosis of dementia made at the hospital without any clinical information suggesting dementia at the time of hospitalization. Nonspecific psychosis (35%), depression (15%), and behavioral disturbances (8%) represented the most common diagnoses proposed by the referring doctor. In conclusion, dementia may be a difficult diagnosis in elderly patients with psychiatric symptoms. This study reminds clinicians that dementia should be considered in these patients.

Quantitative magnetic resonance imaging and the electrophysiology of the carpal tunnel region in floor cleaners.

OBJECTIVES: The purpose of this study was to evaluate possible structural changes of the wrist and subclinical damage in the median nerves of healthy floor cleaners. METHODS: Twenty-four cleaners and 19 referents (noncleaners), all women, underwent bilateral magnetic resonance (MR) wrist examination and nerve conduction studies. They were all randomly selected from an occupational health service. From MR images the volumes of the wrist, carpal tunnel, and thenar and hypothenar muscles were calculated, as well as the signal intensity of the median nerve, bilaterally. RESULTS: No significant difference in the volume of the carpal tunnel was found in the two groups. The relative signal intensity of the median nerve was 0.55 for the cleaners and 0.48 for the referents (P = 0.05). The mean nerve conduction velocity values were 55.2 m.s-1 for the right median nerve of the cleaners and 57.4 m.s-1 for the right median nerve of the referents (P = 0.03). The median nerve of the cleaners had a mean sensory amplitude of 128.2 microV compared with 162.8 microV for the referents (P = 0.01). There was a tendency towards a longer distal latency of the median nerve in the cleaner group. CONCLUSIONS: This study revealed subclinical intrinsic damage to the median nerve, as demonstrated by MR, and poorer electrophysiological nerve function among workers at high risk (cleaners) compared with workers at lower risk (noncleaners).

The rheumatoid wrist: bilateral MR analysis of the distribution of rheumatoid lesions in axial plan in a female population.

In this case-control study, we analyzed 146 wrists: a) to search for the distribution pattern of the rheumatoid lesions and, b) to correlate the distribution pattern of these lesions with the clinical parameters. Thirty-one patients with rheumatoid arthritis (RA) and 42 controls-all women-were examined by means of a bilateral MR fast field echo (FFE) sequence, in axial plan. The wrist was divided into three regions: metacarpal (level I), carpal (level II) and radioulnar (level III). Erosions were present in thirty (97%) patients and in six (14%) controls. They were asymmetrically distributed at all levels, mainly at level II. Marrow infiltration and bone destruction were seen in 35% of the patients in an asymmetrical pattern at level I and II, respectively. These lesions were absent in the control group. Subchondral cysts were asymmetrically present in both groups-in 48% of the patients at levels II and III, and in 11% of the controls at level II. In the patient group, this asymmetrical pattern of the lesions correlated with the disease duration at levels I and II (p = 0.011 and p = 0.013, respectively). Most lesions were found at the radial force-bearing column of the wrist, more in the right side. Synovial hypertrophy and hyperintense median nerve were evident in 96% and 70% of the patients, respectively. We concluded that contrary to common belief rheumatoid damages to the carpal bones become rather asymmetrical as the disease progresses. The line of force along the radial side of the wrist possibly influences the distribution pattern of the rheumatoid lesions.

Bilateral fast MR imaging of the rheumatoid wrist.

To evaluate the structural changes in the carpal tunnel and possible intrinsic median nerve damages in RA patients, quantitative bilateral magnetic resonance imaging (MRI) of the wrists was performed by means of a fast imaging sequence. Thirty-three women with RA and 42 controls were examined. The length of the carpal tunnel, the carpal tunnel volume/wrist volume (CTV/WV) ratio and the signal intensity of the nerve were calculated in both groups, bilaterally. The CTV/WV ratio was 0.12 in the patients and 0.11 in the control group (p = 0.007). A negative association was found between disease duration and carpal tunnel volume/wrist volume ratio (p = 0.049). Mean distal latency in the right motor median nerve was 3.0 +/- 0.4 msec (patients) and 3.4 +/- 0.6 msec (controls) (p = 0.002). Mean values in the right sensory branch were 1.2 +/- 0.1 msec (patients) and 1.4 +/- 0.3 (controls) (p = 0.01). The lack of association between the size of the carpal canal and neurophysiological parameters found in this study may suggest a possible protection of the median nerve by the increased canal size in patients with RA.

Bilateral fast magnetic resonance imaging of the operated carpal tunnel.

Our aim was to quantify the structural changes of the carpal tunnel including area and volume after surgical release. We studied 28 patients who underwent 31 operations for carpal tunnel syndrome (CTS), mean age 54.7 years (range 32-78). All had abnormal nerve conduction studies. Magnetic resonance imaging (MRI) of both wrists was done before and after operation using two fast imaging sequences, turbo spin echo (TSE) and fast field echo (FFE). The same surface coils and parameters were used in both instances. With a computerised analyser we calculated the volume of the whole tunnel from inlet to outlet before and after operation and the wrist volume:carpal tunnel volume ratio. The intensity of the magnetic resonance signal emitted by the median nerve was assessed in all wrists before and after operation. The mean (SD) volume of the tunnel in 31 wrists with CTS was 11511.7 (2857) mm3 before and 13803.4 (3034.9) mm3 after operation (p = 0.0001). The mean (SD) relative signal intensity of the median nerve was 1.7 (1.8) preoperatively and 1.3 (1.1) postoperatively (p = 0.19). Other postoperative changes included persistent nerve enlargement (n = 21), misalignment of the tendons (n = 20), fibrous tissue deposits (n = 20), fat tissue deposits (n = 21), and muscle oedema (n = 6). The modifications of the carpal canal as a consequence of open surgical release (including increased volume and displacement of the flexor tendons) argue for the use of an endoscopic procedure in the treatment of CTS.

Increased risk of median nerve dysfunction in floor cleaners: a controlled clinical and neurophysiological study.

We studied median nerve involvement in a group of asymptomatic handworkers at risk for carpal tunnel syndrome, and we evaluated damage to thin and thick nerve fibres in the distribution area of the median nerve. Considering floor cleaners as workers at high risk of developing cumulative traumatic disorders in the wrist, we included 42 cleaners and 41 controls. We assessed nerve conduction studies, vibration threshold, and temperature and pain thresholds of the median nerve. The cleaners had significantly impaired motor nerve conduction velocity (p = 0.006), longer sensory distal latency (p = 0.01), lower sensory amplitude (p = 0.0005), and increased difference in heat and cold threshold of the median nerve (p = 0.0002). Increased temperature threshold was associated with prolonged sensory distal latency of the median nerve in the cleaners. In conclusion, impaired neurophysiological variables in the median nerve in floor cleaners compared with controls confirm the hypothesis that those workers are at risk of developing median nerve dysfunction. Sensory nerves seem to be more susceptible to injury than motor branches.

Seasonal variation in migraine.

Our group has previously shown that migraineurs, as opposed to individuals with other headaches, are more likely to have headache during the bright arctic summer than during the polar night season. We set out to investigate the impact of seasonal light exposure in migraine with and without aura. We performed a questionnaire-based study of 169 female volunteer migraineurs in an arctic area where light conditions during summer and winter seasons are extreme. We included 98 patients with migraine with aura (MA) and 71 with migraine without aura (MoA). One hundred and seven patients (63%) reported seasonal variation in migraine attack frequency. Close to half (47%) of patients with aura, but only 17% of patients without aura, reported more frequent attacks during the light season (P < 0.001). Patients with MA reported interictal light hypersensitivity and light exposure as an attack precipitating factor significantly more often than individuals with MoA. They also reported significantly more frequent use of sunglasses to prevent attacks. We found no significant differences between MA and MoA as regards sleep disturbances, use of oral contraceptives, impact of headache or circadian variations. Seasonal periodicity of migraine in an arctic population with more frequent attacks during the light season is a convincing phenomenon in MA but not in MoA. The amount of light exposure seems to be pivotal to this variation.

Migraine, as compared to other headaches, is worse during midnight-sun summer than during polar night. A questionnaire study in an Arctic population.

OBJECTIVE: To investigate potential seasonal variation of migraine and other headaches in an Arctic population where light conditions are extreme during both winter and summer. BACKGROUND: Due to the immense seasonal variation in sunlight, focus on seasonal migraine variation in a population living in an Arctic area is interesting even from a theoretical point of view. METHODS: Northern Norway comprises the three Norwegian counties north of the Arctic Circle. There are three neurology centers in this region, which provide service for approximately half a million people. During a 2-year period, 1403 patients (0.3% of the population) were referred to these centers for a specialist assessment of their headache. A questionnaire was mailed to all these patients; the questionnaire included questions on headache characteristics to make it possible to identify migraine according to the International Headache Society criteria. Questions on seasonal variation of headache were also included. RESULTS: One thousand fifty-two patients (75%) returned the questionnaire. Nineteen percent reported that their headaches clearly did vary with season; 11% experienced more headache during polar night, while 7% had more symptoms during midnight sun season. When the migraine and nonmigraine groups were compared, significant differences were demonstrated. Patients with nonmigrainous headache were more likely to have increased headaches during the dark winter season, while patients with migraine experienced more headache during the summer (P =.002). CONCLUSIONS: Patients with migraine were more likely to have headache during the bright Arctic summer season, and this distinguishes migraine from other headaches in this study. This observation may pertain to the increased light sensitivity and recently demonstrated cortical hyperexcitability in patients with migraine, and may perhaps suggest a role of the hypothalamus and/or melatonin secretion in migraine pathophysiology.

[Carpal tunnel syndrome]. / Karpaltunnelsyndrom.

BACKGROUND: Carpal tunnel syndrome is the most common mononeuropathy. Typical symptoms include pain or discomfort in the hand, paresthesia, weakness and altered temperature or dryness of the skin along with neurophysiological findings. The presence of these symptoms in the area of the median nerve distribution supports the diagnosis. MATERIAL AND METHODS: This review article is based on current knowledge about carpal tunnel syndrome as obtained from the Medline and the Cochrane database systems. RESULTS: The prevalence of carpal tunnel syndrome in the population is around 3%. A higher incidence is reported in women and in manual workers in general. The higher incidence in women may be less evident than previously expected. The size of the carpal canal do not predict the disease, but narrowing of the canal in its distal third has been reported in both patients and non-symptomatic controls. INTERPRETATION: Differences in job exposure between men and women may explain the increased incidence in women. Although the relationship between symptom production and structural changes in the carpal tunnel affecting the median nerve is still debated, narrowing of the canal in its distal third may predict the syndrome.

Drug-associated headache is unrecognized in patients treated at a neurological centre.

OBJECTIVE: We studied the frequency of unrecognized headache associated with overuse of analgesic drugs in a population of headache patients treated at a neurological centre. METHODS: Patients in North Norway referred to a neurologist for headache during a 2-year period completed a questionnaire. From a total of 945, 262 patients (28%) reported headache 3 days or more per week and used analgesic drugs on a daily bases. RESULTS: A specific diagnoses given by the neurologist was reported in 134 of the patients (51%). Only two patients reported that they suffered from a possible drug-associated headache. CONCLUSION: This study shows that drug overuse may be the cause of chronic headache in more than 1/4 patients referred to neurologists. Drug-associated headache is a difficult diagnosis which deserves more attention because it is a common and treatable condition.

Are headache patients who initiate their referral to a neurologist satisfied with the consultation? A population study of 927 patients--the North Norway Headache Study (NNHS).

BACKGROUND: Headache is a common problem in primary care. Although most patients are treated by GPs, many are referred to specialist consultation. Knowledge of how the referrals can be improved is therefore an important issue. OBJECTIVES: The aim of this study was to determine the relationship between self-initiating referral to a neurologist and the patient's satisfaction with the specialist consultation. METHODS: All patients who had been examined by a neurologist for headache within a 2-year period from three neurological centres in North Norway completed a questionnaire. RESULTS: A total of 1052 patients from a population of 1403 headache patients (75%) returned the questionnaire while 927 patients answered questions about initiating the referral to the specialist. Two hundred and twenty patients (24%) initiated the referral to the neurologist themselves; 52% of those who self-initiated the referral were dissatisfied with the specialist consultation compared with 42% of those referred by the doctor, P = 0.002. Chronic headache, tension-type headache (TTH) and daily use of analgesic drugs were associated with dissatisfaction. CONCLUSIONS: Patients with headache who initiated the referral to a neurologist themselves were less satisfied with the specialist consultation. Selecting referrals containing proper medical information may improve satisfaction in severe headache patients treated in a neurological practice.

[Clinical neurological examination of patients referred to a neurological department]. / Klinisk-nevrologisk undersøkelse av pasienter henvist til nevrologisk avdeling.

BACKGROUND: We studied reports of clinical neurological status in patients referred from primary and secondary health service to a neurological department. MATERIAL AND METHOD: We evaluated referrals consecutively during 6 months. By using parametric and categorical statistical methods, we studied characteristics in examined patients compared with others. RESULTS: Of a total of 912 patients, 431 (47%) had been examined neurologically. Among the women, 267 women (51%) had been examined; among the 164 men (43%). Patients with musculoskeletal disorders were more often examined, p = 0.0001, while those with faint or seizure disorders were significantly less frequently examined compared with other patients, p = 0.009. Clinical neurological examinations were performed more often in women compared with men, p = 0.03. The mean age was higher in the examined group (49.7 years) compared with others (46.5 years), p = 0.006. INTERPRETATION: Clinical neurological examination in patients referred to a neurological department had more often been performed in women, in higher age groups, and in those with musculoskeletal symptoms. In more than half of the patients, the decision of referring patients to the department of neurology was not based on results obtained from clinical neurological examination.

Does carpal canal stenosis predict outcome in women with carpal tunnel syndrome?

OBJECTIVE: We investigated the role of carpal canal stenosis as a predictor of outcome in patients who underwent surgical treatment for carpal tunnel syndrome (CTS). METHODS: We performed magnetic resonance imaging (MRI) of the wrist in 31 female patients with clinically and neurophysiologically confirmed CTS. With a computerized analyser we quantitatively calculated the focal narrowest point of the tunnel. Patient's assessment of CTS-related symptoms were obtained by using a visual analogue scale before, and 6 months after treatment. RESULTS: Seventeen (56%) patients improved in all symptoms after treatment. The focal narrowest point of the tunnel was identified at its distal third in all patients, at 8 mm from the outlet. The median area of the narrowest point in those who improved clinically (n=17) was 238.9 mm2 compared with 269.8 mm2 in others (n=14), P=0.046. CONCLUSION: Identification of carpal canal stenosis may be important in selecting candidates for treatment in symptomatic CTS.

[Parkinson's disease in a population group in northern Norway]. / Parkinsons sykdom i en nordnorsk befolkningsgruppe.

Parkinson's disease has been studied in a community of Northern Norway. The main object of the study was to find the prevalence of the disease. The prevalence of Parkinson's disease was 133 per 100,000 population (men 113, women 134) and 189 adjusted to the total Norwegian population (both sexes). Prevalence increased with age in both sexes, especially after the 60th year. The average age at onset was 63.1 years (men 60.5, women 65.4 years). Tremor was present in 98% of the patients, hypokinesia in 78%, rigidity in 65%, all three in 56% and pain in 35%. The prevalence, sex distribution, and the age at onset is similar to that in other European and North American studies.