Delayed opportunities for patient-provider communication about medication overuse headache: Mixed methods perspectives from patients and neurologists.

Objectives: Medication overuse headache (MOH) is a common, debilitating condition occurring when migraine patients overuse pain relief medications. We conducted a convergent mixed methods study examining patient-provider communication on MOH. Methods: Migraine patients were identified from one academic health center via electronic health records. Research staff recruited patients and administered a remote survey on MOH awareness, knowledge, and communication; descriptive and bivariate analyses were conducted. Neurologists from the same health center were invited to participate in qualitative interviews; analysis drew from the Rapid Identification of Themes from Audio Recordings procedures. A side-by-side comparison of results followed. Results: Participants included 200 patients and 13 neurologists. More than one third of patients (39.5 %) had never heard of 'medication overuse headache.' Among those who had, 38.4 % learned about MOH ≥ 5 years after their migraine diagnosis. Neurologists similarly reported limited patient awareness of MOH and suggested communication was provider-initiated, reactive to patient-reported symptoms and behaviors. Participants agreed MOH was described as a 'consequence' of frequent medication taking, though specific terminology varied with neurologists suggesting they choose terms they perceive to be easier to understand and less stigmatizing to patients. Neurologists felt they lacked effective patient education resources. Conclusions: Findings reveal delayed opportunities to inform patients about MOH. Standardized education supporting early preventive communication is needed, perhaps in primary care where many patients seek initial care for migraine symptoms.

Determinants of Bluetooth-Enabled Self-Measured Blood Pressure Monitoring in Federally Qualified Health Centers.

BACKGROUND: In 2021, the Health Resources and Services Administration (HRSA) launched the National Hypertension Control Initiative (HTN Initiative) with the goal to enhance HTN control through Bluetooth-enabled self-measured blood pressure (BT-SMBP) monitoring and use this data to inform clinical decisions in Federally Qualified Health Centers (FQHCs) with a large proportion of their population with uncontrolled blood pressure (BP). We sought to understand the experience of Michigan-based FQHCs in implementing the HTN initiative. METHODS: Staff from three Michigan-based FQHCs were invited to participate in semi-structured interviews from September to November 2022. Interviews were conducted in-person and were based on the Tailored Implementation in Chronic Diseases framework. Content analysis was performed by three coders. RESULTS: Ten staff participated in interviews (FQHC 1: n = 6, FQHC 2: n = 1, FQHC 3: n = 3). The FQHCs differed in their stage of implementation and their approach. FQHC 1 created a large-scale, community health worker driven program, FQHC 2 created a small-scale, short term, BP device loan program, and FQHC 3 created a primarily outsourced, large-scale program through a contracted partner. Positive staff attitudes and outcome expectations, previous experience with SMBP grants, supportive clinic leadership, social support, and free BP cuff resources were identified as facilitators to implementation. Patients' high social needs, SMBP-related Technology, and insufficient workforce and staff capacity were identified as barriers. CONCLUSION: BT-SMBP among FQHC patients is promising but challenges in integrating SMBP data into clinic workflow, workforce capacity to support the high social needs of participants, and to assist in reacting to the more frequent BP data remain to be overcome.

Determinants of Bluetooth-enabled Self Measured Blood Pressure monitoring in Federally Qualified Health Centers.

Background: In 2021, the Health Resources and Services Administration (HRSA) launched the National Hypertension Control Initiative (HTN Initiative) with the goal to enhance HTN control through Bluetooth-enabled self-measured blood pressure (BT SMBP) monitoring and use this data to inform clinical decisions in Federally Qualified Health Centers (FQHCs) with large proportion of their population with uncontrolled BP. We sought to understand the experience of Michigan-based FQHCs in implementing the HTN initiative. Methods: Staff from three Michigan-based FQHCs were invited to participate in semi-structured interviews from September to November 2022. Interviews were conducted in-person and were based on the Tailored Implementation of Chronic Diseases framework. Content analysis was performed by three coders. Results: Ten staff participated in interviews (FQHC 1: n=6, FQHC 2: n=1, FQHC 3: n=3). The FQHCs differed in their stage of implementation and their approach. FQHC 1 created a large-scale, community health worker driven program, FQHC 2 created a small-scale, short term, BP device loan program, and FQHC 3 created a primarily outsourced, large-scale program through a contracted partner. Positive staff attitudes and outcome expectations, previous experience with SMBP grants, and supportive clinic leadership were identified as facilitators to implementation; Patients high social needs, SMBP-related Technology, and insufficient workforce and staff capacity were identified as barriers. Conclusion: BT SMBP among FQHC patients is promising but challenges in integrating SMBP data into clinic workflow, workforce capacity to support the high social needs of participants and to assist in reacting to the more frequent BP data remain to be overcome.

A resident boot camp for reducing door-to-needle times at academic medical centers.

BACKGROUND: We sought to determine if a structured educational program for neurology residents can lower door-to-needle (DTN) times at an academic institution. METHODS: A neurology resident educational stroke boot camp was developed and implemented in April 2013. Using a prospective database of 170 consecutive acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA) in our emergency department (ED), we evaluated the effect of the intervention on DTN times. We compared DTN times and other process measures preintervention and postintervention. p Values < 0.05 were considered significant. RESULTS: The proportion of AIS patients treated with tPA within 60 minutes of arrival to our ED tripled from 18.1% preintervention to 61.2% postintervention (p < 0.001) with concomitant reduction in DTN time (median 79 minutes vs 58 minutes, p < 0.001). The resident-delegated task (stroke code to tPA) was reduced (75 minutes vs 44 minutes, p < 0.001), while there was no difference in ED-delegated tasks (door to stroke code [7 minutes vs 6 minutes, p = 0.631], door to CT [18 minutes in both groups, p = 0.547]). There was an increase in stroke mimics treated (6.9% vs 18.4%, p = 0.031), which did not lead to an increase in adverse outcomes. CONCLUSIONS: DTN times were reduced after the implementation of a stroke boot camp and were driven primarily by efficient resident stroke code management. Educational programs should be developed for health care providers involved in acute stroke patient care to improve rapid access to IV tPA at academic institutions.

Spontaneous cerebrospinal fluid leak from an anomalous thoracic nerve root: case report.

The authors report the case of a 28-year-old woman with a spontaneous cerebrospinal fluid leak from the sleeve of a redundant thoracic nerve root. She presented with postural headaches and orthostatic symptoms indicative of intracranial hypotension. CT myelography revealed that the lesion was located at the T-11 nerve root. After failure of conservative management, including blood patches and thrombin glue injections, the patient was successfully treated with surgical decompression and ligation of the duplicate nerve, resulting in full resolution of her orthostatic symptoms.

Quality of life in patients with TIA and minor ischemic stroke.

OBJECTIVE: We investigated health-related quality of life (HRQOL) in patients with TIA and minor ischemic stroke (MIS) using Neuro-QOL, a validated, patient-reported outcome measurement system. METHODS: Consecutive patients with TIA or MIS who had (1) modified Rankin Scale (mRS) score of 0 or 1 at baseline, (2) initial NIH Stroke Scale score of ≤5, (3) no acute reperfusion treatment, and (4) 3-month follow-up, were recruited. Recurrent stroke, disability by mRS and Barthel Index, and Neuro-QOL scores in 5 prespecified domains were prospectively recorded. We assessed the proportion of patients with impaired HRQOL, defined as T scores more than 0.5 SD worse than the general population average, and identified predictors of impaired HRQOL using logistic regression. RESULTS: Among 332 patients who met study criteria (mean age 65.7 years, 52.4% male), 47 (14.2%) had recurrent stroke within 90 days and 41 (12.3%) were disabled (mRS >1 or Barthel Index <95) at 3 months. Any HRQOL impairment was noted in 119 patients (35.8%). In multivariate analysis, age (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.04), initial NIH Stroke Scale score (adjusted OR 1.39, 95% CI 1.17-1.64), recurrent stroke (adjusted OR 2.10, 95% CI 1.06-4.13), and proxy reporting (adjusted OR 3.94, 95% CI 1.54-10.10) were independent predictors of impaired HRQOL at 3 months. CONCLUSIONS: Impairment in HRQOL is common at 3 months after MIS and TIA. Predictors of impaired HRQOL include age, index stroke severity, and recurrent stroke. Future studies should include HRQOL measures in outcome assessment, as these may be more sensitive to mild deficits than traditional disability scales.

Low Yield of Mobile Cardiac Outpatient Telemetry after Cryptogenic Stroke in Patients with Extensive Cardiac Imaging.

BACKGROUND: Detection of paroxysmal atrial fibrillation (AF) after cryptogenic stroke (CS) or transient ischemic attack ranges from 5% to 24%, but previous studies have had varying definitions of both. We aimed to evaluate the yield of up to 30 days of mobile cardiac outpatient telemetry (MCOT) for this dysrhythmia in CS patients who had undergone extensive cardiac imaging before monitoring. METHODS: We reviewed data from our center on patients with CS who completed MCOT within 3 months of the cerebrovascular event from May 2009 to January 2014; 14-30 days of monitoring was performed using one of 3 approved devices after cardiac imaging did not demonstrate a clear embolic source. We estimated the prevalence and 95% confidence intervals of AF. RESULTS: Eighty-five patients met the study criteria; 89.4% underwent transthoracic echocardiogram, 68.2% underwent transesophageal echocardiography, and 38.8% completed cardiac magnetic resonance imaging. We found 4 (4.7%, 95% confidence interval 1.5% to 11.9%) patients with AF by MCOT. There were no univariate predictors of AF. CONCLUSIONS: The diagnostic yield of cardiac rhythm monitoring for up to 30 days in CS patients may be lower than previously reported. This may be because of the routine use of cardiac imaging to identify a likely source of embolism, resulting in a lower incidence of occult AF in patients who are labeled as "cryptogenic." Longer monitoring may be needed to detect this dysrhythmia in high-risk patients who have already undergone extensive cardiac imaging.

Impact of Poststroke Medical Complications on 30-Day Readmission Rate.

BACKGROUND: Some previously identified predictors of 30-day stroke readmission, including age and stroke severity, are nonmodifiable. We assessed the hypothesis that in-hospital medical complications, which are potentially modifiable, after ischemic stroke (IS) and transient ischemic attack (TIA) predict 30-day readmission. METHODS: In a single-center prospective cohort study of IS and TIA patients admitted from August 1, 2012, to July 31, 2013, we identified those who survived to 30-day follow-up or died during a readmission within 30 days. Patients readmitted within 30 days of discharge were identified by telephone assessment and review of hospital records. We evaluated the association between 12 prespecified and prospectively collected poststroke medical complications and 30-day readmission adjusting for baseline characteristics, in-hospital course and treatments, and discharge status using univariable and multivariable Cox proportional hazards models. RESULTS: Among 505 patients, 107 (21.2%) patients had at least 1 medical complication during hospitalization. The most common complications were urinary tract infection (8.7%), venous thromboembolism (6.1%), and pneumonia (4.6%). Seventy-eight (15.4%) patients were readmitted within 30 days. On multivariable Cox proportional hazards analysis, cardioembolic or large-artery atherosclerotic subtype (adjusted hazard ratio [HR], 1.82; 95% confidence interval [CI], 1.17-2.83) and any medical complication (adjusted HR, 1.68; 95% CI, 1.04-2.73) increased the risk of 30-day readmission. Among the 24 readmitted patients who experienced an initial medical complication, 10 (41.6%) were considered potentially preventable. CONCLUSIONS: The occurrence of medical complications after IS or TIA increased the risk of 30-day all-cause readmission. Stroke patients with medical complications may be suitable for targeted interventions to prevent readmissions.

Efficacy and safety of novel oral anticoagulants in patients with cervical artery dissections.

BACKGROUND: American and European guidelines support antiplatelet agents and anticoagulants as reasonable treatments of cervical artery dissection (CAD), though randomized clinical trials are lacking. The utility of novel oral anticoagulants (NOAC), effective in reducing embolic stroke risk in non-valvular atrial fibrillation (NVAF), has not been reported in patients with CAD. We report on the use, safety, and efficacy of NOACs in the treatment of CAD. METHODS: We retrospectively identified patients diagnosed with CAD at a single academic center between January 2010 and August 2013. Patients were categorized by their antithrombotic treatment at hospital discharge with a NOAC (dabigatran, rivaroxaban, or apixaban), traditional anticoagulant (AC: warfarin or treatment dose low-molecular weight heparin), or antiplatelet agent (AP: aspirin, clopidogrel, or aspirin/extended-release dypyridamole). Using appropriate tests, we compared the baseline medical history, presenting clinical symptoms and initial radiographic characteristics among patients in the 3 treatment groups. We then evaluated for the following outcomes: recurrent stroke, vessel recanalization, and bleeding complications. p values <0.05 were considered significant. RESULTS: Of the 149 included patients (mean age 43.4 years; 63.1% female; 70.5% vertebral artery CAD), 39 (26.2%), 70 (47.0%), and 40 (26.8%) were treated with a NOAC, AC, and AP, respectively. More patients with severe stenosis or occlusion were treated with NOAC than with AC or AP (61.8 vs. 60.0 vs. 22.5%, p = 0.002). Other baseline clinical and radiographic findings, including the presence of acute infarction and hematoma, did not differ between the 3 treatment groups. One hundred and thirty-five (90.6%) patients had clinical follow-up (median time 7.5 months) and 125 (83.9%) had radiographic follow-up (median time 5 months) information. There were 2 recurrent strokes in the NOAC group and 1 in each of the AC and AP groups (p = 0.822). There were more major hemorrhagic events in the AC group (11.4%) compared to the NOAC (0.0%) and AP (2.5%) groups (p = 0.034). Three patients treated with NOAC and none treated with AC or AP had a worsened degree of stenosis on follow-up imaging (8.6 vs. 0.0 vs. 0.0%, p = 0.019). CONCLUSION: Compared to traditional anticoagulants for CAD, treatment with NOACs is associated with similar rates of recurrent stroke, fewer hemorrhagic complications, but greater rates of radiographic worsening. These data suggest that NOACs may be a reasonable alternative in the management of CAD. Prospective validation of these findings is needed.