Exploring the impact of patient, physician and technology factors on patient video consultation satisfaction.

Objective: Video consultations (VCs) were made available to the general population during the COVID-19 pandemic to compensate for the cutback of face-to-face doctor-patient interactions. However, little is known about what patient-related (e.g. age), physician-related (e.g. patient-physician relationship) and technology-related (e.g. online privacy concerns) factors contribute to video consultation satisfaction among patients. This study aims to gain a better understanding of what makes patients satisfied with video consultations. Methods: A total of 180 patients who recently engaged in a video consultation were invited to answer questions about patient-, physician- and technology-related variables and their satisfaction with the video consultation. To examine which factors predict patient video consultation satisfaction, a multiple hierarchical regression analysis was performed. Results: Overall, patients were satisfied with their video consultation. The final hierarchical model, including all patient-related, physician-related and technology-related factors, significantly contributed to patient video consultation satisfaction. Predictors of higher patient video consultation satisfaction were experiencing less technical issues, having higher general positive attitudes towards online communication, reporting higher importance of less travel time and being more satisfied with physicians' affective and instrumental communication. Conclusions: Video consultations can be appropriate in a variety of situations, provided that technical issues can be minimized, patients have a positive attitude towards online communication and attach value to reduced travel time and online patient-physician interactions can be experienced as affective and instrumental. Findings from this study contribute to understanding how video consultations can be best utilized for effective patient-physician communication.

Patients' choices regarding online access to laboratory, radiology and pathology test results on a hospital patient portal.

The disclosure of online test results (i.e., laboratory, radiology and pathology results) on patient portals can vary from immediate disclosure (in real-time) via a delay of up to 28 days to non-disclosure. Although a few studies explored patient opinions regarding test results release, we have no insight into actual patients' preferences. To address this, we allowed patients to register their choices on a hospital patient portal. Our research question was: When do patients want their test results to be disclosed on the patient portal and what are the reasons for these choices? We used a mixed methods sequential explanatory design that included 1) patient choices on preferred time delay to test result disclosure on the patient portal for different medical specialties (N = 4592) and 2) semi-structured interviews with patients who changed their mind on their initial choice (N = 7). For laboratory (blood and urine) results, 3530 (76.9%) patients chose a delay of 1 day and 912 (19.9%) patients chose a delay of 7 days. For radiology and pathology results 4352 (94.8%) patients chose a delay of 7 days. 43 patients changed their mind about when they wanted to receive their results. By interviewing seven patients (16%) from this group we learned that some participants did not remember why they made changes. Four participants wanted a shorter delay to achieve transparency in health-related information and communication; to have time to process bad results; for reassurance; to prepare for a medical consultation; monitoring and acting on deviating results to prevent worsening of their disease; and to share results with their general practitioner. Three participants extended their chosen delay to avoid the disappointment about the content and anxiety of receiving incomprehensible information. Our study indicates that most patients prefer transparency in health-related information and want their test results to be disclosed as soon as possible.

Patients Managing Their Medical Data in Personal Electronic Health Records: Scoping Review.

BACKGROUND: Personal electronic health records (PEHRs) allow patients to view, generate, and manage their personal and medical data that are relevant across illness episodes, such as their medications, allergies, immunizations, and their medical, social, and family health history. Thus, patients can actively participate in the management of their health care by ensuring that their health care providers have an updated and accurate overview of the patients' medical records. However, the uptake of PEHRs remains low, especially in terms of patients entering and managing their personal and medical data in their PEHR. OBJECTIVE: This scoping review aimed to explore the barriers and facilitators that patients face when deciding to review, enter, update, or modify their personal and medical data in their PEHR. This review also explores the extent to which patient-generated and -managed data affect the quality and safety of care, patient engagement, patient satisfaction, and patients' health and health care services. METHODS: We searched the MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Web of Science, and Google Scholar web-based databases, as well as reference lists of all primary and review articles using a predefined search query. RESULTS: Of the 182 eligible papers, 37 (20%) provided sufficient information about patients' data management activities. The results showed that patients tend to use their PEHRs passively rather than actively. Patients refrain from generating and managing their medical data in a PEHR, especially when these data are complex and sensitive. The reasons for patients' passive data management behavior were related to their concerns about the validity, applicability, and confidentiality of patient-generated data. Our synthesis also showed that patient-generated and -managed health data ensures that the medical record is complete and up to date and is positively associated with patient engagement and patient satisfaction. CONCLUSIONS: The findings of this study suggest recommendations for implementing design features within the PEHR and the construal of a dedicated policy to inform both clinical staff and patients about the added value of patient-generated data. Moreover, clinicians should be involved as important ambassadors in informing, reminding, and encouraging patients to manage the data in their PEHR.

Poor outcome in frail elderly patient after severe TBI.

OBJECTIVE: To investigate the influence of frailty in elderly with severe TBI on mortality and functional outcome. METHOD: 126 patients with TBI aged 60 years or older and with a presenting Glasgow Coma Scale score of 8 or lower were retrospectively included. To investigate frailty, we used the CSHA Clinical Frailty Scale. The primary outcome measures were mortality, and the secondary outcome measures were Glasgow Outcome Scale Extended (GOSE) at discharge and GOSE at 6 months after trauma. RESULTS: High frailty was a significant predictor for mortality (OR 2.38, p 0.047), if adjusted for the injury severity scale. High frailty was also a significant predictor for poor functional outcome after 6 months (OR 4.35, p 0.03). After 6 months, the GOSE of the low frailty group was significantly higher than in the high frailty group (p 0.019). Also, the improvement of the GOSE was significant in the low frailty group (p 0.007), while in the high frailty group there was no significant improvement of the GOSE (p 0.546) after 6 months. CONCLUSION: Frailty has a significant impact on outcome in elderly with severe TBI. There is a higher mortality in the frail elderly and there is less recovery after TBI.

Update of the CHIP (CT in Head Injury Patients) decision rule for patients with minor head injury based on a multicenter consecutive case series.

OBJECTIVE: To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI). METHODS: The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic. RESULTS: Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69-0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74-0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%). CONCLUSIONS: Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate.

Practice Variation Research in Degenerative Lumbar Disc Surgery: A Literature Review on Design Characteristics and Outcomes.

STUDY DESIGN: Literature review. OBJECTIVE: To describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time. METHODS: Literature databases were searched up to May 4th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman's rho was used to determine the association between the Extreme Quotient (EQ) and year of publication. RESULTS: We identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= -.33, P= .09). CONCLUSIONS: Practice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.

Delayed headache after COVID-19 vaccination: a red flag for vaccine induced cerebral venous thrombosis.

BACKGROUND: Headache is a frequent symptom following COVID-19 immunization with a typical onset within days post-vaccination. Cases of cerebral venous thrombosis (CVT) have been reported in adenovirus vector-based COVID-19 vaccine recipients. FINDINGS: We reviewed all vaccine related CVT published cases by April 30, 2021. We assessed demographic, clinical variables and the interval between the vaccination and onset of headache. We assessed whether the presence of headache was associated with higher probability of death or intracranial hemorrhage. We identified 77 cases of CVT after COVID-19 vaccination. Patients' age was below 60 years in 74/77 (95.8%) cases and 61/68 (89.7%) were women. Headache was described in 38/77 (49.4%) cases, and in 35/38 (92.1%) was associated with other symptoms. Multiple organ thrombosis was reported in 19/77 (24.7%) cases, intracranial hemorrhage in 33/77 (42.9%) cases and 19/77 (24.7%) patients died. The median time between vaccination and CVT-related headache onset was 8 (interquartile range 7.0-9.7) days. The presence of headache was associated with a higher odd of intracranial hemorrhage (OR 7.4; 95% CI: 2.7-20.8, p < 0.001), but not with death (OR: 0.51, 95% CI: 0.18-1.47, p = 0.213). CONCLUSION: Delayed onset of headache following an adenovirus vector-based COVID-19 vaccine is associated with development of CVT. Patients with new-onset headache, 1 week after vaccination with an adenovirus vector-based vaccine, should receive a thorough clinical evaluation and CVT must be ruled out.

Hypothalamic functional MRI activity in the initiation phase of spontaneous and glyceryl trinitrate-induced migraine attacks.

The hypothalamus has been suggested to be important in the initiation cascade of migraine attacks based on clinical and biochemical observations. Previous imaging studies could not disentangle the changes due to the attack and those due to the trigger compound. With a novel approach, we assessed hypothalamic neuronal activity in early premonitory phases of glyceryl-trinitrate (GTN)-induced and spontaneous migraine attacks. We measured the hypothalamic blood oxygen level-dependent (BOLD) response to oral glucose ingestion with 3T-functional magnetic resonance imaging (MRI) in 27 women, 16 with migraine without aura and 11 controls group matched for age and body mass index (BMI), on 1 day without prior GTN administration and on a second day after GTN administration (to coincide with the premonitory phase of an induced attack). Interestingly, subgroups of patients with and without GTN-triggered attacks could be compared. Additionally, five migraineurs were investigated in a spontaneous premonitory phase. Linear mixed models were used to study between- and within-group effects. Without prior GTN infusion, the BOLD response to glucose was similar in migraine participants and controls (P = .41). After prior GTN infusion, recovery occurred steeper and faster in migraineurs (versus Day 1; P < .0001) and in those who developed an attack versus those who did not (P < .0001). Prior GTN infusion did not alter the glucose-induced response in controls (versus baseline; P = .71). Just before spontaneous attacks, the BOLD-response recovery was also faster (P < .0001). In this study, we found new and direct evidence of altered hypothalamic neuronal function in the immediate preclinical phase of both GTN-provoked and spontaneous migraine attacks.

Green Flags and headache: A concept study using the Delphi method.

OBJECTIVE: The aim of this study was to collect and rate Green Flags, that is, symptoms or pieces of information indicating that a patient is more likely to suffer from a primary than from a secondary headache. BACKGROUND: When assessing headaches, a central question to be answered is whether the pain is primary or secondary to another disorder. To maximize the likelihood of a correct diagnosis, relevant signs and symptoms must be sought, identified, and weighed against each other. METHODS: The project was designed as a Delphi study. In the first round, an expert panel proposed green flags that were rated anonymously in two subsequent rounds. Proposals with an average rating of 4.0 and higher on a scale from 0 to 5 reached consensus. RESULTS: Five Green Flags reached consensus: (i) "The current headache has already been present during childhood"; (ii) "The headache occurs in temporal relationship with the menstrual cycle"; (iii) "The patient has headache-free days"; (iv) "Close family members have the same headache phenotype"; and (v) "Headache occurred or stopped more than one week ago." CONCLUSIONS: We propose five Green Flags for primary headache disorders. None being a pathognomonic sign, we recommend searching for both Green Flags and Red Flags. If both are present, a secondary headache should be suspected. Overall, the application of the Green Flag concept in clinical practice is likely to increase diagnostic accuracy and improve diagnostic resource allocation. Prospective studies in clinical populations should be conducted to validate these Green Flags.

Towards eHealth to support the health journey of headache patients: a scoping review.

OBJECTIVE: The aim of this study is to (1) review the digital health tools that have been used in headache studies, and (2) discuss the effectivity and reliability of these tools. BACKGROUND: Many headache patients travel a long and troublesome journey from first symptoms until a meaningful care plan. eHealth, mHealth, and digital therapeutic modalities have been advocated as the way forward to improve patient care. METHOD: Online databases PubMed, Cinahl, and PsycINFO were searched using a predefined search query. A data extraction form was used to gather relevant data elements from the selected papers. RESULTS: A total of 39 studies were selected. The studies included 94,127 participants. The majority of studies focused on diaries (N = 27 out of 39). Digital (cognitive) behavioral therapy were also quite common (N = 7 out of 39). Other digital health tool categories were tele-consultations, telemonitoring and patient portals. CONCLUSION: Many digital health tools for headache patients regarding diaries and behavioral/therapeutical treatment are described in scientific research with limited information on effectivity and reliability. Scientific knowledge with regard to other categories such as tele-consultations, patient portals, telemonitoring including medication adherence, online information resources, wearable, symptom checkers, digital peer support is still scarce or missing.

Abnormal cardiovascular response to nitroglycerin in migraine.

INTRODUCTION: Migraine and vasovagal syncope are comorbid conditions that may share part of their pathophysiology through autonomic control of the systemic circulation. Nitroglycerin can trigger both syncope and migraine attacks, suggesting enhanced systemic sensitivity in migraine. We aimed to determine the cardiovascular responses to nitroglycerin in migraine. METHODS: In 16 women with migraine without aura and 10 age- and gender-matched controls without headache, intravenous nitroglycerin (0.5 µg·kg-1·min-1) was administered. Finger photoplethysmography continuously assessed cardiovascular parameters (mean arterial pressure, heart rate, cardiac output, stroke volume and total peripheral resistance) before, during and after nitroglycerin infusion. RESULTS: Nitroglycerin provoked a migraine-like attack in 13/16 (81.2%) migraineurs but not in controls (p = .0001). No syncope was provoked. Migraineurs who later developed a migraine-like attack showed different responses in all parameters vs. controls (all p < .001): The decreases in cardiac output and stroke volume were more rapid and longer lasting, heart rate increased, mean arterial pressure and total peripheral resistance were higher and decreased steeply after an initial increase. DISCUSSION: Migraineurs who developed a migraine-like attack in response to nitroglycerin showed stronger systemic cardiovascular responses compared to non-headache controls. The stronger systemic cardiovascular responses in migraine suggest increased systemic sensitivity to vasodilators, possibly due to insufficient autonomic compensatory mechanisms.

Risk of Intracranial Complications in Minor Head Injury: The Role of Loss of Consciousness and Post-Traumatic Amnesia in a Multi-Center Observational Study.

Various guidelines for minor head injury focus on patients with a Glasgow Coma Scale (GCS) score of 13-15 and loss of consciousness (LOC) or post-traumatic amnesia (PTA), while clinical management for patients without LOC or PTA is often unclear. We aimed to investigate the effect of presence and absence of LOC or PTA on intracranial complications in minor head injury. A prospective multi-center cohort study of all patients with blunt head injury and GCS score of 15 was conducted at six Dutch centers between 2015 and 2017. Five centers used the national guideline and one center used a local guideline-both based on the CT in Head Injury Patients (CHIP) prediction model-to identify patients in need of a computed tomography (CT) scan. We studied the presence of traumatic findings and neurosurgical interventions in patients with and without LOC or PTA. In addition, we assessed the association of LOC and PTA with traumatic findings with logistic regression analysis and the additional predictive value of LOC and PTA compared with other risk factors in the CHIP model. Of 3914 patients, 2249 (58%) experienced neither LOC nor PTA and in 305 (8%) LOC and PTA was unknown. Traumatic findings were present in 153 of 1360 patients (11%) with LOC or PTA and in 67 of 2249 patients (3%) without LOC and PTA. Five patients without LOC and PTA had potential neurosurgical lesions and one patient underwent a neurosurgical intervention. LOC and PTA were strongly associated with traumatic findings on CT, with adjusted odds ratios of 2.9 (95% confidence interval [CI] 2.2-3.8) and 3.5 (95% CI 2.7-4.6), respectively. To conclude, patients who had minor head injury with neither LOC nor PTA are at risk of intracranial complications. Clinical guidelines should include clinical management for patients without LOC and PTA, and they should include LOC and PTA as separate risk factors rather than as diagnostic selection criteria.

Comparative Effectiveness of Surgery for Traumatic Acute Subdural Hematoma in an Aging Population.

There is uncertainty as to the optimal initial management of patients with traumatic acute subdural hematoma, leading to regional variation in surgical policy. This can be exploited to compare the effect of various management strategies and determine best practices. This article reports such a comparative effectiveness analysis of a retrospective observational cohort of traumatic acute subdural hematoma patients in two geographically distinct neurosurgical departments chosen for their - a-priori defined - diverging treatment preferences. Region A favored a strategy focused on surgical hematoma evacuation, whereas region B employed a more conservative approach, performing primary surgery less often. Region was used as a proxy for preferred treatment strategy to compare outcomes between groups, adjusted for potential confounders using multivariable logistic regression with imputation of missing data. In total, 190 patients were included: 108 from region A and 82 from region B. There were 104 males (54.7%). Matching current epidemiological developments, the median age was relatively high at 68 years (interquartile range [IQR], 54-76). Baseline characteristics were comparable between regions. Primary evacuation was performed in 84% of patients in region A and in 65% of patients in region B (p < 0.01). Mortality was lower in region A (37% vs. 45%, p = 0.29), as was unfavorable outcome (53% vs. 62%, p = 0.23). The strategy favoring surgical evacuation was associated with significantly lower odds of mortality (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.21-0.88) and unfavorable outcome (OR: 0.53; 95% CI: 0.27-1.02) 3-9 months post-injury. Therefore, in the aging population of patients with acute subdural hematoma, a treatment strategy favoring emergency hematoma evacuation might be associated with lower odds of mortality and unfavorable outcome.

Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list.

A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.

The use of the PSH-AM in patients with diffuse axonal injury and autonomic dysregulation: A cohort study and review.

PURPOSE: 1) To determine the clinical expression and consequences of autonomic dysregulation in patients with diffuse axonal injury (DAI), and 2) to study the use of the "paroxysmal sympathetic hyperactivity assessment measure" (PSH-AM). METHODS: Patients clinically diagnosed with autonomic dysregulation were selected from a cohort involving 116 patients with DAI. We studied the incidence of autonomic features, treatment, and outcome. In addition a systematic review was performed. RESULTS: Autonomic dysregulation was diagnosed in 19 of 116 (16.4%). Lower age (OR 0.95) and higher DAI grade (OR 7.2) were risk factors for autonomic dysregulation. Autonomic dysregulation was associated with an unfavourable outcome (OR 5.6) and a longer ICU and hospital stay. On the PSH-AM 57.9% (n = 11) scored a probable paroxysmal sympathetic hyperactivity (PSH), 36.8% (n = 7) scored possible, and 5.2% (n = 1) scored unlikely. The review yielded 30 articles. The incidence of autonomic dysregulation after TBI varied from 7.7-32.6% (mean 13.5%). TBI patients with autonomic dysregulation had a longer ICU stay and poorer outcome. CONCLUSION: Patients with DAI and autonomic dysregulation had a longer ICU stay and a poorer outcome compared to patients without autonomic dysregulation. The PSH-AM is a potential valuable tool to determine the likelihood of autonomic dysregulation.

External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands.

OBJECTIVE: To externally validate four commonly used rules in computed tomography (CT) for minor head injury. DESIGN: Prospective, multicentre cohort study. SETTING: Three university and six non-university hospitals in the Netherlands. PARTICIPANTS: Consecutive adult patients aged 16 years and over who presented with minor head injury at the emergency department with a Glasgow coma scale score of 13-15 between March 2015 and December 2016. MAIN OUTCOME MEASURES: The primary outcome was any intracranial traumatic finding on CT; the secondary outcome was a potential neurosurgical lesion on CT, which was defined as an intracranial traumatic finding on CT that could lead to a neurosurgical intervention or death. The sensitivity, specificity, and clinical usefulness (defined as net proportional benefit, a weighted sum of true positive classifications) of the four CT decision rules. The rules included the CT in head injury patients (CHIP) rule, New Orleans criteria (NOC), Canadian CT head rule (CCHR), and National Institute for Health and Care Excellence (NICE) guideline for head injury. RESULTS: For the primary analysis, only six centres that included patients with and without CT were selected. Of 4557 eligible patients who presented with minor head injury, 3742 (82%) received a CT scan; 384 (8%) had a intracranial traumatic finding on CT, and 74 (2%) had a potential neurosurgical lesion. The sensitivity for any intracranial traumatic finding on CT ranged from 73% (NICE) to 99% (NOC); specificity ranged from 4% (NOC) to 61% (NICE). Sensitivity for a potential neurosurgical lesion ranged between 85% (NICE) and 100% (NOC); specificity from 4% (NOC) to 59% (NICE). Clinical usefulness depended on thresholds for performing CT scanning: the NOC rule was preferable at a low threshold, the NICE rule was preferable at a higher threshold, whereas the CHIP rule was preferable for an intermediate threshold. CONCLUSIONS: Application of the CHIP, NOC, CCHR, or NICE decision rules can lead to a wide variation in CT scanning among patients with minor head injury, resulting in many unnecessary CT scans and some missed intracranial traumatic findings. Until an existing decision rule has been updated, any of the four rules can be used for patients presenting minor head injuries at the emergency department. Use of the CHIP rule is recommended because it leads to a substantial reduction in CT scans while missing few potential neurosurgical lesions.

Female sex hormones in men with migraine.

OBJECTIVE: To assess the role of estradiol and testosterone in men with migraine. METHODS: We measured 17ß-estradiol (E2) and calculated free testosterone (Tf) in serum of 17 medication-free men with migraine and 22 men without migraine group-matched for age and body mass index (BMI), targeted at 20 to 28 kg/m2. Blood was sampled on a single, for migraineurs interictal, day at 9 am, 12 pm, 3 pm, and 6 pm. Migraineurs were subsequently measured 3 to 4 times daily until an attack occurred. Clinical androgen deficiency was assessed with the Androgen Deficiency of Ageing Men questionnaire and the Aging Males' Symptoms (AMS) scale. We analyzed interictal data (mean ± standard error) with repeated-measures analysis of covariance and longitudinal data by generalized estimated equations models. RESULTS: Compared to controls, men with migraine had a lower interictal Tf/E2 ratio (3.9 ± 0.4 vs 5.0 ± 0.3, p = 0.03) due to higher E2 (96.8 ± 6.1 vs 69.1 ± 5.6 pmol/L, p = 0.001) and similar Tf (357.5 ± 21.4 vs 332.6 ± 18.7 pmol/L, p = 0.35) levels. Preictal Tf levels were increased in men with migraine reporting premonitory symptoms (p = 0.03). Men with migraine more frequently reported symptoms of androgen deficiency (11 of 18 [61.1%] vs 6 of 22 [27.3%], p = 0.031), which were also more frequently severe (p = 0.006); their age- and BMI-adjusted AMS scores were higher (27.0 ± 1.2 vs 21.0 ± 1.0, p = 0.002). CONCLUSIONS: In this study, nonobese men with migraine exhibited increased levels of the sex hormone estradiol and showed clinical evidence of relative androgen deficiency. The role of estradiol in modulating migraine susceptibility and activity in men deserves further investigations.

Intracranial Pressure: A Comparison of the Noninvasive HeadSense Monitor versus Lumbar Pressure Measurement.

OBJECTIVE: To compare a new method of noninvasive intracranial pressure (nICP) measurement with conventional lumbar puncture (LP) opening pressure. METHODS: In a prospective multicenter study, patients undergoing LP for diagnostic purposes underwent intracranial pressure measurements with HeadSense, a noninvasive transcranial acoustic device, and indirectly with LP. Noninvasive measurements were conducted with the head in a 30° tilt and in supine position before and after LP. The primary endpoint was the correlation between nICP measurement in supine position before LP and the LP opening pressure. RESULTS: There was no correlation between supine nICPs before LP and the LP opening pressures (r = -0.211, P = 0.358). The 30° head-tilt nICPs correlated with the supine nICPs before LP (r = 0.830, P < 0.01). There was no correlation between supine nICPs before and after LP (r = 0.056, P = 0.831) or between 30° head-tilt nICPs and LP opening pressures (r = -0.038, P = 0.861). CONCLUSIONS: There was no correlation between nICPs and LP opening pressures. Further development is warranted before transcranial acoustic HeadSense can become a clinical tool for investigating patients with neurologic conditions.

Prospective Evaluation of Noninvasive HeadSense Intracranial Pressure Monitor in Traumatic Brain Injury Patients Undergoing Invasive Intracranial Pressure Monitoring.

BACKGROUND: Currently, intracranial pressure (ICP) is measured by invasive methods with a significant risk of infectious and hemorrhagic complications. Because of these high risks, there is a need for a noninvasive ICP (nICP) monitor with an accuracy similar to that of an invasive ICP (iICP) monitor. OBJECTIVE: We sought to assess prospectively the accuracy and precision of an nICP monitor compared with iICP measurement in severe traumatic brain injury (TBI) patients. METHODS: Participants were ICP-monitored patients who had sustained TBI. In parallel with the standard invasive ICP measurements, nICP was measured by the HeadSense HS-1000, which is based on sound propagation. The device generated an acoustic signal using a small transmitter, placed in the patient's ear, and picked up by an acoustic sensor placed in the other ear. The signal is then analyzed using proprietary algorithms, and the ICP value is calculated in millimeter of mercury (mm Hg). RESULTS: Analysis of 2911 paired iICP and nICP measurements from 14 severe TBI patients showed a good accuracy of the nICP monitor indicated by a mean difference of 0.5 mm Hg. The precision was also good with a standard deviation of 3.9 mm Hg. The Pearson r correlation was 0.604 (P < 0.001). CONCLUSIONS: The HeadSense HS-1000 nICP monitor seems sufficiently accurate to measure the ICP in severe TBI patients, is patient friendly, and has minimal risk of complications.

The cavernous sinus in cluster headache - a quantitative structural magnetic resonance imaging study.

Background It has been hypothesized that a constitutionally narrow cavernous sinus might predispose individuals to cluster headache. Cavernous sinus dimensions, however, have never been assessed. Methods In this case-control study, we measured the dimensions of the cavernous sinus, skull base, internal carotid and pituitary gland with high-resolution T2-weighted magnetic resonance imaging in 25 episodic, 24 chronic and 13 probable cluster headache patients, 8 chronic paroxysmal hemicrania patients and 22 headache-free controls. Dimensions were compared between groups, correcting for age, sex and transcranial diameter. Results On qualitative inspection, no relevant pathology or anatomic variants that were previously associated with cluster headache or chronic paroxysmal hemicranias were observed in the cavernous sinus or paracavernous structures. The left-to-right transcranial diameter at the temporal fossa level (mean ± SD) was larger in the headache groups (episodic cluster headache: 147.5 ± 7.3 mm, p = 0.044; chronic cluster headache: 150.2 ± 7.3 mm, p < 0.001; probable cluster headache: 146.0 ± 5.3 mm, p = 0.012; and chronic paroxysmal hemicrania: 145.2 ± 9.4 mm, p = 0.044) compared with controls (140.2 ± 8.0 mm). After adjusting for transcranial diameter and correcting for multiple comparisons, there were no differences in the dimensions of the cavernous sinus and surrounding structures between headache patients and controls. Conclusion Patients with cluster headache or chronic paroxysmal hemicrania had wider skulls than headache-free controls, but the proportional dimensions of the cavernous sinus were similar.