Two-year, real-world erenumab persistence and quality of life data in 82 pooled patients with abrupt onset, unremitting, treatment refractory headache and a migraine phenotype: New daily persistent headache or persistent post-traumatic headache in the majority of cases.

BACKGROUND: Patients diagnosed with New Daily Persistent Headache and Persistent Post-Traumatic Headache belong to a heterogeneous group of primary and secondary headache disorders, with the common clinical feature that these conditions start abruptly, continue unabated, and are refractory to conventional migraine preventive treatments. OBJECTIVE: This is a real-world, medium-term audit to explore whether erenumab improves quality of life in a pooled group of 82 abrupt-onset, unremitting and treatment refractory patients, where the diagnosis is new daily persistent headache and persistent post-traumatic headache in the majority of cases. METHODS: Eighty-two patients were treated with erenumab every 28 days over a two to three-year period, beginning in December 2018. These patients were "longstanding chronic" and refractory with a median of eight (IQR 4-12) prior failed migraine preventive treatments and median duration of disease of seven (IQR 3-11) years. The starting dose of erenumab was 70 mg in 79% of cases and 140 mg in the remaining patients (individuals with a BMI of more than 30). All patients were asked to complete three migraine specific Quality of Life questionnaires or Patient Reported Outcome Measures before starting treatment and typically at 3-12 intervals until the end of June 2021 or cessation of treatment. The Patient Reported Outcome Measures included: Headache Impact Test-6, Migraine Associated Disability Assessment test and Migraine-Specific Quality-of-Life Questionnaire. Patients generally only stayed on treatment after 6-12 months if there was deemed to be an improvement of at least 30% and there were no significant side effects. The longest treated cases have quality of life data for 30 months after starting erenumab. RESULTS: Of the 82 patients, 29 (35%) had improvement in Quality of Life scores, with no significant side effects, and wished to stay on treatment. Fifty-three patients (65%) stopped treatment during the first 6-25 months due to lack of efficacy and/or patient reported side effects (n = 33 and n = 17, respectively) or a combination of both, pregnancy planning (n = 2), and lost to follow up (n = 1). CONCLUSION: Significant improvements in Quality of Life scores were recorded by one-third of patients over a period of 11-30 months, with a 35% persistence after a median of 26 months of treatment. This contrasts with our recently published, treatment resistant, chronic migraine cohort where the persistence with erenumab treatment was almost 55% after a median time of 25 months.

Medium-term real-world data for erenumab in 177 treatment resistant or difficult to treat chronic migraine patients: persistence and patient reported outcome measures after 17-30 months.

BACKGROUND: Many migraine patients do not respond adequately to conventional preventive treatments and are therefore described as treatment/medically resistant or difficult to treat cases. Calcitonin gene-related peptide monoclonal antibodies are a relatively novel molecular treatment for episodic and chronic migraine that have been shown to be effective in short duration clinical trials in approximately 40-50% of all chronic migraine patients. Patient Related Outcome Measures (PROM) or Quality of Life (QoL) questionnaires are used to help measure response to treatment in migraine. Although some open label extension studies have become available for erenumab, there is a lack of real-world data pertaining to quality of life in the medium to long-term for chronic and treatment resistant migraine patients. METHODS: A total of 177 treatment resistant CM patients were started on erenumab (70 mg or 140 mg subcutaneous injection every 4 weeks) in our three specialist Headache Clinics. Of these, 174 had their first injection between December 2018 and October 2019. All patients were evaluated with the following PROM: the Headache Impact Test- 6, Migraine Associated Disability Assessment test and Migraine-Specific QoL Questionnaire, before starting treatment with erenumab and at intervals of 3-12 months after starting treatment. The decision to continue treatment was based on subjective clinical improvement of at least 30% (as reported by the patient), supported with diaries and QoL questionnaires. We present here the QoL measurements for this group of 177 patients. Prior preventive migraine treatments included conventional oral prophylactic medications (such as topiramate, candesartan, propranolol, or amitriptyline), at least two cycles of PREEMPT protocol onabotulinumtoxin A or (in a small number of cases) neuromodulation with single pulse Transcranial Magnetic Stimulation. RESULTS: Of the 177 patients who started treatment with erenumab, 68/177 (38.4%) stopped during the first year, either due to lack of efficacy (no significant benefit or only minimal improvement) and/or possible side effects. 109/177 (61.6%) patients reported clinically significant improvement after 6-12 months and wished to stay on treatment. Twelve of these 109 patients subsequently stopped treatment in the period between 1 year and up to June 2021 (mainly due to a worsening of their migraine). Therefore, a total of 97/177 patients (54.8%) remained on treatment as of June 2021 (duration of treatment 17-30 months, median of 25 months). CONCLUSION: Approximately 55% of treatment resistant or difficult to treat CM patients who trialled erenumab in our clinics reported a subjective benefit and were still on treatment after 17-30 months.

Lost in translation: Telephone referrals to a tertiary neurology referral centre.

BACKGROUND: Cork University Hospital acts as the tertiary referral centre for the HSE southern area, with a catchment population of 1.2 million [1]. The neurology registrars receive telephone consultations from hospitals and primary care practices in the region. While there have been a number of studies examining inpatient neurology consultations in Irish hospitals [2-6], there is a paucity of data examining the support provided by tertiary referral centres to other acute hospitals and primary care centres in their region. AIMS: The aim of this study is to define the workload of the neurology registrar with respect to telephone consultations and to examine the quality of these referrals. METHODS: All calls received from the 19th of October 2021 to the 25th of February 2022 were logged by the receiving registrar. Information collected pertained to the nature of the consult and completeness of the referral. RESULTS: The average volume of calls during the study period was six per week. The median call duration was 8 min. The cumulative time spent resolving outside calls during the study period was at least 41.25 hours. Sixty-three per cent of calls were from other acute hospitals in the region. Thirty-nine per cent of referrals were deemed incomplete with respect to either history, collateral history or examination. CONCLUSIONS: This is a necessary service in a system that is not adequately resourced to provide specialist led care in all hospitals. A greater emphasis on complete and accurate referrals, along with robust communication and documentation, could reduce the inherent risk associated with such consultations.

Patients' Experiences of Remote Neurology Consultations during the COVID-19 Pandemic.

Telemedicine has been widely implemented during the COVID-19 global pandemic to enable continuity of care of chronic illnesses. We modified our general neurology clinic to be conducted using remote audio-only telephone consultations. We included all patients over a 10-week period who agreed to both a telephone consultation and a questionnaire afterwards in order to ascertain the patient's perspective of the experience. There were 212 participants consisting of men (43.8%) and women (56.2%). The mean ± standard deviation of age was 47.8 ± 17.0 (range 17-93) years. For the most part, patients found remote consultations either "just as good" (67.1%) or "better" (9.0%) than face-to-face consultations. Those who deemed it to be "not as good" were significantly older (52.3 ± 17.9 years vs. 46.6 ± 16.6 years, p =0.045) or were more likely to have a neurological disorder that required clinical examination, namely, a neuromuscular condition (66.7%, p = 0.002) or an undiagnosed condition (46.7%, p = 0.031). At the height of the COVID-19 global pandemic, most patients were satisfied with remote consultations. The positive feedback for remote consultations needs to be verified outside of this unique scenario because the results were likely influenced by the patients' apprehension to attend the hospital amongst other factors.

Pregnancy outcomes in women with onset of type 1 diabetes mellitus less than 18 years of age.

BACKGROUND: Pregnancy in women with type 1 diabetes mellitus (T1DM) is associated with an increased risk of congenital malformations, obstetric complications and neonatal morbidity. This study aims to investigate maternal, perinatal and neonatal outcomes of pregnancies in women with onset of T1DM less than 18 years of age. METHODS: This retrospective cohort study extracted data regarding prenatal, intrapartum and postnatal outcomes of pregnancies in women with onset of T1DM<18 years identified from the diabetes in pregnancy register at University Maternity Hospital Limerick, treated from July 1, 2007 to July 1, 2017. RESULTS: Seventeen women with onset of T1DM <18 years gave birth to 23 live infants during the period studied. 73.9% of pregnancies were unplanned. Only 21.7% of pregnancies took preconceptual folic acid. 60.9% of infants required treatment for hypoglycemia. CONCLUSION: The high prevalence of unplanned pregnancy and poor uptake of prepregnancy care must be improved on in order to improve outcomes for this high-risk group.

Interns as medical educators: student and intern experiences from the intern-delivered teaching program at University Hospital Limerick.

BACKGROUND: The acquisition and assimilation of knowledge through history-taking and clinical skills practice are core aspects of training for medical students. Interns, who have recently graduated and have entered into clinical practice, are uniquely positioned to assume a pivotal role in student education. AIMS: The goal of this study was to evaluate feedback from both students as well as intern tutors on the intern-delivered teaching program at University Hospital Limerick (UHL) from 2015 to 2016. METHODS: Eighty-five interns participated in the program at UHL in 2015 and 2016, aiming to deliver four 1-h tutorials to 285 Year 3 or Year 4 students from UL Graduate Entry Medical (GEMS) Program. A flexible schedule focused on practical skills and knowledge translation was created with oversight from Lead Interns and Professor of Medicine, with administrative support. Feedback was assessed using anonymous survey questionnaires. RESULTS: The survey response rate was 74% in 2015 and 75% in 2016. Student feedback on the performance of intern tutors was positive. More than 50% of students deemed tutorials on history-taking and clinical examination as the most valuable. Over 76% of students indicated a desire to participate as tutors after graduation. Logistical issues in agreeing mutually suitable timeslots were identified as the major barrier for delivery of teaching. From the intern perspective, over 85% reported benefits in areas of professional development and knowledge consolidation. CONCLUSIONS: Participation in intern-delivered teaching leads to clinical and educational benefits for both students and interns. However, several logistical barriers were identified and require refinement.

The role of a companion attending consultations with the patient. A systematic review.

OBJECTIVE: To review the literature pertaining to communication patterns and dynamics of doctor-patient-companion or 'triadic' medical encounters as identified in both quantitative and qualitative studies. To consider the role of an attending companion in specialist groups using the context of chronic pain as a group example. METHODS: Studies were identified via database searches and reference lists. The eligibility of studies and data extracted were cross-checked with inclusion and exclusion criteria. RESULTS: Of the 1094 titles identified, 20 studies were included for review. Tables were created for patient settings and study outcomes. Results indicated that companions frequently attended consultations, usually with a relative such as their spouse or adult child and were found to influence communicative processes in the encounter. This influence could either be negative (limiting the exchange of information, particularly relating to sensitive topics) or positive (improvement of self-care management), with study outcomes varying widely. The chronic pain subgroup has not yet been researched in the context of triadic consultations. CONCLUSION: Triadic communication can be advantageous in medical encounters; however, as differences exist depending on the individual medical setting, caution should be asserted in generalising findings.

Irrational use of proton pump inhibitors in general practise.

BACKGROUND: Proton pump inhibitors (PPI) are widely used among general practitioners (GP) and hospital doctors alike as a first-line agent for the management of various approved conditions. However, PPIs do have an established side-effect profile that can be over looked when prescribing these agents outside of their Food Drug Administration (FDA) indications. AIMS: The aim of this audit is to establish that PPIs are often prescribed without any clear documented indication as to why, particularly in the elderly population, despite multiple previous studies conducted which showed an over-use of these medicines. METHODS: We conducted a retrospective observational study of the patients admitted to an acute hospital in Ireland in February 2018. A cohort of patient charts were pulled from medical records and reviewed. Medical notes, GP letters, discharge summaries and prescriptions were reviewed in order to establish the primary indication for PPI prescription. RESULTS: One hundred seventy-four (n = 174) inpatient records were randomly assessed during the audit. Of these patients, 85 of them were taking PPIs regularly. 54.7% (n = 46) were prescribed a PPI without any documented indication. 46.4% (n = 39) of these patients were > 75 years of age. 54.7% (n = 46) of patients were prescribed esomeprazole. The commonest indication for prescribing PPIs was to reduce the risk of gastric ulceration associated with NSAID use, which was 68.4% (n = 26) of those who were prescribed a PPI in accordance with guidelines. CONCLUSION: Irrational prescribing of PPIs continues both in hospital and in general practise. It is imperative that the side-effects of these medicines are weighed against the benefit and cost effectiveness, especially in the elderly population where polypharmacy remains a substantial concern.