Practice Current: How do you diagnose and treat post-concussive headache?

A common complaint after concussion is the development of new or worsening headaches which can make it difficult or even impossible for patients to work or function in their day-to-day lives. Uncertainties associated with the complaints and a wide variety of approaches exist regarding the appropriate work-up and management of these patients. Areas of ongoing debate include the need for neuroimaging; optimal, acute, and preventative treatment; and proper counseling and expectation management. Given the wide variety of potential approaches and the lack of consensus, we sought expert opinion from around the globe on how to evaluate and manage patients with headache following concussion. Similar questions were posed to the rest of our readership in an online survey (links.lww.com/CPJ/A96), the results of which are also presented.

Frequency of Blood-Brain Barrier Disruption Post-Endovascular Therapy and Multiple Thrombectomy Passes in Acute Ischemic Stroke Patients.

Background and Purpose- The high prevalence of hyperintense acute reperfusion marker (HARM) seen after endovascular therapy is suggestive of blood-brain barrier disruption and hemorrhage risk and may be attributable to multiple thrombectomy passes needed to achieve recanalization. Methods- Patients with acute stroke were included if they were screened from January 2015 through February 2019, received an acute ischemic stroke diagnosis involving the anterior circulation, treated with or without IV tPA (intravenous tissue-type plasminogen activator), consented to the NINDS Natural History Study, and imaged with a baseline magnetic resonance imaging before receiving endovascular therapy. Consensus image reads for HARM and hemorrhagic transformation were performed. Good clinical outcome was defined as 0-2 using the latest available modified Rankin Scale score. Results- Eighty patients met all study criteria and were included in the analyses. Median age was 65 years, 64% female, 51% black/African American, median admit National Institutes of Health Stroke Scale=19, 56% treated with IV tPA, and 84% achieved Thrombolysis in Cerebral Infarction score of 2b/3. Multiple-pass patients had significantly higher rates of severe HARM at 24 hours (67% versus 29%; P=0.001), any hemorrhagic transformation (60% versus 36%; P=0.04) and poor clinical outcome (67% versus 36%; P=0.008). Only age (odds ratio, 1.1; 95% CI, 1.01-1.12; P=0.022) and severe HARM at 24 hours post-endovascular therapy were significantly associated with multiple passes (odds ratio, 7.2; 95% CI, 1.93-26.92; P=0.003). Conclusions- In this exploratory study, multiple thrombectomy passes are independently associated with a significant increase in blood-brain barrier disruption detected at 24 hours. Patients with HARM post-endovascular therapy had a >7-fold increase in the odds of having multiple- versus single-pass thrombectomy. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00009243.

The effect of atrial fibrillation on outcomes in patients undergoing carotid endarterectomy or stent placement in general practice.

BACKGROUND: Atrial fibrillation is a common comorbid condition among patients undergoing carotid endarterectomy (CEA) and carotid artery stent placement (CAS); however, the outcomes of patients with atrial fibrillation undergoing CAS have not been fully examined. We sought to investigate the impact of atrial fibrillation on outcomes of CEA and CAS in general practice. METHODS: We analyzed the data from the National Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2009. The primary end point was postoperative stroke, cardiac complication, postoperative mortality, and composite of these end points. Univariate and multivariate regression analyses were performed to determine, first, the association of atrial fibrillation (compared to without atrial fibrillation) and, second, the association of CEA (compared with CAS) in patients with atrial fibrillation with the occurrence of postoperative stroke, cardiac complication, or death. Covariates included in the logistic regression were the patient's gender, age, race/ethnicity, comorbid conditions, and symptom status (symptomatic vs asymptomatic status) and the hospital's characteristics. RESULTS: Of the total 672,074 patients who underwent CAS or CEA, 8.8% (95% confidence interval [CI], 8.7-8.9) of the procedures were performed in patients with atrial fibrillation. Atrial fibrillation was associated with an increased risk of postoperative stroke in patients undergoing CEA (n = 879 [1.7%]; P < .0001; odds ratio [OR], 1.57; 95% CI, 1.32-1.86) but not in patients undergoing CAS. The relative risk of the composite end point of postoperative stroke, cardiac complications, and mortality was increased in patients with atrial fibrillation undergoing CAS (OR, 1.43; 95% CI, 1.18-1.74) and in those undergoing CEA (OR, 3.18; 95% CI, 2.89-3.49). After adjustment for potential confounders, the odds of the composite end point of postoperative stroke, cardiac complications, and mortality (OR, 1.31; 95% CI, 1.08-1.59) in atrial fibrillation patients were significantly higher among patients who underwent CEA (compared with those who underwent CAS). An opposite relationship was seen in patients without atrial fibrillation, in whom the composite end point was significantly lower in patients undergoing CEA. CONCLUSIONS: Our analysis suggests that almost 10% of CAS and CEA is performed in patients with atrial fibrillation in general practice, and higher rates of adverse events are observed among these patients, particularly those undergoing CEA.

Clinical outcomes after thrombectomy for acute ischemic stroke on weekends versus weekdays.

BACKGROUND: The objective of this study was to determine whether clinical outcomes differed in acute ischemic stroke (AIS) patients who underwent thrombectomy on weekends versus weekdays. METHODS: Patients with a primary diagnosis of AIS who underwent thrombectomy were identified from the Nationwide Inpatient Sample from 2005 to 2011 and stratified according to weekend or weekday admission. Logistic regression analysis was performed to identify factors associated with moderate-to-severe disability at hospital discharge in teaching and nonteaching hospitals. RESULTS: Of 12,055 patients with AIS who underwent thrombectomy during the study period, 2862 (23.7%) were admitted on a weekend. In a multivariate logistic regression analysis, factors associated with moderate or severe disability at discharge in nonteaching hospitals were weekend admission (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.8; P = .04), diagnosis of hypertension (OR, 1.9; 95% CI, 1.0-3.6; P = .05), and Medicare or Medicaid insurance status (OR, 2.1; 95% CI 1.1-4.3; P = .02); factors associated with moderate or severe disability at discharge in teaching hospitals were age >70 years (OR, 1.5; 95% CI, 1.1-2.2; P = .02), pneumonia (OR, 4.7; 95% CI, 2.2-10.2; P < .0001), sepsis (OR, 8.2; 95% CI, 1.2-54.8; P = .03), intracranial hemorrhage (OR, 3.3; 95% CI, 1.8-6.1; P = .0001), and treatment in a Northwest hospital region (OR, 1.7; 95% CI, 1.2-2.4; P = .03). CONCLUSIONS: AIS patients undergoing thrombectomy who were admitted to nonteaching hospitals on weekends were more likely to be discharged with moderate-to-severe disability than those admitted on weekdays. No weekend effect on discharge clinical outcome was seen in teaching hospitals.

Patterns of collateral formation in basilar artery steno-occlusive diseases.

BACKGROUND: Augmentation of collateral flow is proposed as a method to reduce ischemic injury in the posterior circulation. However, collateral formation in basilar artery stenosis (BAS) and basilar artery occlusion (BAO) has not been studied thoroughly. METHODS: We identified 24 consecutive patients admitted over a 4-year period with angiographically demonstrated BAS of more than 50% or occlusion. Angiographic images were reviewed for pattern of collaterals by a blinded reviewer. A new grading system by Qureshi [1] (Qureshi AI (2012) J Neuroimaging in press) was utilized for grading. Grades I and II had retrograde filling of the basilar artery through PCA with or without filling of the superior cerebellar artery, respectively. Grades III and IV were bilateral or unilateral anastomoses of cerebellar arteries or PCAs, respectively. Risk factors such as age, gender, race/ethnicities, co-morbidities, NIHSS sore on admission and discharge, tPA administration, in-hospital complications, and discharge status measured by the modified Rankin score were ascertained. RESULTS: THE COLLATERALS WERE CATEGORIZED AS: Grade I A (n = 8), Grade IIIA (n = 5), and none (n = 11). No patient had Grade II collaterals. Grade IA collaterals were more frequent in patients with BAO than those with BAS. The rate of good outcomes (mRS 0-2) at discharge was significantly higher among patients with IA collaterals compared with patients with grade IIIA collaterals (62% vs. 20%). The rate of good outcomes was 54% of patients without collaterals. CONCLUSIONS: The pattern of collateral formation in BAS and BAO varies and is associated with patient outcomes.

Chromosomal study for prognostic grouping in chronic lymphocytic leukemia.

OBJECTIVE: To determine the frequency of various cytogenetic aberrations in newly diagnosed chronic lymphocytic leukemia (CLL) patients, and their detection rate by cytogenetic and fluorescent In situ hybridization (FISH) technique separately. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Clinical and Molecular Cytogenetics Laboratories, University of California, Los Angeles, USA, from November 2007 to July 2008. METHODOLOGY: Analysis was made on 100 diagnosed chronic lymphocytic leukemia patients. Cytogenetics and FISH technique were performed on blood or bone marrow samples. RESULTS: Nineteen out of 100 cases (19%) showed karyotype abnormalities; whereas 55 showed abnormalities using the CLL-specific FISH probes. The most frequent abnormality detected by standard cytogenetics was trisomy 12. The most common abnormality detected by FISH was a deletion of 13q14 (40 out of 55 cases; 72% of the abnormal). CONCLUSION: For prognostic grouping of CLL patients, FISH must always be requested which may even replace standard karyotyping. These chromosomal markers help in choosing the therapeutic options.

The role of leukocyte counts in patients with unstable angina pectoris or myocardial infarction; prognostic significance and correlation with plasma brain natriuretic peptide (BNP) levels.

OBJECTIVE: To study the role of leukocyte count in patients with unstable angina pectoris or myocardial infarction (Acute Coronary Syndrome) its prognostic significance and correlation with plasma brain natriuretic peptide (BNP) levels. METHODS: A total of 143 Patients with unstable angina pectoris, non-ST segment elevation MI and ST segment elevation MI were considered for entry into the study. Plasma BNP levels were measured using a commercial BNP kit (AxSym System BNP Reagent Pack, Abbott Laboratories, Abbott Park, IL, USA). Leukocyte count was measured on CELL DYNE counter of Abbott Laboratories. RESULTS: Mean age of the patients were 58.67 +/- 12.48 years. Mean leukocyte count was 9772 +/- 3006 /cumm. In all 43 (30%) patients had high leukocyte count, and 82 (57%) patients had elevated BNP level. Out of 61 patients with normal BNP level, 49 (80%) had normal leukocyte count and 12 (20%) had elevated leukocyte count. Out of 82 patients with elevated BNP level, 51 (62%) had normal leukocyte count and 31 (38%) had elevated leukocyte count (P = 0.01). CONCLUSION: No statistically significant association was found between Leukocyte count and ACS. Although there is a trend of increased Leukocyte count noted in patients with increase BNP level. This finding necessitates further studies to elucidate its accurate significance.

Low haemoglobin levels, its determinants and associated features among pregnant women in Islamabad and surrounding region.

OBJECTIVE: To estimate the haemoglobin levels in pregnant women and to determine the socio-demographic factors associated with anaemia in pregnancy. PATIENTS AND METHODS: In this cross-sectional survey, a total of 200 patients visiting prenatal clinic of Shifa International Hospital/Shifa Foundation Community Health Centres, Islamabad over the period of six months, both booked and non-booked were included. A detailed questionnaire was filled and complete blood count, peripheral smear and absolute values were performed in all cases. Haemoglobin levels (Hb) of women below 10.5g/dl were considered to be low (anaemia) and were further subjected to urine/stool routine examination. Cases of thalasaemia trait were excluded from the study. All the data was entered in SPSS v 10.0. Descriptive analysis was done obtaining frequencies for socio-demographic factors. Mean haemoglobin levels along with standard deviation and confidence interval were reported. Frequency of helminthic infestation of suspected cases was also reported. Analysis included any significant differences in mean haemoglobin levels of booked versus non-booked cases. RESULTS: Mean haemoglobin of our study population was 11.0 +/- 1.64 g/dl. Frequency of decreased haemoglobin was found to be in 42.5%. Mean haemoglobin of patients having income less than Rs5000 was 10.5 +/- 1.24 g/dl and those with income more than Rs5000/month had a mean Haemoglobin of 11.5 +/- 1.44g/dl. Mean haemoglobin of patients with history with or without pica eating was 10.1 +/- 1.31g/dl and 11.9 +/- 1.56g/dl respectively. CONCLUSION: Low haemoglobin was commonly seen in our population among pregnant women irrespective of their socioeconomic status. The severity of anaemia was significantly associated with lower socioeconomic status and odd eating habits.

Efficacy and safety of total dose infusion of low molecular weight iron dextran in the treatment of iron deficiency anemia during pregnancy.

OBJECTIVE: To determine the efficacy and safety of Total Dose Infusion (TDI) of low molecular weight iron dextran for the treatment of iron deficiency anemia compared to oral iron replacement during pregnancy through improvement in hemoglobin (Hb) after intervention. STUDY DESIGN: Non-randomized control trial. PLACE AND DURATION OF STUDY: Section of Gynaecology and Obstetrics, Shifa International Hospital and Shifa Community Health Centre, Islamabad during January 2005 to January 2006. PATIENTS AND METHODS: A group of 100 pregnant women with gestational age greater than 12 weeks with confirmed diagnosis of iron deficiency anemia attending the antenatal clinics were enrolled in this study. Total dose iron infusion of low molecular iron dextran was given to these patients after calculating iron deficit, in a monitored in-patient setting. Control comprised of a second group of 50 pregnant females matched for age, parity and baseline hemoglobin, tolerant to oral iron supplementation (ferrous sulphate 200 mg three times a day) attending the antenatal clinics during the same period. Post-treatment hemoglobin levels of study group as well as the oral control group were determined between 3 to 4 weeks. RESULTS: In the intervention group, mean pre-infusion hemoglobin level was 8.57 +/- 0.9 gm/dl (range 5-10.5 gm/dl) and mean post-infusion Hb was 11.0 +/- 1.1 (range 8.4-14.3 gm/dl). In control group, mean pre-oral intake Hb level was 9.5 +/- 0.9 gm/dl (range 7-10.5 gm/dl) and mean post-oral intake Hb was 10.2 +/- 1.2 gm/dl (range 6.4-12.8 gm/dl). Mean increase of Hb in intervention group was 2.43 gm/dl (95% CI 2.4 - 3.8) and for controls it was 0.7 gm/dl (95% CI 0.6-2.3). Flushing and palpitations were observed in 4% of interventional group patients and none in the control group. No significant adverse reactions were observed in either group. CONCLUSION: We conclude that the total parenteral iron replacement with low molecular weight iron dextran is an effective and safe method for the treatment of iron deficiency anemia in a selected group of pregnant women.

Prenatal diagnosis of beta-thalassaemia by chorionic villous sampling.

OBJECTIVE: To establish intrauterine diagnosis of thalassaemia major in couples with thalassaemia trait by chorionic villous sampling. METHODS: A total of 60 couples with children suffering from transfusion dependent beta-thalassaemia or couples who were known carriers of beta-thalassaemia were included in this study. The standard procedure was followed for the collection of samples which was finally transferred in appropriate medium to Armed Forces Institute of Pathology Rawalpindi for detection of thalassaemia mutation. RESULTS: After DNA analysis of the submitted samples, no thalassaemia mutation was detected in the foetus in 24 cases. In 8 cases foetus were heterozygote for thalassaemia having a single mutation. In 28 cases, foetus were homozygous for beta-thalassaemia. CONCLUSION: Appropriate and extensive screening, accurate detection and counseling of at risk couples, along with antenatal diagnosis is a promising strategy for the reduction of mortality and morbidity from thalassaemia in countries where it is prevalent. Based on these results, it can be concluded that prenatal diagnosis of beta-thalassaemia for prevention can be done using chorionic villous sampling.

Knowledge of type 2 diabetic patients about their illness: pilot project.

OBJECTIVE: To evaluate the baseline level of knowledge and awareness of diabetic patients about their disease and it's complications. METHODS: It was a Cross Sectional Survey conducted at Foundation Clinic, Shifa College of Medicine, Islamabad, in April 2004. A structured questionnaire was used. Forty diabetic patients were interviewed to know their knowledge attitude and practices about diabetes. All data was entered into SPSS version 10.0. The data was re-validated and analyzed. RESULTS: Mean age of study participants was 45.35 +/- 13.05 years, 11(27.5%) were male and 29(72.5%) were female. The mean BMI of the study participants was 27.06 +/- 6.29 kg/m2. Majority of the patients 27(67.5%) had type 2 diabetes. The mean fasting blood sugar was 159 +/- 73.89 mg/dl and random blood sugar was 200 +/- 91.2 mg/dl, 50% of the patients were using antidiabetic drugs regularly and only 15% of the patients were regularly monitoring their blood glucose at home using a glucometer. Awareness level of the study participants was low. CONCLUSION: The awareness about the disease in majority of diabetic patients was not adequate in this study. Routine individual teaching and counseling represents an effective educational model.

Comparative study of knowledge, attitude and practices among antenatal care facilities utilizing and non-utilizing women.

OBJECTIVE: To compare the knowledge, attitude and practices among antenatal care facilities utilizing and non-utilizing women, aged 15-49 years. METHODS: A Cross-sectional survey was conducted between October 2003 and April 2004, including 200 married women in the age range 15-49 years. Knowledge, attitude and practices of women utilizing and not utilizing antenatal care facilities during their previous pregnancy were compared by calculating odds ratios and 95% confidence intervals. P values were obtained by doing chi-square test. RESULTS: Pallor was significantly lower among women utilizing antenatal care (57%) as compared to those who were not (77.6%). (O.R 0.38 95% CI(0.18-0.81) p value 0.02). Tetanus toxoid coverage was higher among women utilizing antenatal care (92%) compared to those who were not (59.2%) (O.R 10.8 95% CI(4.5-26.2). Knowledge about danger signals in pregnancy and realization of the importance of eating a healthy diet during pregnancy was significantly higher among women utilizing antenatal care. CONCLUSION: Lesser prevalence of Anaemia and better tetanus toxoid coverage was seen among women attending antenatal care facilities. Identification of danger signals in pregnancy and recognition of nutritional demands of pregnancy are better understood by women utilizing antenatal care facilities.

Temperature regulation and standardization practices of clinical laboratories in Karachi.

OBJECTIVE: To examine the temperature regulation and standardization practices of clinical laboratories in Karachi. METHOD: Forty five clinical laboratories in Karachi were examined for observing the standard protocols for running a lab with particular reference to temperature regulation. A questionnaire to the effect was filled. RESULTS: Among the 45 labs included, the mean complete blood count performed per day was 52+/-47. Only 5 (11%) labs had a temperature reader. Thirty (66.7%) labs had an air-conditioner installed, of which only 24 were found in working condition. Maintenance of instruments was carried out every 67.5+/-.30.6 days. The mean number of haemolyzed samples was 2.3+/-1.7. Control was available in 24(53.3%) labs, which was used daily in only 10 labs. Quantity of blood was the same in all the tubes in only 33(73.3%) labs. CONCLUSION: Commercial laboratories should be properly registered and their quality standardized.