Optimal management strategies for primary headache in the emergency department.

PURPOSE: We sought to evaluate the factors associated with better outcomes for emergency department (ED) patients treated for primary headache. METHODS: This was a health records review of consecutive patients over a 3-month period presenting to two tertiary EDs and discharged with a diagnosis of primary headache. The primary outcome was the need for second round medications, defined as medications received > 1 h after the initial physician-ordered medications were administered. We performed multivariate logistic regression analysis to determine treatment factors associated with need for second round medications. RESULTS: We included 553 patients, mean age was 42.2 years and 72.9% were females. The most common diagnoses were headache not otherwise specified (48.8%) and migraine (43%). Ketorolac IV (62.2%) and metoclopramide IV (70.2%) were the most frequently administered medications. 18% of patients met the primary outcome. Dopamine antagonists (OR 0.3 [95% CI 0.1-0.5]) and non-steroidal anti-inflammatory drugs (NSAIDs) (OR 0.5 [95% CI 0.3-0.8]) ordered with initial medications were associated with reduced need for second round medications. Intravenous fluid boluses ≥ 500 ml (OR 2.8 [95% CI: 1.5-5.2]) and non-dopamine antagonist antiemetics (OR 2.2 [95% CI 1.2-4.2]) were associated with increased need. Opioid use approached statistical significance for receiving second round medication (p = 0.06). CONCLUSION: We determined that use of dopamine antagonists and NSAIDs were associated with a reduced need for second round medications in ED primary headache patients. Conversely, non-dopamine antagonist antiemetic medications and intravenous fluids were associated with a significantly increased need for second round medications. Careful choice of initial therapy may optimize management for these patients.

RéSUMé: OBJECTIF: Nous avons cherché à évaluer les facteurs associés à de meilleurs résultats pour les patients des services d'urgence traités pour des céphalées primaires. MéTHODES: Il s'agissait d'un examen des dossiers médicaux de patients consécutifs sur une période de 3 mois se présentant à deux services d'urgence tertiaires et sortis avec un diagnostic de céphalée primaire. Le résultat primaire était la nécessité d'une deuxième série de médicaments, définis comme des médicaments reçus > 1 heure après l'administration des premiers médicaments prescrits par le médecin. Nous avons effectué une analyse de régression logistique multivariée pour déterminer les facteurs de traitement associés au besoin de médicaments de second tour RéSULTATS: Nous avons inclus 553 patients, l'âge moyen était de 42,2 ans et 72,9 % étaient des femmes. Les diagnostics les plus fréquents étaient les céphalées non spécifiées autrement (48,8 %) et la migraine (43 %). Le kétorolac IV (62,2%) et le métoclopramide IV (70,2 %) étaient les médicaments les plus fréquemment administrés. 18 % des patients ont atteint le résultat primaire. Les antagonistes de la dopamine (OR 0,3 [IC 95 % : 0,1-0,5]) et les anti-inflammatoires non stéroïdiens (AINS) (OR 0,5 [IC 95 % : 0,3-0,8]) commandés avec les médicaments initiaux étaient associés à un besoin réduit de médicaments de deuxième série. Les bolus liquidiens intraveineux ≥ 500 ml (OR 2,8 [IC 95 % : 1,5-5,2]) et les antiémétiques non antagonistes de la dopamine (OR 2,2 [IC 95 % : 1,2-4,2]) étaient associés à un besoin accru. L'utilisation d'opioïdes a approché la signification statistique pour la réception d'un médicament de deuxième série (p = 0,06). CONCLUSION: Nous avons déterminé que l'utilisation d'antagonistes de la dopamine et d'AINS était associée à un besoin réduit de médicaments de second tour chez les patients souffrant de céphalées primaires aux urgences. À l'inverse, les médicaments antiémétiques non antagonistes de la dopamine et les fluides intraveineux étaient associés à un besoin significativement accru de médicaments de second tour. Un choix judicieux du traitement initial peut optimiser la prise en charge de ces patients.

Disability, pain, and wound-specific concerns self-reported by adults at risk of limb loss: A cross-sectional study using the World Health Organization Disability Assessment Schedule 2.0.

INTRODUCTION: There has been limited study of patient-reported outcomes (PROs) in patients at risk of limb loss. Our primary objective was to estimate the prevalence of disability in this patient population using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). MATERIALS AND METHODS: We recruited patients referred to a limb-preservation clinic. Patients self-reported their disability status using the 12-domain WHODAS 2.0. Severity of disability in each domain was scored from 1 = none to 5 = extreme and the total normalized to a 100-point scale (total score ≥25 = clinically significant disability). We also asked patients about wound-specific concerns and wound-related discomfort or distress. RESULTS: We included 162 patients. Reasons for clinic referral included arterial-insufficient (37.4%), postoperative (25.9%), and mixed etiology (10.8%) wounds. The mean WHODAS 2.0 disability score was 35.0 (standard deviation = 16.0). One-hundred-and-nineteen (73.5%) patients had clinically significant disability. Patients reported they had the greatest difficulty walking a long distance (mean score = 4.2), standing for long periods of time (mean score = 3.6), taking care of household responsibilities (mean score = 2.7), and dealing with the emotional impact of their health problems (mean score = 2.5). In the two-weeks prior to presentation, 87 (52.7%) patients expressed concern over their wound(s) and 90 (55.6%) suffered a moderate amount or great deal of wound-related discomfort or distress. In adjusted ordinary least squares regression models, although WHODAS 2.0 disability scores varied with changes in wound volume (p = 0.03) and total revised photographic wound assessment tool scores (p<0.001), the largest decrease in disability severity was seen in patients with less wound-specific concerns and wound-related discomfort and distress. DISCUSSION: The majority of people at risk of limb loss report suffering a substantial burden of disability, pain, and wound-specific concerns. Research is needed to further evaluate the WHODAS 2.0 in a multicenter fashion among these patients and determine whether care and interventions may improve their PROs.