Evaluating the Impact of a Training Program in Shared Decision-Making for Neurologists Treating People with Migraine.

INTRODUCTION: Migraine symptoms vary significantly between patients and within the same patient. Currently, an increasing number of therapeutic options are available for symptomatic and preventive treatment. Guidelines encourage physicians to use shared decision-making (SDM) in their practice, listening to patients' treatment preferences in order to select the most suitable and effective therapy. Although training for healthcare professionals could increase their awareness of SDM, results concerning its effectiveness are inconclusive. This study aimed to analyze the impact of a training activity to promote SDM in the context of migraine care. This was addressed by evaluating the impact on patients' decisional conflict (main objective), patient-physician relationship, neurologists' perceptions of the training and patient's perception of SDM. METHODS: A multicenter observational study was conducted in four highly specialized headache units. The participating neurologists received SDM training targeting people with migraine in clinical practice to provide techniques and tools to optimize physician-patient interactions and encourage patient involvement in SDM. The study was set up in three consecutive phases: control phase, in which neurologists were blind to the training activity and performed the consultation with the control group under routine clinical practice; training phase, when the same neurologists participated in the SDM training; and SDM phase, in which these neurologists performed the consultation with the intervention group after the training. Patients in both groups with a change of treatment assessment during the visit completed the Decisional conflict scale (DCS) after the consultation to measure the patient's decisional conflict. Also, patients answered the patient-doctor relationship questionnaire (CREM-P) and the 9-item Shared Decision-Making Questionnaire (SDM-Q-9). The mean ± SD scores obtained from the study questionnaires were calculated for both groups and compared to determine whether there were significant differences (p < 0.05). RESULTS: A total of 180 migraine patients (86.7% female, mean age of 38.5 ± 12.3 years) were included, of which 128 required a migraine treatment change assessment during the consultation (control group, n = 68; intervention group, n = 60). A low decisional conflict was found without significant differences between the intervention (25.6 ± 23.4) and control group (22.1 ± 17.9; p = 0.5597). No significant differences in the CREM-P and SDM-Q-9 scores were observed between groups. Physicians were satisfied with the training and showed greater agreement with the clarity, quality and selection of the contents. Moreover, physicians felt confident communicating with patients after the training, and they applied the techniques and SDM strategies learned. CONCLUSION: SDM is a model currently being actively used in clinical practice for headache consultation, with high patient involvement in the process. This SDM training, while useful from the physician's perspective, may be more effective at other levels of care where there is still room for optimization of patient involvement in decision-making.

Impact of COVID-19 in nutritional and functional status of survivors admitted in intensive care units during the first outbreak. Preliminary results of the NUTRICOVID study.

BACKGROUND & AIMS: COVID-19 patients present a high hospitalization rate with a high mortality risk for those requiring intensive care. When these patients have other comorbid conditions and older age, the risk for severe disease and poor outcomes after ICU admission are increased. The present work aims to describe the preliminary results of the ongoing NUTRICOVID study about the nutritional and functional status and the quality of life of adult COVID-19 survivors after ICU discharge, emphasizing the in-hospital and discharge situation of this population. METHODS: A multicenter, ambispective, observational cohort study was conducted in 16 public hospitals of the Community of Madrid with COVID-19 survivors who were admitted to the ICU during the first outbreak. Preliminary results of this study include data retrospectively collected. Malnutrition and sarcopenia were screened at discharge using MUST and SARC-F; the use of healthcare resources was measured as the length of hospital stay and requirement of respiratory support and tracheostomy during hospitalization; other study variables were the need for medical nutrition therapy (MNT); and patients' functional status (Barthel index) and health-related quality of life (EQ-5D-5L). RESULTS: A total of 176 patients were included in this preliminary analysis. Most patients were male and older than 60 years, who suffered an average (SD) weight loss of 16.6% (8.3%) during the hospital stay, with a median length of stay of 53 (27-89.5) days and a median ICU stay of 24.5 (11-43.5) days. At discharge, 83.5% and 86.9% of the patients were at risk of malnutrition and sarcopenia, respectively, but only 38% were prescribed MNT. In addition, more than 70% of patients had significant impairment of their mobility and to conduct their usual activities at hospital discharge. CONCLUSIONS: This preliminary analysis evidences the high nutritional and functional impairment of COVID-19 survivors at hospital discharge and highlights the need for guidelines and systematic protocols, together with appropriate rehabilitation programs, to optimize the nutritional management of these patients after discharge.

[In-hospital stroke: clinical profile and expectations for treatment]. / Accidentes cerebrovasculares intrahospitalarios: perfil clínico y expectativas terapéuticas.

INTRODUCTION: In-hospital strokes have been poorly reported. They provide an opportunity to shorten intervals for thrombolysis. Our proposals were: a) to describe their clinical features and neurological assessment, and b) regarding thrombolysis, to analyze potential candidates and exclusions at a general tertiary hospital, just before its approval/implementation at the center. METHODS: Cases were retrospectively recruited between May 2001-May 2004. They were identified from discharching diagnosis (ICD-9: 430-439; GRD: 14, 15, 16, 17, 532, 810) and from consultations required to the neurology service. Data collected were: a) admitting diagnosis and service; b) mechanism of stroke (Trial of Org 10172 in Acute Stroke Treatment, TOAST) and clinical syndrome (Oxfordshire Community Stroke Project, OCSP); c) vascular risk factors and previous symptomatic artherioesclerotic disease (PSAD), and d) prognosis, functional status at discharge (mRankin scale, mRS) and timing for neurological assessment. Every case was considered regarding thrombolytic treatment according to Safe Implementation of Trombolysis in Stroke-Monitoring Study (SIST-MOST) criteria. Potential criteria for exclusion were registered. RESULTS: 183 cases were included (26 transient ischemic accident, 149 ischemic strokes, 5 haemorrhages). Mean age: 74.5 years, 25.5%, above 80 years. Main sources of patients were cardiology plus related services (31.8%) and internal medicine (18%). Dominant mechanism was cardioembolism (40%). 18 cases (11.77%) were yatrogenic. 55.8% had had PSAD (stroke: 41; ischemic cardiopathy: 31). Mortality reached 33%. 36% were discharged pointing 3 or above in the mRS. Expert neurological assessment was requested in 89%, but just for 25% it was considered an emergency. From 149 ischemic strokes, 5 cases (3.2%) were potential candidates for thrombolysis. Mayor surgery, ageing (>80 years), severe acute disorders or combinations of them precluded thrombolysis. CONCLUSIONS: In-hospital strokes are particularly prevalent in patients with PSAD. Prognosis is poor. In 3.2% thrombolysis could be administered. To make this possible, a right perception of the timing and emergency should be encouraged among hospital staff.

Accidentes cerebrovasculares intrahospitalarios: perfil clínico y expectativas terapéuticas / The cost of neurological disease

Introducción. Los ictus intrahospitalarios han sido poco descritos. Son una oportunidad única para acortar los intervalos de trombólisis. Nos proponemos: a) describir sus rasgos clínicos y de valoración neurológica, y b) analizar en un hospital general terciario los casos potenciales y las exclusiones de fibrinólisis, justamente antes de su aprobación e implementación en el centro. Métodos. Casos recogidos de modo retrospectivo entre mayo de 2001 y mayo de 2004, identificados desde el archivo del hospital (CIE-9: 430-439; GRD: 14, 15, 16, 17, 532, 810) y a partir de interconsultas del servicio de neurología. Incluimos: a) procedencia y diagnóstico; b) mecanismo (Trial of Org 10172 in Acute Stroke Treatment, TOAST) y síndrome clínico (Escala Oxfordshire Community Stroke Project, OCSP); c) factores de riesgo vascular y enfermedad arterioesclerótica sintomática previa (EASP), y d) pronóstico, situación funcional al alta (escala de Rankin modificada, mRS) e intervalos de evaluación neurológica. Cada caso fue valorado según criterios SIST-MOST (registro europeo para monitorizar la seguridad del tratamiento trombolítico en el ictus-SIST-MOST) para tratamiento trombolítico. Resultados. Incluimos 183 casos (26 TIA, 149 ictus isquémicos y 5 hemorragias). Edad media: 70,1 años; 25%, >80 años. La procedencia más frecuente fue cardiología y servicios afines (31,8%), seguida de medicina interna (18%). El mecanismo dominante fue el cardioembólico (40 %). En 18 casos (11,77 %) fueron yatrogénicos. El 55,8 % habían sufrido EASP (ictus: 41; cardiopatía isquémica: 31). La mortalidad alcanzó el 33%. El 36% puntuaron ≥ 3 en la mRS al alta. Se solicitó valoración neurológica en el 89 %; en el 25% se hizo como urgente. De 149 ictus isquémicos, 5 casos (3,2%) eran candidatos potenciales a trombólisis. La cirugía invasiva, edad mayor de 80 años, enfermedades agudas graves o combinaciones fueron los factores de exclusión más frecuentes. Conclusiones. Los ictus intrahospitalarios son especialmente prevalentes en pacientes con EASP. Tienen mal pronóstico. El 3,2 % pueden ser tratados con fibrinólisis, aunque se requiere una mejor percepción de la urgencia y de los tiempos entre el personal hospitalario

Introduction. In-hospital strokes have been poorly reported. They provide an opportunity to shorten intervals for thrombolysis. Our proposals were: a) to describe their clinical features and neurological assesment, and b) regarding thrombolysis, to analyze potential candidates and exclusions at a general tertiary hospital, just before its approval/implementation at the center. Methods. Cases were retrospectively recruited between May 2001-May 2004. They were identified from discharching diagnosis (ICD-9: 430-439; GRD: 14, 15, 16, 17, 532, 810) and from consultations required to the neurology service. Data collected were: a) admitting diagnosis and service; b) mechanism of stroke (Trial of Org 10172 in Acute Stroke Treatment, TOAST) and clinical syndrome (Oxfordshire Community Stroke Project, OCSP); c) vascular risk factors and previous symptomatic artherioesclerotic disease (PSAD), and d) prognosis, functional status at discharge (mRankin scale, mRS) and timing for neurological assesment. Every case was considered regarding thrombolytic treatment accoding to Safe Implementation of Trombolysis in Stroke-Monitoring Study (SIST-MOST) criteria. Potential criteria for exclusion were registered. Results. 183 cases were included (26 transient ischemic accident, 149 ischemic strokes, 5 haemorrhages). Mean age: 74.5 years, 25.5 %, above 80 years. Main sources of patients were cardiology plus related services (31.8%) and internal medicine (18%). Dominant mecha-nism was cardioembolism (40%). 18 cases (11.77%) were yatrogenic. 55.8% had had PSAD (stroke: 41; ischemic cardiopahty: 31). Mortality reached 33%. 36% were discharged pointing 3 or above in the mRS. Expert neurological assesment was requested in 89%, but just for 25% it was considered an emergency. From 149 ischemic strokes, 5 cases (3.2 %) were potential candidates for thrombolysis. Mayor surgery, ageing (>80 years), severe acute disorders or combinations of them precluded thrombolysis. Conclusions. In-hospital strokes are particularly prevalent in patients with PSAD. Prognosis is poor. In 3.2% thrombolysis could be administered. To make this possible, a right perception of the timing and emergency should be encouraged among hospital staff

[Risk of the development of dementia after interruption of zidovudine treatment]. / Riesgo de desarrollo de demencia tras la interrupción de un tratamiento con zidovudina.

BACKGROUND: Epidemiologic data suggest that zidovudine (ZDV) could prevent the AIDS dementia complex (ADC), but this hypothesis has been specifically studied. PATIENTS AND METHODS: We have reviewed the medical records of all patients with human immunodeficiency virus (HIV) infection admitted to our section between January 1990 and December 1993 who were diagnosed with ADC, and we have compared them to those of a control group with regard to the interruption of ZDV at least 3 months before. Controls were selected from the remaining HIV-related admissions, matched by calendar year, CD4-cell count and previous HIV-disease stage. RESULTS: Thirty-nine cases and 39 controls were available for analysis; twenty-nine (74%) and 25 (64%) were male. The median age was similar for both groups: 30. Thirty-one patients (79%) in each group had a previous diagnosis of AIDS, six (15%) in each group had an AIDS-related complex and in two (5%) the ADC was the first complication of their HIV disease. The median CD4-cell counts were 79.6 and 79.4 x 10(6)/l. Twenty-three patients in each group had taken ZDV. Six of these from the ADC had withdrawn treatment, as compared to 2 from the control group (odds ratio [OR] 3.36; 95% confidence interval [CI]: 0.54-35.76). On the other hand, 16 patients with ADC were still on ZDV at the time of diagnosis, as compared to 21 controls (OR: 0.66; 95% CI: 0.22-1.60). CONCLUSION: In this case-control study, the interruption of treatment with ZDV was not found to be a risk factor for the development of ADC.