Factors Associated With, and Mitigation Strategies for, Health Care Disparities Faced by Patients With Headache Disorders

OBJECTIVE

To review contemporary issues of health care disparities in headache medicine with regard to race/ethnicity, socioeconomic status (SES), and geography and propose solutions for addressing these disparities.

METHODS

An Internet and PubMed search was performed and literature was reviewed for key concepts underpinning disparities in headache medicine. Content was refined to areas most salient to our goal of informing the provision of equitable care in headache treatment through discussions with a group of 16 experts from a range of headache subspecialties.

RESULTS

Taken together, a multitude of factors, including racism, SES, insurance status, and geographical disparities, contribute to the inequities that exist within the health care system when treating headache disorders. Interventions such as improving public education, advocacy, optimizing telemedicine, engaging in community outreach to educate primary care providers, training providers in cultural sensitivity and competence and implicit bias, addressing health literacy, and developing recruitment strategies to increase representation of underserved groups within headache research are proposed as solutions to ameliorate disparities.

CONCLUSION

Neurologists have a responsibility to provide and deliver equitable care to all. It is important that disparities in the management of headache disorders are identified and addressed.

Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and description

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

The development of a diversity, equity, and inclusion committee in a neurology department and residency program

BACKGROUND

Diversity, Equity, and Inclusion (DEI) initiatives have been described in different academic and graduate medical education settings, but not specifically in neurology.

OBJECTIVE

To describe the development of a DEI committee within a neurology department and training program.

METHODS

The need to prioritize DEI as a critical focus within our neurology department led to the appointment of an initial task force who identified strategic priorities and stakeholders to establish a committee. DEI committee members included faculty, trainees, and staff, and this phase of the initiative took place from May 2019 through January 2021.

RESULTS

The DEI committee was established and has met monthly for over one year. Initial meetings formulated goals of the initiative. Specific objectives were developed in the domains of recruitment, education, engagement, training, conflict resolution, and recognition. Early outcomes included augmented resident recruitment efforts of UiM students, curriculum changes including frequent representation of DEI topics in Grand Rounds, and measures to reduce unconscious bias.

CONCLUSIONS

The creation of a DEI Committee within a specialty department such as neurology is feasible and can result in immediate and long-term actions related to recruitment and education in particular. Our blueprint that heavily involves graduate medical education stakeholders may be generalizable to other specialty departments in academic medicine.

Migraine in Women

Migraine is one of the most common neurological disorders, affecting women disproportionally at a rate of 3:1. Prior to puberty, boys and girls are equally affected, but the female preponderance emerges after puberty. Migraine pathophysiology is not fully understood, and although the hormonal effect of estrogen is significant, other factors are at play. This article will focus on the hormonal influence on migraine in women. Here we review our most recent understanding of migraine and menstrual migraine, including epidemiology, pathophysiology, and treatment strategies for this challenging disorder, as well as migraine during pregnancy, postpartum period, breastfeeding, perimenopause, and menopause. We also review the risks and benefits of exogenous hormone use in this population and discuss stroke risk in women with migraine aura. By understanding these aspects of migraine in women, we hope to arm practitioners with the knowledge and tools to help guide treatment of this debilitating disorder in this large population.

Serological survey of hepatitis B immunity in healthcare workers in Catalonia (Spain)

Healthcare workers (HCW) are exposed to preventable infectious diseases, notably hepatitis B (HB). The aim of this study was to determine the immunity of HCW against hepatitis B. We made a seroprevalence study using a self-administered survey and obtained blood samples. Antibodies against the HB surface antigen (anti-HBs) and against the HB core antigen (anti-HBc) were studied. The odds ratio (OR) and 95% confidence intervals (CI) were calculated. The adjusted OR were calculated using logistic regression. Of the 644 HCW who participated (29.7% physicians, 38.7% nurses, 13.4% other clinical workers and 18.3% non-clinical workers), 46.4% were primary care workers and 53.6% hospital workers. The overall prevalence of anti-HBs was 64.4%. HCW aged <25 y had a significantly higher prevalence (86.7%) than those aged 35-44 y (adjusted OR 3.40; 95% CI 1.06-10.90). The prevalence of anti-HBc was 4.1%, and increased with age. Significant differences were found for HCW aged >44 y with respect to those aged 25-34 y. 75.6% of HCW stated they were vaccinated, but only 39.3% had a vaccination card. In HCW who stated they were unvaccinated, 10.8% had a vaccinated serological pattern (anti-HBc-negative and anti-HBs -positive). Written, updated vaccination records are essential to reliably determine the vaccination status.

Norovirus: a growing cause of gastroenteritis in catalonia (Spain)?

Infectious acute gastroenteritis (AGE) is a major health problem worldwide. Salmonella is a leading cause of AGE outbreaks, but viruses may be responsible for up to 80% of cases. We compared the frequency and characteristics of AGE out breaks in Catalonia due to norovirus and Salmonella and the changes in these outbreaks from 2000 through 2010. In 2006 through 2010, we also investigated the distribution by season, setting, and implicated food, the incidence rates of cases associated, and the hospitalization rates. Differences in proportions were estimated by Pearson's chi-square test, and the odds ratio (OR) and 95% confidence interval (CI) were calculated. In 2000 through 2010, the number of AGE outbreaks caused by Salmonella decreased and those caused by norovirus significantly increased. From 2006 onward, norovirus was the most common etiology in AGE outbreaks, but in foodborne outbreaks, Salmonella was the more common cause until 2010. The incidence rate per 10(5) inhabitants was greater for norovirus (20.81 versus 3.97, P < 0.001), and the hospitalization rate was lower for norovirus (0.84 versus 4.69, P < 0.001). Salmonella infections occurred more frequently in the warmer months, and norovirus infections were more common in the colder months, both in terms of total outbreaks (OR = 4.50; 95% CI, 2.85 to 7.11; P < 0.001) and foodborne outbreaks (OR = 4.38; 95% CI, 2.42 to 7.95; P < 0.001). Norovirus infections were less common in private homes (OR = 0.08; 95% CI, 0.04 to 0.14; P < 0.001) and more common in nursing homes (P < 0.001) and hospitals or long-term care facilities (OR = 14.09; 95% CI, 3.35 to 59.33; P < 0.001). Foods most frequently implicated in norovirus infection outbreaks were seafood (22% ; OR = 7.89; 95% CI, 2.59 to 24.3; P < 0.001), and those most common in Salmonella infection outbreaks were mayonnaise and similar items (30.2%; OR = 0.05; 95% CI, 0.01 to 0.22; P < 0.001). Foodborne outbreaks in which the vehicle was not identified were more frequent in cases of norovirus infection (OR = 4.59; 95% CI, 2.54 to 8.30; P < 0.001). Our results indicate that norovirus rather than Salmonella is the most common cause of AGE outbreaks in Catalonia. Foodborne AGE outbreaks were more commonly caused by norovirus than by Salmonella only in 2010, the last year of the study.

Quality in the provision of headache care. 2: defining quality and its indicators

The objective of this study was to define “quality” of headache care, and develop indicators that are applicable in different settings and cultures and to all types of headache. No definition of quality of headache care has been formulated. Two sets of quality indicators, proposed in the US and UK, are limited to their localities and/or specific to migraine and their development received no input from people with headache. We first undertook a literature review. Then we conducted a series of focus-group consultations with key stakeholders (doctors, nurses and patients) in headache care. From the findings we proposed a large number of putative quality indicators, and refined these and reduced their number in consultations with larger international groups of stakeholder representatives. We formulated a definition of quality from the quality indicators. Five main themes were identified: (1) headache services; (2) health professionals; (3) patients; (4) financial resources; (5) political agenda and legislation. An initial list of 160 putative quality indicators in 14 domains was reduced to 30 indicators in 9 domains. These gave rise to the following multidimensional definition of quality of headache care: “Good-quality headache care achieves accurate diagnosis and individualized management, has appropriate referral pathways, educates patients about their headaches and their management, is convenient and comfortable, satisfies patients, is efficient and equitable, assesses outcomes and is safe.” Quality in headache care is multidimensional and resides in nine essential domains that are of equal importance. The indicators are currently being tested for feasibility of use in clinical settings.

Hepatitis A outbreaks: the effect of a mass vaccination programme

A Hepatitis A vaccination programme of people belonging to risk groups begun in Catalonia in 1995 and a universal vaccination programme of pre-adolescents 12 years of age with the hepatitis A + B vaccine was added in 1998. The aim of the study was to investigate the characteristics of hepatitis A outbreaks occurring in Catalonia between 1991 and 2007 to determine the associated risk factors and optimize the use of vaccination. Incidence rates of outbreaks, cases and hospitalizations associated with outbreaks and the rate ratios (RR) of person-to-person transmission outbreaks between the periods before and after mass vaccination and their 95% confidence intervals (CI) were calculated. A rate of 2.45 outbreaks per million persons per year was found. The rate of cases affected in these outbreaks was 1.28 per 10(5) persons per year and the rate of hospitalizations was 0.45 per million persons per year. In person-to-person outbreaks, the highest incidence rate (5.26 and 6.33 per million persons per year) of outbreaks according to the age of the index case was in the 5 to 14 year age group in both periods (RR:0.83; 95% CI:0.48-1.43). A significant increase was observed in the 25 to 44 year age group (RR: 0.35; 95% CI 0.14-0.77). Hepatitis A vaccination has made an important impact on burden and characteristics of outbreaks and could provide greater benefits to the community if the vaccine was administrated to children during their first years of life.

Utility of clinical-epidemiological profiles in outbreaks of foodborne disease, Catalonia, 2002 through 2006

The objective of this study was to evaluate the use of clinical-epidemiological profiles for classifying non-laboratory-confirmed outbreaks of foodborne disease (FBD) in Catalonia between 2002 and 2006 and for elucidating associations among factors contributing to these outbreaks. A total of 275 nonfamily outbreaks were studied, of which 190 (69.1%) were laboratory confirmed and 85 (30.9%) were not. In 176 (92.6%) of laboratory-confirmed outbreaks and 69 (81.2%) of non-laboratory-confirmed outbreaks, information was obtained on contributing factors (P = 0.009). In 72% of non-laboratory-confirmed outbreaks, the etiology was assigned by using clinical-epidemiological profiles; thus, 93% of outbreaks eventually were associated with an etiology. In laboratory-confirmed outbreaks, poor personal hygiene was positively associated with norovirus (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.47 to 4.89; P = 0.0007) and negatively associated with Salmonella and Campylobacter (OR, 0.54; 95% CI, 0.33 to 0.89; P = 0.01), and an unsafe source was positively associated with Salmonella and Campylobacter (OR, 4.07; 95% CI, 1.72 to 10.09; P = 0.001) and negatively associated with norovirus (OR, 0.14; 95% CI, 0.04 to 0.58; P = 0.001). No differences were found among contributing factors associated with outbreaks with a laboratory-confirmed etiology and those associated with outbreaks with an etiology assigned according to the clinical-epidemiological profiles. Clinical-epidemiological profiles are useful for determining what prevention and control strategies are appropriate to the agents involved in each community and for designing outbreak investigations.

Differential features of foodborne gastroenteritis outbreaks of known and unknown etiology

Foodborne diseases (FBD) are a major cause of disease and death, but their etiologies are not always known. Factors associated with determination of the etiologic agent of FBD outbreaks reported to the Department of Health in Catalonia (Spain) during 2002 to 2005 were studied. For each outbreak, the year, number of persons affected, hospitalization, and availability of samples from patients, food handlers, and foods were collected. The delay between the date of onset of symptoms of the second case and the report to the surveillance unit was calculated. The relationship between explanatory variables and determination of the cause of each outbreak was studied by logistic regression. The causal agent was identified in 242 (73.3%) of 330 outbreaks. Factors associated with determining the etiologic agent of the outbreak in the univariate analysis were availability of samples from cases (odd ratio [OR] of 6.0, 95% confidence interval [CI] of 3.2 to 11.1), hospitalization (OR of 5.1, 95% CI of 2.6 to 11.1), availability of samples from food handlers (OR of 2.7, 95% CI of 1.6 to 4.5), size > or = 10 cases (OR of 2.2, 95% CI of 1.3 to 3.2), availability of samples from food (OR of 1.8, 95% CI of 1.1 to 3.0), and the last year (2005) of the study period (OR of 1.9, 95% CI of 1.0 to 3.6). In the multivariate analysis, hospitalization (adjusted OR of 5.1, 95% CI of 2.4 to 11.2), size > or = 10 cases (adjusted OR of 2.1, 95% CI of 1.2 to 3.7), and the year 2005 (OR of 2.1, 95% CI of 1.1 to 4.0) remained associated. Collection and processing of clinical samples from cases and appropriate laboratory diagnoses of all possible etiologies of FBD, including viruses, are very important. Efforts by physicians and public health services to coordinate and improve their activity in these areas may help provide more accurate knowledge concerning the etiologies of FBD outbreaks and lead to more effective preventive procedures.

Thunderclap headache as the presenting symptom of myocardial infarction

Headache as the presenting symptom of myocardial ischemia has been reported in more than 20 cases. These headaches have been described as of gradual onset, associated with exertion and with EKG changes. We present herein the first case of thunderclap headache occurring at rest as the sole symptom of an acute myocardial infarction.

Reversible Anorgasmia With Topiramate Therapy for Headache: A Report of 7 Patients

OBJECTIVE

To describe 7 patients who developed new onset anorgasmia while using topiramate therapy for migraine prophylaxis.

BACKGROUND

Topiramate is an effective drug for the prevention of migraine headaches. Though it is generally well tolerated, it may be associated with a dose-related anorgasmia.

METHODS

Case reports.

RESULTS

Seven patients (5 women, 2 men), between the ages of 40 and 62, developed anorgasmia while using topiramate for headache prevention. Four women and 2 men had migraine without aura, and 1 woman had migraine with aura. None had a prior history of anorgasmia or sexual dysfunction. Doses associated with this side effect ranged from 45 to 200 mg daily. All subjects had symptom resolution. Six patients had resolution within 7 days of discontinuing or decreasing the medication; the exact time frame of resolution for the seventh patient is unknown.

CONCLUSION

In our series, anorgasmia was a reversible, dose-related adverse effect of topiramate. Physicians need to be aware of the potential for topiramate to cause sexual side effects, and should inquire about these symptoms in patients for whom this agent has been prescribed.

The use of acetone to dissolve a Styrofoam impaction of the ear

Foreign bodies in the ear occasionally thwart conventional means of removal. Styrofoam can be particularly problematic because it can be compressed and become tightly impacted in an ear canal. Furthermore, Styrofoam is friable and tends to fragment with usual removal methods. We report the case of a 6-year-old girl who was referred from another tertiary care hospital after failed efforts to remove a painfully impacted piece of Styrofoam from her left ear canal. Instillation of the organic solvent acetone into the ear canal was well tolerated and caused rapid and near-complete dissolution of the Styrofoam impaction. This is the first reported case of organic solvent dissolution of an otic foreign body. Ototoxic considerations are discussed as is a method for safe acetone instillation that minimizes the amount of acetone introduced into the ear canal.