Pattern of Headache in School Going Children Attending Specialized Clinic in a Tertiary Care Hospital in Bangladesh.

Pattern of headache in school going children attending specialized clinic in a tertiary care hospital in bangladesh.

Filed under: Drug and Alcohol Rehabilitation

Oman Med J. 2012 Sep; 27(5): 383-7
Hoque MA, Rahman KM, Haque B, Chowdhury RN, Khan SU, Hasan AH, Mondol MB, Habib M, Mohammad QD

To determine the pattern of headache and its associated symptoms in school going children.The data of all the school going children attending the Headache Clinic in the Dept. of Neurology, Dhaka Medical College Hospital were retrospectively reviewed. A total of 1021 patients from October 1996 to September 2011 were selected. Data were collected through a predesigned questionnaire containing information on age, sex, social status, clinical features, opthalmoscopic findings, management, and in selected cases imaging results.The mean age of headache in school children was 12.6±1.08 years with relatively older age of presentation among girls. The sex ratio was 1.64:1 in favor of girls at older age. Tension type headache (71.1%) was the most common form of headache, followed by migraine (18.4%) and mixed headache (6.7%). Though the girls had more frequent headache of both tension type (59.4%) and migraine (68.1%) variety, the latter was significantly associated in girls (p<0.001). Headache was of moderate severity in 53.3%, whereas severe headache was experienced by 19.9% of the children. The children commonly had nausea and/or vomiting (47.2%), as well as photophobia (24.7%) with headache. Mental stress (34%) and sunlight (30.9%) were common triggering factors whereas a sound sleep relieved headache in the majority (59.4%). Paracetamol (83.3%) and nortryptyline (62.8%) were the most commonly prescribed drug taken by them.Headache is a major health problem in school children, apart from other common health issues at this age. With increasing age, the girls more commonly suffer not only from migraine but also with other chronic headache. The direct causal association is yet to be determined. HubMed – drug


Epilepsy care in ontario: an economic analysis of increasing access to epilepsy surgery.

Filed under: Drug and Alcohol Rehabilitation

Ont Health Technol Assess Ser. 2012; 12(18): 1-41
Bowen JM, Snead OC, Chandra K, Blackhouse G, Goeree R

In August 2011 a proposed epilepsy care model was presented to the Ontario Health Technology Advisory Committee (OHTAC) by an Expert Panel on a Provincial Strategy for Epilepsy Care in Ontario. The Expert Panel recommended leveraging existing infrastructure in the province to provide enhanced capacity for epilepsy care. The point of entry for epilepsy care and the diagnostic evaluation for surgery candidacy and the epilepsy surgery would occur at regional and district epilepsy centres in London, Hamilton, Toronto, and Ottawa and at new centres recommended for northern and eastern Ontario. This economic analysis report was requested by OHTAC to provide information about the estimated budgetary impact on the Ontario health care system of increasing access to epilepsy surgery and to examine the cost-effectiveness of epilepsy surgery in both children and adults.A prevalence-based “top-down” health care system budgetary impact model from the perspective of the Ministry of Health and Long-Term Care was developed to estimate the potential costs associated with expanding health care services to increase access to epilepsy care in general and epilepsy surgery in particular. A 5-year period (i.e., 2012-2016) was used to project annual costs associated with incremental epilepsy care services. Ontario Health Survey estimates of epilepsy prevalence, published epilepsy incidence data, and Canadian Census results for Ontario were used to approximate the number of individuals with epilepsy in the province. Applying these population estimates to data obtained from a recent field evaluation study that examined patterns of care and costs associated with epilepsy surgery in children, a health care system budget impact was calculated and the total costs and incremental costs associated with increasing access to surgery was estimated. In order to examine the cost-effectiveness of epilepsy surgery in children, a decision analysis compared epilepsy surgery to continued medical management in children with medically intractable epilepsy. Data from the field evaluation were combined with various published data to estimate the costs and outcomes for children with drug-refractory epilepsy over a 20-year period. Outcomes were defined as the number of quality-adjusted life years (QALYs) accumulated over 20 years following epilepsy surgery.There are about 20,981 individuals with medically intractable epilepsy in Ontario. Of these, 9,619 (1,441 children and 8,178 adults) could potentially be further assessed at regional epilepsy centres for suitability for epilepsy surgery, following initial evaluation at a district epilepsy care centre. The health care system impact analysis related to increasing access to epilepsy surgery in the Ontario through the addition of epilepsy monitoring unit (EMU) beds with video electroencephalography (vEEG) monitoring (total capacity of 15 pediatric EMU beds and 35 adult EMU beds distributed across the province) and the associated clinical resources is estimated to require an incremental $ 18.1 million (Cdn) annually over the next 5 years from 2012 to 2016. This would allow for about 675 children and 1050 adults to be evaluated each year for suitability for epilepsy surgery representing a 150% increase in pediatric epilepsy surgery evaluation and a 170% increase in adult epilepsy surgery evaluation. Epilepsy surgery was found to be cost-effective compared to continued medical management in children with drug-refractory epilepsy with the incremental cost-effectiveness ratio of $ 25,020 (Cdn) to $ 69,451 (Cdn) per QALY for 2 of the scenarios examined. In the case of choosing epilepsy surgery versus continued medical management in children known to be suitable for surgery, the epilepsy surgery was found to be less costly and provided greater clinical benefit, that is, it was the dominant strategy.Epilepsy surgery for medically intractable epilepsy in suitable candidates has consistently been found to provide favourable clinical outcomes and has been demonstrated to be cost-effective in both adult and child patient populations. The first step to increasing access to epilepsy surgery is to provide access to evidence-based care for all patients with epilepsy, both adults and children, through the provision of resources to expand EMU bed capacity and associated clinical personnel across the province of Ontario. PLAIN LANGUAGE SUMMARY: Epilepsy, characterized by recurrent, unpredictable, and spontaneous seizures, affects approximately 70,000 people in Ontario. About 30% continue to suffer from seizures despite using 2 or more anti-seizure medications. For these individuals epilepsy surgery is a treatment option to stop the seizures or at least reduce their frequency. Awareness of this treatment option is not widespread and people are not commonly referred to those hospitals in Ontario where this surgery is available. A proposal to increase access to epilepsy care and surgery has been made by an expert committee that provided a report to the Ontario Health Technology Advisory Committee (OHTAC). In order to address the lack of access of patients with medically intractable epilepsy to the possibility of curative surgical treatment, it is necessary to design a system that provides equal availability of evidence-based treatment for all epilepsy patients in Ontario, both adults and children. To this end, the establishment of district epilepsy care centres and the further development of the existing regional epilepsy care centres in the province have been proposed. This report outlines the estimated additional funds that will be required to implement the proposal. It also examines the cost-effectiveness of referral to these centres and epilepsy surgery. For the 21,000 people in the province with drug-refractory epilepsy, referral to an epilepsy monitoring unit (EMU) located at one of the epilepsy care centres is the first step to determining if epilepsy surgery is an option for them. The expert committee proposal suggests that the number of EMU beds be increased from the current 19 to 50 to allow for the assessment of those individuals with drug-refractory epilepsy. The health care system budget impact model presented in this report estimates that it would cost approximately $ 18 million (Cdn) each year over the next 5 years to increase the number of EMU beds and expand associated epilepsy care centres to permit the systematic evidence-based care of all Ontarians with epilepsy and evaluate more people for surgery candidacy. This amount would provide appropriate care for patients with epilepsy and ensure that about 675 children and 1050 adults could be assessed each year for suitability for epilepsy surgery. Surgery could then be made available to just over 300 people per year. Epilepsy surgery over the long term is a less expensive treatment alternative for adults and children with medically refractory epilepsy compared with continued drug treatment. In addition, drug treatment does not always work for some patients; nor does it necessarily provide improved quality of life. This report includes a cost-effectiveness analysis comparing referral for assessment for epilepsy surgery with continuing medical management in children with drug-refractory epilepsy. In all the cases examined epilepsy surgery provides good value for money over a 20-year period. Similar studies have found that the benefits from epilepsy surgery outweigh those of continuing medical management in adult patients with medically refractory epilepsy.
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Epilepsy surgery: an evidence summary.

Filed under: Drug and Alcohol Rehabilitation

Ont Health Technol Assess Ser. 2012; 12(17): 1-28

The Medical Advisory Secretariat, the predecessor of Health Quality Ontario, published an evidence-based analysis on functional brain imaging. This analysis highlighted the low uptake of epilepsy surgery in Ontario and internationally.The objective of this analysis was to review the effectiveness of epilepsy surgery at reducing seizure frequency, as well as the safety of epilepsy surgery.The literature search included studies published between January 1995 and March 2012. Search terms included epilepsy, surgery, resection, safety, and complications.Studies were eligible for inclusion if they included at least 20 patients undergoing surgery; had a comparison group of patients with epilepsy who were not undergoing surgery; and reported follow-up periods of at least 1 year. Outcomes of interest included seizure frequency and complications associated with surgery.Six systematic reviews reported pooled seizure-free rates that ranged from 43% to 75%. Two randomized controlled trials compared the effectiveness of epilepsy surgery with no surgery in patients with drug-refractory epilepsy. Both trials reported significant improvements in the seizure frequency in the surgery group compared with the nonsurgery group. Eight retrospective cohort studies reported on the safety of epilepsy surgery. Of the 2,725 patients included in these studies, there were 3 deaths reportedly related to surgery. Other complications included hemiparesis, infection, and visual field defects. The studies had long follow-up periods ranging from a mean of 2 to 7 years.The most recent randomized controlled trial was stopped early due to slow enrolment rates. Thus results need to be interpreted with caution.There is high quality evidence that epilepsy surgery is effective at reducing seizure frequency. Two randomized controlled trials compared surgery to no surgery in patients with drug-refractory epilepsy. Both demonstrated significant reductions in seizure frequency. There are some complications associated with epilepsy surgery. In the published literature identified, we observed a 0.1% mortality rate associated with the surgery. PLAIN LANGUAGE SUMMARY: About 30% of patients with epilepsy continue to have seizures despite optimal drug treatment. In some of these patients, surgery to control the number of seizures may be an option. Patients are carefully selected based on frequency of seizures, location of seizure in the brain, and type of seizures. There is good evidence to indicate that surgery is an effective and safe option for some patients with drug-refractory epilepsy.
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Multiple intravenous infusions phase 1b: practice and training scan.

Filed under: Drug and Alcohol Rehabilitation

Ont Health Technol Assess Ser. 2012; 12(16): 1-132
Cassano-Piché A, Fan M, Sabovitch S, Masino C, Easty A,

Minimal research has been conducted into the potential patient safety issues related to administering multiple intravenous (IV) infusions to a single patient. Previous research has highlighted that there are a number of related safety risks. In Phase 1a of this study, an analysis of 2 national incident-reporting databases (Institute for Safe Medical Practices Canada and United States Food and Drug Administration MAUDE) found that a high percentage of incidents associated with the administration of multiple IV infusions resulted in patient harm.The primary objectives of Phase 1b of this study were to identify safety issues with the potential to cause patient harm stemming from the administration of multiple IV infusions; and to identify how nurses are being educated on key principles required to safely administer multiple IV infusions.A field study was conducted at 12 hospital clinical units (sites) across Ontario, and telephone interviews were conducted with program coordinators or instructors from both the Ontario baccalaureate nursing degree programs and the Ontario postgraduate Critical Care Nursing Certificate programs. Data were analyzed using Rasmussen’s 1997 Risk Management Framework and a Health Care Failure Modes and Effects Analysis.Twenty-two primary patient safety issues were identified with the potential to directly cause patient harm. Seventeen of these (critical issues) were categorized into 6 themes. A cause-consequence tree was established to outline all possible contributing factors for each critical issue. Clinical recommendations were identified for immediate distribution to, and implementation by, Ontario hospitals. Future investigation efforts were planned for Phase 2 of the study.This exploratory field study identifies the potential for errors, but does not describe the direct observation of such errors, except in a few cases where errors were observed. Not all issues are known in advance, and the frequency of errors is too low to be observed in the time allotted and with the limited sample of observations.The administration of multiple IV infusions to a single patient is a complex task with many potential associated patient safety risks. Improvements to infusion and infusion-related technology, education standards, clinical best practice guidelines, hospital policies, and unit work practices are required to reduce the risk potential. This report makes several recommendations to Ontario hospitals so that they can develop an awareness of the issues highlighted in this report and minimize some of the risks. Further investigation of mitigating strategies is required and will be undertaken in Phase 2 of this research. PLAIN LANGUAGE SUMMARY: Patients, particularly in critical care environments, often require multiple intravenous (IV) medications via large volumetric or syringe infusion pumps. The infusion of multiple IV medications is not without risk; unintended errors during these complex procedures have resulted in patient harm. However, the range of associated risks and the factors contributing to these risks are not well understood. Health Quality Ontario’s Ontario Health Technology Advisory Committee commissioned the Health Technology Safety Research Team at the University Health Network to conduct a multi-phase study to identify and mitigate the risks associated with multiple IV infusions. Some of the questions addressed by the team were as follows: What is needed to reduce the risk of errors for individuals who are receiving a lot of medications? What strategies work best? The initial report, Multiple Intravenous Infusions Phase 1a: Situation Scan Summary Report, summarizes the interim findings based on a literature review, an incident database review, and a technology scan. The Health Technology Safety Research Team worked in close collaboration with the Institute for Safe Medication Practices Canada on an exploratory study to understand the risks associated with multiple IV infusions and the degree to which nurses are educated to help mitigate them. The current report, Multiple Intravenous Infusions Phase 1b: Practice and Training Scan, presents the findings of a field study of 12 hospital clinical units across Ontario, as well as 13 interviews with educators from baccalaureate-level nursing degree programs and postgraduate Critical Care Nursing Certificate programs. It makes 9 recommendations that emphasize best practices for the administration of multiple IV infusions and pertain to secondary infusions, line identification, line set-up and removal, and administering IV bolus medications. The Health Technology Safety Research Team has also produced an associated report for hospitals entitled Mitigating the Risks Associated With Multiple IV Infusions: Recommendations Based on a Field Study of Twelve Ontario Hospitals, which highlights the 9 interim recommendations and provides a brief rationale for each one.
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