Shashi S. Seshia

Chronic daily headache in children and adolescents.

OBJECTIVE Characterize chronic daily headache in those less than 20 years of age. MATERIAL AND METHODS STUDY DESIGN Prospective, observational, and sequential. SETTING Private practice Pediatric Neurology Clinic in a Canadian city (Winnipeg). Patients and data collection: Data on those referred with headache between September 1998 and December 2001 were entered on data sheets. Patients were followed up for one month to four years. RESULTS One hundred and forty-three (31%) of 463 referred with headache had chronic daily headache with duration of one month to five years (median: eight months). The age range was 5.5 years to 20 years (median: 13 years). There were significantly more females (N=93) than males (N=50). The main groups were: (1) transformed migraine: 6 (4%), (2) transformed tension-type headache: 80 (56%) and (3) transformed comorbid migraine and tension-type headache: 39 (27%). Tension-type features dominated in 94%. Analgesia overuse occurred in two. Stressors were recognized in 60 (42%); anxiety disorder was diagnosed in 8 (6%), and depression in 13 (9%). Computed tomography scans were done in 31 (22%), and MRI/MR angiography in 8 (6%) and were normal or showed nonspecific incidental findings. Twenty-two (15%) were lost to follow-up; 115 of the remaining 121 (95%) were headache free or greatly improved, 63 (55%) without specific treatment. CONCLUSIONS Chronic daily headache is a common headache disorder in children and adolescents, especially in teenage girls. A prospective neuropsychiatric approach is necessary for evidenced-based management, since the condition has mental health, social and economic ramifications.

Chronic Daily Headache in Children and Adolescents: A Multi-Faceted Syndrome

Chronic daily headache (CDH) is a multi-faceted, often complex pain syndrome in children and adolescents. Chronic daily headache may be primary or secondary. Chronic migraine and chronic tension-type are the most frequent subtypes. Chronic daily headache is co-morbid with adverse life events, anxiety and depressive disorders, possibly with other psychiatric disorders, other pain syndromes and sleep disorders; these conditions contribute to initiating and maintaining CDH. Hence, early management of episodic headache and treatment of associated conditions are crucial to prevention. There is evidence for the benefit of psychological therapies, principally relaxation and cognitive behavioral, and promising information on acupuncture for CDH. Data on drug treatment are based primarily on open label studies. The controversies surrounding CDH are discussed and proposals for improvement presented. The multifaceted nature of CDH makes it a good candidate for a multi-axial classification system. Such an approach should facilitate biopsychosocial management and enhance consistency in clinical research.

The classification of chronic headache: room for further improvement?

In this commentary, the authors briefly discuss their views on some of the limitations in the current terminology and classification of chronic headache. Suggestions for consideration and further debate include the acceptance of chronic daily headache as the umbrella term for this group of headache disorders, a more consistent definition of ‘chronic’ and the use of a multi-axial classification approach.

Evidence-informed person-centred health care (part II): are 'cognitive biases plus' underlying the EBM paradigm responsible for undermining the quality of evidence?

Introduction Recently, some leaders of the evidence-based medicine (EBM) movement drew attention to the “unintended” negative consequences associated with EBM. The term ‘cognitive biases plus’ was introduced in part I to encompass cognitive biases, conflicts of interests, fallacies and certain behaviours. Hypothesis ‘Cognitive biases plus’ in those closely involved in creating and promoting the EBM paradigm are responsible for their (1) inability to anticipate and then recognize flaws in the tenets of EBM; (2) discounting alternative views; and (3) delaying reform. Methods A narrative review style was used, with methods as in part I. Appraisal of literature Over the past two decades there has been mounting qualitative and quantitative methodological evidence to suggest that the faith placed in (1) the EBM hierarchy with randomized controlled trials and systematic reviews at the summit; (2) the reliability of biostatistical methods to quantitate data; and (3) the primacy of sources of pre-appraised evidence, is seriously misplaced. Consequently, the evidence that informs person-centred care is compromised. Discussion Arguments focusing on ‘cognitive biases plus’ are offered to support our hypothesis. To the best of our knowledge, EBM proponents have not provided an explanation. Conclusions Reform is urgently needed to minimize continuing risks to patients. If our hypothesis is correct, then in addition to the suggestions made in part I, deficiencies in the paradigm must be corrected. Meaningful solutions are only possible if the biases of scientific inbreeding and groupthink are minimized by collaboration between EBM leaders and those who have been sounding warning bells.

Inter-Observer Agreement in Assessing Comatose Children

Inter-observer agreement was evaluated for twelve items used in the neurological assessment of comatose children. Data were obtained prospectively on fifteen patients examined independently by two observers in a double-blind fashion. Observer variability was measured by using the Disagreement Rate and Kappa statistic. The Disagreement Rate ranged from 0.01 to 0.12 for all items. Values for Kappa statistic were generally in accordance with those for Disagreement Rate. The data suggest fair to almost perfect inter-observer agreement for the items used to assess comatose children in this study.

'Cognitive biases plus': covert subverters of healthcare evidence.

The evidence-based medicine (EBM) paradigm has been associated with many benefits, but there have also been ‘some negative consequences’. In part, the consequences may be attributable to: (1) limitations in some of the tenets of EBM, and (2) flawed or unethical decisions in healthcare related organisations. We hypothesise that at the core of both is a cascade of predominantly unconscious cognitive processes we have syndromically termed ‘cognitive biases plus’, with conflicts of interest (CoIs) as crucial elements. CoIs (financial, and non-financial including intellectual) catalyse self-serving bias and a cascade of other ‘cognitive biases plus’ with several reinforcing loops. Authority bias, herd effect, scientific inbreeding, replication publication biases, and ethical violations (especially subtle statistical), are key contributors to the cascade; automation biases through uncritical use of statistical software and applications (apps) of preappraised sources of evidence at point of care, may be other increasingly important factors. The ‘cognitive biases plus’ cascade which involves several intricately connected healthcare-related organisations has the potential to facilitate, compound and entrench flaws in the paradigm, evidence and decisions that converge to inform person-centered healthcare. Our reasoning is based on observational data and opinion. However, the susceptibility of all humans to ‘cognitive biases plus’ makes our hypothesis plausible. Individual and collective fallibility may be minimised and the quality of healthcare decisions (including those related to improving EBM) enhanced by being conscious of our vulnerability and open-minded to the ‘outside view’.

Mixed migraine and tension-type: a common cause of recurrent headache in children.

OBJECTIVE Determine relative frequency of recurrent headache (HA) types in children and adolescents referred to a pediatric neurologist. METHODS AND SUBJECTS STUDY DESIGN Prospective, sequential, and observational. SETTING Private practice Pediatric Neurology Clinic in a Canadian city (Winnipeg). Patients and data collection: Information on those referred with HA between September 1998 and December 2001 was entered on data sheets. Patients were followed up for one month to four years. RESULTS Three hundred and twenty (69%) of 463 referred with HA had recurrent HA. There were 172 males (54%) and 148 (46%) females. Their ages ranged from two years to 19 years (median: 11 years). They had had their HA disorder for one month to 14 years (median: two years) prior to assessment. Migraine was the main HA type in 124 (38%), tension-type headache (TTH) in 57 (18%) and mixed migraine and TTH in 101 (32%). Thus, 101 (45%) of 225 with migraine as one HA type also had TTH. CONCLUSIONS Tension-type headache and migraine frequently co-exist and may represent a distinct headache type, at least in children; the association will likely influence response of affected children and adolescents to specific migraine treatments in clinical trials or practice.

Nontraumatic Coma in Children and Adolescents: Diagnosis and Management

The causes of nontraumatic coma (NTC) vary by country, season and period of data collection. Infective diseases are among the major worldwide causes of NTC. Nonaccidental head injury must be in the differential diagnosis. Genetic and ethnic susceptibilities to causes of coma are being recognized. A systematic history and examination are essential for diagnosis, early recognition of herniation syndromes, and management. The management of NTC is discussed, with reference to clinical approach, treatment of seizures, and increased intracranial pressure. Public health measures, education, early diagnosis, and prompt appropriate treatment are the foundations needed to reduce incidence and improve outcome.

Coma in Childhood

Publisher Summary Coma is an important and common clinical problem in pediatric practice. The comatose state in children results from trauma or a wide variety of nontraumatic causes. It is clinically useful to classify causes into (1) those generally associated with structural changes in the brain and (2) those with predominant metabolic dysfunction. The metabolic causes of coma can be associated with structural changes in the brain. The assessment and management of a child in coma requires a multidisciplinary coordinated team approach with each member of the team being assigned a specific responsibility especially when coma is complicated by poor cardiorespiratory function, shock, or status epilepticus, and all of them must be rapidly addressed. Investigations have to be tailored to the individual case and the clinicians diagnostic considerations. Tests for infection (sepsis, meningitis, and encephalitis) include toxicology screen, neuroimaging, conventional electroencephalogram (EEG), continuous EEG monitoring, and serum biomarkers. Those who have suffered a metabolic or toxic encephalopathy have a good outcome provided the secondary effects of the cause are minimized and systemic complications avoided. Several advances have improved our understanding and management of coma in children. These include recognition of a number of inborn errors of metabolism, progress in the prevention, diagnosis, and treatment of infective diseases, prevention of head trauma, magnetic resonance imaging (MRI), and an emerging consensus on the management of raised intracranial pressure (ICP).

Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety

Abstract Introduction Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care–related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement. Hypothesis A model integrating the concepts underlying Reasons Swiss cheese theory and the cognitive‐affective biases plus cascade could advance the understanding of cognitive‐affective processes that underlie decisions and organizational cultures across the continuum of care. Methods Thematic analysis, qualitative information from several sources being used to support argumentation. Discussion Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive‐affective (mental) gates: Reasons successive layers of defence. Like firewalls and antivirus programs, cognitive‐affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive‐affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error‐provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error‐provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive‐affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions. Limitations The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect. Conclusions The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.