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OBJECTIVE: The aim of this review, conducted in April 2020, is to examine available national primary care guidelines for COVID-19 and to explore the ways in which these guidelines support primary care facilities in responding to the demands of the COVID-19 pandemic. DESIGN: Rapid review and narrative synthesis. DATA SOURCES: PubMed, Embase and Google, as well as the websites of relevant national health departments, were searched from 1 January 2020 to 24 April 2020. ELIGIBILITY CRITERIA: Documents included must be issued by a national health authority, must be specific to COVID-19 care, directed at healthcare workers or managers, and must refer to the role of primary care in the COVID-19 response. RESULTS: We identified 17 documents from 14 countries. An adapted framework on primary care challenges and responses to pandemic influenza framed our analysis. Guidelines generally reported on COVID-19 service delivery and mostly made specific recommendations for ensuring continued delivery of essential primary care services through telehealth or other virtual care modalities. Few offered guidance to support surveillance as a public health function. All offered guidance on implementing outbreak control measures, largely through flexible and coordinated organisational models with partners from various sectors. There was a lack of guidance to support supply chain management and practice resilience in primary care, and lack of personal protective equipment represents a serious threat to the provision of quality care during the pandemic. CONCLUSIONS: Current national primary care guidelines for COVID-19 provide guidance on infection control and minimising the risk of spread in primary care practices, while supporting the use of new technology and coordinated partnerships. However, to ensure primary care practice resilience and quality of care are upheld, guidelines must offer recommendations on supply chain management and operational continuity, supported by adequate resources.

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BACKGROUND AND PURPOSE: Although femoral neuropathy is recognized as an adverse consequence following transfemoral neuroendovascular procedures, no reliable estimates are available. We analyzed data from a prospective registry to ascertain the frequency and characteristics of femoral neuropathy following transfemoral neuroendovascular procedures. METHODS: Consecutive patients who underwent neuroendovascular procedures through the transfemoral route were included. Detailed assessment was performed if any patient reported occurrence of sensory or motor symptoms in the femoral or lower extremity region including neurological examination (sensory/motor deficits) and femoral region ultrasound. RESULTS: Femoral neuropathy was diagnosed following 4 of 270 neurovascular procedures with an occurrence rate of 1.5% (95% confidence intervals = .4-3.7%). The symptoms were exclusively sensory without any motor involvement. The femoral neuropathy appeared to involve anterior femoral cutaneous nerves in all and medial cutaneous branches in 2 patients, and more than one nerve distribution in 1 patient in whom lateral cutaneous nerve appeared to be involved. All patients reported resolution of symptoms within a period ranging from 1 week to 2 months. No local hematoma or arterial pseudoaneurysm was identified at femoral region ultrasound. CONCLUSIONS: Femoral neuropathy is a rare occurrence following transfemoral neuroendovascular procedures and it usually occurs with pure sensory manifestations with complete resolution.

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BACKGROUND AND OBJECTIVE: No reliable estimates of headaches following catheter-based cerebral angiography are available. We performed an observational cohort study to ascertain the frequency and type of headaches following catheter-based cerebral angiography. MATERIALS AND METHODS: Consecutive patients who underwent cerebral angiography through the transfemoral (or infrequently radial) route were included. Each patient underwent a brief neurological assessment after the procedure and more detailed assessment was performed if any patient reported occurrence of a headache. The headaches were classified as migraine if the diagnostic criteria specified by International Headache Society were met. The headache severity was classified using a visual numeric rating scale and time to reach pain free status for 2 consecutive hours was ascertained. RESULTS: Migraine headaches occurred in 5 (3.1%, 95% confidence interval [CI] 1.0-7.2%) of 158 patients who underwent cerebral angiography. The median severity of migraine headaches was 10/10 and time to resolution of headaches was 120 minutes (range 60-360 minutes). Migraine headaches occurred in 4 (18.1%, 95% CI 5.2-40.3%) of 22 patients with a history of migraine and 4 (23.5%, 95% CI 6.8-50%) of 17 patients with regular migraine headaches (≥1 episodes per month). Headaches occurred in 6 (3.8%, 95% CI 1.8-8.0%) patients who did not meet the criteria for migraine headaches. CONCLUSIONS: We provide occurrence rates of migraine headaches, an under-recognized adverse event, in patients undergoing catheter-based cerebral angiography.

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BACKGROUND: We performed a prospective study to quantify changes in various aspects of upright posture intolerance in patients with intracranial hypotension. METHODS: Six patients were provided a standard questionnaire before, immediately after epidural blood patch injection and at follow-up visit within 1 month after epidural blood injection inquiring: (a) How long can they stand straight without any support? (b) Do they feel any sense of sickness when they sit or lie down after standing? (c) How long do they have to wait before they are comfortable standing again after they have stood straight? (d) How effectively and fast can they get up from sitting or lying position to stand straight? and (e) Rate their activities in upright posture without support on a standard vertical visual analogue scale between 100 (can do everything) and 0 (cannot do anything). RESULTS: All patients responded that they could not stand straight for ≥30 min (four responding <5 min) on pretreatment evaluation. All patients reported improvement in this measure immediately postprocedure with two reporting ≥30 min. At follow-up, three patients reported further improvement and one patient reported worsening in this measure. The magnitude of improvement ranged from 10 to 80 points increase immediately postprocedure in their ability to perform activities, while they are standing without any support on visual analogue scale. At follow-up, four patient reported additional improvement in their ability to perform activities, while they are standing without any support (ranged from 10 to 20 points increase compared with immediately postprocedure rating). CONCLUSIONS: We present semiquantitative data on various aspects of upright posture intolerance in patients with intracranial hypotension before and after epidural blood injection.

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BACKGROUND: Chest pain has not been recognized as a manifestation of intracranial hypotension secondary to cerebrospinal fluid leakage. CASE REPORT: We report on 4 patients with intracranial hypotension diagnosed by the pattern of headaches, temporal proximity to dural puncture, magnetic resonance imaging findings, and resolution of symptoms after epidural blood patch who presented with chest pain. The chest pain was episodic, located in the sternal and interscapular region for the first 3 patients, with no radiation to any other region and no clear relationship to exertion. The fourth patient had episodic chest pain located in the subclavicular and suprascapular region. Two patients reported dyspnea with chest pain. Underlying coronary artery ischemia was excluded using a combination of the electrocardiogram and cardiac enzyme assays. The pain resolved after epidural blood patch treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should be aware of chest pain that can be seen with intracranial hypotension and cerebrospinal leakage to ensure appropriate diagnostic tests and treatment.

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BACKGROUND AND PURPOSE: Nerves and nerve ganglions are supplied by segmental arteries and the vasa nervorum, but the intra-arterial route has not been used for diagnostic or therapeutic purposes. We present the results of intra-arterial delivery of medication for modulating trigeminal nerve ganglion function in patients with refractory trigeminal neuralgia. METHODS: We administered intra-arterial lidocaine in doses up to 50 mg in the middle meningeal artery territory adjacent to the arterial branch that supplies the trigeminal nerve ganglion. We performed electrophysiologic monitoring to serially assess the latency and amplitude of R1 and R2 responses in the blink reflex before and concurrent with each incremental dose of lidocaine. Clinical outcome assessment included a 10-point numeric rating, 4-point severity grading, and the pain-free time interval pre- and post-treatment. RESULTS: Intra-arterial lidocaine was administered to three patients with trigeminal neuralgia (35-year-old woman, 57-year-old man, and 34-year-old woman). In all patients, there was a latency prolongation and amplitude reduction of R1 or R2 responses or both which was evident after 5-10 mg of lidocaine administration; a more pronounced effect was seen with increasing doses. The second and third patients reported improvement in pain severity on all scales with pain-free intervals of 5 and 3 days, respectively. There was improvement in facial hyperalgesia in all three patients in all dermatomes. All three patients' symptoms had returned to baseline severity 1 month later. CONCLUSIONS: We found that modulation of trigeminal nerve activity via the intra-arterial route is possible based on consistent intraprocedural electrophysiologic suppression and short-term clinical improvement in patients with refractory trigeminal neuralgia.

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INTRODUCTION: We describe the use of intravenous contrast-enhanced ultrasonography to study vasa nervorum using contrast-enhanced ultrasound. METHODS: We imaged the median, femoral, or sciatic nerves in 4 patients in longitudinal plane using high-resolution ultrasound after intravenous bolus of activated Perflutren lipid microspheres. The images were acquired as photopic images (in brown color) in real time using 2-dimensional B-Flow mode scan within a selected region of interest. RESULTS: The vasa nervorum was seen as focal ovoid enhancement along either the superior and inferior aspects of the nerve most pronounced during arterial phase (peak enhancement) in all 4 patients. The fluctuating intensity of enchancement during cardiac cycle confirmed the arterial origin of enhacement. Punctate, linear, or diffuse enhancement was also seen along the trunk of the nerve. CONCLUSIONS: We were able to identify the vasa nervorum along the outer aspect of the studied nerves using contrast-enhanced ultrasound.

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Myotonic dystrophy type 1 (DM1) is the commonest muscular dystrophy in adults, affecting multiple organs in addition to skeletal muscles. Cardiac conduction system abnormalities are well recognized as an important component of DM1 phenotype; however, primary structural myocardial abnormalities, which may predispose these patients to congestive heart failure, are not as well characterized. We reviewed the retrospective analysis of the clinical and echocardiographic findings in adult patients with DM1. Among 27 patients (16 male; age 19-61 years) with DM1, the echocardiogram (ECHAO) was abnormal in 10 (37%) including one of 6 patients (16%) with congenital myotonic dystrophy. Reduced left ventricular ejection fraction (LVEF ≤50%) was noted in 5, diastolic dysfunction in 4, left atrial dilatation in 3, left ventricular hypertrophy in 2, apical hypokinesia in 1 and mitral valve prolapse in 3 patients. One patient had paradoxical septal movement in the setting of left bundle branch block. Echocardiographic abnormalities significantly correlated with older age; however, patients with systolic dysfunction on echocardiogram ranged in age from 27 to 52 years including 2 patients aged 27 and 34 years. We can conclude that echocardiographic abnormalities are frequent in adult patients with DM1. The incidence is similar in the classical and congenital type of DM1. Overall, echocardiographic abnormalities in DM1 correlate with increasing age; however, reduced LVEF is observed even at young age. Cardiac assessment and monitoring in adult patients with DM1 should include evaluation for primary myocardial involvement.

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A 51-year-old man presented with a 5-day history of progressive facial swelling, sensation of head fullness, increasing shortness of breath and paroxysmal nocturnal dyspnea. He denied chest pain, syncope or presyncope. Past medical history included mechanical aortic valve replacement 7 years prior and atrial fibrillation treated with warfarin. A clinical diagnosis of acute superior vena cava (SVC) syndrome was made. Portable chest radiograph showed a widened superior mediastinum. Computed tomography scan of the thorax demonstrated a large type A aortic dissection almost completely effacing the SVC. Acute type A aortic dissection (AD) is an emergency requiring prompt diagnosis and treatment. Patients typically present with acute onset of chest and/or back pain, classically described as "ripping" or "tearing." SVC syndrome is rarely, if ever, mentioned as a presentation, as it is usually due to more chronic conditions. This case illustrates a rare incidence of type A AD actually presenting as SVC syndrome.

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Restless leg syndrome (RLS) is a common neurological disorder which can be accompanied with PLMS and can result in sleep disturbance. Greater understanding of pathophysiology of RLS in recent years has led to increased treatment options for this condition. A comprehensive clinical evaluation and appropriate management using combined nonpharmacologic and pharmacologic strategies can result in significant improvement in treatment outcomes in patients with RLS.

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BACKGROUND: Coronary artery disease affects a significantly larger proportion of Canadians of South Asian origin than Canadians of other ethnic origins. We compared differences in presentation, risk factors and management of myocardial infarction (MI) between South Asian Canadians and matched control subjects. METHODS: We reviewed the charts of 553 South Asian patients and 553 non-South Asian matched control subjects presenting with acute MI (International Classification of Diseases code 410) to 2 hospitals in Canada from January 1994 to April 1999. We identified South Asian subjects by their surnames and first names, and by using self-reported ethnicity and country of birth when available. Patients of Southeast Asian and Middle Eastern origin were excluded. The remaining patients were classified as non-South Asian. Subjects were matched by age within 5 years, sex, discharge date within 6 months and hospital of admission. Presentation characteristics, risk factors and major complications were compared between the 2 groups. RESULTS: The median time from symptom onset to presentation with acute MI was significantly longer among the South Asian subjects than among the control subjects (3.92 v. 3.08 hours) (p = 0.04). The South Asians were more likely than the control subjects to have diabetes mellitus (43.4% v. 28.2%) (p < 0.001) despite having a significantly lower mean body mass index (25.7 v. 28.0) (p = 0.05) but were less likely to have hyperlipidemia (36.2% v. 42.7%, p = 0.05), to smoke (29.3% v. 67.8%) (p < 0.001) or to have pre-existing vascular disease (49.4% v. 55.0%, p = 0.04). Treatment of acute MI was similar between the South Asian and matched control groups. Also similar were the in-hospital outcomes, including mortality (9.6% and 7.8%, p = 0.27). INTERPRETATION: There are clear differences in the risk factor profile between Canadians of South Asian origin and those of non-South Asian origin who have acute MI. Despite the higher incidence of cardiovascular disease in the South Asian population, our results indicate that the in-hospital case-fatality rate for MI is the same for South Asian and non-South Asian Canadians.

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