Social determinants and distance from certified treatment centers are associated with initiation of esketamine nasal spray among patients with challenging-to-treat major depressive disorder

Indicated for treatment-resistant depression or major depression with suicidal ideation, esketamine (ESK) is self-administered under supervision at certified treatment centers. Our study was to determine if social determinants of health and distance were associated with ESK utilization. We conducted a retrospective cohort study among 308 US adults initiating ESK between October 11, 2019 and December 31, 2020 and 1540 propensity-score matched controls with treatment-resistant depression or major depression with suicidal ideation. Adjusting for demographics, prior health care utilization and comorbidities, social determinant variables and distance were regressed separately on each outcome: ESK initiation, failure to complete induction (8 treatments in 45 days), and discontinuation within 6 months. ESK initiation was associated with higher population density (odds ratio [OR]: 2.12), American Indian, Alaska Native, Native Hawaiian, Other Pacific Islander (OR: 3.19), and mental health (OR: 1.55) and primary care providers (OR: 1.55) per capita. Lower likelihood of ESK initiation was associated with living > 7.2 miles from a treatment center (OR: 0.75), living in rural areas (OR: 0.64), and percent non-Hispanic African American (OR: 0.58) and Hispanic (OR: 0.40). Health care providers should tailor patient engagement strategies to mitigate potential barriers to initiating and continuing appropriate treatment. Failing to complete induction was associated with substance use disorder and longer distance to treatment center was associated with discontinuation (hazard ratio: 1.48), as was percent Asian population (hazard ratio: 1.37). Prior psychiatric care and residence in counties with high rates of primary care providers per capita, unemployment, and high school graduation were associated with both higher likelihood of completing induction and lower likelihood of discontinuation.

Vasculogenic Erectile Dysfunction: The Impact of Diet and Lifestyle

Vasculogenic erectile dysfunction has been aptly called the "canary in the coal mine" for cardiovascular disease because it almost always precedes other manifestations of atherosclerotic cardiovascular disease, including myocardial infarction and stroke. It is common, associated with the presence of modifiable cardiovascular risk factors, and impacted by diet and lifestyle choices. This concise review provides an update on the use of dietary and other lifestyle interventions to improve vasculogenic erectile dysfunction and atherosclerotic cardiovascular disease.

Survival of composite restorations after selective or total caries removal in primary teeth and predictors of failures: A 36-months randomized controlled trial

OBJECTIVES

The aim of this study was to assess the survival of composite restorations after selective (SCR) or total caries removal (TCR) and determine predictors of failures after 36 months.

METHODS

120 teeth with deep occlusal or occlusal-proximal carious lesions were randomly divided into control (TCR; n = 54; 69% Class II) and test (SCR; n = 66; 63% Class II) groups. Clinical evaluation was applied using the USPHS criteria, and the presence of Charlie or Delta scores at the marginal integrity were considered as a failure.

RESULTS

The overall survival rate of restorations was 68% after 36 months, 81% for TCR and 57% for SCR (p = 0.004). The multivariable Cox Regression model demonstrated that restorations performed after SCR had 3.44 times greater probability of failure compared to TCR (p = 0.006). The other two predictors for failure of restorations were teeth with Class II cavities (hazard ratio = 3.3) and children with gingival bleeding over 20% (hazard ratio = 2.5).

CONCLUSIONS

Performing composite restorations after SCR in primary teeth had success rate significantly lower than restorations performed after TCR. Complex cavities and worst patient´s oral hygiene were found to be predictors of failure of restorations.

CLINICAL SIGNIFICANCE

Although SCR has been demonstrating high rates of pulp preservation, clinicians should consider that composite restorations fail in a higher frequency compared to TCR in primary teeth and, in some circumstances, may be preferable in terms of restoration longevity.

Abstract 172: Early Impact of a Technology Solution to Transform Care for Cardiometabolic Conditions: Physician Experience and Patient-Centered Outcomes

Objectives: To assess early experience with a digital health solution introduced to primary care.

Background: Managing cardiometabolic conditions (diabetes, hypertension, and dyslipidemia) is challenging for patients and physicians. Patients often lack the understanding and motivation to adopt healthy behaviors and adhere to treatment plans. Physicians face the challenge of having limited time to engage and educate patients at the point-of-care. Electronic health records (EHRs) have not solved this problem; in fact, reports suggest that EHRs increase administrative tasks, reducing time with patients and contributing to burnout. To address these issues we developed CM-SHARE, a web-based application that provides physicians and patients a dashboard of critical health information needed at the point of care, actionable cues to address guideline-based care and quality gaps, and visual tools to educate patients.

Methods: CM-SHARE was designed with input from practicing primary care physicians (PCPs) and launched in two clinics in April 2016. Physician use of CM-SHARE is voluntary, and regular feedback is elicited for ongoing development. Both quantitative and qualitative measures assess the impact of CM-SHARE. Quantitative measures included use (e.g., number of launches, duration of use, clicks on specific features and functions) and measures of physician efficiency based on the EHR audit file logs. Semi-structured interviews were conducted with both physicians and patients to assess perceptions of CM-SHARE’s impact on physician-patient communication, patients’ knowledge of their conditions and motivations to change health behaviors, as well as value, barriers/facilitators of use, and desired improvements. A pre-post, matched control design was used to assess early experience and impact.

Results: From April 27, 2016 to November 1, 2017, CM-SHARE was used in 7,900 encounters for 3,712 patients by 6 PCPs. CM-SHARE was launched in 30% of all encounters, a rate that nearly doubled (to 59%) if cardiometabolic health issues were addressed in the visit. Use of CM-SHARE was associated with a 25%-35% reduction in time spent in the EHR during an encounter and an 11%-20% reduction in the number of EHR clicks during the encounter. Both patients and physicians reported that CM-SHARE enhanced the patient-physician communication, particularly for patients for whom behavior change is necessary to improve clinical measures (e.g., A1c). Following this early experience, CM-SHARE adoption has expanded to 30+ providers, including physicians and an expanded user base of chronic disease case managers and diabetes educators.

Conclusions: Digital health solutions such as CM--SHARE can be successfully integrated into routine care settings and favorably influence physician efficiency and patient experience. Further research will explore the impact of CM-SHARE on longer-term health outcomes.

E-Cigarettes-What a Practicing Cardiologist Needs to Know

Cardiologists and other physicians caring for patients who either smoke tobacco or are potential or active users of E-cigarettes have many questions about this increasingly popular method for delivering nicotine to the brain: (1) What are E-cigarettes? (2) What harm do E-cigarettes pose to users and bystanders? (3) Can E-cigarettes help tobacco smokers quit? (4) Are E-cigarettes a gateway to tobacco smoking, addicting new users, particularly the young, to nicotine? and (5) Should E-cigarettes be tolerated, or even favored over tobacco, as a less harmful substitute for those unable to stop smoking tobacco? This editorial summarizes evidence and expert opinion, preparing the physician for informed discussion of this controversial subject with their patients and colleagues. Although E-cigarettes may be less harmful than tobacco cigarettes, they are definitely not harmless. Particularly concerning are the well-financed commercial interests marketing E-cigarettes to our youth. As new regulatory policies are developed, we must not allow E-cigarettes to reverse our progress in reducing tobacco smoking, the leading cause of preventable death in the United States.

Individual caspase-10 isoforms play distinct and opposing roles in the initiation of death receptor-mediated tumour cell apoptosis

The cysteine protease caspase-8 is an essential executioner of the death receptor (DR) apoptotic pathway. The physiological function of its homologue caspase-10 remains poorly understood, and the ability of caspase-10 to substitute for caspase-8 in the DR apoptotic pathway is still controversial. Here, we analysed the particular contribution of caspase-10 isoforms to DR-mediated apoptosis in neuroblastoma (NB) cells characterised by their resistance to DR signalling. Silencing of caspase-8 in tumour necrosis factor-related apoptosis-inducing ligand (TRAIL)-sensitive NB cells resulted in complete resistance to TRAIL, which could be reverted by overexpression of caspase-10A or -10D. Overexpression experiments in various caspase-8-expressing tumour cells also demonstrated that caspase-10A and -10D isoforms strongly increased TRAIL and FasL sensitivity, whereas caspase-10B or -10G had no effect or were weakly anti-apoptotic. Further investigations revealed that the unique C-terminal end of caspase-10B was responsible for its degradation by the ubiquitin-proteasome pathway and for its lack of pro-apoptotic activity compared with caspase-10A and -10D. These data highlight in several tumour cell types, a differential pro- or anti-apoptotic role for the distinct caspase-10 isoforms in DR signalling, which may be relevant for fine tuning of apoptosis initiation.

Ensuring smokers are adequately informed: reflections on consumer rights, manufacturer responsibilities, and policy implications

The right to information is a fundamental consumer value. Following the advent of health warnings, the tobacco industry has repeatedly asserted that smokers are fully informed of the risks they take, while evidence demonstrates widespread superficial levels of awareness and understanding. There remains much that tobacco companies could do to fulfil their responsibilities to inform smokers. We explore issues involved in the meaning of "adequately informed" smoking and discuss some of the key policy and regulatory implications. We use the idea of a smoker licensing scheme-under which it would be illegal to sell to smokers who had not demonstrated an adequate level of awareness-as a device to explore some of these issues. We also explore some of the difficulties that addiction poses for the notion that smokers might ever voluntarily assume the risks of smoking.

Treatment preferences and the selection of acute migraine medications: results from a population-based survey

Seven oral triptans are available for treating acute migraine. We surveyed US migraine sufferers on the relative importance of treatment attributes for choosing among oral triptans. A multiattribute decision model was used to combine data on the relative importance of efficacy, consistency, and tolerability of acute treatment (determined by 206 triptan-experienced and 209 triptannaive subjects) with data on the performance of the triptans across the attributes (derived from a recent meta-analysis). Efficacy was considered significantly more important than tolerability and consistency: tolerability was significantly more important than consistency for triptan- naive but not triptan-experienced subjects. The multiattribute decision model found that almotriptan, eletriptan, and rizatriptan were significantly closer to the hypothetical ideal triptan than the reference product, sumatriptan 100 mg, for both triptan-naive and triptan-experienced migraine sufferers. Almotriptan, eletriptan, and rizatriptan were the preferred triptans selected on the basis of patients’ own priorities and product performance data.

The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity

This study estimates the 1-year prevalence of migraine in adults in England in relation to the major demographic variables of age, gender and ethnicity, and describes some of its features, including aspects of consequential disability. A telephone survey was conducted of a random sample (n = 4007) of the population aged 16-65 years of mainland England using a previously validated diagnostic interview. The response rate was 76.5%. Overall, 7.6% of males and 18.3% of females reported migraine with or without aura within the last year meeting diagnostic criteria closely approximate to those of the International Headache Society. Prevalence of migraine varied with age, rising through early adult life and declining in the late 40s and early 50s. Prevalence was higher in Caucasians than in other races. Attack rates were > or = 1/month in most migraineurs, and most experienced interference with daily activities in > or = 50% of their attacks. On average, an estimated 5.7 working days were lost per year for every working or student migraineur, although the most disabled 10% accounted for 85% of the total. Results were in keeping with those from surveys in other countries. If these findings in mainland England are projected to the entire UK population, we estimate that 5.85 million people aged 16-65 years experience 190 000 migraine attacks every day and lose 25 million days from work or school each year because of them. Migraine is an important public health problem in the UK, associated with very substantial costs.

The shredding of BAT's defence: McCabe v British American Tobacco Australia

On 11 April 2002, a Victorian supreme court jury ordered British American Tobacco Australia to pay Rolah McCabe $A700 000 in damages. Rolah McCabe is a 51 year old woman dying of lung cancer. She is the first smoker ever in Australia to obtain a damages verdict against the tobacco industry

Migraine in the United States: epidemiology and patterns of health care use

OBJECTIVE

To determine the prevalence and distribution of migraine in the United States as well as current patterns of health care use.

METHODS

A random-digit-dial, computer-assisted telephone interview (CATI) survey was conducted in Philadelphia County, PA, in 1998. The CATI identifies individuals with migraine (categories 1.1 and 1.2) as defined by the diagnostic criteria of the International Headache Society with high sensitivity (85%) and specificity (96%). Interviews were completed in 4,376 subjects to identify 568 with migraine. Those with 6 or more attacks per year (n = 410) were invited to participate in a follow-up interview about health care utilization and family impact of migraine; 246 (60.0%) participated.

RESULTS

The 1-year prevalence of migraine was 17.2% in females and 6.0% in males. Prevalence was highest between the ages of 30 and 49. Whereas 48% of migraine sufferers had seen a doctor for headache within the last year (current consulters), 31% had never done so in their lifetimes and 21% had not seen a doctor for headache for at least 1 year (lapsed consulters). Of current or lapsed consulters, 73% reported a physician-made diagnosis of migraine; treatments varied. Of all migraine sufferers, 49% were treated with over-the-counter medications only, 23% with prescription medication only, 23% with both, and 5% with no medications at all.

CONCLUSION

Relative to prior cross-sectional surveys, epidemiologic profiles for migraine have remained stable in the United States over the last decade. Self-reported rates of current medical consultation have more than doubled. Moderate increases were seen in the percentage of migraine sufferers who use prescription medications and in the likelihood of receiving a physician diagnosis of migraine.

Reliability of the migraine disability assessment score in a population-based sample of headache sufferers

BACKGROUND

The Migraine Disability Assessment (MIDAS) score is used to quantify headache-related disability. In a previous study, we showed that the MIDAS score was highly reliable in population-based samples of migraine headache sufferers in two countries.

OBJECTIVES

To examine the test-retest reliability and internal consistency of the five items comprising the MIDAS score and the overall MIDAS score in a population-based sample of both migraine and nonmigraine headache sufferers.

METHODS

Using a clinically validated telephone interview, a population-based sample of migraine and nonmigraine headache sufferers was identified in Baltimore, Maryland, USA. A total of 97 migraine cases and 80 nonmigraine subjects completed the MIDAS questionnaire on two occasions an average of 3 weeks apart. The MIDAS score is derived from five questions about missed time from work (or school) and household work (one question each about missed days and days with at least 50% reduced productivity) and missed days of nonwork activities.

RESULTS

Among all headache sufferers the test-retest Spearman's correlations of individual MIDAS questions ranged from 0.67 to 0.73. The Spearman's correlation for the MIDAS score (i.e., sum of lost days and reduced effectiveness days in each domain) was 0.84. Cronbach's alpha, a measure of internal consistency, was 0.83. Mean and median item values and the overall MIDAS scores differed between migraine and nonmigraine cases. Even after adjusting for differences in headache frequency, the mean MIDAS scores differed substantially (i.e., 10.3 points) between migraine cases and nonmigraine cases.

CONCLUSIONS

The reliability and internal consistency of the MIDAS score are high, as tested in a population-based sample of headache sufferers. MIDAS scores are substantially higher in migraine cases than in non-migraine cases, supporting the validity of the measure.

Validity of an illness severity measure for headache in a population sample of migraine sufferers

The headache impact questionnaire (HImQ) is used to measure pain and activity limitations from headache over a 3-month recall period. In a prior study, the test-retest reliability of the eight-item HImQ score was found to be relatively high (0.86). In the current study, we examined the validity of the eight-item HImQ by comparing the overall score and individual items to equivalent measures from a 90-day diary. Pain and activity limitations due to headache were assessed in a population-based sample of 132 migraine headache sufferers enrolled in a 90-day daily diary study who completed the HImQ at the end of the study. The HImQ score was derived from four frequency-based questions (i.e. number of headaches, missed days of work, missed days of chores, or missed days of non-work activity) and four summary measures of average experience across headaches (i.e. average pain intensity, and average reduced effectiveness when having a headache at work, during household chores, and in non-work activity). Diary based measures were used as the gold standard in evaluating the HImQ score. Mean and median values of frequency-based HImQ items (e.g. number of headaches) were similar to equivalent diary measures, indicating no systematic bias. In contrast, HImQ measures of average experience across attacks (e.g. average pain intensity) overestimated equivalent diary measures and, in general, better approximated diary measures for migraine headaches, rather than all headaches. The highest correlations between HImQ and diary items were observed for headache frequency and average pain intensity, the two general headache measures, followed by measures of reduced effectiveness. Among frequency-based measures, the strength of the correlation was directly related to the magnitude of the mean. The higher the mean value, the higher the correlation. The correlation between the HImQ score and diary based score was 0.49. The HImQ score is moderately valid. Frequency-based items (e.g. number of missed work days) were found to be unbiased and the highest correlation coefficients were observed for frequency-based items with relatively high mean counts (number of headaches, number of missed non-work days). These findings have implications for measuring severity of chronic episodic conditions like headache, asthma, back pain, arthritis, epilepsy, and panic disorder, which can cause limitations to activities. The validity of illness severity measures may be improved by using frequency-based questions to assess both missed activity days and days with significantly reduced effectiveness or productivity (e.g. by 50% or more). By combining the count for both missed days and days where productivity is substantially reduced, the mean of the frequency-based measure will be increased, a factor which may improve the overall validity of the item. A severity measure can be derived from such items by simple addition and provides a scale with intuitively meaningful units.

Prevalence of frequent headache in a population sample

PURPOSE

Patients with daily or near-daily headaches are commonly seen in neurology practices and in headache subspecialty centers, but there is little information on the prevalence of this condition in the general population. We present the first US-based study describing the prevalence and characteristics of frequent headache in the general population.

METHODS

In Baltimore County, Maryland, 13 343 individuals 18 to 65 years of age were selected by random-digit dialing and interviewed by telephone about their headaches. Subjects reporting 180 or more headaches per year were classified as having frequent headache. Three mutually exclusive subtypes of frequent headache were identified: frequent headache with migrainous features, chronic tension-type headache, and unclassified frequent headache.

RESULTS

The overall prevalence of frequent headache was 4.1% (5.0% female, 2.8% male; 1.8:1 female to male ratio). Frequent headache was 33% more common in Caucasians (4.4%) than in African Americans (3.3%). In both males and females, prevalence was highest in the lowest educational category. Among frequent headache sufferers, more than half (52% female, 56% male) met criteria for chronic tension-type headache, almost one third (33% female, 25% male) met criteria for frequent headache with migrainous features, and the remainder (15% female, 19% male) were unclassified. Overall, 30% of female and 25% of male frequent headache sufferers met International Headache Society (IHS) criteria for migraine (with or without aura).

CONCLUSIONS

Frequent headache is common in the general population and is more prevalent in Caucasians and in those with less than a high school education. Chronic tension-type headache is more common than frequent headache with migrainous features, though the latter is more disabling. Although more common in females than males, the female preponderance of frequent headache is less marked than in migraine. The sex ratio varies by frequent headache subtype.

Reliability of an illness severity measure for headache in a population sample of migraine sufferers

OBJECTIVES

To examine the reliability and related measurement properties of an illness severity measure for headache derived from responses to a 16-item self-administered questionnaire, the Headache Impact Questionnaire (HImQ), and to determine if there is support for combining measures of pain and disability into a single scaled measure of severity.

METHODS

A population-based sample of migraine headache sufferers completed the HImQ twice, an average of 38 days apart. The HImQ included questions about number of headaches in the last 3 months, headache duration, last headache, pain intensity (two questions), need for bedrest (two questions), disability in specific domains of activity (seven questions about interference with ability to work, do household chores, and engage in non-work activity), and symptoms (two questions).

RESULTS

Test-retest correlations of individual questions ranged from 0.65 to 0.93. In principal components analysis, a single factor with significant loading emerged. One measure of pain intensity (average pain score from 0 to 10) and items related to disability (i.e., missed days due to headache, and reduced effectiveness because of headache) in defined activity domains (work for pay, housework, nonwork activities) had the greatest weights on this single factor, supporting prior work on combining measures of pain and disability into a single scale. The HImQ score was derived as the sum of average pain intensity and total lost time in each of the three domains of activity, expressed as lost days. The latter was derived as the sum of actual missed days in each activity domain and reduced effectiveness day equivalents in each activity with a headache. The test-retest correlation was 0.77 for all eligible subjects and 0.85 when one influential outlier was removed. Cronbach's alpha was 0.83.

CONCLUSIONS

The HImQ score, based on eight items, is a highly reliable and internally consistent measure of headache severity.

Neutropenia and agranulocytosis in patients receiving clozapine in the UK and Ireland

BACKGROUND

Clozapine can cause reversible agranulocytosis and neutropenia. This study documents the occurrence of blood dyscrasias and identifies predisposing risk factors.

METHOD

An analysis was made of the haematological, demographic, and dosage data from a central database on 6316 patients receiving clozapine over four and a half years in the UK and Ireland.

RESULTS

During the study period, 2.9% of the patients developed neutropenia and 0.8% developed agranulocytosis. The peak incidence of both disorders was in the first 6-18 weeks of treatment. Fatal agranulocytosis occurred in 0.03% of patients. After the first year of treatment, the incidence of agranulocytosis significantly decreased to the order noted with some phenothiazines.

CONCLUSIONS

The use of a patient monitoring service kept the haematological risks associated with using clozapine within acceptable limits, particularly in view of the benefits of this medication in treatment-resistant schizophrenia.

Variation in migraine prevalence by race

PURPOSE

Estimates of migraine prevalence from African and Asian populations are lower than those observed in European and North American populations. To determine if these international differences reflect differences in cultural, environmental, or genetic factors, we compared the prevalence of migraine among Caucasians, African Americans, and Asian Americans in the United States. If genetic factors predominate, racial differences should persist in the United States.

METHODS

In Baltimore County, Maryland, 12,328 individuals 18 to 65 years of age were selected by random-digit dialing and interviewed by telephone about their headaches. Migraine diagnoses were assigned using International Headache Society criteria.

RESULTS

In women, migraine prevalence was significantly higher in Caucasians (20.4%) than in African (16.2%) or Asian (9.2%) Americans. A similar pattern was observed among men (8.6%, 7.2%, and 4.2%). African Americans were less likely to report nausea or vomiting with their attacks, but more likely to report higher levels of headache pain. In contrast, African Americans tended to be less disabled by their attacks than Caucasians. There were no statistically significant differences in associated features between Asian American and Caucasian migraineurs.

CONCLUSIONS

In the United States, migraine prevalence is highest in Caucasians, followed by African Americans and Asian Americans. While differences in socioeconomic status, diet, and symptom reporting may contribute to differences in estimated prevalence, we suggest that race-related differences in genetic vulnerability to migraine are more likely to predominate as an explanatory factor.

Rater agreement for the Rey-Osterrieth Complex Figure Test

This report assesses the intrarater and interrater reliability of quantitatively scoring the Rey-Osterrieth Complex Figure Test (RCF). The intrarater correlation coefficients were .96, .99, and .96, and the interrater correlation coefficients were .88, .97, and .96 for the Copy, Immediate Recall, and Delayed Recall, respectively. However, statistically significant mean differences in score were found between raters on the Copy, Immediate, and Delayed Recall. Though the majority of structural units within the RCF are reliably scored, several units had a greater magnitude of observed scoring differences compared to the other units after adjusting for expected differences. Overall, reliability estimates demonstrate high intrarater reliability and acceptable interrater reliability except for the potential for systematic scoring differences.

Prospective study of central nervous system function in amateur boxers in the United States

Active amateur boxers from six US cities were studied in 1986-1990 to determine whether changes in central nervous system function over a 2-year interval (as evaluated by tests of perceptual/motor function, attention/concentration, psychomotor speed, memory, visuoconstructional ability, and mental control, measures of ataxia and brain-stem auditory evoked potentials, and electroencephalography) were associated with degree of participation in amateur boxing. A total of 484 participants were examined at baseline; 393 (81.2%) were examined 2 years later. At baseline, 22% of the participants had not yet competed in a bout; 9% had never competed in a bout by the second examination. Exposure was defined by number bouts, sparring-years, and sparring with a professional boxer. Very few statistically significant odds ratios were found between exposure and change in function. Significant tests of trend were found between the total number of bouts incurred before the baseline examination and changes in memory, visuoconstructional ability, and perceptual/motor ability. The significant trends for change in function in the latter two domains were primarily due to performance on the Block Design test, which was common to both test domains. No statistically significant associations were found between more recent bouts (after the baseline visit) and any functional domains, nor between bouts or sparring and any other outcome measures. The significant trends with past bouts, but not more recent bouts, may reflect the need for a long latency period before effects are manifest. Alternatively, given changes in safety practices, the observed association may be related to more severe exposure from bouts that occurred before 1986, when new safety measures were imposed.

Physician consultation for headache pain and history of panic: results from a population-based study

In a population-based telephone interview survey of 10,169 respondents aged 12-29 years in Washington County, Maryland, data were collected on history of panic attacks, on the most recent headache and associated symptoms in the 2 weeks before the interview, and on physician consultation for headache-related problems. Of those who had a headache in the previous 12 months, 14.2% of females and 5.8% of males consulted a physician for headache. The proportion who recently consulted a physician increased with age among females but not among males. An unexpectedly high proportion of those who recently sought physician care for their headache problem had a history of panic. In particular, among those who sought care, 15% of females and 12.8% of males ages 24-29 had a history of panic disorder. Overall, females with panic disorder who had recently seen a physician for headache exhibited the most frequent, severe, and complex headaches. In particular, headaches were of considerably longer duration, more severe, and greater than 50% of these females had five or more headaches in a 4-week period. A very high proportion experienced disability (up to 46.7%) from their headache. Males with a history of panic who did or did not seek physician care differed only in that a considerably higher proportion of the former group (up to 45%) had frequent headaches. Overall, 11.8% of the total population had a migraine headache in the 2 weeks before the interview. In contrast, 21.8% of those who sought physician care and 36% of those with panic disorder who sought physician care had a migraine headache.

Inside-of-the-Body test drawings performed by patients with neuromuscular diseases: a preliminary report

Inside-of-the-Body test drawings were obtained from 50 individuals with various neuromuscular diseases. A mean of 18.0 +/- 5.1 body parts were identified in the drawings. Diseased body structures were emphasized by most patients; for example, thymus was only drawn by individuals with myasthenia gravis, while muscle was only identified by individuals with polymyositis. In contrast, drawings by individuals with neuropathic atrophy omitted the atrophic extremities.

Studies on thyroid and hypophysary thyrotrophic hormone (TSH) in Down syndrome

Serum TSH was studied in 22 patients with Down syndrome, from 4 to 15 years old. In 6 of these patients radioidine uptake by thyroid gland after 2 and 24 hours of administration and clearance rates before and after TSH stimulus (10 mul-IM) were measured. Results show that serum TSH was normal in 17 patients and above normal limits in 5 patients. Thyroid uptake after 2 hours as well clearance rates, both below normal, had a response to TSH stimulus with normal or below values. These data along with previous reports, suggest, that in children with Down syndrome, there is a thyroid dysfunction in which a slow response no TSH stimulus seems to be the basic defect.