Effective Doses of Low-Dose Naltrexone for Chronic Pain - An Observational Study

Purpose

Despite the availability of a wide variety of analgesics, many patients with chronic pain often experience suboptimal pain relief in part related to the absence of any medication to address the nociplastic component of common pain syndromes. Low-dose naltrexone has been used for the treatment of chronic pain, typically at 4.5 mg per day, even though it is also noted that effective doses of naltrexone for chronic pain presentations range from 0.1 to 4.5 mg per day. We performed an observational analysis to determine the range of effective naltrexone daily dosing in 41 patients with chronic musculoskeletal pain.

Methods

Charts of 385 patients, 115 males, 270 females, ages 18-92, were reviewed. Two hundred and sixty patients with chronic diffuse, symmetrical pain were prescribed a titrating dose of naltrexone to determine a maximally effective dose established by self-report of 1) reduction of diffuse/generalized and/or severity level of pain and/or 2) positive effects on mood, energy, and mental clarity. Brief Pain Inventory and PROMIS scales were given pre- and post-determining a maximally effective naltrexone dose.

Results

Forty-one patients met all criteria for inclusion, successfully attained a maximally effective dose, and completed a pre- and post-outcome questionnaire. Hormesis was demonstrated during the determination of the maximally effective dosing, which varied over a wide range, with statistically significant improvement in BPI.

Conclusion

The maximally effective dose of low-dose naltrexone for the treatment of chronic pain is idiosyncratic, suggesting the need for 1) dosage titration to establish a maximally effective dose and 2) the possibility of re-introduction of low-dose naltrexone to patients who had failed initial trials on a fixed dose of naltrexone.

Epigenetic memory of coronavirus infection in innate immune cells and their progenitors

Inflammation can trigger lasting phenotypes in immune and non-immune cells. Whether and how human infections and associated inflammation can form innate immune memory in hematopoietic stem and progenitor cells (HSPC) has remained unclear. We found that circulating HSPC, enriched from peripheral blood, captured the diversity of bone marrow HSPC, enabling investigation of their epigenomic reprogramming following coronavirus disease 2019 (COVID-19). Alterations in innate immune phenotypes and epigenetic programs of HSPC persisted for months to 1 year following severe COVID-19 and were associated with distinct transcription factor (TF) activities, altered regulation of inflammatory programs, and durable increases in myelopoiesis. HSPC epigenomic alterations were conveyed, through differentiation, to progeny innate immune cells. Early activity of IL-6 contributed to these persistent phenotypes in human COVID-19 and a mouse coronavirus infection model. Epigenetic reprogramming of HSPC may underlie altered immune function following infection and be broadly relevant, especially for millions of COVID-19 survivors.

Results of intervention for lupus patients with self-perceived cognitive difficulties

The authors developed an 8-week psychoeducational group intervention for patients with systemic lupus erythematosus (SLE) who reported cognitive dysfunction but were not globally impaired on neuropsychological testing. Results of a nonrandomized, uncontrolled pilot study of this program in 17 women with SLE suggest that metamemory and memory self-efficacy improve after participation. One hundred percent retention throughout the study further suggests that patients with SLE are willing and capable of successfully completing the program.

Quality of life in paediatric lupus

Paediatric systemic lupus erythematosus (SLE) is associated with significant morbidity and has biopsychosocial implications resulting from the disease and its treatment. The aim of this study was to identify domains of quality of life (QOL) impacted by SLE in children. Children with SLE and their parents were asked a single open-ended question related to lupus. Themes derived from children's responses focused primarily on coping and maintaining control of their life despite SLE. Themes from the parents' responses were twofold: a) efforts to cope with their child having SLE; and b) appreciation/sadness in connection with their children's coping process. Qualitative exploration of different facets of QOL in these children is critical for the understanding of specific factors that assist/ease the coping process and formulating interventions for improving children's/family's self-efficacy and disease management.

How do cancer patients who try to take control of their disease differ from those who do not?

The objective of this study was to compare patients who do and do not describe their coping strategies as attempts to control their cancer. This was a cross-sectional study of adult, oncology outpatients from an urban medical centre diagnosed 6-24 months previously. Using open-ended questions, we asked participants if they tried to 'control' their cancer or situation. If 'yes', how? If 'no', how had they 'dealt with' it? The Hospital Anxiety and Depression Scale (HAD) measured anxiety and depression. The Mental Adjustment to Cancer Scale (MAC) assessed six coping styles. Of the 44 participants, 57% were female. The mean age was 57 years. Eighteen (41%) said they used control strategies (control-yes), 11 (25%) said they did not (control-no), and 15 (34%) gave unclear responses (control-unclear). Participants cited 97 different coping strategies that were grouped into proactive (e.g. lifestyle changes) and reactive strategies (e.g. stoic behaviour). In comparing these groups, the control-yes group was more likely to be younger (P = 0.0001), live with other(s) (P = 0.003), be confident of being cured (P = 0.006), have greater 'fighting spirit' on the MAC (P = 0.04) and use more proactive strategies (P = 0.0001). The conclusion of this study is that cancer patients use many coping strategies, but those who think of them as methods of control are younger and more confident of being cured, and use more proactive strategies.

Frequent Triptan Use: Observations on Safety Issues

OBJECTIVE

To examine the safety of frequent triptan use over extended periods. For a small group of patients with refractory migraine plus chronic daily headache, triptans are effective.

METHODS

This retrospective study primarily evaluated the cardiac safety of daily triptan use in 118 patients and, in addition, hematologic tests were assessed. Each patient had utilized a triptan for a minimum of 4 days per week for at least 6 months. Patients with rebound headache had been withdrawn from the triptans. Most patients (97 of 118) averaged 1 tablet daily; most would occasionally go for several days without a triptan. Forty patients had taken a triptan for 6 months to 2 years, 37 patients from 2 to 4 years, and 41 for 4 or more years.

RESULTS

Routine hematologic tests were performed periodically on all patients, and no abnormalities were attributable to triptans. Almost all patients had an electrocardiogram, and no abnormal electrocardiograms were felt to be related to triptans. Cardiac echocardiography was performed in 57 patients. The 10 abnormal echocardiograms were not due to triptans. All 20 cardiac stress tests revealed normal findings. Adverse events were minimal; 9 patients described fatigue due to triptans, and 5 had mild chest tightness.

CONCLUSION

This long-term study of 118 patients indicates that frequent triptan use may be relatively safe.

Measuring recovery after a hip fracture using the SF-36 and Cummings scales

The objective of this study was to assess outcomes of traditional treatment of fractures using the SF-36 and the Cummings Hip Scale. In designing randomized clinical trials, it is necessary to determine the timing of assessment either for progress or for the main outcome. We set out to document the recovery of patients after surgery for hip fracture using current standard methods of medical care. This was a prospective study of a cohort of patients. Patients who were receiving standard medical care completed the SF-36 and the Cummings Hip Scale at previously determined times postoperatively. The SF-36 has eight subscales, including assessments of physical function, physical role behaviors, bodily pain, mental health, social role, emotional role, vitality and general health. Thirty-eight patients completed the questionnaires at 1 year postoperatively as well as previous time points. On the Cummings Hip Scale and the physical function, bodily pain, mental health, social function, emotional role, vitality and general health subscales of the SF-36, recovery is near complete at 6 months. Only the physical role subscale differs, with a statistically significant difference between the values at 6 months and 1 year, (p = 0.02). Patients attained over 90% of the 1 year value by 6 months for all except the physical role subscale. The physical role subscale reached 85%. For a hip fracture patient who is on the road to recovery, the majority of the recovery has therefore taken place by 6 months.

Patients' expectations of knee surgery

BACKGROUND

Patients' expectations of medical care are linked to their requests for treatment and to their assessments of outcome and satisfaction. Our goals were to measure patients" preoperative expectations of knee surgery and to develop and test patient-derived knee expectations surveys.

METHODS

An initial sample of 377 patients (mean age, 54.6 18.2 years; 52% women) was enrolled in the survey-development phase. One hundred and sixty-one (43%) of these patients subsequently underwent total knee arthroplasty; seventy-five (20%), cruciate ligament repair; eighty-five (23%), meniscal surgery; and fifty-six (15%), surgery for another knee condition. Preoperatively, these patients were asked open-ended questions about their expectations of knee surgery. Their responses were grouped with use of qualitative research techniques to generate categories of expectations. Categories were transformed into specific questions and were formatted into two draft surveys, one for patients undergoing total knee arthroplasty and one for patients undergoing other surgical procedures on the knee. A second sample of 163 patients (mean age, 55.1 17.5 years; 49% women) was enrolled in the survey-testing phase, and they completed the draft surveys on two separate occasions to establish test-retest reliability. Items were selected for the final surveys if they were cited by 5% of the patients, if they represented important functional changes resulting from surgery, or if they represented potentially unrealistic expectations. All selected items fulfilled reliability criteria, defined as a kappa (or weighted kappa) value of 0.4, or were deemed to be clinically relevant by a panel of orthopaedic surgeons.

RESULTS

From the survey-development phase, a total of fifty-two categories of expectations were discerned; they included both anticipated items such as pain relief and improvement in walking ability and unanticipated items such as improving psychological well-being. Expectations varied by diagnosis and patient characteristics, including functional status. Two final surveys were generated: the seventeen-item Hospital for Special Surgery Knee Replacement Expectations Survey and the twenty-item Hospital for Special Surgery Knee Surgery Expectations Survey. Each required less than five minutes to complete.

CONCLUSIONS

Patients have multiple expectations of knee surgery in the areas of symptom relief and improvement of physical and psychosocial function, and these expectations vary according to the diagnosis. We developed two valid and reliable surveys that can be used preoperatively to direct patient education and shared decision-making and to provide a framework for setting reasonable goals. Reexamining patients' responses postoperatively could provide a way to assess fulfillment of expectations, which is a crucial patient-derived measure of outcome and satisfaction.

An evaluation of the cuffed oropharyngeal airway for elective pediatric anesthesia

STUDY OBJECTIVE

To evaluate the usefulness in pediatric patients of the cuffed oropharyngeal airway (COPA), an airway device with an inflatable cuff around its distal portion, and which provides airway patency in the majority of anesthetized adult patients.

DESIGN

Prospective evaluation.

SETTING

Pediatric operating room of a tertiary-care medical center.

PATIENTS

50 anesthetized ASA physical status I pediatric patients, under 6 yr of age undergoing elective surgery.

INTERVENTIONS

Patients were fitted with a size 7 COPA placed following anesthetic induction. If an adequate airway was not obtained, a size 8 COPA was placed. If an adequate airway was not obtained despite repositioning the size 8, the COPA was considered failed.

MEASUREMENTS AND MAIN RESULTS

The ease of insertion and ability to manage the airways were evaluated. Complications were evaluated on insertion, during maintenance, and upon awakening. The ability to positive pressure ventilate via the COPA was assessed. The size 7 COPA obtained an initial fit in 38 (76%) of the patients. Nine patients were managed with a size 8 COPA. The COPA was unsuccessful in 3 (6%) patients. Laryngospasm occurred in three patients. Blood was not visible on any of the COPAs. Positive pressure ventilation was achieved with 30 +/- 7 cm H(2)O pressure.

CONCLUSIONS

The results using the COPA in pediatric patients seem to parallel the experience of using larger sizes in adult patients.

Major life events as antecedents to hip fracture

BACKGROUND

This study sought to determine whether the number of antecedent life events reported in the year before hip fracture among elderly patients was normal for the population from which these patients derive. Major life events are events such as births, deaths, major financial dealings, and major health changes.

METHODS

Life events reported in the year before a fall and hip fracture for 111 hip fracture patients were compared with those of a control sample of 90 nonfracture, community-dwelling ambulatory elderly.

RESULTS

The total number of life events was higher in the hip fracture group (p = 0.0001) than in the community control group. Fracture was also associated with the number of events experienced (adjusted OR, 2.1; 95% CI, 1.6-2.7; p < 0.0007), notwithstanding age, marital status, and education.

CONCLUSION

Older persons who had sustained a fall-related traumatic hip fracture experienced an increased number of major life events compared with a nonfracture population sample of community-dwelling elderly controls.

What nursing home residents value in their doctors

Patient satisfaction is influenced by multiple factors, and different populations are expected to define satisfaction in terms of their novel perspectives. Despite growing interest in patient satisfaction, an extensive literature search reveals no studies of nursing home residents' satisfaction with respect to medical care. In an initial qualitative study using transcripts of interviews conducted as part of a state quality control mandate, categories are identified that make up this population's construct of satisfaction and dissatisfaction. These categories serve as building blocks for designing future studies investigating these issues and allowing for comparison of nursing home residents' ideas of satisfaction and dissatisfaction to other older patients, including those in an outpatient geriatric setting.

Developing musculoskeletal education programs for physicians and the general public: findings from a needs assessment

OBJECTIVE

To assess the educational needs and learning preferences of primary care physicians and the general public in receiving musculoskeletal health education.

METHODS

Prospective surveys were mailed simultaneously to 2,250 primary care physicians and 2,250 members of the general public. The surveys included questions about demographics, motivation for attending programs, and preferred education program formats.

RESULTS

The 68 responding physicians attend continuing medical education programs mainly based on topics, speakers, and timing. They prefer lectures and find question and answer sessions least helpful in supporting learning. The 96 responding members of the general public attend programs mainly based on topics, speakers, and fees. The general public stated that question and answer sessions best support learning in programs. A large percentage of responding physicians provide health education to their patients, but a small percentage of the general public respondents stated that they receive health education from physicians.

DISCUSSION

Responses from physicians and the general public were generally not surprising but revealed interesting contrasts between learning preferences. While physicians and the general public both value speakers and topics, the physicians want to increase their knowledge about disease, whereas the general public wants practical information. Physicians and the general public also appear to take different approaches to learning. The contrast between availability and provision of health education is also striking. We cannot generalize our results with absolute confidence because the return rates for the surveys were so low. Nonetheless, we support the need to educate physicians and the general public in ways that match their preferred learning methods and educational needs.

Menstrual migraine with features of cluster headache. A report of 10 cases

Ten patients with menstrually related migraine headaches and significant features of cluster headache are described. The mean age of onset of the headache was 29 years. The duration of the pain was more typical for migraine, with an average of 3 days. The pain was sharp with associated tear formation and nasal congestion. Eight of the women described significant nausea. Only one reported any type of cluster headache outside of the menstrual time. Four patients experienced tension headaches, and four also had migraines not related to menses (without cluster features). Preventive medications were generally not helpful. The abortive medications that did help included sumatriptan, Cafergot PB suppositories, and corticosteroids. Oxygen was useful in two patients. While analgesics did help three patients, lidocaine nasal spray was ineffective in four of the women.

Dominant lethal studies in male mice after exposure to a 50 Hz magnetic field

The potential mutagenicity of power frequency magnetic fields was investigated using a dominant lethal assay in mice. A total of 42 male mice were exposed for 8 weeks to a 50 Hz sinusoidal magnetic field at 10 mT (rms) and 47 males acted as simultaneous cage controls. Each male was subsequently mated with two females on weeks 1, 3, 5, 7, and 9 post-exposure. The numbers of pregnant females, corpora lutea, and live and dead implants were recorded. Multiple logistic regression analyses examined the effects of exposure on pregnancy rate, pre-implantation survival and post-implantation survival. There were no statistically significant differences in overall response between exposed and control groups, nor was there any significant effect of exposure in any post-exposure week. Thus, exposure to power frequency magnetic fields at 10 mT for the approximate period of spermatogenesis did not appear to induce dominant lethal mutation in the germ cells of male mice.

Intranasal lidocaine for cluster headache

Thirty male patients with cluster headache were given 4% lidocaine solution to use intranasally as an abortive therapy. Four sprays of lidocaine were used ipsilateral to the pain, and two more were used, if necessary. Twenty-seven percent of the men reported moderate relief, 27% obtained mild relief, and 46% stated that they had no relief from the lidocaine, Side effects were minimal. In this study, intranasal lidocaine was only a marginally helpful therapy for cluster headache. However, because of the ease of administration and lack of side effects, lidocaine may remain worthwhile as an adjunctive medication.

Precipitating factors in migraine: a retrospective review of 494 patients

The predominance of certain triggers for migraine was assessed in 494 migraine patients. Stress (62%) was the most frequently cited precipitant. Weather changes (43%), missing a meal (40%), and bright sunlight (38%) were also prominent factors. Sexual activity (5%) was the precipitant cited by the least number of patients. Significant differences were found between men and women in their responses to weather changes, perfumes, cigarette smoke, missing a meal, and sexual activity. Spring was cited by 14% of patients as a time for increased migraine attacks, followed by fall (13%), summer (11%), and winter (7%).

Effects of prenatal exposure to 50 Hz magnetic fields on development in mice: I. Implantation rate and fetal development

Pregnant CD1 mice were exposed or sham-exposed from day 0 to day 17 of gestation to a 50 Hz sinusoidal magnetic field at 20 mT (rms). Preimplantation and postimplantation survival were assessed and fetuses examined for the presence of gross external, internal, and skeletal abnormalities. There were no statistically significant field-dependent effects on preimplantation or postimplantation survival, sex ratio, or the incidence of fetuses with internal or skeletal abnormalities. Magnetic field exposure was, however, associated with longer and heavier fetuses at term, with fewer external abnormalities. The results lend no support to suggestions of increased rates of spontaneous abortion or congenital malformation following prenatal exposure to power frequency magnetic fields.

Predicting treatment outcome for incompetent defendants

This study examined the prediction of outcome in a sample of defendants hospitalized for treatment of incompetency. Defendants' demographic characteristics and scores on 18 scales of the Computer-Assisted Determination of Competency to Proceed instrument (CADCOMP) were used to predict competency restoration and length of stay (LOS). During the period of study, almost 90 percent of the defendants were restored to competency after a mean stay of over 280 days. Demographic characteristics were unrelated to outcome. Several CADCOMP scales, including two scales measuring psycholegal ability and one measuring psychopathology, were correlated with both outcome criteria. Discriminant analysis using the CADCOMP scales accurately classified 76.7 percent of the defendants into short and long stay groups. Although promising, the findings are nevertheless consistent with prior research in suggesting that examiners should exercise caution in providing feedback to the courts concerning competency restoration and the period of time needed for treatment.

An analogue study of the factors influencing competency decisions

Forensic psychiatrists who were members of the American Academy of Psychiatry and the Law analyzed case histories to make a competency or incompetency decision. The case histories were created to alter background information, diagnostic information, information about the defendants' understanding of the adversarial process, courtroom behavior, and the nature of the crime. The information that had the most influence on the decisions of the forensic psychiatrists included the cognitive status of the defendant, psychotic features, courtroom behavior, and understanding of the adversarial process. Relationship with the lawyer, alcohol/drug use history, psychiatric history, and criminal history had less influence. The forensic psychiatrists tended to "error" toward a decision for competency unless compelling evidence was presented to the contrary.

Effects of prenatal exposure to 50 Hz magnetic fields on development in mice: II. Postnatal development and behavior

To investigate the potential of magnetic fields to act as a behavioral teratogen, pregnant CD1 mice were exposed or sham-exposed for all of gestation to a 50 Hz/20 mT magnetic field. Maturation of offspring was assessed using a range of standard developmental indices (eye opening, pinna detachment, hair coat, tooth eruption, sexual maturity, and weight) and simple reflexive behaviors (air righting, surface righting, forepaw grasp, cliff avoidance, and negative geotaxis). Activity and coordination levels were explored in juvenile and adult mice using an open field arena, a head-dip board, an accelerating Rotarod, and a residential activity wheel. All assessments were carried out without knowledge of exposure condition. Results from 168 sham-exposed mice from 21 litters and from 184 exposed mice from 23 litters were compared using survival analysis techniques and multivariate regression methods. Three possible field-dependent effects were found: Exposed animals performed the air righting reflex earlier (P < 0.01); exposed males (but not females) were significantly lighter in weight (P = 0.008) at 30 days of age; and exposed animals remained on a Rota-rod for less time as juveniles (P = 0.03). Some of these results have not been reported in other studies and may reflect spurious statistical significance, although some effect of magnetic field exposure cannot be ruled out. Overall, these results suggest that prenatal exposure to a 50 Hz magnetic field does not engender any gross impairments in the postnatal development or behavior of mice. This does not preclude such exposure affecting more subtle aspects of behavior.

A musculoskeletal outreach screening, treatment, and education program for urban minority children

PURPOSE

A hospital-based outreach program was initiated to screen minority children in medically underserved areas of New York City for musculoskeletal diseases. We examine the number of such diseases in this population, and evaluate the program's success to facilitate referral and follow-up of children with referral conditions.

METHODS

Screenings were conducted at schools and day-care centers. Children requiring further evaluation were referred to the sponsoring hospital, a major referral center for musculoskeletal diseases. Bilingual educational strategies, transportation reimbursement, and coverage for uninsured children were used to foster participation and increase follow-up.

RESULTS

A total of 2,523 children were screened, 168 (6.7%) of whom were referred for one of 45 different musculoskeletal disorders, including scoliosis and back problems, foot problems, in- and out-toeing, knee or hip pain, and problems of joint range of motion. Sixty-seven percent of those referred had a follow-up medical consultation.

CONCLUSIONS

A substantial proportion of urban minority children have previously undiagnosed musculoskeletal disorders that, if left untreated, have the potential to lead to significant disability in later life. Targeted screening programs can be effective in identifying such disorders, and providing and opportunity for early diagnosis, treatment, and education.

An anthropometric study of pedophiles and rapists

Anthropometric measurements were obtained on pedophiles (n = 23) and rapists (n = 13) who were in a forensic treatment facility. Hand grip strength was measured with a Jamar hand dynamometer. Ten separate body measurements were taken including height and weight. As an indicator of body fat, triceps skinfold thickness was obtained with calipers on the non-dominant arm. The findings provided mild support for the hypothesis that the rapists in the sample would be stronger, more muscular, and have less body fat than the pedophiles.

An organizational model for developing multidisciplinary clinical research in the academic medical center

OBJECTIVE

To assess the impact of a new organizational model designed to stimulate multidisciplinary clinical research.

METHODS

We conducted a prospective, 3 1/2-year followup of a research training program for residents, fellows, faculty, nurses, and allied health professionals in rheumatology and orthopedic surgery. Program components included a multidisciplinary clinical research conference, a clinical research methods curriculum, consultations, a patient registry, and regular meetings of a Research Methodology Core group. Measures included participation in each program component and the number of new investigators who developed funded clinical research projects.

RESULTS

The multidisciplinary clinical research conference was attended by 369 new health professionals; 218 professionals participated in at least one of the courses; and 280 consultations were provided to 108 professionals. Thirteen new investigators developed 17 new grant proposals, of which 14 were externally funded. Investigators who successfully procured funding for new projects demonstrated significantly more participation in program components compared with those who did not (P < 0.001 overall).

CONCLUSION

Participation in the program was significantly correlated with the development of new prospective patient-based studies. We conclude that our model has the potential to foster such research in other settings.

Adapting the systemic lupus erythematosus self-help (SLESH) course for Latino SLE patients

The Systemic Lupus Erythematosus Self-Help (SLESH) Course is an effective self-management program that provides knowledge and enabling skills to people with systemic lupus erythematosus (SLE) and their families to assist them in coping with the disease. However, many acknowledge that the program has largely failed to meet the needs of people from diverse cultural backgrounds. In order to better understand how the SLESH Course can be more responsive to the needs of people from diverse cultural groups, we conducted a case study to analyze the content, process, and logistics of the course. The purpose of our study was to determine the essential variables to be considered in adapting the program for Latino SLE patients. Utilizing a three-phase approach that involved key-informant interviews, focus groups, and evaluation of skill-building activities, we found that culturally determined health beliefs, language of preference, and outreach efforts are the key variables that must be considered in adapting the SLESH Course for the target population. Culturally determined health beliefs, such as the importance of family roles rather than individual need and an emphasis on the interdependency of family members, need to be considered in adapting self-help programs like the SLESH Course for Latino SLE patients.

MRI in migraineurs

Forty-six migraineurs and 69 age- and sex-matched controls referred for MRI scans of the brain were evaluated for the incidence of intracranial pathology. Axial long TR/short TE and long TR/long TE and sagittal short TR/short TE scans were performed in all patients. Enhancement with Gd-DTPA was performed in all controls and in nine migraineurs. Six of 46 (13%) of the migraineurs had white matter lesions versus three of 69 (4.3%) of the controls. The white matter lesions in migraineurs were seen in a younger age group than in the controls. These findings agree with recent MRI studies. Ischemia or an immune-based white matter demyelination are possible mechanisms for the white matter lesions.

Outpatient repetitive intravenous dihydroergotamine

The efficacy of the repetitive intravenous dihydroergotamine (DHE) inpatient protocol for refractory headache is well established. We conducted a retrospective and prospective study of long-term headache patients at our clinic to evaluate this regimen in an outpatient setting. Treatment consisted of oral metoclopramide and four doses of DHE, with the total dose equaling 4 mg., administered over two days. Patients were followed for up to 10 weeks while they continued to receive prophylactic medication. Responsiveness was rated in terms of decreased frequency or severity of headache: excellent (75% to 100%), moderate (50-75%), mild (25-50%), and none (0-25%). In the retrospective study, 69% (43/62) of patients with chronic daily muscle-contraction-type headache and severe migraine had an excellent response at two days. An excellent or moderate response was sustained over three weeks in 65% (32/49) of the study group (13 patients were dropped from the study for failing to comply with record keeping requirements). At the 6- and 10-week follow-up evaluations, the majority of patients (76% and 70%, respectively) reported mild or no relief. Among patients with refractory daily headache or frequent severe migraine studied prospectively, 80% (28/35) reported an excellent response at two days. After six weeks, 66% (23/35) showed excellent or moderate relief. For both groups combined, 73% (71/97) of patients showed an excellent response to DHE at two days, with 43% (33/77) sustaining excellent or moderate relief at six weeks. Side effects, including nausea, leg cramps, facial flushing, increased blood pressure, diarrhea, burning at the injection site, and tightness in the throat and/or chest, were generally mild and transient.(ABSTRACT TRUNCATED AT 250 WORDS)

Itemmetric and scale analysis of a new computer-assisted competency assessment instrument (CADCOMP)

Male defendants (n = 99) who had been court ordered to a forensic treatment facility as incompetent to stand trial were tested using the Computer-Assisted Determination of Competency to Proceed (CADCOMP) instrument soon after admission (median days = 15). Shortly thereafter, competency was assessed by a forensic psychiatrist and by a majority decision of three mental health professionals who viewed a videotape of the forensic psychiatrist's interview. From the CADCOMP item pool, 18 scales were constructed on conceptual grounds. Internal consistency analyses revealed that most scales had reasonable item homogeneity and scale reliability. In addition, item and scale analyses, with few exceptions, followed predicted patterns of intercorrelation and association with competency as determined by both criteria. Scales and items measuring serious psychopathology, psycholegal ability, and criminal history demonstrated the strongest associations with competency. These findings suggest that additional research on CADCOMP is warranted. The instrument shows promise for use in forensic research and assessment.

Migraine and anticardiolipin antibodies--case reports of 13 patients, and the prevalence of antiphospholipid antibodies in migraineurs

Thirteen patients with both migraine and positive anticardiolipin antibodies (ACL) are discussed. Several of the patients were treated with immunosuppressives, aspirin, and anticoagulants. In addition, one underwent plasmapheresis. Sixty-eight migraineurs were screened for the presence of anticardiolipin antibodies. Low positive IgG ACL were identified in 13 patients, medium positive ACL were present in two patients, and one patient had high IgG levels for ACL. The number of positives in migraineurs was significantly higher than in controls.

Hip fracture in older persons. Does self-efficacy-based intervention have a role in rehabilitation?

Over 250,000 patients are hospitalized each year in the United States for treatment of a fractured hip, resulting in considerable medical, social, and economic costs to society. Most hip fractures occur among older persons who have fallen. The consequences of hip fractures due to falls by older persons include loss of confidence and the accompanying deterioration in global functional capacity for independent living. This article reviews the problem of hip fracture in the elderly and suggests that intervention approaches designed to enhance personal self-efficacy through patient education may have an important role to play in rehabilitation after hip fracture.