The ‘red Ear Syndrome’ Revisited: Two Cases and a Review of Literature

The first description of what subsequently came to be known as the red ear syndrome (RES) was by Lance in 1994 (1) (Table 1, cases 2-4). Subsequently he reported a total of 12 patients with what he called the red ear syndrome (2) (Table 1). The syndrome was characterized by attacks of unilateral ear discomfort or burning during which the ear became red. The discomfort often extended beyond the ear. He reported an association with upper cervical disorders, glossopharyngeal and trigeminal neuralgia, temporomandibular joint (TMJ) dysfunction, and a thalamic syndrome. In two of the 12 cases (Table 1, cases 11 and 12) no cause was apparent. In some cases the episodes were spontaneous and in others they were precipitated by touch, exertion, heat or cold, neck movements, stress, cleaning the ear, washing hair or brushing it the wrong way, and eating or drinking. While some of their patients had a history of headaches (including migraines), a consistent relationship to migraine headaches was not identified.

A review of intractable facial pain secondary to underlying lung neoplasms

We describe a 63-year-old smoker who suffered from intractable facial pain secondary to an underlying lung neoplasm. Data from 30 previously reported and similar cases are also summarized. The clinical triad of a smoker suffering from periauricular pain and an elevated ESR should alert the clinician to the possibility of an occult lung mass. In these cases a computed tomography of the chest should always be obtained. Previously refractory pain typically responds to surgical resection of the mass and/or radiation therapy.

Paradoxical cerebrovascular embolism associated with pulmonary arteriovenous fistula: contrast transoesophageal echocardiographic diagnosis

We report two cases of paradoxical cerebrovascular embolism associated with intrapulmonary arteriovenous fistulas. In both cases the diagnosis was made by the use of contrast transoesophageal echocardiography, which not only detected the fistulas but also localized the arteriovenous fistula to specific pulmonary vascular beds.

Effects of involuntary outpatient commitment and depot antipsychotics on treatment adherence in persons with severe mental illness

This study examines potential improvement in treatment adherence during a study of involuntary outpatient commitment among individuals with severe mental illnesses. Involuntarily hospitalized subjects, awaiting discharge under outpatient commitment, were randomly assigned to be released or continue under outpatient commitment after hospital discharge. A nonrandomized group with a recent history of serious violence was also studied under outpatient commitment. Randomized control and outpatient commitment groups did not differ significantly in group comparisons of treatment adherence. However, analyses of all subjects, including nonrandomized violent subjects, showed that those who underwent sustained periods of outpatient commitment (6 months or more) were significantly more likely to remain adherent with medication and other treatment, compared with those who underwent only brief outpatient commitment or none. Administration of depot antipsychotics also significantly improved treatment adherence independently of the effect of sustained outpatient commitment. Sustained periods of outpatient commitment may significantly improve adherence with community-based mental health treatment for persons with severe mental illness and thus may help improve other clinical outcomes affected by adherence.

Consumer, provider, and informal caregiver opinions on psychiatric advance directives

Psychiatric advance directives (PADs) are legal documents that permit competent adults to make choices in the present about their future psychiatric treatment if they lose their decision-making capacity. PADs may provide for the appointment of surrogate decision-makers. The present project was undertaken to obtain opinions from the consumer (the patient), provider, and informal caregiver/surrogate about the Oregon PAD. Results of this pilot study show that the majority of no-PAD group consumers reported that they did not get enough help with PAD preparation. The PAD group consumers reported feeling empowered by PAD preparation, but at the follow-up interview, they were less enthusiastic and more critical of PAD policy that was relevant to implementation. Many providers also were concerned about successful PAD implementation. PAD legislation alone does not translate into adequate policy.

Medication-induced (analgesic rebound) headache: historical aspects and initial descriptions of the North American experience

A review of the initial descriptions of medication-induced (misuse) headache in the North American literature indicates that this disorder was first identified in the mid-1950s. It was not until the early 1980s that this phenomenon became well established.

A randomized controlled trial of outpatient commitment in North Carolina

OBJECTIVE

A randomized controlled trial of outpatient commitment was conducted in North Carolina to provide empirical data on involuntary outpatient commitment and to evaluate its effectiveness in improving outcomes among persons with severe mental illnesses.

METHODS

A total of 331 involuntarily hospitalized patients awaiting discharge under outpatient commitment were randomly assigned to be released or to undergo outpatient commitment. Each received case management services and outpatient treatment. Participants in both groups were monitored for one year. After the initial 90-day outpatient commitment order, a patient could receive a renewable 180-day extension. Patients in the control group were immune from outpatient commitment for one year. Information was obtained from self-reports and reports of several informants as well as from outpatient treatment, hospital, and arrest records.

RESULTS

In most bivariate analyses, outcomes for the outpatient commitment group and the control group did not differ significantly when the duration of outpatient commitment was not taken into account. However, patients who underwent sustained outpatient commitment and who received relatively intensive outpatient treatment had fewer hospital admissions and fewer days in the hospital, were more likely to adhere to community treatment, and were less likely to be violent or to be victimized. Extended outpatient commitment was also associated with fewer arrests of participants with a combined history of multiple rehospitalizations and previous arrests. The intervention was particularly effective among individuals with psychotic disorders.

CONCLUSIONS

Outpatient commitment can improve treatment outcomes when the court order is sustained and combined with relatively intensive community treatment. A court order alone cannot substitute for effective treatment in improving outcomes.

Reliability and validity of the SF-12 health survey among people with severe mental illness

OBJECTIVE

The objective of this work was to assess the reliability and validity of the Medical Outcomes Study Short-Form 12-Item Health Survey (SF-12) in a large sample of people with severe mental illness (SMI).

METHODS

We examined the internal factor structure of the SF-12, compared component scores for this sample with normative levels, examined test-retest reliability, and examined convergent and divergent validity by comparing SF-12 scores to other indexes of physical and mental health.

RESULTS

The SF-12 distinguished this sample of people with SMI from the general population, was stable over a 1-week interval, consisted of 2 fairly distinct factors, and was related to physical and mental health indexes in expected ways.

CONCLUSIONS

The SF-12 appears to be a psychometrically sound instrument for measuring health-related quality of life for people with SMI.

Zen leadership: balancing energy for mind, body, and spirit harmony

This article explores leadership characteristics and practices that assist us both professionally and personally to be authentic and integrated in mind, body, and spirit for harmony. The transformational leadership characteristics--courage; belief in people; value driven; a life-long learner and teacher; a complexity, ambiguity, and uncertainty expert; and a visionary leader--all deal with the leader's ability to develop relationships through teamwork, collaboration, networking, mentoring, and establishing boundaries. The author realized the importance of reflection to maintaining a healthy relationship not only with others but also with self.

Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness

BACKGROUND

Violent behaviour among persons with severe mental illness (SMI) causes public concern and is associated with illness relapse, hospital recidivism and poor outcomes in community-based treatment.

AIMS

To test whether involuntary out-patient commitment (OPC) may help to reduce the incidence of violence among persons with SMI.

METHOD

One-year randomised trial of the effectiveness of OPC in 262 subjects with psychotic or major mood disorders and a history of hospital recidivism. Involuntarily hospitalised subjects awaiting OPC were randomly assigned to release or court-ordered treatment after discharge. Those with a recent history of serious assault remained under OPC until expiry of the court order (up to 90 days); then OPC orders were renewed at clinical/court discretion. Control subjects had no OPC. Four-monthly follow-up interviews with subject, case manager and collateral informant took place and service records were collected.

RESULTS

A significantly lower incidence of violent behaviour occurred in subjects with > or = 6 months' OPC. Lowest risk of violence was associated with extended OPC combined with regular out-patient services, adherence to prescribed medications and no substance misuse.

CONCLUSIONS

OPC may significantly reduce risk of violent behaviour in persons with SMI, in part by improving adherence to medications while diminishing substance misuse.

Incidence of medically recognized migraine: A 1989-1990 study in Olmsted County, Minnesota

OBJECTIVE

To investigate the incidence of medically recognized migraine in Olmsted County, Minnesota, during the years 1989 to 1990.

METHODS

We used the records-linkage system of the Rochester Epidemiology Project to identify all subjects who sought medical attention for their headache and had their initial visit for migraine within the study period. Incident cases were classified using specified criteria.

RESULTS

From 9837 records screened, we found 713 incident cases. The average annual incidence rate (new cases per 100 000 person-years) was 343.0 in both sexes combined, 481.6 in women, and 194.4 in men. In women, incidence rates were low at the extremes of age and higher among those aged between 10 and 49 years, with a striking peak at the age of 20 to 29 years. Migraine without aura was the most common type of migraine in women. Men had a more constant risk of migraine throughout life with a lesser peak at the age of 10 to 19 years, and they were equally affected by all types of migraine. Women had consistently higher incidence rates than men at all ages, and there were strikingly higher incidence rates of migraine without aura in women than in men.

CONCLUSIONS

Although our incidence rates were restricted to medically recognized cases of migraine, we confirmed previously reported epidemiological patterns.

Psychiatric advance directives: an alternative to coercive treatment?

Psychiatric Advance Directives (PADs) are a legal means by which persons with mental illness, while competent to make healthcare decisions, may specify their preferences for treatment and may designate a surrogate decision-maker to act on their behalf in the event of an incapacitating mental health crisis. PADs have been advocated as a strategy to increase autonomy and decrease coercion in the treatment of severe psychiatric illness, but there has been little research on the actual use and effects of PADs. This article develops a conceptual model for how PADs might work, both directly and indirectly. According to the model proposed here, PADs might provide an effective tool for managing psychiatric crises but might also help to improve participation in regular outpatient treatment. This article further examines arguments for and against PADs and looks optimistically toward their use as an alternative to more coercive approaches to mental health treatment such as outpatient commitment (OPC).

Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals

OBJECTIVE

The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses.

METHOD

Subjects who were hospitalized involuntarily were randomly assigned to be released (N = 135) or to continue under outpatient commitment (N = 129) after hospital discharge and followed for 1 year. Each subject received case management services plus additional outpatient treatment. Outpatient treatment and hospital use data were collected.

RESULTS

In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment.

CONCLUSIONS

Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.

Increasing incidence of medically recognized migraine headache in a United States population

OBJECTIVE

To investigate trends in the incidence of medically recognized migraine in Olmsted County, Minnesota over approximately a decade.

METHODS

The authors used the records-linkage system of the Rochester Epidemiology Project to identify individuals whose records included any diagnostic rubric related to headache for the 3-year period 1979 through 1981 and the 2-year period 1989 through 1990. A nurse abstracter and a neurologist (J.W.S.) reviewed the complete history of each potential case and assigned a diagnosis using the International Headache Society classification (IHS, modified). Only patients who consulted a doctor for their headache and had their initial visit for migraine within the study years were considered as incident cases.

RESULTS

The incidence of medically recognized migraine increased in female subjects between the 1979-through-1981 period and the 1989-through-1990 period for all ages, but particularly among those who were aged 10 to 49 years. The peak incidence rate at age 20 to 29 years increased from 634.5 new cases per 100,000 person-years in 1979 through 1981 to 986.4 in the 1989-through-1990 period (absolute increase 351.9; relative increase 56%). The rise in incidence in female subjects was most sizable for migrainous disorder (IHS code 1.7); smaller increases were noted for migraine without aura and with typical aura. Only a slight absolute increase in migraine incidence rates was observed in male subjects, restricted to those 10 to 19 years of age (absolute increase 174.7; relative increase 89%).

CONCLUSIONS

Although the incidence rates reported here are restricted to patients who consulted a doctor for their headache, the authors suggest that the incidence of migraine has increased over time in female subjects, especially those of reproductive age. The increase was most pronounced for migrainous disorder. Incidence rates were more stable in male subjects over time.

Physicians' legal defensiveness and knowledge of medical law: comparing Denmark and the USA

The impact of legal factors on medical treatment decisions for dying patients has been studied in the USA for years. However, it is unknown how legal factors may affect similar medical decisions in other countries. This exploratory study compared responses between two populations of physicians, from Denmark (n = 62) and the USA (n = 301), who regularly treat terminally ill patients in tertiary care medical centers. We investigated whether Danish and US physicians differed significantly in their attitudes about the influence of law on treatment decisions for terminally ill patients. The Danish physicians demonstrated significantly better knowledge of medical law relevant to end-of-life treatment than did US physicians. The Danish sample also reported significantly lower levels of legal defensiveness than the US sample. These findings are consistent with our previous research showing that, among US physicians, legal defensiveness and knowledge of medical law are inversely related.

Headache After Resection of Acoustic Neuroma

Long-lasting severe headaches are reported to occur in up to 83% of patients who have undergone resection of acoustic neuroma, especially through a suboccipital approach. These headaches, however, are not well defined. The objective of this study was to assess the frequency and character of new-onset headaches after resection of acoustic neuroma by a suboccipital approach with cranioplasty. Review of the medical record was followed by a telephone interview with 48 patients (67% female; mean age, 52 years) who had undergone resection of an acoustic neuroma through a suboccipital craniotomy during the 2 years before the study. Of the 48 patients, 58% had post-operative head pain that lasted more than 7 days and could be categorized into two types. A moderate to severe, short-term head pain with gradual resolution occurred in 35% of the patients, and a mild, unremitting pain was reported by 23%. Both types of pain had a dull ache or pressure quality and were adjacent to or confined to the incisional area. Overall, 77% of the patients were pain-free within 4 months after operation. Age, sex, tumor size, or preoperative history of headache did not influence development of the postoperative pain. We found that new-onset headache after resection of acoustic neuroma by a suboccipital approach with cranioplasty is much less common than previously reported and is best described as mild incisional pain rather than a severe headache. The literature regarding headaches after different surgical approaches for acoustic neuroma resection is reviewed, and possible explanations for development of the pain are discussed.

Autonomic Dysfunction in Migraineurs

OBJECTIVE

To evaluate autonomic function and sympathovagal balance in migraineurs and healthy controls.

BACKGROUND

The pathophysiology of migraine is still largely unknown. An imbalance of the autonomic nervous system could explain many of the clinical manifestations of the disorder.

MATERIALS AND METHODS

We undertook autonomic function tests in 17 women suffering from migraine (8 with aura) (average age 36 +/- 7 years) and 16 healthy women (average age 34 +/- 7 years). Autonomic nervous system studies consisted of tests of sympathetic function (the quantitative sudomotor axon reflex test, beat-to-beat blood pressure responses to the Valsalva maneuver, sustained handgrip, cold pressor test, and head-up tilt and tests of parasympathetic function (heart rate responses to deep breathing and the Valsalva maneuver). The data from the tilt test were further evaluated by time-frequency analysis (Wigner distribution).

RESULTS

Subjects with migraine with aura had a smaller increase of mean blood pressure during phase IV of the Valsalva maneuver (P<0.05) and a lower blood pressure increment during the handgrip test (P=0.08); their time-frequency distribution showed reduced power at the nonrespiratory frequencies in the R-R interval at both minutes 1 (P<0.03) and 5 (P<0.04) of head-up tilt. Sympathovagal balance (a ratio of spectral power of nonrespiratory frequency variations in blood pressure to that at respiratory frequency variations in the R-R interval) was significantly increased in migraineurs, both with and without aura, by 10 minutes of head-up tilt.

CONCLUSION

Subjects with migraine with aura had resting supine sympathetic hypofunction and intact parasympathetic function. With head-up tilt, sympathovagal balance is increased. The dynamic alterations in autonomic nervous system function may contribute to the development of aura in patients with migraine.

Criminal victimization of persons with severe mental illness

OBJECTIVE

The types and amounts of crime experienced by persons with severe mental illness were examined to better understand criminal victimization in this population.

METHODS

Subjects were 331 involuntarily admitted psychiatric inpatients who were ordered by the court to outpatient commitment after discharge. Extensive interviews provided information on subjects' experience with crime in the previous four months and their perceived vulnerability to victimization, as well as on their living conditions and substance use. Medical records provided clinical data.

RESULTS

The rate of nonviolent criminal victimization (22.4 percent) was similar to that in the general population (21.1 percent). The rate of violent criminal victimization was two and a half times greater than in the general population--8.2 percent versus 3.1 percent. Being an urban resident, using alcohol or drugs, having a secondary diagnosis of a personality disorder, and experiencing transient living conditions before hospitalization were significantly associated with being the victim of a crime. In the multivariate analysis, substance use and transient living conditions were strong predictors of criminal victimization; no demographic or clinical variable was a significant predictor. (Given the relatively high crime rates, subjects' perceived vulnerability to victimization was unexpectedly low; only 16.3 percent expressed concerns about personal safety. Those with a higher level of education expressed greater feelings of vulnerability.

CONCLUSIONS

The study found a substantial rate of violent criminal victimization among persons with severe and persistent mental illness. Results suggest that substance use and homelessness make criminal victimization more likely.

Taking the wrong drugs: the role of substance abuse and medication noncompliance in violence among severely mentally ill individuals

Increasing numbers of severely mentally ill individuals are being treated in nonhospital, community-based settings and public concern about potential violence by these individuals has increased, often as a result of tragic, albeit uncommon events. The present study examines potential predictors of serious violence among persons with severe mental illness (SMI), with a specific focus on the joint effect of substance abuse and medication noncompliance. Subjects in the study are involuntarily admitted inpatients with SMI awaiting a period of court-ordered outpatient treatment, termed "involuntary outpatient commitment". During enrollment in a longitudinal outcome study of the effectiveness of OPC, 331 subjects and, whenever feasible, family members or other informants were interviewed. In addition, complementary data were gathered by review of involuntary commitment records and hospital records. Data collection included sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse and violent behavior during the 4 months preceding hospitalization. Descriptive and multivariable logistic regression procedures were used to examine the association between serious violent acts and a number of personal, social, and clinical characteristics. The combination of medication noncompliance and substance abuse was a significant predictor of serious violent acts in the community. Individuals who had problems with both alcohol and illicit drug abuse appear to be at greatest risk for violence. These results suggest that reducing violence risk among persons with SMI requires an aggressive approach to improving medication adherence in the context of integrated mental health and substance abuse treatment.

Risk reconsidered: targets of violence in the social networks of people with serious psychiatric disorders

Risk Reconsidered: Targets of violence in the Social Networks of People with Serious Mental illness. This exploratory analysis addresses the questions: 1) Who among the members of the social network of a person diagnosed with a major psychiatric disorder is likely to become a target of violence? 2) What kind of relationships do targets have with respondents in terms of the quality and quantity of interactions?, and 3) What are the risk factors that contribute to being a target of violence for people who are in the social networks of persons with serious mental disorders? The samples of 169 people with serious mental disorders were followed for 30 months. A logistic regression model of the risk for being a target of violence among the members of the cohort's social network reveals that both target and respondent characteristics are salient, and that mothers who live with adult children who have schizophrenia and co-occurring substance abuse bear a substantially elevated risk of becoming a target of violence, compared to other social network members. Other factors that elevate the risk for being a target of violence are being an immediate family members of the respondent, more time in residence with the respondent, and whether the respondent is financially dependent on the family. Respondents with the most mental health center visits had lower odds of committing an act or threat of violence against a social network member.

Male-female differences in the setting and construction of violence among people with severe mental illness

Data from a sample of severely and persistently mentally ill involuntary patients indicated that differences in violence between males and females in the 4 months prior to hospital admission depended on the measure. In the bivariate analysis, males had a greater prevalence of violence on the two indicators which separated more serious violence from lesser and no violence; but there was no gender difference on the more inclusive measure which incorporated threats and fights not involving weapons or injuries. In multivariate analysis when other relevant predictors were controlled, gender was significant in predicting only the most inclusive indicator of violence and only in interaction with substance abuse problems.

Chronic paroxysmal hemicrania presenting as otalgia with a sensation of external acoustic meatus obstruction: two cases and a pathophysiologic hypothesis

OBJECTIVE

To describe two cases of chronic paroxysmal hemicrania manifested by otalgia with a sensation of external acoustic meatus obstruction and to suggest that the trigeminal-autonomic reflex is a mechanism for the sensation of ear blockage.

BACKGROUND

Maximum pain in chronic paroxysmal hemicrania is most often in the ocular, temporal, maxillary, and frontal regions. It is less often located in the nuchal, occipital, and retro-orbital areas. Review of the literature on chronic paroxysmal hemicrania found no reports of pain primarily localized to the ear and associated with a sensation of external acoustic meatus obstruction.

METHODS

The history, physical examination, imaging studies, and successful treatment plan in two patients with otalgia and ear fullness and a subsequent diagnosis of chronic paroxysmal hemicrania are summarized.

RESULTS

The first patient was a 42-year-old woman with a 10-year history of unilateral, severe, paroxysmal otalgia occurring five times a day with a duration of 2 to 60 minutes. During an attack, the ear became erythematous and the external acoustic meatus felt obstructed. There were no other associated autonomic signs. The second patient was a 49-year-old woman with a 3-year history of unilateral, severe, paroxysmal otalgia occurring 4 to 15 times a day with a duration of 3 to 10 minutes. During an attack, her ear felt obstructed, and she noted ipsilateral eyelid edema and ptosis. Both patients quickly became pain-free after taking indomethacin and required its continued use to prevent headache recurrence.

CONCLUSIONS

Chronic paroxysmal hemicrania may be manifested by otalgia with a sensation of external ear obstruction. When the otalgia is paroxysmal, unilateral, severe, frequent, and associated with autonomic signs, one should consider the diagnosis of chronic paroxysmal hemicrania, especially because of the prompt response to indomethacin. The most important feature to consider when making the diagnosis of chronic paroxysmal hemicrania is the frequent periodicity of discrete, brief attacks of unilateral cephalgia separated by pain-free intervals. It is hypothesized that the sensation of ear obstruction in these patients is due to swelling of the external acoustic meatus mediated through increased blood flow by the trigeminal-autonomic reflex.

Administrative update: utilization of services. I. Comparing use of public and private mental health services: the enduring barriers of race and age

Data from the NIMH-Epidemiologic Catchment Area Project were used to predict differential use of private versus public outpatient mental health services, a salient concern in integrating public and private services in market-based health care reform efforts. Having a recent psychiatric disorder, being age 25-44, female, white, of higher educational level, and unmarried increase the odds of any mental health service use. However, odds of treatment in the public sector are increased for males, African Americans, those with low educational and income levels, and odds are markedly decreased for the elderly, suggesting significant barriers to care for these mentally ill subpopulations.

Violence and severe mental illness: the effects of substance abuse and nonadherence to medication

OBJECTIVE

Violent behavior among individuals with severe mental illness has become an important focus in community-based care. This study examines the joint effect of substance abuse and medication noncompliance on the greater risk of serious violence among persons with severe mental illness.

METHOD

Involuntarily admitted inpatients with severe mental illness who were awaiting a period of outpatient commitment were enrolled in a longitudinal outcome study. At baseline, 331 subjects underwent an extensive face-to-face interview. Complementary data were gathered by a review of hospital records and a telephone interview with a family member or other informant. These data included subjects' sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse, insight into illness, and violent behavior during the 4 months that preceded hospitalization. Associations between serious violent acts and a range of individual characteristics and problems were analyzed by using multivariable logistic regression.

RESULTS

The combination of medication noncompliance and alcohol or substance abuse problems was significantly associated with serious violent acts in the community, after sociodemographic and clinical characteristics were controlled.

CONCLUSIONS

Alcohol or other drug abuse problems combined with poor adherence to medication may signal a higher risk of violent behavior among persons with severe mental illness. Reduction of such risk may require carefully targeted community interventions, including integrated mental health and substance abuse treatment.

Building a successful team through collaboration

This is a tale of successfully building an interdisciplinary team in a stressful and rapidly changing ambulatory environment. It uses a framework where the leader does not have direct control over the assets but tries to influence the group to build trust, improve communication and collaborate toward common goals.

Post gamma knife headache: a new headache syndrome?

Gamma knife surgery has become an effective alternative to microsurgery in the treatment of cerebral arteriovenous malformations. In a number of patients, a de novo headache syndrome has been produced after gamma knife surgery. A case report is presented of a 62-year-old man who developed a migrainous type headache 15 months after gamma knife surgery. The current neurosurgical literature has very poor documentation of postsurgical headaches. A review of the literature was made to try to identify a stereotypic "post gamma knife headache," as well as hypothesize about its mechanism of induction.

Interpreting the effectiveness of involuntary outpatient commitment: a conceptual model

Many experimental trials of community mental health interventions fail to develop testable conceptual models of the specific mechanisms and pathways by which relevant outcomes may occur, thus falling short of usefully interpreting what happens inside the experimental "black box." This paper describes a conceptual model of involuntary outpatient commitment (OPC) for persons with severe and persistent mental disorders. The model represents an attempt to "unpack" the effects of OPC by incorporating several interacting variables at various stages. According to this model, court-mandated outpatient treatment may improve long-term outcomes both directly and indirectly in several ways: by stimulating case management efforts, mobilizing supportive resources, improving individual compliance with treatment in the community, reducing clients' psychiatric symptoms and dangerous behavior, improving clients' social functioning, and finally by reducing the chance of illness relapse and rehospitalization. A randomized clinical trial of OPC is underway in North Carolina that will test the direct and indirect effects suggested by this model, using longitudinal data from the multiple perspectives of mental health clients, family members, and case managers.

Subacute encephalomyelitis presenting as stiff-person syndrome: clinical, polygraphic, and pathologic correlations

A 60-year-old woman presented with stiff-person syndrome (SPS). Treatment with diazepam controlled her painful spasms initially. Two and one-half years after the onset of SPS, new spells of paroxysmal leg jerking and apnea developed. A spell was recorded with simultaneous video and polygraphic techniques that revealed simultaneous firing of motor unit potentials in several muscles (paraspinal, internal hamstring, and abdominal muscles). Apnea was associated with arterial oxygen desaturation. An increase in the dose of diazepam decreased the number and severity of these episodes. Seventeen months later, the patient began to taper the diazepam dose. Shortly thereafter, she had a cardiorespiratory arrest and subsequently died. Autopsy showed small chronic inflammatory foci in the pancreas (some associated with islets) and findings of diffuse encephalomyelitis characterized by perivascular cuffing in the spinal cord, brainstem, thalamus, hippocampus, and amygdala and a dense mononuclear infiltrate in the anterior horns of the lumbar and cervical cord, with relative preservation of axons and myelin. Cell typing showed this infiltrate was polyclonal and reactive. There have been rare cases of SPS associated with encephalomyelitis reported previously. Although the prolonged course in our patient suggested that SPS may have preceded encephalomyelitis, the more likely explanation is that the patient had an unusually long course of encephalomyelitis alone.

Medical futility decisions and physicians' legal defensiveness: the impact of anticipated conflict on thresholds for end-of-life treatment

Does legal defensiveness significantly influence physicians' assessments of medical futility, in ways that may adversely affect the rights of patients and their family members to make their own health care decisions at the end of life? This exploratory study addresses that question with attitudinal data from a survey of 301 physicians practicing in academic medical centers in Texas. The majority of respondents indicated that the probability of success defining futile treatment should hypothetically be lower for patients with potential to benefit more from life-sustaining medical intervention (e.g. typically patients who are sentient), and higher for patients with less potential to benefit (e.g. patients in a persistent vegetative state). That is to say, physicians normally perceive longer odds to be worth pursuing for greater potential gain - a position that seems logically consonant with patients' rational self-interest. However, physicians with an attitude of extreme legal defensiveness did not fit this pattern. Rather, they tended to define futility in a manner that would maximize the physician's latitude to justifiably oppose patient preferences for end-of-life treatment abatement. These findings suggest that some physicians assume an adversarial position in their consideration of medical futility issues - an attitude that anticipates conflict with terminally-ill patients or their surrogates. The analysis presented here is not definitive, but at least raises the question of whether some physicians may inappropriately use their prerogative over medical futility as a means to guard their professional autonomy against perceived threats.

Stereotactic radiosurgery using the gamma knife for acoustic neuromas

PURPOSE

To assess the efficacy and toxicity of stereotactic radiosurgery using the gamma knife for acoustic neuromas.

METHODS AND MATERIALS

Between January 1990 and January 1993, 36 patients with acoustic neuromas were treated with stereotactic radiosurgery using the gamma knife. The median maximum tumor diameter was 21 mm (range: 6-32 mm). Tumor volumes encompassed within the prescribed isodose line varied from 266 to 8,667 mm3 (median: 3,135 mm3). Tumors < or = 20 mm in maximum diameter received a dose of 20 Gy to the margin, tumors between 21 and 30 mm received 18 Gy, and tumors > 30 mm received 16 Gy. The dose was prescribed to the 50% isodose line in 31 patients and to the 45%, 55%, 60%, 70%, and 80% isodose line in one patient each. The median number of isocenters per tumor was 5 (range: 1-12).

RESULTS

At a median follow-up of 16 months (range: 2.5-36 months), all patients were alive. Thirty-five patients had follow-up imaging studies. Nine tumors (26%) were smaller, and 26 tumors (74%) were unchanged. No tumor had progressed. The 1- and 2-year actuarial incidences of facial neuropathy were 52.2% and 66.5%, respectively. The 1- and 2-year actuarial incidences of trigeminal neuropathy were 33.7% and 58.9%, respectively. The 1- and 2-year actuarial incidence of facial or trigeminal neuropathy (or both) was 60.8% and 81.7%, respectively. Multivariate analysis revealed that the following were associated with the time of onset or worsening of facial weakness or trigeminal neuropathy: (a) patients < age 65 years, (b) dose to the tumor margin, (c) maximum tumor diameter > or = 21 mm, (d) use of the 18 mm collimator, and (e) use of > five isocenters. The 1- and 2-year actuarial rates of preservation of useful hearing (Gardner-Robertson class I or II) were 100% and 41.7% +/- 17.3, respectively.

CONCLUSION

Stereotactic radiosurgery using the gamma knife provides short-term control of acoustic neuromas when a dose of 16 to 20 Gy to the tumor margin is used. Preservation of useful hearing can be accomplished in a significant proportion of patients.

Neurologic manifestations of Churg-Strauss syndrome

OBJECTIVE

To determine the frequency and the types of neurologic involvement in a series of patients with Churg-Strauss syndrome (CSS).

DESIGN

We reviewed the medical records of 47 consecutive patients with CSS who were examined at the Mayo Clinic between January 1974 and June 1992.

MATERIAL AND METHODS

The study patients were classified into two groups: (1) those with a histopathologically confirmed diagnosis of CSS who had evidence of either vasculitis or Churg-Strauss granuloma, the presence of asthma, and peripheral eosinophilia (more than 10% eosinophils) on at least one differential leukocyte count (N = 33) and (2) those with a clinical diagnosis of CSS who had evidence of vasculitis based on either multiple mononeuropathy or necrotizing cutaneous lesions, the presence of asthma, and peripheral eosinophilia (more than 10% eosinophils) on at least one differential leukocyte count (N = 14).

RESULTS

Of the 47 patients, 29 (62%) had neurologic involvement. Peripheral neuropathy was detected in 25 patients: 17 had multiple mononeuropathy, 7 had distal symmetric polyneuropathy, and 1 had an asymmetric polyneuropathy. Three patients had cerebral infarctions. Less commonly identified problems included radiculopathies, ischemic optic neuropathy, and bilateral trigeminal neuropathy. Asthma preceded the onset of neurologic involvement in all cases (mean duration, 6.7 years. Follow-up data, when available, showed that corticosteroid therapy usually yielded improvement or stabilization.

CONCLUSION

Neurologic involvement is common in CSS, usually manifesting as peripheral neuropathy. In this series of patients, asthma preceded the neurologic manifestations.

Incidence of cluster headaches: a population-based study in Olmsted County, Minnesota

The epidemiology of cluster headache is virtually unknown. Using the unique resources of the Rochester Epidemiology Project for population-based studies, we identified 26 Olmsted County, Minnesota, residents who fulfilled the International Headache Society criteria for newly diagnosed cluster headache between 1979 and 1981. As part of a large study of migraine and cluster headache, we screened more than 6,400 patient records from several diagnostic rubrics to obtain this cohort, accomplished case ascertainment exclusively through medical record review, and assigned diagnoses by the consensus of two neurologists. The age-adjusted incidence was 15.6 per 100,000 person-years (p-y) (95% CI, 8.9 to 22.3) for males and 4.0 per 100,000 p-y for females (95% CI, 0.4 to 7.6). The overall age- and sex-adjusted incidence was 9.8 per 100,000 p-y (95% CI, 6.0 to 13.6) or approximately 1/25 that of migraine. The peak incidence was among men aged 40 to 49 years and women 60 to 69 years. There was a higher than expected prevalence of history of smoking among males with cluster headaches (p < 0.05), supporting the possibility that smoking predisposes to the development of cluster headaches in men.

Doing all they can: physicians who deny medical futility

Why do some physicians continue to treat patients who are clearly dying or persistently unconscious, while others consider medical intervention to be futile past a certain point? No doubt, medical decisions vary in part because clinical information is often ambiguous in individual cases and because it may support more than one reasonable interpretation of a patient's chances for survival or improvement if a particular treatment is administered. Also, cases vary considerably to the extent that a patient's or a family member's preferences for treatment are communicated, understood, and implemented. But, beyond these contingencies, patients at the end of life may receive more, less, or different treatment because physicians themselves are social actors, individuals who bring to bear on their clinical decisions a variety of personal attitudes, values, concerns, and interests. Legal defensiveness, religious vitalism, authoritarianism, intolerance of ambiguity, and other traits may influence physicians’ behavior, but each may be concealed under the rubric of what is “medically indicated” or “medically appropriate.”

Hispanic Americans and the state mental hospitals in Texas: ethnic parity as a latent function of a fiscal incentive policy

This paper examines patterns of utilization of the state mental hospitals in Texas by Hispanics compared to Anglos over a 5-year period from FY 1984 to FY 1988. Historically, Hispanics have been underrepresented in public mental health client populations in the United States. In the mid-1980s in Texas, the ethnic gap in use of psychiatric facilities was expected to widen as Hispanic population growth outpaced the capacity of the public system to provide accessible mental health services for persons with serious and persistent psychiatric illnesses. But in the inpatient sector, the gap narrowed significantly in the second half of the decade, due to a policy-driven sharp reduction in the overall census of the state mental hospitals. A fiscal incentive program to stimulate the development of community-based mental health services had a markedly different effect on subsequent inpatient utilization by Anglos compared to Hispanics, most notably in counties that were less urban and less affluent and counties with a relatively high proportion of Hispanic residents. The context and mixed implications of these developments are explored.

Trauma and multiple sclerosis: a population-based cohort study from Olmsted County, Minnesota

Utilizing the Olmsted County, Minnesota, population-based records-linkage resource at Mayo Clinic, we identified an incidence and a prevalence cohort with multiple sclerosis (MS), a head injury cohort, and a lumbar disk surgery cohort to evaluate the association between mechanical trauma and MS onset or exacerbation. The MS cohorts consisted of 225 incidence cases (1905 to 1991) and 164 prevalence cases (December 1, 1991) of definite MS in the population of Olmsted County. We assessed the effect of mechanical trauma in the form of spinal injury or extremity fracture with regard to precipitation of MS or exacerbation of an existing neurologic deficit. Fifty-four episodes of trauma, as defined, occurred among 39 MS prevalence cases; most occurred 10 years or more after the onset of disease and were associated with existing MS-related disability. We compared the final disability status of the groups with and without trauma. We found no correlation between the occurrence of peripheral fractures and the onset of MS, exacerbation of MS, or final disability due to MS in the prevalence cohort. In a cohort of 819 head injury cases from the Olmsted County population, none developed MS within 6 months of the trauma. In a lumber disk surgery cohort of 942 local residents, there were five with MS, but onset of MS had preceded the spinal surgery in four of the five. Thus, we found no association of head injury and spinal disk surgery with onset of MS.

Funding, expenditures, and staffing of mental health services in state adult correctional facilities: United States, 1988

State-by-State data concerning the sources of funding, expenditures, and staffing for mental health services in State correctional facilities are reported for 1988 from the first national survey of prison mental health services conducted by the Center for Mental Health Services. Among all States, the total annual funding per prison inmate for mental health services varied widely, ranging from $5.67 to $3,159.41 per inmate, with a mean of $469.67 and median of $303.48 per inmate. States that administered 24-hour hospital mental health care to prisoners solely through the Department of Corrections (DOC) also tended to fund all types of mental health services solely through the DOC. However, in States where the Department of Mental Health (DMH) had primary administrative responsibility for 24-hour hospital mental health care, funding sources for all types of mental health services available to prison inmates were more likely to be mixed--i.e., funded through DOC as well as through DMH and other administrative entities. Master's-level mental health providers outnumbered doctoral-level professionals by more than two to one. At both of these educational levels, psychologists were numerically the largest category of provider, followed by social workers among master's-trained professionals, and followed by psychiatrists among those with doctorates. The single largest category was mental health workers with bachelor's-level training or less; this group accounted for about 44 percent of all mental health staff on State prison payrolls.

Overview of mental health services provided by state adult correctional facilities: United States, 1988

State-by-State data concerning the administrative auspices, volume of use, and sources of funding and expenditures for mental health services in adult correctional facilities are reported for 1988 from the first national survey of prison mental health services conducted by the Center for Mental Health Services. In all States reporting, a total of 11,546 State prison inmates--about 25 per 1,000--were receiving 24-hour psychiatric inpatient or residential treatment care for a psychiatric disorder on September 30, 1988. During the month of September 1988, nearly 10 percent of State prison inmates (95.6 per thousand) received some form of mental health counseling or psychotherapy from a physician, nurse, psychologist, or social worker; about 5 percent (49.7 per thousand inmates) received monitoring or evaluation of a psychotropic medications regimen; and about 4 percent (41.7 per thousand inmates) received psychiatric assessment or psychological testing to determine their mental health or emotional status. In the majority of States, 24-hour mental health care was provided in a mix of psychiatric and prison hospital settings, both on and off prison grounds, through interagency agreements, or through a mix of interagency and contractual arrangements. Individual State figures vary widely on these characteristics, as well as on length of stay for 24-hour hospital and residential treatment care, both within and among auspice types.

Neurological involvement in Wegener's granulomatosis: an analysis of 324 consecutive patients at the Mayo Clinic

Neurological involvement in Wegener's granulomatosis was studied by reviewing the charts of 324 consecutive patients in whom the diagnosis was made at the Mayo Clinic. One hundred nine patients (33.6%) had neurological involvement. Peripheral neuropathy occurred in 53; cranial neuropathy, in 21; external ophthalmoplegia, in 16; cerebrovascular events, in 13; seizures, in 10; cerebritis, in 5; and miscellaneous involvement, in 25. The mean age and sex ratio were similar in the patients with and those without neurological involvement. Among the patients with peripheral neuropathy, 42 had mononeuropathy multiplex; 6, distal symmetrical polyneuropathy; and 5, unclassified peripheral neuropathy. Multiple mononeuropathy was a major presenting symptom in 8 patients. A significantly higher percentage of patients with peripheral neuropathy, compared to those without peripheral neuropathy, had kidney involvement (p < 0.001). The second, sixth, and seventh cranial nerves were most frequently affected. Multiple cranial nerves were affected in 8 patients. Unusual neurological manifestations in the miscellaneous group were spastic paraparesis, temporal arteritis, Horner's syndrome, and papilledema.

Incidence of migraine headache: a population-based study in Olmsted County, Minnesota

To determine the incidence of clinically detected migraine headache in the defined population of Olmsted County, MN, 1979-1981, we screened over 6,400 patient records from several diagnostic rubrics using the unique resources of the Rochester Epidemiology Project for population-based studies. We identified 629 Olmsted County residents who fulfilled the International Headache Society's 1988 criteria for newly diagnosed migraine headache between 1979 and 1981. The overall age-adjusted incidence was 137 per 100,000 person-years for males and 294 per 100,000 person-years for females. The highest incidence in females was among those aged 20 to 24 years (689 per 100,000 person-years), and in males, the highest incidence was among those aged 10 to 14 years (246 per 100,000 person-years). From 1979 to 1981, there was a striking increase in the age-adjusted incidence in those under 45 years of age: the incidence increased 34% in women and 100% for men. This is the first population-based study of migraine incidence across all ages.

A binational school survey of depressive symptoms, drug use, and suicidal ideation

New findings are presented from a survey of depressive symptoms, illicit drug use, and suicidality among 4,157 adolescents attending school in six border cities in Texas and neighboring Tamaulipas, Mexico. Among the Texas youth, 48.08% scored above 16 on the Center for Epidemiologic Studies' Depression Scale (CES-D); 21% reported illicit drug use in the past month; and 23.43% said they had thought about killing themselves during the past week. Rates were lower among the Mexican youth: 39.41% had high CES-D scores; 4.95% reported drug use and 11.57% reported current suicidal ideation. Multivariate models are presented to show the linkage between psychological distress, drug use, and suicidality in this sample of border youth.

Movement disorders as sequelae of central pontine myelinolysis: report of three cases

In three survivors of central pontine myelinolysis, dystonia (in two patients) and rest tremor (in one) were sequelae. The onset of these movements occurred 3 weeks to 5 months after the initial presentation with central pontine myelinolysis. Magnetic resonance imaging revealed basal ganglia lesions suggestive of extra-pontine myelinolysis in all three patients. We propose that the movement disorders seen in our cases are clinical correlates of extra-pontine myelinolysis.

A population-based study of migraine headaches in Olmsted County, Minnesota. Case ascertainment and classification

Using the unique resources of the Rochester Epidemiology Project for population-based studies, we identified 629 Olmsted County, Minn., residents who fulfilled the 1988 International Headache Society criteria for newly diagnosed migraine over a 3-year period. Over 6,400 patient records from several diagnostic rubrics were screened; a substantial proportion of cases had been 'signed-out' to diagnoses other than 'migraine headache'. Medical records were reviewed by two trained nurses who abstracted supporting data for two neurologists. The neurologists determined whether each case met eligibility requirements and assigned a headache diagnosis by consensus. The diagnostic criteria offered some flexibility and were adapted to retrospective record-based research. Most records contained enough information to effectively classify the headache, although information on the frequency and duration of attacks proved to be problematic. A validation re-abstraction of a 10% sample of cases was undertaken with acceptable reproducibility of symptoms and diagnosis. Our study shows that migraine headache can be studied retrospectively through existing detailed medical records.

Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys

Data from the Epidemiologic Catchment Area survey were used to examine the relationship between violence and psychiatric disorders among adults living in the community. Psychiatric assessment of survey respondents was based on the Diagnostic Interview Schedule, which also provided self-report information about violent behavior. Those who reported violent behavior within the preceding year tended to be young, male, and of low socioeconomic status, and more than half met DSM-III criteria for one or more psychiatric disorders. Subjects with alcohol or drug use disorders were more than twice as likely as those with schizophrenia to report violent behavior. In a multivariate model of the predictors of violence, a significant interaction effect was found between major mental illness and substance abuse. The risk of violent behavior increased with the number of psychiatric diagnoses for which respondents met DSM-III criteria.

Multiple sclerosis: update in diagnosis and review of prognostic factors

The cornerstone of the diagnosis of multiple sclerosis is the neurologic history and examination. Support for the diagnosis as well as aid in the exclusion of other disorders can be obtained from other investigations. Analysis of cerebrospinal fluid can provide evidence of a central nervous system inflammatory process; evoked potential studies can provide evidence of subclinical multifocal involvement of the central nervous system. Magnetic resonance imaging can reveal dissemination of white matter lesions and help in the exclusion of other neurologic disorders. These tests have been incorporated into the modern diagnostic criteria for multiple sclerosis. The natural history of multiple sclerosis is variable; accordingly, early in the clinical course of the disorder, predicting the prognosis for a specific patient is usually difficult. Nevertheless, some features have limited predictive value.