Genetics professionals' experiences with grief and loss: implications for support and training.

This study was designed to determine the degree to which clinical genetics professionals are comfortable with grief and loss, whether discomfort with grief and loss is associated with clinician distress, and what factors predict comfort with grief and loss for the purpose of developing recommendations for support and training. We surveyed 300 clinical geneticists (MDs), genetic counselors (GCs) and genetic nurses randomly selected from their professional associations. Out of 225 eligible clinicians, 172 completed surveys (76% response rate). The vast majority of respondents have clinical interactions with patients and families who are experiencing grief, loss and/or death. However, nearly 20% of respondents reported that they did not feel 'comfortable in the presence of grief and loss'. Twenty-nine percent of respondents disagree or strongly disagree that they 'have been adequately trained to address issues of death, dying, grief/bereavement, and end of life care'. Reported discomfort with grief and loss was strongly correlated with clinician distress. Predictors of comfort with grief and loss included perceived adequacy of training, tolerance for uncertainty, significant personal experiences of loss and deriving meaning from patient care. In conclusion, as follows. A significant minority of clinical genetics professionals experience discomfort in the presence of grief and loss, and feel inadequately prepared for such experiences. Greater attention should be paid to training clinicians in how to deal with grief and loss, and supporting them through such difficult experiences in an effort to reduce their distress.

Predictors of variability in urinary incontinence and overactive bladder symptoms.

AIMS: We used data from the General Longitudinal Overactive Bladder Evaluation (GLOBE) to understand predictors of variation in urgency and urinary incontinence (UI) symptoms over time. METHODS: A random sample of Geisinger Clinic primary care patients (men and women) 40+ years of age were recruited for a survey of bladder control symptoms at baseline and 12 months later. Symptom questions used a 4-week recall period. Composite scores were derived for urgency and UI frequency. Logistic regression was used to evaluate predictors of variation in scores at cross-section and longitudinally. RESULTS: A majority of those with UI symptoms and almost 40% of those with urgency symptoms reported episodes of once a week or less often; 17% had symptoms a few times a week or more often. Twenty-one percent with urgency symptoms and 25% with UI symptoms at baseline did not have active symptoms 12 months later. The strongest predictors of active symptoms at follow-up were baseline symptom score and duration of time since first onset of symptoms. Of those with no urgency symptoms at baseline, 22% had urgency at 12 months. Among those with no UI symptoms at baseline, 13% had UI symptoms 12 months later. Among the latter, age (males only) and BMI were the strongest predictors of symptoms at follow-up. CONCLUSIONS: Inter-individual and intra-individual occurrences of urgency and UI symptoms are highly variable in the general population. Use of established predictors to select individuals with less variability in symptoms may help to reduce placebo rates in clinical trials.

Validity and reliability of the Migraine-Treatment Optimization Questionnaire.

Our aim was to establish the validity and reliability of a patient-rated Migraine Treatment Optimization Questionnaire (M-TOQ) in primary care. Patients who met International Classification of Headache Disorders, 2nd edn criteria for migraine completed a 19-item questionnaire containing candidate items for the M-TOQ, and three questionnaires designed to test convergent/construct validity [Migraine Disability Assessment Scale (MIDAS), Headache Impact Test (HIT)-6 and Migraine-Specific Quality of Life Scale (MSQoL)]. A 15-item (M-TOQ-15) and a five-item (M-TOQ-5) questionnaire were derived. Two hundred and fifty-three adult patients were recruited. Five treatment optimization domains were identified: functioning, rapid relief, consistency of relief, risk of recurrence and tolerability; with Cronbach alphas of 0.70-0.84. The Cronbach alpha for M-TOQ-15 was 0.85, and it correlated well with MIDAS, HIT-6 and MSQoL (r = 0.33-0.44). The Cronbach alpha for M-TOQ-5 was 0.66, and it also correlated well with the three questionnaires (r = 0.33-0.41). The utility of the M-TOQ for assessing treatment benefit in research (M-TOQ-15) and primary care (M-TOQ-5) should be further validated.

Familial risk of migraine: variation by proband age at onset and headache severity.

BACKGROUND: It is well established that migraine aggregates within families. Less is known about the influence of proband characteristics (e.g., age at onset, headache severity) on familial aggregation. OBJECTIVE: To examine the association between the proband's migraine severity and age at migraine onset and familial aggregation of migraine. METHODS: The authors investigated the migraine prevalence in first-degree relatives of 532 persons with migraine and control subjects in a population study. Familial aggregation was expressed as the risk of migraine in family members of probands divided by risk in control family members. RESULTS: The relative risk (RR) of migraine in first-degree relatives of migraine probands was elevated compared with family members of controls (RR = 1.88; 95% CI: 1.30 to 2.72). The RR was also significantly higher for relatives of probands reporting onset of migraine before age 16 (2.50; 95% CI: 1.65 to 3.79) compared with those with onset at age 16 or older (1.44; 95% CI: 0.93 to 2.23). Among probands with very severe average pain scores (i.e., 9 to 10 on a 0 to 10 scale), the RR of migraine in family members was 2.38 (95% CI: 1.56 to 3.62) compared with 1.52 (0.99 to 2.34) for less severe pain (p < 0.05). CONCLUSION: Early onset of migraine in the proband as well as the severity of migraines are associated with higher levels of family aggregation.

Patterns of medical diagnosis and treatment of migraine and probable migraine in a health plan.

The objectives of this study were to assess the proportion of subjects with strict migraine (SM, migraine with and without aura), probable migraine (PM), and all migraine (AM, SM and PM pooled together), who receive a medical diagnosis or a specific treatment within a health plan. Eligible participants were 18-55-year participants of a non-profit health maintenance organization (HMO) who had received out-patient, emergency department, or in-patient care from a physician within the past year. We used a validated computer-assisted telephone interview (CATI) survey to identify SM, PM and controls (received out-patient, emergency department, or in-patient care from a physician for any reason within the past year, but did not have SM or PM). Medical and prescription drug claims for the 24-month period were linked to participant files. Among 8579 respondents, we identified 1265 SM sufferers and 1252 PM sufferers, which were compared with 960 randomly selected controls. Just 194 (15.3%) SM, 21 (1.7%) PM, and 215 (8.5%) AM sufferers received an in-patient or out-patient primary migraine claim in the previous 24 months, compared with six (0.5%) controls; 240 (18.9%) SM, 39 (3.1%) PM, 279 (11.1%) AM sufferers, and eight controls (0.6%) received any migraine claim. There were claims for migraine drugs (ICD-9 code for triptans or ergot compounds) for just 140 (11.1%) SM and 34 (2.7%) PM sufferers, and migraine analgesics (butalbital and isomethepthene compounds), for 6.3% SM and 2.2% PM sufferers (0.7% of the controls). Migraine preventives were used for a larger number of SM and PM sufferers (19.6% and 13.1%), but also for controls (10.5%), indicating that they were probably used for other medical reasons. Both SM and PM are underdiagnosed and undertreated within a health plan. Educational strategies should focus on physician education addressing diagnosing the full spectrum of migraine and physician management of migraine with specific migraine therapy in appropriate patients.

Prevalence and impact of migraine and probable migraine in a health plan.

BACKGROUND: A large number of headache sufferers with features of migraine fail to meet criteria for strict migraine (SM; migraine with or without aura) but do meet criteria for probable migraine (PM). OBJECTIVES: To estimate the prevalence of PM, to compare the epidemiologic profiles of SM and PM, and to assess the disability and impact on the health-related quality of life (HRQoL) of these patients. METHODS: Computer-assisted telephone interviews in a sample recruited from a mixed model health maintenance organization were used. SM, PM, and control subjects were identified. Also assessed were demographic features, disability, HRQoL, and depression. RESULTS: The 1-year prevalence for SM was 14.7% (19.2% in women and 6.6% in men); for PM, it was 14.6% (15.9% in women, 12.6% in men). Most subjects with PM (82%) did not meet the associated symptom criteria for migraine. HRQoL was reduced in the PM, SM, and all migraine (AM; SM and PM pooled together) groups compared with controls. The proportion of subjects with high disability was elevated in PM (13%), SM (31%), and AM (22%) groups vs controls (3.7%; p < 0.0001). CONCLUSIONS: Within a health plan, probable migraine is a prevalent form of migraine, with symptom and epidemiologic profiles that overlap with strict migraine. Although strict migraine prevalence was consistent with previous studies, a probable migraine prevalence higher than previously reported was found, perhaps reflecting a difference between health plan and population samples.

Acetaminophen in the treatment of headaches associated with dipyridamole-aspirin combination.

The authors assessed the prevalence of headaches following extended-release dipyridamole/aspirin combination (DAC), and the efficacy of acetaminophen in the treatment of these headaches. Following DAC, 38.7% of the participants developed headaches. The headaches were self-limited (69.4% placebo efficacy in 2 hours) and the incidence markedly declined over time. Acetaminophen was no more effective than placebo in the acute and preemptive treatment of these headaches.

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

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

A self-administered screener for migraine in primary care: The ID Migraine validation study.

BACKGROUND: Migraine is a highly prevalent and disabling illness that remains substantially undiagnosed in primary care. Because of the potential value of a screening tool, the current study was designed to establish the validity and reliability of a brief, self-administered migraine screener in patients with headache complaints in the primary care setting. METHODS: A total of 563 patients presenting for routine primary care appointments and reporting headaches in the past 3 months completed a self-administered migraine screener. All patients were then referred for an independent diagnostic evaluation by a headache expert, of whom 451 (80%) completed a full evaluation. Migraine diagnosis was assigned based on International Headache Society criteria after completing a semi-structured diagnostic interview. RESULTS: Of nine diagnostic screening questions, a three-item subset of disability, nausea, and sensitivity to light provided optimum performance, with a sensitivity of 0.81 (95% CI, 0.77 to 0.85), a specificity of 0.75 (95% CI, 0.64 to 0.84), and positive predictive value of 0.93 (95% CI, 89.9 to 95.8). Test-retest reliability was good, with a kappa of 0.68 (95% CI, 0.54 to 0.82). The sensitivity and specificity of the three-item migraine screener was similar regardless of sex, age, presence of other comorbid headaches, or previous diagnostic status. CONCLUSIONS: The three-item ID Migraine migraine screener was found to be a valid and reliable screening instrument for migraine headaches. Its ease of use and operating characteristics suggest that it could significantly improve migraine recognition in primary care.

The family impact of migraine: population-based studies in the USA and UK.

Despite an extensive body of research on the individual burden of migraine, few studies have examined its impact on the family. We aimed to assess the impact of migraine on family life both from the perspective of those with migraine and from the perspective of their partners. A validated computer-assisted telephone interview (CATI) identified 574 people with migraine from a population sample of 4007 in mainland England, and 568 from 4376 in Philadelphia County, in the USA. Migraine cases with six or more migraine attacks per year and living as married with partners were asked, along with their partners, to participate in this study. In a follow-up interview, questions were asked of the proband (i.e. subject identified with migraine in the survey) about the impact of migraine. Similar questions were also asked of the probands' partners regarding the impact of the proband's migraine on their participation in social, family and leisure activities and on family relationships. The samples from the two countries showed similar characteristics, and were combined. Of 389 people with migraine living with a household partner, 85% reported substantial reductions in their ability to do household work and chores, 45% missed family social and leisure activities, and 32% avoided making plans for fear of cancellation due to headaches. One half believed that, because of their migraine, they were more likely to argue with their partners (50%) and children (52%), while majorities (52-73%) reported other adverse consequences for their relationships with their partner and children, and at work. A third (36%) believed they would be better partners but for their headaches. Participating partners (n = 100) partly confirmed these findings: 29% felt that arguments were more common because of headaches and 20-60% reported other negative effects on relationships at home. Compared with subjects who did not have migraine regarding their work performance, a statistically significantly higher proportion of migraine partners were unsatisfied with work demands placed on them (P = 0.02), with their level or responsibilities and duties (P = 0.02), and with their ability to perform (P = 0.001). Results from this study show that the impact of migraine extends to household partners and other family members.

Migraine headache disability and health-related quality-of-life: a population-based case-control study from England.

The aims of this study were: (i) to compare health-related quality of life (HRQoL) as measured by the Medical Outcomes Study Short Form 36-Item Health Survey (SF-36) in a population sample of migraine headache sufferers and controls without migraine; (ii) to assess the relationship of HRQoL and work-related disability attributed to headache in a population sample. The study was conducted in two phases. First, a population-based, telephone interview survey of 5769 residents of greater London, England was conducted to identify individuals with migraine headache (cases) and controls without migraine. In the second stage, in-person interviews were conducted in a matched sample of 200 migraine cases and 200 controls selected from survey respondents. At the beginning of the in-person interview, participants were asked to complete the SF-36. In addition, a work-related disability score based on the telephone interview was defined as the number of lost work days or days when usual activity was reduced by 50% or more over the previous year. The disability score was trichotomized as mild (n = 98), moderate (n = 49), and severe disability (n = 49). Compared with controls, individuals with migraine headache scored significantly lower in eight of the nine domains of the SF-36 as well as in the overall Physical Component Summary (PCS) score and Mental Component Summary (MCS) score. Further, among migraine sufferers, each of the disability groups scored significantly lower in seven of the nine domains and in the summary scales. Scores showed greater reductions in HRQoL for the moderate and severe disability groups vs. the mild disability group in five of nine scales and in the Total Physical Summary score. We conclude that, in a population-based sample of migraine headache sufferers, individuals with migraine headache have lower HRQoL scores compared with controls. Moreover, among individuals with migraine headache, work-related disability is associated with lower HRQoL scores. Specifically, individuals classified with moderate to severe work-related disability had lower HRQoL scores than those classified with low disability.

Patterns of health care utilization for migraine in England and in the United States.

OBJECTIVE: To assess patterns of medical consultation, diagnosis, and medication use in representative samples of adults with migraine in England and the United States. METHODS: Validated computer-assisted telephone interviews were conducted in the United Kingdom (n = 4,007) and the United States (n = 4,376). Individuals who reported six or more headaches per year meeting the criteria for migraine were interviewed. RESULTS: Patients with migraine in the United Kingdom were more likely to have consulted a doctor for headache at least once in their lifetime (86% vs 69%, p < 0.0001), but also were more likely to have lapsed from medical care (37% vs 21%, p < 0.001). In the United States, patients with migraine who had consulted made more office visits for headache and were more likely to see a specialist. In the United States, but not in the United Kingdom, women with migraine were more likely than men to consult doctors for headache. Patients with migraine in the United Kingdom were more likely to receive a medical diagnosis of migraine (UK 67%, US 56%; p < 0.05). Patterns of medication use were similar in both countries, with most people treating with over-the-counter (OTC) medications. Substantial disability occurred in a high proportion of those who never consulted (UK 60%, US 68%), never received a correct medical diagnosis (UK 64%, US 77%), and treated only with OTC medication (UK 72%, US 70%). CONCLUSION: Medically unrecognized migraine remains an important health problem both in the United States and the United Kingdom. Furthermore, there may be barriers to consultation for men in the United States that do not operate in the United Kingdom.

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

OBJECTIVE: To determine the prevalence and distribution of migraine in the United States as well as current patterns of health care use. METHODS: A random-digit-dial, computer-assisted telephone interview (CATI) survey was conducted in Philadelphia County, PA, in 1998. The CATI identifies individuals with migraine (categories 1.1 and 1.2) as defined by the diagnostic criteria of the International Headache Society with high sensitivity (85%) and specificity (96%). Interviews were completed in 4,376 subjects to identify 568 with migraine. Those with 6 or more attacks per year (n = 410) were invited to participate in a follow-up interview about health care utilization and family impact of migraine; 246 (60.0%) participated. RESULTS: The 1-year prevalence of migraine was 17.2% in females and 6.0% in males. Prevalence was highest between the ages of 30 and 49. Whereas 48% of migraine sufferers had seen a doctor for headache within the last year (current consulters), 31% had never done so in their lifetimes and 21% had not seen a doctor for headache for at least 1 year (lapsed consulters). Of current or lapsed consulters, 73% reported a physician-made diagnosis of migraine; treatments varied. Of all migraine sufferers, 49% were treated with over-the-counter medications only, 23% with prescription medication only, 23% with both, and 5% with no medications at all. CONCLUSION: Relative to prior cross-sectional surveys, epidemiologic profiles for migraine have remained stable in the United States over the last decade. Self-reported rates of current medical consultation have more than doubled. Moderate increases were seen in the percentage of migraine sufferers who use prescription medications and in the likelihood of receiving a physician diagnosis of migraine.

Job turnover and its correlates among residency program directors in internal medicine: a three-year cohort study.

PURPOSE: In 1983, 43% of internal medicine residency program directors had held their positions for less than three years. The purposes of this study were to determine the job turnover rate for internal medicine program directors, and the characteristics of program directors and residency programs that are associated with job turnover. METHOD: In October 1996, questionnaires were sent to all non-military internal medicine residency program directors in the continental United States listed by the Accreditation Council for Graduate Medical Education (ACGME). The questionnaire covered demographics, program characteristics, and job satisfaction. In October 1999, an updated ACGME list was used to contact programs to verify changes in program directors and determine the dates of change. RESULTS: A total of 262 usable responses were received. At the beginning of the study, 49% of the respondents had been on the job for three years or less, and 74 (29%) were no longer program directors three years later. Overall job satisfaction was highly associated (p <.01) with turnover. Multivariate Cox regression modeling yielded four variables independently associated with turnover: low satisfaction with colleague relationships (hazard ratio = 3.2, 95% CI = 1.6-6.4), a high percentage of administrative work time (HR = 2.9, 95% CI = 1.4-6.2), perceiving the job as a "stepping stone" (HR = 1.8, 95% CI = 1.0-3.2), and having had formal training to deal with problem residents (HR = 0.6, 95% CI = 0.4-1.1). Respondents with burnout, with the titles of program director and chair or department chief, and with less than two years on the job had nonsignificant trends toward job turnover. Variables not associated with turnover included gender, rank, salary, and program size. CONCLUSIONS: Yearly turnover for internal medicine residency program directors is substantial. The four independent predictors of turnover identified in this study should be of interest to institutions recruiting or retaining program directors and to aspiring program directors.

Children with asthma and nebulizer use: parental asthma self-care practices and beliefs.

We examined demographic characteristics, patterns of medication use, asthma morbidity, and asthma self-management practices and beliefs among inner-city children currently using a nebulizer. We also describe the relationship between asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room visits, hospitalizations, symptom days and nights, and school absences in this group of school-aged children with asthma. More than three-quarters (81%) reported asthma symptoms consistent with mild persistent or greater severity of asthma, and therefore these subjects should be taking AI medications. Another 16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more likely to agree with the belief that children should use asthma medications daily even when the child is not reporting any symptoms.

Physician opinion about electronic publications.

PURPOSE: Many medical journals are currently offering physicians the option to subscribe electronically, allowing readers access by means of the Internet. However, physicians' opinions about this innovation are not known. This exploratory study was designed to learn more about physicians' opinions and attitudes regarding electronic publications. SUBJECTS AND METHODS: A three-page questionnaire was developed to survey all physicians (faculty and house officers) at a large university-affiliated teaching hospital in Baltimore, Maryland. The questionnaire explored many of the features that make electronic journals distinct from printed journals. RESULTS: Of the 314 physicians surveyed, 255 (81%) returned a completed questionnaire. The mean (+/- SD) age of the respondents was 41 +/- 10 years, 164 (65%) were male, and 50 (20%) were house officers. Twenty-six percent of respondents (n = 66) thought that electronic journals would lower the quality of the medical literature, and 25% (n = 63) believed that the prestige of authorship would be lessened. Seventy to eighty percent of physicians responded that electronic journals would decrease clutter in their offices and homes, be more environmentally friendly than the current system, make it easier to locate research reports that they had read, and offer the benefit of linkage to related articles. Seventy-four percent of physicians (n = 188) were concerned about losing the convenience of being able to read a printed journal anywhere. In multivariate analyses, female sex, being a faculty member (vs house officer), fewer publications, better computer skills, and more frequent use of the Internet were independently associated with positive attitudes toward various aspects of electronic journals. CONCLUSIONS: Physicians responded favorably to the many potential values and applications of electronic publications but were most concerned with the loss of the convenience that printed journals offer.

Maternal depressive symptoms and emergency department use among inner-city children with asthma.

CONTEXT: Inner-city minority children with asthma use emergency departments (ED) frequently. OBJECTIVE: To examine whether maternal depressive symptoms are associated with ED use. DESIGN, SETTING, AND PATIENTS: Baseline and 6-month surveys were administered to mothers of children with asthma in inner-city Baltimore, Md, and Washington, DC. MAIN OUTCOME MEASURES: Use of the ED at 6-month follow-up was examined. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data. RESULTS: Among mothers, nearly half reported significant levels of depressive symptoms. There were no demographic or asthma-related differences between the children of mothers with high and low depressive symptoms. However, in bivariate analyses, mothers with high depressive symptoms were 40% (prevalence ratio [PR], 1.4; 95% confidence interval [CI], 1.0-3.6; P =.04) more likely to report taking their child to the ED. Mothers aged 30 to 35 years were more than twice as likely (PR, 2.2; 95% CI, 1.9-9.3; P =.001) to report ED use, as were children with high morbidity (PR, 1.9; 95% CI, 1.4-7.1; P =.006). Child age and family income were not predictive of ED use. After controlling for asthma symptoms and mother's age, mothers with depressive symptoms were still 30% more likely to report ED use. CONCLUSIONS: Depression is common among inner-city mothers of children with asthma. Beyond asthma morbidity, maternal age and depressive symptoms are strong predictors of reports of ED visits. Identifying and addressing poor psychological adjustment in mothers may reduce unnecessary ED visits and optimize asthma management among inner-city children.

Nebulizer use in inner-city children with asthma: morbidity, medication use, and asthma management practices.

OBJECTIVE: To assess the frequency of nebulizer use, describe morbidity and patterns of medication administration, and examine the potential relationships between inhaled anti-inflammatory medication administration, asthma morbidity, and asthma management practices in children with asthma using a nebulizer compared with children with asthma not using a nebulizer. RESEARCH DESIGN: A cross-sectional, descriptive survey of previous events. SETTING: Elementary schools and participants' homes in Baltimore, Md, and Washington, DC. PARTICIPANTS: Six hundred eighty-six families of children aged 5 to 12 years with a diagnosis of at least mild, persistent asthma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Asthma morbidity, health care utilization, pattern of asthma medication administration, nebulizer use, and asthma management data were collected by telephone survey administered to caregivers. Nebulizer use was defined as use at least 1 or more days per month during the last 6 months. Of 686 children identified, 231 (33%) reported current nebulizer use. Nebulizer users had significantly increased lifetime hospital admissions, hospitalizations, and emergency department visits in the last 6 months compared with nonnebulizer users. Inhaled corticosteroid administration was low for both groups (nonnebulizer users, 8%; nebulizer users, 15%). In the nebulizer users group, administration of inhaled anti-inflammatory medications was associated with increased asthma morbidity (increased hospitalizations, days and nights with symptoms, and oral steroid use). CONCLUSIONS: Nebulizer use by inner-city children with asthma is higher than anticipated but is not associated with reduced asthma morbidity. This group of high-risk children was undertreated with inhaled corticosteroids for long-term control of asthma despite reports of adequate monitoring by a primary care physician.

Migraine, quality of life, and depression: a population-based case-control study.

OBJECTIVE: This study reports on the influence of migraine and comorbid depression on health-related quality of life (HRQoL) in a population-based sample of subjects with migraine and nonmigraine controls. METHODS: Two population-based studies of similar design were conducted in the United States and United Kingdom. A clinically validated, computer-assisted telephone interview was used to identify individuals with migraine, as defined by the International Headache Society, and a nonmigraine control group. During follow-up interviews, 389 migraine cases (246 US, 143 UK) and 379 nonmigraine controls (242 US, 137 UK) completed the Short Form (SF)-12, a generic HRQoL measure, and the Primary Care Evaluation of Mental Disorders, a mental health screening tool. The SF-12 measures HRQoL in two domains: a mental health component score (MCS-12) and a physical health component score (PCS-12). RESULTS: In the United States and United Kingdom, subjects with migraine had lower scores (p < 0.001) on both the MCS-12 and PCS-12 than their nonmigraine counterparts. Significant differences were maintained after controlling for gender, age, and education. Migraine and depression were highly comorbid (adjusted prevalence ratio 2.7, 95% CI 2.1 to 3. 5). After adjusting for gender, age, and education, both depression and migraine remained significantly and independently associated with decreased MCS-12 and PCS-12 scores. HRQoL was significantly associated with attack frequency (for MCS-12 and PCS-12) and disability (MCS-12). CONCLUSIONS: Subjects with migraine selected from the general population have lower HRQoL as measured by the SF-12 compared with nonmigraine controls. Further, migraine and depression are highly comorbid and each exerts a significant and independent influence on HRQoL.

Assessing pediatric clinical asthma practices and perceptions: a new instrument.

Over the past 20 years, the most substantial increases in prevalence, morbidity, and mortality of asthma have been observed among children aged 5-14 years. A survey instrument designed to measure clinical asthma management practices of primary care physicians was developed and evaluated. Study participants included 127 practitioners providing pediatric asthma care in inner-city communities in Baltimore, MD and Washington, DC. Study results found that the instrument assessed four separate dimensions of clinical assessments and five dimensions of physician perceptions. These dimensions should be considered in future research protocols and may be used to design tailored interventions to improve asthma care.