How much information about adverse effects of medication do patients want from physicians?

BACKGROUND: Little information exists concerning the amount of information patients expect from physicians as to the risk for an adverse medication reaction. The present study was designed to determine such opinions in a population sample; to correlate results with sex, age, educational level, and previous experience with adverse effects; and to determine whether patients believe physicians should use discretion in the amount of such information given. METHODS: Two thousand five hundred sequential adults visiting outpatient clinics filled out a 12-item questionnaire. Percentages of subjects desiring information about varying degrees of risk and those believing physicians should and should not use discretion in the amount of such information provided were recorded. Results were correlated with demographic variables and previous experience of adverse effects. RESULTS: Among the respondents, 76.2% desired to be told of all possible adverse effects; 13.3% only if an adverse effect occurred 1 in 100 000 times; and 10.2% only if such occurrence was 1 in 100 times; 0.4% were not interested in any information. (Percentages have been rounded and do not total 100.) Percentages were closely similar to those for the same question that restricted opinion to serious adverse effects. Desire for maximum information was significantly correlated with lower educational level (P<.00l) and previous frequent experience with adverse effects (P<.001) and in older women (P<.001). The opinion that the physician should give the same information to all patients was given by 67.6% of the sample, and 73.4% opined that physicians were never justified in withholding any information. CONCLUSION: Most individuals desire from physicians all information concerning possible adverse effects of prescribed medication and do not favor physician discretion in these decisions.

Naproxen in prophylaxis of migraine.

Naproxen sodium is an inhibitor of platelet aggregation and prostaglandin synthesis and is also a potent anti-inflammatory agent. Because of these properties, it was evaluated in prophylaxis of migraine by a double-blind, placebo-controlled crossover study in 34 patients. Drug "preference" and therapeutic effect were rated by both patient and investigator. Overall, both preferred drug over placebo. An index of migraine activity was calculated from a daily record kept by the patient; it demonstrated a significant reduction in headache severity, duration, disability, and medication needed. Adverse effects were minimal and similar in drug and placebo. Naproxen is a promising agent in the prophylaxis of migraine.

Headache symptoms and psychological profile of headache-prone individuals. A comparison of clinic patients and controls.

OBJECTIVE: To compare the psychological characteristics of headache sufferers who seek medical assistance with those who do not. SUBJECTS: Fifty-one patients seeking medical help for their headache and 53 controls who had not sought medical assistance for their headache within the past 2 years. All subjects completed a structured interview that gathered headache data according to the International Headache Society classification criteria and the Minnesota Multiphasic Personality Inventory-Revised (MMPI-2). DESIGN: A 2 x 2 design was employed. Subject group (patient vs control) was the first factor and headache type (migraine vs mixed) was the second. SETTING: University medical center outpatient headache clinic. RESULTS: Patient and control groups did not differ in age, education, gender, or number of individuals with migraine. The only headache characteristic distinguishing the groups was that clinic patients rated their "most severe headache" as more intense than did controls. On the MMPI-2, the clinic group scored significantly higher on the Hypochondriasis, Depression, Hysteria, Psychasthenia, and Social Introversion scales than did controls. Severity of headache was not responsible for this difference, since it was used as a covariate in the analysis. There were no significant differences on the MMPI-2 for headache type, nor were there any significant interactions. CONCLUSIONS: These results were discussed in light of previous studies. It was concluded that psychological characteristics are important factors in the decision to seek medical help for headache.

Repeated self-induced syncope and subsequent seizures. A case report.

A patient with an unusual "compulsion" to induce syncope over a period of years by bilateral compression of the carotid arteries subsequently had recurrent seizures. The EEG showed patterns typical of cerebral ischemia during the syncope and epileptogenic foci in both temporal lobes after sleep deprivation. It is difficult to distinguish between seizure and syncope associated with involuntary movements when making a differential diagnosis. We hypothesize that the frequent self-induced ischemic insult to the brain caused a cicatrix to develop, which in turn caused the frequent seizure disorder; and that because this ischemia functioned as a stimulus to the reward site in the limbic system, the patient repeatedly induced it.

Onset of multiple sclerosis in a 24-month-old child.

A child, aged 24 months, incurred an episode of ataxic gait. Two months later, she had a recurrent episode of ataxic gait and bilateral blindness. Her symptoms were resolved with steroid therapy. A permanent visual deficit of 20/200 remained in the right eye. When she reached 16 years 10 months of age, she incurred the second episode of bilateral blindness. One month later, she had grand mal seizures. Her myelin basic protein level was elevated. Visual evoked responses were abnormal bilaterally. The combination of cerebellar, cortical, and eye symptoms, with a history of well-defined remissions, allowed the diagnosis of multiple sclerosis (MS) to be made. This is the youngest known patient with MS yet described, with the first attack occurring at 24 months of age.

Abrupt memory loss associated with thalamic tumor.

We report a case in which glioma with apparent major involvement of the right thalamus was manifested initially solely by abrupt onset of severe impairment of both recent and moderately remote memory. Distracting stimuli plays a role in prevention of consolidation of memory.

Trismus. An unusual sign in polymyositis.

Neuromuscular disease is an unusual cause of trismus. However, we describe two patients with severe polymyositis who had difficulty opening their mouths during the acute phase of the illness. Electromyography demonstrated involvement of the masseters, and there was no evidence of myasthenia. The mechanism appeared to be decreased elasticity of the masseter because of inflammation, edema, and perhaps contractures.

Propranolol and amitriptyline in prophylaxis of migraine. Pharmacokinetic and therapeutic effects.

OBJECTIVES: To determine if the effectiveness of propranolol hydrochloride and amitriptyline hydrochloride are correlated with blood levels and/or with standardized test of pharmacologic effect and to determine which clinical variables are predictors of response to one or the other medication. DESIGN: Three-month modules of treatment with each drug and placebo in a randomized crossover design. Headache scores from daily diaries were calculated at monthly intervals, as were simultaneous blood levels of drug, supine and standing blood pressure, pulse rise with exercise, and salivary flow. SETTING: Outpatient headache clinic at the University of Kansas Medical Center, Kansas City. PATIENTS: Thirty consecutive patients with a history of frequent migraine. MAIN OUTCOME MEASUREMENTS: From headache scores, patients were classified as either propranolol responders, amitriptyline responders, or nonspecific responders. Clinical variables as predictors of response to medications were studied, as were effects on frequency, duration, and/or severity of headache. RESULTS AND CONCLUSIONS: No significant correlations were found between changes in headache score and blood level of drug or change in any of the physiologic measurements. Amitriptyline significantly reduced the severity, frequency, and duration of headache attacks; propranolol reduced the severity of attacks only. Amitriptyline response was correlated with female gender and baseline headaches of shortest duration and of highest frequency. Propranolol response was associated with attacks of greatest duration at baseline and with low pulse rise with exercise at baseline. Nonspecific response was associated with male gender and most frequent headaches by history.

Patients' perspectives of the role of care providers in amyotrophic lateral sclerosis.

Interviews with 41 patients with amyotrophic lateral sclerosis regarding their perspectives of the roles of doctor, nurse, and allied health personnel showed that emotional support, information, and access to assistive devices were the primary expectations that they held for each of these professional roles. In addition, physicians were expected to evaluate the progress of the disease, help with immediate problems, and continue research to find a cure. Patients wanted to see a physician at each clinic visit. In being given the diagnosis of amyotrophic lateral sclerosis, patients expected the physician to be straightforward, honest but not premature, sensitive to patients' readiness for information, and to convey some degree of hope. Patients were accurate in their knowledge of the disease, but came to the clinic expecting help in managing the illness.

Headaches preceded by visual aura among adolescents and young adults. A population-based survey.

Clinical descriptions of migraine preceded by visual aura often include a composite of striking and severe symptoms of several attacks in individual patients, but few studies have characterized the spectrum of such attacks. In a population-based telephone survey of 8920 Washington County, Maryland, residents 12 through 29 years old, the attack rate for visual aura headaches during the week prior to the standardized interview was 3.7% in male and 6.1% in female subjects. Among female subjects, the risk for visual aura headache with tension-type symptoms increased with age, whereas the risk for visual aura headache without tension symptoms decreased with increasing age. No clear age-related patterns were observed among male subjects for either type of aura headache. The severity of visual aura headache with and without tension symptoms increased with age among female subjects, but showed an inconsistent pattern among male subjects except for decreasing disability with increasing age. The median interval between the onset of aura symptoms and the onset of headache (aura interval) was 15 minutes in male subjects and 25 minutes in female subjects, with aura intervals longer than 60 minutes reported by 12% of male subjects and 20% of female subjects. In one of the first large population-based studies to characterize the spectrum of visual aura headache, differing age, gender, and subtype patterns were found.

Migraine prophylaxis. A comparison of propranolol and amitriptyline.

The comparative efficacy of propranolol and amitriptyline in the prophylaxis of migraine headache was studied in 30 patients in a double-blind, placebo-controlled, crossover design. Headache response to medication was measured monthly by compilation of headache scores derived from quantitative data recorded by patients in a daily diary; at each visit, Zung and Hamilton tests for depression and the Spielberger state test for anxiety were performed. In the absence of clinical toxicity at monthly visits, the decision to maintain the current dose or raise it was made by a computer, which compared current headache score with that of the previous month. Both drugs were superior to placebo. Neither drug was superior to the other. The effectiveness of neither drug correlated with a decrease in anxiety or depression demonstrated by psychological testing.

Chronic meningitis caused by Sporotrichum schenckii.

The fungus Sporotrichum schenckii caused chronic meningitis in a 48-year-old man. Only three other firmly diagnosed cases were reported previously.

Failure of tyramine to induce migraine.

In a double-blind study of 80 migraine patients, headache was precipitated by ingestion of 200 mg tyramine and not by placebo in eight individuals, but retesting of seven of these patients did not produce the same results. Placebo produced as severe headache as tyramine and in an even larger number of patients. It is concluded that dietary tyramine alone is rarely, if ever, the major precipitant of a migraine attack, although the possibility remains that it has such a role in the presence of particular physiologic states.

Syncope problem solved by continuous ambulatory simultaneous EEG/ECG recording.

In a case of repeated syncope of abrupt onset and questionable origin, we utilized the continuous ambulatory cassette recorder to document simultaneous electroencephalography/electrocardiography (EEG/ECG) changes. Recording during a spontaneous episode established the cardiogenic origin. Problems in differential diagnosis of syncope and seizure are discussed. With this new instrument, if the initial event in ECG abnormality (as in the present case), further cardiologic study is indicated. If epileptiform EEG activity is primary, neurologic investigation is the direction to pursue; if there is nonepileptiform EEG slowing without ECG abnormality, diagnosis of syncope of noncardiac origin (e.g., hypotension, hypoglycemia) should be considered.

Psychiatric symptoms with initiation of carbidopa-levodopa treatment.

Two patients who had had no previous psychiatric symptoms became psychotic after their antiparkinsonism medication was changed from levodopa alone to a combination of levodopa and carbidopa, despite adherence to the appropriate and recommended dosage. Psychiatric symptoms disappeared after treatment with levodopa alone was resumed.

Coccygodynia caused by perineural cyst.

A case of typical coccygodynia caused by a sacral nerve cyst is reported. Relief of the pain by excision of the cyst occurred.

Recurrent Guillain-Barré syndrome following influenza vaccine.

Two patients recovered from an attack of Guillain-Barré syndrome and then had a second attack of this disease, with a shorter latent period, following monovalent influenza vaccination. These cases suggest that an attack of Guillain-Barré syndrome may result in greater risk of future episodes of the syndrome in conjunction with exposure to influenza or other vaccinations.

Amitriptyline in the prophylaxis of migraine. Effectiveness and relationship of antimigraine and antidepressant effects.

Amitriptyline was evaluated as a prophylactic antimigraine agent in 110 patients with severe migraine. This agent improved the migraine more than 50 percent in 72 percent of patients and more than 80 percent in 57 percent of patients. Most of the 31 patients with less than 50 percent improvement had virtually no response. Depression, measured with the Zung Self-Rating Depression Scale, was absent in 40 patients, borderline in 53, and moderate to severe in 17. Overall, depression ratings improved minimally with therapy. There was a weak relationship between improvement in depression and improvement in migraine. Subgroups with a stronger correlation of these could not be found. This work suggests that amitriptyline is effective in migraine prophylaxis and that it has a primary effect on migraine that is relatively independent of its antidepressant action.

Neurologists' knowledge of medication costs.

Using mailed questionnaires, neurologists were asked for (1) estimates of retail prices for 39 common drugs, (2) attitudes about drug costs, and (3) implications for clinical practice. Among these practitioners, (1) more product prices were overestimated than underestimated, (2) old products were as unfamiliar as new products, and (3) community practitioners were more aware of prices than academic neurologists and trainees, but still made errors. Future studies should also consider physician prescribing behavior in terms of adherence to recommended laboratory tests and patient inconvenience factors. Neurologists should be aware of alternative prescription outlets for patients.

Posttetanic potentiation in a patient with myasthenia gravis.

We studied a patient with clinically typical myasthenia gravis (MG) and high serum titer of antibodies to acetylcholine receptor. Unlike the usual response in MG, there was an increment in the amplitude of the electrical response (308% of control) after 10 seconds of voluntary tetanus. Posttetanic facilitation is usually less than 200% in MG and over 200% in Eaton-Lambert syndrome. However, there have been several other cases of typical MG with increments over 200%. Facilitation of this magnitude has also been seen with curare administration in animals and man. However, in myasthenia, as opposed to curare poisoning, competitive blocking is not thought to exist.