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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.