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.

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.

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.

Sociotropic cognition moderates blood pressure response to interpersonal stress in high-risk adolescent girls.

This article tests the hypothesis that 'sociotropic cognition'--heightened preoccupation with being accepted by others--increase vulnerability to cardiovascular stress in females. Adolescent girls (55 African-American; 23 Caucasian) at increased risk of developing essential hypertension due to persisting high normal blood pressure, completed measures of sociotropic cognition, social competence, trait affect and social support. Later, their blood pressure and heart rate were measured during non-social stress (mirror image tracing) and interpersonal stress [Social Competence Interview (SCI)]. Comparisons of blood pressure responses to the tasks disclosed a significant Task main effect, replicating a previous finding that blood pressure is elevated more by SCI than by non-social stress. When Sociotropy was introduced as a moderator, however, a significant Task by Sociotropy interaction indicated that the comparatively greater reactivity to SCI occurred mainly in girls who exhibited high levels of sociotropic thinking. Cognitive sociotropy was associated with a profile of social emotional and environmental deficits suggesting increased susceptibility to chronic stress and impaired coping.

Moving health care education into the community.

The A+ Asthma Club, an educational program developed for elementary school children in inner-city schools, is offered through a series of six sessions during school hours with an additional three booster sessions. This article describes how the program was designed, its theoretical basis, the curriculum and its staffing.

Predictors of injury among 1638 riders in a recreational long-distance bicycle tour: Cycle Across Maryland.

To assess the incidence of and risk factors for injuries in a group of bicyclists with a well-defined exposure to bicycling, we conducted a prospective study of 1638 recreational bicyclists who rode in the 6-day 339-mile Cycle Across Maryland tour in 1994. The mean age of participants was 39 years (range, 7 to 79), and two-thirds were male. All riders wore helmets. During the tour there were 85 acute traumatic injuries (15.4 per 100,000 person-miles), 76 overuse injuries (13.7 per 100,000 person-miles), and 37 other medical problems (6.7 per 100,000 person-miles). Acute traumatic injuries were associated with a history of racing versus none (relative risk = 2.2, 95% confidence limits = 1.3, 3.7) and with inexperience, no previous Cycle Across Maryland tours versus one or more (relative risk = 1.7, 95% confidence limits = 1.04, 2.8), but not with sex, training, or prior injuries. Inexperience and lack of preride conditioning were risk factors for overuse injuries. The most common overuse injuries and medical problems were knee pain, hand or wrist numbness, foot blisters, insect stings and bites, and heat and dehydration. Study results provide exposure-based incidence rates of bicyclist injuries and suggest overuse injuries may be reduced by increased preride conditioning.

A social support intervention for parents of children with juvenile rheumatoid arthritis: results of a randomized trial.

Evaluated a 15-month social support intervention for mothers of children with JRA. Five mentors (mothers of young adults who have had JRA since childhood) were linked to mothers of children with JRA ages 2 to 11 for purposes of enhancing specific types of social support and overall mental health. The total number of reported mental health symptoms decreased in the experimental group and remained the same in the control group. The experimental group showed greater improvement on all indices of support relative to the control group. Trends in the data consistently favored the experimental group, but differences between the experimental and control group were statistically significant on few of the outcome measures. Results provide tentative evidence for positive effects of mentoring interventions for this population of parents.

Schooling, employment, and idleness in young adults with serious physical health conditions: effects of age, disability status, and parental education.

PURPOSE: Education, employment, and "idleness" in young adults with ongoing physical health conditions were examined in relation to parents' education and respondent's age and co-existing disabilities. METHODS: Telephone interviews were conducted with 421 individuals aged 20-24 years randomly drawn from public health programs in two midwestern states. In addition to a chronic health condition, 18% of the sample also had mental retardation, 21% also had a physical disability (but no retardation), and 11% also had a learning disability (but no mental retardation or physical disability). Youth were considered "idle" if they were not in school, not employed, not married, and had no children. RESULTS: Thirty-seven percent of the sample were enrolled in an educational program, and 48% were employed either part-time or full-time. Seventeen percent were both in school and employed, 50% were in school or employed, and 33% were neither in school nor working. Overall, 23% of the sample were idle. Youth with mental retardation were two to three times more likely to be in school compared to youth with a chronic physical condition alone. Youth with mental retardation and physical disabilities were less likely to be employed and more likely to be idle compared to youth with only a chronic condition. Parental education affected rates of schooling and employment. Compared to a general population sample of youth in the same states, youth with ongoing health problems were at higher risk for idleness. CONCLUSIONS: Youth with chronic health conditions and either mental retardation or physical disabilities are at higher risk for idleness compared to youth with a chronic condition alone or to youth in general.

Factors related to functional status after percutaneous transluminal coronary angioplasty.

OBJECTIVE: To describe the recovery process 1 year after percutaneous transluminal coronary angioplasty (PTCA) and measure factors that influence functional status. DESIGN: Prospective, one-group observational study. SETTING: Mid-Atlantic, university-affiliated, tertiary care medical center. PATIENTS: One hundred thirty-five adults who underwent first-time PTCA. The age range was 29 to 78 years (mean 57). OUTCOME MEASURE: Functional status. INTERVENTION: Data collection was initiated before PTCA by personal interview and self-administered questionnaire conducted in the hospital and 12 months after PTCA by mailed questionnaire. Data on clinical, demographic, occupational, and psychosocial factors were collected to determine the predictors of functional status 12 months after PTCA. RESULTS: One-tailed paired t tests were conducted to measure whether there was improvement (positive change) in functional status from before PTCA to 12 months after PTCA. Multivariate and logistic-regression analyses were also conducted. Although there were significant improvements in functional status outcomes in the categories of activities of daily living, mental health, and social interaction 12 months after PTCA, patients continued to report important functional status disabilities in the categories of activities of daily living (14%), social activity (14%), mental health (25%), quality of interaction (10%), and work performance (17%). The variable most predictive of functional status was the patient's baseline score on that particular functional status subscale. CONCLUSION: These findings are consistent with other studies on functional status. They suggest that rehabilitation programs should assess pre-PTCA functional status to identify those individuals at risk for poor outcome after PTCA and design interventions to restore physical and functional status after PTCA.

Self-esteem of young adults with chronic health conditions: appraising the effects of perceived impact.

The relationships between selected condition characteristics and self-esteem were investigated in a randomly drawn, community-based sample of 286 young adults with chronic illnesses and disabilities. Whether appraisals of the impact of the condition mediated relationships between condition characteristics and self-esteem, as measured by the Rosenberg Self-Esteem Scale, was also measured. As a group, the youth in this sample reported positive self-esteem. When sociodemographic and condition-related variables were considered simultaneously, maternal education, unpredictability of symptoms, prognosis, sensory impairment, and the presence of a co-occurring learning disability were found to have direct effects on esteem. Perceived impact mediated the relationship between condition characteristics and self-esteem. The results are discussed in relation to the role of impact appraisal in determining the emotional well-being of young adults with chronic illnesses.

Mental health of young adults with chronic illness: the mediating effect of perceived impact.

Examined psychological symptomatology in a community-based sample of 286 young adults with chronic health conditions randomly drawn from the rolls of two state programs for Children with Special Health Care Needs. The Psychiatric Symptom Index was used to assess mental health. We investigated how selected condition characteristics (e.g., indices of severity, symptom predictability, prognosis, age of onset, and visibility of condition) increased risk of psychological symptoms. Analyses indicate that (a) this population is at high risk for psychological symptoms, (b) selected risk factors (i.e., prognosis, restricted activity days, presence of hearing and speech problems, and perceived unpredictability of symptoms) have significant effects on mental health status when other variables are taken into account, and (c) respondents' perceptions of the impact of the condition mediates associations between selected risk factors and mental health. Results are discussed in relation to preventive interventions for this population of young adults.

Sacral ulcers following cardiac surgery: incidence and risks.

This study examined the incidence and risk factors that relate to the development of sacral pressure ulcers following elective cardiac surgery. Perioperative variables were assessed using 136 adult patients. Ulcers, including 16 Stage I and 21 Stage II-III, occurred on 27.2% (n = 37) of the patients. Factors such as older age, transfer from another hospital, and a history of diabetes, were associated with ulcer development. These findings may be used to identify patients at risk for pressure ulcers during cardiac surgery.

Negative affect, gender, and expressive style predict elevated ambulatory blood pressure in adolescents.

Excessive blood pressure elevations during daily activities increase cardiovascular risk and may be related to individual differences in emotionality and expressive style. Emotional traits and ambulatory blood pressure were measured during a typical school day in 228 Black and White adolescents at risk of developing essential hypertension. Trait affect (depression, anger) predicted prevailing blood pressure levels; this association was moderated by gender, social setting (in classroom vs. with friends), and nonverbal expressive style. Relationships between emotion and blood pressure were not explained by obesity, smoking, or alcohol use. The uniform environment and regimen of the school made it possible to attribute variations in prevailing blood pressure to personality differences involving ways adolescents perceive and negotiate their social world.

Predicting ambulatory blood pressure during school: effectiveness of social and nonsocial reactivity tasks in black and white adolescents.

We evaluated a newly developed stress task, the Social Competence Interview, and three nonsocial tasks (video game, mirror drawing, mental arithmetic) for ability to predict ambulatory blood pressure in 237 black and white adolescents. Blood pressure was measured in laboratory, classroom, and transition (between-class) settings. A resting laboratory baseline explained 10-49% of the variance in ambulatory blood pressure levels; the ability of the stress tasks to explain additional variance was assessed in multiple regression analyses. Only the blood pressure response to the interview enhanced prediction of classroom and transition systolic and diastolic pressures in the total sample and in blacks, whites, females, and males--even when the interview data were entered into a hierarchical regression model after those for the other three tasks were entered. Mirror drawing improved prediction of transition systolic blood pressure in the total sample, and mental arithmetic plus the interview improved prediction of classroom diastolic pressure in black males; however, video game failed to enter any predictive equation. Racial subgroup analyses disclosed that the interview data predicted systolic pressure in whites but predicted diastolic pressure in blacks, indicating biological differences in blood pressure regulation. An interview that elicits characteristic thoughts and social behaviors appears to represent a promising approach to examining environmental influences on blood pressure.

Diminished pulse pressure response to psychological stress: early precursor of essential hypertension?

An excessive blood pressure response to mental stress is a widely reported characteristic of young normotensive offspring of hypertensive parents. At odds with these reports are data from a large biracial study showing that high risk adolescent offspring had diminished pulse pressure under mental stress and no evidence of greater blood pressure reactivity. We examined this apparent contradiction in a similar but larger sample of 213 normotensive adolescents, comparing blood pressure and heart rate responses to video game, mirror drawing, mental arithmetic, interview, and physical exercise in high- and low-risk offspring. Results replicated the diminished pulse pressure finding, suggesting it is characteristic of African Americans and is evoked by behavioral tasks that entail skeletal-motor inhibition. Submaximal physical exercise failed to discriminate between offspring groups. Possible biologic correlates of diminished pulse pressure in black adolescents with "high normal" blood pressure warrant further investigation.

Social competence interview for assessing physiological reactivity in adolescents.

Difficulties in predicting "real life" physiological variation from responses to controlled stress tasks suggest the need for more ecologically valid laboratory challenges. The Social Competence Interview (SCI) measures physiological changes elicited by re-experiencing a life situation in which a valued striving was unexpectedly hindered. The 14-minute interview yields data on subjects' goals, skills, problem-solving strategies, and social resources. We compared the SCI to video game (VG), mirror drawing (MD), and mental arithmetic (MA) in a racially balanced sample of 260 adolescents (age 14 to 15 years). Blood pressure changes during SCI exceeded those during the other tasks, and were unaffected by race or gender. Blood pressure responses to SCI correlated with responses to MA and MD but appeared to capture a unique domain of social reactivity. Test-retest correlations over 6 months in a random subsample of 27 subjects showed that blood pressure reactivity to SCI and other tasks was reproducible. Intrasubject analyses of responses to the different tasks disclosed subgroups of consistently high and consistently low responders who may be at higher or lower risk. The SCI is not threatening and was rated by subjects as less frustrating or demanding than MD or MA. Its demonstrated effectiveness when administered by several different interviewers suggests the SCI is a promising technique for large scale studies of younger populations.