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.

Chiari-1 Malformation, Migraine, and Sudden Death

Sudden death occurring in a young man with Chiari-1 malformation after repeated attacks of headache and syncope that had been diagnosed as basilar migraine is reported. Autopsy revealed only Chiari malformation and syringomyelia. The ominous potential of syncope in this syndrome is emphasized.

Migraine in twins raised together and apart

History of headache and migraine diagnosed by structured interview utilizing International Headache Society criteria was obtained in two samples of female twin pairs--154 raised together and 43 raised apart since infancy. Zygosity was determined by standard methods. Probandwise concordance rates were determined. Assuming that liability to migraine has a multifactorial etiology involving a number of genetic and environmental risk factors acting additively, tetrachoric correlations in the four groups of twins (monozygotic raised together, monozygotic raised apart, dizygotic raised together, and dizygotic raised apart) were then calculated. The genetic and environmental influences in the liability to migraine were estimated using biometrical model-fitting methods. Tetrachoric correlations of migraine were consistently higher in monozygotic than in dizygotic twins, for both reared together and reared apart samples, with a heritability estimate of 52%, Model fitting also suggested that approximately 50% of the variance in liability to migraine was attributable to genetic factors with nonshared environmental factors and measurement errors responsible for the remaining variance.

Opioids in headache treatment. Is there a role?

There may be a population of patients subject to frequent headache and in whom optimal analgesic effect is obtained only by frequent but controlled use of opiate drugs and in whom adverse drug effects are minimal. It is emphasized again that the reality is that there are currently a large amount of opioids being prescribed for headache patients because of patients' demands. One of the major considerations for physicians prescribing such treatment is familiarity with the legal guidelines. The federal law requires physicians to register if they are to maintain or detoxify with opioids addicts defined as "any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety, or welfare, or is so far addicted to the use of narcotic drugs as to have lost the power of self-control with reference to his addiction." A subsequent regulation, however, stated that the law was not intended to impose any limitation on prescription of narcotics for intractable pain. There are also many different state regulations covering, for example, limitations on amounts to be prescribed and reporting of patients who are habitual narcotic users. Obviously, headache patients who request liberal amounts of opioids must be screened. There has been considerable recent effort to provide guidelines regarding which patients with nonmalignant pain might be poor candidates for opioid treatment by reason of both probable treatment failure and risk of drug overuse. Many of these guidelines are not relevant to headache patients in whom pain is rarely continuous and rarely demands scheduled analgesia, as is often the case with pain of other types. There is general agreement that any previous history of any type of substance abuse is an important indicator of danger of recurrence of such behavior. Evaluation of psychological state and personality structure is of great importance. The more evidence of emotional disturbance, the greater the danger both of poor results and of drug abuse. In the chronic daily headache population, treatment failure has been found to correlate with abnormalities on the Minnesota Multiphasic Personality Inventory (MMPI). It is possible that formal psychological testing prior to the prescription of opioid drugs will prove of value in identifying those headache patients at greatest risk for drug abuse. The importance of making opioid treatment part of a multifaceted pain program has been emphasized. Portenoy emphasizes the need for (1) careful discussion with the patient (and often family) of the potential side effects of the drugs, and (2) scrupulous monitoring of adherence to the appropriate dosage and maintenance of prescription by a single physician. The more psychological disturbance evidenced by the patient, the more the risk with failure of drug treatment and of drug abuse. Finally, the analgesic needs of the patient with frequent migraine are different from those of the patient with tension-type headache. Migraine infrequently occurs more than two or three times a week for any period and usually responds to ergotamine, dihydroergotamine, sumatriptan, or a phenothiazine. Addition of codeine or oxycodone for the occasional intractable attack may be needed. When demands in a migraine patient for opioids in amounts greater than 10 to 15 tablets per month occur, there is obvious cause for concern. The opioid agonist-antagonist butorphanol, now available in nasal inhalation form, is alleged to have low abuse potential because it tends to produce dysphoria (an unpleasant emotional state) rather than the euphoria of other opioids. It is therefore unscheduled. The drug, however, does have abuse potential, and the limits needed to be placed on its use are still uncertain. Markley recently recommended a restriction to not more than two bottles (30 treatments) per month. The population with frequent tension-type headaches presents the major problem. Large numbers of these patients use drugs--often in combination

Self-reported disability due to headache: a comparison of clinic patients and controls

OBJECTIVE

To compare the self-reported disability of headache sufferers who seek medical assistance with those who do not seek such help and determine possible relationships between perceived disability and psychological factors.

METHOD

Subjects were 51 headache patients and 53 persons without medical assistance for their headache within the past 2 years. All subjects completed a structured interview that gathered headache data, a headache disability scale, and the Minnesota Multiphasic Personality Inventory-Revised (MMPI-2).

DESIGN

A 2 x 2 ANCOVA design was employed. Subject group (patient vs control) was the first factor and headache type (migraine vs mixed) was the second. Covariates were headache intensity and five subscales of the MMPI-2. Dependent variables were the seven subscales of the headache disability scale. Stepwise discriminant analysis was conducted to determine which factors best classified subjects as patients or controls.

SETTING

University Medical Center headache clinic.

RESULTS

Clinic patients reported significantly greater disability on their occupation than controls--a difference emerging after controlling for level of headache pain and personality variables. Patients differed from controls, although not significantly, in the rank order of life activities most affected by headache. Discriminant analysis revealed that self-reported disability for occupation and the Hysteria scale from the MMPI-2 best differentiated the groups.

Stroke in China, 1986 through 1990

BACKGROUND AND PURPOSE

Incidence of stroke varies markedly in different world populations. In seven Chinese cities, the effect of a program of risk factor modification on the incidence and mortality of stroke was studied and compared with a control population. This article describes the incidence of stroke in the control populations for the years 1986 through 1990.

METHODS

Incidence (first-ever strokes only) for 1986 was obtained by door-to-door interview with heads of households with subsequent verification on examination by a neurologist and review of medical and/or hospital records. In subsequent years, cases were ascertained with a three-tier monitoring system: by community health workers, local medical centers, and the Beijing Neurosurgical Institute.

RESULTS

Average annual age-adjusted incidence per 100,000 was 215.6 (261.5 for males, 174.5 for females; P < .001). There was a significant drop in the total number of cases from 137 in 1986 to 106 in 1990, but the age-adjusted rate showed a significant drop for males only (322.3 to 182.5, P < .001). Marked differences in average annual age-adjusted rates existed among the seven cities, from 486.4 for Harbin to 80.9 for Shanghai. This difference in rate among cities was found for both sexes but was more pronounced in males.

CONCLUSIONS

The stroke incidence rates in China, like those in Japan, are among the higher ones in the world. In recent years, there has been an apparent decline in stroke incidence. Marked differences in rates were found between males and females with decline in incidence occurring almost exclusively in males. There were also marked differences in stroke incidence among the cities studied. These differences may result in part from differences in diet, alcohol and cigarette consumption, or prevalence of hypertension.

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.

Familial psychogenic blindness and headache: a case study

BACKGROUND

Amaurosis is an uncommon conversion phenomenon, which to our knowledge has never been reported in multiple family members.

METHOD

A man and his two adult children, all afflicted with periods of blindness and accompanying severe headaches for varying periods of time (days to years), were examined and extensively studied radiologically and with multiple laboratory tests.

RESULTS

In all three individuals, no evidence of organic disease was found; all three recovered to varying degrees, usually after suggestion.

CONCLUSION

Psychogenic amaurosis with headaches can simulate migraine; the mechanism for occurrence in a family is probably similar to that of mass hysteria.

Opiate and opioid use in patients with refractory headache

Opiate and opioid analgesics are commonly used for pain in general and presumably for headache. Codeine, oxycodone and propoxyphene, among the most commonly prescribed, do carry some risk of abuse, and their efficacy in headache patients has not been well studied. In many patients with other kinds of pain, however, both of neoplastic and non-neoplastic origin, chronic opiate use has been demonstrated to be of benefit without adverse side effects. The type of headache patient with intractable pain who needs frequent opiate analgesic and who does not develop addiction or drug abuse is an important subject for research.

Screening cerebrovascular patients for silent myocardial ischemia with stress testing and ambulatory left ventricular function monitor

Patients with symptomatic cerebrovascular disease suffer a high mortality from myocardial ischemia, which may occur during rest or following the conclusion of exercise. In a pilot study, we screened 11 patients with transient cerebral ischemic attack or stroke for silent myocardial ischemia using bicycle ergometer stress testing with electrocardiographic (EKG) monitoring and ambulatory left ventricular function monitoring (VEST). Three of 11 patients had nondiagnostic exercise EKGs due to failure to achieve their target heart rates during exercise but had positive VEST tests during and after exercise. One patient was falsely positive. VEST may be useful in combination with stress EKG for the detection of silent myocardial ischemia in cerebrovascular patients, but further assessment of the sensitivity and specificity in this patient population needs to be accomplished.

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.

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.

Headache and migraine

That the 'primary' phenomenon in migraine with aura is neuronal ('spreading depression') seems increasingly probable, but the relationship of migraine with and without aura and of both to tension headache remains uncertain. Depression and migraine are related, but other psychological correlates are controversial. Two new therapeutic agents, with action on 5-hydroxytryptamine (5-HT; serotonin) receptors are of promise.

Osteomyelitis of the skull base

Three cases of osteomyelitis of the skull base with associated problems in diagnosis and therapy are discussed. Patients with atypical skull base osteomyelitis are difficult to diagnose as they have no ear abnormalities, but they often develop multiple cranial nerve deficits mimicking symptoms of a posterior fossa mass. We conclude that computed tomographic scans, magnetic resonance imaging studies, bone scans indium-labeled white blood cell scans, and gallium scans are useful in making the diagnosis. A biopsy of the bony lesion often is needed to identify the causative organism and to rule out a tumor. Intravenously administered antibiotics are the mainstay of therapy and should be continued until 1 week after the gallium scan shows no abnormalities. Follow-up gallium scans then are done at 1 week and 3 months after the cessation of antibiotic therapy to search for a recurrence.

Familial migraine in a Mexican population

We investigated the frequency of migraine in first-degree relatives of a group of migraine patients in two Mexican populations, one urban and one rural, and in control groups from the same populations. In the urban population, familial aggregation of migraine was found in 52.7% of patients and in the rural in 38.7%. The differences between controls and subjects were statistically significant in both populations. Our findings support the importance of a hereditary factor in migraine but not an autosomal dominant inheritance pattern.

Magnetic resonance image abnormality in migraine with aura

Cerebral magnetic resonance imaging (MRI) was performed on 18 patients with migraine characterized by aura consisting of both visual symptoms and paresthesias. Fifteen headache-free individuals of the same age range were used as controls. Records were randomized and read in blind fashion by two neuroradiologists. Small subcortical white matter lesions were seen in three migraine cases and two controls. In one migraine case cortical infarctions were seen. In two controls, small areas of increased density similar to those in migraine were seen. No consistent correlation of migraine or its duration with cerebral atrophy was found. It is concluded that identification of both these MRI findings (small subcortical white lesions and cerebral atrophy) as significantly associated with migraine is doubtful.

Prevalence survey of headache in a rural Mexican village

Prevalence of headache was studied by house-to-house survey of a small remote Mexican village where the population was characterized by a low income and high rate of illiteracy. Severe headache was found in 8.9% of the male population and in 10.6% of the females. Approximately half of these individuals gave a history suggestive of headache with aura, but reinterview by a neurologist revealed that in one third of such histories the visual phenomena were probably not true aurae. Only in the over 35-year age-group was headache more prevalent in females. 'Incapacitating' headache was usually equated with 'severe' headache and was 10 times as frequent in the over 55-year age-group as in younger people. Sophisticated interviewers (neurologists) obtained different results from less trained interviewers.

Headache. Public health problem

Headache is, and apparently always has been, a frequent pain syndrome. It is reported in American and Western European societies in very high percentages of the population. Headache, and specifically severe headache, have also been reported as prevalent from a variety of societies worldwide, although prevalence rates have varied (they are very low, for example, in the People's Republic of China). Whether prevalence varies with different socioeconomic groups remains uncertain. Severe headache and specifically migraine is, for reasons still unknown, much more common in women, and, in most studies, is reported to decrease in prevalence in older age groups. Positive family histories are common, but the precise role of genetics is unknown. A major problem in the epidemiologic studies remains the difficulty of uniform definition of headache syndromes.

HIV-related neuromuscular syndrome simulating motor neuron disease

A young homosexual man presented with slowly progressive weakness and diffuse fasciculations. Muscle biopsy was compatible with clinical diagnosis of motor neuron disease. The patient died from opportunistic infections related to acquired immunodeficiency syndrome. Autopsy revealed evidence of myelopathy, patchy fiber loss from anterior nerve roots, marked demyelination within intramuscular twigs of peripheral nerves, and primary myopathic features superimposed on advanced neurogenic atrophy of the skeletal muscles.

Specific headache phenomena: their frequency and coincidence

The correlation of specific headache attack characteristics derived from a standardized questionnaire was studied in a consecutive series of 392 patients attending a headache clinic. In patients reporting headache with aura such attacks tended to be infrequent, and the percentage of their headache attacks that were preceded by aura varied widely, many cases having very low percentages. Paresthesias as auras were uncommon and rarely occurred without visual aura. Unilateral headaches were associated with nausea to widely varying degrees. Most patients reported both unilateral headache and headache with tension characteristics. Definite history of hypertension was significantly correlated specifically with migraine with aura (classic migraine).

Clinical and electrophysiological responses to dietary challenge in migraineurs

Thirty eight patients with a history of diet-induced migraine were studied with recording of clinical responses, electroencephalography in resting state, in response to photic stimulation, and to hyperventilation and visual evoked potentials. Tests were carried out on an initial baseline day and on a second day, after challenge with chocolate, red wine, cheese, and fasting. Lateralized headache occurred in sixteen subjects (42%), four with scintillating scotomata. Electroencephalograms were abnormal on Day 1 and/or Day 2 in twelve subjects (32%), most abnormalities being non-specific slow waves. In three cases there were paroxysmal features. Electroencephalographic response to hyperventilation was calibrated and was found to be exaggerated in eight subjects (21%) on either Day 1 or Day 2; such response was not related to the occurrence of a headache. Photic simulation showed high frequency driving response (so called "H" response) in all 16 individuals who developed headache but in only 14 out of 22 (64%) who did not (p less than 0.01). Pattern reversal visual evoked responses were normal and failed to show any difference in latency or amplitude between headache responders and non-responders.

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.

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.

A prevalence survey of 'incapacitating headache' in the People's Republic of China

Two Chinese populations over age 15 were surveyed as to the point prevalence of "incapacitating" headaches in an urban population of 1,525 persons and a rural one of 1,203. Personal interviews were carried out by a team of instructed interviewers; there was 100% cooperation. In both populations, prevalence in women was twice that in men except in the urban population in the youngest age group. Prevalence in the urban was almost exactly twice that of the rural population, with the highest figure occurring in traders.

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.

Treatment of central nervous system sarcoidosis with radiotherapy

This report documents the twelve-year follow-up of a patient with neurosarcoidosis with multiple progressive central nervous system manifestations. Increased somnolence and seizure activity were associated with proliferation of nodular enhancing brain lesions, as seen on serial computed tomographic (CT) scans. Initially he responded to corticosteroid treatment, but gradually this response became unsatisfactory. After whole-brain irradiation with a total dose of 3,000 rads, his clinical symptoms improved with disappearance of the enhancing brain lesions seen on CT scan.

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.

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.

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.

An overview of the classification, causes, and treatment of headache

Headache has been documented as the reason for approximately 18 million office visits per year in the United States, and may be the most prevalent central nervous system condition for which patients consult doctors. The author presents an overview of the literature on classification, causes, and treatment of headache, including uncertainties about diagnostic criteria for migraine and about differentiation of migraine from muscle contraction headache. He discusses treatment of headache in relation to management of the acute attack, avoidance of trigger factors, and pharmacological and nonpharmacological prophylaxis.

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.

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.

Mercury intoxication simulating amyotrophic lateral sclerosis

A 54-year-old man had a syndrome resembling amyotrophic lateral sclerosis after a brief but intense exposure to elemental mercury. The syndrome resolved as his urinary mercury levels fell. Mercury toxicity must be considered not only in individuals with recent anterior horn-cell dysfunction but also with otherwise unexplained peripheral neuropathy, tremor, ataxia, and a gamut of psychiatric symptoms including confusion and depression.