Robert L. Vogel

Correlates of Generalized Anxiety and Panic Attacks in Dystonia and Parkinson Disease

ObjectiveTo determine prevalences of generalized anxiety, generalized anxiety disorder, panic attacks, and panic disorder in primary dystonia (n = 28) and Parkinson disease (n = 28) and to explore their clinical correlates. BackgroundWe previously identified increases in Diagnostic and Statistical Manual of Mental Disorders, third edition generalized anxiety in dystonia and panic attacks in Parkinson disease. MethodStructured Clinical Interview (SCID) ascertainment of Diagnostic and Statistical Manual of Mental Disorders, third edition, revised, disorders. ResultsGeneralized anxiety disorder was more common in dystonia while panic disorder was more common in Parkinson disease (P = 0.0018). Generalized anxiety developed more commonly after dystonia onset (i.e., secondary generalized anxiety) while panic attacks developed more commonly after Parkinson disease onset (P = 0.0132). Specific life prevalences were: generalized anxiety disorder, 7 subjects (25.0%) in dystonia versus 0 subjects (0.0%) in Parkinson disease; generalized anxiety, 11 (39.3%) versus 0 (0.0%); panic disorder, 2 (7.1%) versus 7 (25.0%); and panic attacks, 2 (7.1%) versus 9 (32.1%). Exploratory analysis in Parkinson disease indicated a relationship of panic disorder (P = 0.027) and secondary panic attacks (P = 0.0009) to motor block frequency. There were nonsignificant trends toward associations of secondary generalized anxiety with lower Mini Mental Status Examination scores (P = 0.058), and of secondary panic attacks with presence of a depressive disorder (P = 0.077). Depressive comorbidity rates are also presented. ConclusionsThese findings suggest relations of generalized anxiety with reduced pallidal inhibition of thalamofrontotemporal projections, and panic attacks with locus coeruleus dysfunction.

Non-parametric comparison of relative versus cause-specific survival in Surveillance, Epidemiology and End Results (SEER) programme breast cancer patients.

Cancer-related mortality can be measured by two dissimilar methods: NAcause-specific survival (based on mortality attributed to a specific cause), and relative survival (based on mortality relative to a matched cohort). We used both methods to determine actuarial survival in a population of 119 502 breast cancer patients from the Surveillance, Epidemiology and End Results (SEER) programme data set, with 20 years of follow-up. The population was divided into four strata by patient age and tumour stage. In all strata, there was only minimal deviation between the two survival methods. Of particular interest was the cause-specific treatment of patients recorded as dead of unknown cause, i.e. those deaths that could not be attributed with certainty to either ‘breast cancer’ or to ‘other causes’. Findings suggest that the most reliable results may be obtained by apportioning these deaths between ‘dead of cause’ and ‘withdrawn at the time of death’. This apportionment is based on the relative number of deaths attributed to ‘breast cancer’ versus ‘other causes’.

Comparison of parametric and non‐parametric survival methods using simulated clinical data

We derived three parametric survival models (the log-normal, log logit, and Weibull) from the clinical data of chemotherapy trials for stage II breast cancer. We then used these models to generate simulated survival data, which we analysed using both parametric (log-normal) and non-parametric (logrank, Gray-Tsiatis and Laska-Meisner) methods. With limited follow-up (5 years), the non-parametric tests had greater power than the log-normal model. This advantage diminished, however, with extended follow-up (15 years). Furthermore, only the log-normal model could distinguish reliably a survival advantage due to an increase in cured fraction from an advantage due to an increase in time to failure.

Are Family Practice Residents Able to Interpret Electrocardiograms

Background: Teaching electrocardiogram (ECG) interpretation is a recommended component of the family practice residency curriculum. Published information concerning the ECG interpretation ability of residents is sparse. This study sought to ascertain the base line knowledge of family practice residents ECG interpretation skills and extent of improvement after one year of training.Methods: A 15 ECG examination was administered to 38 PG-1 and 14 upper level residents at 5 residency programs at the beginning of the academic year and to residents at the authors program at the end of the academic year. Pre-test scores among the five programs were compared using an analysis of variance (ANOVA). Pre-test and post-test scores were compared using a paired randomization test.Results: No difference was found between average scores from each site, or between the beginning and end of the academic year. Residents were more likely to misinterpret items such as myocardial infarction, myocardial ischemia, and a trial fibrillation.Conclusions: Residents in family practice have considerable deficiencies in ECG interpretation skills. Further studies are needed to determine effective ECG teaching curricula.

Patterns of Lyme disease diagnosis and treatment by family physicians in a southeastern state.

This study examined how often physicians in Georgia diagnose and treat Lyme disease as well as the criteria they use to reach a diagnosis of Lyme disease. A survey was sent to 1,331 family physicians in Georgia concerning how many cases of Lyme disease the physicians diagnosed, and the criteria used to make the diagnosis, during the preceding 12 months. Of 710 responses, 167 physicians treated 316 cases of Lyme disease without a firm diagnosis. In addition, 125 physicians diagnosed 262 cases of Lyme disease, 130 without serologic testing and 132 with serologic testing. Family Physicians in Georgia diagnose Lyme disease at a rate 40 times greater than the surveillance case rate reported in Georgia.

P2 flash visual evoked response delay may be a marker of cognitive dysfunction in healthy elderly volunteers.

In an earlier study, 31 healthy elderly volunteers had normal cognitive function as measured by the Mini-Mental State Examination. Twenty-seven returned for further memory testing using the Wechsler Memory Scale-Revised (WMS-R). The P2 latency of the flash visual evoked response was positively correlated with age (p = .0008), but was not significantly related to gender. Nine of these 27 putatively healthy subjects had a delayed P2, suggestive of dementia. Although unaware of any memory deficits, 5 of the 27 had WMS-R Visual Memory Span percentile scores 1 or more standard deviations less than age-matched controls. Four of the five also had a significantly delayed P2 component. This positive correlation, adjusted for age, between poor Visual Memory Span performance and a delayed P2 was statistically significant (p < .025). These findings suggest that a delayed P2 in putatively healthy subjects is indicative of a visuospatial deficit which might be a precursor of dementia later.

Estimated risk of death among employees in agriculture and agriculture-related industries in Georgia, 1985-1994.

ABSTRACT Farming has an enormous impact on the economy of Georgia, with as many as one in six Georgians working in agriculture. The purpose of this study was to compare the risk of death of white and black farmers to non-farmers in Georgia. Mortality data stratified by age and aggregated by race were retrieved from the Georgia Office of Vital Statistics for the years 1985-1994. The classification system used to code occupation on the death certificate was W473-489, which includes farmers and most all other agricultural occupations. For each cause of death, the Breslow-Day Test was used to determine homogeneity of risk across all age strata (a = 0.05). A common odds ratio (OR) and 95% confidence intervals were calculated for all homogenous causes of death using the Mantel-Haenzel procedure. Among white farmers, the risk of death was significantly high for tuberculosis [OR = 1.64 (1.01, 2.65)], fires [OR = 1.60 (1.15, 2.22)], and accidental drowning [OR = 1.52 (1.01, 2.28)]. The leading causes of death among black farmers were accidental drowning [OR = 1.53 (1.03, 2.26)], cerebrovascular disease [OR = 1.27 (1.18, 1.38)], and ischemic heart disease [OR = 1.21 (1.14, 1.29)]. Causes of death reported to be significantly low were also investigated. The findings of this study are varied, but trends related to risk of death appear to be similar to observed national trends.

Treatment and Outcomes in Occupational Low Back Pain

ABSTRACT Low back pain (LBP) is the sin gle larg est musculoskeletal injury inthe working pop u la tion, and the sec ond most com mon reason for vis its to pri mary care physicians. D e spite its frequency, thepathologic diagnosis is un certain in 85% of cases. Out comes, particularly in work related LBP vary widely as does treat ment. Numerous guidelines have been re cently promulgated to speed treatment, improve out comes and minimize cost. This study follows 709 workers with low back pain. Methods: Seven hun dred and nine se rial low back pain pa tients werefol lowed through two years. Their charts were au dited for diag nos tics, ther a peutics, refer rals and out comes. The dif fer ingfacets of clinical treatment paradigms are compared with out comes. Results: Out of five cat e go ries, al most half of back in juries re sulted from heavy lift ing alone. Out of 709 pa tients, 1.4% eventu ally re quired sur gery. Only 10 pa tients were clin i cally dis abled at the end of the study pe riod al though a total of 30 did not re turnto work for a va ri ety of reasons. Al most 39% of pa tients re ceived back X-rays, and 10% re ceived MRIs of the lower back. Ninety-three per cent re ceived NSAIDs as part of their treat ment, and 34% nar cot ics. Nei ther NSAIDs nor mus cle re lax-ants cor re lated with prob a bil ity of re turnto work. The me diantreat ment inter val wasseven days, with the ma jor ity of pa tients (551/709) re turned to reg u lar work withintwo weeks of thefirst of ficevisit. Pro longed duration of treat ment and sur gery cor re lated with lit i ga tion. Con clu sions: De spite popular clinical mythology, thevast majority of occupationally acquired low back pain pa tients do re turnto work in a timely fash ion.

Cardiopulmonary assessment: is improvement needed?

Clinical parameters alone have repeatedly been proven unreliable in assessing cardiopulmonary status, especially in hemodynamically unstable patients. To learn if we had a diagnostic problem in our hospital, we compared physician assessment of cardiac index (CI) and thoracic fluid content (TFC) to values obtained using impedance cardiography (ICG). We selected the newest available ICG monitor, the BioZ, which employs this noninvasive technology. For CI measurements we have shown it to be equivalent to thermodilution and to be more reproducible (variability: 6.3% vs. 24.7%). Physician assessment of CI and TFC (high, normal, or low) was compared to the BioZ monitor’s results in 186 patients, considered to be hemodynamically unstable, from the emergency room, the intensive care units, and the floors. Normal values were defined for CI (2.5–4.2 L/min m2) and for TFC (males: 30–50 kohm−1 and females: 21–37 kohm−1). The concordance between physician assessment and the BioZ was 51% for CI with Kappa of 0.14 and 58% for TFC with Kappa of 0.19. Attendings did slightly better than the surgical residents with CI (52% vs. 48%) but slightly worse with TFC (57% vs. 61%). The potentially serious conditions of low CI and high TFC were misdiagnosed 42% and 46% of the time, respectively, by all physicians. Analysis of the data revealed that physician use of clinically available objective hemodynamic data, such as heart rate, blood pressure, and pulse pressure index, would not have been helpful. Furthermore, assistance from the pulmonary artery catheter (PAC) is often not available in our hospital, which has experienced a 90% decrease in its utilization over the past six years. Considering the increasing acuity of our aging patient population, accurate assessment of cardiopulmonary status is needed. The use of ICG could be a valuable addition to the physician’s armamentarium.