Improving patient follow-up in incidental screening through referral letters.

The effects of referral letters on increasing the likelihood of patients obtaining hypertension follow-up assessments are presented. Seventy-four patients with elevated diastolic blood pressure (between 95 and 120 mm Hg), who were administratively ineligible for longitudinal care from the Veterans Administration, were randomized into one of four groups: a patient letter; a physician letter; both patient and physician letters; or no letter (control group). No evidence of interaction between the patient and physician letters was found. Results revealed that nearly twice as many patients (63%) receiving the patient letter returned for a hypertension evaluation as compared with those who did not (33%). No difference was found between the physician letter and no physician letter conditions. These findings suggest that patient-directed referral letters can increase the likelihood of follow-up in both previously detected and newly detected cases.

Twin studies of Alzheimer's disease: an approach to etiology and prevention.

Epidemiologic studies of environmental factors associated with risk of Alzheimer's disease (AD) have produced inconsistent and disappointing results. By contrast, family/genetic studies and case control investigations suggest that genetic causes of AD are important. The investigation of such genetic causes remains an important aim in all forms of AD including typical, late-onset disease where linkage work is impractical. But the public health burden of AD creates an especially urgent need to identify environment risk factors, if these exist, since they will more likely be susceptible to intervention. Such environmental factors may interact with genetic susceptibility to accelerate or retard disease expression, and environmental interventions that delay onset may constitute an important strategy for prevention. All these issues may be addressed by twin studies of AD, but the few such studies to date have been limited by small samples and other methodologic difficulties. This paper reviews the rationale for twin studies of AD, and describes briefly the work in this area to date. It also discusses a number of suggestions for methodologic improvements. We conclude that the time is ripe for twin studies of AD, and that such work holds considerable potential for the investigation of etiology and, possibly, for the identification of strategies for prevention.

Populations at increased risk of HIV infection: current knowledge and limitations.

Research data describing the prevalence and patterns of behaviors that place persons at increased risk of HIV infection are extremely limited. The scarcity of data has constrained potential applications of surveillance data, research on specific high-risk behaviors, and epidemiological studies. This article critically reviews available research for four population groups: intravenous drug users, homosexual males, and sexually active adolescents and adults. The fallacies inherent in estimating risk group size underscore the need for population-based research that can provide detailed data on sexual and drug use behaviors.

The comorbidity of anxiety and depression in general medical patients: a longitudinal study.

In a general medical clinic setting, 880 patients were screened for depression by using the Diagnostic Interview Schedule version of the DSM-III and the Zung Self-Rating Depression Scale (SDS), as well as the Zung Self-Rating Anxiety Scale (SAS). Based on a morbidity cutoff index of 50 on the SDS and a positive DIS for depression, 112 patients (13%) were found to have a depressive disorder. The SDS showed a 97% sensitivity, a 63% specificity, and an 82% correct classification of depressed and nondepressed control patients. Based on the SDS results and SAS results when anxiety was considered present at a moderate severity level, the comorbidity of anxiety and depression was 67%. Depressed patients were followed for 1 year during which time they were retested with the SDS and SAS at five time points (6 weeks and quarterly). Fifty-one patients who met the criterion of a decrease of greater than or equal to 12 points in the SDS index were assigned to the improved group, 23 who met the criterion of an increase of greater than or equal to 12 points were assigned to the worse group, and 36 patients were assigned to the no-change group. Depressed patients who improved showed a significant decrease in anxiety based on SAS change scores; depressed patients who worsened showed a significant increase in their anxiety index. The decrease in the anxiety index of patients in the no-change group was not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative performance of the MAST, VAST, and CAGE versus DSM-III-R criteria for alcohol dependence.

A number of instruments have been developed to screen for alcoholism. With the advent of DSM-III and lay administered psychiatric diagnostic instruments, a test of the performance of these screens relative to diagnostic instruments is critical. In this paper, we document the relative effectiveness in a general medical clinic of the Michigan Alcoholism Screening Test (MAST), the Veterans Alcoholism Screening Test (VAST), and the CAGE questions in comparison to the DSM-III-R criteria for alcohol dependence as measured in the Composite International Diagnostic Interview (CIDI). All of the screens performed at acceptable levels, but the MAST and VAST tended to have higher performance characteristics. At the recommended cut points, they had higher sensitivity for lifetime alcohol dependence (VAST 95.1%, MAST 90.2%, CAGE 78.0%) as well as higher specificity (VAST 80.3%, MAST 81.7%, CAGE 76.1%). For present alcohol dependence only, at the recommended cut points the MAST and CAGE had sensitivity of 100% but specificity of 62.0 and 61.0% respectively. The VAST had sensitivity of 83.3% and specificity of 89.0%. We conclude that all three perform well relative to DSM-III-R criteria.

Associations among family support, family stress, and personal functional health status.

The self-reported family support and stress of 249 ambulatory adult patients, aged 18-49 years, were studied relative to their self-reported functional health. Support from family members was found to be related positively with emotional function. Stress from family members was associated negatively with symptom status, physical function, and emotional function. Patients' severity of illness was related negatively to their symptom status, physical function, and social function, but not to their emotional function. During the study a new self-report instrument, the Duke Social Support and Stress Scale (DUSOCS), was developed to measure family and non-family support and stress. Also, a new chart audit methodology, the Duke Severity of Illness Scale (DUSOI), was designed to assess severity in the ambulatory setting. Reliability and validity of the DUSOCS and the DUSOI were supported. The importance of the patient's perception of health and its family determinants is emphasized.

Alcohol abuse in elderly emergency department patients.

OBJECTIVES: To determine the prevalence of alcohol abuse in elderly emergency department (ED) patients; to determine the prevalence of alcohol abuse for various categories of illness and injury among these patients; and to determine the frequency of detection of elderly alcohol abusers by ED physicians. DESIGN: Cross-sectional prevalence study. SETTING: The emergency department of a 625-bed university hospital that serves a mixed urban and rural population. PATIENTS: 205 patients aged 65 and over who came to the ED during an 8-week period. MEASURES: A structured interview, which included the CAGE questionnaire and other questions regarding alcohol use, was administered. Emergency department records and past medical records were reviewed. RESULTS: The prevalence of lifetime alcohol abuse (CAGE positive or self-reported drinking problem) was 24%. The prevalence of current alcohol abuse (CAGE positive or self-reported drinking problem and alcohol use within the last year) was 14%. There was a particularly high prevalence (22%) among those presenting with gastrointestinal problems and a surprisingly low prevalence (7%) among those who presented with falls or other trauma. Physicians detected only 21% of the current alcohol abusers. CONCLUSIONS: Alcohol abuse is a prevalent and important problem among elderly ED patients. It is not well detected by physicians in this setting. Alcohol abuse appears to be less common among elderly trauma patients than their younger counterparts, but is very common among patients with gastrointestinal problems.

Direct fluorescent antibody testing for endocervical Chlamydia trachomatis: factors affecting accuracy.

Endocervical swabbings obtained after two previous cleansing swabs from 202 women with indications for testing for genital chlamydial infection were evaluated for the presence of Chlamydia trachomatis by culture and two direct fluorescent monoclonal antibody tests. In comparison with culture, the two direct fluorescent antibody tests showed sensitivities of 37.5 and 56.5% and specificities of 97.0 and 99.4% when read by experienced microbiology technologists recently trained in chlamydia direct fluorescent antibody interpretation and blinded to culture results. Overall sensitivities of 69.6 and 78.3% for the direct fluorescent antibody tests were obtained by an expert interpreter during discrepancy analysis. When only direct fluorescent antibody test specimens from the first swab after endocervical cleansing were considered, recently trained interpreters obtained sensitivities of 53.8 and 69.2%, and both direct fluorescent antibody tests were 100% sensitive for the expert interpreter. These data emphasize the critical importance of observer expertise and swab order to the accuracy of chlamydia direct fluorescent antibody tests. Previous studies of these tests are examined to determine how these factors and others may have influenced the outcome.

Management of general medical patients with symptoms of depression.

This article describes the management of depressive symptoms in a group of ambulatory patients in general medical care during a 1-year period. It also examines patient outcomes by types of management and aggressiveness of treatment. Subjects are 112 male patients longitudinally enrolled in a V.A. General Medical Clinic who screened positively on both the Zung Self-rating Depression Scale and the DSM-III criteria. Medical records were abstracted to obtain information on mental health management. During the follow-up year, 48% of the moderately depressed patients received some form of mental health management compared to 92% of the severely depressed patients. Of the treatment modes, only patients who had a mental health clinic visit and/or psychiatric consultation were significantly more improved than those not so treated--but only at 6 months (p = 0.09) and 9 months (p = 0.02). Actual treatment experience was then classified into three levels based on intensity, duration, and combinations of treatments. Of the three levels, only those patients in the moderately aggressively treated condition were significantly more improved at 3 months (p = 0.02) and at 6 months (p = 0.04) than those in the no-treatment condition.

Correspondence of clinicians' judgments with the Michigan Alcoholism Screening Test in determining alcoholism in Veterans Administration outpatients.

Two independent assessments of alcoholism--clinicians' judgments and the Michigan Alcoholism Screening Test (MAST)--were in agreement only 77.0% of the time, with a Kappa value of .44. Because of its administrative efficiency and greater uniformity and objectivity, the MAST was judged as being preferable to clinicians' judgments in situations in which only one method is needed.

Alcohol abuse and alcoholism in primary health care settings.

Alcohol problems are common in primary care patients, yet they are often not detected and treated. Methods for improving the detection and diagnosis of alcohol problems in the primary care setting are reviewed in terms of pertinent history, physical examination, and laboratory findings. Screening instruments such as the CAGE questionnaire and the Michigan Alcoholism Screening Test are recommended for routine use by primary care physicians. Such instruments have been shown to have higher sensitivity than laboratory tests alone. Although less is known about intervention and management, earlier intervention with innovative (less costly) management techniques may be both efficacious and acceptable to the patient.

Health services research in alcoholism: current status and future directions with special emphasis on opportunities in the Veterans Administration.

Alcoholism has become an important health care problem for the United States and the VA medical care system. The percentage of inpatients in Veterans Administration hospitals with a diagnosis of alcoholism rose from 13.0% in 1970 to a high of 15.6% in 1977. Health services research work in alcoholism has generally fallen into four major areas: community diagnosis; utilization of services by alcoholics; the effectiveness, efficiency, and quality of services; and the organization of information systems and their applicability to alcoholism. Obstacles to research include a poor understanding of the prevalence of the disease among the veteran's population, but the system offers many more opportunities than obstacles. A new information system, SATAR (Substance Abuse Treatment Automated Records), offers a chance for large-scale investigation of the problem of alcoholism among VA patients when combined with other information systems and allows for special comparisons through its large, integrated network of hospitals and clinics.

Recognizing depression in patients receiving medical care.

Depression is a common condition among patients receiving medical care but often goes unrecognized by care providers. After discussing research on the prevalence, recognition, and treatment of depression in general health care settings as well as the factors associated with psychological distress among nonpsychiatric patients, this article explores how social workers can help improve the identification and management of depression in such settings.

A new perspective on multiinstitutional systems management.

To negotiate acceptable environmental accommodations, multiinstitutional systems undertake four types of solutions or transformations: environmental manipulations, internal process modifications, strategic modifications, and most drastically, total reconfigurations. It is helpful to examine the determining factors of these transformations and to look at which types of management use which transformations.

Improving physicians' recognition and treatment of depression in general medical care. Results from a randomized clinical trial.

A randomized clinical trial was performed to assess whether the results of a depression screening instrument, when provided to physicians, could influence their recognition and treatment of depression in a primary care setting. The intervention consisted of randomly informing or not informing physicians of the depression status of 100 patients who screened positively for depression on both the Zung Self-rating Depression Scale (SDS) and a DSM-III screen. For 12 months patients were followed to assess depression status, and medical records were audited to assess depression recognition and treatment. Results show that feedback to physicians of SDS scores of previously unrecognized depressed patients makes a significant difference in greater recognition (56.2% vs. 34.6%) and treatment (56.2% vs. 42.3%) of depression over the 12-month study period. This was especially true for patients with high somatic (P less than 0.05) or low psychologic symptoms of depression (P less than 0.05). These results suggest that routine use of a depression screening instrument can improve physician recognition of depression, with increased initiation of treatment.

Age-related patterns of alcoholism among veterans in ambulatory care.

In a survey of 342 outpatients in two urban Veterans Administration medical centers, 10.2 percent of the patients aged 65 and over and 8.4 percent of those aged 55 to 64 were found to be alcoholic on the Veterans Alcoholism Screening Test. The younger age groups (under age 35, age 35 to 44, and age 45 to 54) were two and a half to three times more likely to be alcoholic than the 65-and-over group. The oldest group was most likely to have never been alcoholic, and least likely to have been formerly alcoholic. Although several authors have proposed that the elderly may increase their intake of alcohol in response to the stresses of aging, study data indicated that half of the 65-and-over alcoholics were longstanding alcoholics. However, while the study suggests that the older groups have proportionately fewer alcoholics, the growing size of the aging population means that in the next few decades there will be greater absolute numbers of elderly chronic alcoholics.

Criteria for onset critically influence the estimation of familial risk in Alzheimer's disease.

The rare early-onset variant of Alzheimer's disease (AD) appears to be transmitted as an autosomal dominant genetic trait. More typical late-onset AD also shows familial aggregation, but possible genetic mechanisms are difficult to examine because the phenotypic expression of the putative AD genotype is often censored by prior death from competing causes. Lifetable methods have been used to examine the age-specific risk of dementia among relatives, and thus to test the hypothesis of genetic transmission of late-onset AD. These methods require the ascertainment of affected relatives and the determination of their age at onset. The latter determination is somewhat arbitrary, since symptoms of AD evolve and develop in a continuous and progressive fashion, and different workers may thus use differing criteria for "onset." This paper demonstrates that the use of divergent thresholds for "caseness" (typically, progressive dementia of several years' duration) and onset (e.g., the first appearance of mild cognitive symptoms, or the first clear evidence of dementia) can introduce substantial bias toward underestimation of risk among relatives. Depending on the definition of onset, familial risk may be underestimated, with apparent cumulative incidence decreased to only 60% of values otherwise expected. We suggest that this problem can be avoided by the use of identical threshold criteria for caseness and for onset.

Effects of drug misuse treatment on symptoms of depression and suicide.

In this longitudinal study of 9,904 clients who were treated at methadone, outpatient drug-free (OPDF), and residential treatment facilities, at intake more than half of all clients reported symptoms of depression or suicide. Females and multiple nonnarcotics users were at highest risk for suicide attempts. Despite a dramatic drop in the level of symptomatology by 4 weeks in treatment, many clients remained suicidal throughout the study period. Suicidal tendencies at both intake and 4 weeks were strongly related to suicidal tendencies at 12 months post-treatment; even more strongly related was the return to weekly or more frequent use of narcotics or nonnarcotics for residential and OPDF clients.

Esophageal cancer staging by CT: long-term follow-up study.

To evaluate the utility of computed tomographic (CT) staging in patients with esophageal cancer, the length of patient survival was compared with pretherapy CT findings in 89 patients. Regardless of therapy, patients with evidence of mediastinal invasion, liver metastases, or abdominal adenopathy had a statistically shortened survival (P less than .05). Specific CT criteria that predicted a shortened survival included evidence of tracheal, aortic, or pericardial invasion. Patients with evidence of both mediastinal invasion and abdominal metastases had a mean survival of 180.4 days; those with no evidence, 479.6 days. The presence of enlarged upper abdominal lymph nodes indicated the worst prognosis (mean survival, 90 days). The patients with squamous cell tumors were classified by the CT staging system, and survival data were compared according to surgical procedure. Patients who underwent attempted curative surgery did not have a statistically significant difference in survival by analysis of survival curves but demonstrated a longer mean survival than those who underwent palliative or no surgery.