PREVENTIVE
4, 328-372 (1975)
MEDICINE
Annotated Bibliography for Preventive Health Care Strategies for Health Maintenance Organizations’ PETER B. PEACOCK American
Health
Foundation.
New York, New York 10019
ANNA C. GELMAN Columbia
University
School of Public Health,
New York, New York 10032
AND
THEODORE A. LUTINS American
Health
Foundation,
New York, New York 10019
CONTENTS I. II. 111. IV.
Screening References Health Hazards References Health Education References Some Chronic Disease References A. Cancer of the Uterine Cervix B. Cancer of the Breast C. Glaucoma D. Obesity E. Coronary Artery Disease F. Chronic Obstructive Pulmonary Disease G. Peripheral Vascular Disease H. Hypertension I. Miscellaneous V. Prenatal Services References VI. Child Health References VII. Mental Health, Drug Abuse and Alcoholism VIII. Preventive Dentistry
I. SCREENING 1. Bernstein, J. M., and Dolan, L. J. Multiphasic
References
REFERENCES screening as part of family doctoring.
Practitioner
203, 798-805 (1969). The authors describe multiphasic screening in a two-man urban practice in Crumpsall, Manchester, England. Of the 402 women between 35-45 years of age offered the testing, cepted. Of these 170, 91 were found to be obese, 53 had blood pressure greater than 140/90, greater than 150/95. In only 25 cases of the 170 was further action felt to be needed. The distinguish between epidemiological screening surveys and case finding surveys. The general tioner is felt best to conduct case finding surveys. 1 This bibliography follows the “Special Report: Preventive Maintenance Organizations” published in Vol. IV, No. 2.
328 Cowrieht 0 1975 by Academic Press, Inc. AII rights of reproduction in any form reserved.
Health
Care Strategies
North 170 acand 18 authors practi-
for Health
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2. Bunow, M. A. Preliminary observations of ranges of blood profiles by ethnic groups based on test results of 21,000 California cannery workers. Ind. Med. Surg. 38, 424-28 (1969). The author presents a study of blood chemistry findings in cannery workers that embodies four ethnic groups (Negro, Oriental, Mexican-American, and other Caucasian), three age categories (less than 35, 35-49, more than or equal to SO),and represents 35 companies and 100 plants. In the 1967 program, over one-half of the population tested had one or more positive findings. In the 1968 series, approximately 4 1% of the examinees had such findings. There were significant variations in the percentage of normals in each group. The author suggests that this might cast doubt as to the value of the application of a single screening level to the total population and that it may be necessary to establish age-, sex-, and ethnic-specific screening levels for each blood chemistry test. 3. Chen, W., Palav, A., and Tricomi, V. Screening for diabetes in a prenatal clinic. Obsret. Gynecol. 40, 567-74 (1972). Subclinical or chemical diabetes is known to increase perinatal mortality. Therefore, screening patients for diabetes mellitus in a perinatal clinic is important, particularly in a municipal hospital where these visits are frequently the only occasions on which the indigent population receives adequate care. Over a 3-year period, 1968-70, 1269 of 8288 patients attending the prenatal clinic at BrooklynCumberland Medical Center were investigated for abnormal glucose tolerance because of obesity, family history of diabetes, previous birth of a large infant, poor obstetric history, or glucosuria. Ninety-one patients, or l.l%, of the total prenatal population were found to have an abnormal glucose tolerance. To determine the population at greatest risk, the significance of various indicators for screening were evaluated by statistical analysis. From the information derived, the detection of abnormal glucose tolerance rose exponentially with each additional screening indication. Thus, multiple indicators for screening in a given subject indicate that carbohydrate metabolism must be investigated immediately. 4. Collen, M. F. Diseases which can and should be detected early. Znd. Med. Sup. 39, 338-40 (1970). The author reviews definitions applicable to early disease detection and multiphasic screening. The author concludes that screening tests for cardiovascular disease, genitourinary disease, metabolic disease, thyroid disease, cancer, hematologic disease, venereal disease, and vision and hearing problems are adequate. However, better detection is needed for mental and psychological problems. 5. Collen, M. F., Dales, L. G., Friedman, G. D., Flagle, C. D., Feldman, R., and Siegelaub, A. B. Multiphasic checkup evaluation study: 4. preliminary cost-benefit analysis for middle-aged men. Prev. Med. 2, 236-46 (1973). Further report of “Muhiphasic Checkup Evaluation Study” as per Cutler et al. (1973), Ramcharan et al. (19’73), and Dales et al. (1973). A preliminary cost-benefit analysis for the program of Multiphasic Health Checkups has suggested a net savings of more than $800 per man over a 7-year period among men urged to take checkups as compared with men not so urged. This difference is reflected primarily in the lower disability and mortality rates observed for the men who were urged to receive checkups. Similar differences have not been demonstrated for women or younger men. 6. Craig, J. L., and Derryberry, 0. M. Applied concepts of automation in an occupational medical program. Ind. Med. Surg. 40, 9-17 (1971). The Tennessee Valley Authority has found that automation relieves the medical staff of time consuming medical and administrative tasks. It frees clerical personnel for other work and assists in maintaining accurate, dependable records. It aids in monitoring the health of employees and helps to detect needs in health services. Automation in the Tennessee Valley Authority health program falls into three major categories: (1) automation of medical records, (2) computer electrocardiography, and (3) automated centralized laboratory. 7. Cutler, J. L., Ramcharan, S., Feldman, R., Siegelaub, A. B., Campbell, B. A., Friedman, G. D., Dales, L. G., and Collen, M. F. Multiphasic checkup evaluation study: 1. methods and population. Prev. Med. 2, 197-206 (1973).
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The authors report on a controlled long-term study conducted among members of the Kaiser Health Plan to evaluate the efficacy of the periodic health examination, utilizing automated multiphasic health screening techniques. A representative sample of approximately 5,000 persons aged 35-54 was selected in 1964 and was urged to undergo annual examinations. The study design, population evaluated, and experience of the sample are described in detail. The mortality, morbidity, and disability of the population and their utilization of medical care are being compared to a similar group allowed to seek care on their own initiative within the same program. The population was relatively healthy and with little disability at the start of the study. About 65% of the group is examined each year, and 78% of the original group is still under surveillance after 7 years. 8. Dales, L. G., Friedman, G. D., Ramcharan, S., Siegelaub, A. B., Campbell, B. A., Feldman, R., and Collen, M. F. Multiphasic checkup evaluation study: 3. outpatient clinic utilization, hospitalization, and mortality experience after seven years. Prev. Med. 2, 22 1-35 (1973). This report continues to discuss the “Multiphasic Checkup Evaluation Study” as per Cutler er al. (1973) and Ramcharan et al. (I 973). This article describes the outpatient clinic utilization, hospitalization, and mortality experience of the study group subjects and the control group subjects. There has been little difference in utilization of outpatient physican and laboratory services other than those directly connected with the Multiphasic Health Checkups. However, the study group subjects have had more diagnoses made. Hospital usage in mates aged 45-54 has been slightly lower in the study group as contrasted with the opposite effect in women. The overall mortality rate has been slightly lower in the study group. For a group of causes of death defined as being potentially postponable or preventable, the mortality rate of the study group has been significantly lower. This is not accounted for by chance fluctuation, underreporting, differentially selective loss to follow-up, or an initial study-control group health status disparity. 9. Gitman, L. Automated multiphasic health screening: usefulness to the practicing physician. N. Y. State J. Med. 70, 1741-44 (1970). The author briefly reviews the history of single disease detection programs and automated multiphasic health testing programs. He cites the Kaiser and Brookdale facilities as the prototype for developing an organization to service a population of various socioeconomic statuses with no prepaid health insurance resources. Simply stated, the usefulness of AMHT to the practicing physician lies in its enhancing the effectiveness of the periodic health examination as a preventive health measure. The Brookdale concept is described, and the manner in which it provides a data base for evaluation by the physician is shown. Hopefully, this will increase the efficiency and effectiveness of the periodic health examination as performed by the physician. 10. Gordon, P. C. Screening for disease in hospital and clinic populations. Canad. J. Pub. Health 57, 249-59 (1966). The author presents several reasons why a profitable yield from screening procedures can be expected in hospital and clinic populations: (1) both hospital and clinic patients represent high-risk groups in which the prevalence of certain diseases can be expected to be higher than in the general population; (2) early detection procedures are now routinely applied on most hospital and clinic patients for some diseases; (3) the principles of early detection need no introduction to these facilities but rather a reemphasis; (4) hospital and clinic patients constitute “captive” populations to which tests may be applied without time-consuming and expensive promotional campaigns frequently required; (5) the laboratories and other testing facilities are available; (6) evaluation tests can be carried out more readily; and (7) the hospital milieu is conducive to the clinical and epidemiological research needed to assess the validity and preventive value of currently available detection techniques and to develop new and better methods. 11. Gordon, R. E. Psychiatric screening through multiphasic health testing. Amer. /. Psychiat. 128, 559-63 (1971). The author takes the position that psychiatrists have generally lagged behind the other specialties in exploring the usefulness of automated multiphasic health testing. The lack of a generally accepted, automated psychological screening device in contrast to those available to test blood chemistry, cardiology, spirometry, etc., probably accounts for this lack of interest. Certainly a number of psycho-
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logical instruments have been and are automated, e.g., the MMPI, but these are more diagnostic in nature and, thus, not suitable to the screening setting. The author discusses automated multiphasic health testing and its potential value to psychiatry. He describes the development and testing of instruments at the University of Florida, College of Medicine, Gainesville, Multiphasic Testing Center, for specific use in AMHT centers. 12. Thamer, M. A., Harvey, J. C., and Reed, J. W. Development of a multiphasic screening examination for medical care patients: III. yield of the multiphasic screening examination. J. Chronic Dis. 15, 849-56 (1962).
The authors deal with the development of a multiphasic screening type of examination for medical care patients at the Medical Care Clinic of the Johns Hopkins Hospital for clients receiving public welfare assistance. The first paper describes the overall program, a historical development of multiphasic screening examinations, and those used at the Johns Hopkins Medical Care Clinic. The second paper provides the details of the sensitivity and specificity determinations, presenting detailed computations. The third paper presents the results of the screening examinations on a representative sample of the 6,000 new clients seen at the clinic since 1955. 13. La Dou, J. Multiphasic health testing in the clinic setting. Calif. Med. 115, 34-37 (1971). The author takes the premise that the economy of automated multiphasic health testing activities patterned after the high-volume Kaiser program can be realized in low-volume settings. The factors that limit the participation of most physicians in programs of multiphasic health testing are (1) the cost of a large computer system, (2) the relative lack of medical centers capable of supporting patient flows that realize the economy of the concept, and (3) the peripheral part most physicians play in mass screening of persons whose testing was ordered by them. Through a grant from the Office of Economic Opportunity, multiphasic health testing was carried out in a six-doctor clinic on a pilot basis. Twenty patients per day were examined using a two-room area, a nurse, and a technologist. The most significant finding of this study was that a 94% follow-up rate was maintained in this setting, which was located in a borderline poverty population. Further experience with an industrial medical clinic specializing largely in preventive medicine demonstrated that by making the physician the center of a multiphasic testing program, a two-doctor industrial medical clinic can serve a 20,000employee industrial area with ease and efficiency. 14. Lenhard, R., Conwell, D., and Smith, H. Establishing a preventive medicine clinic in a public health service hospital. Pub. Health Rep. 80, 55 l-54, (1965). Public Health Service and Coast Guard personnel and their dependents, retired military personnel, and active merchant seamen, in apparent good health and at least 40 years old, were invited to participate in a multiphasic screening examination including a complete physical. Those needing follow-up were referred to the appropriate facility. The authors conclude that this approach revealed a number of unknown abnormalities, and that it was a profitable case-finding procedure in an apparently well population. 15. Lohrenz, F. N., and Wenzel, F. J. The periodic executive examination: comparison of major findings in patients under age fifty with those over age fifty. Ind. Med. Surg. 38, 3 14-l 6 (1969). Seventy male employees under age 50 of a paper manufacturing company were compared to 36 males over age 50 employed by the same company. They were examined annually over a 5-8 year period beginning in 1960. Twenty-five percent of those over 50 had a major diagnosis made at initial screening as compared to 14% in the group smaller than 50. Thirty-one percent of those over 50 had additional diagnoses made subsequent to the first examination as compared to 27% in those under 50. In both groups, 14% developed unpredicted diseases during the period of observation. These findings are compatible with the view that annual examinations in those over 50 should lead to the discovery of more significant, presumably preventable, disease than in those less than 50 years old. 16. Pike, L. A. Screening middle-aged men in a genera1 practice. Practitioner 209, 690-95 (1972). An account is given of a screening clinic for middle-aged men in a National Health Service general practice situation in North Birmingham, England. Of the 309 men invited for testing, 140 accepted
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(45.3%). By the use of a questionnaire, it was determined that 85 out of the 140 (60.5%) wished to discuss one or more problems. Obesity was identified in 44 (31%), anemia in 13 (9%), elevated blood pressure in 7 (5%), elevated serum cholesterol in 17 (12.1%), and diminished respiratory function in 26 (I 8.6%). Twelve of the 140 were referred to hospital clinics (8.3%), and 85 made one further visit to the practice center (58%). 17. Ramcharan, S., Cutler, J. L., Feldman, R., Siegelaub, A. B., Campbell, B. A., Friedman, G. D., Dales, L. G., and Cohen, M. F. Multiphasic checkup evaluation study: 2. disability and chronic disease after seven years of multiphasic health checkups. Prev. Med. 2, 207-20 (1973). This report continues the design set forth by J. L. Cutler et al. (1973) already discussed. Measures of disability, chronic disease, and utilization of medical services were obtained by a questionnaire mailed biennially to study and control subjects. After 5-7 years, a favorable impact on the health of the older study males compared to the older control males was evidenced by (1) a reduction in selfrated disability and reported time lost from work, (2) a greater proportion working, and (3) a lower self-reported utilization of medical services by the sick. The questionnaire is included. 18. Randolph, C. L., Jr. Value of routine X-ray examination of the abdomen during aeromedical evaluation. Aerosp. Med. 38, 307-9 (1967). Chest abnormalities are first discovered commonly by routine chest X-ray examination before the onset of symptoms or physical signs. The ability to detect asymptomatic disease is well recognized. The abdomen is seldom examined unless disease is suspected. Plain film examination of the abdomen for detection of silent pathologic conditions has potential similar to chest X-ray examination, according to the author. Roentgenograms of the abdomen were obtained on each of 2132 flying personnel undergoing aeromedical evaluation at the USAF School of Aerospace Medicine, Brooks Air Force Base, Texas. Included were 544 men being considered for space pilot selection and other special missions. The remainder were being examined to determine fitness for continued flying duties. Significant previously undiagnosed abnormalities were found in the routine chest films of 12 cases (0.5%) and on the abdominal films of 43 cases (2%). Twenty-nine cases of renal abnormalities were discovered, six of these among special missions candidates. Nearly 80% of the abnormalities were discovered in men more than 35 years old, although this age group comprised slightly less than one-half of the total number examined. The results indicate that abdominal films would have their greatest usefulness if employed during initial selection for flying training and at periodic intervals after age 35. 19. Scott, R., and Robertson, P. D. Multiple screening in general practice. Brit. Med. J. 2, 643-47 (1968). Female patients older than 15 years old were invited to take part in a multiple screening program. Of 2158 patients on the practice list, 358 were excluded from the survey. Of the remaining 1800 offered the examination, 43% accepted. The conditions found most frequently were anemia (6%), bacteriuria (4.6%) raised blood pressure (16%), obesity (30%), and hypercholesterolemia (19%). 20. Shenthal, J. E. Multiphasic screening of the well patient: twelve year experience of the Tulane University Cancer Detection Clinic. J. Amer. Med. Ass. 172, 1-9 (1960). The author reports on the operation of the Tulane University Cancer Detection Clinic. A major concern of this facility is with the status of the total well patient and whether asymptomatic conditions might be detected during initial or periodic examinations of such patients. Multiphasic examinations of 10,709 apparently healthy subjects showed that 92% had either organic or functional disease. Malignancy was detected in 77 (0.72%) and cardiopathy in 804 patients, with myocardial disease being the most frequent form (26.5%). The data indicate the importance of systematic health examinations and suggest ways of establishing a baseline of what to expect in various age groups. 21. Trevelyan, H. Study to evaluate the effects of multiphasic screening within general practice in Britain: design and method. Prev. Med. 2, 278-94 (1973). Trevelyan describes a control trial to evaluate the effect of screening in individuals 40-64 years old
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registered in two London general practices. Half were randomly allocated to the intervention or screening group; the rest acted as controls. The design consists of (1) multiphasic screening offered to the screening group at 2-year intervals, (2) a 5-year longitudinal survey of health service usage and sickness absence in both screened and control groups, and (3) a terminal survey, at the end of the 5 years, of both groups measuring the distribution of physical and socioecomic variables and the prevalence of certain symptoms and diseases and disability. No results are given in this paper, but they will be reported later. 22. Weston, A. B., and Fairley I. E. Sixty and up health centers: Vancouver’s first year of experience in geriatric screening and counseling. Can. J. Pub. Health 59, 389-92 (1968). The establishment of a sixty-and-up health center by the Vancouver city administration and the British Columbia Medical Assocation is reviewed. The unit was established as a pilot project to provide medical screening, health assessment, and counseling and referral services. The authors conclude that the extension of services provided by a city health department to include screening and health counseling for the elderly serves an important function by meeting the health needs of this age group. This project also points out the very real and unmet needs in communities, e.g., counseling and information for the elderly and their families as a concrete approach to education for the retirement years and, ultimately, the extension of screening to younger age groups to preclude the emotional and economic trauma to the individual and to the community that result from unrecognized chronic disease.
II. HEALTH HAZARDS REFERENCES 1. Anonymous. Safety chart for common solvents. PIant Eng. 27, 150-52 (1973). The safety chart includes information on the common chemical names of each solvent, boiling point in degrees Fahrenheit, explosive limits (lower and upper), auto-ignition temperature, vapor density, threshold limit value, and major health hazards. The fifty-four identified here are those most likely to be encountered. 2. Anonymous. Electrical safety in class hazardous locations. Nat. Suf. News 107, 59-61 (1973). Class 1 locations are subclassified into groups that designate various flammable gases and vapors. The methodology for controlling such hazards to electrical safety include intrinsically safe systems, explosion-proofing, purging, and inerting. 3. Anonymous. Building in environmental safety. Nat. Saf. News, 107, 90 (1973). The nation’s largest manufacturer of power generation equipment uses a system of fans and filters to clean and recirculate air as well as other antipollutant measures. 4. Anonymous. Pressure vessel dangers. Occup. Health Rev. 25, 182-83 (1973). The term “pressure vessels” includes steam boilers, air receivers, and all containers for liquids and gases at greater than atmospheric pressure. There are many dangers connected not only with their use but also their fabrication. An explanation of the hazards and a description of the detailed design codes is given. 5. Beckett, John C. Dynamics of fresh air: as seen from the view of ionization in a changing environment. Amer. Sot. Heat Refrig. Air-Cond, Eng. J. 1, 47-51 (1959). The author, a chief engineer for a manufacturer of a commercial air ionizer, states that one of the major differences between fresh and purified air is ionization. The sources of ionization are soil radioactivity, cosmic rays, solar radiation, etc. A beneficial effect of ionization on hay fever sufferers has been reported as well as effects on the adrenal gland, ciliary activity, mucus flow rate, etc. 6. Benfer, K. L. Air conditioning-blessing or curse? Pa. Med. 76, 55-58 (1973). Air-conditioning in its present form is a health hazard. Despite its important medical aspects, the profession has had no voice in developing guidelines. Six case histories are described indicating the adverse physiological effects that improper air-conditioning can have, and several recommendations are given.
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7. Burton, D. M. Taking good care of ground crew. Occup. Healrh Rev. 25, 97-102 (1973). The author examines how the introduction of new aircraft such as the Boeing 747 and the supersonic Concorde will affect the health, safety, and working environment of ground staff. Excluding toxic and physical hazards, the environmental factors most closely related to health, comfort. and working efficiency are the thermal, acoustic, and visual environments. 8. Carlson, L. D., et al. “Adaptive Changes During Exposure to Cold,” Proj. 22-1301-0002. Arctic Aeromed. Lab., Ladd AFB, Alaska, 1953. The purpose of this experiment was to demonstrate that readjustments in the peripheral circulation of the extremities cause an actual rise in the skin temperature during exposure to cold. 9. Edholm, 0. G. Tropical fatigue, in “Symposium of Fatigue” (W. Floyd and A. T. Weford, Eds.), pp. 19-20. H. K. Lewis Co., London, 1953. Excluding all tropical disease, prolonged stay in the tropics is often accompanied by physical and mental deterioration. Nearly all objective studies have found that there was an increase in lethargy, reduced mental concentration, retardation of mental alertness, lowered desire to assume responsibility and incentive, and disadvantageous personality changes and memory defects. 10. Freese, A. F. “Protecting Your Family From Accidental Poisoning,” Public Affairs Pamphlet #459. D.H.E.W., F.D.A. (N.D.) This 28-page pamphlet gives extensive information on protective measures for both children and adults against most household dangers. There are an estimated quarter of a million household products, many containing potentially poisonous chemicals, but half of all poisonings are due to only ten kinds of products: aspirin, insecticides, household bleach, detergents, soaps and cleaners, furniture polish, kerosene, iron and vitamin compounds, disinfectants and deodorizers, lye and corrosives, and laxatives. There are times of day that are peak poisoning periods, and very few storage areas that can be safely considered to be removed from a child’s reach. Suggestions are made for medicine containers and packaging for the manufacturers. 11. Hyuarineri, J., Pyykko, I., and Sundleerg, S. Vibration frequencies and amplitudes in the aetiology of traumatic vasospastic disease, Lancet 1, 791-94 (1973). Forty-three Finnish lumberjacks with a history of traumatic vasospastic disease (TVD) associated with the use of the chain saw were investigated. It was concluded that a likely mechanism for the symptoms found was a chronic overexcitation of the pacinean vibration receptors that produce spastic reactions in the vasculature through a reflex linkage with the sympathetic nervous system. 12. Industrial hygiene digest: asbestos as an industrial health hazard, Med. J. Aust. 1, 92 (1973). Asbestos has long been suspect as a cancer-producing agent. This is a report of a meeting attended by participants from twenty countries, organized jointly with the Inter-Agency for Research in Cancer and Pneumoconiosis Unit of the Medical Research Council of Great Britain. Various recommendations about future research into asbestos problems were made including (1) studies of cancer production by asbestos dust, (2) control and protection, (3) quantities that are hazardous, and (4) standardization of diagnostic criteria. 13. International Labor Office. “Encyclopedia of Occupational Health and Safety,” ~01s. I (A-K) and 11 (L-Z), 870 pp. International Labor Office, Geneva 1972. This new encyclopedia is not a scientific treatise; its aim is to make the knowledge now available more readily accessible to those directly responsible for promoting improved conditions for the worker. Its approach is practical, stress being laid throughout on risks and their prevention. 14. International Labor Office. “Guide to Safety and Health in Forestry Work.” 223 pp. International Labor Office, Geneva 1968. In this guide, forestry is taken to comprise all operations undertaken to establish or maintain forest, harvest wood, and transport wood when harvested. Power saws, tractors, motor trucks, cranes, and pesticides are being used increasingly with additional hazards. It is with the safety activities of the individual undertaking that this guide is mainly concerned.
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15. Manufacturing Chemists Association. “Guide for Safety in the Chemical Laboratory,” 2nd ed., 505 pp. Manufacturing Chemists Association, Washington, DC., 1972. This guide provides the essential information that enables the laboratory supervisor to develop a program for maintaining the health and safety of personnel within the field of his responsibility. It includes the Latest methods and equipment for protection of the workers and illustrates modern facilities and procedures. 16. McLean, A., and Clarke, A. C. W. V. Atomic safety. Occup. Health Rev. 25, 171-75 (1973). Types of radiation that can cause injury to the worker (and sometimes to the work) must be controlled. Control depends on the fact that all radiation can be detected and measured. It has been possible to reach a wide measure of international agreement on permissible levels of radiation. This article discusses practice and enforcement. 17. McConnell, W., Houghton, F. C., and Yaglou, C. P. Air motion-high temperatures and various humidities-reactions on human beings. Amer. Sot. Heat Vent. Eng. Trans. 30, 167-92 (1924). This study attempts to relate atmospheric conditions to physiological effects. This is a continuation of a previous study set forth in ASHVE Trans. 29 (654), 13 I-164 by the same authors to cover the effects of air motion. 18. Powell, P. “2000 Accidents, A Shop Floor Study of Their Causes.” 185 pp. National Institute of Industrial Psychology, London 1971. This report is about 2,367 accidents at work (minor and serious) that occurred in four different types of industrial workshops. The study discusses the way in which known facts can be applied usefully to the prevention of accidents in the industrial situation. 19. Schmidek, M., Henderson, T., and Margolis, B. Evaluation of proposed limits for intermittent noise exposures with temporary threshold shift as a criterion. Amer. fnd. Hyg. Ass. J. 33, 543-46 (1972). Standard limits for noise exposure have been proposed for coal mine operations. A key feature of the proposal is the provision to take account of intermittent exposure to noise. Specifically, limiting combinations of noise level, number of noise occurrences, and total daily exposure time are prescribed as safeguards against permanent hearing loss. The protection provided is reviewed, and it is suggested that the safety of the proposed limits is questionable. 20. Smith, D. C. Handling isocyanates safely. Occup. Health Rev. 25, 92-96 (1973). The use of plastics has increased in the motor industry as well as in general life. Their versatility and simple methods of manufacture and the complex forms that can be produced carry added hazards. Although potentially hazardous, isocyanates can be used safely with proper precautions.
III. HEALTH EDUCATION
REFERENCES
1. Adams, J. R. “Behind the Wheel: Self-Analysis in Driver Rehabilitation.” Cont. Research Inst., New York, N.Y., 1971. A regimen is proposed for aiding the problem driver in learning about his own state of mind and how it affects his driving. The process of learning how to learn (sometimes called mentor-Iearning) is in two phases: (1) the driver takes a guide sheet with him and carries out daily self-analysis of his driving performance, and (2) then he returns to a group where he discusses his observations. 2. Allen, W. A., MacFalls, D., and Mattucci, L. P. Getting the cancer message to the community. Int. J. Health Educ. 16, 61-68 (1973). In the second phase of a cancer education and service program in Philadelphia, it was decided to expand the ongoing program to the community through an educational program for community health workers. At the conclusion of the course, which included information on basic physiology, cancer causes, diagnosis, treatment, and major sites of cancer, an examination was given and diplomas awarded. Evaluation revealed that not only had the program made the community workers per-
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sonally more cognizant of cancer but had also motivated them to want to spread the cancer message among their peers. 3. Babioch, C. G. Attitudes and the use of food. J. Amer. Diet. Ass. 38, 546-5 1 (1961). The food therapist must adjust teaching techniques to cultural aspects of the individual. Suggestions for teaching about food include showing range of choice, avoidance of classifying food as a special group, and use of nonspecifics. 4. Blum, H. L. The multipurpose worker-a family specialist. Amer. J. Pub. Health 55, 367-76 (1965). The cost and cumbersomeness of many diverse professional workers’ trying to help families with their health problems calls for new solutions. The author suggests the use of generalists with some education, reinforced by intensive coordinated training by various specialists. Such multipurpose, moderately prepared workers with access to specialists have been successful thus far in other disciplines. 5. Christie, T. G. Educational effectiveness of health exhibits. J. Sch. Health 40, 206-9 (1970). Tests before and after a health exhibit lasting 2 weeks indicated that observation of the exhibits had been a learning experience as indicated by more correct answers to questions after the exhibits were removed. 6. Craig, D. G. Guiding the change process in people. J. Amer. Diet. Ass. 58, 22-25 (1971). People adopt new ideas by awareness, interest, evaluation, trial, and adaptation. Another means is through learning which involves attention, interest, confidence, desire, want, action, and satisfaction. People learn 85% through their eyes, 10% through their ears, and 5% through skin, tongue, and nose. They retain 10% of what they read, 50% of what they see and hear, and 90% of what they say while doing an activity. 7. Driver education and training: plans for evaluating the effectiveness of programs. (Prepared for the U.S. Dept. of Transportation, National Highway Safety Bureau, under contract #FH-1 l-6560.) The Center for Safety, New York University, 1968. A massive compilation of evaluations and recommendations of driver education and training programs is included. The following conclusions were reached: (1) no clear proof has as yet been produced showing that driver education, as presently constituted, has a significant favorable effect on driver performance: and (2) highway safety continues to be a major national problem in terms of human conservation and American economy. 8. Lair, C. V., and Moon, W., The effects of praise and reproof on the performance of middle age and older subjects. Aging Hum. Dev. 33, 279-84 (1972). The effect of praise, censure, and neutral comment on the performance of aged males are compared with results obtained from middle-aged men. 9. Manoff, Richard K. Potential uses of mass media in nutrition programs. Journal of Nutr. Educ. 5, 125-29 (1973). Mass media and advertising techniques could be forceful instruments in nutrition education. This article describes how persuasive techniques could be employed toward rapid change in attitude, habits, or practices. The author’s subheadings are Mass Media: An Untapped Force; Changing Food Habits; Changing Sanitation Habits; Changing Farmers’ Growing Practices; Changing Marketing Practices; and How to Use the Media. 10. McGuire, F. Smoking, driver education and other correlates of accidents among young males. J. Suf. Res. 4, (1) (1972). A sample of 2,961 airmen, aged 17 to 20, was administered a variety of tests and a biographical questionnaire, and the resultant variables related to accident frequency. Among the results were that (1) higher accident frequency is reported from higher socioeconomic levels, (2) high school driver
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education fails to demonstrate any relationship to accident frequency, and (3) current smoking habits show a significant relationship to accident frequency. Some smokers have several personality traits conducive to accidents; and smoking and the automobile are major sources of carbon monoxide. It is postulated that the higher accident rate among smokers may be partially the result of a significant oxygen deficiency and/or the possession of these personality traits. 11. Mills, E. R. Applying learning theory in teaching nutrition. J. Nutr. E&c. 4, 106-7 (1972). College students in a beginning nutrition class showed that an effective way to learn is to teach. Each student taught the principles of good food habits to another person. 12. Nesheim, R. 0. Industry response to the nutrition challenge. Food Technol. 25, 41-44 (197 1). This paper reports one food industry’s policy on the nutrient levels of its products and on labeling. Its policy is to promote nutrition education through advertising and labeling. It also provides special publications and progress notes for schools and women’s organizations, information to food editors, philanthropic organization grants, support for joint nutrition education endeavors of various kinds, and experimental educational television programming. 13. Osman, J. D. Nutrition education: too much, too little, or too bad? J. Sch. Health 42, 592-96 (1972). The author gives a number of practical suggestions on achieving ways to improve the quality of nutrition education. Six basic suggestions are (1) motivating the students through meaningful involvement, (2) reducing prior learning, which tends to interfere with present learning by the identification and elimination of nutrition misconceptions, (3) recognizing the importance of organization and information, (4) increasing “meaning value” of information taught, (5) limiting the quantity of information taught, and (6) using adequate repetition and appropriate reinforcement in memory recall. 14. Roth, R. E., and Helgerson, S. L. “A Review of Research Related to Environmental Education,” 56 pp. Eric Information Analysis Center for Science, Math and Environmental Education, Columbus, Ohio, 1972. The report identifies known research pertaining to environmental education, reviews critically the identified research, and identifies areas for further research. Studies selected include (1) attempts at objective evaluation of programs, outcomes, attitudes, and administrative procedures, and (2) works related to elementary and secondary school and college or adult levels of educational concern. The review is limited to research completed since 1950 with the exception of certain documents of historic value. The reviewers feel if environmental education is to be truly effective, it must emphasize the world-wide nature of the problems of philosophy, program development, evaluation of instructional material, selection of sites and situations appropriate to learning, and the outcomes of programs. The identified research did so but on a local regional and national basis, not on a universal basis. 15. “The Consumer and His Health Dollar” (One of a Series in Expanded Programs of Consumer Education), 80 pp. NYS Educ. Dept., Bureau of Secondary Educ. Curriculum Devel., Albany, 1972. This booklet is designed to supplement the comprehensive health series published by the New York State Education Dept. The booklet is constructed so that the reader can achieve the following objectives: be able to state major achievements and unsolved problems in the health field, know how to seek qualified medical care services, learn to eat wisely and avoid the use of unnecessary food supplements, develop a healthy skepticism about advertising claims for over-the-counter drugs, and become familiar with government programs for medical care service.
IV. SOME CHRONIC DISEASE REFERENCES A. Cancer of Uterine Cervix 1. Alexander, E. R. Possible etiologies of cancer of the cervix other than herpesvirus. Cancer Res. 33, 1485-90 (1973).
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The evidence linking smegma and lack of circumcision with cervical cancer is weak. Sperm DNA may be a mutagen in association with high risk periods of metaplasia. Infectious agents with an established association with cervical cancer are trichomonas, syphilis, gonorrhea, mycoplasma, chlamydial, cytomegaloviruses, and mycoplasma, but none is as likely a candidate for its cause as herpesvirus type 2. 2. Graham, S., Snell, L. M., Graham, J. B., and Ford, L. Social trauma in the epidemiology of cancer of the cervix. J. Chronic Dis. 24, 7 1i-25 (197 1). In a series comparing 447 cases of cervical cancer with 711 controls there was no relationship between life events that were objectively measureable and cancer of the cervix. 3. Kessler, I. I. Perspectives on the epidemiology of cervical cancer, with special references to the herpesvirus hypothesis. Cancer Res. 34, 109l-l 110 (1974). Recent data on mortality (a considerable decrease during 1950- 1969) and morbidity (an approximate doubling in incidence since 1950) are reviewed together with the findings from 13 of the largest cytological surveys for cervical neoplasia in the U.S. The relationship between cervical cancer and coitus, marital factors, penile factors, and the herpes viruses are collated. A large prospective study of the role of HSV-2 is proposed. 4. Thomas, D. B. An epidemiological study of carcinoma in situ and squamous displasia of the uterine cervix. Amer. J. Epidemiol. 98, lo-28 (1973). A comparison of 104 cases of carcinoma in situ and 105 cases of squamous dysplasia with controls from the same population showed the former to resemble invasive cervical cancer in epidemiological characteristics (trichomonas, marital instability, first child before marriage), while the latter resembled an inflammatory condition (trichomonas, vaginal discharge). 5. Wallace, D. L., and Slankard, J. E. Teenage cervical carcinoma in situ. Obstet. Gynecol. 41, 697-700 (1973). The 7520 teenage females who were screened yielded 12 cases of carcinoma in situ and 32 with cervical dysplasia. The screening of sexually active, lower-income teenage families is advised.
B. Cancer
of the Breast
1. Bulbrook, R. D. Endocrine, genetic and viral factors in the etiology of breast cancer. Proc. Roy, Sot. Med. 65, 646-48 (1972). The theory of Cole and MacMahon (q.v.) suggesting that oestriol inhibits the carcinogenic action of oestrone and oestradiol is compared with the author’s findings from Guernsey suggesting that precancer cases excrete significantly less androsterone and aetiocholanelone than do controls. The hormone may potentiate the transformation by viruses of normal breast cells into malignant ones. 2. Carroll, K. K., Gamma], E. B., and Plunkett, E. R. Dietary fat and mammary cancer. Can. Med. Ass. J. 98, 590-94 (1968). Animal experiments and epidemiological studies in humans provide evidence of a positive correlation between incidence of breast cancer and intake of dietary fat. 3. Dodge, 0. G., Jackson, A. W., and Muldal, S. Breast cancer and interstitial-cell tumor in a patient with Klinefelter’s syndrome. Cancer 24, 1027-32 (1969). The high incidence of breast cancer in men with Klinefelter’s syndrome is discussed, and an illustrative case, also showing interstitial cell tumor of the testis, is described. 4. Drasar, B. S., and Irving, D. Environmental factors and cancer of the colon and breast. Brit. J. Cancer 27, 167-72 (1973). Cancer of the breast and colon are shown to be highly correlated with fat and animal protein.
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5. Dunn, J. E. Epidemiology and possible identification of high-risk groups that could develop cancer of the breast. Cancer 23, 775-80 (1969). Women who have had a previous breast cancer, who are single or infertile, and who have a family history are at increased risk, but too many breast cancers occur among others to justify considering only the high-risk segment for screening. 6. Fraumeni, J. F., Lloyd, J. W., Smith, E. M., and Wagoner, J. K. Cancer mortality among nuns: role of marital status in etiology of neoplastic disease in women. J. Nat. Cancer Inst. 42, 455-68 (1969). Among 31,658 white Catholic nuns, cancer of the breast, corpus uteri, ovary, and large intestine showed an excess frequency, while cancer of the cervix was much less frequent when compared with the national white female population. 7. Hakama, M. The peculiar age-specific incidence curve for cancer of the breast-Clemmesen’s hook. Acta Pathol. Microbial. Stand. 75, 370-74 (1969). Age-specific incidence rates for the Nordic countries suggest that one component of breast cancer peaks about at 50 years of age, while another peaks much later. 8. Lemon, H. M. Genetic predisposition to carcinoma of the breast: multiple human genotype for estrogen 16 alpha hydroxylase activity in Caucasians. .I. Surg. Oncol. 4, 255-73 (1972). Among 655 Caucasian women, those with breast cancer had lower urinary ratios of estriobestrone + estradiol than age-matched controls. It is suggested this is due to a recessive allele reducing 16-hydroxylase which normally inactivates the polycyclic hydrocarbon carcinogens. 9. MacMahon, B., Cole, P., Brown, J. B., Aoki, K., Lin, T. M., Morgan, R. W., and Woo, N. C. Oestrogen profiles of Asian and North American women. Lancet 2, 900-2 (1971). In comparing 30 women from U.S. cities with high rates of breast cancer with 28 Asian women from low-incidence areas, the latter (especially in the age group 15-19 years) were found to have relatively more oestriol compared to oestrone and oestradiol. 10. MacMahon, G., Cole, P., and Brown, J. Etiology of human breast cancer: a review. J. Nat. Cancer Inst. 50, 21-42 (1973). This comprehensive review looks at possible endocrine factors (androgens, estrogens, prolactin, progesterone) and the better known major predictors of risk of breast cancer: residence, older age at first birth, certain indicators of ovarian activity (increase with early menarche and late menopause), history of benign breast disease, and a family history of breast cancer. 11. Sarker, N. H., and Moore, D. H. On the possibility of human breast cancer virus. Nature (London) 236, 103-6 (1972). Both B particles resembling the mouse breast cancer virus and C particles resembling leukemia-sarcoma viruses can be found in human milk with about the same proportion being found in women with and without a family history of breast cancer. 12. Strax, P., Venet, L., and Shapiro, S. Mass Screening in mammary cancer. Cancer 23, 875-78 (1969). Mammography enables breast cancer to be detected earlier, and these cases with less axillary nodal involvement can be expected to have a lower mortality rate. Without mammography, about 15% of cases of breast cancer would be missed on screening. Conversely, without clinical examination, more than 40% would be missed. 13. Wynder, E. L. Identification of women at high risk for breast cancer. Cancer 24, 1235-40 (1969). Only women with previous breast cancer and those with a family history require more surveillance for breast cancer than does the average woman.
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C. Glaucoma 1. Dallow, R. L., Adler A., Weihrer, A. L., Urweider, H. A., and Caceres, C. A. Amer. J. Ophthalmol. 70, 922-28 (I 970). Dallow et al. report on automated data acquisition and computer analysis systems developed for processing tonograms. Details of the technical aspects of the programming and processing are given. Tests using 36 selected tonograms showed good correlations between computer readings and those of two independent readers. 2. Lowe, R. F. Primary angle-closure glaucoma: problems of prevention. Trans. Ophthalmol. Sot. UK 90, 323-21 (1970). Primary angle-closure glaucoma remains a very destructive disease for eyes and vision. Most significant in terms of prevention is the recognition of the efficacy of prophylactic iridectomy on the fellow eye. At present, the possibility of preventing most attacks of acute glaucoma in the first eye appears remote. However, much less eye damage could result from quicker presentation, more accurate diagnosis, and more determined therapy. The prevention of benign intermittent attacks developing into destructive acute angle-closure glaucoma depends upon better education, not only of the general public, but also of the medical profession in general and ophthalmologists in particular. 3. Nesterov, A. P., Churbanova, E. K., and Kolotkova, A. 1. 1. Simplified bulbar pressure technique and biomicroscopal compression test. Acta Ophthalmol. (Kbh) 50, 633-40 (1972). Two new diagnostic techniques based on compression of the eye are described. The simplified bulbar pressure test proved to be useful for the early detection of chronic glaucoma. 4. O’Grady, R. 9. Glaucoma. Postgrad. Med. 51, 69-72 (1972). The anatomy, physiology, and pathology of glaucoma are discussed. The author concludes that it is well to remember that the vast majority of all cases of glaucoma, whether primary or secondary, can be detected by recording the intraocular pressure during routine physical examination. This simple measure, plus the knowledge that glaucoma is a definite hazard in long-term topical or systematic steroid therapy, can reduce the number of patients sustaining preventable vision loss. As long as the ultimate cause of glaucoma remains obscure, prevention is remote. Early diagnosis is the keystone to successful therapy. 5. Pereira, P. Screening for glaucoma. Nurs. Times 68, 77 1-74 (I 972). The value of trained ophthalmic nurses in the United Kingdom for screening of patients to diagnose unsuspected glaucoma is shown. 6. Rock, W. .I., Drance, S. M., and Morgan, R. W. A modification of the Arm&y visual field screening technique for glaucoma. Can. J. Ophthalmol. 6, 283-92 (197 1). The method of screening for granulomatous visual field defects proposed by M. F. Armaly [Ocular pressure and visual fields. Arch. Ophthalmol. (Chicago) 81, 25 (1969)] was evaluated in 109 normal people and 49 people with glaucomatous defects. The method was found to have a high sensitivity and a high specificity and, with modifications described in the paper, lends itself to clinical and survey screening. Methodology is described in detail by the authors. 7. Tyler, I. C. A glaucoma screening and study by nurses. Occup. Health Nun. (New York) 19, 1l-12 (1971). A survey by occupational health nurses employed by the Illinois Bell Telephone Company, Chicago, using the Schitz calibrated tonometer is described. Out of 630 individuals screened, 33 were found to have intraocular pressures of 20 mm Hg or greater and were referred to ophthalmologists. Six cases of unsuspected glaucoma were found.
D. Obesity 1. Allen, H. Public health aspects of obesity. J. Maine Med. Ass. 64, 105-6 (1973). After reviewing the definition, pathology, and treatment of obesity, the author indicates that the
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problem of obesity can be ameliorated by the complete cooperation of the patient with the medical profession. 2. Gordon, T., and Kannel, W. B. The effects of overweight on cardiovascular diseases. Geriatrics 28, 80-88 (1973). Gordon and Kannel report data from the Framingham Heart Study. Their conclusion is that while there is substantial excess risk of atherothrombotic brain infarction and congestive heart failure in proportion to the degree of overweight, no additional risk of intermittent claudication occurs in the obese.
3. Harper, P. Psychosomatic medicine: VIII. weight disorders. Practitioner 209, 244-50 (1972). Harper gives a brief overview of classification, clinical features, psychological factors, and management of anorexia nervosa and obesity. The author concludes that psychological factors play a part in the etiology and maintenance of obesity. These factors are more complex than had previously been thought. Any classification system must take note of this. Comprehensive approaches to therapy, with the application of both psychological and physical techniques in association with public education and lay group involvement, are still in their infancy. However, they constitute a necessary development for the future. 4. Seitzer, C. C., Stoudt, H. W., Bell, B., and Mayer J. Reliability of relative body weight as a criterion of obesity. Amer. J. Epidemiol. 92, 339-50 (1970). The competence of relative body weight ratio as an instrument for assessing obesity was investigated in a series of 1761 healthy U.S. Army veterans based on the association of relative body weight values and skinfold measurements. The authors conclude that unwarranted generalizations may result from the use of oversimplified relative body weight ratios as an index of obesity. 5. Sheppard, R. F., Kanero, M., and Ishii, K. Simple indices of obesity. J. Sports Med. Phys. Fitness 11, 154-61 (1971). Under laboratory conditions, simple indices-weight to height ratio, weight/height2 (Quetelet’s index), and height/weight1j3 (Ponderal index)-give less accurate prediction of body fat than measurement of skin fold thickness. 6. Sohar, E., and Sneh, E. Follow-up of obese patients: 14 years after a successful reducing diet. Amer. J. Clin. Nutr. 26, 845-48 (1973). Of 38 patients with varying degrees of obesity who successfully completed a rigorous dietary course in 1957, 27 patients were located and weighed in 1971. Only 5 succeeded in keeping their weight approximately 15% below their 1957 weight, although all 5 were still overweight. 7. Van ItaIlie, T. B., and Campbell, R. G. Multidisciplinary approach to the problem of obesity. 1. Amer. Diet. Ass. 61, 385-90 (1972). Because of the complex interrelationships between regulatory and metabolic factors that affect the energy balance, the etiology of obesity remains unclear. An eclectic approach that uses methodologies drawn from a variety of disciplines would appear to offer the best promise of a solution.
E. Coronary Artery Disease 1. Anderson, T. W., and Le Riche, W. H. Sudden death from ischemic heart disease in Ontario and its correlation with water hardness and other factors. Canad. Med. Ass. J. 105, 155~fjo (1971). In comparing two cities that differed widely in the hardness of their water supply, the proportion of sudden deaths was found to be 20-30% higher in the city using soft water. 2. Anderson, T. W., and Le Riche, W. H. Cold weather and myocardial infarction. Lancet 1, 291-96 (1970). The seasonal fluctuation in ischemic heart disease mortality with a winter excess is less in Ontario (with colder winters) than in England, which suggests that the fluctuation is due to respiratory disease rather than cold temperatures.
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3. Aronow, W. S. Smoking, carbon monoxide and coronary heart disease. Circulation 48, I 169-72 (1973). Cigarette smokers have an increased incidence of morbidity and mortality from coronary heart disease. The angina pectoris, which angina patients develop after exercise following cigarette smoking, is due to increased myocardial oxygen demand in the presence of nicotine and decreased oxygen delivery to the myocardium, which is due to the elevated carboxyhemoglobin level with a leftward shift in the oxyhemoglobin dissociation curve. A smoker who inhales and smokes a cigarette every 30 minutes increases his carboxyhemoglobin from 1.6 to 7.8% after eight cigarettes. In heavy freeway traffic with CO levels of 145 ppm, nonsmoking angina patients will increase their hemoglobin level to 5.1% in 90 minutes. 4. Astrup, P. Carbon monoxide, smoking and cardiovascular disease Circulation 48, 1167-68 (1973). When carbon monoxide-exposed rabbits are fed cholesterol for 8-10 weeks, the aortic content of cholesterol is increased 2.5-5 times. In primates the increase is in the intramural coronary arteries. not the aorta. In young smokers with myocardial infarction, high carboxyhemoglobin levels are usual. 5. Bastenie, P. A., Vanhaelst, L., and Neve, P. Coronary-artery disease in hypothyroidism. Lancet 2, 1221-22 (1967). Premyxoedema and coronary artery disease are related. In a necropsy study of 154 males and 91 females with myocardial infarcts and the same number of controls, 20% and 44% of the former had thyroid lymphocytic infiltrates as compared to 8% and 11% of the control groups. 6. Chakrabarti, R., Hocking. E. D., Fearnley, G. R., Mann, R. D., Attwell, T. N., and Jackson, D. Fibrinolytic activity and coronary artery disease. Lancet 1, 987-90 (1968). In comparing 107 male surviviors of myocardial infarction with 90 age-matched healthy controls, 32% of the former and 12% of the latter were found to have defective fibrinolysis. The difference was maximal in the age group 50-59 years (34 compared to 7%) and negligible after 60 years (11 compared to 8%). 7. Cornfield, J., and Mitchell, S. Selected risk factors in coronary disease: possible intervention effects. Arch. Environ. Healfh 19, 382-94 (1969). Eighteen studies directed at lowering serum cholesterol are summarized. No clear-cut answer emerges. It was noted that at Framingham a 12% difference in cholesterol was associated with a 20-25% high incidence of coronary heart disease at 45 years and older. A difference of this size, even if it could be achieved, could easily be obscured. The authors suggest a larger sized study with adequate randomization (not matching) and counting in of dropouts. 8. Doll, R., and Hill, A. B. Mortality in relation to smoking: ten years’ observations of British doctors. hit. Med. J. 1, 1399-1410, 1460-1467 (1964). A IO-year follow-up on 40,637 physicians on whom baseline smoking data were obtained showed 30% of all deaths (1,376 out of 4,597) to be attributed to coronary disease. Cigarette smokers had 33% more mortality than nonsmokers, and heavy smokers 14% more than light smokers. No excess was observed for pipe or cigar smokers. The difference is greater at younger ages. A reduction in mortality takes place when smoking is stopped, with the excess reduced to 60% after 5-9 years. 9. Doyle, J. T., Dawber, T. R., Kannel, W. B., Kinch, S. H., and Kahn, H. A. The relationship of cigarette smoking to coronary heart disease: the second report of the combined experience of the Albany, N.Y. and Framingham, Mass. studies. J. Amer. Med. Ass. 190, 886-90 (1964). When combining data from 2,282 middle-aged men followed for 10 years in Framingham and 1,838 middle-aged men followed for 8 years in Albany, it was found that one-pack-or-more-a-day cigarette smokers had about three times the risk of developing a myocardial infarction found in nonsmokers, exsmokers, or pipe and cigar smokers.
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10. Fox, S. M., and Naughton, J. P. Physical activity and the prevention of coronary heart disease. Prev. Med. 1, 92-120 (1972). Most studies demonstrate a moderate reduction in coronary heart disease associated with increased physical activity. Activity programs taking the pulse rate up lo-15 beats below the appropriate stress-test level with enough intensity to produce perspiration are reasonable. Activities should be rewarding and fun so as to improve the quality of life. It is possible that the physical acitivity itself is more important than the fitness achieved. 11. Frederickson, D. S. Mutants, hyperlipoproteinemia and coronary artery disease. Brit. Med. J. 2, 187-92 (1971). The Intersociety Commision for Heart Disease Resources (1970) has recommended that Americans eat less than 300 mg of cholesterol each day and that not more than 30% of total calories come from fat equally divided between saturated, monounsaturated, and polyunsaturated. Since this is a contentious diet of still unproven value the author suggests that patients with severe hyperlipoproteinemia (in the upper 5% of normal distribution) might offer the proof needed for extension to their less susceptible but still vulnerable fellows. 12. Golubjatnikov, R., Paskey, T., and Inhorn, S. L. Serum cholesterol levels of Mexican and Wisconsin school children. Amer. J. Epidemiol. 96, 36-39 (1972). Mean cholesterol levels of random samples of 209 Mexican children and 328 Wisconsin children aged 5-14 years were 99.9 and 186.5 mg/lOO ml, with these levels apparently being established by the age of 5 years. 13. Hammond, E. C., and Garlurkel, L. Coronary heart disease, stroke and aortic aneurysm. Factors in the etiology. Arch. Environ. Health 19, 167-82 (1969). A prospective study of 804,409 subjects aged 40-79 years who were recruited by the American Cancer Society and who were followed for 6 years showed an increased death rate from coronary heart disease among males (8.2 to 1 in the 40-49 year group), among older persons, among persons with high blood pressure and diabetes (MR’s of 2.8 and 2.6 for those aged 40-49), among persons with a greater relative weight (MR = 2.25 for men aged 40-49 with a relative weight of 120+), among persons who take no exercise, among cigarette smokers, and among persons who slept 10 hours a night (compared with lower levels), but not among persons who reported being under nervous tension. 14. Heyden, S., Cassell, J. C., Bartel, A., Tyroler, H. A., Hames, C. G., and Cornoni, J. C. Body weight and cigarette smoking as risk factors. Arch. Intern. Med. 128, 915-42 (1971). Among whites in Evans County, smokers ran a much higher risk than nonsmokers (53 compared to lO/lOOO) of developing coronary heart disease, and this risk increased with increase in overweight (not noted among nonsmokers). Among blacks, the rates were lower, but cigarette smoking and overweight were also important risk factors. 15. Hollander, W. Hypertension, antihypertensive drugs and atherosclerosis. Circulation 48, 1112-27(1973). This article presents an adequate brief review of our present state of knowledge concerning the probable pathogenesis of the atheromatous fibrous plaque. Hypertension aggravates and accelerates atherosclerosis, but it is questionable whether it can initiate atherosclerosis. The effects of hypertension are partly mechanical, with the effects of the catecholamine, renin, angiotensin, and the prostaglandins associated with hypertension being questionable. Myocardial oxygen demand is increased. Most investigations have failed to demonstrate significance of antihypertensive treatment on ischemic heart disease. The author was unable to confirm the suggestion of Brunner et al. (1972) that plasma renin was an important coronary disease risk factor in hypertensive patients (note that propanolol and alpha methyl dopa inhibit renin, while diuretics and hydralazine stimulate renin). The diuretics produce an increase in plasma renin and catecholamines (also produced by a low salt diet), with hyperglycemia, hyperuricemia, and gouty arthritis being known side effects.
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16. Hrubec, Z., and Zukel, W. J. Epidemiology of coronary heart disease among young army males of World War II. Amer. Heart J. 87, 722-30 (1974). Some 1,393 confirmed First Army hospital admissions for coronary heart disease in World War 11 were given matched controls on age, service dates, and (for some) race. An increased relative risk was associated with marriage at induction, graduate education, officer rank, the Jewish religion, a heavy frame, and blood group A, with a reduced risk associated with a rural birthplace and an occupation requiring physical activity. An increased blood pressure and weight and a shorter height were also risk factors. 17. Ibrahim, M. A., Pinsky, W., Koh, R. M., Binette, P. J., and Winkelstein, W. Coronary heart disease: screening by familial aggregation: pilot study. Arch. Environ. Health 16, 235-40 (1968). Positive correlations were found between 92 high school students and their parents for cholesterol, systolic blood pressure, and ponderal index. Students with high-risk-factor combinations “predicted” all the parents with ST and T abnormalities on the ECG. 18. Jenkins, C. D., Rosenman, R. H., and Zyzanski, S. J. Prediction of clinical coronary heart disease by a test for the coronary-prone behavior pattern. N. Engl. J. Med. 290, 1271-75 (I 974).
The coronary prone behavior pattern (type A) is characterized by excess competitiveness, striving for achievement, aggressiveness, time urgency, accelerated activity, restlessness, hostility, hyperalertness, and explosiveness of speech. A paper-and-pencil questionnaire (the Jenkins Activity Survey) scored by a computer was developed to identify type A, and test-retest scores between 1965 and 1969 showed that 90% of persons had less than 10 points difference over this period. In 1965 2,750 persons were typed. Over a 4-year period high scorers had significantly more new coronary heart disease than did low scorers. 19. Kannel, W. B., Dawber, T. R., Friedman, G. D., Glennon, W. E., and McNamara, P. M. Risk factors in coronary heart disease: an evaluation of several serum lipids as predictors of coronary heart disease: the Framingham study. Ann. Intern. Med. 61, 888-99 (1964). A study group of 2,282 men (1,975 from a random sample of 3,074 and 3 12 volunteers) and 2,845 women (2,418 from a random sample of 3,433 and 427 volunteers) free of coronary heart disease and aged 30-60 years was constituted in 1949 and reexamined every 2 years. At 6 years only 0.7% had been completely lost to follow-up, outside information was available on 17.1%, 4.5% had died (data known), and 77.7% were examined. Identified risk factors were serum cholesterol, blood pressure, cigarette smoking, vital capacity (low), relative weight (high), and certain ECG findings. Of the lipids examined, including phospholipids and the various beta-lipoproten fractions, serum cholesterol made the most significant contribution, with no “critical” or “safe” level being apparent. 20. Kannel, W. B., Castelli, W. P., and McNamara, P. M. The coronary profile; 12 year follow-up in the Framingham study. J. Occup. Med. 9, 611-19 (1967). It is possible to identify persons who are prime candidates for a “heart attack.” Note that in 10 years, one in ten men and one in 20 women aged 30-60 years at start developed coronary heart disease. One in four attacks were silent, but of those one in three recurred within 5 years with a 50% death rate. The profile of the prime candidate was a sedentary, flabby middle-aged man or elderly female who used excess cigarettes, foods rich in saturated fat and cholesterol, had a high blood pressure but a low vital capacity, and did little physical activity and whose family history included diabetes, gout, and lipemia as well as coronary heart disease. 21. Keys, A., Arvanis, C., Blackburn, H., Van Buchem, F. S. P., Buzina, R., Djorjevic, B. S., Fidanza, F., Karvonen, M. J., Menotti, A., Puddu, V., and Taylor, H. L. Probability of middle-aged men developing coronary heart disease in five years. Circulation 45, 815-28 (1972).
Some 2,404 U.S. railroad men and 8,728 European men aged 40-59 years and free of coronary disease at entry were followed for 5 years, during which time there were 615 cases of coronary heart
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disease. A multiple logistic equation using age, systolic blood pressure, serum cholesterol, the smoking habit, and body mass index served as a good predictor of risk (y = 0.94) for another U.S. railroad population of 6,221 men aged 40-59 years. 22. Leren, P. The effect of plasma cholesterol lowering diet on male survivors of myocardial infarction. Acta Med. Stand. Suppl. 466 5, 92 (1966). Some 412 males aged 30-64 years discharged from Oslo hospitals in 1956-58 with a first diagnosis of myocardial infarction were randomized into two groups, with the diet group getting 264-mg cholesterol daily and 39% of calories from fat (total caloric intake 2,387) with 52% of this polyunsaturated and 26% saturated. Of the dieters 62% were excellent adherers over 5 years. From a mean starting cholesterol of 296 mg/lOO ml the dieters averaged a 17.6% reduction as compared to 3.7% in the controls. The diet group had 43 infarctions in 54 patients with 23 deaths. The incidence of sudden death in the two groups (27) was the same. The difference in relapse rate was only below the age of 60 years.
23. Medalie, J. H., Kahn, H. A., Neufeld, H. N., Riss, E., Goldbourt, V., Perlstein, T., and Oron, D. Myocardial infarction over a five-year period I. Prevalence, incidence and mortality experience. 1. Chronic Dis. 26, 63-84 (1973). In Israel 10,059 male government and municipal employees aged 40 and over were followed from 1963 to 1968, with 98% of the original respondents participating in the final examination. The age-adjusted myocardial infaction rate of 8.7/1000 was high, but the proportion that was silent (40%) was also high and the case fatality rate (16%) was low. Israelis from central and eastern Europe had the highest prevalence and incidence rates, and those from North Africa and the Middle East the lowest. 24. Miettinen, M., Turpeinen, O., Karvonen, M. J., Elosuo, R., and Paavilainen, E. Effects of cholesterol-lowering diet on mortality from coronary heart disease and other causes: a twelve year clinical trial in men and women. Lance1 2, 835-38 (1972). From 1959 to 1965, hospital N used a cholesterol lowering diet on its patients, and from 1965 to 1971 hospital K (previously the control hospital) used the experimental diet (P/S ratio greater than 1.5). Cholesterol levels followed the diets, changing from 217 in period 1 for males in N to 266 in period 2, while for K the corresponding levels were 268 and 234. In both hospitals death rates from CHD were lower in the diet period as were deaths from all causes (in hospital K only after age adjustment), the reduction in CHD being about one-half. 25. Morris, J. N., Chave, S. P. W., Adam C., Sirey, C., Epstein, L., and Sheehan, D. J. Vigorous exercise in leisure-time and the incidence of coronary heart-disease. Lancet 1, 333-39 (1973). Among 16,882 male office workers aged 40-64 who recorded their Friday and Saturday activities for baseline, 232 have, since 1968-70, suffered their tirst clinical attack of coronary heart disease. When each case was matched with two controls it was found that 11% of cases and 26% of controls had reported vigorous activity (swimming, keep-fit exercises, digging, much stair climbing, tennis, hill climbing, running, cycling, etc.) with estimated peak energy outputs of 7.5 kcal/min. Lighter exercise had no such advantage. 26. Paffenbarger, R. S., Wolf, P. A., Notkin, J., and Thorne, M. C. Chronic disease in former college students: 1. early precursors of fatal coronary heart disease. Amer. J. Euidemioi. 83, 3 14-28 (1966). In this study 325 former male students at the University of Pennsylvania or Harvard who were known to have died from coronary heart disease were each paired with two classmate controls who were still alive. Precursors of death were found to be heavy cigarette smoking, high blood pressure, excess weight, short stature, nonparticipation in athletics, early parental death, one-child status, and sociopsychological exhaustion. 27. Pinckney, E. R. Editorial: the potential toxicity of excessive polyunsaturates: do not let the patient harm himself. Amer. Heart J. 85, 723-26 (1973). The author finds no scientific evidence that eating polyunsaturated fatty acids will reduce coronary
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heart disease morbidity or mortality. Polyunsaturates may be linked with cancer (especially gastric). A skin study showed that of persons who forced polyunsaturates, 78% showed clinical signs of premature aging and 60% had had a suspect malignant skin tumor removed as compared to 18% and 8% among a group that made no effort to eat polyunsaturates. 28. Roseman, R. H., Friedman, M., Jenkins, D. Straus, R., Wurm, M., and Kositchek, R. The prediction of immunity to coronary artery disease. J. Amer. Med. Ass. 198, 1159-62 (1966). Among 2,998 normotensive men aged 39-59 years and followed 4 l/2 years, it was found that those with the fully developed B behavior pattern who also had a cholesterol less than 226 mg/lOO ml, a triglyceride less than 126 mg/lOO ml, or a /3/a lipoprotein ratio less than 2.01 were essentially immune to the development of clinical coronary disease. 29. Spain, D. M., and Bradess, V. A. Sudden death from coronary heart disease: survival time, frequency of thrombi and cigarette smoking. Chest 58, 107-l 0 (1970). About 25% of all deaths from acute myocardial ischemia are “sudden” and occur within 1 hour of onset of the attack. The frequency of recent coronary thrombi found at autopsy increased from 18% among persons dying within 1 hour to 36% among those dying in l-8 hours to 57% among those dying in more than 8 hours. The heavy smokers (more than one pack) in the group were mostly in the short-survival group with few recent thrombi. 30. Stitt, F. W., Clayton, D. G., Crawford, M. D., and Morris, J. N. Clinical and biochemical indicators of cardiovascular disease among men living in hard and soft water areas. Lancet 1, 122-26 (1973). When 244 civil servants from six hard-water towns were compared to 245 from six soft-water towns, the mean values for blood pressure, cholesterol, and heart rate were higher in the soft-water group. These differences could account for much of the reduced mortality found in hard-water areas as compared to soft-water areas. 31. Syme, S. L., Borhani, N. O., and Buechely, R. W. Cultural mobility and coronary heart disease in an urban area. Amer. J. Epidemiol. 82, 334-46 (1966). Medically verified coronary disease in 80 cases among white males aged 45-64 years were compared to 80 matched controls. The former contained more children of native-born fathers, more men of foreign-born parents who had themselves gone to college, and more men who had held three or more jobs (especially for short periods). These sociocultural factors were independent of parental longevity, cigarette smoking, relative weight, and physical activity.
F. Chronic
Obstructive
Pulmonary
Disease
I. Baker, T. R., Oscherwitz, M., Corlin, R., Jarboe, T., Teisch, J., and Nichaman, M. Z. Screening and treatment program for mild chronic obstructive pulmonary disease. J. Amer. Med. Ass. 214, 1448-55 (1970). According to the Eighth Aspen Emphysema Conference, Public Health Service Publication 1457 (1966), COPD comprises overlapping types of generalized bronchopulmonary disease including chronic bronchitis, pulmonary emphysema, and bronchial asthma. It affects 5-10 million Americans and causes some 30,000 deaths each year in the U.S. The 5-year survival in severe cases (FEV, less than 1.5 liters) is about 50%, and treatment is of little value at this stage and should start earlier. A population of 750 men screened for COPD (a history of cough and phlegm for 3 months each year and/or an FEV, less than 70%) yielded 252 patients. After dropouts, reconfirmation, and exclusion of other illness, 134 were left and treated with bronchodilator drugs, smoking cessation, and increased fluid intake. Of these 85% were smokers and 11% exsmokers, 36% had chronic bronchitis (history of cough, etc., only), 28% had obstructive lung disease (abnormal FEV only), and 36% were mixed (both factors present). Physical findings and X-ray findings were correlated with this grouping, but forced vital capacity (FVC) was not. ECGs were generally normal. There were 61 men under treatment at 6 months and 25 men at 1 year. Of the 61, 50 were cigarette smokers and 17 stopped. Twenty-nine had fewer symptoms, but the FEV was unchanged. The drugs used (theophylline, ephedrine, phenobarbital) had many unwanted side effects.
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2. Biersteker, K. Air pollution and smoking as causes of bronchitis among 1000 male municipal employees in Rotterdam, Netherlands. Arch. Environ. He&h 18, 531-35 (1969). In comparing 1957 to 1966, deaths from chronic bronchitis and emphysema in Rotterdam among males were found to have increased from 67 to 117 and from 10 to 76, which cannot be accounted for by changes in the population at risk. A study of municipal employees comparing 168 males with symptoms to the same number of symptomless controls showed a clear effect of smoking but no obvious relationship to air pollution. 3. Burrows, B., and Earle, R. H. Course and prognosis of obstructive lung disease. N. Engl. J. Med. 280, 397-404 (1969). The 200 patients followed for 4-8 years showed that the best indicators of prognosis were ventilatory capacity, resting heart rate, and carbon dioxide levels. Yearly changes were usually small. 4. Da Costa, J. L. Chronic obstructive lung disease (COLD): a comparison between men and women. Singapore Med. J. 13, 74-78 (1972). A comparison between 70 men and 13 women showed similar ages at onset for cough and dysnea; similar records for asthma, chest infection, and edema; and similar findings on physical and ECG examination. More women had “pure” emphysema on X-ray that was not related to smoking and was presumably genetically induced. 5. Holland, W. W., and Reid, D. D. The urban factor in chronic bronchitis. Lancer 1, 445-48 (1965). A comparison of 293 post office employees in London with 477 similar employees in three country towns showed the former, even after allowing for the effect of cigarette smoking, to have more respiratory symptoms and sputum production and lower lung function levels. Differences in air pollution seemed to be the most likely cause of the differences. 6. Holland, W. W., Halil, T., Bennett, A. E., and Elliott, A. Factors influencing the onset of chronic respiratory disease. Brit. Med. J. 2, 205-8 (1969). In Kent, 10,97 1 children had levels of peak expiratory flow influenced independently by area of residence, social class, family size, and a past history of pneumonia, bronchitis, or asthma. It is suggested that environmental factors from early life can influence the development of chronic respiratory disease later. 7. Kanner, R. E., Klauber, M. R., Watanabe, S., Renzetti, A. D., and Bigler, A. Pathologic patterns of chronic obstructive pulmonary disease in patients with normal and deficient levels of alpha 1 antitrypsin. Amer. J. Med. 54, 706-12 (1973). The 29 patients with COPD were divided by AAT phenotyping or trypsin inhibitory capacity (TIC) into homozygous ZZ (six patients), heterozygous MS, MS or SZ (ten patients), and homozygous normal MM (13 patients). Spirometry and regional ventilation and perfusion tests with xenon 133 clearly distinguished the three groups. It was concluded that heterozygosity for AAT is an important factor in the development of COPD. 8. Mittman, C., Babela, T., and Lieberman, J. Alpha 1 antitrypsin deficiency as an indicator of susceptibility to pulmonary disease. J. Occup. Med. 15, 33-38 (1973). More than 20 AAT types have been described. Type ZZ is rare (perhaps I/ 1,000) and clearly related to COPD. Other abnormal phenotypes (MZ, MS, SS, etc.) occur in up to 10% of normal people. This latter group develops overt disease later in life and after more intense and prolonged exposure to cigarette smoke and other environmental irritants. A study of 170 patients with COPD compared to a healthy Norwegian population showed the ratio of observed to expected (rates are per 1,000) to be for MM 760/895, for MZ 113/29, for MS 53/41, for SS 1l/l, and for ZZ 40/l. Trypsin inhibitory capacity (TIC) values for these phenotypes were 0.81-1.80, 0.55-1.50, 0.65-1.30, 0.55-0.75, and 0.15-0.25, respectively. Since COPD in AAT deficiency is the result of the interaction of genetic and environmental factors, it is potentially preventable.
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9. Reid, D. D., Anderson, D. O., Ferris, B. G., and Fletcher, C. M. The Anglo-American comparison of the prevalence of bronchitis. Brit. Med. J. 2, 1487-9 1 (1964). By using similar respiratory-symptom questionnaires and the Wright peak flow meter, the prevalence of simple bronchitis was found to be similar in Britain and the U.S. and clearly related to cigarette smoking. However, “complex” bronchitis, with repeated chest illnesses and breathlessness, was more frequent among older males living in British urban conditions. 10. Selikoff, I. J., and Hammond, E. C., III. Community effects of nonoccupational environmental asbestos exposure. Amer. J. Pub. Health 58, 1658-66 (I 968). Specific stigmata of environmental asbestos exposure are pleural calcification (found in 499 of 6,3 12 adults in a heavily exposed village in Finland), pleural plaques (to a lesser extent), pleural mesothelioma, and (of little pathological meaning) asbestos bodies. Peritonial mesothelioma has also been related. An investigation of 76 mesothehomas in London (Newhouse and Thompson, 1965) showed 3 1 of these to be in asbestos workers and 20 to be from persons living within l/2 mile of an asbestos factory or in the household of an asbestos worker. The relationship between asbestos exposure and cigarette smoking is important-of 370 asbestos workers followed for 20 years, none of the 87 nonsmokers developed lung cancer as compared to 24 of the 283 cigarette smokers. 11. Sultz, H. A., Feldman, J. G., Schlesinger, E. R., and Mosher, W. E. An effect of continued exposure to air pollution on the incidence of chronic childhood allergic disease. Amer. J. Pub. Health 60, 891-900 (1970). A study in Erie County showed that hospitalization rates for asthma or eczema in males under the age of 5 years rose steadily within each social class with increasing levels of air pollution.
G. Peripheral Vascular Disease 1. Berry, L. F., and Lichti, E. L. The Doppler ultrasonic flowmeter: report of its use for diagnosis of peripheral vascular disease in the smaller community hospital. Ohio State Med. J. 69, 23-26 (1973). The Doppler ultrasonic flowmeter can be highly useful in the smaller community hospital as an aid to preliminary diagnosis. It represents a practical, relatively inexpensive, atraumatic, transcutaneous method of evaluating peripheral arterial or venuous flow in the hospital or office. 2. McLaughlin, G. A. Thermography in diagnosis of vascular disease of lower limb. Proc. Roy. Sot. Med. 65, 170 (1972). This is an abstract of a paper presented at a meeting of the Section of Surgery Royal Society of Medicine on June 4, 197 1, in Liverpool. Assessment of the diagnostic accuracy of thermography in lower limb arterial disease was made by comparing the arteriographic appearances and thermograms of 28 patients for localization of arterial block and estimation of “peripheral runoff.” Positive correlation was found in only 50% of these cases. Factors limiting accuracy were thickness of subcutaneous fat, greater than 2.8 cm; localized disease with good collateral circulation; and coincident venous disease. If such cases were excluded, the accuracy rose to over 80%. 3. Patman, R. D., and Thompson, J. E. Peripheral vascular disease in the geriatric age group. Tex. Med. 67, 88-93 (1971). The problems of peripheral arteriosclerosis are considered with particular emphasis on atherosclerotic occlusive disease of the lower extremities, aneurysm formation, and cerebrovascular insufficiency. The authors conclude that the major problems of peripheral vascular most commonly seen in practice can be reduced or even avoided provided that the condition is recognized early and treated properly. 4. Soulen, R. L., Lapayowker, M. S., Tyson, R. R., and Korangy, A. A. Angiography, ultrasound, and thermography in the study of peripheral vascular disease. Radiology 105, 115- 19 (1972). This describes a study of angiography, ultrasonography, and thermography that included I66 patients with suspected thrombophlebitis and 300 patients with peripheral arterial disease. It showed that thermography aids in recognizing phlebitis and assessing postoperative, but not preoperative,
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arterial disease. Although Doppler ultrasound cannot reliably detect thrombophlebitis, it permits highly accurate monitoring of peripheral arterial flow and is very helpful in programming arteriography and follow-up after arterial surgery. Both noninvasive techniques are well-suited for serial studies of peripheral vascular disease. 5. Wooling, K. R., and Schechter, J. S. Some instrumental techniques in the clinical study of peripheral vascular disease. J. Zndiana Stare Med. Ass. 65, 407-18 (1972). The study of the peripheral vascular system by mercury strain gauge plethysmography, ultrasonic velocity flow detection, and skin thermography provides information that complements that obtained by history, physical examination, and angiography. By these methods, a vascular profile can be deduced. Noninvasive techniques, which are essentially painless, harmless, and can be repeated as often as desired, are utilized. The authors indicate that these methods have been of greatest use and value in the diagnosis of peripheral occlusive arterial disease.
H. Hypertension 1. Boyle, E. Biological patterns in hypertension by race, sex, body weight and skin color. J. Amer. Med. Ass. 213, 1637-43 (1970). A study of 2,184 residents of Charleston County, South Carolina, showed a high prevalence of hypertension among Charleston Negroes (10% with diastolic over 100 mm in men aged 35-44 years), with no correlation in this group between obesity and hypertension, and a positive correlation between skin pigmentation and hypertension among Negroes, with darker Negroes having a high prevalence (50%) of group B blood type. 2. Cheitlin, M. D. The physician and hypertension. J. Amer. Med. Ass. 228, 1249-50 (1974). A survey by Harris Associates of 3,18 1 individuals, 17 years or older, from 200 locations in the U.S. revealed that 67% (74% for blacks) had had a physical checkup in the last year and 92% (94% for blacks) in the last 5 years, with most having their blood pressure taken. Of these people 75% did not know what “hypertension” meant, 40% thought worry the main cause (very few thought of heart disease and kidney disease as complications), and 50% or more thought symptoms were always present. Stopping medication for hypertension was usually on doctor’s advice. 3. Clark, V. A., Chapman, J. M., and Coulson, A. H. Effects of various factors on systolic and diastolic blood pressure in the Los Angeles heart study. J. Chronic Dis. 20, 57 l-81 (1967). Higher systolic blood pressures were found in 1962 than in 1950 among similar age groups. Time of day, smoking (nonsmokers were higher), alcohol use (users higher), and salt (salt adders lower) made small, insignificant differences. 4. Dustan, H. P., Tarazi, R. C., and Frohlich, E. D. Functional correlates of plasma renin activity in hypertensive patients. Circulation 41, 555-67 (1970). In 31 normotensives and 93 untreated hypertensives (58 essential, 21 renovascular, 14 other), peripheral plasma renin correlated positively with diastolic pressure and inversely with serum sodium and potassium only in the renovascular group. Ventricular ejection rates were correlated with renin activity in the hypertensive groups (except for the three patients with primary aldosteronism), while total blood and plasma volume were correlated with renin activity in normal and essential hypertensive men but not women. Modifying factors are thus important. 5. Eich, R. H., and Jacobsen, E. C. Vascular reactivity in medical students followed for 10 years. J. Chronic Dis. 20, 583-92 (1967). A group of 73 medical students followed for 9-10 years showed little changes in blood pressure, no relationship between heredity and hyperreactivity, no relationship between a positive cold pressor response and other manifestations of hyperreactivity, and no tendency for those with an initial elevated cold pressor test to show a rise in blood pressure over the follow-up period.
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6. Harburg, E., Erfurt, J. C., Chape, C., Hauenstein, L. S., Schull, W. J., and Schork, M. A. Socioeconomic stressor areas and black-white blood pressure: Detroit. J. Chronic Dis. 26, 595-611 (1973). Census traits in Detroit were rank ordered by their “stress scores” by using economic deprivation, residential instability, family instability, crime, and population density as indices for stress. A comparison between high and low stress areas showed black males, black females, and white females to have more hypertension in the high stress areas. 7. Henry, J. P., and Cassell, J. C. Psychosocial factors in essential hypertension. Recent epidemiologic and animal experimental evidence. Amer. J. Epidemiol. 90, 17I-200 (1969). It is suggested that obesity and dietary factors (salt, fat) are less important in explaining variations in blood pressure than repeated arousal of the defense alarm response. It is postulated that populations whose blood pressure does not increase with age lead a less stressful existence. 8. Laragh, J. H., Sealey, J. E., Ledingham, J. G. G., and Newton, M. A. Oral contraceptives, renin, aldosterone and high blood pressure. J. Amer. Med. Ass. 2Q1,9 18-22 (1967). In eight out of 1I patients blood pressure was increased by oral contraceptive therapy, and in six of these eight the blood pressure was corrected when the oral contraceptives were stopped. In patients on oral contraceptives, renin-substrate concentration and the capacity to form angiotensin when exogenous renin was given were increased. 9. Miall, W. E., Heneage, P., Khosla, T., Lovell, H. G., and Moore, F. Factors influencing the degree of resemblance in arterial pressure of close relatives. C/in. Sci. 33, 271-83 (1967). Of 2,680 subjects seen in the first Rhondda Fach and Vale of Glamorgan surveys and on whom blood pressures were taken (in their own homes), 2,15 1 were reexamined 1 l/2- 10 years later and death certificates for the 269 who had died were studied. Regression coefficients for male (systolic 0.252, diastolic 0.172) and female (systolic 0.32 1, diastolic 0.277) relations on all propositi were significantly greater than zero, with resemblances in blood pressure being little influenced by differences in age between the propositi and their relatives. In contrast the regression of husbands on wives (systolic 0.009, diastolic 0.142) showed no positive relationship. The larger values for females suggest that some relevant genes are on the x chromosome. 10. Morton, W. E. Hypertension and drinking water constitutents in Colorado. Amer. J. Pub. Health 61, 1371-78 (1971). A 1960 statewide study of municipal water supplies gave a correlation coefficient of +0.90 for mean nitrate concentrations on 1960 hypertension mortality. It is noted that explosive workers are exposed to nitrates and have an increased amount of hypertension. The relationship reported by Schroeder (1960) with an inverse correlation between water hardness and the hypertensive heart disease death rate was not confirmed in Colorado. 11. Oberman, A., Lane, N. E., Harlan, W. R., Graybiel, A., and Mitchell, R. E. Trends in systolic blood pressure in the thousand aviator cohort over a twenty-four year period. Circulation 36, 812-22 (1967). The 1,056 normotensive men first examined in 1940 at a mean age of 24 years were reexamined in 1951-52 (703 persons), 1957-58 (785 persons), and 1963-64 (675 persons or 85% of the surviving members). Of these, 575 men had blood pressure data from all four examinations. Systolic blood pressures increased very little over time after the age of 35 years, and the correlation coefficient between 1940 and 1963 systolic values was 0.15. Parental longevity (earlier in time) and gain in weight influenced the systolic blood pressure of the cohort. 12. Prior, I. A. M., Evans, J. G., Harvey, H. P. B., Davidson, F., and Lindsey, M. Sodium intake and blood pressure in two Polynesian populations. N. Engl. J. Med. 279, 5 15-20 (1968). In Raratonga, but not in Pukapuka, blood pressure increased with age. Sodium intake in Raratonga is about 50 m. equiv a day higher than in Pukapuka.
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13. Stewart, 1. M. G. Long term observations on high blood pressure presenting in fit young men. Lam-et 1,355-59 (1971). In this study 40 men with uncomplicated essential hypertension and an average age of 35 years were followed for 6 years. In 12, the diastolic fell gradually without treatment from an average of 105 to 88. In the remaining 28, characterized by a relatively high age at onset, professional-type rather than laboring work, involvement in competitive mental stress, and a family history of close relatives affected by premature arteriovascular disease, antihypertensive treatment was given. Despite this, ten developed vascular complications (largely occlusive) during treatment which suggests that therapy may provoke vascular complications. 14. Swaye, P. S., Gifford, R. W., and Berretoni, J. N. Dietary salt and essential hypertension. Amer. .I. Cardiol.
29, 33-38 (1972).
In comparing 7 17 patients with essential hypertension to 8 19 normotensives, the percentages adding salt to food before tasting it were found to be essentially the same (22.7 and 21.2%). In comparing 43 hypertensive women with this habit to 325 without, the former group was found to have more severe hypertension (blood pressure and fundal changes), while in comparing 120 men with this habit to 229 without, the former were found to have more severe hypertensive heart disease (ECG and X ray). 15. Veterans Administration Cooperative Study Group on Antihypertensive Agents (E. D. Freis, Chairman). Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. J. Amer. Med. Ass. 24l2, 1028-34 (1967). In this study 143 male hypertensives (diastolic 115-I 29) were randomized, with 73 in the active treatment group (hydrochlorthiazide plus reserpine plus hydralizine) and 70 given placebo. In the first group there were two major complications and no deaths, and in the latter there were 27 major complications and four deaths. At 24 months, when the trial ended, the average diastolic pressure in the control group was 120, and in the treated group, 92. 16. Veterans Administration Cooperative Study Group on Antihypertensive Agents (E. D. Freis, Chairman). Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressures averaging 90 through 114 mm Hg. J. Amer. Med. Ass. 213, 1143-52 ( 1970). In this study 380 male hypertensives (diastolic 90-l 14) were randomized, with 186 in the active treatment group (hydrochlorthiazide plus reserpine plus hydralizine) and 194 given placebo. In the first group there were nine major complications and eight deaths (two due to myocardial infarction and four to sudden death), and in the latter there were 35 major complications and 19 deaths (three due to myocardial infarction and eight to sudden death). Treatment was most effective in preventing congestive heart failure and stroke.
I. Miscellaneous 1. Aitken, J. M., Hart, D. M., and Lindsay, R. Oestrogen replacement therapy for prevention of osteoporosis after oophorectomy. Brit. Med. J. 3, 5 15- 18 (1973). Aitken et (~1.evaluate the value of oestrogen therapy in the prevention of osteoporosis after oophorectomy in 114 middle-aged women who participated in a double-blind controlled trial of mestranol in an average daily dose of 23 pg. 2. Al Hujaj, M., Schonthal, H., and Elbrechter, J. Differential diagnosis of gout. Lancet 2, 606 (1972). This letter presents results of a screening test using fructose-induced hyperuricemia. The guideline for diagnosis is judgment of the serum uric acid level 2 hours after administration of fructose. The results with 161 patients are reported. The authors consider the test suitable for both screening and assessing the effects of therapy. 3. Cornfield, J. The University group diabetes program. A further statistical analysis of the mortality findings. J. Amer. Med. Ass. 217, 1676-87 (1971).
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The earlier report is confirmed that lowering the blood glucose level with tolbutamide over an 8-year period was no more effective than diet alone in prolonging life and probably caused more cardiovascular mortality. The importance of randomization in achieving comparability between groups under different treatments is emphasized. 4. Fessell, W. J., Siegelaub, A. B., and Johnson, E. S. Correlates and consequences of asymptomatic hyperuricemia. Arch. Intern. Med. 132, 44-54 (1973). From about 150,000 persons taking a multiphasic health check, 124 hyperuricemic individuals (more than two standard deviations from the population mean) with a mean uric acid for males of 9.6 mg/lOO ml and females 7.2 mg/lOO ml were identified: 224 normouricemic controls (male mean 5.6, female mean 4.3) were also identified. Over a SO-month follow-up, eight hyperuricemic persons had hypertension, four diabetes, three gout, two heart disease, and one urolithiasis, while of the normal, two had urolithiasis and one gout. 5. Grunnet, M. L. Cerebrovascular disease: diabetes and cerebral atherosclerosis. Neurology 13, 486-91 (1963). By using the Baker system for coding the circle of Willis of 107 diabetic patients, increased frequency and severity of cerebral atherosclerosis were found in all age groups. 6. Henschel, A., Burton, L. L., Margolies, L., and Smith, J. E. An analysis of the heat deaths in St. Louis during July 1966. Amer. J. Pub. Health 59, 2232-42 (1969). Except for one day, the temperatures each day in St. Louis, MO., were above 90°F from June 22 till July 20, 1966, and above 100°F from July 9 till July 14. In the period July 1l-July 15 there were 211 certified primary heat deaths, accounting from some 65% of the excess deaths during these 5 days. There were more female than male heat deaths, which were concentrated largely in the city core. The impact was largely on older persons. Deaths from cardiovascular disease were strikingly increased as well. Nearly all heat death cases had body temperatures of 103-106°F on admission to hospital. 7. Johnson, J. S., Vaughn, J. H., Hench, P. K., and Blomgren, S. E. Rheumatoid arthritis, 1970-1972. Ann. Intern. Med. 78, 937-53 (1973). The authors discuss the prevalence and genetics of rheumatoid arthritis and its pathologic features, metabolic abnormalities, etiologies, and therapy. They conclude that there is little change in the major principles of management, although methods of assessing disease activity have been improved. 8. Kannel, W. B., Hjortland, M., and Castelli, W. P. Role of diabetes in congestive heart failure: the Framingham study. Amer. J. Cardiol. 34, 29-34 (1974). Among men a twofold and among women a fivefold increased risk of congestive heart failure was found among diabetics (treated with insulin) who were followed for 18 years. 9. Katz, J. L., Weiner, H., Gutman, A., and Yu, T. F. Hyperuricemia, gout, and the executive suite. J. Amer. Med. Ass. 224, 1251-57 (1973). Eight pairs of adult brothers, including one pair of first cousins raised together, all with a family history of gout, and therefore likely to have hyperuricemia, were examined for possible correlations between achievement-related variables and relative serum uric acid (SUA) levels within each pair. Manifest achievement, achievement orientation, and achievement drive did not reliably predict which brother in each pair had the high SUA level. However, when the variable of obesity-dietary content was employed, significant predictive success was attained: obesity did not correlate with achievement drive. The tonic and phasic eating histories of the subjects do suggest a possible explanation for the previous reports of a correlation between SUA level and such achievement related variables. 10. Kuller, L., and Tonascia, S. A follow-up study of the Commission on Chronic Illness morbidity survey in Baltimore: IV. factors influencing mortality from stroke and arteriosclerotic heart disease (1954-1967). J. Chronic Dis. 24, 11 l-24 (1971).
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Only 3.9% of the population was lost to follow-up. Men had higher arteriosclerotic heart disease mortality than women, and a history of heart disease, hypertension, or diabetes increased the risk of this mortality. 11. Lavernhe, J., Blanc, C., and Lafontaine, E. Epilepsy and medical examinations of flight personnel: importance and difficulty of diagnosis. Aerosp. Med. 42, 889-90 (197 1). Three cases of epilepsy among flight personnel are reported. The authors indicated that no medical techniques exist for detecting potential epilepsy. The problem of idiopathic epilepsy remains unsolved, which may be dramatic particularly with regard to air safety. 12. McCarty, D. J. Measurement of arthritic disease disability. Ind. Med. Surg. 42, 9-l 1 (1973). The author discusses documentation of arthritic disability. Described are class I - “complete ability” to perform all useful duties; class II -“adequate” (i.e., normal activities can be performed, but there in some handicap); class III - “limited” (i.e., activities of daily living and little or none of usual occupation done); and class IV -“incapacitated.” This is a functional classification system, which the author considers the best type. The paper also describes other indices of arthritic disease disability such as the Landsbury indices (which chiefly reflect inflammatory manifestations of the disease), fatigue, grip strength measured with a rolled-up blood pressure cuff, aspirin usage measured as number of tablets/day, and the Westergren sedimentation rate (which is least reliable and least reproducible). 13. Meyer, R. J. Interaction with government (arthritis). Ind. Med. Sup. 42, 14-15 (1973). The author discusses the present and future roles of government in regard to arthritic diseases. Prevention is advocated on two levels. Primary prevention includes rubella immunization, since many young people, especially women, are introduced to the arthritides during bouts with German measles. Secondary prevention or the early treatment of atllicted patients is essential if disability is not to proceed to chronic arthritic disorders. The author also identifies the need for vocational rehabilitation. Innovative rehabilitation techniques must be developed, with rheumatologists in the forefront supported by federal and state funds. 14. Pollack, A. A., McGual, T. J., and Macintyre, N. Diabetes mellitus: a review of mortality experience. Arch. Intern. Med. 119, 161-63 (1967). Among 1,680 diabetic persons with insurance policies issued on a substandard basis and with 6.8 19 policy-years of exposure, the mortality rate (observed/expected on standard policies) for those treated by diet alone was 1.31, by oral hypoglycemics 1.91, and by insulin 5.02. Of the deaths 54% were due to heart disease and cerebrovascular accidents. 15. Stout, R. W. Insulin-stimulated lipogenesis in arterial tissue in relation to diabetes and atheroma. Lancer 2, 702-3 (1968). Injecting rats with insulin and C-labelled substrate containing glucose or acetate led to the latter’s being incorporated in excess into the vessel wall. It is suggested that insulin leads to atherosclerosis by increasing the deposition and inhibiting the removal of fat from the arterial wall. 16. Taylor, D. C., and Bower, B. D. Prevention in epileptic disorders. Lancet 2, 1136-38 (197 1). The authors believe that knowledge about epilepsy has reached a stage where some degree of prevention is possible. They consider that it is possible to prevent the birth of persons particularly liable to suffer serious epilepsy, and they discuss eugenics and genetic prevention in Huntington’s chorea, etc. The article also considers prophylaxis against seizures, the prevention of cerebral damage due to seizures, and the forestalling of secondary handicaps in affected individuals, e.g., overprotection of the child and the social stigma attached to epilepsy. 17. Weir, J. M., and Dunn, J. E. Smoking and mortality: a prospective study. Cancer 25, 105-12 (1970). In this study 68,153 men aged 35-64 years were followed over 482,658 person-years of observation, during which 4,706 known deaths occurred. Arteriosclerosis was the major cause of death (1,718),
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with the relative risk for light (one-half pack or less), moderate, or heavy (one and one-half packs or more) cigarette smokers increasing from 1.39 to 1.67 to 1.74. 18. West, R. O., and Hayes, 0. B. Diet and serum cholesterol levels: a comparison between vegetarians and nonvegetarians in a Seventh-Day Adventist group. Amer. J. Clin. Nutr. 21, 853-62 (I 968). In this study 233 nonvegetarians were compared with 233 vegetarians matched for residence, sex, age, marital status, height, weight, and occupation. The nonvegetarians were found to be a diverse group whose cholesterol levels increased as the degree of nonvegetarianism increased. Overall, the mean cholesterol values were 185 for vegetarians and 196 for nonvegetarians.
V. PRENATAL
SERVICES
REFERENCES
1. Apte, S., Iyengar, L., and Nagarajan, V. Effect of antenatal iron supplementation on placental iron. Amer. J. O&et. Gynecol. 110, 350-5 I (I 97 I). The developing fetus derives iron from maternal circulation through the placenta. Evidence is presented from 25 pregnancies that an antenatal supplement of iron promotes deposition of greater amounts of ferritin iron in the placenta for subsequent transfer to the fetus. 2. Aubry, R. H., and Nesbitt, R. E. L. High risk obstetrics: 1. perinatal outcome in relation to a broadened approach to obstetric care for patients at special risk. Amer. J. Obstet. Gynecol. 105, 241-47 (I 969). A special model clinic was set up at Upstate Medical Center, Syracuse, N.Y., using intensified screening and diagnostic procedures to identify patients at high risk. Previously undetected illness was found in one-third of the patients, and more than one-fourth required antepartal hospitalization for diagnostic work-up and treatment. The clinic obtained good results because (I) it was accessible to both private and ward patients (referral by a physician was the only requirement), (2) there was a good doctor: patient ratio, (3) a full-time social worker, psychologist, and nutritionist were employed, (4) an experienced obstetrician was on staff, (5) consultation was possible with physicians in every medical field, (6) special facilities for antenatal evaluation were available, (7) a good laboratory was on hand, and (8) follow-up studies were conducted. High-risk patients were defined by an objective scoring system. Among other services received, patients got a 2 hr postprandial blood sugar and/or glucose tolerance test, bacteriuria screening, thyroid screening and cytohormonal screening. 3. Bergner, L., and Susser, M. W. Low birth weight and prenatal nutrition: an interpretative review. Pediatrics 46, 946-66 (I 970). Birth weight is considered a possible crucial intervening variable between perinatal mortality or retarded child development. Birth weight is shown to have a stronger correlation with perinatal mortality than length of gestation. In New York if black infants had the same weight distribution as white infants and the same weight-specific perinatal death rates as they now do, their expected overall perinatal death rates would equal that of whites. Three conclusions are germane to prevention of low birth weight: (I) fetal growth leading to important variation in birth weight occurs in the last trimester, (2) birth weight is influenced by external as well as maternal environment, and (3) birth weight is influenced by factors having their origin and effect during gestation. The role of maternal nutrition during gestation is examined as a factor in birth weight. Observational studies of wartime deprivation support the nutritional hypothesis, but observational studies of everyday diets in pregnancy and quasi-experimental studies that supplement nutrition in pregnancy have equivocal results. Hypothesis requires testing by experimental approach to eliminate or control extraneous or confounding variables. 4. Burke-Strickland, M. J., and Freeman, D. W. The perinatal care center. Minn. Med. 5.5, 367-68 (1972). The perinatal care center at the Hennepin County General Hospital has been in service for approximately 4 years. Amnioscopy and fetal blood sampling techniques for detecting fetal distress are available. In 1969 electronic monitoring of the fetal heart and a newborn intensive care unit were added. A follow-up high-risk infant care clinic opened in 1970. Interdepartmental discussions were
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found to be useful. The monitoring and intensive care appeared to cut down on deaths, but it is now difficult to assess the quality of life they preserved. Long term follow-up data are needed, but the 24 infants who would not have survived without the respirator assistance appear at present to be doing well. 5. Carter, C. O., Roberts, J. A. F., Evans, K. A., and Buck, A. R. Genetic clinic: a follow-up. LQ,ZCet 1, 281-85 (1971). The first genetic clinic in the British Isles was established in 1946 at the Hospital for Sick Children. This paper is a follow-up from 3 to 10 years after consultation of 455 couples seen in the clinic during 1952-64. The following observations were made: (1) couples did understand information on risks, (2) responsible decisions based on this information were made concerning future pregnancies [where risks were high (one in ten), two-thirds deterred from planning future children; where risks were low (less than one in ten), one-fourth deterred; no high-risk couple with the risk of a serious long-term handicap had children], and (3) predicted risks, on the whole, were accurate (of the subsequent children born to high-risk parents, one in six were affected; of those born to low-risk parents, one in 50 was affected). Over 300 new couples are now seen annually. 6. Chase, H. Perinatal and infant mortality in the United States and six west European countries. Amer. 1. Pub. Health 57, 1735-48 (1967). This article compares the United States with Scandinavia, England and Wales, and the Netherlands and finds that the Netherlands and Scandinavia have lower infant mortality rates that are decreasing at a faster rate. Postnatal asphyxia, atelectasis, respiratory distress syndrome, and hyaline membrane disease are higher in the U.S. than in these other countries. These diseases are usually due to prematurity and low birth weights. The author belives that it is no accident that birth weights are generally higher in those countries that have a lower incidence of the diseases cited than the U.S. More careful recording of diagnostic information is needed to be able to make a more definite statement on the relation between postnatal asphyxia, atelectasis, respiratory distress syndrome, hyaline membrane disease, and low birth weight or prematurity. Beside the differences in fetal weight, England, Wales, and Scandinavia all offer social insurance that covers the expenses of medical care and have a more extensive use of midwives to administer prenatal care and assist in deliveries. These and other factors may play a great part in the lower incidence of the health problems surrounding birth in the countries that offer these services. 7. Chen, W., Palav, A., and Tricomi, V. Screening for diabetes in a prenatal clinic. Obstet. Gynecol. 40, 567-74 (1972). Over a 3-year period, 1,269 patients of the 8,288 attending a prenatal clinic were investigated for abnormal glucose tolerance because of obesity, a family history of diabetes, previous birth of a large infant, poor obstetric history, or glucosuria. Of the total prenatal population 91 or 1.1% were found, for the first time, to have abnormal glucose tolerance. The significance of various indications for screening were evaluated by statistical analysis. From the information derived, the detection of abnormal glucose tolerance rose exponentially with each additional screening indication. Thus, multiple indications for screening, in a given subject, indicate her carbohydrate metabolism must be investigated immediately. Screening for diabetes is important in a prenatal clinic and especially in a municipal hospital (Brooklyn-Cumberland Medical Center), since it is often the only adequate care the patient receives. 8. Danks, D. Intrauterine diagnosis of genetic disorders. Amt. Paediatr. J. 8, 128-30 (1972). It is now possible to diagnose all diseases due to chromosome abnormalities and over 20 caused by inborn errors of metabolism. It is necessary to lay guidelines for the use of this technique in preventive medicine. Follow-up studies are essential, since it must be assured that no long-range damage is done to the child. Amniocentesis should be employed only when the risks are great, and the recommendation that all pregnant patients over 40 years take the test may result in excessive anxiety, since some may not have thought of the possibility of having a mongoloid child. However, the use of this procedure on all women over 40 years is economically advantageous to the community. Even if each mongoloid child cost the community only $1,000 per year and lives for 30 years, the expenditure of
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about $12,000 for 100 amniocentesis tests to prevent the birth of this mongoloid child makes good financial sense. It is preferable to perform the test at the twelfth week, not the fifteenth or sixteenth, since by the time the results are had, it may be necessary to abort in the eighteenth-twentieth week or later. Intrauterine diagnosis of inborn errors of metabolism can generally be applied only to the prevention of second cases in families, because recognition of marriages between carriers by any other means is not practical. Absolute proof of diagnosis in the index case in the family is essential. The author feels that at present amniocentesis should be a preventive tool limited to those known to have high risk and/or anxiety. 9. Emery, A., Watt, M., and Clack, E. The effects of genetic counseling in Duchenne muscular dystrophy. Clin. Genet. 3, 147-50 (1972). The results of a follow-up study of 53 women referred to genetic counseling (1965-69) in families with Duchenne muscular dystrophy (Manchester and Edinburgh regions) are presented. The authors believe most parents act responsibly when told of risks, with those at high risk usually avoiding pregnancy. It is disturbing that many come for genetic counseling when pregnant. This could be overcome if in each family with an affected boy the genetic risks of all near female relatives were determined and all those with high risks followed up. A genetic register system, therefore, is important. Three developments in the past few years have increased interest in Duchenne muscular dystrophy: (1) increased awareness of the need for genetic counseling, (2) a test (serum level of creatine kinase) that can detect female carriers, and (3) possibility of fetal prediction with selective abortion of male fetuses of women with high risk (greater than one in ten). 10. Farquar, J. W. The treatment of the fetus of the diabetic mother. Canad. Med. Ass. J. 105,287-90 (1971).
A special program of care for the diabetic mother should include (1) normalization of the intrauterine environment through general care and hormone therapy; (2) monitoring of the state of the fetus, paying special attention to growth, maternal insulin need, maternal urinary estriol level determinations, etc.; and (3) delivery after the thirty-eighth week if all is satisfactory-if not, cesarean birth may be required. 11. Fort, A. T. Adequate prenatal nutrition. Ubstet. Gynecol. 37, 286-88 (1971). According to the author, to constrict the supply line by limiting nutrition intentionally (in the name of fashion) or unintentionally (poverty) is to arrest the rate of growth, which leaves an indelible imprint on the unborn. Eighteen nations surpass the U.S. in perinatal survival. The only plausible reason is our similar standing in birth weight statistics. He cites several authors, among them R. L. Masland Project Reporter, Spring1 (“Current Status of Collaborative Perinatal Project,” Collaborative Summer 1965, p. 7.), who found (1) a strong inverse relation between birth weight and survival, (2) a strong inverse relation between birth neurologic abnormalities at age 1 year, and (3) weight decreases in general metabolic efficiency caused by low birth weight. In the article there are also three references indicating that IQ decreases with low birth weight. The most recent publication cited is “Effects of Birth Weight on Later Intelligence” by S. Starr [Social Biology 16, 249-256 (1969)]. 12. Friesen, R. F. Pre-pregnancy care-a logical extension of prenatal care. Can. Med. Ass. J. 103, 495-97 (1970). The development of routine prenatal care is one of the outstanding advances in the twentieth century. It has now been realized that at the first visit, usually at the fourth-sixth week after fertilization, the fetus has already passed the most critical period in its development. Furthermore, the effects of various harmful influences on the germ cells before fertilization cannot be nullified by earlier prenatal care. With birth control, it is now feasible for a woman to see a physician before she expects to start a pregnancy. The author has been testing this idea by including it in his family-planning counseling. He suggests that the woman planning a family see a doctor 3 months before discontinuing contraception. He includes a list of items to be included in this visit.
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13. Glass, L., Kolko, N., and Evans, H. Factors influencing predisposition to serious illness in low birth weight infants. Pediatrics 48, 368-71 (1971). Serious illness requiring rehospitalization of low-birth-weight infants following discharge from the Harlem Hospital nursery was related to specific sociomedical factors, viz., (1) failure of mother to receive prenatal care, (2) absence of father from home, (3) receipt of public assistance, and (4) presence of other children in the home. These factors help yield a weighted prognostic index, permitting prospective assignment of a score to each low-birth-weight infant. Those at highest risk of inadequate follow-up care and rehospitalization were identified prior to discharge from the nursery. This may permit direction of intensive medical nursing and social service towards this high-risk group. 14. Gold, E. M., and Stone, M. L. Total maternal and infant care: a realistic appraisal. Amer. J. Pub. Health 58, 1219-29 (1968). High-risk pregnancies often can be attributed to socioeconomic conditions, marital status, lack of prenatal care, repetitive casualties of abortion, premature birth, nutritional deprivation, and complications during the course of pregnancy. The New York Medical College applied for a grant in 1965 in cooperation with the New York City Department of Health for the establishment of a special project at Metropolitan Hospital, located in a high-risk area. Home visits, family planning, nutritional consultation, and infant care are services provided throughout the pregnancy. Residents and thirdyear students rotate through all phases of maternal and infant care for 1 year. 15. Goldschmidt, E. Experiences from 5 years of genetic counseling in eye diseases. Acta Ophthahol. 46, 463-68 (1968). From January 1961 to January 1966,2,932 counseling cases were dealt with at the University Institute of Human Genetics, Copenhagen. The institute helps the centers that give help on abortion, sterilization, and adoption by trying to determine whether the children are free from hereditary disease and adoptable or if the fetus is at risk of a disease. The article lists the ocular anomalies for 185 cases counselled. Congenital cataract is the most common disorder. In order to perform his task, the counselor should obtain a complete, verified history. Since it is the ophthalmologist’s responsibility to prevent blindness, part of his work is to draw attention to the risk of having blind children and let parents decide on the action to be taken. 16. Gordon, H. Genetic counseling: considerations for talking to parents and prospective parents. J. Amer. Med. Ass. 217, 12 15-25 (1971). Prevention of disease through genetic counseling occurs when a diagnosis is made before symptoms begin. Diagnosis of familial polyposis of the colon in one family member should lead to an investigation of all first-degree relatives, so surgery may be performed before the development of cancer. If one child is found to have Wilson’s disease, others should be examined for disturbance of copper metabolism (which precedes clinical manifestations) and treated with penicilhunine, so the development of serious liver and brain disease is prevented, etc. Since genetic counseling is based on a precise diagnosis (the identification of the correct disease and knowledge of how it is inherited) made through the information gathered from the family history and the most recent genetic data available, the author believes that the physician is in the best position to give the advice. Genetic counseling is a form of family practice. 17. Hatch, M. C. Maternal and perinatal mortality-prenatal
care. N.Y. State J. Med. 70, 1800-6
(1970).
The Central New York Maternal and Perinatal Mortality Study examined programs throughout New York State and found good results in the projects at Syracuse and Onondaga County. Prenatal care should begin ideally by education during the teens, before pregnancy. When it first started, prenatal care was applied to prevent eclampsia, abnormal pelvic disorders, and syphilis. Later it attempted to deal with the entire physical health of the mother. Now the complete preparation of her physical and emotional health before she gives birth is the goal. The article gives a detailed account of what should be done at the first visit (type of physical examination, history, laboratory tests, etc.) through the ninth month. 18. Hillsman, G. M. Genetics and the nurse. Nurs. Ourlook 14, 34-9 (1966).
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This article describes the central role of the nurse in a program at the Maternal and Child Health Division of the Ohio Department of Health. Nurses are very much involved in interdisciplinary meetings in which a comprehensive evaluation of the handicapping condition is reached. Referral is made to an agency that can conduct chromosome studies. Such agencies are all too uncommon. Follow-up is conducted. Emphasis is placed on the supportive, social work function of nurses in this program to help mothers overcome the sense of isolation and guilt feelings that often accompany the birth of a handicapped child. 19. Jorgensen, V. Clinical report on Pennsylvania Hospital’s Adolescent Obstetric Clinic. Amer. 1. Obstet. Gynecol. 112, 8 16-l 8 (1972). By definition, adolescent pregnancy equals high risk. This paper reports on an effective program that emphasizes preventive medicine and a teaching program to minimize risk and management factors. It was conducted during an 18-month period (Feb. 1970-Aug. 1971) in which 350 patients were seen and 256 gave birth. The program was tailored to the 97% black clinic population, aged 1l-17 years and of a poor socioeconomic group. (1) Two groups were then formed and remained together throughout the entire prenatal period: (2) each patient attended a teaching program or group therapy session before seeing a resident; (3) a resident under a statf obstetrician trained in adolescent psychiatry was responsible for total obstetric care; (4) the teaching program directed by a hospital Maternal and Infant Care Clinic nurse gave information on prenatal care, labor and delivery, infant care, family planning, venereal disease, and drug abuse (emphasis was on group discussion); (5) social workers and stalf psychiatrists conducted group therapy for social, emotional, and educational help; and (6) patients returned to the clinic for postpartum care and family planning counsel. The article compares the results of the Adolescent Clinic at Pennsylvania Hospital with those of similar programs elsewhere and with Pennsylvania Hospital records prior to the initiation of the clinic according to the following: cesarean section rate, prematurity, anemia, eclampsia, and return to the postpartum clinic. The Adolescent Clinic at Pennsylvania Hospital was superior on all counts. 20. Kauffman, M., and Cunningham, A. Epidemiologic analysis of outcomes in maternal and infant health in evaluation effectiveness of three patient care teams. Amer. J. Pub. Health 60, 1712-25 (1970). In March 1968 the Research Committee of Temple University Health Science Center in Philadelphia, Pa., conducted a study to see which, if any, of the three types of maternal care offered to lowincome populations by the hospital outpatient department and two of its neighborhood health centers was best. The focus was on the outcome of maternal and infant health states in order to perform the evaluation. Prior to this study, the authors could find nothing in the literature to support the idea that prenatal care improved maternal and child health. The patients studied were divided between those who received care and those who did not. A significant relationship was found between the absence of prenatal care and prematurity, fetal and infant mortality, eclampsia, and maternal anemia. Negroes were found to have received less prenatal care and had the most problems. It was also concluded that it was too early to decide which of the three centers giving prenatal care through Temple University was best. 2 1. Kerr, C. Genetic counseling in hereditary disorders of blood coagulation. Mod. Treatment 5, 125-33 (1968). In order to deal with inherited disorders of blood coagluations, it is necessary to obtain a family history, have full facilities for investigating hemostatic mechanisms, and have knowledge of patterns of inheritance and the way in which each mutation expresses itself in the individual. The author claims that the most frequent requests for help come from female relatives of males with sex-linked conditions of classic hemophilia (Factor III deficiency) and Christmas disease (Factor IX deficiency). Almost all others are autosomal recessive disorders. Except for von Willebrand’s disease (autosomal dominant), a deficiency of fibrin-stabilizing factor (Factor XIII) may be inherited in either of two ways, viz., autosomal recessive or sex-linked. The article provides a list of diseases by modes of transmission and gives risks involved. 22. Langley, I. I. Resolved: that the present system of prenatal care is inadequate: a debate. Amer. J. Obstet. Gynecol. 113, 558-68 (1972).
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Among the points discussed were improvements in labor rooms, allowing the father to observe the delivery, and the use of paramedical personnel. The public was said to be stubborn, since it does not make use of services even when there is no charge. One speaker suggested that the medical profession pampers and gives an unnecessary amount of care to 90% who do not need care and does not reach the 10% who do. 23. Lynch, H. T., and Krush, A. J. Genetic counseling: implications for cancer control. South. Med. J. 61, 265-69 (1968). During the past years, more studies confirming patterns of Mendelian inheritance for several premalignant disorders and certain site specific cancers have appeared in the literature. A table is presented that lists different cancers and premalignancies and the way they are inherited. There is also a list of diseases suspect of being precancerous. Studies of “cancer families” show (1) high frequency of adenocarcinoma at all sites (especially colon and endometrium), (2) greater frequency of primary malignant neoplasms than in general population, (3) early age at onset of carcinoma, and (4) apparent autosomal dominant inheritance [see Lynch, H. T., Anderson, D. E., Krush, A. J., and Larsen, A. L., “Heredity and Carcinoma,” Annals of the New York Academy ofScience 155,793-800 (1968)]. This article emphasizes the responsibilities of the physician to recognize that he is dealing with a cancer family and to educate the patient toward prevention. The counselor should inform the patient of the pedigree and risks only when it has been determined the patient is psychologically ready. 24. Milunsky, A., and Littlefield, J. W. The prenatal diagnosis of inborn errors of metabolism. Ann. Rev. Med. 23, 57-76 (1972). Prenatal diagnosis is now possible because of development in the techniques of tissue culture and biochemical methods of application during the last 2 years. A list is presented of all inborn errors of metabolism, and a description is given of how most are diagnosed. The detection of carriers is said to be more likely today. Prenatal diagnosis really begins with heterozygote detection, especially as it involves inborn errors of metabolism. The possibility of detecting an “at risk” couple is now good. An example of this is the screening program for Tay-Sachs disease, which has been developed by Dr. Michael Kaback in Baltimore. Such screening methods are practical if the disease occurs in a recognizable population. The authors give 187 references. 25. Nash, E. M., and Louden, L. M. The premarital medical examination and the Carolina Population Center: what patients desire. J. Amer. Med. Ass. 210, 2365-69 (1969). A questionnaire was administered to 3,592 college students and the following findings resulted: (1) there was widespread ignorance of the purpose of the premarital medical examination, (2) there is hope that the physician will give the extended type of premarital examination and, especially, offer (unasked) contraceptive and sexual counsel, (3) there is a need to extend sex education to younger groups, and (4) a distinction is made between the role of the physician and the clergyman. The doctor should suggest that the couple return after l-3 months to discuss problems or any questions that may have arisen in the interim. 26. O’Brien, J. S. How we detect mental retardation before birth. Med. Times 99, 103-8 (197 1). A list of 27 genetic disorders that were diagnosable prenatally as of July 1971 is given. Tay-Sachs disease is described, its method of transmission and how it progresses. It can be detected by amniocentesis and enzyme assay. The author believes that all pregnant women over 40 years of age should have amniocentesis performed. 27. Osofsky, H. J., Hagen, J. H., and Wood, P. W. A program for pregnant schoolgirls: some early results. Amer. J. Obstet. Gynecol. 100, 1020-27 (1968). The problems of young pregnant women often place them in the high-risk category because of the following possibilities: toxemia, syphilis, prematurity, excessive weight, fetal-to-pelvic disproportion, prolonged labor, anemia, or hyperemesis. The young pregnant woman is also likely to be educationally, socially, and economically disadvantaged; illegitimacy is widespread. The Y-MED Program (Young Mother’s Educational Development), begun in 1965 in Syracuse and Onondaga counties, provides medical, social, psychological, and educational assistance all under one roof. This made possible because of the sponsorship of the Syracuse Board of Education, Onondaga Department of
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Health, and the State University of New York College of Medicine at Syracuse. A description of the girls in terms of race, religion, age, etc., is given. Personal attention is given early in pregnancy and continues to 1 year after birth. Conferences are held among all stti members twice a week. The supervision by a nutritionist of the girls’ own lunch preparation was a particularly beneficial innovation added while the program was already underway. The incidence of excessive weight gain on the part of the infant was greatly reduced. Although the mothers in this program experienced more problems before and during the delivery than the population at large, they had fewer difficulties than those with similar high-risk characteristics who received no care. 28. Rosenwaike, I. Sources of prenatal care of mothers having birth in Maryland. Amer. J. Pub. Health 65 186-90 (1972). In Maryland, one in ten live births occurred outside a hospital in 1950; in 1960 one in 48 occurred outside a hospital. Yet the infant death rate was higher in 1960 than in 1950. Unless controls are used, the observed differences may not be due to the type of care but to socioeconomic class or other factors. In order to assess this, the source of prenatal care of 57,000 Maryland women giving birth in 1968 has been analyzed by race, age, and educational attainment of mother (on the 1968 birth certificate in Maryland, starting 1968). Mothers of high educational status were most likely to have visited hospital or health department clinics. Women who received care at public facilities made their first prenatal visit somewhat later in pregnancy than those who saw private physicians. Exclusive of military families, 67% of ah mothers received care from a private physician. This included over four-fifths of white mothers but less than one-fourth of nonwhite mothers. Differences in the selection of care facilities are largely a function of socioeconomic status. 29. Sarrel, P. M., and Klerman, L. V. The young unwed mother: obstetric results of a program of comprehensive care. Amer. 1. Obstet. Gynecol. 105, 575-78 (1969). This study describes 119 teenage pregnancies cared for by the Young Unwed Mothers Program of the Yale-New Haven Medical Center. Comprehensive prenatal care applied to these pregnancies has yielded encouraging obstetric results in terms of low incidence of antepartum complications, prematurity, and perinatal loss. The central role of the obstetrician and his or her unique contribution to such a program are emphasized. The program, begun in 1965, links both the hospital and the community and aims to break the “unwed mother syndrome” of repeated pregnancies, dropping out of school, dependency on welfare, and the like. The program includes weekly instruction from the sixth month in pregnancy, labor, delivery, and contraception by a social worker with the assistance of an obstetrician, pediatrician, and delivery room nurse. The outcomes of the births in the programs are described. 30. Saylor, L. F. Hemolytic disease of the newborn. Cal$ Med. 112, 79 (1970). Since 1968, Rh immune globulin has been licensed and commercially available. It offers Rh negative women the means for preventing maternal Rh isoimmunization and hemolytic disease of the newborn (HDN) in subsequent pregnancies. HDN accounts for 3% of California’s perinatal mortality, or more than 1,800 deaths in the last 5 years. Rh immune globulin (1) must be given after each pregnancy, (2) must be given 72 hours after the termination of pregnancy, (3) is relatively inexpensive, and (4) cannot be used in mass programs. Since its use in California, problems discovered were (1) refusal of immunization because of the lack of expectation of another pregnancy, (2) contraceptive failures, and (3) conflicts with religious beliefs. The cost has been reduced from $64.00 at the start of administration to $30.00. 3 1. Saylor, L. Premarital examinations for syphilis. Cal$ Med. 115, 78-79 (197 1). California law requires premarital examinations for syphilis not more than 30 days before a couple gets a marital license. The California Administrative Code was amended recently to broaden the range of approved syphilis tests for premarital and prenatal examinations. These now include VDRL slide, automated reagin, fluorescent treponemal antibody (absorption), automated fluorescent trepnemal antibody, and rapid plasma reagin (circle) card tests. Any of these now constitute a “standard test” as required by the California Civil Code and the California Health and Safety Code. The fact that syphilis has risen and most often occurs in young adults makes premarital detection worthwhile.
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A physician must perform a physical examination. Syphilis of less than 2 years duration is considered communicable to the marital partner and offspring unless treated. In females, untreated syphilis of even longer duration can be communicated to the offspring. If the physician is assured that the patient has had adequate treatment, he can sign the marriage health certificate. Treatment with penicillin or other antibodies should be completed before marriage. There is a follow-up of both partners for l-2 years. At present the new law does not include detection and treatment of gonorrhea, but the author believes this should be initiated soon. 32. Slatin, M. Why mothers bypass prenatal care. Amer. J. Nun. 71, 1388-89 (1971). The Maternal and Infant Project at the University of Nebraska was established to provide maternal care without financial burdens and investigations. Project patients came from geographic locations in Omaha where high-risk patients live. Free services offered were all lab work, X rays, medical examinations, dental care, drugs, and help from nutritionists, social workers, and public health nurses. The program was funded by the Children’s Bureau (HEW) in 1965. It has since grown and includes two satellite clinics in addition to the University Hospital. A drop from 12% the first year to 3% the fifth year of the number delivering without prenatal care occurred. The author taught a postpartum course to establish rapport with mothers in the hospital who had never attended a clinic before birth. The women were then interviewed to see why they had not sought prenatal care. The findings are given. The reasons cited in 1965-66 caused the addition of the satellite clinics, a baby-sitting service and transportation. A bus service did not prove satisfactory because the departure hours were fixed. The program now pays the cost for taxis or public transportation. This totals $900 per year as compared to the $1,600 necessary to run a bus service. From the facts gathered and presented above, the author feels that the innovations put into effect after 1966 were useful and attributed to the rising number of women making use of the program in Nebraska. 33. Sinclair, M. G., Saslaw, M. S., and Buff, E. E. Premarital rubella serologies in Miami, Florida. South. Med. J. 64, 820-22 (1971). Of 200 women of child-bearing age surveyed at the time of premarital syphilis testing, 25% were susceptible to rubella. This study reaffirms that the history is of little value in predicting serologic immunity and suggests premarital rubella serologic testing as a rapid, reliable, and inexpensive way to get women vaccinated. 34. Taylor, K., and Merrill, R. E. Progress in the delivery of health care: genetic counseling. Amer. J. Dis. Child. 119, 209-I 1 (1970). Although there is enough knowledge about the inheritance of the disease, this paper summarizes the lack of success in providing useful information to families with boys having progressive muscular dystrophy. The roster of all patients attending a muscular dystrophy clinic was searched, and all male index patients with no affected females in the family and with the progressive disease of the Xlinked Duchenne type were selected. Diagnosis was make by electromyography, muscular biopsy, and enzyme studies. Twenty-one families were included. The survey was conducted by a medical social worker, who was aided by a physician. Interviewing was conducted at home, and questions asked pertained to socioeconomic class, the patients’ level of self-help, their knowledge concerning genetics, their knowledge about risks in other pregnancies, the possibility of carrier sisters, and the . prognosis, i.e., how long the boy was expected to live. Nine families were found to have total and accurate information. Only 14 were told that the disease would shorten life, and eight appreciated the need for a program of education modified to fit the child. The reason for the failure of this clinic is said to be the lack of clear responsibility on the part of designated staff members to assure a complete understanding of all that is involved with the disease. The authors believe that in the future, social workers should try to detect a lack of knowledge, and physicians then would aim to clarify the problem. 35. Thelander, H. E. Defective newborns. C/in. Pediat. 8, 437 (1969). Some adverse factors during the embryonic period are the mother’s age (under 20 years or over 35 years), poor nutrition, drug ingestion, anemia, infections, radiation, physical and emotional trauma, and previous infertility. Later in pregnancy these possible occurrences may harm the fetus: uterine
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bleeding, Rh incompatibility, abnormal placental implantation, and prenatal toxemia. Drugs, trauma, and nutrition also affect the infant during this time. In the paranatal period, medication, hypoxia, and trauma may affect the infant directly. The author states that all these facts are well established and have been known for some time. It is now necessary to educate the public on preventative strategies. More sex education is suggested. 36. Thompson, H. E., McFee, J. G., Haverkamp, A. D., and Longwell, F. H. Factors contributing to improved maternal care and fetal outcome in a medium sized city-county hospital. Amer. J. Obstet. Gynecol. 116, 229-38 (1973). During the past 5 years, the perinatal mortality rate at Denver General Hospital has been reduced from 4.1 to 2.7%. This decrease is due to (1) a federal grant support that made possible establishment of multiple obstetric clinics throughout the city where comprehensive health care and family planning can be obtained, (2) a new, modern hospital, (3) increased competence in the full-time staff, (4) new concepts of evaluation and management of the high-risk gravida and her infant, and (5) the therapeutic abortion law in effect. Among the new techniques included were amniocentesis, amnioscopy, ultrasound, estriol level determinations, fetal monitoring, more liberal use of cesarian section, different modes of anesthesia, new ways of managing respiratory distress syndrome, and Rh immune globin. The entire staff is also more concerned with nutritional, social, psychological, and communication problems. 37. Valentine, G. H. Reproductive counseling services. Can. Med. Ass. J. 106, 757-59 (1972). The term “genetic counseling” is said to be inadequate, since information on such factors as drugs and rubella, etc., also influence the outcome of pregnancies and should be made known. Therefore, “reproductive counseling” is a better term. Mental retardation may be caused by genes, intrauterine infection, or obstetrical mishap. Thus, reproductive counseling should take place in major medical centers, preferably in university-based medical centers, because sophisticated methods are essential for accurate diagnosis. Even if patients must travel a distance to reach these centers, it is worth the inconvenience. The authors describe an ideal counseling service. 38. Wonnell, E. The education of the expectant father for childbirth, Nurs. C/in. N. Amer. 6, 591-603 (1971). Having the father play a role in delivery is still a controversial topic. However, the author believes that there is a great need of a supportive person to help reduce the stress of labor. A program has been in existence for 6 years at the Wilmington (Del.) Medical Center to train fathers for this role. Twelve instructors teach 12 series of 22 couples, equalling 1,500 couples per year. The program is described. It has resulted in making delivery easier for both the wife and husband and increased their sense of self-esteem. 39. Zackler, J., Andelman, S. L., and Bauer, F. The young adolescent as an obstetric risk. Amer. J. Obstet. Gynecol. 103, 305-12 (1969). The outcome of pregnancy was studied in 2,403 girls who received their care at the Chicago Board of Health and were 15 years of age or under at the time of conception. This was compared to the outcome of pregnancy in 4,400 girls of the same age group who had not received care at the Chicago Board of Health. Some of these received private care, some clinic care, and some had no prenatal care at all. The comparison was made with respect to hebdomadal and neonatal mortality, prematurity, and those conditions leading to infant mortality that had direct relationship to obstetric care. The study also included the incidence of complications, both prenatal and intrapartum. The study revealed that the hebdomadal mortality rate was 92% higher and the neonatal mortality rate was 94% higher in the patients who did not receive prenatal care at the health board’s clinics. Other findings were significantly lower in the health board’s patients. The services rendered were postprandial blood sugar determination, bacteriuria screening, electrophoreses for the determination of sickle cell anemia, social service guidance, dental care, homemaker service, better public health nursing service, and nutritional guidance. Anyone designated as high risk (15 years or under, multigravidas over 40 years of age, and primigravadas over 35 years of age in addition to those developing complications during the course of pregnancy) received special arrangements for delivery.
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VI. CHILD HEALTH
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REFERENCES
1. Allen, C. M., and Shinefield, H. R. Pediatric multiphasic program: preliminary description. Amer. J. Dis. Child. 118, 469-72 (1969). A pediatric multiphasic screening program, conducted by San Francisco Kaiser-Permanente Medical Group, Kaiser Foundation Hospital, since 1967, combines into a single health service three separate elements: (1) a group of screening tests administered by nurses or nurses’ aides, (2) computer processing and storage of the test results, and (3) a physician’s examination performed approximately 1 month after the tests are performed. Children older than 10 are tested alone; younger children may be accompanied by a parent. Procedures performed are EKG, blood pressure, pulse, bone age and wrist roentgenogram, anthropometry, visual acuity, respirometry, audiometiy, intelligence tests, drawing tests (Draw-a-person, Bender-Gestalt), Tine test, throat and nose cultures for streptococci, blood, urine, neurological maturity tests, and a self-administered parent response-to-behavior inventory. The pediatric multiphasic program is currently an off-line program, i.e., the test results are not fed into the computer, in order to reduce costs. It is hoped to integrate the results of the Draw-aman, Bender-Gestalt, psychological screening, and behavior questionnaire into a single score for presentation to the child’s pediatrician. 2. Alpert, J. J., Kosa, J., Haggerty, R. J., Robertson, L. S., and Heagerty, M. C. Families receiving comprehensive pediatric care. Amer. J. Pub. He&h 60, 499-506 (1970). The article examines the change in attitudes on the part of low-income families in Boston toward preventive practices, physicians in general, and the relative importance of health. The study shows an increased preference for a primary-care physician but little change in attitude toward more abstract concepts like preventive health practices. 3. Belleville, M., and Green, P. B. Preschool multiphasic screening in rural Kansas. Amer. J. Pub. Health 62, 795-98 (1972). This report presents an overview of a multiphasic screening program for preschool children in rural Kansas. In 1970, one county with 350 preschool children residing in it was studied. There 231 children were screened. Six children were referred to physicians for further vision evaluation, and four for further hearing evaluation and treatment. In the spring of 197 1, a five-county area with 818 children screened was studied. Of these 818, 428 received the Denver Developmental Screening Test; of these 428, 10% needed some type of further evaluation; of the 765 screened for hearing, 4% needed further evalation; of the 458 on whom hemoglobin was reported, 11% were referred to either a physician for medical evaluation or to a public health nurse for nutrition counseling; of the 493 children tested for speech, 37% were referred for further evaluation by a speech clinician. Mantoux tests were performed on 63 1 patients with no referrals made. Vision tests were conducted on 658 patients with 2.5% referred for treatment. 4. Brown, H. B. Multiphasic screening for preschool children: I. methodology and clinical findings in a Spanish-American community. J. Amer. Med. Ass. 219, 1315- 19 (1972). Two pediatric screening clinics staffed by medical students, nursing students, and community volunteers were conducted in low-income, Spanish-American neighborhoods in Albuquerque, New Mexico. The program was designed to examine preschool children by means of history, physical examination, hematocrit, urinalysis, and psychological tests. There were 352 children examined. Abnormalities in lab findings or upon physical examination appeared in 59 out of the 352 (17%). Information on the results of further evaluation of suspected abnormalities is incomplete but suggests that approximately 5% of the children had chronic physical impairment and 7% had significant emotional or mental impairment. 5. Campbell, M. T., Garside, A. H., and Frey, M. E. C. Community needs and how they relate to the school health program: S.H.A.R.P. Amer. J. Pub. Health 60, 507-14 (1970). The article studies the rate of correction of defects found in the Philadelphia elementary schools during regular health screenings. In poverty areas the rate is very low but can be improved significantly if parents are counseled by school nurses and if cases are followed up by school nurses.
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6. Cayler, G. G., and Warren, M. C. Benefits from mass evaluation of school children for heart disease: an experience with 6,625 children. Chest 58, 349-5 1 (197 1). The major benefits of a community program for the mass evaluation of schoolchildren for heart disease was found to be enhanced distribution of pediatric cardiology specialty services. This enhanced distribution is achieved through use of computer heart sound analyzer and by the establishment of a creative partnership among the pediatric cardiologist, the practicing physicians, local health officials, and the local heart association. 7. Chappell, J. A., and Drogos, P. A. Evaluation of infant health care by a nurse practitioner. Pediatrics 49, 871-77 (1972).
The effectiveness of a pediatric nurse practitioner in infant health supervisions was measured by achievement of desired health care goals in the first year of life and by infant health status at age 1. There were no marked differences in these measures between infants cared for by the PNP and those given care by a pediatrician. 8. Cobliner, W. G. Preferred preventive health care facilities: a survey among urban adolescents. Bull. N.Y. Acad. Med. 49, 922-30 (1973). This paper describes a survey relating to adolescent out-of-wedlock pregnancies and the need for the provision of special teenage clinics for preventive services. 9. Eisner, V., and Oglesby, A. Health assessment of school children: V. selecting screening tests. .I. Sch. Health 42, 2 1-24 (1972).
When one must choose which screening test to use for a multitest program, the important considerations are not specificity and sensitivity, as for a screening test for a given condition, but (1) costbenefit relationship, (2) whether or not there is an effective treatment for the disease, and (3) acceptability of the tests. 10. Gordis, L., and Markowitz, M. Evaluation of the effectiveness of comprehensive and continuous pediatric care. Pediatrics 48, 766-76 (197 1). Two controlled studies were undertaken to evaluate the effectiveness of comprehensive and continuous pediatric care. In the first study 220 infants were randomly allocated to either a comprehensivecare (CC) or a traditional-care (TC) group. The CC group received preventive and therapeutic care in a hospital-based program staffed by a pediatrician, a public health nurse, and a social worker. TC infants got care from emergency rooms, well-baby clinics, and outpatient clinics. One year after delivery each mother was interviewed, and her infant’s medical records examined. There was no difference between TC and CC infants in completeness of immunization, use of medical resources, morbidity, or mortality. A second study, attempting to show that compliance with a doctor’s recommendations would be favorably influenced by continuous care, failed similarly. This report is of interest because neither study could show that comprehensive or continuous care was more effective than conventional ambulatory care for children. 11. Hartman, E. E., et al. Health program for Minneapolis Project Headstart, 1966. J. Sch. Health 37, 232-36 (1967). The Minneapolis Health Department was requested to plan and develop the health aspects of the Headstart program in the city since 1965. The project prepared for 1966 included medical, dental, visual acuity, hearing, and laboratory screening as well as immunizations and tuberculin testing. Out of 997 children enrolled in the Headstart schools, 813 were tested, and 63.7% were found to have one or more health problems, with dental problems most frequent (288 out of 813, or 36.8%). Next came problems related to the ears, nutrition, heart murmurs, and the eyes. Overall, medical screening found deviations in 202 out of 8 13 children (24.8%). Of the 5 18 out of 8 13 children with one or more health problems, totaling 770 deviations, follow-up care was given or completed for 391. No treatment was indicated for 148 deviations. The treatment was not completed for 79 children with medical problems and 152 children with dental problems. 12. He&g, M. D., and Birch, H. G. Intellectual levels of school children severely malnourished during the first two years of life. Pediatrics 49, 814-24 (1972).
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Children badly nourished in their first 2 years have lower levels of intelligence at school age than their siblings and classmates. The age when hospitalized for the treatment of severe malnutrition did not relate to the intellectual level of cases, however. 13. Hoffmann, A. D., and Gaman, M. The adolescent outpatient: medical, social and emotional needs. Postgrad. Med. 50, 245-49 (1971). The high incidence of social and emotional problems and the interest in medical and social counseling suggest that medical care for adolescents is most relevant when diagnostic, therapeutic, and preventive measures are aimed at these areas as well as at physiologic needs. The Beth Israel Clinic was organized to do this. It failed partly because of a high dropout rate-a problem to be faced by future programs of this sort. 14. Jelliffe, B. B., and Jelliffe, E. F. P. Adaptive MCH services: a key strategy for overcoming malnutrition in young children. Clin. Pediat. 10, 552-54 (1971). Malnutrition is always caused by social and individual factors as well as by an inadequate diet. These factors vary from place to place, so programs must be adapted to the local situation. An MCH program is always a key strategy in overcoming protein malnutrition within a population. 15. McFarlane, A. H., and Norman, G. R. A medical care information system: evaluation of changing patterns of primary care. Med. Care 10, 481-87 (1972). Data from a computer-based medical information system were used to evaluate patterns of pediatric health maintenance over a period of 1 year at McMaster University Clinic. These data were then used as a guide to modify the delivery of pediatric health care to one more appropriate to family practice. The significant changes were a shift of responsibility to the nurse, a change in the content and frequency of patient contacts, and modification of the immunization and routine screening schedules. Evaluation of care 1 year later provided evidence of the usefulness of these changes. The study demonstrates the need for performance information in evaluating patterns of primary care and illustrates the value of the nurse-practitioner role in pediatric health maintenance. 16. Rosenbloom, A. L., and Allen, C. M. Screening for glucose intolerance in a pediatric multiphasic program. Metabolism 22, 3 19-22 (1973). The authors describe an initial attempt to analyze l-hour post-glucose-ingestion serum glucose values obtained during multiphasic screening of children. Analysis of data is by age group, time of blood sampling, and duration of fast prior to glucose ingestion. The report cites serious limitations of multiphasic screening for glucose intolerance and counsels against such activity without either control of the testing variables or multiple criteria specific for the varying test factors. Conclusions are that multiphasic screening systems have certain basic logistic limitations that make the ideal of controlling dosage of glucose load, time of testing, and duration of fast virtually impossible. 17. Salber, E., Feldman, J. J., Rosenberg, L. A., and Williams, S. Utilization of services at a neighborhood health center. Pediatrics 47, 415-23 (1970). This study describes the services rendered to 1,989 children (of 521 families) registered over a 5-month period at a neighborhood health center in Boston- 87% of whom received at least one professional service and 70% of whom were seen by a pediatrician. Variables such as ADC status, residence, family size, and education of mother had only a minor effect on registration rate of use of the facilities. The child’s age had a far greater influence. Visits to physicians and dentists were higher than the national norms for corresponding ethnic and socioeconomic groups. 18. Schaller, J., and Wedgewood, R. J. Juvenile rheumatoid arthritis: a review. Pediatrics 50, 940-53 (1972). The authors followed 124 children with juvenile rheumatoid arthritis at the Children’s Arthritis Clinic affiliated with the University of Washington Medical School. Three distinct subgroups c&tinguished by clinical manifestations, prognoses, complications, and serologic findings are described. The authors contend that although the significance of juvenile rheumatoid arthritis into such subgroups is unknown, it may prove useful in diagnosis and treatment. What now is termed juvenile rheumatoid arthritis may be more than a single disease.
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19. Sherwin, A. D., Schoelly, M. L., Klein, B. L., Schwartz, M. S., and Khan, M. G. Determination of psychiatric impairment in children. J. Nerv. Menr. Dis. 141, 333-4 1 (1965). This report, from the Payne Whitney Child Psychiatry Department, describes the use of a questionnaire among parents (usually the mother) to obtain reliable determinations of psychiatric impairment in children between the ages of three and 13. Three sample groups were identified: (1) known to be psychiatrically impaired, (2) presumed to be free of any impairment, and (3) composed of a group selected from the community at large. The findings were submitted to both statistical analysis and a clinical evaluation. The questionnaire does detect the presence of psychiatric impairment in children. Although it may fail in some cases where the parent responding is severely disturbed or the child is very young, the evidence to date suggests that it can be used, nevertheless, as a screening device by organizations working with children. 20. Sims, N., Seidel, H. M., and Cooke, R. E. A structured approach to the use of physician extenders in well-child evaluations. J. Pediat. 79, 15l-63 (1971). Systems analysis techniques were used to develop a new method of data acquisition in well-child evaluations. This departure from tradition was designed to increase physician efficiency yet maintain an acceptable patient-physician relationship in providing high-quality care. The results of 104 examinations using the new method provided more information with less time expended by the physician than in examinations conducted in the traditional manner.
VII. MENTAL HEALTH, DRUG ABUSE, ALCOHOLISM REFERENCES
AND
1. Allinsmith, W., and Goethals, G. W. “The Role of Schools in Mental Health.” Basic Books, New York, 1962. This book presents a general view of issues concerning mental health and schools and outlines the approaches being taken by schools to ferret out and correct mental and emotional problems. The authors also discuss the problems involved in classroom teachers’ helping their students in these areas and whether such activities limit more traditional pedagogy. 2. Bennett, A. E. Recognizing the potential suicide. Geriatrics 22 (5), 175-81 (1967). Suicide is not produced by external factors: only internal impulses, an inability to cope with external realities, lead to suicide. Many who attempt suicide do not really contemplate death; they simply seek emotional relief. Among this group are those who wish to call attention to themselves or to obtain love through force. Depressive mental illness is nearly always a cause of suicide. Thus, the physician has a great responsibility to recognize and to evaluate the seriousness of all depressive states. If the risk is considered great, the physician must insist on hospitalization. 3. Bower, E. M. Primary prevention of mental and emotional disorders: a conceptual framework and action possibilities. Amer. .I. Orthopsychiat. 33 832-48 (1963). Prevention has to do with the quality of the interactions and the degree of effectiveness of the society’s institutions in providing the individual with ego strength. This report relates all possibilities of preventive techniques as well as emotional hazards to seven service zones (family, public health, school, religion, job, recreation, and housing). 4. Brunt, H. H., Jr. Organization of a suicide prevention center. J. Med. Sm. N. J. 66 (2), 62-65 (1969). The author describes the operation, structure, and outside relationships of a hospital-based antisuicide program. The entrance point to the system is through a senior statf psychiatrist who “triages” incoming calls to eight selected statf members serving on a daily rotating basis, with each member having a special home telephone to insure constant coverage. Follow-up is coordinated between both the hospital and a number of community health and welfare agencies. 5. Cutting, R. Facts, fallacies and fiction in mental health education, in “The Psychiatric Clinic in Encounter” (A. Tulipan, Ed.), pp. 75-80. Poca Press, Oil City, Pa., 1971.
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Lack of agreement on objectives and processes and the multiplicity of services may have serious impact upon the general acceptance of community mental health and matters such as securing community financing and collaboration. It is unrealistic to think that the new comprehensive health centers are placing much emphasis on community health education. A recent study of eight representative centers made almost no mention of the mental health education programs. Community mental health education should be closely correlated with the prevention of emotional disorders. Training problems for mental health professionals should initiate study in the methods of delivery of community mental health educational services. 6. Farberow, N. L., and Shneidman, E. S. “The Cry for Help.” McGraw-Hill, New York, 1961. This book focuses on the responses by the community and practioner to the suicidal cry for help and describes the activities of the Los Angeles Suicide Prevention Center and other community agencies who are focusing on that cry. It points out the need for an interdisciplinary team in recognizing and preventing suicide. Also, it contains a comprehensive bibliography of 1,200 works on suicide and suicide prevention. 7. Garrard, R. L. Community suicide prevention activities in Greensboro, North Carolina, in “Suicidal Behaviors; Diagnosis and Management.” (H. L. P. Resnik, Ed.), pp. 399-404. Little Brown and Company, Boston, 1968. Suicide prevention services in Greensboro, North Carolina, are centered in the police department. Cooperation is provided by physicians (especially psychiatrists), hospitals, and courts. Promotional services, including professional meetings, film showings, and public programs, are described. An informal police-physician team has been formed. Telephones and squad cars are available on a 24-hour basis. Under cooperative conditions mutual respect and improved efficiency have developed. Legal machinery has been simplified for commitment of mental patients. Other communities have been given information on the process of establishing a suicide prevention service. There are two references. 8. Gibson, R. W. Can mental health be included in the health maintenance organization? Amer. J. Psychiat. 128 (8), 919-26 (1972). The inclusion of mental health care in proposed health maintenance organizations (HMO) is discussed. Prepaid group practice plans, a prototype of the HMO, have usually offered only modest mental health benefits, although there have been substantial improvements in recent years; utilization and costs under these programs have been low. The barriers to inclusion of mental health benefits in HMO’s are discussed, HMO’s are compared to community mental health centers, and psychiatrists are urged to take an active role in ensuring, not only that a mental health component be made an integral part of every HMO, but that linkages be established between HMO’s and other parts of the mental health care system. 9. Haughton, A. Suicide prevention programs in the United States-an overview. Bull. Suicidal. 25-29 July (1968). By 1968 there were over 60 suicide prevention centers in the United States. The majority of these centers are directed by professionally trained personnel who attempt to provide 24-hour answerreferral service for potential suicidal individuals and those in other states of crisis. These centers provide a service that is of unique and special use to their communities and of specific value to those who turn to it. 10. Kalfman, M. Practice of family treatment in Kibbutzes and urban child guidance clinics, in “New Directions in Mental Health” (B. F. Reiss, Ed.), pp. 8-16. Grune and Stratton, New York, 1968. Simulation of mental health practice and facilities in areas outside the United States has long been an aim of the program of the Postgraduate Center for Mental Health. Among trainees have been psychologists, psychiatrists, and social workers from many nations. Dr. KatFman was one of the psychiatric fellows at the Center and returned to his native Israel to head a clinic in Haifa. He describes in this article the basic principles of family therapy found to be effective with groups in urban and rural
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sections of his country. The findings that conjoint concurrent and separate sessions with the family and family subgroups were invaluable and are discussed against the background of Israel’s unique population. 11. Kiev, A. Suicide prevention, in “Identifying Suicidal Potential” (D. B. Anderson, Ed.), pp. 3-13. Behavioral Publications, New York, 1971. A review of major risk categories for suicide is given. It is recommended that suicide prevention centers clarify their objectives, analyze their operations, and determine whom they are helping. 12. Lemkau, P. V. Toward mental health: areas that promise progress. Menr. Hyg. 36, 197-209 (1952). This study shows the integration of the following areas: epidemiology, personality development, and human relationships. 13. Lemkau, P. V. Prevention of psychiatric illnesses. J. Amer. Med. Ass. 162, 854-57 (1956). The author has been dealing with many illnesses, many of which have specific preventions applicable only to them. There are illnesses related to chronic stress. Education and attitudinal change are two means of relieving stress. It may also be possible to reduce individual stress through the relief of broad cultural stress affecting large groups of individuals. 14. Marin, P., and Cohen, A. Y. “Understanding Drug Use, An Adult’s Guide to Drugs and the Young.” Harper and Row, New York, 1971. Aimed at the concerned parent, this is an effective tool for self-education about drugs and youthful druge abuse. The authors take it for granted that at one time or another most children will try drugs and argue that attempts to suppress their use entirely are doomed to failure. They concentrate on the minimization of drug misuse and suggest specific ways in which parents, teachers, community workers, and others can work with adolescents to direct them toward sensible usage. The measures suggested are both long-range and short-range, both preventive and therapeutic. As a guide to the concerned adult, the book also contains a substantial anthology of helpful information on all of the major drugs, explaining the ways in which they are used and their effects and evaluating the dangers, if any, that attend their use. 15. Nelsen, B. Suicide prevention: NIMH wants more attention for taboo-subject. Science 161, 766-71 (1968). The keys to lowering the suicide rate are to educate the public about suicide and to set up an effective system to refer suicide-prone individuals for help. In order that members of the community will become more aware of detecting suicidal intentions, the NIMH center has helped to organize regional workshops, seminars, and training demonstrations. 16. Over the counter drugs -a challenge for drug education. J. Drug Educ. 3 (2) (1973). Society today is acutely aware of drugs and all too often takes drugs without proper thought, knowledge, or precautions. The article professes that drug education should be a complete program including information on the over-the-counter, overused group of self-medicaments. Included are sections on antacids, sleep-aids, laxatives, and analgesics. 17. Parad, H. J., and Parad, L. G. A study of crisis-oriented planned short-term treatment: part I and part II. Sot. Casework 49 (6), 346-55 (1968) and 49 (7), 418-26 (1968). This study of 1,656 cases in planned short-term treatment (PSTT) programs in 54 family agencies and 44 child guidance clinics indicates that PSTT is considered a treatment of choice rather than of expediency and that it is possible to structure the time dimension in treatment in a flexible but meaningful manner. Both the clinical characteristics and the problems presented in PSTT cases seem representative of general client populations. With the clinicians’ impressions as a measure of outcome, two-thirds of the cases showed improvement; with use of the clients’ or patients’ own perceptions (as reported by the worker), three-fourths demonstrated improvement. The modal number of interviews planned for both samples was six; the preferred length of treatment was 9-12 weeks. The planned
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number of interviews and weeks of treatment generally represented an estimated goal or upper limit that both agencies and clinics tended to overestimate. Cases seen for over six interviews were more likely to show improvement. Services were dramatically more accessible in agencies than in clinics. The majority of cases were reported as involving a crisis situation, precipitated by situational rather than maturational events. Other aspects of treatment planning are discussed. 18. Perlin, S., and Schmidt, C. W., Jr. Fellowship program in suicidology: a first report. Bull. Suici&l. 38-42 March (1969). The Johns Hopkins University postgraduate fellowship program in suicidology is the first program devoted exclusively to the training of professionals in the field of suicidology. This article gives the various requirements for admission into this program and outlines the major subject areas covered. 19. Resnik, H. L. P. Critical issues in suicide prevention. Bull. Suiciu’ol. l-3 Fall (1971). Some critical issues in suicide prevention are reviewed, following a report of the status of work in that field. Several programs and services are mentioned, with emphasis on the center for studies of suicide prevention. Among the issues raised are standards of care that the public is led to expect by intensive publicity programs, identification of high-risk suicide persons, treatment programs for the identified person, follow-up and new treatment approaches, reevaluation of volunteer programs, and adequate mental health facilities for treatment. 20. Zimring, F. E. “Chicago’s Crackdown on Drunken Driving.” (The Center for Studies in Criminal Justice.) The University of Chicago, Chicago, Ill., 1971. Analysis of the effect of a mandatory minimum 7-day jail sentence for persons convicted of drunk driving proved inconclusive. However, serious, but not fatal accidents, during the crackdown period showed a relatively sharp decrease in nighttime statistics but no similar decrease in the daytime accidents.
VIII. PREVENTIVE
DENTISTRY
REFERENCES
1. Ast, D. B., Cons, N. C., Pollard, S. T., and Garfmkel, J. Time and cost factors to provide regular periodic dental care for children in a fluoridated and non-fluoridated area: final report. J. Amer. Dent. Ass. 80, 770-76 (1970). A 6-year study of 766 children was conducted in fluoridated Newburgh and fluoride-deficient Kingston to determine the cost and time to provide regular dental care for children by starting when they were 5 and 6 years old. The cost of corrective dental care of the fluoridated children was less than half the cost of the other children; the cost of incremental care was about half. The chair time needed to provide examination prophylaxes and corrective care was about one and one-half times more in the nonfluoridated area. 2. Bohannan, H. M., Ochsenbein, C., and Saxe, S. R. Preventive periodontics. Dent. Clin. N. Amer. 435-43 July (1965). Although periodontal disease afflicts over 95% of the world’s population, most cases of this disease can be prevented. Recommendations for prevention include regular removal of plaque and calculus accompanied by toothbrushing (with soft nylon toothbrush), use of unwaxed dental floss, and use of a water spray. These, the authors think, should lead to an effective program of dental hygiene. 3. Buonocore, M. G. Caries prevention in pits and fissures sealed with an adhesive resin polymerized by ultraviolet light-a 2 year study of a single adhesive application. J. Amer. Dent. Ass. 82, 1090-93 (1971). This reports shows that 2 years after a single application of a liquid adhesive to the pits and fissures of human teeth that involves uv light polymerizing the adhesive, a 99% carries reduction on permanent teeth was found, whereas the surfaces of deciduous teeth showed an 87% reduction. 4. Buonocore, M. Cl. Adhesives for pit and fissure caries control, Dent. Clin. N. Amer. 16, 693-708 (1972).
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The high susceptibility of pits and fissures to caries present a major dental problem, and over the years various attempts have been made to prevent them. While the evidence of the success of adhesives in reducing caries is significant, the author warns that sealants are not indicated for all teeth. 5. Cons, N. C., and Leatherwood, E. C. Dental services in community child care programs. Amer. J. Pub. Health 60, 1245-49 (1970). Health programs for children must include dental care-especially for the poor. This piece outlines the barriers to good dental care, how to surmount such barriers, the essential elements of a good dental program for children, and ways of providing care and operating community programs. 41, 630-35 (1970). 6. Derbyshire, J. C. Patient motivation in periodontics. J. Periodonotol. Patient motivation as it relates to periodontal disease and its treatment requires the close cooperation of both the patient and dentist. The patient has primary responsibility for plaque control and should only depend on the dentist for those things he cannot do for himself. 7. Diorio, L. P., and Madsen, K. 0. Patient education-a health service for the prevention of dental disease. Dent. Clin. N. Amer. 15, 905-17 (1971). An appraisal is made of some of today’s attitudes toward preventive dentistry and patient education. It is pointed out that there are many patient-education programs in dental health. Some emphasize only plaque control, others only disseminate information, few place emphasis on food habits, and only a few combine all of these. What is needed is a unified program and one capable of reaching large numbers of people. 8. Englander, H. R. A perspective on prophylaxis of dental caries by tropical fluoride. Dental Clin. N. Amer. 16, 673-92 (1972). Tropical fluoride therapy is shown to be an effective way to augment the F concentration permanently in the outer surfaces of the enamel of deciduous and permanent teeth. It is recommended to supplement individual home care in the prevention of tooth decay, especially on the smooth coronal tooth surfaces. 9. Gochman, D. S. Context for dental health education. In?. 1. Health. Educ. 16, 37-42 (1973). Evidence is offered that dental health education might be more effective if included in a comprehensive rather than a fragmented health education program. The author’s final suggestion is to attempt to change a person’s overall perception of vulnerability to health problems. 10. Greene, J. C. Oral hygiene and periodontal disease. Amer. J. Pub. Health 53, 913-22 (1963). The prevention of periodontal disease requires improved oral hygiene. This conclusion is drawn on the basis of data presented in this report. The data were obtained by studying 4,000 people of Ecuador in 1959 and some 1,500 American Indians in Montana in 1961. The implications of these data are considerable. If a person were to maintain a good level of oral cleanliness from ages 5 to 50, he very likely would avoid the ravages of destructive periodontal disease during this major part of his life. The author concludes that if a person maintains poor oral hygiene for even a very few years, he will experience rapidly advancing destructive periodontal disease. Much more emphasis should be given in dental health programs to the improvement of oral hygiene as a major step in the prevention of periodontal disease. 11. Horowitz, M. S., and Heifetz, S. B. The current status of topical fluorides in preventive dentistry. J. Amer. Dent. Ass. 81, 166-78 (1970). The use of topical fluorides in protecting the enamel surface of teeth from caries attack has undergone much study in the past 25 years. This article summarizes much of the knowledge on various topical fluoride solutions and their applications and the fluoride prophylaxis pastes. On the subject of self-administration of topical fluorides, the authors believe “at this time there is insufficient evidence to recommend any self-administration procedure for topical fluoride application-be it toothbrushing, mouth rinses or mouthpieces for general use in public health programs.”
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12. Katz, S., McDonald, J. L., and Stookey, G. K. “Preventive Dentistry in Action.” D.C.P. Publishing, Upper Montclair, N.J., 1972. This book tries to place preventive dentistry within its proper scientific and professional perspective. The authors pooled their experience in the research laboratory, the classroom, the dental clinic, and private practice in writing this text. They develop what they call the philosophy of preventive practice, the main objectives of which are (1) to consider the patient as a whole entity, i.e., as a person; (2) to maintain a healthy mouth healthy as long as possible-ideally for a lifetime; (3) when oral health is deteriorating, to stop the progression of the disease as soon as possible and to provide appropriate rehabilitation of form and function at the earliest possible time as perfectly as possible; and (4) to provide the patient with the knowledge, skills, and motivation necessary to prevent the recurrence of the conditions covered in No. 3. 13. Mandel, I. D. New approaches to plaque prevention. Dent. Clin. N. Amer. 16, 661-71 (1972). The author describes the current research on antiplaque and anticalculus substances. At the present it is noted that neither the safety nor efficacy of any particular substance has been established. The mechanical approach is still considered the most effective way of removing plaque. A number of preparations, however, do look very promising. 14. Moen, B. D., and Poetsch, W. E. More preventive care, less tooth repair. J. Amer. Dent. Ass. 81 (1), 25-45 (1970). This survey of dental services rendered in 1969 to 35,793 patients, in comparison to the previous studies in 1950 and 1959, has shown highly significant changes occurring in dental health care during the past 2 decades. The emphasis has gone from reparative care to preventive care, and the dental care of patients has shown definite improvement. More patients received preventive care such as prophylaxis, radiographic examinations, and orthodontic and root canal treatment, while fewer received fillings, extractions, and dentures. “If the trends shown in this survey continue . . . the 70’s will be decisive years for dental health care in this country and for the realization of the prime goal of dental research, effective prevention of dental disease.” 15. Schonfeld, H. K. Periodontal diseases in association with unmet dental needs. Amer. J. Pub. Health 53, 923-3 1 (1963). The data presented in this report show that there is a very strong association between the amount of dental calculus and all forms of manifestations of periodontal disease. There certainly is no question that increases in both age and the unmet dental needs lead to increased periodontal disease. 16. Stahl, S. S. Host resistance and periodontal disease. J. Dent. Res. 49, 248-55 (1970). This article reviews the current knowledge on the relationship between host status and periodontal disease. It is thought that the condition of the host may, in some manner (especially by lowering local resistance), accelerate the initiation of, or accentuate present, inflammatory periodontal disease. Therefore, it is suggested that the investigations relating host status to periodontal disease be given significant priority. 17. Stookey, G. K., and Katz, S. Chairside procedures for using fluorides for preventing dental caries. Dent. Clin. N. Amer. 16, 681-92 (1972). The caries--preventive value of fluorides is universally recognized by the dental profession. The maximal degree of benefit in the fight against dental caries requires a four-stage, multiple fluoride-treatment program; therapy during the period of tooth formation; a semi-annual prophylaxis; a semi-annual topical application; and home use of ADA-accepted fluoride dentifrices. 18. Tank, G., and Storvick, C. A. Caries experience of children one to six years old in two Oregon communities: Corvallis and Albany: II. relation of fluoride to hypoplasia, malocclusion and gingivitis. J. Amer. Dent. Ass. 70, 100-104 (1965). Children of two Oregon communities participated in this study to investigate the effect of prenatal and postnatal fluoridation on the prevalence and incidence of gingivitis. Two hundred forty-six children aged l-6 participated in this study. The results showed that there was a higher prevalence
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of malocclusion in the fluoride-free area and a significantly higher prevalence and incidence of gingivitis in the fluoride-free area. There was also an observable correlation between these conditions and caries activity. 19. West, E. E. Treatment objectives in the deciduous dentition. Amer. J. Orthodont. 55, 617-32 (1969). The author states, “Early treatment of selected malocclusions in the deciduous dentition offers an opportunity to establish a normal relationship of the facial components with the hope that future growth will proceed in a normal, well-coordinated manner. Removal of the interferences and the restraints of an unsatisfactory dental environment is the best way we can help a patient reach his full genetic growth potential. Alteration of abnormal relationships at this age is possible and most desirable.” Acknowledgment The authors wish to thank Mr. Gary Beringer of the Columbia University School of Public Health for his help in compiling these references.
4, 328-372 (1975)
MEDICINE
Annotated Bibliography for Preventive Health Care Strategies for Health Maintenance Organizations’ PETER B. PEACOCK American
Health
Foundation.
New York, New York 10019
ANNA C. GELMAN Columbia
University
School of Public Health,
New York, New York 10032
AND
THEODORE A. LUTINS American
Health
Foundation,
New York, New York 10019
CONTENTS I. II. 111. IV.
Screening References Health Hazards References Health Education References Some Chronic Disease References A. Cancer of the Uterine Cervix B. Cancer of the Breast C. Glaucoma D. Obesity E. Coronary Artery Disease F. Chronic Obstructive Pulmonary Disease G. Peripheral Vascular Disease H. Hypertension I. Miscellaneous V. Prenatal Services References VI. Child Health References VII. Mental Health, Drug Abuse and Alcoholism VIII. Preventive Dentistry
I. SCREENING 1. Bernstein, J. M., and Dolan, L. J. Multiphasic
References
REFERENCES screening as part of family doctoring.
Practitioner
203, 798-805 (1969). The authors describe multiphasic screening in a two-man urban practice in Crumpsall, Manchester, England. Of the 402 women between 35-45 years of age offered the testing, cepted. Of these 170, 91 were found to be obese, 53 had blood pressure greater than 140/90, greater than 150/95. In only 25 cases of the 170 was further action felt to be needed. The distinguish between epidemiological screening surveys and case finding surveys. The general tioner is felt best to conduct case finding surveys. 1 This bibliography follows the “Special Report: Preventive Maintenance Organizations” published in Vol. IV, No. 2.
328 Cowrieht 0 1975 by Academic Press, Inc. AII rights of reproduction in any form reserved.
Health
Care Strategies
North 170 acand 18 authors practi-
for Health
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329
2. Bunow, M. A. Preliminary observations of ranges of blood profiles by ethnic groups based on test results of 21,000 California cannery workers. Ind. Med. Surg. 38, 424-28 (1969). The author presents a study of blood chemistry findings in cannery workers that embodies four ethnic groups (Negro, Oriental, Mexican-American, and other Caucasian), three age categories (less than 35, 35-49, more than or equal to SO),and represents 35 companies and 100 plants. In the 1967 program, over one-half of the population tested had one or more positive findings. In the 1968 series, approximately 4 1% of the examinees had such findings. There were significant variations in the percentage of normals in each group. The author suggests that this might cast doubt as to the value of the application of a single screening level to the total population and that it may be necessary to establish age-, sex-, and ethnic-specific screening levels for each blood chemistry test. 3. Chen, W., Palav, A., and Tricomi, V. Screening for diabetes in a prenatal clinic. Obsret. Gynecol. 40, 567-74 (1972). Subclinical or chemical diabetes is known to increase perinatal mortality. Therefore, screening patients for diabetes mellitus in a perinatal clinic is important, particularly in a municipal hospital where these visits are frequently the only occasions on which the indigent population receives adequate care. Over a 3-year period, 1968-70, 1269 of 8288 patients attending the prenatal clinic at BrooklynCumberland Medical Center were investigated for abnormal glucose tolerance because of obesity, family history of diabetes, previous birth of a large infant, poor obstetric history, or glucosuria. Ninety-one patients, or l.l%, of the total prenatal population were found to have an abnormal glucose tolerance. To determine the population at greatest risk, the significance of various indicators for screening were evaluated by statistical analysis. From the information derived, the detection of abnormal glucose tolerance rose exponentially with each additional screening indication. Thus, multiple indicators for screening in a given subject indicate that carbohydrate metabolism must be investigated immediately. 4. Collen, M. F. Diseases which can and should be detected early. Znd. Med. Sup. 39, 338-40 (1970). The author reviews definitions applicable to early disease detection and multiphasic screening. The author concludes that screening tests for cardiovascular disease, genitourinary disease, metabolic disease, thyroid disease, cancer, hematologic disease, venereal disease, and vision and hearing problems are adequate. However, better detection is needed for mental and psychological problems. 5. Collen, M. F., Dales, L. G., Friedman, G. D., Flagle, C. D., Feldman, R., and Siegelaub, A. B. Multiphasic checkup evaluation study: 4. preliminary cost-benefit analysis for middle-aged men. Prev. Med. 2, 236-46 (1973). Further report of “Muhiphasic Checkup Evaluation Study” as per Cutler et al. (1973), Ramcharan et al. (19’73), and Dales et al. (1973). A preliminary cost-benefit analysis for the program of Multiphasic Health Checkups has suggested a net savings of more than $800 per man over a 7-year period among men urged to take checkups as compared with men not so urged. This difference is reflected primarily in the lower disability and mortality rates observed for the men who were urged to receive checkups. Similar differences have not been demonstrated for women or younger men. 6. Craig, J. L., and Derryberry, 0. M. Applied concepts of automation in an occupational medical program. Ind. Med. Surg. 40, 9-17 (1971). The Tennessee Valley Authority has found that automation relieves the medical staff of time consuming medical and administrative tasks. It frees clerical personnel for other work and assists in maintaining accurate, dependable records. It aids in monitoring the health of employees and helps to detect needs in health services. Automation in the Tennessee Valley Authority health program falls into three major categories: (1) automation of medical records, (2) computer electrocardiography, and (3) automated centralized laboratory. 7. Cutler, J. L., Ramcharan, S., Feldman, R., Siegelaub, A. B., Campbell, B. A., Friedman, G. D., Dales, L. G., and Collen, M. F. Multiphasic checkup evaluation study: 1. methods and population. Prev. Med. 2, 197-206 (1973).
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The authors report on a controlled long-term study conducted among members of the Kaiser Health Plan to evaluate the efficacy of the periodic health examination, utilizing automated multiphasic health screening techniques. A representative sample of approximately 5,000 persons aged 35-54 was selected in 1964 and was urged to undergo annual examinations. The study design, population evaluated, and experience of the sample are described in detail. The mortality, morbidity, and disability of the population and their utilization of medical care are being compared to a similar group allowed to seek care on their own initiative within the same program. The population was relatively healthy and with little disability at the start of the study. About 65% of the group is examined each year, and 78% of the original group is still under surveillance after 7 years. 8. Dales, L. G., Friedman, G. D., Ramcharan, S., Siegelaub, A. B., Campbell, B. A., Feldman, R., and Collen, M. F. Multiphasic checkup evaluation study: 3. outpatient clinic utilization, hospitalization, and mortality experience after seven years. Prev. Med. 2, 22 1-35 (1973). This report continues to discuss the “Multiphasic Checkup Evaluation Study” as per Cutler er al. (1973) and Ramcharan et al. (I 973). This article describes the outpatient clinic utilization, hospitalization, and mortality experience of the study group subjects and the control group subjects. There has been little difference in utilization of outpatient physican and laboratory services other than those directly connected with the Multiphasic Health Checkups. However, the study group subjects have had more diagnoses made. Hospital usage in mates aged 45-54 has been slightly lower in the study group as contrasted with the opposite effect in women. The overall mortality rate has been slightly lower in the study group. For a group of causes of death defined as being potentially postponable or preventable, the mortality rate of the study group has been significantly lower. This is not accounted for by chance fluctuation, underreporting, differentially selective loss to follow-up, or an initial study-control group health status disparity. 9. Gitman, L. Automated multiphasic health screening: usefulness to the practicing physician. N. Y. State J. Med. 70, 1741-44 (1970). The author briefly reviews the history of single disease detection programs and automated multiphasic health testing programs. He cites the Kaiser and Brookdale facilities as the prototype for developing an organization to service a population of various socioeconomic statuses with no prepaid health insurance resources. Simply stated, the usefulness of AMHT to the practicing physician lies in its enhancing the effectiveness of the periodic health examination as a preventive health measure. The Brookdale concept is described, and the manner in which it provides a data base for evaluation by the physician is shown. Hopefully, this will increase the efficiency and effectiveness of the periodic health examination as performed by the physician. 10. Gordon, P. C. Screening for disease in hospital and clinic populations. Canad. J. Pub. Health 57, 249-59 (1966). The author presents several reasons why a profitable yield from screening procedures can be expected in hospital and clinic populations: (1) both hospital and clinic patients represent high-risk groups in which the prevalence of certain diseases can be expected to be higher than in the general population; (2) early detection procedures are now routinely applied on most hospital and clinic patients for some diseases; (3) the principles of early detection need no introduction to these facilities but rather a reemphasis; (4) hospital and clinic patients constitute “captive” populations to which tests may be applied without time-consuming and expensive promotional campaigns frequently required; (5) the laboratories and other testing facilities are available; (6) evaluation tests can be carried out more readily; and (7) the hospital milieu is conducive to the clinical and epidemiological research needed to assess the validity and preventive value of currently available detection techniques and to develop new and better methods. 11. Gordon, R. E. Psychiatric screening through multiphasic health testing. Amer. /. Psychiat. 128, 559-63 (1971). The author takes the position that psychiatrists have generally lagged behind the other specialties in exploring the usefulness of automated multiphasic health testing. The lack of a generally accepted, automated psychological screening device in contrast to those available to test blood chemistry, cardiology, spirometry, etc., probably accounts for this lack of interest. Certainly a number of psycho-
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logical instruments have been and are automated, e.g., the MMPI, but these are more diagnostic in nature and, thus, not suitable to the screening setting. The author discusses automated multiphasic health testing and its potential value to psychiatry. He describes the development and testing of instruments at the University of Florida, College of Medicine, Gainesville, Multiphasic Testing Center, for specific use in AMHT centers. 12. Thamer, M. A., Harvey, J. C., and Reed, J. W. Development of a multiphasic screening examination for medical care patients: III. yield of the multiphasic screening examination. J. Chronic Dis. 15, 849-56 (1962).
The authors deal with the development of a multiphasic screening type of examination for medical care patients at the Medical Care Clinic of the Johns Hopkins Hospital for clients receiving public welfare assistance. The first paper describes the overall program, a historical development of multiphasic screening examinations, and those used at the Johns Hopkins Medical Care Clinic. The second paper provides the details of the sensitivity and specificity determinations, presenting detailed computations. The third paper presents the results of the screening examinations on a representative sample of the 6,000 new clients seen at the clinic since 1955. 13. La Dou, J. Multiphasic health testing in the clinic setting. Calif. Med. 115, 34-37 (1971). The author takes the premise that the economy of automated multiphasic health testing activities patterned after the high-volume Kaiser program can be realized in low-volume settings. The factors that limit the participation of most physicians in programs of multiphasic health testing are (1) the cost of a large computer system, (2) the relative lack of medical centers capable of supporting patient flows that realize the economy of the concept, and (3) the peripheral part most physicians play in mass screening of persons whose testing was ordered by them. Through a grant from the Office of Economic Opportunity, multiphasic health testing was carried out in a six-doctor clinic on a pilot basis. Twenty patients per day were examined using a two-room area, a nurse, and a technologist. The most significant finding of this study was that a 94% follow-up rate was maintained in this setting, which was located in a borderline poverty population. Further experience with an industrial medical clinic specializing largely in preventive medicine demonstrated that by making the physician the center of a multiphasic testing program, a two-doctor industrial medical clinic can serve a 20,000employee industrial area with ease and efficiency. 14. Lenhard, R., Conwell, D., and Smith, H. Establishing a preventive medicine clinic in a public health service hospital. Pub. Health Rep. 80, 55 l-54, (1965). Public Health Service and Coast Guard personnel and their dependents, retired military personnel, and active merchant seamen, in apparent good health and at least 40 years old, were invited to participate in a multiphasic screening examination including a complete physical. Those needing follow-up were referred to the appropriate facility. The authors conclude that this approach revealed a number of unknown abnormalities, and that it was a profitable case-finding procedure in an apparently well population. 15. Lohrenz, F. N., and Wenzel, F. J. The periodic executive examination: comparison of major findings in patients under age fifty with those over age fifty. Ind. Med. Surg. 38, 3 14-l 6 (1969). Seventy male employees under age 50 of a paper manufacturing company were compared to 36 males over age 50 employed by the same company. They were examined annually over a 5-8 year period beginning in 1960. Twenty-five percent of those over 50 had a major diagnosis made at initial screening as compared to 14% in the group smaller than 50. Thirty-one percent of those over 50 had additional diagnoses made subsequent to the first examination as compared to 27% in those under 50. In both groups, 14% developed unpredicted diseases during the period of observation. These findings are compatible with the view that annual examinations in those over 50 should lead to the discovery of more significant, presumably preventable, disease than in those less than 50 years old. 16. Pike, L. A. Screening middle-aged men in a genera1 practice. Practitioner 209, 690-95 (1972). An account is given of a screening clinic for middle-aged men in a National Health Service general practice situation in North Birmingham, England. Of the 309 men invited for testing, 140 accepted
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(45.3%). By the use of a questionnaire, it was determined that 85 out of the 140 (60.5%) wished to discuss one or more problems. Obesity was identified in 44 (31%), anemia in 13 (9%), elevated blood pressure in 7 (5%), elevated serum cholesterol in 17 (12.1%), and diminished respiratory function in 26 (I 8.6%). Twelve of the 140 were referred to hospital clinics (8.3%), and 85 made one further visit to the practice center (58%). 17. Ramcharan, S., Cutler, J. L., Feldman, R., Siegelaub, A. B., Campbell, B. A., Friedman, G. D., Dales, L. G., and Cohen, M. F. Multiphasic checkup evaluation study: 2. disability and chronic disease after seven years of multiphasic health checkups. Prev. Med. 2, 207-20 (1973). This report continues the design set forth by J. L. Cutler et al. (1973) already discussed. Measures of disability, chronic disease, and utilization of medical services were obtained by a questionnaire mailed biennially to study and control subjects. After 5-7 years, a favorable impact on the health of the older study males compared to the older control males was evidenced by (1) a reduction in selfrated disability and reported time lost from work, (2) a greater proportion working, and (3) a lower self-reported utilization of medical services by the sick. The questionnaire is included. 18. Randolph, C. L., Jr. Value of routine X-ray examination of the abdomen during aeromedical evaluation. Aerosp. Med. 38, 307-9 (1967). Chest abnormalities are first discovered commonly by routine chest X-ray examination before the onset of symptoms or physical signs. The ability to detect asymptomatic disease is well recognized. The abdomen is seldom examined unless disease is suspected. Plain film examination of the abdomen for detection of silent pathologic conditions has potential similar to chest X-ray examination, according to the author. Roentgenograms of the abdomen were obtained on each of 2132 flying personnel undergoing aeromedical evaluation at the USAF School of Aerospace Medicine, Brooks Air Force Base, Texas. Included were 544 men being considered for space pilot selection and other special missions. The remainder were being examined to determine fitness for continued flying duties. Significant previously undiagnosed abnormalities were found in the routine chest films of 12 cases (0.5%) and on the abdominal films of 43 cases (2%). Twenty-nine cases of renal abnormalities were discovered, six of these among special missions candidates. Nearly 80% of the abnormalities were discovered in men more than 35 years old, although this age group comprised slightly less than one-half of the total number examined. The results indicate that abdominal films would have their greatest usefulness if employed during initial selection for flying training and at periodic intervals after age 35. 19. Scott, R., and Robertson, P. D. Multiple screening in general practice. Brit. Med. J. 2, 643-47 (1968). Female patients older than 15 years old were invited to take part in a multiple screening program. Of 2158 patients on the practice list, 358 were excluded from the survey. Of the remaining 1800 offered the examination, 43% accepted. The conditions found most frequently were anemia (6%), bacteriuria (4.6%) raised blood pressure (16%), obesity (30%), and hypercholesterolemia (19%). 20. Shenthal, J. E. Multiphasic screening of the well patient: twelve year experience of the Tulane University Cancer Detection Clinic. J. Amer. Med. Ass. 172, 1-9 (1960). The author reports on the operation of the Tulane University Cancer Detection Clinic. A major concern of this facility is with the status of the total well patient and whether asymptomatic conditions might be detected during initial or periodic examinations of such patients. Multiphasic examinations of 10,709 apparently healthy subjects showed that 92% had either organic or functional disease. Malignancy was detected in 77 (0.72%) and cardiopathy in 804 patients, with myocardial disease being the most frequent form (26.5%). The data indicate the importance of systematic health examinations and suggest ways of establishing a baseline of what to expect in various age groups. 21. Trevelyan, H. Study to evaluate the effects of multiphasic screening within general practice in Britain: design and method. Prev. Med. 2, 278-94 (1973). Trevelyan describes a control trial to evaluate the effect of screening in individuals 40-64 years old
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registered in two London general practices. Half were randomly allocated to the intervention or screening group; the rest acted as controls. The design consists of (1) multiphasic screening offered to the screening group at 2-year intervals, (2) a 5-year longitudinal survey of health service usage and sickness absence in both screened and control groups, and (3) a terminal survey, at the end of the 5 years, of both groups measuring the distribution of physical and socioecomic variables and the prevalence of certain symptoms and diseases and disability. No results are given in this paper, but they will be reported later. 22. Weston, A. B., and Fairley I. E. Sixty and up health centers: Vancouver’s first year of experience in geriatric screening and counseling. Can. J. Pub. Health 59, 389-92 (1968). The establishment of a sixty-and-up health center by the Vancouver city administration and the British Columbia Medical Assocation is reviewed. The unit was established as a pilot project to provide medical screening, health assessment, and counseling and referral services. The authors conclude that the extension of services provided by a city health department to include screening and health counseling for the elderly serves an important function by meeting the health needs of this age group. This project also points out the very real and unmet needs in communities, e.g., counseling and information for the elderly and their families as a concrete approach to education for the retirement years and, ultimately, the extension of screening to younger age groups to preclude the emotional and economic trauma to the individual and to the community that result from unrecognized chronic disease.
II. HEALTH HAZARDS REFERENCES 1. Anonymous. Safety chart for common solvents. PIant Eng. 27, 150-52 (1973). The safety chart includes information on the common chemical names of each solvent, boiling point in degrees Fahrenheit, explosive limits (lower and upper), auto-ignition temperature, vapor density, threshold limit value, and major health hazards. The fifty-four identified here are those most likely to be encountered. 2. Anonymous. Electrical safety in class hazardous locations. Nat. Suf. News 107, 59-61 (1973). Class 1 locations are subclassified into groups that designate various flammable gases and vapors. The methodology for controlling such hazards to electrical safety include intrinsically safe systems, explosion-proofing, purging, and inerting. 3. Anonymous. Building in environmental safety. Nat. Saf. News, 107, 90 (1973). The nation’s largest manufacturer of power generation equipment uses a system of fans and filters to clean and recirculate air as well as other antipollutant measures. 4. Anonymous. Pressure vessel dangers. Occup. Health Rev. 25, 182-83 (1973). The term “pressure vessels” includes steam boilers, air receivers, and all containers for liquids and gases at greater than atmospheric pressure. There are many dangers connected not only with their use but also their fabrication. An explanation of the hazards and a description of the detailed design codes is given. 5. Beckett, John C. Dynamics of fresh air: as seen from the view of ionization in a changing environment. Amer. Sot. Heat Refrig. Air-Cond, Eng. J. 1, 47-51 (1959). The author, a chief engineer for a manufacturer of a commercial air ionizer, states that one of the major differences between fresh and purified air is ionization. The sources of ionization are soil radioactivity, cosmic rays, solar radiation, etc. A beneficial effect of ionization on hay fever sufferers has been reported as well as effects on the adrenal gland, ciliary activity, mucus flow rate, etc. 6. Benfer, K. L. Air conditioning-blessing or curse? Pa. Med. 76, 55-58 (1973). Air-conditioning in its present form is a health hazard. Despite its important medical aspects, the profession has had no voice in developing guidelines. Six case histories are described indicating the adverse physiological effects that improper air-conditioning can have, and several recommendations are given.
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7. Burton, D. M. Taking good care of ground crew. Occup. Healrh Rev. 25, 97-102 (1973). The author examines how the introduction of new aircraft such as the Boeing 747 and the supersonic Concorde will affect the health, safety, and working environment of ground staff. Excluding toxic and physical hazards, the environmental factors most closely related to health, comfort. and working efficiency are the thermal, acoustic, and visual environments. 8. Carlson, L. D., et al. “Adaptive Changes During Exposure to Cold,” Proj. 22-1301-0002. Arctic Aeromed. Lab., Ladd AFB, Alaska, 1953. The purpose of this experiment was to demonstrate that readjustments in the peripheral circulation of the extremities cause an actual rise in the skin temperature during exposure to cold. 9. Edholm, 0. G. Tropical fatigue, in “Symposium of Fatigue” (W. Floyd and A. T. Weford, Eds.), pp. 19-20. H. K. Lewis Co., London, 1953. Excluding all tropical disease, prolonged stay in the tropics is often accompanied by physical and mental deterioration. Nearly all objective studies have found that there was an increase in lethargy, reduced mental concentration, retardation of mental alertness, lowered desire to assume responsibility and incentive, and disadvantageous personality changes and memory defects. 10. Freese, A. F. “Protecting Your Family From Accidental Poisoning,” Public Affairs Pamphlet #459. D.H.E.W., F.D.A. (N.D.) This 28-page pamphlet gives extensive information on protective measures for both children and adults against most household dangers. There are an estimated quarter of a million household products, many containing potentially poisonous chemicals, but half of all poisonings are due to only ten kinds of products: aspirin, insecticides, household bleach, detergents, soaps and cleaners, furniture polish, kerosene, iron and vitamin compounds, disinfectants and deodorizers, lye and corrosives, and laxatives. There are times of day that are peak poisoning periods, and very few storage areas that can be safely considered to be removed from a child’s reach. Suggestions are made for medicine containers and packaging for the manufacturers. 11. Hyuarineri, J., Pyykko, I., and Sundleerg, S. Vibration frequencies and amplitudes in the aetiology of traumatic vasospastic disease, Lancet 1, 791-94 (1973). Forty-three Finnish lumberjacks with a history of traumatic vasospastic disease (TVD) associated with the use of the chain saw were investigated. It was concluded that a likely mechanism for the symptoms found was a chronic overexcitation of the pacinean vibration receptors that produce spastic reactions in the vasculature through a reflex linkage with the sympathetic nervous system. 12. Industrial hygiene digest: asbestos as an industrial health hazard, Med. J. Aust. 1, 92 (1973). Asbestos has long been suspect as a cancer-producing agent. This is a report of a meeting attended by participants from twenty countries, organized jointly with the Inter-Agency for Research in Cancer and Pneumoconiosis Unit of the Medical Research Council of Great Britain. Various recommendations about future research into asbestos problems were made including (1) studies of cancer production by asbestos dust, (2) control and protection, (3) quantities that are hazardous, and (4) standardization of diagnostic criteria. 13. International Labor Office. “Encyclopedia of Occupational Health and Safety,” ~01s. I (A-K) and 11 (L-Z), 870 pp. International Labor Office, Geneva 1972. This new encyclopedia is not a scientific treatise; its aim is to make the knowledge now available more readily accessible to those directly responsible for promoting improved conditions for the worker. Its approach is practical, stress being laid throughout on risks and their prevention. 14. International Labor Office. “Guide to Safety and Health in Forestry Work.” 223 pp. International Labor Office, Geneva 1968. In this guide, forestry is taken to comprise all operations undertaken to establish or maintain forest, harvest wood, and transport wood when harvested. Power saws, tractors, motor trucks, cranes, and pesticides are being used increasingly with additional hazards. It is with the safety activities of the individual undertaking that this guide is mainly concerned.
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15. Manufacturing Chemists Association. “Guide for Safety in the Chemical Laboratory,” 2nd ed., 505 pp. Manufacturing Chemists Association, Washington, DC., 1972. This guide provides the essential information that enables the laboratory supervisor to develop a program for maintaining the health and safety of personnel within the field of his responsibility. It includes the Latest methods and equipment for protection of the workers and illustrates modern facilities and procedures. 16. McLean, A., and Clarke, A. C. W. V. Atomic safety. Occup. Health Rev. 25, 171-75 (1973). Types of radiation that can cause injury to the worker (and sometimes to the work) must be controlled. Control depends on the fact that all radiation can be detected and measured. It has been possible to reach a wide measure of international agreement on permissible levels of radiation. This article discusses practice and enforcement. 17. McConnell, W., Houghton, F. C., and Yaglou, C. P. Air motion-high temperatures and various humidities-reactions on human beings. Amer. Sot. Heat Vent. Eng. Trans. 30, 167-92 (1924). This study attempts to relate atmospheric conditions to physiological effects. This is a continuation of a previous study set forth in ASHVE Trans. 29 (654), 13 I-164 by the same authors to cover the effects of air motion. 18. Powell, P. “2000 Accidents, A Shop Floor Study of Their Causes.” 185 pp. National Institute of Industrial Psychology, London 1971. This report is about 2,367 accidents at work (minor and serious) that occurred in four different types of industrial workshops. The study discusses the way in which known facts can be applied usefully to the prevention of accidents in the industrial situation. 19. Schmidek, M., Henderson, T., and Margolis, B. Evaluation of proposed limits for intermittent noise exposures with temporary threshold shift as a criterion. Amer. fnd. Hyg. Ass. J. 33, 543-46 (1972). Standard limits for noise exposure have been proposed for coal mine operations. A key feature of the proposal is the provision to take account of intermittent exposure to noise. Specifically, limiting combinations of noise level, number of noise occurrences, and total daily exposure time are prescribed as safeguards against permanent hearing loss. The protection provided is reviewed, and it is suggested that the safety of the proposed limits is questionable. 20. Smith, D. C. Handling isocyanates safely. Occup. Health Rev. 25, 92-96 (1973). The use of plastics has increased in the motor industry as well as in general life. Their versatility and simple methods of manufacture and the complex forms that can be produced carry added hazards. Although potentially hazardous, isocyanates can be used safely with proper precautions.
III. HEALTH EDUCATION
REFERENCES
1. Adams, J. R. “Behind the Wheel: Self-Analysis in Driver Rehabilitation.” Cont. Research Inst., New York, N.Y., 1971. A regimen is proposed for aiding the problem driver in learning about his own state of mind and how it affects his driving. The process of learning how to learn (sometimes called mentor-Iearning) is in two phases: (1) the driver takes a guide sheet with him and carries out daily self-analysis of his driving performance, and (2) then he returns to a group where he discusses his observations. 2. Allen, W. A., MacFalls, D., and Mattucci, L. P. Getting the cancer message to the community. Int. J. Health Educ. 16, 61-68 (1973). In the second phase of a cancer education and service program in Philadelphia, it was decided to expand the ongoing program to the community through an educational program for community health workers. At the conclusion of the course, which included information on basic physiology, cancer causes, diagnosis, treatment, and major sites of cancer, an examination was given and diplomas awarded. Evaluation revealed that not only had the program made the community workers per-
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sonally more cognizant of cancer but had also motivated them to want to spread the cancer message among their peers. 3. Babioch, C. G. Attitudes and the use of food. J. Amer. Diet. Ass. 38, 546-5 1 (1961). The food therapist must adjust teaching techniques to cultural aspects of the individual. Suggestions for teaching about food include showing range of choice, avoidance of classifying food as a special group, and use of nonspecifics. 4. Blum, H. L. The multipurpose worker-a family specialist. Amer. J. Pub. Health 55, 367-76 (1965). The cost and cumbersomeness of many diverse professional workers’ trying to help families with their health problems calls for new solutions. The author suggests the use of generalists with some education, reinforced by intensive coordinated training by various specialists. Such multipurpose, moderately prepared workers with access to specialists have been successful thus far in other disciplines. 5. Christie, T. G. Educational effectiveness of health exhibits. J. Sch. Health 40, 206-9 (1970). Tests before and after a health exhibit lasting 2 weeks indicated that observation of the exhibits had been a learning experience as indicated by more correct answers to questions after the exhibits were removed. 6. Craig, D. G. Guiding the change process in people. J. Amer. Diet. Ass. 58, 22-25 (1971). People adopt new ideas by awareness, interest, evaluation, trial, and adaptation. Another means is through learning which involves attention, interest, confidence, desire, want, action, and satisfaction. People learn 85% through their eyes, 10% through their ears, and 5% through skin, tongue, and nose. They retain 10% of what they read, 50% of what they see and hear, and 90% of what they say while doing an activity. 7. Driver education and training: plans for evaluating the effectiveness of programs. (Prepared for the U.S. Dept. of Transportation, National Highway Safety Bureau, under contract #FH-1 l-6560.) The Center for Safety, New York University, 1968. A massive compilation of evaluations and recommendations of driver education and training programs is included. The following conclusions were reached: (1) no clear proof has as yet been produced showing that driver education, as presently constituted, has a significant favorable effect on driver performance: and (2) highway safety continues to be a major national problem in terms of human conservation and American economy. 8. Lair, C. V., and Moon, W., The effects of praise and reproof on the performance of middle age and older subjects. Aging Hum. Dev. 33, 279-84 (1972). The effect of praise, censure, and neutral comment on the performance of aged males are compared with results obtained from middle-aged men. 9. Manoff, Richard K. Potential uses of mass media in nutrition programs. Journal of Nutr. Educ. 5, 125-29 (1973). Mass media and advertising techniques could be forceful instruments in nutrition education. This article describes how persuasive techniques could be employed toward rapid change in attitude, habits, or practices. The author’s subheadings are Mass Media: An Untapped Force; Changing Food Habits; Changing Sanitation Habits; Changing Farmers’ Growing Practices; Changing Marketing Practices; and How to Use the Media. 10. McGuire, F. Smoking, driver education and other correlates of accidents among young males. J. Suf. Res. 4, (1) (1972). A sample of 2,961 airmen, aged 17 to 20, was administered a variety of tests and a biographical questionnaire, and the resultant variables related to accident frequency. Among the results were that (1) higher accident frequency is reported from higher socioeconomic levels, (2) high school driver
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education fails to demonstrate any relationship to accident frequency, and (3) current smoking habits show a significant relationship to accident frequency. Some smokers have several personality traits conducive to accidents; and smoking and the automobile are major sources of carbon monoxide. It is postulated that the higher accident rate among smokers may be partially the result of a significant oxygen deficiency and/or the possession of these personality traits. 11. Mills, E. R. Applying learning theory in teaching nutrition. J. Nutr. E&c. 4, 106-7 (1972). College students in a beginning nutrition class showed that an effective way to learn is to teach. Each student taught the principles of good food habits to another person. 12. Nesheim, R. 0. Industry response to the nutrition challenge. Food Technol. 25, 41-44 (197 1). This paper reports one food industry’s policy on the nutrient levels of its products and on labeling. Its policy is to promote nutrition education through advertising and labeling. It also provides special publications and progress notes for schools and women’s organizations, information to food editors, philanthropic organization grants, support for joint nutrition education endeavors of various kinds, and experimental educational television programming. 13. Osman, J. D. Nutrition education: too much, too little, or too bad? J. Sch. Health 42, 592-96 (1972). The author gives a number of practical suggestions on achieving ways to improve the quality of nutrition education. Six basic suggestions are (1) motivating the students through meaningful involvement, (2) reducing prior learning, which tends to interfere with present learning by the identification and elimination of nutrition misconceptions, (3) recognizing the importance of organization and information, (4) increasing “meaning value” of information taught, (5) limiting the quantity of information taught, and (6) using adequate repetition and appropriate reinforcement in memory recall. 14. Roth, R. E., and Helgerson, S. L. “A Review of Research Related to Environmental Education,” 56 pp. Eric Information Analysis Center for Science, Math and Environmental Education, Columbus, Ohio, 1972. The report identifies known research pertaining to environmental education, reviews critically the identified research, and identifies areas for further research. Studies selected include (1) attempts at objective evaluation of programs, outcomes, attitudes, and administrative procedures, and (2) works related to elementary and secondary school and college or adult levels of educational concern. The review is limited to research completed since 1950 with the exception of certain documents of historic value. The reviewers feel if environmental education is to be truly effective, it must emphasize the world-wide nature of the problems of philosophy, program development, evaluation of instructional material, selection of sites and situations appropriate to learning, and the outcomes of programs. The identified research did so but on a local regional and national basis, not on a universal basis. 15. “The Consumer and His Health Dollar” (One of a Series in Expanded Programs of Consumer Education), 80 pp. NYS Educ. Dept., Bureau of Secondary Educ. Curriculum Devel., Albany, 1972. This booklet is designed to supplement the comprehensive health series published by the New York State Education Dept. The booklet is constructed so that the reader can achieve the following objectives: be able to state major achievements and unsolved problems in the health field, know how to seek qualified medical care services, learn to eat wisely and avoid the use of unnecessary food supplements, develop a healthy skepticism about advertising claims for over-the-counter drugs, and become familiar with government programs for medical care service.
IV. SOME CHRONIC DISEASE REFERENCES A. Cancer of Uterine Cervix 1. Alexander, E. R. Possible etiologies of cancer of the cervix other than herpesvirus. Cancer Res. 33, 1485-90 (1973).
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The evidence linking smegma and lack of circumcision with cervical cancer is weak. Sperm DNA may be a mutagen in association with high risk periods of metaplasia. Infectious agents with an established association with cervical cancer are trichomonas, syphilis, gonorrhea, mycoplasma, chlamydial, cytomegaloviruses, and mycoplasma, but none is as likely a candidate for its cause as herpesvirus type 2. 2. Graham, S., Snell, L. M., Graham, J. B., and Ford, L. Social trauma in the epidemiology of cancer of the cervix. J. Chronic Dis. 24, 7 1i-25 (197 1). In a series comparing 447 cases of cervical cancer with 711 controls there was no relationship between life events that were objectively measureable and cancer of the cervix. 3. Kessler, I. I. Perspectives on the epidemiology of cervical cancer, with special references to the herpesvirus hypothesis. Cancer Res. 34, 109l-l 110 (1974). Recent data on mortality (a considerable decrease during 1950- 1969) and morbidity (an approximate doubling in incidence since 1950) are reviewed together with the findings from 13 of the largest cytological surveys for cervical neoplasia in the U.S. The relationship between cervical cancer and coitus, marital factors, penile factors, and the herpes viruses are collated. A large prospective study of the role of HSV-2 is proposed. 4. Thomas, D. B. An epidemiological study of carcinoma in situ and squamous displasia of the uterine cervix. Amer. J. Epidemiol. 98, lo-28 (1973). A comparison of 104 cases of carcinoma in situ and 105 cases of squamous dysplasia with controls from the same population showed the former to resemble invasive cervical cancer in epidemiological characteristics (trichomonas, marital instability, first child before marriage), while the latter resembled an inflammatory condition (trichomonas, vaginal discharge). 5. Wallace, D. L., and Slankard, J. E. Teenage cervical carcinoma in situ. Obstet. Gynecol. 41, 697-700 (1973). The 7520 teenage females who were screened yielded 12 cases of carcinoma in situ and 32 with cervical dysplasia. The screening of sexually active, lower-income teenage families is advised.
B. Cancer
of the Breast
1. Bulbrook, R. D. Endocrine, genetic and viral factors in the etiology of breast cancer. Proc. Roy, Sot. Med. 65, 646-48 (1972). The theory of Cole and MacMahon (q.v.) suggesting that oestriol inhibits the carcinogenic action of oestrone and oestradiol is compared with the author’s findings from Guernsey suggesting that precancer cases excrete significantly less androsterone and aetiocholanelone than do controls. The hormone may potentiate the transformation by viruses of normal breast cells into malignant ones. 2. Carroll, K. K., Gamma], E. B., and Plunkett, E. R. Dietary fat and mammary cancer. Can. Med. Ass. J. 98, 590-94 (1968). Animal experiments and epidemiological studies in humans provide evidence of a positive correlation between incidence of breast cancer and intake of dietary fat. 3. Dodge, 0. G., Jackson, A. W., and Muldal, S. Breast cancer and interstitial-cell tumor in a patient with Klinefelter’s syndrome. Cancer 24, 1027-32 (1969). The high incidence of breast cancer in men with Klinefelter’s syndrome is discussed, and an illustrative case, also showing interstitial cell tumor of the testis, is described. 4. Drasar, B. S., and Irving, D. Environmental factors and cancer of the colon and breast. Brit. J. Cancer 27, 167-72 (1973). Cancer of the breast and colon are shown to be highly correlated with fat and animal protein.
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5. Dunn, J. E. Epidemiology and possible identification of high-risk groups that could develop cancer of the breast. Cancer 23, 775-80 (1969). Women who have had a previous breast cancer, who are single or infertile, and who have a family history are at increased risk, but too many breast cancers occur among others to justify considering only the high-risk segment for screening. 6. Fraumeni, J. F., Lloyd, J. W., Smith, E. M., and Wagoner, J. K. Cancer mortality among nuns: role of marital status in etiology of neoplastic disease in women. J. Nat. Cancer Inst. 42, 455-68 (1969). Among 31,658 white Catholic nuns, cancer of the breast, corpus uteri, ovary, and large intestine showed an excess frequency, while cancer of the cervix was much less frequent when compared with the national white female population. 7. Hakama, M. The peculiar age-specific incidence curve for cancer of the breast-Clemmesen’s hook. Acta Pathol. Microbial. Stand. 75, 370-74 (1969). Age-specific incidence rates for the Nordic countries suggest that one component of breast cancer peaks about at 50 years of age, while another peaks much later. 8. Lemon, H. M. Genetic predisposition to carcinoma of the breast: multiple human genotype for estrogen 16 alpha hydroxylase activity in Caucasians. .I. Surg. Oncol. 4, 255-73 (1972). Among 655 Caucasian women, those with breast cancer had lower urinary ratios of estriobestrone + estradiol than age-matched controls. It is suggested this is due to a recessive allele reducing 16-hydroxylase which normally inactivates the polycyclic hydrocarbon carcinogens. 9. MacMahon, B., Cole, P., Brown, J. B., Aoki, K., Lin, T. M., Morgan, R. W., and Woo, N. C. Oestrogen profiles of Asian and North American women. Lancet 2, 900-2 (1971). In comparing 30 women from U.S. cities with high rates of breast cancer with 28 Asian women from low-incidence areas, the latter (especially in the age group 15-19 years) were found to have relatively more oestriol compared to oestrone and oestradiol. 10. MacMahon, G., Cole, P., and Brown, J. Etiology of human breast cancer: a review. J. Nat. Cancer Inst. 50, 21-42 (1973). This comprehensive review looks at possible endocrine factors (androgens, estrogens, prolactin, progesterone) and the better known major predictors of risk of breast cancer: residence, older age at first birth, certain indicators of ovarian activity (increase with early menarche and late menopause), history of benign breast disease, and a family history of breast cancer. 11. Sarker, N. H., and Moore, D. H. On the possibility of human breast cancer virus. Nature (London) 236, 103-6 (1972). Both B particles resembling the mouse breast cancer virus and C particles resembling leukemia-sarcoma viruses can be found in human milk with about the same proportion being found in women with and without a family history of breast cancer. 12. Strax, P., Venet, L., and Shapiro, S. Mass Screening in mammary cancer. Cancer 23, 875-78 (1969). Mammography enables breast cancer to be detected earlier, and these cases with less axillary nodal involvement can be expected to have a lower mortality rate. Without mammography, about 15% of cases of breast cancer would be missed on screening. Conversely, without clinical examination, more than 40% would be missed. 13. Wynder, E. L. Identification of women at high risk for breast cancer. Cancer 24, 1235-40 (1969). Only women with previous breast cancer and those with a family history require more surveillance for breast cancer than does the average woman.
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C. Glaucoma 1. Dallow, R. L., Adler A., Weihrer, A. L., Urweider, H. A., and Caceres, C. A. Amer. J. Ophthalmol. 70, 922-28 (I 970). Dallow et al. report on automated data acquisition and computer analysis systems developed for processing tonograms. Details of the technical aspects of the programming and processing are given. Tests using 36 selected tonograms showed good correlations between computer readings and those of two independent readers. 2. Lowe, R. F. Primary angle-closure glaucoma: problems of prevention. Trans. Ophthalmol. Sot. UK 90, 323-21 (1970). Primary angle-closure glaucoma remains a very destructive disease for eyes and vision. Most significant in terms of prevention is the recognition of the efficacy of prophylactic iridectomy on the fellow eye. At present, the possibility of preventing most attacks of acute glaucoma in the first eye appears remote. However, much less eye damage could result from quicker presentation, more accurate diagnosis, and more determined therapy. The prevention of benign intermittent attacks developing into destructive acute angle-closure glaucoma depends upon better education, not only of the general public, but also of the medical profession in general and ophthalmologists in particular. 3. Nesterov, A. P., Churbanova, E. K., and Kolotkova, A. 1. 1. Simplified bulbar pressure technique and biomicroscopal compression test. Acta Ophthalmol. (Kbh) 50, 633-40 (1972). Two new diagnostic techniques based on compression of the eye are described. The simplified bulbar pressure test proved to be useful for the early detection of chronic glaucoma. 4. O’Grady, R. 9. Glaucoma. Postgrad. Med. 51, 69-72 (1972). The anatomy, physiology, and pathology of glaucoma are discussed. The author concludes that it is well to remember that the vast majority of all cases of glaucoma, whether primary or secondary, can be detected by recording the intraocular pressure during routine physical examination. This simple measure, plus the knowledge that glaucoma is a definite hazard in long-term topical or systematic steroid therapy, can reduce the number of patients sustaining preventable vision loss. As long as the ultimate cause of glaucoma remains obscure, prevention is remote. Early diagnosis is the keystone to successful therapy. 5. Pereira, P. Screening for glaucoma. Nurs. Times 68, 77 1-74 (I 972). The value of trained ophthalmic nurses in the United Kingdom for screening of patients to diagnose unsuspected glaucoma is shown. 6. Rock, W. .I., Drance, S. M., and Morgan, R. W. A modification of the Arm&y visual field screening technique for glaucoma. Can. J. Ophthalmol. 6, 283-92 (197 1). The method of screening for granulomatous visual field defects proposed by M. F. Armaly [Ocular pressure and visual fields. Arch. Ophthalmol. (Chicago) 81, 25 (1969)] was evaluated in 109 normal people and 49 people with glaucomatous defects. The method was found to have a high sensitivity and a high specificity and, with modifications described in the paper, lends itself to clinical and survey screening. Methodology is described in detail by the authors. 7. Tyler, I. C. A glaucoma screening and study by nurses. Occup. Health Nun. (New York) 19, 1l-12 (1971). A survey by occupational health nurses employed by the Illinois Bell Telephone Company, Chicago, using the Schitz calibrated tonometer is described. Out of 630 individuals screened, 33 were found to have intraocular pressures of 20 mm Hg or greater and were referred to ophthalmologists. Six cases of unsuspected glaucoma were found.
D. Obesity 1. Allen, H. Public health aspects of obesity. J. Maine Med. Ass. 64, 105-6 (1973). After reviewing the definition, pathology, and treatment of obesity, the author indicates that the
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problem of obesity can be ameliorated by the complete cooperation of the patient with the medical profession. 2. Gordon, T., and Kannel, W. B. The effects of overweight on cardiovascular diseases. Geriatrics 28, 80-88 (1973). Gordon and Kannel report data from the Framingham Heart Study. Their conclusion is that while there is substantial excess risk of atherothrombotic brain infarction and congestive heart failure in proportion to the degree of overweight, no additional risk of intermittent claudication occurs in the obese.
3. Harper, P. Psychosomatic medicine: VIII. weight disorders. Practitioner 209, 244-50 (1972). Harper gives a brief overview of classification, clinical features, psychological factors, and management of anorexia nervosa and obesity. The author concludes that psychological factors play a part in the etiology and maintenance of obesity. These factors are more complex than had previously been thought. Any classification system must take note of this. Comprehensive approaches to therapy, with the application of both psychological and physical techniques in association with public education and lay group involvement, are still in their infancy. However, they constitute a necessary development for the future. 4. Seitzer, C. C., Stoudt, H. W., Bell, B., and Mayer J. Reliability of relative body weight as a criterion of obesity. Amer. J. Epidemiol. 92, 339-50 (1970). The competence of relative body weight ratio as an instrument for assessing obesity was investigated in a series of 1761 healthy U.S. Army veterans based on the association of relative body weight values and skinfold measurements. The authors conclude that unwarranted generalizations may result from the use of oversimplified relative body weight ratios as an index of obesity. 5. Sheppard, R. F., Kanero, M., and Ishii, K. Simple indices of obesity. J. Sports Med. Phys. Fitness 11, 154-61 (1971). Under laboratory conditions, simple indices-weight to height ratio, weight/height2 (Quetelet’s index), and height/weight1j3 (Ponderal index)-give less accurate prediction of body fat than measurement of skin fold thickness. 6. Sohar, E., and Sneh, E. Follow-up of obese patients: 14 years after a successful reducing diet. Amer. J. Clin. Nutr. 26, 845-48 (1973). Of 38 patients with varying degrees of obesity who successfully completed a rigorous dietary course in 1957, 27 patients were located and weighed in 1971. Only 5 succeeded in keeping their weight approximately 15% below their 1957 weight, although all 5 were still overweight. 7. Van ItaIlie, T. B., and Campbell, R. G. Multidisciplinary approach to the problem of obesity. 1. Amer. Diet. Ass. 61, 385-90 (1972). Because of the complex interrelationships between regulatory and metabolic factors that affect the energy balance, the etiology of obesity remains unclear. An eclectic approach that uses methodologies drawn from a variety of disciplines would appear to offer the best promise of a solution.
E. Coronary Artery Disease 1. Anderson, T. W., and Le Riche, W. H. Sudden death from ischemic heart disease in Ontario and its correlation with water hardness and other factors. Canad. Med. Ass. J. 105, 155~fjo (1971). In comparing two cities that differed widely in the hardness of their water supply, the proportion of sudden deaths was found to be 20-30% higher in the city using soft water. 2. Anderson, T. W., and Le Riche, W. H. Cold weather and myocardial infarction. Lancet 1, 291-96 (1970). The seasonal fluctuation in ischemic heart disease mortality with a winter excess is less in Ontario (with colder winters) than in England, which suggests that the fluctuation is due to respiratory disease rather than cold temperatures.
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3. Aronow, W. S. Smoking, carbon monoxide and coronary heart disease. Circulation 48, I 169-72 (1973). Cigarette smokers have an increased incidence of morbidity and mortality from coronary heart disease. The angina pectoris, which angina patients develop after exercise following cigarette smoking, is due to increased myocardial oxygen demand in the presence of nicotine and decreased oxygen delivery to the myocardium, which is due to the elevated carboxyhemoglobin level with a leftward shift in the oxyhemoglobin dissociation curve. A smoker who inhales and smokes a cigarette every 30 minutes increases his carboxyhemoglobin from 1.6 to 7.8% after eight cigarettes. In heavy freeway traffic with CO levels of 145 ppm, nonsmoking angina patients will increase their hemoglobin level to 5.1% in 90 minutes. 4. Astrup, P. Carbon monoxide, smoking and cardiovascular disease Circulation 48, 1167-68 (1973). When carbon monoxide-exposed rabbits are fed cholesterol for 8-10 weeks, the aortic content of cholesterol is increased 2.5-5 times. In primates the increase is in the intramural coronary arteries. not the aorta. In young smokers with myocardial infarction, high carboxyhemoglobin levels are usual. 5. Bastenie, P. A., Vanhaelst, L., and Neve, P. Coronary-artery disease in hypothyroidism. Lancet 2, 1221-22 (1967). Premyxoedema and coronary artery disease are related. In a necropsy study of 154 males and 91 females with myocardial infarcts and the same number of controls, 20% and 44% of the former had thyroid lymphocytic infiltrates as compared to 8% and 11% of the control groups. 6. Chakrabarti, R., Hocking. E. D., Fearnley, G. R., Mann, R. D., Attwell, T. N., and Jackson, D. Fibrinolytic activity and coronary artery disease. Lancet 1, 987-90 (1968). In comparing 107 male surviviors of myocardial infarction with 90 age-matched healthy controls, 32% of the former and 12% of the latter were found to have defective fibrinolysis. The difference was maximal in the age group 50-59 years (34 compared to 7%) and negligible after 60 years (11 compared to 8%). 7. Cornfield, J., and Mitchell, S. Selected risk factors in coronary disease: possible intervention effects. Arch. Environ. Healfh 19, 382-94 (1969). Eighteen studies directed at lowering serum cholesterol are summarized. No clear-cut answer emerges. It was noted that at Framingham a 12% difference in cholesterol was associated with a 20-25% high incidence of coronary heart disease at 45 years and older. A difference of this size, even if it could be achieved, could easily be obscured. The authors suggest a larger sized study with adequate randomization (not matching) and counting in of dropouts. 8. Doll, R., and Hill, A. B. Mortality in relation to smoking: ten years’ observations of British doctors. hit. Med. J. 1, 1399-1410, 1460-1467 (1964). A IO-year follow-up on 40,637 physicians on whom baseline smoking data were obtained showed 30% of all deaths (1,376 out of 4,597) to be attributed to coronary disease. Cigarette smokers had 33% more mortality than nonsmokers, and heavy smokers 14% more than light smokers. No excess was observed for pipe or cigar smokers. The difference is greater at younger ages. A reduction in mortality takes place when smoking is stopped, with the excess reduced to 60% after 5-9 years. 9. Doyle, J. T., Dawber, T. R., Kannel, W. B., Kinch, S. H., and Kahn, H. A. The relationship of cigarette smoking to coronary heart disease: the second report of the combined experience of the Albany, N.Y. and Framingham, Mass. studies. J. Amer. Med. Ass. 190, 886-90 (1964). When combining data from 2,282 middle-aged men followed for 10 years in Framingham and 1,838 middle-aged men followed for 8 years in Albany, it was found that one-pack-or-more-a-day cigarette smokers had about three times the risk of developing a myocardial infarction found in nonsmokers, exsmokers, or pipe and cigar smokers.
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10. Fox, S. M., and Naughton, J. P. Physical activity and the prevention of coronary heart disease. Prev. Med. 1, 92-120 (1972). Most studies demonstrate a moderate reduction in coronary heart disease associated with increased physical activity. Activity programs taking the pulse rate up lo-15 beats below the appropriate stress-test level with enough intensity to produce perspiration are reasonable. Activities should be rewarding and fun so as to improve the quality of life. It is possible that the physical acitivity itself is more important than the fitness achieved. 11. Frederickson, D. S. Mutants, hyperlipoproteinemia and coronary artery disease. Brit. Med. J. 2, 187-92 (1971). The Intersociety Commision for Heart Disease Resources (1970) has recommended that Americans eat less than 300 mg of cholesterol each day and that not more than 30% of total calories come from fat equally divided between saturated, monounsaturated, and polyunsaturated. Since this is a contentious diet of still unproven value the author suggests that patients with severe hyperlipoproteinemia (in the upper 5% of normal distribution) might offer the proof needed for extension to their less susceptible but still vulnerable fellows. 12. Golubjatnikov, R., Paskey, T., and Inhorn, S. L. Serum cholesterol levels of Mexican and Wisconsin school children. Amer. J. Epidemiol. 96, 36-39 (1972). Mean cholesterol levels of random samples of 209 Mexican children and 328 Wisconsin children aged 5-14 years were 99.9 and 186.5 mg/lOO ml, with these levels apparently being established by the age of 5 years. 13. Hammond, E. C., and Garlurkel, L. Coronary heart disease, stroke and aortic aneurysm. Factors in the etiology. Arch. Environ. Health 19, 167-82 (1969). A prospective study of 804,409 subjects aged 40-79 years who were recruited by the American Cancer Society and who were followed for 6 years showed an increased death rate from coronary heart disease among males (8.2 to 1 in the 40-49 year group), among older persons, among persons with high blood pressure and diabetes (MR’s of 2.8 and 2.6 for those aged 40-49), among persons with a greater relative weight (MR = 2.25 for men aged 40-49 with a relative weight of 120+), among persons who take no exercise, among cigarette smokers, and among persons who slept 10 hours a night (compared with lower levels), but not among persons who reported being under nervous tension. 14. Heyden, S., Cassell, J. C., Bartel, A., Tyroler, H. A., Hames, C. G., and Cornoni, J. C. Body weight and cigarette smoking as risk factors. Arch. Intern. Med. 128, 915-42 (1971). Among whites in Evans County, smokers ran a much higher risk than nonsmokers (53 compared to lO/lOOO) of developing coronary heart disease, and this risk increased with increase in overweight (not noted among nonsmokers). Among blacks, the rates were lower, but cigarette smoking and overweight were also important risk factors. 15. Hollander, W. Hypertension, antihypertensive drugs and atherosclerosis. Circulation 48, 1112-27(1973). This article presents an adequate brief review of our present state of knowledge concerning the probable pathogenesis of the atheromatous fibrous plaque. Hypertension aggravates and accelerates atherosclerosis, but it is questionable whether it can initiate atherosclerosis. The effects of hypertension are partly mechanical, with the effects of the catecholamine, renin, angiotensin, and the prostaglandins associated with hypertension being questionable. Myocardial oxygen demand is increased. Most investigations have failed to demonstrate significance of antihypertensive treatment on ischemic heart disease. The author was unable to confirm the suggestion of Brunner et al. (1972) that plasma renin was an important coronary disease risk factor in hypertensive patients (note that propanolol and alpha methyl dopa inhibit renin, while diuretics and hydralazine stimulate renin). The diuretics produce an increase in plasma renin and catecholamines (also produced by a low salt diet), with hyperglycemia, hyperuricemia, and gouty arthritis being known side effects.
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16. Hrubec, Z., and Zukel, W. J. Epidemiology of coronary heart disease among young army males of World War II. Amer. Heart J. 87, 722-30 (1974). Some 1,393 confirmed First Army hospital admissions for coronary heart disease in World War 11 were given matched controls on age, service dates, and (for some) race. An increased relative risk was associated with marriage at induction, graduate education, officer rank, the Jewish religion, a heavy frame, and blood group A, with a reduced risk associated with a rural birthplace and an occupation requiring physical activity. An increased blood pressure and weight and a shorter height were also risk factors. 17. Ibrahim, M. A., Pinsky, W., Koh, R. M., Binette, P. J., and Winkelstein, W. Coronary heart disease: screening by familial aggregation: pilot study. Arch. Environ. Health 16, 235-40 (1968). Positive correlations were found between 92 high school students and their parents for cholesterol, systolic blood pressure, and ponderal index. Students with high-risk-factor combinations “predicted” all the parents with ST and T abnormalities on the ECG. 18. Jenkins, C. D., Rosenman, R. H., and Zyzanski, S. J. Prediction of clinical coronary heart disease by a test for the coronary-prone behavior pattern. N. Engl. J. Med. 290, 1271-75 (I 974).
The coronary prone behavior pattern (type A) is characterized by excess competitiveness, striving for achievement, aggressiveness, time urgency, accelerated activity, restlessness, hostility, hyperalertness, and explosiveness of speech. A paper-and-pencil questionnaire (the Jenkins Activity Survey) scored by a computer was developed to identify type A, and test-retest scores between 1965 and 1969 showed that 90% of persons had less than 10 points difference over this period. In 1965 2,750 persons were typed. Over a 4-year period high scorers had significantly more new coronary heart disease than did low scorers. 19. Kannel, W. B., Dawber, T. R., Friedman, G. D., Glennon, W. E., and McNamara, P. M. Risk factors in coronary heart disease: an evaluation of several serum lipids as predictors of coronary heart disease: the Framingham study. Ann. Intern. Med. 61, 888-99 (1964). A study group of 2,282 men (1,975 from a random sample of 3,074 and 3 12 volunteers) and 2,845 women (2,418 from a random sample of 3,433 and 427 volunteers) free of coronary heart disease and aged 30-60 years was constituted in 1949 and reexamined every 2 years. At 6 years only 0.7% had been completely lost to follow-up, outside information was available on 17.1%, 4.5% had died (data known), and 77.7% were examined. Identified risk factors were serum cholesterol, blood pressure, cigarette smoking, vital capacity (low), relative weight (high), and certain ECG findings. Of the lipids examined, including phospholipids and the various beta-lipoproten fractions, serum cholesterol made the most significant contribution, with no “critical” or “safe” level being apparent. 20. Kannel, W. B., Castelli, W. P., and McNamara, P. M. The coronary profile; 12 year follow-up in the Framingham study. J. Occup. Med. 9, 611-19 (1967). It is possible to identify persons who are prime candidates for a “heart attack.” Note that in 10 years, one in ten men and one in 20 women aged 30-60 years at start developed coronary heart disease. One in four attacks were silent, but of those one in three recurred within 5 years with a 50% death rate. The profile of the prime candidate was a sedentary, flabby middle-aged man or elderly female who used excess cigarettes, foods rich in saturated fat and cholesterol, had a high blood pressure but a low vital capacity, and did little physical activity and whose family history included diabetes, gout, and lipemia as well as coronary heart disease. 21. Keys, A., Arvanis, C., Blackburn, H., Van Buchem, F. S. P., Buzina, R., Djorjevic, B. S., Fidanza, F., Karvonen, M. J., Menotti, A., Puddu, V., and Taylor, H. L. Probability of middle-aged men developing coronary heart disease in five years. Circulation 45, 815-28 (1972).
Some 2,404 U.S. railroad men and 8,728 European men aged 40-59 years and free of coronary disease at entry were followed for 5 years, during which time there were 615 cases of coronary heart
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disease. A multiple logistic equation using age, systolic blood pressure, serum cholesterol, the smoking habit, and body mass index served as a good predictor of risk (y = 0.94) for another U.S. railroad population of 6,221 men aged 40-59 years. 22. Leren, P. The effect of plasma cholesterol lowering diet on male survivors of myocardial infarction. Acta Med. Stand. Suppl. 466 5, 92 (1966). Some 412 males aged 30-64 years discharged from Oslo hospitals in 1956-58 with a first diagnosis of myocardial infarction were randomized into two groups, with the diet group getting 264-mg cholesterol daily and 39% of calories from fat (total caloric intake 2,387) with 52% of this polyunsaturated and 26% saturated. Of the dieters 62% were excellent adherers over 5 years. From a mean starting cholesterol of 296 mg/lOO ml the dieters averaged a 17.6% reduction as compared to 3.7% in the controls. The diet group had 43 infarctions in 54 patients with 23 deaths. The incidence of sudden death in the two groups (27) was the same. The difference in relapse rate was only below the age of 60 years.
23. Medalie, J. H., Kahn, H. A., Neufeld, H. N., Riss, E., Goldbourt, V., Perlstein, T., and Oron, D. Myocardial infarction over a five-year period I. Prevalence, incidence and mortality experience. 1. Chronic Dis. 26, 63-84 (1973). In Israel 10,059 male government and municipal employees aged 40 and over were followed from 1963 to 1968, with 98% of the original respondents participating in the final examination. The age-adjusted myocardial infaction rate of 8.7/1000 was high, but the proportion that was silent (40%) was also high and the case fatality rate (16%) was low. Israelis from central and eastern Europe had the highest prevalence and incidence rates, and those from North Africa and the Middle East the lowest. 24. Miettinen, M., Turpeinen, O., Karvonen, M. J., Elosuo, R., and Paavilainen, E. Effects of cholesterol-lowering diet on mortality from coronary heart disease and other causes: a twelve year clinical trial in men and women. Lance1 2, 835-38 (1972). From 1959 to 1965, hospital N used a cholesterol lowering diet on its patients, and from 1965 to 1971 hospital K (previously the control hospital) used the experimental diet (P/S ratio greater than 1.5). Cholesterol levels followed the diets, changing from 217 in period 1 for males in N to 266 in period 2, while for K the corresponding levels were 268 and 234. In both hospitals death rates from CHD were lower in the diet period as were deaths from all causes (in hospital K only after age adjustment), the reduction in CHD being about one-half. 25. Morris, J. N., Chave, S. P. W., Adam C., Sirey, C., Epstein, L., and Sheehan, D. J. Vigorous exercise in leisure-time and the incidence of coronary heart-disease. Lancet 1, 333-39 (1973). Among 16,882 male office workers aged 40-64 who recorded their Friday and Saturday activities for baseline, 232 have, since 1968-70, suffered their tirst clinical attack of coronary heart disease. When each case was matched with two controls it was found that 11% of cases and 26% of controls had reported vigorous activity (swimming, keep-fit exercises, digging, much stair climbing, tennis, hill climbing, running, cycling, etc.) with estimated peak energy outputs of 7.5 kcal/min. Lighter exercise had no such advantage. 26. Paffenbarger, R. S., Wolf, P. A., Notkin, J., and Thorne, M. C. Chronic disease in former college students: 1. early precursors of fatal coronary heart disease. Amer. J. Euidemioi. 83, 3 14-28 (1966). In this study 325 former male students at the University of Pennsylvania or Harvard who were known to have died from coronary heart disease were each paired with two classmate controls who were still alive. Precursors of death were found to be heavy cigarette smoking, high blood pressure, excess weight, short stature, nonparticipation in athletics, early parental death, one-child status, and sociopsychological exhaustion. 27. Pinckney, E. R. Editorial: the potential toxicity of excessive polyunsaturates: do not let the patient harm himself. Amer. Heart J. 85, 723-26 (1973). The author finds no scientific evidence that eating polyunsaturated fatty acids will reduce coronary
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heart disease morbidity or mortality. Polyunsaturates may be linked with cancer (especially gastric). A skin study showed that of persons who forced polyunsaturates, 78% showed clinical signs of premature aging and 60% had had a suspect malignant skin tumor removed as compared to 18% and 8% among a group that made no effort to eat polyunsaturates. 28. Roseman, R. H., Friedman, M., Jenkins, D. Straus, R., Wurm, M., and Kositchek, R. The prediction of immunity to coronary artery disease. J. Amer. Med. Ass. 198, 1159-62 (1966). Among 2,998 normotensive men aged 39-59 years and followed 4 l/2 years, it was found that those with the fully developed B behavior pattern who also had a cholesterol less than 226 mg/lOO ml, a triglyceride less than 126 mg/lOO ml, or a /3/a lipoprotein ratio less than 2.01 were essentially immune to the development of clinical coronary disease. 29. Spain, D. M., and Bradess, V. A. Sudden death from coronary heart disease: survival time, frequency of thrombi and cigarette smoking. Chest 58, 107-l 0 (1970). About 25% of all deaths from acute myocardial ischemia are “sudden” and occur within 1 hour of onset of the attack. The frequency of recent coronary thrombi found at autopsy increased from 18% among persons dying within 1 hour to 36% among those dying in l-8 hours to 57% among those dying in more than 8 hours. The heavy smokers (more than one pack) in the group were mostly in the short-survival group with few recent thrombi. 30. Stitt, F. W., Clayton, D. G., Crawford, M. D., and Morris, J. N. Clinical and biochemical indicators of cardiovascular disease among men living in hard and soft water areas. Lancet 1, 122-26 (1973). When 244 civil servants from six hard-water towns were compared to 245 from six soft-water towns, the mean values for blood pressure, cholesterol, and heart rate were higher in the soft-water group. These differences could account for much of the reduced mortality found in hard-water areas as compared to soft-water areas. 31. Syme, S. L., Borhani, N. O., and Buechely, R. W. Cultural mobility and coronary heart disease in an urban area. Amer. J. Epidemiol. 82, 334-46 (1966). Medically verified coronary disease in 80 cases among white males aged 45-64 years were compared to 80 matched controls. The former contained more children of native-born fathers, more men of foreign-born parents who had themselves gone to college, and more men who had held three or more jobs (especially for short periods). These sociocultural factors were independent of parental longevity, cigarette smoking, relative weight, and physical activity.
F. Chronic
Obstructive
Pulmonary
Disease
I. Baker, T. R., Oscherwitz, M., Corlin, R., Jarboe, T., Teisch, J., and Nichaman, M. Z. Screening and treatment program for mild chronic obstructive pulmonary disease. J. Amer. Med. Ass. 214, 1448-55 (1970). According to the Eighth Aspen Emphysema Conference, Public Health Service Publication 1457 (1966), COPD comprises overlapping types of generalized bronchopulmonary disease including chronic bronchitis, pulmonary emphysema, and bronchial asthma. It affects 5-10 million Americans and causes some 30,000 deaths each year in the U.S. The 5-year survival in severe cases (FEV, less than 1.5 liters) is about 50%, and treatment is of little value at this stage and should start earlier. A population of 750 men screened for COPD (a history of cough and phlegm for 3 months each year and/or an FEV, less than 70%) yielded 252 patients. After dropouts, reconfirmation, and exclusion of other illness, 134 were left and treated with bronchodilator drugs, smoking cessation, and increased fluid intake. Of these 85% were smokers and 11% exsmokers, 36% had chronic bronchitis (history of cough, etc., only), 28% had obstructive lung disease (abnormal FEV only), and 36% were mixed (both factors present). Physical findings and X-ray findings were correlated with this grouping, but forced vital capacity (FVC) was not. ECGs were generally normal. There were 61 men under treatment at 6 months and 25 men at 1 year. Of the 61, 50 were cigarette smokers and 17 stopped. Twenty-nine had fewer symptoms, but the FEV was unchanged. The drugs used (theophylline, ephedrine, phenobarbital) had many unwanted side effects.
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2. Biersteker, K. Air pollution and smoking as causes of bronchitis among 1000 male municipal employees in Rotterdam, Netherlands. Arch. Environ. He&h 18, 531-35 (1969). In comparing 1957 to 1966, deaths from chronic bronchitis and emphysema in Rotterdam among males were found to have increased from 67 to 117 and from 10 to 76, which cannot be accounted for by changes in the population at risk. A study of municipal employees comparing 168 males with symptoms to the same number of symptomless controls showed a clear effect of smoking but no obvious relationship to air pollution. 3. Burrows, B., and Earle, R. H. Course and prognosis of obstructive lung disease. N. Engl. J. Med. 280, 397-404 (1969). The 200 patients followed for 4-8 years showed that the best indicators of prognosis were ventilatory capacity, resting heart rate, and carbon dioxide levels. Yearly changes were usually small. 4. Da Costa, J. L. Chronic obstructive lung disease (COLD): a comparison between men and women. Singapore Med. J. 13, 74-78 (1972). A comparison between 70 men and 13 women showed similar ages at onset for cough and dysnea; similar records for asthma, chest infection, and edema; and similar findings on physical and ECG examination. More women had “pure” emphysema on X-ray that was not related to smoking and was presumably genetically induced. 5. Holland, W. W., and Reid, D. D. The urban factor in chronic bronchitis. Lancer 1, 445-48 (1965). A comparison of 293 post office employees in London with 477 similar employees in three country towns showed the former, even after allowing for the effect of cigarette smoking, to have more respiratory symptoms and sputum production and lower lung function levels. Differences in air pollution seemed to be the most likely cause of the differences. 6. Holland, W. W., Halil, T., Bennett, A. E., and Elliott, A. Factors influencing the onset of chronic respiratory disease. Brit. Med. J. 2, 205-8 (1969). In Kent, 10,97 1 children had levels of peak expiratory flow influenced independently by area of residence, social class, family size, and a past history of pneumonia, bronchitis, or asthma. It is suggested that environmental factors from early life can influence the development of chronic respiratory disease later. 7. Kanner, R. E., Klauber, M. R., Watanabe, S., Renzetti, A. D., and Bigler, A. Pathologic patterns of chronic obstructive pulmonary disease in patients with normal and deficient levels of alpha 1 antitrypsin. Amer. J. Med. 54, 706-12 (1973). The 29 patients with COPD were divided by AAT phenotyping or trypsin inhibitory capacity (TIC) into homozygous ZZ (six patients), heterozygous MS, MS or SZ (ten patients), and homozygous normal MM (13 patients). Spirometry and regional ventilation and perfusion tests with xenon 133 clearly distinguished the three groups. It was concluded that heterozygosity for AAT is an important factor in the development of COPD. 8. Mittman, C., Babela, T., and Lieberman, J. Alpha 1 antitrypsin deficiency as an indicator of susceptibility to pulmonary disease. J. Occup. Med. 15, 33-38 (1973). More than 20 AAT types have been described. Type ZZ is rare (perhaps I/ 1,000) and clearly related to COPD. Other abnormal phenotypes (MZ, MS, SS, etc.) occur in up to 10% of normal people. This latter group develops overt disease later in life and after more intense and prolonged exposure to cigarette smoke and other environmental irritants. A study of 170 patients with COPD compared to a healthy Norwegian population showed the ratio of observed to expected (rates are per 1,000) to be for MM 760/895, for MZ 113/29, for MS 53/41, for SS 1l/l, and for ZZ 40/l. Trypsin inhibitory capacity (TIC) values for these phenotypes were 0.81-1.80, 0.55-1.50, 0.65-1.30, 0.55-0.75, and 0.15-0.25, respectively. Since COPD in AAT deficiency is the result of the interaction of genetic and environmental factors, it is potentially preventable.
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9. Reid, D. D., Anderson, D. O., Ferris, B. G., and Fletcher, C. M. The Anglo-American comparison of the prevalence of bronchitis. Brit. Med. J. 2, 1487-9 1 (1964). By using similar respiratory-symptom questionnaires and the Wright peak flow meter, the prevalence of simple bronchitis was found to be similar in Britain and the U.S. and clearly related to cigarette smoking. However, “complex” bronchitis, with repeated chest illnesses and breathlessness, was more frequent among older males living in British urban conditions. 10. Selikoff, I. J., and Hammond, E. C., III. Community effects of nonoccupational environmental asbestos exposure. Amer. J. Pub. Health 58, 1658-66 (I 968). Specific stigmata of environmental asbestos exposure are pleural calcification (found in 499 of 6,3 12 adults in a heavily exposed village in Finland), pleural plaques (to a lesser extent), pleural mesothelioma, and (of little pathological meaning) asbestos bodies. Peritonial mesothelioma has also been related. An investigation of 76 mesothehomas in London (Newhouse and Thompson, 1965) showed 3 1 of these to be in asbestos workers and 20 to be from persons living within l/2 mile of an asbestos factory or in the household of an asbestos worker. The relationship between asbestos exposure and cigarette smoking is important-of 370 asbestos workers followed for 20 years, none of the 87 nonsmokers developed lung cancer as compared to 24 of the 283 cigarette smokers. 11. Sultz, H. A., Feldman, J. G., Schlesinger, E. R., and Mosher, W. E. An effect of continued exposure to air pollution on the incidence of chronic childhood allergic disease. Amer. J. Pub. Health 60, 891-900 (1970). A study in Erie County showed that hospitalization rates for asthma or eczema in males under the age of 5 years rose steadily within each social class with increasing levels of air pollution.
G. Peripheral Vascular Disease 1. Berry, L. F., and Lichti, E. L. The Doppler ultrasonic flowmeter: report of its use for diagnosis of peripheral vascular disease in the smaller community hospital. Ohio State Med. J. 69, 23-26 (1973). The Doppler ultrasonic flowmeter can be highly useful in the smaller community hospital as an aid to preliminary diagnosis. It represents a practical, relatively inexpensive, atraumatic, transcutaneous method of evaluating peripheral arterial or venuous flow in the hospital or office. 2. McLaughlin, G. A. Thermography in diagnosis of vascular disease of lower limb. Proc. Roy. Sot. Med. 65, 170 (1972). This is an abstract of a paper presented at a meeting of the Section of Surgery Royal Society of Medicine on June 4, 197 1, in Liverpool. Assessment of the diagnostic accuracy of thermography in lower limb arterial disease was made by comparing the arteriographic appearances and thermograms of 28 patients for localization of arterial block and estimation of “peripheral runoff.” Positive correlation was found in only 50% of these cases. Factors limiting accuracy were thickness of subcutaneous fat, greater than 2.8 cm; localized disease with good collateral circulation; and coincident venous disease. If such cases were excluded, the accuracy rose to over 80%. 3. Patman, R. D., and Thompson, J. E. Peripheral vascular disease in the geriatric age group. Tex. Med. 67, 88-93 (1971). The problems of peripheral arteriosclerosis are considered with particular emphasis on atherosclerotic occlusive disease of the lower extremities, aneurysm formation, and cerebrovascular insufficiency. The authors conclude that the major problems of peripheral vascular most commonly seen in practice can be reduced or even avoided provided that the condition is recognized early and treated properly. 4. Soulen, R. L., Lapayowker, M. S., Tyson, R. R., and Korangy, A. A. Angiography, ultrasound, and thermography in the study of peripheral vascular disease. Radiology 105, 115- 19 (1972). This describes a study of angiography, ultrasonography, and thermography that included I66 patients with suspected thrombophlebitis and 300 patients with peripheral arterial disease. It showed that thermography aids in recognizing phlebitis and assessing postoperative, but not preoperative,
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arterial disease. Although Doppler ultrasound cannot reliably detect thrombophlebitis, it permits highly accurate monitoring of peripheral arterial flow and is very helpful in programming arteriography and follow-up after arterial surgery. Both noninvasive techniques are well-suited for serial studies of peripheral vascular disease. 5. Wooling, K. R., and Schechter, J. S. Some instrumental techniques in the clinical study of peripheral vascular disease. J. Zndiana Stare Med. Ass. 65, 407-18 (1972). The study of the peripheral vascular system by mercury strain gauge plethysmography, ultrasonic velocity flow detection, and skin thermography provides information that complements that obtained by history, physical examination, and angiography. By these methods, a vascular profile can be deduced. Noninvasive techniques, which are essentially painless, harmless, and can be repeated as often as desired, are utilized. The authors indicate that these methods have been of greatest use and value in the diagnosis of peripheral occlusive arterial disease.
H. Hypertension 1. Boyle, E. Biological patterns in hypertension by race, sex, body weight and skin color. J. Amer. Med. Ass. 213, 1637-43 (1970). A study of 2,184 residents of Charleston County, South Carolina, showed a high prevalence of hypertension among Charleston Negroes (10% with diastolic over 100 mm in men aged 35-44 years), with no correlation in this group between obesity and hypertension, and a positive correlation between skin pigmentation and hypertension among Negroes, with darker Negroes having a high prevalence (50%) of group B blood type. 2. Cheitlin, M. D. The physician and hypertension. J. Amer. Med. Ass. 228, 1249-50 (1974). A survey by Harris Associates of 3,18 1 individuals, 17 years or older, from 200 locations in the U.S. revealed that 67% (74% for blacks) had had a physical checkup in the last year and 92% (94% for blacks) in the last 5 years, with most having their blood pressure taken. Of these people 75% did not know what “hypertension” meant, 40% thought worry the main cause (very few thought of heart disease and kidney disease as complications), and 50% or more thought symptoms were always present. Stopping medication for hypertension was usually on doctor’s advice. 3. Clark, V. A., Chapman, J. M., and Coulson, A. H. Effects of various factors on systolic and diastolic blood pressure in the Los Angeles heart study. J. Chronic Dis. 20, 57 l-81 (1967). Higher systolic blood pressures were found in 1962 than in 1950 among similar age groups. Time of day, smoking (nonsmokers were higher), alcohol use (users higher), and salt (salt adders lower) made small, insignificant differences. 4. Dustan, H. P., Tarazi, R. C., and Frohlich, E. D. Functional correlates of plasma renin activity in hypertensive patients. Circulation 41, 555-67 (1970). In 31 normotensives and 93 untreated hypertensives (58 essential, 21 renovascular, 14 other), peripheral plasma renin correlated positively with diastolic pressure and inversely with serum sodium and potassium only in the renovascular group. Ventricular ejection rates were correlated with renin activity in the hypertensive groups (except for the three patients with primary aldosteronism), while total blood and plasma volume were correlated with renin activity in normal and essential hypertensive men but not women. Modifying factors are thus important. 5. Eich, R. H., and Jacobsen, E. C. Vascular reactivity in medical students followed for 10 years. J. Chronic Dis. 20, 583-92 (1967). A group of 73 medical students followed for 9-10 years showed little changes in blood pressure, no relationship between heredity and hyperreactivity, no relationship between a positive cold pressor response and other manifestations of hyperreactivity, and no tendency for those with an initial elevated cold pressor test to show a rise in blood pressure over the follow-up period.
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6. Harburg, E., Erfurt, J. C., Chape, C., Hauenstein, L. S., Schull, W. J., and Schork, M. A. Socioeconomic stressor areas and black-white blood pressure: Detroit. J. Chronic Dis. 26, 595-611 (1973). Census traits in Detroit were rank ordered by their “stress scores” by using economic deprivation, residential instability, family instability, crime, and population density as indices for stress. A comparison between high and low stress areas showed black males, black females, and white females to have more hypertension in the high stress areas. 7. Henry, J. P., and Cassell, J. C. Psychosocial factors in essential hypertension. Recent epidemiologic and animal experimental evidence. Amer. J. Epidemiol. 90, 17I-200 (1969). It is suggested that obesity and dietary factors (salt, fat) are less important in explaining variations in blood pressure than repeated arousal of the defense alarm response. It is postulated that populations whose blood pressure does not increase with age lead a less stressful existence. 8. Laragh, J. H., Sealey, J. E., Ledingham, J. G. G., and Newton, M. A. Oral contraceptives, renin, aldosterone and high blood pressure. J. Amer. Med. Ass. 2Q1,9 18-22 (1967). In eight out of 1I patients blood pressure was increased by oral contraceptive therapy, and in six of these eight the blood pressure was corrected when the oral contraceptives were stopped. In patients on oral contraceptives, renin-substrate concentration and the capacity to form angiotensin when exogenous renin was given were increased. 9. Miall, W. E., Heneage, P., Khosla, T., Lovell, H. G., and Moore, F. Factors influencing the degree of resemblance in arterial pressure of close relatives. C/in. Sci. 33, 271-83 (1967). Of 2,680 subjects seen in the first Rhondda Fach and Vale of Glamorgan surveys and on whom blood pressures were taken (in their own homes), 2,15 1 were reexamined 1 l/2- 10 years later and death certificates for the 269 who had died were studied. Regression coefficients for male (systolic 0.252, diastolic 0.172) and female (systolic 0.32 1, diastolic 0.277) relations on all propositi were significantly greater than zero, with resemblances in blood pressure being little influenced by differences in age between the propositi and their relatives. In contrast the regression of husbands on wives (systolic 0.009, diastolic 0.142) showed no positive relationship. The larger values for females suggest that some relevant genes are on the x chromosome. 10. Morton, W. E. Hypertension and drinking water constitutents in Colorado. Amer. J. Pub. Health 61, 1371-78 (1971). A 1960 statewide study of municipal water supplies gave a correlation coefficient of +0.90 for mean nitrate concentrations on 1960 hypertension mortality. It is noted that explosive workers are exposed to nitrates and have an increased amount of hypertension. The relationship reported by Schroeder (1960) with an inverse correlation between water hardness and the hypertensive heart disease death rate was not confirmed in Colorado. 11. Oberman, A., Lane, N. E., Harlan, W. R., Graybiel, A., and Mitchell, R. E. Trends in systolic blood pressure in the thousand aviator cohort over a twenty-four year period. Circulation 36, 812-22 (1967). The 1,056 normotensive men first examined in 1940 at a mean age of 24 years were reexamined in 1951-52 (703 persons), 1957-58 (785 persons), and 1963-64 (675 persons or 85% of the surviving members). Of these, 575 men had blood pressure data from all four examinations. Systolic blood pressures increased very little over time after the age of 35 years, and the correlation coefficient between 1940 and 1963 systolic values was 0.15. Parental longevity (earlier in time) and gain in weight influenced the systolic blood pressure of the cohort. 12. Prior, I. A. M., Evans, J. G., Harvey, H. P. B., Davidson, F., and Lindsey, M. Sodium intake and blood pressure in two Polynesian populations. N. Engl. J. Med. 279, 5 15-20 (1968). In Raratonga, but not in Pukapuka, blood pressure increased with age. Sodium intake in Raratonga is about 50 m. equiv a day higher than in Pukapuka.
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BIBLIOGRAPHY
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13. Stewart, 1. M. G. Long term observations on high blood pressure presenting in fit young men. Lam-et 1,355-59 (1971). In this study 40 men with uncomplicated essential hypertension and an average age of 35 years were followed for 6 years. In 12, the diastolic fell gradually without treatment from an average of 105 to 88. In the remaining 28, characterized by a relatively high age at onset, professional-type rather than laboring work, involvement in competitive mental stress, and a family history of close relatives affected by premature arteriovascular disease, antihypertensive treatment was given. Despite this, ten developed vascular complications (largely occlusive) during treatment which suggests that therapy may provoke vascular complications. 14. Swaye, P. S., Gifford, R. W., and Berretoni, J. N. Dietary salt and essential hypertension. Amer. .I. Cardiol.
29, 33-38 (1972).
In comparing 7 17 patients with essential hypertension to 8 19 normotensives, the percentages adding salt to food before tasting it were found to be essentially the same (22.7 and 21.2%). In comparing 43 hypertensive women with this habit to 325 without, the former group was found to have more severe hypertension (blood pressure and fundal changes), while in comparing 120 men with this habit to 229 without, the former were found to have more severe hypertensive heart disease (ECG and X ray). 15. Veterans Administration Cooperative Study Group on Antihypertensive Agents (E. D. Freis, Chairman). Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. J. Amer. Med. Ass. 24l2, 1028-34 (1967). In this study 143 male hypertensives (diastolic 115-I 29) were randomized, with 73 in the active treatment group (hydrochlorthiazide plus reserpine plus hydralizine) and 70 given placebo. In the first group there were two major complications and no deaths, and in the latter there were 27 major complications and four deaths. At 24 months, when the trial ended, the average diastolic pressure in the control group was 120, and in the treated group, 92. 16. Veterans Administration Cooperative Study Group on Antihypertensive Agents (E. D. Freis, Chairman). Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressures averaging 90 through 114 mm Hg. J. Amer. Med. Ass. 213, 1143-52 ( 1970). In this study 380 male hypertensives (diastolic 90-l 14) were randomized, with 186 in the active treatment group (hydrochlorthiazide plus reserpine plus hydralizine) and 194 given placebo. In the first group there were nine major complications and eight deaths (two due to myocardial infarction and four to sudden death), and in the latter there were 35 major complications and 19 deaths (three due to myocardial infarction and eight to sudden death). Treatment was most effective in preventing congestive heart failure and stroke.
I. Miscellaneous 1. Aitken, J. M., Hart, D. M., and Lindsay, R. Oestrogen replacement therapy for prevention of osteoporosis after oophorectomy. Brit. Med. J. 3, 5 15- 18 (1973). Aitken et (~1.evaluate the value of oestrogen therapy in the prevention of osteoporosis after oophorectomy in 114 middle-aged women who participated in a double-blind controlled trial of mestranol in an average daily dose of 23 pg. 2. Al Hujaj, M., Schonthal, H., and Elbrechter, J. Differential diagnosis of gout. Lancet 2, 606 (1972). This letter presents results of a screening test using fructose-induced hyperuricemia. The guideline for diagnosis is judgment of the serum uric acid level 2 hours after administration of fructose. The results with 161 patients are reported. The authors consider the test suitable for both screening and assessing the effects of therapy. 3. Cornfield, J. The University group diabetes program. A further statistical analysis of the mortality findings. J. Amer. Med. Ass. 217, 1676-87 (1971).
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The earlier report is confirmed that lowering the blood glucose level with tolbutamide over an 8-year period was no more effective than diet alone in prolonging life and probably caused more cardiovascular mortality. The importance of randomization in achieving comparability between groups under different treatments is emphasized. 4. Fessell, W. J., Siegelaub, A. B., and Johnson, E. S. Correlates and consequences of asymptomatic hyperuricemia. Arch. Intern. Med. 132, 44-54 (1973). From about 150,000 persons taking a multiphasic health check, 124 hyperuricemic individuals (more than two standard deviations from the population mean) with a mean uric acid for males of 9.6 mg/lOO ml and females 7.2 mg/lOO ml were identified: 224 normouricemic controls (male mean 5.6, female mean 4.3) were also identified. Over a SO-month follow-up, eight hyperuricemic persons had hypertension, four diabetes, three gout, two heart disease, and one urolithiasis, while of the normal, two had urolithiasis and one gout. 5. Grunnet, M. L. Cerebrovascular disease: diabetes and cerebral atherosclerosis. Neurology 13, 486-91 (1963). By using the Baker system for coding the circle of Willis of 107 diabetic patients, increased frequency and severity of cerebral atherosclerosis were found in all age groups. 6. Henschel, A., Burton, L. L., Margolies, L., and Smith, J. E. An analysis of the heat deaths in St. Louis during July 1966. Amer. J. Pub. Health 59, 2232-42 (1969). Except for one day, the temperatures each day in St. Louis, MO., were above 90°F from June 22 till July 20, 1966, and above 100°F from July 9 till July 14. In the period July 1l-July 15 there were 211 certified primary heat deaths, accounting from some 65% of the excess deaths during these 5 days. There were more female than male heat deaths, which were concentrated largely in the city core. The impact was largely on older persons. Deaths from cardiovascular disease were strikingly increased as well. Nearly all heat death cases had body temperatures of 103-106°F on admission to hospital. 7. Johnson, J. S., Vaughn, J. H., Hench, P. K., and Blomgren, S. E. Rheumatoid arthritis, 1970-1972. Ann. Intern. Med. 78, 937-53 (1973). The authors discuss the prevalence and genetics of rheumatoid arthritis and its pathologic features, metabolic abnormalities, etiologies, and therapy. They conclude that there is little change in the major principles of management, although methods of assessing disease activity have been improved. 8. Kannel, W. B., Hjortland, M., and Castelli, W. P. Role of diabetes in congestive heart failure: the Framingham study. Amer. J. Cardiol. 34, 29-34 (1974). Among men a twofold and among women a fivefold increased risk of congestive heart failure was found among diabetics (treated with insulin) who were followed for 18 years. 9. Katz, J. L., Weiner, H., Gutman, A., and Yu, T. F. Hyperuricemia, gout, and the executive suite. J. Amer. Med. Ass. 224, 1251-57 (1973). Eight pairs of adult brothers, including one pair of first cousins raised together, all with a family history of gout, and therefore likely to have hyperuricemia, were examined for possible correlations between achievement-related variables and relative serum uric acid (SUA) levels within each pair. Manifest achievement, achievement orientation, and achievement drive did not reliably predict which brother in each pair had the high SUA level. However, when the variable of obesity-dietary content was employed, significant predictive success was attained: obesity did not correlate with achievement drive. The tonic and phasic eating histories of the subjects do suggest a possible explanation for the previous reports of a correlation between SUA level and such achievement related variables. 10. Kuller, L., and Tonascia, S. A follow-up study of the Commission on Chronic Illness morbidity survey in Baltimore: IV. factors influencing mortality from stroke and arteriosclerotic heart disease (1954-1967). J. Chronic Dis. 24, 11 l-24 (1971).
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Only 3.9% of the population was lost to follow-up. Men had higher arteriosclerotic heart disease mortality than women, and a history of heart disease, hypertension, or diabetes increased the risk of this mortality. 11. Lavernhe, J., Blanc, C., and Lafontaine, E. Epilepsy and medical examinations of flight personnel: importance and difficulty of diagnosis. Aerosp. Med. 42, 889-90 (197 1). Three cases of epilepsy among flight personnel are reported. The authors indicated that no medical techniques exist for detecting potential epilepsy. The problem of idiopathic epilepsy remains unsolved, which may be dramatic particularly with regard to air safety. 12. McCarty, D. J. Measurement of arthritic disease disability. Ind. Med. Surg. 42, 9-l 1 (1973). The author discusses documentation of arthritic disability. Described are class I - “complete ability” to perform all useful duties; class II -“adequate” (i.e., normal activities can be performed, but there in some handicap); class III - “limited” (i.e., activities of daily living and little or none of usual occupation done); and class IV -“incapacitated.” This is a functional classification system, which the author considers the best type. The paper also describes other indices of arthritic disease disability such as the Landsbury indices (which chiefly reflect inflammatory manifestations of the disease), fatigue, grip strength measured with a rolled-up blood pressure cuff, aspirin usage measured as number of tablets/day, and the Westergren sedimentation rate (which is least reliable and least reproducible). 13. Meyer, R. J. Interaction with government (arthritis). Ind. Med. Sup. 42, 14-15 (1973). The author discusses the present and future roles of government in regard to arthritic diseases. Prevention is advocated on two levels. Primary prevention includes rubella immunization, since many young people, especially women, are introduced to the arthritides during bouts with German measles. Secondary prevention or the early treatment of atllicted patients is essential if disability is not to proceed to chronic arthritic disorders. The author also identifies the need for vocational rehabilitation. Innovative rehabilitation techniques must be developed, with rheumatologists in the forefront supported by federal and state funds. 14. Pollack, A. A., McGual, T. J., and Macintyre, N. Diabetes mellitus: a review of mortality experience. Arch. Intern. Med. 119, 161-63 (1967). Among 1,680 diabetic persons with insurance policies issued on a substandard basis and with 6.8 19 policy-years of exposure, the mortality rate (observed/expected on standard policies) for those treated by diet alone was 1.31, by oral hypoglycemics 1.91, and by insulin 5.02. Of the deaths 54% were due to heart disease and cerebrovascular accidents. 15. Stout, R. W. Insulin-stimulated lipogenesis in arterial tissue in relation to diabetes and atheroma. Lancer 2, 702-3 (1968). Injecting rats with insulin and C-labelled substrate containing glucose or acetate led to the latter’s being incorporated in excess into the vessel wall. It is suggested that insulin leads to atherosclerosis by increasing the deposition and inhibiting the removal of fat from the arterial wall. 16. Taylor, D. C., and Bower, B. D. Prevention in epileptic disorders. Lancet 2, 1136-38 (197 1). The authors believe that knowledge about epilepsy has reached a stage where some degree of prevention is possible. They consider that it is possible to prevent the birth of persons particularly liable to suffer serious epilepsy, and they discuss eugenics and genetic prevention in Huntington’s chorea, etc. The article also considers prophylaxis against seizures, the prevention of cerebral damage due to seizures, and the forestalling of secondary handicaps in affected individuals, e.g., overprotection of the child and the social stigma attached to epilepsy. 17. Weir, J. M., and Dunn, J. E. Smoking and mortality: a prospective study. Cancer 25, 105-12 (1970). In this study 68,153 men aged 35-64 years were followed over 482,658 person-years of observation, during which 4,706 known deaths occurred. Arteriosclerosis was the major cause of death (1,718),
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with the relative risk for light (one-half pack or less), moderate, or heavy (one and one-half packs or more) cigarette smokers increasing from 1.39 to 1.67 to 1.74. 18. West, R. O., and Hayes, 0. B. Diet and serum cholesterol levels: a comparison between vegetarians and nonvegetarians in a Seventh-Day Adventist group. Amer. J. Clin. Nutr. 21, 853-62 (I 968). In this study 233 nonvegetarians were compared with 233 vegetarians matched for residence, sex, age, marital status, height, weight, and occupation. The nonvegetarians were found to be a diverse group whose cholesterol levels increased as the degree of nonvegetarianism increased. Overall, the mean cholesterol values were 185 for vegetarians and 196 for nonvegetarians.
V. PRENATAL
SERVICES
REFERENCES
1. Apte, S., Iyengar, L., and Nagarajan, V. Effect of antenatal iron supplementation on placental iron. Amer. J. O&et. Gynecol. 110, 350-5 I (I 97 I). The developing fetus derives iron from maternal circulation through the placenta. Evidence is presented from 25 pregnancies that an antenatal supplement of iron promotes deposition of greater amounts of ferritin iron in the placenta for subsequent transfer to the fetus. 2. Aubry, R. H., and Nesbitt, R. E. L. High risk obstetrics: 1. perinatal outcome in relation to a broadened approach to obstetric care for patients at special risk. Amer. J. Obstet. Gynecol. 105, 241-47 (I 969). A special model clinic was set up at Upstate Medical Center, Syracuse, N.Y., using intensified screening and diagnostic procedures to identify patients at high risk. Previously undetected illness was found in one-third of the patients, and more than one-fourth required antepartal hospitalization for diagnostic work-up and treatment. The clinic obtained good results because (I) it was accessible to both private and ward patients (referral by a physician was the only requirement), (2) there was a good doctor: patient ratio, (3) a full-time social worker, psychologist, and nutritionist were employed, (4) an experienced obstetrician was on staff, (5) consultation was possible with physicians in every medical field, (6) special facilities for antenatal evaluation were available, (7) a good laboratory was on hand, and (8) follow-up studies were conducted. High-risk patients were defined by an objective scoring system. Among other services received, patients got a 2 hr postprandial blood sugar and/or glucose tolerance test, bacteriuria screening, thyroid screening and cytohormonal screening. 3. Bergner, L., and Susser, M. W. Low birth weight and prenatal nutrition: an interpretative review. Pediatrics 46, 946-66 (I 970). Birth weight is considered a possible crucial intervening variable between perinatal mortality or retarded child development. Birth weight is shown to have a stronger correlation with perinatal mortality than length of gestation. In New York if black infants had the same weight distribution as white infants and the same weight-specific perinatal death rates as they now do, their expected overall perinatal death rates would equal that of whites. Three conclusions are germane to prevention of low birth weight: (I) fetal growth leading to important variation in birth weight occurs in the last trimester, (2) birth weight is influenced by external as well as maternal environment, and (3) birth weight is influenced by factors having their origin and effect during gestation. The role of maternal nutrition during gestation is examined as a factor in birth weight. Observational studies of wartime deprivation support the nutritional hypothesis, but observational studies of everyday diets in pregnancy and quasi-experimental studies that supplement nutrition in pregnancy have equivocal results. Hypothesis requires testing by experimental approach to eliminate or control extraneous or confounding variables. 4. Burke-Strickland, M. J., and Freeman, D. W. The perinatal care center. Minn. Med. 5.5, 367-68 (1972). The perinatal care center at the Hennepin County General Hospital has been in service for approximately 4 years. Amnioscopy and fetal blood sampling techniques for detecting fetal distress are available. In 1969 electronic monitoring of the fetal heart and a newborn intensive care unit were added. A follow-up high-risk infant care clinic opened in 1970. Interdepartmental discussions were
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found to be useful. The monitoring and intensive care appeared to cut down on deaths, but it is now difficult to assess the quality of life they preserved. Long term follow-up data are needed, but the 24 infants who would not have survived without the respirator assistance appear at present to be doing well. 5. Carter, C. O., Roberts, J. A. F., Evans, K. A., and Buck, A. R. Genetic clinic: a follow-up. LQ,ZCet 1, 281-85 (1971). The first genetic clinic in the British Isles was established in 1946 at the Hospital for Sick Children. This paper is a follow-up from 3 to 10 years after consultation of 455 couples seen in the clinic during 1952-64. The following observations were made: (1) couples did understand information on risks, (2) responsible decisions based on this information were made concerning future pregnancies [where risks were high (one in ten), two-thirds deterred from planning future children; where risks were low (less than one in ten), one-fourth deterred; no high-risk couple with the risk of a serious long-term handicap had children], and (3) predicted risks, on the whole, were accurate (of the subsequent children born to high-risk parents, one in six were affected; of those born to low-risk parents, one in 50 was affected). Over 300 new couples are now seen annually. 6. Chase, H. Perinatal and infant mortality in the United States and six west European countries. Amer. 1. Pub. Health 57, 1735-48 (1967). This article compares the United States with Scandinavia, England and Wales, and the Netherlands and finds that the Netherlands and Scandinavia have lower infant mortality rates that are decreasing at a faster rate. Postnatal asphyxia, atelectasis, respiratory distress syndrome, and hyaline membrane disease are higher in the U.S. than in these other countries. These diseases are usually due to prematurity and low birth weights. The author belives that it is no accident that birth weights are generally higher in those countries that have a lower incidence of the diseases cited than the U.S. More careful recording of diagnostic information is needed to be able to make a more definite statement on the relation between postnatal asphyxia, atelectasis, respiratory distress syndrome, hyaline membrane disease, and low birth weight or prematurity. Beside the differences in fetal weight, England, Wales, and Scandinavia all offer social insurance that covers the expenses of medical care and have a more extensive use of midwives to administer prenatal care and assist in deliveries. These and other factors may play a great part in the lower incidence of the health problems surrounding birth in the countries that offer these services. 7. Chen, W., Palav, A., and Tricomi, V. Screening for diabetes in a prenatal clinic. Obstet. Gynecol. 40, 567-74 (1972). Over a 3-year period, 1,269 patients of the 8,288 attending a prenatal clinic were investigated for abnormal glucose tolerance because of obesity, a family history of diabetes, previous birth of a large infant, poor obstetric history, or glucosuria. Of the total prenatal population 91 or 1.1% were found, for the first time, to have abnormal glucose tolerance. The significance of various indications for screening were evaluated by statistical analysis. From the information derived, the detection of abnormal glucose tolerance rose exponentially with each additional screening indication. Thus, multiple indications for screening, in a given subject, indicate her carbohydrate metabolism must be investigated immediately. Screening for diabetes is important in a prenatal clinic and especially in a municipal hospital (Brooklyn-Cumberland Medical Center), since it is often the only adequate care the patient receives. 8. Danks, D. Intrauterine diagnosis of genetic disorders. Amt. Paediatr. J. 8, 128-30 (1972). It is now possible to diagnose all diseases due to chromosome abnormalities and over 20 caused by inborn errors of metabolism. It is necessary to lay guidelines for the use of this technique in preventive medicine. Follow-up studies are essential, since it must be assured that no long-range damage is done to the child. Amniocentesis should be employed only when the risks are great, and the recommendation that all pregnant patients over 40 years take the test may result in excessive anxiety, since some may not have thought of the possibility of having a mongoloid child. However, the use of this procedure on all women over 40 years is economically advantageous to the community. Even if each mongoloid child cost the community only $1,000 per year and lives for 30 years, the expenditure of
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about $12,000 for 100 amniocentesis tests to prevent the birth of this mongoloid child makes good financial sense. It is preferable to perform the test at the twelfth week, not the fifteenth or sixteenth, since by the time the results are had, it may be necessary to abort in the eighteenth-twentieth week or later. Intrauterine diagnosis of inborn errors of metabolism can generally be applied only to the prevention of second cases in families, because recognition of marriages between carriers by any other means is not practical. Absolute proof of diagnosis in the index case in the family is essential. The author feels that at present amniocentesis should be a preventive tool limited to those known to have high risk and/or anxiety. 9. Emery, A., Watt, M., and Clack, E. The effects of genetic counseling in Duchenne muscular dystrophy. Clin. Genet. 3, 147-50 (1972). The results of a follow-up study of 53 women referred to genetic counseling (1965-69) in families with Duchenne muscular dystrophy (Manchester and Edinburgh regions) are presented. The authors believe most parents act responsibly when told of risks, with those at high risk usually avoiding pregnancy. It is disturbing that many come for genetic counseling when pregnant. This could be overcome if in each family with an affected boy the genetic risks of all near female relatives were determined and all those with high risks followed up. A genetic register system, therefore, is important. Three developments in the past few years have increased interest in Duchenne muscular dystrophy: (1) increased awareness of the need for genetic counseling, (2) a test (serum level of creatine kinase) that can detect female carriers, and (3) possibility of fetal prediction with selective abortion of male fetuses of women with high risk (greater than one in ten). 10. Farquar, J. W. The treatment of the fetus of the diabetic mother. Canad. Med. Ass. J. 105,287-90 (1971).
A special program of care for the diabetic mother should include (1) normalization of the intrauterine environment through general care and hormone therapy; (2) monitoring of the state of the fetus, paying special attention to growth, maternal insulin need, maternal urinary estriol level determinations, etc.; and (3) delivery after the thirty-eighth week if all is satisfactory-if not, cesarean birth may be required. 11. Fort, A. T. Adequate prenatal nutrition. Ubstet. Gynecol. 37, 286-88 (1971). According to the author, to constrict the supply line by limiting nutrition intentionally (in the name of fashion) or unintentionally (poverty) is to arrest the rate of growth, which leaves an indelible imprint on the unborn. Eighteen nations surpass the U.S. in perinatal survival. The only plausible reason is our similar standing in birth weight statistics. He cites several authors, among them R. L. Masland Project Reporter, Spring1 (“Current Status of Collaborative Perinatal Project,” Collaborative Summer 1965, p. 7.), who found (1) a strong inverse relation between birth weight and survival, (2) a strong inverse relation between birth neurologic abnormalities at age 1 year, and (3) weight decreases in general metabolic efficiency caused by low birth weight. In the article there are also three references indicating that IQ decreases with low birth weight. The most recent publication cited is “Effects of Birth Weight on Later Intelligence” by S. Starr [Social Biology 16, 249-256 (1969)]. 12. Friesen, R. F. Pre-pregnancy care-a logical extension of prenatal care. Can. Med. Ass. J. 103, 495-97 (1970). The development of routine prenatal care is one of the outstanding advances in the twentieth century. It has now been realized that at the first visit, usually at the fourth-sixth week after fertilization, the fetus has already passed the most critical period in its development. Furthermore, the effects of various harmful influences on the germ cells before fertilization cannot be nullified by earlier prenatal care. With birth control, it is now feasible for a woman to see a physician before she expects to start a pregnancy. The author has been testing this idea by including it in his family-planning counseling. He suggests that the woman planning a family see a doctor 3 months before discontinuing contraception. He includes a list of items to be included in this visit.
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13. Glass, L., Kolko, N., and Evans, H. Factors influencing predisposition to serious illness in low birth weight infants. Pediatrics 48, 368-71 (1971). Serious illness requiring rehospitalization of low-birth-weight infants following discharge from the Harlem Hospital nursery was related to specific sociomedical factors, viz., (1) failure of mother to receive prenatal care, (2) absence of father from home, (3) receipt of public assistance, and (4) presence of other children in the home. These factors help yield a weighted prognostic index, permitting prospective assignment of a score to each low-birth-weight infant. Those at highest risk of inadequate follow-up care and rehospitalization were identified prior to discharge from the nursery. This may permit direction of intensive medical nursing and social service towards this high-risk group. 14. Gold, E. M., and Stone, M. L. Total maternal and infant care: a realistic appraisal. Amer. J. Pub. Health 58, 1219-29 (1968). High-risk pregnancies often can be attributed to socioeconomic conditions, marital status, lack of prenatal care, repetitive casualties of abortion, premature birth, nutritional deprivation, and complications during the course of pregnancy. The New York Medical College applied for a grant in 1965 in cooperation with the New York City Department of Health for the establishment of a special project at Metropolitan Hospital, located in a high-risk area. Home visits, family planning, nutritional consultation, and infant care are services provided throughout the pregnancy. Residents and thirdyear students rotate through all phases of maternal and infant care for 1 year. 15. Goldschmidt, E. Experiences from 5 years of genetic counseling in eye diseases. Acta Ophthahol. 46, 463-68 (1968). From January 1961 to January 1966,2,932 counseling cases were dealt with at the University Institute of Human Genetics, Copenhagen. The institute helps the centers that give help on abortion, sterilization, and adoption by trying to determine whether the children are free from hereditary disease and adoptable or if the fetus is at risk of a disease. The article lists the ocular anomalies for 185 cases counselled. Congenital cataract is the most common disorder. In order to perform his task, the counselor should obtain a complete, verified history. Since it is the ophthalmologist’s responsibility to prevent blindness, part of his work is to draw attention to the risk of having blind children and let parents decide on the action to be taken. 16. Gordon, H. Genetic counseling: considerations for talking to parents and prospective parents. J. Amer. Med. Ass. 217, 12 15-25 (1971). Prevention of disease through genetic counseling occurs when a diagnosis is made before symptoms begin. Diagnosis of familial polyposis of the colon in one family member should lead to an investigation of all first-degree relatives, so surgery may be performed before the development of cancer. If one child is found to have Wilson’s disease, others should be examined for disturbance of copper metabolism (which precedes clinical manifestations) and treated with penicilhunine, so the development of serious liver and brain disease is prevented, etc. Since genetic counseling is based on a precise diagnosis (the identification of the correct disease and knowledge of how it is inherited) made through the information gathered from the family history and the most recent genetic data available, the author believes that the physician is in the best position to give the advice. Genetic counseling is a form of family practice. 17. Hatch, M. C. Maternal and perinatal mortality-prenatal
care. N.Y. State J. Med. 70, 1800-6
(1970).
The Central New York Maternal and Perinatal Mortality Study examined programs throughout New York State and found good results in the projects at Syracuse and Onondaga County. Prenatal care should begin ideally by education during the teens, before pregnancy. When it first started, prenatal care was applied to prevent eclampsia, abnormal pelvic disorders, and syphilis. Later it attempted to deal with the entire physical health of the mother. Now the complete preparation of her physical and emotional health before she gives birth is the goal. The article gives a detailed account of what should be done at the first visit (type of physical examination, history, laboratory tests, etc.) through the ninth month. 18. Hillsman, G. M. Genetics and the nurse. Nurs. Ourlook 14, 34-9 (1966).
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This article describes the central role of the nurse in a program at the Maternal and Child Health Division of the Ohio Department of Health. Nurses are very much involved in interdisciplinary meetings in which a comprehensive evaluation of the handicapping condition is reached. Referral is made to an agency that can conduct chromosome studies. Such agencies are all too uncommon. Follow-up is conducted. Emphasis is placed on the supportive, social work function of nurses in this program to help mothers overcome the sense of isolation and guilt feelings that often accompany the birth of a handicapped child. 19. Jorgensen, V. Clinical report on Pennsylvania Hospital’s Adolescent Obstetric Clinic. Amer. 1. Obstet. Gynecol. 112, 8 16-l 8 (1972). By definition, adolescent pregnancy equals high risk. This paper reports on an effective program that emphasizes preventive medicine and a teaching program to minimize risk and management factors. It was conducted during an 18-month period (Feb. 1970-Aug. 1971) in which 350 patients were seen and 256 gave birth. The program was tailored to the 97% black clinic population, aged 1l-17 years and of a poor socioeconomic group. (1) Two groups were then formed and remained together throughout the entire prenatal period: (2) each patient attended a teaching program or group therapy session before seeing a resident; (3) a resident under a statf obstetrician trained in adolescent psychiatry was responsible for total obstetric care; (4) the teaching program directed by a hospital Maternal and Infant Care Clinic nurse gave information on prenatal care, labor and delivery, infant care, family planning, venereal disease, and drug abuse (emphasis was on group discussion); (5) social workers and stalf psychiatrists conducted group therapy for social, emotional, and educational help; and (6) patients returned to the clinic for postpartum care and family planning counsel. The article compares the results of the Adolescent Clinic at Pennsylvania Hospital with those of similar programs elsewhere and with Pennsylvania Hospital records prior to the initiation of the clinic according to the following: cesarean section rate, prematurity, anemia, eclampsia, and return to the postpartum clinic. The Adolescent Clinic at Pennsylvania Hospital was superior on all counts. 20. Kauffman, M., and Cunningham, A. Epidemiologic analysis of outcomes in maternal and infant health in evaluation effectiveness of three patient care teams. Amer. J. Pub. Health 60, 1712-25 (1970). In March 1968 the Research Committee of Temple University Health Science Center in Philadelphia, Pa., conducted a study to see which, if any, of the three types of maternal care offered to lowincome populations by the hospital outpatient department and two of its neighborhood health centers was best. The focus was on the outcome of maternal and infant health states in order to perform the evaluation. Prior to this study, the authors could find nothing in the literature to support the idea that prenatal care improved maternal and child health. The patients studied were divided between those who received care and those who did not. A significant relationship was found between the absence of prenatal care and prematurity, fetal and infant mortality, eclampsia, and maternal anemia. Negroes were found to have received less prenatal care and had the most problems. It was also concluded that it was too early to decide which of the three centers giving prenatal care through Temple University was best. 2 1. Kerr, C. Genetic counseling in hereditary disorders of blood coagulation. Mod. Treatment 5, 125-33 (1968). In order to deal with inherited disorders of blood coagluations, it is necessary to obtain a family history, have full facilities for investigating hemostatic mechanisms, and have knowledge of patterns of inheritance and the way in which each mutation expresses itself in the individual. The author claims that the most frequent requests for help come from female relatives of males with sex-linked conditions of classic hemophilia (Factor III deficiency) and Christmas disease (Factor IX deficiency). Almost all others are autosomal recessive disorders. Except for von Willebrand’s disease (autosomal dominant), a deficiency of fibrin-stabilizing factor (Factor XIII) may be inherited in either of two ways, viz., autosomal recessive or sex-linked. The article provides a list of diseases by modes of transmission and gives risks involved. 22. Langley, I. I. Resolved: that the present system of prenatal care is inadequate: a debate. Amer. J. Obstet. Gynecol. 113, 558-68 (1972).
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Among the points discussed were improvements in labor rooms, allowing the father to observe the delivery, and the use of paramedical personnel. The public was said to be stubborn, since it does not make use of services even when there is no charge. One speaker suggested that the medical profession pampers and gives an unnecessary amount of care to 90% who do not need care and does not reach the 10% who do. 23. Lynch, H. T., and Krush, A. J. Genetic counseling: implications for cancer control. South. Med. J. 61, 265-69 (1968). During the past years, more studies confirming patterns of Mendelian inheritance for several premalignant disorders and certain site specific cancers have appeared in the literature. A table is presented that lists different cancers and premalignancies and the way they are inherited. There is also a list of diseases suspect of being precancerous. Studies of “cancer families” show (1) high frequency of adenocarcinoma at all sites (especially colon and endometrium), (2) greater frequency of primary malignant neoplasms than in general population, (3) early age at onset of carcinoma, and (4) apparent autosomal dominant inheritance [see Lynch, H. T., Anderson, D. E., Krush, A. J., and Larsen, A. L., “Heredity and Carcinoma,” Annals of the New York Academy ofScience 155,793-800 (1968)]. This article emphasizes the responsibilities of the physician to recognize that he is dealing with a cancer family and to educate the patient toward prevention. The counselor should inform the patient of the pedigree and risks only when it has been determined the patient is psychologically ready. 24. Milunsky, A., and Littlefield, J. W. The prenatal diagnosis of inborn errors of metabolism. Ann. Rev. Med. 23, 57-76 (1972). Prenatal diagnosis is now possible because of development in the techniques of tissue culture and biochemical methods of application during the last 2 years. A list is presented of all inborn errors of metabolism, and a description is given of how most are diagnosed. The detection of carriers is said to be more likely today. Prenatal diagnosis really begins with heterozygote detection, especially as it involves inborn errors of metabolism. The possibility of detecting an “at risk” couple is now good. An example of this is the screening program for Tay-Sachs disease, which has been developed by Dr. Michael Kaback in Baltimore. Such screening methods are practical if the disease occurs in a recognizable population. The authors give 187 references. 25. Nash, E. M., and Louden, L. M. The premarital medical examination and the Carolina Population Center: what patients desire. J. Amer. Med. Ass. 210, 2365-69 (1969). A questionnaire was administered to 3,592 college students and the following findings resulted: (1) there was widespread ignorance of the purpose of the premarital medical examination, (2) there is hope that the physician will give the extended type of premarital examination and, especially, offer (unasked) contraceptive and sexual counsel, (3) there is a need to extend sex education to younger groups, and (4) a distinction is made between the role of the physician and the clergyman. The doctor should suggest that the couple return after l-3 months to discuss problems or any questions that may have arisen in the interim. 26. O’Brien, J. S. How we detect mental retardation before birth. Med. Times 99, 103-8 (197 1). A list of 27 genetic disorders that were diagnosable prenatally as of July 1971 is given. Tay-Sachs disease is described, its method of transmission and how it progresses. It can be detected by amniocentesis and enzyme assay. The author believes that all pregnant women over 40 years of age should have amniocentesis performed. 27. Osofsky, H. J., Hagen, J. H., and Wood, P. W. A program for pregnant schoolgirls: some early results. Amer. J. Obstet. Gynecol. 100, 1020-27 (1968). The problems of young pregnant women often place them in the high-risk category because of the following possibilities: toxemia, syphilis, prematurity, excessive weight, fetal-to-pelvic disproportion, prolonged labor, anemia, or hyperemesis. The young pregnant woman is also likely to be educationally, socially, and economically disadvantaged; illegitimacy is widespread. The Y-MED Program (Young Mother’s Educational Development), begun in 1965 in Syracuse and Onondaga counties, provides medical, social, psychological, and educational assistance all under one roof. This made possible because of the sponsorship of the Syracuse Board of Education, Onondaga Department of
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Health, and the State University of New York College of Medicine at Syracuse. A description of the girls in terms of race, religion, age, etc., is given. Personal attention is given early in pregnancy and continues to 1 year after birth. Conferences are held among all stti members twice a week. The supervision by a nutritionist of the girls’ own lunch preparation was a particularly beneficial innovation added while the program was already underway. The incidence of excessive weight gain on the part of the infant was greatly reduced. Although the mothers in this program experienced more problems before and during the delivery than the population at large, they had fewer difficulties than those with similar high-risk characteristics who received no care. 28. Rosenwaike, I. Sources of prenatal care of mothers having birth in Maryland. Amer. J. Pub. Health 65 186-90 (1972). In Maryland, one in ten live births occurred outside a hospital in 1950; in 1960 one in 48 occurred outside a hospital. Yet the infant death rate was higher in 1960 than in 1950. Unless controls are used, the observed differences may not be due to the type of care but to socioeconomic class or other factors. In order to assess this, the source of prenatal care of 57,000 Maryland women giving birth in 1968 has been analyzed by race, age, and educational attainment of mother (on the 1968 birth certificate in Maryland, starting 1968). Mothers of high educational status were most likely to have visited hospital or health department clinics. Women who received care at public facilities made their first prenatal visit somewhat later in pregnancy than those who saw private physicians. Exclusive of military families, 67% of ah mothers received care from a private physician. This included over four-fifths of white mothers but less than one-fourth of nonwhite mothers. Differences in the selection of care facilities are largely a function of socioeconomic status. 29. Sarrel, P. M., and Klerman, L. V. The young unwed mother: obstetric results of a program of comprehensive care. Amer. 1. Obstet. Gynecol. 105, 575-78 (1969). This study describes 119 teenage pregnancies cared for by the Young Unwed Mothers Program of the Yale-New Haven Medical Center. Comprehensive prenatal care applied to these pregnancies has yielded encouraging obstetric results in terms of low incidence of antepartum complications, prematurity, and perinatal loss. The central role of the obstetrician and his or her unique contribution to such a program are emphasized. The program, begun in 1965, links both the hospital and the community and aims to break the “unwed mother syndrome” of repeated pregnancies, dropping out of school, dependency on welfare, and the like. The program includes weekly instruction from the sixth month in pregnancy, labor, delivery, and contraception by a social worker with the assistance of an obstetrician, pediatrician, and delivery room nurse. The outcomes of the births in the programs are described. 30. Saylor, L. F. Hemolytic disease of the newborn. Cal$ Med. 112, 79 (1970). Since 1968, Rh immune globulin has been licensed and commercially available. It offers Rh negative women the means for preventing maternal Rh isoimmunization and hemolytic disease of the newborn (HDN) in subsequent pregnancies. HDN accounts for 3% of California’s perinatal mortality, or more than 1,800 deaths in the last 5 years. Rh immune globulin (1) must be given after each pregnancy, (2) must be given 72 hours after the termination of pregnancy, (3) is relatively inexpensive, and (4) cannot be used in mass programs. Since its use in California, problems discovered were (1) refusal of immunization because of the lack of expectation of another pregnancy, (2) contraceptive failures, and (3) conflicts with religious beliefs. The cost has been reduced from $64.00 at the start of administration to $30.00. 3 1. Saylor, L. Premarital examinations for syphilis. Cal$ Med. 115, 78-79 (197 1). California law requires premarital examinations for syphilis not more than 30 days before a couple gets a marital license. The California Administrative Code was amended recently to broaden the range of approved syphilis tests for premarital and prenatal examinations. These now include VDRL slide, automated reagin, fluorescent treponemal antibody (absorption), automated fluorescent trepnemal antibody, and rapid plasma reagin (circle) card tests. Any of these now constitute a “standard test” as required by the California Civil Code and the California Health and Safety Code. The fact that syphilis has risen and most often occurs in young adults makes premarital detection worthwhile.
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A physician must perform a physical examination. Syphilis of less than 2 years duration is considered communicable to the marital partner and offspring unless treated. In females, untreated syphilis of even longer duration can be communicated to the offspring. If the physician is assured that the patient has had adequate treatment, he can sign the marriage health certificate. Treatment with penicillin or other antibodies should be completed before marriage. There is a follow-up of both partners for l-2 years. At present the new law does not include detection and treatment of gonorrhea, but the author believes this should be initiated soon. 32. Slatin, M. Why mothers bypass prenatal care. Amer. J. Nun. 71, 1388-89 (1971). The Maternal and Infant Project at the University of Nebraska was established to provide maternal care without financial burdens and investigations. Project patients came from geographic locations in Omaha where high-risk patients live. Free services offered were all lab work, X rays, medical examinations, dental care, drugs, and help from nutritionists, social workers, and public health nurses. The program was funded by the Children’s Bureau (HEW) in 1965. It has since grown and includes two satellite clinics in addition to the University Hospital. A drop from 12% the first year to 3% the fifth year of the number delivering without prenatal care occurred. The author taught a postpartum course to establish rapport with mothers in the hospital who had never attended a clinic before birth. The women were then interviewed to see why they had not sought prenatal care. The findings are given. The reasons cited in 1965-66 caused the addition of the satellite clinics, a baby-sitting service and transportation. A bus service did not prove satisfactory because the departure hours were fixed. The program now pays the cost for taxis or public transportation. This totals $900 per year as compared to the $1,600 necessary to run a bus service. From the facts gathered and presented above, the author feels that the innovations put into effect after 1966 were useful and attributed to the rising number of women making use of the program in Nebraska. 33. Sinclair, M. G., Saslaw, M. S., and Buff, E. E. Premarital rubella serologies in Miami, Florida. South. Med. J. 64, 820-22 (1971). Of 200 women of child-bearing age surveyed at the time of premarital syphilis testing, 25% were susceptible to rubella. This study reaffirms that the history is of little value in predicting serologic immunity and suggests premarital rubella serologic testing as a rapid, reliable, and inexpensive way to get women vaccinated. 34. Taylor, K., and Merrill, R. E. Progress in the delivery of health care: genetic counseling. Amer. J. Dis. Child. 119, 209-I 1 (1970). Although there is enough knowledge about the inheritance of the disease, this paper summarizes the lack of success in providing useful information to families with boys having progressive muscular dystrophy. The roster of all patients attending a muscular dystrophy clinic was searched, and all male index patients with no affected females in the family and with the progressive disease of the Xlinked Duchenne type were selected. Diagnosis was make by electromyography, muscular biopsy, and enzyme studies. Twenty-one families were included. The survey was conducted by a medical social worker, who was aided by a physician. Interviewing was conducted at home, and questions asked pertained to socioeconomic class, the patients’ level of self-help, their knowledge concerning genetics, their knowledge about risks in other pregnancies, the possibility of carrier sisters, and the . prognosis, i.e., how long the boy was expected to live. Nine families were found to have total and accurate information. Only 14 were told that the disease would shorten life, and eight appreciated the need for a program of education modified to fit the child. The reason for the failure of this clinic is said to be the lack of clear responsibility on the part of designated staff members to assure a complete understanding of all that is involved with the disease. The authors believe that in the future, social workers should try to detect a lack of knowledge, and physicians then would aim to clarify the problem. 35. Thelander, H. E. Defective newborns. C/in. Pediat. 8, 437 (1969). Some adverse factors during the embryonic period are the mother’s age (under 20 years or over 35 years), poor nutrition, drug ingestion, anemia, infections, radiation, physical and emotional trauma, and previous infertility. Later in pregnancy these possible occurrences may harm the fetus: uterine
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bleeding, Rh incompatibility, abnormal placental implantation, and prenatal toxemia. Drugs, trauma, and nutrition also affect the infant during this time. In the paranatal period, medication, hypoxia, and trauma may affect the infant directly. The author states that all these facts are well established and have been known for some time. It is now necessary to educate the public on preventative strategies. More sex education is suggested. 36. Thompson, H. E., McFee, J. G., Haverkamp, A. D., and Longwell, F. H. Factors contributing to improved maternal care and fetal outcome in a medium sized city-county hospital. Amer. J. Obstet. Gynecol. 116, 229-38 (1973). During the past 5 years, the perinatal mortality rate at Denver General Hospital has been reduced from 4.1 to 2.7%. This decrease is due to (1) a federal grant support that made possible establishment of multiple obstetric clinics throughout the city where comprehensive health care and family planning can be obtained, (2) a new, modern hospital, (3) increased competence in the full-time staff, (4) new concepts of evaluation and management of the high-risk gravida and her infant, and (5) the therapeutic abortion law in effect. Among the new techniques included were amniocentesis, amnioscopy, ultrasound, estriol level determinations, fetal monitoring, more liberal use of cesarian section, different modes of anesthesia, new ways of managing respiratory distress syndrome, and Rh immune globin. The entire staff is also more concerned with nutritional, social, psychological, and communication problems. 37. Valentine, G. H. Reproductive counseling services. Can. Med. Ass. J. 106, 757-59 (1972). The term “genetic counseling” is said to be inadequate, since information on such factors as drugs and rubella, etc., also influence the outcome of pregnancies and should be made known. Therefore, “reproductive counseling” is a better term. Mental retardation may be caused by genes, intrauterine infection, or obstetrical mishap. Thus, reproductive counseling should take place in major medical centers, preferably in university-based medical centers, because sophisticated methods are essential for accurate diagnosis. Even if patients must travel a distance to reach these centers, it is worth the inconvenience. The authors describe an ideal counseling service. 38. Wonnell, E. The education of the expectant father for childbirth, Nurs. C/in. N. Amer. 6, 591-603 (1971). Having the father play a role in delivery is still a controversial topic. However, the author believes that there is a great need of a supportive person to help reduce the stress of labor. A program has been in existence for 6 years at the Wilmington (Del.) Medical Center to train fathers for this role. Twelve instructors teach 12 series of 22 couples, equalling 1,500 couples per year. The program is described. It has resulted in making delivery easier for both the wife and husband and increased their sense of self-esteem. 39. Zackler, J., Andelman, S. L., and Bauer, F. The young adolescent as an obstetric risk. Amer. J. Obstet. Gynecol. 103, 305-12 (1969). The outcome of pregnancy was studied in 2,403 girls who received their care at the Chicago Board of Health and were 15 years of age or under at the time of conception. This was compared to the outcome of pregnancy in 4,400 girls of the same age group who had not received care at the Chicago Board of Health. Some of these received private care, some clinic care, and some had no prenatal care at all. The comparison was made with respect to hebdomadal and neonatal mortality, prematurity, and those conditions leading to infant mortality that had direct relationship to obstetric care. The study also included the incidence of complications, both prenatal and intrapartum. The study revealed that the hebdomadal mortality rate was 92% higher and the neonatal mortality rate was 94% higher in the patients who did not receive prenatal care at the health board’s clinics. Other findings were significantly lower in the health board’s patients. The services rendered were postprandial blood sugar determination, bacteriuria screening, electrophoreses for the determination of sickle cell anemia, social service guidance, dental care, homemaker service, better public health nursing service, and nutritional guidance. Anyone designated as high risk (15 years or under, multigravidas over 40 years of age, and primigravadas over 35 years of age in addition to those developing complications during the course of pregnancy) received special arrangements for delivery.
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REFERENCES
1. Allen, C. M., and Shinefield, H. R. Pediatric multiphasic program: preliminary description. Amer. J. Dis. Child. 118, 469-72 (1969). A pediatric multiphasic screening program, conducted by San Francisco Kaiser-Permanente Medical Group, Kaiser Foundation Hospital, since 1967, combines into a single health service three separate elements: (1) a group of screening tests administered by nurses or nurses’ aides, (2) computer processing and storage of the test results, and (3) a physician’s examination performed approximately 1 month after the tests are performed. Children older than 10 are tested alone; younger children may be accompanied by a parent. Procedures performed are EKG, blood pressure, pulse, bone age and wrist roentgenogram, anthropometry, visual acuity, respirometry, audiometiy, intelligence tests, drawing tests (Draw-a-person, Bender-Gestalt), Tine test, throat and nose cultures for streptococci, blood, urine, neurological maturity tests, and a self-administered parent response-to-behavior inventory. The pediatric multiphasic program is currently an off-line program, i.e., the test results are not fed into the computer, in order to reduce costs. It is hoped to integrate the results of the Draw-aman, Bender-Gestalt, psychological screening, and behavior questionnaire into a single score for presentation to the child’s pediatrician. 2. Alpert, J. J., Kosa, J., Haggerty, R. J., Robertson, L. S., and Heagerty, M. C. Families receiving comprehensive pediatric care. Amer. J. Pub. He&h 60, 499-506 (1970). The article examines the change in attitudes on the part of low-income families in Boston toward preventive practices, physicians in general, and the relative importance of health. The study shows an increased preference for a primary-care physician but little change in attitude toward more abstract concepts like preventive health practices. 3. Belleville, M., and Green, P. B. Preschool multiphasic screening in rural Kansas. Amer. J. Pub. Health 62, 795-98 (1972). This report presents an overview of a multiphasic screening program for preschool children in rural Kansas. In 1970, one county with 350 preschool children residing in it was studied. There 231 children were screened. Six children were referred to physicians for further vision evaluation, and four for further hearing evaluation and treatment. In the spring of 197 1, a five-county area with 818 children screened was studied. Of these 818, 428 received the Denver Developmental Screening Test; of these 428, 10% needed some type of further evaluation; of the 765 screened for hearing, 4% needed further evalation; of the 458 on whom hemoglobin was reported, 11% were referred to either a physician for medical evaluation or to a public health nurse for nutrition counseling; of the 493 children tested for speech, 37% were referred for further evaluation by a speech clinician. Mantoux tests were performed on 63 1 patients with no referrals made. Vision tests were conducted on 658 patients with 2.5% referred for treatment. 4. Brown, H. B. Multiphasic screening for preschool children: I. methodology and clinical findings in a Spanish-American community. J. Amer. Med. Ass. 219, 1315- 19 (1972). Two pediatric screening clinics staffed by medical students, nursing students, and community volunteers were conducted in low-income, Spanish-American neighborhoods in Albuquerque, New Mexico. The program was designed to examine preschool children by means of history, physical examination, hematocrit, urinalysis, and psychological tests. There were 352 children examined. Abnormalities in lab findings or upon physical examination appeared in 59 out of the 352 (17%). Information on the results of further evaluation of suspected abnormalities is incomplete but suggests that approximately 5% of the children had chronic physical impairment and 7% had significant emotional or mental impairment. 5. Campbell, M. T., Garside, A. H., and Frey, M. E. C. Community needs and how they relate to the school health program: S.H.A.R.P. Amer. J. Pub. Health 60, 507-14 (1970). The article studies the rate of correction of defects found in the Philadelphia elementary schools during regular health screenings. In poverty areas the rate is very low but can be improved significantly if parents are counseled by school nurses and if cases are followed up by school nurses.
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6. Cayler, G. G., and Warren, M. C. Benefits from mass evaluation of school children for heart disease: an experience with 6,625 children. Chest 58, 349-5 1 (197 1). The major benefits of a community program for the mass evaluation of schoolchildren for heart disease was found to be enhanced distribution of pediatric cardiology specialty services. This enhanced distribution is achieved through use of computer heart sound analyzer and by the establishment of a creative partnership among the pediatric cardiologist, the practicing physicians, local health officials, and the local heart association. 7. Chappell, J. A., and Drogos, P. A. Evaluation of infant health care by a nurse practitioner. Pediatrics 49, 871-77 (1972).
The effectiveness of a pediatric nurse practitioner in infant health supervisions was measured by achievement of desired health care goals in the first year of life and by infant health status at age 1. There were no marked differences in these measures between infants cared for by the PNP and those given care by a pediatrician. 8. Cobliner, W. G. Preferred preventive health care facilities: a survey among urban adolescents. Bull. N.Y. Acad. Med. 49, 922-30 (1973). This paper describes a survey relating to adolescent out-of-wedlock pregnancies and the need for the provision of special teenage clinics for preventive services. 9. Eisner, V., and Oglesby, A. Health assessment of school children: V. selecting screening tests. .I. Sch. Health 42, 2 1-24 (1972).
When one must choose which screening test to use for a multitest program, the important considerations are not specificity and sensitivity, as for a screening test for a given condition, but (1) costbenefit relationship, (2) whether or not there is an effective treatment for the disease, and (3) acceptability of the tests. 10. Gordis, L., and Markowitz, M. Evaluation of the effectiveness of comprehensive and continuous pediatric care. Pediatrics 48, 766-76 (197 1). Two controlled studies were undertaken to evaluate the effectiveness of comprehensive and continuous pediatric care. In the first study 220 infants were randomly allocated to either a comprehensivecare (CC) or a traditional-care (TC) group. The CC group received preventive and therapeutic care in a hospital-based program staffed by a pediatrician, a public health nurse, and a social worker. TC infants got care from emergency rooms, well-baby clinics, and outpatient clinics. One year after delivery each mother was interviewed, and her infant’s medical records examined. There was no difference between TC and CC infants in completeness of immunization, use of medical resources, morbidity, or mortality. A second study, attempting to show that compliance with a doctor’s recommendations would be favorably influenced by continuous care, failed similarly. This report is of interest because neither study could show that comprehensive or continuous care was more effective than conventional ambulatory care for children. 11. Hartman, E. E., et al. Health program for Minneapolis Project Headstart, 1966. J. Sch. Health 37, 232-36 (1967). The Minneapolis Health Department was requested to plan and develop the health aspects of the Headstart program in the city since 1965. The project prepared for 1966 included medical, dental, visual acuity, hearing, and laboratory screening as well as immunizations and tuberculin testing. Out of 997 children enrolled in the Headstart schools, 813 were tested, and 63.7% were found to have one or more health problems, with dental problems most frequent (288 out of 813, or 36.8%). Next came problems related to the ears, nutrition, heart murmurs, and the eyes. Overall, medical screening found deviations in 202 out of 8 13 children (24.8%). Of the 5 18 out of 8 13 children with one or more health problems, totaling 770 deviations, follow-up care was given or completed for 391. No treatment was indicated for 148 deviations. The treatment was not completed for 79 children with medical problems and 152 children with dental problems. 12. He&g, M. D., and Birch, H. G. Intellectual levels of school children severely malnourished during the first two years of life. Pediatrics 49, 814-24 (1972).
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Children badly nourished in their first 2 years have lower levels of intelligence at school age than their siblings and classmates. The age when hospitalized for the treatment of severe malnutrition did not relate to the intellectual level of cases, however. 13. Hoffmann, A. D., and Gaman, M. The adolescent outpatient: medical, social and emotional needs. Postgrad. Med. 50, 245-49 (1971). The high incidence of social and emotional problems and the interest in medical and social counseling suggest that medical care for adolescents is most relevant when diagnostic, therapeutic, and preventive measures are aimed at these areas as well as at physiologic needs. The Beth Israel Clinic was organized to do this. It failed partly because of a high dropout rate-a problem to be faced by future programs of this sort. 14. Jelliffe, B. B., and Jelliffe, E. F. P. Adaptive MCH services: a key strategy for overcoming malnutrition in young children. Clin. Pediat. 10, 552-54 (1971). Malnutrition is always caused by social and individual factors as well as by an inadequate diet. These factors vary from place to place, so programs must be adapted to the local situation. An MCH program is always a key strategy in overcoming protein malnutrition within a population. 15. McFarlane, A. H., and Norman, G. R. A medical care information system: evaluation of changing patterns of primary care. Med. Care 10, 481-87 (1972). Data from a computer-based medical information system were used to evaluate patterns of pediatric health maintenance over a period of 1 year at McMaster University Clinic. These data were then used as a guide to modify the delivery of pediatric health care to one more appropriate to family practice. The significant changes were a shift of responsibility to the nurse, a change in the content and frequency of patient contacts, and modification of the immunization and routine screening schedules. Evaluation of care 1 year later provided evidence of the usefulness of these changes. The study demonstrates the need for performance information in evaluating patterns of primary care and illustrates the value of the nurse-practitioner role in pediatric health maintenance. 16. Rosenbloom, A. L., and Allen, C. M. Screening for glucose intolerance in a pediatric multiphasic program. Metabolism 22, 3 19-22 (1973). The authors describe an initial attempt to analyze l-hour post-glucose-ingestion serum glucose values obtained during multiphasic screening of children. Analysis of data is by age group, time of blood sampling, and duration of fast prior to glucose ingestion. The report cites serious limitations of multiphasic screening for glucose intolerance and counsels against such activity without either control of the testing variables or multiple criteria specific for the varying test factors. Conclusions are that multiphasic screening systems have certain basic logistic limitations that make the ideal of controlling dosage of glucose load, time of testing, and duration of fast virtually impossible. 17. Salber, E., Feldman, J. J., Rosenberg, L. A., and Williams, S. Utilization of services at a neighborhood health center. Pediatrics 47, 415-23 (1970). This study describes the services rendered to 1,989 children (of 521 families) registered over a 5-month period at a neighborhood health center in Boston- 87% of whom received at least one professional service and 70% of whom were seen by a pediatrician. Variables such as ADC status, residence, family size, and education of mother had only a minor effect on registration rate of use of the facilities. The child’s age had a far greater influence. Visits to physicians and dentists were higher than the national norms for corresponding ethnic and socioeconomic groups. 18. Schaller, J., and Wedgewood, R. J. Juvenile rheumatoid arthritis: a review. Pediatrics 50, 940-53 (1972). The authors followed 124 children with juvenile rheumatoid arthritis at the Children’s Arthritis Clinic affiliated with the University of Washington Medical School. Three distinct subgroups c&tinguished by clinical manifestations, prognoses, complications, and serologic findings are described. The authors contend that although the significance of juvenile rheumatoid arthritis into such subgroups is unknown, it may prove useful in diagnosis and treatment. What now is termed juvenile rheumatoid arthritis may be more than a single disease.
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19. Sherwin, A. D., Schoelly, M. L., Klein, B. L., Schwartz, M. S., and Khan, M. G. Determination of psychiatric impairment in children. J. Nerv. Menr. Dis. 141, 333-4 1 (1965). This report, from the Payne Whitney Child Psychiatry Department, describes the use of a questionnaire among parents (usually the mother) to obtain reliable determinations of psychiatric impairment in children between the ages of three and 13. Three sample groups were identified: (1) known to be psychiatrically impaired, (2) presumed to be free of any impairment, and (3) composed of a group selected from the community at large. The findings were submitted to both statistical analysis and a clinical evaluation. The questionnaire does detect the presence of psychiatric impairment in children. Although it may fail in some cases where the parent responding is severely disturbed or the child is very young, the evidence to date suggests that it can be used, nevertheless, as a screening device by organizations working with children. 20. Sims, N., Seidel, H. M., and Cooke, R. E. A structured approach to the use of physician extenders in well-child evaluations. J. Pediat. 79, 15l-63 (1971). Systems analysis techniques were used to develop a new method of data acquisition in well-child evaluations. This departure from tradition was designed to increase physician efficiency yet maintain an acceptable patient-physician relationship in providing high-quality care. The results of 104 examinations using the new method provided more information with less time expended by the physician than in examinations conducted in the traditional manner.
VII. MENTAL HEALTH, DRUG ABUSE, ALCOHOLISM REFERENCES
AND
1. Allinsmith, W., and Goethals, G. W. “The Role of Schools in Mental Health.” Basic Books, New York, 1962. This book presents a general view of issues concerning mental health and schools and outlines the approaches being taken by schools to ferret out and correct mental and emotional problems. The authors also discuss the problems involved in classroom teachers’ helping their students in these areas and whether such activities limit more traditional pedagogy. 2. Bennett, A. E. Recognizing the potential suicide. Geriatrics 22 (5), 175-81 (1967). Suicide is not produced by external factors: only internal impulses, an inability to cope with external realities, lead to suicide. Many who attempt suicide do not really contemplate death; they simply seek emotional relief. Among this group are those who wish to call attention to themselves or to obtain love through force. Depressive mental illness is nearly always a cause of suicide. Thus, the physician has a great responsibility to recognize and to evaluate the seriousness of all depressive states. If the risk is considered great, the physician must insist on hospitalization. 3. Bower, E. M. Primary prevention of mental and emotional disorders: a conceptual framework and action possibilities. Amer. .I. Orthopsychiat. 33 832-48 (1963). Prevention has to do with the quality of the interactions and the degree of effectiveness of the society’s institutions in providing the individual with ego strength. This report relates all possibilities of preventive techniques as well as emotional hazards to seven service zones (family, public health, school, religion, job, recreation, and housing). 4. Brunt, H. H., Jr. Organization of a suicide prevention center. J. Med. Sm. N. J. 66 (2), 62-65 (1969). The author describes the operation, structure, and outside relationships of a hospital-based antisuicide program. The entrance point to the system is through a senior statf psychiatrist who “triages” incoming calls to eight selected statf members serving on a daily rotating basis, with each member having a special home telephone to insure constant coverage. Follow-up is coordinated between both the hospital and a number of community health and welfare agencies. 5. Cutting, R. Facts, fallacies and fiction in mental health education, in “The Psychiatric Clinic in Encounter” (A. Tulipan, Ed.), pp. 75-80. Poca Press, Oil City, Pa., 1971.
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Lack of agreement on objectives and processes and the multiplicity of services may have serious impact upon the general acceptance of community mental health and matters such as securing community financing and collaboration. It is unrealistic to think that the new comprehensive health centers are placing much emphasis on community health education. A recent study of eight representative centers made almost no mention of the mental health education programs. Community mental health education should be closely correlated with the prevention of emotional disorders. Training problems for mental health professionals should initiate study in the methods of delivery of community mental health educational services. 6. Farberow, N. L., and Shneidman, E. S. “The Cry for Help.” McGraw-Hill, New York, 1961. This book focuses on the responses by the community and practioner to the suicidal cry for help and describes the activities of the Los Angeles Suicide Prevention Center and other community agencies who are focusing on that cry. It points out the need for an interdisciplinary team in recognizing and preventing suicide. Also, it contains a comprehensive bibliography of 1,200 works on suicide and suicide prevention. 7. Garrard, R. L. Community suicide prevention activities in Greensboro, North Carolina, in “Suicidal Behaviors; Diagnosis and Management.” (H. L. P. Resnik, Ed.), pp. 399-404. Little Brown and Company, Boston, 1968. Suicide prevention services in Greensboro, North Carolina, are centered in the police department. Cooperation is provided by physicians (especially psychiatrists), hospitals, and courts. Promotional services, including professional meetings, film showings, and public programs, are described. An informal police-physician team has been formed. Telephones and squad cars are available on a 24-hour basis. Under cooperative conditions mutual respect and improved efficiency have developed. Legal machinery has been simplified for commitment of mental patients. Other communities have been given information on the process of establishing a suicide prevention service. There are two references. 8. Gibson, R. W. Can mental health be included in the health maintenance organization? Amer. J. Psychiat. 128 (8), 919-26 (1972). The inclusion of mental health care in proposed health maintenance organizations (HMO) is discussed. Prepaid group practice plans, a prototype of the HMO, have usually offered only modest mental health benefits, although there have been substantial improvements in recent years; utilization and costs under these programs have been low. The barriers to inclusion of mental health benefits in HMO’s are discussed, HMO’s are compared to community mental health centers, and psychiatrists are urged to take an active role in ensuring, not only that a mental health component be made an integral part of every HMO, but that linkages be established between HMO’s and other parts of the mental health care system. 9. Haughton, A. Suicide prevention programs in the United States-an overview. Bull. Suicidal. 25-29 July (1968). By 1968 there were over 60 suicide prevention centers in the United States. The majority of these centers are directed by professionally trained personnel who attempt to provide 24-hour answerreferral service for potential suicidal individuals and those in other states of crisis. These centers provide a service that is of unique and special use to their communities and of specific value to those who turn to it. 10. Kalfman, M. Practice of family treatment in Kibbutzes and urban child guidance clinics, in “New Directions in Mental Health” (B. F. Reiss, Ed.), pp. 8-16. Grune and Stratton, New York, 1968. Simulation of mental health practice and facilities in areas outside the United States has long been an aim of the program of the Postgraduate Center for Mental Health. Among trainees have been psychologists, psychiatrists, and social workers from many nations. Dr. KatFman was one of the psychiatric fellows at the Center and returned to his native Israel to head a clinic in Haifa. He describes in this article the basic principles of family therapy found to be effective with groups in urban and rural
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sections of his country. The findings that conjoint concurrent and separate sessions with the family and family subgroups were invaluable and are discussed against the background of Israel’s unique population. 11. Kiev, A. Suicide prevention, in “Identifying Suicidal Potential” (D. B. Anderson, Ed.), pp. 3-13. Behavioral Publications, New York, 1971. A review of major risk categories for suicide is given. It is recommended that suicide prevention centers clarify their objectives, analyze their operations, and determine whom they are helping. 12. Lemkau, P. V. Toward mental health: areas that promise progress. Menr. Hyg. 36, 197-209 (1952). This study shows the integration of the following areas: epidemiology, personality development, and human relationships. 13. Lemkau, P. V. Prevention of psychiatric illnesses. J. Amer. Med. Ass. 162, 854-57 (1956). The author has been dealing with many illnesses, many of which have specific preventions applicable only to them. There are illnesses related to chronic stress. Education and attitudinal change are two means of relieving stress. It may also be possible to reduce individual stress through the relief of broad cultural stress affecting large groups of individuals. 14. Marin, P., and Cohen, A. Y. “Understanding Drug Use, An Adult’s Guide to Drugs and the Young.” Harper and Row, New York, 1971. Aimed at the concerned parent, this is an effective tool for self-education about drugs and youthful druge abuse. The authors take it for granted that at one time or another most children will try drugs and argue that attempts to suppress their use entirely are doomed to failure. They concentrate on the minimization of drug misuse and suggest specific ways in which parents, teachers, community workers, and others can work with adolescents to direct them toward sensible usage. The measures suggested are both long-range and short-range, both preventive and therapeutic. As a guide to the concerned adult, the book also contains a substantial anthology of helpful information on all of the major drugs, explaining the ways in which they are used and their effects and evaluating the dangers, if any, that attend their use. 15. Nelsen, B. Suicide prevention: NIMH wants more attention for taboo-subject. Science 161, 766-71 (1968). The keys to lowering the suicide rate are to educate the public about suicide and to set up an effective system to refer suicide-prone individuals for help. In order that members of the community will become more aware of detecting suicidal intentions, the NIMH center has helped to organize regional workshops, seminars, and training demonstrations. 16. Over the counter drugs -a challenge for drug education. J. Drug Educ. 3 (2) (1973). Society today is acutely aware of drugs and all too often takes drugs without proper thought, knowledge, or precautions. The article professes that drug education should be a complete program including information on the over-the-counter, overused group of self-medicaments. Included are sections on antacids, sleep-aids, laxatives, and analgesics. 17. Parad, H. J., and Parad, L. G. A study of crisis-oriented planned short-term treatment: part I and part II. Sot. Casework 49 (6), 346-55 (1968) and 49 (7), 418-26 (1968). This study of 1,656 cases in planned short-term treatment (PSTT) programs in 54 family agencies and 44 child guidance clinics indicates that PSTT is considered a treatment of choice rather than of expediency and that it is possible to structure the time dimension in treatment in a flexible but meaningful manner. Both the clinical characteristics and the problems presented in PSTT cases seem representative of general client populations. With the clinicians’ impressions as a measure of outcome, two-thirds of the cases showed improvement; with use of the clients’ or patients’ own perceptions (as reported by the worker), three-fourths demonstrated improvement. The modal number of interviews planned for both samples was six; the preferred length of treatment was 9-12 weeks. The planned
HMO
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number of interviews and weeks of treatment generally represented an estimated goal or upper limit that both agencies and clinics tended to overestimate. Cases seen for over six interviews were more likely to show improvement. Services were dramatically more accessible in agencies than in clinics. The majority of cases were reported as involving a crisis situation, precipitated by situational rather than maturational events. Other aspects of treatment planning are discussed. 18. Perlin, S., and Schmidt, C. W., Jr. Fellowship program in suicidology: a first report. Bull. Suici&l. 38-42 March (1969). The Johns Hopkins University postgraduate fellowship program in suicidology is the first program devoted exclusively to the training of professionals in the field of suicidology. This article gives the various requirements for admission into this program and outlines the major subject areas covered. 19. Resnik, H. L. P. Critical issues in suicide prevention. Bull. Suiciu’ol. l-3 Fall (1971). Some critical issues in suicide prevention are reviewed, following a report of the status of work in that field. Several programs and services are mentioned, with emphasis on the center for studies of suicide prevention. Among the issues raised are standards of care that the public is led to expect by intensive publicity programs, identification of high-risk suicide persons, treatment programs for the identified person, follow-up and new treatment approaches, reevaluation of volunteer programs, and adequate mental health facilities for treatment. 20. Zimring, F. E. “Chicago’s Crackdown on Drunken Driving.” (The Center for Studies in Criminal Justice.) The University of Chicago, Chicago, Ill., 1971. Analysis of the effect of a mandatory minimum 7-day jail sentence for persons convicted of drunk driving proved inconclusive. However, serious, but not fatal accidents, during the crackdown period showed a relatively sharp decrease in nighttime statistics but no similar decrease in the daytime accidents.
VIII. PREVENTIVE
DENTISTRY
REFERENCES
1. Ast, D. B., Cons, N. C., Pollard, S. T., and Garfmkel, J. Time and cost factors to provide regular periodic dental care for children in a fluoridated and non-fluoridated area: final report. J. Amer. Dent. Ass. 80, 770-76 (1970). A 6-year study of 766 children was conducted in fluoridated Newburgh and fluoride-deficient Kingston to determine the cost and time to provide regular dental care for children by starting when they were 5 and 6 years old. The cost of corrective dental care of the fluoridated children was less than half the cost of the other children; the cost of incremental care was about half. The chair time needed to provide examination prophylaxes and corrective care was about one and one-half times more in the nonfluoridated area. 2. Bohannan, H. M., Ochsenbein, C., and Saxe, S. R. Preventive periodontics. Dent. Clin. N. Amer. 435-43 July (1965). Although periodontal disease afflicts over 95% of the world’s population, most cases of this disease can be prevented. Recommendations for prevention include regular removal of plaque and calculus accompanied by toothbrushing (with soft nylon toothbrush), use of unwaxed dental floss, and use of a water spray. These, the authors think, should lead to an effective program of dental hygiene. 3. Buonocore, M. G. Caries prevention in pits and fissures sealed with an adhesive resin polymerized by ultraviolet light-a 2 year study of a single adhesive application. J. Amer. Dent. Ass. 82, 1090-93 (1971). This reports shows that 2 years after a single application of a liquid adhesive to the pits and fissures of human teeth that involves uv light polymerizing the adhesive, a 99% carries reduction on permanent teeth was found, whereas the surfaces of deciduous teeth showed an 87% reduction. 4. Buonocore, M. Cl. Adhesives for pit and fissure caries control, Dent. Clin. N. Amer. 16, 693-708 (1972).
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The high susceptibility of pits and fissures to caries present a major dental problem, and over the years various attempts have been made to prevent them. While the evidence of the success of adhesives in reducing caries is significant, the author warns that sealants are not indicated for all teeth. 5. Cons, N. C., and Leatherwood, E. C. Dental services in community child care programs. Amer. J. Pub. Health 60, 1245-49 (1970). Health programs for children must include dental care-especially for the poor. This piece outlines the barriers to good dental care, how to surmount such barriers, the essential elements of a good dental program for children, and ways of providing care and operating community programs. 41, 630-35 (1970). 6. Derbyshire, J. C. Patient motivation in periodontics. J. Periodonotol. Patient motivation as it relates to periodontal disease and its treatment requires the close cooperation of both the patient and dentist. The patient has primary responsibility for plaque control and should only depend on the dentist for those things he cannot do for himself. 7. Diorio, L. P., and Madsen, K. 0. Patient education-a health service for the prevention of dental disease. Dent. Clin. N. Amer. 15, 905-17 (1971). An appraisal is made of some of today’s attitudes toward preventive dentistry and patient education. It is pointed out that there are many patient-education programs in dental health. Some emphasize only plaque control, others only disseminate information, few place emphasis on food habits, and only a few combine all of these. What is needed is a unified program and one capable of reaching large numbers of people. 8. Englander, H. R. A perspective on prophylaxis of dental caries by tropical fluoride. Dental Clin. N. Amer. 16, 673-92 (1972). Tropical fluoride therapy is shown to be an effective way to augment the F concentration permanently in the outer surfaces of the enamel of deciduous and permanent teeth. It is recommended to supplement individual home care in the prevention of tooth decay, especially on the smooth coronal tooth surfaces. 9. Gochman, D. S. Context for dental health education. In?. 1. Health. Educ. 16, 37-42 (1973). Evidence is offered that dental health education might be more effective if included in a comprehensive rather than a fragmented health education program. The author’s final suggestion is to attempt to change a person’s overall perception of vulnerability to health problems. 10. Greene, J. C. Oral hygiene and periodontal disease. Amer. J. Pub. Health 53, 913-22 (1963). The prevention of periodontal disease requires improved oral hygiene. This conclusion is drawn on the basis of data presented in this report. The data were obtained by studying 4,000 people of Ecuador in 1959 and some 1,500 American Indians in Montana in 1961. The implications of these data are considerable. If a person were to maintain a good level of oral cleanliness from ages 5 to 50, he very likely would avoid the ravages of destructive periodontal disease during this major part of his life. The author concludes that if a person maintains poor oral hygiene for even a very few years, he will experience rapidly advancing destructive periodontal disease. Much more emphasis should be given in dental health programs to the improvement of oral hygiene as a major step in the prevention of periodontal disease. 11. Horowitz, M. S., and Heifetz, S. B. The current status of topical fluorides in preventive dentistry. J. Amer. Dent. Ass. 81, 166-78 (1970). The use of topical fluorides in protecting the enamel surface of teeth from caries attack has undergone much study in the past 25 years. This article summarizes much of the knowledge on various topical fluoride solutions and their applications and the fluoride prophylaxis pastes. On the subject of self-administration of topical fluorides, the authors believe “at this time there is insufficient evidence to recommend any self-administration procedure for topical fluoride application-be it toothbrushing, mouth rinses or mouthpieces for general use in public health programs.”
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12. Katz, S., McDonald, J. L., and Stookey, G. K. “Preventive Dentistry in Action.” D.C.P. Publishing, Upper Montclair, N.J., 1972. This book tries to place preventive dentistry within its proper scientific and professional perspective. The authors pooled their experience in the research laboratory, the classroom, the dental clinic, and private practice in writing this text. They develop what they call the philosophy of preventive practice, the main objectives of which are (1) to consider the patient as a whole entity, i.e., as a person; (2) to maintain a healthy mouth healthy as long as possible-ideally for a lifetime; (3) when oral health is deteriorating, to stop the progression of the disease as soon as possible and to provide appropriate rehabilitation of form and function at the earliest possible time as perfectly as possible; and (4) to provide the patient with the knowledge, skills, and motivation necessary to prevent the recurrence of the conditions covered in No. 3. 13. Mandel, I. D. New approaches to plaque prevention. Dent. Clin. N. Amer. 16, 661-71 (1972). The author describes the current research on antiplaque and anticalculus substances. At the present it is noted that neither the safety nor efficacy of any particular substance has been established. The mechanical approach is still considered the most effective way of removing plaque. A number of preparations, however, do look very promising. 14. Moen, B. D., and Poetsch, W. E. More preventive care, less tooth repair. J. Amer. Dent. Ass. 81 (1), 25-45 (1970). This survey of dental services rendered in 1969 to 35,793 patients, in comparison to the previous studies in 1950 and 1959, has shown highly significant changes occurring in dental health care during the past 2 decades. The emphasis has gone from reparative care to preventive care, and the dental care of patients has shown definite improvement. More patients received preventive care such as prophylaxis, radiographic examinations, and orthodontic and root canal treatment, while fewer received fillings, extractions, and dentures. “If the trends shown in this survey continue . . . the 70’s will be decisive years for dental health care in this country and for the realization of the prime goal of dental research, effective prevention of dental disease.” 15. Schonfeld, H. K. Periodontal diseases in association with unmet dental needs. Amer. J. Pub. Health 53, 923-3 1 (1963). The data presented in this report show that there is a very strong association between the amount of dental calculus and all forms of manifestations of periodontal disease. There certainly is no question that increases in both age and the unmet dental needs lead to increased periodontal disease. 16. Stahl, S. S. Host resistance and periodontal disease. J. Dent. Res. 49, 248-55 (1970). This article reviews the current knowledge on the relationship between host status and periodontal disease. It is thought that the condition of the host may, in some manner (especially by lowering local resistance), accelerate the initiation of, or accentuate present, inflammatory periodontal disease. Therefore, it is suggested that the investigations relating host status to periodontal disease be given significant priority. 17. Stookey, G. K., and Katz, S. Chairside procedures for using fluorides for preventing dental caries. Dent. Clin. N. Amer. 16, 681-92 (1972). The caries--preventive value of fluorides is universally recognized by the dental profession. The maximal degree of benefit in the fight against dental caries requires a four-stage, multiple fluoride-treatment program; therapy during the period of tooth formation; a semi-annual prophylaxis; a semi-annual topical application; and home use of ADA-accepted fluoride dentifrices. 18. Tank, G., and Storvick, C. A. Caries experience of children one to six years old in two Oregon communities: Corvallis and Albany: II. relation of fluoride to hypoplasia, malocclusion and gingivitis. J. Amer. Dent. Ass. 70, 100-104 (1965). Children of two Oregon communities participated in this study to investigate the effect of prenatal and postnatal fluoridation on the prevalence and incidence of gingivitis. Two hundred forty-six children aged l-6 participated in this study. The results showed that there was a higher prevalence
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of malocclusion in the fluoride-free area and a significantly higher prevalence and incidence of gingivitis in the fluoride-free area. There was also an observable correlation between these conditions and caries activity. 19. West, E. E. Treatment objectives in the deciduous dentition. Amer. J. Orthodont. 55, 617-32 (1969). The author states, “Early treatment of selected malocclusions in the deciduous dentition offers an opportunity to establish a normal relationship of the facial components with the hope that future growth will proceed in a normal, well-coordinated manner. Removal of the interferences and the restraints of an unsatisfactory dental environment is the best way we can help a patient reach his full genetic growth potential. Alteration of abnormal relationships at this age is possible and most desirable.” Acknowledgment The authors wish to thank Mr. Gary Beringer of the Columbia University School of Public Health for his help in compiling these references.
