B E H A V I O R A L MEDICINE A B S T R A C T S A c a d e m i c Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
256
A m e r i c a n Heart Journal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
256
A m e r i c a n Journal o f Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
257
A m e r i c a n Journal o f Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
258
A m e r i c a n Journal o f Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
261
A m e r i c a n Journal o f Public Health
262
Annals o f Internal Medicine
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..........................................................................
264
Annals o f the R h e u m a t i c Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
264
Archives o f General Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
265
Archives o f Neurology
265
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Archives o f Physical Medicine and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
266
Arthritis Care and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
267
Arthritis and R h e u m a t i s m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
268
Behavioral Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
268
Behaviour Research and T h e r a p y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
269
British Journal o f Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
269
Cephalalgia
.........................................................................................
270
Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
270
Clinical Journal o f Pain
272
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Diabetes Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
274
T h e Diabetes Educator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
274
The Gerontologist
275
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". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
275
H e a d a c h e Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
277
Health Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
277
Heart and Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
280
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
281
International Journal o f Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
281
International Journal o f Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
281
Journal o f A b n o r m a l Child Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
282
Journal o f A b n o r m a l Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
282
Journal o f the A m e r i c a n A c a d e m y o f Child and Adolescent Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
283
Journal o f the A m e r i c a n Dental Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
283
Journal o f the A m e r i c a n Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
284
Journal o f Behavioral Medicine
287
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Journal o f Consulting and Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
288
Journal o f D e v e l o p m e n t a l and Behavioral Pediatrics
289
Journal o f General Internal Medicine
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Journals o f Gerontology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
290 291
Journal o f Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
292
Journal o f Occupational Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
293
Journal o f Pain and S y m p t o m M a n a g e m e n t
294
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254
VOLUME 17, N U M B E R 3, 1995
Journal of Rheumatology
.............................................................................
255
294
The Lancet ..........................................................................................
294
Neurology
296
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New England Journal of Medicine .....................................................................
297
Pain ................................................................................................
297
Pediatric Dentistry ...................................................................................
299
Pediatrics ...........................................................................................
300
Psychological Medicine ...............................................................................
302
Psychology and Health
304
Psychosomatic Medicine
............................................................................... .............................................................................
305
Stress Medicine ......................................................................................
305
Subject Index ........................................................................................
307
had not. To measure consistency in the SPs' performances and accuracy in assessing the physicians' performances, most interactions were audiotaped using a hidden microphone. Pearson chi-square, Fisher exact two-tailed test, and kappa coefficients were used for analysis. Results. Significantly higher ratings were found for the CME physicians in two areas: breast cancer riskfactor determination (determined maternal history: 80% versus 52%, p = .03; determined age at first period: 16% versus 0%, p : .02), and smoking cessation counseling (providing written material: 32% versus 9%, p = .03). The CME physicians were rated higher on all 19 study variables in the target areas of early detection of breast cancer and smoking cessation. The results show that the physicians' performances were better in those areas where the CME program had used performance-based learning, such as role playing or viewing and discussing a videotaped role-play encounter. Conclusion. The educational techniques that rehearsed or portrayed clinical applications seem to have increased the physicians' performances of cancer-control clinical activities. The standardized-patient instrument seems to be particularly useful in evaluating interventions that address specific skills training. Reprint Address: P.A. Carney, Department of Community and Family Medicine, HB 7920, Dartmouth Medical School, Lebanon, NH 03756.
ACADEMIC MEDICINE
173-0409
Stress, Coping, and Well-Being among ThirdYear Medical Students
Mosley Jr., T.H., Perrin, S.G., Neral, S.M., et al. 69(9):765-767, 1994. Background. Medical school is recognized as a stressful environment that often exerts a negative effect on the academic performance, physical health, and psychological well-being of the student. Method. Stress, coping, depression, and somatic distress were examined among 69 third-year students completing a psychiatry clerkship in 1992-93 at the University of Mississippi School of Medicine. Stress was assessed using the Medical Education Hassles Scale--R. Coping was assessed using the Coping Strategies Inventory. Depression was assessed using the Center for Epidemiologic Studies--Depression Scale, and somatic distress was assessed using the Wahler Physical Symptoms Inventory. Statistical methods included correlational analysis and hierarchical regression. Results. Clinical levels of depression were found in 16 (23%) of the students, and 39 (57%) endorsed high levels of somatic distress. Stress accounted for a large percentage of the distress variance (i.e., 29% to 50%). Coping efforts contributed significant variance to the prediction of distress above and beyond that accounted for by stress alone, especially in relation to depression. Coping efforts classified by Engagement strategies were associated with fewer depressive symptoms, while coping efforts classified by Disengagement strategies were associated with higher levels of depressive symptoms. Conclusions. Because students who employed coping efforts characterized by Engagement strategies suffered from fewer depressive symptoms, the results suggest that training in these types of strategies may be a useful intervention to lessen the negative consequences of stress among medical students. Reprint Address: T.H. Mosley, Jr., Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505.
AMERICAN HEART JOURNAL
173-0411
Use of Skin Conductance Changes during Mental Stress Testing as an Index of Autonomic Arousal in Cardiovascular Research
Jacobs, S.C., Friedman, R., Parker, J.D., et al. 128:1170-1177, 1994. Mental stress testing is used to study the cardiovascular changes caused by psychologic stress. To examine the effects of cardiac drugs on mental stress-induced changes, it is useful to attain a degree of arousal that can be replicated in serial studies. Skin conductance level, a cholinergically mediated index of arousal, was assessed for its stability in serial studies and under conditions of~/-blockade. In normal subjects, skin conductance increased in response to mental stress (p < 0.001) and was stable across three sessions. In patients with mild hypertension, skin conductance was elevated during mental stress during both placebo and nadolol therapy (p < 0.001). As expected, nadolol reduced baseline and stress-induced peak arterial pressure and heart rate but had no significant effect on skin conductance. Thus skin conductance level can serve as a stable and useful index of autonomic arousal in clinical trials, even in patients using ~-blocking medications. Reprint Address: S.C. Jacobs, Department of Counseling, University of North Dakota, P.O. Box 8262, Grand Forks, ND 58202-8262.
173-0410
A Standardized-Patient Assessment of a Continuing Medical Education Program to Improve Physicians' Cancer-Control Clinical Skills Carney, P.A., Dietrich, A.J., Freeman Jr., D.H., and Mott, L,A. 70(1):52-58, 1995. Background. Although continuing medical education (CME) has long been used to inform physicians and teach specific skills, its efficacy in many areas is not well established. This randomized controlled trial assessed the effects of differing educational techniques on the cancer-control skills of 57 physicians. Method. The CME program was part of the Cancer Prevention in Community Practice Project in Hanover, New Hampshire, and was implemented in 1988. The program used several methods in its presentation, including interactive small-group discussion, role playing, videotaped clinical encounters, lecture presentations, and trigger tapes. Measurements included cross-sectional observations made by unannounced standardized patients (SPs) who, one year after the CME program, assessed 25 physicians who had participated in the program and 32 physicians who
173-0412
Physical Activity and Mortality in Women in the Framingham Heart Study
Sherman, S.E., D'Agostino, R.B., Cobb, J.L., and Kannel, W.B. 128:879-884, 1994. Men who are more active live longer, but it is not clear if the same is true for women. We monitored 1,404 women aged 256
V O L U M E 17, N U M B E R 3, 1995
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American Heart Journal (continued) 50 to 74 who were free of cardiovascular disease. We assessed physical activity levels and ranked subjects into quartiles. After 16 years, 319 (23%) women had died. The relative risk of mortality, compared to the least active quartile, was as follows: second quartile, 0.95 (95% confidence interval [CI] 0.72 to 1.26); third quartile, 0.63 (95% CI 0.46 to 0.86); most active quartile, 0.67 (95% CI 0.48 to 0.92). The relative risks were not changed by adjustment for cardiac risk factors, chronic obstructive pulmonary disease, or cancer or by excluding all subjects who died in the first 6 years (to eliminate occult disease at baseline). There was no association between activity levels and cardiovascular morbidity or mortality. We conclude that women who were more active lived longer; this effect was not the result of decreased cardiovascular disease. Reprint Address: S.E. Sherman, PACE Center--00PG, Veterans Affairs Medical Center, 16111 Plummer Street, Sepulveda, CA 91343.
173-0413
Does Exercise Reduce Mortality Rates in the Elderly? Experience from the Framingham Heart Study
Sherman, S.E., D'Agostino, R.B., Cobb, J.L., and Kannel, W.B. 128:965-972, 1994. Regular physical activity decreases the mortality rate in middle-aged men and probably in middle-aged women. It is unknown whether this is also true in the elderly. We studied 285 men and women aged 75 years or older who were free of cardiovascular disease. Subjects were ranked by baseline physical activity levels and grouped into quartiles. After adjustments were made for cardiac risk factors, chronic obstructive pulmonary disease, and cancer, women in the second most active quartile had a much lower risk of mortality at 10 years (relative risk 0.24, 95% confidence interval 0.12 to 0.51). There was no statistically significant difference in men. There appeared to be an excess of sudden cardiac deaths in the most active women, although this group still lived longer than the least active women. We conclude that women aged 75 years or older who are more active live longer. This benefit may be attenuated in those who are extremely active. Reprint Address: S.E. Sherman, PACE Center--00PG, Veterans Affairs Medical Center, 16111 Plummer Street, Sepulveda, CA 91343.
AMERICAN JOURNAL OF CARDIOLOGY
173-0414
Effect of Preocclusion Stenosis Severity on Heart Rate Reactions to Coronary Occlusion
Airaksinen, K.E.J., Ik~iheimo, M.J., Peuhkurinen, K.J., et al. 74.'864-868, 1994. Autonomic mechanisms may have an important role in the clinical presentation of acute coronary occlusion. This research was designed to evaluate the effect of preocclusion stenosis severity on the immediate autonomic heart rate (HR) responses to a subsequent acute occlusion of the coronary artery. HR and
its variability in the time and frequency domains were analyzed in patients with mild to moderate (-85%) (group 2, n = 18) left anterior descending coronary artery stenosis immediately before and during balloon occlusion (mean 108 seconds). The ranges of nonspecific responses were determined by analyzing HR reactions in a control group (n = 13) with no ischemia during balloon inflation of a totally occluded coronary artery. An abnormal increase in HR variability and/or bradycardia as a sign of vagal activation occurred in 6 patients (32%) in group 1 and in 3 patients (17%) in group 2. A significant decrease in HR variability or tachycardia, or both, was observed in 5 patients (26%) in group 1, but in none of the patients in group 2. Compared with the control group, the balloon occlusion of mild to moderate stenosis caused abnormal HR reactions more often than did occlusion of tight stenosis (58% vs 17%, p < 0.05). Balloon occlusions in group 1 caused chest pain (I3 < 0.01), ST-segment changes (p < 0.001), and narrowing of pulse pressure (p < 0.05) more often than did occlusions of severe stenoses. Severe chest pain also resulted more often (p < 0.01) in a premature deflation of the balloon in group 1. Thus, patients with mild coronary stenosis often develop abnormal autonomic responses to a subsequent acute coronary occlusion, which may modify the clinical presentation of the acute occlusion. On the other hand, if a severe coronary artery stenosis occludes, autonomic responses are rare, possibly due to chronic ischemic preconditioning or better collateral development. Reprint Address: K.E.J. Airaksinen, Division of Cardiology,Department of Medicine, Oulu University Hospital, 90220 Oulu, Finland.
173-0415
Risk Factors for Exercise-Induced Silent Myocardial Ischemia in Healthy Volunteers
Katzel, L.I., Sorkin, J.D., Colman, E., et al. 74:869-874, 1994. This study determined the risk factors for exercise-induced silent ischemia (SI) in 281 apparently healthy volunteers aged 40 to 87 years and compared their risk factor profiles with those of 132 patients with overt coronary artery disease (CAD). SI (concordant exercise-induced asymptomatic ST-segment depression on" electrocardiography and perfusion defects on tomographic thallium-201 scintigraphy) was detected in 37 of 225 men (16%), versus 2 of 56 women (4%, p < 0.05). The prevalence of SI increased with age from 6% in men aged < 55 years to 18% in men aged 55 to 70 years, and to 25% in men aged >70 years (p < 0.001). Compared with the 118 men with concordant normal exercise electrocardiogram and thallium scan (normals), men with SI were older (p < 0.001), and had a higher waist-to-hip ratio (p < 0.005), higher plasma triglyceride levels (p < 0.001), and lower high-density lipoprotein (HDL) cholesterol levels (p < 0.001). In stepwise logistic regression analysis, age, waist-to-hip ratio, and HDL levels were independent predictors of SI in men. Compared with 108 men with overt CAD, men with SI were younger (67 _+ 2 vs 73 __ 1 years, p < 0.001) but had similar plasma lipids and waist-to-hip ratio. Thus, older age, male gender, abdominal obesity, and reduced HDL levels-all well-established risk factors for overt CAD--were risk factors for exercise-induced SI in these asymptomatic volunteers. Reprint Address: L.I. Katzel, Baltimore Veterans AffairsMedical Center, Geriatrics Service (18), 10 North Greene Street, Baltimore, MD 21201.
258
A N N A L S OF BEHAVIORAL M E D I C I N E
American Journal of Cardiology (continued) 173-0416
Gender Differences in the Utilization of Cardiac Catheterization for the Diagnosis of Chest Pain Vaitkus, P.T. 75:79-81, 1995. Reprint Address: P.T. Vaitkus, Cardiology Unit, 1-McClure, Medical Center Hospital of Vermont, 111 Colchester Avenue, Burlington, VT 05401. 173-0417
Reproducibility of Power Spectral Measures of Heart Rate Variability Obtained from ShortTerm Sampling Periods Freed, L.A., Stein, K.M., Gordon, M., Urban, M., and Kligfield, P. 74:972-973, 1994. Reprint Address: P. Kligfield, 525 East 68th Street, New York, NY 10021.
AMERICAN JOURNAL OF EPIDEMIOLOGY
173-0418
Parity, Contraception, Infertility, and the Risk of Epithelial Ovarian Cancer Risch, H.A., Marrett, L.D., and Howe, G.R. 140(7):585-597, 1994. A case-control study of reproductive factors and cancer of the ovary was conducted during 1989-1992 in metropolitan Toronto and nearby areas of Southern Ontario, Canada. In total, 450 women aged 35-79 years with histologically verified new primary epithelial ovarian cancers were interviewed concerning their reproductive histories. Over the same time period, 564 randomly selected population controls, frequency-matched to the cases according to three 15-year age groups, were also interviewed. Continuous unconditional logistic regression methods were used for analysis. It was found that childbearing and use of oral contraceptives were associated with significant decreasing trends in risk of ovarian cancer; the respective odds ratios were 0.78 for each full-term pregnancy (p < 10 -8) and 0.92 for each year of use (p < 10-6). Hysterectomy was also associated with reduced risk, even after more than 20 years. Among parous women, infertility did not appear to affect risk; for nulliparous women, some evidence of increased risk was present, although fertility problems were reported by only a small fraction of nuUiparae. It is suggested that the relatively lower parity of cases as compared with controls may be due to voluntary choices for having fewer children. Reprint Address: H.A. Risch, Department of Epidemiology and Public Health, Yale University School of Medicine, 60 College Street, P.O. Box 3333, New Haven, CT 06510. 173-0419
Alcohol Consumption and Breast Cancer: Estrogen Receptor Status and Histology Nasca, P.C., Liu, S., Baptiste, M.S., et al. 140(11):980-987, 1994. Data from a case-control study conducted in New York State during 1982-1984 were used to evaluate the relation between alcohol consumption and estrogen receptor-positive and estrogen receptor-negative breast cancers and alcohol and var-
ious histologic subtypes. The cases were women between 20 and 79 years of age with a diagnosis of primary breast cancer. A total of 794 estrogen receptor-positive and 358 estrogen receptor-negative breast cancer cases were available for study. Controis (n = 1,617) were selected from driver's license files of the New York State Department of Motor Vehicles. Information on estrogen receptor status and histology was obtained from hospital records. The risk of estrogen receptor-positive breast cancer was shown to increase with increasing amounts of alcohol consumption in grams per day (odds ratio (OR) = 1.18 (95% confidence interval (CI) 0.88-1.57) for < 1.5 g/day, 1.28 (95% CI 0.91-1.80) for 1.5--4.9 g/day, 1.28 (95% CI 0.96-1.70) for 5.0-14.9 g/day, and 1.35 (95% CI 0.99-1.85) for -> 15.0 g/day). There was no relation between alcohol consumption and estrogen receptor-negative tumors (OR = 0.92 (95% CI 0.62-1.36) for < 1.5 g/day, 1.19 (95% CI 0.77-1.83) for 1.5--4.9 g/day, 0.94 (95% CI 0.64-1.35) for 5.0-14.9 g/day, and 1.05 (95% CI 0.701.59) for >--15.0 g/day). The risk for each of the histologic subtypes studied increased with increasing daily alcohol consumption. These findings suggest that alcohol may only increase a woman's risk of estrogen receptor-positive breast cancers. Reprint Address: P.C. Nasca, School of Public Health and Health Sciences, University of Massachusetts, Room 406, Arnold House, Amherst, MA 01003-0430.
173-0420
Case-Control Study of Caffeinated Beverages and Preterm Delivery Pastore, L.M. and Savitz, D.A. 141(1):6t-69, 1995. Although many women reduce their caffeine consumption once they know they are pregnant, 70-80% of pregnant women still consume caffeine. To evaluate the relation between caffeine consumption and preterm delivery, a case-control study was conducted to identify all preterm (< 37 weeks gestation) infants born to women in selected North Carolina counties from September 1988 through April 1991. Randomly selected full-term, normal-weight livebirths (matched by race and hospital) served as controls. The study population consisted of 408 cases and 490 controls. Telephone interviews with participants assessed the consumption of caffeinated coffee, tea, cola soft drinks, and noncola caffeinated soft drinks, with caffeine consumption measured by the number of daily servings of each beverage and the total milligrams of caffeine. Third-trimester caffeine consumption from all beverages combined showed a nonsignificant inverse association with preterm delivery. Both first- and secondtrimester consumption of 1-150 mg/day were associated with a modestly increased risk of preterm delivery, while no association was found at higher consumption levels. Overall, these results do not support an association between caffeinated beverage consumption and preterm delivery, as is true in most previous studies. Reprint Address."D.A. Savitz, School of Public Health, Epidemiology Department, CB #7400, University of North Carolina, Chapel Hill, NC 27599. 173-0421
Use of Sunbeds or Sunlamps and Malignant Melanoma in Southern Sweden Westerdahl, J., Olsson, H., M/lsb/ick, A., et al. 140(8):691--699, 1994. In a population-based, matched case-control study from the South Swedish Health Care Region, which has the highest
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259
American Journal of Epidemiology (continued) risk for melanoma in Sweden, the relation between the use of sunbeds or sunlamps and malignant melanoma was investigated. Between July 1, 1988, and June 30, 1990, a total of 400 melanoma patients and 640 healthy controls aged 15-75 years answered a comprehensive questionnaire containing different epidemiologic variables. Questions regarding the use of sunbeds or sunlamps were included. The odds ratio for developing malignant melanoma after ever having used sunbeds or sunlamps was 1.3. Considering all age groups, the odds ratio was significantly elevated after exposure more than 10 times a year to sunbeds or sunlamps (odds ratio (OR) = 1.8). When the study was restricted to patients and controls younger than age 30 years because the use of tanning devices is much more common among young persons, the odds ratio was higher (OR = 7.7 for more than 10 times a year vs. none). These findings were independent of constitutional factors and factors regarding sun exposure. A dose-response relation was evident. Furthermore, among melanoma patients in this young age group, the ratio of females to males was significantly higher than in older patients. When different melanoma presentation sites were considered, only lesions of the trunk were significantly associated with sunbed or sunlamp use (OR = 4.2 for more than 10 times a year vs. none). Reprint Address:J. Westerdahl, Department of Surgery,University Hospital, S-221 85 Lund, Sweden.
173-0422
Risk Factors for Cervical lntraepithelial Neoplasia: Differences between Low- and HighGrade Lesions
Brisson, J., Morin, C., Fortier, M., et al. 140(8):700-710, 1994. This case-control study assesses relations of human papillomavirus (HPV) type 16 infection, sexual history, cigarette smoking, and oral contraceptive use to low- and high-gradc cervical intraepithelial neoplasia (CIN). A total of 548 highgrade and 338 low-grade CIN cases and 612 controls were identified among women seen at a colposcopy clinic in Quebec, Canada, in 1988-1989. Interviews, colposcopy, cervical scrapings, and colposcopically directed biopsies were performed. One pathologist reviewed all histologic slides. Southern blot techniques were used to assay specimens for HPV 16 DNA. Lifetime number of sexual partners was related to low- and high-grade CIN. Presence of HPV 16 DNA was associated with a 8.7-fold (95% confidence interval 5.l-l 5.0) elevation is estimated relative risk of high-grade CIN. Relative risk of high-grade CIN increased with amount of HPV 16 DNA (p < 0.0001). Estimated relative risk of high-grade CIN in current cigarette smokers was 2.4 (95% confidence interval 1.8-3.2) compared with never smokers and increased with number of pack-years of exposure (p < 0.0001). Long-term (6 years or more) users of oral contraceptives had an estimated relativc risk ofhigh-grade CIN of 1.9 (95% confidence interval 1.1-3.3) compared with those who never used such contraceptives. In contrast, presence of HPV 16 DNA, cigarette smoking, and oral contraceptive use showed little or no relation to low-grade CIN. Risk factors for low- and high-grade CIN may differ substantially. Reprint Address: J. Brisson, Epidemiology Research Unit, H6pital du Saint-Sacrement, 1050, Chemin Ste-Foy, Quebec, PQ GIS 4L8, Canada.
173-0423
Physical Activity and Stroke Risk: The Framingham Study
Kiely, D.K., Wolf, P.A., Cupples, L.A., Beiser, A.S., and Kannel, W.B. 140(7):608-620, 1994. The authors prospectively examined the influence of increased levels of physical activity on risk of stroke in members of the Framingham Study cohort. Two separate analyses were performed, one during midlife in 1,897 men (mean age = 49.7 years) and 2,299 women (mean age = 49.9 years) and another when the cohort was older (1,361 men (mean age = 63.0) and 1,862 women (mean age = 63.7)). A structured questionnaire administered at two separate examinations was used to estimate the amount of metabolic work done during a typical 24-hour period. Physical activity was categorized into tertiles, and medium and high levels of physical activity were compared with a low level of physical activity, which was used as the referent group. Cox proportional hazards, life table, and time-dependent covariate analyses were used to examine the relation between level of physical activity and stroke risk over a follow-up period of up to 32 years. In men, adjusted analyses revealed that increased levels of physical activity were protective. The strongest effect was obtained from an analysis involving older cohort members in the medium tertile (risk ratio = 0.41, 95% confidence interval 0.24-0.69). High levels of physical activity did not confer an additional benefit over medium levels. Adjusted analyses showed no significant protective effect in women. These results indicate that medium and high levels of physical activity among men are protective against stroke relative to low levels. Reprint Address: P.A. Wolf, Department of Neurology, Boston University School of Medicine, 80 East Concord Street, B-608, Boston, MA 02118-2334.
173-0424
A Prospective Study of Alcohol Intake and Change in Body Weight among U.S. Adults
Liu, S., Serdula, M.K., Williamson, D.F., Mokdad, A.H., and Byers, T. 140(10):912-920, 1994. Little is known about the role of alcohol in determining change in body weight. In this paper, the authors examine the relation between alcohol intake and body weight in 7,230 US adults aged 25-74 years who participated in the First National Health and Nutrition Examination Survey (1971-1975) and who were reweighed 10 years later (1982-1984). Both cross-sectional and prospective analyses were adjusted for age, race, height, education, health status, smoking status, diet status, physical activity, and total nonalcoholic caloric intake. At baseline, women who reported at least one drink per day weighed 2.3 kg less than nondrinkers (95% confidence interval (CI) - 0 . 4 to -4.2). Little relation was observed between body weight and alcohol intake cross-sectionally among men. Prospectively, both men and women drinkers tended to gain less weight than did nondrinkers (p = 0.006 for trend in women, p = 0.11 for trend in men). Drinkers also had more stable weight over the 10-year followup period. Drinkers were less likely to have major weight gain or loss (gaining or losing >- l0 kg) than were nondrinkers. Compared with nondrinkers, for those who consumed 1-6.9 drinks per week, women had an odds ratio (OR) = 0.7 (95% CI 0.5 to 0.9) for major weight gain and an OR = 0.7 (95% CI 0.5 to 1.1) for major weight loss, while men had an OR = 1.0 (95% CI 0.6 to 1.6) for major weight gain and an OR = 0.7 (95% CI 0.5 to
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American Journal of Epidemiology (continued) 1.2) for major weight loss. For those who consumed >2 drinks per day, women had an OR = 0.5 (95% CI 0.3 to 1.0) for major weight gain and an OR = 0.8 (95% CI 0.4 to 1.6) for major weight loss, while men had an OR = 0.9 (95% CI 0.5 to 1.6) for major weight gain and an OR = 1.0 (95% CI 0.6 to 1.7) for major weight loss. These data suggest that alcohol intake does not increase the risk of obesity. Reprint Address: S. Liu, Division of Nutrition (K-26), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341-3724.
Parent Monitoring and the Incidence of Drug Sampling in Urban Elementary School Children Chilcoat, H.D., Dishion, T.J., and Anthony, J.C. 141(1):25-31, 1995. An epidemiologic study of urban-dwelling children aged 8I0 years in Baltimore, Maryland, was undertaken to test the hypothesis that close monitoring and supervision by parents might signal a reduced risk of drug use in the elementary school years. Drug use, monitoring by parents, peer drug use, and other suspected risk factors for early drug use were first assessed in 1989, identifying 947 children with no prior history of drug use. One year later, 4.2 percent of these children were found to have started using alcohol, tobacco, or other drugs on their own for the first time during the follow-up observation interval. Risk of starting drug use was higher for children with lower levels of parent monitoring (relative risk = 4.39, 95% confidence interval 1.48-13.0). In addition, for children with declining levels of parent monitoring, there was an increased risk of starting to use drugs on their own. Reprint Address: H.D. Chilcoat, Henry Ford Health Science Center, Department of Psychiatry, 1 Ford Place, Detroit, MI 48202.
adjustment for smoking, serum cholesterol, and blood pressure, the hazard rate ratio was 0.74 (95% CI 0.54-1.02). Among women, the corresponding hazard rate ratios were 0.49 (95% CI 0.21-1.12) and 0.73 (95% CI 0.30-1.71), respectively. Therefore, it can be estimated that in both sexes nearly half of the decrease in coronary mortality hazard was associated with the changes in risk factors. The fall in serum cholesterol level among men and the decrease in blood pressure among women contributed most of the decrease in coronary mortality hazard. Reprint Address: P. Jousilahti, National Public Health Institute, Department of Epidemiology and Health Promotion, Mannerheimintie 166, FIN-00300 Helsinki, Finland.
173-0425
173-0426
Effect of Risk Factors and Changes in Risk Factors on Coronary Mortality in Three Cohorts of Middle-Aged People in Eastern Finland Jousilahti, P., Vartiainen, E., Toumilehto, J., Pekkanen, J., and Puska, P. 141(1):50-60,1995. The association of smoking, serum cholesterol, and blood pressure with coronary mortality and the contribution of changes in these risk factors to the decline in coronary mortality was assessed in three cohorts of middle-aged population examined in 1972, 1977, and 1982 in Eastern Finland. A total of 10,758 men and 11,112 women were included in this study. The followup time of each subject was 8 years. Age-adjusted coronary mortality decreased from 54 per 10,000 person-years in the 1972 cohort to 30 per 10,000 person-years in the 1982 cohort among men and from eight per 10,000 person-years to four per 10,000 person-years among women in the 1972 and 1982 cohorts, respectively. Concomitantly with the decrease in coronary mortality, there was a marked decrease in cardiovascular risk factors. Among men, the age- and geographic area-adjusted hazard rate ratio of coronary mortality between 1972 and 1982 cohorts was 0.52 (95% confidence interval (CI) 0.38-0.72). After further
173-0427
A Population-Based Case-Cohort Evaluation of the Efficacy of Mammographic Screening for Breast Cancer Thompson, R.S., Barlow, W.E., Taplin, S.H., et al. 140(10):889-901, 1994. Screening efficacy may be evaluated in population-based, observational studies, provided one addresses biases that arise in nonrandomized screening evaluations. The authors evaluated the association of mammographic screening with breast cancer mortality among women without prevalent breast cancer. The cohort consisted of 94,656 women, aged >--40years, enrolled in a large health maintenance organization in Washington State during the period 1982-1988. A case-cohort design limited chart abstraction of risk factor and screening information to 4% of the cohort. There were 1,144 incident breast cancer cases, including 126 who died of breast cancer during the study interval. An age-stratified proportional hazards analysis compared the screening experience of the breast cancer deaths with that of 2,237 controls. The family history of breast cancer, previous biopsy, and parity were included in the model to control for potential confounding effects of selection bias. With a mean follow-up of only 3.5 years postscreening, there was a small but statistically nonsignificant reduction in the risk of breast cancer mortality among women screened 1 year prior to diagnosis compared with unscreened women. The relative risk was 0.80 (95% confidence interval 0.34-1.85) for women aged _>40 years and 0.61 (95% confidence interval 0.23-1.62) for women aged _>50 years. This paper illustrates how case-cohort methodology can be used to perform efficient assessment of screening efficacy in large cohorts, while eliminating or controlling for sources of bias. ReprintAddress:R.S. Thompson, Department of Preventive Care, Group Health Cooperative of Puget Sound, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.
173-0428
Risk of Premenopausal Breast Cancer and Use of Electric Blankets Vena, J.E., Freudenheim, J.L., Marshall, J.R., et al. 140(11):974-979, 1994. Electric blanket use, estimated to significantly increase background exposure to 60-Hz electromagnetic fields, has been
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American Journal of Epidemiology (continued) hypothesized to increase breast cancer risk. From 1986 to 1991 in western New York State, the authors investigated the use of electric blankets as a risk factor for breast cancer in a casecontrol study of premenopausal women. A total of 290 premenopausal breast cancer cases and 289 age-matched randomly selected community controls were queried in regard to their use of electric blankets in the previous 10 years, including frequency of use in season and mode of use. After adjusting for age, education, and other risk factors, the odds ratio for use of an electric blanket at any time in the previous 10 years (40% of cases and 37% of controls) was 1.18 (95% confidence interval (CI) 0.83-1.68). Estimates of risk did not differ in a dose-response fashion for number of years of electric blanket use. The risk associated with daily use in season relative to nonuse was 1.27 (95% CI 0.86-1.88). The risk of breast cancer among those who reported use of the blanket through the night was 1.43 (95% CI 0.94-2.17). However, the risk for those who reported daily use in season, continuously throughout the night for the previous 10 years was 1.10 (95% CI 0.59-2.05). These findings do not support the hypothesis that electric blanket use is associated with an increased risk for breast cancer. Studies with improved measures of more highly exposed individuals with quantification of total electromagnetic field exposure might clarify the uncertainties regarding risk of breast cancer associated with such exposure. Reprint Address:J.E. Vena, Department of Social and Preventive Medicine, SUNY, 270 Farber Hall, 3435 Main Street, Buffalo, NY 14214.
173-0429
Cigarette Smoking: An Independent Risk Factor for Impotence? Mannino, D.M., Klevens, R.M., and Flanders, W.D. 140(11):1003-1008, 1994. The authors sought to determine whether current cigarette smoking was associated with impotence among middle-aged men. This is a secondary analysis of a cross-sectional survey of 4,462 US Army Vietnam-era veterans aged 31-49 years who took part in the Vietnam Experience Study in 1985-1986. The main outcome measurement was the odds ratio for reported impotence, which was calculated by comparing current smokers with nonsmokers while controlling for multiple confounders. The study sample consisted of 1,162 never smokers, 1,292 former smokers, and 2,008 current smokers. The prevalence of impotence was 2.2% among never smokers, 2.0% among former smokers, and 3.7% among current smokers (p = 0.005). The unadjusted odds ratio (OR) of the association between smoking and reported impotence was 1.8 (95% confidence interval (CI) 1.2-2.6). The association held even after adjustments were made for confounders, including vascular disease, psychiatric disease, hormonal factors, substance abuse, marital status, race, and age (OR = 1.5, 95% CI 1.0-2.2). Neither years smoked nor cigarettes smoked daily were significant predictors of impotence in current smokers. The authors concluded that, among the men in this study, a higher percentage of cigarette smokers reported impotence than did nonsmokers. This observation could not be totally explained by comorbidity factors related to smoking. Reprint Address: D.M. Mannino, National Center for Environmental Health, CDC, MS-F39, 4770 Buford Highway NE, Atlanta, GA 303413724.
AMERICAN JOURNAL OF PSYCHIATRY
173-0430
Prevalence and Correlates of Dysthymia and Major Depression among Patients with Alzheimer's Disease Migliorelli, R., Tes6n, A., Sabe, L., et al. 152(1):37--44, 1995. Objective: The purpose of this study was to examine the prevalence, risk factors, and correlates of depression among patients with Alzheimer's disease. Method: A consecutive series of 103 patients with probable Alzheimer's disease were examined with a structured psychiatric interview and were assessed for the presence of cognitive impairments, deficits in activities of daily living, social functioning, and anosognosia. Results: Fifty-one percent of the patients had depression (28% had dysthymia and 23% major depression). Women had a significantly higher prevalence ofboth major depression and dysthymia than men. Depressed and nondepressed patients had a similar frequency of family and personal histories of depression, a similar frequency of personality disorders before the onset of depression, and no significant differences in cognitive deficits and impairment in activities of daily living. Dysthymia usually started after the onset of dementia and was significantly more prevalent in the early stages of dementia; patients with dysthymia had a significantly better awareness of intellectual deficits than patients with major or no depression. On the other hand, patients with major depression had an earlier onset of depression (half of them before the onset of dementia), and the prevalence of major depression was similar across the different stages of the illness. Conclusions: This study demonstrates a high prevalence ofdysthymia and major depression among patients with probable Alzheimer's disease. While dysthymia may be an emotional reaction to the progressive cognitive decline, major depression may be related to biological factors. Reprint Address: S.E. Starkstein, Rafil Carrea Institute of Neurological Research, Montafieses 2325, 1428 Buenos Aires, Argentina.
173-0431
Sleep Events among Veterans with CombatRelated Posttraumatic Stress Disorder Mellman, T.A., Kulick-Bell, R., Ashlock, L.E., and Nolan, B. 152(1):110-115, 1995. Objective: Sleep disturbances are important features of posttraumatic stress disorder (PTSD); however, the published data characterizing PTSD sleep phenomena are limited. The authors report on the phenomenology and physiological correlates of symptomatic sleep events in PTSD. Method: The study data included survey results that addressed sleep symptoms during the past month in combat veterans with and without PTSD (N = 58), sleep diary records of awakenings from combat veterans with PTSD hospitalized on an inpatient rehabilitation unit (N = 52), and overnight polysomnography recordings obtained from 21 medication-free combat veterans with PTSD and eight healthy comparison subjects not exposed
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American Journal of Psychiatry (continued) to combat. Results: Recurrent awakenings, threatening dreams, thrashing movements during sleep, and awakenings with startle or panic features represented the most prevalently reported sleeprelated symptoms. Laboratory findings of longer time awake, micro-awakenings, and a trend for patients to exhibit body and limb movements during sleep are consistent with the subjectively reported symptom profile. Prospectively assessed symptomatic awakenings featured startle or panic symptoms or anxiety related to threatening dreams. Laboratory findings revealed a trend for the symptomatic awakenings (with and without dream recall) to be disproportionately preceded by REM sleep, and the two recorded awakenings with objective physiological arousal were preceded by REM. Conclusions: PTSD features intrusions into sleep of more highly aroused behaviors and states, which appear partially conditioned to REM sleep. Reprint Address:T.A. Mellman, Miami VA Medical Center, Psychiatry Service 116A, 1201 16th Street, Miami, FL 33125.
173-0432
Subthreshold Depression and Depressive Disorder: Clinical Characteristics of General Medical and Mental Health Specialty Outpatients
Sherbourne, C.D., Wells, K.B., Hays, R.D., et al. 151(12):1777-1784, 1994. Objective: The authors examined the clinical significance of depressive symptoms below the threshold for depressive disorder in outpatient samples. Method: The subjects were 775 adult patients with current depressive disorder, 1,420 patients with subthreshold depression, and 1,767 hypertensive patients with and without depression, all of whom were visiting the offices of mental health specialists and general medical care providers in three U.S. cities. Data on demographic characteristics, severity of depression, extent of psychiatric and medical comorbidity, family psychiatric history, and treatment history for the patients with depressive disorder and those with subthreshold depression were compared. Results: The percentage of patients with subthreshold depression who had a family history of depression (41%) was nearly as high as that of the patients with depressive disorder (59%). The two groups of patients had similar levels ofmedical and psychiatric comorbidity except for anxiety disorders, which were greater among the patients with depressive disorder. Among the hypertensive patients in the general medical sector, those with subthreshold depression were more similar to those with depressive disorder than to the nondepressed hypertensive patients. Treatment rates were considerably lower for patients with subthreshold depression than for patients with depressive disorder in the general medical sector, but they were similar in the mental health specialty sector. Conclusions: In these outpatients, subthreshold depression appeared to be a variant of affective disorder and was treated as such in the mental health specialty sector but not in the general medical sector. The findings emphasize the importance of treatment outcome studies of patients with subthreshold depression. Reprint Address: C.D. Sherbourne, RAND, 1700 Main Street, Santa Monica, CA 90407-2138.
AMERICAN JOURNAL OF PUBLIC HEALTH
173-0433
Does the Promotion and Distribution of Condoms Increase Teen Sexual Activity? Evidence from an HIV Prevention Program for Latino Youth
Sellers, D.E., McGraw, S.A., and McKinlay, J.B. 84(12): 1952-1959, 1994. Objectives. Opponents of condom availability programs argue that the promotion and distribution of condoms increases adolescent sexual activity. This assertion was tested empirically with data from the evaluation of a human immunodeficiency virus (HIV) prevention program for Latino adolescents. Methods. The onset of sexual activity, changes in the frequency of sex, and changes in the proportion of respondents with multiple partners were compared for intervention and comparison groups. MuLtivariate regression analysis was used to assess the effect of the intervention on these outcomes after adjustment for baseline differences between the intervention and comparison groups. Results. Male respondents in the intervention city were less likely than those in the comparison city to initiate first sexual activity (odds ratio [OR] = 0.08). Female respondents in the intervention city were less likely to have multiple partners (OR = 0.06). The program promoting and distributing condoms had no effect on the onset of sexual activity for females, the chances of multiple partners for males, or the frequency of sex for either males or females. Conclusions. An HIV prevention program that included the promotion and distribution of condoms did not increase sexual activity among the adolescents in this study. Reprint Address: J.B. McKinlay, New England Research Institute, 9 Galen Street, Watertown, MA 02172.
173-0434
Recruitment Activities and Sociodemographic Factors That Predict Attendance at a Mammographic Screening Program Hurley, S.F., Huggins, R.M., Jolley, D.J., and Reading, D. 84(10):!655-1658, 1994. A random sample of 2266 women aged 50 to 69 years was used to investigate factors that predict attendance at a free Australian mammographic screening program. The most important predictor was receipt of a personal invitation letter. A letter that included an appointment time increased attendance 132-fold initially and decreased to 20 times baseline after 14 days. A letter that did not include an appointment time increased attendance 12-fold, and a second letter to nonattenders increased attendance approximately 13-fold. Attendance declined with increasing distance from the program and with increases in the percentage of non-English speaking women in a neighborhood, but was higher in areas of higher socioeconomic status. Reprint Address: S.F. Hurley, Department of Public Health and Community Medicine, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053, Australia.
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American Journal of Public Health (continued) 173-0435
Seat Belt Use among Drinking Drivers in Minnesota
Foss, R.D., Beirness, D.J., and Sprattler, K. 84(11):1732-1737, 1994. Objectives. Among the reasons cited for recent declines in alcohol-related traffic fatalities is the enactment of seat belt use laws by most states. It is suspected that drinking drivers are less likely to comply with such laws, although evidence on the relationship between belt use and drinking by drivers is sparse and conflicting. The purpose of this study was to examine the relationship of drinking to driver seat belt use. Methods. Observational, self-report, and chemical breath test data were collected on nighttime drivers in 16 Minnesota communities during September, 1990. Results. Drivers with an illegal blood alcohol concentration (_> 100 mg/dL) were substantially less likely to be wearing a seat belt (odds ratio [OR] = 2.17). Belt use was also more common among females (OR = 2.02) and before midnight (OR = 1.47). Males who had been drinking were less likely to be belted. Belt use was related to drinking before, but not after, midnight. Belt use was not related to drinking status among college graduates, but it was strongly related to drinking status among those with less education. Conclusions. The present findings provide further argument for rapid implementation of passive countermeasures (airbags) and for development of creative, carefully focused interventions to target high-risk populations. Reprint Address: R.D. Foss, UNC Highway Safety Research Center, 1341/2 East Franklin Street, CB #3430, Chapel Hill, NC 27599-3430.
173-0436
Health Care-Seeking Behavior Related to the Transmission of Sexually Transmitted Diseases in Kenya
Moses, S., Ngugi, E.N., Bradley, J.E., et al. 84(12): 1947-1951, 1994. Objectives. The purpose of this study was to identify healthcare seeking and related behaviors relevant to controlling sexually transmitted diseases in Kenya. Methods. A total of 380 patients with sexually transmitted diseases (n = 189 men and 191 women) at eight public clinics were questioned about their health-care seeking and sexual behaviors. Results. Women waited longer than men to attend study clinics and were more likely to continue to have sex while symptomatic. A large proportion of patients bad sought treatment previously in both the public and private sectors without relief of symptoms, resulting in delays in presenting to study clinics. For women, being married and giving a recent history of selling sex were both independently associated with continuing to have sex while symptomatic. Conclusions. Reducing the transmission of sexually transmitted diseases in Kenya will require improved access, particularly for women, to effective health services, preferably at the point of first contact with the health system. It is also critical to encourage people to reduce sexual activity while symptomatic, seek treatment promptly, and increase condom use. Reprint Address: S. Moses, Department of Community Health, University of Nairobi, P.O. Box 19676, Nairobi, Kenya.
173-0437
Weight Control Practices in Adults: Results of a Multistate Telephone Survey Serdula, M.K., Williamson, D.F., Anda, R.F., et al. 84(11):1821-1824, 1994. In this study, data collected in 1989 in a random-digit dialing telephone survey of 60,590 adults in 38 states and the District of Columbia were analyzed. Approximately 38% of women and 24% of men reported that they were currently trying to lose weight. Methods reported were counting calories (24% of women, 14% of men), participating in organized weight loss programs (10%, 3%), taking special supplements (10%, 7%), taking diet pills (4%, 2%), and fasting for 24 hours or longer (5%, 5%). Among both sexes, only half of those trying to lose weight reported using the recommended method of caloric restriction combined with physical activity. Reprint Address: M.K. Serdula, Division of Nutrition (K26), Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341-3724. 173-0438
Mother-Daughter Correlations of Obesity and Cardiovascular Disease Risk Factors in Black and White Households: The NHLBI Growth and Health Study Morrison, J.A., Payne, G., Barton, B.A., Khoury, P.R., and Crawford, P. 84(11):1761-1767, 1994. Objectives. This study sought to evaluate obesity as a potential explanatory factor for the increased relative risk for cardiovascular disease in Black compared with White women. Methods. Familial associations for obesity and cardiovascular disease risk factors were assessed in 720 White and 580 Black mother-daughter pairs from the National Heart, Lung, and Blood Institute's Growth and Health Study by using Pearson's chi square, Spearman's correlations, and partial correlations. Results. Black girls and mothers were significantly heavier and had higher body mass indices than their White counterparts. In each racial group, significant, positive mother-daughter correlations existed for weight, body mass index, and triceps skinfolds, and for all cardiovascular disease risk factors. Obesity measures correlated positively with systolic blood pressure and triglycerides and inversely with high-density lipoprotein cholesterol in girls and mothers of both races. Correlations between mothers and daughters for exercise and ideal body shape were weak and did not explain obesity associations. Conclusions. Intrafamilial associations of obesity, cardiovascular disease risk factors, and the obesity-cardiovascular disease risk factor relationship support the position that increased cardiovascular disease morbidity and mortality rates in Black women may be linked to excess obesity in Black women compared with White ones. Reprint Address: B.A. Barton, Maryland Medical Research Institute, 600 Wyndhurst Avenue, Baltimore, MD 21210. 173-0439
Factors Mediating Changes in Sexual HIV Risk Behaviors among Gay and Bisexual Male Adolescents Rotheram-Borus, M.J., Reid, H., and Rosario, M. 84(12):1938-1946, 1994. Objectives. Factors mediating changes in sexual behaviors that increase the risk of human immunodeficiency virus (HIV)
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American Journal of Public Health (continued) infection were monitored in a group of gay and bisexual male adolescents. Methods. One hundred thirty-six males aged 14 to 19 years (Hispanic, 51%; African-American, 31%) were recruited from one gay-identified agency, were assessed at four points over a 1-year period, and participated in HIV preventive intervention sessions. Results. Significant reductions occurred in the number of unprotected same-sex anal and oral acts. Those with less risk in their previous sexual history, those who did not engage in commercial sex, and those who attended more HIV intervention sessions were more likely to reduce their sexual risk. The impact of sessions varied significantly by race/ethnicity: African-American youths reduced their risk acts most dramatically. Abstinence was consistently and significantly more likely among younger youths and those who had been abstinent before enrollment. The youths significantly reduced the number of sexual partners following the intervention; this reduction in partners was maintained through the 12-month follow-up and was greatest among youths with no involvement in commercial sexual activity (prostitution). Conclusions. The efficacy of HIV prevention programs must be empirically evaluated. Reprint Address:M.J. Rotheram-Borus, Division of Social Psychiatry, Neuropsychiatric Institute, University of California, 10920 Wilshire Boulevard, Suite 1103, Los Angeles, CA 90024.
ANNALS OF INTERNAL MEDICINE
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Predictors of Automobile Crashes and Moving Violations among Elderly Drivers Marottoli, R.A., Cooney Jr., L.M., Wagner, D.R., Doucette, J., and Tinetti, M.E. 121:842-846, 1994. Objective: To identify the factors associated with automobile crashes, moving violations, and being stopped by police in a cohort of elderly drivers. Design: Prospective cohort study. Setting: Urban community. Participants: All 283 persons who drove between 1990 and 1991, selected from a representative cohort of community-living persons aged 72 years and older in New Haven, Connecticut. Measurements: Data on independent variables in five domains (demographic, health, psychosocial, activity, and physical performance) were collected in structured interviews before events occurred. The outcome measure was the self-report of involvement in automobile crashes, moving violations, or being stopped by police in a 1-year period. Results: Of the 283 drivers, 13% reported a crash, a moving violation, or being stopped by police in 1 year. The baseline factors associated with the occurrence of adverse events in multivariable analysis (with adjustment for driving frequency and housing type) were the following: poor design copying on the MiniMental State Examination (relative risk, 2.7; 95% CI, 1.5 to 5.0), fewer blocks walked (relative risk, 2.3; CI, 1.3 to 4.0), and more foot abnormalities (relative risk, 1.9; CI, 1.1 to 3.3). These risk factors were combined for assessment of their ability to predict the occurrence of adverse driving events. If no factors were present, 6% of drivers had events; if 1 factor was present, 12% had events; if 2 factors were present, 26% had events; and
if 3 factors were present, 47% had events. Conclusions: In this urban population, several simple clinical measures correlated with the risk for adverse driving events. 173-0441
Estrogen Replacement Therapy and Fractures in Older Women
Cauley, J.A., Seeley, D.G., Ensrud, K., et al. 122:9-16, 1995. Objective: To determine the relation between estrogen replacement therapy and fractures. Design: Prospective cohort study. Setting: Four clinical centers in Baltimore County, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania. Participants: 9704 ambulatory, non-Black women 65 years of age or older. Measurements: Estrogen use, medical history, and anthropometric data were obtained by questionnaire, interview, and examination. Appendicular bone mass was measured by single-photon absorptiometry. Incident fractures were validated by radiographic report. Results: After adjustment for potential confounders, current estrogen use was associated with a decrease in the risk for wrist fractures (relative risk [RR], 0.39; 95% CI, 0.24 to 0.64) and for all nonspinal fractures (RR, 0.66; CI, 0.54 to 0.80) when compared with no estrogen use. Results were similar for women using unopposed estrogen or estrogen plus progestin, for women younger or older than 75 years of age, and for current smokers or nonsmokers. The effect of estrogen remained after adjustment was made for appendicular bone mass. The relative risk for hip fracture tended to be lower among current users (RR, 0.60; CI, 0.36 to 1.02) than among never-users. Estrogen was most effective in preventing hip fracture among those older than 75 years. Current users who started estrogen within 5 years of menopause had a decreased risk for hip fractures (RR, 0.29; CI, 0.09 to 0.92), wrist fractures (RR, 0.29; CI, 0.13 to 0.68), and all nonspinal fractures (RR, 0.50; CI, 0.36 to 0.70) when compared with women who had never used estrogen. Previous use of estrogen for more than 10 years or use begun soon after menopause had no substantial effect on the risk for fractures. Conclusions: Current use of estrogen appears to decrease the risk for fracture in older women. These results suggested that for protection against fractures, estrogen should be initiated soon after menopause and continued indefinitely.
ANNALS OF THE RHEUMATIC DISEASES
173-0442
Relationship between Weakness and Muscle Wasting in Rheumatoid Arthritis
Helliwell, P.S. and Jackson, S. 53(11):726-728, 1994. Objective--To relate weakness of grip to loss of forearm muscle bulk, hand joint deformity, and hand joint tenderness in patients with rheumatoid arthritis (RA). Methods--Using anthropometric data we have estimated the anatomical cross-
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Annals of the Rheumatic Diseases (continued) sectional area (CSA) of forearm muscles in 100 subjects with RA compared with 100 aged and sex-matched normal subjects. We also recorded hand joint tenderness using a modification of the Ritchie articular index, and a simple index of hand joint deformity. Results--We found a significant reduction in anatomical CSA in RA (forearm CSA in normal subjects 29.7 cm(2) and in RA 25.9 cm(2); p = 0.002). In simple linear regression we found that 46.3% of the variation in grip strength in normal subjects was explained by variation in muscle CSA; in RA this figure decreased to 33.4%. Adding terms for joint deformity and pain in a multiple regression model improved the amount of variation explained to 37.9%. Conclusions--Although there is significant muscle wasting in RA, it is likely that reduction in strength is also attributable to joint deformity and pain leading to inhibition of grip directly and, indirectly, by arthrogenous muscle inhibition. Doubts remain about the quality of muscle in RA. Reprint Address:P.S. Helliwell, Rheumatology and Rehabilitation Research, 36 Clarendon Road, Leeds, West Yorkshire LS2 9NZ, England.
ARCHIVES OF GENERAL PSYCHIATRY
Functioning and Well-Being Outcomes of Patients with Depression Compared with Chronic General Medical Illnesses Hays, R.D., Wells, K.B., Sherbourne, C.D., Rogers, W., and Spritzer, K. 52:11-19,1995. Background: Cross-sectional studies have found that depression is uniquely associated with limitations in well-being and functioning that were equal to or greater than those of chronic general medical conditions such as diabetes and arthritis. However, whether these relative limitations persist over time is not known. Methods: We conducted a 2-year observational study of 1790 adult outpatients with depression, diabetes, hypertension, recent myocardial infarction, and/or congestive heart failure. Change in functional status and well-being was compared for depressed patients vs patients with chronic general medical illnesses, controlling statistically for medical comorbidity, sociodemographics, system, and specialty of care. Results: Over 2 years of follow-up, limitations in functioning and well-being improved somewhat for depressed patients; even so, at the end of 2 years, these limitations were similar to or worse than those attributed to chronic medical illnesses. Similar patterns were observed for depressed patients in the mental health specialty sector and those in the general medical sector, but the patients in the mental health specialty sector improved more. More severely depressed patients improved more in functioning, but even initially depressed patients without depressive disorder had substantial persistent limitations. Conclusion: Depressed patients have substantial and long-lasting decrements in multiple domains of functioning and well-being that equal or exceed those of patients with chronic medical illnesses. 173-0443
173-0444
Hypochondriasis and Panic Disorder: Boundary and Overlap Barsky, A.J., Barnett, M.C., and Cleary, P.D. 51:918-925, 1994. Background: To determine the nosological and phenomenological overlap and boundaries between panic disorder and hypochondriasis, we compared the symptoms, disability, comorbidity, and medical care of primary care patients with each diagnosis. Methods: Patients with DSM-III-R panic disorder were recruited by screening consecutive primary care clinic attenders and then administering a structured diagnostic interview for panic disorder. Patients also completed self-report questionnaires, and their primary care physicians completed questionnaires about them. They were then compared with patients with DSM-III-R hypochondriasis from the same setting who had been studied previously. Results: One thousand six hundred thirty-four patients were screened; 135 (71.0% of the 190 eligible patients) completed the research battery; 100 met lifetime panic disorder criteria. Twenty-five of these had comorbid hypochondriasis. Those without comorbid hypochondriasis (n = 75) were then compared with patients with hypochondriasis without comorbid panic disorder (n = 51). Patients with panic disorder were less hypochondriacal (P < .001), somatized less (P < .05), were less disabled (P < .001), were more satisfied with their medical care (P < .001), and were rated by their physicians as less help rejecting (P < .05) and less demanding (P < .01). Major depression was more prevalent in the group with panic disorder (66.7% vs 45.1%; P < .05), as were phobias (76.0% vs 37.3%; P < .001), but somatization disorder symptoms (P < .0001) and generalized anxiety disorder were less prevalent (74.5% vs 16.0%; P < .001) in panic disorder than was hypochondriasis. Conclusions: While hypochondriasis and panic disorder co-occur to some extent in a primary care population, the overlap is by no means complete. These patients are phenomenologically and functionally differentiable and distinct and are viewed differently by their primary care physicians.
ARCHIVES OF NEUROLOGY
Neurologic Evaluation of the Optimally Healthy Oldest Old Kaye, J.A., Oken, B.S., Howieson, D.B., et al. 51:1205-1211, 1994. Objective: Individuals aged 85 years or older (the "oldest old") are the fastest-growing age group in the United States. Because there is little information characterizing expected neurologic function in this group, our goal was to determine clinical neurologic traits characteristic of the optimally healthy oldest old. Design: Standardized neurologic evaluation findings of optimaUy healthy persons older than 84 years compared with those of equally healthy control subjects aged 65 to 74 years. Setting: Community-based, longitudinal aging study. Participants: Community-residing, consecutively recruited volunteers who were screened for the absence of chronic disease or medication 173-0445
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Archives of Neurology (continued) use. Main Outcome Measure: Standardized neurologic examination coded into ordinal or interval variables. Results: Significant between-group differences were greatest for tests of mental status, sensory function (ie, smell, hearing, vibratory discrimination, and stereognosis), oculomotor function, distal movement speed, and balance. Discriminant function analysis suggests that of these changes, membership in the oldest group is best predicted by poor performance on clinical tests of balance (heel-toe walking and one-leg balancing with eyes closed), smell, and visual pursuit. Conclusions: Many neurologic signs appear with aging that cannot be attributed to disease, even in the very old. Deficits in balance, olfaction, and visual pursuit discriminate best between the aging changes of the healthy very old and changes seen in younger elderly persons. Reprint Address: J.A. Kaye, Department of Neurology, L226, Oregon Health Sciences University, 3181 Sam Jackson Park Road, Portland, OR 97201. 173-0446
Factors Affecting Course and Survival in Alzheimer's Disease: A 9-Year Longitudinal Study Bracco, L., Gallato, R., Grigoletto, F., et al. 51:1213-1219, 1994. Objective: To evaluate mean survival and to identify prognostic factors in a cohort of patients with Alzheimer's disease (AD). Design: Multicentric 9-year cohort analytic study. Setting: Seven neurology departments throughout Italy between April 1982 and January 1984. Patients: We recruited a consecutive sample of 145 patients affected by probable AD (Multicenter Italian Study on Dementia protocol, National Institute of Neurological Disorders and Slroke--Alzheimer's Disease and Related Disorders Association criteria). Five were misdiagnosed, and 21 could not participate in the longitudinal study. The clinicodemographic characteristics of the 119 enrolled patients (49 men, 70 women; mean age, 64.7 years; SD, 4.1 years; mean duration of disease, 3.1 years; SD, 1.8 years) did not differ from those of the 26 excluded patients. All underwent extensive cliniconeuropsychological testing every 6 months for at least 2 years until the patient died or our survey ended (April 30, 1991). Mean follow-up was 5.1 years (SD, 2.5 years). Main Outcome Measures: Death, severe functional impairment (a score ---17 on the Blessed Dementia Scale), and severe cognitive impairment (a score of-< 7 on the Information-Memory-Concentration Test). Results: Survival curves obtained by the Kaplan-Meier method indicated that (1) patients with early- and late-onset disease (ie, before or after age 65 years) showed no difference either in relative survival or in time to reach predetermined functional and cognitive end points; (2) severely aphasic patients became profoundly demented significantly sooner than those with mild to moderate aphasia (P < .0001). Among clinicodemographic variables analyzed by a Cox model, severe language disability and functional loss proved to be the best predictors of death independent of age at onset or degree of dementia. Conclusions: Age at onset did not influence course and survival in AD. Severe aphasia appears to be the best predictor of death and unfavorable course. ReprintAddress:L. Bracco, Department of Neurological and Psychiatric Sciences, University of Florence, Policlinico di Careggi, 85 Viale Morgagni, 50134 Florence, Italy.
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Autonomic and Peripheral Neuropathies in Patients with Chronic Alcoholism: A DoseRelated Toxic Effect of Alcohol Monforte, R., Estruch, R., Valis-SoIr, J., et al. 52:45-51, 1995. Objective: To assess autonomic and peripheral nervous system function in patients with chronic alcoholism. Design: A cross-sectional study. Patients: A consecutive sample of 107 alcoholic patients and 61 controls. Main Outcome Measure: For autonomic assessment, heart rate variations during deep breathing and Valsalva maneuver and on standing were measured. Blood pressure response to standing up and to sustained handgrip were also evaluated. For assessment of the peripheral nervous system, an electrophysiologic examination was performed. Results: Alcoholic patients exhibited reduced heart rate variability compared with controls (P < .01, on all parasympathetic tests), whereas no differences in the mean values of the blood pressure responses between both groups were found. Twentysix patients (24.3%) had criteria of autonomic neuropathy, and 34 (32%) had electrophysiologic criteria of peripheral neuropathy. None of the controls exhibited criteria of autonomic neuropathy, and only one had criteria of peripheral neuropathy. The estimated total lifetime dose of alcohol correlated inversely with the parasympathetic indexes (r = - . 4 8 to -.51; P < .001 on all parasympathetic tests) and the sensory potential amplitudes of upper and lower limbs (r = -.43; P < .00 l, both limbs). Finally, a significant correlation between autonomic and peripheral neuropathies was observed (P = .0 l). By contrast, these lesions were not related to age, nutritional status, or other alcohol-related diseases. Conclusions: Autonomic and peripheral neuropatbies are common among hospitalized alcoholic patients. Alcohol appears to be toxic 1o autonomic and peripheral nerves in a dose-dependent manner. Reprint Address:R. Estruch, Department of Internal Medicine, Hospital Clinic, ViUarroel 170, 08036 Barcelona, Spain.
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
173-0448
The Pain Disability Index: Factor Structure and Normative Data Chibnall, J.T. and Tait, R.C. 75(11):1082-1086, 1994. Reprint Address: J.T. Chibnall, Division of Behavioral Medicine, Saint Louis University School of Medicine, 1221 South Grand Boulevard, St. Louis, MO 63104. 173-0449
Return to Work following an Aquafitness and Muscle Strengthening Program for the Low Back Injured LeFort, S.M. and Hannah, T.E. 75(11):1247-1255, 1994. Reprint Address: S.M. LeFort, 111 Slrawberry Marsh Road, St. John's, NF A1B 2V7, Canada.
V O L U M E 17, N U M B E R 3, 1995
ARTHRITIS CARE AND RESEARCH
Promoting Patient Cooperation with Exercise Programs: Linking Research, Theory, and Practice Jensen, G.M. and Lorish, C.D. 7(1):181-189, 1994. Managing patient-nonadherence with prescribed exercise regimens is not an uncommon task for physical therapists working with individuals with arthritis. Yet little is known about the factors that influence patient adherence with exercise programs or therapist knowledge and use of theoretically based adherence management techniques. Survey research with physical therapists and patients was used to provide a database for further insight into the barriers experienced in implementing exercise programs in clinical practice. In this paper, we suggest that the cooperation with an exercise regimen is mediated by the patient's belief system and requires a therapeutic process of mutual inquiry, problem solving, and negotiation between the therapist and patient. Concepts from research, theory, and practice are integrated into a Process Model for Patient-Practitioner Collaboration for use in clinical practice. Reprint Address: G.M. Jensen, Department of Physical Therapy, 2500 California Plaza, Creighton University, Omaha, NE 68178.
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last, areas of future research and roles of clinicians in managing fatigue relative to exercise performance are proposed. Reprint Address: B. Belza, Physiological Nursing Department, SM-28, University of Washington, Seattle, WA 98195.
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173-0451 Exercise Tests as Outcome Measures Burckhardt, C.S., Moncur, C., and Minor, M.A. 7(4): 169-175, 1994. Outcome assessments of physical fitness attributes such as endurance, strength, and flexibility are not measured routinely in clinical trials or clinical practice in either adults or children with rheumatic diseases. Although physical fitness is not a measure of disease severity, it can be a critical indicator of capacity to function. Adequate fitness is necessary for the performance of positive health behaviors that enhance health status and wellness in spite of chronic disease. The purpose of this paper is to explore the conceptual, methodologic, and analytic issues related to the use of exercise tests as outcome measurements of physical functioning in persons with rheumatic disease. Reprint Address: C.S. Burckhardt, Department of Mental Health Nursing, School of Nursing, Oregon Health Sciences University, Portland, OR 97201.
173-0452 The Impact of Fatigue on Exercise Performance Belza, B. 7(4):176-180, 1994. The purpose of this paper is to discuss the impact of fatigne on exercise performance. First, fatigue will be defined and distinguished from similar constructs. Second, examples of instruments to measure fatigue in the rheumatic diseases are highlighted. Next, the social implications of fatigue are briefly mentioned. Fourth, methods in which fatigue impacts exercise performance are discussed. Fifth, the prevalence of fatigue in arthritis and its relationship to exercise will be presented. And
173-0453
Exercise Considerations for Postmenopausal Women with Osteoporosis Allen, S.H. 7(4):205-214, 1994. Individuals with osteoporosis are at an increased risk of fracture due to a net loss of bone mass. The cellular mechanisms causing decreased bone mass are increased osteoclast-mediated bone resorption and/or decreased osteoblast-mediated bone formation. Clinical studies have shown that bone loss can be prevented by estrogen replacement therapy and calcium supplementation. Weight-bearing and strengthening exercise may also play a role in retarding bone loss in the postmenopausal woman, and it may even increase bone mass. The essential components of an exercise program include intensity, duration, frequency, and type of activity. Additional goals of a therapeutic exercise program are to improve flexibility and balance, and to prevent falls. Structure-function relationships in normal and osteoporotic bone and the effects of exercise on bone are reviewed. A rational approach for exercise strategies is discussed. Reprint Address: S.H. Allen, Department of Internal Medicine, D110A Health Sciences Center, One Hospital Drive, University of Missouri, Columbia, MO 65212.
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Physical Conditioning in Children with Arthritis: Assessment and Guidelines for Exercise Prescription Klepper, S.E. and Giannini, M.J. 7(4):226-236, 1994. Objective. To review the literature in the area of physical fitness and conditioning programs for individuals with chronic illnesses, and increase the awareness of the need to include fitness testing and conditioning programs in the therapeutic management of children and adolescents with chronic arthritis. Methods. This article provides a review of original research reports, information from principal texts, and review articles related to physical fitness testing and training in children. Resuits. Several factors limit the exercise capacity of children with chronic arthritis, and studies report that these children have lower aerobic endurance and muscle performance than their peers. Preliminary studies suggest that fitness testing is safe for most children with arthritis, and physical conditioning programs, which appear to benefit adults with arthritis and children with other chronic illnesses, may also benefit children with arthritis. Easily administered, inexpensive field tests of fitness are available. Guidelines for prescribing physical conditioning programs are provided. The risks and benefits of increased exercise are discussed. Conclusions. Assessment of exercise capacity and muscle function and individualized prescription of physical conditioning programs are indicated for children with chronic arthritis, soon after diagnosis. Reprint Address: S.E. Klepper, 70 Jacobs Creek Road, West Trenton, NJ 08628.
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ARTHRITIS AND RHEUMATISM
173-0455
Measurement of Health Status in Children with Juvenile Rheumatoid Arthritis
Sing,h, G., Athreya, B.H., Fries, J.F., and Goldsmith, D.P. 37(12):1761-1769, 1994. Objective. To develop and validate a self- or parent-administered instrument for measuring functional status in children with juvenile rheumatoid arthritis (JRA). Methods. We adapted the Stanford Health Assessment Questionnaire (HAQ) for use in children ages 1-19 years, by adding several new questions, such that for each functional area, there was at least 1 question relevant to children of all ages. The face validity of the instrument was evaluated by a group of 20 health professionals and parents of 22 healthy children. The questionnaire was then administered to parents of 72 JRA patients (mean age 9.1 years, onset type systemic in 16, polyarticular in 21, pauciarticular in 35). Results. The instrument showed excellent internal reliability (Cronbach's alpha = 0.94), with a mean inter-item correlation of 0.6. The convergent validity was demonstrated by strong correlations of the Disability Index (average of scores on all functional areas) with Steinbrocker functional class (Kendali's tau b = 0.77, P < 0.0001), number of involved joints (Kendall's tau b = 0.67, P < 0.0001), and morning stiffness (Kendall's tau b -- 0.54, P < 0.000t). Spearman's correlation coefficient between Disability Index scores from questionnaires administered to parents and those from questionnaires administered to older children (> 8 years) was 0.84 (n = 29; P < 0.001), showing that parents can accurately report for their children. The test-retest reliability, studied at a 2-week interval, revealed virtually identical Disability Index scores measured on the 2 occasions (0.96 versus 0.96; P > 0.9 by paired t-test; Spearman's correlation coefficient = 0.8, P < 0.002). Conclusion. The Childhood HAQ, which takes less than 10 minutes to complete, is a valid, reliable, and sensitive instrument for measuring functional status in children with JRA. Reprint Address: G. Singh, School of Medicine, Med, Stanford University, Rheumatology and Immunology, 1000 Welch Road, Suite 203, Palo Alto, CA 94304.
BEHAVIORAL MEDICINE
173-0456
Pressor Reactivity, Ethnicity, and 24-Hour Ambulatory Monitoring in Children from Hypertensive Families Treiber, F.A., Murphy, J.K., Davis, H., et al. 20(3):133-142, 1994. We assessed blood pressure responses of a multiethnic (Black and White) sample of 120 children of hypertensive families to orthostasis, video game, forehead cold, and dynamic exercise, and monitored the children's ambulatory pressure 24 hours later. Thirteen children were studied twice (1-year stability). The Black
children exhibited higher 24-hour ambulatory systolic and diastolic pressures than the White children. Regardless of ethnicity, peak and mean systolic pressures during each task were generally positively correlated with mean systolic pressure while the children were awake and asleep. Associations between diastolic pressor responses and ambulatory measurements were somewhat dependent upon ethnicity and task. Relatively few reactivity-ambulatory correlations were significant, using pressor reactivity change scores. The children who participated twice exhibited significant 1-year stability for most ambulatory and pressor measurements. Children's pressor responses to laboratory tasks may generalize to the natural environment. Reprint Address: F.A. Treiber, Georgia Prevention Institute, HS1640, Medical College of Georgia, Augusta, GA 30912.
173-0457
Effectiveness of a Videotaped Behavioral Intervention for Dental Anxiety: The Role of Gender and the Need for Information Carpenter, D.J., Gatchel, R.J., and Hasegawa, T. 20(3):123-132, 1994. The authors evaluated the effectiveness of a videotaped behavioral treatment program in reducing dental anxiety. They compared patients who witnessed the intervention videotape with patients who saw a placebo program and with a no-treatment control group. The subjects were 66 patients who visited a dentistry clinic for prophylaxis and general dental treatment. Groups were balanced for gender and level of preference for information as measured by the Krantz Health Opinion Survey-Information subscale. Self-report, physiological, and observed behavioral measures were assessed at specified times. Results demonstrated significant Group X Gender interaction effects during the different assessment periods, with men responding best to the treatment videotape, whereas women responded best to the placebo videotape. The level of information preference was found to be a significant contributing factor at certain assessment periods. Overall, these results suggest that preparatory videotaped interventions are particularly effective in decreasing dental anxiety when patient characteristics are matched with characteristics of the intervention. Reprint Address: R.J. Gatchel, Department of Psychiatry, Division of Psychology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9044.
173-0458
Chronic Back Pain: Integrating Psychological and Physical Therapy--An Overview Linton, S.J. 20(3):101-104, 1994. Chronic back pain is a major consumer of costly healthcare resources in the Western world. Patients' suffering affects their families and associates, leads to diminished self-confidence, and prevents their effective participation in the workplace. Although medical treatments and analgesics are generally successful in treating acute back pain, and some patients recover spontaneously, conventional approaches are less successful in dealing with chronic pain and may be contraindicated. In the first of two articles, the author offers an overview of research on cognitive-behavioral programs, using operant activity and relaxation training, that have led to reductions in patients' pain and
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Behavioral Medicine (continued) to increases in their activity levels. Part 2 provides a step-bystep description of how to incorporate basic psychological techniques and physical therapy procedures for chronic pain sufferers. Patient and therapist cooperate in operant activities, with the patient monitoring progress and carrying out regular homework assignments as he or she seeks to perform target activities; applied relaxation encourages the patient to cope with pain by disrupting the connection between anxiety, despair, and pain. The techniques outlined are suitable for dealing with other musculoskeletal conditions as well as with chronic back pain. Reprint Address: S.J..Linton, Department of Occupational and Environmental Medicine, Orebro Medical Center, S-70185 ()rebro, Sweden.
BEHAVIOUR RESEARCH AND THERAPY
173-0459
Chronic Low Back Pain and Inaccurate Predictions of Pain: Is Being Too Tough a Risk Factor for the Development and Maintenance of Chronic Pain? Amtz, A. and Peters, M. 33(1):49-53, 1995. The present study tests whether chronic low back pain (CLBP) patients show a tendency to overpredict or to underpredict pain. Twenty CLBP patients and 20 healthy controls underwent 6 trials of laboratory induced pressure pain. Ratings of predicted and experienced pain intensity were obtained. In contradiction with the hypothesis that CLBP patients show a generalized tendency to overpredict pain, CLBP patients showed a tendency to underpredict the laboratory pain, whereas controls appeared to be more accurate. This finding replicates a previous finding, that there may be a substantial group of CLBP patients who underestimate pain. The tendency to underpredict pain may constitute a risk factor for the development and maintenance of CLBP. Reprint Address: A. Arntz, Department of Medical Psychology, University of Limburg, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
173-0460
The Assessment of Obesity: Theoretical Background and Practical Advice
Wardle, J. 33(1):107-117, 1995. Developments in understanding the causes and consequences of obesity have important implications for the assessment of weight problems. Simple measurement of body weight is no longer sufficient. The evaluation should include measures of body composition, dietary quality, energy expenditure, risk factor status and body image. In this paper, the arguments in favour of a broader-based evaluation of obesity are presented and a range of assessment methods are discussed. Reprint Address: J. Wardle, Health Behaviour Unit, Institute of Psychiatry, University of London, De Crespigny Park, London SE5 8AF, UK.
BRITISH JOURNAL OF CLINICAL PSYCHOLOGY
173-0461
Chronic Pain and Attention: A Cognitive Approach
Eccleston, C. 33(4):535-547, 1994. The present study draws upon resource-based models of attention in suggesting that the processing of chronic and persistent pain is a task that demands the application of central and executive attention. Ifa chronic and persistent pain stimulus is demanding of central, attentional resources, it follows that it will compete with a second attention-demanding task for those limited resources. Here it is hypothesized that performance of an attention-demanding interference task will be detrimentally affected by the demands of persistent pain. In Expt 1, patients in high pain, patients in low pain and control subjects without pain performed an attention-demanding numerical interference task. There were no significant differences between any of the groups on any measure of performance. Expt 2 repeated Expt 1 with a more difficult and more complex task. Only when the task was at its most difficult and its most complex (i.e. at the greatest demand of limited resources) did those patients in high levels of pain (i.e. at the greatest demand of limited resources) show performance decrements. The results of both experiments are discussed in relation to the debate concerning the use of cognitive methods for pain control and in relation to the application of cognitive psychology to the study of chronic pain. Reprint Address: C. Eccleston, School of Social Sciences, University of Bath, Claverton Down, Bath BA2 7AY, UK. 173-0462
The Dentist's Attitudes and Their Interaction with Patient Involvement in Oral Hygiene Compliance Sandell, R., Camner, L.G., and Sarhed, G. 33(4):549-558, 1994. The influence on patient compliance of the dentist's attitudes to his or her job and to his or her patient was studied in a sample of 82 patients. The dentist's attitudes were assessed at the beginning of dental treatment. Treatment consisted of cleaning, depuration and motivation. At follow-up examination after six months, attendance at follow-up and the development of plaque, calculus and gingivitis were significantly predicted by the dentist's attitudes. A causal model, which also included factors of patient involvement, was developed. The complianceproducing factors were, primarily, the establishment of sympathy and an informal relationship between dentist and patient. The patient's habit of regularly making visits to a dentist, in a complex way, also contributed to compliance. Reprint Address: R. Sandell, Stockholm County Council Institute of Psychotherapy, Bj/Srngttrdsgatan 25, S-118 52 Stockholm, Sweden. 173-0463
The Effects of Minor Events, Optimism and Self-Esteem on Health Lyons, A. and Chamberlain, K. 33(4):559-570, 1994. Recent research shows upper respiratory infections (URIs) are influenced by minor daily events, especially those that are
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British Journal of Clinical Psychology (continued) desirable and interpersonal in nature. The present study used a longer time frame, broader health measures and a betweensubjects design to examine this effect. It also predicted that optimism and self-esteem would interact with minor events to affect health. One hundred and fifty participants provided information regarding minor events, disposition and physical health on two separate occasions. Results show that increases in both desirable and undesirable events (hassles and uplifts) affected URIs over a two-week period. Interpersonal hassles interacted with optimism, having a greater impact on physical symptoms for optimists than for pessimists. Self-esteem did not interact with minor events to affect health. These results extend previous findings to show that minor events affect URIs and not other health outcomes, and that this effect is apparent between subjects over a number of days. Further, the influence of interpersonal events on health appears to be moderated by optimism. It is concluded that consideration and integration of findings from studies with different methodologies will be beneficial in furthering our understanding of minor event effects on health. Reprint Address: A. Lyons, Department of Psychology, Massey University, Private Bag, Palmerston North, New Zealand. 173-0464
Stress, Arousal, Cortisol and Secretory Immunoglobulin A in Students Undergoing Assessment Evans, P., Bristow, M., Hucklebridge, F., Clow, A., and Pang, F.-Y. 33(4):575-576, 1994. Cortisol, salivary immunoglobulin A, stress and arousal reports were measured in students undergoing academic assessment. In accordance with hypotheses, all measures were higher on the day of assessment than a week before, and were highest of all immediately after assessment. Reprint Address: P. Evans, Divisions of Psychology/Biomedical Sciences, University of Westminster, 309 Regent Street, London W1R 8AL, UK.
CEPHALALGIA
Personality Characteristics before and after Treatment of Different Head Pain Syndromes Mongini, F., Ibertis, F., and Ferla, E. 14(5):368-373, 1994. In order to examine whether, in patients with different types of headache and craniofacial pain, MMPI and STAI scores are significantly different before and after treatment, 114 patients with tension-type headache (n = 34), atypical facial pain (n -20), temporomandibular joint dysfunction (n = 36), migraine (n = 16), cluster headache (n = 4), chronic paroxysmal hemicrania (n = 2), trigeminal neuralgia (n = 2) were examined. A pain index was calculated (0-10) which quantified pattern, duration and frequency of pain. The Italian MMPI (356 item abbreviated version) and the STAI tests were administered before and after treatment. A paired t-test was used to assess pre-
and post-treatment differences, and multiple regression analysis was employed to examine whether such differences correlated with the improvement in the pain index. In the total group after treatment, there was a significant reduction of certain MMPI scores (Hs, D, Hy, Pa, Pt, Sc, Si) and of STAI 1 and 2 scores. Separate analysis confirmed this among women but not among men. No relation was found between MMPI and STAI changes and the degree of improvement as assessed through the pain index. Clinical improvement leads to normalization of MMPI profiles and STAI scores in women. The psychometric data before treatment were not predictive for treatment outcome. Reprint Address: F. Mongini, Centre for Craniofacial Pathophysiology, University of Turin, Corso Dogliotti, 14, 10126 Torino, Italy.
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If Migraine Prophylaxis Does Not Work, Think about Compliance Steiner, T.J., Catarci, T., Hering, R., Whitmarsh, T., and Couturier, E.G.M. 14(6):463-464, 1994. Data are presented on nine patients with migraine by IHS criteria, recruited from those presenting to the clinic for treatment and needing prophylaxis. Pizotifen 0.5 mg tds was prescribed for 8 weeks and dispensed in special containers with an electronic event recorder concealed in the lid. This responded to the pressure change with each opening of the container and recorded it in real time. The information was later downloaded to a PC for analysis. At trial end, two patients had been lost to follow-up, one had not started the treatment at all, two had dropped out because of alleged side effects (drowsiness), and four patients had completed the study. For these, the quantity of tablets used as a percentage of that prescribed (i.e., compliance assessed on the basis of returned-tablet count) ranged from 62.6% to 91.9%; the percentage of days in which three doses had been taken ranged from only 15.8% to 79%; the percentage of doses taken on schedule (8 h _ 25% after the previous dose) ranged from 21.1% to 47.3%. It is possible that all evaluations of efficacy and tolerance of migraine prophylactics reported so far have been unsoundly based. Reprint Address: T.J. Steiner, Academic Unit of Neuroscience, Chafing Cross and Westminster Medical School, St. Dunstan's Road, London W6 8RP, UK.
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CIRCULATION
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Prospective Study of Phobic Anxiety and Risk of Coronary Heart Disease in Men Kawachi, I., Colditz, G.A., Ascherio, A., et al. 89:1992-1997, 1994. Background. To examine prospectively the association between self-reported symptoms of phobic anxiety and subsequent risk of coronary heart disease, a 2-year follow-up study was conducted of a cohort of 33,999 US male health professionals, aged 42 to 77 years in 1988, who were free of diagnosed car-
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Circulation (continued) diovascular disease at baseline. Levels of phobic anxiety were assessed using the Crown-Crisp index, a short, diagnostic selfrating scale used for common phobias. Main outcomes were incidents of coronary heart disease consisting of nonfatal myocardial infarction (MI) and fatal coronary heart disease (CHD). Methods and Results. One hundred sixty-eight incident cases of CHD occurred during 2 years of follow-up (128 cases of nonfatal MI and 40 cases of fatal CHD). The age-adjusted relative risk of fatal CHD among men with highest levels of phobic anxiety (scoring 4 or higher on the Crown-Crisp index) was 3.01 (95% confidence interval, 1.31 to 6.90) compared with men with the lowest levels ofanxiety (scoring 0 or 1 on the phobia index). Risk of fatal CHD increased with levels of phobic anxiety (P trend = .002). When fatal CHD was further categorized into sudden and nonsudden coronary death, the excess risk was confined to sudden death (relative risk among men scoring 3 or higher on the phobia index was 6.08; 95% confidence interval, 2.35 to 15.73). No association was found between phobic anxiety and risk of nonfatal MI. These findings remained essentially unchanged after adjusting for a broad range of cardiovascular risk factors. Conclusions. The specificity, strength, and doseresponse gradient of the association, together with the consistency and biological plausibility of the experimental and epidemiologic evidence, support a strong causal association between phobic anxiety and fatal CHD. Reprint Address: I. Kawachi, Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
173-0468
Diagnosis of Mild Hypertension by Ambulatory Blood Pressure Monitoring
Weber, M.A., Neutel, J.M., Smith, D.H.G., and Graettinger, W.F. 90:2291-2298, 1994. Background. Between 20% and 30% of patients with clinically diagnosed hypertension have normal blood pressure (BP) values during automated ambulatory 24-hour BP monitoring. It has not been clear, however, whether these patients can be regarded as normotensive or whether they should be treated in the same way as confirmed hypertensive patients. Methods and Results. Ambulatory BP monitoring was performed in 88 normal control subjects and 171 hypertensive patients (office diastolic BP >-90 mm Hg on three visits; never treated or off treatment for more than 6 months). Hypertensive patients were classified as nonconfirmed or white coat (n = 58) if their 24hour diastolic averages were __20%. Metabolism-flow autoregulation was tested by varying the temperature (CMRo2) and measuring the coupling of CBF and CMRo2. Individual patient autoregulation was correlated with changes in cognitive measures. Cognitive performance declined in 6 of 9 measures after CABG surgery. Age predicted cognitive decline in 7 of 9 measures; short-term memory showed the greatest effect of age. Pressure-flow autoregulation during hypothermic CPB showed a small but significant (P < .0001) effect of pressure on CBF. There was no effect of age on the slope of CBF response to changes in MAP (pressureflow autoregulation). There was a major effect of temperature on CBF during CPB (P < .0001). Coupling CBF and CMRo2 with changing temperature was unaffected by age. Changes in cognition were not associated with measures of cerebral autoregulation. However, increasing C(AV)o2 is associated with cognitive deficits in 5 of 9 measures; these associations were independent of age. Conclusions. Increased age predisposes to impaired cognition after cardiac surgery. This decline in cognitive function in the elderly is not associated with age-related changes in cerebral blood flow autoregulation. The association of increased oxygen extraction with decline in some measures of cognitive function suggests that an imbalance in cerebral tissue oxygen supply, which is unrelated to age, contributes to acute cognitive dysfunction after cardiac surgery. Cognitive dysfunction after CPB in the elderly cannot be explained by impaired CBF autoregulation. Reprint Address: M.F. Newman, Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710. 173-0471
Relation of Smoking with Carotid Artery Wall Thickness and Stenosis in Older Adults: The Cardiovascular Health Study Tell, G.S., Polak, J.F., Ward, B.J., et al. 90:2905-2908, 1994. Background. Cigarette smoking has been associated with increased risk of atherosclerotic diseases in hospital-based stud-
ies and in studies of middle-aged populations but not in population-based studies of older adults with and without clinical cardiovascular disease. Methods and Results. We investigated the relation of smoking to carotid artery atherosclerotic disease, expressed as intimal-medial wall thickness and arterial lumen narrowing (stenosis) measured by ultrasound. Subjects were 5116 older adults participating in the baseline examination of the Cardiovascular Health Study, a community-based study of cardiovascular diseases in older age. With increased smoking there was significantly greater internal and common carotid wall thickening and internal carotid stenosis: current smokers > former smokers > never-smokers; for instance, the unadjusted percent stenosis was 24%, 20%, and 16%, respectively (P < .0001). A significant dose-response relation was seen with packyears of smoking. These findings persisted after adjusting for other cardiovascular risk factors and were also confirmed when analyses were restricted to those without prevalent cardiovascular disease. The difference in internal carotid wall thickness between current smokers and nonsmokers was greater than the difference associated with 10 years of age among never-smoking participants (0.39 m m versus 0.31 mm). Among all participants, the prevalence of clinically significant (> 50%) internal carotid stenosis increased from 4.4% in never-smokers to 7.3% in former smokers to 9.5% in current smokers (P < .0001). Conclusions. These findings extend previous reports of a positive relation between smoking and carotid artery disease to a population-based sample of older adults using several different indicators of atherosclerotic disease. Reprint Address: CHS Coordinating Center, University of Washington, Century Square, Suite 2025, 1501 Fourth Avenue, Seattle, WA 98101.
173-0472
Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases Lenfant, C. 90:2609-2617, 1994. Reprmt Address: C. French, NHLB1, Building 31, Room 5A03, NIH, 31 Center Drive, MSC 2482, Bethesda, MD 20892-2482.
CLINICAL JOURNAL OF PAIN
173-0473
The Short Form of the Beck Depression Inventory: Validity Issues with Chronic Pain Patients Chibnall, J.T. and Tait, R.C. 10:261-266, 1994. Objective: To investigate the validity of the Beck Depression Inventory short form when used to screen for depression in chror~ic pain patients, Setting: A multidisciptinary pain management center located in a major university medical center, Patients: Seven hundred sixty-five persons presenting for evaluation of chronic pain, including low back pain, head/neck pain, and extremity pain. Measures: Beck Depression Inventory short form, McGill Pain Questionnaire, Pain Disability Index, pain
V O L U M E 17, N U M B E R 3, 1995
Clinical Journal of Pain (continued) drawing, and Quality of Life Scale. Results and Conclusions: Items on the Beck Depression Inventory short form reflecting pain-related interference with function (i.e., disability) were endorsed to a greater degree than affective and cognitive terms. A factor analysis of the inventory yielded two affective/cognitive factors and one "disability" factor (work inhibition and fatigue). The correlations between the factor scores and the Pain Disability Index suggested that endorsement of the work inhibition and fatigue items by chronic pain patients may not be indicative of affective disturbance. The results suggest that these items should be evaluated critically for their contribution to the total score of the Beck Depression Inventory short form when assessing depression in chronic pain patients. Reprint Address: J.T. Chibnall, Department of Psychiatry and Human Behavior, Division of Behavioral Medicine, St. Louis University School of Medicine, 1221 South Grand Boulevard, St. Louis, MO 63104.
173-0474
Childhood Abuse, Depression, and Chronic Pain 10.277-281, 1994. Objective: To investigate the relationships among history of childhood abuse, type of pain, and depression. Design: Survey, consecutive sample, correlational. Setting: An interdisciplinary pain-management center in a rehabilitation hospital. Patients: The participants were 201 consecutive patients with chronic pain complaints, 68% women, mean age 38 years, of whom 28% complained of pain in more than three major sites, 26% had low back pain, 19% had craniofacial pain, and 25% had pain in other regions. Outcome Measures: Beck Depression Inventory, Childhood History recorded presence or absence of abuse, age of onset, age when abuse was acknowledged, duration and frequency of abuse, relationship of abuser to the participant. Pain type was classified by IASP. Results: Patients with history of both sexual and physical abuse in childhood had more depression. The differences among abuse groups was significant (17 < 0.03). The impact of childhood abuse and type of pain on depression was tested by a two-factor analysis of variance. The influence of childhood abuse was significant (p < 0.04), whereas the influence of type of pain (p < 0.76) and the interaction between type of pain and childhood abuse (17 < 0.40) were not significant. Conclusions: There is a positive, significant relationship between depression and history of childhood sexual and physical abuse. The influence of type of pain on depression was not significant. Prevailing research explained depression as an expected, natural consequence of chronic pain. Our research suggests that the relationship between chronic pain and depression may be attributable in part to childhood abuse history. Reprint Address: R.T. Goldberg, Spaulding Rehabilitation Hospital, 125 Nashua Street, Boston, MA 02114. Goldberg, R.T.
173-0475
Pain in Young Adults: I. Relationship to Gender and Family Pain History Lester, N., Lefebvre, J.C., and Keefe, F.J. 10:282-289, 1994. Objectives/Design: Two studies were carried out to examine how gender and family pain history related to pain and activity interference in young adults. The first study (n = 252 college students) examined how gender and family pain history
273
related to pain intensity and the second study (n = 206 college students) examined how these variables related to pain intensity, location, and activity interference. Whenever possible, data from the two studies were combined for purposes of data analyses. Results: Results indicated that more than half of the young adults studied reported experiencing some type of pain at the time of the investigation. The intensity of the pain was in the low range and the most frequent sites of pain were in the head and legs or feet. Gender differences were noted, with women reporting a greater number of sites of pain. Family pain history was found to be related to pain and activity interference. Subjects who had a strong family history of pain problems reported a greater number of pain sites, and higher levels of pain-related activity interference. Conclusions: Generalizability of results is limited due to the group of young adults studied, yet several conclusions relative to this group may be suggested. First, this group of young adults do appear to experience pain. Second, there may be gender differences in the types of pain they report and the ways they react to pain. Third, family history of pain may be related to the pain experiences of this group of young adults. Reprint Address: F.J. Keefe, Box 3159, Department of Psychiatry, Duke University Medical Center, Durham, NC 27710.
173-0476
Acupuncture and Subtypes of Chronic Pain: Assessment of Long-Term Results Carlsson, C.P.O. and SjOlund, B.H. 10:290-295, 1994. Objective: To determine patients' opinions of pain relief for a longer time after one treatment period of acupuncture for chronic pain. Patients and setting: Two hundred and eleven patients had acupuncture treatment for chronic pain at the Pain Clinic of Maim6 University Hospital during 1983-5. Their mean duration of pain was 10.4 years prior to treatment. Intervention: The patients were treated with needle acupuncture with a combination of local and distal points every 1-2 weeks. Both manual and electrical stimulation was utilized. The mean number of treatments was 7.8. Design: In 1988, all patient documents were screened, and the pain conditions were classified as nociceptive, neurogenic, or psychogenic. Of the 211 treated patients, initial results could be evaluated from the clinic records in 202 cases. Eighty-five of these patients (42.1%) experienced pain relief immediately after the treatment period. These patients were sent a 1-page questionnaire by mail in 1988. Outcome Measures: Pain relief over defined time periods (yes/no); do more work at home or at workplace (yes/no); analgesic consumption. Results: Only 35 patients (17.3% of all patients) still experienced pain relief 6 months after treatment. Among those with nociceptive pain, 70 of 142 (49%) had experienced initial pain relief, while those with neurogenic or psychogenic pain experienced relief in only I I of 34 and four of 26 of the cases, respectively. Pain relief for >6 months was experienced by 33 of 142 of the cases with nociceptive pain, but by only two of 34 of those with neurogenic pain, and by none of those with psychogenic pain. Conclusion: Only patients with nociceptive pain can be expected to get pain relief for > 6 months after one treatment period of acupuncture, and of these only a small proportion will be helped. Reprint Address: B.H. Sj61und, Department of Rehabilitation, Lund University Hospital, S-221 85 Lund, Sweden.
274
ANNALS OF BEHAVIORAL MEDICINE
DIABETES CARE
173-0477
Comparison of Excess Costs of Care and Production Losses Because of Morbidity in Diabetic Patients Olsson, J., Persson, U., Tollin, C., Nilsson, S., and Melander, A. 17(11):1257-1263, 1994. Objective--To assess and compare excess costs of care and production losses because of morbidity in diabetic patients and the general population of a Swedish community. Research Design and Methods--Costs of production losses were calculated from medical and social insurance records on sickness benefit days (short-term illness) and premature retirement (permanent disability) in people with diabetes and in the entire population of the community (a municipality comprising a town and rural surroundings, with 28,000 inhabitants). Care costs included those of consultations and inpatient care, as well as costs of insulin, oral antidiabetic medications, other drugs, test material, and treatment devices, and they were obtained from patient records, the health care administration, and the statistics of community pharmacy sales. Results--Of the diabetic patients < 65 years of age, above which both diabetic and nondiabetic people get retirement pension, and sickness benefits cease, 62% of those on insulin treatment in each gender had insulin-dependent diabetes mellitus (IDDM). All insulin-treated non-insulin-dependent diabetes mellitus (NIDDM) patients were >40 years of age. Both the insulin-treated and the non-insulin-treated diabetic patients were prematurely retired twice as often as the average population and had twice as many inpatient days. The insulin-treated subjects also had twice as many sickness benefit days. The excess costs of production losses as a result of morbidity in people with diabetes were about $7,000 per individual and year. The corresponding excess costs of inpatient care were $800. The therapeutic expenditures for control of diabetes were about $600 per individual and year. If converted to U.S. conditions, the costs of lost production as a result of excess morbidity (
256
A m e r i c a n Heart Journal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
256
A m e r i c a n Journal o f Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
257
A m e r i c a n Journal o f Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
258
A m e r i c a n Journal o f Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
261
A m e r i c a n Journal o f Public Health
262
Annals o f Internal Medicine
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264
Annals o f the R h e u m a t i c Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
264
Archives o f General Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
265
Archives o f Neurology
265
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Archives o f Physical Medicine and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
266
Arthritis Care and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
267
Arthritis and R h e u m a t i s m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
268
Behavioral Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
268
Behaviour Research and T h e r a p y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
269
British Journal o f Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
269
Cephalalgia
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270
Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
270
Clinical Journal o f Pain
272
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Diabetes Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
274
T h e Diabetes Educator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
274
The Gerontologist
275
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". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
275
H e a d a c h e Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
277
Health Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
277
Heart and Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
280
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
281
International Journal o f Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
281
International Journal o f Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
281
Journal o f A b n o r m a l Child Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
282
Journal o f A b n o r m a l Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
282
Journal o f the A m e r i c a n A c a d e m y o f Child and Adolescent Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
283
Journal o f the A m e r i c a n Dental Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
283
Journal o f the A m e r i c a n Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
284
Journal o f Behavioral Medicine
287
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Journal o f Consulting and Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
288
Journal o f D e v e l o p m e n t a l and Behavioral Pediatrics
289
Journal o f General Internal Medicine
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Journals o f Gerontology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
290 291
Journal o f Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
292
Journal o f Occupational Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
293
Journal o f Pain and S y m p t o m M a n a g e m e n t
294
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254
VOLUME 17, N U M B E R 3, 1995
Journal of Rheumatology
.............................................................................
255
294
The Lancet ..........................................................................................
294
Neurology
296
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New England Journal of Medicine .....................................................................
297
Pain ................................................................................................
297
Pediatric Dentistry ...................................................................................
299
Pediatrics ...........................................................................................
300
Psychological Medicine ...............................................................................
302
Psychology and Health
304
Psychosomatic Medicine
............................................................................... .............................................................................
305
Stress Medicine ......................................................................................
305
Subject Index ........................................................................................
307
had not. To measure consistency in the SPs' performances and accuracy in assessing the physicians' performances, most interactions were audiotaped using a hidden microphone. Pearson chi-square, Fisher exact two-tailed test, and kappa coefficients were used for analysis. Results. Significantly higher ratings were found for the CME physicians in two areas: breast cancer riskfactor determination (determined maternal history: 80% versus 52%, p = .03; determined age at first period: 16% versus 0%, p : .02), and smoking cessation counseling (providing written material: 32% versus 9%, p = .03). The CME physicians were rated higher on all 19 study variables in the target areas of early detection of breast cancer and smoking cessation. The results show that the physicians' performances were better in those areas where the CME program had used performance-based learning, such as role playing or viewing and discussing a videotaped role-play encounter. Conclusion. The educational techniques that rehearsed or portrayed clinical applications seem to have increased the physicians' performances of cancer-control clinical activities. The standardized-patient instrument seems to be particularly useful in evaluating interventions that address specific skills training. Reprint Address: P.A. Carney, Department of Community and Family Medicine, HB 7920, Dartmouth Medical School, Lebanon, NH 03756.
ACADEMIC MEDICINE
173-0409
Stress, Coping, and Well-Being among ThirdYear Medical Students
Mosley Jr., T.H., Perrin, S.G., Neral, S.M., et al. 69(9):765-767, 1994. Background. Medical school is recognized as a stressful environment that often exerts a negative effect on the academic performance, physical health, and psychological well-being of the student. Method. Stress, coping, depression, and somatic distress were examined among 69 third-year students completing a psychiatry clerkship in 1992-93 at the University of Mississippi School of Medicine. Stress was assessed using the Medical Education Hassles Scale--R. Coping was assessed using the Coping Strategies Inventory. Depression was assessed using the Center for Epidemiologic Studies--Depression Scale, and somatic distress was assessed using the Wahler Physical Symptoms Inventory. Statistical methods included correlational analysis and hierarchical regression. Results. Clinical levels of depression were found in 16 (23%) of the students, and 39 (57%) endorsed high levels of somatic distress. Stress accounted for a large percentage of the distress variance (i.e., 29% to 50%). Coping efforts contributed significant variance to the prediction of distress above and beyond that accounted for by stress alone, especially in relation to depression. Coping efforts classified by Engagement strategies were associated with fewer depressive symptoms, while coping efforts classified by Disengagement strategies were associated with higher levels of depressive symptoms. Conclusions. Because students who employed coping efforts characterized by Engagement strategies suffered from fewer depressive symptoms, the results suggest that training in these types of strategies may be a useful intervention to lessen the negative consequences of stress among medical students. Reprint Address: T.H. Mosley, Jr., Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505.
AMERICAN HEART JOURNAL
173-0411
Use of Skin Conductance Changes during Mental Stress Testing as an Index of Autonomic Arousal in Cardiovascular Research
Jacobs, S.C., Friedman, R., Parker, J.D., et al. 128:1170-1177, 1994. Mental stress testing is used to study the cardiovascular changes caused by psychologic stress. To examine the effects of cardiac drugs on mental stress-induced changes, it is useful to attain a degree of arousal that can be replicated in serial studies. Skin conductance level, a cholinergically mediated index of arousal, was assessed for its stability in serial studies and under conditions of~/-blockade. In normal subjects, skin conductance increased in response to mental stress (p < 0.001) and was stable across three sessions. In patients with mild hypertension, skin conductance was elevated during mental stress during both placebo and nadolol therapy (p < 0.001). As expected, nadolol reduced baseline and stress-induced peak arterial pressure and heart rate but had no significant effect on skin conductance. Thus skin conductance level can serve as a stable and useful index of autonomic arousal in clinical trials, even in patients using ~-blocking medications. Reprint Address: S.C. Jacobs, Department of Counseling, University of North Dakota, P.O. Box 8262, Grand Forks, ND 58202-8262.
173-0410
A Standardized-Patient Assessment of a Continuing Medical Education Program to Improve Physicians' Cancer-Control Clinical Skills Carney, P.A., Dietrich, A.J., Freeman Jr., D.H., and Mott, L,A. 70(1):52-58, 1995. Background. Although continuing medical education (CME) has long been used to inform physicians and teach specific skills, its efficacy in many areas is not well established. This randomized controlled trial assessed the effects of differing educational techniques on the cancer-control skills of 57 physicians. Method. The CME program was part of the Cancer Prevention in Community Practice Project in Hanover, New Hampshire, and was implemented in 1988. The program used several methods in its presentation, including interactive small-group discussion, role playing, videotaped clinical encounters, lecture presentations, and trigger tapes. Measurements included cross-sectional observations made by unannounced standardized patients (SPs) who, one year after the CME program, assessed 25 physicians who had participated in the program and 32 physicians who
173-0412
Physical Activity and Mortality in Women in the Framingham Heart Study
Sherman, S.E., D'Agostino, R.B., Cobb, J.L., and Kannel, W.B. 128:879-884, 1994. Men who are more active live longer, but it is not clear if the same is true for women. We monitored 1,404 women aged 256
V O L U M E 17, N U M B E R 3, 1995
257
American Heart Journal (continued) 50 to 74 who were free of cardiovascular disease. We assessed physical activity levels and ranked subjects into quartiles. After 16 years, 319 (23%) women had died. The relative risk of mortality, compared to the least active quartile, was as follows: second quartile, 0.95 (95% confidence interval [CI] 0.72 to 1.26); third quartile, 0.63 (95% CI 0.46 to 0.86); most active quartile, 0.67 (95% CI 0.48 to 0.92). The relative risks were not changed by adjustment for cardiac risk factors, chronic obstructive pulmonary disease, or cancer or by excluding all subjects who died in the first 6 years (to eliminate occult disease at baseline). There was no association between activity levels and cardiovascular morbidity or mortality. We conclude that women who were more active lived longer; this effect was not the result of decreased cardiovascular disease. Reprint Address: S.E. Sherman, PACE Center--00PG, Veterans Affairs Medical Center, 16111 Plummer Street, Sepulveda, CA 91343.
173-0413
Does Exercise Reduce Mortality Rates in the Elderly? Experience from the Framingham Heart Study
Sherman, S.E., D'Agostino, R.B., Cobb, J.L., and Kannel, W.B. 128:965-972, 1994. Regular physical activity decreases the mortality rate in middle-aged men and probably in middle-aged women. It is unknown whether this is also true in the elderly. We studied 285 men and women aged 75 years or older who were free of cardiovascular disease. Subjects were ranked by baseline physical activity levels and grouped into quartiles. After adjustments were made for cardiac risk factors, chronic obstructive pulmonary disease, and cancer, women in the second most active quartile had a much lower risk of mortality at 10 years (relative risk 0.24, 95% confidence interval 0.12 to 0.51). There was no statistically significant difference in men. There appeared to be an excess of sudden cardiac deaths in the most active women, although this group still lived longer than the least active women. We conclude that women aged 75 years or older who are more active live longer. This benefit may be attenuated in those who are extremely active. Reprint Address: S.E. Sherman, PACE Center--00PG, Veterans Affairs Medical Center, 16111 Plummer Street, Sepulveda, CA 91343.
AMERICAN JOURNAL OF CARDIOLOGY
173-0414
Effect of Preocclusion Stenosis Severity on Heart Rate Reactions to Coronary Occlusion
Airaksinen, K.E.J., Ik~iheimo, M.J., Peuhkurinen, K.J., et al. 74.'864-868, 1994. Autonomic mechanisms may have an important role in the clinical presentation of acute coronary occlusion. This research was designed to evaluate the effect of preocclusion stenosis severity on the immediate autonomic heart rate (HR) responses to a subsequent acute occlusion of the coronary artery. HR and
its variability in the time and frequency domains were analyzed in patients with mild to moderate (-85%) (group 2, n = 18) left anterior descending coronary artery stenosis immediately before and during balloon occlusion (mean 108 seconds). The ranges of nonspecific responses were determined by analyzing HR reactions in a control group (n = 13) with no ischemia during balloon inflation of a totally occluded coronary artery. An abnormal increase in HR variability and/or bradycardia as a sign of vagal activation occurred in 6 patients (32%) in group 1 and in 3 patients (17%) in group 2. A significant decrease in HR variability or tachycardia, or both, was observed in 5 patients (26%) in group 1, but in none of the patients in group 2. Compared with the control group, the balloon occlusion of mild to moderate stenosis caused abnormal HR reactions more often than did occlusion of tight stenosis (58% vs 17%, p < 0.05). Balloon occlusions in group 1 caused chest pain (I3 < 0.01), ST-segment changes (p < 0.001), and narrowing of pulse pressure (p < 0.05) more often than did occlusions of severe stenoses. Severe chest pain also resulted more often (p < 0.01) in a premature deflation of the balloon in group 1. Thus, patients with mild coronary stenosis often develop abnormal autonomic responses to a subsequent acute coronary occlusion, which may modify the clinical presentation of the acute occlusion. On the other hand, if a severe coronary artery stenosis occludes, autonomic responses are rare, possibly due to chronic ischemic preconditioning or better collateral development. Reprint Address: K.E.J. Airaksinen, Division of Cardiology,Department of Medicine, Oulu University Hospital, 90220 Oulu, Finland.
173-0415
Risk Factors for Exercise-Induced Silent Myocardial Ischemia in Healthy Volunteers
Katzel, L.I., Sorkin, J.D., Colman, E., et al. 74:869-874, 1994. This study determined the risk factors for exercise-induced silent ischemia (SI) in 281 apparently healthy volunteers aged 40 to 87 years and compared their risk factor profiles with those of 132 patients with overt coronary artery disease (CAD). SI (concordant exercise-induced asymptomatic ST-segment depression on" electrocardiography and perfusion defects on tomographic thallium-201 scintigraphy) was detected in 37 of 225 men (16%), versus 2 of 56 women (4%, p < 0.05). The prevalence of SI increased with age from 6% in men aged < 55 years to 18% in men aged 55 to 70 years, and to 25% in men aged >70 years (p < 0.001). Compared with the 118 men with concordant normal exercise electrocardiogram and thallium scan (normals), men with SI were older (p < 0.001), and had a higher waist-to-hip ratio (p < 0.005), higher plasma triglyceride levels (p < 0.001), and lower high-density lipoprotein (HDL) cholesterol levels (p < 0.001). In stepwise logistic regression analysis, age, waist-to-hip ratio, and HDL levels were independent predictors of SI in men. Compared with 108 men with overt CAD, men with SI were younger (67 _+ 2 vs 73 __ 1 years, p < 0.001) but had similar plasma lipids and waist-to-hip ratio. Thus, older age, male gender, abdominal obesity, and reduced HDL levels-all well-established risk factors for overt CAD--were risk factors for exercise-induced SI in these asymptomatic volunteers. Reprint Address: L.I. Katzel, Baltimore Veterans AffairsMedical Center, Geriatrics Service (18), 10 North Greene Street, Baltimore, MD 21201.
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American Journal of Cardiology (continued) 173-0416
Gender Differences in the Utilization of Cardiac Catheterization for the Diagnosis of Chest Pain Vaitkus, P.T. 75:79-81, 1995. Reprint Address: P.T. Vaitkus, Cardiology Unit, 1-McClure, Medical Center Hospital of Vermont, 111 Colchester Avenue, Burlington, VT 05401. 173-0417
Reproducibility of Power Spectral Measures of Heart Rate Variability Obtained from ShortTerm Sampling Periods Freed, L.A., Stein, K.M., Gordon, M., Urban, M., and Kligfield, P. 74:972-973, 1994. Reprint Address: P. Kligfield, 525 East 68th Street, New York, NY 10021.
AMERICAN JOURNAL OF EPIDEMIOLOGY
173-0418
Parity, Contraception, Infertility, and the Risk of Epithelial Ovarian Cancer Risch, H.A., Marrett, L.D., and Howe, G.R. 140(7):585-597, 1994. A case-control study of reproductive factors and cancer of the ovary was conducted during 1989-1992 in metropolitan Toronto and nearby areas of Southern Ontario, Canada. In total, 450 women aged 35-79 years with histologically verified new primary epithelial ovarian cancers were interviewed concerning their reproductive histories. Over the same time period, 564 randomly selected population controls, frequency-matched to the cases according to three 15-year age groups, were also interviewed. Continuous unconditional logistic regression methods were used for analysis. It was found that childbearing and use of oral contraceptives were associated with significant decreasing trends in risk of ovarian cancer; the respective odds ratios were 0.78 for each full-term pregnancy (p < 10 -8) and 0.92 for each year of use (p < 10-6). Hysterectomy was also associated with reduced risk, even after more than 20 years. Among parous women, infertility did not appear to affect risk; for nulliparous women, some evidence of increased risk was present, although fertility problems were reported by only a small fraction of nuUiparae. It is suggested that the relatively lower parity of cases as compared with controls may be due to voluntary choices for having fewer children. Reprint Address: H.A. Risch, Department of Epidemiology and Public Health, Yale University School of Medicine, 60 College Street, P.O. Box 3333, New Haven, CT 06510. 173-0419
Alcohol Consumption and Breast Cancer: Estrogen Receptor Status and Histology Nasca, P.C., Liu, S., Baptiste, M.S., et al. 140(11):980-987, 1994. Data from a case-control study conducted in New York State during 1982-1984 were used to evaluate the relation between alcohol consumption and estrogen receptor-positive and estrogen receptor-negative breast cancers and alcohol and var-
ious histologic subtypes. The cases were women between 20 and 79 years of age with a diagnosis of primary breast cancer. A total of 794 estrogen receptor-positive and 358 estrogen receptor-negative breast cancer cases were available for study. Controis (n = 1,617) were selected from driver's license files of the New York State Department of Motor Vehicles. Information on estrogen receptor status and histology was obtained from hospital records. The risk of estrogen receptor-positive breast cancer was shown to increase with increasing amounts of alcohol consumption in grams per day (odds ratio (OR) = 1.18 (95% confidence interval (CI) 0.88-1.57) for < 1.5 g/day, 1.28 (95% CI 0.91-1.80) for 1.5--4.9 g/day, 1.28 (95% CI 0.96-1.70) for 5.0-14.9 g/day, and 1.35 (95% CI 0.99-1.85) for -> 15.0 g/day). There was no relation between alcohol consumption and estrogen receptor-negative tumors (OR = 0.92 (95% CI 0.62-1.36) for < 1.5 g/day, 1.19 (95% CI 0.77-1.83) for 1.5--4.9 g/day, 0.94 (95% CI 0.64-1.35) for 5.0-14.9 g/day, and 1.05 (95% CI 0.701.59) for >--15.0 g/day). The risk for each of the histologic subtypes studied increased with increasing daily alcohol consumption. These findings suggest that alcohol may only increase a woman's risk of estrogen receptor-positive breast cancers. Reprint Address: P.C. Nasca, School of Public Health and Health Sciences, University of Massachusetts, Room 406, Arnold House, Amherst, MA 01003-0430.
173-0420
Case-Control Study of Caffeinated Beverages and Preterm Delivery Pastore, L.M. and Savitz, D.A. 141(1):6t-69, 1995. Although many women reduce their caffeine consumption once they know they are pregnant, 70-80% of pregnant women still consume caffeine. To evaluate the relation between caffeine consumption and preterm delivery, a case-control study was conducted to identify all preterm (< 37 weeks gestation) infants born to women in selected North Carolina counties from September 1988 through April 1991. Randomly selected full-term, normal-weight livebirths (matched by race and hospital) served as controls. The study population consisted of 408 cases and 490 controls. Telephone interviews with participants assessed the consumption of caffeinated coffee, tea, cola soft drinks, and noncola caffeinated soft drinks, with caffeine consumption measured by the number of daily servings of each beverage and the total milligrams of caffeine. Third-trimester caffeine consumption from all beverages combined showed a nonsignificant inverse association with preterm delivery. Both first- and secondtrimester consumption of 1-150 mg/day were associated with a modestly increased risk of preterm delivery, while no association was found at higher consumption levels. Overall, these results do not support an association between caffeinated beverage consumption and preterm delivery, as is true in most previous studies. Reprint Address."D.A. Savitz, School of Public Health, Epidemiology Department, CB #7400, University of North Carolina, Chapel Hill, NC 27599. 173-0421
Use of Sunbeds or Sunlamps and Malignant Melanoma in Southern Sweden Westerdahl, J., Olsson, H., M/lsb/ick, A., et al. 140(8):691--699, 1994. In a population-based, matched case-control study from the South Swedish Health Care Region, which has the highest
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American Journal of Epidemiology (continued) risk for melanoma in Sweden, the relation between the use of sunbeds or sunlamps and malignant melanoma was investigated. Between July 1, 1988, and June 30, 1990, a total of 400 melanoma patients and 640 healthy controls aged 15-75 years answered a comprehensive questionnaire containing different epidemiologic variables. Questions regarding the use of sunbeds or sunlamps were included. The odds ratio for developing malignant melanoma after ever having used sunbeds or sunlamps was 1.3. Considering all age groups, the odds ratio was significantly elevated after exposure more than 10 times a year to sunbeds or sunlamps (odds ratio (OR) = 1.8). When the study was restricted to patients and controls younger than age 30 years because the use of tanning devices is much more common among young persons, the odds ratio was higher (OR = 7.7 for more than 10 times a year vs. none). These findings were independent of constitutional factors and factors regarding sun exposure. A dose-response relation was evident. Furthermore, among melanoma patients in this young age group, the ratio of females to males was significantly higher than in older patients. When different melanoma presentation sites were considered, only lesions of the trunk were significantly associated with sunbed or sunlamp use (OR = 4.2 for more than 10 times a year vs. none). Reprint Address:J. Westerdahl, Department of Surgery,University Hospital, S-221 85 Lund, Sweden.
173-0422
Risk Factors for Cervical lntraepithelial Neoplasia: Differences between Low- and HighGrade Lesions
Brisson, J., Morin, C., Fortier, M., et al. 140(8):700-710, 1994. This case-control study assesses relations of human papillomavirus (HPV) type 16 infection, sexual history, cigarette smoking, and oral contraceptive use to low- and high-gradc cervical intraepithelial neoplasia (CIN). A total of 548 highgrade and 338 low-grade CIN cases and 612 controls were identified among women seen at a colposcopy clinic in Quebec, Canada, in 1988-1989. Interviews, colposcopy, cervical scrapings, and colposcopically directed biopsies were performed. One pathologist reviewed all histologic slides. Southern blot techniques were used to assay specimens for HPV 16 DNA. Lifetime number of sexual partners was related to low- and high-grade CIN. Presence of HPV 16 DNA was associated with a 8.7-fold (95% confidence interval 5.l-l 5.0) elevation is estimated relative risk of high-grade CIN. Relative risk of high-grade CIN increased with amount of HPV 16 DNA (p < 0.0001). Estimated relative risk of high-grade CIN in current cigarette smokers was 2.4 (95% confidence interval 1.8-3.2) compared with never smokers and increased with number of pack-years of exposure (p < 0.0001). Long-term (6 years or more) users of oral contraceptives had an estimated relativc risk ofhigh-grade CIN of 1.9 (95% confidence interval 1.1-3.3) compared with those who never used such contraceptives. In contrast, presence of HPV 16 DNA, cigarette smoking, and oral contraceptive use showed little or no relation to low-grade CIN. Risk factors for low- and high-grade CIN may differ substantially. Reprint Address: J. Brisson, Epidemiology Research Unit, H6pital du Saint-Sacrement, 1050, Chemin Ste-Foy, Quebec, PQ GIS 4L8, Canada.
173-0423
Physical Activity and Stroke Risk: The Framingham Study
Kiely, D.K., Wolf, P.A., Cupples, L.A., Beiser, A.S., and Kannel, W.B. 140(7):608-620, 1994. The authors prospectively examined the influence of increased levels of physical activity on risk of stroke in members of the Framingham Study cohort. Two separate analyses were performed, one during midlife in 1,897 men (mean age = 49.7 years) and 2,299 women (mean age = 49.9 years) and another when the cohort was older (1,361 men (mean age = 63.0) and 1,862 women (mean age = 63.7)). A structured questionnaire administered at two separate examinations was used to estimate the amount of metabolic work done during a typical 24-hour period. Physical activity was categorized into tertiles, and medium and high levels of physical activity were compared with a low level of physical activity, which was used as the referent group. Cox proportional hazards, life table, and time-dependent covariate analyses were used to examine the relation between level of physical activity and stroke risk over a follow-up period of up to 32 years. In men, adjusted analyses revealed that increased levels of physical activity were protective. The strongest effect was obtained from an analysis involving older cohort members in the medium tertile (risk ratio = 0.41, 95% confidence interval 0.24-0.69). High levels of physical activity did not confer an additional benefit over medium levels. Adjusted analyses showed no significant protective effect in women. These results indicate that medium and high levels of physical activity among men are protective against stroke relative to low levels. Reprint Address: P.A. Wolf, Department of Neurology, Boston University School of Medicine, 80 East Concord Street, B-608, Boston, MA 02118-2334.
173-0424
A Prospective Study of Alcohol Intake and Change in Body Weight among U.S. Adults
Liu, S., Serdula, M.K., Williamson, D.F., Mokdad, A.H., and Byers, T. 140(10):912-920, 1994. Little is known about the role of alcohol in determining change in body weight. In this paper, the authors examine the relation between alcohol intake and body weight in 7,230 US adults aged 25-74 years who participated in the First National Health and Nutrition Examination Survey (1971-1975) and who were reweighed 10 years later (1982-1984). Both cross-sectional and prospective analyses were adjusted for age, race, height, education, health status, smoking status, diet status, physical activity, and total nonalcoholic caloric intake. At baseline, women who reported at least one drink per day weighed 2.3 kg less than nondrinkers (95% confidence interval (CI) - 0 . 4 to -4.2). Little relation was observed between body weight and alcohol intake cross-sectionally among men. Prospectively, both men and women drinkers tended to gain less weight than did nondrinkers (p = 0.006 for trend in women, p = 0.11 for trend in men). Drinkers also had more stable weight over the 10-year followup period. Drinkers were less likely to have major weight gain or loss (gaining or losing >- l0 kg) than were nondrinkers. Compared with nondrinkers, for those who consumed 1-6.9 drinks per week, women had an odds ratio (OR) = 0.7 (95% CI 0.5 to 0.9) for major weight gain and an OR = 0.7 (95% CI 0.5 to 1.1) for major weight loss, while men had an OR = 1.0 (95% CI 0.6 to 1.6) for major weight gain and an OR = 0.7 (95% CI 0.5 to
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American Journal of Epidemiology (continued) 1.2) for major weight loss. For those who consumed >2 drinks per day, women had an OR = 0.5 (95% CI 0.3 to 1.0) for major weight gain and an OR = 0.8 (95% CI 0.4 to 1.6) for major weight loss, while men had an OR = 0.9 (95% CI 0.5 to 1.6) for major weight gain and an OR = 1.0 (95% CI 0.6 to 1.7) for major weight loss. These data suggest that alcohol intake does not increase the risk of obesity. Reprint Address: S. Liu, Division of Nutrition (K-26), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341-3724.
Parent Monitoring and the Incidence of Drug Sampling in Urban Elementary School Children Chilcoat, H.D., Dishion, T.J., and Anthony, J.C. 141(1):25-31, 1995. An epidemiologic study of urban-dwelling children aged 8I0 years in Baltimore, Maryland, was undertaken to test the hypothesis that close monitoring and supervision by parents might signal a reduced risk of drug use in the elementary school years. Drug use, monitoring by parents, peer drug use, and other suspected risk factors for early drug use were first assessed in 1989, identifying 947 children with no prior history of drug use. One year later, 4.2 percent of these children were found to have started using alcohol, tobacco, or other drugs on their own for the first time during the follow-up observation interval. Risk of starting drug use was higher for children with lower levels of parent monitoring (relative risk = 4.39, 95% confidence interval 1.48-13.0). In addition, for children with declining levels of parent monitoring, there was an increased risk of starting to use drugs on their own. Reprint Address: H.D. Chilcoat, Henry Ford Health Science Center, Department of Psychiatry, 1 Ford Place, Detroit, MI 48202.
adjustment for smoking, serum cholesterol, and blood pressure, the hazard rate ratio was 0.74 (95% CI 0.54-1.02). Among women, the corresponding hazard rate ratios were 0.49 (95% CI 0.21-1.12) and 0.73 (95% CI 0.30-1.71), respectively. Therefore, it can be estimated that in both sexes nearly half of the decrease in coronary mortality hazard was associated with the changes in risk factors. The fall in serum cholesterol level among men and the decrease in blood pressure among women contributed most of the decrease in coronary mortality hazard. Reprint Address: P. Jousilahti, National Public Health Institute, Department of Epidemiology and Health Promotion, Mannerheimintie 166, FIN-00300 Helsinki, Finland.
173-0425
173-0426
Effect of Risk Factors and Changes in Risk Factors on Coronary Mortality in Three Cohorts of Middle-Aged People in Eastern Finland Jousilahti, P., Vartiainen, E., Toumilehto, J., Pekkanen, J., and Puska, P. 141(1):50-60,1995. The association of smoking, serum cholesterol, and blood pressure with coronary mortality and the contribution of changes in these risk factors to the decline in coronary mortality was assessed in three cohorts of middle-aged population examined in 1972, 1977, and 1982 in Eastern Finland. A total of 10,758 men and 11,112 women were included in this study. The followup time of each subject was 8 years. Age-adjusted coronary mortality decreased from 54 per 10,000 person-years in the 1972 cohort to 30 per 10,000 person-years in the 1982 cohort among men and from eight per 10,000 person-years to four per 10,000 person-years among women in the 1972 and 1982 cohorts, respectively. Concomitantly with the decrease in coronary mortality, there was a marked decrease in cardiovascular risk factors. Among men, the age- and geographic area-adjusted hazard rate ratio of coronary mortality between 1972 and 1982 cohorts was 0.52 (95% confidence interval (CI) 0.38-0.72). After further
173-0427
A Population-Based Case-Cohort Evaluation of the Efficacy of Mammographic Screening for Breast Cancer Thompson, R.S., Barlow, W.E., Taplin, S.H., et al. 140(10):889-901, 1994. Screening efficacy may be evaluated in population-based, observational studies, provided one addresses biases that arise in nonrandomized screening evaluations. The authors evaluated the association of mammographic screening with breast cancer mortality among women without prevalent breast cancer. The cohort consisted of 94,656 women, aged >--40years, enrolled in a large health maintenance organization in Washington State during the period 1982-1988. A case-cohort design limited chart abstraction of risk factor and screening information to 4% of the cohort. There were 1,144 incident breast cancer cases, including 126 who died of breast cancer during the study interval. An age-stratified proportional hazards analysis compared the screening experience of the breast cancer deaths with that of 2,237 controls. The family history of breast cancer, previous biopsy, and parity were included in the model to control for potential confounding effects of selection bias. With a mean follow-up of only 3.5 years postscreening, there was a small but statistically nonsignificant reduction in the risk of breast cancer mortality among women screened 1 year prior to diagnosis compared with unscreened women. The relative risk was 0.80 (95% confidence interval 0.34-1.85) for women aged _>40 years and 0.61 (95% confidence interval 0.23-1.62) for women aged _>50 years. This paper illustrates how case-cohort methodology can be used to perform efficient assessment of screening efficacy in large cohorts, while eliminating or controlling for sources of bias. ReprintAddress:R.S. Thompson, Department of Preventive Care, Group Health Cooperative of Puget Sound, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.
173-0428
Risk of Premenopausal Breast Cancer and Use of Electric Blankets Vena, J.E., Freudenheim, J.L., Marshall, J.R., et al. 140(11):974-979, 1994. Electric blanket use, estimated to significantly increase background exposure to 60-Hz electromagnetic fields, has been
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American Journal of Epidemiology (continued) hypothesized to increase breast cancer risk. From 1986 to 1991 in western New York State, the authors investigated the use of electric blankets as a risk factor for breast cancer in a casecontrol study of premenopausal women. A total of 290 premenopausal breast cancer cases and 289 age-matched randomly selected community controls were queried in regard to their use of electric blankets in the previous 10 years, including frequency of use in season and mode of use. After adjusting for age, education, and other risk factors, the odds ratio for use of an electric blanket at any time in the previous 10 years (40% of cases and 37% of controls) was 1.18 (95% confidence interval (CI) 0.83-1.68). Estimates of risk did not differ in a dose-response fashion for number of years of electric blanket use. The risk associated with daily use in season relative to nonuse was 1.27 (95% CI 0.86-1.88). The risk of breast cancer among those who reported use of the blanket through the night was 1.43 (95% CI 0.94-2.17). However, the risk for those who reported daily use in season, continuously throughout the night for the previous 10 years was 1.10 (95% CI 0.59-2.05). These findings do not support the hypothesis that electric blanket use is associated with an increased risk for breast cancer. Studies with improved measures of more highly exposed individuals with quantification of total electromagnetic field exposure might clarify the uncertainties regarding risk of breast cancer associated with such exposure. Reprint Address:J.E. Vena, Department of Social and Preventive Medicine, SUNY, 270 Farber Hall, 3435 Main Street, Buffalo, NY 14214.
173-0429
Cigarette Smoking: An Independent Risk Factor for Impotence? Mannino, D.M., Klevens, R.M., and Flanders, W.D. 140(11):1003-1008, 1994. The authors sought to determine whether current cigarette smoking was associated with impotence among middle-aged men. This is a secondary analysis of a cross-sectional survey of 4,462 US Army Vietnam-era veterans aged 31-49 years who took part in the Vietnam Experience Study in 1985-1986. The main outcome measurement was the odds ratio for reported impotence, which was calculated by comparing current smokers with nonsmokers while controlling for multiple confounders. The study sample consisted of 1,162 never smokers, 1,292 former smokers, and 2,008 current smokers. The prevalence of impotence was 2.2% among never smokers, 2.0% among former smokers, and 3.7% among current smokers (p = 0.005). The unadjusted odds ratio (OR) of the association between smoking and reported impotence was 1.8 (95% confidence interval (CI) 1.2-2.6). The association held even after adjustments were made for confounders, including vascular disease, psychiatric disease, hormonal factors, substance abuse, marital status, race, and age (OR = 1.5, 95% CI 1.0-2.2). Neither years smoked nor cigarettes smoked daily were significant predictors of impotence in current smokers. The authors concluded that, among the men in this study, a higher percentage of cigarette smokers reported impotence than did nonsmokers. This observation could not be totally explained by comorbidity factors related to smoking. Reprint Address: D.M. Mannino, National Center for Environmental Health, CDC, MS-F39, 4770 Buford Highway NE, Atlanta, GA 303413724.
AMERICAN JOURNAL OF PSYCHIATRY
173-0430
Prevalence and Correlates of Dysthymia and Major Depression among Patients with Alzheimer's Disease Migliorelli, R., Tes6n, A., Sabe, L., et al. 152(1):37--44, 1995. Objective: The purpose of this study was to examine the prevalence, risk factors, and correlates of depression among patients with Alzheimer's disease. Method: A consecutive series of 103 patients with probable Alzheimer's disease were examined with a structured psychiatric interview and were assessed for the presence of cognitive impairments, deficits in activities of daily living, social functioning, and anosognosia. Results: Fifty-one percent of the patients had depression (28% had dysthymia and 23% major depression). Women had a significantly higher prevalence ofboth major depression and dysthymia than men. Depressed and nondepressed patients had a similar frequency of family and personal histories of depression, a similar frequency of personality disorders before the onset of depression, and no significant differences in cognitive deficits and impairment in activities of daily living. Dysthymia usually started after the onset of dementia and was significantly more prevalent in the early stages of dementia; patients with dysthymia had a significantly better awareness of intellectual deficits than patients with major or no depression. On the other hand, patients with major depression had an earlier onset of depression (half of them before the onset of dementia), and the prevalence of major depression was similar across the different stages of the illness. Conclusions: This study demonstrates a high prevalence ofdysthymia and major depression among patients with probable Alzheimer's disease. While dysthymia may be an emotional reaction to the progressive cognitive decline, major depression may be related to biological factors. Reprint Address: S.E. Starkstein, Rafil Carrea Institute of Neurological Research, Montafieses 2325, 1428 Buenos Aires, Argentina.
173-0431
Sleep Events among Veterans with CombatRelated Posttraumatic Stress Disorder Mellman, T.A., Kulick-Bell, R., Ashlock, L.E., and Nolan, B. 152(1):110-115, 1995. Objective: Sleep disturbances are important features of posttraumatic stress disorder (PTSD); however, the published data characterizing PTSD sleep phenomena are limited. The authors report on the phenomenology and physiological correlates of symptomatic sleep events in PTSD. Method: The study data included survey results that addressed sleep symptoms during the past month in combat veterans with and without PTSD (N = 58), sleep diary records of awakenings from combat veterans with PTSD hospitalized on an inpatient rehabilitation unit (N = 52), and overnight polysomnography recordings obtained from 21 medication-free combat veterans with PTSD and eight healthy comparison subjects not exposed
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American Journal of Psychiatry (continued) to combat. Results: Recurrent awakenings, threatening dreams, thrashing movements during sleep, and awakenings with startle or panic features represented the most prevalently reported sleeprelated symptoms. Laboratory findings of longer time awake, micro-awakenings, and a trend for patients to exhibit body and limb movements during sleep are consistent with the subjectively reported symptom profile. Prospectively assessed symptomatic awakenings featured startle or panic symptoms or anxiety related to threatening dreams. Laboratory findings revealed a trend for the symptomatic awakenings (with and without dream recall) to be disproportionately preceded by REM sleep, and the two recorded awakenings with objective physiological arousal were preceded by REM. Conclusions: PTSD features intrusions into sleep of more highly aroused behaviors and states, which appear partially conditioned to REM sleep. Reprint Address:T.A. Mellman, Miami VA Medical Center, Psychiatry Service 116A, 1201 16th Street, Miami, FL 33125.
173-0432
Subthreshold Depression and Depressive Disorder: Clinical Characteristics of General Medical and Mental Health Specialty Outpatients
Sherbourne, C.D., Wells, K.B., Hays, R.D., et al. 151(12):1777-1784, 1994. Objective: The authors examined the clinical significance of depressive symptoms below the threshold for depressive disorder in outpatient samples. Method: The subjects were 775 adult patients with current depressive disorder, 1,420 patients with subthreshold depression, and 1,767 hypertensive patients with and without depression, all of whom were visiting the offices of mental health specialists and general medical care providers in three U.S. cities. Data on demographic characteristics, severity of depression, extent of psychiatric and medical comorbidity, family psychiatric history, and treatment history for the patients with depressive disorder and those with subthreshold depression were compared. Results: The percentage of patients with subthreshold depression who had a family history of depression (41%) was nearly as high as that of the patients with depressive disorder (59%). The two groups of patients had similar levels ofmedical and psychiatric comorbidity except for anxiety disorders, which were greater among the patients with depressive disorder. Among the hypertensive patients in the general medical sector, those with subthreshold depression were more similar to those with depressive disorder than to the nondepressed hypertensive patients. Treatment rates were considerably lower for patients with subthreshold depression than for patients with depressive disorder in the general medical sector, but they were similar in the mental health specialty sector. Conclusions: In these outpatients, subthreshold depression appeared to be a variant of affective disorder and was treated as such in the mental health specialty sector but not in the general medical sector. The findings emphasize the importance of treatment outcome studies of patients with subthreshold depression. Reprint Address: C.D. Sherbourne, RAND, 1700 Main Street, Santa Monica, CA 90407-2138.
AMERICAN JOURNAL OF PUBLIC HEALTH
173-0433
Does the Promotion and Distribution of Condoms Increase Teen Sexual Activity? Evidence from an HIV Prevention Program for Latino Youth
Sellers, D.E., McGraw, S.A., and McKinlay, J.B. 84(12): 1952-1959, 1994. Objectives. Opponents of condom availability programs argue that the promotion and distribution of condoms increases adolescent sexual activity. This assertion was tested empirically with data from the evaluation of a human immunodeficiency virus (HIV) prevention program for Latino adolescents. Methods. The onset of sexual activity, changes in the frequency of sex, and changes in the proportion of respondents with multiple partners were compared for intervention and comparison groups. MuLtivariate regression analysis was used to assess the effect of the intervention on these outcomes after adjustment for baseline differences between the intervention and comparison groups. Results. Male respondents in the intervention city were less likely than those in the comparison city to initiate first sexual activity (odds ratio [OR] = 0.08). Female respondents in the intervention city were less likely to have multiple partners (OR = 0.06). The program promoting and distributing condoms had no effect on the onset of sexual activity for females, the chances of multiple partners for males, or the frequency of sex for either males or females. Conclusions. An HIV prevention program that included the promotion and distribution of condoms did not increase sexual activity among the adolescents in this study. Reprint Address: J.B. McKinlay, New England Research Institute, 9 Galen Street, Watertown, MA 02172.
173-0434
Recruitment Activities and Sociodemographic Factors That Predict Attendance at a Mammographic Screening Program Hurley, S.F., Huggins, R.M., Jolley, D.J., and Reading, D. 84(10):!655-1658, 1994. A random sample of 2266 women aged 50 to 69 years was used to investigate factors that predict attendance at a free Australian mammographic screening program. The most important predictor was receipt of a personal invitation letter. A letter that included an appointment time increased attendance 132-fold initially and decreased to 20 times baseline after 14 days. A letter that did not include an appointment time increased attendance 12-fold, and a second letter to nonattenders increased attendance approximately 13-fold. Attendance declined with increasing distance from the program and with increases in the percentage of non-English speaking women in a neighborhood, but was higher in areas of higher socioeconomic status. Reprint Address: S.F. Hurley, Department of Public Health and Community Medicine, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053, Australia.
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American Journal of Public Health (continued) 173-0435
Seat Belt Use among Drinking Drivers in Minnesota
Foss, R.D., Beirness, D.J., and Sprattler, K. 84(11):1732-1737, 1994. Objectives. Among the reasons cited for recent declines in alcohol-related traffic fatalities is the enactment of seat belt use laws by most states. It is suspected that drinking drivers are less likely to comply with such laws, although evidence on the relationship between belt use and drinking by drivers is sparse and conflicting. The purpose of this study was to examine the relationship of drinking to driver seat belt use. Methods. Observational, self-report, and chemical breath test data were collected on nighttime drivers in 16 Minnesota communities during September, 1990. Results. Drivers with an illegal blood alcohol concentration (_> 100 mg/dL) were substantially less likely to be wearing a seat belt (odds ratio [OR] = 2.17). Belt use was also more common among females (OR = 2.02) and before midnight (OR = 1.47). Males who had been drinking were less likely to be belted. Belt use was related to drinking before, but not after, midnight. Belt use was not related to drinking status among college graduates, but it was strongly related to drinking status among those with less education. Conclusions. The present findings provide further argument for rapid implementation of passive countermeasures (airbags) and for development of creative, carefully focused interventions to target high-risk populations. Reprint Address: R.D. Foss, UNC Highway Safety Research Center, 1341/2 East Franklin Street, CB #3430, Chapel Hill, NC 27599-3430.
173-0436
Health Care-Seeking Behavior Related to the Transmission of Sexually Transmitted Diseases in Kenya
Moses, S., Ngugi, E.N., Bradley, J.E., et al. 84(12): 1947-1951, 1994. Objectives. The purpose of this study was to identify healthcare seeking and related behaviors relevant to controlling sexually transmitted diseases in Kenya. Methods. A total of 380 patients with sexually transmitted diseases (n = 189 men and 191 women) at eight public clinics were questioned about their health-care seeking and sexual behaviors. Results. Women waited longer than men to attend study clinics and were more likely to continue to have sex while symptomatic. A large proportion of patients bad sought treatment previously in both the public and private sectors without relief of symptoms, resulting in delays in presenting to study clinics. For women, being married and giving a recent history of selling sex were both independently associated with continuing to have sex while symptomatic. Conclusions. Reducing the transmission of sexually transmitted diseases in Kenya will require improved access, particularly for women, to effective health services, preferably at the point of first contact with the health system. It is also critical to encourage people to reduce sexual activity while symptomatic, seek treatment promptly, and increase condom use. Reprint Address: S. Moses, Department of Community Health, University of Nairobi, P.O. Box 19676, Nairobi, Kenya.
173-0437
Weight Control Practices in Adults: Results of a Multistate Telephone Survey Serdula, M.K., Williamson, D.F., Anda, R.F., et al. 84(11):1821-1824, 1994. In this study, data collected in 1989 in a random-digit dialing telephone survey of 60,590 adults in 38 states and the District of Columbia were analyzed. Approximately 38% of women and 24% of men reported that they were currently trying to lose weight. Methods reported were counting calories (24% of women, 14% of men), participating in organized weight loss programs (10%, 3%), taking special supplements (10%, 7%), taking diet pills (4%, 2%), and fasting for 24 hours or longer (5%, 5%). Among both sexes, only half of those trying to lose weight reported using the recommended method of caloric restriction combined with physical activity. Reprint Address: M.K. Serdula, Division of Nutrition (K26), Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341-3724. 173-0438
Mother-Daughter Correlations of Obesity and Cardiovascular Disease Risk Factors in Black and White Households: The NHLBI Growth and Health Study Morrison, J.A., Payne, G., Barton, B.A., Khoury, P.R., and Crawford, P. 84(11):1761-1767, 1994. Objectives. This study sought to evaluate obesity as a potential explanatory factor for the increased relative risk for cardiovascular disease in Black compared with White women. Methods. Familial associations for obesity and cardiovascular disease risk factors were assessed in 720 White and 580 Black mother-daughter pairs from the National Heart, Lung, and Blood Institute's Growth and Health Study by using Pearson's chi square, Spearman's correlations, and partial correlations. Results. Black girls and mothers were significantly heavier and had higher body mass indices than their White counterparts. In each racial group, significant, positive mother-daughter correlations existed for weight, body mass index, and triceps skinfolds, and for all cardiovascular disease risk factors. Obesity measures correlated positively with systolic blood pressure and triglycerides and inversely with high-density lipoprotein cholesterol in girls and mothers of both races. Correlations between mothers and daughters for exercise and ideal body shape were weak and did not explain obesity associations. Conclusions. Intrafamilial associations of obesity, cardiovascular disease risk factors, and the obesity-cardiovascular disease risk factor relationship support the position that increased cardiovascular disease morbidity and mortality rates in Black women may be linked to excess obesity in Black women compared with White ones. Reprint Address: B.A. Barton, Maryland Medical Research Institute, 600 Wyndhurst Avenue, Baltimore, MD 21210. 173-0439
Factors Mediating Changes in Sexual HIV Risk Behaviors among Gay and Bisexual Male Adolescents Rotheram-Borus, M.J., Reid, H., and Rosario, M. 84(12):1938-1946, 1994. Objectives. Factors mediating changes in sexual behaviors that increase the risk of human immunodeficiency virus (HIV)
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American Journal of Public Health (continued) infection were monitored in a group of gay and bisexual male adolescents. Methods. One hundred thirty-six males aged 14 to 19 years (Hispanic, 51%; African-American, 31%) were recruited from one gay-identified agency, were assessed at four points over a 1-year period, and participated in HIV preventive intervention sessions. Results. Significant reductions occurred in the number of unprotected same-sex anal and oral acts. Those with less risk in their previous sexual history, those who did not engage in commercial sex, and those who attended more HIV intervention sessions were more likely to reduce their sexual risk. The impact of sessions varied significantly by race/ethnicity: African-American youths reduced their risk acts most dramatically. Abstinence was consistently and significantly more likely among younger youths and those who had been abstinent before enrollment. The youths significantly reduced the number of sexual partners following the intervention; this reduction in partners was maintained through the 12-month follow-up and was greatest among youths with no involvement in commercial sexual activity (prostitution). Conclusions. The efficacy of HIV prevention programs must be empirically evaluated. Reprint Address:M.J. Rotheram-Borus, Division of Social Psychiatry, Neuropsychiatric Institute, University of California, 10920 Wilshire Boulevard, Suite 1103, Los Angeles, CA 90024.
ANNALS OF INTERNAL MEDICINE
173-0440
Predictors of Automobile Crashes and Moving Violations among Elderly Drivers Marottoli, R.A., Cooney Jr., L.M., Wagner, D.R., Doucette, J., and Tinetti, M.E. 121:842-846, 1994. Objective: To identify the factors associated with automobile crashes, moving violations, and being stopped by police in a cohort of elderly drivers. Design: Prospective cohort study. Setting: Urban community. Participants: All 283 persons who drove between 1990 and 1991, selected from a representative cohort of community-living persons aged 72 years and older in New Haven, Connecticut. Measurements: Data on independent variables in five domains (demographic, health, psychosocial, activity, and physical performance) were collected in structured interviews before events occurred. The outcome measure was the self-report of involvement in automobile crashes, moving violations, or being stopped by police in a 1-year period. Results: Of the 283 drivers, 13% reported a crash, a moving violation, or being stopped by police in 1 year. The baseline factors associated with the occurrence of adverse events in multivariable analysis (with adjustment for driving frequency and housing type) were the following: poor design copying on the MiniMental State Examination (relative risk, 2.7; 95% CI, 1.5 to 5.0), fewer blocks walked (relative risk, 2.3; CI, 1.3 to 4.0), and more foot abnormalities (relative risk, 1.9; CI, 1.1 to 3.3). These risk factors were combined for assessment of their ability to predict the occurrence of adverse driving events. If no factors were present, 6% of drivers had events; if 1 factor was present, 12% had events; if 2 factors were present, 26% had events; and
if 3 factors were present, 47% had events. Conclusions: In this urban population, several simple clinical measures correlated with the risk for adverse driving events. 173-0441
Estrogen Replacement Therapy and Fractures in Older Women
Cauley, J.A., Seeley, D.G., Ensrud, K., et al. 122:9-16, 1995. Objective: To determine the relation between estrogen replacement therapy and fractures. Design: Prospective cohort study. Setting: Four clinical centers in Baltimore County, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania. Participants: 9704 ambulatory, non-Black women 65 years of age or older. Measurements: Estrogen use, medical history, and anthropometric data were obtained by questionnaire, interview, and examination. Appendicular bone mass was measured by single-photon absorptiometry. Incident fractures were validated by radiographic report. Results: After adjustment for potential confounders, current estrogen use was associated with a decrease in the risk for wrist fractures (relative risk [RR], 0.39; 95% CI, 0.24 to 0.64) and for all nonspinal fractures (RR, 0.66; CI, 0.54 to 0.80) when compared with no estrogen use. Results were similar for women using unopposed estrogen or estrogen plus progestin, for women younger or older than 75 years of age, and for current smokers or nonsmokers. The effect of estrogen remained after adjustment was made for appendicular bone mass. The relative risk for hip fracture tended to be lower among current users (RR, 0.60; CI, 0.36 to 1.02) than among never-users. Estrogen was most effective in preventing hip fracture among those older than 75 years. Current users who started estrogen within 5 years of menopause had a decreased risk for hip fractures (RR, 0.29; CI, 0.09 to 0.92), wrist fractures (RR, 0.29; CI, 0.13 to 0.68), and all nonspinal fractures (RR, 0.50; CI, 0.36 to 0.70) when compared with women who had never used estrogen. Previous use of estrogen for more than 10 years or use begun soon after menopause had no substantial effect on the risk for fractures. Conclusions: Current use of estrogen appears to decrease the risk for fracture in older women. These results suggested that for protection against fractures, estrogen should be initiated soon after menopause and continued indefinitely.
ANNALS OF THE RHEUMATIC DISEASES
173-0442
Relationship between Weakness and Muscle Wasting in Rheumatoid Arthritis
Helliwell, P.S. and Jackson, S. 53(11):726-728, 1994. Objective--To relate weakness of grip to loss of forearm muscle bulk, hand joint deformity, and hand joint tenderness in patients with rheumatoid arthritis (RA). Methods--Using anthropometric data we have estimated the anatomical cross-
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Annals of the Rheumatic Diseases (continued) sectional area (CSA) of forearm muscles in 100 subjects with RA compared with 100 aged and sex-matched normal subjects. We also recorded hand joint tenderness using a modification of the Ritchie articular index, and a simple index of hand joint deformity. Results--We found a significant reduction in anatomical CSA in RA (forearm CSA in normal subjects 29.7 cm(2) and in RA 25.9 cm(2); p = 0.002). In simple linear regression we found that 46.3% of the variation in grip strength in normal subjects was explained by variation in muscle CSA; in RA this figure decreased to 33.4%. Adding terms for joint deformity and pain in a multiple regression model improved the amount of variation explained to 37.9%. Conclusions--Although there is significant muscle wasting in RA, it is likely that reduction in strength is also attributable to joint deformity and pain leading to inhibition of grip directly and, indirectly, by arthrogenous muscle inhibition. Doubts remain about the quality of muscle in RA. Reprint Address:P.S. Helliwell, Rheumatology and Rehabilitation Research, 36 Clarendon Road, Leeds, West Yorkshire LS2 9NZ, England.
ARCHIVES OF GENERAL PSYCHIATRY
Functioning and Well-Being Outcomes of Patients with Depression Compared with Chronic General Medical Illnesses Hays, R.D., Wells, K.B., Sherbourne, C.D., Rogers, W., and Spritzer, K. 52:11-19,1995. Background: Cross-sectional studies have found that depression is uniquely associated with limitations in well-being and functioning that were equal to or greater than those of chronic general medical conditions such as diabetes and arthritis. However, whether these relative limitations persist over time is not known. Methods: We conducted a 2-year observational study of 1790 adult outpatients with depression, diabetes, hypertension, recent myocardial infarction, and/or congestive heart failure. Change in functional status and well-being was compared for depressed patients vs patients with chronic general medical illnesses, controlling statistically for medical comorbidity, sociodemographics, system, and specialty of care. Results: Over 2 years of follow-up, limitations in functioning and well-being improved somewhat for depressed patients; even so, at the end of 2 years, these limitations were similar to or worse than those attributed to chronic medical illnesses. Similar patterns were observed for depressed patients in the mental health specialty sector and those in the general medical sector, but the patients in the mental health specialty sector improved more. More severely depressed patients improved more in functioning, but even initially depressed patients without depressive disorder had substantial persistent limitations. Conclusion: Depressed patients have substantial and long-lasting decrements in multiple domains of functioning and well-being that equal or exceed those of patients with chronic medical illnesses. 173-0443
173-0444
Hypochondriasis and Panic Disorder: Boundary and Overlap Barsky, A.J., Barnett, M.C., and Cleary, P.D. 51:918-925, 1994. Background: To determine the nosological and phenomenological overlap and boundaries between panic disorder and hypochondriasis, we compared the symptoms, disability, comorbidity, and medical care of primary care patients with each diagnosis. Methods: Patients with DSM-III-R panic disorder were recruited by screening consecutive primary care clinic attenders and then administering a structured diagnostic interview for panic disorder. Patients also completed self-report questionnaires, and their primary care physicians completed questionnaires about them. They were then compared with patients with DSM-III-R hypochondriasis from the same setting who had been studied previously. Results: One thousand six hundred thirty-four patients were screened; 135 (71.0% of the 190 eligible patients) completed the research battery; 100 met lifetime panic disorder criteria. Twenty-five of these had comorbid hypochondriasis. Those without comorbid hypochondriasis (n = 75) were then compared with patients with hypochondriasis without comorbid panic disorder (n = 51). Patients with panic disorder were less hypochondriacal (P < .001), somatized less (P < .05), were less disabled (P < .001), were more satisfied with their medical care (P < .001), and were rated by their physicians as less help rejecting (P < .05) and less demanding (P < .01). Major depression was more prevalent in the group with panic disorder (66.7% vs 45.1%; P < .05), as were phobias (76.0% vs 37.3%; P < .001), but somatization disorder symptoms (P < .0001) and generalized anxiety disorder were less prevalent (74.5% vs 16.0%; P < .001) in panic disorder than was hypochondriasis. Conclusions: While hypochondriasis and panic disorder co-occur to some extent in a primary care population, the overlap is by no means complete. These patients are phenomenologically and functionally differentiable and distinct and are viewed differently by their primary care physicians.
ARCHIVES OF NEUROLOGY
Neurologic Evaluation of the Optimally Healthy Oldest Old Kaye, J.A., Oken, B.S., Howieson, D.B., et al. 51:1205-1211, 1994. Objective: Individuals aged 85 years or older (the "oldest old") are the fastest-growing age group in the United States. Because there is little information characterizing expected neurologic function in this group, our goal was to determine clinical neurologic traits characteristic of the optimally healthy oldest old. Design: Standardized neurologic evaluation findings of optimaUy healthy persons older than 84 years compared with those of equally healthy control subjects aged 65 to 74 years. Setting: Community-based, longitudinal aging study. Participants: Community-residing, consecutively recruited volunteers who were screened for the absence of chronic disease or medication 173-0445
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Archives of Neurology (continued) use. Main Outcome Measure: Standardized neurologic examination coded into ordinal or interval variables. Results: Significant between-group differences were greatest for tests of mental status, sensory function (ie, smell, hearing, vibratory discrimination, and stereognosis), oculomotor function, distal movement speed, and balance. Discriminant function analysis suggests that of these changes, membership in the oldest group is best predicted by poor performance on clinical tests of balance (heel-toe walking and one-leg balancing with eyes closed), smell, and visual pursuit. Conclusions: Many neurologic signs appear with aging that cannot be attributed to disease, even in the very old. Deficits in balance, olfaction, and visual pursuit discriminate best between the aging changes of the healthy very old and changes seen in younger elderly persons. Reprint Address: J.A. Kaye, Department of Neurology, L226, Oregon Health Sciences University, 3181 Sam Jackson Park Road, Portland, OR 97201. 173-0446
Factors Affecting Course and Survival in Alzheimer's Disease: A 9-Year Longitudinal Study Bracco, L., Gallato, R., Grigoletto, F., et al. 51:1213-1219, 1994. Objective: To evaluate mean survival and to identify prognostic factors in a cohort of patients with Alzheimer's disease (AD). Design: Multicentric 9-year cohort analytic study. Setting: Seven neurology departments throughout Italy between April 1982 and January 1984. Patients: We recruited a consecutive sample of 145 patients affected by probable AD (Multicenter Italian Study on Dementia protocol, National Institute of Neurological Disorders and Slroke--Alzheimer's Disease and Related Disorders Association criteria). Five were misdiagnosed, and 21 could not participate in the longitudinal study. The clinicodemographic characteristics of the 119 enrolled patients (49 men, 70 women; mean age, 64.7 years; SD, 4.1 years; mean duration of disease, 3.1 years; SD, 1.8 years) did not differ from those of the 26 excluded patients. All underwent extensive cliniconeuropsychological testing every 6 months for at least 2 years until the patient died or our survey ended (April 30, 1991). Mean follow-up was 5.1 years (SD, 2.5 years). Main Outcome Measures: Death, severe functional impairment (a score ---17 on the Blessed Dementia Scale), and severe cognitive impairment (a score of-< 7 on the Information-Memory-Concentration Test). Results: Survival curves obtained by the Kaplan-Meier method indicated that (1) patients with early- and late-onset disease (ie, before or after age 65 years) showed no difference either in relative survival or in time to reach predetermined functional and cognitive end points; (2) severely aphasic patients became profoundly demented significantly sooner than those with mild to moderate aphasia (P < .0001). Among clinicodemographic variables analyzed by a Cox model, severe language disability and functional loss proved to be the best predictors of death independent of age at onset or degree of dementia. Conclusions: Age at onset did not influence course and survival in AD. Severe aphasia appears to be the best predictor of death and unfavorable course. ReprintAddress:L. Bracco, Department of Neurological and Psychiatric Sciences, University of Florence, Policlinico di Careggi, 85 Viale Morgagni, 50134 Florence, Italy.
173-0447
Autonomic and Peripheral Neuropathies in Patients with Chronic Alcoholism: A DoseRelated Toxic Effect of Alcohol Monforte, R., Estruch, R., Valis-SoIr, J., et al. 52:45-51, 1995. Objective: To assess autonomic and peripheral nervous system function in patients with chronic alcoholism. Design: A cross-sectional study. Patients: A consecutive sample of 107 alcoholic patients and 61 controls. Main Outcome Measure: For autonomic assessment, heart rate variations during deep breathing and Valsalva maneuver and on standing were measured. Blood pressure response to standing up and to sustained handgrip were also evaluated. For assessment of the peripheral nervous system, an electrophysiologic examination was performed. Results: Alcoholic patients exhibited reduced heart rate variability compared with controls (P < .01, on all parasympathetic tests), whereas no differences in the mean values of the blood pressure responses between both groups were found. Twentysix patients (24.3%) had criteria of autonomic neuropathy, and 34 (32%) had electrophysiologic criteria of peripheral neuropathy. None of the controls exhibited criteria of autonomic neuropathy, and only one had criteria of peripheral neuropathy. The estimated total lifetime dose of alcohol correlated inversely with the parasympathetic indexes (r = - . 4 8 to -.51; P < .001 on all parasympathetic tests) and the sensory potential amplitudes of upper and lower limbs (r = -.43; P < .00 l, both limbs). Finally, a significant correlation between autonomic and peripheral neuropathies was observed (P = .0 l). By contrast, these lesions were not related to age, nutritional status, or other alcohol-related diseases. Conclusions: Autonomic and peripheral neuropatbies are common among hospitalized alcoholic patients. Alcohol appears to be toxic 1o autonomic and peripheral nerves in a dose-dependent manner. Reprint Address:R. Estruch, Department of Internal Medicine, Hospital Clinic, ViUarroel 170, 08036 Barcelona, Spain.
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
173-0448
The Pain Disability Index: Factor Structure and Normative Data Chibnall, J.T. and Tait, R.C. 75(11):1082-1086, 1994. Reprint Address: J.T. Chibnall, Division of Behavioral Medicine, Saint Louis University School of Medicine, 1221 South Grand Boulevard, St. Louis, MO 63104. 173-0449
Return to Work following an Aquafitness and Muscle Strengthening Program for the Low Back Injured LeFort, S.M. and Hannah, T.E. 75(11):1247-1255, 1994. Reprint Address: S.M. LeFort, 111 Slrawberry Marsh Road, St. John's, NF A1B 2V7, Canada.
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ARTHRITIS CARE AND RESEARCH
Promoting Patient Cooperation with Exercise Programs: Linking Research, Theory, and Practice Jensen, G.M. and Lorish, C.D. 7(1):181-189, 1994. Managing patient-nonadherence with prescribed exercise regimens is not an uncommon task for physical therapists working with individuals with arthritis. Yet little is known about the factors that influence patient adherence with exercise programs or therapist knowledge and use of theoretically based adherence management techniques. Survey research with physical therapists and patients was used to provide a database for further insight into the barriers experienced in implementing exercise programs in clinical practice. In this paper, we suggest that the cooperation with an exercise regimen is mediated by the patient's belief system and requires a therapeutic process of mutual inquiry, problem solving, and negotiation between the therapist and patient. Concepts from research, theory, and practice are integrated into a Process Model for Patient-Practitioner Collaboration for use in clinical practice. Reprint Address: G.M. Jensen, Department of Physical Therapy, 2500 California Plaza, Creighton University, Omaha, NE 68178.
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last, areas of future research and roles of clinicians in managing fatigue relative to exercise performance are proposed. Reprint Address: B. Belza, Physiological Nursing Department, SM-28, University of Washington, Seattle, WA 98195.
173-0450
173-0451 Exercise Tests as Outcome Measures Burckhardt, C.S., Moncur, C., and Minor, M.A. 7(4): 169-175, 1994. Outcome assessments of physical fitness attributes such as endurance, strength, and flexibility are not measured routinely in clinical trials or clinical practice in either adults or children with rheumatic diseases. Although physical fitness is not a measure of disease severity, it can be a critical indicator of capacity to function. Adequate fitness is necessary for the performance of positive health behaviors that enhance health status and wellness in spite of chronic disease. The purpose of this paper is to explore the conceptual, methodologic, and analytic issues related to the use of exercise tests as outcome measurements of physical functioning in persons with rheumatic disease. Reprint Address: C.S. Burckhardt, Department of Mental Health Nursing, School of Nursing, Oregon Health Sciences University, Portland, OR 97201.
173-0452 The Impact of Fatigue on Exercise Performance Belza, B. 7(4):176-180, 1994. The purpose of this paper is to discuss the impact of fatigne on exercise performance. First, fatigue will be defined and distinguished from similar constructs. Second, examples of instruments to measure fatigue in the rheumatic diseases are highlighted. Next, the social implications of fatigue are briefly mentioned. Fourth, methods in which fatigue impacts exercise performance are discussed. Fifth, the prevalence of fatigue in arthritis and its relationship to exercise will be presented. And
173-0453
Exercise Considerations for Postmenopausal Women with Osteoporosis Allen, S.H. 7(4):205-214, 1994. Individuals with osteoporosis are at an increased risk of fracture due to a net loss of bone mass. The cellular mechanisms causing decreased bone mass are increased osteoclast-mediated bone resorption and/or decreased osteoblast-mediated bone formation. Clinical studies have shown that bone loss can be prevented by estrogen replacement therapy and calcium supplementation. Weight-bearing and strengthening exercise may also play a role in retarding bone loss in the postmenopausal woman, and it may even increase bone mass. The essential components of an exercise program include intensity, duration, frequency, and type of activity. Additional goals of a therapeutic exercise program are to improve flexibility and balance, and to prevent falls. Structure-function relationships in normal and osteoporotic bone and the effects of exercise on bone are reviewed. A rational approach for exercise strategies is discussed. Reprint Address: S.H. Allen, Department of Internal Medicine, D110A Health Sciences Center, One Hospital Drive, University of Missouri, Columbia, MO 65212.
173-0454
Physical Conditioning in Children with Arthritis: Assessment and Guidelines for Exercise Prescription Klepper, S.E. and Giannini, M.J. 7(4):226-236, 1994. Objective. To review the literature in the area of physical fitness and conditioning programs for individuals with chronic illnesses, and increase the awareness of the need to include fitness testing and conditioning programs in the therapeutic management of children and adolescents with chronic arthritis. Methods. This article provides a review of original research reports, information from principal texts, and review articles related to physical fitness testing and training in children. Resuits. Several factors limit the exercise capacity of children with chronic arthritis, and studies report that these children have lower aerobic endurance and muscle performance than their peers. Preliminary studies suggest that fitness testing is safe for most children with arthritis, and physical conditioning programs, which appear to benefit adults with arthritis and children with other chronic illnesses, may also benefit children with arthritis. Easily administered, inexpensive field tests of fitness are available. Guidelines for prescribing physical conditioning programs are provided. The risks and benefits of increased exercise are discussed. Conclusions. Assessment of exercise capacity and muscle function and individualized prescription of physical conditioning programs are indicated for children with chronic arthritis, soon after diagnosis. Reprint Address: S.E. Klepper, 70 Jacobs Creek Road, West Trenton, NJ 08628.
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ARTHRITIS AND RHEUMATISM
173-0455
Measurement of Health Status in Children with Juvenile Rheumatoid Arthritis
Sing,h, G., Athreya, B.H., Fries, J.F., and Goldsmith, D.P. 37(12):1761-1769, 1994. Objective. To develop and validate a self- or parent-administered instrument for measuring functional status in children with juvenile rheumatoid arthritis (JRA). Methods. We adapted the Stanford Health Assessment Questionnaire (HAQ) for use in children ages 1-19 years, by adding several new questions, such that for each functional area, there was at least 1 question relevant to children of all ages. The face validity of the instrument was evaluated by a group of 20 health professionals and parents of 22 healthy children. The questionnaire was then administered to parents of 72 JRA patients (mean age 9.1 years, onset type systemic in 16, polyarticular in 21, pauciarticular in 35). Results. The instrument showed excellent internal reliability (Cronbach's alpha = 0.94), with a mean inter-item correlation of 0.6. The convergent validity was demonstrated by strong correlations of the Disability Index (average of scores on all functional areas) with Steinbrocker functional class (Kendali's tau b = 0.77, P < 0.0001), number of involved joints (Kendall's tau b = 0.67, P < 0.0001), and morning stiffness (Kendall's tau b -- 0.54, P < 0.000t). Spearman's correlation coefficient between Disability Index scores from questionnaires administered to parents and those from questionnaires administered to older children (> 8 years) was 0.84 (n = 29; P < 0.001), showing that parents can accurately report for their children. The test-retest reliability, studied at a 2-week interval, revealed virtually identical Disability Index scores measured on the 2 occasions (0.96 versus 0.96; P > 0.9 by paired t-test; Spearman's correlation coefficient = 0.8, P < 0.002). Conclusion. The Childhood HAQ, which takes less than 10 minutes to complete, is a valid, reliable, and sensitive instrument for measuring functional status in children with JRA. Reprint Address: G. Singh, School of Medicine, Med, Stanford University, Rheumatology and Immunology, 1000 Welch Road, Suite 203, Palo Alto, CA 94304.
BEHAVIORAL MEDICINE
173-0456
Pressor Reactivity, Ethnicity, and 24-Hour Ambulatory Monitoring in Children from Hypertensive Families Treiber, F.A., Murphy, J.K., Davis, H., et al. 20(3):133-142, 1994. We assessed blood pressure responses of a multiethnic (Black and White) sample of 120 children of hypertensive families to orthostasis, video game, forehead cold, and dynamic exercise, and monitored the children's ambulatory pressure 24 hours later. Thirteen children were studied twice (1-year stability). The Black
children exhibited higher 24-hour ambulatory systolic and diastolic pressures than the White children. Regardless of ethnicity, peak and mean systolic pressures during each task were generally positively correlated with mean systolic pressure while the children were awake and asleep. Associations between diastolic pressor responses and ambulatory measurements were somewhat dependent upon ethnicity and task. Relatively few reactivity-ambulatory correlations were significant, using pressor reactivity change scores. The children who participated twice exhibited significant 1-year stability for most ambulatory and pressor measurements. Children's pressor responses to laboratory tasks may generalize to the natural environment. Reprint Address: F.A. Treiber, Georgia Prevention Institute, HS1640, Medical College of Georgia, Augusta, GA 30912.
173-0457
Effectiveness of a Videotaped Behavioral Intervention for Dental Anxiety: The Role of Gender and the Need for Information Carpenter, D.J., Gatchel, R.J., and Hasegawa, T. 20(3):123-132, 1994. The authors evaluated the effectiveness of a videotaped behavioral treatment program in reducing dental anxiety. They compared patients who witnessed the intervention videotape with patients who saw a placebo program and with a no-treatment control group. The subjects were 66 patients who visited a dentistry clinic for prophylaxis and general dental treatment. Groups were balanced for gender and level of preference for information as measured by the Krantz Health Opinion Survey-Information subscale. Self-report, physiological, and observed behavioral measures were assessed at specified times. Results demonstrated significant Group X Gender interaction effects during the different assessment periods, with men responding best to the treatment videotape, whereas women responded best to the placebo videotape. The level of information preference was found to be a significant contributing factor at certain assessment periods. Overall, these results suggest that preparatory videotaped interventions are particularly effective in decreasing dental anxiety when patient characteristics are matched with characteristics of the intervention. Reprint Address: R.J. Gatchel, Department of Psychiatry, Division of Psychology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9044.
173-0458
Chronic Back Pain: Integrating Psychological and Physical Therapy--An Overview Linton, S.J. 20(3):101-104, 1994. Chronic back pain is a major consumer of costly healthcare resources in the Western world. Patients' suffering affects their families and associates, leads to diminished self-confidence, and prevents their effective participation in the workplace. Although medical treatments and analgesics are generally successful in treating acute back pain, and some patients recover spontaneously, conventional approaches are less successful in dealing with chronic pain and may be contraindicated. In the first of two articles, the author offers an overview of research on cognitive-behavioral programs, using operant activity and relaxation training, that have led to reductions in patients' pain and
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Behavioral Medicine (continued) to increases in their activity levels. Part 2 provides a step-bystep description of how to incorporate basic psychological techniques and physical therapy procedures for chronic pain sufferers. Patient and therapist cooperate in operant activities, with the patient monitoring progress and carrying out regular homework assignments as he or she seeks to perform target activities; applied relaxation encourages the patient to cope with pain by disrupting the connection between anxiety, despair, and pain. The techniques outlined are suitable for dealing with other musculoskeletal conditions as well as with chronic back pain. Reprint Address: S.J..Linton, Department of Occupational and Environmental Medicine, Orebro Medical Center, S-70185 ()rebro, Sweden.
BEHAVIOUR RESEARCH AND THERAPY
173-0459
Chronic Low Back Pain and Inaccurate Predictions of Pain: Is Being Too Tough a Risk Factor for the Development and Maintenance of Chronic Pain? Amtz, A. and Peters, M. 33(1):49-53, 1995. The present study tests whether chronic low back pain (CLBP) patients show a tendency to overpredict or to underpredict pain. Twenty CLBP patients and 20 healthy controls underwent 6 trials of laboratory induced pressure pain. Ratings of predicted and experienced pain intensity were obtained. In contradiction with the hypothesis that CLBP patients show a generalized tendency to overpredict pain, CLBP patients showed a tendency to underpredict the laboratory pain, whereas controls appeared to be more accurate. This finding replicates a previous finding, that there may be a substantial group of CLBP patients who underestimate pain. The tendency to underpredict pain may constitute a risk factor for the development and maintenance of CLBP. Reprint Address: A. Arntz, Department of Medical Psychology, University of Limburg, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
173-0460
The Assessment of Obesity: Theoretical Background and Practical Advice
Wardle, J. 33(1):107-117, 1995. Developments in understanding the causes and consequences of obesity have important implications for the assessment of weight problems. Simple measurement of body weight is no longer sufficient. The evaluation should include measures of body composition, dietary quality, energy expenditure, risk factor status and body image. In this paper, the arguments in favour of a broader-based evaluation of obesity are presented and a range of assessment methods are discussed. Reprint Address: J. Wardle, Health Behaviour Unit, Institute of Psychiatry, University of London, De Crespigny Park, London SE5 8AF, UK.
BRITISH JOURNAL OF CLINICAL PSYCHOLOGY
173-0461
Chronic Pain and Attention: A Cognitive Approach
Eccleston, C. 33(4):535-547, 1994. The present study draws upon resource-based models of attention in suggesting that the processing of chronic and persistent pain is a task that demands the application of central and executive attention. Ifa chronic and persistent pain stimulus is demanding of central, attentional resources, it follows that it will compete with a second attention-demanding task for those limited resources. Here it is hypothesized that performance of an attention-demanding interference task will be detrimentally affected by the demands of persistent pain. In Expt 1, patients in high pain, patients in low pain and control subjects without pain performed an attention-demanding numerical interference task. There were no significant differences between any of the groups on any measure of performance. Expt 2 repeated Expt 1 with a more difficult and more complex task. Only when the task was at its most difficult and its most complex (i.e. at the greatest demand of limited resources) did those patients in high levels of pain (i.e. at the greatest demand of limited resources) show performance decrements. The results of both experiments are discussed in relation to the debate concerning the use of cognitive methods for pain control and in relation to the application of cognitive psychology to the study of chronic pain. Reprint Address: C. Eccleston, School of Social Sciences, University of Bath, Claverton Down, Bath BA2 7AY, UK. 173-0462
The Dentist's Attitudes and Their Interaction with Patient Involvement in Oral Hygiene Compliance Sandell, R., Camner, L.G., and Sarhed, G. 33(4):549-558, 1994. The influence on patient compliance of the dentist's attitudes to his or her job and to his or her patient was studied in a sample of 82 patients. The dentist's attitudes were assessed at the beginning of dental treatment. Treatment consisted of cleaning, depuration and motivation. At follow-up examination after six months, attendance at follow-up and the development of plaque, calculus and gingivitis were significantly predicted by the dentist's attitudes. A causal model, which also included factors of patient involvement, was developed. The complianceproducing factors were, primarily, the establishment of sympathy and an informal relationship between dentist and patient. The patient's habit of regularly making visits to a dentist, in a complex way, also contributed to compliance. Reprint Address: R. Sandell, Stockholm County Council Institute of Psychotherapy, Bj/Srngttrdsgatan 25, S-118 52 Stockholm, Sweden. 173-0463
The Effects of Minor Events, Optimism and Self-Esteem on Health Lyons, A. and Chamberlain, K. 33(4):559-570, 1994. Recent research shows upper respiratory infections (URIs) are influenced by minor daily events, especially those that are
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British Journal of Clinical Psychology (continued) desirable and interpersonal in nature. The present study used a longer time frame, broader health measures and a betweensubjects design to examine this effect. It also predicted that optimism and self-esteem would interact with minor events to affect health. One hundred and fifty participants provided information regarding minor events, disposition and physical health on two separate occasions. Results show that increases in both desirable and undesirable events (hassles and uplifts) affected URIs over a two-week period. Interpersonal hassles interacted with optimism, having a greater impact on physical symptoms for optimists than for pessimists. Self-esteem did not interact with minor events to affect health. These results extend previous findings to show that minor events affect URIs and not other health outcomes, and that this effect is apparent between subjects over a number of days. Further, the influence of interpersonal events on health appears to be moderated by optimism. It is concluded that consideration and integration of findings from studies with different methodologies will be beneficial in furthering our understanding of minor event effects on health. Reprint Address: A. Lyons, Department of Psychology, Massey University, Private Bag, Palmerston North, New Zealand. 173-0464
Stress, Arousal, Cortisol and Secretory Immunoglobulin A in Students Undergoing Assessment Evans, P., Bristow, M., Hucklebridge, F., Clow, A., and Pang, F.-Y. 33(4):575-576, 1994. Cortisol, salivary immunoglobulin A, stress and arousal reports were measured in students undergoing academic assessment. In accordance with hypotheses, all measures were higher on the day of assessment than a week before, and were highest of all immediately after assessment. Reprint Address: P. Evans, Divisions of Psychology/Biomedical Sciences, University of Westminster, 309 Regent Street, London W1R 8AL, UK.
CEPHALALGIA
Personality Characteristics before and after Treatment of Different Head Pain Syndromes Mongini, F., Ibertis, F., and Ferla, E. 14(5):368-373, 1994. In order to examine whether, in patients with different types of headache and craniofacial pain, MMPI and STAI scores are significantly different before and after treatment, 114 patients with tension-type headache (n = 34), atypical facial pain (n -20), temporomandibular joint dysfunction (n = 36), migraine (n = 16), cluster headache (n = 4), chronic paroxysmal hemicrania (n = 2), trigeminal neuralgia (n = 2) were examined. A pain index was calculated (0-10) which quantified pattern, duration and frequency of pain. The Italian MMPI (356 item abbreviated version) and the STAI tests were administered before and after treatment. A paired t-test was used to assess pre-
and post-treatment differences, and multiple regression analysis was employed to examine whether such differences correlated with the improvement in the pain index. In the total group after treatment, there was a significant reduction of certain MMPI scores (Hs, D, Hy, Pa, Pt, Sc, Si) and of STAI 1 and 2 scores. Separate analysis confirmed this among women but not among men. No relation was found between MMPI and STAI changes and the degree of improvement as assessed through the pain index. Clinical improvement leads to normalization of MMPI profiles and STAI scores in women. The psychometric data before treatment were not predictive for treatment outcome. Reprint Address: F. Mongini, Centre for Craniofacial Pathophysiology, University of Turin, Corso Dogliotti, 14, 10126 Torino, Italy.
173-0466
If Migraine Prophylaxis Does Not Work, Think about Compliance Steiner, T.J., Catarci, T., Hering, R., Whitmarsh, T., and Couturier, E.G.M. 14(6):463-464, 1994. Data are presented on nine patients with migraine by IHS criteria, recruited from those presenting to the clinic for treatment and needing prophylaxis. Pizotifen 0.5 mg tds was prescribed for 8 weeks and dispensed in special containers with an electronic event recorder concealed in the lid. This responded to the pressure change with each opening of the container and recorded it in real time. The information was later downloaded to a PC for analysis. At trial end, two patients had been lost to follow-up, one had not started the treatment at all, two had dropped out because of alleged side effects (drowsiness), and four patients had completed the study. For these, the quantity of tablets used as a percentage of that prescribed (i.e., compliance assessed on the basis of returned-tablet count) ranged from 62.6% to 91.9%; the percentage of days in which three doses had been taken ranged from only 15.8% to 79%; the percentage of doses taken on schedule (8 h _ 25% after the previous dose) ranged from 21.1% to 47.3%. It is possible that all evaluations of efficacy and tolerance of migraine prophylactics reported so far have been unsoundly based. Reprint Address: T.J. Steiner, Academic Unit of Neuroscience, Chafing Cross and Westminster Medical School, St. Dunstan's Road, London W6 8RP, UK.
173-0465
CIRCULATION
173-0467
Prospective Study of Phobic Anxiety and Risk of Coronary Heart Disease in Men Kawachi, I., Colditz, G.A., Ascherio, A., et al. 89:1992-1997, 1994. Background. To examine prospectively the association between self-reported symptoms of phobic anxiety and subsequent risk of coronary heart disease, a 2-year follow-up study was conducted of a cohort of 33,999 US male health professionals, aged 42 to 77 years in 1988, who were free of diagnosed car-
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Circulation (continued) diovascular disease at baseline. Levels of phobic anxiety were assessed using the Crown-Crisp index, a short, diagnostic selfrating scale used for common phobias. Main outcomes were incidents of coronary heart disease consisting of nonfatal myocardial infarction (MI) and fatal coronary heart disease (CHD). Methods and Results. One hundred sixty-eight incident cases of CHD occurred during 2 years of follow-up (128 cases of nonfatal MI and 40 cases of fatal CHD). The age-adjusted relative risk of fatal CHD among men with highest levels of phobic anxiety (scoring 4 or higher on the Crown-Crisp index) was 3.01 (95% confidence interval, 1.31 to 6.90) compared with men with the lowest levels ofanxiety (scoring 0 or 1 on the phobia index). Risk of fatal CHD increased with levels of phobic anxiety (P trend = .002). When fatal CHD was further categorized into sudden and nonsudden coronary death, the excess risk was confined to sudden death (relative risk among men scoring 3 or higher on the phobia index was 6.08; 95% confidence interval, 2.35 to 15.73). No association was found between phobic anxiety and risk of nonfatal MI. These findings remained essentially unchanged after adjusting for a broad range of cardiovascular risk factors. Conclusions. The specificity, strength, and doseresponse gradient of the association, together with the consistency and biological plausibility of the experimental and epidemiologic evidence, support a strong causal association between phobic anxiety and fatal CHD. Reprint Address: I. Kawachi, Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
173-0468
Diagnosis of Mild Hypertension by Ambulatory Blood Pressure Monitoring
Weber, M.A., Neutel, J.M., Smith, D.H.G., and Graettinger, W.F. 90:2291-2298, 1994. Background. Between 20% and 30% of patients with clinically diagnosed hypertension have normal blood pressure (BP) values during automated ambulatory 24-hour BP monitoring. It has not been clear, however, whether these patients can be regarded as normotensive or whether they should be treated in the same way as confirmed hypertensive patients. Methods and Results. Ambulatory BP monitoring was performed in 88 normal control subjects and 171 hypertensive patients (office diastolic BP >-90 mm Hg on three visits; never treated or off treatment for more than 6 months). Hypertensive patients were classified as nonconfirmed or white coat (n = 58) if their 24hour diastolic averages were __20%. Metabolism-flow autoregulation was tested by varying the temperature (CMRo2) and measuring the coupling of CBF and CMRo2. Individual patient autoregulation was correlated with changes in cognitive measures. Cognitive performance declined in 6 of 9 measures after CABG surgery. Age predicted cognitive decline in 7 of 9 measures; short-term memory showed the greatest effect of age. Pressure-flow autoregulation during hypothermic CPB showed a small but significant (P < .0001) effect of pressure on CBF. There was no effect of age on the slope of CBF response to changes in MAP (pressureflow autoregulation). There was a major effect of temperature on CBF during CPB (P < .0001). Coupling CBF and CMRo2 with changing temperature was unaffected by age. Changes in cognition were not associated with measures of cerebral autoregulation. However, increasing C(AV)o2 is associated with cognitive deficits in 5 of 9 measures; these associations were independent of age. Conclusions. Increased age predisposes to impaired cognition after cardiac surgery. This decline in cognitive function in the elderly is not associated with age-related changes in cerebral blood flow autoregulation. The association of increased oxygen extraction with decline in some measures of cognitive function suggests that an imbalance in cerebral tissue oxygen supply, which is unrelated to age, contributes to acute cognitive dysfunction after cardiac surgery. Cognitive dysfunction after CPB in the elderly cannot be explained by impaired CBF autoregulation. Reprint Address: M.F. Newman, Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710. 173-0471
Relation of Smoking with Carotid Artery Wall Thickness and Stenosis in Older Adults: The Cardiovascular Health Study Tell, G.S., Polak, J.F., Ward, B.J., et al. 90:2905-2908, 1994. Background. Cigarette smoking has been associated with increased risk of atherosclerotic diseases in hospital-based stud-
ies and in studies of middle-aged populations but not in population-based studies of older adults with and without clinical cardiovascular disease. Methods and Results. We investigated the relation of smoking to carotid artery atherosclerotic disease, expressed as intimal-medial wall thickness and arterial lumen narrowing (stenosis) measured by ultrasound. Subjects were 5116 older adults participating in the baseline examination of the Cardiovascular Health Study, a community-based study of cardiovascular diseases in older age. With increased smoking there was significantly greater internal and common carotid wall thickening and internal carotid stenosis: current smokers > former smokers > never-smokers; for instance, the unadjusted percent stenosis was 24%, 20%, and 16%, respectively (P < .0001). A significant dose-response relation was seen with packyears of smoking. These findings persisted after adjusting for other cardiovascular risk factors and were also confirmed when analyses were restricted to those without prevalent cardiovascular disease. The difference in internal carotid wall thickness between current smokers and nonsmokers was greater than the difference associated with 10 years of age among never-smoking participants (0.39 m m versus 0.31 mm). Among all participants, the prevalence of clinically significant (> 50%) internal carotid stenosis increased from 4.4% in never-smokers to 7.3% in former smokers to 9.5% in current smokers (P < .0001). Conclusions. These findings extend previous reports of a positive relation between smoking and carotid artery disease to a population-based sample of older adults using several different indicators of atherosclerotic disease. Reprint Address: CHS Coordinating Center, University of Washington, Century Square, Suite 2025, 1501 Fourth Avenue, Seattle, WA 98101.
173-0472
Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases Lenfant, C. 90:2609-2617, 1994. Reprmt Address: C. French, NHLB1, Building 31, Room 5A03, NIH, 31 Center Drive, MSC 2482, Bethesda, MD 20892-2482.
CLINICAL JOURNAL OF PAIN
173-0473
The Short Form of the Beck Depression Inventory: Validity Issues with Chronic Pain Patients Chibnall, J.T. and Tait, R.C. 10:261-266, 1994. Objective: To investigate the validity of the Beck Depression Inventory short form when used to screen for depression in chror~ic pain patients, Setting: A multidisciptinary pain management center located in a major university medical center, Patients: Seven hundred sixty-five persons presenting for evaluation of chronic pain, including low back pain, head/neck pain, and extremity pain. Measures: Beck Depression Inventory short form, McGill Pain Questionnaire, Pain Disability Index, pain
V O L U M E 17, N U M B E R 3, 1995
Clinical Journal of Pain (continued) drawing, and Quality of Life Scale. Results and Conclusions: Items on the Beck Depression Inventory short form reflecting pain-related interference with function (i.e., disability) were endorsed to a greater degree than affective and cognitive terms. A factor analysis of the inventory yielded two affective/cognitive factors and one "disability" factor (work inhibition and fatigue). The correlations between the factor scores and the Pain Disability Index suggested that endorsement of the work inhibition and fatigue items by chronic pain patients may not be indicative of affective disturbance. The results suggest that these items should be evaluated critically for their contribution to the total score of the Beck Depression Inventory short form when assessing depression in chronic pain patients. Reprint Address: J.T. Chibnall, Department of Psychiatry and Human Behavior, Division of Behavioral Medicine, St. Louis University School of Medicine, 1221 South Grand Boulevard, St. Louis, MO 63104.
173-0474
Childhood Abuse, Depression, and Chronic Pain 10.277-281, 1994. Objective: To investigate the relationships among history of childhood abuse, type of pain, and depression. Design: Survey, consecutive sample, correlational. Setting: An interdisciplinary pain-management center in a rehabilitation hospital. Patients: The participants were 201 consecutive patients with chronic pain complaints, 68% women, mean age 38 years, of whom 28% complained of pain in more than three major sites, 26% had low back pain, 19% had craniofacial pain, and 25% had pain in other regions. Outcome Measures: Beck Depression Inventory, Childhood History recorded presence or absence of abuse, age of onset, age when abuse was acknowledged, duration and frequency of abuse, relationship of abuser to the participant. Pain type was classified by IASP. Results: Patients with history of both sexual and physical abuse in childhood had more depression. The differences among abuse groups was significant (17 < 0.03). The impact of childhood abuse and type of pain on depression was tested by a two-factor analysis of variance. The influence of childhood abuse was significant (p < 0.04), whereas the influence of type of pain (p < 0.76) and the interaction between type of pain and childhood abuse (17 < 0.40) were not significant. Conclusions: There is a positive, significant relationship between depression and history of childhood sexual and physical abuse. The influence of type of pain on depression was not significant. Prevailing research explained depression as an expected, natural consequence of chronic pain. Our research suggests that the relationship between chronic pain and depression may be attributable in part to childhood abuse history. Reprint Address: R.T. Goldberg, Spaulding Rehabilitation Hospital, 125 Nashua Street, Boston, MA 02114. Goldberg, R.T.
173-0475
Pain in Young Adults: I. Relationship to Gender and Family Pain History Lester, N., Lefebvre, J.C., and Keefe, F.J. 10:282-289, 1994. Objectives/Design: Two studies were carried out to examine how gender and family pain history related to pain and activity interference in young adults. The first study (n = 252 college students) examined how gender and family pain history
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related to pain intensity and the second study (n = 206 college students) examined how these variables related to pain intensity, location, and activity interference. Whenever possible, data from the two studies were combined for purposes of data analyses. Results: Results indicated that more than half of the young adults studied reported experiencing some type of pain at the time of the investigation. The intensity of the pain was in the low range and the most frequent sites of pain were in the head and legs or feet. Gender differences were noted, with women reporting a greater number of sites of pain. Family pain history was found to be related to pain and activity interference. Subjects who had a strong family history of pain problems reported a greater number of pain sites, and higher levels of pain-related activity interference. Conclusions: Generalizability of results is limited due to the group of young adults studied, yet several conclusions relative to this group may be suggested. First, this group of young adults do appear to experience pain. Second, there may be gender differences in the types of pain they report and the ways they react to pain. Third, family history of pain may be related to the pain experiences of this group of young adults. Reprint Address: F.J. Keefe, Box 3159, Department of Psychiatry, Duke University Medical Center, Durham, NC 27710.
173-0476
Acupuncture and Subtypes of Chronic Pain: Assessment of Long-Term Results Carlsson, C.P.O. and SjOlund, B.H. 10:290-295, 1994. Objective: To determine patients' opinions of pain relief for a longer time after one treatment period of acupuncture for chronic pain. Patients and setting: Two hundred and eleven patients had acupuncture treatment for chronic pain at the Pain Clinic of Maim6 University Hospital during 1983-5. Their mean duration of pain was 10.4 years prior to treatment. Intervention: The patients were treated with needle acupuncture with a combination of local and distal points every 1-2 weeks. Both manual and electrical stimulation was utilized. The mean number of treatments was 7.8. Design: In 1988, all patient documents were screened, and the pain conditions were classified as nociceptive, neurogenic, or psychogenic. Of the 211 treated patients, initial results could be evaluated from the clinic records in 202 cases. Eighty-five of these patients (42.1%) experienced pain relief immediately after the treatment period. These patients were sent a 1-page questionnaire by mail in 1988. Outcome Measures: Pain relief over defined time periods (yes/no); do more work at home or at workplace (yes/no); analgesic consumption. Results: Only 35 patients (17.3% of all patients) still experienced pain relief 6 months after treatment. Among those with nociceptive pain, 70 of 142 (49%) had experienced initial pain relief, while those with neurogenic or psychogenic pain experienced relief in only I I of 34 and four of 26 of the cases, respectively. Pain relief for >6 months was experienced by 33 of 142 of the cases with nociceptive pain, but by only two of 34 of those with neurogenic pain, and by none of those with psychogenic pain. Conclusion: Only patients with nociceptive pain can be expected to get pain relief for > 6 months after one treatment period of acupuncture, and of these only a small proportion will be helped. Reprint Address: B.H. Sj61und, Department of Rehabilitation, Lund University Hospital, S-221 85 Lund, Sweden.
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DIABETES CARE
173-0477
Comparison of Excess Costs of Care and Production Losses Because of Morbidity in Diabetic Patients Olsson, J., Persson, U., Tollin, C., Nilsson, S., and Melander, A. 17(11):1257-1263, 1994. Objective--To assess and compare excess costs of care and production losses because of morbidity in diabetic patients and the general population of a Swedish community. Research Design and Methods--Costs of production losses were calculated from medical and social insurance records on sickness benefit days (short-term illness) and premature retirement (permanent disability) in people with diabetes and in the entire population of the community (a municipality comprising a town and rural surroundings, with 28,000 inhabitants). Care costs included those of consultations and inpatient care, as well as costs of insulin, oral antidiabetic medications, other drugs, test material, and treatment devices, and they were obtained from patient records, the health care administration, and the statistics of community pharmacy sales. Results--Of the diabetic patients < 65 years of age, above which both diabetic and nondiabetic people get retirement pension, and sickness benefits cease, 62% of those on insulin treatment in each gender had insulin-dependent diabetes mellitus (IDDM). All insulin-treated non-insulin-dependent diabetes mellitus (NIDDM) patients were >40 years of age. Both the insulin-treated and the non-insulin-treated diabetic patients were prematurely retired twice as often as the average population and had twice as many inpatient days. The insulin-treated subjects also had twice as many sickness benefit days. The excess costs of production losses as a result of morbidity in people with diabetes were about $7,000 per individual and year. The corresponding excess costs of inpatient care were $800. The therapeutic expenditures for control of diabetes were about $600 per individual and year. If converted to U.S. conditions, the costs of lost production as a result of excess morbidity (
