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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43
A m e r i c a n Journal o f Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43
A m e r i c a n Journal o f Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44
A m e r i c a n Journal o f Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
A m e r i c a n Journal o f Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
A m e r i c a n Journal o f Public Health
50
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Annals o f Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
52
Annals o f the R h e u m a t i c Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
53
Archives o f Neurology
53
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Archives o f Physical Medicine and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
54
Archives o f Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
54
Arthritis Care and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
55
Arthritis and R h e u m a t i s m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
56
Behavioral Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
56
Behaviour Research a n d T h e r a p y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57
British Journal o f Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
Cephalalgia
62
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Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62
Child D e v e l o p m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
63
Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
63
Clinical Journal o f Pain
64
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Diabetes Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
65
The Diabetes Educator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
67
Gastroenterology
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68
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68
The Gerontologist
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
68
Headache Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
Health Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
Health and Social W o r k . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
71
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
71
International Journal o f Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
International Journal o f Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
Journal o f A b n o r m a l Child Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
73
Journal o f A b n o r m a l Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
73
Journal o f Adolescent Health
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74
Journal o f A d v a n c e d Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
75
Journal o f the A m e r i c a n A c a d e m y o f Child a n d Adolescent Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
75
Journal o f the A m e r i c a n Dental Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
76
Journal o f Behavioral Medicine
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76
Journal o f Clinical Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
78
41
42
ANNALS OF BEHAVIORAL MEDICINE
Journal o f Consulting a n d Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
79
Journal o f E p i d e m i o l o g y a n d C o m m u n i t y H e a l t h
79
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Journals o f G e r o n t o l o g y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
80
Journal o f Occupational Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8l
Journal o f Pain a n d S y m p t o m M a n a g e m e n t
82
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Journal o f Sex Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
82
T h e Lancet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
84
Neurology
85
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Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
89
Patient Education a n d Counseling
90
Physical T h e r a p y
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Psychological Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
92 93
Psychology a n d H e a l t h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
95
P s y c h o s o m a t i c Medicine
96
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S c a n d i n a v i a n Journal o f B e h a v i o u r T h e r a p y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
96
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
97
Subject I n d e x . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
99
ademic performance, stress, and social support included factor analysis, hierarchical multiple-regression analysis, and Pearson correlational analysis. Results. Data from 120 students (78% of the cohort) were used for correlational analysis. Of these students, 79 (66%) were men and 41 (34%) were women. Because eight of the questionnaires contained incomplete data, 112 questionnaires (73%) were used for multiple-regression analysis. No buffering effect was found for social support. Rather, social support from outside the medical school explained significant variance in academic performances and in role stress. Higher levels of outside support were associated with poorer clerkship grades for women, but with lower levels of stress for men. Also, total support (outside and inside combined) was negatively related to clerkship grades for the entire sample. Conclusion. The results suggest that contrary to the study's hypotheses, social support in general is related to lower levels of academic performance for both men and women, and that the negative effects of support from outside the medical school context may be particularly salient for women. These results are understandable given the nature of medical training, which places great demands on students' time. Therefore, it may be more appropriate for medical schools to promote time-management strategies than supportbuilding interventions, especially for women.
ACADEMIC MEDICINE
171-0001
Medical Education about Substance Abuse: Changes in Curriculum and Faculty between 1976 and 1992 Fleming, M., Barry, K., Davis, A., et at. 69:362-369, 1994. Purpose. To examine changes in substance abuse education in U.S. medical schools between 1976 and 1992. Methods. In 1991-92 the authors conducted a 16-year follow-up survey of six clinical departments in each of the 126 U.S. medical schools. Two previous surveys by scholars and surveys conducted by the Liaison Committee on Medical Education, Association of American Medical Colleges, and the National Center for Medical Fellowships in the Addictions provided baseline data for comparison. The statistical methods used in the comparisons were paired t-tests, one-way analyses of variance, and tests of differences between proportions. Results. Significant increases were found in the numbers of required and elective curriculum units for medical students between 1986-87 and 1991-92. The number of medical schools requiring courses in substance abuse treatment increased from five to eight between 1986-87 and 1991-92. For residents, there were significant increases in the numbers of curriculum units for residents in family medicine and pediatrics. The average number of faculty in the I 16 medical schools that reported units on substance abuse was 4. I. There were 45 fellowships in addiction medicine identified in 199192, with a total of 61 fellows in training. Conclusion. While the findings confirm positive changes, the amount of curricula time and the number of faculty having expertise in substance abuse education do not compare well with the amounts of time and numbers of faculty involved in clinical problems of similar prevalence, such as cancer and heart disease. Reprint Address:M. Fleming, Office of Alcohol and Addiction Studies, Department of Family Medicine, 777 South Mills, Madison, W153715.
171-0002
AMERICAN JOURNAL OF CARDIOLOGY
171-0003
Moderate- and High-Intensity Exercise Lowers Blood Pressure in Normotensive Subjects 60 to 79 Years of Age Braith, R.W., Pollock, M.L., Lowenthal, D.T., Graves, J.E., and Limacher, M.C. 73:1124-1128,1994. To investigate the effects of exercise intensity on resting blood pressure (BP) in normotensive elderly subjects, 44 sedentary healthy subjects aged 60 to 79 years of age were studied during 6 months of walking exercise. Subjects were ranked according to maximal oxygen consumption and randomly stratified to groups that trained at 70% (n = 19) or 80% to 85% (n = 14) of maximal heart rate reserve, or to a control group (n = 11) that did not train. Initial BP was established during a 2- to 3-week control period. During the first 3 months, both exercise groups progressed to 70% of heart rate reserve for 40 minutes 3 times each week. The moderate-intensity group continued to train at 70% (45-minute duration) for an additional 3 months, whereas the high-intensity group progressed to training at 85% of heart rate reserve (35-minute duration). Maximal oxygen consumption increased (13 -< 0.05) during the initial 3 months in both exercise groups (25.2 to 28.1 ml-kg-' .min -~ and 26.3 to 29.3 ml.kg-~.min -t) and continued to increase (13 -< 0.05) after 3 additional months of training, but the increase was greater (p -< 0.05) in the high-intensity group (28.1 to 29.4 ml-kg -~. rain -~ and 29.3 to 32.8 ml.kg -~ .min-~). Systolic BP decreased (p -< 0.05) similarly at 6 months in both training groups (120
Effects of Social Support on Medical Students' Performances
Rospenda, K.M., Halpert, J., and Richman, J.A. 69:496-500, 1994. Background. Stress among medical students has been linked to poor academic performance, while supportive social relationships have been associated with the alleviation of psychological stress. This study examines social support as a potential buffer against stress and hence as a potential strengthener of students' academic performances. Method. A cohort of 153 thirdyear students at the University of Illinois College of Medicine at Chicago was asked in the fall of 1990 to complete a questionnaire assessing role stress (stress involving competing demands between school and social and/or family life), social support, and sources of support (outside or inside medical school). Grades for the five major clerkships through which all the students rotated during their third year were collected from student transcripts. Statistical analyses of the relationships among ac43
44
ANNALS OF BEHAVIORAL MEDICINE
American Journal of Cardiology (continued) to 111 m m Hg and 120 to 112 mm Hg). Diastolic BP also decreased (p -< 0.05) similarly at 6 months in both training groups (72 to 64 m m Hg and 75 to 68 mm Hg). Resting heart rate decreased (p -< 0.05) to the same magnitude at 6 months in both training groups (71 to 66 beats/rain and 69 to 63 beats/ rain). Body weight did not change in any group (p >_ 0.05). The sum of 7 skinfold fat measures decreased (p -< 0.05) similarly at 6 months in both training groups 075 to 164 m m and 173 to 159 ram). Our data indicate that walking exercise between 70% and 85% of heart rate reserve lowers resting BP in normotensive elderly subjects, and produces a moderately favorable conditioning benefit similar to that observed in younger persons. Reprint Address: R.W. Braith, Department of Physiology, P.O. Box 100274, College of Medicine, University of F'lorida, Gainesville, FL 32610.
171-0004
Abnormal Autonomic Control of the Cardiovascular System in Syndrome X Rosano, G.M.C., Ponikowski, P., Adamopoulos, S., et al. 73:1174-1179, 1994. Anomalies of autonomic control of the coronary circulation may play a role in the development of syndrome X (angina pectoris, ischemic-appearing results on exercise test, and normal coronary arteriograms). Twenty-six patients with syndrome X and 20 healthy sex- and age-matched control subjects were studied by means of analysis of heart rate variability during 24-hour Holter monitoring. Spectral and nonspectral parameters of heart rate variability were investigated. Mean heart rate was similar in patients with syndrome X and in control subjects. Patients with syndrome X had significantly lower standard deviation of all normal RR intervals, a lower percentage of adjacent normal RR intervals >50 ms in difference 026.4 -+ 22 vs 149 _+ 43 ms, p < 0.05; 6.3 -+ 4 vs l 1.2 _+ 7%, p < 0.05; respectively), and a trend toward lower values of time-domain parameters. Lower values of total power and low frequency were also observed in patients with syndrome X (1273 +_ 693 vs 1790 _+ 989 ms 2, p < 0.05; 406 _+ 176 vs 729 _+ 455 ms 2, p < 0.01, respectively). An inverse correlation between heart rate and measures of heart rate variability was found in syndrome X but not in control subjects. High- and low-frequency power showed a similar circadian pattern in syndrome X patients and control subjects. Patients and control subjects were then allocated into 2 groups according to the median RR duration: syndrome X 1 and control 1 with high mean heart rate, and syndrome X2 and control 2 with low mean heart rate. The syndrome X 1 group had a significantly lower standard deviation of all normal RR intervals, root-mean-square difference of successive RR intervals, percentage of adjacent normal RR intervals > 50 ms different, and high and low frequency than did the syndrome X2, control l, and control 2 groups. In conclusion, patients with syndrome X have a sympathovagal balance shifted toward sympathetic predominance that is more evident in those with an increased mean heart rate. This dysfunction appears to persist throughout the 24 hours and may indicate heterogeneity in autonomic function in syndrome X. Reprint Address: G.M.C. Rosano, Department of Cardiac Medicine, National Heart & Lung Institute, Dovehouse Street, London SW3 6LY, UK.
AMERICAN JOURNAL OF EPIDEMIOLOGY
171-0005
A Case-Control Study of Oral Contraceptive Use and lnvasive Epithelial Ovarian Cancer Rosenberg, L., Palmer, J.R., Zauber, A.G., et al. 139(7):654-661, 1994. The relation of oral contraceptive use to the risk of ovarian cancer was assessed with data collected during 1977-1991 from patients under 65 years of age in hospitals in Boston, New York, Philadelphia, and Baltimore. We compared 441 women with recently diagnosed invasive epithelial ovarian cancer to 2,065 control women. Logistic regression was used to control risk factors for ovarian cancer. The multivariate relative risk estimate decreased with the increasing duration of oral contraceptive use (p < 0.05): the estimate was close to 1.0 for duration categories of less than 3 years; it was reduced for the categories of 3--4 years of use and greater, but it did not decline further as the duration of use increased. For ->3 years of use, the estimate was 0.6 (95% confidence interval 0.4-0.8). The inverse association of risk with >_3 years of use was consistently present across categories of age, parity, interview year, and geographic area. It was apparent for as long as 15-19 years after cessation. Many different specific oral contraceptive formulations appeared related to a decreased risk; however, data were sparse for the newer types, particularly phasic preparations, and the ability to assess specific preparations in the context of use of multiple preparations was limited. The present data confirm previous reports of an inverse association of ovarian cancer risk with oral contraceptive use of several years in duration. They also suggest that the association may persist for as long as two decades and that it is not confined to any particular type of oral contraceptive formulation. Reprint Address: L. Rosenberg, Slone Epidemiology Unit, 1371 Beacon Street, Brooldine, MA 02146.
171-0006
Menopausal Hormone Usage and Breast Cancer in Saskatchewan: A Record-Linkage Cohort Study Riseh, H.A. and Howe, G.R. 139(7):670-683,1994. The association between the occurrence of carcinoma of the breast and previous usage of menopausal estrogens, progestins, and oral contraceptives is examined in a record-linkage study using the Saskatchewan Health Prescription-Drug-Plan Database. Saskatchewan Health is a governmental agency that funds publicly insured health care for essentially all residents of the province. For this study, all women aged 43-49 years in 1976 resident in Saskatchewan were identified from the Saskatchewan Health master registration file. These women were linked by registration beneficiary number to the Drug-Plan Database for the period from January 1976 to June 1987 and to the Provincial Cancer Registry Database for the period from March 1960 to December 1990. The fact and date of death or emigration from the province were obtained through the annual updates ofthe health plan. Of the 33,003 women initially in the cohort, 213 had a breast cancer diagnosed before 1976 and were
V O L U M E 17, N U M B E R 1, 1995
45
American Journal of Epidemiology (continued) omitted from this analysis. Between 1976 and 1990, 742 new primary breast cancer cases occurred. Women taking estrogens unopposed by progestins had an elevated risk of breast cancer, the risk increasing by 7% (relative risk ~ 1.072, 95% confidence interval 1.02-1.13; p = 0.008) for each 252 tablets used (approximately 1 year of use). Usage of estrogens opposed by progestins showed no association with risk (p = 0.48). Women taking oral contraceptives during this follow-up period also had a higher risk, increasing by 14% (relative risk = 1.144, 95% confidence interval 1.05-1.24; p -- 0.002) for every 252 tablets used. These 1-year risk elevations are small but become appreciable at longer durations. For example, at 5 years of unopposed estrogen use, the relative risk is 1.42; for 5 years of oral contraceptive use, it is 1.96. 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.
171-0007
Physical Activity in Older Middle-Aged Men and Reduced Risk of Stroke: The Honolulu Heart Program Abbott, R.D., Rodrignez, B.L., Burchfiel, C.M., and Curb, J.D. 139(9):881-893, 1994. From 1965 to 1968, the Honolulu Heart Program began following 8,006 men in a prospective study of cardiovascular disease. At the time of study enrollment, an estimate of current 24-hour habitual physical activity was collected from each subject. On the basis of a calculated physical activity index, subjects were classified as being inactive, partially active, or active. This report examines the relation between the levels of physical activity and stroke that occurred among 7,530 of the men over 22 years of follow-up. Risk of stroke was examined separately in younger (45-54 years) middle-aged men and older (55-68 years) middle-aged men. Among the older men, those who were inactive or partially active experienced a three- to fourfold excess incidence of hemorrhagic stroke as compared with active men (p < 0.01). There was a two- to threefold excess ofintracerebral hemorrhage in men who were inactive or partially active as compared with those who were active (p < 0.05). An excess of subaraclmoid hemorrhage was observed in inactive older men, with only one event occurring in those who were active (p < 0.05). After exclusion of subjects with hypertension, diabetes mellitus, and left ventricular hypertrophy, the relative risk of hemorrhagic stroke for inactive men versus active men was 3.7 (95% confidence interval (CO 1.3-10.4). In older men who did not smoke cigarettes, the relative risk of thromboembolic stroke among inactive men versus active men was 2.8 (95% CI 1.2-6.7), and when partially active older men were compared with those who were active, the relative risk was 2.4 (95% CI 1.0-5.7). These findings persisted after control for the residual effects of systolic blood pressure and other risk factors for stroke. Benefits of physical activity in reducing the risk of thromboembolic stroke were not observed in men who smoked cigarettes. The authors conclude that physical activity may be important in reducing the risk of stroke, particularly among nonsmoking men in older middle age. Reprint Address:R.D. Abbott, Division of Biostatistics, Department of Medicine, Box 432, University of Virginia School of Medicine, Charlottesville, VA 22908.
171-0008
Maternal Smoking during Pregnancy as a Predictor of Lung Function in Children Cunningham, J., Dockery, D.W., and Speizer, F.E. 139(12):1139-1152, 1994. Recent studies have suggested that prenatal exposure to environmental tobacco smoke may lead to lower lung function in infants. The authors examined the relation of maternal smoking during prenancy to persistent deficits in the lung function of older children. Subjects were 8,863 nonsmoking white children aged 8-12 years from 22 North American communities. Information on maternal smoking was provided by the child's mother. Pulmonary function testing of the children was conducted at school in 1988-1991. Children whose mothers smoked during pregnancy, whether or not they still smoked in the year prior to the study, had significantly lower lung function than did children whose mothers did not smoke in either period. On average, forced expiratory flow between 65 and 75 percent of forced vital capacity (FEF6~_Ts~), forced expiratory flow between 25 and 75 percent of forced vital capacity (FEF25_75~),and forced expiratory volume in 3/4of a second (FEV070 were 5.7%, 4.9%, and 1.7% lower, respectively, for children whose mothers smoked during pregnancy. After adjusting for maternal smoking during pregnancy, the authors found that current maternal smoking was not associated with significant differences on any lung function measure. These results show a persistent deficit in lung function associated with maternal smoking during pregnancy that is not explained by current maternal smoking alone. The strongest effects were observed with pulmonary function measures of flow in the small airways. The authors conclude that the effects of exposure to tobacco smoking by the mother during pregnancy and/or environmental tobacco smoke exposure in the first few years of life persist into childhood and may affect the pulmonary function attained throughout the child's life. Reprint Address: D.W. Doekery, Environmental Epidemiology Program, Department of Environmental Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115.
171-0009
Higher Levels of Conditioning Leisure Time Physical Activity are Associated with Reduced Levels of Stored Iron in Finnish Men Lakka, T.A., Nyyssonen, K., and Salonen, J.T. 140(2):148-160, 1994. The authors investigated the association of the amount and intensity of conditioning leisure time physical activity with serum ferritin and blood hemoglobin concentrations in 1,743 eastern Finnish men who were aged 42-60 years during the period 1984-1989. The duration and frequency of physical activity were associated inversely with serum ferritin (p ffi 0.003 for duration and p < 0.001 for frequency) and blood hemoglobin (p = 0.002 for duration and p = 0.019 for frequency) in multivariate regression models, after adjustment for major confounders. Men in the highest quartile of duration (>2.6 hours/ week) had a 16.8% lower mean serum ferritin concentration and men in the highest category of frequency (>3 sessions/week) had a 19.9% lower mean serum ferritin concentration than men with a low duration (55 years) with the highest perceived risk, highest health media use, and highest blood pressure and cholesterol levels. The subgroup with the lowest proportion of positive changers (42%) was the least educated, was the most likely to be Hispanic, and had the lowest health knowledge and self-efficacy scores. Conclusions. The differing composition of subgroups who respond or do not respond to community cardiovascular disease interventions illustrates the need to develop specific interventions that target different age, socioeconomic, and cultural subgroups. Reprint Address: M.A. Winideby, Stanford Center for Research in Disease Prevention, Stanford University School of Medicine, 1000 Welch Road, Palo Alto, CA 94304-1885.
171-0031
The Consumption of Well-Done Red Meat and the Risk of Colorectul Cancer Muscat, J.E. and Wynder, E.L. 84(5):856-858, 1994. Heterocyclic aromatic amines and polycyclic aromatic hydrocarbons are mutagens that are produced in highly cooked meats. A case--control study of 511 patients with colorectal cancer and 500 matched control subjects examined whether consumption of well-done cooked beef is related to the risk of developing large bowel cancer. Approximately 16% of men and women consumed well-done beef, and 50% ate medium-cooked beef. For both sexes, there was no association between consumption of well-done or medium-cooked beef and colorectal cancer. This paper discusses whether questionnaire data accurately reflect dietary intake of heterocyclic aromatic amines and polycyclic aromatic hydrocarbons. Reprint Address:J.E. Muscat, Division of Epidemiology,American Health Foundation, 320 East 43rd Street, New York, NY 10017.
171-0032
Smoking and Mortality among Residents of a California Retirement Community Paganini-Hill, A. and Hsu, G. 84(6):992-995, 1994. Smoking cessation decreases mortality among the elderly. Participants in the Leisure World Cohort Study initiated in 1981 were followed until death or January 1, 1991. The 8869 women and 4999 men (median age = 73 years at initial survey) contributed 105,952 person-years of follow-up; 4002 had died. All-cause mortality rates were highest among current smokers; compared with never smokers the age-adjusted relative risks (and 95% confidence intervals) were 1.67 (1.46, 1.92) for women and 1.95 (1.66, 2.30) for men. Current smokers had increased risks of coronary heart disease, other cardiovascular disease, and cancer. Risk of death from smoking-related cancers continued to be high among former smokers, although lower than the risk among current smokers. Relative risks of mortality from cancer and cardiovascular disease increased with the number of cigarettes smoked per
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American Journal of Public Health (continned) day and with a decreasing number of years since cessation of smoking. Reprint Address: A. Paganini-Hill, Preventive Medicine, University of Southern CaliforniaSchool of Medicine, 1721 GriffinAvenue #103, Los Angeles, CA 90031.
ANNALS OF NEUROLOGY
171-0033
PredictiveValue of Induction of Psychogenic Seizures by Suggestion I.ancman, M.E., AsconaI~, J.J., Craven, W.J., Howard, G., and Penry, J.IC 35(3):359-361, 1994. Induction by suggestion has previously been reported to be effective in the diagnosis of psychogenic seizures (PS). However, the sensitivity and specificity of this procedure has not previously been studied. Results of induction of PS by suggestion were analyzed in 93 patients with purely PS. The diagnosis of PS was based on the recording of a clinical event on video-electroencephalography, the absence of clinical or electroencephalographic evidence of epilepsy, and the subsequent fonow-up and withdrawal ofanticonvulsants supporting the diagnosis ofPS. A control group was composed of 20 patients with epilepsy in which induction was tried. Both groups were comparable for age, sex, and educational level. Induction was performed following a standardized protocol. The test was carried out #acing a colored patch on the neck. The test was considered positive when the induced clinical events were typical, according to a witness familiar with the patient's seizures. Induction was positive in 72 of 93 cases with PS and in none with epilepsy. Sensitivity of this test for the diagnosis of PS was 77.4%, specificity 100%, positive predictive value 100%, and negative predictive value 48.7~ Reprint Address: M.E. Laneman, Box 776, Department of Neurology, Cleveland Clinic, 9500 Euclic Avenue, Cleveland,OH 44195.
CognitiveFunctions and Quality of Life in Patients with Low-Grade Gfiomas: The Impact of Radiotherapy Taphoorn, M.J.B., Schiphorst, A.IC, Snoek, F.J., et al. 36(1):48-54, 1994. The role of early radiotherapy in the treatment of low-grade gliomas is controversial. For this reason the impact of radiotherapy on quality of life was studied in long-term survivors of biopsy-proved low-grade gliomas without signs of tumor recurrence. Twenty patients (age range, 18-66 years) had been treated with early radiotherapy; the other 21 patients (age range, 19-65 years) had undergone surgery or biopsy only. The interval from diagnosis to testing ranged from 1 to 12 years (mean, 3.5 years). Nineteen patients with low-grade hematological malignancies, surviving 1 to 15 years without central nervous system involvement, served as control subjects. Apart from the neurological and functional status, the patients' cognitive, affective, and psychological status was determined. None of the survivors had signif-
icant neurological impairment and the Karnofsky index for them was at least 70. However, more specific examinations of cognitive functions and the affective status (Profile of Mood States) indicated that, compared to the control subjects, the patients with low-grade gliomas had significantly more cognitive disturbances and suffered more frequently from fatigue and depressed moods. The two groups with low-grade gliomas, on the other hand, did not differ significantly on any of these measures. It is concluded that radiotherapy did not cause these disturbances and had no negative impact on quality of life in these patients. Reprint Address: MJ.B. Taphoorn, Department of Neurology,Free University Hospital, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
171-0035
ChronicOpioid Therapy us Alternative Treatment for Post-Herpetic Neuralgia Pappagallo, M. and Campbell, J.N. 35(Suppl.):S54--S56, 1994. Neurosurgical procedures such as the dorsal root entry zone operation, ganglionectomy, and spinal-cord stimulation have been offered to patients with intractable post-herpetic neuralgia (PHN). Poor efficacyor high morbidity have limited the overall usefulness of these procedures. We recently conducted a preliminary openlabel study with long-acting oral opioids. The mean pretreatment pain score, on a scale of 0 to 10 (0 = no pain) was 9.0 +_ 0.3 (mean + SEM, N = 20). At two months of treatment the average pain score was 4.0 _ 0.4 (p < 0.00 l, paired t test), and at six months the average pain score was 3.8 + 0.2 (p < 0.001, N = 16). These observations warrent a controlled opioid trial for patients affected by PHN. Reprint Address: J.N. Campbell, Department of Neurosurgery, John., Hopkins Hospital, Baltimore, MD 21287.
ANNALS OF THE RHEUMATIC DISEASES
171-0034
171-0036
A Prospective Study of Psychiatric Disorder and Cognitive Function in Systemic Lupus Erythematosus Hay, E.M., Huddy, A., Black, D., et al. 53(5):298--303, 1994. Objectives--To investigate change in psychiatric disorder and change in cognitive function in patients with systemic lupus erythematosus (SLE) assessed on two occasions two years apart. Methods--A prospective cohort study of 49 patients with SLE using standardised psychiatric and clinical research methods. Resuits--The point prevalence of psychiatric disorder (20% and 24%), and of cognitive impairment (23% and 18%), was similar at first and second interview for the whole group. There was, however, considerable change in individual patient's psychiatric status and cognitive function: only 1/9 patients with impairment on two or more cognitive tests at first interview was still impaired
VOLUME 17, N U M B E R 1, 1995
53
Annals of the Rheumatic Diseases (continued) at second interview. Change in cognitive function appeared to mirror change in psychiatric status. Conclusions--These findings suggest that the previously reported high prevalence of cognitive impairment in SLE may be explained by coexisting psychiatric disorder, rather than reflecting subclinical central nervous system (CNS) involvement. Reprint Address:E.M. Hay, ARC EpidemiologyResearch Unit, Stopford Building, Universityof Manchester, Oxford Road, ManchesterM 13 9PT, UK.
171-0037
Low Prevalence of Rheumatoid Arthritis in Black-Caribbeans Compared with Whites in Inner City Manchester MacGregor, A.J., Riste, L.K., Hazes, J.M.W., and Silman, A.J. 53(5):293-297, 1994. Objective--To compare the prevalence of rheumatoid arthritis (RA) in Black-Caribbeans and Whites living in the same urban area. Methods--Cases of inflammatory joint disease were ascertained initially from a postal screening survey of 1851 Black and 1829 age and sex-matched non-Blacks identified from general practice age-sex registers of seven general practices in the Moss Side and Hulme districts of Manchester. The ethnicity of respondents was confirmed using data from a postal screening questionnaire. Those reporting joint swelling or a history of arthritis were reviewed by a rheumatologist at surgeries held in each practice. The clinical records of the questionnaire non-responders and questionnaire-positive non-attenders at surgery were reviewed. Results--In an adjusted denominator population of 1046 BlackCaribbeans and 997 Whites, the cumulative prevalence of RA was 2.9/1000 in Black-Caribbeans and 8/1000 in Whites, representing a prevalence in Black-Caribbeans of 0.36 times that found in Whites (95% confidence interval 0.1-1.3). Conclusions-Rheumatoid arthritis occurs less commonly in Black-Caribbeans than in Whites. The findings are consistent with published studies showing a low RA prevalence in rural African Black populations. Reprint Address: A.J. MacGregor, ARC EpidemiologyResearch Unit, University of Manchester, Stopford Building, Oxford Road, Manchester MI3 9PT, UK.
psychologist "blinded" to clinical diagnosis. Patients with MS and CFS were additionally evaluated with a Structured Clinical Interview for DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition) disorders. Setting: Institutional and private neurological practices and the community at large. Patients: Twenty patients with CFS diagnosed in accord with the Centers for Disease Control and Preventionrevised criteria who had cognitive complaints; 20 patients with clinically definite MS who were ambulatory and were matched for fatigue severity, age, and education to CFS subjects; and 20 age- and education-matched healthy controls. Results: Patients with CFS had significantly elevated depression symptoms compared with patients with MS and healthy controls (P < .001) and had a greater lifetime prevalence of depression and dysthymia compared with MS subjects. Patients with CFS, relative to controls, performed more poorly on the Digit Symbol subtest (P =.023) and showed a trend for poorer performance on logical memory (P -- .087). Patients with MS compared with controls had more widespread differences of greater magnitude on the Digit Span (P < .004) and Digit Symbol (P < .001), Trail Making parts A (P -- .022) and B (P = .037), and Controlled Oral Word Association (P = .043) tests. Patients with MS also showed a trend of poorer performance on the Booklet Category Test (P = .089). When patients with CFS and MS were directly compared, MS subjects had lower scores on all measures, but the differences reached significance only for the Digit Span measure of attention (P = .035). Conclusions: Patients with CFS compared with MS have more depressive symptoms but less cognitive impairment. Relative to controls, a subset of CFS subjects did poorly on tests of visuomotor search and on the logical memory measure of the Wechsler Memory Scale--revised. Poor performance of logical memory in CFS appears to be related to depression, while visuomotor deficits in CFS are unrelated. Cognitive deficits in patients with MS are more widespread compared with those in patients with CFS and are independent of depressive symptoms. Reprint Address: L.B. Krupp, Department of Neurology, HSC T-12020, SUN'Y, Stony Brook, NY 11794.
171-0039
ARCHIVES OF NEUROLOGY
171-0038
Cognitive Functioning and Depression in Patients with Chronic Fatigue Syndrome and Multiple Sclerosis Krupp, L.B., Sliwinski, M., Masur, D.M., Friedberg, F., and Coyle, P.K. 5/(7):705-710, 1994. Objective: To assess cognitive function in patients with chronic fatigue syndrome (CFS) and multiple sclerosis (MS) and to evaluate the role of depressive symptoms in cognitive performance. Design: Case-control. All subjects were given a neuropsychological battery, self-report measures of depression and fatigue, and a global cognitive impairment rating by a neuro-
The Natural History of Alzheimer's Disease: Description of Study Cohort and Accuracy of Diagnosis Becker, J.T., Boiler, F., Lopez, O.L., et al. 5/(6):585-594, 1994. Objective: We describe the sampling, initial evaluation, and final diagnostic classification of subjects enrolled in a natural history study of Alzheimer's disease (AD). Design: Volunteer cohort study. Setting: Multidisciplinary behavioral neurology research clinic. Patients or Other Participants: Three-hundred nineteen individuals were enrolled in the Alzheimer Research Program between March 1983 and March 1988. Of these, 204 were originally classified with AD, 102 were normal elderly control subjects, and 13 were considered special cases. Main Outcome Measures: Final consensus clinical diagnosis, final neuropathologic diagnosis, and death. Results: Of the 204 patients enrolled in the study, re-review after as many as 5 years of follow-up resulted in a final clinical classification of 188 with probable AD. Seven patients were believed to have a significant
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Archives of Neurology (continued) vascular component to the dementia, three were found to have developed depression, and six were excluded on other clinical grounds. Neuropathologic examination of 50 brains indicated definite AD in 43. After removing these seven misdiagnosed patients, the final group of probable/definite AD totaled 181 individuals. Accuracy of the baseline clinical diagnosis relative to neuropathology was 86%, and when follow-up clinical data were considered, 91.4%. Detailed neuropsychologieal testing yielded high sensitivity (0.988) and specificity (0.983) to dementia. Analyses of survival time from study entry until death revealed that older patients were significantly more likely to die during follow-up, but neither sex, years of education, nor pattern of cognitive impairment were related to survival. Conclusions: These data provide the descriptive basis for future studies of this cohort. They indicate that longitudinal follow-up of demented cases increases accuracy of diagnosis, and that detailed cognitive testing aids in early classification. Reprint Address:J.T. Becker,NeuropsychologyResearch Program, Suite 502, Iroquois Building, 3600 Forbes Avenue, Pittsburgh, PA 15213.
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
171-0040
Reflex Sympathetic Dystrophy: Early Treatment and Psychological Aspects Geertzen, J.H.B, de Bruijn, H., de Bruijn-Kofman, A.T., and Arendzen, J.H. 75(4):442-446, 1994. Reprint Address: J.H.B. Geertzen, Department of Rehabilitation, University Hospital Groningen, Oostersingel 59, Groningen, The Netherlands.
171-0041
Psychopathology and the Rehabilitation of Patients with Chronic Low Back Pain Disability Gatchel, R.J., Polatin, P.B., Mayer, T.G., and Garcy, P.D. 75(6):666-670, 1994. Reprint Address: R.J. Gatchel, Department of Psychiatry-Divisionof Psychology,University of Texas SouthwesternMedical Center, 5323 Harry Hines Boulevard,Dallas, TX 75235-9044.
171-0042
Outcomes in Treatment of Pain in GeriaU'ic and Younger Age Groups Cutler, R.B., Fishbain, D.A., Rosomoff, R.S., and Rosomoff, H.L. 75(4):457-464, 1994. Reprint Address: R.B. Cutler, Comprehensive Pain and Rehabilitation Center, 600 Alton Road, Miami Beach, FL 33139.
171-0043
Factors Associated with the Quality of Life of Long-Term Spinal Cord Injured Persons Clayton, K.S. and Chubon, R.A. 75(6):633--638, 1994. Reprint Address: K.S. Clayton, Occupational Therapy Educational Department, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425.
ARCHIVES OF SEXUAL BEHAVIOR
171-0044 Gay Men as Victims of Nonconsensual Sex Hickson, F.C.I., Davies, P.M., Hunt, A.J., et al. 23(3):281-294, 1994. Incidents ofnonconsensual sexual activity among 930 homosexually active men living in England and Wales are analyzed. Of these men, 27.6% said they had been sexually assaulted or had sex against their will at some point in their lives; one third had been forced into sexual activity (usually anal intercourse) by men with whom they had previously had, or were currently having, consensual sexual activity. The contention that male rape is usually committed by heterosexually identified men, primarily as an expression of power and control, is not supported. Recognition that gay men rape other gay men is needed, both by the gay community and support services for victims. Reprint Address: F.C.I. Hickson, Project SIGMA, Department of Sociology, University of Essex, Colchester,UIC 171-0045 The Conditioning of Human Sexual Arousal O'Donohue, W. and Plaud, J.J. 23(3):321-344, 1994. Although most theories of human sexual behavior claim that much normal sexual behavior is learned, and theories of the etiology and modification of paraphilic and dysfunctional sexual behavior also claim that abnormal sexual behavior is learned and can be counterconditioned, there is no systematic review examining the relationship between conditioning and human sexual behavior. We review research addressing whether habituation, sensitization, classical conditioning, and operant conditioning processes are involved in human sexual behavior. We conclude that, due to the methodological problems of extant studies, the basis for asserting the existence of relationships between habituation, sensitization, classical conditioning, operant conditioning, and sexual behavior is tenuous. Reprint Address: W. O'Donohue, Northern Illinois University, DeKalb, IL 60115.
ARTHRITIS CARE AND RESEARCH
171-0046
Clinical Implications of Depression in Rheumatoid Arthritis Morrow, ICA., Parker, J.C, and Russell, J.L. 7(2):58-63, 1994. The clinical implications of depression in the context of rheumatoid arthritis are described. An overview of the diagnostic criteria for depression is provided, with specific focus on major depression and the associated subtypes. The neurobiological literature on major depression is briefly reviewed and the implications of the depression literature for the care of persons with rheumatoid arthritis are discussed. Reprint Address:J.C. Parker,PsychologyService(116B),Harry S. Truman MemorialVeteran's Hospital, 800 Hospital Drive, Columbia,MO 65201.
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Arthritis Care and Research (continued) 171-0047
Life Activities of Persons with Rheumatoid Arthritis with and without Depressive Symptoms Katz, P.P. and Yelin, E.H. 7(2):69-77, 1994. Objective. Persons with rheumatoid arthritis (RA) report more activity losses than persons without RA. Persons with RA who report depressive symptoms experience lower levels of functioning. We integrated these findings and examined the association of depressive symptoms with the activities in which persons with RA participate. Methods. We surveyed 726 persons with RA and 192 matched controls. Within each group, we examined the perceived importance and actual performance of 65 life activities by individuals with and without depressive symptoms. Results. Significantly more individuals with RA reported depressive symptoms. Among persons with RA, those who had depressive symptoms performed fewer activities, particularly fewer valued activities. In contrast, among controls, those who were depressed rated fewer activities as important, but exhibited few sitmificant differences in the performance of activities. Conclusions. Depressive symptoms and life activities are associated differently among persons with RA and controls. The higher rate of depression among persons with RA may be partially due to the inability to perform valued activities. Reprint Address: P.P. Katz, Arthritis Research Group, University of California, 1388 Sutter Street, Suite 700, San Francisco, CA 94143. 171-0048
Pain Behavior of Rheumatoid Arthritis Patients Enrolled in Experimental Drug Trials Anderson, ICO., Bradley, L.A., Turner, R.A., Agudelo, C.A., and Pisko, E.J. 7(2):64-68, 1994. Objective. This study examined the sensitivity of a behavioral observation method for the assessment of arthritis pain as an outcome measure in clinical drug trials. Methods. The subjects were 33 rheumatoid arthritis patients who were receiving either an active experimental drug or a placebo. Disease activity measures, self-reports of pain, and pain behavior observations were completed for each subject prior to drug initiation, 6 weeks after drug initiation, and 12 weeks after drug initiation. Results. Significant reductions in measures of disease activity and self-report of pain were found for the subjects who received an active drug, relative to those who received the placebo. The pain behavior scores produced by both groups of subjects remained relatively stable during the study. Conclusion. The lack of change in pain behavior suggests that arthritis pain behavior may lack sensitivity to short-term changes accompanying drug therapy. Reprint Address: K.O. Anderson, Department of Anesthesiology, University of Massachusetts Medical Center, Worcester,MA 01655. Characteristics of Participants in Water Exercise Programs Compared to Patients Seen in a Rheumatic Disease Cfinic Meyer, C.L. and Hawley, D.J. 7(2):85-89, 1994. Purpose. To determine if community-based water exercise programs are serving people with significant levels of disability and pain. Methods. Eighty-seven participants in water exercise classes and 174 patients from a rheumatic disease clinic were matched for age, sex, and diagnosis and comparisons were made between the groups for the study variables. Results. Patients had significantly higher disability, pain, global disease severity, anxiety, and depression and lower grip strength than participants. Osteoarthritis (OA) patients (n = 126) compared to OA partic-
ipants (n = 63) had similar significant differences for all variables. Rheumatoid arthritis (RA) patients' (n = 48) scores were all more severe than RA participants' scores (n = 24), and these differences were similar in magnitude to OA differences, but only global disease severity and grip strength were statistically significantly different. Conclusions. Water exercise classes are reaching persons with important levels of dysfunction and pain, but more severely affected patients are underrepresented in such programs. Reprint Address: D.J. Hawley,Department of Nursing, Box 41, Wichita State University, Wichita, KS 67208. 171-0050
Continuation of Group Physical Therapy is Necessary in Ankylosing Spondylitis: Results of a Randomized Controlled Trial Hidding, A., van der Linden, S., Gielen, X., et al. 7(2):90-96, 1994. Purpose. Group physical therapy in patients with ankylosing spondylitis was studied to determine whether beneficial effects persisted after cessation of the intervention. Methods. After a 9-month period of supervised group physical therapy, 68 patients were randomized for another 9 months to unsupervised daily exercises at home (discontinuation group) or continuation of weekly sessions of supervised group physical therapy (continuation group). Endpoints were spinal mobility (thoraco-lumbar flexion and extension, chest expansion, cervical rotation), fitness (maximum work capacity), functioning (Sickness Impact Profile [SIP], Health Assessment Questionnaire for the Spondylarthropathies [HAQ-S], Functional Index [FI]), and patient's global health assessment on a visual analogue scale. Results. Time for exercises at home was significantly higher in the continuation than in the discontinuation group (mean duration 1.9 versus 1.2 hr per week, P < 0.05). The continuation group improved in global health (mean improvement 1.6; 32%) and in SIP score. Scores for thoraco-lumbar mobility and HAQ-S did not change very much, whereas chest expansion, cervical rotation, fitness, and FI deteriorated. The average attendance for group therapy sessions was 62%. The discontinuation group improved only marginally (0.2; 4O/o)in global health, whereas all other endpoints decreased. Only for global health and HAQ-S were the differences statistically significant in favor of the continuation group. Conclusions. Global health and functioning are sustained or even improved further if group physical therapy is continued. Spinal mobility decreased slightly in both groups. Reprint Address: A. I-Iidding,Department of Internal Medicine,Division of R.heumatology,University Hospital Maastricht, P.O. Box 5800, NL6202 AZ Maastricht, The Netherlands.
171-0049
ARTHRITIS AND RHEUMATISM
171-0051
Differences between Men and Women Undergoing Major Orthopedic Surgery for Degenerative Arthritis Katz, J.N., Wright, E.A., Guadagnoli, E., et al. 37(5):687-694, 1994. Objective. To determine whether women have worse functional status than men at the time of laminectomy for degener-
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ANNALS OF BEHAVIORAL MEDICINE
Arthritis Care and Rheumatism (continued) ative spinal stenosis or total joint arthroplasty for degenerative arthritis of the hip and knee. Methods. Consecutive patients undergoing laminectomy for degenerative lumbar spinal stenosis or unilateral, primary hip or knee arthroplasty for advanced degenerative arthritis were recruited. Functional status was measured with self-administered questionnaires. We compared preoperative functional status scores of men and women, using linear regression models that adjusted for age, comorbid conditions, work status, education, living arrangement, and body mass index. We also compared the rates of in-hospital complications and 6-month followup functional status scores for men and women. Results. Women had much worse functional status than men prior to laminectomy for spinal stenosis (P < 0.01) and prior to total hip arthroplasty (P < 0.001) and total knee arthroplasty (P < 0.0001). These differences persisted after statistical adjustment for demographic and clinical characteristics. Women had comparable or greater functional improvement following surgery and experienced a similar number of complications compared with men. Conclusions. The observed gender differences in functional status prior to major orthopedic surgery indicate that women are operated on at a more advanced stage in the course of their disease. These results are not due to gender differences in demographic or clinical characteristics of the patients, and cannot be justified by differences between men and women in the outcome of surgery. The role of patient preferences and differential access to these procedures should be explored in future studies. Reprint Address: J.N. Katz, Department of Rheumatology and Immunology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. 17141052
Breast-Feeding and the Onset of Rheumatoid Arthritis Brennan, P. and Silman, A. 37(6):808--813, 1994. Objective. In a recent study we demonstrated that the postpartum period, particularly after the first pregnancy, is a time of increased risk for the development of rheumatoid arthritis (RA). The present study was undertaken to investigate whether this risk might be explained by breast-feeding. Methods. Through a nationwide media campaign, we identified 187 women who had developed RA within 12 months of a pregnancy, and we compared their breast-feeding histories with those of 149 similarly aged women chosen from the patient registers of a nationwide group of general practitioners. Results. In all, 88 of the women with RA developed the disease after their first pregnancy. Eightyone percent of these 88 women had breast-fed. This was higher than the breast-feeding prevalence of 50% in the 129 controls whose first pregnancy had resulted in a live birth (adjusted odds ratio [OR] 5.4, 95% confidence interval 2.5-11.4). There was a smaller increased risk of breast-feeding after a second pregnancy in the RA cases (OR 2.0) and no increase after a third pregnancy (OR 0.6). The increase in risk was greatest in those cases whose disease was erosive and who were rheumatoid factor positive. Conclusion. In a small group of susceptible women, exposure to breast-feeding after the first pregnancy is associated with a significant increase in risk for RA development. We postulate that this may reflect hormonal influences, specifically the high level of the proinflammatory hormone prolactin. Reprint Address: P. Brennan, Arthritis and Rheumatism Council, EpidemiologyResearchUnit, Manchester University Medical School, Manchester M13 9PT, UK.
BEHAVIORAL MEDICINE
171-0053
Preparing Patients for Invasive Medical and Surgical Procedures 1: Adding Behavioral and Cognitive Interventions Home, D.J. de L., Vatmanidis, P., and Careri, A. Spring:5-26, 1994. The authors of three related articles look at various aspects of preparing adult and child patients psychologically for invasive surgical procedures. The first article is a review of the literature in the field, primarily from the last 30 years. Researchers have examined anxiety and coping mechanisms, patient-practitioner relationships, medical phobias, and the effectiveness of different types of psychological intervention. In the second article, the authors offer practical suggestions for implementing preparatory psychological interventions, describing effective communication techniques such as active listening, role plays, imaging, modeling, and progressive relaxation. In the final article in the series, the author considers policy, practice, and educational implications of the use of behavioral and cognitive interventions for patients, medical practitioners, and healthcare planners.
171-0054
The Aftermath of Captivity: An 18-Year Followup of Israeli Ex-POWs Ohry, A., Solomon, Z., Neria, Y., et al. Spring:27-33, 1994. This is an 18-year follow-up of 164 former prisoners of war (POWs) and 190 controls. The study examined long-term morbidity, psychophysiological complaints, and illness-related behaviors. Psychophysiologieal complaints were found to be significantly higher among the POWs than among the controls. A significant association was also found between such complaints and symptoms of posttraumatic stress disorder (PTSD). The individuars degree of impairment was associated with both objective and subjective characteristics of captivity. The authors outline differences in types of illness observed in POWs in the current study and in studies conducted in other countries, and consider the implication of characteristics of captivity and culture.
171-0055
Religious Predictors of Cigarette Smoking: Findings for African American Women of Childbearing Age Ab_med, F., Brown, D.R., Gary, L.E., and Saadatmand, F. Spring:34--43, 1994. Data from a community-based survey of 252 African American women 18 to 44 years of age were used to examine the relation between cigarette smoking and two measures of religious involvement. Findings indicated that cigarette smoking among African American women of childbearing age is related to their denominational affiliation. Specifically, Pentecostal women had significantly lower odds of being a current smoker and higher odds of quitting smoking than did women who belonged to other religious denominations. No significant association was found, however, between smoking and the degree of religiosity. Older
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Behavioral Medicine (continued) age and lower level of education predicted current smoking, whereas having few daily hassles was associated with quitting smoking.
BEHAVIOUR RESEARCH AND THERAPY
17141056
Perceived Symptoms and Discomfort during Induced Bronchospasm: The Role of Temporal Adaptation and Anxiety Nouwen, A., Freeston, M.H., Cournoyer, I., Deschesnes, F., and Boulet, L.-P. 32(6):623-628, 1994. Using a mixed within-between design, this study was designed to evaluate the sensorial and cognitive/evaluative aspects of bronchoconstriction induced by progressive methacholine inhalation. 25 asthmatic patients and 15 normal controls were given two consecutive bronchoconstriction tests, inducing a fall of > 30% of the forced expiratory volume in 1 sec (FEV~), which was measured after each inhalation of methacholine. Immediately before each FEV1 measurement, Ss rated perceived bronchial dosing, discomfort of breathing and anxiety, as well as the need to use a bronchodilator. In addition to state-anxiety, after each bronchoconstriction test asthma symptoms were evaluated by means of a Free Symptom Report and the Asthma Symptom Checklist. The results show that during the first test, asthmatic patients perceived their symptoms more accurately than non-asthmatic controls. However, during the second test, asthmatic patients became less accurate, while normal controls increased their accuracy of symptom report. These changes were not parallelled for the Free Symptom Report or the Asthma Symptom Checklist. These results suggest that, depending on situational circumstances, patients rely on their cognitive schemata to report asthma symptoms. Need for bronchodilator use was related to perceived discomfort but not to actual or perceived bronchial closing. Clinical implications of this study are discussed. Reprint Address:A. Nouwen, Laboratory of BehavioralMedicine, School of Psychology,Laval University, PQ G1K 7P4, Canada. 1714)057
The Prevalence of Respiratory Disorders in Panic Disorder, Major Depressive Disorder and V-Code Patients Spinhoven, P., Ros, M., Westgeest, A., Van der Does, A.J.W. 32(6):647-649, 1994. Point prevalence and lifetime prevalence of respiratory disorders were assessed in 100 panic disorder (PD), 100 major depressive disorder (DD) and 100 V-code (VC) patients. Both current and past frequency of respiratory diseases were significantly higher in PD patients in comparsion to VC patients, while no significant differences in point and lifetime prevalence between PD and DD or DE) and VC patients were observed. It is hypothesized that a disturbed respiratory physiology may have differential effects depending upon the nature of the disorder and the appraisal by the patient. Reprint Address: P. Spinhoven, Department of Psychiatry,University of Leiden, Postbus 1251, 2340 BG Oegstgeest,The Netherlands.
171-0058
The Effects of Stress, Mood, and Coping on Blood Glucose in NIDDM: A Prospective Pilot Evaluation Goetsch, V.L, Abel, J.L, and Pope, M.K. 32(5):503-510, 1994. Eight subjects (Ss) with non-insulin-dependent diabetes (NIDDM) monitored their stress, blood glucose (BG), food intake, activity (via pedometer), mood, and coping responses for 8 days. The alternated 2 daily, self-selected ADA food-exchange diets to control for the effects of stress on adherence to diet. BG was significantly higher on high-stress compared to low-stress days. This effect was at least partially mediated by the effect of stress on activity; Ss were significantly less active on high-stress days. Further analyses suggested idiosyncratic relationships between mood and BG, and some evidence was found to suggest a relation between stress, coping, and BG. Reprint Address: V.L. Goetseh, Department of BehavioralMedicine and Psychiatry, West Virginia University, Morgantown, WV 26506.
BRITISH JOURNAL OF CLINICAL PSYCHOLOGY
17141059 The Contribution of Worry to Insomnia Watts, F.N., Coyle, IC, and East, M.P. 33(2):211-220, 1994. Recent research has pointed to the importance of cognitive activity in interfering with sleep, and suggested a close relationship between worry and insomnia. To explore the relationship between worry and insomnia in more detail, a sample was studied in which worry and insomnia were combined in a 2 x 2 design. The content of sleep-interfering cognitions was explored both with a previously developed Sleep Disturbance Questionnaire and a newly developed checklist of the content of thoughts that arose if people could not sleep. Both supported the importance of a distinction between sleep-related and other thoughts. Whereas worried insomniacs show a broad range of sleep-interfering thoughts, the thoughts of non-worried insomniacs focused mainly on sleep itsels ReprintAddress:F.N. Watts, MRC Applied PsychologyUnit, 15 Chaucer Road, Cambridge, CB2 2EF, UK.
171-0060
The Influence of Mood on Memories of Parental Rearing Practices Gerlsma, C., Kramer, J.J.A.M., Scholing, A., and Emmelkarnp, P.M.G. 33(2):159-172, I994. Parental rearing styles are often found to be related to adult psychological disorders. In general, conclusions are based on the data of retrospective studies, in which patients' memories of their parents' behavior are investigated. However, it has been widely recognized that memories may be sensitive to current mood states. The possible mood sensitivity of autobiographic memories is a powerful alternative explanation of the relationship commonly
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ANNALS OF BEHAVIORAL MEDICINE
British Journal of Clinical Psychology (continued) found between parental rearing styles and psychopathology, with implications for the hypothesis of early parenting as a vulnerability factor in the aetiology of such disorders. The present study examined whether memories of parental rearing styles are influenced by present mood. To this aim, both mood and memories of parental rearing styles were assessed on two occasions in a sample of 315 healthy subjects from the general community (Study 1) and in a group of 46 socially phobic patients (Study 2). Results showed that memories of early parenting remained quite stable, even in the face of significant and considerable changes in anxiety, depression, and hostility.The theoretical and practicalimplicationsof these findings are discussed. Reprint Address: C. Gerlsma, Department of Clinical Psychology, Academic Hospital, Oostersingel 59, 9713 EZ Groningen, The Netherlands.
171-0061
Reliability of Self-Rated Tinnitus Distress and Association with Psychological Symptom Patterns Hiller, W., Goebel, G., and Rief, W. 33(2):231-239, 1994. Psychological complaints were investigated in two samples of 60 and 138 in-patients suffering from chronic tinnitus. We administered the Tinnitus Questionnaire (TQ), a 52-item selfrating scale which differentiates between dimensions of emotional and cognitive distress, intrusiveness, auditory perceptual diffculties, sleep disturbances and somatic complaints. The test-retest reliability was .94 for the TQ global score and between .86 and .93 for subseales. Three independent analyses were conducted to estimate the split-half reliability (internal consistency) which was only slightly lower than the test-retest values for scales with a relatively small number of items. Reliability was sufficient also on the level of single items. Low correlations between the TQ and the Hopkins Symptom Checklist (SCL-90-R) indicate a distinct quality of tinnnitus-related and general psychological disturbances. ReprintAddress:W. Hiller, Clinic Roseneck, Center for Behavioural Medicine, Am Roseneck 6, D-83209 Prien, Germany.
171-0062
Spinal Cord Injury: A Search for Determinants of Depression Two Years after the Event Craig, A.R., Hancock, ICM., and Dickson, H.G. 33(2):221-230, 1994. A prospective longitudinal study employing repeated measures was used to isolate factors which might predispose a person to depression two years after sustaining spinal cord injury (SCI). Thirty-one subjects who suffered acute spinal injuries resulting in permanent loss of movement, and who had no head injuries or any pre-existing psychopathology, were at least 17 years of age, and who were able to speak English, participated in the study. Using the Beck Depression Inventory (BDI) as a measure of depression, a regression analysis demonstrated that the experience of pain two years post-injury and feeling out of control of one's life prior to hospital discharge were predictive of depression two years post-injury. No demographic variables or injury characteristics such as level of lesion or completeness of lesion were related to long-term depression. Pain management and rehabilitation techniques that enhance the individual's belief of control over their lives are therefore recommended as interventions that
could act to reduce depression in the long term in persons with spinal cord injury. ReprintAddress:A.R. Craig, UTS, P.O. Box 123, Broadway,NSW 2007, Australia.
CANCER
171-0063
Changing Trends: An Overview of Breast Cancer Incidence and Mortality Garfinkel, L., Boring, C.C., and Heath Jr., C.W. 74:222-227, 1994. The incidence of breast cancer rose about 1% per year between 1940 and 1980 according to data in the Connecticut Tumor Registry. A sharp increase of 32% was reported between 1980 and 1987 in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute. Data from this program shows that the increase in incidence was due to localized cases and cancers of less than 2 cm in greatest dimension. In addition, a sharp increase in carcinoma in situ was observed. The increase in breast cancer incidence coincides with an increased use of mammography in asymptomatic women in the 1980s. Mortality from breast cancer has changed little since the 1930s, but the increases in localized and small-size tumors and decreases in the rate of tumors of 3 cm or larger at diagnosis indicates that breast cancer mortality may start to decrease. Evidence from provisional breast cancer monthly mortality data suggests that there was a 3-6% drop in 1991 compared to 1990. Reprint Address: L. Garfinkel, American Cancer Society, 1180 Avenue of the Americas, New York, NY 10036.
171-0064 Byers, T.
Nutritional Risk Factors for Breast Cancer 74:288-295, 1994. The observation of large differences in breast cancer rates between countries has led to the hypothesis that excessive intake of dietary fat is an important risk factor for breast cancer in women. Case--control and prospective studies, however, generally have failed to show associations between dietary fat and breast cancer risk. There therefore is only weak evidence that modest reductions in fat intake (for instance to levels of 30% of caloric intake from fat) will reduce breast cancer risk. The possible benefits of lowering fat intake to levels substantially below 30% of calories will need to be tested in a randomized trial. In the meantime, the possible roles of micronutrient imbalances and childhood nutritional factors need to be studied better. Obesity is related to breast cancer in a complex way that suggests that a hormonal correlate of excessive body weight might affect breast cancer growth and metastasis. The potential benefit of intentional weight loss as an adjunct breast cancer treatment deserves further study. Many studies have suggested that drinking alcohol, even at modest levels, might increase breast cancer risk. Because the potential benefits of modest levels of alcohol for cardiovascular disease may outweigh the risk for breast cancer, recommenda-
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Cancer (continued) tions for total alcohol abstinence m a y be premature for w o m e n with an average breast cancer risk.W o m e n at unusually high risk for breast cancer who have a lower-than-average risk for cardiovascular disease, however, might make an informed decision to abstain from alcohol intake. Following current dietary advice to increase the amount of fruits,vegetables, and whole grains in the diet while reducing fats is certainly prudent for w o m e n to reduce their risk of several chronic disease, but current data points to the somber conclusion that such changes probably will have little effect on breast cancer risk. Reprint Address:T. Byers,Chronic Disease PreventionBranch, Division of Nutrition, National Center for Chronic Disease, Prevention and Health Promotion, 4770 BufordHighway,NE, MailstopK26, Atlanta, GA 303413724.
Screeningfor Breast Cancer and Mortality Reduction among Women 40-49 Years of Age Kopans, D.B. 74:311-322,1994.
of psychologic well being. Results. Factor analysis of the CDIS revealed that the physician's caring attitude was perceived by the women as most important, with information-giving as a much weaker component. Multiple regression analysis supported the hypothesis that psychologic adjustment was predicted by physician behavior during the cancer diagnostic interview. Other significant predictors of adjustment were a history of psychiatric problems and premorbid life stressors. Conclusions. Provision of information needed for decision-making appears to be valued largely within the context of a caring physician-patient relationship. Specific surgeons' behaviors believed to fac'flitate patient adjustment include expressing empathy, allowing sufficient time for patients to absorb the cancer diagnosis, providing information, and engaging the patient in treatment decision-making. ReprintAddress:C.S. Roberts, H. Lee Moflitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612-9497.
171-0065
The recent withdrawal of screening support for w o m e n ages 40-49 years isnot scientificallysupported. The subgroup analyses that have been used severely compromise the statisticalpower of the trials.None of the trialshas the statisticalpower to be able to provide clear proof of benefit for screening w o m e n ages 40-49 years because none of the trialsinvolved sul~cient numbers of w o m e n in these age groups. Despite having not been designed to evaluate w o m e n ages 40--49 years as a separate group, five of the eight randomized, controlled trialsbavc demonstrated mortality reductions for these w o m e n that range from 2 2 % to 49%. In addition, data from other nonrandomized trialsshow that there is no difference in survival for w o m e n ages 40-49 years than for w o m e n ages 50-59 years. The detection rate for small, early cancers, using modern mammography, is similar for w o m e n in both decades. There is no scicntilicreason to believe that there is a sudden change in detection or cure at age 50 years, or even at menopause. The available data suggest that w o m e n ages 4049 years can benefit from screening,just as can w o m e n ages 5059 years. ReprintAddress:D.B. Kopans, Department of Radiology, Massachusetts General Hospital, 15 Parkman Street, Level 2, Suite 219, Boston, MA 02114.
171-0066
Influenceof Physician Communication on Newly Diagnosed Breast Patients' Psychologic Adjustment and Decision-Making Roberts, C.S., Cox, C.E., Reintgen, D.S., Baile, W.F., and Gibertini, M. 74:336-341,1994. Background. Physician-patient communication is of critical importance when a breast cancer diagnosis is made, because the emotionally overwhelmed patient must be educated about her disease and available treatments so she can participate in decisions about her care. A research study addressed the hypothesis that patients whose surgeons used psychotherapeutic techniques during the cancer diagnostic interview would have better psychologic adjustment to their cancer. Methods. One hundred women surveyed 6 months after surgery completed the Cancer Diagnostic Interview Scale (CDIS) and the SCL-90-R, a measure
171-0067
Visceral Obesity and Breast Cancer Risk
Schapira, D.V., Clark, R.A., Wolff, P.A., et al. 74:632-639, 1994. Background. The risk for breast cancer and the sex hormone abnormalities noted in breast cancer patients have been demonstrated in women with upper body fat obesity. The objective of this study was to determine if the visceral component of upper body fat obesity was correlated with breast cancer risk. Methods. A case-control study of 40 consecutively enrolled women with breast cancer and 40 community-based age, weight, and waist circumference-matched control subjects was conducted. The areas of visceral fat, subcutaneous fat, and total fat were measured using computed tomography at the L-4 vertebral body. Calculations of relative risk for breast cancer were based on these fat compartments. Results. Patients with breast cancer had a significantly greater visceral fat area (P = 0.01), visceral-to-total-fat area ratio (VT ratio) (P < 0.001) and significantly lower subcutaneous-to-visceral-fat area ratio (SV ratio) (P < 0.001 ) compared with the matched controls. The relative risk for breast cancer increased with increasing VT ratio (0.24 = 9.5) (P < 0.0001) and decreasing SV ratio (->3.64 = 1.0; --5 cm), the survival was 80.8% for ages 40--49, 72.1% for ages 50-59, and 61.7% for ages 60-69. Discussion. Due to the higher breast cancer survival rates among women aged 40-49 with poorer prognostic characteristics, the breast cancer survival advantage for having a smaller tumor, no positive lymph nodes, or breast cancer detected by mammography alone was lower for women aged 40--49 than women aged 50 or older at diagnosis. These differences in survival advantage may help to account for the differences in mortality by age in the randomized clinical trials. Reprint Address: C. Byme, Environmental Epidemiology Branch, Division of Cancer Etiology, NCI, EPN-443, Bethesda, MD 20892.
171-0071
Interventions to Increase Breast Screening: Lifespan and Ethnicity Issues Rimer, B.K. 74:323-328,1994. Background. In spite of the fact that the value of mammography had been demonstrated, it remains underused by those in need, such as older women and minority women. A consideration of lifespan and ethnicity issues may help in designing interventions designed to overcome the barriers women may face at diffeint stages in their lives as well as the barriers that may be most salient for minority women. Methods. There now are reports from a number of published trials indicating the value of different kinds of interventions. Interventions can be characterized as individual-
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Cancer (continued) directed, system-directed, social network, or muitistrategy. Although little is known about what interventions may be specifically appropriate for women in their 40s, both individual-directed and multistrategy interventions have increased use of mammography sjLmificantly among women in their 50s, 60s, and 70s, including African American women. Conclusions. Although there is a considerable distance to go before all American women are getting regular mammograms, progress is being made. Attention to developing tailored interventions sensitive to lifespan and ethnicity concerns may be helpful. Reprint Address: B.K. Rimer, Cancer Prevention, Detection and Control Research, Duke University Medical Center, 2020 West Main Street, Suite 101, Durham, NC 27705.
171-0072
Ovarian Carcinoma: A Review of the Significance of Familial Risk Factors and the Role of Prophylactic Oophorectomy in Cancer Prevention Nguyen, H.N., Averette, H.E., and Janicek, M. 74:545-555, 1994. Women with a family history of ovarian cancer are at increased risk of ovarian cancer. Prophylactic oophorectomy (PO) remains the only effective method of ovarian cancer prevention. This study reviewed current data on the si~ificance of family history and how prophylactic oophorectomy should be used in different risk groups. Approximately 7% of ovarian cancer patients have a positive family history of whom 3-9% may eventually manifest certain hereditary cancer syndromes. Women in direct genetic lineage of family cancer syndromes have up to a 50% lifetime risk of ovarian cancer. Because of the high risk, PO is indicated for women with familial cancer syndromes after childbearing or between the ages of 35-40 at the latest. The majority of women with a positive family history of ovarian cancer do not have one of the recoL,nized syndromes. Women with one or two affected relatives have an increased lifetime risk of ovarian cancer from a baseline of 1.6 to 5-7%. This risk is not high enough to warrant PO for a large number of women. After being properly informed, the patient still chooses surgical prevention, she then receives PO. For women without a family history of ovarian cancer, the role of PO remains controversial. Assuming an annual incidence of 22,000 new cases of ovarian cancer, it is estimated that at least 1000 may be prevented if PO is diligently practiced during hysterectomy. Despite ovarian and breast cancer prevention, PO would lead to shorter life expectancy if estrogen therapy compliance were less than perfect. Thus, the decision on PO as a concurrent procedure should depend on the individual patient and her ability to comply with lifelong estrogen therapy. ReprintAddress:H.N. Nguyen, Division of GynecologicOncology,Cleveland Clinic Florida, 3000 West Cypress Creek Road, Ft. Lauderdale, FL 33309.
171-0073
The Effect of Risk on Changes in Breast Cancer Screening Rates in Los Angeles, 1988-1990 Roetzheim, R.G., Fox, S.A., and Leake, B. 74:625--631, 1994. Background. Although there have been clear secular trends of increased use of some breast cancer screening modalities, such as mammography, it is less certain that similar trends have oc-
curred among high risk women. Methods. Population-based surveys were conducted in three socioeconomically diverse Los Angeles communities in 1988 and 1990. Trends in breast cancer screening behavior and key determinants of scr~ning were compared separately for women with a family history of breast cancer, a personal history of benign breast disease, and for women without these risks. Results: In two independent samples drawn in 1988 and 1990, women at a higher risk of breast cancer (positive family history) showed smaller increases in the prevalence of selfreported breast cancer screening than a comparison group of women without a family history of breast cancer or a history of benign breast disease. This was especially true for family-historypositive minority women and women aged 65 years and older, for whom screening actually decreased. In 1990, mammograms for the prior year were reported by only 39% of women with a positive family history, 54% of women with benign breast disease, and 35% of women without these risks. Trends in physicians' office visit discussions of breast cancer screening paralleled trends observed in screening behavior. Conclusions. Although breast cancer screening increased substantially among lower risk women, rates were unchanged for women at increased risk because of a family history of breast cancer. By identifying and counseling higher risk women, physicians can play an important role in promoting appropriate screening to this group. Reprint Address: R.G. Roetz_heim,UCLA Division of Family Medicine, 50-071 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90024-1683.
171-0074
Prostate Specific Antigen Doubling Time and Disease Relapse after Radiotherapy for Prostate Cancer Pollack, A., Zagars, G.K., and Kavadi, V.S. 74:670-678, 1994. Background. Serum prostate specific antigen (PSA) correlates with prostate tumor volume. Therefore, PSA-doubling time (PSADT) in patients with a rising PSA profile after radiotherapy should be predictive of the time to clinical disease relapse. The purpose of this study was to characterize the relationship between PSADT and the time to disease relapse after the onset of a rising PSA (PSA-TTR) in 427 men treated in the PSA-era with high dose radiotherapy for Stages T1-4 adenocarcinoma of the prostate. Methods. There were 119 patients with a rising PSA profile after radiotherapy, and of these, there was sufficient information to calculate PSA-DT using nonlinear least squares regression in 100. There were 44 patients in this cohort who had documented disease relapse. The m ~ i a n patient follow-up was 38 months. Resuits. The average PSA-DT was 13.5 plus or minus 11.6 mo (_+standard deviation). PSA-DT values correlated with tumor grade, pretreatment PSA, and stage. PSA-DT was also strongly related to the outcome measures of local relapse, distant metastases, and any disease relapse. The shorter the PSA-DT, the greater the risk of disease relapse. The average PSA-TTR was 10.1 plus or minus 8.2. The only prognostic factor that correlated with PSA-TTR was tumor grade. A linear regression analysis of normalized PSA-DT and PSA-TTR revealed a si~ificant correlation in which a PSA-DT of 11 months predicted for disease relapse 24 months later. Because several factors including physician and patient preferences could alter this relationship, a comparison was made between the actuarial PSA rise time for patients treated in the PSA-era and actuarial clinical disease relapse using a cohort
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ANNALS OF BEHAVIORAL MEDICINE
Cancer (continued) of similarly treated men from the pre-PSA-era (n ffi 798). The results showed the lead time to be over 40 months in the majority of patients and that this lead time was much shorter in those with high grade tumors. Conclusions. PSA-DT is a strong prognostic factor for patients with biochemical evidence of failure after radiotherapy. A short PSA-DT predicts for more rapid progression to symptoms. The timing of the progression from a rising PSA to clinical disease relapse is probably longer than expected and is estimated to be 40 months on average. Reprint Address."A. Pollack,Department of Radiotherapy (97), The University of Texas M.D. Anderson Cancer Center, 15! 5 Holcombe Boulevard, Houston, TX 77030.
ferent drugs. The cumulative doses of derivatives of para-aminophenol, pyrazolone, and salicylic acid in some cases reached a maximum of several kilograms. Most drugs were classified by the patients as "moderately effective". The rating "very effective" was assigned primarily to barbiturates; however, barbiturates are no longer used as components of compound analgesic drugs in Austria. At the time of investigation, patients consumed 2.5 (mean) different drugs, primarily as compound preparations. Seventeen patients (21%) showed signs of possible analgesics- or ergotamineinduced headache and were therefore advised to undergo withdrawal therapy. Our results show that patients with tension-type headache are at considerable risk of becoming drug-dependent and of acquiring analgesics-induced headache. Reprint Address: P. Schnider, NeurologicalUniversity Clinic, Wahringer Gtirtel 18-20, A-1090 Vienna, Austria.
CEPHALALGIA CHEST 171-0075
Psychopathology in Individuals with PostTraumatic Headaches and Other Pain Types
Ham, L.P., Andrasik, F., Packard, R.C., and Bundrick, C.M. 14(2):118-126, 1994. In this study, the psychological functioning of patients with chronic post-traumatic headache (PTH), chronic combination headache and chronic low back pain without headache, whose time of onset was similar, and a matched group of controls was investigated. The Symptom Checklist 90-Revised (SCL-90-R), State-Trait Anger Expression Inventory (STAXI), State-Trait Anxiety Inventory, Form Y (STAI-Y), and Beck Depression Inventory (BDI) were used to assess the degree of psychopathology. A MANOVA test indicated highly significant differences between groups. In general, the pain groups fell along a continuum with PTH subjects demonstrating the highest elevations, back pain subjects demonstrating the next highest elevations, and combination subjects demonstrating fewer elevations. A cluster analysis indicated that findings were best classified into four clusters, but no one pain diagnosis predominated in any cluster. Eighty-nine percent of controls were assigned to clusters 1 or 2, which revealed essentially normal scores on all tests. It is suggested that while chronic pain patients demonstrate more psychopathology than non-pain controls, a variety of coping styles exists within each pain group independent of diagnostic categorization. ReprintAddress:L.P. Ham, Headache Managementand Neurology,5500 North Davis Highway, Pensacola, FL 32503.
17141076
Use and Abuse of Analgesics in Tension-Type Headache Schnider, P., AUll, S., Feucht, M., et al. 14(2):162-167, 1994. Eighty patients suffering from tension-type headache for an average of 21 years were asked to report on all drugs they had ever taken (type, dosage, duration of intake, efficacy) or were taking currently. The patients had consumed on average 6.3 dif-
171-0077
Mortality Risk and Patterns of Practice in 2,070 Patients with Acute Myocardial Infarction, 198792: Relative Importance of Age, Sex, and Medical Therapy Tsuyuki, R.T., Teo, K.IC, Ikuta, R.M., et al. 105(6):1687-1692, 1994. Objective: To define contemporary age- and sex-related mortality risks and patterns of medical practice in acute myocardial infarction (AMI). Design: Retrospective comparison of demographic and clinical variables, including the use of proven effective AMI medical therapy, among AMI patients cohorts from 1987 to 1992. Patients/Setting: Of a total of 2,070 AMI patients, 629 were women and 1,44 l, men; 951 patients were managed in university hospitals, 641 in a regional hospital, and 478 in community hospitals. Interventions: No direct study interventions; results of practice patterns and risk analyses of the earlier (198790) AMI cohorts, however, were published concurrently with the actual practices of the more recent (1991-92) cohorts and may have had some indirect effect on the recent practice patterns. Results: Univariate analysis showed that mortality was higher (p < 0.0001) and use of thrombolysis, beta blockers, and acetylsalicylic acid was lower (13 < 0.0001) in patients 70 years of age and older, compared with younger patients, and in women, compared with men. Multivariate analysis of the entire patient sample revealed age of 75 years or older (154 percent) and age 70 to 74 years (141 percent) to be associated with the highest relative risk of death in hospital. The increased relative risk associated with previous AMI was 45 percent. Acetylsalicylic acid use was associated with the greatest decrease in relative risk of death ( - 6 9 percent), followed by beta blockers ( - 3 6 percent) and thrombolysis (-31 percent). These patterns of relative risk were the same for men and women. Conclusions: Among contemporary AMI patients, advanced age and female sex are associated with relative under-utilization of proven effective medical therapy and
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Chest (continued) increased risk of dying in the hospital. Although the contribution of age to AMI risk appears greater than that of gender, survival in any high risk group would likely be improved by increased use of proven medical therapy. Reprint Address: T.J. Montague, 2C2 Mackenzie Centre, University of Alberta Hospitals, Edmonton, AB T6G 2B7, Canada.
head circumference. Although birthweight, previous illness, and parental education were also related to development, the relations between infant growth and cognition remained significant even after these variables were statistically controlled. Reprint Address: S.A. Rose, Department of Pediatrics, Kennedy 215, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461.
CHILD DEVELOPMENT
171-0078
Genetic and Environmental Influences on Perceptions of Self-Worth and Competence in Adolescence: A Study of Twins, Full Siblings, and Step-Siblings McGuire, S., Neidcrhiser, J.M., Reiss, D., Hetherington, E.M., and Plomin, R. 65:785-799, 1994. Although it is generally assumed that the origins of adolescents' perceptions of self-competence he in shared family environmental influences, the contributions of nonshared environmental or genetic influences have not been explored. We investigated sibling resemblance for perceived competence and self-worth in 720 adolescent pairs aged 10 to 18 years, using a twin, full sibling, and step-sibling design. Our goals were to assess the magnitude of shared and nonshared environmental influences and to disentangle resemblance due to shared genetic heritage from that due to shared environmental experiences. Shared enviroument was not significant for any of the scales. 4 of the subscales showed significant genetic influence: scholastic, social, physical, and athletic competence. We also explored possible sources of genetic influences on perceived competence. Bivariate models revealed common genetic variance between scholastic competence and vocabulary and social competence and sociability. These measures, however, did not account for all of the genetic variance in perceived social and scholastic competence. Reprint Address: S. McGuire, Department of Psychology, University of California/San Diego, La JoUa, CA 92093-0109.
171-0079
Relation between Physical Growth and Information Processing in Infants Born in India Rose, S.A. 65:889-902, 1994. The relation between physical growth and cognitive development in infants growing up in India was examined in this study. Subjects were 183 5-12-month-olds. Weight and length, two anthropometric measures commonly used to index nutritional status in developing countries, related to infant measures of visual recognition memory and tactual-visual cross-modal transfer. Underweight infants performed relatively poorly on both cognitive measures and failed to show the clear age-related improvements in speed of processing found among the heavier infants. Weight and length correlated with both measures of infant cognition, r = .25 to r = .45, as did, to a lesser degree,
CIRCULATION
171-0080
Heart Rate Spectral Analysis, Cardiac Norepinephrine Spillover, and Muscle Sympathetic Nerve Activity during Human Sympathetic Nervous Activation and Failure KingweU, B.A., Thompson, J.M., Kaye, D.M., et al. 90:234-240, 1994. Background. Although heart rate variability (HRV) at 0.1 Hz has been proposed as a noninvasive clinical measure of cardiac sympathetic nerve firing, this premise has not been sulficientiy validated by comparison with techniques such as microneurography and the measurement ofnorepinephrine spillover from the heart that more directly reflect presynaptic sympathetic activity. Methods and Results. We compared the three techniques under conditions of effective cardiac sympathetic denervation, pure autonomic failure (n = 4), dopamine fl-hydroxylase deficiency (n = 1), and after cardiac transplantation (n = 9) as well as in the context of sympathetic nervous activation in cardiac failure (n = 15) and with aging (n = 10). Age-matched comparisons were made in each case with healthy individuals drawn from a pool of 52 volunteers. In pure autonomic failure and early after transplantation, cardiac norepinephrine spillover was negligible, and HRV was low. Late after transplantation, however, cardiac norepinephrine spiUover returned to normal levels, and HRV remained low. In comparison to younger subjects (18 to 35 years old), older individuals (60 to 75 years old) had higher muscle sympathetic nerve activity (young, 22.9 _+ 1.9; old, 31.3 _+ 5.8 bursts per minute; P < .05) and cardiac norepinephrine spillover (young, 14.3 _+ 2.5; old, 20.1 _+ 3.0 ng/min; P < .05). In contrast, total HRV was reduced by 89%, and at 0.1 Hz it was reduced by 93% (P < .05). Cardiac failure was also characterized by elevated cardiac norepinephrine spillover (cardiac failure patients, 59 + 4; healthy volunteers, 18 + 3 ng/min; P < .01) but reduced 0.1 Hz HRV (cardiac failure patients, 49 + 17; healthy volunteers, 243 + 4 ms2; P < .05). Conclusions. HRV at 0.1 I-Iz depends on factors in addition to cardiac sympathetic nerve firing rates, including multiple neural reflexes, cardiac adrenergic receptor sensitivity, postsynaptic signal transduction, and electrochemical coupling, and is not directly related to cardiac norepinephrine spillover, which is a more direct measure of the sympathetic nerve firing rate. Reprint Address: B.A. Kingwell, Alfred and Baker Medical Unit, Baker Medical Research Institute, Commercial Road, Prahran, VIC 3181, Australia.
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ANNALS OF BEHAVIORAL MEDICINE
Circulation (continued) 171-0081
CircadianRhythms of Frequency Domain Measures of Heart Rate Variability in Healthy Subjects and Patients with Coronary Artery Disease: Effects of Arousal and Upright Posture Huikuri, H.V., Niemelii, M.J., Ojala, S., et al. 90:121-126, 1994. Background. Altered neural regulation of the cardiovascular system may be an important factor for various manifestations of ischemic heart disease. This research was designed to compare the circadian rhythm of cardiac neural regulation and autonomic responses to arousal and upright posture between patients with uncomplicated coronary artery disease (CAD) and age-matched subjects with no evidence of heart disease. Methods and Results. Twenty-four-hour heart rate variability (HRV) in the frequency domain was analyzed in 20 male patients (mean age, 52 _+ 7 years) with angiographic evidence of CAD without prior myocardial infarction and in 20 healthy men (mean age, 51 _+ 8 years) with no clinical, echocardiographic, or exercise ECG evidence of heart disease. None of the 24-hour average frequency-domain components of HRV differed significantly between the two groups. Healthy subjects had a significant circadian rhythm of normalized units of high-frequency (HF) power of HRV with higher values during sleep. Normalized units of low-frequency (LF) power and the LF/I-IF ratio also showed a sitmificant circadian rhythm in healthy subjects, with higher values during the daytime. No significant circadian rhythms in any of the normalized spectral components of HRV were observed in patients with CAD, and the night-day difference in LF/HF ratio was smaller in the patients with CAD than in the healthy subjects (0.5 + 1.4 versus 1.8 + 0.7, P < .001). Awakening when in the supine position resulted in a significant increase in the LF/HF ratio (P < .01 ) in the healthy subjects, but no si~ificant changes in HRV were observed after awakening in patients with CAD. Assumption of upright position resulted in a comparable decrease in the components of HRV between the groups. Conclusions. The circadian rhythm of cardiac neural regulation is altered in patients with uncomplicated CAD. Reduced autonomic responses to sleep-wake rhythm suggest that the modulation of cardiac autonomic function by stimuli from the central nervous system is impaired in CAD. Reprint Address: H.V. Huikuri, Division of Cardiology, Department of Medicine,Oulu UniversityCentral Hospital, Kajaaninfie50, 90220 Oulu, Finland.
171-0082
Physical Activity and 23-Yeur Incidence of Coronary Heart Disease Morbidity and Mortality among Middle-Aged Men: The Honolulu Heart Program Rodriguez, B.L., Curb, J.D., Burchiiel, C.M., et al. 89:2540--2544, 1994. Background. The purpose of the study was to examine the association between physical activity and 23-year incidence of coronary heart disease morbidity and mortality. This cohort study continues to follow 8006 Japanese-American men who were 45 to 68 years of age and living in Oahu, Hawaii, in 1965, for the development of coronary heart disease morbidity and mortality. Methods and Results. The Framingham physical activity index was calculated by summing the product of average hours spent at each activity level and a weighting factor based on oxygen consumption. Study subjects were divided into tertiles of physical
activity index at baseline. Relative risks and 95% confidence intervals (CO for incidence of coronary heart disease morbidity and mortality were obtained using the Cox model. After age adjustment and using the lowest physical activity index tertile as a reference group, the relative risk for coronary heart disease incidence for the highest tertile of physical activity was 0.83 (CI, 0.70 to 0.99). After adjusting for age, hypertension, smoking, alcohol intake, diabetes, cholesterol, and body mass index, the relative risk was 0.95 and CI included 1 (CI, 0.80 to 1.14). For coronary heart disease mortality, the age-adjusted relative risk was 0.74 (CI, 0.56 to 0.97) and 0.85 (CI, 0.65 to 1.13) after risk factor adjustment. Conclusions. The results suggest that the impact of physical activity index on coronary heart disease is mediated through its effects on hypertension, diabetes, cholesterol, and body mass index. These findings support the hypothesis that physical activity is inversely associated with coronary heart disease morbidity and mortality and suggest that physical activity interventions in middle-aged men, by improving cardiovascular risk factor levels, may have significant public health implications in the prevention of coronary heart disease. Reprint Address: B.L. Rodriguez, Honolulu Heart Program, 347 North Kuakini Street, Honolulu, HI 96817.
CLINICAL JOURNAL OF PAIN
171-0083
Can Treatment Outcome of Chronic Low Back Pain Be Predicted? Psychological Disease Consequences Clarifying the Issue Talo, S., Puukka, P., RytOkoski, U., Rtnnemaa, T., and Kallio, V. 10(2):107-121, 1994. Objective: To search for generalizable, psychological predictors of chronic pain treatment outcome. Design: The prognostic power of the psychological predictors, classified into subareas of function, i.e., impairments, disabilities, and handicaps, was compared in predictive situations varying with the quality of patient samples, programs, and outcome measures. Setting: Four rehabilitation centers in Finland providing "functioning activation" or more passive "spa resort" treatment programs for low back pain patients. Patients: 173 low back pain patients for whom the inpatient rehabilitation program was funded by the Finnish Social Insurance Institution. Outcome measures: The measures were panel assessment of global functioning (DSM III Axis V), selfreport of handicap (Minion), panel assessment of handicap (WHO index), panel assessment of adherence (four rating scales), and self-report of well-being (Faces scale). Results: Multivariate, stepwise regression analyses suggested that the disability and handicap measures of functioning may be more effective predictors than impairment measures, which, however, add to the variance explained by the former. However, the predictive power of psychological impairments, disabilities, and handicaps varied with differences in patient group, outcome measure, and program. Conclusion: The "general predictors" of chronic pain treatment outcome may be difficult to find. Therefore, planning treatment for the individual patient may always have to be based on
VOLUME 17, NUMBER 1, 1995
65
Clinical Journal of Pain (continued) accurate multiaxial and multidimensional assessment ofpatient functioning. Reprint Address: S. Talo, The Social Insurance Institution, Research and Development Center, Peltolantie 3, 20720 Turku, Finland.
171-0084
The Coping Strategies Questionnaire and Chronic Pain Adjustment: A Conceptual and Empirical Reanalysis Geisser, M.E., Robinson, M.E., and Henson, C.D. 10(2):98-106, 1994. Objective: Some studies have found significant relations between both the factor scores and subscales of the Coping Strategies Questionnaire (CSQ) and various measures of adjustment to chronic pain. In their review of the literature on coping with chronic pain, Jensen et al. (Pain 1991;47:249-83) suggest that conceptual overlap between the subscales may inflate these observed correlations. In the present study, we examine the factor structure of the CSQ subscales which reflect coping, excluding the CSQ subscales which measure appraisal or activity. We then examine the relationship between the CSQ factors and subscales and pain adjustment, while controlling for selected variables. Design and Subjects: One hundred fifty-two chronic pain patients were administered the CSQ. Seventy-three were also administered the Multidimensional Pain Inventory (MPD. Adjustment to chronic pain was defined based on patients' cluster membership on the MPI and responses to the Interference, Pain Severity, and Negative Affect subscales. Setting: Tertiary care center. Resuits: Multiple regression analyses revealed that the Pain Avoidance factor was positively related to pain severity, interference, and MPI cluster membership. In addition, the catastrophizing subseale was positively related to negative affect and MPI cluster membership even when controlling for level of depression, ability to decrease pain was related to lower levels of pain severity, and ability to control pain was related to MPI cluster membership. Neither the Conscious Cognitive Coping factor nor the Increasing Activities subscale was related to the adjustment measures. Follow-up analyses revealed that the Praying/Hoping subscale appeared to account for the relationship between pain avoidance and adjustment. Conclusion: The results suggest that praying/ hoping and catastrophizing are related to poorer adjustment to chronic pain, that ability to control and decrease pain are related to better adjustment, and that catastrophizing appears to be a separate construct from depression. The results also suggest that the individual CSQ subscales may have greater utility in terms of examining coping, appraisals, and pain adjustment compared to the composite scores. Reprint Address." M.E. Geisser, Department of Physical Medicine and Rehabilitation, Med_Rehab-Universityof Michigan Medical Center, 355 Briarwood Circle, Ann Arbor, MI 48108-0742. 171-0085
Depression and Pain Behavior in Patients with Chronic Pain Krause, S.J,, Wiener, R.L., and Tait, R.C. 10(2):122-127, 1994. Objective: Previous studies of pain behavior in patients with chronic pain have shown that depressed patients exhibit more pain behavior than nondepressed patients. This study sought to extend these findings and to examine the possible causes of the observed differences. Design: Patients completed the short form
of the Beck Depression Inventory, and their pain behavior was simultaneously rated by themselves and trained observers. Patients: Subjects were 37 inpatients in a chronic pain program. Results: Both depressed and nondepressed subjects rated themselves as exhibiting more pain behavior than did nurse ratings. While nurses rated pain behaviors as similar among the depressed and the nondepressed groups, patient ratings indicated significantly more pain behavior among depressed than nondepressed patients. Conclusions: These results suggest that cognitive factors may influen~ self-ratings of pain behavior by depressed subjects. Reprint Address:S.J. Krause, 2700 West 9th Avenue,Oshkosh, W154904.
171-0086
Observationof Pain Behaviors during Episodes of Sickle Cell Disease Pain Gil, ICM., Phillips, G., Edens, J., Martin, N.J., and Abrams, M. 10(2):128-132, 1994. Objective: To assess the utility of a brief behavioral observation method to quantify pain. Design: Correlational study. Patients: 31 sickle cell disease (SCD) patients first seen in an outpatient clinic in painful crisis. Outcome Measures: Observed pain behaviors, physician rating of patient pain on a 0 to 10 scale, patient rating of pain on a 0 to 10 scale, and patient pain report from the McGiil Pain Questionnaire. Results: High interrater reliability for the brief behavioral observation was found, and observed pain behavior was found to correlate significantly with physician ratings of pain. Conclusions: This study is an important first step toward developing a systematic behaviorobservation methodology for the analysis of SCD pain. The current methodology was found to be reliable and easily implemented in a busy, outpatient clinic. Reprint Address: K.M. Gil, Pain Management Program, Box 3159, Duke University Medical Center, Durham, NC 27710.
DIABETES CARE
171-0087
PreventiveEye Care in People with Diabetes Is Cost-Saving to the Federal Government: Implications for Health-Care Reform Javitt, J.C., Aiello, L.P., Chiang, Y., et at. 17(8):909-917, 1994. Objective--Diabetic retinopathy, which leads to macular edema and retinal neovascularization, is the leading cause of blindness among working-age Americans. Previous research has demonstrated significant cost savings associated with detection of eye disease in Americans with Type I diabetes. However, detection and treatment of eye disease among those with Type II diabetes was previously thought not to be cost-saving. Our purpose was to estimate the current and potential federal savings resulting from the screening and treatment of retinopathy in patients with Type II diabetes, based on recently available data concerning efficacy of treating both macular edema and neovascularization along with new data on federal budgetary costs of blindness. Research Design and Methods--We used corn-
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ANNALS OF BEHAVIORAL MEDICINE
Diabetes Care (continued) puter modeling, incorporating data from population-based epidemiological studies and multicenter clinical trials. Monte Carlo simulation was used, combined with sensitivity analysis and present value analysis of cost savings. Results--Screening and treatment for eye disease in patients with Type II diabetes generates annual savings of $247.9 million to the federal budget and 53,986 person-years of sight, even at current suboptimal (600/0) levels of care. If all patients with Type II diabetes receive recommended care, the predicted net savings (discounted at 5%) exceeds $472.1 million and 94,304 person-years of sight. Nearly all savings are associated with detection and treatment of diabetic macular edema. Enrolling each additional person with Type II diabetes into currently recommended ophthalmological care results in an average net savings of $975/person, even if all costs of care are borne by the federal government. Conclus i o n s - O u r analysis indicates that prevention programs aimed at improving eye care for patients with diabetes not only reduce needless vision loss but also will provide a financial return on the investment of public funds. Reprint Address: J.C. Javitt, Center for Sight, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, DC 20007.
171-0088
Health-Insurance Coverage for Adults with Diabetes in the U.S. Population Harris, M.I., Cowie, C.C., and Eastman, R. 17(6):585-591, 1994. Objective--To compare the extent and types of health insurance coverage for adults with diabetes to coverage for those without diabetes in the U.S. population. Research Design and Methods--Nationally representative samples of 2,405 adults with diabetes and 20,131 adults who were not known to have diabetes in the U.S. completed a questionnaire on current health insurance, including coverage through Medicare, private insurance, the military, and Medicaid and other public programs. Results--Among all adults with diabetes, 92.0% have some form of health insurance, including 86.5% of those 18--64 years of age and 98.8% of those >_65 years of age. Approximately 41% are covered by more than one health insurance mechanism, but almost 600,000 people with diabetes do not have any form of health-care coverage. Little difference was found by type of diabetes in the proportion who have health insurance. Only small differences exist between people with diabetes and those without diabetes in the percentages covered and the types of health-care coverage. Government-funded programs are responsible for health-care coverage of 57.4% of adults with diabetes, including 26.4% of those 18--64 years of age and 96.0% of those >--65years of age. Private health insurance is held by 69.3% of diabetic people. Lack of private insurance appears to be attributable primarily to lower income. Conclusions--Almost all patients with diabetes who are >-65 years of age have health-care coverage, but 13.5% of those 18--64 years of age have no health insurance. Few differences exist in coverage between individuals with and without diabetes. However, the absence of insurance should have a substantially greater impact on the ability of patients with diabetes to obtain services necessary for care of their disease, compared with those without diabetes. Government-funded insurance mechanisms cover a large proportion of diabetic patients, which indicates a significant societal burden
associated with diabetes. Any changes in government reimbursement and coverage policies could have a major impact on health care for patients with diabetes. Reprint Address: M.I. Harris, NIDDK/NIH, Westwood Building, Room 620, Bethesda, MD 20892.
171-0089
Diabetes Meilitus and Cigarette Smoking: Findings from the 1989 National Health Interview Survey Ford, E.S., Malarcher, A.M., Herman, W.H., and Aubert, R.E. 17(7):688--692, 1994. Objective--To compare the prevalence of current smoking in the U.S. diabetic population with that of the nondiabetic population. Research Design and Methods--Using data from the 1989 National Health Interview S u r v e y - a nationally representative sample--we calculated the prevalence of current smoking for 2,405 people with self-reported diabetes and 20,131 people without this condition. Results--Overall, the age-adjusted prevalence of smoking was 27.3% among people with diabetes and 25.9% among people without diabetes. The prevalence of smoking did not differ significantly between participants with and without diabetes when they were stratified by age, sex, race, or education. Black and Hispanic men with diabetes had a higher prevalence of smoking than did White men with diabetes and Black and Hispanic men without diabetes, but none of these differences were statistically significant. Among people with diabetes, age, race, sex, and educational status were independent predictors of current smoking in a multiple-logistic regression model. Duration of diabetes was not related to smoking. Conclusions--These data again emphasize the need to prevent and reduce smoking in the diabetic population. Smoking cessation programs should particularly target people with diabetes who are __18 years of age in the U.S. population. The questionnaire inquired about whether these individuals had ever attended a diabetes education class or program. Sociodemographic and clinical factors that may influence participation in patient education were also determined. Results--Of all people with diabetes, 35.1% had attended a class or program about diabetes at some time during the course of their disease, including 58.6% of individuals with insulin-dependent diabetes mellitus, 48.9% of insulin-treated individuals with non-insulindependent diabetes mellitus (NIDDM), and 23.7% of N I D D M individuals not treated with insulin. Younger age, black race, residence in the midwest region of the U.S., higher level of education, and presence of diabetes complications were consistently associated with having had diabetes education for people with NIDDM. Although increasing income was associated with patient education for N I D D M individuals not treated with insulin, it was not an independent determinant for insulin-treated N I D D M individuals. N I D D M individuals not treated with insulin who lived alone were more likely to have had patient education than those who did not live alone. Not having a diabetes physician or not visiting one in the past year was associated with a higher likelihood of patient education for noninsulin-treated NIDDM individuals. Conclusions--A large proportion of patients with diabetes has never received diabetes education. Patient education has been recognized for its contributions to reducing the morbidity and mortality of diabetes. Consequently, special attention should be directed to the subgroups of individuals, such as those not taking insulin, those with lower socioeconomic status, and those living outside urban
areas, in which the frequency of diabetes patient education is particularly low. ReprintAddress: M.I. Harris, NIDDK/NIH, Westwood Building, Room 620, Bethesda, MD 20892.
THE DIABETES EDUCATOR
171-0092
Perceptions of the Importance Placed on Religion and Folk Medicine by Non-MexicanAmerican Hispanic Adults with Diabetes Zaldivar, A. and Smolowitz, J. 20(4):303-306, 1994. The high incidence of diabetes and diabetes-related complications in Hispanic adults in the United States continues to be of concern among healthcare providers. The underutilization of screening services and early treatment centers by Hispanic adults seems to contribute to the problem. This survey examined whether religious, spiritual, and folk medicine beliefs play a role in the participants' view of diabetes and treatment choices. One hundred four non-Mexican-American Hispanic adults with diabetes were surveyed using a self-report questionnaire. Results showed that 78% of patients believed they had diabetes because it was God's will; 17% of patients reported using herbs to treat their diabetes. This survey demonstrates the importance of addressing religion and spirituality when dealing with the issues of disease and health in this population. Reprint Address: The Diabetes Educator, 367 West Chicago Avenue, Chicago, IL 60610.
171-0093
The Relationship between Eating Patterns and Metabolic Control in Patients with Non-InsulinDependent Diabetes Mellitus (NIDDM)
Schmidt, L.E., Rost, K.M., McGill, J.B., and Santiago, J.V. 20(4):317, 1994. The most important element in the therapeutic plan of patients with non-insulin-dependent diabetes meUitus (NIDDM) is dietary modification. Dietary instructions target patient behaviors in two areas: following an exchange-based diet and adbering to the same basic eating pattern every day. However, there is little empirical data that addresses the relationship between dietary instruction and metabolic control. Fifty patients with N I D D M were enrolled in an 8-week study to ascertain if either dietary approach was more predictive of improved metabolic control. The effect on metabolic control was determined by changes in HbA,c over a 2- to 3-month period. Patients added or deleted almost half of all prescribed exchanges, and added or deleted an average of one prescribed meal or snack per day. Deviations in prescribed eating patterns, particularly breakfastskipping and snack additions and deletions, were related to poorer metabolic control. Maintaining consistent eating patterns should be further evaluated as an important component of dietary instruction for patients with NIDDM. Reprint Address: The Diabetes Educator, 367 West Chicago Avenue, Chicago, IL 60610.
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ANNALS OF BEHAVIORAL MEDICINE
GASTROENTEROLOGY
171-0094
Relaxation Training Reduces Symptom Reports and Acid Exposure in Patients with Gast3"oesophageal Reflux Disease
McDonald-Haile, J., Bradley, L.A., Bailey, M.A., Schan, C.A., and Richter, J.E. 107:61-69, 1994. Background/Aims: Previous studies have shown that psychological factors play a role in symptom perception among patients with gastroesophageai reflux disease. This report describes the first controlled study showing the effects of relaxation training on symptom reports and eosophageal acid exposure in patients with reflux disease. Methods: Twenty subjects with documented reflux disease were studied during psychologically neutral and stressful tasks, followed immediately by either a relaxation or attention-placebo control intervention. Results: Stressful tasks, relative to neutral tasks, produced significant increases in blood pressure, subjective ratings of anxiety, and reports of reflux symptoms. Despite increased symptom reports, stressful tasks did not significantly increase objective measures of esophageal acid exposure. Subjects who received a relaxation intervention after the stressful task had significantly lower heart rate values and subjective ratings of anxiety compared with subjects who received the attention-placebo control intervention. Subjects who received relaxation training also had significantly lower reflux symptom ratings and total esophageal acid exposure than subjects who received the attention-placebo control intervention. Conclusions: Relaxation may be a useful adjunct to traditional antireflux therapy in patients who experience increased symptoms during stress. Reprint Address: L.A. Bradley, Division of Gastroenterology,633 Zeigler Research Building, University of Alabama, Birmingham, At. 35294.
number of negative life events for women. For both genders IHLC was related to the importance placed on good health. Reprint Address: M.I. Wallhagen, Department of PhysiologicalNursing, School of Nursing, University of California, San Francisco, CA 941430610.
171-0096
Physical and Functional Health Assessment in Normal Aging and in Alzheimer's Disease: SelfReports vs Family Reports
Kiyak, H.A., Ted, L., and Borson, S. 34(3):324-330, 1994. This longitudinal 2-year study compared self and family members' reports of physical and functional health among 40 patients with Alzheimer's disease and 53 age-matched nondemented healthy older persons. Functional health was consistently rated as more impaired by family caregivers of demented patients than by the patients themselves, a discrepancy not observed in the cognitively intact comparison group. Caregiver reports correlated significantly with declines in patients' cognitive abilities as measured by formal testing, but self-reports did not. Patients did recognize deterioration in ADLs over time, despite progressively worsening cognitive ability. These data indicate that the capacity for self-observation is partially preserved in Alzheimer's patients in mild to moderate stages. Patient self-reports can provide valuable data for clinicians, but should be supplemented by detailed information from caregivers. Reprint Address: H.A. KAyak,Departments of Oral and Maxillofacial Surgeryand Psychology,University of Washington, SB-24, Seattle, WA 98195.
HEADACHE
171-0097
THE GERONTOLOGIST
171-0095
Impact of Internal Health Locus of Control on Health Outcomes for Older Men and Women: A Longitudinal Perspective
WaUhagen, M.I., Strawbridge, W.J., Kaplan, G.A., and Cohen, R.D. 34(3):299-306, 1994. We investigated the relationship between baseline internal health locus of control (IHLC) and 6-year change in physical functioning in 356 older adults. IHLC was strongly related to change in physical functioning for women at all levels of baseline functioning, but only affected men with lower baseline functioning. Cross-sectional analyses indicated no relationship between IHLC and health seeking activities except changing eating patterns when sick. Other findings were that IHLC was related to depression and not having childhood illness for men and to
Migraine as a Sequela to Chronic Low Back Pain Duckro, P.N., Schultz, K.T., and ChibnaU, J.T. 34(5):279-281, 1994. The occurrence of headache as a sequela of low back pain was examined in a sample of chronic pain patients. All patients had low back pain without history of head, neck, or upper back injury or headache onset simultaneous with the low back pain. Consistent with prior research, headache was found to be a common concomitant of back pain. In many patients, headache was found to have begun or exacerbated markedly after onset of low back pain. Prevalence of migraine in female patients was significantly higher than the population prevalence for females in the United States; this was not true for male patients. Potential mechanisms for explaining the high prevalence of migraine following low back pain are discussed, including increased muscle tension, psychosocial factors, and analgesic overuse. Reprint Address: P.N. Duckro, Saint Louis University Health Sciences Center, Division of BehavioralMedicine, 1221 South Grand Boulevard, St. Louis, MO 63104.
V O L U M E 17, N U M B E R 1, 1995
HEADACHE QUARTERLY
171-0098
Interrelationships among Dally and Global SelfReport Measures of Headache Penzien, D.B., Johnson, C.A., Seville, J.L., et al. V(1):27-33, 1994. Objective. To carefully examine the interrelationships among various daily and global self-report indices of headache in a large clinical sample of headache sufferers. Design. Prospective study examining correlations among headache measures and diagnostic group differences in correlations. Setting. Outpatient, university medical center-based headache clinic. Patients. 150 recurrent headache sufferers who experienced at least three headaches per month. Main Outcome Measures. Summary scores derived from patients' daily self-monitoring and global, retrospective reports of headache activity including: (a) peak headache intensity, (b) number of headache days per week, and (c) daily headache index. Results. The interrelationships among the various headache measures across headache diagnostic groups could not be differentiated, and the frequency and intensity measures appeared to tap discrete dimensions of headache activity for both daily and global ratings. While one would expect two different measures of the same construct (e.g., frequency) to be strongly correlated, only minimal correspondence was observed between comparable measures assessed via daily versus global methods--global ratings of peak headache intensity overestimated and global ratings of headache frequency underestimated daily ratings of the same construct. Con.clusions. Both consumers and producers of the headache literature should be cognizant of the potential variability among types of headache measures. Clearly, daily and global measures of headache activity should not be considered equivalent. Relative to daily self-report measures, global, retrospective measures tend to overestimate headache activity. Reprint Address: D.B. Penzien, UMC Headache Clinic, Department of Psychiatry and Human Behavior, The University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505.
HEALTH PSYCHOLOGY
171-0099
Chronic Stress, Social Support, and Persistent Alterations in the Natural Killer Cell Response to Cytokines in Older Adults Esterling, B.A., Kiecolt-Glaser, J.K., Bodnar, J.C., and Glaser, R. 13(4):291-298, 1994. To address the long-term physiological consequences of chronic stressors, 14 continuing or current family caregivers of Alzheimer's disease (AD) patients, 17 former AD caregivers, and 31 control subjects were compared. Continuing and former caregivers did not differ on depressive symptomatology or perceived stress; both groups were significantly more depressed and stressed than controls. Furthermore, continuing and former caregivers did not differ in the response of NK cells in vitro to
69
recombinant interferon-7 and recombinant interleukin-2, and both groups had a significantly poorer response to these cytokines than controls. The physiological and psychological consequences of chronic stressors may persist well beyond the cessation of the actual stressor. Reprint Address: R. Glaser, Department of Medical Microbiologyand Immunology, 218 Meiling Hall, 320 West 9th Avenue, Ohio State University Medical Center, Columbus, OH 43210-1238. 171-0100
Realistic Acceptance as a Predictor of Decreased Survival Time in Gay Men with AIDS Reed, G.M., Kemeny, M.E., Taylor, S.E., Wang, H.-Y.L, and Visscher, B.R. 13(4):299-307, 1994. Although theoretical accounts of adaptation in the terminally ill suggest that realistic acceptance of one's disease is adaptive, some investigations suggest that such responses are associated with increased mortality. This prospective psychobiological investigation involved 74 gay men with AIDS. Six scores reflecting responses to disease were derived from a detailed psychosocial questionnaire. One pattern of response, Realistic Acceptance, was a significant predictor of decreased survival time. Median estimated survival time for participants with low Realistic Acceptance scores was 9 months greater than for participants with high Realistic Acceptance scores. This effect was not accounted for by time since diagnosis with AIDS, self-reported health status, number ofCD4 T lymphocyte cells, psychological distress, age, education, initial diagnosing condition, use of AZT, smoking, or alcohol and drug use. Reprint Address: G.M. Reed, Department of Psychiatry and Biobehavioral Sciences, School of Medicine, University of California, 760 Westwood Plaza, Los Angeles, CA 90024-1759. 171-0101
Psychological Adjustment in Adults with Cancer: The Self as Mediator Heidrich, S.M., Forsthoff, C.A., and Ward, S.E. 13(4):346-353, 1994. The role of the self in adjustment to cancer has been noted but is not weU understood. Research and theory on the self suggest that discrepancies between actual and ideal self-conceptions influence adjustment and mediate the effects of diseaserelated health problems on psychological well-being. This relationship was investigated in a cross-sectional study of 108 persons with cancer. Cancer patients who had more symptoms and worse functional health and perceived their cancer as a chronic rather than an acute disease had higher levels of selfdiscrepancies and poorer adjustment. Self-discrepancy was a significant mediator of the effects of perceived health status on purpose in life, positive relations with others, and depression. Reprint Address: S.M. Heidrich, University of Wisconsin, School of Nursing, 575 Ctmningham Hall, Milwaukee, WI 53201. 171-0102
Empirical Tests of an Information-MotivationBehavioral Skills Model of AIDS-Preventive Behavior with Gay Men and Heterosexual University Stndents Fisher, J.D., Fisher, W.A., Williams, S.S., and Malloy, T.E. 13(3):238-250, 1994. This article contains empirical tests of the informationmotivation-behavioral skills (IMB) model of AIDS-preventive
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ANNALS OF BEHAVIORAL MEDICINE
Health Psychology (continued) behavior, which has been designed to understand and predict the practice of AIDS-preventive acts. The IMB model holds that AIDS-preventive behavior is a function of individuals' information about AIDS prevention, motivation to engage in AIDS prevention, and behavioral skills for performing the specific acts involved in prevention. The model further assumes that AIDSprevention information and motivation generally work through AIDS-prevention behavioral skills to influence the initiation and maintenance of AIDS-preventive behavior. Supportive tests of the model, using structural equation modeling techniques, are reported with populations of gay male affinity group members (n = 91) and heterosexual university students (n = 174). Reprint Address: J.D. Fisher, Department of Psychology,U-20, Room 107, 406 BabbidgeRoad, University of Connecticut, Storrs, CT 062691020.
171-0103
Consequences of Dieting to Lose Weight: Effects on Physical and Mental Health French, S.A. and Jeffery, R.W. 13(3):195-212, 1994. Concern has been raised that negative physiological and psychological effects of dieting may outweigh aesthetic and health benefits. This review of the literature concludes the following: (a) The measurement of dieting is an important unresolved issue; (b) current dieting, chronic dieting, desire to lose weight, specific weight control behaviors, and weight changes may have different effects on health and need to be distinguished; (c) dieting is usually not associated with nutritional deficiencies, adverse physiologic adaptations, severe psychological reactions, or the development of eating disorders; and (d) recommendations against weight loss efforts involving moderate changes in eating and exercise habits are not warranted. Reprint Address: S.A. French, Division of Epidemiology,School of Public Health, University of Minnesota, 1300 South Second Street, Suite 300, MinneapoLis, MN 55454-1015.
171-0104
Cognitive Distortion, Helplessness, and Depressed Mood in Rheumatoid Arthritis: A Four-Year Longitudinal Analysis Smith, T.W., Christensen, A.J., Peck, J.R., and Ward, J.R. 13(3)'213-217, 1994. Cognitive models of depression have been invoked to explain the development of depressive symptoms and disorders in patients with chronic pain. However, few long-term, prospective studies have examined A. T. Beck's (1967, 1987) model in this context. Seventy-two patients with rheumatoid arthritis completed the Beck Depression Inventory, the Cognitive Errors Questionnaire, and the Arthritis Helplessness Index during an initial assessment and again 4 years later. Initial levels of cognitive distortion were significantly related to follow-up levels of depressed mood, controlling for initial depression levels. This was also true for perceptions of helplessness. In contrast, initial depression levels did not predict changes in these cognitive processes. These results suggest that cognitive distortion and helplessness contribute to depressed mood among patients with arthritis. Reprint Address: T.W. Smith, Department of Psychology, Behavioral Sciences Building, University of Utah, Salt Lake City, UT 84112.
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The UCLA Multidimensional Condom Attitudes Scale: Documenting the Complex Determinants of Condom Use in College Students Helweg-Larsen, M. and Collins, B.E. 13(3):224-237, 1994. This article describes the development and validation of the UCLA Multidimensional Condom Attitudes Scale (MCAS). The relationships between the MCAS and gender, sexual experience, intentions to use a condom, and past condom use were assessed. The MCAS has five distinct factors: (a) Reliability and Effectiveness of condoms, (b) the sexual Pleasure associated with condom use, (c) the stigma attached to persons who use condoms (Identity Stigma), (d) the Embarrassment About Negotiation and Use of condoms, and (e) the Embarrassment About the Purchase of condoms. The results strongly suggest that condom attitudes are multidimensional and thus cannot meaningfully be summed to a single global score. Results further indicate that men and women hold very different attitudes toward condoms. Implications of scale multidimensionality and directions for future research are discussed. Reprint Address: M. Helweg-Larsen,Department of Psychology,University of California, 405 Hilgard Avenue, Los Angeles, CA 900241563. 171-0106
Substance Use and Sexual Risk Taking among Black Adolescents and White Adolescents Cooper, M.L., Peirce, R.S., and Huselid, R.F. 13(3):251-262, 1994. Analyses of data from a random sample of 1,259 sexually active adolescents revealed that substance use was associated with increased sexual risk taking on 2 occasions of intercourse (lst intercourse ever and 1st intercourse with most recent partnet), even after controlling for demographic, experiential, and dispositional confounders. Within-persons analyses yielded similar results, indicating that adolescents who used substances, on 1 of the 2 occasions, reported higher levels of risk taking on the occasion when substances were used than on the no-substance-use occasion. However, substance use was both more common and more strongly linked to risk taking among White than Black adolescents, suggesting that White adolescents are at greater risk ofnegative consequences related to substance use proximal to intercourse. Reprint Address: M.L. Cooper, Department of Psychology, 348 Park Hall, SUNY, Buffalo, NY 14260-4110. 171-0107
Impact of Social Support, Social Cognitive Variables, and Perceived Threat on Depression among Adults with Diabetes Connell, C.M., Davis, W.K., Gallant, M.P., and Sharpe, P.A. 13(3):263-273, 1994. Tested was a model of social support and cognitive appraisal of self-effcacy, outcome expectancies, and illness threat on depression. Study participants were community-dwelling adults with diabetes who completed a mailed questionnaire (N = 362). Results of structural equation modeling indicated that 52% of the variance in depression was explained by the model-largely by the direct effects of physical functioning, the perceived availability of social support, and the perceived threat of diabetes as well as the indirect paths from perceived support to
V O L U M E 17, N U M B E R 1, 1995
Health Psychology (continued) perceived threat and from physical functioning to perceived support and perceived threat of diabetes. Diabetes-specific social support, self-efficacy, and outcome expectancies were not significant predictors of depression. Reprint Address: C.M. Connell, Department of Health Behavior and Health Education, School of Public Health, 1420 Washington Heights, University of Michigan, Ann Arbor, MI 48109-2029. 171-0108
The Physician-Delivered Smoking Intervention Project: Can Short-Term Interventions Produce Long-Term Effects for a General Outpatient Population? Ockene, J.K., Kristeller, J., Pbert, L., et al. ]3(3):278-281, 1994. Patterns of smoking cessation using 6- and 12-month follow-up data are reported for 1,261 primary care patients randomized to 3 physician-delivered smoking interventions: advice only (AO), counseling (CI), and counseling plus availability of nicotine-containing gum (CI + NCG). One-week-point-prevalence cessation rates at 12 months did not differ among the interventions: AO (15.2~ CI (12.9%) and CI + NCG (16.7%). However, maintained cessation rates (abstinent at both 6 and 12 months) increased with intervention intensity: AO (6.0%), CI (7.8%) and CI + NCG (10.0%): Test of trend • = 5.06, p = .02. CI + NCG was significantly higher than AO (p ffi .02). The findings support the following conclusions: Brief physiciandelivered intervention with availability of nicotine-containing gum can have a beneficial long-term effect on smoking cessation, and cohort data as well as point-prevalence rates are important when assessing the long-term impact of lifestyle interventions. Reprint Address: J.IC Ockene, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Avenue, North, Worcester, MA 01655.
followed was designed to stimulate the youths through reflection, dialogue, and planning for action. Reprint Address: A. Malekoff, North Shore Family Guidances Center, 480 Old Westbury Road, Roslyn Heights, NY 11577.
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Psychosocial Characteristics of Pregnant Women with and without a History of Substance Abuse Marcenko, M.O., Spence, M., and Rohweder, C. 19(1): 17-22, 1994. This study was undertaken to identify the psychosocial characteristics and service needs of pregnant women with substance abuse histories. Two hundred and twenty-five pregnant women defined as having high-risk pregnancies for psychosocial reasons were interviewed using a structured questionnaire when they presented for prenatal care at a large urban clinic. Women who admitted to problems with substance abuse were compared to those who denied a history of substance abuse. Women with an admitted history of substance abuse were significantly older, had more children, were more likely to live on their own or in an institutional setting, and more frequently reported that they currently smoked cigarettes. In addition, women with substance abuse problems delayed prenatal care an average of one month longer. Other differences between the two groups, as well as the implications of the findings for social work practice in health care settings, are discussed. Reprint Address: M.O. Marcenko, Department of Mental Health Sciences, Hahnemann University, 1427 Vine Street, Philadelphia, PA 19102.
HYPERTENSION
171-0111
HEALTH A N D S O C I A L W O R K
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Action Research: An Approach to Preventing Substance Abuse and Promoting Social Competency Malekoff, A. 19(1):46-53, 1994. This article demonstrates the use of action research, an approach combining various social work methods to raise community consciousness, stimulate intergroup and intergenerational interaction, and motivate people to work toward change both individually and collectively. The project described represents an effort to mobilize youths and adults living in a rapidly changing, culturally pluralistic, low-income suburban community to confront the impact of drug and alcohol abuse in a context of mutual respect and support. The central them of investigation was local youths' perceptions about drug and alcohol abuse in the context of their own lives. A group of youths, in partnership with professionals, surveyed their contemporaries with a questionnaire of their own creation. The community meeting that
71
Exercise Blood Pressure Predicts Cardiovascular Mortality in Middle-Aged Men Mundal, R., Kjeldsen, S.E., Sandvik, L., et al. 24:56-62, 1994. The outcome of 1999 apparently healthy men aged 40 to 59 years investigated from 1972 through 1975 was ascertained after 16 years to determine whether systolic blood pressure measured with subjects in the sitting position during a bicycle ergometer exercise test adds prognostic information on cardiovascular mortality beyond that of casual blood pressure measured after 5 minutes of supine rest. During a total follow-up of 31,984 patient years, 278 patients died, 150 from cardiovascular causes. Casual blood pressure and pulse pressure as well as peak exercise systolic blood pressure during 6 minutes on the starting workload of 600 kpm/min (approximately 100 W, 5880 J/rain) were all related to cardiovascular mortality. The relative risk (RR) of dying from cardiovascular causes associated with an increment of 48.5 m m Hg (=2 SD) in systolic blood pressure at 600 kilopondmeter (kpm)/min was significant (RR = 1.5, 95% confidence interval [CI] ffi 1.1-2.3, P = .040) even when adjusting for a large number of variables measured in the present study, including age, exercise capacity, smoking habits, and casual blood pressures. The influence of blood pressure at 600 kpm/min was
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Hypertension (continued) so strong that the predictive value of resting casual blood pressures became nonsignificant when these were analyzed as continuous variables also including exercise blood pressure as a covariate. However, the maximal systolic blood pressure during the exercise test was unrelated to cardiovascular mortality. Among the 520 men with resting systolic blood pressure of 140 m m Hg or greater, those 304 who increased their systolic blood pressure to 200 m m Fig or greater during 6 minutes of the starting exercise workload of 600 kpm/min had a 16-year cardiovascular death rate of 16.1% compared with 6.0% among those with a systolic blood pressure less than 200 m m Hg at 600 kpm/min (n = 216, RR = 2.0, 95% CI = 1.1--4.0, P = .025). The cardiovascular death rate was also 6.0% among those who were normotensive at rest (n = 1479). Thus, an early rise of systolic blood pressure during exercise adds prognostic information on cardiovascular mortality among otherwise healthy middle-aged men with mildly elevated casual blood pressure. Reprint Address: S.E. Kjeldsen, Department of Internal Medicine, UIlevaal Hospital, N-0407 Oslo, Norway.
INTERNATIONAL JOURNAL OF EATING DISORDERS
171-0112
Resting Metabolic Rate and Total Energy Expenditure in Acute and Weight Recovered Patients with Anorexia Nervosa and in Healthy Young Women Platte, P., Pirke, ICM., Trimborn, P., et al. 16(1):45-52, 1994. Reprint Address: K.M. Pirke, Center of Psychobiology and Psychosomatic Research, Department of Psyehoendocrinology, University of Trier, Building D, Box 3825, 5500 Trier, Germany.
cancer. This study was done to evaluate the risk of female lung cancer from PS, especially that during childhood and adolescence. Methods. Using household exposure to tobacco smoke as an estimate of PS, a 1:1 paired case-control study was conducted in Harbin, China. We interviewed 114 female primary lung cancer cases, aged 30--69 years, and their hospital-based controls. The controls were non-cancer patients, selected from the same hospital as the cases, and matched on age (+_ 5 years), residential area and smoking status over their lifetime. There were 59 pairs who ever smoked and 55 pairs who never smoked. Information on PS was collected by residence for each of the following periods: 0--6, 7-14, 15-22, 23-30 and 31-69 years. Results. Household PS significantly increases the risk of female lung cancer for those exposed at ages 22 or younger, who have ever smoked. The risk was also increased for those non-smoking pairs when exposed under the age of 15 years. Exposure to maternal smoking at ages 14 or younger increased the risk by about 170% (odds ratio, OR 2.7, 95% confidence interval [CI]: 1.49-4.88), but not to paternal smoking (OR 1.40, 95% CI: 0.922.50). The risk was highest for those exposed under the age of seven (OR 3.46, 95% CI: 1.80-6.65) and was also significant at ages 7-14 (OR 3.08, 95% CI: 1.62-5.57) and 15-22 (OR 3.10, 95% CI: 1.52-6.31) years. Under the age of 23 years, the OR increased with amount of PS(P < 0.001). Of note, the OR in all five exposure periods for non-smoking pairs were similar to those for all 114 paris studied. Conclusions. Household PS, particularly that during childhood, increases the risk of female lung cancer. The assessment of PS should be done by different periods of exposure. Reprint Address: F.-L. Wang, Department of Community Health Sciences, Faculty of Medicine, University of Calgary, 3330 Hospital Drive, NW, Calgary, AB T2N 4N1, Canada.
171-0115
171-0113
Body Weight and Dieting in Adolescence: Impact of Socioeconomic Status Drewnowski, A., Kurth, C.L., and Krahn, D.D. ]60):61--65, 1994. Reprint Address: A. Drewnowski, Human Nutrition Program, School of Public Health M-5170, University of Michigan, Ann Arbor, MI 48109-2029.
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
171-0114
Childhood and Adolescent Passive Smoking and the Risk of Female Lung Cancer Wang, F.-L., Love, E.J., Lui, N., and Dai, X.-D. 23(2):223-230, 1994. Background. Few studies have reported the relationship between passive smoking (PS) in early life and the risk of lung
EmploymentStatus, Non-Daytime Work and Gastric Ulcer in Men Tiichsen, F., Jeppesen, H.J., and Bach, E. 23(2):365-370, 1994. Background. An excess risk of gastric ulcer (GU) (ICD-8: 531) has formerly been found in shift workers and ex-shiftworkers but little is known about the risk of GU associated with other forms of non-daytime work. This study deals with associations between non-daytime work and GU. Methods. A fixed cohort of 122,116 men in occupations in which at least 20% had non-daytime work and a reference group of 593,281 men in occupations with daytime work only, was followed in the National Inpatient Register for first discharges with GU as the principal diagnosis. Results. For men with daytime work only we found a steep inverse association between GU and employment status. Men in occupational groups with late evening work had a standardized hospitalization ratio (SHR) of 236 (90% confidence interval [CI]: 184--299), groups working in rosters covering 24-hour services had an SHR of 147 (90% CI: 116183). A slightly raised risk of 114 (90% CI: 101-128) was found in groups having other forms of non-daytime work. For all men in groups with non-daytime work we found a significant SHR of 130 (90% CI: 118-142). Conclusions. We conclude that both
V O L U M E 17, N U M B E R 1, 1995
International Journal of Epidemiology (continued) low employment status and non-daytime work are associated with an increased risk of GU. Reprint Address: F. Tiichsen, National Institute of Occupational Health, Department of Occupational Medicine, Lerso Parkalle 105, DK-2100 Copenhagen O, Denmark.
171-0116
not support the existence of a threshold in the relation between alcohol and blood pressure. Reprint Address: K. Wakabayashi, Department of Public Health, National Defense Medical College, Tokorozawa, Saitama 359, Japan.
Moderate and Vigorous Leisure-Time Physical
Activity and Cardiovascular Disease Risk Factors in West Germany, 1984-1991 Helmert, U., Herman, B., and Shea, S. 23(2):285-292, 1994. The relationship between leisure-time physical activity (LTPA) and cardiovascular disease (CVD) risk factors was analysed based on data of three cross-sectional National Health Surveys, carried out in West Germany between 1984 and 1991. A total of 7663 males and 7722 females, aged 25--69 years, were examined. A self-administered questionnaire was used to assess LTPA which was defined as the mean duration of time (in minutes) spent during the past week on 14 specified sports during the previous 3 months. The mean time for LTPA per week was 102 minutes for males and 70 minutes for females. No significant differences were observed in LTPA mean duration for the three surveys. Younger age and higher social class were strong predictors for greater LTPA. In multiple linear regression models, after adjustment for age and social class, LTPA was significantly associated with lower systolic and diastolic blood pressure (both sexes), total cholesterol (males only), cigarette smoking (males only) and body mass index (females only), and with higher HDL-cholesterol (both sexes). The data suggest that LTPA plays an important role if aiming at reducing CVD risk factors in the general population. Reprint Address: U. Helmert, Division of Epidemiology, Bremen Institute for Prevention Research and Social Medicine (BIPS), P.O. Box 106767, D-28067 Bremen, Germany.
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Alcohol Consumption and Blood Pressure: An Extended Study of Self-Defence Oilidals in Japan Wakabayashi, K., Nakamura, K., Kono, S., Shinchi, K., and Imanishi, K. 23(2):307-311, 1994. Background. It remains controversial whether the relation between alcohol intake and blood pressure is linear or nonlinear. Methods. The relation between alcohol intake and blood pressure was investigated in 2341 male self-defence officials who received a preretirement health examination at the Self-Defense Forces Fukuoka Hospital between October 1986 and December 1990. Average alcohol intake in the past year was ascertained by a self-administered questionnaire. The study excluded past drinkers, and allowed for smoking, body mass index and glucose tolerance. Results. Blood pressure was higher at higher levels of alcohol intake across the range from 0 to 40-59 ml of alcohol per day, but was not progressively higher in men consuming > 60 ml per day. Blood pressure was significantly higher even among light drinkers (< 20 ml per day) compared to non-drinkers; adjusted mean differences were 3.1 mmHg (95% confidence interval (CI): 1.1-5.2) in systolic pressure and 2.1 m m H g (95% CI: 0.7-3.5) in diastolic pressure. Conclusions. Our findings do
JOURNAL OF ABNORMAL CHILD PSYCHOLOGY
171-0118
IndividualDifferences in Preschoolers' Physiological and Verbal Responses to Videotaped Angry Interactions El-Sheikh, M., Ballard, M., and Cummings, E.M., 22(3):303-320, 1994. Individual differences in selection of intensity of angry interactions and physiological and self-reported responses to interadult anger were examined in preschoolers (N = 34). Children watched two videotaped angry interactions between adults, while their heart rates and skin conductance responses and levels were monitored; then they were interviewed. Before the second argument, children were given the perceived choice of watching an intense or mild angry exchange. Individual differences in responding to the angry interactions were found. Both (a) children with relatively higher externalizing behavior problems and Co) boys who chose to watch intense anger had lower tonic heart rates; 80% of boys with externalizing problems chose to watch intense anger. Further, children who chose to watch intense anger (a) exhibited lower declines in heart rates upon the presentation of the argument, Co) perceived the actors as more angry, and (c) reported lower amounts of distress during the argument than those who chose mild anger. Reprint Address:M. El-Sheikh, Department of Psychology,Auburn University, Auburn, AL 36849-5214.
JOURNAL OF ABNORMAL PSYCHOLOGY
171-0119
Differential Relationships between Stress and Disease Activity for Immunologically Distinct Subgroups of People with Rheumatoid Arthritis Stewart, M.W., Knight, R.G., Palmer, D.G., and Highton, J. 103(2):251-258, 1994. Immunologically distinct subgroups of patients with rheumatoid arthritis (RA)--those with the autoantibody rheumatoid factor (seropositive RA) and those without (seronegative RA)-were compared on a variety of clinical and self-report measures in a consecutive series of women with disease of 7 years' or less duration. The groups were comparable on clinical, pain, func-
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ANNALS OF BEHAVIORAL MEDICINE
Journal of Abnormal Psychology (continued) tional, and psychosocial variables. However, the seronegative RA group reported elevated levels ofpreonset negative life event stress. Postonset life event stress and disease activity were significantly correlated for the seronegative RA group, but not for the seropositive RA group. Results suggest that stress factors may be more important in the etiology and maintenance of seronegative RA and that the seronegative RA group may possibly derive particular benefit from psychological techniques to enhance stress management skills. Reprint Address: M.W. Stewart, Psychiatric Liaison, Middlemore Hospital, Private Bag, Otahtthu, Auckland 6, New Zealand.
171-0120
Word Completion in Chronic Pain: Evidence for Schematic Representation of Pain? Edwards, L.C. and Pearce, S.A. 103(2):379-382,1994. Schematic representation of pain information was investigated in chronic pain patients, health professionals, and nonpatient controls. Under the guise of an English-language experiment, Ss were presented with 12 word stems to be completed with the first 2 English words that came to mind. Four of the stems could be completed with sensory pain words, 4 with affective, and 4 with words associated with pain or illness. All could be completed with at least 3 other nonpain words of equal or greater frequency. Results indicate that chronic pain Ss produced significantly more pain-related completions than control Ss and that in all 3 groups the types of pain words produced were related to the extent of personal experience of pain. The theoretical implications of these findings are discussed in relation to the organization of schema, implicit memory, and the activation of mental representations of pain (schema). Reprint Address: L.C. Edwards, Department of Psychology,University College London, Gower Street, London WC1E 6BT, UIC
JOURNAL OF ADOLESCENT HEALTH
171-0121
Prospective Study of Psychological Development of Adolescent Female Athletes: Initial Assessment Theintz, G., Ladame, F., Kehrer, E., et al. 15:258-262, 1994. Purpose: This study aimed at assessing the impact of physical training on psychological functioning at the onset of a prospective study of psychological and somatic maturation of adolescent female athletes. Methods: Twenty-seven highly trained gymnasts aged 12.7 + 1.1 year (mean + SD, training load = 18-26 hr/week) and 16 age-matched but moderately trained swimmers (13.0 _+ 0.9 yr, training load 4-15 hr/wk) were submitted to standardized somatic and psychiatric examinations during training camps. Results: Gymnasts were significantly shorter, lighter and thinner (p < 0.001) than swimmers. Their bone age was moderately but significantly retarded (-1.42 _+
0.99 yr, p < 0.001) in contrast with swimmers in whom it was adequate for chronological age (+0.28 ___ 0.94 year, ns). Only 7.4% of gymnasts has already had menarche in contrast with 50% of age-matched swimmers (p = 0.003). Psychological functioning was considered as normal in all subjects. However, seven athletes including 3/27 gymnasts and 4/16 swimmers (p = 0.394) were considered as subjects "at risk" to develop a manifest mental disorder over time. Ten gymnasts (41.7%) presented with a global delay in psychological maturation, whereas no such case was observed among swimmers (p = 0.015). No correlation could be established between psychological delay and pubertal retardation (p = 0.210). Conclusion: Strenuous training in gymnastics for more than 1 yr has so far no detectable interference with the normal maturational events of adolescence. The outcome of athletes at risk to develop psychopathology as well as those with a global delay in psychological maturation who presented as if they were still in the latency period, remains uncertain. Reprint Address: G. Theintz, Hrpital de l'Enfance, Case postale, 1004 Lausanne, Switzerland.
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The Relationship between Aggressive Behavior and Puberty in Normal Adolescents: A Longitudinal Study Finkelstein, J.W., Von Eye, A., and Preece, M.A., 15:319-326, 1994. Purpose: To assess changes in aggressive behaviors as related to progression from early to late puberty in normal adolescents. Methods: Subjects were normal English schoolchildren. An observational cohort design was employed. Pubertal status was measured by Tanner staging. Self-reports of verbal aggression against adults, physical aggression against peers, aggressive impulses and aggressive inhibitory responses, were collected at three points in time. Analyses were performed for the entire group of 106 subjects in 1983, 77 subjects in 1985 and 70 subjects in 1987. Statistical methods included analysis of variance, regression and correlation and cluster formation. Results: There were decreases in all aggression variables except in aggressive impulses over this time period. When analyzed by gender, boys were initially more aggressive than girls, but by late puberty all gender differences in self-reported aggressive behaviors had disappeared. When only those subjects who were evaluated at all three data collection times were grouped by similar responses on both aggression and physical variables, three clusters of boys and girls were identified. Clusters contained varying proportions of boys and girls. Cluster one (48.5% of the entire sample) was a low aggression group. Cluster two (30.3%) was a high aggression group, and cluster three (21.20/o) was an intermediate aggression group. These clusters seemed to have relatively stable aggression characteristics over time. Conclusions: These data suggest that groups of boys and girls who report similar aggression characteristics and have similar growth and pubertal characteristics can be identified. Neither gender alone, nor pubertal status alone, nor by inference, hormones alone is sufficient to explain the complex set of behaviors which are involved in aggression. ReprintAddress:J.W. Finkelstein, Program in Behavioral Health, E-210 Henderson, University Park, PA 16802.
V O L U M E 17, N U M B E R 1, 1995
JOURNAL OF ADVANCED NURSING
Psychoneuroimmunology and Cancer: An Integrated Review Bauer, S.M. 19(6):1114-1120, 1994. The new field of psychoneuroimmunology (PNI) studies the measurable interaction between psychological and physiological processes. Specifically, PNI is the study of the intricate interaction of consciousness (psycho), central nervous system (neuro), and the body's defence against external infection and abherrant cell division (immunology). Over the last 30 years, the body of knowledge in PNI has emerged and in the last 10 years has flourished. PNI has many implications for clinical nursing practice. This study provides supportive empirical evidence to systems theories, which have played a major role in nursing's attempt to comprehend the interaction between the mind and the body. Nurses are ideal candidates to take a lead in this new field because it reinforces the holistic perspective which is the essence and uniqueness of our discipline. Although a variety of clinical populations have been used in PNI research, the scope of this integrated review will be limited to PNI and cancer. Research studies addressing psychosocial variables' effect on aetiology, response to treatment, immunocompetence and overall survival in the oncology population will be examined. Reprint Address: S.M. Bauer, 520 West Stratford Place, Apartment 209, Chicago, IL 60657. 171-0123
Parents' Experience of Coming to Know the Care of a Chronically I11 Child Jerrett, M.D. 19(6):1050-1056, 1994. The family is the primary source of care for a chronically ill child, and it is the parents who must manage the child's illness on a daily basis. This qualitative study was undertaken to investigate the ways in which 10 two-parent families of children with juvenile arthritis experience their child's illness. In this paper the theme of coming to terms with the management of the illness and what it entails for the parents is examined. The data provide evidence of how the parents learn, and their efforts and experience of learning to care for the child on a daily basis. This is a complex process and includes the different phases the parents experience as they move through the learning process. The findings suggest that the parents learn the child's care and make adjustments to the demands of managing the child's illness in a way that works best for them. Reprint Address: M.D. Jerrett, Queen's University, School of Nursing, 90 Barrio Street, Kingston, ON K7I 3N6, Canada. 171-0124
Serf-Efficacy in Caregivers of Cognitively Impaired Elderly People: A Concept Analysis Mowat, J. and Laschinger, H.K.S. 19(6):1105-1113, 1994. Research with caregivers of cognitively impaired individuals has provided evidence which suggests that most caregivers experience at least some degree of burden. However, it has been postulated that it is the caregiver's subjective interpretation of the situation that is the primary factor responsible for mediating 171-0125
75
the degree of burden experienced. Caregivers who cope well with this type of stress may possess a high level of self-efficacy. The purpose of this paper is to analyze the concept of self-efficacy and its relationship to health care using Walker & Avant's concept analysis methodology. Uses of the concept of self-efficacy, as well as its defining attributes, antecedents, consequences and empirical referents, are discussed. Also, model, borderline, related, contrary and invented cases are constructed to illustrate the concept further. The relevance of the concept to nursing practice and areas requiting future investigation are noted. Reprint Address: J. Mowat, Faculty of Nursing, Health SciencesCentre, The University of Western Ontario, London, ON N6A 5C1, Canada.
171-0126
PreparingChildren and Families Psychologically for Day Surgery: An Evaluation Ellerton, M.-L. and Merriam, C. 19(6):1057-1062, 1994. The increasing use of ambulatory care settings for children's surgery places more responsibility on parents for psychological preparation of children for surgery and for their post-operative care. This paper describes the evaluation of a pre-admission programme to prepare children between the ages of 3 and 15 years and their families psychologically for day surgery. Seventyfive families comprised the study sample, 23 in the programme group and 53 in the non-intervention group. The programme focused on familiarizing families with the physical and procedural components of day surgery through a videotape of a family in a naturally occurring day surgery situation, a tour, and hospital play. Fewer children and parents in the programme group reported high anxiety levels awaiting surgery. Children and parents with previous surgical experience reported higher levels of pre-surgical anxiety than inexperienced families. Families reported the physicians and day surgery nurse as their primary sources of information and rated the day surgery nurse highest in their satisfaction with information received. Implications for practice, particularly for meeting the needs of young children and out-of-town families, are discussed. Reprint Address: M.-L. Ellerton, School of Nursing, Dalhousie University, Halifax, NS B3H 3J5, Canada.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
Cellular Immunity in Depressed, Conduct Disorder, and Normal Adolescents: Role of Adverse Life Events Birmaher, B., Rabin, B.S., Garcia, M.R., et al. 33(5):671-678, 1994. Objective: To determine whether adolescents with major depressive disorder have disturbances in their cellular immunity and to study whether the immunological changes detected are specific to depression or are general responses to stress. Method: Twenty subjects with major depressive disorder, 17 nondepressed subjects with conduct disorder, and 17 normal adolescents were recruited. Subjects were assessed with a clinical in171-0127
76
ANNALS OF BEHAVIORAL MEDICINE
Journal of the American Academy of Child and Adolescent Psychiatry (continued) terview for DMS-III-R and a modified version of the Coddington Life Events Checklist. Blood samples were drawn for total white blood cells, lymphocytes subsets, natural killer cell activity, lymphocyte proliferation response to phytohemagglutinin, and cortisol plasma levels. Results: Overall, there were no significant between-group differences in any of the cellular immune measurements. Natural killer cell activity was significantly negatively correlated with past year and lifetime adverse life events across all effector-target cell ratios. Controlling for diagnoses and socioeconomic status yielded similar results. There were no significant effects of age, sex, race, sleep, nutrition, cigarette use, menstrual cycle, or cortisol on any of the immunological va:~iables. Conclusions: In this sample of adolescents, we found that independent of the diagnoses and socioeconomic status, increases in adverse life events were associated with low natural killer cell activity. Reprint Address: B. Birmaher, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA 15213.
JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
171-1028
Report of a Pilot Study: A Program to Help Major I~ague Baseball Players Quit Using Spit Tobacco Greene, J.C., Walsh, M.M., and Masouredis, C. 125(5):559-568, 1994. There are few reports in the scientific literature that describe tested methods for helping people quit using spit (smokeless) tobacco. This paper reports data from a pilot study to determine the effectiveness of two dental-oriented interventions to promote cessation of ST use among major league baseball players. These preliminary findings suggest that interventions involving an oral examination and advice to quit, combined with behavioral counseling, may effectively decrease ST use among professional baseball players. Reprint Address:J.C. Greene, School of Dentistry, Box 0430, University of California, San Francisco, CA 94143-0430.
171-0129
Perspectives on the Interaction of Biological, Psychological and Social Factors in TMD Dworkin, S.F. 125(7):856-863, 1994. Temporomandibular disorders remain a poorly understood but related collection of clinical syndromes involving pain and function limitations. This article discusses TMD from the perspective of a chronic pain illness, which shares some features found in common chronic pain conditions, such as tension headache and benign back pain. From these perspectives, TMD may be viewed as a self-limiting chronic pain illness not associated with progressive physical deterioration. Reprint Address: S.F. Dworkin, Department of Oral Medicine, SC-63, University of Washington, Seattle, WA 98195.
JOURNAL OF BEHAVIORAL MEDICINE
171-0130
Temperament as a Potential Predictor of Mortality: Evidence from a 41-Year Prospective Study Graves, P.L., Mead, L.A., Wang, N.-Y., Liang, K.-Y, and Klag, M.J. 17(2):111-126, 1994. Psychological factors were hypothesized to influence mortality, in particular, early versus later mortality. To explore the relationship between temperament, a psychological factor, and mortality in a prospective study of 1337 medical students, we constructed a measure portraying three temperament types, using latent class analysis. Death occurred in 113 subjects over 25--41 years of follow-up. In univariate survival analysis, subjects tending to direct tension "inward" when under stress ("Tension-In") had a higher risk of morlality than "TensionOut" or "Stable" types. These associations persisted after adjustment for age, smoking, cholesterol level, and Quetelet Index. The relative risk (RR) of mortality for Tension-in was 1.56 (95% confidence interval, 1.00-2.44) compared with the Stable group. The risk was due entirely to the excess risk in persons under 55 years of age (RR, 2.59; 95% confidence interval, 1.46--4.62); the corresponding risk of death in older persons was 0.66 (0.301.48). Thus temperament is a significant risk factor for mortality, in particular, premature death. Reprint Address: P.L. Graves, The Precursors Study, 550 North Broadway, Room 503, Baltimore, MD 21205.
171-0131
Subtypes of Psychosocial Adjustment to Breast Cancer Nelson, D.V., Friedman, UC., Baer, P.E., Lane, M., and Smith, F.E. 17(2):127-141, 1994. By means of cluster analytic techniques, four subtypes of psychosocial adjustment were identified in a sample of 122 breast cancer patients who completed the Psychosocial Adjustment to Illness Scale. Internal consistency and internal validity of the derived typology were suggested by the finding that two different hierarchical agglomerative clustering methods (average linkage between groups, Ward's) produced similar solutions. Three of the derived subtypes reported normal affect levels but different patterns of relative strengths and dysfunctions, while the fourth subtype appeared to be highly distressed and globally maladjusted. External validation was demonstrated by differentiating the subtypes on variables of negative affect, avoidance coping, and fighting spirit. The clinical and heuristic implications of these findings are discussed. The findings highlight the need for comprehensive assessment ofpsychosocial functioning of cancer patients. They demonstrate that even non-emotionally distressed patients can have very different profiles of adjustment and may benefit from correspondingly individually tailored psychosocial interventions. Reprint Address: D.V. Nelson, Departments of Anesthesiologyand Psychiatry and Behavioral Sciences, The University of Texas--Houston Health Science Center, 6431 Fannin, MSB 5.020, Houston, TX 77030.
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Journal of Behavioral Medicine (continued) 171-0132
Immunity and Depression: Insomnia, Retardation, and Reduction of Natural Killer Cell Activity Cover, H. and Irwin, M. 17(2):217-223, 1994. Depressed patients show a reduction of natural killer (NK) cell activity which may be associated with specific depressive symptoms. The present study demonstrated that sleep disturbance and retardation, but not other depressive symptoms, were negatively correlated with N K activity in 38 depressed patients. Specific behavioral changes in depression such as sleep disturbance and retardation were found to predict 16% of the variance of cytotoxicity levels in depression. Reprint Address:M. Irwin, Department of Psychiatry, 9116-A, VA Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161. 171-0133 Lobel, M.
Conceptualizations, Measurement, and Effects of Prenatal Maternal Stress on Birth Outcomes 17(3):225-272, 1994.
This article analyzes the conceptual and methodological approaches which have been used to investigate effects of prenatal maternal stress on birth outcomes and highlights the major findings of this research. By viewing the most widely used operational definitions of prenatal stress in a broader theoretical framework, it can be seen that most studies have failed to conceptualize stress reliably. This, in addition to common methodological and design flaws which are described in the article, has produced equivocal findings about the role of stress in adverse birth outcomes such as preterm delivery and low birth weight. Recent studies using more powerful, multidimensional approaches to stress definition and measurement provide more definitive evidence and suggest some precise effects. Implications and strategies for future research are presented. Reprint Address: M. Lobel, Department of Psychology, SUNY, Stony Brook, NY 11794-2500. 171-0134
Evaluation of a Home-Based Intervention Program to Reduce Infant Passive Smoking and Lower Respiratory Illness
Greenberg, R.A., Strecher, V.J., Bauman, K.E., et al. 17(3):273-290, 1994. We conducted a randomized controlled trial to determine whether a home-based intervention program could reduce infant passive smoking and lower respiratory illness. The intervention consisted of four nurse home visits during the first 6 months of life, designed to assist families to reduce the infant's exposure to tobacco smoke. Among the 121 infants of smoking mothers who completed the study, there was a significant difference in trend over the year between the intervention and the control groups in the amount of exposure to tobacco smoke; infants in the intervention group were exposed to 5.9 fewer cigarettes per day at 12 months. There was no group difference in infant urine cotinine excretion. The prevalence of persistent lower respiratory symptoms was lower among intervention-group infants of smoking mothers whose head of household had no education beyond high school: intervention group, 14.6%, and controls, 34.0%. Reprint Address: R.A. Greenberg, Department of Pediatrics, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112.
171-0135
Personal Models of Osteoarthritis and Their Relation to Serf-Management Activities and Quality of Life Hampson, S.E., Glasgow, R.E., and Zeiss, A.M. 17(2):143-158, 1994. We examined the personal models of osteoarthritis (OA) of 61 patients over 60 years of age. Models were elicited using a structured interview. Shared beliefs included perceiving OA as a serious, painful, chronic, and incurable condition that can be managed by recommended medical treatment. Considerable individual differences were found on six personal-model constructs: Symptoms, Seriousness, Cause, Control, Helpfulness of Treatment, and Negative Feelings about Treatment. The constructs of Symptoms and Seriousness were consistently related to a variety of important outcomes. For example, participants with higher scores on Symptoms and Seriousness reported higher levels of self-management (both concurrently and prospectively), reported more utilization of medical services, and experienced a poorer quality of life. The implications for the design of health-education materials and for patient-provider interactions are discussed. Reprint Address: S.E. Hampson, Oregon Research Institute, 1899 Willamette Street, Eugene, OR 97401.
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Cultural Diversity in Causal Attributions for Illness: The Role of the Supernatural Landrine, H. and Klonoff, E.A. 17(2):181-193, 1994. We investigated cultural diversity in beliefs about the causes of illness and assessed the possibility that popular free-form methodologies (asking subjects to generate causes) inhibit minorities from expressing their belief in supernatural causes. As predicted, when asked to generate causes of illness and rate these in terms of their importance, Whites and minorities did not differ in the number or type (natural vs supernatural) of causes they generated or in the importance rating they assigned to these. However, when these same subjects were provided with natural and supernatural causes to rate in terms of importance, minorities rated supernatural causes significantly more important than did Whites, and more minorities than Whites endorsed such causes. Cultural differences in causal attributions for illness are examined, and the role of methodology in determining such attributions is highlighted. Reprint Address: H. I.andrine, Public Health Foundation, 13200 Crossroads Parkway, North, Suite 135, City of Industry, CA 91747. Testing the Generulizability of Intervening Mechanism Theories: Understanding the Effects of Adolescent Drug Use Prevention Interventions Donaldson, S.I., Graham, J.W., and Hanson, W.B. 17(2): 195-216, 1994. Outcome research has shown that drug prevention programs based on theories of social influence often prevent the onset of adolescent drug use. However, little is known empirically about the processes through which they have their effects. The purpose of the present study was to evaluate intervening mechanism theories of two program models for preventing the onset of adolescent drug use. Analyses based on a total of 3077 fifth graders participating in the Adolescent Alcohol Prevention 171-0137
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Journal of Behavioral Medicine (continued) Trial revealed that both normative education and resistance training activated the causal processes they targeted. While beliefs about prevalence and acceptability significantly mediated the effects of normative education on subsequent adolescent drug use, resistance skills did not significantly predict subsequent drug use. More impressively, this pattern of results was virtually the same across sex, etlmicity, context (public versus private school students), drugs (alcohol, cigarettes, and marijuana) and levels of risk and was durable across time. These findings strongly suggest that successful social influence-based prevention programs may be driven primarily by their ability to foster social norms that reduce an adolescent's social motivation to begin using alcohol, cigarettes, and marijuana. Reprint Address: S.I. Donaldson, USC Institute for Health Promotion and Disease Prevention Research, 1000 South Fremont Avenue, Suite 641, Alhambra, CA 91803-1358.
171-0138
The Effect of Instructions on Cognitive Strategies and Performance in Biofeedback Utz, S.W. 17(3):291-308, 1994. An experimental study was conducted in which 40 subjects, randomly assigned to four groups, were given differing instructions about using auditory biofeedback to lower forehead muscle tension. During each of three sessions, measures were taken of forehead electromyograph (EMG) and ability to discriminate and control muscle tension in order to measure learning during biofeedback. Cognitive strategies used by subjects were measured by taped verbal reports which were judged using four criteria based on two models of learning in biofeedback: "feedforward" and "feedback." Data were analyzed by chi-square, ANOVA, ANCOVA, and content analysis. Results indicate that subjects used predominantly a feedforward type of learning strategy in all four groups. Implications for teaching during biofeedback are discussed. Reprint Address: S.W. Utz, University of Virginia School of Nursing, McLeod Hall, Charlottesville, VA 22903-3395.
171-0139
Maintenance and Generalizability of Laboratory-Based Heart Rate Reactivity Control Training Sharpley, C.F. 17(3):309-329, 1994. The maintenance over time (4 months) and generalizability (to a work setting) of laboratory-based heart rate reactivity control training was investigated. Forty-three subjects received 5 weeks of biofeedback, imagery, and breathing training and 41 subjects acted as controls. Although there were no significant differences between the reactivities of the control and those of the treatment subjects at any of three pretraining tests, significant differences were noted immediately following training, 7 weeks, and 4 months later, showing maintenance effects. Data collected during work activities on the frequency of reactivity of a magnitude similar to that in the laboratory also showed that treatment subjects had significantly fewer incidents of reactivity than control subjects after training. Followup interviews with treatment subjects indicated that lifestyles were also en-
hanced in a variety of areas, suggesting that the training had wider benefits. Issues for further research are discussed. Reprint Address: C.F. Sharpley, Centre for Stress Management and Research, Faculty of Education-SGS, Monash University, Clayton, VIC 3168, Australia.
171-0140
Cultural Diversity in the Predictors of Adolescent Cigarette Smoking: The Relative Influence of Peers Landrine, H., Richardson, J.L., Klonoff, E.A., and Flay, B. 17(3):331-346, 1994. A culturally diverse sample of 4375 adolescents completed a self-report inventory assessing their current amount of smoking, and several psychosocial predictors of smoking (e.g., depression, anger, stress, smoking among peers, etc). Results revealed that Whites smoke more than Blacks, Asians, and less acculturated Latinos but not more than highly acculturated Latinos. Stepwise regression analyses of the predictors of smoking found significant ethnic and acculturation differences in the relative predictive power of 18 well-known risk factors. Smoking among peers was the best predictor of smoking for White adolescents (accounting for 23.5% of the variance) but accounted for only 15% of the variance for Latino youth, 9.6% of the variance for Asian youth, and none of the variance for Black youth. Results are discussed in terms of their implications for smoking prevention programs that focus on resisting peer influences. Reprint Address: H. Landrine, Public Health Foundation, 13200 Crossroads Parkway North, Suite 135, City of Industry, CA 91746.
JOURNAL OF CLINICAL EPIDEMIOLOGY
171-0141
A Randomized Trial of Low Fat High Fibre Diet in the Recurrence of Colorectal Polyps McKeown-Eyssen, G.E., Bright-See, E., Bruce, W.R., Jazmaji, V., and The Toronto Polyp Prevention Group 47(5):525-536, 1994. After polypectomy for adenomatous colorectal polyps, 201 persons were randomized to receive counseling on a diet low in fat (the lesser of 50 g/day or 20% of energy) and high in fibre (50 g/day) (LFHF), or to follow a normal western diet (ND), high in fat and low in fibre. After 12 months of counseling, fat consumption was about 25% of energy in the LFHF group and 33% in the ND group; fibre consumption was 35 g and 16 g respectively. After an average of two years of follow-up, an intention to treat analysis led to a ratio of cumulative incidence rates of 1.2 (95% CL 0.6-2.2) for recurrence of neoplastic polyps, a finding which suggest no significant difference between dietary groups over the period of observation. An exploratory analysis conducted among 142 persons with substantial diet counselling indicated a reduced risk of neoplastic polyp recurrence in women (RR = 0.5), associated with reduced concentrations of faecal bile acids while on the LFHF diet, but indicated an increased risk of recurrence in men (RR = 2.1), associated with increased
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Journal of Clinical Epidemiology (continued) faecal bile acids. Although a larger study would be needed to rule out the role of chance, these findings of gender-specific associations between diet counselling and both faecal bile acid concentrations and recurrence of colorectal neoplasia are consistent with recently published evidence of differences between genders. Reprint Address: G.E. MeKeown-Eyssen, Department of Preventive Medicine and Biostatistics, University of Toronto, 12 Queen's Park Crescent, West, Toronto, ON M5S 1A8, Canada.
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
Four-Year Cross-Lagged Associations between Physical and Mental Health in the Medical Outcomes Study Hays, R.D., Marshall, G.N., Wang, E.Y.I., and Sherbourne, C.D. 62(3):441-449, 1994. This article provides an application of structural equation modeling to the evaluation of cross-lagged panel models. Selfreports of physical and mental health at 3 different time points spanning a 4-year interval were analyzed to illustrate the crosslagged analysis methodology. Data were collected from a sample of 856 patients with hypertension, diabetes, heart disease, or depression (or any combination of these) participating in the Medical Outcomes Study. Cross-lagged analyses of physical and mental health constructs revealed substantial stability effects across time. A structural model with standard effects revealed positive effects of physical health on mental health but negative (suppression) effects of mental health on physical health. The effects of mental health on physical health became nonsignificant when the model was revised by adding nonstandard effects (direct effects of measured variable residuals on latent variables). Recommendations for structural equation modeling of crosslagged panel data are provided. Reprint Address: R.D. Hays, Social Policy Department, RAND, 1700 Main Street, Santa Monica, CA 90407-2138.
iological index of metabolic control. These results were partially replicated in a private practice sample where conflict was significantly related to parents' ratings of adherence and to metabolic control. Conflict accounted for unique variance in diabetes outcome beyond that associated with other measures of the parent-child relationship, but the relation between conflict and metabolic control was no longer significant when adherence ratings were entered into regression equations first. Reprint Address: R.E. Emery, Department of Psychology,Gilmer Hall, University of Virginia, Charlottesville, VA 22903.
JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH
171-0142
171-0143
Parent-Child Relationships and the Management of Insulin-Dependent Diabetes Mellitus Miller-Johnson, S., Emery, R.E., Marvin, R.S., et al. 62(3):603--610, 1994. Several dimensions of parent-child relationships were examined as predictors of adherence to treatment and metabolic control in a multi-informant study of 88 children and adolescents with insulin-dependent diabetes meUitus who were recruited from 2 endocrinology clinics. Ratings of parent--child discipline, warmth, and behavioral support were not significantly associated with diabetes outcome, but parent-child conflict was a consistent correlate of both adherence and metabolic control. Within a public hospital subsample, conflict was related to parent, child, and nurse ratings of adherence and to a phys-
171-0144
Coronary Heart Disease: Prevalence and Dietary Sugars in Scotland Bolton-Smith, C. and Woodward, M. 48(2):119-122, 1994. Study objective--The aim was to investigate the effects of dietary intakes of different types of sugars (extrinsic, intrinsic, and lactose) and the dietary fat to sugar ratio on prevalent corunary heart disease (CHD). Design--This was a baseline cross sectional survey of CHD risk factors. Setting--Twenty two Scottish health districts were surveyed between 1984 and t986. Participants -- A total of 10,359 men and women aged 40-59 years were screened as part of the Scottish Heart Health Study, and a further 1267 men and women aged 25-39 and 60-64 years were screened as part of the Scottish MONICA (monitoting trends and determinants in cardiovascular disease) Study. The response rates were 74% and 64% respectively. Methods-Subjects completed a questionnaire which included sociodemographic, health, and food frequency information. Medical history, response to the Rose chest pain questionnaire, and results ofa 12 lead ECG recording were used to categorise subjects into CHD diagnosed, previously CHD undiagnosed, or no CHD groups. The X2 statistic was used to determine whether the CHD groups differed in their sugar consumption, and multiple logistic regression analysis, with adjustment for other potential coronary risk factors, was used to calculate odds ratios for prevalent CHD by intake fifths of dietary sugars. Main results--Men, but not women, differed in their sugar consumption by CHD group. The odds ratios showed a tendency for a U shaped relationship for extrinsic sugar intake with CHD prevalence, but no significant effect of the fat to sugar ratio (possible marker of obesity) on CHD was seen. Conclusions--The results suggest that neither extrinsic sugar, intrinsic sugar, nor the fat to sugar ratio are significant independent predictors of prevalent CHD in the Scotfish population, when the other major risk factors such as cigarette smoking, blood cholesterol concentration, and antioxidant vitamins intake are accounted for. These new data for different sugar types agree with the consensus view that total sugar intake is not a major marker of coronary heart disease. Reprint Address: C. BoRon-Smith,Cardiovascular EpidemiologyUnit, University of Dtmdee, NineweUsHospital and Medical School,Dundee DDI 9SY, UK.
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Journal of Epidemiology and Community Health (continued) 171-0145
Acute Myocardial Infarction: Association with Time Since Stopping Smoking in Italy Negri, E., La Vecchia, C., D'Avanzo, B., Nobili, A., and La Malfa, R.G. 48(2):129-133, 1994. Study objective--The study aimed to investigate the relationship between years since stopping smoking and the risk of acute myocardial infarction. Design--This was a hospital based, multicentre, case-control study conducted in Italy between September 1988 and June 1989 within the framework of the GISSI-2 clinical trial. Setting--Over 80 coronary care units in various Italian regions participated. Subjects-A total of 916 incident cases of acute myocardial infarction, below age 75 years, and with no history of ischaemic heart disease, and 1106 control subjects admitted to the same hospitals for acute, non-neoplastic, cardiovascular or cerebrovascular conditions that were not known or suspected to be related to cigarette smoking took part in the study. Main outcome measures and results--Measures were relative risk (RR) estimates of acute myocardial infarction according to the time since stopping smoking and adjusted for identified potential confounding factors. Compared with never smokers, the multivariate RRs were 1.6 (95% confidence interval (CI) 0.8, 3.2) for subjects who had given up smoking for one year; 1.4 (95% CI 0.9, 2.1) for those who had stopped for two to five years; 1.2 (95% CI 0.7, 2.1) for six to l0 years; and l.l (95% CI 0.8, 1.8) for those who had not smoked for over 10 years. The estimated RR for current smokers was 2.9 (95% CI 2.2, 3.9). The risks of quitters were higher for heavier smokers and those below age 50 years, while no difference emerged in relation to the duration of smoking, sex, and other risk factors for myocardial infarction. Conclusions--These results indicate that there is already a substantial drop in the risk of acute myocardial infarction one year after stopping. The risk in exsmokers, however, seemed higher (although not significantly) than that of those who had never smoked, even more than l 0 years after quitting. This could support the existence of at least two mechanisms linking cigarette smoking with acute myocardial infarction--one involving thrombogcncsis or spasms that occur over the short term, and another involving atherosclerosis that is a long term effect. Reprint Address: E. Negri, lstituto di Ricerche Farmacologiche Mario Negri, Via Eritrea 62, 20157-Milano, Italy. 171-0146
Aetiology of Peptic Ulcer: A Prospective Population Study in Norway Johnsen, R., Forde, O.H., Stranme, B., and Burhol, P.G. 48(2): 156-160, 1994. Study objective--To analyse simultaneously the effect of several risk factors for peptic ulcer. Design--Cohort study where all patients with new or incident peptic ulcers in a well defined population were registered for a seven year period. The follow up started with a comprehensive health survey including a questionnaire on diet, lifestyle, psychological and social conditions, and health. Relative risks, both sex specific and separate, for gastric and duodenal ulcers were estimated from proportional hazard regression analysis. Setting--A population based survey conducted in the municipality of Tromso, northern Norway. Participants--In 1980, a total of 21,440 men and women, aged 20 to 54 years and 20 to 49 years respectively, were invited to participate. A total of 14,667 people attended and returned the
questionnaire. Main results--A total of 328 people had their first peptic ulcer in the follow up period. Age, cigarette smoking, first degree relatives with peptic ulcer, and low educational level were shared risk factors for peptic ulcer in both men and women. In men, frequent upper respiratory infections increased the risk of gastric ulcer and drinking a great deal of milk increased the risk of duodenal ulcer. None of the other dietary variables, including coffee and alcohol consumption, contributed significantly to the risk. Use of analgesics was not a risk factor, and none of the psychological indicators analysed carried any significant risk. Conclusions--Age, inheritance, and cigarette smoking are all important risk factors for peptic ulcer. The increased risk associated with low educational background indicate that social strains, comprising lifestyle and diet habits, are part of the multifactorial aetiology of peptic ulcer. No support was found for the assumption that peptic ulcer disease is a psychosomatic disorder. This study did not support the view that duodenal and gastric ulcers have different aetiologies-rather it showed a similarity in risk patterns. Reprint Address: R. Johnsen, Institute of Community Medicine, University of Tromso, N-9037 Tromso, Norway.
JOURNALS OF GERONTOLOGY
171-0147
Age Differences and Changes in Reaction Time: The Baltimore Longitudinal Study of Aging Fozard, J.L., Vercruyssen, M., Reynolds, S.L., Hancock, P.A., and Quilter, R.E. 49(4):P179-PI89, 1994. This study analyzed auditory reaction time (RT) data from 1,265 community-dwelling volunteers (833 males and 432 females) who ranged in age from 17 to 96. Cross-sectional analyses revealed slowing of simple (SRT) and relatively greater slowing of disjunctive (DRT; aka "go-no-go") reaction time across decades for both males and females. Repeated testing within participants (longitudinal analyses) over eight years showed consistent slowing and increased variability with age. Males were faster than females across age groups, RT tasks, and visits. Beginning at about age 20, RTs increased at a rate of approximately 0.5 msec/yr for SRT and 1.6 msec/yr for DRT. Errors also increased, making unlikely a tradeoff of accuracy for faster responses. The findings are consistent with the hypotheses that slowing of behavior is: (a) a continuous process over the adult life span; Co)characterized by age-associated increases in withinparticipant variability; (c) a direct function of task complexity and, presumably, the degree of mediation by higher regions in the central nervous system; and (d) greater in women than men. 171-0148
Physical Function and Social Class among Swedish Oldest Old Parker, M.G., Thorslund, M., and Lundberg, O. 49(4):S196-$201, 1994. The relationship between physical ability and social class in later life was explored through an interview survey conducted on a nationally representative sample of persons aged 77-98
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Journals of Gerontology (continued) (N = 537). Physical ability was measured with activities of daily living, an index of mobility, and performance tests. Social class was measured according to previous occupation. Physical function was found to be correlated with social class, that is, former white-collar workers had better function than blue-collar workers. The differences were significant for all three measures of physical function.
171-0149
Fear of Falling and Fall-Related Efficacy in Relationship to Functioning among CommunityLiving Elders Tinetti, M.E., Mendes de Leon, C.F., Doucette, J.T., and Baker, D.I. 49(3):M140-M147, 1994. Background. The relationships of fear of falling and fallrelated efficacy with measures of basic and instrumental activities of daily living (ADL-IADL) and physical and social functioning were evaluated in a cohort of community-living elderly persons. Methods. Sociodemographic, medical, psychological, and physical performance (e.g., gait speed, timed hand function) measures were administered, during an in-home assessment, to a probability sample of 1,103 residents of New Haven, Connecticut, who were >72 years of age. Falls and injuries in the past year, fear of falling, and responses to the Falls Efficacy Scale were also ascertained. The three dependent variables included a 1G-item ADL-IADL scale, an 8-item social activity scale, and a scale of relative physical activity level. Results. Among cohort members, 57% denied fear of falling whereas 24% acknowledged fear but denied effect on activity; 19% acknowledged avoiding activities because of fear of falling. Twenty-four percent of recent railers vs 15% of nonfallers acknowledged this activity restriction (x 2 = 13.1; p < .001). Mean fall-related efficacy score among the cohort was 84.9 (SD 20.5), 79.8 (SD 23.4), and 88.1 (SD 17.9) among fallers and nonfallers, respectively (p -< .0001). Fall-related efficacy proved a potent independent correlate of ADL-IADL (partial correlation = .265,p < .001); physical (partial correlation = .234, p < .00 I); and social (partial correlation = .088, p < .01), functioning in multiple regression models after adjusting for sociodemographic, medical, psychological, and physical performance covariates as well as history of recent fails and injuries. Fear of falling was only marginally related (p = .05) with ADL-IADL functioning and was not associated with higher level physical or social functioning. Conclusions. The strong independent association between self-efficacy and function found in this study suggests that clinical programs in areas such as prevention, geriatric evaluation and management, and rehabilitation should attempt simultaneously to improve physical skills and confidence. Available knowledge of the factors influencing efficacy should guide the development of these efficacy-building programs.
171-0150
The Validity of Survey Data on Utilization of Health and Social Services among the Very Old Carsj~, K., Thorslund, M., and W~irneryd, B. 49(3):S156--S164, 1994. Survey responses to questions regarding utilization of health and social services among very old persons were compared to
independently registered utilization records. Survey data came from in-person interviews with a sample ofnoninstitutionalized 75-84-year-olds and all noninstitutionalized individuals over the age of 84 in a Swedish community. Agreement regarding utilization vs no utilization during the past three months was found to be very high for hospitalizations and home help, somewhat lower for home visits by nurses, and lower yet for visits to physicians and to nurses. Except for visits to nurses, aggregate survey estimates of proportion with utilization were not significantly different from those based on records. Reporting patterns were generally in agreement with predictions made on the basis of frequency and saliency of service utilization. Reasons for over- and underreporting were investigated on the basis of register data, and some evidence for telescoping was observed.
JOURNAL OF OCCUPATIONAL REHABILITATION
171-0151
Back Injury Prevention Programs: A Critical Review of the Literature King, P.M. 3(3):145-158, 1993. Back schools are increasingly utilized as an injury prevention strategy employed at the worksite. Yet, evidence of the efficacy of back schools is limited and controversial. A review of the literature showed variance in methodologies and consequently, outcomes. Outcome measures used include physical capacity, functional abilities, costs, lost time, absenteeism, perception of pain, lifting performance, attitudes, and job satisfaction. In many studies, lack of randomization and control was found to be a limitation in experimental design. Studies which used the behavioral approach of measuring lifting behavior lacked followup and evidence of long-term effects. The type of education and feedback or reinforcement was an important issue not well-defined in the literature. A variety of hypothetical mechanisms were described as contributing to the outcome of back injury prevention programs. Additional controlled research is necessary to determine the specific mechanisms of change in an effort to further improve outcome in this area. ReprintAddress:P.M. King, Oeculmtional Therapy Program, University of Wisconsin, P.O. Box 413, Milwaukee, WI 53130.
171-0152
Factors Contributing to Job Satisfaction following Rehabilitation for Musculoskeletal Impairments Schmidt, S.H., Meijman, T.F., Scholten, A., van Oel, C.J., and Oort-Marburger, D. 3(4):213-222, 1993. The study investigates whether changing jobs is related to work-related well-being of people with musculoskeletal impairments. In order to assess this relationship subjects who began new jobs after rehabilitation (N = 52) were compared with subjects who returned to their former employment (N = 63). Work-related well-being was measured by means of the scales
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Journal of Occupational Rehabilitation (continued) "job satisfaction" and "need to recover after work." After controlling for individual characteristics (gender, age, working hours per week, and pain complaints) and job characteristics (job demands and decision latitude), job satisfaction could be predicted by job change. Recover need after work was predicted by pain complaints, job demands, and decision latitude, but not by job change. Reprint Address: S.H. Sclamidl,Institute of Social Medicine, Faculty of Medicine, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands. 171-0153
The Role of the Supervisor in Successful Adjustment to Work with a Disabling Condition: Issues for Disability Policy and Practice Gates, L.B. 3(4):179-190, 1993. Results from an investigation of the role of supervisors in the process of adjusting to work with a disabling condition are presented. Workers with disabling conditions were interviewed about the responsiveness of their workplaces to their needs. Analyses showed that successful adjustment to work was related to the ability to complete job requirements, get along with others at work, see a future at work and feel good about work. Many supervisory behaviors were associated with these factors ineluding the extent to which supervisors treat workers fairly, allow workers to participate in decisions related to their work and utilize the workers' skills. Implications for the development of workplace policy and disability management efforts are discussed. Reprint Address: L.B. Gates, Center for Social Policy and Practice in the Workplace, Columbia University School of Social Work, 622 West 113th Street, New York, NY 10025.
171-0154
Factors Influencing the Cost of Workers' Compensation Claims: The Effects of Settlement Method, Injury Characteristics, and Demographics Wood, G.A., Morrison, D.L., and Macdonald, S. 3(4):201-211, 1993. This paper estimates an empirical model of the total costs of fmalised workers' compensation claims. The sample was comprised of 8232 claims, made by workers in Western Australia, that were closed in 1990. It is reported that the variables representing the method of claim settlement is an important determinant of the cost of individual workers' compensation claims. In addition, it is also found that type of injury, gender, age, and occupational classification have significant effects on the model. Workers who, sustain musculoskeletal injuries, are male, and/or who are white collar workers incur significantly more costs. In addition to these effects, a positive linear relationship between age and costs was also observed. The empirical models, of the kind specified in this paper, may be capable of performing a useful prescriptive role in rehabilitation programs. Such models can enable "problematic'" cases to be identified early in the claim process, so that they might be appropriately referred for intensive rehabilitation intervention. Reprint Address: G.A. Wood, School of Economies and Commerce, Murdoch University, WA 6150, Australia.
JOURNAL OF PAIN AND SYMPTOM MANAGEMENT
171-0155 The Experience of Chronic Nonmalignant Pain Hitchcock, L.S., FerreU, B.R., and McCaffery, M. 9(5):312-318, 1994. This article reports the results of a survey of 204 persons with chronic nonmalignant pain who were members of a national self-help organization. The survey evaluated the organization, explored the perceived effect of pain on quality of life, and assessed experiences with and perceptions of health-care providers. Response rate was 40%. Of survey respondents, 50% reported inadequate pain relief. Respondents identified depression as one of the worst problems caused by their chronic pain: 50% reported that they had considered suicide due to feelings of hopelessness associated with their pain, 51% reported taking only as much medication as prescribed, and 44% reported taking less medication than prescribed. Further investigation is needed to describe the personal impact of chronic nonmalignant pain. Reprint Address: L.S. Hitchcock, The National Chronic Pain Outreach Association, 7979 Old Georgetown Road, Suite 100, Bethesda, MD 20814-2429. 171-0156 Depression and Suicide in Patients with Cancer Massie, M.J., Gagnon, P., and Holland, J.C. 9(5):325-340, 1994. Depression is a prevalent psychiatric syndrome in the cancer population. We review ~ e spectrum of conditions in which depressive features are present, from normal responses to crises in cancer to depression secondary to organic causes. The different modalities of treatment, including pharmacologic, psychotherapeutic and social interventions, are described. Specific guidelines for the management of the suicidal cancer patient are given and physician-assisted death is discussed. Reprint Address: M.J. Massie, Psychiatry Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021.
JOURNAL OF SEX RESEARCH
171-0157
Understanding Hysterectomies: Sexual Satisfaction and Quality of Life Darling, C.A. and McKoy-Smith, Y.M. 30(4):324-335, 1993. Because a hysterectomy is one of the more frequently performed surgical procedures in the U.S., we used a causal model to study those women who had and had not experienced a hysterectomy. Using family stress theory, we examined the quality of life of these two groups of women as it was related to physiological and psychological health stressors, family stress, resources, meaning of the stressors, and the perceived sexual satisfaction. A survey research design was employed with a national random sample of women (N = 346) between the ages
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Journal of Sex Research (continued) of 45 and 60 who were members of an association of collegeeducated women. Research instruments included the Family Inventory of Life Events and Changes Scale, Women's Health Questionnaire, Family Crisis Oriented Personal Evaluation Scale, Index of Sexual Satisfaction, and Generalized Life Contentment Scale. There was no significant difference in the quality of life of those women who had and had not experienced a hysterectomy, but women who had a hysterectomy perceived greater sexual satisfaction than those who had not experienced a hysterectomy. For those women who had experienced a hysterectomy, the proposed model indicated that psychological health stress, family stress, and the meaning of the stressors had the greatest total association with the quality of life. The greatest total relationships to quality of life for those women who had not experienced a hysterectomy were psychological and physiological health stressors, but not family stress. An important implication of this investigation is the need to understand further the role of physiological and psychological health stressors, as well as family stress, in the lives of women. Reprint Address: C.A. Darling, Department of Family and Child Sciences, The Florida State University, Tallahassee, FL 32306-2033.
171-0158
Sexual Identity and HIV: The Mule Prostitute
Boles, J. and Elifson, K.W. 31(1):39-46, 1994. We e~amined the relationships among sexual self-identity, sexual and drug use behaviors, and human immunodeficiency virus (HIV) infection among a sample of 224 male street prostitutes. Structured interviews were administered, and blood samples were collected and tested for HIV, syphilis, and hepatitis B. The sample included 17.9% homosexual, 46.4% heterosexual, and 35.7% bisexually identified men. Congruence between the prostitutes' non-paid sexual behavior and their sexual self-identification were closest for the heterosexual and homosexual identified men. The significant demographic and occupational differences between the prostitutes in each sexual self-identity category included education, history of physical abuse, homelessness, and geographical mobility. Based on selfidentification, the rate of HIV infection was 50% for the homosexuals, 36.5% for the bisexuals, and 18.5% for the heterosexuals. The differences in HIV infection rates between the men of each sexual self-identity category were significantly related to self-reported receptive anal sex, number of non-paid sexual partners, cocaine use, injection drug use, acquaintance with a person with AIDS, history of syphilis, and history of hepatitis. Sexual self-identity was not a significant predictor of HIV serostatus. Reprint Address: J. Boles, Georgia State University, Department of Sociology, University Plaza, Atlanta, GA 30303.
171-0159
Unprotected Anal Intercourse in HIV-lnfected and Non-HIV-Infected Gay Men
Gold, R.S., Skinner, M.J., and Ross, M.W. 31(1):59-77, 1994. In 1990, gay men (N = 296) in Sydney, Australia, were asked to recall two sexual encounters from the preceding yea~. one in which they had unprotected anal intercourse ("unsafe" encounter) and one in which they had resisted a strong temptation to have unprotected intercourse ("safe" encounter). The
alms were to record self-justifications for unprotected intercourse used in the unsafe encounter and to identify situational factors distinguishing between the encounters. Among men who had been HIV infected at the time of the unsafe encounter (n = 88), the most common self-justification had been the thought that they had nothing more to lose; among uninfected men (n = 207), it had been a resolution to have intercourse without ejaculation. The first factor emerging from a factor analysis of the infected group's self-justifications involved reactions to a negative mood state; in the uninfected group it involved inferring from perceptible characteristics that the partner was unlikely to be infected. Some variables (e.g., closeness of the relationship to the partner, mood, communication, and use of "dirty talk") distinguished between the unsafe and safe encounters equally among those who had been infected in both encounters (n ffi 76) and those who had been uninfected in both (n = 170). Other variables (knowledge that unprotected intercourse is a high risk activity, drug use, use of pornography, and condom availability) did not distinguish between the encounters in either group. Desire to seek adventure and excitement through sex distinguished between the encounters only in the infected group, and level of intoxication did so only in the uninfected group. Results are discussed in relation to those obtained in our earlier studies of gay men in Melbourne; we also discuss how such data might be put to use in AIDS education programs for gay men. Reprint Address: R.S. Gold, School of Psychology, Deakin University (Rusden Campus), 662 Blackburn Road, Clayton, VIC 3168, Australia.
171-0160
Urban Hispanic Adolescents and Young Adults: Relationship of Acculturation to Sexual Behavior
Ford, IC and Norris, A.E. 30(4):316-323, 1993. As Hispanic persons in the U.S. are exposed to U.S. culture, changes may occur in values, attitudes, and behavior. This process of change has been called acculturation. The objectives of this research were to describe the sexual behavior of low income, urban Hispanic youth in Detroit and to evaluate the relationship of acculturation to sexual behavior. Data were drawn from a household probability sample of 711 low income, urban youth. The relationship of acculturation to sexual activity, types of intercourse, number and ethnicity ofparmers, condom use, and use of other methods were estimated for never married men and women. Level of acculturation was associated with sexual behavior. Specifically, women with high acculturation were much more likely to have had at least one sexual partner in the last year, to have non-Hispanic partners, to have oral and anal sex, and to have used condoms. For men, high acculturation was positively associated with oral sex and having non-Hispanic partners. Use of contraceptive methods other than condoms was not related to acculturation for either gender. For women, the strong association of acculturation with sexual activity in the last year increased women's exposure to health risks, sexually transmitted diseases, and unplanned pregnancy, although increased condom use may have reduced these risks. Reprint Address: IC Ford, Department of Population Planning and In. temational Health, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029.
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Journal of Sex Research (continued) Sexual and Substance Use Acts of Gay and Bisexual Male Adolescents in New York City Rotheram-Borus, M.J., Rosario, M., Meyer-Bahlburg, H.F.L., et al. 31(1):47-57, 1994. Lifetime and current sexual and substance use behaviors were examined among 131 predominantly Hispanic and Black gay and bisexual adolescent males in New York City. Many youths engaged in anal sex with males (80%), and 22% bartered sex for money or drugs. Condom use with male partners typically was initiated one year after a youth became sexually active, was more common with male than female partners, and was more common with anal than with oral sex. Condoms with male partners were never or inconsistently used by 52% of youths. Youths reported high rates of lifetime alcohol (76%), marijuana (42%), and cocaine/crack (25%) use; none reported intravenous drug use. Current alcohol and drug use was significantly related to sexual risk acts. These findings indicate that HIV-prevention programs for homosexual and bisexual male youths are critical and must address sex with females, inconsistent condom use, and sexual practices while under the influence of drugs and alcohol. Reprint Address: M.J. Rotheram-Borus, Division of Child Psychiatry, Columbia University, 722 West 168 Street, Unit 29, New York, NY 10032. 171-0161
THE LANCET
Mediterranean Alpha-Linolenic Acid-Rich Diet in Secondary Prevention of Coronary Heart Disease de Lorgeril, M., Renaud, S., Mamelle, N., et at. 343:1454--1459, 1994. In a prospective, randomised single-blinded secondary prevention trial we compared the effect of a Mediterranean alphalinolenic acid-rich diet to the usual post-infarct prudent diet. After a first myocardial infarction, patients were randomly assigned to the experimental (n = 302) or control group (n = 303). Patients were seen again 8 weeks after randomisation, and each year for 5 years. The experimental group consumed significantly less lipids, saturated fat, cholesterol, and linoleic acid but more oleic and alpha-linolenic acids confirmed by measurements in plasma. Serum lipids, blood pressure, and body mass index remained similar in the 2 groups. In the experimental group, plasma levels of albumin, vitamin E, and vitamin C were increased, and granulocyte count decreased. After a mean follow up of 27 months, there were 16 cardiac deaths in the control and 3 in the experimental group; 17 non-fatal myocardial infarctions in the control and 5 in the experimental groups: a risk ratio for these two main endpoints combined of 0.27 (95% CI 0.12-0.59, p = 0.001) after adjustment for prognostic variables. Overall mortality was 20 in the control, 8 in the experimental group, an adjusted risk ratio of 0.30 (95% CI 0.11-0.82, p = 0.02). An alpha-linolenic acid-rich Mediterranean diet seems to
be more efficient than presently used diets in the secondary prevention of coronary events and death. ReprintAddress: M. de Lorgeril, The Lyon Diet Heart Study, INSERM, Units 63, 22 avenue Doyen IApine, CP 18, 69675 Bron Cedex, France. Fatty Acid Composition of Erythrocytes and Plasma Triglyceride and Cardiovascular Risk in Asian Diabetic Patients Peterson, D.B., Fisher, K., Carter, R.D., and Mann, J. 343:1528-1530, 1994. 171-0163
The excess of coronary heart disease in Indian Asians compared with Europeans is unexplained by conventional risk factors, although the high prevalence of diabetes may play a part. To explore the contribution of diet we compared the fatty acid composition of erythrocyte membrane phospholipid and plasma trigiyceride in 36 Gujarati Asians and 24 Europeans with noninsulin-dependent diabetes. Erythrocytes from Asian subjects contained higher proportions of linoleic, dihomogammalinolenic, and arachidonic acids, and lower proportions of oleic and n-3 series fatty acids; triglycerides contained higher linoleic and lower oleic acid levels. For example, mean percentage (SE) of oleic acid (18:1 n-9) in erythrocytes was 16.7 (0.2) in Asians and 20.5 (0.6) in Europeans (p = 0.0001), and total n-6:n-3 ratio was, respectively, 12.8 (0.7) and 6.7 (0.7) (p = 0.0001). A high dietary intake oflinoleic acid may not be cardioprotective unless balanced by significant intakes ofoleic and n-3 series fatty acids, at least in diabetic Indian Asians. By itself, the conventional recommendation to substitute polyunsaturated for saturated fat in the diet may be inadequate to reduce thrombogenesis, and the overall balance of fatty acids, including monounsaturates, should be considered. Reprint Address:D.B. Peterson, Luton and Dunstable Hospital, Lewsey Road, Luton, Bedfordshire LU40DZ, UK.
171-0162
171-0164
Why Do People Sue Doctors? A Study of Patients and Relatives Taking Legal Action Vincent, C., Young, M., and Phillips, A. 343:1609-1613, 1994. To examine the reasons patients and their relatives take legal action, we surveyed 227 patients and relatives who were taking legal action through five firms of plaintiff medical negligence solicitors. Over 70% of respondents were seriously affected by incidents that gave rise to litigation with long-term effects on work, social life, and family relationships. Intense emotions were aroused and continued to be felt for a long time. The decision to take legal action was determined not only by the original injury, but also by insensitive handling and poor communication after the original incident. Where explanations were given, less than 15% were considered satisfactory. Four main themes emerged from the analysis of reasons for litigation: concern with standards of care--both patients and relatives wanted to prevent similar incidents in the future; the need for an explanation--to know how the injury happened and why; compensation--for actual losses, pain and suffering or to provide care in the future for an injured person; and accountabili t y - a belief that the staffor organisation should have to account for their actions. Patients taking legal action wanted greater honesty, an appreciation of the severity of the trauma they had suffered, and assurances that lessons had been learnt from their
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The Lancet (continued) experiences. A no-fault compensation system, however well intended, would not address all patients' concerns. If litigation is viewed solely as a legal and financial problem, many fundamental issues will not be addressed or resolved. Reprint Address: C. Vincent, Academic Department of Psychiatry, St. Mary's Hospital, Praed Street, London W2 1NY, UK.
NEUROLOGY
171-0165
Migraine Classification and Diagnosis: International Headache Society Criteria Olesen, J. and Lipton, R.B. 44(Suppl. 4):$6--S10, 1994. In 1988, the International Headache Society (IHS) classification committee published operational diagnostic criteria for a broad range of headache disorders, including migraine. These criteria have been translated into more than 10 languages, providing uniform terminology for clinical practice, multinational clinical trials, and biologic and epidemiologic research. The criteria have also been evaluated in a limited number of field studies intended to address their reliability, validity, comprehensiveness, and generalizability. The IHS criteria for migraine provide one method for targeting a group of headache patients in need of care. Reprint Address: J. Olesen, Department of Neurology, Gentofte Hospital, University of Copenhagen, Niels Andersens Vej 65, DK-2900, Copenhagen, HeUerup, Denmark. 171-0166
Diagnostic Criteria for Migraine: A Validity Study Merikangas, ICR., Dartigues, J.F., Whitaker, A., and Angst, J. 44(Suppl. 4):S11-S16, 1994. To identify the optimum combination of symptoms for the International Headache Society (IHS) diagnostic criteria for migraine, the criteria were systematically assessed for validity using an epidemiologic sample from Zurich, Switzerland. The indicators of validity used included subjective distress, occupational impairment, family history of migraine, and treatment. The symptoms that provided the best discrimination between migraine and other headache subtypes were photophobia, phonophobia, and osmophobia, in combination with gastrointestinal symptoms. The evaluation of the validity of the IHS classification of migraine is impeded by several factors, including: the presence of multiple headache syndromes within an individual, the tendency for headache characteristics to change over a lifetime, the effects of headache treatments in obscuring syndromes, and the lack of generalizability of findings based on clinical samples. The methods used in this study serve as a model for applying statistical techniques for evaluating the validity of diagnostic criteria. The findings, however, should be replicated in additional studies to determine their generalizability to specific demographic and clinical subgroups. Reprint Address:K.R. Merikangas, Genetic EpidemiologyResearch Unit, Yale University School of Medicine, 40 Temple Street--Lower Level, New Haven, CT 06510-3223.
171-0167
Migraine Prevalence: A Review of PopulationBased Studies Stewart, W.F., Shechter, A., and Rasmussen, B.K. 44(Suppl. 4):S 17-$23, 1994. Obtaining accurate and reliable information on the prevalence of migraine is essential to understanding the burden it places on society. Although the epidemiology of headache has been described in more than 50 population-based studies, only 24 of these have described the gender- and age-specific prevalence of migraine. Essentially five different case definitions have been used in these studies. Variation in the prevalence of migraine among studies is largely due to differences in case definition and in the age and gender distribution of study populations. Among four recent studies that used the diagnostic criteria of the International Headache Society (IHS), a coherent picture emerges. The prevalence of migraine is approximately 6% among men and 15 to 17% among women. Prevalence varies by age, increasing to about age 40 years and declining thereafter in both men and women. The gender ratio also appears to vary by age, increasing from menarche to about age 42 years and declining thereafter. Although the use of the IHS criteria has resulted in a more coherent picture across population-based studies, efforts must be made to assess the reliability and validity of these criteria in population-based samples. Reprint Address: W.F. Stewart, Department of Epidemiology, Johns Hopkins School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, MD 21205. 171-0168
Migraine Heterogeneity: Disability, Pain Intensity, and Attack Frequency and Duration Stewart, W.F., Shechter, A., and Lipton, R.B. 44(Suppl. 4):$24-$39, 1994. Data from population-based studies are summarized to characterize the full range and variability of the impact migraine has on the individual. Despite differences in methods and data collection in population-based studies describing disability, pain intensity, and attack frequency as well as the duration of migraine and other headaches, several patterns emerge. On average, migraine headaches are more disabling, more painful, and longer in duration than other types of headaches. Females report more pain and disability with headache than do males. Although disability measurements are important in demonstrating the effect of headache on both the individual and society, actual measurements often fall short. Most studies use only workdays lost as the sole measure of disability. Most migraineurs do not miss work while experiencing a headache; instead, they attempt to function on the job, with considerably reduced effectiveness. Computing only workdays lost does not account for impairment at work nor does it show the impact of migraine on other aspects of life. In addition, evidence suggests the presence of a pain intensity threshold for disability. Headache-related pain intensity below the threshold is not associated with disability. Despite the threshold of pain intensity for disability, a significant proportion of migraine sufferers report levels of pain intensity above the threshold in the absence of work-related disability. The grading of headache severity should be a composite that would permit a more complete image of the heterogeneity of migraine's effects and a more accurate idea of the need for healthcare services. This composite should include two areas: (1) more corn-
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Neurology (continued) plete measures of life impact, encompassing daily activities in a number of domains, including work, family, and social activities; and (2) an assessment of pain intensity and attack frequency. Reprint Address: W.F. Stewart, Department of Epidemiology, Johns Hopkins School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, MD 21205.
171-0169 Assessing Headache Severity: New Directions Von Korff, M., Stewart, W.F., and Lipton, R.B. 44(Suppl. 4):$40--$46, 1994. Headache is a heterogeneous condition that varies widely in global severity and in severity of individual attacks. Whereas recent efforts have focused on improving the diagnostic criteria for classifying headache, less effort has been directed toward developing reliable, valid, and clinically useful methods of assessing the impact or severity of headache. Existing measures of severity include one or more of the following weaknesses: (1) only pain intensity is assessed or the measure is incomplete in other ways, (2) measures have little or no prognostic value for relevant outcomes, (3) the reliability or the validity of the measure has not been assessed, or (4) the measure is too cumbersome for clinical practice or field research. We describe a brief, simple method for grading the severity of headache, the Chronic Pain Index, which assumes that a continuum of pain intensity and disability is the underlying dimension of severity. Along this continuum, lower levels of severity are differentiated by pain intensity and higher levels by interference with function. The prognostic value of the results from a seven-item questionnaire for grading headache severity is compared with that of alternative measures. The Chronic Pain Index showed the strongest independent cross-sectional and prospective correlation with measures of headache impact, depression, and use ofhealtheare services. These results support the potential utility of brief methods of assessing headache severity and exemplify the importance of including measures of interference with function when assessing severity. Reprint Address: M. Yon Korif, Center for Health Studies, Group Health Cooperative of Puget Sound, Suite 1600, 1730 Minor Avenue, Seattle, WA 98101. 171-0170 Migraine:Patterns of Healthcare Use Stang, P.E., Osterhaus, J.T., and Celentano, D.D. 44(Suppl. 4):$47-$55, 1994. Data on use of heaithcare from several sources reflect low rates of consultation among migraineurs, many of whom are severely disabled, and limited detection of migraine among those seeking care. Most migraineurs who seek medical care are motivated by the need for pain relief and are initially seen by a general practitioner. Use of healthcare seems to follow a pattern, with a maximum use of services and technology within the first year, followed by a precipitous decrease over the ensuing years. The use of services appears to be concentrated among a small proportion of the migraineurs who seek care. In total volume, the migraineur uses two to five times more healthcare services than nonmigraineurs, reflecting the contribution of comorbidities and help-seeking behavior. Use of emergency departments and sophisticated diagnostic testing appears to be greater in the United States than in other countries. Hospitalization of the migraineur is uncommon and remains costly. Reprint Address: P.E. Stang, Applied Healthcare Research, Glaxo Inc., Five Moore Drive, CS-1130, Research Triangle Park, NC 27709.
171-0171
The Economic Cost of Migraine: Present State of Knowledge de Lissovoy, G. and Lazarus, S.S. 44(Suppl. 4):$56--$62, 1994. The costs of medical care and lost productivity associated with migraine headache impose an economic burden on society. Knowledge of the costs that can be attributed to migraine would provide a basis for evaluating alternative diagnosis and treatment strategies. The most widely used approaches to analyzing the cost of illness analysis are the willingness-to-pay and human capital methods. Using these as a framework, all recent published studies (from 19g0 to the present) relevant to the economic cost of migraine were reviewed. The literature reviewed demonstrates that the economic burden of migraine headache is substantial. To estimate the cost of migraine to society more precisely, data are needed on incidence and prevalence among carefully selected samples representative of the underlying population. Use of medical care must be expressed as units of specific types of services rendered over known periods. Health insurance coverage, an important determinant of access to care, should also be known. Absenteeism and work losses must be linked to occupation and earnings levels. Reprint Address: G. de Lissovoy, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, 624 North Broadway, 4th Floor, Baltimore, MD 21205-1996. 171-0172
Migraine: Identifying and Removing Barriers to Care Lipton, R.B., Amatniek, J.C., Ferrari, M.D., and Gross, M. 44(Suppl. 4): $63-$68, 1994. The high levels of pain and disability associated with undiagnosed migraine or inadequate treatment of migraine offer a potential target for healthcare intervention. Both the individual patient and society are affected by decisions regarding which migraine sufferers are most in need of medical care. Pain is the most important symptom for the individual patient, but disability may be the most important consequence of migraine for an increasingly cost-conscious society. These two perspectives are the components of a migraine severity or impact measure being developed to define migraine sufferers most in need of care. The criteria for developing screening programs provide a context for evaluating healthcare interventions for migraine. Barriers to effective care occur on at least three levels: many people with migraine do not consult doctors; consulters may not receive the correct diagnosis; and even when the correct diagnosis is made, many migraineurs do not receive effective treatment. Screening and impact measures may help both to improve diagnosis and to determine which migraineurs are most in need of care. Public and physician education, screening, and impact measures might circumvent many of the barriers to effective care for people with migraine. Reprint Address: R.B. Lipton, Montefiore Medical Center, Headache Unit, 111 East 210th Street, Bronx, NY 10467. 171-0173 Diagnosing the Severe Headache Dalessio, D.J. 44(Suppl. 3):$6-S12, 1994. A patient's medical history, age of onset, location of pain, pain characteristics, pain chronology, associated signs and symptoms, and signs ofneurologic dysfunction are all important considerations in making a diagnosis. The International Head-
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Neurology (continued) ache Society has developed a thorough classification system to aid in the diagnosis of headache, which includes primary disorders of migraine, tension-type headache, and cluster headache, as well as secondary, organic disorders. Reprint Address: D.J. Dalessio, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037.
171-0174
Migraine: A Pharmacologic Review with Newer Options and Delivery ModaHties Baumel, B. 44(Suppl. 3):S13-S17, 1994. The management of migraine usually centers on two approaches: preventive and abortive therapy. Preventive therapy, designed to reduce the frequency, duration, and intensity of attacks, can be accomplished through a wide variety of medications. The most commonly used are t-blockers, but calcium channel blockers, antidepressants, anticonvulsants, and nonsteroidal anti-inflammatory agents have all been used with success. Agents used in abortive migraine therapy treat the intensity and duration of pain, as well as the associated symptoms. New treatment options have been developed, including such newly approved medications as sumatriptan. Sumatriptan is a very effective agent that has joined the ranks of other effective abortive migraine treatments, such as ergotamine, dihydroergotamine, and nonsteroidal anti-inflammatory agents, as well as narcotic analgesics. New delivery systems, such as the nasal-spray formulation of butorphanol, allow for a route of administration previously unavailable to migraine sufferers. These new and developing treatment modalities will # v e physicians a wider choice of outpatient therapy options. Reprint Address: B. Baumel, Baumel-Eisner Neuromedical Institute, 1135 Kane Concourse, Bay Harbor Islands, Miami Beach, FL 331542025. 171-0175
Chronic Headache: Appropriate Use of Opiate Analgesics Marldey, H.G. 44(Suppl. 3):$18--$24, 1994. The question of the appropriate use of opiate analgesics in the management of chronic headache pain is under debate. Often, the management of headache pain is complicated by the overuse of dependency-promoting analgesics. Because of confusion about the use of analgesics in pain management, some patients are denied access to necessary opioid analgesia, whereas others receive large quantifies of combination analgesics. The proper use of opiate analgesics is presented here, including a review of the pharmacology of these agents. Signs of analgesic dependence, analgesic rebound headache, and methods of withdrawal are also presented. The potential use of such new treatment modalities as butorphanol nasal spray is discussed. Reprint Address: H.G. Markley, Department of Neurology,The Medical Center of Central Massachusetts, 119 Belmont Street, Worcester, MA 01605. 171-0176 Recurrent Migraine: Cost-Effective Care Rapoport, A.M. 44(Suppl. 3):$25-$28, 1994. The cost of untreated or ineffectively treated migraine is staggering. A case study is presented that demonstrates the importance of developing an individually tailored home treatment program for migraine patients aimed at keeping them out of healthcare facilities on an acute basis. Treatment programs should include preventive medications if attacks occur more than twice
per month, as well as appropriate abortive and symptomatic agents in the event of a severe, acute migraine attack. New agents and treatment modalities are making acute treatment more costeffective and making it less likely that unnecessary time be spent seeking medical help at the time of an attack. Reprint Address: A.M. Rapoport, The New England Center for Headache, 778 Long Ridge Road, Stamford, C-q"06902.
171-0177
The Henry Ford Hospital Headache Disability Inventory (HDI) Jacobson, G.P., Ramadan, N.M., Aggarwal, S.K., and Newman, C.W. 44(5):837-842, 1994. To quantify the impact of headache on daily living, we developed a 25-item headache disability inventory (HDI). The alpha version of the HDI (a-HDI) consisted of 40 items, each requiring a "yes" (four points), "sometimes" (two points), or "no" (zero points) response based on items derived empirically from case history responses of subjects with headache. From the a-HDI, we derived a 25-item beta version (~-HDI) with the items subgrouped into functional and emotional subscales. The internal consistency/reliability was strong, as was construct validity. The test-retest reliability for the fl-HDI was acceptable for the total score and functional and emotional subscale scores. A 29-point change (95% confidence interval) or greater in the total score from test-retest must occur before the changes can be attributed to treatment effects. The HDI is useful in assessing the impact of headache, and its treatment, on daily living. Reprint Address: G.P. Jacobson, Division of Audiology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202. 171-0178
Opioid Responsiveness of Cancer Pain Syndromes Caused by Nearopathic or Nociceptive Mechanisms: A Combined Analysis of Controlled, Single-Dose Studies Cherny, N.I., Thaler, H.T., Friedlander-Klar, H., et al. 44(5):857-861, 1994. We performed a combined analysis of the results from four controlled single-dose relative-potency studies to assess the impact of inferred pain mechanism on the response to an opioid drug. A total of 168 patients received 474 administrations of either morphine or heroin, and we assessed the analgesic response during a 6-hour period with visual analog scales. We summarized this as a total pain relief (TOTPAR) score. Two experienced pain clinicians reviewed information about pain characteristics and designated each case according to the inferred pain mechanism (neuropathic, nociceptive, or mixed) and the degree of confidence in the inferred mechanism (definite versus probable/possible). They grouped the cases as follows: nociceptive pain only (n ffi 205), neuropathic pain only (n = 49), and mixed (n ffi 220). We compared pain relief achieved by patients with different mechanisms, with TOTPAR adjusted for significant covariates (duration of prior opioid administration, doses of opioid administered in the previous 48 hours, pain intensity at the start of the study, BUN:creatinine ratio, and dose of administered opioid). The adjusted mean TOTPAR score of the group with any neuropathic pain was significantly lower than that of the group with nociceptive pain only (26.1 versus 20.4, p ffi 0.02). The score of the group with definite nociceptive pain alone (adjusted mean TOTPAR = 28.0) was significantly higher than scores of the groups with possible/probable nociceptive pain (TOTPAR = 19.9), mixed mechanisms (TOTPAR = 20.2),
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Neurology (continued) definite neuropathic pain alone (TOTPAR = 20.6), and possible/probable neuropathic pain alone (TOTPAR = 22.9). In pairwise comparisons, there were no significant differences in the adjusted mean TOTPAR scores among the latter four groups. Among the patients with neuropathic pain, the dose-response relationship was significant. These data support the postulate that opioid responsiveness is a continuum with extensive overlap in the responsiveness of pains mediated by neuropathic, nociceptive, and mixed pain mechanisms. Reprint Address: R.K. Portenoy, Pain Service, Department of Neurology,Memorial Sloan-KetteringCancer Center, 1275 York Avenue, New York, NY 10021. 171-0179
Validation of a New Instrument for Determining Migraine Prevalence: The UCSD Migraine Questionnaire Tom, T., Brody, M., Valabhji, A., et al. 44(5):925-928, 1994. To provide a reliable instrument for use in large population surveys, we developed a short questionnaire based on existing International Headache Society diagnostic criteria and administered ~ e questionnaire to 50 consecutive patients seeking evaluation at a university-based headache clinic. A single neurologist subsequently examined all patients. Based only on the questionnaires, reviewers scored each patient as having migraine with aura, migraine without aura, or nonmigrainous headache. High predictive validity and low interobserver variability between the examining neurologist and the independent reviewers suggest that the quenstionnaire may be quite useful as a survey instrument. Reprint Address: T. Tom, Department of Neurology, UCSD Medical Center, 200 West Arbor Drive, San Diego, CA 92103. 171-0180
'Sympathetically Maintained Pain.' I. Phentolamine Block Questions the Concept Verdugn, R.J. and Ochoa, J.L. 44(6):1003-1010, 1994. Patients with "reflex sympathetic dystrophy" or "causalgia" underwent sympathetic blocks. In protocol A (77 patients), we infused placebo (saline) for 30 minutes followed by phentolamine (35 mg). In protocol B (23 patients), the saline phase was followed by double-blind infusion ofphentolamine or phenylephrine (500 zg), a second phase of saline, and then the other active drug. We assessed magnitudes of pain and mechanical hyperalgesias on a 0-to-10 pain scale and monitored sensory and sympathetic effects. With protocol A, pain diminished significantly (_>50%) during placebo in 22 patients (28.9%) and during phentolamine in seven (9.20/0). With protocol B, four patients (17.3%) had relief of pain during placebo, four (17.3%) during phenylephrine, and two (8.7%) during phentolamine. All "phentolamine responders" had progressive pain relief from placebo. Two patients expressed relief during phenylephrine and worsening during phentolamine. Most patients did not respond significantly to saline or drugs. Thus, pharmacologic manipulation of the alpha-1 adrenergic receptor by either agonist or antagonist drug does not influence neuropathic pains. These results raise questions about the existence of "sympathetically maintained pain," as diagnosed by sympathetic blocks improperly controlled for placebo. Reprint Address:J.L. Oehoa, Neuromuscular Unit, Department of Neurology, Good Samaritan Hospital and Medical Center, 1040 NW 22rid Avenue, Suite 460, Portland, OR 97210.
171-0181
Phentolamine Sympathetic Block in Painful Polyneuropathies. II. Further Questioning of the Concept of 'Sympathetically Maintained Pain' Verdugn, R.J., Campero, M., and Ochoa, J.L. 44(6):1010-1014, 1994. To test for the presence of "sympathetically maintained pain" (SMP), we administered placebo-controlled phentolamine sympathetic blocks to 14 patients with painful polyneuropathies. Six received IV infusion of saline for 30 minutes, followed by phentolamine (35 mg). In eight patients, the saline phase was followed by double-blind infusion of phentolamine or phenylephrine (500 ~g), a second saline phase, and then the other active drug. We measured magnitudes of spontaneous pain and mechanical hyperalgesias on a 0-to-10 pain scale every 5 minutes and monitored sensory and sympathetic effects clinically and through quantitative thermotest and thermography. Five patients reported significant diminution of pain (>50%), all in response to placebo. Neither phentolamine nor phenylephrine provided relief, although all patients had signs of physiologic abnormalities reputed to be determinants or predictors of SMP. These results complement previous studies demonstrating the nonexistence of SMP among "reflex sympathetic dystrophy" patients and further question the concept of SMP. Reprint Address: J.L. Ochoa, Neuromuscular Unit, Department of Neu-
rology, Good Samaritan Hospital and Medical Center, 1040 NW 22nd Avenue, Suite 460, Portland, OR 97210. 171-0182
Precursors of Extracranial Carotid Atherosclerosis in the Framingham Study Fine-Edelstein, J.S., Wolf, P.A., O'Leary, D.H., et al. 44(6):1046-1050, 1994. To investigate cardiovascular risk factors and carotid atherosclerosis, we related previously measured risk factors to carotid atherosclerosis as determined by duplex ultrasonography in the Framingham Study cohort. Risk factors measured prospectively on 1,I 16 cohort members, ages 66 to 93, were related to the severity of carotid atherosclerosis measured by carotid ultrasonography performed during biennial examination no. 20 (1988 to 1990). The degree of carotid atherosclerosis was expressed as a percent carotid stenosis and, for statistical analysis, subjects were divided into four groups according to percent carotid stenosis. The prevalence of significant carotid stenosis in the general population was low--7% in women and 9% in men. A multivariate logistic regression model showed that age, cigarette smoking, systolic blood pressure, and cholesterol were independently related to carotid atherosclerosis. Alcohol consumption was also significant in men, but not in women. In addition, our results indicate that both current and former smoking in both sexes was related to the degree of carotid atherosclerosis. Reprint Address: P.A. Wolf, Robinson Building B-608, Neurology, 80 East Concord Street, Boston, MA 02118. 171-0183
Cerebral White Matter Lesions, Vascular Risk Factors, and Cognitive Function in a PopulationBased Study: The Rotterdam Study Breteler, M.M.B., van Swieten, J.C., Bots, M.L., et al. 44(7): 1246-1252, 1994. Cerebral white matter lesions are a common finding on MRI in elderly persons. We studied the prevalence of white matter
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Neurology (continued) lesions and their relation with classic cardiovascular risk factors, thrombogenic factors, and cognitive function in an age- and gender-stratified random sample from the general population that consisted of 111 subjects 65 to 84 years of age. Overall, 27% of subjects had white matter lesions. The prevalence and severity of lesions increased with age. A history of stroke or myocardial infarction, factor VIIc activity, and fibrinogen level were each significantly and independently associated with the presence of white matter lesions. Significant relations with blood pressure level, hypertension, and plasma cholesterol were present only for subjects aged 65 to 74 years. White matter lesions tended to be associated with lower scores on tests of cognitive function and were significantly associated with subjective mental decline. This study suggests that classic cardiovascular risk factors, as well as thrombogenic factors, are associated with white matter lesions in subjects over 65 years of age in the general population, and that these lesions may be related to cognitive function.
Reprint Address: M.M.B. Breteler, Department of Epidemiology and Biostatistics, Erasmus University Medical School, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
PAIN
171-0184
Cognitive-Behaviorai Classifications of Chronic Pain: Replication and Extension of Empirically Derived Patient Profiles Jamison, R.N., Rudy, T.E., Penzien, D.B., and Mosley Jr., T.H. 57:277-292, 1994. Many attempts have been made to classify patients with chronic pain in order to make sense of a very complex problem and to direct patients towards appropriate treatments for their condition. Unfortunately, these efforts have not been empirically based and have demonstrated limited clinical use. Predominant emphasis has been placed on either biomedical or psychopathological elements of the chronic pain experience with little integration of cognitive-behavioral factors. Turk and Rudy (1988) introduced an empirically derived pain patient taxonomy based on analyses of the Multidimensional Pain Inventory (MPI). The primary purpose of the present study was to replicate this classification system by using different measures for similar constructs in different groups of chronic pain patients. Items designed to measure 4 constructs (activity interference, emotional distress, pain intensity, and perceived support) were collected from 1594 pain patients evaluated at two separate pain treatment facilities. Confirmatory factor analytic results indicated high reliability of the items in measuring these 4 constructs. Replicated clustering techniques demonstrated the robustness of 3 patient profiles across the patient samples. The 3 clusters corresponded remarkably well to the groups initially labeled by Turk and Rudy (1988) as Dysfunctional, Interpersonally Distressed and Adaptive Copers. External validation of the classification system supported replication of the 3 groups and offered further interpretational clarity to the patient profiles. Strong evidence was found for a taxonomy of 3 chronic pain patient
groups. Implication for predicting treatment outcome and for future research are discussed. Reprint Address: R.N. Jamison, Pain Management Center, Department of Anesthesia, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
171-0185
Relationship of Pain-Specific Beliefs to Chronic Pain Adjustment Jensen, M.P., Turner, J.A., Romano, J.M., and Lawler, B.K. 57:301-309, 1994. Cognitive-behavioral models suggest that pain patients' beliefs about their pain play a critical role in their adjustment. This study sought to replicate and extend previous research that has examined the relationship between pain-specific beliefs and adjustment to chronic pain. Two hundred forty-one chronic pain patients evaluated for possible admission to an inpatient pain treatment program completed the Sickness Impact Profile (SIP) and the Survey of Pain Attitudes (SOPA), as well as measures of pain, medical services utilization and demographic characteristics. The results indicated that the beliefs that emotions affect pain, that others should be solicitous when the patient experiences pain, and (for subjects reporting low and medium levels of pain severity) that one is disabled by pain were associated positively with psychosocial dysfunction. The beliefs that one is disabled and that activity should be avoided because pain signifies damage were associated positively with physical disability. None of the beliefs assessed was significantly associated with number of physician visits in the previous 3 months, although belief in the appropriateness of medications for managing chronic pain was associated positively with pain-related emergency room visits. The results support a cognitive-behavioral model ofchronic pain adjustment and suggest specific pain beliefs to target in treatment studies examining causal relationships between beliefs and adjustment. Reprint Address: M.P. Jensen, Department of Rehabilitation Medicine, RJ-30, University of Washington School of Medicine, Seattle, WA 98195.
171-0186
Are Runners Stoical? An Examination of Pain Sensitivity in Habitual Runners and Normally Active Cont3"ols Janal, M.N., Glusman, M., Kulfl, J.P., and Clark, W.C. 58:109-116, 1994. Anecdotal and clinical reports suggest that athletes are stoical. However, there are few studies comparing persons who exercise regularly with those who do not. This study compared two independent samples of regular runners and normally active controls, both without recent exercise, on cold pressor, cutaneous heat, and tourniquet ischemic pain tests. Results demonstrated that the runners' threshold for noxious cold was significantly higher than that of controls. The heart rate and blood pressure responses to cold were similar in the 2 groups, suggesting that differences in cold pain report did not result from differences in autonomic reactivity to cold. Signal detection theory measures demonstrated that runners discriminated among noxious thermal stimuli significantly better than controls, but neither noxious nor innocuous thermal report criteria differed between groups. The cohorts also did not differ in their report of ischemic pain sensations. Thus, these data do not generally support the hypothesis of pain insensitivity or stoicism in ha-
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Pain (continued) bitual runners. Rather, insensitivity occurs only in their response to noxious cold, which is suggested to be an adaptation to regular training. Reprint Address: M.N. Janal, Box 50, NYS Psychiatric Institute, 722 West 168 Street, New York, NY 10032. 171-0187
Effects of Experimental and Clinical Noxious Counterirritants on Pain Perception
Sigurdsson, A. and Maixner, W. 57:265-275, 1994. It is commonly accepted that application of a sustained noxious stimulus frequently suppresses the perception of pain. In this investigation, we have determined whether painful forearm ischemia suppresses tooth pain resulting from an acute irreversible pulpitis. We have also determined whether the physiological responses to toothache alter the perception of pain evoked by experimental procedures. Ten male subjects experiencing a painful toothache (group TA) and 7 age-matched pain-free male subjects (group PF) participated in these studies. During session 1, heat pain threshold and tolerance values were determined for both groups. The times to ischemic pain onset and ischemic pain tolerance were determined for both groups using the submaximal effort tourniquet procedure. The effect of the tourniquet procedure on the intensity, unpleasantness, and spatial distribution of toothache was also assessed. Session 2 was conducted on 7 TA and 7 PF subjects 1 week later and was conducted like session 1 with the exception that group TA was not experiencing tooth pain during this session. Measures of thermal pain perception and forearm ischemic pain perception were not altered by the occurrence of toothache. In contrast, sustained noxious forearm ischemia produced a marked reduction in the intensity, unpleasantness and spatial distribution of puipal pain. These effects on pulpal pain remained for at least 5 rain after removal of the tourniquet while the arm was pain free. These findings suggest that a noxious conditioning stimulus does not universally inhibit pain perception but instead depends on unidentified interactions between the noxious test and conditioning stimuli. Reprint Address:W. Maixner, Room 03, Dental Research Center, University of North Carolina, Chapel Hill, NC 27599-7455.
continuous pain for the month preceding assessment. Sixty-five percent of patients with pain reported taking medications for pain and 90% of these patients evaluated their medication(s) as 50% effective or better. Nevertheless, patients with pain reported poorer mental health and more social-role handicap. Discussion focuses on the need for routine assessment of pain and the comprehensive evaluation of the effectiveness of pain interventions in the therapeutic management of patients with MS. Reprint Address: C.J. Archibald, Department of Psychology, Dalhousie University, Halifax, NS B3H 4J 1, Canada. 171-0189
Coping with Long-Term Musculoskeletal Pain and Its Consequences: Is Gender a Factor? Jensen, I., Nygren, A., Gamberale, F., Goldie, I., and Westerholm, P. 57:167-172, 1994. We did a descriptive study of 121 patients (71 women and 50 men) to explore the role of gender in coping with long-term intractable pain of the neck, shoulder and back and to determine the consequences of pain. Questionnaires used to assess the dependent variables were the Coping Strategy Questionnaire (CSQ) and the Multidimensional Pain Inventory (MPI). Distinctions were found between men and women. In particular, the coping strategies used by women were those which in previous research had been found to be associated with dysfunction and poor outcome in terms of rehabilitation. Moreover, considering the consequences of pain on daily living, a more complex pattern of related factors was found in women rather than men. Given the high proportion of working women in Sweden with long-term musculoskeletal pain and considering recent observations in controlled studies showing that the benefits of cognitive behaviourally based treatmenls are confined to women, our findings suggest the need to tailor rehabilitative strategies differently for men and women and point to a research agenda which pays more attention to the distinctive challenges of women in the workplace when they are affected by chronic ailments. Reprint Address: I. Jensen, NiirRehab, Ribbingsgatan 1-3, 703 63 Orebro, Sweden. 171-0190
171-0188
Pain Prevalence, Severity and Impact in a Clinic Sample of Multiple Sclerosis Patients Archibald, C.J., McGrath, P.J., Ritvo, P.G., et al. 58:89-93, 1994. Previous studies have reported variable prevalence of pain in multiple sclerosis (MS) and have not documented the impact of pain on daily living. In this consecutive series, we report on data collected from structured interviews with 85 patients seen within a 16-month period at a regional referral clinic. The prevalence of pain for the month preceding assessment was 53%. There were no significant differences between patients who did and those who did not report pain on the basis of patient demographics (age, gender) and disease characteristics (disease subtype, duration and neurologic symptom severity). Disease duration and neurologic symptom severity were significantly correlated with the number of hours of pain per week but were not correlated with pain severity, the number of pain sites or pain-related distress. There was wide variability in the number of pain hours/week reported with 17.6% of the sample reporting
Do Benzodiazepines Have a Role in Chronic Pain Management? Dellemijn, P.L.I. and Fields, H.L. 57:137-152, 1994. Reprint Address: H.L. Fields, Department of Neurology (M-794), University of California, San Francisco, CA 94143-0114.
PATIENT EDUCATION AND COUNSELING
171-0191 Stretch-Based Relaxation Training Carlson, C.R. and Curran, S.L. 23:5-I2, I994. This paper is a review of progressive relaxation training based on muscle stretching exercises. Stretch-based relaxation training is an alternative to traditional tense-release methods for teaching self-regulation of muscle activity. The rationale and basic procedures for stretch-based relaxation are presented, along
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Patient Education and Counseling (continued) with a review of research studies exploring the clinical efficacy of the techniques. Experimental evidence has demonstrated decreases in subjective measures of muscle tension and activation, as well as decreases in EMG activity at selected target muscle sites when stretch-based relaxation procedures are employed. The clinical application of stretch-based relaxation is presented and illustrated with a case study describing the use of these procedures to assist in the treatment of neck tension/pain and anxiety. Discussion centers on the potential role of stretch-based relaxation in the management of anxiety and musculoskeletal disorders. Reprint Address: C.R. Carlson, Department of Psychology, University of Kentucky, Lexington, KY 40506-0044.
Problem Solving Anchored Instruction about Sick Days for Adolescents with Diabetes Pichert, J.W., Snyder, G.M., Kinzer, C.IC, and Boswell, E.J. 23:115-124, 1994. This study's hypotheses were that both shortly after instruction and after an 8-month follow-up, diabetic children taught via anchored instruction (AI), a format for problem solving, would outperform controls. Subjects were 81 9-15-year-old campers with insulin dependent diabetes who were randomly assigned to AI or control groups for two 45-rain small group teaching sessions. AIs viewed a video about a girl who mismanages her diabetes during intercurrent illness, and they were challenged to identify, define and solve her errors. Controls learned sick-day management via conventional direct instruction. At the end of the 2-week camp, AI and control groups' scores on factual knowledge were equal. AIs were more likely than controls at the end of the camp (0.75 vs. 0.54, P < 0.05) and 8 months later (0.59 vs. 0.38, P < 0.02) to provide a rationale for the use of remembered guidelines. Across all campers, this ability to link guidelines and their rationales was significantly correlated (r = 0.55, P < 0.01) with the number of self-management practices employed by campers who suffered an illness between the end of camp and the 8-month follow-up. Only one long-term behavioral difference between groups emerged: AIs' parents shared in making most diabetes decisions on sick days, while controls' parents left more decision making to their children. AI appears at least as good as conventional teaching, and may better 'link' rules and reasons, perhaps aiding daily real-life problem solving. Reprint Address: J.W. Pichert, 315 Medical Arts Building, Vanderbilt University School of Medicine, Nashville, "IN 37232-1229.
significant level within all groups. The increase persisted at each of four follow-ups. An analysis of variance determined there was no significant difference between groups in the changes in frequency and confidence. Thus, the method of teaching had little impact on the long-range practise of BSE in terms of these two variables. It was observed that 10.8% of the group receiving individual instruction would not accept teaching on their own breasts. Less than 1.5% in each of the other groups would not accept all aspects of the teaching protocol for their respective group. This development should be taken into account in determining whether practise on one's own body is a necessary component of BSE teaching programs. Reprint Address: S.Y. Alcoe, Faculty of Nursing, University of New Brunswick, Fredericton, NB E3B 5A3, Canada.
171-0192
171-0193
The Effects of Teaching Breast SelfExamination: Reported Confidence and Frequency of Practise over a Six-Year Period Alcoc, S.Y., Gilbey, V.J., McDermot, R.S.R., and Wallace, D.G. 23:13-21, 1994. Breast serf-examination (BSE) was taught to 614 women. They were randomly assigned to one of three groups identified as content only, content plus supervised practise on a model with implanted lumps and content plus individual instruction on their own breasts. They were followed for 6 years. Reported frequency of practise and level of confidence increased at a
171-0194
Self-Management of the Health Care Regimen: A Comparison of Nurses' and Cardiac Patients' Perceptions Dodge, J.A., Janz, N.K., and Clark, N.M. 23:73--82, 1994. This study compared perceptions of 129 elderly cardiac patients regarding their health status and self-management skills with corresponding assessments by outpatient nursing staff members. Nurse-patient perceptions were most congruent on general questions regarding the heart condition. Differences were most apparent regarding how aware patients were of being asked to follow a regimen for managing their heart problems; what specific components comprised the regimens the patients were to follov~, and how much confidence patients had in their ability to comply with specific components of the regimen. Congruence in perceptions of nurses and patients varied by the sex of the patient. Findings suggest that careful and continuous assessment of patients' perceptions about their condition and ongoing instruction regarding specifics of the therapeutic regimen are key elements in efforts to enhance elderly patients' self-management skills. Reprint Address: N.M. Clark, School of Public Health, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029.
171-0195
A Comparison of Younger-Aged and Older-Aged Women in a Behavioral Self-Control Smoking Program O'Hara, P. and Portser, S.A. 23:91-96, 1994. This study examines differences in motivation for quitting smoking, withdrawal experiences and weight changes in younger and older aged women who entered a smoking cessation program designed specifically for women smokers. In an assessment prior to quitting smoking 26 women aged 20--49 years (youngeraged women) and 19 women aged 50-75 years (older-aged women) did not show differences in number of prior quit attempts or their dependence on nicotine (as measured in the Fagerstrom Tolerance Questionnaire). The older aged women smoked for a significantly greater number of years but smoked fewer cigarettes per day than the younger women. In a selfreport questionnaire the two age groups differed in their reasons stated for wanting to give up cigarettes and symptoms of illness they experienced related to smoking. The average weight gains
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Patient Education and Counseling (continued) for women who quit smoking were minimal (3.5 lb, younger; 3.9 lb, older; 1 lb = 0.453 592/37 kg) although more younger women than older women reported they expected difficulty with weight gain after cessation. Changes in withdrawal experiences were not significantly different at any point during the initial phase of quitting (24, 48 and 72 11). Reprint Address: P. O'Hara, University of Miami School of Medicine, Department of Epidemiology and Public Health, 1029 NW 15th Street, R-669, Miami, FL 33136.
171-0196
Informationto Patients with Malignant Melanoma: A Randomized Group Study Brandberg, Y., Bergenmar, M., Bolund, C., et al. 23:97-105, 1994. An information programme for patients with cutaneous malignant melanoma, Stage I, aiming at increasing satisfaction with information, was carried out at the Department of Oncology CRadiumhemmet). The programme consisted of a group meeting and a brochure. A total of 231 consecutive patients were included, and 149 (65%) reported interest in participation and were randomized to the Information group (n = 77) or to the Control group. A total of 67 patients (29%) were not interested (the NI-group). To evaluate the programme, the patients in the three groups completed questionnaires regarding satisfaction with information, knowledge of melanoma and psychological and psychosomatic variables before randomization and at the first visit for follow-up at Radiumhemmet. After the information programme, the Information group was significantly more satisfied with information, had a higher level of knowledge and a lower proportion requested further information as compared with the Control group. No differences were found on the psychological and psychosomatic variables. Reprint Address: Y. Brandberg, Psychosocial Unit, Radiumhemmet, Karolinska Hospital, S 104 01, Sweden.
PHYSICAL THERAPY
171-0197
Work Hardening and Work Conditioning Interventions: Do They Affect Disability? Lechner, D.E. 74(5):471-493, 1994. The purpose of this article is to review the research on the effectiveness of work hardening and work conditioning programs. Twelve studies of work hardening and work conditioning programs in the United States and abroad were reviewed. One study produced convincing evidence in a randomized study that a work conditioning program was useful in producing a higher percentage of return to work and an earlier return to work in a group of patients off work for at least 2 months. Another study demonstrated that a work hardening program increased the rate of return to work by 52% in patients off work for greater than 4 months. Most of the other studies reviewed suggested positive results, but more carefully documented, randomized, and controlled studies are needed to support the efficacy of these pro-
grams and to determine the optimum and most cost-effective work hardening and work conditioning interventions. Reprint Address: D.E. Lechner, Division of Physical Therapy, School of Health Related Professions, The University of Alabama, B-41 SHRP Building, 1714 Ninth Avenue South, UAB Station, Birmingham, AL 35294-1270.
171-0198
Efficacy of Electromyographic Biofeedback Compared with Conventional Physical Therapy for Upper-Extremity Function in Patients Following Stroke: A Research Overview and Meta-Analysis Moreland, J, and Thomson, M.A. 74(6):534-547, 1994. Background and Purpose. The purpose of this study was to examine the efficacy of electromyographic biofeedback compared with conventional physical therapy for improving upperextremity function in patients following a stroke. Subjects and Methods. A literature search was done for the years 1976 to 1992. The selection criteria included single-blinded randomized control trials. Study quality was assessed for nine criteria. For functional (disability index or stage of recovery) and impairment outcomes, meta-analyses were performed on odds ratios for improvement versus no improvement. Mann-Whitney U-Test probability values were combined across studies. Results. Six studies were selected, and outcome data were obtained for five studies. The common odds ratio was 2.2 for function and 1.1 for impairments in favor of biofeedback. The estimate of the number needed to treat to prevent a nonresponder was 11 for function and 22 for impairments. None of the meta-analyses were statistically significant. Conclusions and Discussion. The results do not conclusively indicate superiority of either form of therapy. Although there is a chance of Type II error, the estimated size of the effect is small. Given this estimate of little or no difference, therapists need to consider cost, ease of application, and patient preference when selecting these therapies. Reprint Address: J. Moreland, Physiotherapy Department, St. Joseph's Hospital, 50 Chadton Avenue East, Hamilton, ON L8N 4A6, Canada.
171-0199 Disability in Poliomyelitis Sequelae Grimby, G. and J~Snsson, A.-L.T. 74(5):415-424, 1994. Patients who have been affected by poliomyelitis may develop new symptoms such as muscle weakness, muscle atrophy, muscle or joint pain, and unexplained fatigue several decades after the onset of their poliomyelitis Loost-polio syndrome [PPS]). We report on the results of our study of 59 patients with poliomyelitis using a number of instruments for disability assessment, including a 4- to 5-year follow-up. The main impact of disability for most patients is in mobility-related activities. Dependence in personal activities of daily living is fairly rare, whereas dependence and difficulties in instrumental activities of daffy living (eg, cooking, transportation, cleaning, shopping) are more common and also more severe in persons with PPS. Mental health, emotional reactions and social activity, interaction, and isolation are usually less affected, although considerable coping problems may occur, especially in persons with PPS who have new health problems and increasing disabilities. Examples of disabilities, intervention measures, and coping processes are given with case reports. The importance of a broad
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Physical Therapy (continued) and interdisciplinary approach is emphasized, in which impairment as well as disability aspects should be considered in treatment and intervention programs. Reprint Address: G. Grimby, Department of Rehabilitation Medicine, University of G6teborg, G6teborg, S-41345 Sweden.
closes with a discussion of directions for future research aimed at explaining the interaction between perceived support and acute stress. Reprint Address: R.C. Kessler, Institute for Social Research, The University of Michigan, Ann Arbor, MI 48106-1248.
171-0200
171-0202
Assessing Change Over Time in Patients with Low Back Pain
Stratford, P.W., Binkley, J., Solomon, P., Gill, C., and Finch, E. 74(6):528-533, 1994. Background and Purpose. This study compared the ability of the Roland-Morris (RM), Oswestry (OSW), and Jan van Breemen Institute 0VB) pain and function questionnaires to detect change over time. Subjects. The sample consisted of 88 patients with mechanical low back pain who were referred by physicians to the outpatient physical therapy department of a teaching hospital. Methods. Questionnaires were completed by the subjects at their initial visit and 4 to 6 weeks later. Clinically important change was estimated by having the subject and the clinician independently complete two rating scales. Sensitivity to change was assessed using receiver operating characteristic (ROC) curve analysis. Results. The ROC curve areas for the RM (0.79), OSW (0.78), and JVB pain (0.79) questionnaires were significantly greater than for the JVB function questionnaire (0.66). Blank and multiple responses per item were present on approximately 20% of the OSW questionnaires and 14% of the JVB questionnaires. Words rather than checks were evident on 3% of the RM questionnaires. Conclusion and Discussion. Based on the latter finding, we believe the RM questionnaire may be the preferred instrument for assessing change over time in patients with low back pain. Reprint Address: P.W. Stratford, School of Occupational Therapy and Physiotherapy, Health Sciences Centre (Room 1J11), McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada.
Spouse Similarity for Psychological Distress and Well-Being: A Population Study du Fort, G.G., Kovess, V., and Boivin, J.-F. 24:431--447, 1994. While spouse similarity for psychiatric morbidity has been the object of numerous studies, most of these focused on clinical samples and, consequently, the interpretation of their results is limited by the existence of a selection bias. In this study, conducted on a sample of 845 general population couples, significant spouse similarity was observed for psychological distress and well-being, characterized by a marked symmetry in the relation between spouses' scores. The sex differences observed in many earlier studies would appear essentially to be artefactual. Spouse similarity was also found to be significant in the subpopulation of couples married less than two years, which pointed to assortative mating for psychological distress and wellbeing. While many studies have found educational dissimilarity and age difference between spouses to be associated with certain health variables, such as high blood pressure and coronary heart disease, these variables do not have a significant influence on individual levels of psychological distress and well-being. Spouse similarity for socio-demographic characteristics does not play a significant role in explaining spouse similarity for mental health. Consequently, assortative mating for psychological distress and well-being would appear to be primarily due to personal preference. Reprint Address: G.G. du Fort, Douglas Hospital ResearchCentre, 6875 LaSalle Boulevard, Verdun, PQ H4H IR3, Canada.
171-0203
PSYCHOLOGICAL MEDICINE
171-0201
Perceived Support and Adjustment to Stress in a General Population Sample of Female Twins
Kessler, R.C., Kendler, K.S., Heath, A., Neale, M.C., and Eaves, L.J. 24:317-334, 1994. The stress-buffering effect of perceived support is explored in a large panel survey of adult female twins. The analysis begins by documenting a significant interaction between perceived support and acute stress in predicting DSM-III-R major depression. Various hypotheses are investigated to explain this interaction. These include the possibilities that the interaction is due to a stress-buffering effect of perceived support which is mediated by received support, that perceived support promotes either the increased use or the increased effectiveness of certain coping strategies, or that there is some underlying genetic factor that affects both the perception of support and adjustment to stress. No evidence was found for any of these hypotheses. The paper
The Impact of Unemployment on the Psychological Well-Being of British Asians Shams, M. and Jackson, P.R. 24:347-355, 1994. This paper presents the results of a study of unemployment among British Asians living in the north of England. The sample comprises 139 employed and unemployed men. Using standardized psychological questionnaires with a semi-structured interview schedule, the psychological consequences of unemployment are examined in relation to other psychosocial variables. The results showed that the unemployed group had lower levels of psychological well-being, self-esteem, and employment commitment with high external beliefs, than the employed group. Length of unemployment was a significant determinant of psychological well-being and respondents with a longer period of unemployment had a lower level of psychological well-being than those who had been unemployed for a shorter period. The findings are examined in the context of existing empirical evidence, and the need to examine the psychological impact of unemployment among other British Asian groups is emphasized. ReprintAddress:M. Shams, Department of Psychology,Facultyof Health Care and Social Studies, University of Luton, Park Square, Luton, Bedfordshire LU1 3JU, UK~
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Psychological Medicine (continued) 171-0204
The Differential Response of Chronic Fatigue, Neurotic and Muscular Dystrophy Patients to Experimental Psychological Stress Wood, G.C., Bentall, R.P., Gopfert, M., Dewey, M.E., and Edwards, R.H.T. 24:357-364, 1994. A group of patients suffering from chronic fatigue (CF) attending a medical clinic were compared with a group of muscular dystrophy (MD) patients from the same clinic and a psychiatric control (PC) group who were attending a psychiatric unit. A checklist was used to assess the patients' subjective physical and psychological state before and after exposure to a psychological stressor. For both physical and psychological symptoms the CF group had the largest response, the PC group was intermediate, and the MD group had the least response. Explanations may involve physiological arousal and attentional focusing. Reprint Address: G.C. Wood, Avondale Unit, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 4HT, UK.
171-0205
Complaintsof Cognitive Decline in the Elderly: A Comparison of Reports by Subjects and Informants in a Community Survey Jorm, A.F., Christensen, H., Henderson, A.S., et al. 24:365-374, 1994. In a community survey, subjects and their informants were asked the same questions about memory and intellectual decline in the subjects. Subjects and informants both commonly reported cognitive decline, although in most cases the decline was not seen as interfering with daily life. However, when responses from subjects and informants were cross-tabulated, agreement was found to be poor. For subjects, reports of cognitive decline were correlated with anxiety and depression symptoms and with trait neuroticism. Subjects' reports were uncorrelated with age and only weakly correlated with cognitive test performance, indicating little validity. By contrast, informants' reports were correlated with the subjects' cognitive test performance and age, but also with the informants' own anxiety and depression symptoms. Although informants' reports have validity, they may also be contaminated by the informants' affective state. ReprintAddress:A.F. Jorm, NI-I&MRCSocial Psychiatry Research Unit, The Australian National University, Canberra, ACT 0200, Australia.
A Longitudinal Study of Bereavement Phenomena in Recently Widowed Elderly Men Byme, G.J.A. and Raphael, B. 24:411--421, 1994. A three-phase longitudinal design was used to study bereavement phenomena in a cohort (N = 78) of recently widowed elderly Australian men. One group of 57 widowers was compared with a second group of 21 widowers on a waiting list. A brief, interviewer-administered, structured questionnaire was used to rate the frequency of 22 self-reported bereavement phenomena. The prevalence and temporal evolution of these phenomena are described. Half of a subgroup of elderly widowers reporting high levels of bereavement phenomena at 6 weeks post-bereavement went on to exhibit persistent or chronic grief at 13 months post-bereavement. The prevalence of persistent
or chronic grief throughout the first 13 months post-bereavement was 8.8%. Income, education and expectedness of the death were all negatively correlated with frequency of self-reported bereavement phenomena at 6 weeks post-bereavement. In a multiple regression analysis only expectedness of the death contributed significantly to prediction of the frequency of bereavement phenomena at 6 weeks post-bereavement. Widowers who were unable to anticipate their wife's death, even when their wife had suffered a long final illness, had a more severe bereavement reaction. Reprint Address: G.J.A. Byrne, Department of Psychiatry, The University of Queensland, Room El5, Clinical Sciences Building, Royal Brisbane Hospital, Herston, QSL 4029, Australia.
171-0207
Diminished Recall and the Cohort Effect of Major Depression: A Simulation Study Ginffra, L.A. and Risch, N. 24:375-383, 1994. Several large-scale epidemiological surveys have reported increasing lifetime rates of psychopathology among recently born cohorts. In the case of Major Depressive Disorder (MDD) younger cohorts tend to manifest higher lifetime prevalences of the condition than older cohorts, at any given age. In some studies, cohort differences are so large that the youngest cohort exceeds the lifetime prevalence of the oldest cohort well before passing through their total period of risk. The data on lifetime prevalences that support the existence of secular differences, however, has typically been collected in cross-sectional studies. Thus, individuals are interviewed at a single point in time and asked to recall all prior psychopathology. Due to poor recall, this design may greatly underestimate earlier experiences. In fact, cohort differences are not limited to MDD; similar results have been reported for a wide range of psychopathology, suggesting methodological problems at data collection. We have conducted a simulation study to examine the magnitude of annual rates of forgetting that could produce the secular trends reported for MDD. Small, but constant annual rates produce striking, 'cohort effect-like' curves. The rates needed to reconstruct the reported effect are compatible with published values for test-retest studies of lifetime recall of MDD. This simulation study does not rule out the existence of a cohort effect in some psychiatric disorders, but stresses the possible limitations of using crosssectional studies to investigate secular trends. Reprint Address: L.A. Giuffra, Department of Psychiatry, Washington University School of Medicine, The Jewish Hospital of St. Louis, 216, South Kingshighway, St. Louis, MO 63110.
171-0206
171-0208
An Unusual Presentation of Multiple Sclerosis
Hotopf, M.H., Pollock, S., and Lishman, W.A. 24:525-528, 1994. Two male patients who presented with unusual pictures of dementia in the absence of other obvious symptoms or signs are reported. Investigations demonstrated changes highly suggestive of multiple sclerosis (MS) on magnetic resonance imaging, cerebrospinal fluid analysis and electrophysiological tests. We suggest this represents a rare presentation of multiple sclerosis. Reprint Address: W.A. Lishman, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.
V O L U M E 17, N U M B E R 1, 1995
PSYCHOLOGY AND HEALTH
171-0209
Optimism, Vulnerability, and Self-Beliefs as Health-Related Cognitions: A Systematic Overview Schwarzer, R. 9(3):161-180, 1994. This paper disentangles a number of closely related cognitions by dividing them into the categories of defensive and functional optimism. Optimistic biases in risk perception are discussed that may represent barriers in the adoption of preventive health behaviors. Instead of defensive optimism, some sense of vulnerability is seen as indispensable for behavioral change operating jointly with beliefs about positive health outcomes, instrumental actions, and appropriate coping resources. A distinction is made between three kinds of functional optimism that depend either on attributional style, outcome expectancies, or personal agency. Findings are presented that corroborate the strength of these constructs in predicting health outcomes. In terms of health behavior change, it is argued that optimistic self-beliefs are the most beneficial because of their operative power that helps to set goals, initiate actions, and maintain motivation. Reprint Address: R. Schwarzer, Institut fib"Psychologie, FB 12, WE 7, Freie Universit~t Berlin, Habelschwerdter Allee 45, 14195 Berlin, Germany. 171-0210
The Relationship between Loneliness, Interpersonal Competence, and Immunologic Status in HIV-Infected Men Straits-TrYster, K.A., Patterson, T.L., Semple, S.J., et al. 9(4):205-219, 1994. The relationships among interpersonal competence, loneliness, depression, and immune status were examined in HIVinfected men and healthy controls. A sample of 108 men [88 HIV-I antibody seropositive (HI'V+) and 20 HIV-1 antibody seronegative (HIV-)] completed the Interpersonal Competence Questionnaire at baseline and the UCLA Loneliness scale at two consecutive six-month timepoints as part of the psychosocial component of the HIV Neurobehavioral Research Center longitudinal study. Absolute number of CD4+ helper cells and depression were determined at baseline. Among seropositive men, loneliness was negatively correlated with self-perceived competence in all five relationship domains assessed: initiation of social interactions, turning down unreasonable demands (negative assertion), self-disclosure, providing emotional support to others, and conflict management. Competence or level of comfort in initiation of social interaction and management of interpersonal conflict accounted for 39% of the variance in loneliness at baseline. Level of comfort in initiation of interactions and self-disclosure accounted for 44% of the variance in loneliness at followup. After controlling for loneliness at baseline, an additional 12% of the variance in loneliness at followup was accounted for by all domains of interpersonal competence, suggesting that these dimensions of social skill may be partial determinants of loneliness. High-lonely HIV+ men had significantly fewer CD4 + helper cells than did low-lonely HIV + men. The relationship between loneliness and CD4 + cell number was
95
independent of stage of HIV disease. Lonely HIV+ men may be at greater risk for disease progression. Clinical intervention efforts to reduce loneliness and increase quality of life should consider targeting interpersonal skills. Reprint Address: ICA. Straits-TrYster, HNRC, 2760 Fifth Avenue, Suite 200, San Diego, CA 92103.
Psychological Effects of Exercise among Adult Women: The Impact of Menopausal Status Slaven, L. and Lee, C. 9(4):297-303, 1994. 171-0211
The psychological and physical benefits of regular physical activity are well established, but the majority of research to date has focused on younger male samples. Two studies examined the impact of menopausal status on the ability of women to derive psychological benefits from exercise. Regular exercisers, assessed immediately following an exercise class, scored significantly lower on negative mood dimensions and higher on positive mood than did non-exercisers, regardless of menopausal status. Regular exercisers also showed significant improvements in mood state when assessed before and after a single exercise session; again this effect was independent of menopausal status. The results suggest that the acute mood-enhancing effects of exercise are maintained despite the endocrine changes associated with menopause. It is argued that encouraging menopausal women to adopt appropriate exercise patterns may assist in the alleviation of psychological distress as well as providing physical benefits. Reprint Address:C. Lee, Department of Psychology, University of Newcastle, Callaghan NSW 2308, Australia.
171-0212
Effects of a Post-Hospitalization Group Health Education Programme for Patients with Coronary Heart Disease van Elderen, T., Maes, S., Seegers, G., Kragten, H., and Relik-van Wely, L. 9(4):317-330, 1994. A health education programme was offered to groups of coronary heart patients and their partners after discharge from hospital. A randomized pre-test post-test control group design was used to evaluate the effects of this experimental intervention. The health education programme was offered to 109 coronary heart patients in groups of between five and eight patients together with their partners in addition to standard medical care and physical training. A control group of 108 patients received only standard medical care and physical training. The intervention consisted of eight weekly two-hour group health education sessions and one follow-up session. All sessions focused on the promotion of healthy habits and the reduction of adverse psychosocial consequences of the incident. In the short term (about four months after the inciden0 the health education programme showed statistically significant intervention effects on knowledge about coronary heart diseases, smoking cessation, healthy eating habits and the number of consultations with the family physician, but no effects on emotional distress. In the long term (one year after the incident) there was only a significant intervention effect on smoking cessation. These results suggest that the effects of the programme are modest, especially in terms of maintenance of behavioural change. As a consequence, it is suggested that the programme should not be offered to all cor-
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ANNALS OF BEHAVIORAL MEDICINE
Psychology and Health (continued) onary patients during cardiac rehabilitation, but only to those who can be expected to profit most from it. Reprint Address: T. van Elderen, Department of Clinical and Health Psychology, University of Leiden, P.O. Box 9555, 2300 RB Leiden, The Netherlands.
PSYCHOSOMATIC
171-0213
MEDICINE
known history of coronary heart, or other atherosclerotic, disease. The percentage of subjects reporting that they snore "usually" or "always/loudly" increased across the four CAD severity groupings (nonpatient controls = 19.6%, 1 vessel = 44.4%, 2 vessel = 41.9%, 3 vessel = 56.0%) with a p value of .005. Hypertension, body mass index, and pack years of smoking were found to be associated with both coronary artery disease severity and snoring. When these variables were controlled in a multiple regression analysis, the relationship of snoring and CAD severity remained significant at p = .050. Reprint Address: M.W. Ketterer, Henry Ford Hospital/CFP3, 2799 West Grand Boulevard, Detroit, MI 48202.
Quantifying and Predicting Recovery after Heart Surgery
Jenkins, C.D., Stanton, B.-A., and Jono, R.T. 56:203-212, 1994. The validity of the biopsychosocial approach to the study of health and illness is reaffirmed by the prospective findings of the Recovery Study. This is a multidisciplinary examination, conducted in four teaching hospitals, of the predictors of symptoms of cardiac illness in 463 patients 6 months after coronary artery bypass or cardiac valve surgery. We found that the following preoperative measures predict freedom from cardiac symptoms 6 months after surgery: low levels of all of the following: angina pain, shortness of breath, fatigue and sleep problems, lifetime cigarette usage, and preoperative hospitalization for cardiac treatment; low levels of anxiety, depression, and hostility, and few life change events; high levels of all of the following: self-esteem, well-being, vigor; prevalence of activities and hobbies, social participation, and social support. The six variables in bold print contributed independently in a multiple regression equation that accounted for 21% of the variance of the symptoms score and was associated with an estimated 45% difference in success of recovery. The statistical strength and general nature of many of the predictors indicate that the predictors may also be important in recovery from other health crises. Psychosocial and biomedical factors correlate across time (predictively), as well as cross-sectionally, indicating that psychological, social, and biological mechanisms may be parts of a single general multifaceted process influencing recovery of health. A clinical trial could determine if psychological, social, or behavioral interventions will hasten and improve recovery from physical illness or trauma. Reprint Address: C.D. Jenkins, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX 77555-1053.
SCANDINAVIAN JOURNAL OF BEHAVIOUR THERAPY
171-0215
Coping Strategies Questionnaire (CSQ): Reliability of the Swedish Version of the CSQ
Jensen, I.B. and Linton, S.J.
171-0216
Functional Analysis of Hearing Handicap
Andersson, G. and Melin, L.
171-0214
Snoring and the Severity of Coronary Artery Disease in Men
Ketterer, M.W., Brymer, J., Rhoads, K., Kraft, P., and Kenyon, L. 56:232-236, 1994. Previous studies have found associations between snoring, or polysomnographic documented sleep apnea, and hypertension, cerebral vascular disease, and myocardial infarction. The present study examined the relationship of coronary artery disease (CAD) and snoring. One hundred and twenty-two males with positive angiographic studies were compared with fifty-six men, matched in age and socioeconomic status, who had no
22(3-4):139-145, 1993.
We present a study with the aim of investigating the internal consistency and reliability of a Swedish version of the Coping Strategies Questionnaire (CSQ). The study group consisted of 282 subjects suffering from long term back pain. Internal consistency was investigated by calculating alpha coefficients and test-retest reliability was investigated by a correlation analysis with two different test-related intervals. The results reveal that the internal consistency of the Swedish CSQ is high (alpha range between 0.7 and 0.8) and consistent with the American version. The test-retest reliability was not equally satisfactory (correlation ranged between 0.4 and 0.9) but the results support the usefulness of the CSQ as a tool in the clinical assessment of pain coping strategies. The test-retest results indicate the need for further research. In conclusion, the results from the present study are encouraging and support the usefulness of the instrument but to improve the utility and application of the Swedish version of the CSQ further research is warranted. Reprint Address: I.B. Jensen, Folksam Research, Folksam, S-106 60 Stockholm, Sweden.
22(3-4):147-157, 1993.
Rehabilitation of patients with hearing impairment is rarely based on functional analysis of specific target situations, needs, and treatment goals. In this paper a behavioural approach to hearing disability is presented and exemplified with a singlecase description of a 70 years old male who was given a brief behavioural treatment according to the results of functional analysis. Self-ratings of hearing disability at pretreatment, posttreatment, and at a 15-month follow-up showed favourable effects of the treatment, whereas no effects were found on a measure of dispositional optimism. Reprint Address: G. Andcrsson, Department of Clinical Psychology, Uppsala University, Box 1225, S-751 42 Uppsala, Sweden.
V O L U M E 17, N U M B E R
1, 1995
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Scandinavian Journal of Behavior Therapy (continued) 171-0217
Voluntary Blood Pressure Control: Operant Conditioning by a Continuous Blood Pressure Feedback Technique Weitkunat, R., Brody, S., Knost, B., et al. 22(3-4):179-191, 1993. The present study evaluated a single session operant conditioning of blood pressure in borderline hypertensives. A double blind randomized two period (each lasting for 20 minutes) cross over study consisting of a treatment (operant conditioning of mean arterial blood pressure) and a control condition (heart rate) was performed. Sequence of treatments was randomly assigned. Fourteen borderline hypertensive subjects participated and were trained to decrease their continuously measured blood pressure (Finapres) and heart rate. Subjects receiving blood pressure feedback during the first session showed a significant (4.3 mmHg) decrease in diastolic blood pressure. In contrast, subjects receiving blood pressure training during the second session showed a non-significant increase in diastolic blood pressure. Treatment consisting of more sessions is a promising adjunct to antihypertensive regimens. Reprint Address: H. Rau, Eberhard-Karls-University of Tiibingen, Institute for Medical Psychology and Behavioral Neurobiology, Gartenstrasse 29, D 72074 Tfibingen, Germany.
171-0219
An International Comparison of Back Surgery Rates Cherkin, D.C., Deyo, R.A., Loeser, J.D., Bush, T., and Waddell, G. 19(11):1201-1206, 1994.
Summary of Background Data. Although high geographic variation in back surgery rates within the United States have been documented, international comparisons have not been published. Methods. The authors compared rates of back surgery in eleven developed countries to determine if back surgery rates are higher: l) in the United States than in other developed countries, 2) in countries with more neurologic and orthopaedic surgeons per capita, and 3) in countries with higher rates of other surgical procedures. Data on back surgery rates and physician supply were obtained from health agencies within these eleven countries. Country-specific rates of other surgical procedures were available from published sources. Results. The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country. Countries with high back surgery rates also had high rates of other discretionary procedures such as tonsillectomy and hysterectomy. Conclusions. These findings illustrate the potentially large impact of health system differences on rates of back surgery. Better outcome studies, however, are needed to determine whether Americans are being subjected to excessive surgery or if those in other developed countries are suffering because back surgery is underutilized.
SPINE 171-0220
171-0218
The Cost of 1989 Workers' Compensation LOw Back Pain Claims Webster, B.S. and Snook, S.H. 19(10):1111-1116, 1994.
Study Design. Cost data were gathered from computerized records of the Liberty Mutual Insurance Company for low back pain workers' compensation claims (N -- 119,107) and for all claims (N = 731,087) initiated from 45 jurisdictions (states) during 1989. Objective. This study provided more current, accurate, and additional information to estimate the costs and incidence associated with compensable low back pain compared with all compensation claims. Methods. The first group of data included all compensable low back claims selected by specific codes: body part codes consisted of low back area, sacrum and coccyx, disc, and multiple trunk; injury codes consisted of strain, sprain, inflammation, rupture, hernia, fracture, and contusion. The second sample included all compensable claims, including both occupational injuries and illnesses. Results. Low back pain cases represented 16% of all claims but 33% of all claims costs; 55.4% of the low back pain cases received medical payments only (i.e., did not receive indemnity payments for lost time). The mean cost per case for low back pain was $8321; median cost per case was $396. Medical costs represented 32.4% of the total costs; indemnity costs (i.e., payment for lost time) represented 65.8%. Conclusions. Since indemnity costs represent the greatest percentage of workers' compensation expenditure, the primary goal of low back pain management should be the prevention or reduction of prolonged disability.
Low Back Pain Hospitalization: Recent United States Trends and Regional Variations Taylor, V.M., Deyo, R.A., Cherkin, D.C., and Kreuter, W. 19(11):1207-1213, 1994.
Study Design. This study describes recent United States trends and regional variations in the management of low back pain. Objectives. The authors investigated recent temporal trends and compared practices in different geographic regions. Summary of Background Data. Controversy exists concerning the appropriate medical and surgical management of patients with low back pain. Methods. National Hospital Discharge Survey data from 1979 through 1990 were analyzed. Case selection was based on previously developed algorithms intended to exclude nonmechanical causes of back pain. Results. Over the period of study, nonsurgical hospitalizations for low back pain decreased dramatically. In contrast, low back operation rates, particularly for fusion surgery, increased substantially. In recent years, surgery and hospitalization rates were highest in the South and lowest in the West. Conclusions. Rapidly increasing surgical rates and wide geographic variations suggest the need for a more consistent approach to back problems. 171-0221
Successful Treatment of Low Back Pain and Neck Pain after a Motor Vehicle Accident Despite Litigation Schofferman, J. and Wasserman, S. 19(9): 1007-1010, 1994.
Objective. This prospective study evaluated 39 consecutive patients with low back pain (LBP) or neck pain that resulted
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ANNALS OF BEHAVIORAL MEDICINE
Spine (continued) from a motor vehicle accident who had litigation pending. Methods. Patients completed a McGill Pain Questionnaire (MPQ) to quantify pain and an Oswestry Low Back Disability Questionnaire (OSW) to quantify function and were interviewed regarding medications and work status at initial and final visits. Results. Thirty-three patients completed an MPQ at initial and final visits. Pain decreased in 29 (88%) and increased in four (12%). Thirty-eight patients completed at OSW at initial and final visits. Function improved in 34 and worsened in four. The authors observed statistically significant improvements in pain, function, and medication use. Conclusion. Patients with low back pain or neck pain resulting from a motor vehicle accident showed a statistically significant improvement with treatment despite ongoing litigation. 171-0222
Development of the Hispanic Low Back Pain Symptom Check List Leavitt, F., Gilbert, N.S., and Mooney, V. 19(9): 1048-1053, 1994. Study Design. The Low Back Pain Symptom Check List identifies psychological disturbance in patients with low back pain. This report traces the development of a translation for Hispanic populations. Objective. The study explores the reliability and assesses the equivalence of the translation in providing pain and psychological information. Summary of Background Data. A number of psychometric measures appear suitable for routinely assessing psychological disturbance among back injured patients. Unfortunately, there are few measures with language translations that can be applied to Hispanic populations. Methods. In study 1, the English form was translated by two bilingual physicians. In study 2, reliability was examined using Cronbach's measure of internal consistency. In study 3,
the equivalence of the Hispanic and English forms in predicting treatment outcome was examined. Results. Coefficient alphas and mean pain scores were similar for the English and Hispanic forms. Overall agreement between the two forms in tracking psychological disturbance was 91%. The Hispanic form was equally accurate in predicting treatment outcome. Conclusions. The Hispanic form is reliable and provides pain and psychological information much like the English form. 171-0223
Group Education Interventions for People with Low Back Pain: An Overview of the Literature Cohen, J.E., Goel, V., Frank, J.W., et al. 19(11):1214-1222, 1994. Study Design. This study systematically reviewed the literature on group education for people with low back pain. Findings are considered in relation to parameters such as the characteristics of the study participants, the intervention, and the setting. Objective. To make a recommendation regarding the effectiveness of group education as an intervention for people with low back pain. Results. Based on a systematic search of the literature, 13 primary studies are cited; 6 of these were sufficiently well designed and executed for their findings to be considered. Of the four quality studies with chronic back pain subjects, only one found a positive short-term effect on one of the outcome measures considered (pain intensity). In the two studies with acute cases, group education was found by one of the studies to reduce pain duration and initial sick leave duration in the short term, but the intervention also included work-site visits. At 1 year of follow-up, there was no evidence in the six studies of clinically important benefits on any of the outcome measures. Conclusions. There is insufficient evidence to recommend group education for people with low back pain.
A c a d e m i c Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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A m e r i c a n Journal o f Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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A m e r i c a n Journal o f Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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A m e r i c a n Journal o f Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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A m e r i c a n Journal o f Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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A m e r i c a n Journal o f Public Health
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Annals o f Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Annals o f the R h e u m a t i c Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Archives o f Neurology
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Archives o f Physical Medicine and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Archives o f Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Arthritis Care and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Arthritis and R h e u m a t i s m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Behavioral Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Behaviour Research a n d T h e r a p y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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British Journal o f Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Cephalalgia
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Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Child D e v e l o p m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Clinical Journal o f Pain
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Diabetes Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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The Diabetes Educator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Gastroenterology
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The Gerontologist
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Headache Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Health Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Health and Social W o r k . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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International Journal o f Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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International Journal o f Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f A b n o r m a l Child Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f A b n o r m a l Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f Adolescent Health
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Journal o f A d v a n c e d Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f the A m e r i c a n A c a d e m y o f Child a n d Adolescent Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f the A m e r i c a n Dental Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f Behavioral Medicine
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Journal o f Clinical Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f Consulting a n d Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f E p i d e m i o l o g y a n d C o m m u n i t y H e a l t h
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Journals o f G e r o n t o l o g y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Journal o f Occupational Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8l
Journal o f Pain a n d S y m p t o m M a n a g e m e n t
82
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Journal o f Sex Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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T h e Lancet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
84
Neurology
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Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Patient Education a n d Counseling
90
Physical T h e r a p y
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Psychological Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
92 93
Psychology a n d H e a l t h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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P s y c h o s o m a t i c Medicine
96
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S c a n d i n a v i a n Journal o f B e h a v i o u r T h e r a p y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Subject I n d e x . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
99
ademic performance, stress, and social support included factor analysis, hierarchical multiple-regression analysis, and Pearson correlational analysis. Results. Data from 120 students (78% of the cohort) were used for correlational analysis. Of these students, 79 (66%) were men and 41 (34%) were women. Because eight of the questionnaires contained incomplete data, 112 questionnaires (73%) were used for multiple-regression analysis. No buffering effect was found for social support. Rather, social support from outside the medical school explained significant variance in academic performances and in role stress. Higher levels of outside support were associated with poorer clerkship grades for women, but with lower levels of stress for men. Also, total support (outside and inside combined) was negatively related to clerkship grades for the entire sample. Conclusion. The results suggest that contrary to the study's hypotheses, social support in general is related to lower levels of academic performance for both men and women, and that the negative effects of support from outside the medical school context may be particularly salient for women. These results are understandable given the nature of medical training, which places great demands on students' time. Therefore, it may be more appropriate for medical schools to promote time-management strategies than supportbuilding interventions, especially for women.
ACADEMIC MEDICINE
171-0001
Medical Education about Substance Abuse: Changes in Curriculum and Faculty between 1976 and 1992 Fleming, M., Barry, K., Davis, A., et at. 69:362-369, 1994. Purpose. To examine changes in substance abuse education in U.S. medical schools between 1976 and 1992. Methods. In 1991-92 the authors conducted a 16-year follow-up survey of six clinical departments in each of the 126 U.S. medical schools. Two previous surveys by scholars and surveys conducted by the Liaison Committee on Medical Education, Association of American Medical Colleges, and the National Center for Medical Fellowships in the Addictions provided baseline data for comparison. The statistical methods used in the comparisons were paired t-tests, one-way analyses of variance, and tests of differences between proportions. Results. Significant increases were found in the numbers of required and elective curriculum units for medical students between 1986-87 and 1991-92. The number of medical schools requiring courses in substance abuse treatment increased from five to eight between 1986-87 and 1991-92. For residents, there were significant increases in the numbers of curriculum units for residents in family medicine and pediatrics. The average number of faculty in the I 16 medical schools that reported units on substance abuse was 4. I. There were 45 fellowships in addiction medicine identified in 199192, with a total of 61 fellows in training. Conclusion. While the findings confirm positive changes, the amount of curricula time and the number of faculty having expertise in substance abuse education do not compare well with the amounts of time and numbers of faculty involved in clinical problems of similar prevalence, such as cancer and heart disease. Reprint Address:M. Fleming, Office of Alcohol and Addiction Studies, Department of Family Medicine, 777 South Mills, Madison, W153715.
171-0002
AMERICAN JOURNAL OF CARDIOLOGY
171-0003
Moderate- and High-Intensity Exercise Lowers Blood Pressure in Normotensive Subjects 60 to 79 Years of Age Braith, R.W., Pollock, M.L., Lowenthal, D.T., Graves, J.E., and Limacher, M.C. 73:1124-1128,1994. To investigate the effects of exercise intensity on resting blood pressure (BP) in normotensive elderly subjects, 44 sedentary healthy subjects aged 60 to 79 years of age were studied during 6 months of walking exercise. Subjects were ranked according to maximal oxygen consumption and randomly stratified to groups that trained at 70% (n = 19) or 80% to 85% (n = 14) of maximal heart rate reserve, or to a control group (n = 11) that did not train. Initial BP was established during a 2- to 3-week control period. During the first 3 months, both exercise groups progressed to 70% of heart rate reserve for 40 minutes 3 times each week. The moderate-intensity group continued to train at 70% (45-minute duration) for an additional 3 months, whereas the high-intensity group progressed to training at 85% of heart rate reserve (35-minute duration). Maximal oxygen consumption increased (13 -< 0.05) during the initial 3 months in both exercise groups (25.2 to 28.1 ml-kg-' .min -~ and 26.3 to 29.3 ml.kg-~.min -t) and continued to increase (13 -< 0.05) after 3 additional months of training, but the increase was greater (p -< 0.05) in the high-intensity group (28.1 to 29.4 ml-kg -~. rain -~ and 29.3 to 32.8 ml.kg -~ .min-~). Systolic BP decreased (p -< 0.05) similarly at 6 months in both training groups (120
Effects of Social Support on Medical Students' Performances
Rospenda, K.M., Halpert, J., and Richman, J.A. 69:496-500, 1994. Background. Stress among medical students has been linked to poor academic performance, while supportive social relationships have been associated with the alleviation of psychological stress. This study examines social support as a potential buffer against stress and hence as a potential strengthener of students' academic performances. Method. A cohort of 153 thirdyear students at the University of Illinois College of Medicine at Chicago was asked in the fall of 1990 to complete a questionnaire assessing role stress (stress involving competing demands between school and social and/or family life), social support, and sources of support (outside or inside medical school). Grades for the five major clerkships through which all the students rotated during their third year were collected from student transcripts. Statistical analyses of the relationships among ac43
44
ANNALS OF BEHAVIORAL MEDICINE
American Journal of Cardiology (continued) to 111 m m Hg and 120 to 112 mm Hg). Diastolic BP also decreased (p -< 0.05) similarly at 6 months in both training groups (72 to 64 m m Hg and 75 to 68 mm Hg). Resting heart rate decreased (p -< 0.05) to the same magnitude at 6 months in both training groups (71 to 66 beats/rain and 69 to 63 beats/ rain). Body weight did not change in any group (p >_ 0.05). The sum of 7 skinfold fat measures decreased (p -< 0.05) similarly at 6 months in both training groups 075 to 164 m m and 173 to 159 ram). Our data indicate that walking exercise between 70% and 85% of heart rate reserve lowers resting BP in normotensive elderly subjects, and produces a moderately favorable conditioning benefit similar to that observed in younger persons. Reprint Address: R.W. Braith, Department of Physiology, P.O. Box 100274, College of Medicine, University of F'lorida, Gainesville, FL 32610.
171-0004
Abnormal Autonomic Control of the Cardiovascular System in Syndrome X Rosano, G.M.C., Ponikowski, P., Adamopoulos, S., et al. 73:1174-1179, 1994. Anomalies of autonomic control of the coronary circulation may play a role in the development of syndrome X (angina pectoris, ischemic-appearing results on exercise test, and normal coronary arteriograms). Twenty-six patients with syndrome X and 20 healthy sex- and age-matched control subjects were studied by means of analysis of heart rate variability during 24-hour Holter monitoring. Spectral and nonspectral parameters of heart rate variability were investigated. Mean heart rate was similar in patients with syndrome X and in control subjects. Patients with syndrome X had significantly lower standard deviation of all normal RR intervals, a lower percentage of adjacent normal RR intervals >50 ms in difference 026.4 -+ 22 vs 149 _+ 43 ms, p < 0.05; 6.3 -+ 4 vs l 1.2 _+ 7%, p < 0.05; respectively), and a trend toward lower values of time-domain parameters. Lower values of total power and low frequency were also observed in patients with syndrome X (1273 +_ 693 vs 1790 _+ 989 ms 2, p < 0.05; 406 _+ 176 vs 729 _+ 455 ms 2, p < 0.01, respectively). An inverse correlation between heart rate and measures of heart rate variability was found in syndrome X but not in control subjects. High- and low-frequency power showed a similar circadian pattern in syndrome X patients and control subjects. Patients and control subjects were then allocated into 2 groups according to the median RR duration: syndrome X 1 and control 1 with high mean heart rate, and syndrome X2 and control 2 with low mean heart rate. The syndrome X 1 group had a significantly lower standard deviation of all normal RR intervals, root-mean-square difference of successive RR intervals, percentage of adjacent normal RR intervals > 50 ms different, and high and low frequency than did the syndrome X2, control l, and control 2 groups. In conclusion, patients with syndrome X have a sympathovagal balance shifted toward sympathetic predominance that is more evident in those with an increased mean heart rate. This dysfunction appears to persist throughout the 24 hours and may indicate heterogeneity in autonomic function in syndrome X. Reprint Address: G.M.C. Rosano, Department of Cardiac Medicine, National Heart & Lung Institute, Dovehouse Street, London SW3 6LY, UK.
AMERICAN JOURNAL OF EPIDEMIOLOGY
171-0005
A Case-Control Study of Oral Contraceptive Use and lnvasive Epithelial Ovarian Cancer Rosenberg, L., Palmer, J.R., Zauber, A.G., et al. 139(7):654-661, 1994. The relation of oral contraceptive use to the risk of ovarian cancer was assessed with data collected during 1977-1991 from patients under 65 years of age in hospitals in Boston, New York, Philadelphia, and Baltimore. We compared 441 women with recently diagnosed invasive epithelial ovarian cancer to 2,065 control women. Logistic regression was used to control risk factors for ovarian cancer. The multivariate relative risk estimate decreased with the increasing duration of oral contraceptive use (p < 0.05): the estimate was close to 1.0 for duration categories of less than 3 years; it was reduced for the categories of 3--4 years of use and greater, but it did not decline further as the duration of use increased. For ->3 years of use, the estimate was 0.6 (95% confidence interval 0.4-0.8). The inverse association of risk with >_3 years of use was consistently present across categories of age, parity, interview year, and geographic area. It was apparent for as long as 15-19 years after cessation. Many different specific oral contraceptive formulations appeared related to a decreased risk; however, data were sparse for the newer types, particularly phasic preparations, and the ability to assess specific preparations in the context of use of multiple preparations was limited. The present data confirm previous reports of an inverse association of ovarian cancer risk with oral contraceptive use of several years in duration. They also suggest that the association may persist for as long as two decades and that it is not confined to any particular type of oral contraceptive formulation. Reprint Address: L. Rosenberg, Slone Epidemiology Unit, 1371 Beacon Street, Brooldine, MA 02146.
171-0006
Menopausal Hormone Usage and Breast Cancer in Saskatchewan: A Record-Linkage Cohort Study Riseh, H.A. and Howe, G.R. 139(7):670-683,1994. The association between the occurrence of carcinoma of the breast and previous usage of menopausal estrogens, progestins, and oral contraceptives is examined in a record-linkage study using the Saskatchewan Health Prescription-Drug-Plan Database. Saskatchewan Health is a governmental agency that funds publicly insured health care for essentially all residents of the province. For this study, all women aged 43-49 years in 1976 resident in Saskatchewan were identified from the Saskatchewan Health master registration file. These women were linked by registration beneficiary number to the Drug-Plan Database for the period from January 1976 to June 1987 and to the Provincial Cancer Registry Database for the period from March 1960 to December 1990. The fact and date of death or emigration from the province were obtained through the annual updates ofthe health plan. Of the 33,003 women initially in the cohort, 213 had a breast cancer diagnosed before 1976 and were
V O L U M E 17, N U M B E R 1, 1995
45
American Journal of Epidemiology (continued) omitted from this analysis. Between 1976 and 1990, 742 new primary breast cancer cases occurred. Women taking estrogens unopposed by progestins had an elevated risk of breast cancer, the risk increasing by 7% (relative risk ~ 1.072, 95% confidence interval 1.02-1.13; p = 0.008) for each 252 tablets used (approximately 1 year of use). Usage of estrogens opposed by progestins showed no association with risk (p = 0.48). Women taking oral contraceptives during this follow-up period also had a higher risk, increasing by 14% (relative risk = 1.144, 95% confidence interval 1.05-1.24; p -- 0.002) for every 252 tablets used. These 1-year risk elevations are small but become appreciable at longer durations. For example, at 5 years of unopposed estrogen use, the relative risk is 1.42; for 5 years of oral contraceptive use, it is 1.96. 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.
171-0007
Physical Activity in Older Middle-Aged Men and Reduced Risk of Stroke: The Honolulu Heart Program Abbott, R.D., Rodrignez, B.L., Burchfiel, C.M., and Curb, J.D. 139(9):881-893, 1994. From 1965 to 1968, the Honolulu Heart Program began following 8,006 men in a prospective study of cardiovascular disease. At the time of study enrollment, an estimate of current 24-hour habitual physical activity was collected from each subject. On the basis of a calculated physical activity index, subjects were classified as being inactive, partially active, or active. This report examines the relation between the levels of physical activity and stroke that occurred among 7,530 of the men over 22 years of follow-up. Risk of stroke was examined separately in younger (45-54 years) middle-aged men and older (55-68 years) middle-aged men. Among the older men, those who were inactive or partially active experienced a three- to fourfold excess incidence of hemorrhagic stroke as compared with active men (p < 0.01). There was a two- to threefold excess ofintracerebral hemorrhage in men who were inactive or partially active as compared with those who were active (p < 0.05). An excess of subaraclmoid hemorrhage was observed in inactive older men, with only one event occurring in those who were active (p < 0.05). After exclusion of subjects with hypertension, diabetes mellitus, and left ventricular hypertrophy, the relative risk of hemorrhagic stroke for inactive men versus active men was 3.7 (95% confidence interval (CO 1.3-10.4). In older men who did not smoke cigarettes, the relative risk of thromboembolic stroke among inactive men versus active men was 2.8 (95% CI 1.2-6.7), and when partially active older men were compared with those who were active, the relative risk was 2.4 (95% CI 1.0-5.7). These findings persisted after control for the residual effects of systolic blood pressure and other risk factors for stroke. Benefits of physical activity in reducing the risk of thromboembolic stroke were not observed in men who smoked cigarettes. The authors conclude that physical activity may be important in reducing the risk of stroke, particularly among nonsmoking men in older middle age. Reprint Address:R.D. Abbott, Division of Biostatistics, Department of Medicine, Box 432, University of Virginia School of Medicine, Charlottesville, VA 22908.
171-0008
Maternal Smoking during Pregnancy as a Predictor of Lung Function in Children Cunningham, J., Dockery, D.W., and Speizer, F.E. 139(12):1139-1152, 1994. Recent studies have suggested that prenatal exposure to environmental tobacco smoke may lead to lower lung function in infants. The authors examined the relation of maternal smoking during prenancy to persistent deficits in the lung function of older children. Subjects were 8,863 nonsmoking white children aged 8-12 years from 22 North American communities. Information on maternal smoking was provided by the child's mother. Pulmonary function testing of the children was conducted at school in 1988-1991. Children whose mothers smoked during pregnancy, whether or not they still smoked in the year prior to the study, had significantly lower lung function than did children whose mothers did not smoke in either period. On average, forced expiratory flow between 65 and 75 percent of forced vital capacity (FEF6~_Ts~), forced expiratory flow between 25 and 75 percent of forced vital capacity (FEF25_75~),and forced expiratory volume in 3/4of a second (FEV070 were 5.7%, 4.9%, and 1.7% lower, respectively, for children whose mothers smoked during pregnancy. After adjusting for maternal smoking during pregnancy, the authors found that current maternal smoking was not associated with significant differences on any lung function measure. These results show a persistent deficit in lung function associated with maternal smoking during pregnancy that is not explained by current maternal smoking alone. The strongest effects were observed with pulmonary function measures of flow in the small airways. The authors conclude that the effects of exposure to tobacco smoking by the mother during pregnancy and/or environmental tobacco smoke exposure in the first few years of life persist into childhood and may affect the pulmonary function attained throughout the child's life. Reprint Address: D.W. Doekery, Environmental Epidemiology Program, Department of Environmental Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115.
171-0009
Higher Levels of Conditioning Leisure Time Physical Activity are Associated with Reduced Levels of Stored Iron in Finnish Men Lakka, T.A., Nyyssonen, K., and Salonen, J.T. 140(2):148-160, 1994. The authors investigated the association of the amount and intensity of conditioning leisure time physical activity with serum ferritin and blood hemoglobin concentrations in 1,743 eastern Finnish men who were aged 42-60 years during the period 1984-1989. The duration and frequency of physical activity were associated inversely with serum ferritin (p ffi 0.003 for duration and p < 0.001 for frequency) and blood hemoglobin (p = 0.002 for duration and p = 0.019 for frequency) in multivariate regression models, after adjustment for major confounders. Men in the highest quartile of duration (>2.6 hours/ week) had a 16.8% lower mean serum ferritin concentration and men in the highest category of frequency (>3 sessions/week) had a 19.9% lower mean serum ferritin concentration than men with a low duration (55 years) with the highest perceived risk, highest health media use, and highest blood pressure and cholesterol levels. The subgroup with the lowest proportion of positive changers (42%) was the least educated, was the most likely to be Hispanic, and had the lowest health knowledge and self-efficacy scores. Conclusions. The differing composition of subgroups who respond or do not respond to community cardiovascular disease interventions illustrates the need to develop specific interventions that target different age, socioeconomic, and cultural subgroups. Reprint Address: M.A. Winideby, Stanford Center for Research in Disease Prevention, Stanford University School of Medicine, 1000 Welch Road, Palo Alto, CA 94304-1885.
171-0031
The Consumption of Well-Done Red Meat and the Risk of Colorectul Cancer Muscat, J.E. and Wynder, E.L. 84(5):856-858, 1994. Heterocyclic aromatic amines and polycyclic aromatic hydrocarbons are mutagens that are produced in highly cooked meats. A case--control study of 511 patients with colorectal cancer and 500 matched control subjects examined whether consumption of well-done cooked beef is related to the risk of developing large bowel cancer. Approximately 16% of men and women consumed well-done beef, and 50% ate medium-cooked beef. For both sexes, there was no association between consumption of well-done or medium-cooked beef and colorectal cancer. This paper discusses whether questionnaire data accurately reflect dietary intake of heterocyclic aromatic amines and polycyclic aromatic hydrocarbons. Reprint Address:J.E. Muscat, Division of Epidemiology,American Health Foundation, 320 East 43rd Street, New York, NY 10017.
171-0032
Smoking and Mortality among Residents of a California Retirement Community Paganini-Hill, A. and Hsu, G. 84(6):992-995, 1994. Smoking cessation decreases mortality among the elderly. Participants in the Leisure World Cohort Study initiated in 1981 were followed until death or January 1, 1991. The 8869 women and 4999 men (median age = 73 years at initial survey) contributed 105,952 person-years of follow-up; 4002 had died. All-cause mortality rates were highest among current smokers; compared with never smokers the age-adjusted relative risks (and 95% confidence intervals) were 1.67 (1.46, 1.92) for women and 1.95 (1.66, 2.30) for men. Current smokers had increased risks of coronary heart disease, other cardiovascular disease, and cancer. Risk of death from smoking-related cancers continued to be high among former smokers, although lower than the risk among current smokers. Relative risks of mortality from cancer and cardiovascular disease increased with the number of cigarettes smoked per
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ANNALS OF BEHAVIORAL MEDICINE
American Journal of Public Health (continned) day and with a decreasing number of years since cessation of smoking. Reprint Address: A. Paganini-Hill, Preventive Medicine, University of Southern CaliforniaSchool of Medicine, 1721 GriffinAvenue #103, Los Angeles, CA 90031.
ANNALS OF NEUROLOGY
171-0033
PredictiveValue of Induction of Psychogenic Seizures by Suggestion I.ancman, M.E., AsconaI~, J.J., Craven, W.J., Howard, G., and Penry, J.IC 35(3):359-361, 1994. Induction by suggestion has previously been reported to be effective in the diagnosis of psychogenic seizures (PS). However, the sensitivity and specificity of this procedure has not previously been studied. Results of induction of PS by suggestion were analyzed in 93 patients with purely PS. The diagnosis of PS was based on the recording of a clinical event on video-electroencephalography, the absence of clinical or electroencephalographic evidence of epilepsy, and the subsequent fonow-up and withdrawal ofanticonvulsants supporting the diagnosis ofPS. A control group was composed of 20 patients with epilepsy in which induction was tried. Both groups were comparable for age, sex, and educational level. Induction was performed following a standardized protocol. The test was carried out #acing a colored patch on the neck. The test was considered positive when the induced clinical events were typical, according to a witness familiar with the patient's seizures. Induction was positive in 72 of 93 cases with PS and in none with epilepsy. Sensitivity of this test for the diagnosis of PS was 77.4%, specificity 100%, positive predictive value 100%, and negative predictive value 48.7~ Reprint Address: M.E. Laneman, Box 776, Department of Neurology, Cleveland Clinic, 9500 Euclic Avenue, Cleveland,OH 44195.
CognitiveFunctions and Quality of Life in Patients with Low-Grade Gfiomas: The Impact of Radiotherapy Taphoorn, M.J.B., Schiphorst, A.IC, Snoek, F.J., et al. 36(1):48-54, 1994. The role of early radiotherapy in the treatment of low-grade gliomas is controversial. For this reason the impact of radiotherapy on quality of life was studied in long-term survivors of biopsy-proved low-grade gliomas without signs of tumor recurrence. Twenty patients (age range, 18-66 years) had been treated with early radiotherapy; the other 21 patients (age range, 19-65 years) had undergone surgery or biopsy only. The interval from diagnosis to testing ranged from 1 to 12 years (mean, 3.5 years). Nineteen patients with low-grade hematological malignancies, surviving 1 to 15 years without central nervous system involvement, served as control subjects. Apart from the neurological and functional status, the patients' cognitive, affective, and psychological status was determined. None of the survivors had signif-
icant neurological impairment and the Karnofsky index for them was at least 70. However, more specific examinations of cognitive functions and the affective status (Profile of Mood States) indicated that, compared to the control subjects, the patients with low-grade gliomas had significantly more cognitive disturbances and suffered more frequently from fatigue and depressed moods. The two groups with low-grade gliomas, on the other hand, did not differ significantly on any of these measures. It is concluded that radiotherapy did not cause these disturbances and had no negative impact on quality of life in these patients. Reprint Address: MJ.B. Taphoorn, Department of Neurology,Free University Hospital, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
171-0035
ChronicOpioid Therapy us Alternative Treatment for Post-Herpetic Neuralgia Pappagallo, M. and Campbell, J.N. 35(Suppl.):S54--S56, 1994. Neurosurgical procedures such as the dorsal root entry zone operation, ganglionectomy, and spinal-cord stimulation have been offered to patients with intractable post-herpetic neuralgia (PHN). Poor efficacyor high morbidity have limited the overall usefulness of these procedures. We recently conducted a preliminary openlabel study with long-acting oral opioids. The mean pretreatment pain score, on a scale of 0 to 10 (0 = no pain) was 9.0 +_ 0.3 (mean + SEM, N = 20). At two months of treatment the average pain score was 4.0 _ 0.4 (p < 0.00 l, paired t test), and at six months the average pain score was 3.8 + 0.2 (p < 0.001, N = 16). These observations warrent a controlled opioid trial for patients affected by PHN. Reprint Address: J.N. Campbell, Department of Neurosurgery, John., Hopkins Hospital, Baltimore, MD 21287.
ANNALS OF THE RHEUMATIC DISEASES
171-0034
171-0036
A Prospective Study of Psychiatric Disorder and Cognitive Function in Systemic Lupus Erythematosus Hay, E.M., Huddy, A., Black, D., et al. 53(5):298--303, 1994. Objectives--To investigate change in psychiatric disorder and change in cognitive function in patients with systemic lupus erythematosus (SLE) assessed on two occasions two years apart. Methods--A prospective cohort study of 49 patients with SLE using standardised psychiatric and clinical research methods. Resuits--The point prevalence of psychiatric disorder (20% and 24%), and of cognitive impairment (23% and 18%), was similar at first and second interview for the whole group. There was, however, considerable change in individual patient's psychiatric status and cognitive function: only 1/9 patients with impairment on two or more cognitive tests at first interview was still impaired
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Annals of the Rheumatic Diseases (continued) at second interview. Change in cognitive function appeared to mirror change in psychiatric status. Conclusions--These findings suggest that the previously reported high prevalence of cognitive impairment in SLE may be explained by coexisting psychiatric disorder, rather than reflecting subclinical central nervous system (CNS) involvement. Reprint Address:E.M. Hay, ARC EpidemiologyResearch Unit, Stopford Building, Universityof Manchester, Oxford Road, ManchesterM 13 9PT, UK.
171-0037
Low Prevalence of Rheumatoid Arthritis in Black-Caribbeans Compared with Whites in Inner City Manchester MacGregor, A.J., Riste, L.K., Hazes, J.M.W., and Silman, A.J. 53(5):293-297, 1994. Objective--To compare the prevalence of rheumatoid arthritis (RA) in Black-Caribbeans and Whites living in the same urban area. Methods--Cases of inflammatory joint disease were ascertained initially from a postal screening survey of 1851 Black and 1829 age and sex-matched non-Blacks identified from general practice age-sex registers of seven general practices in the Moss Side and Hulme districts of Manchester. The ethnicity of respondents was confirmed using data from a postal screening questionnaire. Those reporting joint swelling or a history of arthritis were reviewed by a rheumatologist at surgeries held in each practice. The clinical records of the questionnaire non-responders and questionnaire-positive non-attenders at surgery were reviewed. Results--In an adjusted denominator population of 1046 BlackCaribbeans and 997 Whites, the cumulative prevalence of RA was 2.9/1000 in Black-Caribbeans and 8/1000 in Whites, representing a prevalence in Black-Caribbeans of 0.36 times that found in Whites (95% confidence interval 0.1-1.3). Conclusions-Rheumatoid arthritis occurs less commonly in Black-Caribbeans than in Whites. The findings are consistent with published studies showing a low RA prevalence in rural African Black populations. Reprint Address: A.J. MacGregor, ARC EpidemiologyResearch Unit, University of Manchester, Stopford Building, Oxford Road, Manchester MI3 9PT, UK.
psychologist "blinded" to clinical diagnosis. Patients with MS and CFS were additionally evaluated with a Structured Clinical Interview for DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition) disorders. Setting: Institutional and private neurological practices and the community at large. Patients: Twenty patients with CFS diagnosed in accord with the Centers for Disease Control and Preventionrevised criteria who had cognitive complaints; 20 patients with clinically definite MS who were ambulatory and were matched for fatigue severity, age, and education to CFS subjects; and 20 age- and education-matched healthy controls. Results: Patients with CFS had significantly elevated depression symptoms compared with patients with MS and healthy controls (P < .001) and had a greater lifetime prevalence of depression and dysthymia compared with MS subjects. Patients with CFS, relative to controls, performed more poorly on the Digit Symbol subtest (P =.023) and showed a trend for poorer performance on logical memory (P -- .087). Patients with MS compared with controls had more widespread differences of greater magnitude on the Digit Span (P < .004) and Digit Symbol (P < .001), Trail Making parts A (P -- .022) and B (P = .037), and Controlled Oral Word Association (P = .043) tests. Patients with MS also showed a trend of poorer performance on the Booklet Category Test (P = .089). When patients with CFS and MS were directly compared, MS subjects had lower scores on all measures, but the differences reached significance only for the Digit Span measure of attention (P = .035). Conclusions: Patients with CFS compared with MS have more depressive symptoms but less cognitive impairment. Relative to controls, a subset of CFS subjects did poorly on tests of visuomotor search and on the logical memory measure of the Wechsler Memory Scale--revised. Poor performance of logical memory in CFS appears to be related to depression, while visuomotor deficits in CFS are unrelated. Cognitive deficits in patients with MS are more widespread compared with those in patients with CFS and are independent of depressive symptoms. Reprint Address: L.B. Krupp, Department of Neurology, HSC T-12020, SUN'Y, Stony Brook, NY 11794.
171-0039
ARCHIVES OF NEUROLOGY
171-0038
Cognitive Functioning and Depression in Patients with Chronic Fatigue Syndrome and Multiple Sclerosis Krupp, L.B., Sliwinski, M., Masur, D.M., Friedberg, F., and Coyle, P.K. 5/(7):705-710, 1994. Objective: To assess cognitive function in patients with chronic fatigue syndrome (CFS) and multiple sclerosis (MS) and to evaluate the role of depressive symptoms in cognitive performance. Design: Case-control. All subjects were given a neuropsychological battery, self-report measures of depression and fatigue, and a global cognitive impairment rating by a neuro-
The Natural History of Alzheimer's Disease: Description of Study Cohort and Accuracy of Diagnosis Becker, J.T., Boiler, F., Lopez, O.L., et al. 5/(6):585-594, 1994. Objective: We describe the sampling, initial evaluation, and final diagnostic classification of subjects enrolled in a natural history study of Alzheimer's disease (AD). Design: Volunteer cohort study. Setting: Multidisciplinary behavioral neurology research clinic. Patients or Other Participants: Three-hundred nineteen individuals were enrolled in the Alzheimer Research Program between March 1983 and March 1988. Of these, 204 were originally classified with AD, 102 were normal elderly control subjects, and 13 were considered special cases. Main Outcome Measures: Final consensus clinical diagnosis, final neuropathologic diagnosis, and death. Results: Of the 204 patients enrolled in the study, re-review after as many as 5 years of follow-up resulted in a final clinical classification of 188 with probable AD. Seven patients were believed to have a significant
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Archives of Neurology (continued) vascular component to the dementia, three were found to have developed depression, and six were excluded on other clinical grounds. Neuropathologic examination of 50 brains indicated definite AD in 43. After removing these seven misdiagnosed patients, the final group of probable/definite AD totaled 181 individuals. Accuracy of the baseline clinical diagnosis relative to neuropathology was 86%, and when follow-up clinical data were considered, 91.4%. Detailed neuropsychologieal testing yielded high sensitivity (0.988) and specificity (0.983) to dementia. Analyses of survival time from study entry until death revealed that older patients were significantly more likely to die during follow-up, but neither sex, years of education, nor pattern of cognitive impairment were related to survival. Conclusions: These data provide the descriptive basis for future studies of this cohort. They indicate that longitudinal follow-up of demented cases increases accuracy of diagnosis, and that detailed cognitive testing aids in early classification. Reprint Address:J.T. Becker,NeuropsychologyResearch Program, Suite 502, Iroquois Building, 3600 Forbes Avenue, Pittsburgh, PA 15213.
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
171-0040
Reflex Sympathetic Dystrophy: Early Treatment and Psychological Aspects Geertzen, J.H.B, de Bruijn, H., de Bruijn-Kofman, A.T., and Arendzen, J.H. 75(4):442-446, 1994. Reprint Address: J.H.B. Geertzen, Department of Rehabilitation, University Hospital Groningen, Oostersingel 59, Groningen, The Netherlands.
171-0041
Psychopathology and the Rehabilitation of Patients with Chronic Low Back Pain Disability Gatchel, R.J., Polatin, P.B., Mayer, T.G., and Garcy, P.D. 75(6):666-670, 1994. Reprint Address: R.J. Gatchel, Department of Psychiatry-Divisionof Psychology,University of Texas SouthwesternMedical Center, 5323 Harry Hines Boulevard,Dallas, TX 75235-9044.
171-0042
Outcomes in Treatment of Pain in GeriaU'ic and Younger Age Groups Cutler, R.B., Fishbain, D.A., Rosomoff, R.S., and Rosomoff, H.L. 75(4):457-464, 1994. Reprint Address: R.B. Cutler, Comprehensive Pain and Rehabilitation Center, 600 Alton Road, Miami Beach, FL 33139.
171-0043
Factors Associated with the Quality of Life of Long-Term Spinal Cord Injured Persons Clayton, K.S. and Chubon, R.A. 75(6):633--638, 1994. Reprint Address: K.S. Clayton, Occupational Therapy Educational Department, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425.
ARCHIVES OF SEXUAL BEHAVIOR
171-0044 Gay Men as Victims of Nonconsensual Sex Hickson, F.C.I., Davies, P.M., Hunt, A.J., et al. 23(3):281-294, 1994. Incidents ofnonconsensual sexual activity among 930 homosexually active men living in England and Wales are analyzed. Of these men, 27.6% said they had been sexually assaulted or had sex against their will at some point in their lives; one third had been forced into sexual activity (usually anal intercourse) by men with whom they had previously had, or were currently having, consensual sexual activity. The contention that male rape is usually committed by heterosexually identified men, primarily as an expression of power and control, is not supported. Recognition that gay men rape other gay men is needed, both by the gay community and support services for victims. Reprint Address: F.C.I. Hickson, Project SIGMA, Department of Sociology, University of Essex, Colchester,UIC 171-0045 The Conditioning of Human Sexual Arousal O'Donohue, W. and Plaud, J.J. 23(3):321-344, 1994. Although most theories of human sexual behavior claim that much normal sexual behavior is learned, and theories of the etiology and modification of paraphilic and dysfunctional sexual behavior also claim that abnormal sexual behavior is learned and can be counterconditioned, there is no systematic review examining the relationship between conditioning and human sexual behavior. We review research addressing whether habituation, sensitization, classical conditioning, and operant conditioning processes are involved in human sexual behavior. We conclude that, due to the methodological problems of extant studies, the basis for asserting the existence of relationships between habituation, sensitization, classical conditioning, operant conditioning, and sexual behavior is tenuous. Reprint Address: W. O'Donohue, Northern Illinois University, DeKalb, IL 60115.
ARTHRITIS CARE AND RESEARCH
171-0046
Clinical Implications of Depression in Rheumatoid Arthritis Morrow, ICA., Parker, J.C, and Russell, J.L. 7(2):58-63, 1994. The clinical implications of depression in the context of rheumatoid arthritis are described. An overview of the diagnostic criteria for depression is provided, with specific focus on major depression and the associated subtypes. The neurobiological literature on major depression is briefly reviewed and the implications of the depression literature for the care of persons with rheumatoid arthritis are discussed. Reprint Address:J.C. Parker,PsychologyService(116B),Harry S. Truman MemorialVeteran's Hospital, 800 Hospital Drive, Columbia,MO 65201.
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Arthritis Care and Research (continued) 171-0047
Life Activities of Persons with Rheumatoid Arthritis with and without Depressive Symptoms Katz, P.P. and Yelin, E.H. 7(2):69-77, 1994. Objective. Persons with rheumatoid arthritis (RA) report more activity losses than persons without RA. Persons with RA who report depressive symptoms experience lower levels of functioning. We integrated these findings and examined the association of depressive symptoms with the activities in which persons with RA participate. Methods. We surveyed 726 persons with RA and 192 matched controls. Within each group, we examined the perceived importance and actual performance of 65 life activities by individuals with and without depressive symptoms. Results. Significantly more individuals with RA reported depressive symptoms. Among persons with RA, those who had depressive symptoms performed fewer activities, particularly fewer valued activities. In contrast, among controls, those who were depressed rated fewer activities as important, but exhibited few sitmificant differences in the performance of activities. Conclusions. Depressive symptoms and life activities are associated differently among persons with RA and controls. The higher rate of depression among persons with RA may be partially due to the inability to perform valued activities. Reprint Address: P.P. Katz, Arthritis Research Group, University of California, 1388 Sutter Street, Suite 700, San Francisco, CA 94143. 171-0048
Pain Behavior of Rheumatoid Arthritis Patients Enrolled in Experimental Drug Trials Anderson, ICO., Bradley, L.A., Turner, R.A., Agudelo, C.A., and Pisko, E.J. 7(2):64-68, 1994. Objective. This study examined the sensitivity of a behavioral observation method for the assessment of arthritis pain as an outcome measure in clinical drug trials. Methods. The subjects were 33 rheumatoid arthritis patients who were receiving either an active experimental drug or a placebo. Disease activity measures, self-reports of pain, and pain behavior observations were completed for each subject prior to drug initiation, 6 weeks after drug initiation, and 12 weeks after drug initiation. Results. Significant reductions in measures of disease activity and self-report of pain were found for the subjects who received an active drug, relative to those who received the placebo. The pain behavior scores produced by both groups of subjects remained relatively stable during the study. Conclusion. The lack of change in pain behavior suggests that arthritis pain behavior may lack sensitivity to short-term changes accompanying drug therapy. Reprint Address: K.O. Anderson, Department of Anesthesiology, University of Massachusetts Medical Center, Worcester,MA 01655. Characteristics of Participants in Water Exercise Programs Compared to Patients Seen in a Rheumatic Disease Cfinic Meyer, C.L. and Hawley, D.J. 7(2):85-89, 1994. Purpose. To determine if community-based water exercise programs are serving people with significant levels of disability and pain. Methods. Eighty-seven participants in water exercise classes and 174 patients from a rheumatic disease clinic were matched for age, sex, and diagnosis and comparisons were made between the groups for the study variables. Results. Patients had significantly higher disability, pain, global disease severity, anxiety, and depression and lower grip strength than participants. Osteoarthritis (OA) patients (n = 126) compared to OA partic-
ipants (n = 63) had similar significant differences for all variables. Rheumatoid arthritis (RA) patients' (n = 48) scores were all more severe than RA participants' scores (n = 24), and these differences were similar in magnitude to OA differences, but only global disease severity and grip strength were statistically significantly different. Conclusions. Water exercise classes are reaching persons with important levels of dysfunction and pain, but more severely affected patients are underrepresented in such programs. Reprint Address: D.J. Hawley,Department of Nursing, Box 41, Wichita State University, Wichita, KS 67208. 171-0050
Continuation of Group Physical Therapy is Necessary in Ankylosing Spondylitis: Results of a Randomized Controlled Trial Hidding, A., van der Linden, S., Gielen, X., et al. 7(2):90-96, 1994. Purpose. Group physical therapy in patients with ankylosing spondylitis was studied to determine whether beneficial effects persisted after cessation of the intervention. Methods. After a 9-month period of supervised group physical therapy, 68 patients were randomized for another 9 months to unsupervised daily exercises at home (discontinuation group) or continuation of weekly sessions of supervised group physical therapy (continuation group). Endpoints were spinal mobility (thoraco-lumbar flexion and extension, chest expansion, cervical rotation), fitness (maximum work capacity), functioning (Sickness Impact Profile [SIP], Health Assessment Questionnaire for the Spondylarthropathies [HAQ-S], Functional Index [FI]), and patient's global health assessment on a visual analogue scale. Results. Time for exercises at home was significantly higher in the continuation than in the discontinuation group (mean duration 1.9 versus 1.2 hr per week, P < 0.05). The continuation group improved in global health (mean improvement 1.6; 32%) and in SIP score. Scores for thoraco-lumbar mobility and HAQ-S did not change very much, whereas chest expansion, cervical rotation, fitness, and FI deteriorated. The average attendance for group therapy sessions was 62%. The discontinuation group improved only marginally (0.2; 4O/o)in global health, whereas all other endpoints decreased. Only for global health and HAQ-S were the differences statistically significant in favor of the continuation group. Conclusions. Global health and functioning are sustained or even improved further if group physical therapy is continued. Spinal mobility decreased slightly in both groups. Reprint Address: A. I-Iidding,Department of Internal Medicine,Division of R.heumatology,University Hospital Maastricht, P.O. Box 5800, NL6202 AZ Maastricht, The Netherlands.
171-0049
ARTHRITIS AND RHEUMATISM
171-0051
Differences between Men and Women Undergoing Major Orthopedic Surgery for Degenerative Arthritis Katz, J.N., Wright, E.A., Guadagnoli, E., et al. 37(5):687-694, 1994. Objective. To determine whether women have worse functional status than men at the time of laminectomy for degener-
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Arthritis Care and Rheumatism (continued) ative spinal stenosis or total joint arthroplasty for degenerative arthritis of the hip and knee. Methods. Consecutive patients undergoing laminectomy for degenerative lumbar spinal stenosis or unilateral, primary hip or knee arthroplasty for advanced degenerative arthritis were recruited. Functional status was measured with self-administered questionnaires. We compared preoperative functional status scores of men and women, using linear regression models that adjusted for age, comorbid conditions, work status, education, living arrangement, and body mass index. We also compared the rates of in-hospital complications and 6-month followup functional status scores for men and women. Results. Women had much worse functional status than men prior to laminectomy for spinal stenosis (P < 0.01) and prior to total hip arthroplasty (P < 0.001) and total knee arthroplasty (P < 0.0001). These differences persisted after statistical adjustment for demographic and clinical characteristics. Women had comparable or greater functional improvement following surgery and experienced a similar number of complications compared with men. Conclusions. The observed gender differences in functional status prior to major orthopedic surgery indicate that women are operated on at a more advanced stage in the course of their disease. These results are not due to gender differences in demographic or clinical characteristics of the patients, and cannot be justified by differences between men and women in the outcome of surgery. The role of patient preferences and differential access to these procedures should be explored in future studies. Reprint Address: J.N. Katz, Department of Rheumatology and Immunology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. 17141052
Breast-Feeding and the Onset of Rheumatoid Arthritis Brennan, P. and Silman, A. 37(6):808--813, 1994. Objective. In a recent study we demonstrated that the postpartum period, particularly after the first pregnancy, is a time of increased risk for the development of rheumatoid arthritis (RA). The present study was undertaken to investigate whether this risk might be explained by breast-feeding. Methods. Through a nationwide media campaign, we identified 187 women who had developed RA within 12 months of a pregnancy, and we compared their breast-feeding histories with those of 149 similarly aged women chosen from the patient registers of a nationwide group of general practitioners. Results. In all, 88 of the women with RA developed the disease after their first pregnancy. Eightyone percent of these 88 women had breast-fed. This was higher than the breast-feeding prevalence of 50% in the 129 controls whose first pregnancy had resulted in a live birth (adjusted odds ratio [OR] 5.4, 95% confidence interval 2.5-11.4). There was a smaller increased risk of breast-feeding after a second pregnancy in the RA cases (OR 2.0) and no increase after a third pregnancy (OR 0.6). The increase in risk was greatest in those cases whose disease was erosive and who were rheumatoid factor positive. Conclusion. In a small group of susceptible women, exposure to breast-feeding after the first pregnancy is associated with a significant increase in risk for RA development. We postulate that this may reflect hormonal influences, specifically the high level of the proinflammatory hormone prolactin. Reprint Address: P. Brennan, Arthritis and Rheumatism Council, EpidemiologyResearchUnit, Manchester University Medical School, Manchester M13 9PT, UK.
BEHAVIORAL MEDICINE
171-0053
Preparing Patients for Invasive Medical and Surgical Procedures 1: Adding Behavioral and Cognitive Interventions Home, D.J. de L., Vatmanidis, P., and Careri, A. Spring:5-26, 1994. The authors of three related articles look at various aspects of preparing adult and child patients psychologically for invasive surgical procedures. The first article is a review of the literature in the field, primarily from the last 30 years. Researchers have examined anxiety and coping mechanisms, patient-practitioner relationships, medical phobias, and the effectiveness of different types of psychological intervention. In the second article, the authors offer practical suggestions for implementing preparatory psychological interventions, describing effective communication techniques such as active listening, role plays, imaging, modeling, and progressive relaxation. In the final article in the series, the author considers policy, practice, and educational implications of the use of behavioral and cognitive interventions for patients, medical practitioners, and healthcare planners.
171-0054
The Aftermath of Captivity: An 18-Year Followup of Israeli Ex-POWs Ohry, A., Solomon, Z., Neria, Y., et al. Spring:27-33, 1994. This is an 18-year follow-up of 164 former prisoners of war (POWs) and 190 controls. The study examined long-term morbidity, psychophysiological complaints, and illness-related behaviors. Psychophysiologieal complaints were found to be significantly higher among the POWs than among the controls. A significant association was also found between such complaints and symptoms of posttraumatic stress disorder (PTSD). The individuars degree of impairment was associated with both objective and subjective characteristics of captivity. The authors outline differences in types of illness observed in POWs in the current study and in studies conducted in other countries, and consider the implication of characteristics of captivity and culture.
171-0055
Religious Predictors of Cigarette Smoking: Findings for African American Women of Childbearing Age Ab_med, F., Brown, D.R., Gary, L.E., and Saadatmand, F. Spring:34--43, 1994. Data from a community-based survey of 252 African American women 18 to 44 years of age were used to examine the relation between cigarette smoking and two measures of religious involvement. Findings indicated that cigarette smoking among African American women of childbearing age is related to their denominational affiliation. Specifically, Pentecostal women had significantly lower odds of being a current smoker and higher odds of quitting smoking than did women who belonged to other religious denominations. No significant association was found, however, between smoking and the degree of religiosity. Older
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Behavioral Medicine (continued) age and lower level of education predicted current smoking, whereas having few daily hassles was associated with quitting smoking.
BEHAVIOUR RESEARCH AND THERAPY
17141056
Perceived Symptoms and Discomfort during Induced Bronchospasm: The Role of Temporal Adaptation and Anxiety Nouwen, A., Freeston, M.H., Cournoyer, I., Deschesnes, F., and Boulet, L.-P. 32(6):623-628, 1994. Using a mixed within-between design, this study was designed to evaluate the sensorial and cognitive/evaluative aspects of bronchoconstriction induced by progressive methacholine inhalation. 25 asthmatic patients and 15 normal controls were given two consecutive bronchoconstriction tests, inducing a fall of > 30% of the forced expiratory volume in 1 sec (FEV~), which was measured after each inhalation of methacholine. Immediately before each FEV1 measurement, Ss rated perceived bronchial dosing, discomfort of breathing and anxiety, as well as the need to use a bronchodilator. In addition to state-anxiety, after each bronchoconstriction test asthma symptoms were evaluated by means of a Free Symptom Report and the Asthma Symptom Checklist. The results show that during the first test, asthmatic patients perceived their symptoms more accurately than non-asthmatic controls. However, during the second test, asthmatic patients became less accurate, while normal controls increased their accuracy of symptom report. These changes were not parallelled for the Free Symptom Report or the Asthma Symptom Checklist. These results suggest that, depending on situational circumstances, patients rely on their cognitive schemata to report asthma symptoms. Need for bronchodilator use was related to perceived discomfort but not to actual or perceived bronchial closing. Clinical implications of this study are discussed. Reprint Address:A. Nouwen, Laboratory of BehavioralMedicine, School of Psychology,Laval University, PQ G1K 7P4, Canada. 1714)057
The Prevalence of Respiratory Disorders in Panic Disorder, Major Depressive Disorder and V-Code Patients Spinhoven, P., Ros, M., Westgeest, A., Van der Does, A.J.W. 32(6):647-649, 1994. Point prevalence and lifetime prevalence of respiratory disorders were assessed in 100 panic disorder (PD), 100 major depressive disorder (DD) and 100 V-code (VC) patients. Both current and past frequency of respiratory diseases were significantly higher in PD patients in comparsion to VC patients, while no significant differences in point and lifetime prevalence between PD and DD or DE) and VC patients were observed. It is hypothesized that a disturbed respiratory physiology may have differential effects depending upon the nature of the disorder and the appraisal by the patient. Reprint Address: P. Spinhoven, Department of Psychiatry,University of Leiden, Postbus 1251, 2340 BG Oegstgeest,The Netherlands.
171-0058
The Effects of Stress, Mood, and Coping on Blood Glucose in NIDDM: A Prospective Pilot Evaluation Goetsch, V.L, Abel, J.L, and Pope, M.K. 32(5):503-510, 1994. Eight subjects (Ss) with non-insulin-dependent diabetes (NIDDM) monitored their stress, blood glucose (BG), food intake, activity (via pedometer), mood, and coping responses for 8 days. The alternated 2 daily, self-selected ADA food-exchange diets to control for the effects of stress on adherence to diet. BG was significantly higher on high-stress compared to low-stress days. This effect was at least partially mediated by the effect of stress on activity; Ss were significantly less active on high-stress days. Further analyses suggested idiosyncratic relationships between mood and BG, and some evidence was found to suggest a relation between stress, coping, and BG. Reprint Address: V.L. Goetseh, Department of BehavioralMedicine and Psychiatry, West Virginia University, Morgantown, WV 26506.
BRITISH JOURNAL OF CLINICAL PSYCHOLOGY
17141059 The Contribution of Worry to Insomnia Watts, F.N., Coyle, IC, and East, M.P. 33(2):211-220, 1994. Recent research has pointed to the importance of cognitive activity in interfering with sleep, and suggested a close relationship between worry and insomnia. To explore the relationship between worry and insomnia in more detail, a sample was studied in which worry and insomnia were combined in a 2 x 2 design. The content of sleep-interfering cognitions was explored both with a previously developed Sleep Disturbance Questionnaire and a newly developed checklist of the content of thoughts that arose if people could not sleep. Both supported the importance of a distinction between sleep-related and other thoughts. Whereas worried insomniacs show a broad range of sleep-interfering thoughts, the thoughts of non-worried insomniacs focused mainly on sleep itsels ReprintAddress:F.N. Watts, MRC Applied PsychologyUnit, 15 Chaucer Road, Cambridge, CB2 2EF, UK.
171-0060
The Influence of Mood on Memories of Parental Rearing Practices Gerlsma, C., Kramer, J.J.A.M., Scholing, A., and Emmelkarnp, P.M.G. 33(2):159-172, I994. Parental rearing styles are often found to be related to adult psychological disorders. In general, conclusions are based on the data of retrospective studies, in which patients' memories of their parents' behavior are investigated. However, it has been widely recognized that memories may be sensitive to current mood states. The possible mood sensitivity of autobiographic memories is a powerful alternative explanation of the relationship commonly
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British Journal of Clinical Psychology (continued) found between parental rearing styles and psychopathology, with implications for the hypothesis of early parenting as a vulnerability factor in the aetiology of such disorders. The present study examined whether memories of parental rearing styles are influenced by present mood. To this aim, both mood and memories of parental rearing styles were assessed on two occasions in a sample of 315 healthy subjects from the general community (Study 1) and in a group of 46 socially phobic patients (Study 2). Results showed that memories of early parenting remained quite stable, even in the face of significant and considerable changes in anxiety, depression, and hostility.The theoretical and practicalimplicationsof these findings are discussed. Reprint Address: C. Gerlsma, Department of Clinical Psychology, Academic Hospital, Oostersingel 59, 9713 EZ Groningen, The Netherlands.
171-0061
Reliability of Self-Rated Tinnitus Distress and Association with Psychological Symptom Patterns Hiller, W., Goebel, G., and Rief, W. 33(2):231-239, 1994. Psychological complaints were investigated in two samples of 60 and 138 in-patients suffering from chronic tinnitus. We administered the Tinnitus Questionnaire (TQ), a 52-item selfrating scale which differentiates between dimensions of emotional and cognitive distress, intrusiveness, auditory perceptual diffculties, sleep disturbances and somatic complaints. The test-retest reliability was .94 for the TQ global score and between .86 and .93 for subseales. Three independent analyses were conducted to estimate the split-half reliability (internal consistency) which was only slightly lower than the test-retest values for scales with a relatively small number of items. Reliability was sufficient also on the level of single items. Low correlations between the TQ and the Hopkins Symptom Checklist (SCL-90-R) indicate a distinct quality of tinnnitus-related and general psychological disturbances. ReprintAddress:W. Hiller, Clinic Roseneck, Center for Behavioural Medicine, Am Roseneck 6, D-83209 Prien, Germany.
171-0062
Spinal Cord Injury: A Search for Determinants of Depression Two Years after the Event Craig, A.R., Hancock, ICM., and Dickson, H.G. 33(2):221-230, 1994. A prospective longitudinal study employing repeated measures was used to isolate factors which might predispose a person to depression two years after sustaining spinal cord injury (SCI). Thirty-one subjects who suffered acute spinal injuries resulting in permanent loss of movement, and who had no head injuries or any pre-existing psychopathology, were at least 17 years of age, and who were able to speak English, participated in the study. Using the Beck Depression Inventory (BDI) as a measure of depression, a regression analysis demonstrated that the experience of pain two years post-injury and feeling out of control of one's life prior to hospital discharge were predictive of depression two years post-injury. No demographic variables or injury characteristics such as level of lesion or completeness of lesion were related to long-term depression. Pain management and rehabilitation techniques that enhance the individual's belief of control over their lives are therefore recommended as interventions that
could act to reduce depression in the long term in persons with spinal cord injury. ReprintAddress:A.R. Craig, UTS, P.O. Box 123, Broadway,NSW 2007, Australia.
CANCER
171-0063
Changing Trends: An Overview of Breast Cancer Incidence and Mortality Garfinkel, L., Boring, C.C., and Heath Jr., C.W. 74:222-227, 1994. The incidence of breast cancer rose about 1% per year between 1940 and 1980 according to data in the Connecticut Tumor Registry. A sharp increase of 32% was reported between 1980 and 1987 in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute. Data from this program shows that the increase in incidence was due to localized cases and cancers of less than 2 cm in greatest dimension. In addition, a sharp increase in carcinoma in situ was observed. The increase in breast cancer incidence coincides with an increased use of mammography in asymptomatic women in the 1980s. Mortality from breast cancer has changed little since the 1930s, but the increases in localized and small-size tumors and decreases in the rate of tumors of 3 cm or larger at diagnosis indicates that breast cancer mortality may start to decrease. Evidence from provisional breast cancer monthly mortality data suggests that there was a 3-6% drop in 1991 compared to 1990. Reprint Address: L. Garfinkel, American Cancer Society, 1180 Avenue of the Americas, New York, NY 10036.
171-0064 Byers, T.
Nutritional Risk Factors for Breast Cancer 74:288-295, 1994. The observation of large differences in breast cancer rates between countries has led to the hypothesis that excessive intake of dietary fat is an important risk factor for breast cancer in women. Case--control and prospective studies, however, generally have failed to show associations between dietary fat and breast cancer risk. There therefore is only weak evidence that modest reductions in fat intake (for instance to levels of 30% of caloric intake from fat) will reduce breast cancer risk. The possible benefits of lowering fat intake to levels substantially below 30% of calories will need to be tested in a randomized trial. In the meantime, the possible roles of micronutrient imbalances and childhood nutritional factors need to be studied better. Obesity is related to breast cancer in a complex way that suggests that a hormonal correlate of excessive body weight might affect breast cancer growth and metastasis. The potential benefit of intentional weight loss as an adjunct breast cancer treatment deserves further study. Many studies have suggested that drinking alcohol, even at modest levels, might increase breast cancer risk. Because the potential benefits of modest levels of alcohol for cardiovascular disease may outweigh the risk for breast cancer, recommenda-
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Cancer (continued) tions for total alcohol abstinence m a y be premature for w o m e n with an average breast cancer risk.W o m e n at unusually high risk for breast cancer who have a lower-than-average risk for cardiovascular disease, however, might make an informed decision to abstain from alcohol intake. Following current dietary advice to increase the amount of fruits,vegetables, and whole grains in the diet while reducing fats is certainly prudent for w o m e n to reduce their risk of several chronic disease, but current data points to the somber conclusion that such changes probably will have little effect on breast cancer risk. Reprint Address:T. Byers,Chronic Disease PreventionBranch, Division of Nutrition, National Center for Chronic Disease, Prevention and Health Promotion, 4770 BufordHighway,NE, MailstopK26, Atlanta, GA 303413724.
Screeningfor Breast Cancer and Mortality Reduction among Women 40-49 Years of Age Kopans, D.B. 74:311-322,1994.
of psychologic well being. Results. Factor analysis of the CDIS revealed that the physician's caring attitude was perceived by the women as most important, with information-giving as a much weaker component. Multiple regression analysis supported the hypothesis that psychologic adjustment was predicted by physician behavior during the cancer diagnostic interview. Other significant predictors of adjustment were a history of psychiatric problems and premorbid life stressors. Conclusions. Provision of information needed for decision-making appears to be valued largely within the context of a caring physician-patient relationship. Specific surgeons' behaviors believed to fac'flitate patient adjustment include expressing empathy, allowing sufficient time for patients to absorb the cancer diagnosis, providing information, and engaging the patient in treatment decision-making. ReprintAddress:C.S. Roberts, H. Lee Moflitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612-9497.
171-0065
The recent withdrawal of screening support for w o m e n ages 40-49 years isnot scientificallysupported. The subgroup analyses that have been used severely compromise the statisticalpower of the trials.None of the trialshas the statisticalpower to be able to provide clear proof of benefit for screening w o m e n ages 40-49 years because none of the trialsinvolved sul~cient numbers of w o m e n in these age groups. Despite having not been designed to evaluate w o m e n ages 40--49 years as a separate group, five of the eight randomized, controlled trialsbavc demonstrated mortality reductions for these w o m e n that range from 2 2 % to 49%. In addition, data from other nonrandomized trialsshow that there is no difference in survival for w o m e n ages 40-49 years than for w o m e n ages 50-59 years. The detection rate for small, early cancers, using modern mammography, is similar for w o m e n in both decades. There is no scicntilicreason to believe that there is a sudden change in detection or cure at age 50 years, or even at menopause. The available data suggest that w o m e n ages 4049 years can benefit from screening,just as can w o m e n ages 5059 years. ReprintAddress:D.B. Kopans, Department of Radiology, Massachusetts General Hospital, 15 Parkman Street, Level 2, Suite 219, Boston, MA 02114.
171-0066
Influenceof Physician Communication on Newly Diagnosed Breast Patients' Psychologic Adjustment and Decision-Making Roberts, C.S., Cox, C.E., Reintgen, D.S., Baile, W.F., and Gibertini, M. 74:336-341,1994. Background. Physician-patient communication is of critical importance when a breast cancer diagnosis is made, because the emotionally overwhelmed patient must be educated about her disease and available treatments so she can participate in decisions about her care. A research study addressed the hypothesis that patients whose surgeons used psychotherapeutic techniques during the cancer diagnostic interview would have better psychologic adjustment to their cancer. Methods. One hundred women surveyed 6 months after surgery completed the Cancer Diagnostic Interview Scale (CDIS) and the SCL-90-R, a measure
171-0067
Visceral Obesity and Breast Cancer Risk
Schapira, D.V., Clark, R.A., Wolff, P.A., et al. 74:632-639, 1994. Background. The risk for breast cancer and the sex hormone abnormalities noted in breast cancer patients have been demonstrated in women with upper body fat obesity. The objective of this study was to determine if the visceral component of upper body fat obesity was correlated with breast cancer risk. Methods. A case-control study of 40 consecutively enrolled women with breast cancer and 40 community-based age, weight, and waist circumference-matched control subjects was conducted. The areas of visceral fat, subcutaneous fat, and total fat were measured using computed tomography at the L-4 vertebral body. Calculations of relative risk for breast cancer were based on these fat compartments. Results. Patients with breast cancer had a significantly greater visceral fat area (P = 0.01), visceral-to-total-fat area ratio (VT ratio) (P < 0.001) and significantly lower subcutaneous-to-visceral-fat area ratio (SV ratio) (P < 0.001 ) compared with the matched controls. The relative risk for breast cancer increased with increasing VT ratio (0.24 = 9.5) (P < 0.0001) and decreasing SV ratio (->3.64 = 1.0; --5 cm), the survival was 80.8% for ages 40--49, 72.1% for ages 50-59, and 61.7% for ages 60-69. Discussion. Due to the higher breast cancer survival rates among women aged 40-49 with poorer prognostic characteristics, the breast cancer survival advantage for having a smaller tumor, no positive lymph nodes, or breast cancer detected by mammography alone was lower for women aged 40--49 than women aged 50 or older at diagnosis. These differences in survival advantage may help to account for the differences in mortality by age in the randomized clinical trials. Reprint Address: C. Byme, Environmental Epidemiology Branch, Division of Cancer Etiology, NCI, EPN-443, Bethesda, MD 20892.
171-0071
Interventions to Increase Breast Screening: Lifespan and Ethnicity Issues Rimer, B.K. 74:323-328,1994. Background. In spite of the fact that the value of mammography had been demonstrated, it remains underused by those in need, such as older women and minority women. A consideration of lifespan and ethnicity issues may help in designing interventions designed to overcome the barriers women may face at diffeint stages in their lives as well as the barriers that may be most salient for minority women. Methods. There now are reports from a number of published trials indicating the value of different kinds of interventions. Interventions can be characterized as individual-
V O L U M E 17, N U M B E R 1, 1995
61
Cancer (continued) directed, system-directed, social network, or muitistrategy. Although little is known about what interventions may be specifically appropriate for women in their 40s, both individual-directed and multistrategy interventions have increased use of mammography sjLmificantly among women in their 50s, 60s, and 70s, including African American women. Conclusions. Although there is a considerable distance to go before all American women are getting regular mammograms, progress is being made. Attention to developing tailored interventions sensitive to lifespan and ethnicity concerns may be helpful. Reprint Address: B.K. Rimer, Cancer Prevention, Detection and Control Research, Duke University Medical Center, 2020 West Main Street, Suite 101, Durham, NC 27705.
171-0072
Ovarian Carcinoma: A Review of the Significance of Familial Risk Factors and the Role of Prophylactic Oophorectomy in Cancer Prevention Nguyen, H.N., Averette, H.E., and Janicek, M. 74:545-555, 1994. Women with a family history of ovarian cancer are at increased risk of ovarian cancer. Prophylactic oophorectomy (PO) remains the only effective method of ovarian cancer prevention. This study reviewed current data on the si~ificance of family history and how prophylactic oophorectomy should be used in different risk groups. Approximately 7% of ovarian cancer patients have a positive family history of whom 3-9% may eventually manifest certain hereditary cancer syndromes. Women in direct genetic lineage of family cancer syndromes have up to a 50% lifetime risk of ovarian cancer. Because of the high risk, PO is indicated for women with familial cancer syndromes after childbearing or between the ages of 35-40 at the latest. The majority of women with a positive family history of ovarian cancer do not have one of the recoL,nized syndromes. Women with one or two affected relatives have an increased lifetime risk of ovarian cancer from a baseline of 1.6 to 5-7%. This risk is not high enough to warrant PO for a large number of women. After being properly informed, the patient still chooses surgical prevention, she then receives PO. For women without a family history of ovarian cancer, the role of PO remains controversial. Assuming an annual incidence of 22,000 new cases of ovarian cancer, it is estimated that at least 1000 may be prevented if PO is diligently practiced during hysterectomy. Despite ovarian and breast cancer prevention, PO would lead to shorter life expectancy if estrogen therapy compliance were less than perfect. Thus, the decision on PO as a concurrent procedure should depend on the individual patient and her ability to comply with lifelong estrogen therapy. ReprintAddress:H.N. Nguyen, Division of GynecologicOncology,Cleveland Clinic Florida, 3000 West Cypress Creek Road, Ft. Lauderdale, FL 33309.
171-0073
The Effect of Risk on Changes in Breast Cancer Screening Rates in Los Angeles, 1988-1990 Roetzheim, R.G., Fox, S.A., and Leake, B. 74:625--631, 1994. Background. Although there have been clear secular trends of increased use of some breast cancer screening modalities, such as mammography, it is less certain that similar trends have oc-
curred among high risk women. Methods. Population-based surveys were conducted in three socioeconomically diverse Los Angeles communities in 1988 and 1990. Trends in breast cancer screening behavior and key determinants of scr~ning were compared separately for women with a family history of breast cancer, a personal history of benign breast disease, and for women without these risks. Results: In two independent samples drawn in 1988 and 1990, women at a higher risk of breast cancer (positive family history) showed smaller increases in the prevalence of selfreported breast cancer screening than a comparison group of women without a family history of breast cancer or a history of benign breast disease. This was especially true for family-historypositive minority women and women aged 65 years and older, for whom screening actually decreased. In 1990, mammograms for the prior year were reported by only 39% of women with a positive family history, 54% of women with benign breast disease, and 35% of women without these risks. Trends in physicians' office visit discussions of breast cancer screening paralleled trends observed in screening behavior. Conclusions. Although breast cancer screening increased substantially among lower risk women, rates were unchanged for women at increased risk because of a family history of breast cancer. By identifying and counseling higher risk women, physicians can play an important role in promoting appropriate screening to this group. Reprint Address: R.G. Roetz_heim,UCLA Division of Family Medicine, 50-071 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90024-1683.
171-0074
Prostate Specific Antigen Doubling Time and Disease Relapse after Radiotherapy for Prostate Cancer Pollack, A., Zagars, G.K., and Kavadi, V.S. 74:670-678, 1994. Background. Serum prostate specific antigen (PSA) correlates with prostate tumor volume. Therefore, PSA-doubling time (PSADT) in patients with a rising PSA profile after radiotherapy should be predictive of the time to clinical disease relapse. The purpose of this study was to characterize the relationship between PSADT and the time to disease relapse after the onset of a rising PSA (PSA-TTR) in 427 men treated in the PSA-era with high dose radiotherapy for Stages T1-4 adenocarcinoma of the prostate. Methods. There were 119 patients with a rising PSA profile after radiotherapy, and of these, there was sufficient information to calculate PSA-DT using nonlinear least squares regression in 100. There were 44 patients in this cohort who had documented disease relapse. The m ~ i a n patient follow-up was 38 months. Resuits. The average PSA-DT was 13.5 plus or minus 11.6 mo (_+standard deviation). PSA-DT values correlated with tumor grade, pretreatment PSA, and stage. PSA-DT was also strongly related to the outcome measures of local relapse, distant metastases, and any disease relapse. The shorter the PSA-DT, the greater the risk of disease relapse. The average PSA-TTR was 10.1 plus or minus 8.2. The only prognostic factor that correlated with PSA-TTR was tumor grade. A linear regression analysis of normalized PSA-DT and PSA-TTR revealed a si~ificant correlation in which a PSA-DT of 11 months predicted for disease relapse 24 months later. Because several factors including physician and patient preferences could alter this relationship, a comparison was made between the actuarial PSA rise time for patients treated in the PSA-era and actuarial clinical disease relapse using a cohort
62
ANNALS OF BEHAVIORAL MEDICINE
Cancer (continued) of similarly treated men from the pre-PSA-era (n ffi 798). The results showed the lead time to be over 40 months in the majority of patients and that this lead time was much shorter in those with high grade tumors. Conclusions. PSA-DT is a strong prognostic factor for patients with biochemical evidence of failure after radiotherapy. A short PSA-DT predicts for more rapid progression to symptoms. The timing of the progression from a rising PSA to clinical disease relapse is probably longer than expected and is estimated to be 40 months on average. Reprint Address."A. Pollack,Department of Radiotherapy (97), The University of Texas M.D. Anderson Cancer Center, 15! 5 Holcombe Boulevard, Houston, TX 77030.
ferent drugs. The cumulative doses of derivatives of para-aminophenol, pyrazolone, and salicylic acid in some cases reached a maximum of several kilograms. Most drugs were classified by the patients as "moderately effective". The rating "very effective" was assigned primarily to barbiturates; however, barbiturates are no longer used as components of compound analgesic drugs in Austria. At the time of investigation, patients consumed 2.5 (mean) different drugs, primarily as compound preparations. Seventeen patients (21%) showed signs of possible analgesics- or ergotamineinduced headache and were therefore advised to undergo withdrawal therapy. Our results show that patients with tension-type headache are at considerable risk of becoming drug-dependent and of acquiring analgesics-induced headache. Reprint Address: P. Schnider, NeurologicalUniversity Clinic, Wahringer Gtirtel 18-20, A-1090 Vienna, Austria.
CEPHALALGIA CHEST 171-0075
Psychopathology in Individuals with PostTraumatic Headaches and Other Pain Types
Ham, L.P., Andrasik, F., Packard, R.C., and Bundrick, C.M. 14(2):118-126, 1994. In this study, the psychological functioning of patients with chronic post-traumatic headache (PTH), chronic combination headache and chronic low back pain without headache, whose time of onset was similar, and a matched group of controls was investigated. The Symptom Checklist 90-Revised (SCL-90-R), State-Trait Anger Expression Inventory (STAXI), State-Trait Anxiety Inventory, Form Y (STAI-Y), and Beck Depression Inventory (BDI) were used to assess the degree of psychopathology. A MANOVA test indicated highly significant differences between groups. In general, the pain groups fell along a continuum with PTH subjects demonstrating the highest elevations, back pain subjects demonstrating the next highest elevations, and combination subjects demonstrating fewer elevations. A cluster analysis indicated that findings were best classified into four clusters, but no one pain diagnosis predominated in any cluster. Eighty-nine percent of controls were assigned to clusters 1 or 2, which revealed essentially normal scores on all tests. It is suggested that while chronic pain patients demonstrate more psychopathology than non-pain controls, a variety of coping styles exists within each pain group independent of diagnostic categorization. ReprintAddress:L.P. Ham, Headache Managementand Neurology,5500 North Davis Highway, Pensacola, FL 32503.
17141076
Use and Abuse of Analgesics in Tension-Type Headache Schnider, P., AUll, S., Feucht, M., et al. 14(2):162-167, 1994. Eighty patients suffering from tension-type headache for an average of 21 years were asked to report on all drugs they had ever taken (type, dosage, duration of intake, efficacy) or were taking currently. The patients had consumed on average 6.3 dif-
171-0077
Mortality Risk and Patterns of Practice in 2,070 Patients with Acute Myocardial Infarction, 198792: Relative Importance of Age, Sex, and Medical Therapy Tsuyuki, R.T., Teo, K.IC, Ikuta, R.M., et al. 105(6):1687-1692, 1994. Objective: To define contemporary age- and sex-related mortality risks and patterns of medical practice in acute myocardial infarction (AMI). Design: Retrospective comparison of demographic and clinical variables, including the use of proven effective AMI medical therapy, among AMI patients cohorts from 1987 to 1992. Patients/Setting: Of a total of 2,070 AMI patients, 629 were women and 1,44 l, men; 951 patients were managed in university hospitals, 641 in a regional hospital, and 478 in community hospitals. Interventions: No direct study interventions; results of practice patterns and risk analyses of the earlier (198790) AMI cohorts, however, were published concurrently with the actual practices of the more recent (1991-92) cohorts and may have had some indirect effect on the recent practice patterns. Results: Univariate analysis showed that mortality was higher (p < 0.0001) and use of thrombolysis, beta blockers, and acetylsalicylic acid was lower (13 < 0.0001) in patients 70 years of age and older, compared with younger patients, and in women, compared with men. Multivariate analysis of the entire patient sample revealed age of 75 years or older (154 percent) and age 70 to 74 years (141 percent) to be associated with the highest relative risk of death in hospital. The increased relative risk associated with previous AMI was 45 percent. Acetylsalicylic acid use was associated with the greatest decrease in relative risk of death ( - 6 9 percent), followed by beta blockers ( - 3 6 percent) and thrombolysis (-31 percent). These patterns of relative risk were the same for men and women. Conclusions: Among contemporary AMI patients, advanced age and female sex are associated with relative under-utilization of proven effective medical therapy and
V O L U M E 17, N U M B E R 1, 1995
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Chest (continued) increased risk of dying in the hospital. Although the contribution of age to AMI risk appears greater than that of gender, survival in any high risk group would likely be improved by increased use of proven medical therapy. Reprint Address: T.J. Montague, 2C2 Mackenzie Centre, University of Alberta Hospitals, Edmonton, AB T6G 2B7, Canada.
head circumference. Although birthweight, previous illness, and parental education were also related to development, the relations between infant growth and cognition remained significant even after these variables were statistically controlled. Reprint Address: S.A. Rose, Department of Pediatrics, Kennedy 215, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461.
CHILD DEVELOPMENT
171-0078
Genetic and Environmental Influences on Perceptions of Self-Worth and Competence in Adolescence: A Study of Twins, Full Siblings, and Step-Siblings McGuire, S., Neidcrhiser, J.M., Reiss, D., Hetherington, E.M., and Plomin, R. 65:785-799, 1994. Although it is generally assumed that the origins of adolescents' perceptions of self-competence he in shared family environmental influences, the contributions of nonshared environmental or genetic influences have not been explored. We investigated sibling resemblance for perceived competence and self-worth in 720 adolescent pairs aged 10 to 18 years, using a twin, full sibling, and step-sibling design. Our goals were to assess the magnitude of shared and nonshared environmental influences and to disentangle resemblance due to shared genetic heritage from that due to shared environmental experiences. Shared enviroument was not significant for any of the scales. 4 of the subscales showed significant genetic influence: scholastic, social, physical, and athletic competence. We also explored possible sources of genetic influences on perceived competence. Bivariate models revealed common genetic variance between scholastic competence and vocabulary and social competence and sociability. These measures, however, did not account for all of the genetic variance in perceived social and scholastic competence. Reprint Address: S. McGuire, Department of Psychology, University of California/San Diego, La JoUa, CA 92093-0109.
171-0079
Relation between Physical Growth and Information Processing in Infants Born in India Rose, S.A. 65:889-902, 1994. The relation between physical growth and cognitive development in infants growing up in India was examined in this study. Subjects were 183 5-12-month-olds. Weight and length, two anthropometric measures commonly used to index nutritional status in developing countries, related to infant measures of visual recognition memory and tactual-visual cross-modal transfer. Underweight infants performed relatively poorly on both cognitive measures and failed to show the clear age-related improvements in speed of processing found among the heavier infants. Weight and length correlated with both measures of infant cognition, r = .25 to r = .45, as did, to a lesser degree,
CIRCULATION
171-0080
Heart Rate Spectral Analysis, Cardiac Norepinephrine Spillover, and Muscle Sympathetic Nerve Activity during Human Sympathetic Nervous Activation and Failure KingweU, B.A., Thompson, J.M., Kaye, D.M., et al. 90:234-240, 1994. Background. Although heart rate variability (HRV) at 0.1 Hz has been proposed as a noninvasive clinical measure of cardiac sympathetic nerve firing, this premise has not been sulficientiy validated by comparison with techniques such as microneurography and the measurement ofnorepinephrine spillover from the heart that more directly reflect presynaptic sympathetic activity. Methods and Results. We compared the three techniques under conditions of effective cardiac sympathetic denervation, pure autonomic failure (n = 4), dopamine fl-hydroxylase deficiency (n = 1), and after cardiac transplantation (n = 9) as well as in the context of sympathetic nervous activation in cardiac failure (n = 15) and with aging (n = 10). Age-matched comparisons were made in each case with healthy individuals drawn from a pool of 52 volunteers. In pure autonomic failure and early after transplantation, cardiac norepinephrine spillover was negligible, and HRV was low. Late after transplantation, however, cardiac norepinephrine spiUover returned to normal levels, and HRV remained low. In comparison to younger subjects (18 to 35 years old), older individuals (60 to 75 years old) had higher muscle sympathetic nerve activity (young, 22.9 _+ 1.9; old, 31.3 _+ 5.8 bursts per minute; P < .05) and cardiac norepinephrine spillover (young, 14.3 _+ 2.5; old, 20.1 _+ 3.0 ng/min; P < .05). In contrast, total HRV was reduced by 89%, and at 0.1 Hz it was reduced by 93% (P < .05). Cardiac failure was also characterized by elevated cardiac norepinephrine spillover (cardiac failure patients, 59 + 4; healthy volunteers, 18 + 3 ng/min; P < .01) but reduced 0.1 Hz HRV (cardiac failure patients, 49 + 17; healthy volunteers, 243 + 4 ms2; P < .05). Conclusions. HRV at 0.1 I-Iz depends on factors in addition to cardiac sympathetic nerve firing rates, including multiple neural reflexes, cardiac adrenergic receptor sensitivity, postsynaptic signal transduction, and electrochemical coupling, and is not directly related to cardiac norepinephrine spillover, which is a more direct measure of the sympathetic nerve firing rate. Reprint Address: B.A. Kingwell, Alfred and Baker Medical Unit, Baker Medical Research Institute, Commercial Road, Prahran, VIC 3181, Australia.
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ANNALS OF BEHAVIORAL MEDICINE
Circulation (continued) 171-0081
CircadianRhythms of Frequency Domain Measures of Heart Rate Variability in Healthy Subjects and Patients with Coronary Artery Disease: Effects of Arousal and Upright Posture Huikuri, H.V., Niemelii, M.J., Ojala, S., et al. 90:121-126, 1994. Background. Altered neural regulation of the cardiovascular system may be an important factor for various manifestations of ischemic heart disease. This research was designed to compare the circadian rhythm of cardiac neural regulation and autonomic responses to arousal and upright posture between patients with uncomplicated coronary artery disease (CAD) and age-matched subjects with no evidence of heart disease. Methods and Results. Twenty-four-hour heart rate variability (HRV) in the frequency domain was analyzed in 20 male patients (mean age, 52 _+ 7 years) with angiographic evidence of CAD without prior myocardial infarction and in 20 healthy men (mean age, 51 _+ 8 years) with no clinical, echocardiographic, or exercise ECG evidence of heart disease. None of the 24-hour average frequency-domain components of HRV differed significantly between the two groups. Healthy subjects had a significant circadian rhythm of normalized units of high-frequency (HF) power of HRV with higher values during sleep. Normalized units of low-frequency (LF) power and the LF/I-IF ratio also showed a sitmificant circadian rhythm in healthy subjects, with higher values during the daytime. No significant circadian rhythms in any of the normalized spectral components of HRV were observed in patients with CAD, and the night-day difference in LF/HF ratio was smaller in the patients with CAD than in the healthy subjects (0.5 + 1.4 versus 1.8 + 0.7, P < .001). Awakening when in the supine position resulted in a significant increase in the LF/HF ratio (P < .01 ) in the healthy subjects, but no si~ificant changes in HRV were observed after awakening in patients with CAD. Assumption of upright position resulted in a comparable decrease in the components of HRV between the groups. Conclusions. The circadian rhythm of cardiac neural regulation is altered in patients with uncomplicated CAD. Reduced autonomic responses to sleep-wake rhythm suggest that the modulation of cardiac autonomic function by stimuli from the central nervous system is impaired in CAD. Reprint Address: H.V. Huikuri, Division of Cardiology, Department of Medicine,Oulu UniversityCentral Hospital, Kajaaninfie50, 90220 Oulu, Finland.
171-0082
Physical Activity and 23-Yeur Incidence of Coronary Heart Disease Morbidity and Mortality among Middle-Aged Men: The Honolulu Heart Program Rodriguez, B.L., Curb, J.D., Burchiiel, C.M., et al. 89:2540--2544, 1994. Background. The purpose of the study was to examine the association between physical activity and 23-year incidence of coronary heart disease morbidity and mortality. This cohort study continues to follow 8006 Japanese-American men who were 45 to 68 years of age and living in Oahu, Hawaii, in 1965, for the development of coronary heart disease morbidity and mortality. Methods and Results. The Framingham physical activity index was calculated by summing the product of average hours spent at each activity level and a weighting factor based on oxygen consumption. Study subjects were divided into tertiles of physical
activity index at baseline. Relative risks and 95% confidence intervals (CO for incidence of coronary heart disease morbidity and mortality were obtained using the Cox model. After age adjustment and using the lowest physical activity index tertile as a reference group, the relative risk for coronary heart disease incidence for the highest tertile of physical activity was 0.83 (CI, 0.70 to 0.99). After adjusting for age, hypertension, smoking, alcohol intake, diabetes, cholesterol, and body mass index, the relative risk was 0.95 and CI included 1 (CI, 0.80 to 1.14). For coronary heart disease mortality, the age-adjusted relative risk was 0.74 (CI, 0.56 to 0.97) and 0.85 (CI, 0.65 to 1.13) after risk factor adjustment. Conclusions. The results suggest that the impact of physical activity index on coronary heart disease is mediated through its effects on hypertension, diabetes, cholesterol, and body mass index. These findings support the hypothesis that physical activity is inversely associated with coronary heart disease morbidity and mortality and suggest that physical activity interventions in middle-aged men, by improving cardiovascular risk factor levels, may have significant public health implications in the prevention of coronary heart disease. Reprint Address: B.L. Rodriguez, Honolulu Heart Program, 347 North Kuakini Street, Honolulu, HI 96817.
CLINICAL JOURNAL OF PAIN
171-0083
Can Treatment Outcome of Chronic Low Back Pain Be Predicted? Psychological Disease Consequences Clarifying the Issue Talo, S., Puukka, P., RytOkoski, U., Rtnnemaa, T., and Kallio, V. 10(2):107-121, 1994. Objective: To search for generalizable, psychological predictors of chronic pain treatment outcome. Design: The prognostic power of the psychological predictors, classified into subareas of function, i.e., impairments, disabilities, and handicaps, was compared in predictive situations varying with the quality of patient samples, programs, and outcome measures. Setting: Four rehabilitation centers in Finland providing "functioning activation" or more passive "spa resort" treatment programs for low back pain patients. Patients: 173 low back pain patients for whom the inpatient rehabilitation program was funded by the Finnish Social Insurance Institution. Outcome measures: The measures were panel assessment of global functioning (DSM III Axis V), selfreport of handicap (Minion), panel assessment of handicap (WHO index), panel assessment of adherence (four rating scales), and self-report of well-being (Faces scale). Results: Multivariate, stepwise regression analyses suggested that the disability and handicap measures of functioning may be more effective predictors than impairment measures, which, however, add to the variance explained by the former. However, the predictive power of psychological impairments, disabilities, and handicaps varied with differences in patient group, outcome measure, and program. Conclusion: The "general predictors" of chronic pain treatment outcome may be difficult to find. Therefore, planning treatment for the individual patient may always have to be based on
VOLUME 17, NUMBER 1, 1995
65
Clinical Journal of Pain (continued) accurate multiaxial and multidimensional assessment ofpatient functioning. Reprint Address: S. Talo, The Social Insurance Institution, Research and Development Center, Peltolantie 3, 20720 Turku, Finland.
171-0084
The Coping Strategies Questionnaire and Chronic Pain Adjustment: A Conceptual and Empirical Reanalysis Geisser, M.E., Robinson, M.E., and Henson, C.D. 10(2):98-106, 1994. Objective: Some studies have found significant relations between both the factor scores and subscales of the Coping Strategies Questionnaire (CSQ) and various measures of adjustment to chronic pain. In their review of the literature on coping with chronic pain, Jensen et al. (Pain 1991;47:249-83) suggest that conceptual overlap between the subscales may inflate these observed correlations. In the present study, we examine the factor structure of the CSQ subscales which reflect coping, excluding the CSQ subscales which measure appraisal or activity. We then examine the relationship between the CSQ factors and subscales and pain adjustment, while controlling for selected variables. Design and Subjects: One hundred fifty-two chronic pain patients were administered the CSQ. Seventy-three were also administered the Multidimensional Pain Inventory (MPD. Adjustment to chronic pain was defined based on patients' cluster membership on the MPI and responses to the Interference, Pain Severity, and Negative Affect subscales. Setting: Tertiary care center. Resuits: Multiple regression analyses revealed that the Pain Avoidance factor was positively related to pain severity, interference, and MPI cluster membership. In addition, the catastrophizing subseale was positively related to negative affect and MPI cluster membership even when controlling for level of depression, ability to decrease pain was related to lower levels of pain severity, and ability to control pain was related to MPI cluster membership. Neither the Conscious Cognitive Coping factor nor the Increasing Activities subscale was related to the adjustment measures. Follow-up analyses revealed that the Praying/Hoping subscale appeared to account for the relationship between pain avoidance and adjustment. Conclusion: The results suggest that praying/ hoping and catastrophizing are related to poorer adjustment to chronic pain, that ability to control and decrease pain are related to better adjustment, and that catastrophizing appears to be a separate construct from depression. The results also suggest that the individual CSQ subscales may have greater utility in terms of examining coping, appraisals, and pain adjustment compared to the composite scores. Reprint Address." M.E. Geisser, Department of Physical Medicine and Rehabilitation, Med_Rehab-Universityof Michigan Medical Center, 355 Briarwood Circle, Ann Arbor, MI 48108-0742. 171-0085
Depression and Pain Behavior in Patients with Chronic Pain Krause, S.J,, Wiener, R.L., and Tait, R.C. 10(2):122-127, 1994. Objective: Previous studies of pain behavior in patients with chronic pain have shown that depressed patients exhibit more pain behavior than nondepressed patients. This study sought to extend these findings and to examine the possible causes of the observed differences. Design: Patients completed the short form
of the Beck Depression Inventory, and their pain behavior was simultaneously rated by themselves and trained observers. Patients: Subjects were 37 inpatients in a chronic pain program. Results: Both depressed and nondepressed subjects rated themselves as exhibiting more pain behavior than did nurse ratings. While nurses rated pain behaviors as similar among the depressed and the nondepressed groups, patient ratings indicated significantly more pain behavior among depressed than nondepressed patients. Conclusions: These results suggest that cognitive factors may influen~ self-ratings of pain behavior by depressed subjects. Reprint Address:S.J. Krause, 2700 West 9th Avenue,Oshkosh, W154904.
171-0086
Observationof Pain Behaviors during Episodes of Sickle Cell Disease Pain Gil, ICM., Phillips, G., Edens, J., Martin, N.J., and Abrams, M. 10(2):128-132, 1994. Objective: To assess the utility of a brief behavioral observation method to quantify pain. Design: Correlational study. Patients: 31 sickle cell disease (SCD) patients first seen in an outpatient clinic in painful crisis. Outcome Measures: Observed pain behaviors, physician rating of patient pain on a 0 to 10 scale, patient rating of pain on a 0 to 10 scale, and patient pain report from the McGiil Pain Questionnaire. Results: High interrater reliability for the brief behavioral observation was found, and observed pain behavior was found to correlate significantly with physician ratings of pain. Conclusions: This study is an important first step toward developing a systematic behaviorobservation methodology for the analysis of SCD pain. The current methodology was found to be reliable and easily implemented in a busy, outpatient clinic. Reprint Address: K.M. Gil, Pain Management Program, Box 3159, Duke University Medical Center, Durham, NC 27710.
DIABETES CARE
171-0087
PreventiveEye Care in People with Diabetes Is Cost-Saving to the Federal Government: Implications for Health-Care Reform Javitt, J.C., Aiello, L.P., Chiang, Y., et at. 17(8):909-917, 1994. Objective--Diabetic retinopathy, which leads to macular edema and retinal neovascularization, is the leading cause of blindness among working-age Americans. Previous research has demonstrated significant cost savings associated with detection of eye disease in Americans with Type I diabetes. However, detection and treatment of eye disease among those with Type II diabetes was previously thought not to be cost-saving. Our purpose was to estimate the current and potential federal savings resulting from the screening and treatment of retinopathy in patients with Type II diabetes, based on recently available data concerning efficacy of treating both macular edema and neovascularization along with new data on federal budgetary costs of blindness. Research Design and Methods--We used corn-
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Diabetes Care (continued) puter modeling, incorporating data from population-based epidemiological studies and multicenter clinical trials. Monte Carlo simulation was used, combined with sensitivity analysis and present value analysis of cost savings. Results--Screening and treatment for eye disease in patients with Type II diabetes generates annual savings of $247.9 million to the federal budget and 53,986 person-years of sight, even at current suboptimal (600/0) levels of care. If all patients with Type II diabetes receive recommended care, the predicted net savings (discounted at 5%) exceeds $472.1 million and 94,304 person-years of sight. Nearly all savings are associated with detection and treatment of diabetic macular edema. Enrolling each additional person with Type II diabetes into currently recommended ophthalmological care results in an average net savings of $975/person, even if all costs of care are borne by the federal government. Conclus i o n s - O u r analysis indicates that prevention programs aimed at improving eye care for patients with diabetes not only reduce needless vision loss but also will provide a financial return on the investment of public funds. Reprint Address: J.C. Javitt, Center for Sight, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, DC 20007.
171-0088
Health-Insurance Coverage for Adults with Diabetes in the U.S. Population Harris, M.I., Cowie, C.C., and Eastman, R. 17(6):585-591, 1994. Objective--To compare the extent and types of health insurance coverage for adults with diabetes to coverage for those without diabetes in the U.S. population. Research Design and Methods--Nationally representative samples of 2,405 adults with diabetes and 20,131 adults who were not known to have diabetes in the U.S. completed a questionnaire on current health insurance, including coverage through Medicare, private insurance, the military, and Medicaid and other public programs. Results--Among all adults with diabetes, 92.0% have some form of health insurance, including 86.5% of those 18--64 years of age and 98.8% of those >_65 years of age. Approximately 41% are covered by more than one health insurance mechanism, but almost 600,000 people with diabetes do not have any form of health-care coverage. Little difference was found by type of diabetes in the proportion who have health insurance. Only small differences exist between people with diabetes and those without diabetes in the percentages covered and the types of health-care coverage. Government-funded programs are responsible for health-care coverage of 57.4% of adults with diabetes, including 26.4% of those 18--64 years of age and 96.0% of those >--65years of age. Private health insurance is held by 69.3% of diabetic people. Lack of private insurance appears to be attributable primarily to lower income. Conclusions--Almost all patients with diabetes who are >-65 years of age have health-care coverage, but 13.5% of those 18--64 years of age have no health insurance. Few differences exist in coverage between individuals with and without diabetes. However, the absence of insurance should have a substantially greater impact on the ability of patients with diabetes to obtain services necessary for care of their disease, compared with those without diabetes. Government-funded insurance mechanisms cover a large proportion of diabetic patients, which indicates a significant societal burden
associated with diabetes. Any changes in government reimbursement and coverage policies could have a major impact on health care for patients with diabetes. Reprint Address: M.I. Harris, NIDDK/NIH, Westwood Building, Room 620, Bethesda, MD 20892.
171-0089
Diabetes Meilitus and Cigarette Smoking: Findings from the 1989 National Health Interview Survey Ford, E.S., Malarcher, A.M., Herman, W.H., and Aubert, R.E. 17(7):688--692, 1994. Objective--To compare the prevalence of current smoking in the U.S. diabetic population with that of the nondiabetic population. Research Design and Methods--Using data from the 1989 National Health Interview S u r v e y - a nationally representative sample--we calculated the prevalence of current smoking for 2,405 people with self-reported diabetes and 20,131 people without this condition. Results--Overall, the age-adjusted prevalence of smoking was 27.3% among people with diabetes and 25.9% among people without diabetes. The prevalence of smoking did not differ significantly between participants with and without diabetes when they were stratified by age, sex, race, or education. Black and Hispanic men with diabetes had a higher prevalence of smoking than did White men with diabetes and Black and Hispanic men without diabetes, but none of these differences were statistically significant. Among people with diabetes, age, race, sex, and educational status were independent predictors of current smoking in a multiple-logistic regression model. Duration of diabetes was not related to smoking. Conclusions--These data again emphasize the need to prevent and reduce smoking in the diabetic population. Smoking cessation programs should particularly target people with diabetes who are __18 years of age in the U.S. population. The questionnaire inquired about whether these individuals had ever attended a diabetes education class or program. Sociodemographic and clinical factors that may influence participation in patient education were also determined. Results--Of all people with diabetes, 35.1% had attended a class or program about diabetes at some time during the course of their disease, including 58.6% of individuals with insulin-dependent diabetes mellitus, 48.9% of insulin-treated individuals with non-insulindependent diabetes mellitus (NIDDM), and 23.7% of N I D D M individuals not treated with insulin. Younger age, black race, residence in the midwest region of the U.S., higher level of education, and presence of diabetes complications were consistently associated with having had diabetes education for people with NIDDM. Although increasing income was associated with patient education for N I D D M individuals not treated with insulin, it was not an independent determinant for insulin-treated N I D D M individuals. N I D D M individuals not treated with insulin who lived alone were more likely to have had patient education than those who did not live alone. Not having a diabetes physician or not visiting one in the past year was associated with a higher likelihood of patient education for noninsulin-treated NIDDM individuals. Conclusions--A large proportion of patients with diabetes has never received diabetes education. Patient education has been recognized for its contributions to reducing the morbidity and mortality of diabetes. Consequently, special attention should be directed to the subgroups of individuals, such as those not taking insulin, those with lower socioeconomic status, and those living outside urban
areas, in which the frequency of diabetes patient education is particularly low. ReprintAddress: M.I. Harris, NIDDK/NIH, Westwood Building, Room 620, Bethesda, MD 20892.
THE DIABETES EDUCATOR
171-0092
Perceptions of the Importance Placed on Religion and Folk Medicine by Non-MexicanAmerican Hispanic Adults with Diabetes Zaldivar, A. and Smolowitz, J. 20(4):303-306, 1994. The high incidence of diabetes and diabetes-related complications in Hispanic adults in the United States continues to be of concern among healthcare providers. The underutilization of screening services and early treatment centers by Hispanic adults seems to contribute to the problem. This survey examined whether religious, spiritual, and folk medicine beliefs play a role in the participants' view of diabetes and treatment choices. One hundred four non-Mexican-American Hispanic adults with diabetes were surveyed using a self-report questionnaire. Results showed that 78% of patients believed they had diabetes because it was God's will; 17% of patients reported using herbs to treat their diabetes. This survey demonstrates the importance of addressing religion and spirituality when dealing with the issues of disease and health in this population. Reprint Address: The Diabetes Educator, 367 West Chicago Avenue, Chicago, IL 60610.
171-0093
The Relationship between Eating Patterns and Metabolic Control in Patients with Non-InsulinDependent Diabetes Mellitus (NIDDM)
Schmidt, L.E., Rost, K.M., McGill, J.B., and Santiago, J.V. 20(4):317, 1994. The most important element in the therapeutic plan of patients with non-insulin-dependent diabetes meUitus (NIDDM) is dietary modification. Dietary instructions target patient behaviors in two areas: following an exchange-based diet and adbering to the same basic eating pattern every day. However, there is little empirical data that addresses the relationship between dietary instruction and metabolic control. Fifty patients with N I D D M were enrolled in an 8-week study to ascertain if either dietary approach was more predictive of improved metabolic control. The effect on metabolic control was determined by changes in HbA,c over a 2- to 3-month period. Patients added or deleted almost half of all prescribed exchanges, and added or deleted an average of one prescribed meal or snack per day. Deviations in prescribed eating patterns, particularly breakfastskipping and snack additions and deletions, were related to poorer metabolic control. Maintaining consistent eating patterns should be further evaluated as an important component of dietary instruction for patients with NIDDM. Reprint Address: The Diabetes Educator, 367 West Chicago Avenue, Chicago, IL 60610.
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GASTROENTEROLOGY
171-0094
Relaxation Training Reduces Symptom Reports and Acid Exposure in Patients with Gast3"oesophageal Reflux Disease
McDonald-Haile, J., Bradley, L.A., Bailey, M.A., Schan, C.A., and Richter, J.E. 107:61-69, 1994. Background/Aims: Previous studies have shown that psychological factors play a role in symptom perception among patients with gastroesophageai reflux disease. This report describes the first controlled study showing the effects of relaxation training on symptom reports and eosophageal acid exposure in patients with reflux disease. Methods: Twenty subjects with documented reflux disease were studied during psychologically neutral and stressful tasks, followed immediately by either a relaxation or attention-placebo control intervention. Results: Stressful tasks, relative to neutral tasks, produced significant increases in blood pressure, subjective ratings of anxiety, and reports of reflux symptoms. Despite increased symptom reports, stressful tasks did not significantly increase objective measures of esophageal acid exposure. Subjects who received a relaxation intervention after the stressful task had significantly lower heart rate values and subjective ratings of anxiety compared with subjects who received the attention-placebo control intervention. Subjects who received relaxation training also had significantly lower reflux symptom ratings and total esophageal acid exposure than subjects who received the attention-placebo control intervention. Conclusions: Relaxation may be a useful adjunct to traditional antireflux therapy in patients who experience increased symptoms during stress. Reprint Address: L.A. Bradley, Division of Gastroenterology,633 Zeigler Research Building, University of Alabama, Birmingham, At. 35294.
number of negative life events for women. For both genders IHLC was related to the importance placed on good health. Reprint Address: M.I. Wallhagen, Department of PhysiologicalNursing, School of Nursing, University of California, San Francisco, CA 941430610.
171-0096
Physical and Functional Health Assessment in Normal Aging and in Alzheimer's Disease: SelfReports vs Family Reports
Kiyak, H.A., Ted, L., and Borson, S. 34(3):324-330, 1994. This longitudinal 2-year study compared self and family members' reports of physical and functional health among 40 patients with Alzheimer's disease and 53 age-matched nondemented healthy older persons. Functional health was consistently rated as more impaired by family caregivers of demented patients than by the patients themselves, a discrepancy not observed in the cognitively intact comparison group. Caregiver reports correlated significantly with declines in patients' cognitive abilities as measured by formal testing, but self-reports did not. Patients did recognize deterioration in ADLs over time, despite progressively worsening cognitive ability. These data indicate that the capacity for self-observation is partially preserved in Alzheimer's patients in mild to moderate stages. Patient self-reports can provide valuable data for clinicians, but should be supplemented by detailed information from caregivers. Reprint Address: H.A. KAyak,Departments of Oral and Maxillofacial Surgeryand Psychology,University of Washington, SB-24, Seattle, WA 98195.
HEADACHE
171-0097
THE GERONTOLOGIST
171-0095
Impact of Internal Health Locus of Control on Health Outcomes for Older Men and Women: A Longitudinal Perspective
WaUhagen, M.I., Strawbridge, W.J., Kaplan, G.A., and Cohen, R.D. 34(3):299-306, 1994. We investigated the relationship between baseline internal health locus of control (IHLC) and 6-year change in physical functioning in 356 older adults. IHLC was strongly related to change in physical functioning for women at all levels of baseline functioning, but only affected men with lower baseline functioning. Cross-sectional analyses indicated no relationship between IHLC and health seeking activities except changing eating patterns when sick. Other findings were that IHLC was related to depression and not having childhood illness for men and to
Migraine as a Sequela to Chronic Low Back Pain Duckro, P.N., Schultz, K.T., and ChibnaU, J.T. 34(5):279-281, 1994. The occurrence of headache as a sequela of low back pain was examined in a sample of chronic pain patients. All patients had low back pain without history of head, neck, or upper back injury or headache onset simultaneous with the low back pain. Consistent with prior research, headache was found to be a common concomitant of back pain. In many patients, headache was found to have begun or exacerbated markedly after onset of low back pain. Prevalence of migraine in female patients was significantly higher than the population prevalence for females in the United States; this was not true for male patients. Potential mechanisms for explaining the high prevalence of migraine following low back pain are discussed, including increased muscle tension, psychosocial factors, and analgesic overuse. Reprint Address: P.N. Duckro, Saint Louis University Health Sciences Center, Division of BehavioralMedicine, 1221 South Grand Boulevard, St. Louis, MO 63104.
V O L U M E 17, N U M B E R 1, 1995
HEADACHE QUARTERLY
171-0098
Interrelationships among Dally and Global SelfReport Measures of Headache Penzien, D.B., Johnson, C.A., Seville, J.L., et al. V(1):27-33, 1994. Objective. To carefully examine the interrelationships among various daily and global self-report indices of headache in a large clinical sample of headache sufferers. Design. Prospective study examining correlations among headache measures and diagnostic group differences in correlations. Setting. Outpatient, university medical center-based headache clinic. Patients. 150 recurrent headache sufferers who experienced at least three headaches per month. Main Outcome Measures. Summary scores derived from patients' daily self-monitoring and global, retrospective reports of headache activity including: (a) peak headache intensity, (b) number of headache days per week, and (c) daily headache index. Results. The interrelationships among the various headache measures across headache diagnostic groups could not be differentiated, and the frequency and intensity measures appeared to tap discrete dimensions of headache activity for both daily and global ratings. While one would expect two different measures of the same construct (e.g., frequency) to be strongly correlated, only minimal correspondence was observed between comparable measures assessed via daily versus global methods--global ratings of peak headache intensity overestimated and global ratings of headache frequency underestimated daily ratings of the same construct. Con.clusions. Both consumers and producers of the headache literature should be cognizant of the potential variability among types of headache measures. Clearly, daily and global measures of headache activity should not be considered equivalent. Relative to daily self-report measures, global, retrospective measures tend to overestimate headache activity. Reprint Address: D.B. Penzien, UMC Headache Clinic, Department of Psychiatry and Human Behavior, The University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505.
HEALTH PSYCHOLOGY
171-0099
Chronic Stress, Social Support, and Persistent Alterations in the Natural Killer Cell Response to Cytokines in Older Adults Esterling, B.A., Kiecolt-Glaser, J.K., Bodnar, J.C., and Glaser, R. 13(4):291-298, 1994. To address the long-term physiological consequences of chronic stressors, 14 continuing or current family caregivers of Alzheimer's disease (AD) patients, 17 former AD caregivers, and 31 control subjects were compared. Continuing and former caregivers did not differ on depressive symptomatology or perceived stress; both groups were significantly more depressed and stressed than controls. Furthermore, continuing and former caregivers did not differ in the response of NK cells in vitro to
69
recombinant interferon-7 and recombinant interleukin-2, and both groups had a significantly poorer response to these cytokines than controls. The physiological and psychological consequences of chronic stressors may persist well beyond the cessation of the actual stressor. Reprint Address: R. Glaser, Department of Medical Microbiologyand Immunology, 218 Meiling Hall, 320 West 9th Avenue, Ohio State University Medical Center, Columbus, OH 43210-1238. 171-0100
Realistic Acceptance as a Predictor of Decreased Survival Time in Gay Men with AIDS Reed, G.M., Kemeny, M.E., Taylor, S.E., Wang, H.-Y.L, and Visscher, B.R. 13(4):299-307, 1994. Although theoretical accounts of adaptation in the terminally ill suggest that realistic acceptance of one's disease is adaptive, some investigations suggest that such responses are associated with increased mortality. This prospective psychobiological investigation involved 74 gay men with AIDS. Six scores reflecting responses to disease were derived from a detailed psychosocial questionnaire. One pattern of response, Realistic Acceptance, was a significant predictor of decreased survival time. Median estimated survival time for participants with low Realistic Acceptance scores was 9 months greater than for participants with high Realistic Acceptance scores. This effect was not accounted for by time since diagnosis with AIDS, self-reported health status, number ofCD4 T lymphocyte cells, psychological distress, age, education, initial diagnosing condition, use of AZT, smoking, or alcohol and drug use. Reprint Address: G.M. Reed, Department of Psychiatry and Biobehavioral Sciences, School of Medicine, University of California, 760 Westwood Plaza, Los Angeles, CA 90024-1759. 171-0101
Psychological Adjustment in Adults with Cancer: The Self as Mediator Heidrich, S.M., Forsthoff, C.A., and Ward, S.E. 13(4):346-353, 1994. The role of the self in adjustment to cancer has been noted but is not weU understood. Research and theory on the self suggest that discrepancies between actual and ideal self-conceptions influence adjustment and mediate the effects of diseaserelated health problems on psychological well-being. This relationship was investigated in a cross-sectional study of 108 persons with cancer. Cancer patients who had more symptoms and worse functional health and perceived their cancer as a chronic rather than an acute disease had higher levels of selfdiscrepancies and poorer adjustment. Self-discrepancy was a significant mediator of the effects of perceived health status on purpose in life, positive relations with others, and depression. Reprint Address: S.M. Heidrich, University of Wisconsin, School of Nursing, 575 Ctmningham Hall, Milwaukee, WI 53201. 171-0102
Empirical Tests of an Information-MotivationBehavioral Skills Model of AIDS-Preventive Behavior with Gay Men and Heterosexual University Stndents Fisher, J.D., Fisher, W.A., Williams, S.S., and Malloy, T.E. 13(3):238-250, 1994. This article contains empirical tests of the informationmotivation-behavioral skills (IMB) model of AIDS-preventive
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Health Psychology (continued) behavior, which has been designed to understand and predict the practice of AIDS-preventive acts. The IMB model holds that AIDS-preventive behavior is a function of individuals' information about AIDS prevention, motivation to engage in AIDS prevention, and behavioral skills for performing the specific acts involved in prevention. The model further assumes that AIDSprevention information and motivation generally work through AIDS-prevention behavioral skills to influence the initiation and maintenance of AIDS-preventive behavior. Supportive tests of the model, using structural equation modeling techniques, are reported with populations of gay male affinity group members (n = 91) and heterosexual university students (n = 174). Reprint Address: J.D. Fisher, Department of Psychology,U-20, Room 107, 406 BabbidgeRoad, University of Connecticut, Storrs, CT 062691020.
171-0103
Consequences of Dieting to Lose Weight: Effects on Physical and Mental Health French, S.A. and Jeffery, R.W. 13(3):195-212, 1994. Concern has been raised that negative physiological and psychological effects of dieting may outweigh aesthetic and health benefits. This review of the literature concludes the following: (a) The measurement of dieting is an important unresolved issue; (b) current dieting, chronic dieting, desire to lose weight, specific weight control behaviors, and weight changes may have different effects on health and need to be distinguished; (c) dieting is usually not associated with nutritional deficiencies, adverse physiologic adaptations, severe psychological reactions, or the development of eating disorders; and (d) recommendations against weight loss efforts involving moderate changes in eating and exercise habits are not warranted. Reprint Address: S.A. French, Division of Epidemiology,School of Public Health, University of Minnesota, 1300 South Second Street, Suite 300, MinneapoLis, MN 55454-1015.
171-0104
Cognitive Distortion, Helplessness, and Depressed Mood in Rheumatoid Arthritis: A Four-Year Longitudinal Analysis Smith, T.W., Christensen, A.J., Peck, J.R., and Ward, J.R. 13(3)'213-217, 1994. Cognitive models of depression have been invoked to explain the development of depressive symptoms and disorders in patients with chronic pain. However, few long-term, prospective studies have examined A. T. Beck's (1967, 1987) model in this context. Seventy-two patients with rheumatoid arthritis completed the Beck Depression Inventory, the Cognitive Errors Questionnaire, and the Arthritis Helplessness Index during an initial assessment and again 4 years later. Initial levels of cognitive distortion were significantly related to follow-up levels of depressed mood, controlling for initial depression levels. This was also true for perceptions of helplessness. In contrast, initial depression levels did not predict changes in these cognitive processes. These results suggest that cognitive distortion and helplessness contribute to depressed mood among patients with arthritis. Reprint Address: T.W. Smith, Department of Psychology, Behavioral Sciences Building, University of Utah, Salt Lake City, UT 84112.
171-0105
The UCLA Multidimensional Condom Attitudes Scale: Documenting the Complex Determinants of Condom Use in College Students Helweg-Larsen, M. and Collins, B.E. 13(3):224-237, 1994. This article describes the development and validation of the UCLA Multidimensional Condom Attitudes Scale (MCAS). The relationships between the MCAS and gender, sexual experience, intentions to use a condom, and past condom use were assessed. The MCAS has five distinct factors: (a) Reliability and Effectiveness of condoms, (b) the sexual Pleasure associated with condom use, (c) the stigma attached to persons who use condoms (Identity Stigma), (d) the Embarrassment About Negotiation and Use of condoms, and (e) the Embarrassment About the Purchase of condoms. The results strongly suggest that condom attitudes are multidimensional and thus cannot meaningfully be summed to a single global score. Results further indicate that men and women hold very different attitudes toward condoms. Implications of scale multidimensionality and directions for future research are discussed. Reprint Address: M. Helweg-Larsen,Department of Psychology,University of California, 405 Hilgard Avenue, Los Angeles, CA 900241563. 171-0106
Substance Use and Sexual Risk Taking among Black Adolescents and White Adolescents Cooper, M.L., Peirce, R.S., and Huselid, R.F. 13(3):251-262, 1994. Analyses of data from a random sample of 1,259 sexually active adolescents revealed that substance use was associated with increased sexual risk taking on 2 occasions of intercourse (lst intercourse ever and 1st intercourse with most recent partnet), even after controlling for demographic, experiential, and dispositional confounders. Within-persons analyses yielded similar results, indicating that adolescents who used substances, on 1 of the 2 occasions, reported higher levels of risk taking on the occasion when substances were used than on the no-substance-use occasion. However, substance use was both more common and more strongly linked to risk taking among White than Black adolescents, suggesting that White adolescents are at greater risk ofnegative consequences related to substance use proximal to intercourse. Reprint Address: M.L. Cooper, Department of Psychology, 348 Park Hall, SUNY, Buffalo, NY 14260-4110. 171-0107
Impact of Social Support, Social Cognitive Variables, and Perceived Threat on Depression among Adults with Diabetes Connell, C.M., Davis, W.K., Gallant, M.P., and Sharpe, P.A. 13(3):263-273, 1994. Tested was a model of social support and cognitive appraisal of self-effcacy, outcome expectancies, and illness threat on depression. Study participants were community-dwelling adults with diabetes who completed a mailed questionnaire (N = 362). Results of structural equation modeling indicated that 52% of the variance in depression was explained by the model-largely by the direct effects of physical functioning, the perceived availability of social support, and the perceived threat of diabetes as well as the indirect paths from perceived support to
V O L U M E 17, N U M B E R 1, 1995
Health Psychology (continued) perceived threat and from physical functioning to perceived support and perceived threat of diabetes. Diabetes-specific social support, self-efficacy, and outcome expectancies were not significant predictors of depression. Reprint Address: C.M. Connell, Department of Health Behavior and Health Education, School of Public Health, 1420 Washington Heights, University of Michigan, Ann Arbor, MI 48109-2029. 171-0108
The Physician-Delivered Smoking Intervention Project: Can Short-Term Interventions Produce Long-Term Effects for a General Outpatient Population? Ockene, J.K., Kristeller, J., Pbert, L., et al. ]3(3):278-281, 1994. Patterns of smoking cessation using 6- and 12-month follow-up data are reported for 1,261 primary care patients randomized to 3 physician-delivered smoking interventions: advice only (AO), counseling (CI), and counseling plus availability of nicotine-containing gum (CI + NCG). One-week-point-prevalence cessation rates at 12 months did not differ among the interventions: AO (15.2~ CI (12.9%) and CI + NCG (16.7%). However, maintained cessation rates (abstinent at both 6 and 12 months) increased with intervention intensity: AO (6.0%), CI (7.8%) and CI + NCG (10.0%): Test of trend • = 5.06, p = .02. CI + NCG was significantly higher than AO (p ffi .02). The findings support the following conclusions: Brief physiciandelivered intervention with availability of nicotine-containing gum can have a beneficial long-term effect on smoking cessation, and cohort data as well as point-prevalence rates are important when assessing the long-term impact of lifestyle interventions. Reprint Address: J.IC Ockene, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Avenue, North, Worcester, MA 01655.
followed was designed to stimulate the youths through reflection, dialogue, and planning for action. Reprint Address: A. Malekoff, North Shore Family Guidances Center, 480 Old Westbury Road, Roslyn Heights, NY 11577.
171-0110
Psychosocial Characteristics of Pregnant Women with and without a History of Substance Abuse Marcenko, M.O., Spence, M., and Rohweder, C. 19(1): 17-22, 1994. This study was undertaken to identify the psychosocial characteristics and service needs of pregnant women with substance abuse histories. Two hundred and twenty-five pregnant women defined as having high-risk pregnancies for psychosocial reasons were interviewed using a structured questionnaire when they presented for prenatal care at a large urban clinic. Women who admitted to problems with substance abuse were compared to those who denied a history of substance abuse. Women with an admitted history of substance abuse were significantly older, had more children, were more likely to live on their own or in an institutional setting, and more frequently reported that they currently smoked cigarettes. In addition, women with substance abuse problems delayed prenatal care an average of one month longer. Other differences between the two groups, as well as the implications of the findings for social work practice in health care settings, are discussed. Reprint Address: M.O. Marcenko, Department of Mental Health Sciences, Hahnemann University, 1427 Vine Street, Philadelphia, PA 19102.
HYPERTENSION
171-0111
HEALTH A N D S O C I A L W O R K
171-0109
Action Research: An Approach to Preventing Substance Abuse and Promoting Social Competency Malekoff, A. 19(1):46-53, 1994. This article demonstrates the use of action research, an approach combining various social work methods to raise community consciousness, stimulate intergroup and intergenerational interaction, and motivate people to work toward change both individually and collectively. The project described represents an effort to mobilize youths and adults living in a rapidly changing, culturally pluralistic, low-income suburban community to confront the impact of drug and alcohol abuse in a context of mutual respect and support. The central them of investigation was local youths' perceptions about drug and alcohol abuse in the context of their own lives. A group of youths, in partnership with professionals, surveyed their contemporaries with a questionnaire of their own creation. The community meeting that
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Exercise Blood Pressure Predicts Cardiovascular Mortality in Middle-Aged Men Mundal, R., Kjeldsen, S.E., Sandvik, L., et al. 24:56-62, 1994. The outcome of 1999 apparently healthy men aged 40 to 59 years investigated from 1972 through 1975 was ascertained after 16 years to determine whether systolic blood pressure measured with subjects in the sitting position during a bicycle ergometer exercise test adds prognostic information on cardiovascular mortality beyond that of casual blood pressure measured after 5 minutes of supine rest. During a total follow-up of 31,984 patient years, 278 patients died, 150 from cardiovascular causes. Casual blood pressure and pulse pressure as well as peak exercise systolic blood pressure during 6 minutes on the starting workload of 600 kpm/min (approximately 100 W, 5880 J/rain) were all related to cardiovascular mortality. The relative risk (RR) of dying from cardiovascular causes associated with an increment of 48.5 m m Hg (=2 SD) in systolic blood pressure at 600 kilopondmeter (kpm)/min was significant (RR = 1.5, 95% confidence interval [CI] ffi 1.1-2.3, P = .040) even when adjusting for a large number of variables measured in the present study, including age, exercise capacity, smoking habits, and casual blood pressures. The influence of blood pressure at 600 kpm/min was
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Hypertension (continued) so strong that the predictive value of resting casual blood pressures became nonsignificant when these were analyzed as continuous variables also including exercise blood pressure as a covariate. However, the maximal systolic blood pressure during the exercise test was unrelated to cardiovascular mortality. Among the 520 men with resting systolic blood pressure of 140 m m Hg or greater, those 304 who increased their systolic blood pressure to 200 m m Fig or greater during 6 minutes of the starting exercise workload of 600 kpm/min had a 16-year cardiovascular death rate of 16.1% compared with 6.0% among those with a systolic blood pressure less than 200 m m Hg at 600 kpm/min (n = 216, RR = 2.0, 95% CI = 1.1--4.0, P = .025). The cardiovascular death rate was also 6.0% among those who were normotensive at rest (n = 1479). Thus, an early rise of systolic blood pressure during exercise adds prognostic information on cardiovascular mortality among otherwise healthy middle-aged men with mildly elevated casual blood pressure. Reprint Address: S.E. Kjeldsen, Department of Internal Medicine, UIlevaal Hospital, N-0407 Oslo, Norway.
INTERNATIONAL JOURNAL OF EATING DISORDERS
171-0112
Resting Metabolic Rate and Total Energy Expenditure in Acute and Weight Recovered Patients with Anorexia Nervosa and in Healthy Young Women Platte, P., Pirke, ICM., Trimborn, P., et al. 16(1):45-52, 1994. Reprint Address: K.M. Pirke, Center of Psychobiology and Psychosomatic Research, Department of Psyehoendocrinology, University of Trier, Building D, Box 3825, 5500 Trier, Germany.
cancer. This study was done to evaluate the risk of female lung cancer from PS, especially that during childhood and adolescence. Methods. Using household exposure to tobacco smoke as an estimate of PS, a 1:1 paired case-control study was conducted in Harbin, China. We interviewed 114 female primary lung cancer cases, aged 30--69 years, and their hospital-based controls. The controls were non-cancer patients, selected from the same hospital as the cases, and matched on age (+_ 5 years), residential area and smoking status over their lifetime. There were 59 pairs who ever smoked and 55 pairs who never smoked. Information on PS was collected by residence for each of the following periods: 0--6, 7-14, 15-22, 23-30 and 31-69 years. Results. Household PS significantly increases the risk of female lung cancer for those exposed at ages 22 or younger, who have ever smoked. The risk was also increased for those non-smoking pairs when exposed under the age of 15 years. Exposure to maternal smoking at ages 14 or younger increased the risk by about 170% (odds ratio, OR 2.7, 95% confidence interval [CI]: 1.49-4.88), but not to paternal smoking (OR 1.40, 95% CI: 0.922.50). The risk was highest for those exposed under the age of seven (OR 3.46, 95% CI: 1.80-6.65) and was also significant at ages 7-14 (OR 3.08, 95% CI: 1.62-5.57) and 15-22 (OR 3.10, 95% CI: 1.52-6.31) years. Under the age of 23 years, the OR increased with amount of PS(P < 0.001). Of note, the OR in all five exposure periods for non-smoking pairs were similar to those for all 114 paris studied. Conclusions. Household PS, particularly that during childhood, increases the risk of female lung cancer. The assessment of PS should be done by different periods of exposure. Reprint Address: F.-L. Wang, Department of Community Health Sciences, Faculty of Medicine, University of Calgary, 3330 Hospital Drive, NW, Calgary, AB T2N 4N1, Canada.
171-0115
171-0113
Body Weight and Dieting in Adolescence: Impact of Socioeconomic Status Drewnowski, A., Kurth, C.L., and Krahn, D.D. ]60):61--65, 1994. Reprint Address: A. Drewnowski, Human Nutrition Program, School of Public Health M-5170, University of Michigan, Ann Arbor, MI 48109-2029.
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
171-0114
Childhood and Adolescent Passive Smoking and the Risk of Female Lung Cancer Wang, F.-L., Love, E.J., Lui, N., and Dai, X.-D. 23(2):223-230, 1994. Background. Few studies have reported the relationship between passive smoking (PS) in early life and the risk of lung
EmploymentStatus, Non-Daytime Work and Gastric Ulcer in Men Tiichsen, F., Jeppesen, H.J., and Bach, E. 23(2):365-370, 1994. Background. An excess risk of gastric ulcer (GU) (ICD-8: 531) has formerly been found in shift workers and ex-shiftworkers but little is known about the risk of GU associated with other forms of non-daytime work. This study deals with associations between non-daytime work and GU. Methods. A fixed cohort of 122,116 men in occupations in which at least 20% had non-daytime work and a reference group of 593,281 men in occupations with daytime work only, was followed in the National Inpatient Register for first discharges with GU as the principal diagnosis. Results. For men with daytime work only we found a steep inverse association between GU and employment status. Men in occupational groups with late evening work had a standardized hospitalization ratio (SHR) of 236 (90% confidence interval [CI]: 184--299), groups working in rosters covering 24-hour services had an SHR of 147 (90% CI: 116183). A slightly raised risk of 114 (90% CI: 101-128) was found in groups having other forms of non-daytime work. For all men in groups with non-daytime work we found a significant SHR of 130 (90% CI: 118-142). Conclusions. We conclude that both
V O L U M E 17, N U M B E R 1, 1995
International Journal of Epidemiology (continued) low employment status and non-daytime work are associated with an increased risk of GU. Reprint Address: F. Tiichsen, National Institute of Occupational Health, Department of Occupational Medicine, Lerso Parkalle 105, DK-2100 Copenhagen O, Denmark.
171-0116
not support the existence of a threshold in the relation between alcohol and blood pressure. Reprint Address: K. Wakabayashi, Department of Public Health, National Defense Medical College, Tokorozawa, Saitama 359, Japan.
Moderate and Vigorous Leisure-Time Physical
Activity and Cardiovascular Disease Risk Factors in West Germany, 1984-1991 Helmert, U., Herman, B., and Shea, S. 23(2):285-292, 1994. The relationship between leisure-time physical activity (LTPA) and cardiovascular disease (CVD) risk factors was analysed based on data of three cross-sectional National Health Surveys, carried out in West Germany between 1984 and 1991. A total of 7663 males and 7722 females, aged 25--69 years, were examined. A self-administered questionnaire was used to assess LTPA which was defined as the mean duration of time (in minutes) spent during the past week on 14 specified sports during the previous 3 months. The mean time for LTPA per week was 102 minutes for males and 70 minutes for females. No significant differences were observed in LTPA mean duration for the three surveys. Younger age and higher social class were strong predictors for greater LTPA. In multiple linear regression models, after adjustment for age and social class, LTPA was significantly associated with lower systolic and diastolic blood pressure (both sexes), total cholesterol (males only), cigarette smoking (males only) and body mass index (females only), and with higher HDL-cholesterol (both sexes). The data suggest that LTPA plays an important role if aiming at reducing CVD risk factors in the general population. Reprint Address: U. Helmert, Division of Epidemiology, Bremen Institute for Prevention Research and Social Medicine (BIPS), P.O. Box 106767, D-28067 Bremen, Germany.
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73
Alcohol Consumption and Blood Pressure: An Extended Study of Self-Defence Oilidals in Japan Wakabayashi, K., Nakamura, K., Kono, S., Shinchi, K., and Imanishi, K. 23(2):307-311, 1994. Background. It remains controversial whether the relation between alcohol intake and blood pressure is linear or nonlinear. Methods. The relation between alcohol intake and blood pressure was investigated in 2341 male self-defence officials who received a preretirement health examination at the Self-Defense Forces Fukuoka Hospital between October 1986 and December 1990. Average alcohol intake in the past year was ascertained by a self-administered questionnaire. The study excluded past drinkers, and allowed for smoking, body mass index and glucose tolerance. Results. Blood pressure was higher at higher levels of alcohol intake across the range from 0 to 40-59 ml of alcohol per day, but was not progressively higher in men consuming > 60 ml per day. Blood pressure was significantly higher even among light drinkers (< 20 ml per day) compared to non-drinkers; adjusted mean differences were 3.1 mmHg (95% confidence interval (CI): 1.1-5.2) in systolic pressure and 2.1 m m H g (95% CI: 0.7-3.5) in diastolic pressure. Conclusions. Our findings do
JOURNAL OF ABNORMAL CHILD PSYCHOLOGY
171-0118
IndividualDifferences in Preschoolers' Physiological and Verbal Responses to Videotaped Angry Interactions El-Sheikh, M., Ballard, M., and Cummings, E.M., 22(3):303-320, 1994. Individual differences in selection of intensity of angry interactions and physiological and self-reported responses to interadult anger were examined in preschoolers (N = 34). Children watched two videotaped angry interactions between adults, while their heart rates and skin conductance responses and levels were monitored; then they were interviewed. Before the second argument, children were given the perceived choice of watching an intense or mild angry exchange. Individual differences in responding to the angry interactions were found. Both (a) children with relatively higher externalizing behavior problems and Co) boys who chose to watch intense anger had lower tonic heart rates; 80% of boys with externalizing problems chose to watch intense anger. Further, children who chose to watch intense anger (a) exhibited lower declines in heart rates upon the presentation of the argument, Co) perceived the actors as more angry, and (c) reported lower amounts of distress during the argument than those who chose mild anger. Reprint Address:M. El-Sheikh, Department of Psychology,Auburn University, Auburn, AL 36849-5214.
JOURNAL OF ABNORMAL PSYCHOLOGY
171-0119
Differential Relationships between Stress and Disease Activity for Immunologically Distinct Subgroups of People with Rheumatoid Arthritis Stewart, M.W., Knight, R.G., Palmer, D.G., and Highton, J. 103(2):251-258, 1994. Immunologically distinct subgroups of patients with rheumatoid arthritis (RA)--those with the autoantibody rheumatoid factor (seropositive RA) and those without (seronegative RA)-were compared on a variety of clinical and self-report measures in a consecutive series of women with disease of 7 years' or less duration. The groups were comparable on clinical, pain, func-
74
ANNALS OF BEHAVIORAL MEDICINE
Journal of Abnormal Psychology (continued) tional, and psychosocial variables. However, the seronegative RA group reported elevated levels ofpreonset negative life event stress. Postonset life event stress and disease activity were significantly correlated for the seronegative RA group, but not for the seropositive RA group. Results suggest that stress factors may be more important in the etiology and maintenance of seronegative RA and that the seronegative RA group may possibly derive particular benefit from psychological techniques to enhance stress management skills. Reprint Address: M.W. Stewart, Psychiatric Liaison, Middlemore Hospital, Private Bag, Otahtthu, Auckland 6, New Zealand.
171-0120
Word Completion in Chronic Pain: Evidence for Schematic Representation of Pain? Edwards, L.C. and Pearce, S.A. 103(2):379-382,1994. Schematic representation of pain information was investigated in chronic pain patients, health professionals, and nonpatient controls. Under the guise of an English-language experiment, Ss were presented with 12 word stems to be completed with the first 2 English words that came to mind. Four of the stems could be completed with sensory pain words, 4 with affective, and 4 with words associated with pain or illness. All could be completed with at least 3 other nonpain words of equal or greater frequency. Results indicate that chronic pain Ss produced significantly more pain-related completions than control Ss and that in all 3 groups the types of pain words produced were related to the extent of personal experience of pain. The theoretical implications of these findings are discussed in relation to the organization of schema, implicit memory, and the activation of mental representations of pain (schema). Reprint Address: L.C. Edwards, Department of Psychology,University College London, Gower Street, London WC1E 6BT, UIC
JOURNAL OF ADOLESCENT HEALTH
171-0121
Prospective Study of Psychological Development of Adolescent Female Athletes: Initial Assessment Theintz, G., Ladame, F., Kehrer, E., et al. 15:258-262, 1994. Purpose: This study aimed at assessing the impact of physical training on psychological functioning at the onset of a prospective study of psychological and somatic maturation of adolescent female athletes. Methods: Twenty-seven highly trained gymnasts aged 12.7 + 1.1 year (mean + SD, training load = 18-26 hr/week) and 16 age-matched but moderately trained swimmers (13.0 _+ 0.9 yr, training load 4-15 hr/wk) were submitted to standardized somatic and psychiatric examinations during training camps. Results: Gymnasts were significantly shorter, lighter and thinner (p < 0.001) than swimmers. Their bone age was moderately but significantly retarded (-1.42 _+
0.99 yr, p < 0.001) in contrast with swimmers in whom it was adequate for chronological age (+0.28 ___ 0.94 year, ns). Only 7.4% of gymnasts has already had menarche in contrast with 50% of age-matched swimmers (p = 0.003). Psychological functioning was considered as normal in all subjects. However, seven athletes including 3/27 gymnasts and 4/16 swimmers (p = 0.394) were considered as subjects "at risk" to develop a manifest mental disorder over time. Ten gymnasts (41.7%) presented with a global delay in psychological maturation, whereas no such case was observed among swimmers (p = 0.015). No correlation could be established between psychological delay and pubertal retardation (p = 0.210). Conclusion: Strenuous training in gymnastics for more than 1 yr has so far no detectable interference with the normal maturational events of adolescence. The outcome of athletes at risk to develop psychopathology as well as those with a global delay in psychological maturation who presented as if they were still in the latency period, remains uncertain. Reprint Address: G. Theintz, Hrpital de l'Enfance, Case postale, 1004 Lausanne, Switzerland.
171-0122
The Relationship between Aggressive Behavior and Puberty in Normal Adolescents: A Longitudinal Study Finkelstein, J.W., Von Eye, A., and Preece, M.A., 15:319-326, 1994. Purpose: To assess changes in aggressive behaviors as related to progression from early to late puberty in normal adolescents. Methods: Subjects were normal English schoolchildren. An observational cohort design was employed. Pubertal status was measured by Tanner staging. Self-reports of verbal aggression against adults, physical aggression against peers, aggressive impulses and aggressive inhibitory responses, were collected at three points in time. Analyses were performed for the entire group of 106 subjects in 1983, 77 subjects in 1985 and 70 subjects in 1987. Statistical methods included analysis of variance, regression and correlation and cluster formation. Results: There were decreases in all aggression variables except in aggressive impulses over this time period. When analyzed by gender, boys were initially more aggressive than girls, but by late puberty all gender differences in self-reported aggressive behaviors had disappeared. When only those subjects who were evaluated at all three data collection times were grouped by similar responses on both aggression and physical variables, three clusters of boys and girls were identified. Clusters contained varying proportions of boys and girls. Cluster one (48.5% of the entire sample) was a low aggression group. Cluster two (30.3%) was a high aggression group, and cluster three (21.20/o) was an intermediate aggression group. These clusters seemed to have relatively stable aggression characteristics over time. Conclusions: These data suggest that groups of boys and girls who report similar aggression characteristics and have similar growth and pubertal characteristics can be identified. Neither gender alone, nor pubertal status alone, nor by inference, hormones alone is sufficient to explain the complex set of behaviors which are involved in aggression. ReprintAddress:J.W. Finkelstein, Program in Behavioral Health, E-210 Henderson, University Park, PA 16802.
V O L U M E 17, N U M B E R 1, 1995
JOURNAL OF ADVANCED NURSING
Psychoneuroimmunology and Cancer: An Integrated Review Bauer, S.M. 19(6):1114-1120, 1994. The new field of psychoneuroimmunology (PNI) studies the measurable interaction between psychological and physiological processes. Specifically, PNI is the study of the intricate interaction of consciousness (psycho), central nervous system (neuro), and the body's defence against external infection and abherrant cell division (immunology). Over the last 30 years, the body of knowledge in PNI has emerged and in the last 10 years has flourished. PNI has many implications for clinical nursing practice. This study provides supportive empirical evidence to systems theories, which have played a major role in nursing's attempt to comprehend the interaction between the mind and the body. Nurses are ideal candidates to take a lead in this new field because it reinforces the holistic perspective which is the essence and uniqueness of our discipline. Although a variety of clinical populations have been used in PNI research, the scope of this integrated review will be limited to PNI and cancer. Research studies addressing psychosocial variables' effect on aetiology, response to treatment, immunocompetence and overall survival in the oncology population will be examined. Reprint Address: S.M. Bauer, 520 West Stratford Place, Apartment 209, Chicago, IL 60657. 171-0123
Parents' Experience of Coming to Know the Care of a Chronically I11 Child Jerrett, M.D. 19(6):1050-1056, 1994. The family is the primary source of care for a chronically ill child, and it is the parents who must manage the child's illness on a daily basis. This qualitative study was undertaken to investigate the ways in which 10 two-parent families of children with juvenile arthritis experience their child's illness. In this paper the theme of coming to terms with the management of the illness and what it entails for the parents is examined. The data provide evidence of how the parents learn, and their efforts and experience of learning to care for the child on a daily basis. This is a complex process and includes the different phases the parents experience as they move through the learning process. The findings suggest that the parents learn the child's care and make adjustments to the demands of managing the child's illness in a way that works best for them. Reprint Address: M.D. Jerrett, Queen's University, School of Nursing, 90 Barrio Street, Kingston, ON K7I 3N6, Canada. 171-0124
Serf-Efficacy in Caregivers of Cognitively Impaired Elderly People: A Concept Analysis Mowat, J. and Laschinger, H.K.S. 19(6):1105-1113, 1994. Research with caregivers of cognitively impaired individuals has provided evidence which suggests that most caregivers experience at least some degree of burden. However, it has been postulated that it is the caregiver's subjective interpretation of the situation that is the primary factor responsible for mediating 171-0125
75
the degree of burden experienced. Caregivers who cope well with this type of stress may possess a high level of self-efficacy. The purpose of this paper is to analyze the concept of self-efficacy and its relationship to health care using Walker & Avant's concept analysis methodology. Uses of the concept of self-efficacy, as well as its defining attributes, antecedents, consequences and empirical referents, are discussed. Also, model, borderline, related, contrary and invented cases are constructed to illustrate the concept further. The relevance of the concept to nursing practice and areas requiting future investigation are noted. Reprint Address: J. Mowat, Faculty of Nursing, Health SciencesCentre, The University of Western Ontario, London, ON N6A 5C1, Canada.
171-0126
PreparingChildren and Families Psychologically for Day Surgery: An Evaluation Ellerton, M.-L. and Merriam, C. 19(6):1057-1062, 1994. The increasing use of ambulatory care settings for children's surgery places more responsibility on parents for psychological preparation of children for surgery and for their post-operative care. This paper describes the evaluation of a pre-admission programme to prepare children between the ages of 3 and 15 years and their families psychologically for day surgery. Seventyfive families comprised the study sample, 23 in the programme group and 53 in the non-intervention group. The programme focused on familiarizing families with the physical and procedural components of day surgery through a videotape of a family in a naturally occurring day surgery situation, a tour, and hospital play. Fewer children and parents in the programme group reported high anxiety levels awaiting surgery. Children and parents with previous surgical experience reported higher levels of pre-surgical anxiety than inexperienced families. Families reported the physicians and day surgery nurse as their primary sources of information and rated the day surgery nurse highest in their satisfaction with information received. Implications for practice, particularly for meeting the needs of young children and out-of-town families, are discussed. Reprint Address: M.-L. Ellerton, School of Nursing, Dalhousie University, Halifax, NS B3H 3J5, Canada.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
Cellular Immunity in Depressed, Conduct Disorder, and Normal Adolescents: Role of Adverse Life Events Birmaher, B., Rabin, B.S., Garcia, M.R., et al. 33(5):671-678, 1994. Objective: To determine whether adolescents with major depressive disorder have disturbances in their cellular immunity and to study whether the immunological changes detected are specific to depression or are general responses to stress. Method: Twenty subjects with major depressive disorder, 17 nondepressed subjects with conduct disorder, and 17 normal adolescents were recruited. Subjects were assessed with a clinical in171-0127
76
ANNALS OF BEHAVIORAL MEDICINE
Journal of the American Academy of Child and Adolescent Psychiatry (continued) terview for DMS-III-R and a modified version of the Coddington Life Events Checklist. Blood samples were drawn for total white blood cells, lymphocytes subsets, natural killer cell activity, lymphocyte proliferation response to phytohemagglutinin, and cortisol plasma levels. Results: Overall, there were no significant between-group differences in any of the cellular immune measurements. Natural killer cell activity was significantly negatively correlated with past year and lifetime adverse life events across all effector-target cell ratios. Controlling for diagnoses and socioeconomic status yielded similar results. There were no significant effects of age, sex, race, sleep, nutrition, cigarette use, menstrual cycle, or cortisol on any of the immunological va:~iables. Conclusions: In this sample of adolescents, we found that independent of the diagnoses and socioeconomic status, increases in adverse life events were associated with low natural killer cell activity. Reprint Address: B. Birmaher, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA 15213.
JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
171-1028
Report of a Pilot Study: A Program to Help Major I~ague Baseball Players Quit Using Spit Tobacco Greene, J.C., Walsh, M.M., and Masouredis, C. 125(5):559-568, 1994. There are few reports in the scientific literature that describe tested methods for helping people quit using spit (smokeless) tobacco. This paper reports data from a pilot study to determine the effectiveness of two dental-oriented interventions to promote cessation of ST use among major league baseball players. These preliminary findings suggest that interventions involving an oral examination and advice to quit, combined with behavioral counseling, may effectively decrease ST use among professional baseball players. Reprint Address:J.C. Greene, School of Dentistry, Box 0430, University of California, San Francisco, CA 94143-0430.
171-0129
Perspectives on the Interaction of Biological, Psychological and Social Factors in TMD Dworkin, S.F. 125(7):856-863, 1994. Temporomandibular disorders remain a poorly understood but related collection of clinical syndromes involving pain and function limitations. This article discusses TMD from the perspective of a chronic pain illness, which shares some features found in common chronic pain conditions, such as tension headache and benign back pain. From these perspectives, TMD may be viewed as a self-limiting chronic pain illness not associated with progressive physical deterioration. Reprint Address: S.F. Dworkin, Department of Oral Medicine, SC-63, University of Washington, Seattle, WA 98195.
JOURNAL OF BEHAVIORAL MEDICINE
171-0130
Temperament as a Potential Predictor of Mortality: Evidence from a 41-Year Prospective Study Graves, P.L., Mead, L.A., Wang, N.-Y., Liang, K.-Y, and Klag, M.J. 17(2):111-126, 1994. Psychological factors were hypothesized to influence mortality, in particular, early versus later mortality. To explore the relationship between temperament, a psychological factor, and mortality in a prospective study of 1337 medical students, we constructed a measure portraying three temperament types, using latent class analysis. Death occurred in 113 subjects over 25--41 years of follow-up. In univariate survival analysis, subjects tending to direct tension "inward" when under stress ("Tension-In") had a higher risk of morlality than "TensionOut" or "Stable" types. These associations persisted after adjustment for age, smoking, cholesterol level, and Quetelet Index. The relative risk (RR) of mortality for Tension-in was 1.56 (95% confidence interval, 1.00-2.44) compared with the Stable group. The risk was due entirely to the excess risk in persons under 55 years of age (RR, 2.59; 95% confidence interval, 1.46--4.62); the corresponding risk of death in older persons was 0.66 (0.301.48). Thus temperament is a significant risk factor for mortality, in particular, premature death. Reprint Address: P.L. Graves, The Precursors Study, 550 North Broadway, Room 503, Baltimore, MD 21205.
171-0131
Subtypes of Psychosocial Adjustment to Breast Cancer Nelson, D.V., Friedman, UC., Baer, P.E., Lane, M., and Smith, F.E. 17(2):127-141, 1994. By means of cluster analytic techniques, four subtypes of psychosocial adjustment were identified in a sample of 122 breast cancer patients who completed the Psychosocial Adjustment to Illness Scale. Internal consistency and internal validity of the derived typology were suggested by the finding that two different hierarchical agglomerative clustering methods (average linkage between groups, Ward's) produced similar solutions. Three of the derived subtypes reported normal affect levels but different patterns of relative strengths and dysfunctions, while the fourth subtype appeared to be highly distressed and globally maladjusted. External validation was demonstrated by differentiating the subtypes on variables of negative affect, avoidance coping, and fighting spirit. The clinical and heuristic implications of these findings are discussed. The findings highlight the need for comprehensive assessment ofpsychosocial functioning of cancer patients. They demonstrate that even non-emotionally distressed patients can have very different profiles of adjustment and may benefit from correspondingly individually tailored psychosocial interventions. Reprint Address: D.V. Nelson, Departments of Anesthesiologyand Psychiatry and Behavioral Sciences, The University of Texas--Houston Health Science Center, 6431 Fannin, MSB 5.020, Houston, TX 77030.
V O L U M E 17, N U M B E R 1, 1995
77
Journal of Behavioral Medicine (continued) 171-0132
Immunity and Depression: Insomnia, Retardation, and Reduction of Natural Killer Cell Activity Cover, H. and Irwin, M. 17(2):217-223, 1994. Depressed patients show a reduction of natural killer (NK) cell activity which may be associated with specific depressive symptoms. The present study demonstrated that sleep disturbance and retardation, but not other depressive symptoms, were negatively correlated with N K activity in 38 depressed patients. Specific behavioral changes in depression such as sleep disturbance and retardation were found to predict 16% of the variance of cytotoxicity levels in depression. Reprint Address:M. Irwin, Department of Psychiatry, 9116-A, VA Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161. 171-0133 Lobel, M.
Conceptualizations, Measurement, and Effects of Prenatal Maternal Stress on Birth Outcomes 17(3):225-272, 1994.
This article analyzes the conceptual and methodological approaches which have been used to investigate effects of prenatal maternal stress on birth outcomes and highlights the major findings of this research. By viewing the most widely used operational definitions of prenatal stress in a broader theoretical framework, it can be seen that most studies have failed to conceptualize stress reliably. This, in addition to common methodological and design flaws which are described in the article, has produced equivocal findings about the role of stress in adverse birth outcomes such as preterm delivery and low birth weight. Recent studies using more powerful, multidimensional approaches to stress definition and measurement provide more definitive evidence and suggest some precise effects. Implications and strategies for future research are presented. Reprint Address: M. Lobel, Department of Psychology, SUNY, Stony Brook, NY 11794-2500. 171-0134
Evaluation of a Home-Based Intervention Program to Reduce Infant Passive Smoking and Lower Respiratory Illness
Greenberg, R.A., Strecher, V.J., Bauman, K.E., et al. 17(3):273-290, 1994. We conducted a randomized controlled trial to determine whether a home-based intervention program could reduce infant passive smoking and lower respiratory illness. The intervention consisted of four nurse home visits during the first 6 months of life, designed to assist families to reduce the infant's exposure to tobacco smoke. Among the 121 infants of smoking mothers who completed the study, there was a significant difference in trend over the year between the intervention and the control groups in the amount of exposure to tobacco smoke; infants in the intervention group were exposed to 5.9 fewer cigarettes per day at 12 months. There was no group difference in infant urine cotinine excretion. The prevalence of persistent lower respiratory symptoms was lower among intervention-group infants of smoking mothers whose head of household had no education beyond high school: intervention group, 14.6%, and controls, 34.0%. Reprint Address: R.A. Greenberg, Department of Pediatrics, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112.
171-0135
Personal Models of Osteoarthritis and Their Relation to Serf-Management Activities and Quality of Life Hampson, S.E., Glasgow, R.E., and Zeiss, A.M. 17(2):143-158, 1994. We examined the personal models of osteoarthritis (OA) of 61 patients over 60 years of age. Models were elicited using a structured interview. Shared beliefs included perceiving OA as a serious, painful, chronic, and incurable condition that can be managed by recommended medical treatment. Considerable individual differences were found on six personal-model constructs: Symptoms, Seriousness, Cause, Control, Helpfulness of Treatment, and Negative Feelings about Treatment. The constructs of Symptoms and Seriousness were consistently related to a variety of important outcomes. For example, participants with higher scores on Symptoms and Seriousness reported higher levels of self-management (both concurrently and prospectively), reported more utilization of medical services, and experienced a poorer quality of life. The implications for the design of health-education materials and for patient-provider interactions are discussed. Reprint Address: S.E. Hampson, Oregon Research Institute, 1899 Willamette Street, Eugene, OR 97401.
171-0136
Cultural Diversity in Causal Attributions for Illness: The Role of the Supernatural Landrine, H. and Klonoff, E.A. 17(2):181-193, 1994. We investigated cultural diversity in beliefs about the causes of illness and assessed the possibility that popular free-form methodologies (asking subjects to generate causes) inhibit minorities from expressing their belief in supernatural causes. As predicted, when asked to generate causes of illness and rate these in terms of their importance, Whites and minorities did not differ in the number or type (natural vs supernatural) of causes they generated or in the importance rating they assigned to these. However, when these same subjects were provided with natural and supernatural causes to rate in terms of importance, minorities rated supernatural causes significantly more important than did Whites, and more minorities than Whites endorsed such causes. Cultural differences in causal attributions for illness are examined, and the role of methodology in determining such attributions is highlighted. Reprint Address: H. I.andrine, Public Health Foundation, 13200 Crossroads Parkway, North, Suite 135, City of Industry, CA 91747. Testing the Generulizability of Intervening Mechanism Theories: Understanding the Effects of Adolescent Drug Use Prevention Interventions Donaldson, S.I., Graham, J.W., and Hanson, W.B. 17(2): 195-216, 1994. Outcome research has shown that drug prevention programs based on theories of social influence often prevent the onset of adolescent drug use. However, little is known empirically about the processes through which they have their effects. The purpose of the present study was to evaluate intervening mechanism theories of two program models for preventing the onset of adolescent drug use. Analyses based on a total of 3077 fifth graders participating in the Adolescent Alcohol Prevention 171-0137
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ANNALS OF BEHAVIORAL MEDICINE
Journal of Behavioral Medicine (continued) Trial revealed that both normative education and resistance training activated the causal processes they targeted. While beliefs about prevalence and acceptability significantly mediated the effects of normative education on subsequent adolescent drug use, resistance skills did not significantly predict subsequent drug use. More impressively, this pattern of results was virtually the same across sex, etlmicity, context (public versus private school students), drugs (alcohol, cigarettes, and marijuana) and levels of risk and was durable across time. These findings strongly suggest that successful social influence-based prevention programs may be driven primarily by their ability to foster social norms that reduce an adolescent's social motivation to begin using alcohol, cigarettes, and marijuana. Reprint Address: S.I. Donaldson, USC Institute for Health Promotion and Disease Prevention Research, 1000 South Fremont Avenue, Suite 641, Alhambra, CA 91803-1358.
171-0138
The Effect of Instructions on Cognitive Strategies and Performance in Biofeedback Utz, S.W. 17(3):291-308, 1994. An experimental study was conducted in which 40 subjects, randomly assigned to four groups, were given differing instructions about using auditory biofeedback to lower forehead muscle tension. During each of three sessions, measures were taken of forehead electromyograph (EMG) and ability to discriminate and control muscle tension in order to measure learning during biofeedback. Cognitive strategies used by subjects were measured by taped verbal reports which were judged using four criteria based on two models of learning in biofeedback: "feedforward" and "feedback." Data were analyzed by chi-square, ANOVA, ANCOVA, and content analysis. Results indicate that subjects used predominantly a feedforward type of learning strategy in all four groups. Implications for teaching during biofeedback are discussed. Reprint Address: S.W. Utz, University of Virginia School of Nursing, McLeod Hall, Charlottesville, VA 22903-3395.
171-0139
Maintenance and Generalizability of Laboratory-Based Heart Rate Reactivity Control Training Sharpley, C.F. 17(3):309-329, 1994. The maintenance over time (4 months) and generalizability (to a work setting) of laboratory-based heart rate reactivity control training was investigated. Forty-three subjects received 5 weeks of biofeedback, imagery, and breathing training and 41 subjects acted as controls. Although there were no significant differences between the reactivities of the control and those of the treatment subjects at any of three pretraining tests, significant differences were noted immediately following training, 7 weeks, and 4 months later, showing maintenance effects. Data collected during work activities on the frequency of reactivity of a magnitude similar to that in the laboratory also showed that treatment subjects had significantly fewer incidents of reactivity than control subjects after training. Followup interviews with treatment subjects indicated that lifestyles were also en-
hanced in a variety of areas, suggesting that the training had wider benefits. Issues for further research are discussed. Reprint Address: C.F. Sharpley, Centre for Stress Management and Research, Faculty of Education-SGS, Monash University, Clayton, VIC 3168, Australia.
171-0140
Cultural Diversity in the Predictors of Adolescent Cigarette Smoking: The Relative Influence of Peers Landrine, H., Richardson, J.L., Klonoff, E.A., and Flay, B. 17(3):331-346, 1994. A culturally diverse sample of 4375 adolescents completed a self-report inventory assessing their current amount of smoking, and several psychosocial predictors of smoking (e.g., depression, anger, stress, smoking among peers, etc). Results revealed that Whites smoke more than Blacks, Asians, and less acculturated Latinos but not more than highly acculturated Latinos. Stepwise regression analyses of the predictors of smoking found significant ethnic and acculturation differences in the relative predictive power of 18 well-known risk factors. Smoking among peers was the best predictor of smoking for White adolescents (accounting for 23.5% of the variance) but accounted for only 15% of the variance for Latino youth, 9.6% of the variance for Asian youth, and none of the variance for Black youth. Results are discussed in terms of their implications for smoking prevention programs that focus on resisting peer influences. Reprint Address: H. Landrine, Public Health Foundation, 13200 Crossroads Parkway North, Suite 135, City of Industry, CA 91746.
JOURNAL OF CLINICAL EPIDEMIOLOGY
171-0141
A Randomized Trial of Low Fat High Fibre Diet in the Recurrence of Colorectal Polyps McKeown-Eyssen, G.E., Bright-See, E., Bruce, W.R., Jazmaji, V., and The Toronto Polyp Prevention Group 47(5):525-536, 1994. After polypectomy for adenomatous colorectal polyps, 201 persons were randomized to receive counseling on a diet low in fat (the lesser of 50 g/day or 20% of energy) and high in fibre (50 g/day) (LFHF), or to follow a normal western diet (ND), high in fat and low in fibre. After 12 months of counseling, fat consumption was about 25% of energy in the LFHF group and 33% in the ND group; fibre consumption was 35 g and 16 g respectively. After an average of two years of follow-up, an intention to treat analysis led to a ratio of cumulative incidence rates of 1.2 (95% CL 0.6-2.2) for recurrence of neoplastic polyps, a finding which suggest no significant difference between dietary groups over the period of observation. An exploratory analysis conducted among 142 persons with substantial diet counselling indicated a reduced risk of neoplastic polyp recurrence in women (RR = 0.5), associated with reduced concentrations of faecal bile acids while on the LFHF diet, but indicated an increased risk of recurrence in men (RR = 2.1), associated with increased
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Journal of Clinical Epidemiology (continued) faecal bile acids. Although a larger study would be needed to rule out the role of chance, these findings of gender-specific associations between diet counselling and both faecal bile acid concentrations and recurrence of colorectal neoplasia are consistent with recently published evidence of differences between genders. Reprint Address: G.E. MeKeown-Eyssen, Department of Preventive Medicine and Biostatistics, University of Toronto, 12 Queen's Park Crescent, West, Toronto, ON M5S 1A8, Canada.
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
Four-Year Cross-Lagged Associations between Physical and Mental Health in the Medical Outcomes Study Hays, R.D., Marshall, G.N., Wang, E.Y.I., and Sherbourne, C.D. 62(3):441-449, 1994. This article provides an application of structural equation modeling to the evaluation of cross-lagged panel models. Selfreports of physical and mental health at 3 different time points spanning a 4-year interval were analyzed to illustrate the crosslagged analysis methodology. Data were collected from a sample of 856 patients with hypertension, diabetes, heart disease, or depression (or any combination of these) participating in the Medical Outcomes Study. Cross-lagged analyses of physical and mental health constructs revealed substantial stability effects across time. A structural model with standard effects revealed positive effects of physical health on mental health but negative (suppression) effects of mental health on physical health. The effects of mental health on physical health became nonsignificant when the model was revised by adding nonstandard effects (direct effects of measured variable residuals on latent variables). Recommendations for structural equation modeling of crosslagged panel data are provided. Reprint Address: R.D. Hays, Social Policy Department, RAND, 1700 Main Street, Santa Monica, CA 90407-2138.
iological index of metabolic control. These results were partially replicated in a private practice sample where conflict was significantly related to parents' ratings of adherence and to metabolic control. Conflict accounted for unique variance in diabetes outcome beyond that associated with other measures of the parent-child relationship, but the relation between conflict and metabolic control was no longer significant when adherence ratings were entered into regression equations first. Reprint Address: R.E. Emery, Department of Psychology,Gilmer Hall, University of Virginia, Charlottesville, VA 22903.
JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH
171-0142
171-0143
Parent-Child Relationships and the Management of Insulin-Dependent Diabetes Mellitus Miller-Johnson, S., Emery, R.E., Marvin, R.S., et al. 62(3):603--610, 1994. Several dimensions of parent-child relationships were examined as predictors of adherence to treatment and metabolic control in a multi-informant study of 88 children and adolescents with insulin-dependent diabetes meUitus who were recruited from 2 endocrinology clinics. Ratings of parent--child discipline, warmth, and behavioral support were not significantly associated with diabetes outcome, but parent-child conflict was a consistent correlate of both adherence and metabolic control. Within a public hospital subsample, conflict was related to parent, child, and nurse ratings of adherence and to a phys-
171-0144
Coronary Heart Disease: Prevalence and Dietary Sugars in Scotland Bolton-Smith, C. and Woodward, M. 48(2):119-122, 1994. Study objective--The aim was to investigate the effects of dietary intakes of different types of sugars (extrinsic, intrinsic, and lactose) and the dietary fat to sugar ratio on prevalent corunary heart disease (CHD). Design--This was a baseline cross sectional survey of CHD risk factors. Setting--Twenty two Scottish health districts were surveyed between 1984 and t986. Participants -- A total of 10,359 men and women aged 40-59 years were screened as part of the Scottish Heart Health Study, and a further 1267 men and women aged 25-39 and 60-64 years were screened as part of the Scottish MONICA (monitoting trends and determinants in cardiovascular disease) Study. The response rates were 74% and 64% respectively. Methods-Subjects completed a questionnaire which included sociodemographic, health, and food frequency information. Medical history, response to the Rose chest pain questionnaire, and results ofa 12 lead ECG recording were used to categorise subjects into CHD diagnosed, previously CHD undiagnosed, or no CHD groups. The X2 statistic was used to determine whether the CHD groups differed in their sugar consumption, and multiple logistic regression analysis, with adjustment for other potential coronary risk factors, was used to calculate odds ratios for prevalent CHD by intake fifths of dietary sugars. Main results--Men, but not women, differed in their sugar consumption by CHD group. The odds ratios showed a tendency for a U shaped relationship for extrinsic sugar intake with CHD prevalence, but no significant effect of the fat to sugar ratio (possible marker of obesity) on CHD was seen. Conclusions--The results suggest that neither extrinsic sugar, intrinsic sugar, nor the fat to sugar ratio are significant independent predictors of prevalent CHD in the Scotfish population, when the other major risk factors such as cigarette smoking, blood cholesterol concentration, and antioxidant vitamins intake are accounted for. These new data for different sugar types agree with the consensus view that total sugar intake is not a major marker of coronary heart disease. Reprint Address: C. BoRon-Smith,Cardiovascular EpidemiologyUnit, University of Dtmdee, NineweUsHospital and Medical School,Dundee DDI 9SY, UK.
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Journal of Epidemiology and Community Health (continued) 171-0145
Acute Myocardial Infarction: Association with Time Since Stopping Smoking in Italy Negri, E., La Vecchia, C., D'Avanzo, B., Nobili, A., and La Malfa, R.G. 48(2):129-133, 1994. Study objective--The study aimed to investigate the relationship between years since stopping smoking and the risk of acute myocardial infarction. Design--This was a hospital based, multicentre, case-control study conducted in Italy between September 1988 and June 1989 within the framework of the GISSI-2 clinical trial. Setting--Over 80 coronary care units in various Italian regions participated. Subjects-A total of 916 incident cases of acute myocardial infarction, below age 75 years, and with no history of ischaemic heart disease, and 1106 control subjects admitted to the same hospitals for acute, non-neoplastic, cardiovascular or cerebrovascular conditions that were not known or suspected to be related to cigarette smoking took part in the study. Main outcome measures and results--Measures were relative risk (RR) estimates of acute myocardial infarction according to the time since stopping smoking and adjusted for identified potential confounding factors. Compared with never smokers, the multivariate RRs were 1.6 (95% confidence interval (CI) 0.8, 3.2) for subjects who had given up smoking for one year; 1.4 (95% CI 0.9, 2.1) for those who had stopped for two to five years; 1.2 (95% CI 0.7, 2.1) for six to l0 years; and l.l (95% CI 0.8, 1.8) for those who had not smoked for over 10 years. The estimated RR for current smokers was 2.9 (95% CI 2.2, 3.9). The risks of quitters were higher for heavier smokers and those below age 50 years, while no difference emerged in relation to the duration of smoking, sex, and other risk factors for myocardial infarction. Conclusions--These results indicate that there is already a substantial drop in the risk of acute myocardial infarction one year after stopping. The risk in exsmokers, however, seemed higher (although not significantly) than that of those who had never smoked, even more than l 0 years after quitting. This could support the existence of at least two mechanisms linking cigarette smoking with acute myocardial infarction--one involving thrombogcncsis or spasms that occur over the short term, and another involving atherosclerosis that is a long term effect. Reprint Address: E. Negri, lstituto di Ricerche Farmacologiche Mario Negri, Via Eritrea 62, 20157-Milano, Italy. 171-0146
Aetiology of Peptic Ulcer: A Prospective Population Study in Norway Johnsen, R., Forde, O.H., Stranme, B., and Burhol, P.G. 48(2): 156-160, 1994. Study objective--To analyse simultaneously the effect of several risk factors for peptic ulcer. Design--Cohort study where all patients with new or incident peptic ulcers in a well defined population were registered for a seven year period. The follow up started with a comprehensive health survey including a questionnaire on diet, lifestyle, psychological and social conditions, and health. Relative risks, both sex specific and separate, for gastric and duodenal ulcers were estimated from proportional hazard regression analysis. Setting--A population based survey conducted in the municipality of Tromso, northern Norway. Participants--In 1980, a total of 21,440 men and women, aged 20 to 54 years and 20 to 49 years respectively, were invited to participate. A total of 14,667 people attended and returned the
questionnaire. Main results--A total of 328 people had their first peptic ulcer in the follow up period. Age, cigarette smoking, first degree relatives with peptic ulcer, and low educational level were shared risk factors for peptic ulcer in both men and women. In men, frequent upper respiratory infections increased the risk of gastric ulcer and drinking a great deal of milk increased the risk of duodenal ulcer. None of the other dietary variables, including coffee and alcohol consumption, contributed significantly to the risk. Use of analgesics was not a risk factor, and none of the psychological indicators analysed carried any significant risk. Conclusions--Age, inheritance, and cigarette smoking are all important risk factors for peptic ulcer. The increased risk associated with low educational background indicate that social strains, comprising lifestyle and diet habits, are part of the multifactorial aetiology of peptic ulcer. No support was found for the assumption that peptic ulcer disease is a psychosomatic disorder. This study did not support the view that duodenal and gastric ulcers have different aetiologies-rather it showed a similarity in risk patterns. Reprint Address: R. Johnsen, Institute of Community Medicine, University of Tromso, N-9037 Tromso, Norway.
JOURNALS OF GERONTOLOGY
171-0147
Age Differences and Changes in Reaction Time: The Baltimore Longitudinal Study of Aging Fozard, J.L., Vercruyssen, M., Reynolds, S.L., Hancock, P.A., and Quilter, R.E. 49(4):P179-PI89, 1994. This study analyzed auditory reaction time (RT) data from 1,265 community-dwelling volunteers (833 males and 432 females) who ranged in age from 17 to 96. Cross-sectional analyses revealed slowing of simple (SRT) and relatively greater slowing of disjunctive (DRT; aka "go-no-go") reaction time across decades for both males and females. Repeated testing within participants (longitudinal analyses) over eight years showed consistent slowing and increased variability with age. Males were faster than females across age groups, RT tasks, and visits. Beginning at about age 20, RTs increased at a rate of approximately 0.5 msec/yr for SRT and 1.6 msec/yr for DRT. Errors also increased, making unlikely a tradeoff of accuracy for faster responses. The findings are consistent with the hypotheses that slowing of behavior is: (a) a continuous process over the adult life span; Co)characterized by age-associated increases in withinparticipant variability; (c) a direct function of task complexity and, presumably, the degree of mediation by higher regions in the central nervous system; and (d) greater in women than men. 171-0148
Physical Function and Social Class among Swedish Oldest Old Parker, M.G., Thorslund, M., and Lundberg, O. 49(4):S196-$201, 1994. The relationship between physical ability and social class in later life was explored through an interview survey conducted on a nationally representative sample of persons aged 77-98
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Journals of Gerontology (continued) (N = 537). Physical ability was measured with activities of daily living, an index of mobility, and performance tests. Social class was measured according to previous occupation. Physical function was found to be correlated with social class, that is, former white-collar workers had better function than blue-collar workers. The differences were significant for all three measures of physical function.
171-0149
Fear of Falling and Fall-Related Efficacy in Relationship to Functioning among CommunityLiving Elders Tinetti, M.E., Mendes de Leon, C.F., Doucette, J.T., and Baker, D.I. 49(3):M140-M147, 1994. Background. The relationships of fear of falling and fallrelated efficacy with measures of basic and instrumental activities of daily living (ADL-IADL) and physical and social functioning were evaluated in a cohort of community-living elderly persons. Methods. Sociodemographic, medical, psychological, and physical performance (e.g., gait speed, timed hand function) measures were administered, during an in-home assessment, to a probability sample of 1,103 residents of New Haven, Connecticut, who were >72 years of age. Falls and injuries in the past year, fear of falling, and responses to the Falls Efficacy Scale were also ascertained. The three dependent variables included a 1G-item ADL-IADL scale, an 8-item social activity scale, and a scale of relative physical activity level. Results. Among cohort members, 57% denied fear of falling whereas 24% acknowledged fear but denied effect on activity; 19% acknowledged avoiding activities because of fear of falling. Twenty-four percent of recent railers vs 15% of nonfallers acknowledged this activity restriction (x 2 = 13.1; p < .001). Mean fall-related efficacy score among the cohort was 84.9 (SD 20.5), 79.8 (SD 23.4), and 88.1 (SD 17.9) among fallers and nonfallers, respectively (p -< .0001). Fall-related efficacy proved a potent independent correlate of ADL-IADL (partial correlation = .265,p < .001); physical (partial correlation = .234, p < .00 I); and social (partial correlation = .088, p < .01), functioning in multiple regression models after adjusting for sociodemographic, medical, psychological, and physical performance covariates as well as history of recent fails and injuries. Fear of falling was only marginally related (p = .05) with ADL-IADL functioning and was not associated with higher level physical or social functioning. Conclusions. The strong independent association between self-efficacy and function found in this study suggests that clinical programs in areas such as prevention, geriatric evaluation and management, and rehabilitation should attempt simultaneously to improve physical skills and confidence. Available knowledge of the factors influencing efficacy should guide the development of these efficacy-building programs.
171-0150
The Validity of Survey Data on Utilization of Health and Social Services among the Very Old Carsj~, K., Thorslund, M., and W~irneryd, B. 49(3):S156--S164, 1994. Survey responses to questions regarding utilization of health and social services among very old persons were compared to
independently registered utilization records. Survey data came from in-person interviews with a sample ofnoninstitutionalized 75-84-year-olds and all noninstitutionalized individuals over the age of 84 in a Swedish community. Agreement regarding utilization vs no utilization during the past three months was found to be very high for hospitalizations and home help, somewhat lower for home visits by nurses, and lower yet for visits to physicians and to nurses. Except for visits to nurses, aggregate survey estimates of proportion with utilization were not significantly different from those based on records. Reporting patterns were generally in agreement with predictions made on the basis of frequency and saliency of service utilization. Reasons for over- and underreporting were investigated on the basis of register data, and some evidence for telescoping was observed.
JOURNAL OF OCCUPATIONAL REHABILITATION
171-0151
Back Injury Prevention Programs: A Critical Review of the Literature King, P.M. 3(3):145-158, 1993. Back schools are increasingly utilized as an injury prevention strategy employed at the worksite. Yet, evidence of the efficacy of back schools is limited and controversial. A review of the literature showed variance in methodologies and consequently, outcomes. Outcome measures used include physical capacity, functional abilities, costs, lost time, absenteeism, perception of pain, lifting performance, attitudes, and job satisfaction. In many studies, lack of randomization and control was found to be a limitation in experimental design. Studies which used the behavioral approach of measuring lifting behavior lacked followup and evidence of long-term effects. The type of education and feedback or reinforcement was an important issue not well-defined in the literature. A variety of hypothetical mechanisms were described as contributing to the outcome of back injury prevention programs. Additional controlled research is necessary to determine the specific mechanisms of change in an effort to further improve outcome in this area. ReprintAddress:P.M. King, Oeculmtional Therapy Program, University of Wisconsin, P.O. Box 413, Milwaukee, WI 53130.
171-0152
Factors Contributing to Job Satisfaction following Rehabilitation for Musculoskeletal Impairments Schmidt, S.H., Meijman, T.F., Scholten, A., van Oel, C.J., and Oort-Marburger, D. 3(4):213-222, 1993. The study investigates whether changing jobs is related to work-related well-being of people with musculoskeletal impairments. In order to assess this relationship subjects who began new jobs after rehabilitation (N = 52) were compared with subjects who returned to their former employment (N = 63). Work-related well-being was measured by means of the scales
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ANNALS OF BEHAVIORAL MEDICINE
Journal of Occupational Rehabilitation (continued) "job satisfaction" and "need to recover after work." After controlling for individual characteristics (gender, age, working hours per week, and pain complaints) and job characteristics (job demands and decision latitude), job satisfaction could be predicted by job change. Recover need after work was predicted by pain complaints, job demands, and decision latitude, but not by job change. Reprint Address: S.H. Sclamidl,Institute of Social Medicine, Faculty of Medicine, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands. 171-0153
The Role of the Supervisor in Successful Adjustment to Work with a Disabling Condition: Issues for Disability Policy and Practice Gates, L.B. 3(4):179-190, 1993. Results from an investigation of the role of supervisors in the process of adjusting to work with a disabling condition are presented. Workers with disabling conditions were interviewed about the responsiveness of their workplaces to their needs. Analyses showed that successful adjustment to work was related to the ability to complete job requirements, get along with others at work, see a future at work and feel good about work. Many supervisory behaviors were associated with these factors ineluding the extent to which supervisors treat workers fairly, allow workers to participate in decisions related to their work and utilize the workers' skills. Implications for the development of workplace policy and disability management efforts are discussed. Reprint Address: L.B. Gates, Center for Social Policy and Practice in the Workplace, Columbia University School of Social Work, 622 West 113th Street, New York, NY 10025.
171-0154
Factors Influencing the Cost of Workers' Compensation Claims: The Effects of Settlement Method, Injury Characteristics, and Demographics Wood, G.A., Morrison, D.L., and Macdonald, S. 3(4):201-211, 1993. This paper estimates an empirical model of the total costs of fmalised workers' compensation claims. The sample was comprised of 8232 claims, made by workers in Western Australia, that were closed in 1990. It is reported that the variables representing the method of claim settlement is an important determinant of the cost of individual workers' compensation claims. In addition, it is also found that type of injury, gender, age, and occupational classification have significant effects on the model. Workers who, sustain musculoskeletal injuries, are male, and/or who are white collar workers incur significantly more costs. In addition to these effects, a positive linear relationship between age and costs was also observed. The empirical models, of the kind specified in this paper, may be capable of performing a useful prescriptive role in rehabilitation programs. Such models can enable "problematic'" cases to be identified early in the claim process, so that they might be appropriately referred for intensive rehabilitation intervention. Reprint Address: G.A. Wood, School of Economies and Commerce, Murdoch University, WA 6150, Australia.
JOURNAL OF PAIN AND SYMPTOM MANAGEMENT
171-0155 The Experience of Chronic Nonmalignant Pain Hitchcock, L.S., FerreU, B.R., and McCaffery, M. 9(5):312-318, 1994. This article reports the results of a survey of 204 persons with chronic nonmalignant pain who were members of a national self-help organization. The survey evaluated the organization, explored the perceived effect of pain on quality of life, and assessed experiences with and perceptions of health-care providers. Response rate was 40%. Of survey respondents, 50% reported inadequate pain relief. Respondents identified depression as one of the worst problems caused by their chronic pain: 50% reported that they had considered suicide due to feelings of hopelessness associated with their pain, 51% reported taking only as much medication as prescribed, and 44% reported taking less medication than prescribed. Further investigation is needed to describe the personal impact of chronic nonmalignant pain. Reprint Address: L.S. Hitchcock, The National Chronic Pain Outreach Association, 7979 Old Georgetown Road, Suite 100, Bethesda, MD 20814-2429. 171-0156 Depression and Suicide in Patients with Cancer Massie, M.J., Gagnon, P., and Holland, J.C. 9(5):325-340, 1994. Depression is a prevalent psychiatric syndrome in the cancer population. We review ~ e spectrum of conditions in which depressive features are present, from normal responses to crises in cancer to depression secondary to organic causes. The different modalities of treatment, including pharmacologic, psychotherapeutic and social interventions, are described. Specific guidelines for the management of the suicidal cancer patient are given and physician-assisted death is discussed. Reprint Address: M.J. Massie, Psychiatry Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021.
JOURNAL OF SEX RESEARCH
171-0157
Understanding Hysterectomies: Sexual Satisfaction and Quality of Life Darling, C.A. and McKoy-Smith, Y.M. 30(4):324-335, 1993. Because a hysterectomy is one of the more frequently performed surgical procedures in the U.S., we used a causal model to study those women who had and had not experienced a hysterectomy. Using family stress theory, we examined the quality of life of these two groups of women as it was related to physiological and psychological health stressors, family stress, resources, meaning of the stressors, and the perceived sexual satisfaction. A survey research design was employed with a national random sample of women (N = 346) between the ages
V O L U M E 17, N U M B E R
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Journal of Sex Research (continued) of 45 and 60 who were members of an association of collegeeducated women. Research instruments included the Family Inventory of Life Events and Changes Scale, Women's Health Questionnaire, Family Crisis Oriented Personal Evaluation Scale, Index of Sexual Satisfaction, and Generalized Life Contentment Scale. There was no significant difference in the quality of life of those women who had and had not experienced a hysterectomy, but women who had a hysterectomy perceived greater sexual satisfaction than those who had not experienced a hysterectomy. For those women who had experienced a hysterectomy, the proposed model indicated that psychological health stress, family stress, and the meaning of the stressors had the greatest total association with the quality of life. The greatest total relationships to quality of life for those women who had not experienced a hysterectomy were psychological and physiological health stressors, but not family stress. An important implication of this investigation is the need to understand further the role of physiological and psychological health stressors, as well as family stress, in the lives of women. Reprint Address: C.A. Darling, Department of Family and Child Sciences, The Florida State University, Tallahassee, FL 32306-2033.
171-0158
Sexual Identity and HIV: The Mule Prostitute
Boles, J. and Elifson, K.W. 31(1):39-46, 1994. We e~amined the relationships among sexual self-identity, sexual and drug use behaviors, and human immunodeficiency virus (HIV) infection among a sample of 224 male street prostitutes. Structured interviews were administered, and blood samples were collected and tested for HIV, syphilis, and hepatitis B. The sample included 17.9% homosexual, 46.4% heterosexual, and 35.7% bisexually identified men. Congruence between the prostitutes' non-paid sexual behavior and their sexual self-identification were closest for the heterosexual and homosexual identified men. The significant demographic and occupational differences between the prostitutes in each sexual self-identity category included education, history of physical abuse, homelessness, and geographical mobility. Based on selfidentification, the rate of HIV infection was 50% for the homosexuals, 36.5% for the bisexuals, and 18.5% for the heterosexuals. The differences in HIV infection rates between the men of each sexual self-identity category were significantly related to self-reported receptive anal sex, number of non-paid sexual partners, cocaine use, injection drug use, acquaintance with a person with AIDS, history of syphilis, and history of hepatitis. Sexual self-identity was not a significant predictor of HIV serostatus. Reprint Address: J. Boles, Georgia State University, Department of Sociology, University Plaza, Atlanta, GA 30303.
171-0159
Unprotected Anal Intercourse in HIV-lnfected and Non-HIV-Infected Gay Men
Gold, R.S., Skinner, M.J., and Ross, M.W. 31(1):59-77, 1994. In 1990, gay men (N = 296) in Sydney, Australia, were asked to recall two sexual encounters from the preceding yea~. one in which they had unprotected anal intercourse ("unsafe" encounter) and one in which they had resisted a strong temptation to have unprotected intercourse ("safe" encounter). The
alms were to record self-justifications for unprotected intercourse used in the unsafe encounter and to identify situational factors distinguishing between the encounters. Among men who had been HIV infected at the time of the unsafe encounter (n = 88), the most common self-justification had been the thought that they had nothing more to lose; among uninfected men (n = 207), it had been a resolution to have intercourse without ejaculation. The first factor emerging from a factor analysis of the infected group's self-justifications involved reactions to a negative mood state; in the uninfected group it involved inferring from perceptible characteristics that the partner was unlikely to be infected. Some variables (e.g., closeness of the relationship to the partner, mood, communication, and use of "dirty talk") distinguished between the unsafe and safe encounters equally among those who had been infected in both encounters (n ffi 76) and those who had been uninfected in both (n = 170). Other variables (knowledge that unprotected intercourse is a high risk activity, drug use, use of pornography, and condom availability) did not distinguish between the encounters in either group. Desire to seek adventure and excitement through sex distinguished between the encounters only in the infected group, and level of intoxication did so only in the uninfected group. Results are discussed in relation to those obtained in our earlier studies of gay men in Melbourne; we also discuss how such data might be put to use in AIDS education programs for gay men. Reprint Address: R.S. Gold, School of Psychology, Deakin University (Rusden Campus), 662 Blackburn Road, Clayton, VIC 3168, Australia.
171-0160
Urban Hispanic Adolescents and Young Adults: Relationship of Acculturation to Sexual Behavior
Ford, IC and Norris, A.E. 30(4):316-323, 1993. As Hispanic persons in the U.S. are exposed to U.S. culture, changes may occur in values, attitudes, and behavior. This process of change has been called acculturation. The objectives of this research were to describe the sexual behavior of low income, urban Hispanic youth in Detroit and to evaluate the relationship of acculturation to sexual behavior. Data were drawn from a household probability sample of 711 low income, urban youth. The relationship of acculturation to sexual activity, types of intercourse, number and ethnicity ofparmers, condom use, and use of other methods were estimated for never married men and women. Level of acculturation was associated with sexual behavior. Specifically, women with high acculturation were much more likely to have had at least one sexual partner in the last year, to have non-Hispanic partners, to have oral and anal sex, and to have used condoms. For men, high acculturation was positively associated with oral sex and having non-Hispanic partners. Use of contraceptive methods other than condoms was not related to acculturation for either gender. For women, the strong association of acculturation with sexual activity in the last year increased women's exposure to health risks, sexually transmitted diseases, and unplanned pregnancy, although increased condom use may have reduced these risks. Reprint Address: IC Ford, Department of Population Planning and In. temational Health, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029.
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Journal of Sex Research (continued) Sexual and Substance Use Acts of Gay and Bisexual Male Adolescents in New York City Rotheram-Borus, M.J., Rosario, M., Meyer-Bahlburg, H.F.L., et al. 31(1):47-57, 1994. Lifetime and current sexual and substance use behaviors were examined among 131 predominantly Hispanic and Black gay and bisexual adolescent males in New York City. Many youths engaged in anal sex with males (80%), and 22% bartered sex for money or drugs. Condom use with male partners typically was initiated one year after a youth became sexually active, was more common with male than female partners, and was more common with anal than with oral sex. Condoms with male partners were never or inconsistently used by 52% of youths. Youths reported high rates of lifetime alcohol (76%), marijuana (42%), and cocaine/crack (25%) use; none reported intravenous drug use. Current alcohol and drug use was significantly related to sexual risk acts. These findings indicate that HIV-prevention programs for homosexual and bisexual male youths are critical and must address sex with females, inconsistent condom use, and sexual practices while under the influence of drugs and alcohol. Reprint Address: M.J. Rotheram-Borus, Division of Child Psychiatry, Columbia University, 722 West 168 Street, Unit 29, New York, NY 10032. 171-0161
THE LANCET
Mediterranean Alpha-Linolenic Acid-Rich Diet in Secondary Prevention of Coronary Heart Disease de Lorgeril, M., Renaud, S., Mamelle, N., et at. 343:1454--1459, 1994. In a prospective, randomised single-blinded secondary prevention trial we compared the effect of a Mediterranean alphalinolenic acid-rich diet to the usual post-infarct prudent diet. After a first myocardial infarction, patients were randomly assigned to the experimental (n = 302) or control group (n = 303). Patients were seen again 8 weeks after randomisation, and each year for 5 years. The experimental group consumed significantly less lipids, saturated fat, cholesterol, and linoleic acid but more oleic and alpha-linolenic acids confirmed by measurements in plasma. Serum lipids, blood pressure, and body mass index remained similar in the 2 groups. In the experimental group, plasma levels of albumin, vitamin E, and vitamin C were increased, and granulocyte count decreased. After a mean follow up of 27 months, there were 16 cardiac deaths in the control and 3 in the experimental group; 17 non-fatal myocardial infarctions in the control and 5 in the experimental groups: a risk ratio for these two main endpoints combined of 0.27 (95% CI 0.12-0.59, p = 0.001) after adjustment for prognostic variables. Overall mortality was 20 in the control, 8 in the experimental group, an adjusted risk ratio of 0.30 (95% CI 0.11-0.82, p = 0.02). An alpha-linolenic acid-rich Mediterranean diet seems to
be more efficient than presently used diets in the secondary prevention of coronary events and death. ReprintAddress: M. de Lorgeril, The Lyon Diet Heart Study, INSERM, Units 63, 22 avenue Doyen IApine, CP 18, 69675 Bron Cedex, France. Fatty Acid Composition of Erythrocytes and Plasma Triglyceride and Cardiovascular Risk in Asian Diabetic Patients Peterson, D.B., Fisher, K., Carter, R.D., and Mann, J. 343:1528-1530, 1994. 171-0163
The excess of coronary heart disease in Indian Asians compared with Europeans is unexplained by conventional risk factors, although the high prevalence of diabetes may play a part. To explore the contribution of diet we compared the fatty acid composition of erythrocyte membrane phospholipid and plasma trigiyceride in 36 Gujarati Asians and 24 Europeans with noninsulin-dependent diabetes. Erythrocytes from Asian subjects contained higher proportions of linoleic, dihomogammalinolenic, and arachidonic acids, and lower proportions of oleic and n-3 series fatty acids; triglycerides contained higher linoleic and lower oleic acid levels. For example, mean percentage (SE) of oleic acid (18:1 n-9) in erythrocytes was 16.7 (0.2) in Asians and 20.5 (0.6) in Europeans (p = 0.0001), and total n-6:n-3 ratio was, respectively, 12.8 (0.7) and 6.7 (0.7) (p = 0.0001). A high dietary intake oflinoleic acid may not be cardioprotective unless balanced by significant intakes ofoleic and n-3 series fatty acids, at least in diabetic Indian Asians. By itself, the conventional recommendation to substitute polyunsaturated for saturated fat in the diet may be inadequate to reduce thrombogenesis, and the overall balance of fatty acids, including monounsaturates, should be considered. Reprint Address:D.B. Peterson, Luton and Dunstable Hospital, Lewsey Road, Luton, Bedfordshire LU40DZ, UK.
171-0162
171-0164
Why Do People Sue Doctors? A Study of Patients and Relatives Taking Legal Action Vincent, C., Young, M., and Phillips, A. 343:1609-1613, 1994. To examine the reasons patients and their relatives take legal action, we surveyed 227 patients and relatives who were taking legal action through five firms of plaintiff medical negligence solicitors. Over 70% of respondents were seriously affected by incidents that gave rise to litigation with long-term effects on work, social life, and family relationships. Intense emotions were aroused and continued to be felt for a long time. The decision to take legal action was determined not only by the original injury, but also by insensitive handling and poor communication after the original incident. Where explanations were given, less than 15% were considered satisfactory. Four main themes emerged from the analysis of reasons for litigation: concern with standards of care--both patients and relatives wanted to prevent similar incidents in the future; the need for an explanation--to know how the injury happened and why; compensation--for actual losses, pain and suffering or to provide care in the future for an injured person; and accountabili t y - a belief that the staffor organisation should have to account for their actions. Patients taking legal action wanted greater honesty, an appreciation of the severity of the trauma they had suffered, and assurances that lessons had been learnt from their
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The Lancet (continued) experiences. A no-fault compensation system, however well intended, would not address all patients' concerns. If litigation is viewed solely as a legal and financial problem, many fundamental issues will not be addressed or resolved. Reprint Address: C. Vincent, Academic Department of Psychiatry, St. Mary's Hospital, Praed Street, London W2 1NY, UK.
NEUROLOGY
171-0165
Migraine Classification and Diagnosis: International Headache Society Criteria Olesen, J. and Lipton, R.B. 44(Suppl. 4):$6--S10, 1994. In 1988, the International Headache Society (IHS) classification committee published operational diagnostic criteria for a broad range of headache disorders, including migraine. These criteria have been translated into more than 10 languages, providing uniform terminology for clinical practice, multinational clinical trials, and biologic and epidemiologic research. The criteria have also been evaluated in a limited number of field studies intended to address their reliability, validity, comprehensiveness, and generalizability. The IHS criteria for migraine provide one method for targeting a group of headache patients in need of care. Reprint Address: J. Olesen, Department of Neurology, Gentofte Hospital, University of Copenhagen, Niels Andersens Vej 65, DK-2900, Copenhagen, HeUerup, Denmark. 171-0166
Diagnostic Criteria for Migraine: A Validity Study Merikangas, ICR., Dartigues, J.F., Whitaker, A., and Angst, J. 44(Suppl. 4):S11-S16, 1994. To identify the optimum combination of symptoms for the International Headache Society (IHS) diagnostic criteria for migraine, the criteria were systematically assessed for validity using an epidemiologic sample from Zurich, Switzerland. The indicators of validity used included subjective distress, occupational impairment, family history of migraine, and treatment. The symptoms that provided the best discrimination between migraine and other headache subtypes were photophobia, phonophobia, and osmophobia, in combination with gastrointestinal symptoms. The evaluation of the validity of the IHS classification of migraine is impeded by several factors, including: the presence of multiple headache syndromes within an individual, the tendency for headache characteristics to change over a lifetime, the effects of headache treatments in obscuring syndromes, and the lack of generalizability of findings based on clinical samples. The methods used in this study serve as a model for applying statistical techniques for evaluating the validity of diagnostic criteria. The findings, however, should be replicated in additional studies to determine their generalizability to specific demographic and clinical subgroups. Reprint Address:K.R. Merikangas, Genetic EpidemiologyResearch Unit, Yale University School of Medicine, 40 Temple Street--Lower Level, New Haven, CT 06510-3223.
171-0167
Migraine Prevalence: A Review of PopulationBased Studies Stewart, W.F., Shechter, A., and Rasmussen, B.K. 44(Suppl. 4):S 17-$23, 1994. Obtaining accurate and reliable information on the prevalence of migraine is essential to understanding the burden it places on society. Although the epidemiology of headache has been described in more than 50 population-based studies, only 24 of these have described the gender- and age-specific prevalence of migraine. Essentially five different case definitions have been used in these studies. Variation in the prevalence of migraine among studies is largely due to differences in case definition and in the age and gender distribution of study populations. Among four recent studies that used the diagnostic criteria of the International Headache Society (IHS), a coherent picture emerges. The prevalence of migraine is approximately 6% among men and 15 to 17% among women. Prevalence varies by age, increasing to about age 40 years and declining thereafter in both men and women. The gender ratio also appears to vary by age, increasing from menarche to about age 42 years and declining thereafter. Although the use of the IHS criteria has resulted in a more coherent picture across population-based studies, efforts must be made to assess the reliability and validity of these criteria in population-based samples. Reprint Address: W.F. Stewart, Department of Epidemiology, Johns Hopkins School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, MD 21205. 171-0168
Migraine Heterogeneity: Disability, Pain Intensity, and Attack Frequency and Duration Stewart, W.F., Shechter, A., and Lipton, R.B. 44(Suppl. 4):$24-$39, 1994. Data from population-based studies are summarized to characterize the full range and variability of the impact migraine has on the individual. Despite differences in methods and data collection in population-based studies describing disability, pain intensity, and attack frequency as well as the duration of migraine and other headaches, several patterns emerge. On average, migraine headaches are more disabling, more painful, and longer in duration than other types of headaches. Females report more pain and disability with headache than do males. Although disability measurements are important in demonstrating the effect of headache on both the individual and society, actual measurements often fall short. Most studies use only workdays lost as the sole measure of disability. Most migraineurs do not miss work while experiencing a headache; instead, they attempt to function on the job, with considerably reduced effectiveness. Computing only workdays lost does not account for impairment at work nor does it show the impact of migraine on other aspects of life. In addition, evidence suggests the presence of a pain intensity threshold for disability. Headache-related pain intensity below the threshold is not associated with disability. Despite the threshold of pain intensity for disability, a significant proportion of migraine sufferers report levels of pain intensity above the threshold in the absence of work-related disability. The grading of headache severity should be a composite that would permit a more complete image of the heterogeneity of migraine's effects and a more accurate idea of the need for healthcare services. This composite should include two areas: (1) more corn-
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Neurology (continued) plete measures of life impact, encompassing daily activities in a number of domains, including work, family, and social activities; and (2) an assessment of pain intensity and attack frequency. Reprint Address: W.F. Stewart, Department of Epidemiology, Johns Hopkins School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, MD 21205.
171-0169 Assessing Headache Severity: New Directions Von Korff, M., Stewart, W.F., and Lipton, R.B. 44(Suppl. 4):$40--$46, 1994. Headache is a heterogeneous condition that varies widely in global severity and in severity of individual attacks. Whereas recent efforts have focused on improving the diagnostic criteria for classifying headache, less effort has been directed toward developing reliable, valid, and clinically useful methods of assessing the impact or severity of headache. Existing measures of severity include one or more of the following weaknesses: (1) only pain intensity is assessed or the measure is incomplete in other ways, (2) measures have little or no prognostic value for relevant outcomes, (3) the reliability or the validity of the measure has not been assessed, or (4) the measure is too cumbersome for clinical practice or field research. We describe a brief, simple method for grading the severity of headache, the Chronic Pain Index, which assumes that a continuum of pain intensity and disability is the underlying dimension of severity. Along this continuum, lower levels of severity are differentiated by pain intensity and higher levels by interference with function. The prognostic value of the results from a seven-item questionnaire for grading headache severity is compared with that of alternative measures. The Chronic Pain Index showed the strongest independent cross-sectional and prospective correlation with measures of headache impact, depression, and use ofhealtheare services. These results support the potential utility of brief methods of assessing headache severity and exemplify the importance of including measures of interference with function when assessing severity. Reprint Address: M. Yon Korif, Center for Health Studies, Group Health Cooperative of Puget Sound, Suite 1600, 1730 Minor Avenue, Seattle, WA 98101. 171-0170 Migraine:Patterns of Healthcare Use Stang, P.E., Osterhaus, J.T., and Celentano, D.D. 44(Suppl. 4):$47-$55, 1994. Data on use of heaithcare from several sources reflect low rates of consultation among migraineurs, many of whom are severely disabled, and limited detection of migraine among those seeking care. Most migraineurs who seek medical care are motivated by the need for pain relief and are initially seen by a general practitioner. Use of healthcare seems to follow a pattern, with a maximum use of services and technology within the first year, followed by a precipitous decrease over the ensuing years. The use of services appears to be concentrated among a small proportion of the migraineurs who seek care. In total volume, the migraineur uses two to five times more healthcare services than nonmigraineurs, reflecting the contribution of comorbidities and help-seeking behavior. Use of emergency departments and sophisticated diagnostic testing appears to be greater in the United States than in other countries. Hospitalization of the migraineur is uncommon and remains costly. Reprint Address: P.E. Stang, Applied Healthcare Research, Glaxo Inc., Five Moore Drive, CS-1130, Research Triangle Park, NC 27709.
171-0171
The Economic Cost of Migraine: Present State of Knowledge de Lissovoy, G. and Lazarus, S.S. 44(Suppl. 4):$56--$62, 1994. The costs of medical care and lost productivity associated with migraine headache impose an economic burden on society. Knowledge of the costs that can be attributed to migraine would provide a basis for evaluating alternative diagnosis and treatment strategies. The most widely used approaches to analyzing the cost of illness analysis are the willingness-to-pay and human capital methods. Using these as a framework, all recent published studies (from 19g0 to the present) relevant to the economic cost of migraine were reviewed. The literature reviewed demonstrates that the economic burden of migraine headache is substantial. To estimate the cost of migraine to society more precisely, data are needed on incidence and prevalence among carefully selected samples representative of the underlying population. Use of medical care must be expressed as units of specific types of services rendered over known periods. Health insurance coverage, an important determinant of access to care, should also be known. Absenteeism and work losses must be linked to occupation and earnings levels. Reprint Address: G. de Lissovoy, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, 624 North Broadway, 4th Floor, Baltimore, MD 21205-1996. 171-0172
Migraine: Identifying and Removing Barriers to Care Lipton, R.B., Amatniek, J.C., Ferrari, M.D., and Gross, M. 44(Suppl. 4): $63-$68, 1994. The high levels of pain and disability associated with undiagnosed migraine or inadequate treatment of migraine offer a potential target for healthcare intervention. Both the individual patient and society are affected by decisions regarding which migraine sufferers are most in need of medical care. Pain is the most important symptom for the individual patient, but disability may be the most important consequence of migraine for an increasingly cost-conscious society. These two perspectives are the components of a migraine severity or impact measure being developed to define migraine sufferers most in need of care. The criteria for developing screening programs provide a context for evaluating healthcare interventions for migraine. Barriers to effective care occur on at least three levels: many people with migraine do not consult doctors; consulters may not receive the correct diagnosis; and even when the correct diagnosis is made, many migraineurs do not receive effective treatment. Screening and impact measures may help both to improve diagnosis and to determine which migraineurs are most in need of care. Public and physician education, screening, and impact measures might circumvent many of the barriers to effective care for people with migraine. Reprint Address: R.B. Lipton, Montefiore Medical Center, Headache Unit, 111 East 210th Street, Bronx, NY 10467. 171-0173 Diagnosing the Severe Headache Dalessio, D.J. 44(Suppl. 3):$6-S12, 1994. A patient's medical history, age of onset, location of pain, pain characteristics, pain chronology, associated signs and symptoms, and signs ofneurologic dysfunction are all important considerations in making a diagnosis. The International Head-
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Neurology (continued) ache Society has developed a thorough classification system to aid in the diagnosis of headache, which includes primary disorders of migraine, tension-type headache, and cluster headache, as well as secondary, organic disorders. Reprint Address: D.J. Dalessio, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037.
171-0174
Migraine: A Pharmacologic Review with Newer Options and Delivery ModaHties Baumel, B. 44(Suppl. 3):S13-S17, 1994. The management of migraine usually centers on two approaches: preventive and abortive therapy. Preventive therapy, designed to reduce the frequency, duration, and intensity of attacks, can be accomplished through a wide variety of medications. The most commonly used are t-blockers, but calcium channel blockers, antidepressants, anticonvulsants, and nonsteroidal anti-inflammatory agents have all been used with success. Agents used in abortive migraine therapy treat the intensity and duration of pain, as well as the associated symptoms. New treatment options have been developed, including such newly approved medications as sumatriptan. Sumatriptan is a very effective agent that has joined the ranks of other effective abortive migraine treatments, such as ergotamine, dihydroergotamine, and nonsteroidal anti-inflammatory agents, as well as narcotic analgesics. New delivery systems, such as the nasal-spray formulation of butorphanol, allow for a route of administration previously unavailable to migraine sufferers. These new and developing treatment modalities will # v e physicians a wider choice of outpatient therapy options. Reprint Address: B. Baumel, Baumel-Eisner Neuromedical Institute, 1135 Kane Concourse, Bay Harbor Islands, Miami Beach, FL 331542025. 171-0175
Chronic Headache: Appropriate Use of Opiate Analgesics Marldey, H.G. 44(Suppl. 3):$18--$24, 1994. The question of the appropriate use of opiate analgesics in the management of chronic headache pain is under debate. Often, the management of headache pain is complicated by the overuse of dependency-promoting analgesics. Because of confusion about the use of analgesics in pain management, some patients are denied access to necessary opioid analgesia, whereas others receive large quantifies of combination analgesics. The proper use of opiate analgesics is presented here, including a review of the pharmacology of these agents. Signs of analgesic dependence, analgesic rebound headache, and methods of withdrawal are also presented. The potential use of such new treatment modalities as butorphanol nasal spray is discussed. Reprint Address: H.G. Markley, Department of Neurology,The Medical Center of Central Massachusetts, 119 Belmont Street, Worcester, MA 01605. 171-0176 Recurrent Migraine: Cost-Effective Care Rapoport, A.M. 44(Suppl. 3):$25-$28, 1994. The cost of untreated or ineffectively treated migraine is staggering. A case study is presented that demonstrates the importance of developing an individually tailored home treatment program for migraine patients aimed at keeping them out of healthcare facilities on an acute basis. Treatment programs should include preventive medications if attacks occur more than twice
per month, as well as appropriate abortive and symptomatic agents in the event of a severe, acute migraine attack. New agents and treatment modalities are making acute treatment more costeffective and making it less likely that unnecessary time be spent seeking medical help at the time of an attack. Reprint Address: A.M. Rapoport, The New England Center for Headache, 778 Long Ridge Road, Stamford, C-q"06902.
171-0177
The Henry Ford Hospital Headache Disability Inventory (HDI) Jacobson, G.P., Ramadan, N.M., Aggarwal, S.K., and Newman, C.W. 44(5):837-842, 1994. To quantify the impact of headache on daily living, we developed a 25-item headache disability inventory (HDI). The alpha version of the HDI (a-HDI) consisted of 40 items, each requiring a "yes" (four points), "sometimes" (two points), or "no" (zero points) response based on items derived empirically from case history responses of subjects with headache. From the a-HDI, we derived a 25-item beta version (~-HDI) with the items subgrouped into functional and emotional subscales. The internal consistency/reliability was strong, as was construct validity. The test-retest reliability for the fl-HDI was acceptable for the total score and functional and emotional subscale scores. A 29-point change (95% confidence interval) or greater in the total score from test-retest must occur before the changes can be attributed to treatment effects. The HDI is useful in assessing the impact of headache, and its treatment, on daily living. Reprint Address: G.P. Jacobson, Division of Audiology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202. 171-0178
Opioid Responsiveness of Cancer Pain Syndromes Caused by Nearopathic or Nociceptive Mechanisms: A Combined Analysis of Controlled, Single-Dose Studies Cherny, N.I., Thaler, H.T., Friedlander-Klar, H., et al. 44(5):857-861, 1994. We performed a combined analysis of the results from four controlled single-dose relative-potency studies to assess the impact of inferred pain mechanism on the response to an opioid drug. A total of 168 patients received 474 administrations of either morphine or heroin, and we assessed the analgesic response during a 6-hour period with visual analog scales. We summarized this as a total pain relief (TOTPAR) score. Two experienced pain clinicians reviewed information about pain characteristics and designated each case according to the inferred pain mechanism (neuropathic, nociceptive, or mixed) and the degree of confidence in the inferred mechanism (definite versus probable/possible). They grouped the cases as follows: nociceptive pain only (n ffi 205), neuropathic pain only (n = 49), and mixed (n ffi 220). We compared pain relief achieved by patients with different mechanisms, with TOTPAR adjusted for significant covariates (duration of prior opioid administration, doses of opioid administered in the previous 48 hours, pain intensity at the start of the study, BUN:creatinine ratio, and dose of administered opioid). The adjusted mean TOTPAR score of the group with any neuropathic pain was significantly lower than that of the group with nociceptive pain only (26.1 versus 20.4, p ffi 0.02). The score of the group with definite nociceptive pain alone (adjusted mean TOTPAR = 28.0) was significantly higher than scores of the groups with possible/probable nociceptive pain (TOTPAR = 19.9), mixed mechanisms (TOTPAR = 20.2),
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Neurology (continued) definite neuropathic pain alone (TOTPAR = 20.6), and possible/probable neuropathic pain alone (TOTPAR = 22.9). In pairwise comparisons, there were no significant differences in the adjusted mean TOTPAR scores among the latter four groups. Among the patients with neuropathic pain, the dose-response relationship was significant. These data support the postulate that opioid responsiveness is a continuum with extensive overlap in the responsiveness of pains mediated by neuropathic, nociceptive, and mixed pain mechanisms. Reprint Address: R.K. Portenoy, Pain Service, Department of Neurology,Memorial Sloan-KetteringCancer Center, 1275 York Avenue, New York, NY 10021. 171-0179
Validation of a New Instrument for Determining Migraine Prevalence: The UCSD Migraine Questionnaire Tom, T., Brody, M., Valabhji, A., et al. 44(5):925-928, 1994. To provide a reliable instrument for use in large population surveys, we developed a short questionnaire based on existing International Headache Society diagnostic criteria and administered ~ e questionnaire to 50 consecutive patients seeking evaluation at a university-based headache clinic. A single neurologist subsequently examined all patients. Based only on the questionnaires, reviewers scored each patient as having migraine with aura, migraine without aura, or nonmigrainous headache. High predictive validity and low interobserver variability between the examining neurologist and the independent reviewers suggest that the quenstionnaire may be quite useful as a survey instrument. Reprint Address: T. Tom, Department of Neurology, UCSD Medical Center, 200 West Arbor Drive, San Diego, CA 92103. 171-0180
'Sympathetically Maintained Pain.' I. Phentolamine Block Questions the Concept Verdugn, R.J. and Ochoa, J.L. 44(6):1003-1010, 1994. Patients with "reflex sympathetic dystrophy" or "causalgia" underwent sympathetic blocks. In protocol A (77 patients), we infused placebo (saline) for 30 minutes followed by phentolamine (35 mg). In protocol B (23 patients), the saline phase was followed by double-blind infusion ofphentolamine or phenylephrine (500 zg), a second phase of saline, and then the other active drug. We assessed magnitudes of pain and mechanical hyperalgesias on a 0-to-10 pain scale and monitored sensory and sympathetic effects. With protocol A, pain diminished significantly (_>50%) during placebo in 22 patients (28.9%) and during phentolamine in seven (9.20/0). With protocol B, four patients (17.3%) had relief of pain during placebo, four (17.3%) during phenylephrine, and two (8.7%) during phentolamine. All "phentolamine responders" had progressive pain relief from placebo. Two patients expressed relief during phenylephrine and worsening during phentolamine. Most patients did not respond significantly to saline or drugs. Thus, pharmacologic manipulation of the alpha-1 adrenergic receptor by either agonist or antagonist drug does not influence neuropathic pains. These results raise questions about the existence of "sympathetically maintained pain," as diagnosed by sympathetic blocks improperly controlled for placebo. Reprint Address:J.L. Oehoa, Neuromuscular Unit, Department of Neurology, Good Samaritan Hospital and Medical Center, 1040 NW 22rid Avenue, Suite 460, Portland, OR 97210.
171-0181
Phentolamine Sympathetic Block in Painful Polyneuropathies. II. Further Questioning of the Concept of 'Sympathetically Maintained Pain' Verdugn, R.J., Campero, M., and Ochoa, J.L. 44(6):1010-1014, 1994. To test for the presence of "sympathetically maintained pain" (SMP), we administered placebo-controlled phentolamine sympathetic blocks to 14 patients with painful polyneuropathies. Six received IV infusion of saline for 30 minutes, followed by phentolamine (35 mg). In eight patients, the saline phase was followed by double-blind infusion of phentolamine or phenylephrine (500 ~g), a second saline phase, and then the other active drug. We measured magnitudes of spontaneous pain and mechanical hyperalgesias on a 0-to-10 pain scale every 5 minutes and monitored sensory and sympathetic effects clinically and through quantitative thermotest and thermography. Five patients reported significant diminution of pain (>50%), all in response to placebo. Neither phentolamine nor phenylephrine provided relief, although all patients had signs of physiologic abnormalities reputed to be determinants or predictors of SMP. These results complement previous studies demonstrating the nonexistence of SMP among "reflex sympathetic dystrophy" patients and further question the concept of SMP. Reprint Address: J.L. Ochoa, Neuromuscular Unit, Department of Neu-
rology, Good Samaritan Hospital and Medical Center, 1040 NW 22nd Avenue, Suite 460, Portland, OR 97210. 171-0182
Precursors of Extracranial Carotid Atherosclerosis in the Framingham Study Fine-Edelstein, J.S., Wolf, P.A., O'Leary, D.H., et al. 44(6):1046-1050, 1994. To investigate cardiovascular risk factors and carotid atherosclerosis, we related previously measured risk factors to carotid atherosclerosis as determined by duplex ultrasonography in the Framingham Study cohort. Risk factors measured prospectively on 1,I 16 cohort members, ages 66 to 93, were related to the severity of carotid atherosclerosis measured by carotid ultrasonography performed during biennial examination no. 20 (1988 to 1990). The degree of carotid atherosclerosis was expressed as a percent carotid stenosis and, for statistical analysis, subjects were divided into four groups according to percent carotid stenosis. The prevalence of significant carotid stenosis in the general population was low--7% in women and 9% in men. A multivariate logistic regression model showed that age, cigarette smoking, systolic blood pressure, and cholesterol were independently related to carotid atherosclerosis. Alcohol consumption was also significant in men, but not in women. In addition, our results indicate that both current and former smoking in both sexes was related to the degree of carotid atherosclerosis. Reprint Address: P.A. Wolf, Robinson Building B-608, Neurology, 80 East Concord Street, Boston, MA 02118. 171-0183
Cerebral White Matter Lesions, Vascular Risk Factors, and Cognitive Function in a PopulationBased Study: The Rotterdam Study Breteler, M.M.B., van Swieten, J.C., Bots, M.L., et al. 44(7): 1246-1252, 1994. Cerebral white matter lesions are a common finding on MRI in elderly persons. We studied the prevalence of white matter
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Neurology (continued) lesions and their relation with classic cardiovascular risk factors, thrombogenic factors, and cognitive function in an age- and gender-stratified random sample from the general population that consisted of 111 subjects 65 to 84 years of age. Overall, 27% of subjects had white matter lesions. The prevalence and severity of lesions increased with age. A history of stroke or myocardial infarction, factor VIIc activity, and fibrinogen level were each significantly and independently associated with the presence of white matter lesions. Significant relations with blood pressure level, hypertension, and plasma cholesterol were present only for subjects aged 65 to 74 years. White matter lesions tended to be associated with lower scores on tests of cognitive function and were significantly associated with subjective mental decline. This study suggests that classic cardiovascular risk factors, as well as thrombogenic factors, are associated with white matter lesions in subjects over 65 years of age in the general population, and that these lesions may be related to cognitive function.
Reprint Address: M.M.B. Breteler, Department of Epidemiology and Biostatistics, Erasmus University Medical School, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
PAIN
171-0184
Cognitive-Behaviorai Classifications of Chronic Pain: Replication and Extension of Empirically Derived Patient Profiles Jamison, R.N., Rudy, T.E., Penzien, D.B., and Mosley Jr., T.H. 57:277-292, 1994. Many attempts have been made to classify patients with chronic pain in order to make sense of a very complex problem and to direct patients towards appropriate treatments for their condition. Unfortunately, these efforts have not been empirically based and have demonstrated limited clinical use. Predominant emphasis has been placed on either biomedical or psychopathological elements of the chronic pain experience with little integration of cognitive-behavioral factors. Turk and Rudy (1988) introduced an empirically derived pain patient taxonomy based on analyses of the Multidimensional Pain Inventory (MPI). The primary purpose of the present study was to replicate this classification system by using different measures for similar constructs in different groups of chronic pain patients. Items designed to measure 4 constructs (activity interference, emotional distress, pain intensity, and perceived support) were collected from 1594 pain patients evaluated at two separate pain treatment facilities. Confirmatory factor analytic results indicated high reliability of the items in measuring these 4 constructs. Replicated clustering techniques demonstrated the robustness of 3 patient profiles across the patient samples. The 3 clusters corresponded remarkably well to the groups initially labeled by Turk and Rudy (1988) as Dysfunctional, Interpersonally Distressed and Adaptive Copers. External validation of the classification system supported replication of the 3 groups and offered further interpretational clarity to the patient profiles. Strong evidence was found for a taxonomy of 3 chronic pain patient
groups. Implication for predicting treatment outcome and for future research are discussed. Reprint Address: R.N. Jamison, Pain Management Center, Department of Anesthesia, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
171-0185
Relationship of Pain-Specific Beliefs to Chronic Pain Adjustment Jensen, M.P., Turner, J.A., Romano, J.M., and Lawler, B.K. 57:301-309, 1994. Cognitive-behavioral models suggest that pain patients' beliefs about their pain play a critical role in their adjustment. This study sought to replicate and extend previous research that has examined the relationship between pain-specific beliefs and adjustment to chronic pain. Two hundred forty-one chronic pain patients evaluated for possible admission to an inpatient pain treatment program completed the Sickness Impact Profile (SIP) and the Survey of Pain Attitudes (SOPA), as well as measures of pain, medical services utilization and demographic characteristics. The results indicated that the beliefs that emotions affect pain, that others should be solicitous when the patient experiences pain, and (for subjects reporting low and medium levels of pain severity) that one is disabled by pain were associated positively with psychosocial dysfunction. The beliefs that one is disabled and that activity should be avoided because pain signifies damage were associated positively with physical disability. None of the beliefs assessed was significantly associated with number of physician visits in the previous 3 months, although belief in the appropriateness of medications for managing chronic pain was associated positively with pain-related emergency room visits. The results support a cognitive-behavioral model ofchronic pain adjustment and suggest specific pain beliefs to target in treatment studies examining causal relationships between beliefs and adjustment. Reprint Address: M.P. Jensen, Department of Rehabilitation Medicine, RJ-30, University of Washington School of Medicine, Seattle, WA 98195.
171-0186
Are Runners Stoical? An Examination of Pain Sensitivity in Habitual Runners and Normally Active Cont3"ols Janal, M.N., Glusman, M., Kulfl, J.P., and Clark, W.C. 58:109-116, 1994. Anecdotal and clinical reports suggest that athletes are stoical. However, there are few studies comparing persons who exercise regularly with those who do not. This study compared two independent samples of regular runners and normally active controls, both without recent exercise, on cold pressor, cutaneous heat, and tourniquet ischemic pain tests. Results demonstrated that the runners' threshold for noxious cold was significantly higher than that of controls. The heart rate and blood pressure responses to cold were similar in the 2 groups, suggesting that differences in cold pain report did not result from differences in autonomic reactivity to cold. Signal detection theory measures demonstrated that runners discriminated among noxious thermal stimuli significantly better than controls, but neither noxious nor innocuous thermal report criteria differed between groups. The cohorts also did not differ in their report of ischemic pain sensations. Thus, these data do not generally support the hypothesis of pain insensitivity or stoicism in ha-
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Pain (continued) bitual runners. Rather, insensitivity occurs only in their response to noxious cold, which is suggested to be an adaptation to regular training. Reprint Address: M.N. Janal, Box 50, NYS Psychiatric Institute, 722 West 168 Street, New York, NY 10032. 171-0187
Effects of Experimental and Clinical Noxious Counterirritants on Pain Perception
Sigurdsson, A. and Maixner, W. 57:265-275, 1994. It is commonly accepted that application of a sustained noxious stimulus frequently suppresses the perception of pain. In this investigation, we have determined whether painful forearm ischemia suppresses tooth pain resulting from an acute irreversible pulpitis. We have also determined whether the physiological responses to toothache alter the perception of pain evoked by experimental procedures. Ten male subjects experiencing a painful toothache (group TA) and 7 age-matched pain-free male subjects (group PF) participated in these studies. During session 1, heat pain threshold and tolerance values were determined for both groups. The times to ischemic pain onset and ischemic pain tolerance were determined for both groups using the submaximal effort tourniquet procedure. The effect of the tourniquet procedure on the intensity, unpleasantness, and spatial distribution of toothache was also assessed. Session 2 was conducted on 7 TA and 7 PF subjects 1 week later and was conducted like session 1 with the exception that group TA was not experiencing tooth pain during this session. Measures of thermal pain perception and forearm ischemic pain perception were not altered by the occurrence of toothache. In contrast, sustained noxious forearm ischemia produced a marked reduction in the intensity, unpleasantness and spatial distribution of puipal pain. These effects on pulpal pain remained for at least 5 rain after removal of the tourniquet while the arm was pain free. These findings suggest that a noxious conditioning stimulus does not universally inhibit pain perception but instead depends on unidentified interactions between the noxious test and conditioning stimuli. Reprint Address:W. Maixner, Room 03, Dental Research Center, University of North Carolina, Chapel Hill, NC 27599-7455.
continuous pain for the month preceding assessment. Sixty-five percent of patients with pain reported taking medications for pain and 90% of these patients evaluated their medication(s) as 50% effective or better. Nevertheless, patients with pain reported poorer mental health and more social-role handicap. Discussion focuses on the need for routine assessment of pain and the comprehensive evaluation of the effectiveness of pain interventions in the therapeutic management of patients with MS. Reprint Address: C.J. Archibald, Department of Psychology, Dalhousie University, Halifax, NS B3H 4J 1, Canada. 171-0189
Coping with Long-Term Musculoskeletal Pain and Its Consequences: Is Gender a Factor? Jensen, I., Nygren, A., Gamberale, F., Goldie, I., and Westerholm, P. 57:167-172, 1994. We did a descriptive study of 121 patients (71 women and 50 men) to explore the role of gender in coping with long-term intractable pain of the neck, shoulder and back and to determine the consequences of pain. Questionnaires used to assess the dependent variables were the Coping Strategy Questionnaire (CSQ) and the Multidimensional Pain Inventory (MPI). Distinctions were found between men and women. In particular, the coping strategies used by women were those which in previous research had been found to be associated with dysfunction and poor outcome in terms of rehabilitation. Moreover, considering the consequences of pain on daily living, a more complex pattern of related factors was found in women rather than men. Given the high proportion of working women in Sweden with long-term musculoskeletal pain and considering recent observations in controlled studies showing that the benefits of cognitive behaviourally based treatmenls are confined to women, our findings suggest the need to tailor rehabilitative strategies differently for men and women and point to a research agenda which pays more attention to the distinctive challenges of women in the workplace when they are affected by chronic ailments. Reprint Address: I. Jensen, NiirRehab, Ribbingsgatan 1-3, 703 63 Orebro, Sweden. 171-0190
171-0188
Pain Prevalence, Severity and Impact in a Clinic Sample of Multiple Sclerosis Patients Archibald, C.J., McGrath, P.J., Ritvo, P.G., et al. 58:89-93, 1994. Previous studies have reported variable prevalence of pain in multiple sclerosis (MS) and have not documented the impact of pain on daily living. In this consecutive series, we report on data collected from structured interviews with 85 patients seen within a 16-month period at a regional referral clinic. The prevalence of pain for the month preceding assessment was 53%. There were no significant differences between patients who did and those who did not report pain on the basis of patient demographics (age, gender) and disease characteristics (disease subtype, duration and neurologic symptom severity). Disease duration and neurologic symptom severity were significantly correlated with the number of hours of pain per week but were not correlated with pain severity, the number of pain sites or pain-related distress. There was wide variability in the number of pain hours/week reported with 17.6% of the sample reporting
Do Benzodiazepines Have a Role in Chronic Pain Management? Dellemijn, P.L.I. and Fields, H.L. 57:137-152, 1994. Reprint Address: H.L. Fields, Department of Neurology (M-794), University of California, San Francisco, CA 94143-0114.
PATIENT EDUCATION AND COUNSELING
171-0191 Stretch-Based Relaxation Training Carlson, C.R. and Curran, S.L. 23:5-I2, I994. This paper is a review of progressive relaxation training based on muscle stretching exercises. Stretch-based relaxation training is an alternative to traditional tense-release methods for teaching self-regulation of muscle activity. The rationale and basic procedures for stretch-based relaxation are presented, along
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Patient Education and Counseling (continued) with a review of research studies exploring the clinical efficacy of the techniques. Experimental evidence has demonstrated decreases in subjective measures of muscle tension and activation, as well as decreases in EMG activity at selected target muscle sites when stretch-based relaxation procedures are employed. The clinical application of stretch-based relaxation is presented and illustrated with a case study describing the use of these procedures to assist in the treatment of neck tension/pain and anxiety. Discussion centers on the potential role of stretch-based relaxation in the management of anxiety and musculoskeletal disorders. Reprint Address: C.R. Carlson, Department of Psychology, University of Kentucky, Lexington, KY 40506-0044.
Problem Solving Anchored Instruction about Sick Days for Adolescents with Diabetes Pichert, J.W., Snyder, G.M., Kinzer, C.IC, and Boswell, E.J. 23:115-124, 1994. This study's hypotheses were that both shortly after instruction and after an 8-month follow-up, diabetic children taught via anchored instruction (AI), a format for problem solving, would outperform controls. Subjects were 81 9-15-year-old campers with insulin dependent diabetes who were randomly assigned to AI or control groups for two 45-rain small group teaching sessions. AIs viewed a video about a girl who mismanages her diabetes during intercurrent illness, and they were challenged to identify, define and solve her errors. Controls learned sick-day management via conventional direct instruction. At the end of the 2-week camp, AI and control groups' scores on factual knowledge were equal. AIs were more likely than controls at the end of the camp (0.75 vs. 0.54, P < 0.05) and 8 months later (0.59 vs. 0.38, P < 0.02) to provide a rationale for the use of remembered guidelines. Across all campers, this ability to link guidelines and their rationales was significantly correlated (r = 0.55, P < 0.01) with the number of self-management practices employed by campers who suffered an illness between the end of camp and the 8-month follow-up. Only one long-term behavioral difference between groups emerged: AIs' parents shared in making most diabetes decisions on sick days, while controls' parents left more decision making to their children. AI appears at least as good as conventional teaching, and may better 'link' rules and reasons, perhaps aiding daily real-life problem solving. Reprint Address: J.W. Pichert, 315 Medical Arts Building, Vanderbilt University School of Medicine, Nashville, "IN 37232-1229.
significant level within all groups. The increase persisted at each of four follow-ups. An analysis of variance determined there was no significant difference between groups in the changes in frequency and confidence. Thus, the method of teaching had little impact on the long-range practise of BSE in terms of these two variables. It was observed that 10.8% of the group receiving individual instruction would not accept teaching on their own breasts. Less than 1.5% in each of the other groups would not accept all aspects of the teaching protocol for their respective group. This development should be taken into account in determining whether practise on one's own body is a necessary component of BSE teaching programs. Reprint Address: S.Y. Alcoe, Faculty of Nursing, University of New Brunswick, Fredericton, NB E3B 5A3, Canada.
171-0192
171-0193
The Effects of Teaching Breast SelfExamination: Reported Confidence and Frequency of Practise over a Six-Year Period Alcoc, S.Y., Gilbey, V.J., McDermot, R.S.R., and Wallace, D.G. 23:13-21, 1994. Breast serf-examination (BSE) was taught to 614 women. They were randomly assigned to one of three groups identified as content only, content plus supervised practise on a model with implanted lumps and content plus individual instruction on their own breasts. They were followed for 6 years. Reported frequency of practise and level of confidence increased at a
171-0194
Self-Management of the Health Care Regimen: A Comparison of Nurses' and Cardiac Patients' Perceptions Dodge, J.A., Janz, N.K., and Clark, N.M. 23:73--82, 1994. This study compared perceptions of 129 elderly cardiac patients regarding their health status and self-management skills with corresponding assessments by outpatient nursing staff members. Nurse-patient perceptions were most congruent on general questions regarding the heart condition. Differences were most apparent regarding how aware patients were of being asked to follow a regimen for managing their heart problems; what specific components comprised the regimens the patients were to follov~, and how much confidence patients had in their ability to comply with specific components of the regimen. Congruence in perceptions of nurses and patients varied by the sex of the patient. Findings suggest that careful and continuous assessment of patients' perceptions about their condition and ongoing instruction regarding specifics of the therapeutic regimen are key elements in efforts to enhance elderly patients' self-management skills. Reprint Address: N.M. Clark, School of Public Health, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029.
171-0195
A Comparison of Younger-Aged and Older-Aged Women in a Behavioral Self-Control Smoking Program O'Hara, P. and Portser, S.A. 23:91-96, 1994. This study examines differences in motivation for quitting smoking, withdrawal experiences and weight changes in younger and older aged women who entered a smoking cessation program designed specifically for women smokers. In an assessment prior to quitting smoking 26 women aged 20--49 years (youngeraged women) and 19 women aged 50-75 years (older-aged women) did not show differences in number of prior quit attempts or their dependence on nicotine (as measured in the Fagerstrom Tolerance Questionnaire). The older aged women smoked for a significantly greater number of years but smoked fewer cigarettes per day than the younger women. In a selfreport questionnaire the two age groups differed in their reasons stated for wanting to give up cigarettes and symptoms of illness they experienced related to smoking. The average weight gains
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A N N A L S OF B E H A V I O R A L M E D I C I N E
Patient Education and Counseling (continued) for women who quit smoking were minimal (3.5 lb, younger; 3.9 lb, older; 1 lb = 0.453 592/37 kg) although more younger women than older women reported they expected difficulty with weight gain after cessation. Changes in withdrawal experiences were not significantly different at any point during the initial phase of quitting (24, 48 and 72 11). Reprint Address: P. O'Hara, University of Miami School of Medicine, Department of Epidemiology and Public Health, 1029 NW 15th Street, R-669, Miami, FL 33136.
171-0196
Informationto Patients with Malignant Melanoma: A Randomized Group Study Brandberg, Y., Bergenmar, M., Bolund, C., et al. 23:97-105, 1994. An information programme for patients with cutaneous malignant melanoma, Stage I, aiming at increasing satisfaction with information, was carried out at the Department of Oncology CRadiumhemmet). The programme consisted of a group meeting and a brochure. A total of 231 consecutive patients were included, and 149 (65%) reported interest in participation and were randomized to the Information group (n = 77) or to the Control group. A total of 67 patients (29%) were not interested (the NI-group). To evaluate the programme, the patients in the three groups completed questionnaires regarding satisfaction with information, knowledge of melanoma and psychological and psychosomatic variables before randomization and at the first visit for follow-up at Radiumhemmet. After the information programme, the Information group was significantly more satisfied with information, had a higher level of knowledge and a lower proportion requested further information as compared with the Control group. No differences were found on the psychological and psychosomatic variables. Reprint Address: Y. Brandberg, Psychosocial Unit, Radiumhemmet, Karolinska Hospital, S 104 01, Sweden.
PHYSICAL THERAPY
171-0197
Work Hardening and Work Conditioning Interventions: Do They Affect Disability? Lechner, D.E. 74(5):471-493, 1994. The purpose of this article is to review the research on the effectiveness of work hardening and work conditioning programs. Twelve studies of work hardening and work conditioning programs in the United States and abroad were reviewed. One study produced convincing evidence in a randomized study that a work conditioning program was useful in producing a higher percentage of return to work and an earlier return to work in a group of patients off work for at least 2 months. Another study demonstrated that a work hardening program increased the rate of return to work by 52% in patients off work for greater than 4 months. Most of the other studies reviewed suggested positive results, but more carefully documented, randomized, and controlled studies are needed to support the efficacy of these pro-
grams and to determine the optimum and most cost-effective work hardening and work conditioning interventions. Reprint Address: D.E. Lechner, Division of Physical Therapy, School of Health Related Professions, The University of Alabama, B-41 SHRP Building, 1714 Ninth Avenue South, UAB Station, Birmingham, AL 35294-1270.
171-0198
Efficacy of Electromyographic Biofeedback Compared with Conventional Physical Therapy for Upper-Extremity Function in Patients Following Stroke: A Research Overview and Meta-Analysis Moreland, J, and Thomson, M.A. 74(6):534-547, 1994. Background and Purpose. The purpose of this study was to examine the efficacy of electromyographic biofeedback compared with conventional physical therapy for improving upperextremity function in patients following a stroke. Subjects and Methods. A literature search was done for the years 1976 to 1992. The selection criteria included single-blinded randomized control trials. Study quality was assessed for nine criteria. For functional (disability index or stage of recovery) and impairment outcomes, meta-analyses were performed on odds ratios for improvement versus no improvement. Mann-Whitney U-Test probability values were combined across studies. Results. Six studies were selected, and outcome data were obtained for five studies. The common odds ratio was 2.2 for function and 1.1 for impairments in favor of biofeedback. The estimate of the number needed to treat to prevent a nonresponder was 11 for function and 22 for impairments. None of the meta-analyses were statistically significant. Conclusions and Discussion. The results do not conclusively indicate superiority of either form of therapy. Although there is a chance of Type II error, the estimated size of the effect is small. Given this estimate of little or no difference, therapists need to consider cost, ease of application, and patient preference when selecting these therapies. Reprint Address: J. Moreland, Physiotherapy Department, St. Joseph's Hospital, 50 Chadton Avenue East, Hamilton, ON L8N 4A6, Canada.
171-0199 Disability in Poliomyelitis Sequelae Grimby, G. and J~Snsson, A.-L.T. 74(5):415-424, 1994. Patients who have been affected by poliomyelitis may develop new symptoms such as muscle weakness, muscle atrophy, muscle or joint pain, and unexplained fatigue several decades after the onset of their poliomyelitis Loost-polio syndrome [PPS]). We report on the results of our study of 59 patients with poliomyelitis using a number of instruments for disability assessment, including a 4- to 5-year follow-up. The main impact of disability for most patients is in mobility-related activities. Dependence in personal activities of daily living is fairly rare, whereas dependence and difficulties in instrumental activities of daffy living (eg, cooking, transportation, cleaning, shopping) are more common and also more severe in persons with PPS. Mental health, emotional reactions and social activity, interaction, and isolation are usually less affected, although considerable coping problems may occur, especially in persons with PPS who have new health problems and increasing disabilities. Examples of disabilities, intervention measures, and coping processes are given with case reports. The importance of a broad
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Physical Therapy (continued) and interdisciplinary approach is emphasized, in which impairment as well as disability aspects should be considered in treatment and intervention programs. Reprint Address: G. Grimby, Department of Rehabilitation Medicine, University of G6teborg, G6teborg, S-41345 Sweden.
closes with a discussion of directions for future research aimed at explaining the interaction between perceived support and acute stress. Reprint Address: R.C. Kessler, Institute for Social Research, The University of Michigan, Ann Arbor, MI 48106-1248.
171-0200
171-0202
Assessing Change Over Time in Patients with Low Back Pain
Stratford, P.W., Binkley, J., Solomon, P., Gill, C., and Finch, E. 74(6):528-533, 1994. Background and Purpose. This study compared the ability of the Roland-Morris (RM), Oswestry (OSW), and Jan van Breemen Institute 0VB) pain and function questionnaires to detect change over time. Subjects. The sample consisted of 88 patients with mechanical low back pain who were referred by physicians to the outpatient physical therapy department of a teaching hospital. Methods. Questionnaires were completed by the subjects at their initial visit and 4 to 6 weeks later. Clinically important change was estimated by having the subject and the clinician independently complete two rating scales. Sensitivity to change was assessed using receiver operating characteristic (ROC) curve analysis. Results. The ROC curve areas for the RM (0.79), OSW (0.78), and JVB pain (0.79) questionnaires were significantly greater than for the JVB function questionnaire (0.66). Blank and multiple responses per item were present on approximately 20% of the OSW questionnaires and 14% of the JVB questionnaires. Words rather than checks were evident on 3% of the RM questionnaires. Conclusion and Discussion. Based on the latter finding, we believe the RM questionnaire may be the preferred instrument for assessing change over time in patients with low back pain. Reprint Address: P.W. Stratford, School of Occupational Therapy and Physiotherapy, Health Sciences Centre (Room 1J11), McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada.
Spouse Similarity for Psychological Distress and Well-Being: A Population Study du Fort, G.G., Kovess, V., and Boivin, J.-F. 24:431--447, 1994. While spouse similarity for psychiatric morbidity has been the object of numerous studies, most of these focused on clinical samples and, consequently, the interpretation of their results is limited by the existence of a selection bias. In this study, conducted on a sample of 845 general population couples, significant spouse similarity was observed for psychological distress and well-being, characterized by a marked symmetry in the relation between spouses' scores. The sex differences observed in many earlier studies would appear essentially to be artefactual. Spouse similarity was also found to be significant in the subpopulation of couples married less than two years, which pointed to assortative mating for psychological distress and wellbeing. While many studies have found educational dissimilarity and age difference between spouses to be associated with certain health variables, such as high blood pressure and coronary heart disease, these variables do not have a significant influence on individual levels of psychological distress and well-being. Spouse similarity for socio-demographic characteristics does not play a significant role in explaining spouse similarity for mental health. Consequently, assortative mating for psychological distress and well-being would appear to be primarily due to personal preference. Reprint Address: G.G. du Fort, Douglas Hospital ResearchCentre, 6875 LaSalle Boulevard, Verdun, PQ H4H IR3, Canada.
171-0203
PSYCHOLOGICAL MEDICINE
171-0201
Perceived Support and Adjustment to Stress in a General Population Sample of Female Twins
Kessler, R.C., Kendler, K.S., Heath, A., Neale, M.C., and Eaves, L.J. 24:317-334, 1994. The stress-buffering effect of perceived support is explored in a large panel survey of adult female twins. The analysis begins by documenting a significant interaction between perceived support and acute stress in predicting DSM-III-R major depression. Various hypotheses are investigated to explain this interaction. These include the possibilities that the interaction is due to a stress-buffering effect of perceived support which is mediated by received support, that perceived support promotes either the increased use or the increased effectiveness of certain coping strategies, or that there is some underlying genetic factor that affects both the perception of support and adjustment to stress. No evidence was found for any of these hypotheses. The paper
The Impact of Unemployment on the Psychological Well-Being of British Asians Shams, M. and Jackson, P.R. 24:347-355, 1994. This paper presents the results of a study of unemployment among British Asians living in the north of England. The sample comprises 139 employed and unemployed men. Using standardized psychological questionnaires with a semi-structured interview schedule, the psychological consequences of unemployment are examined in relation to other psychosocial variables. The results showed that the unemployed group had lower levels of psychological well-being, self-esteem, and employment commitment with high external beliefs, than the employed group. Length of unemployment was a significant determinant of psychological well-being and respondents with a longer period of unemployment had a lower level of psychological well-being than those who had been unemployed for a shorter period. The findings are examined in the context of existing empirical evidence, and the need to examine the psychological impact of unemployment among other British Asian groups is emphasized. ReprintAddress:M. Shams, Department of Psychology,Facultyof Health Care and Social Studies, University of Luton, Park Square, Luton, Bedfordshire LU1 3JU, UK~
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ANNALS OF BEHAVIORAL MEDICINE
Psychological Medicine (continued) 171-0204
The Differential Response of Chronic Fatigue, Neurotic and Muscular Dystrophy Patients to Experimental Psychological Stress Wood, G.C., Bentall, R.P., Gopfert, M., Dewey, M.E., and Edwards, R.H.T. 24:357-364, 1994. A group of patients suffering from chronic fatigue (CF) attending a medical clinic were compared with a group of muscular dystrophy (MD) patients from the same clinic and a psychiatric control (PC) group who were attending a psychiatric unit. A checklist was used to assess the patients' subjective physical and psychological state before and after exposure to a psychological stressor. For both physical and psychological symptoms the CF group had the largest response, the PC group was intermediate, and the MD group had the least response. Explanations may involve physiological arousal and attentional focusing. Reprint Address: G.C. Wood, Avondale Unit, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 4HT, UK.
171-0205
Complaintsof Cognitive Decline in the Elderly: A Comparison of Reports by Subjects and Informants in a Community Survey Jorm, A.F., Christensen, H., Henderson, A.S., et al. 24:365-374, 1994. In a community survey, subjects and their informants were asked the same questions about memory and intellectual decline in the subjects. Subjects and informants both commonly reported cognitive decline, although in most cases the decline was not seen as interfering with daily life. However, when responses from subjects and informants were cross-tabulated, agreement was found to be poor. For subjects, reports of cognitive decline were correlated with anxiety and depression symptoms and with trait neuroticism. Subjects' reports were uncorrelated with age and only weakly correlated with cognitive test performance, indicating little validity. By contrast, informants' reports were correlated with the subjects' cognitive test performance and age, but also with the informants' own anxiety and depression symptoms. Although informants' reports have validity, they may also be contaminated by the informants' affective state. ReprintAddress:A.F. Jorm, NI-I&MRCSocial Psychiatry Research Unit, The Australian National University, Canberra, ACT 0200, Australia.
A Longitudinal Study of Bereavement Phenomena in Recently Widowed Elderly Men Byme, G.J.A. and Raphael, B. 24:411--421, 1994. A three-phase longitudinal design was used to study bereavement phenomena in a cohort (N = 78) of recently widowed elderly Australian men. One group of 57 widowers was compared with a second group of 21 widowers on a waiting list. A brief, interviewer-administered, structured questionnaire was used to rate the frequency of 22 self-reported bereavement phenomena. The prevalence and temporal evolution of these phenomena are described. Half of a subgroup of elderly widowers reporting high levels of bereavement phenomena at 6 weeks post-bereavement went on to exhibit persistent or chronic grief at 13 months post-bereavement. The prevalence of persistent
or chronic grief throughout the first 13 months post-bereavement was 8.8%. Income, education and expectedness of the death were all negatively correlated with frequency of self-reported bereavement phenomena at 6 weeks post-bereavement. In a multiple regression analysis only expectedness of the death contributed significantly to prediction of the frequency of bereavement phenomena at 6 weeks post-bereavement. Widowers who were unable to anticipate their wife's death, even when their wife had suffered a long final illness, had a more severe bereavement reaction. Reprint Address: G.J.A. Byrne, Department of Psychiatry, The University of Queensland, Room El5, Clinical Sciences Building, Royal Brisbane Hospital, Herston, QSL 4029, Australia.
171-0207
Diminished Recall and the Cohort Effect of Major Depression: A Simulation Study Ginffra, L.A. and Risch, N. 24:375-383, 1994. Several large-scale epidemiological surveys have reported increasing lifetime rates of psychopathology among recently born cohorts. In the case of Major Depressive Disorder (MDD) younger cohorts tend to manifest higher lifetime prevalences of the condition than older cohorts, at any given age. In some studies, cohort differences are so large that the youngest cohort exceeds the lifetime prevalence of the oldest cohort well before passing through their total period of risk. The data on lifetime prevalences that support the existence of secular differences, however, has typically been collected in cross-sectional studies. Thus, individuals are interviewed at a single point in time and asked to recall all prior psychopathology. Due to poor recall, this design may greatly underestimate earlier experiences. In fact, cohort differences are not limited to MDD; similar results have been reported for a wide range of psychopathology, suggesting methodological problems at data collection. We have conducted a simulation study to examine the magnitude of annual rates of forgetting that could produce the secular trends reported for MDD. Small, but constant annual rates produce striking, 'cohort effect-like' curves. The rates needed to reconstruct the reported effect are compatible with published values for test-retest studies of lifetime recall of MDD. This simulation study does not rule out the existence of a cohort effect in some psychiatric disorders, but stresses the possible limitations of using crosssectional studies to investigate secular trends. Reprint Address: L.A. Giuffra, Department of Psychiatry, Washington University School of Medicine, The Jewish Hospital of St. Louis, 216, South Kingshighway, St. Louis, MO 63110.
171-0206
171-0208
An Unusual Presentation of Multiple Sclerosis
Hotopf, M.H., Pollock, S., and Lishman, W.A. 24:525-528, 1994. Two male patients who presented with unusual pictures of dementia in the absence of other obvious symptoms or signs are reported. Investigations demonstrated changes highly suggestive of multiple sclerosis (MS) on magnetic resonance imaging, cerebrospinal fluid analysis and electrophysiological tests. We suggest this represents a rare presentation of multiple sclerosis. Reprint Address: W.A. Lishman, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.
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PSYCHOLOGY AND HEALTH
171-0209
Optimism, Vulnerability, and Self-Beliefs as Health-Related Cognitions: A Systematic Overview Schwarzer, R. 9(3):161-180, 1994. This paper disentangles a number of closely related cognitions by dividing them into the categories of defensive and functional optimism. Optimistic biases in risk perception are discussed that may represent barriers in the adoption of preventive health behaviors. Instead of defensive optimism, some sense of vulnerability is seen as indispensable for behavioral change operating jointly with beliefs about positive health outcomes, instrumental actions, and appropriate coping resources. A distinction is made between three kinds of functional optimism that depend either on attributional style, outcome expectancies, or personal agency. Findings are presented that corroborate the strength of these constructs in predicting health outcomes. In terms of health behavior change, it is argued that optimistic self-beliefs are the most beneficial because of their operative power that helps to set goals, initiate actions, and maintain motivation. Reprint Address: R. Schwarzer, Institut fib"Psychologie, FB 12, WE 7, Freie Universit~t Berlin, Habelschwerdter Allee 45, 14195 Berlin, Germany. 171-0210
The Relationship between Loneliness, Interpersonal Competence, and Immunologic Status in HIV-Infected Men Straits-TrYster, K.A., Patterson, T.L., Semple, S.J., et al. 9(4):205-219, 1994. The relationships among interpersonal competence, loneliness, depression, and immune status were examined in HIVinfected men and healthy controls. A sample of 108 men [88 HIV-I antibody seropositive (HI'V+) and 20 HIV-1 antibody seronegative (HIV-)] completed the Interpersonal Competence Questionnaire at baseline and the UCLA Loneliness scale at two consecutive six-month timepoints as part of the psychosocial component of the HIV Neurobehavioral Research Center longitudinal study. Absolute number of CD4+ helper cells and depression were determined at baseline. Among seropositive men, loneliness was negatively correlated with self-perceived competence in all five relationship domains assessed: initiation of social interactions, turning down unreasonable demands (negative assertion), self-disclosure, providing emotional support to others, and conflict management. Competence or level of comfort in initiation of social interaction and management of interpersonal conflict accounted for 39% of the variance in loneliness at baseline. Level of comfort in initiation of interactions and self-disclosure accounted for 44% of the variance in loneliness at followup. After controlling for loneliness at baseline, an additional 12% of the variance in loneliness at followup was accounted for by all domains of interpersonal competence, suggesting that these dimensions of social skill may be partial determinants of loneliness. High-lonely HIV+ men had significantly fewer CD4 + helper cells than did low-lonely HIV + men. The relationship between loneliness and CD4 + cell number was
95
independent of stage of HIV disease. Lonely HIV+ men may be at greater risk for disease progression. Clinical intervention efforts to reduce loneliness and increase quality of life should consider targeting interpersonal skills. Reprint Address: ICA. Straits-TrYster, HNRC, 2760 Fifth Avenue, Suite 200, San Diego, CA 92103.
Psychological Effects of Exercise among Adult Women: The Impact of Menopausal Status Slaven, L. and Lee, C. 9(4):297-303, 1994. 171-0211
The psychological and physical benefits of regular physical activity are well established, but the majority of research to date has focused on younger male samples. Two studies examined the impact of menopausal status on the ability of women to derive psychological benefits from exercise. Regular exercisers, assessed immediately following an exercise class, scored significantly lower on negative mood dimensions and higher on positive mood than did non-exercisers, regardless of menopausal status. Regular exercisers also showed significant improvements in mood state when assessed before and after a single exercise session; again this effect was independent of menopausal status. The results suggest that the acute mood-enhancing effects of exercise are maintained despite the endocrine changes associated with menopause. It is argued that encouraging menopausal women to adopt appropriate exercise patterns may assist in the alleviation of psychological distress as well as providing physical benefits. Reprint Address:C. Lee, Department of Psychology, University of Newcastle, Callaghan NSW 2308, Australia.
171-0212
Effects of a Post-Hospitalization Group Health Education Programme for Patients with Coronary Heart Disease van Elderen, T., Maes, S., Seegers, G., Kragten, H., and Relik-van Wely, L. 9(4):317-330, 1994. A health education programme was offered to groups of coronary heart patients and their partners after discharge from hospital. A randomized pre-test post-test control group design was used to evaluate the effects of this experimental intervention. The health education programme was offered to 109 coronary heart patients in groups of between five and eight patients together with their partners in addition to standard medical care and physical training. A control group of 108 patients received only standard medical care and physical training. The intervention consisted of eight weekly two-hour group health education sessions and one follow-up session. All sessions focused on the promotion of healthy habits and the reduction of adverse psychosocial consequences of the incident. In the short term (about four months after the inciden0 the health education programme showed statistically significant intervention effects on knowledge about coronary heart diseases, smoking cessation, healthy eating habits and the number of consultations with the family physician, but no effects on emotional distress. In the long term (one year after the incident) there was only a significant intervention effect on smoking cessation. These results suggest that the effects of the programme are modest, especially in terms of maintenance of behavioural change. As a consequence, it is suggested that the programme should not be offered to all cor-
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ANNALS OF BEHAVIORAL MEDICINE
Psychology and Health (continued) onary patients during cardiac rehabilitation, but only to those who can be expected to profit most from it. Reprint Address: T. van Elderen, Department of Clinical and Health Psychology, University of Leiden, P.O. Box 9555, 2300 RB Leiden, The Netherlands.
PSYCHOSOMATIC
171-0213
MEDICINE
known history of coronary heart, or other atherosclerotic, disease. The percentage of subjects reporting that they snore "usually" or "always/loudly" increased across the four CAD severity groupings (nonpatient controls = 19.6%, 1 vessel = 44.4%, 2 vessel = 41.9%, 3 vessel = 56.0%) with a p value of .005. Hypertension, body mass index, and pack years of smoking were found to be associated with both coronary artery disease severity and snoring. When these variables were controlled in a multiple regression analysis, the relationship of snoring and CAD severity remained significant at p = .050. Reprint Address: M.W. Ketterer, Henry Ford Hospital/CFP3, 2799 West Grand Boulevard, Detroit, MI 48202.
Quantifying and Predicting Recovery after Heart Surgery
Jenkins, C.D., Stanton, B.-A., and Jono, R.T. 56:203-212, 1994. The validity of the biopsychosocial approach to the study of health and illness is reaffirmed by the prospective findings of the Recovery Study. This is a multidisciplinary examination, conducted in four teaching hospitals, of the predictors of symptoms of cardiac illness in 463 patients 6 months after coronary artery bypass or cardiac valve surgery. We found that the following preoperative measures predict freedom from cardiac symptoms 6 months after surgery: low levels of all of the following: angina pain, shortness of breath, fatigue and sleep problems, lifetime cigarette usage, and preoperative hospitalization for cardiac treatment; low levels of anxiety, depression, and hostility, and few life change events; high levels of all of the following: self-esteem, well-being, vigor; prevalence of activities and hobbies, social participation, and social support. The six variables in bold print contributed independently in a multiple regression equation that accounted for 21% of the variance of the symptoms score and was associated with an estimated 45% difference in success of recovery. The statistical strength and general nature of many of the predictors indicate that the predictors may also be important in recovery from other health crises. Psychosocial and biomedical factors correlate across time (predictively), as well as cross-sectionally, indicating that psychological, social, and biological mechanisms may be parts of a single general multifaceted process influencing recovery of health. A clinical trial could determine if psychological, social, or behavioral interventions will hasten and improve recovery from physical illness or trauma. Reprint Address: C.D. Jenkins, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX 77555-1053.
SCANDINAVIAN JOURNAL OF BEHAVIOUR THERAPY
171-0215
Coping Strategies Questionnaire (CSQ): Reliability of the Swedish Version of the CSQ
Jensen, I.B. and Linton, S.J.
171-0216
Functional Analysis of Hearing Handicap
Andersson, G. and Melin, L.
171-0214
Snoring and the Severity of Coronary Artery Disease in Men
Ketterer, M.W., Brymer, J., Rhoads, K., Kraft, P., and Kenyon, L. 56:232-236, 1994. Previous studies have found associations between snoring, or polysomnographic documented sleep apnea, and hypertension, cerebral vascular disease, and myocardial infarction. The present study examined the relationship of coronary artery disease (CAD) and snoring. One hundred and twenty-two males with positive angiographic studies were compared with fifty-six men, matched in age and socioeconomic status, who had no
22(3-4):139-145, 1993.
We present a study with the aim of investigating the internal consistency and reliability of a Swedish version of the Coping Strategies Questionnaire (CSQ). The study group consisted of 282 subjects suffering from long term back pain. Internal consistency was investigated by calculating alpha coefficients and test-retest reliability was investigated by a correlation analysis with two different test-related intervals. The results reveal that the internal consistency of the Swedish CSQ is high (alpha range between 0.7 and 0.8) and consistent with the American version. The test-retest reliability was not equally satisfactory (correlation ranged between 0.4 and 0.9) but the results support the usefulness of the CSQ as a tool in the clinical assessment of pain coping strategies. The test-retest results indicate the need for further research. In conclusion, the results from the present study are encouraging and support the usefulness of the instrument but to improve the utility and application of the Swedish version of the CSQ further research is warranted. Reprint Address: I.B. Jensen, Folksam Research, Folksam, S-106 60 Stockholm, Sweden.
22(3-4):147-157, 1993.
Rehabilitation of patients with hearing impairment is rarely based on functional analysis of specific target situations, needs, and treatment goals. In this paper a behavioural approach to hearing disability is presented and exemplified with a singlecase description of a 70 years old male who was given a brief behavioural treatment according to the results of functional analysis. Self-ratings of hearing disability at pretreatment, posttreatment, and at a 15-month follow-up showed favourable effects of the treatment, whereas no effects were found on a measure of dispositional optimism. Reprint Address: G. Andcrsson, Department of Clinical Psychology, Uppsala University, Box 1225, S-751 42 Uppsala, Sweden.
V O L U M E 17, N U M B E R
1, 1995
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Scandinavian Journal of Behavior Therapy (continued) 171-0217
Voluntary Blood Pressure Control: Operant Conditioning by a Continuous Blood Pressure Feedback Technique Weitkunat, R., Brody, S., Knost, B., et al. 22(3-4):179-191, 1993. The present study evaluated a single session operant conditioning of blood pressure in borderline hypertensives. A double blind randomized two period (each lasting for 20 minutes) cross over study consisting of a treatment (operant conditioning of mean arterial blood pressure) and a control condition (heart rate) was performed. Sequence of treatments was randomly assigned. Fourteen borderline hypertensive subjects participated and were trained to decrease their continuously measured blood pressure (Finapres) and heart rate. Subjects receiving blood pressure feedback during the first session showed a significant (4.3 mmHg) decrease in diastolic blood pressure. In contrast, subjects receiving blood pressure training during the second session showed a non-significant increase in diastolic blood pressure. Treatment consisting of more sessions is a promising adjunct to antihypertensive regimens. Reprint Address: H. Rau, Eberhard-Karls-University of Tiibingen, Institute for Medical Psychology and Behavioral Neurobiology, Gartenstrasse 29, D 72074 Tfibingen, Germany.
171-0219
An International Comparison of Back Surgery Rates Cherkin, D.C., Deyo, R.A., Loeser, J.D., Bush, T., and Waddell, G. 19(11):1201-1206, 1994.
Summary of Background Data. Although high geographic variation in back surgery rates within the United States have been documented, international comparisons have not been published. Methods. The authors compared rates of back surgery in eleven developed countries to determine if back surgery rates are higher: l) in the United States than in other developed countries, 2) in countries with more neurologic and orthopaedic surgeons per capita, and 3) in countries with higher rates of other surgical procedures. Data on back surgery rates and physician supply were obtained from health agencies within these eleven countries. Country-specific rates of other surgical procedures were available from published sources. Results. The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country. Countries with high back surgery rates also had high rates of other discretionary procedures such as tonsillectomy and hysterectomy. Conclusions. These findings illustrate the potentially large impact of health system differences on rates of back surgery. Better outcome studies, however, are needed to determine whether Americans are being subjected to excessive surgery or if those in other developed countries are suffering because back surgery is underutilized.
SPINE 171-0220
171-0218
The Cost of 1989 Workers' Compensation LOw Back Pain Claims Webster, B.S. and Snook, S.H. 19(10):1111-1116, 1994.
Study Design. Cost data were gathered from computerized records of the Liberty Mutual Insurance Company for low back pain workers' compensation claims (N -- 119,107) and for all claims (N = 731,087) initiated from 45 jurisdictions (states) during 1989. Objective. This study provided more current, accurate, and additional information to estimate the costs and incidence associated with compensable low back pain compared with all compensation claims. Methods. The first group of data included all compensable low back claims selected by specific codes: body part codes consisted of low back area, sacrum and coccyx, disc, and multiple trunk; injury codes consisted of strain, sprain, inflammation, rupture, hernia, fracture, and contusion. The second sample included all compensable claims, including both occupational injuries and illnesses. Results. Low back pain cases represented 16% of all claims but 33% of all claims costs; 55.4% of the low back pain cases received medical payments only (i.e., did not receive indemnity payments for lost time). The mean cost per case for low back pain was $8321; median cost per case was $396. Medical costs represented 32.4% of the total costs; indemnity costs (i.e., payment for lost time) represented 65.8%. Conclusions. Since indemnity costs represent the greatest percentage of workers' compensation expenditure, the primary goal of low back pain management should be the prevention or reduction of prolonged disability.
Low Back Pain Hospitalization: Recent United States Trends and Regional Variations Taylor, V.M., Deyo, R.A., Cherkin, D.C., and Kreuter, W. 19(11):1207-1213, 1994.
Study Design. This study describes recent United States trends and regional variations in the management of low back pain. Objectives. The authors investigated recent temporal trends and compared practices in different geographic regions. Summary of Background Data. Controversy exists concerning the appropriate medical and surgical management of patients with low back pain. Methods. National Hospital Discharge Survey data from 1979 through 1990 were analyzed. Case selection was based on previously developed algorithms intended to exclude nonmechanical causes of back pain. Results. Over the period of study, nonsurgical hospitalizations for low back pain decreased dramatically. In contrast, low back operation rates, particularly for fusion surgery, increased substantially. In recent years, surgery and hospitalization rates were highest in the South and lowest in the West. Conclusions. Rapidly increasing surgical rates and wide geographic variations suggest the need for a more consistent approach to back problems. 171-0221
Successful Treatment of Low Back Pain and Neck Pain after a Motor Vehicle Accident Despite Litigation Schofferman, J. and Wasserman, S. 19(9): 1007-1010, 1994.
Objective. This prospective study evaluated 39 consecutive patients with low back pain (LBP) or neck pain that resulted
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ANNALS OF BEHAVIORAL MEDICINE
Spine (continued) from a motor vehicle accident who had litigation pending. Methods. Patients completed a McGill Pain Questionnaire (MPQ) to quantify pain and an Oswestry Low Back Disability Questionnaire (OSW) to quantify function and were interviewed regarding medications and work status at initial and final visits. Results. Thirty-three patients completed an MPQ at initial and final visits. Pain decreased in 29 (88%) and increased in four (12%). Thirty-eight patients completed at OSW at initial and final visits. Function improved in 34 and worsened in four. The authors observed statistically significant improvements in pain, function, and medication use. Conclusion. Patients with low back pain or neck pain resulting from a motor vehicle accident showed a statistically significant improvement with treatment despite ongoing litigation. 171-0222
Development of the Hispanic Low Back Pain Symptom Check List Leavitt, F., Gilbert, N.S., and Mooney, V. 19(9): 1048-1053, 1994. Study Design. The Low Back Pain Symptom Check List identifies psychological disturbance in patients with low back pain. This report traces the development of a translation for Hispanic populations. Objective. The study explores the reliability and assesses the equivalence of the translation in providing pain and psychological information. Summary of Background Data. A number of psychometric measures appear suitable for routinely assessing psychological disturbance among back injured patients. Unfortunately, there are few measures with language translations that can be applied to Hispanic populations. Methods. In study 1, the English form was translated by two bilingual physicians. In study 2, reliability was examined using Cronbach's measure of internal consistency. In study 3,
the equivalence of the Hispanic and English forms in predicting treatment outcome was examined. Results. Coefficient alphas and mean pain scores were similar for the English and Hispanic forms. Overall agreement between the two forms in tracking psychological disturbance was 91%. The Hispanic form was equally accurate in predicting treatment outcome. Conclusions. The Hispanic form is reliable and provides pain and psychological information much like the English form. 171-0223
Group Education Interventions for People with Low Back Pain: An Overview of the Literature Cohen, J.E., Goel, V., Frank, J.W., et al. 19(11):1214-1222, 1994. Study Design. This study systematically reviewed the literature on group education for people with low back pain. Findings are considered in relation to parameters such as the characteristics of the study participants, the intervention, and the setting. Objective. To make a recommendation regarding the effectiveness of group education as an intervention for people with low back pain. Results. Based on a systematic search of the literature, 13 primary studies are cited; 6 of these were sufficiently well designed and executed for their findings to be considered. Of the four quality studies with chronic back pain subjects, only one found a positive short-term effect on one of the outcome measures considered (pain intensity). In the two studies with acute cases, group education was found by one of the studies to reduce pain duration and initial sick leave duration in the short term, but the intervention also included work-site visits. At 1 year of follow-up, there was no evidence in the six studies of clinically important benefits on any of the outcome measures. Conclusions. There is insufficient evidence to recommend group education for people with low back pain.
