Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates

The prevalence of Body Dysmorphic Disorder (BDD), based on structured and unstructured clinical interviews, was compared in two samples of psychiatric outpatients drawn from the same practice setting. In the first sample, 500 patients were diagnosed according to a routine, unstructured clinical interview. In the second sample, 500 subjects were diagnosed according to information obtained by the Structured Clinical Interview for DSM-IV (SCID). No patient was diagnosed with BDD in the clinical sample, whereas 16 (3.2%) patients were diagnosed with BDD in the SCID sample. Compared with patients without BDD, patients with BDD received significantly more current axis I diagnoses, and were more likely to be diagnosed with current obsessive-compulsive disorder (OCD) and social phobia. Both groups were diagnosed with major depression at similar rates. Patients with BDD, versus those without, tended to be sicker and more functionally impaired. It appears that BDD is an infrequent disorder in an outpatient setting, which is rarely recognized when clinicians conduct their routine diagnostic interview. Although it was not usually a patient's principal reason for seeking treatment, the majority of patients with BDD in this sample wanted their treatment to address these symptoms.

Prospective assessment of the ability of endoscopic ultrasound to diagnose, exclude, or establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography

BACKGROUND

Our aim was to verify endoscopic ultrasound (EUS) accuracy to diagnose, rule out, and establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Patients undergoing ERCP for unexplained abdominal pain and/or suspected chronic pancreatitis underwent EUS. EUS was performed by experienced operators who were aware of the history but blinded to ERCP results. Chronic pancreatitis was defined using the Cambridge classification: 0 to 1 = "normal," 2 to 4 = "all chronic pancreatitis," 3 to 4 = "moderate to severe chronic pancreatitis." The number of EUS criteria required to obtain sensitivity, specificity, positive and negative predictive values > or = 85% was determined. EUS criteria for chronic pancreatitis are hyperechoic foci, hyperechoic strands, lobularity, hyperechoic duct, irregular duct, visible side-branches, ductal dilation, calcification, and cysts.

RESULTS

One hundred twenty-six patients underwent EUS and ERCP. EUS was highly sensitive and specific (> 85%) depending on the number of criteria present. Chronic pancreatitis is likely (PPV > 85%) when more than two criteria (for "all chronic pancreatitis") and more than six criteria (for "moderate to severe chronic pancreatitis") are present. "Moderate to severe chronic pancreatitis" is unlikely (NPV > 85%) when fewer than three criteria are present. Independent predictors of chronic pancreatitis were "calcification" (p = 0.000001), history of alcohol abuse (p = 0.002), and the total number of EUS criteria (p = 0.008).

CONCLUSIONS

EUS can accurately diagnose, rule out, and establish the severity of chronic pancreatitis found by ERCP.

Oral manifestations in 100 Zimbabwean HIV/AIDS patients referred to a specialist centre

OBJECTIVE

To document the prevalence, age, sex ratio and clinical features of oral lesions associated with HIV/AIDS among patients referred to the two largest specialist centres in Zimbabwe.

DESIGN

Prospective study.

SETTING

University Hospital.

SUBJECTS

100 consecutive patients with oral manifestations of HIV/AIDS were interviewed and examined by Dental Surgeons and Physicians.

METHODS

Inspection and palpation of head and neck was done in all cases. Examination of the oral cavity and oropharynx with torchlight and wooden spatula was performed and lesions recorded according to WHO recording form for oral lesions possibly related to HIV infection.

RESULTS

The median age was 35 years (range 19 to 66 years). The male to female ratio was 4:1. General symptoms and signs found were: weight loss in 52, diarrhoea in 34, lymphadenopathy in 21 and Herpes zoster in 12 patients. Ninety two patients had oral lesions of some sort. These consisted of: oral ulcerations in 26, candidiasis in 22, osteomyelitis in three, necrotizing gingivitis in two and herpetic gingivostomatitis in one patient. Neoplasms recorded were: Kaposi's sarcoma in 72 patients, squamous cell carcinoma in two patients. Four other tumours not associated with HIV/AIDS were found. No hairy leukoplakia was found in this study.

CONCLUSIONS

The peak prevalence was in the age group 31 to 40 years with a male dominance of 4:1. The most frequent lesion was Kaposi's sarcoma, M:F ratio 3:1, followed by oral ulcers and candidiasis.

Erosive tooth wear: prevalence and severity in Swedish winetasters

Full-time Swedish winetasters test on average 20-50 different wines, nearly 5 days a week. As the pH of wines ranges from 3.0 to 3.6, there is a potential risk for tooth erosion. The aims of this study were to document the prevalence and severity of tooth erosion in qualified winetasters in relation to number of years of winetasting, salivary flow rate, and buffer capacity. The subjects comprised all 19 qualified winetasters (7 women and 12 men, aged 29-64 years employed in Stockholm by Vin & Sprit AB, the state-owned company marketing wines and spirits. At intraoral examination, tooth surface loss was registered and documented by photography. Salivary flow rate and buffer capacity of unstimulated and stimulated saliva were measured. Data on occupational background and dental and medical histories were collected. Fourteen subjects had tooth erosion, the severity varying from mild to extreme, mainly on the labio-cervical surfaces of maxillary incisors and canines. The severity of the erosion tended to increase with years of occupational exposure. Caries activity in all subjects was low. 14 subjects had low unstimulated salivary flow rates. It was concluded that full-time winetasting is an occupation associated with increased risk for tooth erosion.

Anatomic reconstruction of the posterolateral cranial base with titanium micromesh for combined transpetrosal approach: technical note

OBJECTIVE

We describe a new technique for the anatomic closure of the posterior petrosectomy defect after the combined supra-infratentorial transpetrosal approach for petroclival lesions.

METHODS

With this technique, a titanium micromesh, tailored according to the defect of the drilled petrous bone and contoured to the outer appearance of the posterolateral cranial base, is used to cover the petrosectomy area. The mesh is fixed to the cranium and to the repositioned bone flap with titanium microscrews.

RESULTS AND CONCLUSION

To date, this technique has proven to be simple and rapid and has been used in 10 patients who were operated on for various tumorous and vascular lesions of the petroclival region. Excellent cosmetic results were achieved, and no technique-related complications occurred.

Psychiatric screening in primary care: what do patients really want?

Psychiatric disorders are common in primary care, but underdiagnosed. U.S. physician reluctance to diagnose psychiatric illnesses is partly attributable to the belief that patients do not want their primary care physician to assess mental health. Six hundred one patients in a U.S. general internal medicine practice completed the SCREENER, a self-report questionnaire which screens for 15 psychiatric disorders, and another questionnaire about the SCREENER. Patients were predominantly female, unmarried, black, high school graduates. Only 3% thought that their physician should never evaluate their mental health. More than 60% desired periodic mental health screening, and one third wanted psychiatric assessment only when a problem was suspected. Attitudes toward questionnaire screening were less positive than toward physician interview. Patients were more likely to want screening if they were female, unmarried, young, had a history of mental health treatment, reported psychiatric symptoms, or were in fair-poor subjective physical or mental health.

Suicide screening in a primary care setting at a Veterans Affairs Medical Center

Seven-hundred and three patients from a general medical outpatient clinic at a Veterans Affairs hospital completed the SCREENER, a brief self-report questionnaire that screens for psychiatric disorders. The authors found that 7.3% of the patients had suicidal ideation. The younger and white patients were at increased risk. The risk was increased twelvefold in those patients with subjectively fair or poor mental health, sevenfold in the patients with a history of mental health treatment, and fourfold in the patients with fair or poor perceived physical health. When major depression was controlled for, anxiety and substance abuse disorders continued to show an association with suicidal ideation. The suicidal patients made more visits to their primary care physician. Screening patients for anxiety disorders and drug abuse, as well as depression, is a better approach for identifying suicidal ideation in primary care settings than screening for depression alone and may help prevent suicide and suicide attempts.

Change in trabecular architecture as measured by fractal dimension

The objective of this work was to expose dried trabecular bone material to a decalcifying environment and to quantify the change in the spatial distribution of the bone with a fractal measure. Digitized radiographic images were produced from four separate slices of human vertebral bone as they dissolved within a solution of nitric acid. Pixel data from a region of interest (ROI) within the trabecular bone were used to estimate the time-dependent change in fractal dimension of the ROI as the bone dissolved. Results demonstrated that a change in the spatial distribution of trabecular material may be expressed in terms of a concurrently changing estimate of the fractal dimension.

Schizophrenia and affective disorder--distinct entities or continuum?: an analysis based on a prospective 6-year follow-up

The purpose of this study was to determine whether the preponderance of data support a continuum hypothesis of the psychoses or a concept of separate, autonomous illnesses. Patients (N = 70) were hospitalized for nonmanic psychoses, given structured interviews and a dexamethasone suppression test (DST), and diagnosed according to the Research Diagnostic Criteria (RDC). Patients were then evaluated at 1 year and 6 years with a structured interview. Diagnoses were made at three points of time: intake, 1 year, and 6 years. The patients were divided into groups that had a consistent (over the three points) set of affective disorder diagnoses (affective disorder or schizoaffective disorder, mainly affective [AD group]) and those that had a consistent set of schizophrenic diagnoses (schizophrenic or schizoaffective disorder, mainly schizophrenic [S group]). A third group (inconsistently diagnosed) consisted of subjects who at one point were diagnosed in the AD group and at another in the S group. A series of discriminant function analyses suggested that the AD group differs widely from the S group; and the inconsistently diagnosed group most closely resembled the AD group. The family background of the inconsistent group was similar to that of the AD group. The DST and outcome showed that the inconsistent group was more like the AD group than the S group. Using the characteristics of the medical model-clinical picture, outcome, laboratory tests, and family history-the group that was inconsistent with regard to diagnosis over time appeared similar to the AD group. Taking the follow-up evaluation into account, the data favor the possibility that patients who have a variable clinical diagnosis over time do not suffer from schizophrenia.

Primary care patients' reactions to mental health screening

OBJECTIVE

The authors examined whether there is empirical support for the notion that medical patients are upset by being asked questions about psychiatric disorders.

METHOD

Six hundred and one patients attending a primary care clinic completed the SCREENER-a newly developed, brief self-administered questionnaire that surveys a broad range of psychopathology. In addition, they completed a second questionnaire that assessed their attitudes toward the SCREENER.

RESULTS

We found a high level of acceptance by patients. The questions were judged easy to answer, and they rarely aroused significant negative affect. Fewer than 2 percent of the patients judged the questions difficult to answer, and fewer than 3 percent were "very much" embarrassed, upset, annoyed, or uncomfortable with the questions. Individuals with a history of psychiatric treatment and poorer current mental health reacted more unfavorably to the questionnaire.

CONCLUSIONS

From the patient's perspective, it is feasible and acceptable to use self-administered questionnaires for routine screening of psychiatric problems in primary care settings.

Esophageal adenocarcinoma associated with Barrett's esophagus: long-term management with laser ablation

We report the use of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser ablation to treat high-grade dysplasia and intramucosal esophageal adenocarcinoma associated with Barrett's esophagus in a patient who refused surgery. Throughout laser therapy, the patient received omeprazole 40 mg/day. After 1 1/2 yr, five laser treatments totaling 22,055 J given over a period of 13 months achieved squamous reepithelialization and absence of malignant transformation in the first area in which carcinoma was diagnosed. Squamous reepithelialization was maintained 1 yr later, confirming recent reports that photoablation plus omeprazole can achieve regression of Barrett's esophagus. During the last year of follow-up, a second contiguous area discovered to contain carcinoma was treated three times by photoablation, with a total of 13,164 J; biopsy showed only low-grade dysplasia in this area after two laser treatments totaling 8,108 J. No complications were seen during or after any of the laser sessions, and the patient remained asymptomatic 2 1/2 yr after the first photoablation and 3 yr after presentation.

Interferon alfa-2b for chronic hepatitis C: effects of dose increment and duration of treatment on response rates. Results of the first multicentre Australian trial. Australia Hepatitis C Study Group

Two hundred and thirty patients with histologically proven chronic hepatitis C were randomized to receive one of the following treatment protocols: (a) 3 million units of interferon alfa-2b thrice weekly for 6 months, (b) 5 million units thrice weekly for 6 months, or (c) 3 million units thrice weekly for 2 years. The short-term response to treatment was defined by normal alanine aminotransferase for at least 3 months and until the end of treatment, and was confirmed by loss of hepatitis C viraemia in 42 (91%) of 46 cases as determined by reverse transcription-polymerase chain reaction. Short-term response to interferon alfa-2b was independent of the incremental dose, being 64% for 5 million units and 58% for 3 million units. Long-term response to interferon alfa-2b was defined by continued normality of alanine aminotransferase levels for at least 6 months after treatment withdrawal. The long-term response rates among responders treated for 6 months and those treated for 2 years were 29% and 54%, respectively (p < 0.001). Among all 18 patients tested, serum HCV-RNA was negative at both 6 and 12 months of follow-up in all long-term responders, and none have subsequently relapsed. Improvement in hepatic necroinflammatory changes was confirmed by quantitative histology (Scheuer score) in responders at the end of interferon alfa-2b treatment. The changes were significantly greater among those who had been treated for 2 years compared with those treated for 6 months (p < 0.05 and p < 0.02, respectively, for portal and lobular inflammation scores). Several pretreatment characteristics could be correlated with a favourable response to interferon alfa-2b. Thus, absence of cirrhosis was associated with a short-term response of 75%, while only 42% of patients with cirrhosis had a short-term response (p < 0.001). The frequency of short-term response to interferon alfa-2b also differed according to mode of disease acquisition, being best for injecting drug use (71%), less favourable for blood transfusion (56%) and worst for sporadic cases (43%) (p < 0.01). This observed difference, however, was not independent of histology on multivariate analysis. In summary, a 5 million unit dose of interferon alfa-2b failed to improve the short-term or long-term response to interferon alfa-2b treatment, but prolongation of interferon alfa-2b treatment to 2 years resulted in substantially improved long-term response rate.

Suicidal ideation among urban medical outpatients

The prevalence of current suicidal ideation among urban primary care outpatients was assessed, and suicidal and non-suicidal patients were compared with regard to their demographic characteristics and their attitudes toward mental health screening. Twenty (3.3%) patients reported having thoughts of killing themselves. The patients who had suicidal ideation were significantly younger and more frequently divorced. Almost all (97.6%) of the patients indicated that their physicians should inquire about emotional health issues at some time, and the suicidal patients were nonsignificantly more likely to recommend inquiry about psychiatric symptoms at every visit (55.0% vs 37.0%, p < 0.11). Only half of the suicidal patients reported lifetime histories of mental health treatment. The majority (70.2%) of the patients believed that it would be easy to discuss mental health problems with their medical physicians. Among the patients who had previously received psychiatric treatment, the suicidal patients were nearly three times more likely to anticipate that it would be difficult or very difficult to talk to their physicians about psychiatric problems. In contrast, among the patients who had no history of mental health treatment, there was no association between suicidal ideation and anticipated discomfort in talking with their physicians about emotional health.

Computerized measurements of the lower third molar related to chronologic age in young adults

Chronologic age is an utmost important birth record in many industrialized Western countries. When the date of birth is unknown, there is a demand for establishing the chronologic age. Dental methods for age estimations are considered more reliable than most other methods by the majority of researchers and are among the most commonly used means to determine age. Traditionally, these methods have most often been based on subjectively estimated, radiographic stages of tooth development. In the present study metric measurements of the length of the forming root have been used and are compared with one standard method. The formed part of the root of the lower third molar as seen in a panoramic radiograph was digitized. Data were directly stored in a computer for subsequent statistical analysis. The technique of collecting data with the aid of a computer had some statistical advantages. The precision of age estimations was, however, slightly inferior to the standard method.

Management of hemoptysis in a Third World city hospital: a retrospective study

BACKGROUND

Massive hemoptysis (defined as blood loss greater than 600 ml/24h) is said to have a fatal outcome in up to 85% of patients when managed only medically.

METHODS

A retrospective patient chart study was undertaken to analyse underlying pathology, management and outcome of hemoptysis patients in a hospital with no thoracic surgical, bronchoscopic or embolisation facilities.

RESULTS

63 patients were admitted for hemoptysis during a 2.5 year study period. Tuberculosis and sequelae of previous tuberculosis accounted for 65% of the cases. The patients with expectoration of more than 600 ml/24h had a shorter duration of hemoptysis (P = 0.033) and more often a history of tuberculosis (P = 0.023). The mortality rate was 6% (4/63 patients). Recurrent bleeding was not frequent (11%) and never severe enough for admission.

CONCLUSIONS

Hemoptysis in a Third World city hospital is mainly caused by infectious disease. Under the above-mentioned circumstances, in view of a low mortality and recurrence rate, conservative treatment of hemoptysis in in-patients seems justified.

Psychiatric screening in geriatric primary care: should it be for depression alone?

Depression in the elderly is highly prevalent, associated with functional disability and increased medical costs, and treatable; however, it is infrequently recognized and treated. The Agency for Health Care Policy and Research has advocated, therefore, increased case-finding efforts for depression in primary geriatric care. Anxiety, substance, and somatoform disorders in the elderly are similarly prevalent, associated with disability and cost, treatable, and also infrequently detected and treated. We believe that psychiatric case-finding in geriatric primary care should attend to these disorders, therefore, as well as to depression. In the present study, we examined whether the association between depressive and nondepressive forms of psychopathology was similar in geriatric and nongeriatric medical patients. We also examined the relationship between each type of pathology and health care utilization and global ratings of physical and mental health. In a VA hospital general medical outpatient clinic, 508 patients completed the SCREENER, which is a brief self-report questionnaire that screens for a range of psychiatric disorders, along with a self-report questionnaire regarding subjective health and medical care utilization. Of these patients, 98% were male, and the median age was 63 years. Patients aged 63 and over were compared to younger patients. In both geriatric and younger adult patients, we found substantial comorbidity between depressive and nondepressive forms of pathology. Moreover, in both age groups, there were significant associations between both depressive and nondepressive symptoms and fair-to-poor self-rated physical and mental health and increased medical care utilization. Approximately half of the cases of nondepressive disorders in the elderly were not comorbid with depression, and thus would not have been detected by screening for depression alone. Therefore, psychiatric case finding in primary care of geriatric males should be directed at anxiety, substance, and somatoform disorders, as well as at depression, for treatment resources to be triaged to maximally decrease morbidity and cost.

Increase in neuronal Jun immunoreactivity and epidermal NGF levels following UV exposure of rat skin

Effects of cutaneous ultraviolet (UV) irradiation on superficial nerve fibres are controversial. In the present study we demonstrate by electron microscopy that single high-dose UV exposure of rat skin results in membrane damage in peripheral nerves. Furthermore, a UV-induced accumulation of nerve growth factor (NGF) within the irradiated epidermis and a delayed increase in nuclear Jun immunoreactivity in dorsal root ganglion neurones were detected by immunohistochemistry. Our results suggest that UV-mediated alterations of axonal membranes leads to an activation of Jun transcription factor within affected neurones despite an increase in neurotrophic NGF within their innervation area.

Calcitonin gene-related peptide, substance P and nitric oxide are involved in cutaneous inflammation following ultraviolet irradiation

Evidence from our previous work suggests that neurogenic mediators contribute to the inflammation following ultraviolet (UV) irradiation of the skin. We have investigated whether calcitonin gene-related peptide (CGRP), substance P and nitric oxide (NO) participate in the cutaneous inflammatory reaction of the rat hind paw and ear to UV irradiation. Skin blood flow was measured by laser Doppler technique. Oedema was quantified using a spring loaded micrometer to measure ear thickness. UV irradiation of the rat skin lead to a long lasting increase in skin blood flow. This increase was dose dependently attenuated by the CGRP receptor antagonist CGRP-(8-37) (0.15 nmol in 25 microliters to 6.0 nmol in 25 microliters, s.c.) up to 51% with a maximum of effectiveness at 24 h post irradiation. The inhibitor of NO synthase NG-nitro-L-arginine methyl ester hydrochloride (L-NAME, 25 nmol in 25 microliters, s.c.) attenuated skin blood flow by 38%. Concurrent injections s.c. of CGRP-(8-37) (1.5 nmol in 12.5 microliters) and L-NAME (25 nmol in 12.5 microliters) demonstrated an augmentive effect in attenuating skin blood flow. The tachykinin NK1 receptor antagonist CP-96,345 (6.0 nmol in 25 microliters, s.c.) attenuated skin blood flow by 27%. NG-Nitro-D-arginine methyl ester hydrochloride (D-NAME) and CP-96.344 showed no effects on skin blood flow after UV irradiation. CGRP-(8-37) (0.6 nmol in 10 microliters) i.d. and L-NAME (10 nmol in 10 microliters) i.d. had no effect of oedema formation after UV irradiation. Furthermore, post UV irradiation enhanced CGRP- and NO synthase-immunoreactivity in nerve fibres in the exposed skin area were visible. Taken these findings together we suggest the involvement of the neuropeptides CGRP and substance P and of neuronal NO on the vasodilatory component of the UV-induced inflammatory reaction of the rat skin. CGRP contributing to UV-induced vasodilation acts in an endothelial NO-independent manner.

Utilization of dental services in refugees in Sweden 1975-1985

Prior to 1940 the population of Sweden was one of the most homogeneous in Europe, with only 0.5% foreign born. Fifty years later, in 1990, the proportion of immigrants was around 15%. In order to describe and analyze consumption of dental care in different refugee groups in Sweden, data registered by the Department of Immigration and the National Social Insurance Board, on a random sample of 2489 refugees arriving in Sweden 1975-85, were merged. Information on nationality, date of arrival in Sweden, date of granting of permanent resident status and statistics on consumption of dental care were retrieved. During the period studied a total of 50,521 refugees arrived in Sweden. The average interval between arrival in Sweden and the first dental visit was 4.5 yr (95% < 1: 4.2-4.7). The total treatment time during the first course of treatment was 165.5 min (95% < 1: 148.7-182.3). Consumption of dental care did not decrease with an increased number of treatments. Only 38% of the refugees had visited a dentist at all in Sweden. With increasing number of years in Sweden the number of courses of dental treatment increased, but 41% of the refugees who had visited the dentist in Sweden had done so only once. This study shows a low utilization of dental services among refugees in Sweden in general. Refugees with dental visits in Sweden, in particular, had a high dental consumption.

The Cognitive Bias Task and lateralized frontal lobe functions in males

The Cognitive Bias Task (CBT) is a multiple-choice response selection paradigm characterized by inherent ambiguity. All items offer a range from extremely context-dependent to extremely context-invariant responses. Lateralized prefrontal lesions produce extreme, and opposite, response biases on CBT in right-handed males. Healthy control subjects perform in the middle range. Findings suggest a dynamic balance between two synergistic decision-making systems in the frontal lobes: context-dependent in the left hemisphere and context-invariant in the right. The robust lateralized effects, which are dependent on task ambiguity, are sensitive and specific to frontal dysfunction. CBT is discussed in comparison with the Wisconsin Card Sorting Test as a potential cognitive activation task for functional neuroimaging of the frontal lobes.

Electrocardiographic changes associated with anaphylaxis in a patient with normal coronary arteries

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Killing of Giardia lamblia by cryptdins and cationic neutrophil peptides

Antimicrobial polypeptides such as the defensins kill a wide range of organisms, including bacteria, fungi, viruses, and tumor cells. Because of the recent finding that intestinal defensins, also known as cryptdins, are synthesized by the Paneth cells of the small intestinal crypts and released into the lumen, we asked whether defensins and other small cationic antimicrobial peptides could kill the trophozoites of Giardia lamblia, which colonize the small intestine. Four mouse cryptdins, two neutrophil defensins (HNP-1 [human] and NP-2 [rabbit]), and the unique tryptophan-rich bovine neutrophil polypeptide indolicidin each had some antigiardial activity against trophozoites in vitro. Cryptdins 2 and 3, indolicidin, and NP-2 each reduced viability by more than 3 log units in 2 h, and killing by all peptides was dose and time dependent. Exposure of trophozoites to peptides frequently resulted in cell aggregation and dramatic changes in morphology. The mechanism of binding and lysis appeared to involve charge interactions, since 150 mM NaCl as well as millimolar levels of Ca2+ and Mg2+ inhibited killing by most of the peptides. Our studies show that G. lamblia is sensitive to defensins and indolicidin and suggest that these small polypeptides could play a role in nonimmune host defenses.

Screening for depression in medical patients. Is the focus too narrow?

There is growing consensus that depression is a major public health problem causing significant psychosocial morbidity and mortality which should be addressed by case-finding effects in primary care settings. A large amount of literature has examined the ability of self-report questionnaires to detect depression in medical patients and the results have been encouraging. However, studies of general population and psychiatric patient samples indicate that depression is frequently comorbid with other psychiatric disorders, and that psychiatric disorders other than depression are also associated with significant morbidity and mortality. Consequently, we believe that psychiatric screening in primary care should be broad based. We administered a newly developed, multidimensional questionnaire (the SCREENER), that simultaneously screens for a range of DSM-III-R psychiatric disorders, to 508 medical outpatients attending a VA general medical clinic. Compared with nondepressed cases, the depressed patients significantly more often reported all of the nondepressive symptoms. Nine of the ten nondepressive disorders screened for by the SCREENER were significantly more frequent in the depressed group. Most patients who screened positive for depression also screened positive for at least one nondepressive disorder. Compared with patients who only screened positive for depression, those who screened positive for both depression and a nondepressive disorder rated their physical and emotional health more poorly and made more visits to the doctor. Compared with patients who did not screen positive for any disorder, those who only screened positive for a nondepressive disorder rated their physical and emotional health more poorly, and more frequently had a history of mental health treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review

OBJECTIVE

To develop a reliable measure of physician attitudes postulated to influence resource utilization.

DESIGN

Statements related to attitudes that may influence resource use were culled from the literature and informal discussions with physicians.

SETTING

Academic medical center.

PARTICIPANTS

All faculty and housestaff in internal medicine, pediatrics, family medicine, and surgery at an academic medical center were surveyed. The response rate was 59% (n = 428).

RESULTS

Exploratory factor analysis of all internal medicine surveys revealed four prominent domains. These closely corresponded with our a-priori hypothesized domains and were interpreted as cost-consciousness, discomfort with uncertainty, fear of malpractice, and annoyance with utilization review. A replication of the analysis using 25 survey items and conducted on the remainder of the data (surgeons, pediatricians, and family practitioners) revealed a similar four-factor solution. Scales were constructed for each of the four domains. Cronbach's alpha ranged from 0.66 to 0.88. Discomfort from uncertainty and fear of malpractice were moderately correlated (r = 0.42); other scale-scale correlations were modest. Of the four attitude measures, only cost-consciousness was associated with lower self-estimates of resource use. Both annoyance with utilization review and fear of malpractice increased as the proportion of time spent in patient care increased.

CONCLUSIONS

Although various physician attitudes and beliefs have been hypothesized to influence health services resource use, reliable and valid measures for most of these have not been developed. The authors developed a 19-item survey instrument designed to measure these attitudes reliably. The four scales developed in this study may help identify physician attitudes that are important determinants of physician decision making and help foster a better understanding of physicians' reactions and acculturation to different practice environments.

Health education and community empowerment: conceptualizing and measuring perceptions of individual, organizational, and community control

The prevailing emphasis in health education is on understanding and changing life-style choices and individual health behaviors related to health status. Although such approaches are appropriate for some health problems, they often ignore the association between increased morbidity and mortality and social, structural, and physical factors in the environment, such as inadequate housing, poor sanitation, unemployment, exposure to toxic chemicals, occupational stress, minority status, powerlessness or alienation, and the lack of supportive interpersonal relationships. A conceptual model of the stress process incorporates the relationships among these environmental factors, powerlessness (or conversely empowerment), social support, and health status. The concept of empowerment has been examined in diverse academic disciplines and professional fields. However, there is still a lack of clarity on the conceptualization of empowerment at different levels of practice, including its measurement, relationship to health, and application to health education. The purpose of this article is to address these issues as they relate to the concept of community empowerment. It provides a definition of community empowerment that includes individual, organizational, and community levels of analysis; describes how empowerment fits within a broader conceptual model of stress and its relationship to health status; and examines a series of scales that measure perceptions of individual, organizational, community, and multiple levels of control. The article concludes with broad guidelines for and barriers to a community empowerment approach for health education practice.

Screening for psychiatric disorders in medical patients: a feasibility and patient acceptance study

This study examines whether medical patients were bothered or upset by being asked to complete a questionnaire about emotional and substance use problems, and whether a newly developed, brief questionnaire that screens for several psychiatric disorders (the SCREENER) was easy for patients to complete. A consecutive series of outpatients attending the General Medical Clinic at the Philadelphia Veterans Affair Medical Center (VAMC) was approached to ask their participation in a research study requiring the completion of a brief questionnaire about their emotions, moods, thoughts, and behaviors, and a second questionnaire that asked their opinion about the first measure. Only 3.1% of the patients indicated that the questions were difficult to answer, whereas 84.6% found the questions easy or very easy to answer. Between 80% to 90% of the patients were not embarrassed, upset, annoyed, or uncomfortable by answering the questions. Individuals with a history of psychiatric treatment and poorer current mental health were the most likely to have a negative reaction to the questionnaire. Thus, the medical patients in this study reacted favorably to the completion of a broad-based questionnaire about emotional problems. The questions were judged easy to answer and rarely aroused significant negative affect.

Prevalence of fluorosis and other enamel defects related to caries among adults in communities with optimal and low water fluoride concentrations

The aim of this Swedish study, performed in 1982, was to determine the prevalence of fluorotic and nonfluorotic enamel defects among adults in areas with optimal and low fluoride concentrations in water. The fluorosis prevalence was also related to caries prevalence in these areas. The study was based on clinical examinations of subjects born between 1939-1951 who had been drinking water with a fluoride content representative of their area of residence all their lives. This water was the only appreciable source of fluoride during tooth formation. Two hundred and sixty individuals living in the optimal fluoride area were included in the study and 236 individuals from the low fluoride area. The results showed first, a low prevalence of mild dental fluorosis in the area with optimal fluoride content in its drinking water; secondly, a low prevalence of non-fluorotic enamel defects, which was, however, higher in the low fluoride area than in the optimal fluoride area; thirdly, that caries prevalence was lower among those with fluorotic enamel defects in the optimal fluoride area; and lastly, caries prevalence was not influenced by non-fluorotic enamel defects.

Diagnosing personality disorders. A review of issues and research methods

Many questions face researchers conducting personality disorder research. Which measure should be used? When should patients be evaluated--at initial presentation when they are still symptomatic, or after symptom resolution? Can a patient accurately describe his or her personality, or must an informant be contacted? What do you do when personality traits change during an individual's lifetime? I discuss these and other issues of personality disorder assessment in the DSM-III/DSM-III-R era, and examine the empiric literature bearing on these questions. First, I review studies of diagnostic reliability and stability, because studies of the above questions can only be interpreted in the context of the limitations imposed by modest reliability.

Attitudes and knowledge about preventive dental care in Chilean refugees in Sweden

The aim of this study was to evaluate the effects of a simplified oral health programme on attitudes to and knowledge of preventive dentistry. The subjects were Chilean refugees and the programme was delivered at one or two sessions in the form of group information/discussion. Because of increasing immigration, Sweden has become a multicultural society. The number of non-Nordic immigrants has doubled in the past decade. The major refugee groups have come from Iran, Chile and Poland. The subjects comprised 193 Chilean refugees: 106 in a single-visit group and 87 in a two-visit group. The oral health programme was completed by 94 and 65 subjects respectively and was evaluated after 6 months. Positive effects were discernible in attitudes to and knowledge of preventive dentistry, particularly with respect to oral hygiene. A key to success may have been group discussion in which the refugees could relate oral health problems to their own ethnic group. This could have an important function in bridging cultural, linguistic and situational barriers. Different forms of outreach programmes for oral health via groups, organisations or authorities in close contact with refugees shortly after arrival in Sweden are proposed. This approach may be particularly effective in a multicultural society and also in the context of the turbulent conditions the newly-arrived refugee experiences.

DSM-III and DSM-III-R: what are American psychiatrists using and why?

The purpose of this study was to determine whether American psychiatrists have switched from DSM-III to DSM-III-R as their primary diagnostic reference, and to examine what factors predicted the continued use of DSM-III. In 1989, we conducted a mail survey of practicing psychiatrists (N = 454), residency program directors (N = 128), residents (N = 1,331), and researchers (N = 196) regarding their training in, use of, and opinions about DSM-III and DSM-III-R. Approximately 30% of practitioners continued to use DSM-III as their primary diagnostic reference, although this was less frequently true of researchers and residents. In none of the four groups did a majority believe that DSM-III-R was needed, despite the fact that the majority of each group indicated that it was an improvement over DSM-III. The most commonly perceived reasons for publishing DSM-III-R were that it corrected problems with DSM-III and new research indicated changes were warranted. Compared with DSM-III-R users, DSM-III users more frequently believed that the 7-year interval between the two editions was too short, that DSM-III-R was not needed, and that the revised manual was little better than the original. Thus, 2 years after the publication of DSM-III-R 90% of psychiatrists were using DSM-III-R, at least in part, although a substantial minority continued to use DSM-III as their primary diagnostic manual. Even among DSM-III-R users, many believed that the revised manual was not needed. The perceived need for DSM-III-R was associated with the reasons ascribed to its publication; therefore, acceptance of DSM-IV may be partially a function of how its development is promoted and justified. That nearly one third of a random sample of practicing psychiatrists continued to use DSM-III supports concerns that the publication of DSM manuals every 6 or 7 years will divide the psychiatric community into subgroups using different diagnostic criteria.

A five-minute psychiatric screening interview

Recent studies indicate that as many as 30% of primary care patients have some type of psychiatric disorder. Although common, these disorders are often neither detected nor treated by primary care physicians. A brief interview is described that can be used as an effective screening tool to identify patients who require further evaluation.

Simplified preventive dentistry program for Chilean refugees: effectiveness of one versus two instructional sessions

A simplified dental health program for newly arrived refugees was evaluated. The efficacy of presenting the program in one instructional session or two was compared. 193 Chilean refugees, granted residency in Stockholm in Spring 1981 or in Spring 1982, participated. The subjects were divided into two groups. One group received a dental health program only at the first visit, in conjunction with the baseline examination, and the other group was recalled for a further session 3 months after the baseline examination. Both groups were recalled for evaluation 6 months after the initial visit. At follow-up the groups comprised 94 and 65 subjects respectively. The mean relative reductions in gingivitis (relating GBI reduction to baseline GBI) were 33.2% (95% < I: 29.1 to 37.3%) in the single-visit group and 40.5% (95% < I: 35.9 to 45.8%) in the two-visit group. The reduction in periodontal pocket depth was mainly a reduction of shallow pockets. The maximum effect was attained after one instructional session.

A method to detect intercenter differences in the application of contemporary diagnostic criteria

The use of specified diagnostic criteria is part of routine psychiatric practice and research. However, there is evidence that the same criteria may be interpreted and applied differently at different research centers. The next question is whether it is possible to detect these systematic intercenter differences in diagnostic practices. An inexpensive, nonlaborious, standardized method is needed that can easily be used at any site. In the present report, we demonstrate how self-report questionnaires can provide a method of detecting systematic differences in the application of contemporary diagnostic criteria. Sixty consecutively admitted inpatients with nonpsychotic major depressive disorder were interviewed with standardized schedules and diagnosed according to two interpretations of the Research Diagnostic Criteria (RDC) and DSM-III endogenous/melancholia criteria. The patients also completed the Inventory to Diagnose Depression, a self-report scale designed to diagnose major depression and subtype patients according to RDC and DSM-III endogenous/melancholia criteria. The interview to self-report ratio for diagnosing endogenous depression and melancholia was associated with diagnosticians' interpretation of the criteria. A broader application of the criteria resulted in a higher ratio. A paper-and-pencil questionnaire could be useful in detecting systematic interinvestigator differences in the broadness or narrowness with which criteria are applied. The advantage of a self-report scale is that it is free from systematic biases and tendencies of clinician raters. Of course, ratings on questionnaires are not free of bias; however, it is less likely that differences between samples will reflect a systematic variation in response set.

Caries prevalence among adults in communities with optimal and low water fluoride concentrations

The aim of this study was to compare the dental health status of adults measured as caries prevalence in two socioeconomically similar communities with optimal and low water fluoride concentrations respectively. Other topical fluoride sources are also taken into consideration. The study is based on clinical and radiological examinations of 30-40-yr-old subjects who for all their lives have been drinking water with a fluoride concentration representative for the community. 260 individuals resident in the optimal fluoride area and 236 from the low fluoride are included in the study. The results show that caries prevalence was lower in the optimal fluoride area. Caries prevalence was higher in women than in men within both groups. The prevalence of primary caries was low but significantly higher in the low fluoride area, principally in the form of proximal caries. Caries prevalence was not influenced by other topical fluoride sources.

Consumers' attitudes toward DSM-III and DSM-III-R: a 1989 survey of psychiatric educators, researchers, practitioners, and senior residents

To understand how DSM-III and DSM-III-R are used and perceived by educators, researchers, practitioners, and trainees, in the spring of 1989 we surveyed all US psychiatric residency training directors (N = 197), 337 active psychiatrist researchers, a nationwide random sample of 952 practicing psychiatrists, and all PGY-3 and -4 residents. We describe the factors influencing the use of DSM-III and DSM-III-R and the perceptions of strengths and weaknesses of the DSMs from various perspectives (training, research, and practice). A modest increase in the acceptance of the DSM system was noted in comparing the results from the current survey and a similar 1984 survey about DSM-III. The implications of these findings for the development of DSM-IV are discussed.

The mushroom message

A basic law of ecology is that living things are tightly dependent on one another, often in ways that are not easy to imagine. Who, for example, would have predicted that when the last dodo was killed in 1675, that death would lead to the slow extermination of the tambalocoque tree, whose fruits germinate only after passing through the dodo's digestive system? Now no natural strands of tambalocoque younger than 300 years can be found. Or who would have predicted that clear-cutting tropical rainforests would so significantly alter local weather patterns that the tropical rainforest biome itself and its vast diversity of life might not survive? Such interactions are worth noting because of the possible ramifications of a phenomenon that ecologists have just begun to document. Mushrooms worldwide appear to be in a catastrophic state of decline. Throughout Europe, in countries with terrains as diverse as Holland, Germany, Austria, Czechoslovakia, Poland and England, wild mushrooms are becoming increasingly difficult to find. Those fungi that are found are significantly smaller than those found years ago. Preliminary data suggest that the same troubling situation is occurring throughout North American as well. The decline has been so precipitous that biologists have begun to refer to it as a mass extinction. The 2 obvious explanations for the demise of the mushrooms--habitat destruction and overpicking of edible types by an ever growing human population--have been ruled out. Sophisticated sampling schemes designed by ecologists control for the fact that there is less land available for wild mushrooms; they have been declining at a rate that far exceeds the rate at which land is being developed. The fact that the decline has affected both edible and inedible mushrooms equally indicates that humans hunting for tasty treats are not the main cause of the problem. The loss of wild mushrooms worldwide might not seem like that big a deal, but the consequences may well be grave because of the way those fungi interact with other life forms. If the mushrooms die off, ecologists fear that our forests may not be far behind. Many mushrooms live in close association with trees; the mushrooms provide the trees with water and minerals while the trees supply the mushrooms with carbohydrates. The mushrooms' underground filaments often extend much deeper into the soil than do the roots of trees, thus making available to trees resources that would otherwise be unusable. Ecologists have found that trees lacking mushrooms are significantly more susceptible to environmental stress than those growing with the fungi. Eef Arnolds, an ecologist specializing in mushrooms at the Agricultural University of the Netherlands thinks that "severe frost or drought could lead to a mass dying of trees." Although the cause of the decline has not be pinpointed, most experts believe that the mushrooms are responding to abnormal atmospheric levels of nitrogen, sulfur, and ozone. Dr. Arnolds suggests that in Holland the main culprit appears to be excessive nitrogen applied as fertilizer to agricultural fields. Once again it appears that we are seeing the unpredicted effects of our wanton pollution of our environment. If the experts are correct about the cause of the decrease in mushroom populations, the mushrooms can provide us with some very critical information and insight like the canaries that miners used to bring into mine shafts to warn of a lack of breathable air, these small indicator species are warning us about the state of our planet. We can only hope that collectively we have enough sense to begin to pay attention.

Health-related quality of life among patients undergoing percutaneous transluminal coronary angioplasty

A randomized clinical trial was recently conducted to investigate whether a new antiplatelet agent could prevent restenosis in patients who had undergone percutaneous transluminal coronary artery angioplasty (PTCA). Approximately 1,200 patients were enrolled at 13 separate clinical sites. To assess the impact of this intervention on health-related quality of life, a patient questionnaire for telephone administration was developed. This questionnaire focused attention on several specific dimensions likely to be important in this patient population: physical well-being, perceived health, emotional well-being, home management, work, recreation, and social and sexual functioning. This paper describes the instrument that was used in this trial and reports on its psychometric [corrected] properties based on completed interviews with approximately 500 patients at study entry and 1 month after PTCA.

Cathepsin B and L activities in isolated osteoclasts

Cathepsin B and L activities were examined with chicken osteoclasts isolated by sequential filtration and inhibitors were added to disaggregated rat osteoclasts on cortical bovine bone. Z-Phe-Phe-CHN2, a selective inhibitor of cathepsin L, at 1, 5, and 10 microM, inhibited bone resorption by rat osteoclasts 50, 85, and 100 per cent and, in chicken osteoclasts, cathepsin L activity was comparably inhibited. Cathepsin L in avian osteoclasts was also 25-fold higher than cathepsin B. Chicken osteoclasts treated with Z-Phe-Ala-CHN2, a generalized cysteine proteinase inhibitor, had both cathepsins inhibited to the same extent. Cathepsin L may play a key role in resorption.

Major depression and personality disorder

The authors examined an interview and paper-and-pencil assessment of the DSM-III personality disorders (PDs) in depressed inpatients, and depressed relatives of psychiatric patients and never-ill controls who had a lifetime history of major depression. The rates of PDs according to the Structured Interview for DSM-III Personality Disorders (SIDP) were similar in the two groups, except for borderline PD which was more frequent in the inpatients. Of the individuals with a PD, the patients were more likely than the relatives to have two or more PDs, and the borderline and histrionic patients were more prototypic of these disorders than were the borderline and histrionic relatives. In contrast to the SIDP results, the rates of PDs according to the Personality Disorders Questionnaire (PDQ) were higher in the patient sample. These results thus extend the previously described high rates of PDs in depressed patients to a sample of individuals with a lifetime history of treated or untreated depression, and they suggest that interview assessments of personality may be less sensitive to the state effects of depression than are questionnaires.

Fluoride sources and dental attendance habits among adults in communities with optimal and low water fluoride concentrations

The aim of this study was to obtain data on local fluoride supply, dental attendance, and dental care habits in two sociologically similar municipalities with optimal, 1.0 ppm, and low, 0.3 ppm, water fluoride concentrations, respectively. The participants in the study were 30- to 40-year-old lifetime residents in the two municipalities: 569 individuals from the 1-ppm fluoride community and 466 from the low-fluoride community. There were no intergroup differences in the fluoride mouthrinse utilization rate of 1%. Fluoride toothpaste was much more common in the low-fluoride area. In the 1-ppm fluoride area more people drank tea, and they went more regularly to the dentist. It is suggested that dental attendance habits and various fluoride sources should be taken into account in studies evaluating the effect of fluoride in drinking water.

DSM-IV: a nosology sold before its time?

OBJECTIVE

The purpose of this study was to determine whether American psychiatrists believe that DSM-IV is being published too soon after DSM-III-R.

METHOD

The authors conducted a mail survey of the attitudes of practicing psychiatrists (N = 454), residency program directors (N = 128), residents (N = 1,331), and researchers (N = 196) toward the scheduled publication of DSM-IV in the early 1990s.

RESULTS

They found that the majority of all four groups believed that DSM-IV is being published prematurely. In contrast to respondents who believed that the timing of DSM-IV is appropriate, those who indicated that it is being published too soon had more recently completed their residency training and also believed that DSM-III-R was published prematurely. There was no association between the psychiatrists' responses and their theoretical orientation, Board certification status, ownership of the DSM manuals, the length of time they had used DSM-III, and the diagnostic manual (DSM-III or DSM-III-R) they were currently using.

CONCLUSIONS

The belief that DSM-IV is being published too soon could contribute to underuse of DSM-IV by substantial numbers of psychiatrists. Thus, to foster compliance with it, APA must preserve in its efforts to demonstrate that the advantages of publishing it in 1993 outweigh the disadvantages of adopting yet another manual.