Psychological impact of predicting individuals' risks of illness: a systematic review

The aim of this review is to determine the frequency and circumstances under which predicting individuals' risk of illness has adverse psychological effects. Using systematic review methodology, the literature was searched for studies that had assessed the adverse psychological outcomes of risk assessment programmes. The outcomes investigated are emotional (anxiety, depression, distress) cognitive (intrusive thoughts, perceptions of health) and behaviour (work absenteeism). The impact of both positive and negative test results are summarised in terms of the number of studies showing significant effects between and within groups in the short (one month or less) and longer term (more than one month). Where sufficient data were available, a meta-analysis was conducted to assess effect size. Fifty-four studies met the criteria for inclusion. The studies assessed the impact of informing individuals about cardiovascular risk (21), risk of AIDS (eight), risk of cancer (10), risk of Huntington's disease (10), risk of diabetes (two), risk of spinocerebellar ataxia (one) and risk of osteoporosis (two). Overall, the quality of studies assessed was limited, with only two using a randomised design to determine the psychological impact of risk assessment. Receiving a positive test result was associated in the short term in the great majority of studies with depression, anxiety, poorer perceptions of health and psychological distress. Data were available for a quantitative synthesis of results on three outcomes, anxiety, depression and distress. Anxiety and depression were significantly higher in those tested positive compared with those tested negative in the short term but not the longer term. Distress could only be assessed in the longer term: there was no evidence of an increase for those receiving positive test results. The five experimental studies that reported interventions aimed at preventing some of these adverse effects all reported favourable results. There was little evidence of any adverse psychological effects of receiving an unfavourable test result. Adverse psychological effects are a common immediate consequence of positive test results following risk assessment. Results from the few experimental studies reviewed suggest that these adverse outcomes should not be seen as inevitable.     

Spindle cell carcinoma of the breast,a mimicker of benign lesions: case report and review of the literature

The clinical and pathologic features of a breast tumor with unusual morphology in a 69-year-old woman are presented. Spindle cell carcinoma is considered one of the variants of metaplastic carcinoma and is commonly described in the upper aerodigestive tract, but it is relatively rare in the breast. This case is uniquely different from the usual cases of spindle cell carcinoma because of the lack of squamous differentiation or a recognizable infiltrating ductal component at the light microscopic level. With immunohistochemical stains using keratin and actin, a rather prominent network of infiltrating compressed ductal structures became apparent. These immunohistochemical features are consistent with the current concept of myoepithelial origin for metaplastic carcinomas. Although mention has been made in the literature of cases in which this "bland" carcinoma could be confused with benign nonneoplastic conditions, few illustrated examples exist. The prognosis for this particular subgroup of metaplastic carcinoma may be somewhat better than that for ordinary ductal carcinoma. For prognostic purposes, this entity should be distinguished from other metaplastic carcinomas and sarcomas, but more importantly, it should be differentiated from lesions such as nodular fasciitis, reactive granulation tissue, and fibromatosis, with which it may be confused histologically.     

Hand Infections: Treatment Recommendations for Specific Types

Hand infections can be associated with considerable morbidity. Expeditious treatment is needed to minimize permanent dysfunction, loss of work, and medical cost. Hand infections can affect the skin, subcutaneous tissues, fascia, subfascial and synovial spaces, joints, and bone. Pathogens include a variety of bacteria, viruses, yeasts, fungi, and mycoplasmata. Management frequently involves rest, elevation, incision and drainage, and appropriate antibiotic therapy. The orthopaedic surgeon must be knowledgeable about the pertinent anatomy and how this influences the behavior of specific types of infections, the role of immunocompromise, and the importance of early mobilization.     

Harvard community health plan's mental health redesign project: A managerial and clinical partnership

Harvard Community Health Plan, founded in 1969 as a staff model HMO, is currently a staff and group model HMO with 521,000 members, 19 health centers and 12 independently owned group practices with 26 locations. In 1987, the Plan initiated a review of its mental health benefit and program because its costs were rising, member and clinician dissatisfaction was increasing and many believed the problem was the nature and scope of the benefit. After two years of study, surveys, interviews, cost and utilization analysis, the Plan identified its professional staff as its key asset but recognized many problem areas, including problems with access, variation from site to site, inconsistent service delivery, lack of consistent utilization management and the need for greater diversity along the spectrum of care available to members. From 1989 to 1990, more than 200 clinicians and support staff were engaged in the process of developing a variety of components to the mental health redesign program. Three simultaneous efforts included developing a method of categorizing patients, restructuring the delivery system and redesigning the benefit. A Mental Health Patient Assessment Tool was created which assists clinicians in performing comprehensive evaluations, administers the benefit, measures progress and supports outcomes research. Delivery system changes included the implementation of self-referral, access standards, intake triage functions by non-clinical staff, program development and an outpatient utilization management function.     

Bone mineralization outcomes in human milk-fed preterm infants.

We evaluated bone mineralization by single photon absorptiometry at 2 y in a cohort of preterm infants studied since birth. Infants were fed human milk fortified with Ca [to achieve 80 mg/dL (19.96 mmol/L)] and P [40 mg/dL (12.91 mmol/L)] from wk 2 through 8 after birth. After hospital discharge, infants were divided into two groups (HM and F) determined by the timing of the introduction of cow milk-based formula. Mid-radius bone mineral content (BMC) was assessed in 10 infants who were breast-fed (HM) for a minimum of 2 mo after hospital discharge and 11 who were bottle-fed (F). The mean duration of human milk-feeding differed by design between HM and F groups (31 +/- 15 versus 11 +/- 3 wk, respectively). Although we had observed previously that group F had significantly greater BMC values at 16, 25, and 52 wk compared with values in group HM, we found similarities in BMC values (180 +/- 30 mg/cm) between groups at 2 y. The 2-y cohort comprised healthy infants and the groups had similar birth weights, lengths of gestation, and values for weight (10.8 +/- 1.1 kg), length (82 +/- 2 cm), and bone width (7.8 +/- 1.1 mm). Follow-up outcomes at 2 y in preterm infants fed fortified human milk in hospital suggest that if they continue to receive human milk after hospital discharge, radius BMC will "catch-up" to that of similar infants given formula in the posthospitalization period.     

Liver function values in adults receiving total parenteral nutrition.

A retrospective review was made of results of conventional liver function tests in adult patients who received fat-free total parenteral nutrition (TPN) for two weeks or longer and who did not have other obvious causes for liver function abnormalities. A "meaningful" increase (greater than or equal 50% increase above baseline pre-TPN value) in SGOT levels was noted in 68% of patients, in alkaline phosphatase levels in 54%, and in serum bilirubin levels in 21% of patients. The median peak values for SGOT, alkaline phosphatase, and bilirubin were 3-, 1.9-, and 0.25-fold above the upper limit of normal, respectively. The median time interval of peak increase for each of the three tests was between 9 and 12 days after TPN was started. Liver biopsy specimens from four patients, taken when liver function values were abnormal, showed pronounced steatosis in three patients and mild periportal cholestasis in the fourth patient. The cause(s) of the elevated liver values is unknown, but possibilities include cellular damage, such as steatosis, and an "overshoot" of enzymes when starved patients are refed.     

The effects of antioxidants on the content of polyunsaturated fatty acids in the hen's egg.

In experiments to see whether, in the possible interests of human health, the polyunsaturated fatty acid (PUFA) content of the chicken's egg can be increased by nutritional means, three strains of hen, light, medium, and heavy, each at the peak of lay, were first fed a basal, commercial, low-fat diet. The hens were then transferred to one of the following diets: basal + safflower oil (SO); basal + SO + butylated hydroxytoluene; or basal + SO + dl-a-toco-pheryl acetate. The diets were designated "Blank", "BHT", and "Vitamin E", respectively, the second and third containing the added antioxidants. The eggs produced were weighed, and their yolks weighed and analysed for lipid components. Additional of SO (7.5%) to the basal diet led to the PUFA content of the yolk lipids rising by 15.4% (linoleic acid, 14.1%), the magnitude of the increases being unaffected by the antioxidants. Diet "BHT" produced larger eggs and yolks than the other diets, but the proportion of yolk was the same on the three types of feed. The total cholesterol content of egg yolks was significantly affected neither by diet, nor by strain or age of hen. The implications of these results are discussed.