Sam Shapiro

Utilization of health and mental health services by non-institutionalized persons aged 18 years and older is examined based on interviews with probability samples of 3,000 to 3,500 persons in each of three sites of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program: New Haven, Conn, Baltimore, and St Louis. In all three ECAs, 6% to 7% of the adults made a visit during the prior six months for mental health reasons; proportions were considerably higher among persons with recent DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) or severe cognitive impairment. Between 24% and 38% of all ambulatory visits by persons with DIS disorders were to mental health specialists. In seeking mental health services, men were more likely to turn to the specialty sector than to the generalist; women used both sectors about equally. The aged infrequently received care from mental health specialists. Visits for mental health reasons varied considerably depending on specific types of DIS disorder.

BACKGROUND: Over the past 30 years, eight major randomized controlled trials of breast cancer screening--with mammography and/or clinical breast examination--have been conducted. Results from several trials have been updated during the past year, and initial results of three other trials have been reported. PURPOSE: The National Cancer Institute held an International Workshop on Screening for Breast Cancer in February 1993 to conduct a thorough and objective critical review of the world's most recent clinical trial data on breast cancer screening, consider the new evidence, assess the current state of knowledge, and identify issues needing further research. METHODS: Investigators representing the eight randomized controlled trials of breast cancer screening in women aged 40-74 presented published and unpublished data. Evidence relating to the effectiveness of breast cancer screening in different age groups, especially women aged 40-49, was presented. RESULTS: For women aged 40-49, randomized controlled trials consistently demonstrated no benefit from screening in the first 5-7 years after study entry. A meta-analysis of six trials found a relative risk of 1.08 (95% confidence interval = 0.85-1.39) after 7 years' follow-up. After 10-12 years of follow-up, none of four trials have found a statistically significant benefit in mortality; a combined analysis of Swedish studies showed a statistically insignificant 13% decrease in mortality at 12 years. Only one trial (Health Insurance Plan) has data beyond 12 years of follow-up, and results show a 25% decrease in mortality at 10-18 years. Statistical significance of this result is disputed, however. In women aged 50-69, all studies show mortality reductions; three of four studies show reductions of about 30% at 10-12 years after study entry. Results from two of these trials were statistically significant. Too few women over age 70 have been included in studies for adequate analysis. CONCLUSIONS: For women aged 40-49, randomized controlled trials of breast cancer screening show no benefit 5-7 years after entry. At 10-12 years, benefit is uncertain and, if present, marginal; thereafter, it is unknown. For women aged 50-69, screening reduces breast cancer mortality by about a third. Currently available data for women age 70 or older are inadequate to judge the effectiveness of screening. IMPLICATIONS: Randomized trials have provided stronger scientific evidence regarding the effectiveness of screening for breast cancer than for any other cancer. However, much still needs to be learned. Periodic gatherings of scientists in the field should speed the process.

To assess the role of ventricular premature beats in influencing mortality of coronary patients, 1739 men with prior myocardial infarction were monitored for ectopic activity for one hour at a standard base-line examination, and followed for mortality for periods up to four years (average, 24.4 months). Analyses of survival taking into account other important prognostic variables establish that the presence of complex premature beats (R on T, runs of 2 or more, multiform or bigeminal premature beats) in the monitoring hour is associated with a risk of sudden coronary death three times that of the men free of complex ventricular premature beats. The corresponding risk of death from any cause is twice that of men without such complex beats in the hour. These arrhythmias make an independent contribution to increased risk of death that persists over the length of this observation period.

Given the wide usage and proven value of the Abbreviated Injury Scale (AIS) in rating severity of trauma, it is essential that certain reliability issues concerning its application be resolved. This article describes a study designed to address these reliability issues. Each of 15 raters with varying qualifications was asked to identify AIS code injuries sustained by 375 trauma patients admitted to four Baltimore area hospitals. Results showed that as a group, physicians and nurses tend to be more reliable in their ratings than either emergency medical technicians (EMTs) or nonclinical technicians, although a research assistant who is well trained in AIS coding and is a diligent worker can use the AIS to code severity as reliably as the physicians when sufficient information is provided in the medical chart. Reliability of AIS scoring was somewhat higher for blunt (vehicular and nonvehicular) versus penetrating injuries.

Results in the breast cancer screening project of the Health Insurance Plan of Greater New York that started the end of 1963 have been updated through December 31, 1975. The HIP study is a randomized trial designed to test whether periodic screening with clinical examination and mammography results in reduced breast cancer mortality among women aged 40–64 years at the start. Study women were offered screening examinations; 65% appeared for initial examinations and a large majority of these women had at least one of the three additional screenings at annual intervals. The control group of women continued to receive their usual medical care. New data support earlier reported results on benefits. During the nine years following date of entry there were 128 breast cancer deaths in the control group as compared with 91 in the study group (screenees plus refusers). The impact of the screening program continues to be confined to women 50 years of age and over with no benefit at ages 40–49 years. Seven-year case fatality rates show similar relationships. Several issues related to screening benefit are considered. Of major importance is the observation of no reduction among women under 50 in breast cancer mortality. The possibility that under different screening conditions (e.g., with current mammography equipment) a benefit would be found needs to be investigated. There is a clear need for rapidly determining whether a new randomized trial is the only way to answer the question and whether experience in the 27 NCI-ACS demonstration projects can provide useful data. Another critical issue concerns the incremental value of mammography in a screening program. Over an eight-year period after diagnosis, breast cancer cases that were positive only on mammography when screened had a case fatality rate of 14%; this compares with 32% for cases positive only in the clinical examination and 41% for cases positive on both modalities. Excluding mammography would have reduced the benefit of screening by an estimated one-third. With regard to risk associated with screening, it is concluded that the increment in risk resulting from radiation exposure in mammography does not offset the benefits of screening above 50 years of age. Below that age, although the risk increment is small, the risk-benefit balance is negative because of the absence of a demonstrated benefit. Another source of risk is related to the possible increase in biopsies. Assessment of the HIP experience suggests that only timing of biopsies was affected, but the potential for considerable variation if screening is adopted widely exists. Based on current findings in the HIP study, there appears to be strong support for periodic screening at ages 50 years and over with clinical examination and mammography; to justify screening under 50, new information from other studies is required.