The utility of the CES-D as a depression screening measure among low-income women attending primary care clinics. The Center for Epidemiologic Studies-Depression.

OBJECTIVE: Depressive disorders are among the most common medical disorders seen in primary care practice. The Center for Epidemiologic Studies-Depression (CES-D) scale is one of the measures commonly suggested for detecting depression in these clinics. However, to our knowledge, there have been no previous studies examining the validity of the CES-D among low-income women attending primary care clinics. METHOD: Low-income women attending public primary care clinics (n = 179, ages 20-77) completed the CES-D and the Diagnostic Interview Schedule for the DSM-IV (DIS-IV). RESULTS: The results supported the validity of the CES-D. The standard cut-score of 16 and above yielded a sensitivity of .95 and specificity of .70 in predicting Major Depressive Disorder (MDD). However, over two-thirds of those who screened positive did not meet criteria for MDD (positive predictive value = .28). The standard cut-score appears valid, but inefficient for depression screening in this population. An elevated cut-score of 34 yielded a higher specificity (.95) and over 50 percent of the patients who screened positive had a MDD (positive predictive value = .53), but at great cost to sensitivity (.45). CONCLUSION: Results indicated that the CES-D appears to be as valid for low-income, minority women as for any other demographic group examined in the literature. Despite similar validity, the CES-D appears to be inadequate for routine screening in this population. The positive predictive value remains very low no matter which cut-scores are used. The costs of the false positive rates could be prohibitive, especially in similar public primary care settings.

Maximizing medication adherence in low-income hypertensives: a pilot study.

A pilot study was conducted to examine the association between free medication and comprehensive care on blood pressure control for 60 adults with uncontrolled essential hypertension (mean blood pressure = 157/96 mm Hg) referred from a variety of primary care clinics at a public teaching hospital. Subjects received comprehensive care, free antihypertensive medication dispensed in the clinic, and patient education regarding hypertension and medication compliance. Matched-pair t-tests revealed average drops in blood pressure of 22 mm Hg systolic and 13 mm Hg diastolic for the entire sample from baseline to 6 months post-enrollment (both P's < .001). The comprehensive hypertension management program with education and free medication was significantly related to reduced blood pressure across the 6 months of the study period.

Minor stressors and generalized anxiety disorder among low-income patients attending primary care clinics.

The total number of minor life events and subjective ratings of distress associated with these events were assessed for individuals with generalized anxiety disorder (GAD) and for nonanxious controls. Participants consisted of 256 randomly selected, low-income patients from primary care medical clinics. Diagnoses were obtained using the Diagnostic Interview Schedule for the DSM-IV (DIS-IV). An analysis of variance revealed that GAD individuals reported significantly more minor life events than did nonanxious controls (F = 50.97, p < .001). An analysis of covariance indicated that persons with GAD perceived their minor stressors as significantly more stressful than did nonanxious controls, even after the total number of events was controlled (F = 42.07, p < .001). These findings are consistent with cognitive theories of GAD and current revisions to the definition of the disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Implications for theory and research on GAD are discussed.

Complications of laparoscopic urological surgery: experience at St. Louis University.

A total of 221 patients underwent laparoscopic surgery at our institution. An outcome analysis with regard to type of procedure, success and complications was done. Overall, 216 of 221 procedures (97.7%) were performed as originally planned. One operation was converted to an open procedure. Complications producing morbidity occurred in 33 of 217 patients (15.2%). There was no associated mortality. Most complications occurred early in the participating surgeons experience. Of the complications 11 (5.0%) were considered major and included formation of symptomatic lymphoceles (4 patients), vascular injury (1), ureteral transection (1), bladder perforation (1), bowel obstruction (1), cecal perforation (1) and cerebrovascular accident (1). One patient had an idiopathic reaction to the inhalation anesthetic. Of the 11 major complications 9 occurred among 98 patients undergoing pelvic lymphadenectomy and 7 of these occurred among a subset of 15 patients undergoing an extended dissection. Adjuvant surgical intervention was necessary in 13 patients: celiotomy in 5, laparoscopic techniques in 4 and minor surgical procedures or percutaneous techniques in 4. Our experience suggests that urological laparoscopic surgery is safe and offers a shorter convalescence. However, the technique must be regarded as major surgery, associated with a steep learning curve.

Laparoscopic internal spermatic vein ligation: report of a new technique.

Over the past 22 months, 51 laparoscopic internal vein ligations have been performed to determine its application and practicality in treating the infertile male with varicoceles. Of the 33 cases available for a follow-up of greater than 6 months, 16 pregnancies are reported. Five patients reporting pregnancies refused to submit a postoperative semenogram. Of the reportable series, 17 of 33 had significant improvement in sperm density (51%), 15 of 33 (45%) in sperm viability, and 15 of 33 (45%) in sperm motility. No major complications were seen and minor complications were few and transient. Morbidity was extremely low. Laparoscopic internal spermatic vein ligations would appear to be a reasonable, practical, and effective method to correct varicoceles.

Simultaneous laparoscopic varicocelectomy and removal of an intrascrotal atrophic testicle.

We report on the concomitant removal of an atrophic intrascrotal left testicle secondary to mumps orchitis and a right varicocelectomy for athenospermia done laparoscopically. The procedure proved to be quite simple to complete, avoiding the need for secondary incisions, which would have been required otherwise if a standard open approach was chosen. The convalescence period was uneventful with the patient returning to regular activities within 72 h of the procedure. We feel that in selected cases a laparoscopic orchiectomy offers distinct advantages to conventional open surgical approaches.

Malignant tumor of the colon metastatic to the epididymis as a first sign of recurrence of colon cancer.

Metastatic tumors to the epididymis are rare. Most reported cases represent another occurrence of widespread disease. This is a report and review of the literature of a case of adenocarcinoma of the colon three years post resection in which the only site of recurrence was in the epididymis.

Laparoscopic varicocelectomy: preliminary report of a new technique.

The use of varicocelectomy for the treatment of subfertility seems to be incontrovertible. However, there is a difference of opinion as to the proper surgical method of varicocele ablation. The inguinal and high retroperitoneal approaches are the most commonly accepted methods to date. However, significant postoperative morbidity is common and return to normal activity often is prolonged. Also, bilateral operations are being performed more commonly. These considerations have prompted many to search for alternative techniques. We developed a laparoscopic procedure that is as simple and effective as more traditional methods. In addition, it offers lower morbidity, allows for microscopic dissection with preservation of the spermatic artery and is amenable to bilateral ligation without a second incision. Ten patients 16 to 54 years old underwent laparoscopic ligation of the spermatic veins at the internal inguinal ring. The diagnosis was based on physical examination. Indications for the operation were infertility with a stress sperm pattern in 5 patients, testicular atrophy in 4 and scrotal pain in 1. Four patients underwent bilateral ligation. Preliminary followup showed resolution of the varicocele in all patients and disappearance of pain in the patient treated for this symptom. No morbidity related to this procedure has been encountered and all patients resumed normal activity within 2 days. We believe that this new method is a viable alternative for varicocelectomy.

Human chorionic gonadotropin in the treatment of the infertile man.

We have treated 128 men with proved infertility with human chorionic gonadotropin. Excellent results were obtained in the patients who underwent varicocelectomy but who did not respond to the operation. Good results were obtained in the idiopathic oligospermic men, that is with sperm density less than 20 million. Indeterminate results were obtained in patients with sperm values more than 20 million. However, therapy was deemed inappropriate in those patients who either had elevation of follicle-stimulating hormone, an untreated varicocele or biopsy findings of hyalinization, or atrophy, which would preclude success of therapy.

Nonoperative management of renal artery embolus.

Two cases of renal artery emboli were treated nonsurgically with intravenous heparin. Both patients experienced prompt and total relief of the apparent embolization.

Chorionic gonadotropins in the treatment of the subfertile male.

Sixty-four men with idiopathic subfertility were given human chorionic gonadotropin, 50,000 units in 10 divided doses. Sixty-nine per cent of the men demonstrated significant improvement in semen quality in response to the medication, and thirty-six per cent achieved a pregnancy. Eight patients have achieved a second pregnancy without additional therapy.

Testicular biopsies in 101 cases of varicocele.

Testicular biopsies were done on 101 patients who underwent ligation of the internal spermatic vein as primary treatment for infertility. Retrospective analysis included evaluation of tubular thickening, Leydig cell hyperplasia, premature sloughing, maturation arrest and decreased spermatogenesis. A comparison was made of biopsy profiles, sperm counts and pregnancies in an attempt to determine further the value of testicular biopsy in the subfertile man. The pregnancy rate was 40 per cent over-all, with 32 per cent of the patients with tubular thickening reporting pregnancies. There was only 1 pregnancy in patients with Leydig cell hyperplasia. The controversial finding of premature sloughing had no consistent relationship to results.

Meiotic indices in the oligospermic male.

Thirty-four oligospermic males were evaluated by determining the meiotic index in testicular biopsy specimens. Only 1 patient of 10 with a meiotic index of less than 15 achieved pregnancy, whereas 16 of 24 patients with a meiotic index of more than 15 had a successful outcome. Corresponding increases in the semenogram were also noted to be related to the meiotic index.

A clinical evaluation of a new Silastic seminal fluid collection device.

A new Silastic seminal fluid collection device has been tested clinically and comparison studies have been made with both the polyethylene sheath and commercial latex condoms. In a series of 100 patients, the Silastic seminal fluid device has been found to be superior to the polyethylene sheath with regard to patient comfort and also has had greater reliability. In comparison with the latex device, the Silastic seminal fluid collection device is nearly as comfortable and has been found to be far more reliable.

Adenocarcinoma of rete testis.

Adenocarcinoma of the rete testis is a very rare malignant neoplasm originating in the epithelium of the rete testis. Histologically, it appears as a papillary adenocarcinoma. The first case was reported in the literature in 1853 and since that time only 16 additional cases have been reported. This report represents the eighteenth case.

Meiotic figures in the testicular biopsy of subfertile males.

The phases and sequence of meiotic division are herein reviewed and illustrated as they occur in the human testis. Normally all phases of meiosis can be identified, and arrest at a phase is indicative of faulty spermatogenesis. The correlation of these arrest patterns with the clinical course and response to clinical therapy is now in progress. These meiotic studies can be undertaken in any laboratory with cytogenetic capabilities, and this study is intended to serve as a base line illustration of the normal.