The temporal relationship of psychosocial stress to cellular immunity and herpes labialis recurrences.

This study used a prospective single-subject study design and time series analysis for repeated measures data to investigate the hypothesis that variations in psychosocial stress are associated with changes in cellular immunity in a study subject with recurrent herpes labialis. A study subject who was antibody positive for HSV-1 but reported no clinical manifestations of disease served as a control. Psychosocial stress, as measured by a questionnaire; cellular immunity, as measured by the monoclonal antibodies CD4 (OKT4), which defines the helper/inducer subset of T lymphocytes; and CD8 (OKT8), which defines the suppressor/cytotoxic subset, were measured weekly over the 32-week study period. Analysis of data using bivariate time series (ARIMA) demonstrated significant inverse correlations between stress level scores and percent CD4 helper/inducer T lymphocytes in both subjects. In the study subject with recurrent herpes simplex labialis, a Mann-Whitney U statistic determined that the percent of CD4 in the early stages of a recurrence were significantly lower than the percent of CD4 at other times when blood samples were drawn. The data presented are repeated measures on two individuals with positive antibodies to the herpes simplex virus, one with recurrent herpes and one without a history of recurrent herpes. Relevance for stress research is discussed.

The individual over time: time series applications in health care research.

This paper presents a summary and a brief theoretical introduction to time series ARIMA modeling of single subject data. Time series, a statistical technique that may be appropriate when data are measured repeatedly and at nearly equal intervals of time, has potential research applications in the study of chronic diseases such as diabetes, hypertension, and herpes simplex. Both intervention models and multivariate models are covered, with examples illustrating the utility of time series techniques in chronic disease research. Time series modeling of a subject with diabetes before and after being placed on a regimen of chlorpropamide is used to demonstrate the potential of intervention analysis. Multivariate time series techniques are illustrated by modeling the relationship between exercise and blood glucose, and by modelling the relationship between psychosocial distress and lymphocyte subsets of the cellular immune system.

Power in academic medicine.

The inherent strengths from which family medicine can gain power in the academic medical center include the following. 1. Family medicine is the ambulatory primary care discipline. Consider increasing your capabilities of teaching in ambulatory settings. With the changing nature of the hospital patient population, it is becoming increasingly difficult to find a non-seriously ill patient who is alert and cooperative for simple teaching programs such as basic history taking and physical diagnosis. One can recruit more practicing family physicians as part-time faculty. In some medical schools the Introduction to Clinical Medicine field experience is in the office of practicing physicians. One might consider assuming responsibility for a neighborhood health center, particularly if this is a designated U.S. Public Health Service Corps Site. There would be an advantage to having students experience firsthand this mechanism of financing the medical education of primary care physicians. One might consider developing a purely private teaching practice. One could take a university faculty salary and divide it among three or four people in a group practice. This would compensate for the extra time it takes to have students and/or residents seeing patients in private offices. 2. Graduates of family practice residency programs comprise the major primary care referral base for open staff hospitals. Energies devoted to recruiting residency graduates to use our teaching hospitals will be well spent. Imaginative joint ventures between the hospital and the departments and/or graduates would help these recruiting efforts. The gradual increase in this primary care referral base over several years would greatly strengthen the position of family medicine within the academic medical center.(ABSTRACT TRUNCATED AT 250 WORDS)

Stress as a precipitating factor in subjects with recurrent herpes labialis.

The model of recurrent herpes labialis was selected to evaluate the role played by stress in increasing susceptibility to illness. Initially, 35 paid volunteers with recurrent herpes were enrolled in the project. Compared with 35 age- and sex-matched controls, this group demonstrated a familial predisposition for recurrent herpes labialis. Eighteen subjects without confounding variables known to precipitate recurrent herpes infections completed a pretested "stress" questionnaire during a dormant and again during an active stage of infection. In the week prior to the appearance of a recurrence, this group experienced increased daily hassles, increased stressful life events, and higher state anxiety. These findings are discussed in the broader context of stress-associated disease with some speculations concerning a possible biologic mechanism, which involves modulations of T-lymphocyte function.

Troubled marriages and divorce: a prospective suburban study.

A longitudinal survey of adjustment to divorce in Cleveland, Ohio, suburbs was conducted with a matched sample of married persons in order to identify some of the common complaints, feelings, concerns, and health hazards among separated and divorced persons. The study findings show that substantial numbers of divorced and married people turn to their physicians for help with personal problems, suggesting that physicians need to be prepared to help them appropriately. Based upon these findings, opportunities are described that are open to the family physician for detecting distress in the troubled marriage and in divorce, as well as for therapeutic intervention. Types of interventions include anticipatory guidance, counseling, and referral for more intensive therapy. In the troubled marriage there is often an extended period of unhappiness and indecision. A physician alerted to the frequency with which marital distress is exhibited in physical or psychological symptoms may be able to provide assistance in sorting out priorities and options. Following a crisis model of adjustment, the heightened physical and psychological distress experienced during the early stages of the divorce process decreases with time. Many divorced parents are not aware of the im pact of marital turmoil and divorce on their children. The family physician plays an important part in helping parents recognize their continuing role in the lives of their children even if the marital relationship ends.

When is it helpful to convene the family?

There are three factors supporting current efforts to bring the family into the mainstream of American medicine: (1) research capabilities of the discipline of epidemiology, (2) the intervention skills developed by family therapy, and (3) pressures to provide cost-effective care as economic resources diminish. The fundamental question addressed in this paper is, when can it be helpful for the family physician to convene the family in the consultation room? Physicians in the field and residents in training are often reluctant to take this step because of time constraints, awkwardness in talking to two or more members of the family, and unfamiliarity with what to do with the information that is gathered. From currently available research data, a list of 14 medical conditions is presented in which it can be predicted that family functioning or nonfunctioning is contributing to the cause of disease, or that the family will experience a major reaction to the illness. These medical conditions offer an ideal opportunity to begin working with families. A specific case history illustrating this approach is presented to demonstrate that convening the family can be an important dimension of family medicine.

The family as the unit of medical care.

This review of the literature on the family and medical care involves an expedition into the sister disciplines of epidemiology, sociology, and psychology. There is a considerable volume of evidence that documents how important to the individual's health is his family. This material has been organized into four categories: (1) the family's contribution to the "cause" of disease, (2) the family's contribution to the "cure" of disease, (3) the family's response to serious or chronic disease, and (4) the family's desire and/or need for family-oriented care. In the conclusion, some implications for the future of the discipline of family medicine are discussed in relation to the material presented.

The use of video-tape techniques in the psychiatric training of family physicians.

This paper describes the use of video-tape techniques in the training of family physicians. Some general objectives for the psychiatric curriculum for family medicine training programs are enumerated. The implementation of these goals include (1) development of a library of video recordings which contain illustrative examples of psychiatric syndromes and management problems that appear frequently in family practices; and (2) use of video-tape recordings of the trainee during routine medical encounters and during counseling sessions for later review with supervising faculty. Some specific examples are cited of what to look for in the medical encounters and of how the video tape allows faculty to be more concrete in their instruction.

Referral patterns in an individual family practice.

This retrospective study of referral patterns in an individual private practice demonstrates that the family physician provides a definitive care for the large majority of patient problems in everyday practice and does not function primarily as a triage officer. Ninety-seven percent of all patient contacts, both ambulatory and in-hospital, were managed by the individual physician and his staff. Two-and-one-half percent of patient contacts required consultation with local specialists, and only .5 percent required referral to a tertiary care center. These results are compared with other large-scale population studies of the "ecology" of medical care and with other recent studies of referral patterns in family practice.