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Background: A methodology is needed for classification of health problems by severity., Objectives: We aimed to test the Duke Severity of Illness Checklist (DUSOI) for feasibility and usefulness., Method: The DUSOI was field tested internationally by 22 family/general practitioners in 9 countries., Results: The DUSOI was found to be feasible for rating severity of illness of health problems in family/general practice. The measure was shown to be clinically useful in older patients and those with chronic and more severe health problems. Variability of severity ratings was less within the same rater than between different raters (i.e. higher intrarater than interrater reliability). Clinical face validity was supported by the finding that DUSOI ratings classified patients with the same diagnosis and those with different diagnoses according to the severity differences that would be expected clinically., Conclusions: Although research is needed to improve reliability and to test validity further, the DUSOI was shown in the present study to be a methodology that is reasonable for consideration as an international classification of health problems by their severity in primary care patients.

Primary care patients in the United States, Israel and Japan received the Inventory to Diagnose Depression and the Dartmouth COOP Functional Status Charts modified for international use. Patients were classified as having major depressive disorder or minor depression. Although demographic characteristics varied by country, the rank order and frequency of the depressive symptoms were similar for both major and minor depression. Functional impairment was most severe in patients with major depression, less severe in those with minor depression and was least impaired in those not depressed. The results suggest that depressive disorders have similar presentations in the three countries studied, although the separate cultures confer different consequences on patients receiving these diagnoses.

In a sample of 276 Japanese adult patient attenders at two primary care clinics affiliated with the Department of Hygiene and Preventive Medicine at the Okayama University Medical School major depression was diagnosed in 5.8% and minor depression in 7.2% of patients studied. Functional impairment was significantly more severe in patients with either major or minor depression than in those not affected. None of the 36 patients with major or minor depression had received a diagnosis of depression or had been given antidepressant therapy. Possible explanations for the marked underdiagnosis of depression and lack of specific antidepressant therapy in these patients include severe stigma associated with a diagnosis of mental disorders, focus of the mental health system on hospitalization with consequent trivialization of mental problems in ambulatory patients, and the extraordinarily high work load of primary care doctors.

Major depressive disorder (MDD) is highly prevalent in ambulatory primary care patients. Severe functional impairment and risk of suicide are features of the condition. Although treatment can reduce morbidity, detection of MDD by primary care physicians is suboptimal. The aim of this study is to assess the inventory to diagnose depression (IDD) as compared with clinical psychiatric assessment for case finding in primary care patients. Adult members of an Israeli kibbutz (communal settlement), where all psychiatric diagnoses made by the family physician are confirmed by psychiatric consultation, were asked to complete the IDD; a 22 question, self-administered questionnaire. Patients whose scores indicated MDD, if not previously diagnosed, were also referred to psychiatrists. Patients' medical charts were reviewed for the diagnosis of MDD and response to therapy prior to the administration of the IDD. Of the sample of 312 patients, 207 (66.3%) completed the IDD. Refusers were younger (P = 0.04), more likely to be native born Israelis (P = 0.02), and had a higher prevalence of known MDD (P = 0.05) than participants. MDD by IDD scores was present in seven patients, in three of whom the diagnosis had previously been established; the other four were newly diagnosed. In the three previously diagnosed patients, one (metastatic carcinoma) refused treatment and two were receiving psychotherapy; all were clinically depressed. Four additional previously diagnosed patients whose IDD scores were insufficient for MDD had had a successful response to current therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

The articles reviewed for this issue of 'Selections' concern potential therapies to prevent osteoporosis and cardiovascular disease in postmenopausal women. Each therapy is controversial and provokes more questions than answers. The most benign intervention is the administration of calcium to postmenopausal women whose daily calcium intake is less than 400 mg. Although there have been reports that calcium administration failed to demonstrate benefit in this group, the treatment is unlikely to do harm. Etidronate can increase bone mineralization in women with osteoporosis, but will it be useful for prophylaxis? Oestrogens can prevent bone loss, but is the increased risk of breast cancer sufficient to preclude their use? Do oestrogens increase or decrease the risk of cardiovascular disease? A combination of oestrogen and progesterone may avoid the increased risk of uterine cancer but what are the effects of long term administration? Do the potential benefits of hormone therapy justify the costs and treatment of large numbers of women who without therapy would never have developed complications attributable to oestrogen lack? (Herman J: Fam Phys 1990; 18: 39-40) Given these uncertainties, is postmenopausal administration of hormones reasonable or prudent? The current literature does not provide adequate answers to these questions. Uncertainty, however, is not new for clinicians, who will weigh the evidence, evaluate the multiple variables in the individual patient that influence therapy, and with their patients decide whether the risks outweigh the benefits.

The prevalence of asymptomatic microhematuria (two to four or more erythrocytes per high-power field) in 1341 male Air Force personnel was 5.4%. The most powerful predictor of microhematuria (nearly 15-fold increased prevalence) was a history of recurrent microhematuria during the previous five years. Recurrent microscopic hematuria was present in 14.5% (8/55) of men with a history of urethritis, accounting for 26% (8/31) of the cases of recurrent microscopic hematuria. The prevalence of microhematuria was not affected by physical exercise, flight duty, or sexual intercourse during the 24 h preceding the urinalysis.

To investigate how family/household problems could be classified 186 problems recorded in 55 families by 14 Israeli family physicians were studied. Four major categories were used which included health problems in one family member affecting others in the household, relationship problems, social problems and health problems in more than one family member. Over half of the 186 problems were psychological or physical problems in the individual which affected other household members. Specific diagnostic titles from the International Classification of Health Problems in Primary Care (ICHPPC-2-Defined) were suitable to classify virtually all identified family/household problems. More problems were identified in mothers than in fathers or children and mothers were perceived as being affected most by social and relationship problems. Additional studies are suggested.

This issue of 'Selections' focuses on studies of cholesterol reduction in asymptomatic adults. Treatment of persons with coronary heart disease involves other issues and the need to consider additional evidence from other studies. Elevated blood cholesterol levels are associated with increased coronary heart disease in young adults. The real question is whether or not lowering cholesterol levels with diet and drugs is possible and if possible, whether it reduces the risk of morbidity and mortality. Even if the relative risk can be reduced it is necessary to consider the absolute risk reduction. Reduction of the risk of fatal myocardial infarction from 2.0% to 1.6% over a seven year period while at the same time increasing the risk for gallbladder surgery from 1.3% to 1.9% may not be an attractive gamble. There is little evidence that elevated cholesterol levels are a risk factor in adults over the age of 60 years. Intervention trials have not been conducted in women or in the aged, and overall mortality has not been reduced in any of the studies. The Department of Health and Human Services of the United States recommends an approach that if implemented could have initial costs that exceed 10 billion dollars. Yearly costs are likely to exceed the initial cost. In a recent editorial Professor Joseph Herman expresses concern that the Israel Society for Research on Atherosclerosis and the European Atherosclerosis Society have adopted similar recommendations to those recently announced in the United States. He also points to large variations reported from 5000 laboratories given standard samples to be tested for total cholesterol. Currently blood cholesterol levels are available to shoppers at a supermarket in Florida (New York Times 1989, January 3). The end of this controversy is not yet in sight.