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A performance rating scale was developed and tested on a class of junior medical students who rated themselves and four to ten of their peers. When 928 ratings were factor analysed, two strong factors, knowledge and relationship, emerged. Test-retest reliabilities were good. Validity was measured by correlation of ratings with grades, and though both sources of ratings correlated significantly with grades given by faculty, peer ratings were more highly related to grades than were self ratings. Students tended to rate themselves lower than they were rated by their peers. Grades are probably not the best estimate of performance, but are currently one of the most reliable. Use of the scale to judge performance of physicians in practice has not been tested. The question of how such evaluation of peer and self would relate to other measures of quality of care is raised.

Elderly persons living in the community were compared with those living in a nursing home regarding experiences with stressful life events. The number of events recalled over the prior two years did not differ; however, the perceived degree of stress was more for those in the community. When persons were divided by high and low perceived stress groups and compared across the two environments, those who perceived more stress had significantly more depression, anxiety, and interpersonal difficulties. Nursing home patients may perceive less stress because there are fewer responsibilities for making decisions in nursing homes than in the community and the nursing home itself may provide a support in helping the elderly cope with stress. However, findings suggest that high perceived stress in either environment is associated with adverse psychological symptoms.

To determine if additional burn-care facilities or educational programs for burn care were needed within Florida, 73 of the state's 220 hospitals were studied. Data were collected on hospital statistics for a one-year period, as well as on 1656 patients admitted for burns to these hospitals during that year. When results were adjusted for severity of the injury, there was no evidence that outcomes of patients were better in any one or group of the State's eight regions, or in hospitals that had special burn units. Considerable evidence, however, indicated the need for additional educational programs in burn care. Many records were poor, admissions were inappropriate, patients with minor burns stayed too long, and burn shock was too frequent.

Older patients discharged from nursing homes were randomly assigned to student teams from medicine, nursing, and social work (C.A.R.E.) or to no specific aftercare. Patients seen by student teams had significantly more knowledge about community resources than did control patients, but showed no difference in rate of readmission or level of adjustment. The 24 students in the program developed significantly better attitudes toward the aged than control students. A student team approach offering services to the elderly may be one way of positively shaping attitudes of young preprofessionals in the health field.

The aim was to determine the effects of stress on immune status and surgical outcome in 24 healthy men undergoing hernia repair. Stressful life events over the prior 6 mo and social support was assessed at time of admission. Physiological response to a cold pressor test was measured the day before surgery. Lymphocyte blastogenesis and neutrophil chemotaxis were measured before and 3 and 30 days after surgery in patients and controls. Surgical outcomes were assessed by length of stay, narcotics used, and complications. Data were analyzed in 2 x 2 factorial designs for multivariate analysis of covariance where one factor was life stress and the other was response to the cold pressor. Age and social support were covaried in comparing immune responses before surgery. High responders to life stress had significantly less response to PHA, and high responders to cold pressor stress had lower PWM responses. With preoperative immune status covaried, high responders to cold pressor stress had significantly lower PWM response after surgery, indicating some T-B cell interaction defect and more narcotics and complications. Data suggest that high psychological and physiological stress responses before surgery (that is itself an additional psychophysiologic stressor) lead to poorer outcomes even in otherwise healthy men undergoing relatively simple elective surgical procedures.

Attitudes, personality, and career preferences of Anglo and Hispanic (Cuban) male and female junior students at the University of Miami School of Medicine were studied when they entered their surgical clerkship, and their performance in seven areas was measured 12 weeks later. Cuban females had more intolerance of ambiguity, felt less in control of their lives, anticipated more from the clerkship, preferred pediatrics, scored lower on written and verbal examinations, but performed higher on ward behaviors than other groups. Anglo females had the best written and verbal performance of any group and higher overall grades. Anglo and Cuban males preferred a surgical career more than other students did. Most differences observed were a result of the Hispanic females who, because of their role in the Cuban family, may not as yet be as assimilated into the core culture as the Cuban male.

The aims were twofold: to determine differences between the very old and younger patients in ambulatory care and to examine their self-assessments of health and whether these related to: subjective data such as symptoms and attitudes, objective data such as utilization of health services, and physician assessments of the patient's health. Although they had about one more diagnosis, the very old were similar in most respects to younger patients. Variables that discriminated the groups were physician ratings. About two-thirds of the older and younger patients regarded their health as good. Good health perceptions were associated with fewer symptoms, outpatient visits, and hospitalizations in both groups. Physician assessments were only lowly correlated with patient assessments of health. Patient perceptions of health were highly stable over a two month follow up. The subjective belief that one is healthy or ill may be more important than actual medical condition in maintaining good emotional and behavioral functioning.

Much has been written about working with the dying. Few, if any, controlled studies have examined the application of principles set forth. The authors evaluate the effectiveness of working with dying cancer patients by assessing changes in quality of life, physical functioning, and survival. One-hundred twenty men with end-stage cancer were randomly assigned to experimental or control groups; the 62 experimental group patients were seen regularly by a counselor. Patients were assessed before random assignment and at one, three, six, nine, and 12 months on quality of live and functional status. Experimental group patients improved significantly more than the control group on quality of life within three months. Functional status and survival did not differ between groups. A subsample of lung cancer patients provided cross-validation of findings. Although survival was not expected to differ, it was predicted that functioning would be enhanced if quality of life improved. One interpretation is that little can be done to alter physical function and survival when intervention occurs late in the progression of a fatal disease. This in no way reduces the value of improving overall quality of life, since enhancing the quality of survival for end-stage cancer patients is a high priority medical goal.

The purpose of the authors in the study reported here was to compare perceived stress in junior medical students (n = 169) before and after a clinical clerkship and to determine the relationship of unfavorable and favorable stress to personality and performance. Degree of stress and whether the stress was considered favorable or unfavorable were determined by the students' ratings on a stress scale administered before and after their surgical clerkship. Locus of control and self-esteem scales were used as measures of personality. It was determined that students likely to experience more unfavorable stress were more external in control and lower in self-esteem as compared with the other students. The students' cognitive performance was evaluated by two written and two oral examinations; their attitudes and skills were assessed by a behavioral scale completed by faculty members and residents. The major finding was that unfavorable stress was associated with poor performance. Since stress predictably will increase in the residency and in the practice years, students should be exposed to stress management techniques to help prevent the known high consequences of stress, such as substance abuse and suicide, among practicing physicians.

The physician plays a central role in the emotional as well as the physical care of the dying patient. The concerns of the terminally ill cancer patient include (1) emotional response to the physical limitations of illness, (2) communication with significant others, (3) self-concept, and (4) resolution regarding impending death. Although a busy physician would not be able to spend much time talking with the patient about these concerns, the physician could communicate to the patient in just a few minutes an empathic understanding of the emotional crises the patient faces. Sometimes only a word or touch of the hand can covey the physician's support and understanding which are so meaningful for a terminally ill patient.

The aims were to determine (1) if post-clerkship interest in surgery could be predicted from students' learning styles and preclinical interests a:; well as interest in surgery before their clerkship; (2) if interest in surgery related to performance in the clearkship; and (3) if interest related to later choice of a surgical residency. All juniors in one academic year were tested before and after their surgical clerkship and followed up a year later to determine their residency choice. Students changed significantly and positively in interest by the end of the clerkship. Pre-clerkship interest in surgery and learning styles associated with being a “doer” predicted postclerkship interest. Level of interest was unrelated to performance as measured by grades. Post-clerkship interest correlated with later choice of a surgical residency. There seems to be a continuum of interest associated with learning style that begins before the clerkship, is molded by the clerkship, and is involved in the appreciation of the role of surgery in overall medical care as well as in actual career choice.

In 1973 a survey was done in Florida to identify needs throughout the state’s eight regions for improvement in burn patient care [l]. It was found that no specific regional needs existed and, furthermore, that gross mortality rates in Florida seemed, at worst, to be the same as elsewhere in the country. In a sense, therefore, this satisfied the initial purpose of the survey. The question arose, however, as to whether or not results might not be equally bad (rather than equally good) all over the country and therefore subject to improvement by upgrading the facilities for burn care. In reviewing the literature, there was no difficulty in finding uniform agreement among leading authorities that special burn care facilities, such as burn units, burn programs, or bum centers, represent the way in which optimal management can be provided and optimal results can be obtained. Unfortunately, not a single reference was found comparing outcomes of bum patients treated in institutions with such special care facilities to those of patients treated in institutions without such facilities. Since the Florida Burn Survey contained a substantial pool of clinical and institutional data, it was decided to use this information to provide at

This study tests the effects of nursing home staff training in care for the dying on the quality of life of terminally ill patients. Ten matched community nursing homes were assigned randomly to experimental (training) or control (no training) conditions. Patients ( N = 306) admitted to the homes were assessed at admission, one month, and three months concerning quality of life as measured by depression, alienation, self-esteem, and locus of control. Satisfaction with care was also measured at one and three months. Patients in trained homes had less depression and greater satisfaction with care than patients in control homes at one and three months. Training effects were similar in all of the five homes. The study shows that a favorable impact on patient care can be achieved when staff in nursing homes are trained to work with dying patients.

The role of the surgical clerkship in the curriculum has often been debated. This study highlights its function in the students' decision making process. Junior students (N = 164) were measured on interest in surgery before and after the clerkship and divided into groups that changed significantly in a positive or negative direction, or that remained essentially unchanged. Background factors, learning styles of the students, and their evaluations of the clerkship showed that students who changed negatively (12%), compared with those who changed positively (44%), did not learn as well from clinical experiences and evaluated certain aspects of the clerkship, related to time and clinical demands, less positively. The unchanged group resembled the positive change students. Performance in the clerkship did not differ significantly among the three groups. The group that changed positively had none interested in surgery as a career before the clerkship, 15% who chose surgery afterward, and who later entered a surgical residency. The negative change group entered with high, perhaps unrealistic, levels of interest, left with none selecting surgery, and a third entering nonclinical type residencies. The surgical clerkship appears to have a unique role to help students make decisions about future careers based on their underlying personalities and learning styles.

The authors compared the attitudes of men and women junior medical students at one medical school before and after completing the surgery clerkship. The attitudes surveyed pertained to the students' confidence in dealing with problems in the doctor-patient relationship, concerns about future practice, and attitudes about preventive care. The women and men differed in only one career preference, with more women than men choosing obstetrics-gynecology. The class as a whole had more positive attitudes in all three areas after the clerkship. The men and women did not differ before or after the clerkship in their confidence in handling problems in the doctor-patient relationship. The women, however, had higher levels of concern than the men about preventive care after the clerkship. Although the men and women overall entered the clerkship with similar attitudes, the women left the surgical clerkship with more positive attitudes overall but also with more concerns about future practice than the men. Because of the demands made on students' time during the surgery clerkship, some women students may become concerned about conflicts that could arise from balancing career roles and homemaker roles, and they may need support at this time in dealing with these concerns.

A revised version of the Rapid Disability Rating Scale (RDRS-2) is presented. Item definitions have been sharpened and directions expanded to indicate that ratings are based upon the patient's performance in regard to behavior, and that prosthesis normally used by the patient should be included in the assessment. Three items have been added to increase the breadth of the scale. Response items have been changed from three-point to four-point ratings in order to increase group discrimination amd make the scale more sensitive to changes in treatment. The new appraisals of reliability, factor structure, and validity are reported, along with the potential uses of the scale.

Older and younger malnourished and well-nourished head and neck cancer patients scheduled for surgery were studied. More of the young (75%) compared with the old (58%) underwent curative surgery, and only the old with lower clinical states of cancer were selected. When data on those undergoing surgery were analyzed in regard to older and younger malnourished and well-nourished men, the malnourished old had the poorest surgical outcomes of any group, with significantly more complications and morbidity rates. The well-nourished old had outcomes that did not differ from younger patients. On further examination, 60% of the young malnourished and only 20% of the old malnourished received preoperative enteral or parenteral nutritional support. Findings suggest that more attention to the needs of the older malnourished patients could improve surgical outcomes.

The purpose of this research was to determine whether a specialized telephone service could cut down on unscheduled visits to ambulatory care and improve satisfaction with care. Patients who were to receive care (N = 561) were assigned randomly to a specialized telephone service or a control group. They were measured with regard to satisfaction with care before being assigned and 6 months later. The number of scheduled and unscheduled visits also were monitored for a 1-year follow-up period. The telephone service, which provided a triage system for referrals as well as a source of central contact for scheduling or for complaints, helped to improve satisfaction and reduce the number of unscheduled visits within 6 months. Such a service also may have application in other problem areas in the delivery of quality ambulatory care.

The development of a 54-item, multidimensional, self-report scale to measure physical, emotional, and social function is described in regard to reliability, validity, and factor structure. The scale appears to measure the following dimensions: physical disability, symptoms of aging, self-esteem, social satisfaction, depression, and personal control. The scale was derived from two studies of 826 persons age 60 and older. The scale is recommended when a comprehensive, relatively short, self-report assessment is needed for screening or research purposes.

Although emphasis has been placed on including content on treating the elderly in the medical school curriculum, little attention has been given to whether content on surgical management of the elderly should be provided in the surgical clerkship. The purpose of this paper is to describe geriatric principles emphasized in a surgical clerkship and changes in attitudes of students. Junior students (N = 175) were tested on attitudes before and after the clerkship. Attitudes about treating the elderly and surgery in the elderly changed significantly and positively. Attitudes about emergency surgery in the elderly became more realistic, particularly in those selecting surgery as a career. This study differs from others that found that students became more negative about treating the elderly as they progressed through medical school. The surgical clerkship provides a different perspective of the older patient from that seen on medicine or in long-term care, in that the elderly are usually admitted and treated successfully in a short time. The fact that the surgical clerkship, in contrast to other medical school experiences, can positively influence attitudes about aging for all students, regardless of career choice, is encouraging and suggests that including content on surgical management of the elderly can help students become more favorable about treating older patients.

Concern has been expressed regarding the extensive use of psychotropic drugs in ambulatory care. The aim of this study was to examine the relationship between age and use of these drugs in terms of differences in personal characteristics, medical histories, use of medical services and symptoms. Male veterans (N = 992), randomly selected from ambulatory care, were divided into five age groups (44 years and younger, 45 through 54, 55 through 64, 65 through 74, 75 years and older) as well as according to whether or not they were currently taking psychoactive medication. Psychotropic medications were used most frequently by the two middle-aged groups (45-54 and 55-64) and least frequently by the older age group, with significantly less use by blacks in all age groups. Regardless of age, drug users had more diagnoses, more outpatient visits, and considered their health to be better than did nonusers. Other medications, such as antispasmodics and sleeping, pain and heart medications, were also associated with use of psychotropic drugs. Furthermore, users in all groups had more symptoms of anxiety, depression, interpersonal problems, obsessiveness-compulsiveness and concern with their bodies. These findings allow the physician to recognize the clinical profile of patients who are more likely to rely on psychotropic medications and to treat them accordingly.

This article examines perceptions of stress and career choice. One hundred sixty-nine junior students specified what they thought were the two most and two least stressful careers, as well as their own career preferences before and after a 12-week surgical clerkship. The class was divided for analysis into three groups: those who selected careers that they said were A) most stressful (42%), B) least stressful (10%), and C) neither most nor least stressful (48%). Surgery was cited as one of the two most stressful choices by 99% of the class before and 93% after the clerkship. The next most stressful career was internal medicine, cited by 43% before and 35% after the clerkship. The two least stressful careers were dermatology and radiology, cited by approximately 50% of the class before and after the clerkship. Those who chose careers that they said were most stressful had significantly higher self-esteem (p less than 0.05), experienced less unfavorable stress themselves as measured by a 31-item stress scale before and after the clerkship (p less than 0.01), and experienced more favorable (in their view) stress (p less than 0.05) than did the other two groups. Reanalysis of data comparing those who selected surgery with those who did not confirmed findings similar to that of the matched high-stress career group. The study suggests that some students may be able to tolerate stress better and in fact, tend to thrive in an environment that they perceive as stressful, and that such students are more likely to go into a surgical career, which they foresee as one of the most stressful that they can enter.

This study examined the degree of liver damage, reflected by standard laboratory tests, in a group of male veterans in regard to their self-reported histories and diagnosis of alcoholism. Fifty-two percent of the patients were diagnosed as alcoholic. The correlation between liver damage, judged by a physician reviewing the tests, and diagnosis of alcoholism was r =.33. Although liver damage does not develop in some alcoholics, this minimal correlation suggests the need to look for other nutritional and genetic factors that may interact with alcoholism in development of liver damage.

The purpose was to determine if students could identify their own strengths and weaknesses as viewed by their peers and whether peer or self ratings of knowledge and interpersonal skills could predict scores on National Board Medical Examinations and final grades in surgery. Ninety-eight juniors rated themselves on a 13-item scale; 830 peer ratings (about eight per student) were also obtained and averaged to provide a peer score for each student. There were low but significant correlations between the two sets of ratings. Peer scores were excellent predictors of both National Boards and final grade. Self scores were only weakly associated with these outcomes. Interpersonal skill ratings were inversely related to grades. Peer ratings seem to be a valuable addition to evaluation of student performance. Self ratings may be more useful as a means of helping students learn to accurately assess their strengths and weaknesses.

Some of the problems facing evaluators of medical care have been dealt with by individuals examining mental health programs. Mental health research has focused more on outcome studies that include a multidimensional approach in evaluation. Techniques have been devised in that field that make the evaluative process patient specific and goal oriented. Borrowing some of these methods to make medical care evaluation include a problem-oriented outcome, which incorporates patient satisfaction, compliance with medical therapy, and relief of symptoms, could lead to more accurate data on the health delivery system.

In light of limited health care funds, there is a need for reliable information relating costs to clinical outcomes. Distinction should be made between diseases for which improved outcomes relate to intensity of care and those for which limits of current knowledge preclude improved results. A survey of 1,656 burn admissions to 73 hospitals over a one-year period showed that length of stay, unpaid bills, and the proportion of unpaid bills to total bills were two to six times greater than for nonburn admissions to the same hospitals. Three hospitals had special burn facilities, and even when adjustments were made for severity of injury, these hospitals had poorer outcomes and higher costs when all their burn patients were studied. When only those patients with greater than 30 per cent burn were compared between hospitals with and without special burn programs, or when patients were matched for degree of burn the hospitals with the special programs still had no better patient outcomes than those without such facilities. The crucial question, then, is whether mortality and complications were lower in special facilities. Although there was no evidence in this survey that they were, the final answer must come from a prospective study of outcome. If these survey results are confirmed, burns might be identified as an illness for which current limits in management abilities limit the ultimate proportion of successful outcomes.

The aim of this study is to test a multiple choice test generated by the computer (CGE) with the National Board Examination (NBE) used for evaluation of surgical clerks. The CGE was developed and tested over a 2-year period prior to the study. It resembles the NBE in length and format but is geared to content covered in the 12-week surgical rotation. The research question concerned whether the CGE could replace the NBE. One hundred seventy-two students were randomly assigned to four groups at the end of each quarter of the year. They were tested twice, 1 day apart as follows: 1. NBE-NBE; 2. CGE-CGE; 3. NBE-CGE; 4. CGE-NBE. Correlations between NBE and CGE were in the moderate range. Analysis of variance between scores on CGE and NBE showed differences that were almost of borderline significance ( P

Much has been written about working with dying patients. To evaluate counseling, 120 terminally ill cancer patients were randomly assigned to counseling or no counseling and studied before random assignment and at 1, 3, 6, 9, and 12 months on quality of life variables (alienation, depression, locus of control, life satisfaction, self-esteem) as well as functional status and survival. Counseled patients changed significantly in comparison to controls and in a favorable direction by 3 months. The purpose here was to see if older and younger cancer patients differed at baseline and if outcomes of counseling differed by age. Patients under age 60 were compared with those 60 and over. There was no multivariate difference at baseline but univariate differences of more disability and less life satisfaction in the older group. Overall, response to therapy was similar in old and young, with both improving.

Twenty-one plug-in kidneys were used to dialyze thirteen dogs. Blood urea nitrogen levels were successfully lowered in three fourths of the animals either on the first or second perfusions. Perfusions were carried out for one to seven hours. Grafts functioned better when preperfusion blood urea nitrogen levels were higher. Larger kidneys from male donors appeared to work best. Of twenty-one homografts, ten were rated good, five were fair, and six were poor. Graft results on the second perfusion were never the same as they were on the first. Until further research is done the variability of graft performance seems to preclude the short-term use of extracorporeal kidneys as a safe and effective means clinically to combat chronic uremia. As a laboratory test model, however, the plug-in kidney would permit parameters of study of histopathology, arteriovenous differences, and renal functioning which could be monitored serially with comparative ease. In addition, the active pathologic, biochemical, physiologic, and immunologic processes are much easier to observe. For these reasons the use of the ex vivo kidney has great potential in experiments.

The hyperacute rejection of renal allografts has much in common with pig-to-dog renal xenograft rejections. An analysis of the xenograft model revealed new functional aspects of graft rejection that appear to be an integral part of the humoral immune injury. Anaphylatoxin or C5a, a cleavage product of the fifth complement component was shown to play a major role in the rejection of isolated kidneys; it was generated in pig and dog serum by activation of the complement system and caused severe Vasoconstriction in the renal vasculature. It is suggested that histocompatibility antibodies and complement may affect allograft survival via this potent mediator.

There are indications that more alcoholics are being placed in nursing homes than ever before. To determine in what ways these patients differ from others going to nursing homes, all alcoholics (72) placed from hospital to nursing homes were studied prior to placement and followed 6 months in 35 homes. Seventy-one nonalco-holics placed during the same period were randomly selected for comparison. Hospital disability ratings from physicians, evaluations from social workers, and diagnostic data from records indicated no significant differences in levels of disability or impairment. Alcoholics were less likely to be currently married and had less income. Although they were younger, they had a significantly higher number of diagnoses than other nursing home patients (P< .01); however, with the exception of cirrhosis and brain syndrome, they had fewer serious illnesses such as cancer and diabetes. Outcome after 6 months showed 28 percent left the nursing home, 45 percent were still in the home, 10 percent were hospitalized, and 16 percent had expired. These outcomes were not significantly different from other nursing home patients. Results indicate alcoholics are as much in need of nursing home services as other patients, even though they differ along social and specific illness patterns *

The sine que non for a successful repair of large omphaloceles, gastroschisis, and large ventral hernias is the gradual replacement of the viscera into the contracted abdominal cavity. A satisfactory method is a staged surgical approach using dacron reinforced Silastic sheets. The experimental and clinical uses of these sheets are described.

Porcine renal xenografts were prolonged ten to twenty times longer than controls by specific suppression of the dog's antipig erythrocyte antibody. Depression of antibody levels was achieved by techniques involving either multiple xenografting or intravenous administration of pig stroma. Depletion of up to 95% of the dog's antipig erythrocyte antibody was achieved without affecting normal levels of antibody against sheep erythrocytes. Addition of the dog's own pretreatment serum, given while xenografts were doing well, caused immediate rejection. Since the same canine antibody involved in rejection is also directed against the pig erythrocyte, it is likely that at least one “transplantation antigen” is common to both erythrocytes and kidney cells of the pig.

In a review of 292 hospital patients who had cardiac arrests over a period of two and a half years patients aged 60 and over were contrasted with those under 60, based on a 50-item clinical questionary completed at the time of the episode. Survival rates were identical (23%) in these two groups. On contrasting patients who survived with those who did not it was again found that age did not influence outcome. Patients with multiple arrests or without cardiographic evidence of ventricular standstill were much more likely to recover. Whether or not a doctor initiated therapy did not affect survival.

The purpose was to see if students changed their attitudes about medical care during the surgical clerkship and whether those who selected surgery as a career differed from other students at the end of the clerkship and time of entrance into a residency. Students were assessed before and after the clerkship in regard to confidence about handling problems in the doctor-patient relationship, concerns about future practice, and attitudes about preventive aspects of care. In general, the class changed positively in dealing with patients, had more concerns about future practice, and were more negative about preventive aspects of care. Potential surgeons had concerns about future practices similar to those of other students but differed from the rest of the class by having more confidence in dealing with patients and more positive attitudes about preventive aspects of care. When they entered the clerkship, would-be surgeons had more favorable ratings than did other students on ego strength and acceptance of people. The study suggests that attention may need to be given to the experiences of students in the clerkship that lead to their increased concerns about future practice and, for those not selecting surgery as a career, their increased negative attitudes about preventive care.

People face death in many different ways. Counselling may help some while others prefer to meet death in their own private way; helping a person face death starts with this recognition of individual style. Thus, our own values concerning what needs to be done should not be imposed and the person’s own wishes are to be respected above all else.

Authorities are not in full agreement in regard to risk of surgery in the elderly. One hundred eight studies of surgery in the elderly over the past 40 years were reviewed. The purpose was not merely to tabulate results, but to identify differences existing between reports with regard to data reported that could affect results independent of the surgical management itself. Sources of variance that need to be taken into account in comparing mortality rates between studies, such as whether mortality was computed by number of patients or operations, differing lengths of follow-up for recording mortality, proportions of emergency versus elective operations, and types of surgical procedures, were documented. A nine-item confidence in results scale was used to classify studies into high and low confidence groups. Surgical specialties scored substantially higher than general surgical studies. More recent studies received higher scores than earlier studies. Although mortality rates varied widely depending on methods of their calculation, there appeared to be a trend toward increases in elective, but not emergency, mortality rates in general surgery since 1941 that should be examined more closely. One thing that cannot be answered clearly from these studies is the relative risk of surgery with age. Some control of variations between studies and standardization of reporting surgical deaths are required before risk of surgery in the elderly can be assessed more accurately.

This study measured depressive symptoms in 98 men of whom 49 had and 49 had not had a recent experience of family death or serious family illness. The relationships of depression and occurrence of the stressful event to immune function was explored. Persons with higher scores on depression in both groups showed less responsiveness of their lymphocytes to phytohemagglutinin and to allogeneic cells. Data indicate that not all persons react the same way to stressful events and that those with high and low depressive features can be differentiated by their immune responses.

Surgery has sometimes been studied as a stressful event. The aim here was to determine the relationship between degrees of anxiety before surgery and postoperative outcomes in healthy old and young men. Old and young men were selected if they had no illnesses or prior surgery and were scheduled for elective hernia repair. Levels of anxiety were measured preoperatively along with other physiologic, psychologic, and immunologic modalities. Operative data and follow-up data for 30 days were obtained. Old and young men did not differ significantly before surgery. When age groups were divided by preoperative anxiety and their postoperative outcomes compared, more anxiety was associated with more pain-relieving medications and more disability days in each age group. Furthermore, the old anxious had even more disability days and complications than did other groups. The study points to the need to prepare the old, even those essentially in very good health, for even a minor surgical stress in order to improve their overall health outcomes.

The extent to which medical records supply reliable and valid data about a patient's condition is unknown. Recent emphasis on evaluation of quality of care by record review makes this an important issue. One hundred and three male patients (mean age 65) discharged from hospital to extended care were studied. At hospital discharge, the patient was rated by his physician on a 13-item impairment scale. Another physician, using only medical records, rated the same patients on the same scale. Similarity between ratings was found to be low. Validity was studied by following patients six months later to classify them as living (75) or dead (28). Each set of ratings was then used to predict death, on the assumption that degree of impairment would be related to subsequent death. Both sources predicted death at a highly significant level; however, slightly different predictors were elicited depending on whether records or personal knowledge were used. Common predictors were respiratory, hepatic, and neurologic impairment, with in person ratings adding upper gastrointestinal and record ratings adding vascular and psychiatric impairment. What might be concluded is that both sources were valid, but both incomplete. Records had missing data, and physicians using personal knowledge tended to think only of the patient's treated condition.