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Biomedical subjects

E A Walker

Publications and source records attributed to E A Walker.

140 records · Page 8Linked to original sources
PubMedDate not supplied

Medical and psychiatric symptoms in women with childhood sexual abuse.

Although there is increasing awareness of the short-term psychological and social adaptations to childhood sexual abuse, little is known about the long-term effects of such abuse, particularly its effect on subsequent medical utilization and the experience and reporting of physical symptoms. We re-analyzed data from a previous study of 100 women scheduled for diagnostic laparoscopy (50 for chronic pain, 50 for tubal ligation or infertility evaluation) who received structured, physician-administered psychiatric and sexual abuse interviews. Women were regrouped by severity of childhood sexual abuse, and we compared the groups with respect to lifetime psychiatric diagnoses and medically unexplained symptom patterns. Unadjusted odds ratios showed that risk for lifetime diagnoses of major depression, panic disorder, phobia, somatization disorder and drug abuse, and current diagnoses of major depression and somatoform pain disorder were significantly higher in the severely abused group compared with women with no abuse or less severe abuse. Logistic regression analysis demonstrated that number of somatization symptoms, lifetime panic disorder and drug dependence were predictive of a prior history of severe childhood sexual abuse. Psychiatric disorders and medical symptoms, particularly chronic pelvic pain, are common in women with histories of severe childhood sexual abuse. Clinicians should inquire about childhood sexual and physical abuse experiences in patients with multiple medical and psychiatric symptoms, particularly patients with chronic pelvic pain.

Abdominal Pain↗
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Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: I. Psychiatric diagnoses and functional disability.

OBJECTIVE: Recent studies of the relationship between fibromyalgia and psychiatric disorders have yielded conflicting findings, and many of these inconsistencies seem to result from methodological differences. METHOD: We compared 36 patients with fibromyalgia and 33 patients with rheumatoid arthritis from a tertiary care clinic using physician-administered, structured psychiatric interviews and self-reported measures of illness appraisal, coping, and functional disability. RESULTS: Patients with fibromyalgia had significantly higher lifetime prevalence rates of mood and anxiety disorders, as well as higher mean numbers of medically unexplained physical symptoms across several organ systems. Ninety percent of the patients with fibromyalgia had a prior psychiatric diagnosis compared with less than half of the patients with rheumatoid arthritis. CONCLUSIONS: Despite the absence of organic pathology, the patients with fibromyalgia had equal or greater functional disability and were less well adapted to their illness. Although the pathophysiology of fibromyalgia remains unclear, co-morbid psychiatric disorders and functional disability remain an important focus of treatment in this population.

Activities of Daily Living↗
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Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect.

OBJECTIVE: Two recent reports have found associations between fibromyalgia and sexual victimization, but had methodologic characteristics that limited their interpretation. METHOD: We compared 36 patients with fibromyalgia and 33 patients with rheumatoid arthritis by using structured interviews for sexual, physical, and emotional victimization histories, as well as dimensional self-report measures of victimization severity. RESULTS: Compared with the patients with rheumatoid arthritis, those with fibromyalgia had significantly higher lifetime prevalence rates of all forms of victimization, both adult and childhood, as well as combinations of adult and childhood trauma. Although childhood maltreatment was found to be a general risk factor for fibromyalgia, particular forms of maltreatment (eg, sexual abuse per se) did not have specific effects. Experiences of physical assault in adulthood, however, showed a strong and specific relationship with unexplained pain. Trauma severity was correlated significantly with measures of physical disability, psychiatric distress, illness adjustment, personality, and quality of sleep in patients with fibromyalgia but not in those with rheumatoid arthritis. CONCLUSIONS: Fibromyalgia seems to be associated with increased risk of victimization, particularly adult physical abuse. Sexual, physical, and emotional trauma may be important factors in the development and maintenance of this disorder and its associated disability in many patients.

Activities of Daily Living↗
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Depression and self-reported physical health in patients with coronary disease: mediating and moderating factors.

OBJECTIVES: The purpose of this study was to define how the relation between depression and self-reported physical health in patients with coronary disease is modified by other patient-centered factors. METHODS: We conducted a prospective cohort study of 111 patients (members of a health maintenance organization) with angiographically documented coronary disease, examining factors (physical symptoms, psychological states and traits, and spousal support) modifying the relation between depression and patient-reported physical health 5 years later using multiple hierarchical regression models. RESULTS: Five regression models (all including demographic and disease severity covariates) were constructed to predict physical health from depression only (R2 = 0.22); depression plus angina and fatigue (R2 = 0.53); depression plus positive affect and novelty seeking and their interaction (R2 = 0.48); depression plus spousal support (R2 = 0.27); and depression, angina, fatigue, positive affect, and novelty seeking (overall model) (R2 = 0.65). Depression remained significant in each model, but the proportion of variance it predicted was diminished in the presence of the other variables (bivariate r = 0.39, partial r = 0.37-0.13). CONCLUSIONS: The effect of depression on self-reported physical health is significantly mediated by physical symptoms (angina and fatigue), personality states and traits (positive affect and novelty seeking), and spousal support. Positive affect and novelty seeking had more marked effects on physical health in the presence of more depression. Thus, a broad range of factors beyond the severity of coronary disease itself affect the perceived physical health of patients with coronary heart disease.

Affect↗
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How diabetes specialists treat their own diabetes: findings from a study of the AADE and ADA membership.

PURPOSE: The purpose of this study was to determine how diabetes specialists, who themselves have diabetes, manage their own care. METHODS: An independent research organization faxed anonymous, 1-page surveys to all professional members of the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA) who had valid fax numbers. Only those individuals with diabetes were asked to fill out and return the survey. RESULTS: Of the 12,525 surveys that were distributed, 802 (6.4%) were returned. The prevalence of type 1 diabetes in this sample was estimated to be 13 times higher than in the general US population, whereas the prevalence of type 2 diabetes was 42% to 54% lower. Of the respondents with type 1 diabetes, most (96%) practiced intensive treatment regimens, and more than half used an insulin infusion pump. CONCLUSIONS: Diabetes specialists treat their own diabetes according to current standards of medical care, with insulin pumps being the preferred method of insulin therapy for type 1 diabetes in this sample. Knowing that experts almost universally practice intensive treatment regimens may be a powerful motivator for patients and sends a strong message to primary care providers and payers regarding the need for treating diabetes according to current standards of care.

Adult↗
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Dissemination of diabetes care guidelines: lessons learned from community health centers.

PURPOSE: This study was conducted to evaluate the impact of a provider problem-based learning (PBL) intervention on screening for complications of diabetes in community health centers. METHODS: A successive sampling design was used to compare selected standards of diabetes care delivered preintervention with the care delivered postintervention at 2 community health centers and 1 comparison centers. Two randomly assigned intervention sites received a PBL intervention focused on care guidelines for prevention of diabetes complications, with telephone follow-up over 12 months. Effects of the intervention were determined from an audit of 200 charts from each site. RESULTS: The odds of having a glycosylated hemoglobin test more than doubled from preintervention to postintervention, and the odds of having a foot examination more than tripled across centers. Measurement of creatinine and glycosylated hemoglobin were associated; the odds of having one test tripled when the other had been measured. Rates for documentation of patient education were significantly lower at the intervention site where free patient education booklets were distributed. CONCLUSIONS: Improvements in diabetes care were not consistent among community health centers. Interventions involving system and policy changes may be more effective in implementing and sustaining improvements than just provider education.

Adult↗
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Local survey of optometrists about dilated funduscopic examinations for patients with diabetes: making use of phone book yellow-page listings.

The risk of blindness from retinopathy and macular edema is significantly greater in people with diabetes than in the general public. Annual dilated funduscopic examinations are recommended for early detection and treatment before these problems become serious and threaten vision. Yet national health survey data indicate that only about half of patients with diabetes obtain an annual dilated funduscopic examination. This study surveyed optometrists listed in the NYNEX Yellow Pages (for the Bronx, NY) to assess their knowledge, attitudes, and practices related to dilated funduscopic examinations for patients with diabetes. Over half of the optometry practices in the survey indicated that dilated funduscopic examinations were available at a relatively modest cost. However, the optometrists reported that less than one fourth of the patients they saw with diabetes had knowledge about the purpose of an annual dilated examination. Optometrists are readily available through yellow-page listings. Their role as primary eye care providers in retinopathy screening may increase with managed care.

Diabetic Retinopathy↗
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Development and formative evaluation of a foot self-care program for African Americans with diabetes.

African Americans with diabetes have a higher rate of lower-extremity amputation due to diabetic foot complications than the general public. Education about proper foot care can help prevent serious diabetic foot complications and assist in early detection of problems. The purpose of this project was to develop, formatively evaluate, and pilot test a self-care, take-home program for the prevention of foot problems in African Americans with diabetes. The program included a brief, one-on-one orientation session and a take-home foot self-care packet. Through telephone follow-up subjects reported the following: good to excellent overall rating of the program, favorable reactions to the patient instruction booklet, an overwhelming positive response to the large hand mirror, and a positive effect on their daily foot-care practices. The Afrocentricity of the patient education materials was preferred by younger subjects; older subjects found this approach too restrictive.

Black or African American↗
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Characteristics of the adult learner.

PURPOSE: This article provides an overview of adult learner characteristics, with an emphasis on those characteristics studied in diabetes patient education research. METHODS: A selected review of the conceptual and research literature on general adult education and adult learning was conducted, with particular attention to diabetes patient education studies. RESULTS: Characteristics reviewed included learning styles, literacy level, age/aging, ethnicity or culture, gender, and knowledge. Studies of the learning style of group vs individual education indicated some positive benefits for group learning; questions remain about optimal size or periodicity. Studies evaluating the benefits of culturally specific interventions for diabetes management have yielded some information. Characteristics related to gender and age have been studied, but often in pilot or feasibility studies without the power to answer the study questions. CONCLUSIONS: There continue to be many gaps in knowledge related to adult learner characteristics in diabetes education. Lessons from both general adult learning literature and patient education literature from other chronic diseases should be evaluated and incorporated. The complexities of these learner characteristics create challenges in designing studies. However, evidence to support the need for effective educational interventions is of great importance for implementing change in health care.

Adult↗
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Understanding and caring for the distressed patient with multiple medically unexplained symptoms.

BACKGROUND: Although physicians commonly encounter patients with complicated medical problems, some have a mix of unexplained medical symptoms and distress that can seem overwhelming to patient and physician alike. METHODS: We describe a model for thinking about and helping these complex patients. The model was developed from our personal clinical experience as primary care psychiatric consultants, as well as from a review of the literature using such key words as "difficult," "frustrating," and "somatization." RESULTS: The model involves understanding predisposing factors that render the patient vulnerable to the development of a disabling condition, precipitating factors that initiate an episode of illness, and perpetuating factors that maintain maladaptive illness behaviors with time. CONCLUSIONS: Awareness of these factors allows the clinician not only to tolerate and gradually unravel the complicated interactions that create and sustain distress in patients with multiple medically unexplained symptoms, but also devise practical and effective management strategies for these complex patients.

Adult↗
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Detection and treatment of depressive syndromes in a rural island clinic.

BACKGROUND: Major depression is a serious and often persistent problem for 5 to 10 percent of patients in primary care. The detection and treatment of depression can be a particular challenge in rural settings. This study describes patterns of care for depression at a rural primary care clinic on an island off the coast of Washington State. METHODS: For a period of 2 months, 226 primary care patients were evaluated for depression using a two-stage screening method. Structured chart abstraction was conducted for patients meeting criteria for major depression or dysthymia. RESULTS: Ten percent of the study sample met Diagnostic and Statistical Manual of Medical Disorders, fourth edition, criteria for major depression, 4 percent met criteria for dysthymia, and 8 percent met criteria for major depression and dysthymia. Of the patients who had a diagnosis of major depression or dysthymia by the PRIME-MD, approximately 50 percent had their condition detected by their primary care provider, and approximately 50 percent received guideline level antidepressant treatment. Less than 40 percent of patients whose depression was treated with antidepressants made more than two visits during the 8 weeks after the initial prescription. CONCLUSIONS: These findings are consistent with those from other primary care settings and suggest that there are many opportunities for improving the quality of care for depressed patients in rural primary care settings.

Adult↗
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Depression after childbirth.

BACKGROUND AND METHODS: Depression following childbirth is an illness occurring in 10 to 20 percent of women in the year postpartum. Researchers have debated whether postpartum depression is a different illness from depression at other times. We critically review the literature on postpartum depression, as distinguished from postpartum blues and psychosis. RESULTS: Problems with definition, study design, and the validity of the diagnosis have hampered investigation. Studies do not clearly distinguish postpartum depression from major depression occurring at other times CONCLUSIONS: Depression after childbirth is probably the same illness as depression at other times. It is not known whether biological and psychological factors unique to the puerperium alter the expression of the illness. Nonetheless, physicians caring for women and infants should learn to screen for, diagnose, and treat depression in women after childbirth.

Cross-Cultural Comparison↗
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The prevalence rate of sexual trauma in a primary care clinic.

BACKGROUND: Despite the high prevalence rate of sexual victimization in the general population, little is known about the characteristics of abuse victims in primary care. We studied the prevalence rate of childhood and adult sexual trauma in a primary care clinic, associated psychological distress, and patients' attitudes about physician inquiry into past sexual victimization. METHODS: Self-report questionnaires were given to 162 women in a primary care clinic inquiring about past episodes of childhood sexual abuse, adult sexual assault, and patients' desire that their physicians be aware of their sexually traumatic experiences. The women also completed the Trauma Symptom Checklist-40 (TSC-40), a measure of psychological distress. RESULTS: The rates of childhood sexual abuse (37 percent) and adult sexual assault (29 percent) in this primary care clinic were comparable with, but somewhat above, the rates reported for the general population. Although most of the women (61 percent) believed it was appropriate for their physician to ask about previous victimization, only 4 percent had been asked. Women who had experienced sexual trauma were more distressed when compared with nonvictimized women, as measured by the TSC-40. Childhood sexual abuse was associated with greater distress than was adult sexual assault, and combinations of childhood and adult trauma were associated with the highest distress levels. CONCLUSIONS: A history of sexual abuse or assault can be a relatively common finding in primary care clinics. Patients might benefit from routine physician inquiry into histories of childhood and adult sexual victimization, and physicians should be mindful of the long-term medical and psychological sequelae that frequently result from this trauma.

Adolescent↗