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Indexes of functional disability are being used increasingly to rate the status of patients studied in clinical research or treated in clinical practice. To determine why so many indexes have been developed and to evaluate their scientific quality, we reviewed the construction and other attributes of 43 indexes that offer ratings for activities of daily living. The six most prominent problems, and some proposed solutions, are as follows: Ratings for the magnitude of performed tasks will be misleading unless the patient's effort or collaboration is suitably considered. Each patient's preferences should be sought to determine which types of disability are the most important goals of therapy. Special transition indexes should be developed if subtle or overt changes are not discerned from the repeated use of single-state indexes. Hierarchical scale arrangements can avoid the loss of descriptive power that occurs when multiple variables are aggregated merely as summations. Documentary evidence can be required to demonstrate the anticipated achievements of an index. New indexes can be constructed if the high statistical "reliability" and "validity" of established indexes are not accompanied by satisfactory clinical "sensibility." [ABSTRACT FROM AUTHOR]

The 'epidemiological necropsy' is a newly proposed research strategy in which the size and composition of the epidemiological reservoir of undetected disease is estimated from the relative frequency of necropsy surprise patients, in whom the disease was not suspected during life. The current study was done to help validate a basic premise of the strategy. We examined the surprise necropsy discovery of two upper gastrointestinal malignancies: oesophageal cancer, for which an undetected reservoir would not be expected because the cancer has little room to grow, and gastric cancer, for which a sizeable reservoir might be anticipated. In a review of 15,812 necropsies during 1953-1982 at Yale-New Haven Hospital, 70 cases of oesophageal cancer were identified postmortem. Except for five surprise cases, located at the gastro-oesophageal junction where there is room to grow, no oesophageal cancer reservoir was found during the 30-year period. In the same secular period, however, a distinctive set of reservoir cases was found among 162 necropsy instances of gastric cancer. About two-thirds of these gastric cancers had been previously diagnosed during life, but the remainder consisted of either necropsy surprise cases or patients with wrong primary cancer diagnoses during life. The secular rates of occurrence remained stable and similar in both sexes for surprise gastric cancer cases during the three 10-year periods from 1953-1982, but no wrong primary diagnoses occurred during 1978-1982, after the introduction of improved methods of premortem diagnosis. The results help validate the cancer reservoir theory for malignancies that have room to grow, and confirm the concept that the 'epidemiological necropsy' can reflect qualitative and quantitative changes in cancer reservoirs.