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Biomedical subjects

E L Spitznagel

Publications and source records attributed to E L Spitznagel.

At least 55 records · Page 3Linked to original sources
PubMed1993

Subjective reports of withdrawal among cocaine users: recommendations for DSM-IV.

The proposed DSM-IV criteria for substance use disorders have included, as an option, a subtyping for physiologic dependence, characterized by either tolerance or withdrawal. Even if this option is not chosen at this stage of system revision, this weighting scheme justifies wider surveillance of these symptoms, especially for the more newly described cocaine dependence disorder. Wider surveillance of withdrawal is possible with the CIDI Substance Abuse Module (SAM), a WHO/ADAMHA diagnostic interview which covers criteria of substance use disorders according to the DSM-III, III-R, ICD-10 and proposed DSM-IV systems. To aid in this effort, we used the SAM, which includes a master list of all symptoms (n = 16) in the DSM manuals related to withdrawal from any substance to assess withdrawal symptoms from all substances. In this study, we hypothesized that the persons who used opiates with cocaine might misattribute their symptoms to cocaine; thus, we compared the responses of persons who used cocaine and opiates (opiate users) with the responses of persons who used cocaine without opiates (non-opiate users). Data from two St. Louis studies were combined for these analyses, users not in treatment or newly enrolled to drug-free or methadone treatment from a NIDA demonstration project and users selected for the St. Louis DSM-IV Field Trial. Of the 196 persons included from the field trial, 80% reported lifetime cocaine use compared with 91% of the 412 persons from the demonstration project. The symptoms mentioned in the diagnostic manuals were among the most frequently endorsed by both cocaine use groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Cytomegalovirus infection and pneumonitis. Impact after isolated lung transplantation. Washington University Lung Transplant Group.

Using aggressive surveillance of blood, bronchoalveolar lavage (BAL) fluid, and lung tissue, we sought to determine the incidence of cytomegalovirus (CMV) pneumonitis in isolated lung transplant recipients and to characterize its impact on pulmonary function, chronic rejection, and survival. Forty-six lung transplant recipients who survived greater than 30 days had prospective documentation of CMV infection in blood and BAL fluid and regular surveillance with transbronchial lung biopsy. CMV infection was documented in 92% of patients who were D-/R+, D+/R+, or D+/R-, and the incidence of histologically confirmed CMV pneumonitis among these patients was 75%. No D-/R- patient experienced CMV infection or disease. D+/R- patients experienced more frequent and severe episodes, and ganciclovir prophylaxis during the first 2 wk was not useful. CMV pneumonitis was accompanied by detectable radiographic changes in less than one third of cases. The detection of CMV in BAL fluid was not predictive of CMV pneumonitis on biopsy, except in D+/R- patients during the first 90 days after transplantation. There was no evidence of an adverse impact because of CMV infection on pulmonary function during the first year after transplantation. A relationship between CMV infection and bronchiolitis obliterans could not be documented; however, D+/R- patients had higher morbidity and a trend toward lower survival. In a multivariate analysis, D+/R- status was an independent predictor of death.

Adult↗
PubMed1993

Is antisocial personality a valid diagnosis among the homeless?

OBJECTIVE: It has been argued that among the homeless many of the features of antisocial personality may be artifacts of homelessness and that strict application of the diagnostic criteria may be insensitive to social and cultural factors in this group. The authors studied a large group of homeless men and women to investigate the appropriateness of the diagnosis of antisocial personality disorder among the homeless. METHOD: Six hundred homeless men and 300 homeless women were randomly selected from shelters and street locations in St. Louis and interviewed with the National Institute of Mental Health Diagnostic Interview Schedule. RESULTS: In this sample of homeless men and women, most, but not all, adult symptoms of antisocial personality disorder were significantly associated with number of childhood conduct disorder symptoms. The onset of symptoms of antisocial personality disorder usually preceded the onset of homelessness. The rates of antisocial personality disorder were not significantly affected by discounting the antisocial disorder symptoms thought to be confounded with homelessness. CONCLUSIONS: Overall, the data support the appropriateness of the diagnosis of antisocial personality disorder among homeless populations. It cannot be said from these data that homelessness often leads to antisocial behaviors.

Adolescent↗
PubMed1993

Epidermoid carcinoma of the oral cavity and oropharynx: validity of the current AJCC staging system and new statistical tools for the prediction of subclinical neck disease.

The 1983 and 1988 AJCC T- and N-staging systems were compared using the case records of 531 patients with primary epidermoid malignancies of the oral cavity. All patients had a minimum followup of 5 years. There were 390 patients with early stage (T1, T2) disease and 141 with advanced stage (T3, T4) lesions according to both the 1983 and 1988 T-definitions: 342 patients manifested no clinical nodes (NO), 189 had clinically evident nodes (N1-N3), and none had metastatic disease. Cox regression analysis demonstrated that the 1983/1988 T-stage definitions differentiated survival successfully (p < 0.001). The 1988 staging system for nodal disease showed a highly significant separation of N2 and N3 when compared with the 1983 system (p < 0.001). Of the 342 patients who were staged N0, 154 had primary neck dissection. Logistic regression predicted the incidence of subclinical disease according to the site and the T-stage of the primary tumor with a sensitivity of 78% and a specificity of 95%. We conclude that the 1988 N-stage definition is a better prognosticator of survival than the 1983 definition. Furthermore, a logistic regression model can be used to predict the probability of subclinical disease in primary oral cavity cancers.

Adolescent↗
PubMed1993

Clinical staging for primary malignancies of the supraglottic larynx.

A study of 520 patients with primary supraglottic cancer was conducted. The tumors were staged according to the 1983 and 1988 American Joint Committee on Cancer (AJCC) T- and N-stage definitions. There were 293 patients with early stage (T1, T2) tumors, 227 with advanced stage (T3, T4) tumors and 428 with early nodal disease (N0, N1) in both systems. In the 1983 N-staging, there were 44 N2 and 48 N3 lesions; in the 1988 N-staging, there were 62 N2 and 30 N3 lesions. Cox regression analysis showed that the 1983 and 1988 T-stage (T1 through T4) definitions successfully prognosticate for survival when patients were without neck node involvement. In contrast, when neck nodes were present, the N-stage (N0 through N3) of the disease prognosticated survival better than T-stage. Further analyses showed that the 1988 N-stage definition provided a better separation between N2 and N3 lesions compared to the 1983 version. Combined-modality treatment (surgery and radiation) significantly improved survival compared to single-modality treatment (surgery or radiation alone) when patients were staged T4 and N0 through N3 neck disease, but not when patients advanced from T1 to T3. Comparison of treatment efficacy over the last four decades for single- and combined-modality treatment did not reveal statistically significant differences in survival rates in our patient population. This was consistent with cumulative results of various institutions over the last four decades. We conclude that the 1988 AJCC T- and N-stage definitions successfully prognosticate for T-stage (T1 through T4) and N-stage (N0 through N3) with better separation of N2 and N3 lesions compared to the 1983 version.

Adenocarcinoma↗
PubMed1993

Alcohol, drugs, and psychiatric comorbidity among homeless women: an epidemiologic study.

BACKGROUND: Very little is known about the mental health of homeless women. The present study is one of the first to focus on psychiatric diagnosis and comorbidity in a population of homeless women systematically interviewed with a structured instrument. METHOD: Three hundred homeless women randomly selected from St. Louis shelters were interviewed using the Diagnostic Interview Schedule (DIS). RESULTS: The population of homeless women in St. Louis is predominantly young adult, single, and black; most have young children and average nearly a high school education. Schizophrenia and bipolar affective disorder account for only a small portion of the mental illness in these women. Nearly one in three has a history of substance abuse, with drug abuse being more prevalent than alcoholism. One third of the sample met lifetime criteria for posttraumatic stress disorder. One fourth of the women have received inpatient psychiatric care, and the majority with a nonsubstance Axis I diagnosis have received some mental health treatment. CONCLUSION: Although major mental illness is overrepresented among these homeless women, the majority do not suffer from major mental illness. Despite the severity of the stressors these women face, the large numbers escaping psychiatric disorders speak to their resilience and to the likelihood that important factors other than mental illness contribute to their homelessness. Future studies to examine positive outcomes and investigate protective factors might provide a valuable source of information on coping with the stresses associated with homelessness and point to more effective interventions.

Adolescent↗
PubMed1992

Posttraumatic stress disorder among substance users from the general population.

OBJECTIVE: The purpose of the study was to evaluate the prevalence of posttraumatic stress disorder (PTSD) among substance users in the general population. METHOD: The St. Louis Epidemiologic Catchment Area study, a survey of psychiatric illness in the general population, collected data on PTSD and substance use with the Diagnostic Interview Schedule. Among the 2,663 respondents, 430 reported a traumatic event that could qualify for PTSD; however, the rate of PTSD was low, 1.35% overall. To evaluate the relationship between PTSD and substance use, respondents were hierarchically classified into one of four substance use categories ranging from polydrug use to alcohol use only. Substance users from each category as well as substance users in general were compared with persons who did not meet the substance use threshold (comparison subjects). RESULTS: Findings indicate that cocaine/opiate users are over three times as likely as comparison subjects to report a traumatic event, report more symptoms and events, and are more likely to meet diagnostic criteria for PTSD. Physical attack, but not combat-related events, was the most prevalent event reported among cocaine/opiate users. Onset of substance use preceded onset of posttraumatic symptoms, suggesting that substance use predisposes the individual to exposure to traumatic events. When other variables--including antisocial behavior--were controlled, female gender and use of cocaine/opiates predicted PTSD. CONCLUSIONS: These analyses of the co-occurrence of substance abuse and PTSD warrant further study and suggest that PTSD is much more common among substance abusers than was previously known.

Adolescent↗
PubMed1991

Do life events or depression exacerbate inflammatory bowel disease? A prospective study.

OBJECTIVE: To determine whether depressed mood or life events are associated with an exacerbation of inflammatory bowel disease. DESIGN: A prospective study of a consecutive sample of patients with relapsing inflammatory bowel disease, followed by monthly questionnaires and periodic office visits. SETTING: A referral-based gastroenterology clinic at a medical school. PATIENTS: A consecutive sample of 32 patients with inflammatory bowel disease who had had at least one relapse in a 2-year period after entry into the study. MEASUREMENTS AND MAIN RESULTS: The Social Readjustment Rating Scale (measuring life events), the Beck Depression Inventory (a visual analog scale for depressed mood) and an inventory of intestinal symptoms were completed monthly by each subject with a 78% rate of compliance. A mean of 2.2 exacerbations was seen per subject during the study period. Life events were not temporally associated with changes in intestinal symptoms. Significant associations were found between intestinal symptoms and the two mood scales (P less than 0.05 for each), but no directionality in symptom occurrence could be detected in a time-lagged analysis. The results were similar when the months preceding exacerbations of inflammatory bowel disease were analyzed separately. CONCLUSIONS: Although these findings suggest that mood changed concurrently with exacerbation of inflammatory bowel disease, no evidence indicated that stressful life events or depressed mood precipitated exacerbations in this study group.

Colitis, Ulcerative↗
PubMed1991

Agreement between DSM-III and III-R substance use disorders.

With proposed criteria for DSM-IV substance dependence imminent, an evaluation of the impact of changes from DSM-III to DSM-III-R would be informative. Recent admissions to St. Louis drug treatment centers were interviewed with the DIS-III-R, which covers criteria from both systems. Kappa values for system agreement, diagnostic overlap and percent positive agreement are reported by substance. The DSM-III-R system cast a wider net for dependence than DSM-III for alcohol, tobacco and amphetamines. Neither system predominated for cannabis, opioids and barbiturates/sedatives/hypnotics. Reasons for differences and implications of findings are discussed.

Adolescent↗
PubMed1991

New methods in cross-cultural psychiatry: psychiatric illness in Taiwan and the United States.

OBJECTIVE: Cross-cultural psychiatric research has suffered from many methodological shortcomings. To answer some of these shortcomings, the present study compared rates of psychiatric disorders in Taiwan and the United States by combining data from both countries into a single data set. METHOD: Results from large, community-based surveys in the United States and Taiwan, the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area survey and the Taiwan Psychiatric Epidemiological Project, were combined into a single data set. This integration of the data sets was possible because both surveys used the NIMH Diagnostic Interview Schedule to ascertain cases. The integrated data sets were then analyzed with identical algorithms to generate lifetime prevalence rates of psychiatric disorders according to DSM-III criteria for both the United States and Taiwan. RESULTS: Lifetime prevalence rates of psychiatric illness in Taiwan were generally lower than U.S. rates. The rates of any disorder were 21.56% in Taiwan and 35.55% in the United States (Z = 22.34, p less than 10(-109]. The rates of most specific disorders were lower in Taiwan, and none of the rates was higher in Taiwan. CONCLUSIONS: While a culturally determined response bias may have lowered the rates in Taiwan somewhat, the results appear to be valid. Implications for the future use of structured diagnostic interviews in cross-cultural research are discussed.

Algorithms↗
PubMed1991

Surgical pathology of cancer of the oral cavity and oropharynx.

A study was designed to determine the influence of certain surgical pathologic findings on tumor spread and survival in patients with cancer of the oral cavity and oropharynx. All patients with the histopathological diagnosis of carcinoma of the oral cavity or oropharynx from 1955 to 1983 were included in the study. Using the Head and Neck Tumor Registry of the department of otolaryngology of the Washington University School of Medicine, information was obtained regarding preoperative evaluation, staging, classification, diagnosis, treatment, surgical pathology parameters, and outcome results. The patient populations consisted of 545 patients with oral cavity cancer and 224 patients with oropharynx cancer, all of whom were eligible for 3-year follow-up. Information from a retrospective analysis of the pretreatment examination records regarding site and size of the primary tumor and neck dissection, and specific treatment, and from surgical pathology reports regarding site, size, tumor spread and resection margins, was correlated with treatment outcome. The database file was analyzed using dbase III and its companion program Framework, and SAS PC (Statistical Analysis Systems for personal computers).

Cause of Death↗
PubMed1990

Anticonvulsant therapy increases fentanyl requirements during anaesthesia for craniotomy.

This study was designed to determine whether patients receiving chronic anticonvulsant therapy demonstrate an altered requirement for fentanyl during anaesthesia. Sixty-one patients undergoing craniotomy were studied; 20 controls (MED = 0) who had never received anticonvulsants and 41 epileptics in whom therapeutic plasma concentrations of either one (MED = 1), two (MED = 2), or three (MED = 3) different anticonvulsants were documented. During anaesthesia with 60-70 per cent N2O in O2 and 0.2 per cent isoflurane, a maintenance dose (MD) of fentanyl was administered using a continuous variable-rate IV fentanyl infusion, supplemented by intermittent 50 micrograms IV boluses. In order to define the minimal dosage of fentanyl required, the MD was titrated according to increases or decreases in the heart rate and/or mean arterial pressure exceeding 15 per cent of baseline ward values. A progressively higher fentanyl MD was required in the epileptic patients (MED = 1-4.3 +/- 0.5 microgram.kg-1.hr-1; MED = 2-5.4 +/- 0.6; MED = 3-7.6 +/- 0.6) compared with the control MD (MED = 0-2.6 +/- 0.5) (P less than 0.001). These findings indicate that there appears to be a dose-effect relationship between the number of anticonvulsants received and the maintenance dose of fentanyl required during balanced anaesthesia.

Adolescent↗
PubMed1990

The relation of ulcerative colitis to psychiatric factors: a review of findings and methods.

The authors reviewed all known English-language literature on the association between psychiatric factors and ulcerative colitis to ascertain the evidence for such an association and evaluate the methods used in these studies. Most of the 138 studies contained serious flaws in research design, such as lack of control subjects, unspecified manner of data collection, and absence of diagnostic criteria. Analysis revealed that methodological flaws were significantly related to the finding of a positive association between psychiatric factors and ulcerative colitis. Seven studies represented solid systematic investigation, and all seven failed to find such an association.

Adult↗
PubMed1990

Resistance to atracurium-induced neuromuscular blockade in patients with intractable seizure disorders treated with anticonvulsants.

Previous studies have demonstrated that, with the exception of atracurium, resistance to the neuromuscular blocking effects of various muscle relaxants develops in patients receiving anticonvulsant therapy. We studied the effects of 0.5 mg/kg IV atracurium in 53 neurosurgical patients: 21 nonepileptic patients receiving no anticonvulsant therapy (MED = 0); 14 epileptic patients treated with carbamazepine for years (MED = 1); and 18 epileptic patients treated with carbamazepine plus either phenytoin or valproic acid for years (MED = 2). The evoked compound electromyogram of the adductor pollicis brevis was recorded, and results were analyzed using analysis of covariance, with weight and age as covariables. The onset time was not significantly different among the three groups. Times for recovery of baseline and train-of-four responses to stimuli were significantly shorter in the MED = 1 and MED = 2 groups than in control patients (MED = 0). The recovery index (time between 25% and 75% recovery of baseline electromyogram values) was progressively shorter in the three groups (MED = 0: 8.02 min; MED = 1: 5.93 min; MED = 2: 1.96 min; P less than 0.001). This study demonstrates that atracurium, when used on epileptic patients requiring long-term (that is, years of) anticonvulsant therapy, has a shorter duration of action than when used in nonepileptic patients.

Adolescent↗
PubMed1990

Clinical classification and staging for primary malignancies of the maxillary antrum.

A study of 51 patients with primary malignant maxillary sinus neoplasms was conducted. None of the patients had neck nodes and/or metastases, and each had 5-year follow-up. The tumors were staged according to the 1983 and 1988 American Joint Committee on Cancer staging systems for maxillary sinus cancers. There were 13 early stage (T1, T2) and 38 advanced (T3, T4) tumors in both systems. Cox regression analyses of survival curves showed increasingly worse prognoses for advanced tumors in both T-staging systems. Further analyses showed a significant difference in survival between T3 and T4 in the 1988, but not in the 1983 system. There were no significant differences in survival according to treatment modality or histological type of malignancy. We conclude that the 1988 system prognosticates successfully for T-stage (1 to 4) and demonstrates significant improvement in detecting T3 versus T4 differences compared to the 1983 system. The 1988 system applies equally for epidermoid cancer and other malignancies of the antrum.

Adult↗
PubMed1988

Scheduling mammograms for asymptomatic women.

A decision theoretic model was used to investigate the relative importance of risk level, radiation hazard, mammographic accuracy, and cost in mammographic screening decision. The model uses woman-specific medical and family history facts and clinic-specific information regarding mammographic accuracy and practice to profile both woman and clinic, and to formulate periodic screening recommendations. Model parameters were varied extensively to investigate the sensitivity of screening schedules to input values. Multivariate risk was estimated within the program using published data from the Breast Cancer Detection Demonstration Project 5-year follow-up study. Radiation hazard estimates were developed from published radiation physics and radioepidemiologic risk data. Benchmark values for mammographic sensitivity and specificity under screening conditions were calculated from Breast Cancer Detection Demonstration Project data. Procedural costs used in the analysis were varied around values reflecting conditions at the Washington University Medical Center. Mortality advantages of early versus late breast cancer detection were accounted for using Health Insurance Plan of New York case survival rates. Results are compared with published screening policies to provide insight into implicit assumptions behind those policies. This analysis emphasizes the importance of accounting for variations in clinical accuracy under screening circumstances, in costs, in radiation exposure, and in woman-specific risk when recommending mammographic screening.

Aged↗