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Biomedical subjects

R S Epstein

Publications and source records attributed to R S Epstein.

At least 19 recordsLinked to original sources
PubMed2001

Gender differences in posttraumatic stress disorder after motor vehicle accidents.

OBJECTIVE: Women have higher rates of posttraumatic stress disorder (PTSD) than men. The authors examined prior trauma, PTSD, major depression, anxiety disorder not including PTSD, and peritraumatic dissociation; current peritraumatic dissociation; and passenger injury as possible explanations for the different rates of acute PTSD in women and men after a serious motor vehicle accident. METHOD: Subjects age 18-65 years who had been in a serious motor vehicle accident (N=122) were assessed with the Structured Clinical Interview for DSM-III-R and the Peritraumatic Dissociative Experiences Questionnaire-Rater Version 1 month after the accident. RESULTS: Women did not differ from men in meeting the overall reexperiencing criterion for a diagnosis of PTSD (criterion B), but women were at greater risk for the specific reexperiencing symptoms of intense feelings of distress in situations similar to the motor vehicle accident and physical reactivity to memories of the motor vehicle accident. Women were 4.7 times more likely than men to meet the overall avoidance/numbing criterion (criterion C) and 3.8 times more likely to meet the overall arousal criterion (criterion D). Women were more likely than men to report the criterion C symptoms of avoiding thoughts and situations associated with the accident, loss of interest in significant activities, and a sense of foreshortened future and the criterion D symptoms of trouble sleeping, difficulty concentrating, and exaggerated startle response. Multiple logistic regression analysis indicated that the gender differences in acute PTSD were not associated with prior trauma, PTSD, peritraumatic dissociation, major depression, or anxiety disorder not including PTSD or with passenger injury. However, peritraumatic dissociative symptoms at the time of the accident were associated with a significantly higher risk for acute PTSD in women than in men. CONCLUSIONS: Gender differences in peritraumatic dissociation may help explain differences in risk for PTSD and for some PTSD symptoms in women and men.

Accidents, Traffic↗
PubMed2000

Peritraumatic dissociation following motor vehicle accidents: relationship to prior trauma and prior major depression.

Individuals who dissociate at the time of a traumatic event (peritraumatic dissociation) are more likely to develop acute and chronic posttraumatic stress disorder (PTSD). However, little is known about who is at risk of peritraumatic dissociation. Motor vehicle accident subjects (N = 122) were systematically recruited and followed over 12 months. We used the Structured Clinical Interview for DSM-III-R (SCID) and the Peritraumatic Dissociative Experiences Questionnaire-Rater Version (PDEQ-RV). Younger subjects were more likely to experience peritraumatic dissociation as were white versus nonwhites, and single versus married subjects. Younger subjects reported a greater number of peritraumatic dissociative symptoms as did subjects with an injured passenger. After adjusting for age and passenger injury, prior major depression was significantly related to more peritraumatic dissociative symptoms. An interaction of age and prior major depression indicated that those who were younger and reported a history of major depression had the greatest number of peritraumatic dissociative symptoms.

Accidents, Traffic↗
PubMed2000

Apolipoprotein E gene polymorphism and bone loss: estrogen status modifies the influence of apolipoprotein E on bone loss.

The identification of genes that contribute to bone mineral density (BMD) and bone loss has widespread implications for the understanding and prevention of osteoporosis. The objective of this study was to examine the relationship between the presence and absence of the apolipoprotein E*4 (APOE*4) allele and both BMD and annualized percentage rate of change in BMD at the lumbar spine and hip in a population of 392 healthy, pre-, peri-, and postmenopausal white women participating in the Women's Healthy Lifestyle Project. APOE genotype was analyzed by restriction enzyme analysis from genomic DNA. BMD at the lumbar spine and hip was measured at baseline and after a mean of 2.5 years using dual-energy X-ray absorptiometry (DXA). In premenopausal women, there were no significant differences in BMD or in the annualized percentage rate of change in BMD at the spine or hip when comparing women with and without the APOE*4 allele. In contrast, spine bone loss was significantly greater in peri- and postmenopausal women having an APOE*4 allele than in women without this allele (-1.75 + 1.5% per year vs. -0.98 +/- 1.4% per year, respectively, p = 0.018). Among peri- and postmenopausal women currently using hormone replacement therapy (HRT), there were no differences in the annualized percentage rate of change in spine BMD; whereas, among non-HRT users, there was a 2-fold higher rate of spine bone loss in women with an APOE*4 allele compared with women without this allele (-2.31 +/- 1.5% per year vs. -1.27 +/- 1.3% per year, respectively, p = 0.033; APOE*4 x HRT interaction, p = 0.076). In conclusion, this study shows the importance of APOE*4 allele in spine bone loss in peri- and postmenopausal women and, more importantly, it provides evidence for a genetic and lifestyle interaction in modulating spine bone loss.

Adult↗
PubMed1999

Development and validation of the mini-osteoporosis quality of life questionnaire (OQLQ) in osteoporotic women with back pain due to vertebral fractures. Osteoporosis Quality of Life Study Group.

The objective of the study was to evaluate a shortened osteoporosis quality of life questionnaire (OQLQ) in osteoporotic women with back pain due to vertebral fractures. From the longer 30-item OQLQ (four to nine items per domain) we created the mini-OQLQ by choosing the two items with the highest impact in each of five domains (symptoms, physical function, activities of daily living, emotional function, leisure). We administered the OQLQ, the Sickness Impact Profile, the SF-36 and the Brief Pain Index to patients at baseline, after 2 weeks and after 6 months. The intraclass correlations between baseline and the 2-week follow-up for the five mini-OQLQ domains ranged from 0.72 to 0.86. Cross-sectional correlations between the domains of the mini-OQLQ and other health instruments were moderate to large (0.35-0.80) and greater than predicted. The mini-OQLQ items showed moderate to large correlations with items omitted from the shortened questionnaire (0. 44-0.88). Correlations between the OQLQ domains and the other three instruments were greater than those of the mini-OQLQ, and partial correlations between OQLQ items omitted from the mini-OQLQ and the other three instruments after considering mini-OQLQ items were substantial (0.19-0.71) and statistically significant. Sample sizes of less than 200 per group should be required to detect minimally important differences in parallel-group clinical trials. Longitudinal correlations between the mini-OQLQ and the other measures were often significant but generally lower than predicted (0.10-0.49). The partial correlations revealed that the omitted items explained a significant portion of the longitudinal variance in each domain. We conclude that in a selected group of patients with back pain caused by vertebral fractures, the mini-OQLQ demonstrated good discriminative and adequate evaluative properties. The mini-questionnaire should be useful in clinical settings.

Aged↗
PubMed1999

Effect of a lifestyle intervention on bone mineral density in premenopausal women: a randomized trial.

BACKGROUND: The positive association between body weight and bone mineral density (BMD) is well documented; in contrast, the effect of changes in body weight on BMD is not well understood, particularly, in normal-weight populations. OBJECTIVE: We examined the effect of a lifestyle intervention aimed at lowering dietary fat intake and increasing physical activity to produce modest weight loss or prevent weight gain on BMD in a population of 236 healthy, premenopausal women aged 44-50 y. DESIGN: All women were participating in a clinical trial known as The Women's Healthy Lifestyle Project and were randomly assigned to intervention or control groups. Dual-energy X-ray absorptiometry of BMD at the lumbar spine and proximal femur were made before and after 18 mo of participation in the trial. RESULTS: The intervention group (n = 115) experienced a mean (+/-SD) weight loss of 3.2 +/- 4.7 kg over the 18 mo compared with a weight gain of 0.42 +/- 3.6 kg in the control group (n = 121) (P < 0.001). The annualized rate of hip BMD loss was 2-fold higher (P < 0.015) in the intervention group (0.81 +/- 1.3%) than in the control group (0.42 +/- 1.1%); a similar, although nonsignificant pattern was observed for the loss in spine BMD: 0.70 +/- 1.4% and 0.37 +/- 1.5% (P = 0.093) in the intervention and control groups, respectively. Large increases in physical activity attenuated spine BMD loss, but had no significant effect on BMD loss at the hip. CONCLUSIONS: The intervention group, who modified their lifestyle to lose weight, had a higher rate of BMD loss at the hip and lumbar spine than did the weight-stable control group. Recommendations for weight loss must be made with consideration that such an endorsement may result in BMD loss.

Adult↗
PubMed1999

Peritraumatic dissociation and posttraumatic stress disorder following motor vehicle accidents.

OBJECTIVE: This study examined the relation between peritraumatic dissociation and posttraumatic stress disorder (PTSD) in victims of motor vehicle accidents. METHOD: Victims of serious motor vehicle accidents (N = 122) were assessed for peritraumatic dissociation with the Peritraumatic Dissociative Experiences Questionnaire-Rater Version and followed longitudinally to assess acute and chronic PTSD (1 month and 3 months after the accident) with the Structured Clinical Interview for DSM-III-R. RESULTS: The most common peritraumatic dissociative symptom was time distortion (56.6%). Subjects with peritraumatic dissociation were 4.12 times more likely than those without to have acute PTSD and 4.86 times more likely to develop chronic PTSD. The risk was independent of risk associated with the presence of PTSD before the accident. CONCLUSIONS: Peritraumatic dissociation is common following motor vehicle accidents and is a risk factor for acute and chronic PTSD, independent of risk associated with prior PTSD.

Accidents, Traffic↗
PubMed1999

Acute and chronic posttraumatic stress disorder in motor vehicle accident victims.

OBJECTIVE: This study reports the rates of acute and chronic posttraumatic stress disorder (PTSD) in a suburban community study group of 122 victims of serious motor vehicle accidents and a comparison group of 42 (who had been involved in minor, non-motor-vehicle accidents) followed over 12 months. METHOD: Motor vehicle accident victims were systematically recruited and examined with comparison subjects at 1, 3, 6, 9, and 12 months after the accident. The authors used the Structured Clinical Interview for DSM-III-R to assess DSM-III-R axis I disorders including PTSD. RESULTS: One month after the accident, 34.4% of the motor vehicle accident victims met criteria for PTSD (versus 2.4% of the comparison subjects). Similarly, at 3 and 6 months, rates of PTSD were higher (25.2% and 18.2%) in the motor vehicle accident victims than in the comparison group. Female victims were 4.64 times more likely than male victims to have PTSD at 1 month. Victims with a history of PTSD were 8.02 times more likely at 1 month and 6.81 times more likely at 3 months to have PTSD than those without a history of PTSD. Having an axis II disorder increased the risk for PTSD at 6 months. After adjustment for a history of PTSD and potentially confounding variables, women were 4.39 times more likely than men to develop PTSD at 1 month but did not have a higher risk for chronic PTSD; at 6 months, those with an axis II disorder were at greater risk of PTSD. CONCLUSIONS: Rates of PTSD are high in victims of serious motor vehicle accidents and remain high 9 months later. Female victims have an increased risk of acute but not chronic PTSD. Individuals with a history of PTSD are at risk of acute and chronic PTSD. An axis II disorder increases the risk for chronic but not acute PTSD.

Accidents↗
PubMed1999

Frontier ethics: mental health care needs and ethical dilemmas in rural communities.

Roughly 15 million of the 62 million rural U.S. residents struggle with mental illness and substance abuse. These rural dwellers have significant health care needs but commonly experience obstacles to obtaining adequate psychiatric services. Important but little-recognized ethical dilemmas also affect rural mental health care delivery. Six attributes of isolated settings with limited resources appear to intensify these ethical dilemmas: overlapping relationships, conflicting roles, and altered therapeutic boundaries between caregivers, patients, and families; challenges in preserving patient confidentiality; heightened cultural dimensions of mental health care; "generalist" care and multidisciplinary team issues; limited resources for consultation about clinical ethics; and greater stresses experienced by rural caregivers. The authors describe these features of rural mental health care and provide vignettes illustrating dilemmas encountered in the predominantly rural and frontier states of Alaska and New Mexico. They also outline constructive approaches to rural ethical dilemmas in mental health care.

Adult↗
PubMed1998

Are menopausal symptoms associated with bone mineral density and changes in bone mineral density in premenopausal women?

BACKGROUND: The relationship between menopausal symptoms and bone mineral density (BMD) was examined in 290 premenopausal women, ages 44-50 years, participating in a randomized clinical trial of a dietary and exercise intervention: The Women's Healthy Lifestyle Project. METHODS: Information on hot flashes (presence, absence), menstrual cycles (irregular, regular) and menstrual flow per period (variable, same) over the past 6 months was collected at entry. Participants reporting at least one menopausal symptom were classified as symptomatic and compared to those having no symptoms. Bone mineral density (BMD) at the lumbar spine (L1-L4), total hip and whole-body were made at baseline and at 30 months using a dual-energy X-ray absorptiometer (Hologic QDR 2000 densitometer). RESULTS: Baseline BMD at the spine, hip and whole-body were significantly reduced in women reporting menopausal symptoms compared to asymptomatic women, after adjustment for age, weight and intervention status (all p < 0.05). Women with irregular menstrual cycles had greater annualized rates of bone loss at the spine and hip than asymptomatic women (spine, -0.77 (1.6)% per year vs. -0.19 (1.0)% per year, p = 0.0043; hip, -0.37 (1.1)% per year vs. -0.04 (1.0)% per year, p = 0.061), after adjustments for age, percent change in weight, intervention status, and baseline BMD. Similar findings were not found for whole-body BMD. CONCLUSIONS: These results suggest that menopausal symptoms are useful for the effective identification of premenopausal women at higher risk of low BMD and perhaps, of osteoporosis.

Absorptiometry, Photon↗
PubMed1998

Cytokine production and bone mineral density at the lumbar spine and femoral neck in premenopausal women.

Cytokines such as interleukin-1 (IL-1beta), interleukin-6 (IL-6) and tumor necrosis factor (TNF-alpha) can influence both bone resorption and bone formation. The objective of this cross-sectional study was to examine the relationship between cytokine production by peripheral blood mononuclear cells (PBMC) and bone mineral density (BMD); the annual rate of change in BMD was examined. Subjects participating in a randomized clinical trial entitled the Women's Healthy Lifestyle Project in Allegheny County, Pennsylvania were used. They included 50 healthy premenopausal women, aged 45-52 years, who had regular menses within the past 3 months and were not on replacement estrogens. Dual-energy X-ray absorptiometry measurements at the AP lumbar spine and femoral neck were made at baseline and at the first annual exam using a Hologic QDR 2000 densitometer. Cytokine production of IL-1beta, IL-6, and TNF-alpha by PBMC was measured at the annual exam. The median values for stimulated cytokine production by PBMC were 3.92 ng/ml, 31.3 ng/ml, and 1.05 ng/ml, for IL-1beta, IL-6, and TNF-alpha, respectively. There were modest correlations between cytokine production and cross-sectional BMD, ranging from r = -0.30 to r = -0.13. Trends of greater spinal bone loss were observed in women with "high" (>/=75th percentile) cytokine production of stimulated IL-1beta and IL-6 (IL-1beta: "high" = -1.56% +/- 0.70 versus "low" (<75th percentile) = -0.56% +/- 0.35, P = 0.21). In contrast, greater annual gains in femoral neck BMD were observed in those with high cytokine production of IL-1beta and IL-6 (IL-1beta: high = 3.39% +/- 1.16 versus low = -0. 85 +/- 0.58, P = 0.002). There was no association between stimulated TNF production and annual change in BMD. In this population of healthy premenopausal women, the relationship between cytokine production by PBMC and the rate of change in BMD was significantly different for the lumbar spine and femoral neck, possibly reflecting differences in the proportion of trabecular and cortical bone at these sites.

Adult↗
PubMed1998

A pharmacy benefit manager perspective.

Lipid-lowering therapy can account for 7% of per patient per month drug costs. Because this can be a significant proportion of a payer's drug expenditure, this class of drugs attracts payers' attention and thus becomes a focus of efforts designed to control drug expenditures. Pharmacy benefit managers (PBMs) use several techniques and capabilities to affect the use of these drugs to improve overall medical care and to capture financial opportunities. There is a gap between the marketplace needs for lipid therapy value information and current pharmacoeconomic evaluations of lipid therapy. The measurement units that current pharmacoeconomic analyses tend to use are not necessarily intuitive and do not easily conform to the existing conceptual framework of policy makers. The successful evaluation of PBM activities will be contingent on a recognizable and widely accepted quantitative measurement framework.

Journal Article↗
PubMed1998

Posttraumatic stress disorder following an air disaster: a prospective study.

OBJECTIVE: The purpose of this study was to determine predictors of posttraumatic stress disorder (PTSD) in health care workers exposed to a disaster, in order to facilitate early case identification and prevention of subsequent morbidity. METHOD: Following an air disaster, 355 military medical health care workers were studied over an 18-month follow-up period. Measures included assessment of peritraumatic reactions associated with the disaster, the frequency of other stressful events after the disaster, and standard PTSD rating scales at 6, 12, and 18 months. RESULTS: Multivariate logistic regression of data on health care workers who cared for victims of the air disaster showed that PTSD was more likely to develop in those who had not completed college, those who had worked with burn victims, those who had experienced more stressful life events in a period of approximately 6 months following the disaster, and those who experienced emotional numbness immediately after the disaster. CONCLUSIONS: Results suggest that lower levels of education, exposure to grotesque burn injuries, stressful life events following exposure, and feelings of numbness following exposure are useful predictors of subsequent development of PTSD.

Accidents, Aviation↗
PubMed1998

Eight-year outcome associated with clinical options in the management of femoral neck fractures.

This study involved a review of the medical records of 367 patients treated surgically after femoral neck fracture. Linkage of these records with claims files from the Health Care Financing Administration allowed as many as 8 years of followup to analyze the rates of hospital readmission rates for revision, other postoperative complications and mortality. The results revealed: (1) a significantly higher revision rate was associated with internal fixation for the treatment of displaced femoral neck fractures in patients older than 80 years of age; no differences in revision rates were seen between internal fixation or hemiarthroplasty for the treatment of nondisplaced femoral neck fractures in this patient age group; (2) no differences in revision rates were found between internal fixation or hemiarthroplasty for the treatment of displaced femoral neck fractures in patients between the ages of 65 to 80 years; (3) a significantly higher mortality rate was associated with internal fixation than hemiarthroplasty for patients who were between the ages of 65 and 80 years; and (4) no differences in medical or surgical complications, revision rates, or other outcomes were found between unipolar and bipolar prostheses, or between anterior and posterior surgical approaches for hemiarthroplasty in patients who were age 65 years or older.

Age Factors↗
PubMed1997

Phalangeal bone density and hip fracture risk.

OBJECTIVE: To assess the long-term predictive usefulness of radiographic absorptiometry measurements of phalangeal bone density for hip fracture risk. METHODS: Participants were members of the First National Health and Nutrition Examination Survey Epidemiologic Follow Up Study cohort. Subjects were followed up for a maximum of 16 years. The First National Health and Nutrition Examination Survey data were obtained from a nationally representative sample of non-institutionalized civilians. A cohort of 3481 white and black subjects (1559 white women) aged 45 through 74 years at baseline (1971-1975) were observed through 1987. Ninety-eight percent of the original cohort completed the study. Hospital records and death certificates were used to identify a total of 72 hip fracture cases. Phalangeal bone density at baseline was measured using photodensitometry (PD), and later reanalyzed by radiographic absorptiometry (RA), a newer, more sophisticated technique. RESULTS: Results were evaluated to determine the relative risk for hip fracture per 1-SD decrease in bone density, after controlling for age at baseline, race, gender, weight, and previous fractures. Both RA and PD measurements showed a significant inverse relationship to hip fracture risk, with RA density measurements showing a slightly higher adjusted relative risk per 1-SD density decrease than PD measurements. For RA bone density, the relative risk for all subjects was 1.81 (95% confidence interval, 1.34-2.44) compared with 1.57 (95% confidence interval, 1.19-2.07) for PD bone density after adjusting for age at baseline, race, gender, weight, and previous fractures. Results for white women were essentially the same as those for all subjects for RA bone density and PD bone density. CONCLUSIONS: Phalangeal bone density determined from standard hand x-ray films is a significant predictor of future hip fracture risk. Availability of a valid method to assess fracture risk using conventional radiographs will expand the ability to identify individuals with osteoporosis.

Absorptiometry, Photon↗
PubMed1997

Risk factors associated with women's compliance with estrogen replacement therapy.

An epidemiologic study was carried out in 2106 women 46-63 years of age to determine risk factors associated with their compliance or noncompliance with estrogen replacement therapy (ERT). Data were obtained from prescription refill and medical claims information from centralized prescription and medical claims databases of a United Healthcare-affiliated health plan in Minnesota. Study participants filled their first ERT prescription during calendar year 1989 or 1990. Our results indicate that women who are older, use a progestin, experience hormone replacement therapy side effects, or see a gynecologist or male physician are more likely to be noncompliant. Women who have cardiovascular problems, experience menopausal symptoms, or use transdermal estrogen are more likely to be compliant. These results suggest that the factors associated with compliance are those that indicate that women perceive a benefit from ERT use. The factors associated with noncompliance are hormone side effects and gender and specialty of the physician prescribing the estrogen.

Aged↗