Biomedical subjects
Garrett Fitzmaurice
Publications and source records attributed to Garrett Fitzmaurice.
Pain management of first-trimester surgical abortion: effects of selection of local anesthesia with and without lorazepam or intravenous sedation.
OBJECTIVE: This prospective observational study compared the effectiveness and acceptability of three commonly used regimens to reduce pain during first-trimester surgical abortion with local anesthesia. METHOD: Women undergoing suction curettage at less than 14 weeks gestation received preoperative ibuprofen and an intraoperative paracervical block. Participants then selected (1) no additional medication (local arm), (2) sublingual lorazepam (0.5 to 1 mg, approximately 20 min preoperatively) or (3) intravenous sedation with fentanyl and midazolam (doses from 50 to 125 microg of fentanyl and 1-2 mg of midazolam). Our primary outcome was intraoperative pain as measured on an 11-point verbal rating scale (0=no pain and 10=worst pain ever). RESULTS: Three-hundred thirty women were enrolled, 105 chose local, 106 opt for lorazepam and 119 picked intravenous sedation. Mean pain scores were 6.2 for local, 6.8 for lorazepam and 5.7 for intravenous sedation. Increased preoperative anxiety, depression and expected pain and a lower volume of local anesthesia used (10 mL vs. 20 mL) were positive predictors of intraoperative pain. Using multivariable analyses to control for these confounders, plus gestational age, alcohol use and body mass index, intravenous sedation was associated with a 0.86 point lower pain score (p<.005), and the local and lorazepam groups were not significantly different. Compared with the referent group (local), participants who received lorazepam were significantly less satisfied with pain control (23.8% vs. 6% unsatisfied; OR=1.93, 95% CI=1.13 to 3.26). CONCLUSION: In women who self-selected their type of anesthesia, intravenous sedation using fentanyl and midazolam decreased pain with suction curettage under local anesthesia. Sublingual lorazepam as studied did not decrease pain compared with local anesthesia alone and was associated with more dissatisfaction with pain control.
Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital.
BACKGROUND: Because of the relationship between inpatient hyperglycemia and adverse patient outcomes, current guidelines recommend glucose levels less than 180 mg/dL in the non-ICU inpatient setting and the use of effective insulin protocols for appropriate patients. OBJECTIVE: To determine the current state of glucose management on an academic hospitalist service and the relationship between insulin-ordering practices and glycemic control. DESIGN: Prospective cohort study. SETTING: Hospitalist-run general medicine service of an academic teaching hospital. PATIENTS: 107 consecutive patients with diabetes mellitus or inpatient hyperglycemia. MEASUREMENTS: We collected data on up to 4 bedside glucose measurements per day, detailed clinical information, and all orders related to glucose management. The primary outcomes were rate of hyperglycemia (glucose > 180 mg/dL) per patient and mean glucose level per patient-day. RESULTS: The mean rate of hyperglycemia was 31% of measurements per patient. Basal insulin was ordered for 43% of patients, and scheduled rapid- or short-acting insulin was ordered for 4% of patients. Sixty-five percent of patients who had at least 1 episode of hyper- or hypoglycemia had no change made to any insulin order during the first 5 days of the hospitalization. When adjusted for clinical factors, the use of sliding-scale insulin by itself was associated with a 20 mg/dL higher mean glucose level per patient-day. CONCLUSIONS: Management of diabetes and hyperglycemia on a general medicine service showed several deficiencies in process and outcome. Possible targets for improvement include increased use of basal and nutritional insulin and daily insulin adjustment in response to hyperglycemia.
Confounding: regression adjustment.
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Major depression in the transition to adulthood: the impact of active and past depression on young adult functioning.
This study examined the association between active and past major depression and deficits in young adult functioning using data from a longitudinal community study (N = 354). Three groups were compared: (1) participants with a 1-year diagnosis of major depression at age 26 (active group); (2) those who experienced major depression during the transition to adulthood, ages 18-25, but did not have active depression at age 26 (past group); and (3) individuals not meeting diagnostic criteria for depression during the transition period. Results highlight serious deficits in psychosocial functioning at age 26 linked to both active and past depression. Although participants with active depression experienced the greatest number of problems, those with past depression evidenced similar deficits across many important domains of functioning. The significant impairments characterizing those with past depression indicate the need for continued monitoring to decrease the risk of recurrence and the establishment of a chronic course of illness.
Maternal smoking during pregnancy and offspring overt and covert conduct problems: a longitudinal study.
BACKGROUND: Empirical evidence demonstrates that conduct disorder (CD) symptoms tend to cluster into covert and overt domains. We hypothesized that overt and covert CD symptoms may be distinct constructs with distinct risk factors. An important risk factor for CD is maternal smoking during pregnancy. We further investigated this association, attending to overt and covert CD symptom subtypes. Also, we tested whether gender and socioeconomic status (SES) modified this association. METHOD: Participants were male and female adult offspring (n = 682) of a community sample of pregnant women followed longitudinally from prenatal life to age 22. Prospective assessments of maternal smoking during pregnancy were used to predict self-reported DSM-III CD symptoms. RESULTS: Prenatal exposure to smoking was significantly associated with increased overt CD symptoms for participants of low SES, but not for participants of high SES, whereas covert CD symptoms were not associated with prenatal exposure. Gender did not significantly modify the relationship between maternal smoking and CD symptom subtypes. CONCLUSIONS: These results suggest that the previously documented association between maternal smoking and CD may be specific to overt CD symptoms, providing support for the heuristic value of differentiating overt and covert CD symptoms as distinct syndromes. These findings further support smoking prevention programs for pregnant women.
The application of a random effects model to censored twin data.
The authors propose a random effects model to analyze the latent genetic and environmental effects on determining censored outcomes in twin studies. In this model, six normally distributed random effects are used to describe the correlation within twin pairs. The authors employ a Monte Carlo Expectation-Maximization approach for obtaining maximum likelihood estimates of fixed effects and the variances of random effects. The variances of the random effects are reparameterized to be equivalent to genetic and environmental effects in traditional twin models. The authors illustrate this model using data from the Vietnam Era Twin Registry to explore the magnitude of the genetic influence on twin similarity for the age of onset of alcohol abuse. Our results show genetic factors contribute about one third of twin similarity in the age of onset of alcohol abuse in male twins. The application of this model to twin data is discussed.
Effects of marital transitions on changes in dietary and other health behaviours in US male health professionals.
STUDY OBJECTIVE: To examine the effect of change in marital status on health behaviours among men. DESIGN: Longitudinal study of repeated measures of marital status and health behaviours collected at four year intervals (1986-90; 1990-94). SETTING: US male health professionals. PARTICIPANTS: 38 865 men aged 40-75 in 1986. MAIN RESULTS: Relative to men who stayed married over four years, men who became widowed increased their alcohol consumption. Men who become divorced or widowed experienced decreases in body mass index. Compared with men who remained unmarried, men who remarried exhibited increases in body mass index along with decreased physical activity. Becoming divorced or widowed was associated with decreased vegetable intake while remarriage was linked to greater consumption. CONCLUSIONS: Marital termination may adversely affect health and dietary behaviours among men.
Genetic and environmental contributions to the development of alcohol dependence in male twins.
BACKGROUND: Information on the heritability of the development of alcohol dependence could provide a better understanding of the importance of genetic components in disease transition. OBJECTIVE: To examine the genetic and nongenetic contributions to the age at onset of regular alcohol use, the age at diagnosis of alcohol dependence, and the transition from regular alcohol use to alcohol dependence. DESIGN: Classic twin study. SETTING: General community. PARTICIPANTS: This study included 3372 twin pairs of known zygosity from the Vietnam Era Twin Registry. The diagnosis of DSM-III-R-defined alcohol dependence and related information were obtained through telephone-administered interviews conducted in 1992. MAIN OUTCOME MEASURES: Standardized proportions due to genetic vs nongenetic factors of the total variation in twin resemblance on the age at onset of regular alcohol use, the age at meeting criteria for a diagnosis of alcohol dependence, and the transition period from regular alcohol use to a diagnosis of alcohol dependence. RESULTS: Genetic influence accounted for 49% of the variation in the age at diagnosis of alcohol dependence. After adjusting for co-occurring psychiatric diseases, additive genetic factors still explained more than 37% of the variance in age at onset of alcohol dependence and at least 25% of the variance in the transition period between regular drinking and the diagnosis of alcohol dependence. Additionally, after grouping participants as early and late regular users of alcohol, the genetic effects on the transition period for early regular users were statistically significantly greater than those for late regular users. CONCLUSION: Our results demonstrate a substantial heritable basis for alcohol dependence according to its developmental sequence, including age at onset of regular use, age at diagnosis, and the transition period between regular use and diagnosis.
Adjusting for confounding.
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Genetic and environmental contributions to age of onset of alcohol dependence symptoms in male twins.
AIMS: To investigate genetic and environmental influences on the development of specific alcohol dependence symptoms. DESIGN AND PARTICIPANTS: A classical twin study of 3372 male-male twin pairs in the Vietnam Era Twin (VET) Registry based on telephone interviews about alcohol use. MEASUREMENTS: The nine diagnostic symptoms according to the Diagnostic and Statistical Manual of Mental Disorder, version III (revised) (DSM-III-R) definition of alcohol dependence. Symptoms were grouped into those based on impaired control, biological effects and social consequences (Beresford's classification) or early versus late symptoms (Nelson's classification). Survival models with random effects were used to examine the age of onset of each symptom. FINDINGS: Approximately 38% of the variation in age of onset of each symptom group based on Beresford's classification is due to additive genetic factors. The age of onset of late symptoms from Nelson's classification appears to be most affected by genetic factors. Estimates of genetic effects for impaired control symptoms are greatly decreased when twins with comorbid psychiatric disorders are excluded. CONCLUSIONS: Our results support the heritability of age of onset of DSM-III-R-defined symptoms for alcohol dependence. However, no symptom group in Beresford's classification could be identified as more heritable than other symptom groups. A strong association between genetic vulnerability and co-occurring diseases for symptoms indicative of impaired control could be found. In addition, our findings show that the late symptom group could be a good candidate for subsequent genetic research.
The use of multiple informants in identifying the risk factors of depressive and disruptive disorders--are they interchangeable?
OBJECTIVE: The aim of this study was to asses whether children and their parents identify the same risk factors for disruptive and depressive disorders and to analyze whether combining informant data with a rule that classifies the diagnosis as present if confirmed by at least one informant (OR rule) masks distinctive patterns identified in informant-specific analyses. METHOD: Bivariate logistic regression equations were estimated using the diagnostic classification, based on DISC 2.1, as the outcome variable and informant (parent or child), characteristics of the youth (gender and age), indicators of the context of the interview (site), and family characteristics (income, parental monitoring, and adverse family environment) as predictors. The same predictors were also analyzed with the combined informant (OR rule) as outcome variable. RESULTS: Prevalence of all diagnoses varied with informant. Depressive disorders were more prevalent when the informant was the youth and disruptive disorders when the informant was the parent. The effect of age varied with informant. Odds of being classified as having a DISC disorder increased with age when the informant was the youth but the same effect was not observed when the parent was the informant. When information from parents and youth are combined (with an OR rule) the age effect for disruptive disorders vanishes, and its effect for depressive disorders weakens. CONCLUSIONS: Informants are not interchangeable. Parent- and youth-based estimates of the prevalence of disruptive and depressive disorders were different and showed distinctive age relationships. Combining information from different sources (parents and youths) obscures the apparent effect of age noted in the two informant groups.
Confused by confounding?
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Childhood and adolescent predictors of major depression in the transition to adulthood.
OBJECTIVE: The identification of predictors of major depression in the transition to adulthood has direct application to prevention and intervention efforts designed to forestall depression in this high-risk period. The current study identified childhood and adolescent familial and behavioral-emotional factors predicting depression during this critical developmental stage. METHOD: The 354 participants were part of a single-age cohort from a predominately Caucasian working-class community whose psychosocial development has been traced prospectively since age 5. In these analyses, data collected during childhood and adolescence were related to diagnoses of major depression at ages 18-26. RESULTS: During the transition to adulthood, 82 participants (23.2%) experienced major depression. Bivariate indicators of later depression included a family history of depression or substance use disorders, family composition, and childhood family environments perceived as violent and lacking cohesiveness. Also significant were self- and mother-reported internalizing behaviors, as well as self-rated anxiety and depressive symptoms. Multivariable analyses showed family violence, family composition, internalizing problems during adolescence, and low family cohesion to be the most salient factors. CONCLUSIONS: These results highlight familial and behavioral-emotional predictors of depression that can serve as foci for identifying youth in need of intervention.
Social ties and change in social ties in relation to subsequent total and cause-specific mortality and coronary heart disease incidence in men.
The authors prospectively examined the effects of social ties and change in social ties, as measured by a well-known social network index, on total and cause-specific mortality and on coronary heart disease incidence in 28,369 US male health professionals aged 42-77 years in 1988. Over 10 years, the relative risk of total mortality for men in the lower two levels of social integration compared with more socially integrated men was 1.19 (95% confidence interval: 1.06, 1.34) after controlling for age, occupation, health behaviors, general physical condition, coronary risk factors, and dietary habits. In multivariate analysis, deaths from accidents and suicide and from other noncancer, noncardiovascular causes were significantly increased among less socially connected men. Socially isolated men also had an increased risk of fatal coronary heart disease (multivariate relative risk = 1.82, 95% confidence interval: 1.02, 3.23). An increase in the overall social network index between 1988 and 1996 was not significantly associated with subsequent 2-year mortality. In analyses of change in social network components restricted to older men, each categorical unit increase in number of close friends was significantly associated with a 29% decrease in risk of death. Increase in religious service attendance over time was also significantly predictive of decreased mortality.
Dimensional measures of psychopathology. The probability of being classified with a psychiatric disorder using empirically derived symptom scales.
OBJECTIVES: We sought to develop a ranking scheme that assigns a probability of having one of four psychiatric disorders to children based on their scores on a symptom scale. We then estimated the impact of each scale symptom on the prevalence of the disorder in the population. METHOD: Logistic regressions were specified for ADHD, ODD, depressive, and conduct disorders using all the individual symptoms in the pertinent scale as predictors. Individual fitted values from the regression function then served as a probability scale measure. We combined the prevalence and influence of each scale symptom to calculate its overall impact on the prevalence of the disorder. RESULTS: Probability distributions had a wide range of values and discriminated between cases and non-cases. Those having a disorder were consistently associated with higher probabilities in the scale. The estimated probability corresponds to the empiric prevalence of the diagnosis in a group of persons sharing the same estimated probabilities. Symptoms varied on their impact on the prevalence of the disorder. CONCLUSIONS: We recommend the estimated probability of the disorder based on the empirically defined scales as dimensional measures that complement prevalence of the disorder. Different symptoms are identified as targets for screening when selection is based on their impact on the prevalence of the disorder than when selection is based on the strength of the association with the disorder. We recommend using a common nosology with different classification schemes; the categorical definition of the disorder, the probability of having the disorder, and the impact of each symptom in the prevalence. Different measures serve different purposes.
Measurement error and reliability.
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