Biomedical subjects
Publications and source records attributed to H Andrews.
Pre-natal aspiration, under ultrasound control, was performed on a sacrococcygeal cyst measuring 19 cm in diameter in a 38 week fetus to allow normal vaginal delivery of a live baby girl. This is the first report of such intervention leading to normal delivery.
Previous studies of the relationship between cancer stage, age, and race have not controlled for social class and health care setting. Logistic regression analyses, using information from the New York State Tumor Registry and area-level social class indicators, demonstrated that, in New York City, older Black, lower class women in public hospitals were 3.75 and 2.54 times more likely to have late stage breast or cervical cancer, respectively, than were younger White, high social class women in non-public hospitals.
This study describes use of medical, mental health, alcohol, and drug services by 832 adult residents of the New York City homeless shelter system and examines associations between service use during the past three months and an array of predisposing, enabling, and need factors. Utilization rates were 23% for medical services, 13% for mental health services, and 10 and 7.5% for alcohol and drug treatment services, respectively. Service contacts were more often hospitals than ambulatory care clinics. Logistic regression analyses revealed that need factors were stronger predictors of all four types of service use. Predisposing factors other than education and black ethnic status were not significant, and the enabling factor of enrollment in Medicaid and/or Medicare was significant only for use of medical and drug services. Among the need factors, measures of mental health status were analyzed as indices of distress to test a stress-utilization model of prediction for all four types of service use. While these measures did not predict use of nonmental health services, physical health problems were associated with use of all four types of services. Implications for future health services research and for service delivery to the homeless are discussed, including the need for more information on availability of services and on psychosocial and cultural characteristics of homeless persons that may affect their help-seeking behavior.
This study attempts to define whether there is an increased need for reoperation in patients with small bowel Crohn's disease treated by strictureplasty compared with those treated by small bowel resection. Previous studies of the rate of reoperation for small bowel Crohn's disease do not distinguish between reoperation performed because of a lesion at the original operation site and that undertaken because of a lesion at a distant site. This study analyses the need for reoperation only at the original site of operation and measures operation-free intervals. The site specific operation-free intervals in 41 patients with small bowel Crohn's disease treated by strictureplasty were not significantly different from the similar intervals in 41 patients treated by a small bowel resection.
Twenty-eight patients with vaginal fistulas complicating Crohn's disease, seen between 1970 and 1987, are described. Twelve required early operation; five of them had rectal excision. Conservative management was used in 16 patients but in none of these did the fistula close spontaneously. Subsequent proctocolectomy was required in seven patients though two patients with high vaginal fistulas were managed by total colectomy, end ileostomy, and oversewing of the rectal stump. Only two high fistulas resulting from ileal Crohn's disease resolved with resection and anastomosis of the diseased segment alone. Local repair was unsuccessful despite repeated operations in two of five patients. Two patients died of malignancy arising within a chronic vaginal fistula. Although some vaginal fistulas complicating Crohn's disease cause little disability and can be managed symptomatically, they do not heal by conservative therapy or by a proximal defunctioning stoma alone. In time, severe bowel symptoms develop in the majority of patients and necessitate proctectomy.
Although several studies suggest that schizophrenics suffer from an impairment in the interhemispheric transfer (IHT) of information, methodological weaknesses in these studies preclude clear interpretation of their results. This study addresses these criticisms in order to provide a clearer test of the IHT theory. Schizophrenics, depressives, normal controls, and normals with schizoid tendencies were assessed on five measures of IHT (verbal and nonverbal dichotic listening, intermanual transfer, bimanual block design, finger sequence repetition) and two measures of unilateral hemispheric processing (lateral eye movements, auditory thresholds). Results consistently failed to support an IHT deficit interpretation of schizophrenia. Schizoid normals had a significantly greater right-ear advantage on verbal dichotic listening than both psychiatric groups, a result suggesting enhanced left-hemisphere activation in schizoid normals. It is concluded that the IHT theory requires stronger empirical substantiation than has been obtained to date to warrant further consideration as a central theory of schizophrenia.
The proposed Diagnosis Related Group (DRG) for prepaid child psychiatric hospitalizations is based on a mean length of stay of 6.6 days. This study examined data on 2,266 admissions to four state and four municipal hospitals providing child psychiatric care to residents of New York City. The results indicate: (1) use of this single mean is only appropriate for youngsters admitted to pediatric units and discharged with a psychiatric diagnosis but would result in substantial underpayment for acute and long-term care in psychiatric units; (2) a category reflecting type of service could be used to define a set of three DRGs that would provide more equitable reimbursement. Payment inequities arising from interhospital differences in disposition resources and treatment strategies are discussed.
There is considerable interest in the development of a viable prospective payment system for psychiatry. Under the currently proposed system, all child/adolescent psychiatric admissions would be assigned to a single DRG. An alternative set of three DRGs, based on a service variable, were previously identified. Assuming no decrease in the per diem cost for extended lengths of stay, the eight public hospitals in the sample would be compensated at 54% of cost using the single-DRG model and at 83% of cost using the three-DRG model.
Forty-four patients seen between 1975 and 1985 with anorectal strictures complicating Crohn's disease have been reviewed to determine the natural history and outcome of surgical treatment. Proctitis was present in 98 per cent, and 93 per cent of patients had sever perianal disease. The site of strictures was rectal in 22, anal in 15 and anorectal in 11 (4 patients had a stricture at 2 sites). Initial treatment was by rectal excision alone in 6, dilatation in 33, and 5 needed no treatment at all. Single dilatation was effective in 15, 8 required two dilatations and in 10 repeated dilatation was necessary. Proctocolectomy was eventually required in 19 patients, 2 have a loop ileostomy and 1 has an ileostomy with a rectal stump in situ. Only 21 remain asymptomatic while 3 continue to need dilatation. Perineal wound healing was delayed in 9 of 19 patients having a proctocolectomy and in 3 the perineal wound has never healed.
Successful implementation of cancer control programs depends on efficient targeting to those at highest risk of developing and dying from the disease. This study presents a methodology for targeting cancer screening on the basis of population and disease variation among small geographic areas. Techniques for quantifying the impact of targeting on the predictive value of a positive test are demonstrated, using 329 New York City health areas. Age-truncated crude incidence, late-stage incidence and mortality rates for breast, cervix, and colorectal cancer are used, using site-specific truncation points relevant to the age groups appropriate for screening. Coefficient alpha was used to determine rate stability with 2, 3, 5 and 7 years of data. The stability of most small area rates was found to reach acceptable levels only with 5 and 7 years of data. Targeting into areas where breast cancer prevalence was high increased the expected predictive value of a positive test by as much as 50% when compared with areas of average prevalence. Geographic targeting will be most useful where between-area variability in prevalence is large and within-area variability is small. The implications of these results are discussed and future studies are suggested.
Large fetal ovarian cysts are rare; however, widespread use of antenatal ultrasound examination has led to an increased detection rate and surgical removal. A case presenting with bowel obstruction is described along with four other cases that presented in the last 24 years. Previously reported series are reviewed and compared. It is stressed that complications are very rare and hasty surgical management of cases detected by ultrasound scanning is not warranted.
Fifty male patients with proctitis were examined and the clinical, microbiological, serological and proctological features compared with 51 known male homosexuals attending the genitourinary (GU) clinic at the same hospital. The homosexuals had a short history of bowel symptoms, minor sigmoidoscopic and histological changes on rectal biopsy and many positive serological markers of sexually transmitted infection. There was some evidence of sexually transmitted disease in the IBD patients and three were homosexuals. IgG antibodies were positive for chlamydia trachomatis (n = 10) and hepatitis A (n = 7). One had a positive screening test for syphilis. Stool examination and rectal swab cultures were positive in two patients for cryptosporidium and cytomegalovirus respectively. Gastroenterologists must be aware of the possibility of specific infection in IBD patients and a clinical history should include sexual preferences and practices. If homosexuality is admitted, specific infection must be sought and excluded.
Seventy-four patients have had a one-stage proctocolectomy for the management of Crohn's disease. Indications for operation were: acute colitis 28 per cent, chronic colitis 39 per cent, perianal disease 13 per cent, proctitis and perianal disease 8 per cent, bleeding 5 per cent, coexisting colonic malignancy 7 per cent. There were two hospital deaths (2.7 per cent), both associated with sepsis. Late deaths (n = 13) were most commonly associated with reoperations for recurrent disease (n = 3), cardiovascular disease (n = 4) and colorectal carcinoma (n = 1). Postoperative complications were principally associated with sepsis. Cumulative reoperation rates at 5 and 10 years were 19 and 24 per cent respectively. Recurrence was unrelated to the age of the patients, the duration of disease, or the presence of ileal disease at the time of colectomy.
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One hundred and sixty two consecutive patients attending a clinic for inflammatory bowel disease (91 Crohn's, 71 ulcerative colitis) were assessed for the presence of anxiety and depression using a simple self-rating questionnaire (HAD scale) and a detailed evaluation (DSM-III). The overall prevalence of psychiatric illness (DSM-III) in ulcerative colitis and Crohn's disease was 34% and 33% respectively. There was no statistically significant association in ulcerative colitis patients between the presence of psychiatric illness and the present physical illness. Psychiatric illness was more common in the physically ill patients with Crohn's disease, compared with those who were well: 50% v 8% (p less than 0.01), using (HAD) criteria 66% v 37% (p less than 0.001). The presence of patients between the presence of psychiatric illness and the presence of physical illness. Psychiatric who were well: 50% v 8% (p less than 0.01) by DSM-III criteria, using (HAD) criteria 66% v 37% (p less than 0.001). The presence of psychiatric illness adversely affected physical recovery. Seventeen percent recovered when psychiatrically ill v 53% when psychiatrically well (p less than 0.025). The HAD scale was assessed as a screening method for psychiatric illness in this medical setting and had a sensitivity of 76% and a specificity of 79%.
Social area analysis (SAA) is a well-established methodology for geographically based analysis of service delivery and other health related outcome measures. However, SAA has been limited in application by the complexities of computerized geocoding and difficulties in obtaining appropriate measures of community characteristics. In this paper we demonstrate that these problems can be overcome by employing zip code as well as the unit of analysis for SAA and obtaining commercially available measures of community characteristics. Regression analyses, using New York City zip code populations as the unit of observation were used to illustrate the role of epidemiologic risk factors in predicting rates of inpatient discharge and ambulatory care visits.
Melatonin profiles were studied in five males with cytogenetic and clinical features of the fragile-X syndrome including megalo-orchidia and macrogenitosomia. In comparison with age-matched normal controls, the fragile-X group showed lower melatonin values and a significant impairment of the nocturnal rise in this hormone. Melatonin deficiency may thus be responsible for some of the phenotypic features of this disorder.
During the investigation of somatosensory evoked cortical potentials arising from a complex vibro-tactile stimulus to the forefingers, an abnormal lack of lateralisation of response was found in 10 out of 21 schizophrenic patients. Eight patients with severe affective illness all had the expected degree of lateralisation of cortical potentials, as did 12 out of 15 normals. Three normals and 3 schizophrenic patients had a loss of lateralisation of the evoked response on stimulation of one hand but a normal lateralisation on stimulation of the other. The considerable technical problems of this and related techniques are discussed, but it is suggested that further exploration of this technique is justified. At this stage, no conclusion can be drawn about the cause of the abnormalities.