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Biomedical subjects

R S Epstein

Publications and source records attributed to R S Epstein.

At least 55 records · Page 3Linked to original sources
PubMed1994

Natural history of prostatism: impact of urinary symptoms on quality of life in 2115 randomly selected community men.

OBJECTIVES: To assess the impact of urinary symptoms on health-related quality of life (QoL), including degree of bother, worry, interference with daily activities, psychological well-being, sexual function, and general health in a community-based cohort of men. METHODS: Eligible white men (n = 2115) aged 40 to 79 years who had not undergone previous prostate surgery or had prostate cancer were randomly selected from county residents. These subjects completed a questionnaire, which asked them about frequency and bother of urinary symptoms, interference with daily activities, psychological well-being, worry about urologic disease, sexual functioning, and general health. RESULTS: Men with moderate to severe voiding symptoms reported, on average, four to six times the degree of bother and interference with daily activities and twice the level of worry of men with mild symptoms. Nearly five times the degree of bother and interference was reported for those with mild than with no symptoms. A higher percentage of men with moderate to severe symptoms (26% to 33%) than mild symptoms (< 8%) reported limiting fluids before bed, travel, or driving 2 hours. Receiver operating characteristic curves support the recommended symptom index cutpoint for moderate symptoms (= 8) by differentiating men with and without bother, interference with daily living, or dissatisfaction with urinary condition. CONCLUSIONS: Moderate to severe urinary symptoms have a significant impact on men's lives in terms of degree of bother, worry, interference with daily living, and psychological well-being. The recommended cutpoint on symptom index differentiates men with and without decrement in health-related quality of life.

Activities of Daily Living↗
PubMed1994

Normal ranges for bone loss rates.

We reported previously that the variability in bone loss rates among postmenopausal women decreases dramatically during the first few years of followup. In this paper, we have examined the distributions of bone loss rates measured at the calcaneus, distal radius and proximal radius. The incidence of physical impairment was five times greater among women with bone loss rates faster than 2 S.D. below the mean. Because the rate of change in bone density was skewed at the lower end of the distribution (representing rapid bone loss), the influence of values at the extreme ends of the distribution were statistically removed in order to estimate the normal distribution of bone loss rates. For the convenience of clinicians, the upper and lower limits of the 90 and 70% normal ranges are presented. Because average bone loss rates vary with age, normal ranges are provided separately by age group. The width of each normal range decreased by at least half after 3 or 4 years of followup, compared to less than 1 year. Consequently, measured loss rates which were well within the normal range at 1 year were sometimes far outside the normal range for longer followup times. We conclude that followup duration has a profound effect on estimates of the normal range, and must be considered when interpreting the clinical significance of measured loss rates.

Adult↗
PubMed1994

Factor analysis of the General Health Questionnaire.

We present the factor structure of the General Health Questionnaire-60 as derived from a population of 2115 Army soldiers. An eight-factor principal components analysis provided the most clinically relevant solution and explained 58.0% of the variance. We distinguished two types of depressive symptomatology, suggesting the questionnaire may be useful in differentiating shame-ridden dysphoria from anergic disinterest.

Adolescent↗
PubMed1994

Using Medicare claims for outcomes research.

Medicare claims databases have several advantages for use in constructing episodes of care for outcomes research. They are population-based, relatively inexpensive to obtain, include large numbers of cases, and can be used for long-term follow-up. However, the sheer size of these claims databases, along with their primarily administrative (as opposed to clinical) nature, requires that researchers take special care in using them. The 10 PORTs using Medicare claims provided information on their approach to several key issues in working with these data, including: 1) identifying the index cases or patient cohorts to be studied; 2) defining the length of the episode; and 3) measuring outcomes. This paper reports the experience and knowledge gained by these PORTs in using these claims to create and analyze episodes of care.

Databases, Factual↗
PubMed1993

Quality of life issues in women with vertebral fractures due to osteoporosis.

OBJECTIVE: To learn about the physical, emotional, and social limitations experienced by postmenopausal women who have back pain due to vertebral fractures resulting from osteoporosis. METHODS: We conducted a cross-sectional survey of female patients with persistent pain due to vertebral fractures. RESULTS: Respondents had a mean (+/- SD) bone density of 0.87 +/- 0.13 gm/cm2 and a mean (+/- SD) of 2.84 +/- 2.18 fractures. Disability was identified in pain, movement, activities of daily living, and emotion. There was a poor correlation between quality of life and findings on radiography or densitometry. CONCLUSION: To evaluate the effects of osteoporosis on a patient's functional status, direct questioning is required.

Aged↗
PubMed1993

A new method for vertebral fracture diagnosis.

A number of methods have been proposed for estimating the prevalence of vertebral fractures. Most methods are based on the distribution of normal vertebral dimensions in the population. However, these methods fail to identify a significant proportion (20-30% or more) of fractures documented on serial radiographs. This may occur because vertebral size varies between individuals as a result of differences in body size (and possibly other factors), and a normal range based on population reference data may be too large. In this paper, a new method is described for identifying vertebral fractures that are missed using diagnostic criteria based on vertebral dimension distributions of the population. This new method is based on calculating the average vertebral size, and statistical confidence limits, for the individual. The average vertebral size method was evaluated by testing its ability to identify incident fractures (which were identified from changes in dimensions compared to previous radiographs), using only the final film. The new method correctly identified most (81% of crush and 83% of wedge) incident fractures on the final radiograph. In contrast, criteria based on population distributions correctly identified only 53% of crush and 72% of wedge incident fractures. Using prospective data, prevalent fractures identified using both population-based and individual size-based criteria predicted the risk of incident fractures. Furthermore, incident fractures identified using both methods (population- and individual-based criteria) were associated with increased back pain. These data suggest that both types of prevalent deformities are important indicators of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

The costs of prostatectomy for benign prostatic hyperplasia.

Using claims data for a 5% random sample of Medicare beneficiaries, we estimated the costs of surgical treatment for benign prostatic hyperplasia (BPH), including those related to the initial prostatectomy, the treatment of postsurgical complications, and reoperation within one year. We identified 14,480 men who underwent prostatectomy for BPH during 1986-1987, including 13,730 transurethral and 750 open procedures. Mean total inpatient costs (including all hospital charges and professional service fees) for these procedures were estimated to be $6,501 and $10,223, respectively. Among patients who underwent transurethral and open prostatectomy, we identified 938 (6.8%) and 39 (5.2%) individuals who had at least one readmission for postsurgical complications or reoperation. Total expected costs of transurethral and open prostatectomy, inclusive of readmissions for complications and reoperations within one year, were estimated to be $6,823 and $10,477, respectively. Our study indicates the economic burden represented by surgical treatment of BPH.

Aged↗
PubMed1993

Interpretation of quality of life changes.

The clinical significance of quality of life changes has little to do with the QOL as a measure, but is rather a reflection on the novelty of the measures and researcher's inexperience in their use. This article discusses possible ways of evaluating quality of life measures in terms of patient-clinician interactions and how the clinician can assess the importance of these changes of QOL in terms of treatment and management of disease.

Activities of Daily Living↗
PubMed1992

Ability of vertebral dimensions from a single radiograph to identify fractures.

It has been proposed that vertebral dimensions be used to objectively identify vertebral fractures, permitting standardization of methodology for comparisons between studies. In this report, we evaluate the ability of various vertebral dimensions and ratios to identify "abnormal" vertebrae. As no "gold standard" exists for prevalent vertebral fractures, we examined the ability of cross-sectional dimensions (at a single point in time) to detect fractured vertebrae that had been identified from changes in dimensions compared with previous radiographs. Theoretically, a cutoff of 3 SD below the mean will rarely misclassify normal vertebrae as fractured (specificity = 99.9%). However, we found that this cutoff correctly identified only about 70% of the incident fractures. A less stringent criterion (2 SD below the mean; theoretical specificity = 97.7%) identified about 85-90% of true fractures. Dividing by stature or other vertebral heights sometimes yielded marginal improvements in the ability of the anterior or posterior height dimensions to diagnose fractures. The results suggest that the true fracture prevalence may sometimes be substantially higher than suggested by cross-sectional vertebral measurements.

Bone and Bones↗
PubMed1992

Validation of a new quality of life questionnaire for benign prostatic hyperplasia.

In planning a longitudinal study to characterize the natural history of benign prostatic hyperplasia (BPH), we validated a new disease-specific quality of life questionnaire in a pilot study. We studied 110 men in Rochester, Minnesota who spanned the severity of BPH, from men with no known BPH to men who underwent surgery for this condition. Baseline data were obtained on all men, and the 30 who underwent prostatectomy were re-interviewed to test responsiveness. Reproducibility was examined on the pre-post responses (10 weeks apart) of the 37 men with BPH who did not undergo prostatectomy. Six of twelve question domains were retained in the final questionnaire on the basis of their responsiveness to change, reproducibility, internal consistency, and validity. These were: urinary symptoms, degree of bother due to urinary symptoms, BPH-specific interference with activities, general psychological well-being, worries and concerns, and sexual satisfaction. Most of the more generic measures were deleted.

Adult↗
PubMed1992

A model for evaluating the cost-effectiveness of cholesterol-lowering treatment.

We describe and illustrate the use of a generalizable model for evaluating the cost-effectiveness of alternative cholesterol-lowering treatments. We combine standard incidence-based techniques for measuring the cost of illness with logistic risk functions from the Framingham Heart Study to project, for persons with known coronary risk characteristics, the likelihood of developing coronary heart disease (CHD) over a lifetime as well as a number of related outcomes, including the expected loss of years of life due to CHD, the expected lifetime direct and indirect costs of CHD, and the changes in these outcomes that would result from cholesterol-lowering treatment.

Adult↗
PubMed1992

Evaluation of impairment of health related quality of life in asthma: development of a questionnaire for use in clinical trials.

BACKGROUND: In the past only physiological and clinical outcomes have been used to assess the effect of asthma interventions and the effect of the intervention on the lives of the patients has not been determined. The objective of this study was to assess health related impairment of quality of life in adult asthmatic patients and to develop a questionnaire for measuring quality of life in clinical trials in asthma. METHODS: Impairment of quality of life in adults with asthma was evaluated from structured interviews in which patients were asked to identify the parts of their daily lives affected by asthma. On the basis of these results, an asthma quality of life questionnaire was developed in an interviewer and self administered form and tested for comprehension and acceptability. A total of 150 adults with asthma and with a wide range of airway hyperresponsiveness were enrolled from previous clinical trials, local asthma clinics, and notices in the media. RESULTS: Areas of quality of life impairment included symptoms classically associated with asthma, responses to environmental stimuli, the need to avoid these stimuli, limitation of activities, and emotional dysfunction. Areas of impairment were similar across strata of airway hyperresponsiveness, age, and treatment requirements and between sexes, thus allowing a single questionnaire suitable for all adults with asthma to be developed. The questionnaire contains 32 items and takes 5-10 minutes to administer; in the pretesting it was shown to be acceptable to a wide range of patients. CONCLUSIONS: The questionnaire includes areas of quality of life impairment that are important to adult asthmatic patients. It has been designed to be responsive to within subject change and therefore may be used as a measure of outcome in clinical trials in asthma.

Adolescent↗
PubMed1992

Assessing boundary violations in psychotherapy: survey results with the Exploitation Index.

The usefulness of the Exploitation Index (Epstein & Simon, 1990) was evaluated in a survey of psychiatrists. Forty-three percent of the respondents indicated that at least one item alerted them to behavior they thought could have been counterproductive to treatment. Twenty-nine percent found that they were stimulated to make specific changes in future treatment practice. On average, female respondents endorsed fewer boundary violations than males.

Ethics, Professional↗
PubMed1991

Pre-existing fractures and bone mass predict vertebral fracture incidence in women.

OBJECTIVE: To determine the independent contributions of bone mass and existing fractures as predictors of the risk for new vertebral fractures. SUBJECTS: Postmenopausal Japanese-American women. MEASUREMENTS: Baseline measurements of the distal radius, the proximal radius, and the calcaneus were obtained in 1981 using single-photon absorptiometry. Measurements of the lumbar spine were obtained in 1984 using dual-photon absorptiometry. Prevalent vertebral fractures were identified using dimensions measured on lateral radiographs; vertebral height values more than 3 SD below vertebra-specific means were considered to indicate fracture. Statistical models were used to evaluate the utility of bone mass and existing (prevalent) fractures to predict the risk for new fractures during an average follow-up of 4.7 years. MAIN RESULTS: Differences of 2 SD in bone mass were associated with fourfold to sixfold increases in the risk for new vertebral fractures. A single fracture at the baseline examination increased the risk for new vertebral fractures fivefold. Presence of two or more fractures at baseline increased the risk 12-fold. A combination of low bone mass (below the 33d percentile) and the presence of two or more prevalent fractures increased the risk 75-fold, relative to women with the highest bone mass (above the 67th percentile) and no prevalent fractures. Stature, body mass index, arm span, and spinal conditions such as scoliosis, osteoarthritis, and sacroiliitis did not predict fracture incidence (P greater than 0.05). Weight was marginally predictive (P = 0.04) of fracture incidence but became nonpredictive after adjusting for bone mass (P greater than or equal to 0.05). CONCLUSIONS: Both bone mass and prevalent vertebral fractures are powerful predictors of the risk for new vertebral fractures. Combining information about bone mass and prevalent fracture appears to be better for predicting new fractures than either variable alone. Physicians can use these risk factors to identify patients at greatest risk for new fractures.

Absorptiometry, Photon↗
PubMed1991

Age-related differences in risk factors for prostatectomy for benign prostatic hyperplasia: the VA Normative Aging Study.

The Veterans Administration Normative Aging Study (VANAS) is an ongoing study of a cohort of 2,280 men assembled between 1963-1968 and followed to the present time. Among this cohort of men, urinary symptoms were found to be strongly predictive of surgery for benign prostatic hyperplasia (BPH), and this risk varied by age. Nocturia (OR 1.8) and hesitancy (OR 4.3) were found to be predictive of surgery for younger men (age range 49-55), while only nocturia (OR 2.4) was predictive among older men (age range 62-68). This age-related difference in both identification of risk factors and magnitude of association with surgery was independent of assessing other commonly studied risk factors. Ultimately, the decision to operate is a combination of patient's need, access to care, and patient's preference. Further research will be required to assess which factor or factors are responsible for the age-related differences in surgical risk factors.

Adult↗
PubMed1991

Urinary symptom and quality of life questions indicative of obstructive benign prostatic hyperplasia. Results of a pilot study.

In a pilot study of a urinary symptom and health-related quality-of-life questionnaire for benign prostatic hyperplasia (BPH), responses from 64 Mayo Clinic patients with cystoscopic evidence of obstructive BPH were compared with those of 14 men with no cystoscopic evidence of BPH and a community sample of 64 comparably aged men with no medical history of prostate enlargement. Questions which best discriminated between the groups were those dealing with urinary symptom frequency, bother due to urinary symptoms, and worry and concern about urinary problems. The results suggest that urinary-symptom-bother and worry due to urinary symptoms may be important additions to the more usual questions asked about urinary frequency in the identification of men with BPH. These findings are preliminary, however, and will be verified in an ongoing natural history study of BPH.

Humans↗
PubMed1990

The Exploitation Index: an early warning indicator of boundary violations in psychotherapy.

Exploitive behavior by therapists is highly disruptive in psychotherapy because it violates the sense of trust derived from a coherent treatment boundary. Such behavior may be difficult to detect because it is often associated with self-deception. The compensatory need to feel "special," a state of mind often associated with exploitiveness, suggests that narcissistic mechanisms play a significant role. The authors present an "Exploitation Index" (EI), a self-assessment questionnaire for therapists that is designed to serve as an early warning indicator of boundary violations.

Ethics, Medical↗