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Biomedical subjects

R S Stern

Publications and source records attributed to R S Stern.

At least 55 records · Page 3Linked to original sources
PubMed1996

The pattern of topical corticosteroid prescribing in the United States, 1989-1991.

BACKGROUND: Topical corticosteroids are widely used in the treatment of skin diseases. These preparations vary greatly in potency. They are available in both brand name and generic formulations, as well as in combination products. OBJECTIVE: Our purpose was to determine the pattern of topical corticosteroids prescribing in the United States and the relation of patient and prescriber attributes to the type of corticosteroid preparation prescribed. METHODS: Data from the 1989 to 1991 National Ambulatory Medical Care Survey were used to estimate the number of visits with a topical corticosteroid preparation prescribed and to identify prescribers with specific characteristics. RESULTS: In the United States, topical corticosteroids are prescribed or recommended at an average of 14 million visits per year to office-based health practitioners. Forty percent of these visits were to dermatologists. Dermatologists were 3.9 times more likely to prescribe very high potency steroids than were other physicians. Physicians other than dermatologists were 8.4 times more likely than dermatologists to prescribe combination agents containing moderate- or high-potency topical corticosteroids and an antiinfective agent. CONCLUSION: The pattern of topical corticosteroid prescribing is substantially different for dermatologists and other physicians. These differences may reflect differences in severity or complexity of the disease or differences in prescribing habits. The importance of these differences to the outcome of treated patients is not established.

Administration, Cutaneous↗
PubMed1996

The outcomes movement and new measures of the severity of psoriasis.

Traditionally physicians have assessed the severity of psoriasis on the basis of involved surface area or other physical features. These measures are not highly reliable and do not quantify the extent to which the disease affects the patient. New approaches to health care assessment have been developed, including evaluation of the outcome of medical care. This new direction in health care assessment has been described as the "outcomes movement." This emphasizes the assessment of patients' outcomes with respect to quality of life and functional capacity, rather than traditional techniques that rely on the results of physical or laboratory examinations. New measures to assess treatment effectiveness will almost certainly be used to allocate health care resources. We review the status of measures of psoriasis and the implications of newer methods for assessing disease impact and outcomes of therapy.

Activities of Daily Living↗
PubMed1996

Managed care and the treatment of skin diseases. Dermatologists do it less often.

BACKGROUND AND DESIGN: Data from the 1985 and 1992 National Ambulatory Medical Care Survey and the 1992 National Health Interview Study were used to determine changes in total visit rates for patients with common skin disease and the proportion of all visits to dermatologists that were provided as part of managed care plans. The setting was a sample of office-based practitioners across the United States. The patients were from a sample of 106,200 office visits in 1985 and 1992 and 128,412 persons who provided data for a population-based interview study. The main outcome measure were number of visits per year and percentage increase from 1985 to 1992 by reason for visit, specialty of physician consulted, and type of insurance expected to pay for the visit and the percentage of persons with specific demographic characteristics who have managed care coverage. The changing source of payment for all office visits and visits for skins diseases as a result of managed care is assessed. RESULTS: From 1985 to 1992, the percentage of office visits with managed care coverage more than doubled. The proportion of managed care patients with skin complaints cared for by dermatologists declined. The age-adjusted rates of visits for adults with managed care insurance to dermatologists are less than one third the rate for other adults without prepaid care. CONCLUSION: Managed care is rapidly growing as the source of payment for the office-based care of skin complaints. The role of dermatologists in providing this care is diminishing.

Adolescent↗
PubMed1995

Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis.

BACKGROUND: Toxic epidermal necrolysis and Stevens-Johnson syndrome are rare, life-threatening, drug-induced cutaneous reactions. We conducted a case-control study to quantify the risks associated with the use of specific drugs. METHODS: Data were obtained through surveillance networks in France, Germany, Italy, and Portugal. Drug use before the onset of disease was compared in 245 people who were hospitalized because of toxic epidermal necrolysis or Stevens-Johnson syndrome and 1147 patients hospitalized for other reasons (controls). Crude relative risks were calculated and adjusted for confounding by multivariate methods when numbers were large enough. RESULTS: Among drugs usually used for short periods, the risks were increased for trimethoprim-sulfamethoxazole and other sulfonamide antibiotics (crude relative risk, 172; 95 percent confidence interval, 75 to 396), chlormezanone (crude relative risk, 62; 21 to 188), aminopenicillins (multivariate relative risk, 6.7; 2.5 to 18), quinolones (multivariate relative risk, 10; 2.6 to 38), and cephalosporins (multivariate relative risk, 14; 3.2 to 59). For acetaminophen, the multivariate relative risk was 0.6 (95 percent confidence interval, 0.2 to 1.3) in France but 9.3 (3.9 to 22) in the other countries. Among drugs usually used for months or years, the increased risk was confined largely to the first two months of treatment, when crude relative risks were as follows: carbamazepine, 90 (95 percent confidence interval, 19 to infinity); phenobarbital, 45 (19 to 108); phenytoin, 53 (11 to infinity); valproic acid, 25 (4.3 to infinity); oxicam nonsteroidal antiinflammatory drugs (NSAIDs), 72 (25 to 209); allopurinol, 52 (16 to 167); and corticosteroids, 54 (23 to 124). For many drugs, including thiazide diuretics and oral hypoglycemic agents, there was no significant increase in risk. CONCLUSIONS: The use of antibacterial sulfonamides, anticonvulsant agents, oxicam NSAIDs, allopurinol, chlormezanone, and corticosteroids is associated with large increases in the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. But for none of the drugs does the excess risk exceed five cases per million users per week.

Adrenal Cortex Hormones↗
PubMed1995

The safety of etretinate as long-term therapy for psoriasis: results of the etretinate follow-up study.

BACKGROUND: Etretinate is an aromatic retinoid given orally to treat severe psoriasis, a chronic disease that often requires long-term therapy. OBJECTIVE: We assessed the safety of long-term therapy with etretinate for psoriasis. METHODS: This 5-year prospective study of a cohort of 956 patients with psoriasis treated with etretinate assessed the frequency of adverse events in relation to total use and in relation to the frequency of these events in control populations. RESULTS: Our data do not provide evidence for an increased risk of cardiovascular disease, cancer, diabetes, or inflammatory bowel disease in association with long-term etretinate use. Although some patients reported that joint problems improved with the use of etretinate, a greater number associated the use of etretinate with joint problems. CONCLUSION: With proper patient selection and monitoring, long-term etretinate therapy (up to 4 years) does not appear to be accompanied by a substantial increased risk of major adverse effects.

Adult↗
PubMed1995

Dye laser treatment of port-wine stains: comparison of the continuous-wave dye laser with a robotized scanning device and the pulsed dye laser.

BACKGROUND: Despite good results in the treatment of most port-wine stains (PWS) with continuous-wave visible-light lasers, light PWS and those in certain locations respond less favorably and have a higher risk of scarring. Robotized scanning devices such as the Hexascan device have been developed for continuous-wave laser sources to produce greater target specificity, to increase reproducibility of results, and to decrease the incidence of adverse effects. OBJECTIVE: The purpose of this study was to compare the effects of the same wavelength of light (585 nm) on test sites within PWS with the flashlamp-pumped pulsed dye laser and a continuous-wave tunable dye laser scanned through a Hexascan robotized scanning device. METHODS: Two adjacent, noncontiguous sites within PWS were treated in 29 patients, one site with the flashlamp-pumped pulsed dye laser and the other with an argon-pumped continuous-wave tunable dye laser affixed to a Hexascan device. RESULTS: Twenty-eight patients completed the study. The pulsed dye laser was found to be superior to the continuous-wave dye laser with the Hexascan device in 45% of patients, whereas the continuous-wave tunable dye laser with the Hexascan device was considered superior in 15%. There was no difference in the remaining 40%. Undesirable side effects were infrequent with both treatments. There was no significant difference in hypopigmentation or atrophic and hypertrophic scarring, but hyperpigmentation was more frequent with the continuous-wave dye laser with the Hexascan device. CONCLUSION: Both the pulsed dye laser and continuous tunable-wave dye laser with the Hexascan device produce slight lightening after one treatment. The pulsed dye laser produces slightly greater lightening than the continuous-wave tunable dye laser with the Hexascan device 6 weeks after treatment of test areas within PWS in 40% of those treated. It also produced slightly less hypopigmentation and hyperpigmentation.

Adolescent↗
PubMed1995

Photosensitivity associated with combined UV-B and calcipotriene therapy.

BACKGROUND: Ultraviolet B phototherapy is an effective agent for the treatment of psoriasis; its most frequent acute side effect is burning of the skin. It has been combined with various other topical or systemic agents to augment therapeutic effect. Recently, UV-B therapy has been used with calcipotriene ointment (Dovonex, Westwood-Squibb, Buffalo, NY), a new vitamin D analogue. OBSERVATIONS: We report four cases of chronic plaque psoriasis that developed in patients who used UV-B phototherapy for a substantial period without ill effects and in whom photosensitivity reactions within psoriatic plaques developed after calcipotriene ointment was added, without changes in their UV-B dosage or frequency of treatment. The time from starting calcipotriene therapy to the development of photosensitivity ranged from 4 to 28 days, and the number of UV-B exposures during this period varied between one and 12 treatments. The mean UV-B dose at burning was 1114mJ/cm2. Twenty-two patients had used calcipotriene in combination with UV-B therapy of a total of 103 UV-B-treated patients during the period when the adverse events occurred. Half these patients started calcipotriene therapy prior to starting treatment with UV-B. However, cases of photosensitivity occurred only in the remaining half of the patients in whom calcipotriene therapy was added during UV-B therapy. Combined therapy was able to be continued or resumed in two patients by reduction of the UV-B dose. In three cases, phototesting, confirmed greater photosensitivity to calcipotriene-treated skin than to skin to which hydrated petrolatum was applied. CONCLUSIONS: Calcipotriene ointment should be introduced with caution in patients already receiving UV-B phototherapy, particularly those receiving high doses of UV-B. The mechanism of this photosensitivity reaction is unknown. This increased sensitivity to UV-B may be a result of the effect of calcipotriene on stratum corneum thickness, epidermal melanization, a result of its effect on the inflammatory reaction to UV-B irradiation, or, possibly, because it is a phototoxic agent.

Adult↗
PubMed1995

Epidemiology of adverse cutaneous reactions to drugs.

Adverse cutaneous reactions to drugs are among the most frequent adverse reactions to many systemically administered therapeutic agents. In addition to these reactions resulting in discontinuation of drugs important to a patient's treatment, some adverse cutaneous reactions to drugs may result in substantial morbidity or even death. The early recognition of these clinically important reactions is made on clinical grounds. Epidemiologic data do suggest, however, that a relatively small number of drugs are responsible most often for these most serious reactions.

Drug Eruptions↗
PubMed1994

The carcinogenic risk of treatments for severe psoriasis. Photochemotherapy Follow-up Study.

BACKGROUND: Common treatments used for severe psoriasis include psoralen and ultraviolet A radiation (PUVA), methotrexate, ultraviolet B (UVB), and tar. These therapies are often used for prolonged periods and may be carcinogenic. METHODS: For more than 13 years, the authors have prospectively determined the incidence of skin cancer and use of treatments for psoriasis in a 1380 patient cohort originally enrolled in a therapeutic trial of PUVA at 16 university centers. RESULTS: Squamous cell carcinoma (SCC) developed in more than one fourth of patients exposed to high doses of PUVA. In this group, the standard morbidity ratio for these tumors was 83 (95% confidence interval [CI], 72-96) compared with the expected number of these tumors in the general population. High-level exposure to methotrexate is a significant independent risk factor for developing SCC (relative risk, 2.1 for high versus low or no exposure; 95% CI, 1.4-2.8). Metastatic disease developed in seven patients with SCC. No significant increase in the risk of SCC was associated with long term exposure to UVB or topical tar, and no substantial increase in the risk of basal cell carcinoma was noted in association with prolonged use of any of these treatments. CONCLUSIONS: Long term exposure to PUVA and methotrexate significantly increases the risk of SCC in patients with psoriasis. This risk should be considered in selection of treatment. The ultimate morbidity of these tumors is undetermined.

Basal Cell Carcinoma↗
PubMed1994

Laser therapy versus cryotherapy of lentigines: a comparative trial.

BACKGROUND: Lentigines are common sun-induced benign melanocytic proliferations. Many therapies have been advocated, but few have been systemically evaluated. OBJECTIVE: We studied the effectiveness of two laser modalities in comparison with liquid nitrogen cryotherapy for lentigines. METHODS: We conducted a randomized, controlled, prospective trial comparing liquid nitrogen cryotherapy, argon laser light delivered by a Dermascan shuttered delivery system, and low-fluence carbon dioxide laser irradiation in the treatment of solar lentigines at 99 sites in 13 patients. RESULTS: Cryotherapy was more likely to produce substantial lightening than either argon or CO2 laser treatment, which gave similar results (p < 0.05 for both comparisons). The odds of an excellent results were about 50% higher with cryosurgery than with CO2 or argon laser therapy. CONCLUSION: Liquid nitrogen cryotherapy was superior to argon and CO2 laser therapy in the treatment of benign epidermal pigmented lesions. This study demonstrates that comparative rather than uncontrolled studies are needed to judge the relative efficacy of therapies for benign pigmented lesions such as lentigines.

Argon↗
PubMed1994

Photoreactions with a fluoroquinolone antimicrobial: evening versus morning dosing.

Quinolone antimicrobials absorb ultraviolet radiation and, with appropriate drug concentrations, may cause photoreactions. Photoreactions have been reported for several quinolones, including lomefloxacin, a difluorinated quinolone antimicrobial. This study was designed to determine whether the interval between administration of lomefloxacin and exposure to ultraviolet A (UVA) light would affect skin responses. The minimal erythema dose (MED) and severity of local reactions were the main parameters of evaluation. Exposure to UVA radiation 2 hours after morning dosing caused an increase in skin sensitivity as assessed by changes in MED (p < 0.05). No changes were observed with exposure 16 hours after evening dosing (p = 1.00). Edema and blisters at the radiation sites were observed in only the morning dosing group. A significant negative correlation was observed between lomefloxacin plasma concentrations and change MEDs (r = -0.72; p < 0.05). An evening dosing strategy may minimize the risk of phototoxic effects.

Adult↗
PubMed1994

Epidemiology of skin disease in HIV infection: a cohort study of health maintenance organization members.

The medical literature suggests that persons infected with human immunodeficiency virus (HIV) have an increased risk of many common and uncommon cutaneous diseases. Further, it has been suggested that in HIV-infected people these conditions may be more persistent and they may be more prone to developing adverse cutaneous reactions to drugs. We have identified a cohort of 684 HIV-infected persons who were members of a large Massachusetts health maintenance organization. Based on review of hospital records, automated ambulatory records, and automated prescription data for these patients, we determined the occurrence of skin disease including adverse reactions to drugs. In this 2.8-year study, these HIV-infected persons averaged 3.7 separate skin diagnoses each, a significantly higher rate (p < 0.001) than in a comparable uninfected group of enrollees in this health maintenance organization. The rate of visits for many common skin diagnoses increased as HIV infection progressed. Cutaneous drug reactions were also significantly more frequent (per course of drug) in AIDS patients compared to patients with asymptomatic HIV infection. Skin disease is a frequent and important cause of morbidity in HIV-infected persons. The development of a specific cutaneous disease may act as a prognostic marker for progression of HIV infection. In HIV-infected persons, adverse cutaneous reactions to drugs frequently limit treatment with essential drugs.

AIDS-Related Opportunistic Infections↗
PubMed1994

Ocular lens findings in patients treated with PUVA. Photochemotherapy Follow-Up-Study.

In some animal species, exposure of the ocular lens to 8-methoxypsoralen (8-MOP) and ultraviolet-A radiation (PUVA) induces lens opacities. Case reports have suggested that PUVA therapy in humans may be associated with an increased risk of ocular lens abnormalities. To examine this risk, we compared the results of the initial and final examinations, which were performed on an average of 10 years apart in 1,235 individuals enrolled in the PUVA Follow-up Study. After adjustment for age and sex, there was no significant relation between the risk of developing an ocular lens abnormality or cataract and the level of exposure to PUVA. A higher incidence of cataract was noted, however, in the PUVA cohort compared to a large population-based study. In addition, rates of cataract extraction were significantly higher among male members of the PUVA study compared to enrollees in the Physician Health Study. Overall, our data strongly argue against a dose-dependent increase in the risk of cataract or other lens abnormality in association with PUVA therapy in a cohort most of whose members we believe usually used recommended eye protection. Our data do not explain the higher incidence and prevalence of ocular lens pathology in our cohort compared to groups without psoriasis. These differences could reflect differences in criteria for defining these abnormalities, other exposures, or PUVA.

Aged↗
PubMed1994

The impact of patient socioeconomic status and other social factors on readmission: a prospective study in four Massachusetts hospitals.

Readmissions to hospitals may serve as markers for morbidity, high costs, and potentially poor quality of care, yet little is known about the relation of socioeconomic factors to the likelihood of readmission. In this article, we used logistic regression models to examine the readmission experience of nearly 12,000 patients, adjusting for age, gender, hospital, severity of illness, and the overall probability of readmission within each diagnosis related group (DRG). After adjustment, patients were more likely to be readmitted within 60 days if they were poor (OR = 1.25, p < .05), worked in unskilled or semiskilled occupations (OR = 1.25, p < .05), or rented their homes (OR = 1.23, p < .01). Nonwhites (OR = .76, p < .01) and uninsured patients (OR = .48, p < .01) were less likely to be readmitted. Within a 7-day period, patients who rented their homes were more likely to be readmitted (OR = 1.32), while patients were less likely to be readmitted if they were uninsured (OR = .36) or nonwhite (OR = .72) (all p < .05). Social support factors including marital status, living situation, and availability of help at home were not associated significantly with the risk of readmission. Our results suggest that patients in lower socioeconomic positions have higher readmission rates, at least for readmissions within longer time periods. Providers designing interventions to reduce the risk of readmission may want to target the groups identified by our study.

Demography↗