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Biomedical subjects

R S Stern

Publications and source records attributed to R S Stern.

At least 91 records · Page 5Linked to original sources
PubMed1991

Outcomes of pregnancies among women and partners of men with a history of exposure to methoxsalen photochemotherapy (PUVA) for the treatment of psoriasis.

Because oral methoxsalen and UV-A radiation (PUVA) therapy is mutagenic, concern exists about the potential for teratogenic effects resulting from the use of this therapy at the time of conception and during pregnancy. After 12.8 years of prospective study, we documented the pregnancy outcomes among 1380 patients (892 men and 488 women) who received PUVA treatments. Ninety-four men reported 167 pregnancies in their partners, and 93 women reported 159 pregnancies. For 34% of pregnancies among partners of male patients, the man received PUVA therapy near the time of conception. Nineteen percent of female patients reported exposure to PUVA at the time of conception or during pregnancy. Induced and spontaneous abortions were reported as the outcome of pregnancy more often by female than by male patients (12% vs 30%). Two congenital malformations and two stillbirths occurred, an incidence not significantly different from that expected for the general population. Although the power of our study to detect an increase in the risk of specific defects is limited, our data show no evidence to suggest that PUVA is a potent teratogen. Still, because PUVA is mutagenic, we believe it prudent for patients to avoid PUVA treatment during pregnancy whenever practical.

Abortion, Induced↗
PubMed1991

Magnitude and duration of UV-B-induced tolerance.

Using repeated minimal erythema dose (MED) testing, we investigated the magnitude and duration of tolerance to short-wave UV radiation in the B range (UV-B) in 37 patients with psoriasis who received at least 12 UV-B phototherapy treatments. Without substantial erythema developing, half of the patients received UV-B doses in excess of 13 times their pretreatment MED dose and a fourth received UV-B doses in excess of 28 times their pretreatment MED dose. On average, tolerance faded to about half that present at the last UV-B treatment in 3 weeks. Six weeks after therapy was stopped, most posttreatment MEDs were less than twice the pretreatment MED. The magnitude of tolerance achieved and the rate of decay did not vary with skin type. Our findings indicate that repeated exposures to suberythemal or mildly erythematous doses of UV-B can induce exceptional degrees of tolerance to UV-B radiation. The duration of this increase in tolerance is, however, short.

Adult↗
PubMed1990

Genital tumors among men with psoriasis exposed to psoralens and ultraviolet A radiation (PUVA) and ultraviolet B radiation. The Photochemotherapy Follow-up Study.

Squamous-cell cancer occurs only rarely on the male genitalia. In a 12.3-year prospective study of 892 men in a cohort of patients with psoriasis who had been treated with oral methoxsalen (8-methoxypsoralen) and ultraviolet A photochemotherapy (PUVA), we identified 14 patients (1.6 percent) with 30 genital neoplasms. The standard morbidity ratio (which was used as a measure of the risk of a genital neoplasm) comparing morbidity among patients treated with PUVA with that expected on the basis of population incidence data was 95.7 (95 percent confidence interval, 43.8 to 181.8) for invasive squamous-cell carcinoma of the penis and scrotum, and 58.8 (26.9 to 111.7) for invasive and in situ penile tumors. In patients exposed to high levels of PUVA, the incidence of invasive squamous-cell carcinoma was 286 times that in the general population and 16.3 times that in patients exposed to low levels (P less than 0.001 for both comparisons). After controlling for the level of exposure to PUVA, we found that patients exposed to high levels of ultraviolet B radiation had a risk of genital tumors 4.6 times higher than that in other patients (95 percent confidence interval, 1.4 to 15.1). The strongly dose-dependent increase in the risk of genital tumors associated with exposure to PUVA and ultraviolet B radiation that we observed makes it prudent for men to use genital protection whenever they are exposed to PUVA or other forms of ultraviolet radiation for therapeutic, recreational, or cosmetic reasons.

Adult↗
PubMed1990

Do the poor cost more? A multihospital study of patients' socioeconomic status and use of hospital resources.

There is controversy about whether hospitalized poor patients use more resources and whether hospitals that provide care for the poor therefore merit supplementary payment under per-case prospective payment systems. We previously reported that patients of low socioeconomic status with connective-tissue disease had longer hospital stays and higher costs than patients of higher socioeconomic status at a single hospital. To examine the generalizability of this phenomenon, we interviewed 16,908 (83 percent) of 20,278 consecutive adult patients (excluding obstetrical and psychiatric patients) admitted in 1987 to five Massachusetts hospitals, to obtain information on three direct measures of socioeconomic status (income, occupation, and education). We divided each measure into three strata. Thus, there were 15 comparisons--three measures of socioeconomic status applied to each of five hospitals. After excluding outliers and adjusting for diagnosis-related group (DRG), we found that the patients of the lowest socioeconomic status had hospital stays 3 to 30 percent longer than those of patients of higher status, the differences varying with the hospital and the indicator of socioeconomic status (P less than or equal to 0.05 for 11 of the 15 comparisons). Hospital charges were 1 to 18 percent higher for the patients of lowest socioeconomic status than for those of higher status (P less than or equal to 0.05 for 9 of 15 comparisons). When we adjusted for age, severity of illness, and DRG, the patients of lowest socioeconomic status had longer stays than those of higher status in 14 of 15 comparisons (P less than 0.05 for 7 of the 15) and higher charges in 13 of 15 comparisons (P less than 0.05 for 6 of the 15). The differences between patients of high and low status ranged up to 21 percent for length of stay and 13 percent for charges. Our findings suggest that hospitalized patients of lower socioeconomic status have longer stays and probably require more resources. Supplementary payments to hospitals for the treatment of poor patients merit further consideration.

Diagnosis-Related Groups↗
PubMed1990

Photoaging/photodamage and photoprotection.

Exposure to sunlight can produce both acute and long-term effects. Acute changes include erythema, photosensitivity, and immunologic alterations. Long-term consequences include carcinogenesis and photoaging. All effects can be minimized by photoprotection. This article reviews the adverse effects of sun exposure and strategies to reduce photodamage.

Humans↗
PubMed1990

The prevalence of malignant tumors in patients with psoriasis.

A possible association between psoriasis and cancer was investigated by linking the Swedish Psoriasis Association's membership registry to the Swedish Cancer Registry. The population studied was 20,328 living persons. Since 1958 a cancer was recorded in 520 of them. The expected number, based on the prevalence of cancer in Sweden, was 540. Among 43 cancer sites for men and 46 for women selected primarily for analysis, a significant association with psoriasis was found only in two types of cancer. For male breast cancer the observed number was 4 and the expected number was 0.58, and for female kidney cancers the observed number was 17 and the expected number was 6.1. The statistically significant excess risk found for these two forms of cancer may be the result of multiple statistical testing rather than a phenomenon of true biologic significance. Thus psoriasis patients seem not to deviate from the general population with regard to cancer prevalence.

Adolescent↗
PubMed1990

The incidence of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis. A population-based study with particular reference to reactions caused by drugs among outpatients.

We carried out a study to estimate the incidence of erythema multiforme (EM), Stevens Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) requiring hospitalization and to determine which drug therapies were associated with these reactions. We reviewed the clinical records of all patients who were hospitalized with these discharge diagnoses at Group Health Cooperative (GHC) of Puget Sound, Seattle, Wash, from 1972 through 1986. During this 14-year period, an average of about 260,000 persons, with demographic characteristics similar to those of the general population, received their care from GHC, and there were about 25,000 admissions to hospitals per year at the GHC hospitals. Based on International Classification of Diseases-Adapted coding, a total of 61 suspect cases of EM, SJS, or TEN were identified from the computerized hospital discharge file. Based on record review and the application of a uniform set of diagnostic criteria, a total of 37 patients (61%) were classified as having EM, SJS, or TEN. Of these, 16 cases (43%) were attributed to drugs administered to these patients prior to hospitalization. The overall incidence of hospitalization for EM, SJS, or TEN due to all causes was 4.2 per 10(6) person-years. The incidence of TEN alone due to all causes was 0.5 per 10(6) person-years. The incidence of EM, SJS, or TEN associated with drug use were 7.0, 1.8, and 9.0 per 10(6) person-years, respectively, for persons younger than 20 years of age, 20 to 64 years of age, and 65 years of age and older. Drug therapies with reaction rates in excess of 1 per 100,000 exposed individuals include phenobarbital (20 per 100,000), nitrofurantoin (7 per 100,000), sulfamethoxazole and trimethoprim, and ampicillin (both 3 per 100,000), and amoxicillin (2 per 100,000). Overall, our data suggest that cases of EM, SJS, and TEN sufficiently severe to require hospitalization are infrequent among outpatients using well-established drug therapies. A continuing challenge is the evaluation of these severe cutaneous reactions that are associated with newly marketed or less frequently prescribed drug therapies.

Adolescent↗
PubMed1989

Are topical corticosteroids useful in phototherapy for psoriasis?

A prospective, randomized, double-blind, placebo-controlled trial was performed to assess the effect of a potent topical corticosteroid cream used in conjunction with ultraviolet B (UVB) phototherapy on psoriasis with respect to time to clearing and duration of remission after clearing. Of the 53 outpatients who received suberythemogenic UVB phototherapy three times per week, 24 applied the topical corticosteroid and 29 applied the placebo cream twice daily until clearing was achieved. Nine patients in each group failed to comply with the protocol. Although there was a trend toward a slightly more rapid response in the topical corticosteroid-treated group, there was no significant difference in patients' early response to therapy, number of treatments, and UVB dose required to achieve clearing. Patients in the topical corticosteroid-treated group remained in remission longer than did patients in the control group (183 vs 116 days). Life-table analysis predicts that 62% of emollient-treated patients flare within 6 months of clearing compared with only 42% of topical corticosteroid-treated patients (p less than 0.1). For most patients with psoriasis who receive UVB therapy in an outpatient setting, the use of potent topical corticosteroids appears to produce, at most, a modest beneficial effect.

Administration, Topical↗
PubMed1989

Usefulness of case report literature in determining drugs responsible for toxic epidermal necrolysis.

To evaluate the usefulness of the case report literature concerning toxic epidermal necrolysis, we surveyed English-language reports published from January 1966 to April 1987, using epidermal necrolysis as a key word in the MEDLINE database. Of the 345 articles identified, 80 definitely or possibly contained individual case reports of at least 100 words; 59 of these 82 (72%) were available and reviewed. These 59 reports included a total of 73 separate cases of toxic epidermal necrolysis possibly related to drugs, which represents less than 5% of the case of toxic epidermal necrolysis that occurred in this period. In 62% of these 73 cases the apparent purpose of the report was to show an association between a given drug and the development of toxic epidermal necrolysis. The drugs most frequently associated with toxic epidermal necrolysis are allopurinol, the nonsteroidal anti-inflammatory agents, phenytoin, and the sulfonamide antibiotics. Given that only a small proportion of cases of toxic epidermal necrolysis appear in the case report literature, except to present association with drugs not previously reported, the contribution of case reports in providing an estimate of the relative risk of drug-associated toxic epidermal necrolysis is limited. Furthermore, our analysis suggests that the adoption of specific diagnostic criteria for and more uniform reporting of signs, symptoms, and therapy could greatly increase the usefulness of the case report literature. We propose a minimum set of informational and specific diagnostic criteria.

Adolescent↗
PubMed1989

Many ways to grow: creative art therapies.

So often, the prevailing thought surrounding treatment is that to be effective the treatment must be serious in tone. Yet, when you ask creative art therapists to describe their work, more often than not they will say that the ability to mix enjoyment with clinical technique is the "secret of our success." Again and again, recalcitrant, angry, underfocused, lethargic, and delayed children spring to life within an arts therapy session. Whether the modality used is music, dance, or the visual arts, children find in it the pleasure, stimulation, fun, and communication that may be missing from other aspects of their world. The creative art therapist helps a child by presenting the two-pronged approach of using the art form to foster mastery while allowing it to be a metaphor for ideas and concerns. Thus, both the process of "making something" and the symbols within the content are simultaneously providing therapeutic acid. Most exciting is the ability of the creative art therapist to unlock the child's inner world and bring new vitality to children and families alike. The creative art therapies are an important and unique tool among the constellation of health services.

Art Therapy↗
PubMed1989

A comparison of length of stay and costs for health maintenance organization and fee-for-service patients.

Enrollees of health maintenance organizations (HMOs) are less frequently hospitalized than are patients cared for by fee-for-service physicians. To determine if care provided to HMO and fee-for-service patient is different once they are hospitalized, we compared length of stay, total costs, and severity of illness for 617 HMO and fee-for-service patients hospitalized during the period 1983 through 1985 at a major teaching hospital. Severity was gauged in the following two ways: the Severity of Illness Index developed by Horn, and ratings by two physicians who were given all records from the first day of each patient's hospitalization. Length of stay was shorter and total costs were less for HMO patients in 7 of 11 diagnosis related groups. Using regression analysis to adjust for age, sex, emergency ward admission, diagnosis related group, and severity, we found that overall length of stay was 14% shorter for HMO patients than for fee-for-service patients (6.2 vs 5.3 days, P less than .01), whereas total costs were only 4% less ($4251 vs $4090, P greater than .2). These findings indicate that while patterns of utilization may vary by diagnosis related groups, HMO patients had shorter lengths of stay but comparable overall costs. Whether shorter lengths of stay represent greater efficiency, substitution of outpatient for inpatient care, or diminution in the quality of care is not clear.

Boston↗
PubMed1989

Allergic cutaneous reactions to drugs.

Because the pathophysiology of many drug eruptions is unknown, the presumption that a drug eruption is due to immune mechanisms is often based on clinical features. The drug exanthem, urticaria, and contact dermatitis are the most common adverse cutaneous reactions to medications. Drug exanthems occur in 2 to 3 per cent of medical inpatients and are most commonly caused by antibiotics and blood products. The incidence of drug exanthems is much higher in certain patient populations (for example, patients with AIDS treated with trimethoprim-sulfamethoxazole). Urticaria is the second most common allergic cutaneous reaction to drugs. Individual urticarial lesions last for less than 24 hours and do not leave hyperpigmentation or scarring. Urticaria not accompanied by systemic symptoms should not be treated with systemic corticosteroids or parenteral epinephrine. Allergic contact dermatitis is commonly caused by neomycin, benzocaine, ethylenediamine, diphenhydramine, and transdermal patches. The clinical spectrum of other, less common drug eruptions is wide. Toxic epidermal necrolysis, erythema multiforme, and fixed drug eruptions share similar pathologic features, are caused by many of the same drugs, and may have a similar pathogenesis. Photoallergic drug reactions require the interaction of drugs, UV irradiation, and the immune system. Drugs implicated in causing photoallergy include thiazide diuretics, sulfonamides, and phenothiazines. Eruptions seen in serum sickness include the drug exanthem, urticaria, vasculitis, urticarial vasculitis, and erythema multiforme. Identifying and discontinuing the responsible drug is usually essential for successful therapy of drug eruptions.

Drug Eruptions↗