Irene D. Feurer

Examination of DSM-IV criteria for attention deficit/hyperactivity disorder in a county-wide sample.

&NA; This study replicated, in the subsequent academic year, teacher‐reported prevalence rates for attention deficit/hyperactivity disorder (ADHD) based on DSM‐IV. Teachers in grades K‐5 in a Tennessee county (10 schools, 214 teachers, and 4323 children) completed questionnaires on all their students consisting of the DSM‐IV symptoms for disruptive behavior disorders, except for eight conduct disorder symptoms, seven symptoms screening for anxiety or depression, ratings of performance, and questions about the presence of ADHD, stimulant medication treatment, and behavioral or academic problems. The prevalence rates were 16.1% for ADHD‐all types, 8.8% for ADHD‐inattentive type (AD), 2.6% for ADHD‐hyperactive/impulsive type (HI), and 4.7% for ADHD‐combined type and 6.8, 3.2, 0.6, and 2.9%, respectively, when impairment was taken into consideration. The rates of problems differed mostly between ADHD‐AD and ADHD‐HI (30% vs. 68%) for behavior and (56% vs. 16%) for academics. Few (11‐33%) had an ADHD diagnosis or were treated with stimulant treatment (8‐26%). DSM‐IV criteria are likely to increase the prevalence but may better characterize the heterogeneity of this disorder.

Patterns and mental health predictors of domestic violence in the United States - Results from the National Comorbidity Survey

Ronald C. Kessler*, Beth E. Molnar, Irene D. Feurer, Mark Appelbaum Professor, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115-5899, USA Research Fellow, Department of Maternal and Child Health, Harvard School of Public Health, Boston, MA, USA Research Associate Professor, Department of Psychiatry, Vanderbilt University, Nashville, TN, USA Professor, Department of Psychology, University of California at San Diego, USA

The impact of lymph node involvement on survival in patients with papillary and follicular thyroid carcinoma

BACKGROUND The prognostic role of lymph node metastases in well-differentiated thyroid carcinoma remains controversial. We investigated impact of lymph node involvement on survival in patients with well-differentiated thyroid cancer. METHODS We queried the Surveillance, Epidemiology, and End Results registry for patients diagnosed with well-differentiated thyroid carcinoma between 1988 and 2003. Cases were stratified by age (<45 vs >/=45 years) and pathology (papillary/follicular). Four separate Cox regression models were developed to test the effects of demographic and clinical covariates on survival. RESULTS We identified 33,088 patients. 30,504 patients (49% >/=45 years) had papillary carcinoma and 2,584 patients (55% >/=45 years) had follicular carcinoma. Age affected survival in all models (P < .001). In patients with papillary carcinoma <45 years, lymph node disease did not influence survival (P = .535), whereas in patients >/=45 years, lymph node involvement was associated with 46% increased risk of death (P < .001). In patients with follicular carcinoma, lymph node involvement conferred increased risk of death in both age groups (P </= .002). Effects of other covariates varied between models. CONCLUSION Cervical lymph node metastases conferred independent risk in all patients with follicular carcinoma and in those patients with papillary carcinoma aged >/=45 years, but did not affect survival in patients with papillary carcinoma <45 years.

Energy expenditure in malnourished cancer patients.

It is widely believed that the presence of a malignancy causes increased energy expenditure in the cancer patient. To test this hypothesis, resting energy expenditure (REE) was measured by bedside indirect calorimetry in 200 heterogeneous hospitalized cancer patients. Measured resting energy expenditure (REE-M) was compared with expected energy expenditure (REE-P) as defined by the Harris-Benedict formula. The study population consisted of 77 males and 123 females with a variety of tumor types: 44% with gastrointestinal malignancy, 29% with gynecologic malignancy, and 19% with a malignancy of genitourinary origin. Patients were classified as hypometabolic (REE < 90% of predicted), normometabolic (90–110% of predicted) or hypermetabolic(>110% of predicted). Fifty-nine per cent of patients exhibited aberrant energy expenditure outside the normal range. Thirty-three per cent were hypometabolic (79.2% REE-P), 41% were normometabolic (99.5% REE-P), and 26% were hypermetabolic (121.9% REE-P) (p < 0.001). Aberrations in REE were not due to age, height, weight, sex, nutritional status (% weight loss, visceral protein status), tumor burden (no gross tumor, local, or disseminated disease), or presence of liver metastasis. Hypermetabolic patients had significantly longer duration of disease (p < 0.04) than normometabolic patients (32.8 vs. 12.8 months), indicating that the duration of a malignancy may have a major impact upon energy metabolism. Cancer patients exhibit major aberrations in energy metabolism, but are not uniformly hypermetabolic. Energy expenditure cannot be accurately predicted in cancer patients using standard predictive formulae.

Obtaining Systematic Teacher Reports of Disruptive Behavior Disorders Utilizing DSM-IV

This study examines the psychometric properties of the Vanderbilt AD/HD Diagnostic Teacher Rating Scale (VADTRS) and provides preliminary normative data from a large, geographically defined population. The VADTRS consists of the complete list of DSM-IV AD/HD symptoms, a screen for other disruptive behavior disorders, anxiety and depression, and ratings of academic and classroom behavior performance. Teachers in one suburban county completed the scale for their students during 2 consecutive years. Statistical methods included (a) exploratory and confirmatory latent variable analyses of item data, (b) evaluation of the internal consistency of the latent dimensions, (c) evaluation of latent structure concordance between school year samples, and (d) preliminary evaluation of criterion-related validity. The instrument comprises four behavioral dimensions and two performance dimensions. The behavioral dimensions were concordant between school years and were consistent with a priori DSM-IV diagnostic criteria. Correlations between latent dimensions and relevant, known disorders or problems varied from .25 to .66.

Health-related quality of life after different types of solid organ transplantation.

ObjectiveTo describe functional health and health-related quality of life (QOL) before and after transplantation; to compare and contrast outcomes among liver, heart, lung, and kidney transplant patients, and compare these outcomes with selected norms; and to explore whether physiologic performance, demographics, and other clinical variables are predictors of posttransplantation overall subjective QOL. Summary Background DataThere is increasing demand for outcomes analysis, including health-related QOL, after medical and surgical interventions. Because of the high cost, interest in transplantation outcomes is particularly intense. With technical surgical experience and improved immunosuppression, survival after solid organ transplantation has matured to acceptable levels. More sensitive measures of outcomes are necessary to evaluate further developments in clinical transplantation, including data on objective functional outcome and subjective QOL. MethodsThe Karnofsky Performance Status was assessed objectively for patients before transplantation and up to 4 years after transplantation, and scores were compared by repeated measures analysis of variance. Subjective evaluation of QOL over time was obtained using the Short Form-36 (SF-36) and the Psychosocial Adjustment to Illness Scale (PAIS). These data were analyzed using multivariate and univariate analysis of variance. A summary model of health-related QOL was tested by path analysis. ResultsTools were administered to 100 liver, 94 heart, 112 kidney, and 65 lung transplant patients. Mean age at transplantation was 48 years; 36% of recipients were female. The Karnofsky Performance Status before transplantation was 37±1 for lung, 38±2 for heart, 53±3 for liver, and 75±1 for kidney recipients. After transplantation, the scores improved to 67±1 at 3 months, 77±1 at 6 months, 82±1 at 12 months, 86±1 at 24 months, 84±2 at 36 months, and 83±3 at 48 months. When patients were stratified by initial performance score as disabled or able, both groups merged in terms of performance by 6 months after liver and heart transplantation; kidney transplant patients maintained their stratification 2 years after transplantation. The SF-36 physical and mental component scales improved after transplantation. The PAIS score improved globally. Path analysis demonstrated a direct effect on the posttransplant Karnofsky score by time after transplantation and diabetes, with trends evident for education and preoperative serum creatinine level. Although neither time after transplantation nor diabetes was directly predictive of a composite QOL score that incorporated all 15 subjective domains, recent Karnofsky score and education level were directly predictive of the QOL composite score. ConclusionsDifferent types of transplant patients have a different health-related QOL before transplantation. Performance improved after transplantation for all four types of transplants, but the trajectories were not the same. Subjective QOL measured by the SF-36 and the PAIS also improved after transplantation. Path analysis shows the important predictors of health-related QOL. These data provide clearly defined and widely useful QOL outcome benchmarks for different types of solid organ transplants.

Energy expenditure in malnourished gastrointestinal cancer patients.

Cancer cachexia, a common finding in patients with gastrointestinal (GI) malignancy, is frequently attributed to tumor‐induced aberrations in host energy expenditure. To characterize the frequency and severity of aberrations in energy expenditure in GI cancer patients, and to identify the potential influence of tumor characteristics in this group, the authors measured resting energy expenditure (REE) by indirect calorimetry in 173 patients and compared REE to predicted energy expenditure (PEE) from the Harris‐Benedict formulae based on current body weight. Fifty‐eight percent of patients had abnormal REE (normal REE = ±10% PEE); 36% (62 of 173) were hypometabolic (REE <90% PEE), and 22% (39 of 173) were hypermetabolic (REE >110% PEE). Host and tumor factors were compared between metabolic groups to identify potential determinants of abnormal energy expenditure. Differences between groups cannot be explained by differences in patient age, sex, body size, nutritional status, tumor burden, or duration of disease. Resting energy expenditure does not correlate with percent of weight loss, serum albumin, or duration of disease. Analysis by tumor site reveals patients with pancreatic or hepatobiliary tumors to be predominantly hypometabolic; gastric cancer patients tend to be hypermetabolic, whereas patients with colorectal or esophageal neoplasms are more evenly distributed across metabolic groups, the largest portion being normometabolic (X2 = 20.7, P <0.02). The majority of GI cancer patients have abnormal REE which is unpredictable and not uniformly hypermetabolic. The determinants of these abnormalities do not appear to be age, sex, body size, nutritional status or tumor burden. Primary tumor site is a major determinant of energy expenditure in GI cancer patients. Cancer 53:1265‐1273, 1984.

Resting energy expenditure in patients with pancreatitis.

ObjectiveTo assess the resting energy-expenditure of hospitalized patients with pancreatitis. DesignProspective, case-referent study. SettingNutrition support service in a university tertiary care hospital. PatientsPatients referred to the Nutrition Support Service with the diagnosis of pancreatitis. Excluded from study entry included those with cancer, obesity (>150% ideal body weight), those measured within 3 postoperative days, or patients requiring ventilator support with an Fio2 of >0.5. Forty-eight patients with either acute pancreatitis (n = 13), chronic pancreatitis (n = 24), acute pancreatitis with sepsis (n = 7), or chronic pancreatitis with sepsis (n = 7) were studied. The two septic groups were combined into a single pancreatitis-with-sepsis group, since no significant differences among measured variables were observed between individual septic groups. InterventionsNone. Measurements and Main ResultsResting energy expenditure was measured by indirect calorimetry and compared with the predicted energy expenditure, as determined by the Harris-Benedict equations. Resting energy expenditure (percent of predicted energy expenditure) was significantly (p < .02) greater for patients with pancreatitis complicated by sepsis (120 ± 11%) compared with the nonseptic chronic pancreatitis group (105 ± 14%). Resting energy expenditure for the nonseptic acute pancreatitis patients (112 ± 17%) was not significantly different from the other groups. The septic pancreatitis group had the largest percentage (82%) of hypermetabolic (resting energy expenditure >110% of predicted energy expenditure) patients, whereas 61% and 33% of the acute and chronic pancreatitis groups were hypermetabolic, respectively (p < .02). ConclusionsResting energy expenditure is variable in patients with pancreatitis (77% to 139% of predicted energy expenditure). The Harris-Benedict equations are an unreliable estimate of caloric expenditure. Septic complications are associated with hypermetabolism and may be the most important factor influencing resting energy expenditure in pancreatitis patients. (Crit Care Med 1991; 19:484)

Decreased dopamine type 2 receptor availability after bariatric surgery: Preliminary findings

BACKGROUND Diminished dopaminergic neurotransmission contributes to decreased reward and negative eating behaviors in obesity. Bariatric surgery is the most effective therapy for obesity and rapidly reduces hunger and improves satiety through unknown mechanisms. We hypothesized that dopaminergic neurotransmission would be enhanced after Roux-en-Y-Gastric Bypass (RYGB) and Vertical Sleeve Gastrectomy (VSG) surgery and that these changes would influence eating behaviors and contribute to the positive outcomes from bariatric surgery. METHODS Five females with obesity were studied preoperatively and at approximately 7 weeks after RYGB or VSG surgery. Subjects underwent positron emission tomography (PET) imaging with a dopamine type 2 (DA D2) receptor radioligand whose binding is sensitive to competition with endogenous dopamine. Regions of interest (ROI) relevant to eating behaviors were delineated. Fasting enteroendocrine hormones were quantified at each time point. RESULTS Body weight decreased as expected after surgery. DA D2 receptor availability decreased after surgery. Regional decreases (mean+/-SEM) were caudate 10+/-3%, putamen 9+/-4%, ventral striatum 8+/-4%, hypothalamus 9+/-3%, substantia nigra 10+/-2%, medial thalamus 8+/-2%, and amygdala 9+/-3%. These were accompanied by significant decreases in plasma insulin (62%) and leptin (41%). CONCLUSION The decreases in DA D2 receptor availability after RYGB and VSG most likely reflect increases in extracellular dopamine levels. Enhanced dopaminergic neurotransmission may contribute to improved eating behavior (e.g. reduced hunger and improved satiety) following these bariatric procedures.

Self-Injurious Behavior and Prader-Willi Syndrome: Behavioral Forms and Body Locations

With few exceptions (e.g., Lesch-Nyhan syndrome), the specific nature of self-injury in relation to identified genetic syndromes associated with mental retardation is poorly understood. In the present study we surveyed the families of 62 persons with Prader-Willi syndrome to determine the prevalence, topographies, and specific body locations of self-injurious behavior. Self-injury was reported for 81% of the participants. Skin-picking was the most prevalent form, with the front of the legs and head being disproportionately targeted as preferred self-injury body sites. Individuals with the 15q11-q13 deletion injured significantly more body sites than did individuals with maternal disomy 15. Results are discussed in relation to previous self-injury body site findings and implications for the relevance of syndrome-specific behavioral phenotypes.