Showing papers by "John Concato published in 2002"

How good is the evidence linking breastfeeding and intelligence

Abstract: Background. We conducted a critical review of the many studies that have tried to determine whether breastfeeding has a beneficial effect on intellect. Design/Methods. By searching Medline and the references of selected articles, we identified publications that evaluated the association between breastfeeding and cognitive outcomes. We then appraised and described each study according to 8 principles of clinical epidemiology: 1) study design, 2) target population: whether full-term infants were studied, 3) sample size, 4) collection of feeding data: whether studies met 4 standards of quality— suitable definition and duration of breastfeeding, and appropriate timing and source of feeding data, 5) control of susceptibility bias: whether studies controlled for socioeconomic status and stimulation of the child, 6) blinding: whether observers of the outcome were blind to feeding status, 7) outcome: whether a standardized individual test of general intelligence at an age older than 2 years was used, and 8) format of results: whether studies reported an effect size or some other strategy to interpret the clinical impact of results. Results. We identified 40 pertinent publications from 1929 to February 2001. Twenty-seven (68%) concluded that breastfeeding promotes intelligence. Many studies, however, had methodological flaws. Only 2 papers studied full-term infants and met all 4 standards of high-quality feeding data, controlled for 2 critical confounders, reported blinding, used an appropriate test, and allowed the reader to interpret the clinical significance of the findings with an effect size. Of these 2, 1 study concluded that the effect of breastfeeding on intellect was significant, and the other did not. Conclusion. Although the majority of studies concluded that breastfeeding promotes intelligence, the evidence from higher quality studies is less persuasive.

Thrombolysis for acute stroke in routine clinical practice.

Abstract: Background: Studies have demonstrated that thrombolytic therapy for acute stroke can be given safely and effectively in study settings with experienced clinicians, but the patient outcomes associated with thrombolytic therapy in routine clinical practice require investigation. Objectives: To compare outcomes among patients given intravenous thrombolysis in routine clinical practice with the results of the National Institute of Neurological Disorders and Stroke rt-PA Study (NINDS cohort) and to examine whether protocol deviations are associated with adverse events. Methods: Retrospective cohort of community-based patients given thrombolysis for acute stroke from May 1, 1996, through December 31, 1998, in 16 Connecticut hospitals (Connecticut cohort). Results: Forty-two (67%) of 63 patients in the Connecticut cohort had at least 1 major protocol deviation, and 61 (97%) had major or minor protocol deviations. Overall, the in-hospital mortality was higher in the Connecticut cohort (16/63 [25%]) compared with the NINDS cohort (40/312 [13%]; P=.01). The serious extracranial hemorrhage rate was also higher for the Connecticut cohort (8/63 [13%] vs 5/312 [2%]; P=.001). Patients in the Connecticut cohort without major protocol deviations had outcomes similar to those in the NINDS cohort; however, patients in the Connecticut cohort with major protocol deviations had higher rates of in-hospital mortality (13/42 [31%] vs 40/312 [13%]; P=.002) and serious extracranial hemorrhage (7/42 [17%] vs 5/312 [2%]; P=.001). Conclusions: Protocol deviations occur commonly when thrombolytic therapy is given to stroke patients in routine clinical practice. Patients who receive thrombolysis with major protocol deviations have higher rates of inhospital mortality and serious extracranial hemorrhage than patients in the NINDS cohort. Arch Intern Med. 2002;162:1994-2001

Stressful Life Events Among Community‐living Older Persons

Abstract: OBJECTIVES: To identify the life events that older persons experience as most stressful, to evaluate older persons’ perceptions of the consequences of these stressful events for their lives, and to evaluate the relationship of demographic factors and measures of health and functional status to these perceptions.

The health-related effects of alcohol use in older persons: a systematic review.

Abstract: Increased alcohol consumption is associated with substantial morbidity and mortality in young and middle-aged adult populations, but its effects on the health of older adults have received less attention. The objective of the study was to review published studies that assessed the effects of alcohol on falls or fall injuries, functional impairment, cognitive impairment, and all-cause mortality among older adults. MEDLINE database and bibliographies of selected citations were searched for English language studies published between 1966 and 1998 that examined the relationship between alcohol and one or more of the above outcomes. Also a study was analyzed if it included participants 60 years of age or older, or a broader age range of participants and reported results for older subgroups, or predominantly older participants as evidenced by a mean age of 65 years of age or above. Information on studies' sample sizes, exposure and outcome measures, and risk estimates were extracted, and articles were evaluated for methodologic quality using predetermined criteria. Eighty-four studies were identified that examined 91 potential exposure–outcome associations including falls or fall injuries (n = 26); functional impairment (n = 13); cognitive impairment (n = 32); and all-cause mortality (n = 20). The percentage of studies demonstrating harm, no association, or benefit by outcome included falls (15% vs. 81% vs. 4%); functional disability (38% vs. 46% vs. 16%); cognitive impairment (31% vs. 66% vs. 3%); and all-cause mortality (15% vs. 65% vs. 20%). Studies (n = 84) inconsistently adhered to methodologic standards. Although 90% provided eligibility criteria; 61% cited participation rates; and 73% described the methods used to measure alcohol exposure; only 44% adjusted for potentially important confounding factors; and 26% distinguished former drinkers from nondrinkers. Of the cohort studies (n = 47), 30% assessed for change in participants' exposure status over time, and 17% determined whether losses to follow-up varied by exposure status. The magnitude of risk posed by alcohol use for falls or fall injuries, functional disability, cognitive impairment, and all-cause mortality among older adults remains uncertain. Prospective studies are needed to better define the health-related effects of alcohol use in older populations.

Unwillingness of rheumatoid arthritis patients to risk adverse effects

Abstract: Objective To evaluate patient willingness to accept the risk of adverse effects (AEs) commonly associated with arthritis medications. Methods Rheumatoid arthritis patients were asked to rate their willingness to take a medication associated with 17 specific AEs using a visual analogue scale. Results We interviewed 100 patients. Eighty-one were currently using one or more disease-modifying anti-rheumatic drugs (DMARDs) and 29 had previously experienced AEs related to DMARDs. Seventy-five stated that they were doing very well or well with respect to their arthritis compared with other people their age. Thirty-five per cent of those interviewed were unwilling to accept the risk of cosmetic changes, 38% were unwilling to accept the risk of temporary discomfort and 45% were unwilling to accept the risk of major toxicity. Patients who had previously experienced AEs were more willing to accept the risk of cosmetic changes (83 vs. 58%, P=0.02), temporary discomfort (79 vs. 55%, P=0.02) and major toxicity (83 vs. 44%, P=0.001) compared with those who had not previously experienced AEs. Conclusions Many rheumatoid arthritis patients are very concerned about potential drug toxicity. However, risk adversity appeared to be attenuated by past experience with AEs. Our results suggest that certain patients, especially those with milder disease activity, might be reluctant to accept commonly used arthritis medications if they are fully informed of their potential toxicity.

Utility of Captopril Renal Scans for Detecting Renal Artery Stenosis

Abstract: Background Captopril renal scanning (CRS) is commonly recommended as a noninvasive method for detecting renal artery stenosis (RAS), based on performance characteristics determined in research settings. Scant data are available, however, regarding the utility of CRS in clinical practice. Methods We evaluated the performance characteristics (sensitivity, specificity, and predictive values) of CRS in a consecutive series of 90 patients who underwent both CRS and renal arteriography within a 6-month period (January 1, 1991, through December 31, 1995) at a university hospital. Results Among 86 eligible patients (and 169 kidneys), the prevalence of RAS was 43%. The sensitivity of CRS was 74% (95% confidence interval [CI], 62%-83%); the specificity was 59% (95% CI, 49%-69%); the positive predictive value was 58% (95% CI, 47%-68%); and the negative predictive value was 75% (95% CI, 64%-84%). Also, there was evidence of spectrum bias, because the sensitivity and specificity (as well as the positive and negative predictive values) were different for groups with and without vascular disease. Conclusions The results of CRS were substantially worse in a clinical practice setting than previously reported in research settings, despite a similar prevalence of RAS. Captopril renal scanning should not be used as an initial screening test for diagnosing RAS, even among patients with high clinical likelihood of disease.

Pain-Related Disability Among Older Male Veterans Receiving Primary Care

Abstract: Background . Pain is common among older persons and is associated with substantial disability, but factors that increase the risk for pain-related disability remain poorly defined. We sought to identify factors associated with disability due to pain in a sample of older veterans receiving primary care. Methods . Participants ( N � 494) in this cross-sectional study included male veterans aged 65 years and older who were enrolled in a Veterans Affairs primary care clinic and who reported pain within the prior 12 months. Candidate factors included demographic, psychological, medical, and pain (e.g., intensity, site, duration) characteristics and were ascertained during face-to-face interviews. We assessed participants’ level of pain-related disability by asking them to rate on a 0 to 10 scale the extent to which pain interfered with their ability to do daily activities (0 � no interference at all and 10 � no longer doing daily activities due to pain). Patients with scores of 0, 1‐6, and 7‐10 (approximate upper quartile) were classified as having no, low/moderate, and high pain-related disability. Results . The distribution of pain-related disability was none � 149 (30%), low/moderate � 210 (43%), and high � 135 (27%). Factors associated with high (vs no) pain-related disability included the presence of depressive symptoms, defined as a score of 16 or greater on the Center for Epidemiologic Studies‐Depression scale (adjusted odds ratio [AOR] � 3.12, 95% confidence interval [CI] � 1.42‐6.85), and pain intensity, defined as a one-unit increase on a 0‐10 numeric rating scale (AOR � 1.84, 95% CI � 1.61‐2.12). Other factors associated with high pain-related disability included the presence of pain on most days of every month (AOR � 3.59, 95% CI � 1.82‐7.08) and low back pain (AOR � 2.36, 95% CI � 1.13‐4.94). Depressive symptoms, pain intensity, and the presence of pain on most days of every month were also significantly and independently associated with low/moderate (vs no) pain-related disability.

Patient preferences for treatment of lupus nephritis

Abstract: Objective To examine the amount of improvement in renal survival that lupus patients require before choosing cyclophosphamide over azathioprine for the treatment of lupus nephritis. Methods Patients were presented with descriptions of cyclophosphamide and azathioprine and asked to indicate their preferred choice if each conferred an equal probability of renal survival. Strength of preference was assessed by systematically increasing the probability of renal survival of the more toxic treatment until the respondent's choice switched. Results Ninety-three well-educated women (mean age ± SD 40 ± 7 years) participated in the study. Ninety-eight percent (91/93) of the participants chose azathioprine over cyclophosphamide when both drugs conferred an equal probability of renal survival. Although most subjects switched preferences to cyclophosphamide for better renal survival, 31% (28/91) were unwilling to switch from azathioprine to cyclophosphamide for improved short-term renal survival, and 15% (14/91) were unwilling to switch from azathioprine to cyclophosphamide for improved long-term renal survival. Conclusion Although the majority of patients switched preferences to cyclophosphamide for better renal survival, a substantial minority was unwilling to accept the toxicity associated with cyclophosphamide, even if it was much better than azathioprine at preventing renal failure.

Use of alcohol, illicit drugs, and tobacco among characters on prime-time television.

Abstract: Previous research of addictive substances suggests that use of alcohol, illicit drugs, and tobacco is overrepresented on prime-time television (TV). These studies, however, have relied on frequency counts of the substance, rather than the prevalence of use among characters. Therefore, the objectives of this study were to compare the prevalence of alcohol, illicit drug, and tobacco users among characters on prime-time TV during 1995 and 1996 with rates of use in the United States. In addition, we determined if the ratio of male to female, young to old, and white to minority addictive substance users on prime-time TV were similar to the equivalent U.S. ratios. Comparing results for prime-time TV characters versus the U.S. population (respectively), 11.0% (99% CI, 9.8-12.1) drank alcohol versus 51.0%; 0.8% (99% CI, 0.5-1.1) used illicit drugs versus 6.1%; and 2.5% (99% CI, 2.0-3.1) smoked tobacco versus 28.9%. In addition, no consistent pattern was evident in our analyses that assessed whether addictive substance users on prime-time TV were more frequently represented as men, young, or minority compared to the similar U.S. ratio. These results indicate that contrary to prevailing beliefs, alcohol, illicit drug, and tobacco users are uncommon on prime-time TV and are less prevalent than in the U.S. population.