Training physicians to help patients who drink too much.
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Alcoholism↗
Biomedical subjects
E B Larson
Publications and source records attributed to E B Larson.
Directional asymmetries in interhemispheric transmission time: evidence from visual evoked potentials.
The hypothesis was tested that interhemispheric transfer time (IHTT), as measured in the latency of bilaterally recorded visual evoked potentials, is directionally asymmetric, i.e. that an IHTT is faster for transmission from right-to-left hemisphere, than from left-to-right. A meta-analysis of 18 experiments within the published literature reporting visual evoked potential IHTTs indicates a significant experiment-wise predominance of faster right-to-left IHTTs. A new experiment is also reported in which significantly faster right-to-left IHTT was found in visual evoked potentials recorded from parietal electrodes to lateral visual field presentations while subjects performed a task requiring complex stimulus recognition and analysis, and a choice response.
Choice Behavior↗
The Mini-Mental State Examination score and the clinical diagnosis of dementia.
To set a working cutoff score for the referral to diagnostic examination, we evaluated 150 consecutive patients with complaints potentially related to dementia, using the Mini-Mental State Examination (MMSE). All patients were later given a complete, standardized work-up and diagnosis as part of our Alzheimer's Disease Patient Registry protocol. Dementia diagnosis was made, consistent with accepted criteria, by consensus of the physicians and psychologist. Diagnosis was reaffirmed after 1-year follow-up exam; 133 of the 150 original patients completed follow-up (80 dementia, 53 no dementia). We evaluated the initial MMSE score compared with the follow-up diagnosis. Sensitivity, specificity, and predictive values were calculated for MMSE scores ranging from 22 through 29. The conventional cutoff score of < 24 shows a sensitivity of 0.63 and a specificity of 0.96; sensitivity increased at higher cutoff scores. Multivariate analysis showed that educational level added significant prediction only at scores of > or = 27. We conclude that an MMSE score of 26 or 27 should be used as a cutoff score in symptomatic populations with similar educational and socioeconomic backgrounds when the goal is to miss few true cases. Population surveys where the expected prevalence is low may require a different cutoff score to indicate the need for further diagnostic evaluation.
Aged↗
Assessing cognitive abilities and dementia in a predominantly illiterate population of older individuals in Kinmen.
A community survey of dementia was conducted on a Chinese islet. A total of 221 men and 234 women in the age range of 50-92 were assessed. The Cognitive Abilities Screening Instrument (CASI), a 100-point cognitive test designed for cross-cultural studies and adapted in Chinese for individuals with little or no formal education, was administered twice by trained field workers with a retest interval of 3 to 4 weeks. In addition, all participants were assessed by physicians who did not know the CASI scores. The physicians' assessment included a complete neurological examination, plus semi-structured tests and interviews covering cognitive abilities, daily activities, depression, cerebrovascular disease, and Parkinson's disease. Dementia was diagnosed by consensus among the physicians according to the DSM-III-R criteria. Among the 455 participants, 16 cases of dementia were identified, including 13 with probable Alzheimer's disease and 1 each with vascular dementia, Parkinson's disease, and alcoholism. The rates of dementia were 0, 3.9 and 11.5% for the age groups of 50-69, 70-79 and 80-92; and 4.4, 2.0 and 0% for the education groups of 0-1, 2-6 and 7-15 years of schooling. No sex difference was found after controlling for education. The Chinese version of the CASI had an intraclass retest reliability of 0.90. Using a cut-off score of < or = 50 for dementia, the sensitivity was 0.88 and the specificity was 0.94. The preliminary study suggests that the CASI can be used in Chinese populations with generally low education levels and that Alzheimer's disease was the most common type of dementia in this population.
Aged↗
Opportunities and challenges in international collaborative epidemiologic research of dementia and its subtypes: studies between Japan and the U.S.
Estimates of the prevalence rates for dementia vary significantly among countries. Such variation may be explained, at least in part, by methodologic differences in studies. The disparities in prevalence rates of dementia subtypes, particularly Alzheimer's disease and multi-infarct dementia, are especially apparent in studies conducted in Eastern and Western countries. In Japan and China, the prevalence of multi-infarct dementia exceeds that of Alzheimer's disease, whereas in the West, Alzheimer's disease predominates in the vast majority of studies. Clearly, cross-cultural studies of incidence using standard methods are needed to investigate whether a true difference in risk exists, and which risk factors differentially contribute to this variation. Migrant studies of genetically homogeneous populations offer a unique opportunity to answer these questions. This article explores the value of migrant studies, their application to etiologic questions of dementia and its subtypes, and recommendations concerning how to conduct such studies.
Aged↗
Symptom patterns and comorbidity in the early stages of Alzheimer's disease.
OBJECTIVE: To learn whether patients with early Alzheimer's disease tend to under-report or over-report symptoms and to compare their comorbidity with non-demented patients. DESIGN: Case Control Study in a population-based dementia registry. SETTING AND PATIENTS: Three groups of subjects (mean age 76) were enrolled from an HMO base population: 154 cases had clinically diagnosed probable Alzheimer's disease, 92 subjects were found to be not demented although they had complaints of cognitive impairment, and another 129 cognitively intact controls were enrolled after frequency-matching for age and sex. MEASUREMENTS AND RESULTS: Medical records were examined for the 2 years prior to enrollment. Symptoms suggestive of cognitive impairment were evident 7.8 months prior to enrollment (median 6 months) in 95% of cases, in 77% of the not demented subjects, and in 6% of controls. After corrections for multiple comparisons, only symptoms of cognitive impairment were more frequent in cases, whereas several common symptoms not suggestive of cognitive impairment (eg, gastrointestinal discomfort, joint pain, vision problems) occurred more often in controls and the not demented group, even though comorbidity was similar among all three groups (Charlson Index mean scores: case = 0.7, not demented = 0.7, control = 0.5). CONCLUSIONS: Persons with Alzheimer's disease do complain of symptoms clearly related to cognitive impairment early in the course of illness, but may under-report common symptoms not suggestive of cognitive impairment, even though their comorbidity is similar to patients without dementia.
Aged↗
Causes of death associated with Alzheimer disease: variation by level of cognitive impairment before death.
OBJECTIVE: To describe causes of death for patients with Alzheimer disease (AD) and other dementing illnesses enrolled in a population-based Alzheimer disease patient registry (ADPR) and to describe the variation in causes by the level of cognitive impairment before death in probable AD cases. SETTING: The ADPR enrolls and diagnoses newly recognized potential dementia cases occurring in a large, stable health maintenance organization. To date, 654 cases have been enrolled and followed annually to monitor cognitive decline and verify initial diagnosis. DESIGN: Longitudinal descriptive study. PATIENTS: ADPR enrollees who have died. MEASUREMENTS: Death certificates were obtained for all who died (total n = 104, probable AD = 55); reported causes of death were reviewed by a physician to determine the underlying cause. AD patients were categorized according to their Mini-Mental State Exam score (cognitive impairment) within 12 months of death as (a) mildly (21+), (b) moderately (15-20), or (c) severely (0-14) impaired, and underlying cause and all reported causes of death for each group were tabulated. MAIN RESULTS: Among probable AD patients, pneumonia and AD were most often recorded on death certificates when cognitive impairment within the year prior to death had reached the severe level; heart disease, stroke, and other common causes of death predominated in AD patients who were less cognitively impaired. CONCLUSIONS: When AD cases were followed from first diagnosis to death, the causes of death varied by level of cognitive impairment. Illnesses potentially amenable to treatment caused death at all levels of disease, but more so early in the course of AD. Cognitive impairment may make patients less able to recognize and report symptoms of medical problems, thereby complicating efforts to intervene.
Aged↗
Parkinson's disease in Kin-Hu, Kinmen: a community survey by neurologists.
A door-to-door survey by neurologists in Kin-Hu township, Republic of China, of a sample of the Chinese population of 683 persons aged 50 years and over was performed in August, 1992. A total of 482 subjects (70.6%) completed the study. Kin-Hu, a township of Kinmen, is predominantly rural with agriculture as the main occupation. Six subjects (5 men, 1 woman) were diagnosed with Parkinson's disease (PD). Of these six, five were newly diagnosed; one of the five also had dementia. The crude prevalence rate per 1,000 persons over 50 years of age of PD in Kin-Hu was 6.2. The age-specific prevalence rates per 1,000 persons (95% confidence intervals) were 0 for age 50-59, 7.8 (0-22.9) for age 60-69, 17.5 (5.2-29.8) for age 70-79, and 25.4 (10.9-39.9) for age > or = 80. These rates are considerably higher than those reported in the People's Republic of China, and similar to rates found in Western countries. The higher prevalence of PD found in this pilot study suggests that environmental factors may be more important than racial factors in the pathogenesis of PD. If confirmed, the results suggest that epidemiologic studies looking for environmental risk factors might be of value.
Aged↗
How much is too much? Advising patients about safe levels of alcohol consumption.
United States physicians are increasingly encouraged to advise patients about health-related behaviors, such as smoking, but there is minimal discussion in the US medical literature about the need to advise patients about safe levels of alcohol consumption. Several factors likely contribute to this lack of focus on safe drinking practices. These include the complex relationship between drinking and health, limitations in the available epidemiologic data, misinterpretation of the disease model of alcoholism, and physician attitudes. Nevertheless, epidemiologic evidence clearly relates increasing levels of alcohol consumption to increased morbidity and mortality, and research has shown that physician advice can reduce both alcohol consumption and alcohol-related problems. We propose that physicians thoroughly assess patients' alcohol consumption and advise patients who drink about safe levels of consumption.
Alcohol Drinking↗
Randomized clinical trials in single patients during a 2-year period.
OBJECTIVE: To describe the feasibility of a single patient trial (SPT) service and study the influence of formal SPTs on therapeutic precision. DESIGN: Descriptive and evaluate study of SPTs. All planned trials were double-blind, randomized, multiple crossover trials. Other key features of individual trials were random assignment of order and assessment of predetermined explicit outcomes. Patients and physicians rated level of confidence in treatment before and after the SPT on visual analog scales. SETTING: Two-year experience (September 1988 to September 1990) of an SPT trial referral service available to physicians in an academic medical center. OUTCOME MEASURES: The number of planned and completed SPTs; proportion of completed trials yielding definitive answers; patient- and physician-rated levels of confidence in treatment pre- and post-SPT; time-motion studies to estimate resource consumption (costs) for selected SPTs. RESULTS: Of 34 completed trials, 17 were judged to give definitive results whereas 17 showed trends only. Results favored active treatment in 16 trials that led to treatment being continued (nine patients) or started (seven patients). Treatment was discontinued (seven patients) or not started (11 patients) based on 18 trial results that demonstrated active treatment was ineffective (seven), harmful (two), or apparently equivalent (nine). Most patients (65%) reported no change in their already high level of confidence in therapy as a result of trials, whereas physicians' confidence levels in therapy either increased or decreased post-SPT depending on the direction of trial results. Patients consistently rated the SPT service as extremely useful. Time-motion estimates indicate that 16.75 staff hours were spent per trial leading to a direct cost estimate of approximately $450 to $500 per trial. CONCLUSION: We conclude that an SPT service is feasible, trial costs compare favorably with other conventional services, and clinicians appear to gain confidence and precision from SPTs. When patients or clinicians are uncertain about the value (including the possibility of side effects) of treatment for symptomatic chronic diseases, we believe an SPT can be offered to a patient and will likely yield results that will effect subsequent treatment.
Academic Medical Centers↗
The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. Myocardial Infarction Triage and Intervention Project Investigators.
BACKGROUND: During the past decade the use of coronary angiography after acute myocardial infarction has substantially increased. Among the possible contributing factors, the increasing availability of cardiac catheterization facilities was the focus of our investigation. METHODS: We investigated whether the availability of cardiac catheterization facilities at an admitting hospital was associated with the likelihood that a patient would undergo coronary angiography. After adjusting for age, sex, cardiac history, and cardiac complications during hospitalization, we evaluated this association in 5867 consecutive patients with acute myocardial infarction admitted to 19 Seattle-area hospitals. We also assessed the association between the presence of on-site cardiac catheterization facilities and in-hospital mortality. RESULTS: Patients admitted to hospitals with on-site cardiac catheterization facilities were far more likely to undergo coronary angiography (odds ratio, 3.21; 95 percent confidence interval, 2.81 to 3.67) than patients admitted to hospitals where transfer to another institution would be required to perform cardiac catheterization. Admission to a hospital with on-site facilities was more strongly associated with the use of coronary angiography than any characteristic of the patient. Although our study had limited power to detect differences in mortality, the availability of coronary angiography had no discernible association with in-hospital mortality rates (odds ratio for mortality among patients admitted to hospitals with on-site facilities vs. patients admitted to hospitals without such facilities, 0.88; 95 percent confidence interval, 0.71 to 1.09). CONCLUSIONS: In this community-wide study, the availability of on-site cardiac catheterization facilities was associated with a higher likelihood that a patient would undergo coronary angiography. However, admission to hospitals with these facilities did not appear to be associated with lower short-term mortality.
Aged↗
Cholesterol reduction and the risk for stroke in men. A meta-analysis of randomized, controlled trials.
OBJECTIVE: Reducing serum cholesterol lowers the risk for ischemic heart disease, but its effects on other vascular diseases are unknown. Published trials were reviewed to determine the effect of cholesterol-lowering interventions on fatal and nonfatal stroke. DESIGN: Meta-analysis of randomized, controlled trials. DATA IDENTIFICATION: A literature search of English-language studies examining the effect of modified diets or medications on cardiovascular end points from 1965 to 1992 using MEDLINE and a review of references of five quantitative overviews of cholesterol reduction and coronary disease. DATA ANALYSIS: Thirteen studies met three eligibility criteria: patients randomized to intervention or control; fatal or nonfatal stroke reported separately; and end points assessed without knowledge of treatment status. Heterogeneity among studies and overall effects of treatment on fatal and nonfatal stroke were estimated using the Mantel-Haenszel-Peto method to combine independent study results. The influence of various study designs and interventions was explored using subgroup comparisons. RESULTS: For fatal stroke, the overall odds ratio associated with cholesterol-lowering interventions in 13 trials was 1.32 (95% Cl, 0.94 to 1.86), and the odds ratio for the 10 single-intervention trials was 1.34 (Cl, 0.91 to 1.96). Among eight trials reporting nonfatal events, the summary odds ratio for nonfatal stroke for treated participants compared with controls was 0.88 (Cl, 0.70 to 1.11), and the odds ratio for total strokes was 0.98 (Cl, 0.80 to 1.19). Among three trials using clofibrate, treatment significantly increased the risk for fatal stroke (odds ratio, 2.64; Cl, 1.42 to 4.92) but not for nonfatal stroke (odds ratio, 0.87; Cl, 0.61 to 1.26). Regression analysis showed no statistical association between the magnitude of cholesterol reduction and the risk for fatal stroke. CONCLUSIONS: Lowering serum cholesterol through modified diets or medications does not reduce stroke mortality or morbidity in middle-aged men. Clofibrate appears to increase the risk for fatal strokes, but the mechanism for this effect is unknown.
Anticholesteremic Agents↗
Use of peer ratings to evaluate physician performance.
OBJECTIVE: To assess the feasibility and measurement characteristics of ratings completed by professional associates to evaluate the performance of practicing physicians. DESIGN: The clinical performance of physicians was evaluated using written questionnaires mailed to professional associates (physicians and nurses). Physician-associates were randomly selected from lists provided by both the subjects and medical supervisors, and detailed information was collected concerning the professional and social relationships between the associate and the subject. Responses were analyzed to determine factors that affect ratings and measurement characteristics of peer ratings. SETTING AND PARTICIPANTS: Physician-subjects were selected from among practicing internists in New York, New Jersey, and Pennsylvania who received American Board of Internal Medicine certification 5 to 15 years previously. MAIN OUTCOME MEASURE: Physician performance as assessed by peers. RESULTS: Peer ratings are not biased substantially by the method of selection of the peers or the relationship between the rater and the subject. Factor analyses suggest a two-dimensional conceptualization of clinical skills: one factor represents cognitive and clinical management skills and the other factor represents humanistic qualities and management of psychosocial aspects of illness. Ratings from 11 peer physicians are needed to provide a reliable assessment in these two areas. CONCLUSIONS: These findings suggest that it is feasible to obtain assessments from professional associates of practicing physicians in areas such as clinical skills, humanistic qualities, and communication skills. Using a shorter version of the questionnaire used in this study, peer ratings provide a practical method to assess clinical performance in areas such as humanistic qualities and communication skills that are difficult to assess with other measures.
Clinical Competence↗
Illnesses causing dementia in the very elderly.
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Aged↗
Adverse drug effects: the harder we look, the more we find.
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Adverse Drug Reaction Reporting Systems↗
Delay from symptom to diagnosis and treatment of breast cancer in Washington State and British Columbia.
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Adult↗
Relationship between cigarette smoking and Alzheimer's disease in a population-based case-control study.
We investigated whether cigarette smoking is negatively associated with Alzheimer's disease (AD) in a population-based, frequency-matched, case-control study of 152 AD patients and 180 controls. Ever having smoked was associated with lower risk of AD (adjusted odds ratio = 0.61; 95% confidence interval: 0.37-0.99). Additional multivariate analyses demonstrated that education and history of hypertension modified this association. The direction of the modification was for higher education level and history of hypertension to further reduce the risk. The "dose-response" pattern showed the greatest risk reduction among those who smoked least and suggests a biologic mechanism of a dose-dependent up-regulation of nicotinic (cholinergic) brain receptors. These data, although consistent with current opinion about pathophysiology of AD, do not suggest smoking should be used as a preventive strategy for AD.
Aged↗
Could distance be a proxy for severity-of-illness? A comparison of hospital costs in distant and local patients.
OBJECTIVE: We test the hypothesis that hospital costs, after adjusting for DRG mix, are higher in distant patients than in local patients. DATA SOURCES AND STUDY SETTING: Data were obtained from the Washington State Commission Hospital Abstract Reporting System (CHARS) and included all patients discharged from 15 metropolitan hospitals in the state of Washington during fiscal year 1987 (N = 181,072). STUDY DESIGN: Distant patients were initially defined as those patients residing outside a 15-mile radius of the hospital from which they were discharged; all other patients were considered local. Distance was determined using the patient's residence zip code. Hospital charge, calculated for all patients regardless of payer, served as a proxy for cost and was adjusted using the DRG weight. PRINCIPAL FINDINGS: Average charge (adjusted for DRG weight) was higher for distant patients in all but two hospitals. Overall adjusted charge for distant patients was 15 percent higher (p < .001). This finding persisted when different distances were used to dichotomize distant and local patients. When the 20 most common DRGs were examined individually, little charge difference was found in surgical DRGs that require tertiary center services (tertiary DRGs) and in those DRGs with both moderate and predictable resource use (routine DRGs); the charge difference seemed most prominent in those DRGs with a wide array of possible resource use (heterogeneous DRGs). CONCLUSIONS: Results suggest that patients traveling long distances use more resources and incur higher hospital charges than local patients. This is not accounted for in prospective payment. We postulate that distance might serve in part as a proxy for severity-of-illness.
Catchment Area, Health↗