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Biomedical subjects

J B McKinlay

Publications and source records attributed to J B McKinlay.

At least 37 records · Page 2Linked to original sources
PubMed2000

To boldly go....

The threshold of the new millennium offers an opportunity to celebrate remarkable past achievements and to reflect on promising new directions for the field of public health. Despite historic achievements, much will always remain to be done (this is the intrinsic nature of public health). While every epoch has its own distinct health challenges, those confronting us today are unlike those plaguing public health a century ago. The perspectives and methods developed during the infectious and chronic disease eras have limited utility in the face of newly emerging challenges to public health. In this paper, we take stock of the state of public health in the United States by (1) describing limitations of conventional US public health, (2) identifying different social philosophies and conceptions of health that produce divergent approaches to public health, (3) discussing institutional resistance to change and the subordination of public health to the authority of medicine, (4) urging a move from risk factorology to multilevel explanations that offer different types of intervention, (5) noting the rise of the new "right state" with its laissez-faire attitude and antipathy toward public interventions, (6) arguing for a more ecumenical approach to research methods, and (7) challenging the myth of a value-free public health.

Epidemiologic Methods↗
PubMed2000

Upstream healthy public policy: lessons from the battle of tobacco.

Many consider public health and politics to be entirely separate worlds. Public health activities are generally well-motivated by public interest, perceived as value-free, scientific, and devoid of partisan preference. Politics, in contrast, can be viewed as a distasteful activity involving self-interested pressure groups, misuse of state power, and influence of money on national decisions. Public health and politics are inappropriate bedfellows if politics is reduced to party politics. Politics, of course, involves more than just party activities; it concerns the structure, distribution, and effects of power in society. Which groups pattern the social order? What are their sources of influence? How do they retain privileged status? What social effects result from the policies these groups shape? Viewed in this broader sense, politics is essential for effective public health and thus is the inescapable context of public health interventions. To disregard sociopolitical determinants of health is to relegate public health to prevention and promotion of individual risk behaviors. If public health is to be more successful in the 21st century, it must comprehend the magnitude of the forces against it and the strategies used to engineer its defeat. Public health interventions in the new millennium must be appropriate to their sociocultural context.

Humans↗
PubMed2000

Testosterone, sex hormone-binding globulin, and the development of type 2 diabetes in middle-aged men: prospective results from the Massachusetts male aging study.

OBJECTIVE: The objective was to examine prospectively the association between low testosterone and sex hormone-binding globulin (SHBG) levels and the subsequent development of type 2 diabetes in men. RESEARCH DESIGN AND METHODS: Analyses were conducted on the cohort of the Massachusetts Male Aging Study, a population-based random sample of men aged 40-70. Of the 1,709 men enrolled in 1987-1989 (T1), 1,156 were followed up 7-10 years later (T2). Testosterone and SHBG levels at T1 were used to predict new cases of diabetes between T1 and T2. RESULTS: After controlling for potential confounders, diabetes at follow-up was predicted jointly and independently by lower baseline levels of free testosterone and SHBG. The odds ratio for future diabetes was 1.58 for a decrease of 1SD in free testosterone (4 ng/dl) and 1.89 for a 1SD decrease in SHBG (16 nmol/l), both significant at P < 0.02. CONCLUSIONS: Our prospective findings are consistent with previous, mainly cross-sectional reports, suggesting that low levels of testosterone and SHBG play some role in the development of insulin resistance and subsequent type 2 diabetes.

Adult↗
PubMed2000

Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study.

PURPOSE: We estimated the incidence of erectile dysfunction in men 40 to 69 years old at study entry during an average 8.8-year followup, and determined how risk varied with age, socioeconomic status and medical conditions. MATERIALS AND METHODS: Data from a randomly sampled population based longitudinal study of Massachusetts men were analyzed. A total of 1,709 men completed the baseline interview during 1987 to 1989 and 1,156 survivors completed followup from 1995 to 1997. The analysis sample consisted of 847 men without erectile dysfunction at baseline and with complete followup information. Erectile dysfunction was assessed by discriminant analysis of 13 questions from a self-administered sexual function questionnaire and a single global self-rating question. RESULTS: The crude incidence rate for erectile dysfunction was 25.9 cases per 1,000 man-years (95% confidence interval [CI] 22.5 to 29.9). The annual incidence rate increased with each decade of age and was 12.4 cases per 1,000 man-years (95% CI 9.0 to 16.9), 29.8 (24.0 to 37.0) and 46.4 (36.9 to 58.4) for men 40 to 49, 50 to 59 and 60 to 69 years old, respectively. The age adjusted risk of erectile dysfunction was higher for men with lower education, diabetes, heart disease and hypertension. Population projections for men 40 to 69 years old suggest that 17,781 new cases of erectile dysfunction in Massachusetts and 617,715 in the United States (white males only) are expected annually. CONCLUSIONS: Although prevalence estimates and cross-sectional correlates of erectile dysfunction have recently been established, incidence estimates were lacking. Incidence is necessary to assess risk, and plan treatment and prevention strategies. The risk of erectile dysfunction was about 26 cases per 1,000 men annually, and increased with age, lower education, diabetes, heart disease and hypertension.

Adult↗
PubMed1999

Serum prostate-specific antigen levels (PSA) in men without clinical evidence of prostate cancer: age-specific reference ranges for total PSA, free PSA, and percent free PSA.

OBJECTIVES: To investigate the relationship between age and total prostate-specific antigen (tPSA), free PSA (fPSA), and percent free PSA (%fPSA) in men 48 to 79 years old without clinical evidence of prostate cancer. We determined age-specific ranges for each parameter and compared the results with previously published studies in similar populations. METHODS: Nine hundred eighty-three men (96% white) from the random-sample community-based Massachusetts Male Aging Study were analyzed. Men with PSA 4.1 ng/mL or greater were referred for biopsy and those with positive biopsies or with medical record, cancer registry, or self-reported evidence of prostate cancer were excluded. RESULTS: The median tPSA increased 38.6% per decade (95% confidence interval 28.7% to 49.3%). Because of the greater variability at older ages, the 95th percentile increased faster than the median, leading to the following age-specific upper limits of normal: 2.84 for 50 to 59 years, 5.87 for 60 to 69 years, and 9.03 for 70 to 79 years. The pattern of association between fPSA and age was similar to tPSA. The 50th and 5th percentiles of %fPSA were 25.3% and 13.2%, respectively, regardless of age. CONCLUSIONS: Establishing age-specific screening cutoffs based on the age-specific upper limits of normal will ensure low false-positive biopsy rates but may also lead to low true positive rates (ie, low sensitivity) in older age groups. Both sensitivity and specificity should be considered when counseling patients. The independence of %fPSA with age confirms others' findings.

Age Factors↗
PubMed1999

Patient assertiveness and physician decision-making among older breast cancer patients.

The objective of this study was to determine whether assertive patient behavior influences physician decision-making in the treatment of older breast cancer patients. One hundred and twenty-eight physicians saw videotapes depicting women seeking care for breast cancer and then recommended evaluation and treatment plans. Identical scripts were used, but the age, race, socioeconomic status, mobility, general health, and assertive behavior of the patients were experimentally varied along with the physician's specialty and length of practice. No direct effects of assertive patient behavior were seen. However, black, comorbid, and lower SES women were more likely to have full staging of their tumors ordered when they made an assertive request. Treatment recommendations also showed an interaction of assertiveness with patient's age and social class as well as physicians' specialty. The results indicate that a moderately assertive patient request may change provider behavior, although the effects of assertiveness vary most by what type of patient demonstrates this behavior. In particular, assertiveness led to more careful diagnostic testing for patients who came from groups that are "disadvantaged."

Aged↗
PubMed1999

Relation of dehydroepiandrosterone and dehydroepiandrosterone sulfate with cardiovascular disease risk factors in women: longitudinal results from the Massachusetts Women's Health Study.

Low circulating levels of the adrenal steroids dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) are thought to be associated with increased risk of cardiovascular disease (CVD) in men. In women, either a positive or null association with CVD has been found. The nature of the relation between DHEAS and CVD risk factors in women is unclear and is based on cross-sectional data. We present results from a longitudinal investigation of serum DHEA and DHEAS and cardiovascular disease risk factors in 236 women, initially 50-60 years old, from a population-based prospective (1986-1995) study of the menopausal transition. We used generalized estimating equations to model the relation of serum DHEA and DHEAS to systolic and diastolic blood pressure and serum levels of total cholesterol, high density lipoprotein cholesterol, and apolipoproteins A and B, adjusting for other factors related to CVD. Both DHEA and DHEAS were positively related to diastolic and systolic blood pressure, and DHEAS was negatively related to apolipoprotein A. DHEA and DHEAS were also positively related to smoking, alcohol use, estrone, and estradiol levels, and inversely related to age. Our results suggest that higher levels of DHEA and DHEAS in middle-aged women may indicate increased CVD risk.

Aged↗
PubMed1999

The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences.

OBJECTIVES: To project the likely worldwide increase in the prevalence of erectile dysfunction (ED) over the next 25 years, and to identify and discuss some possible health-policy consequences using the recent developments in the UK as a case study. METHODS: Using the United Nations projected male population distributions by quinquennial age groups for 2025, the prevalence rates for ED were applied from the Massachusetts Male Aging Study (MMAS) to calculate the likely incidence of ED. The MMAS has the advantage of being the first study to provide population-based rates rather than rates based on clinical samples. All the projections were age-adjusted. RESULTS: It is estimated that in 1995 there were over 152 million men worldwide who experienced ED; the projections for 2025 show a prevalence of approximately 322 million with ED, an increase of nearly 170 million men. The largest projected increases were in the developing world, i.e. Africa, Asia and South America. DISCUSSION: The likely worldwide increase in the prevalence of ED (associated with rapidly ageing populations) combined with newly available and highly publicized medical treatments, will raise challenging policy issues in nearly all countries. Already under-funded national health systems will be confronted with unanticipated resource requests and challenges to existing government funding priorities. The projected trends represent a serious challenge for healthcare policy makers to develop and implement policies to prevent or alleviate ED.

Age Distribution↗
PubMed1999

Evidence that the CAG repeat in the androgen receptor gene is associated with the age-related decline in serum androgen levels in men.

In men over 30 years old, serum levels of testosterone (T) decrease with age. A shorter polymorphic CAG repeat length in exon 1 of the androgen receptor (AR) gene is associated with higher transcription activation by the AR. We determined the number of CAG repeats for 882 men aged between 40 and 70 years from the Massachusetts Male Aging Study (MMAS). MMAS is a population-based random sample survey of men for whom baseline (1987-1989, mean age 53+/-8 years) and follow-up (1995-1997, mean age 61+/-8 years) serum hormone levels were available. Multiple linear regression was used to determine if CAG repeat length would be predictive of hormone levels at follow-up. Hormone levels measured included T, free T, albumin-bound T, dihydrotestosterone (DHT), sex hormone-binding globulin (SHBG) and luteinizing hormone (LH). The CAG repeat length was significantly associated with T (P=0.041), albumin-bound T (P=0.025) and free T (P=0.003) when controlled for age, baseline hormone levels and anthropometrics. Follow-up levels of T decreased by 0.74%+/-0.36 per CAG repeat decrement. Likewise, the percentages of free and albumin-bound T decreased by 0.93%+/-0.31 and 0.71%+/-0.32 per CAG repeat decrement respectively. These results suggest that androgen levels may be modulated by AR genotype.

Adult↗
PubMed1998

Low dehydroepiandrosterone sulfate and heart disease in middle-aged men: cross-sectional results from the Massachusetts Male Aging Study.

PURPOSE: Serum concentrations of the adrenal androgen dehydroepiandrosterone (DHEA) and its sulfate ester (DHEAS), both of which decline with age more markedly than other sex hormone levels, have been alternately credited and discredited as "protective" correlates of heart disease. Baseline data from the Massachusetts Male Aging Study (MMAS), collected in 1987-89, provided a large population-based random sample (n = 1709) in which to examine cross-sectionally the relation of DHEA and DHEAS levels to heart disease, while controlling for a comprehensive set of potential confounders including serum lipid and hormone levels as well as smoking, alcohol intake, obesity, hypertension, diabetes, diet, medication, physical activity, and psychological measures. METHODS: The subjects were men aged 40-70 years, randomly sampled from the Massachusetts state census listing, measured and interviewed at home. Nonfasting blood samples were assayed for hormones and lipids. RESULTS: In all strata of age, smoking, and alcohol intake, the age-adjusted odds ratio for self-reported heart disease was between 0.55 and 0.85 per standard deviation (SD) of log DHEA and DHEAS concentration. Multiple logistic regression analysis indicated a strong independent role for DHEAS as a predictor of self-reported heart disease, controlling for age and the potential confounders listed above. The multiply-adjusted odds ratio for heart disease was 0.64 per SD log DHEAS concentration, with 95% confidence interval (CI) 0.50-0.83 (P = 0.0002). The DHEAS effect was not diminished by controlling for use of cardiac, vasodilator, antihypertensive, or lipid-lowering medication. CONCLUSIONS: These findings suggest that serum DHEAS levels bear an inverse relationship to heart disease, independently of a large set of established cardiovascular risk factors. The cross-sectional nature of this study requires that the findings be interpreted with caution.

Aged↗
PubMed1998

Physician variability and uncertainty in the management of breast cancer. Results from a factorial experiment.

OBJECTIVES: The purpose of this research was to determine the influence of patient and physician characteristics on physicians' level of variability and certainty in breast cancer care. METHODS: One hundred twenty-eight physicians viewed a videotape of a simulated physician-patient interaction in which the patient has an "atypical" breast lump. Six patient characteristics (age, race, socioeconomic status, physical mobility, comorbidity, presentation style) were manipulated experimentally, resulting in a balanced set of 32 different "patients." Physician subjects were recruited to fill four equal strata defined by specialty (surgeons versus nonsurgeons) and experience (< or = 15 or > 15 years since graduation from medical school). RESULTS: More than half of the physicians offered a diagnosis of benign breast disease, a third offered a diagnosis of breast cancer, and the rest believed that the patient had a normal breast or something "other." Results also indicated that physicians' level of certainty and test ordering behavior varied with the diagnosis that was offered. Of the six patient characteristics, only socioeconomic status influenced physician certainty; physicians were more certain of their diagnosis when the patient was of a higher socioeconomic status. Surgeons were found to be more certain of their diagnosis compared with nonsurgeons. However, surgeons were less likely to order radiologic tests or a tissue sample for metastatic evaluation than were nonsurgeons. CONCLUSIONS: Overall, physicians displayed considerable variability and uncertainty when diagnosing and managing possible breast cancer.

Adult↗
PubMed1997

Interviewer effects in a cohort study. Results from the Massachusetts Women's Health Study.

Although interviewer error is widely recognized as an important source of variation in epidemiologic investigations, scant published information exists documenting the impact of interviewer variation on study findings. Using data from the Massachusetts Women's Health Study, a population-based cohort study of 2,569 middle-aged women (1982-1987), the authors evaluated interviewer variation in responses to different types of questions, and assessed the impact of interviewer variation on inferences derived from study data. Respondent sociodemographic and lifestyle characteristics were similar for the four study interviewers at the first follow-up. No interviewer variation was detected for questions concerning recall of specific events, but responses to questions regarding recall of subjective or personal information or those which required further probing did differ significantly by interviewer. Adjustment for interviewer effects had no impact on the conclusions obtained from one analysis of predictors of depression, despite significant interviewer variation in the outcome and predictor variables, but it did change conclusions from an analysis of the impact of support networks on psychological symptoms, wherein the interviewer variable was strongly related to the outcome after data were controlled for predictor variables. Given these findings, examination of data for interviewer effects is advisable despite incorporation of quality control measures in a study's design.

Depression↗
PubMed1997

Physician characteristics: do they influence the evaluation and treatment of breast cancer in older women?

BACKGROUND: To determine if physician specialty, length of time in practice, and fear of malpractice influence the diagnosis and management of breast cancer in older women. METHODS: We used a fractional factorial design that controlled for patient age (65 or 80 years), race, socioeconomic status, mobility, comorbidity, and assertive behavior through 2 videotaped scenarios (a potential breast cancer [no. 1] and a known stage IIA breast cancer [no. 2]). One hundred twenty-eight white male physicians equally divided by specialty (surgeon versus nonsurgeon) and time in practice (< or = 15 or >15 years) viewed the videotapes and made recommendations. RESULTS: The physician subjects saw 46 patients per week, 59% female, and 47% age > or = 65. Their concern over malpractice was 4.7 (on a 10-point Likert scale with a higher score indicating more concern) and did not differ by specialty or time in practice (P values > 0.7). After viewing scenario no. 1, surgeons were less likely than nonsurgeons to consider breast cancer as the principal diagnosis (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2 to 0.9) and to obtain a tissue diagnosis (OR = 0.3, 95% CI = 0.1 to 0.9). However, in scenario no. 2, surgeons were more likely to offer reconstruction (OR = 3.8, 95% CI = 1.4 to 10.4). Physicians in practice < or = 15 years were more likely than those in practice <15 years to obtain a tissue diagnosis in scenario no. 1 (OR = 6.1, 95% CI = 1.9 to 19.2) and to perform full primary therapy in scenario no. 2 (OR = 2.8, 95% CI = 1.2 to 6.9). Physicians who performed an extensive metastatic evaluation (bone or computer tomography [CT] scan) had greater concern over malpractice than those who did not, as did physicians who performed an axillary node dissection (OR = 2.1, 95% CI 1.3 to 3.4 and OR = 1.8, 95% CI = 1.1 to 3.0). CONCLUSIONS: With the uncertainty of how to diagnose and treat older women with breast cancer, physician specialty, length of time in practice, and concern over malpractice do influence clinical decisions.

Age Factors↗
PubMed1997

Understanding the variability in the effectiveness of community heart health programs: a meta-analysis.

Over the past 25 years, community interventions to reduce cardiovascular disease (CVD) have been conducted around the world with very mixed results. This study uses meta-analysis to assess whether the variation in the observed effectiveness of community heart health programs (CHHP) is related to characteristics of the intervention program, the population under study, or the evaluation methods. A CHHP is defined as any primary prevention program that attempted to reduce the population burden of CVD by shifting the distribution of risk factors in a general population. To be included in the meta-analysis, a study must have utilized a reference group in the evaluation, employed a repeated independent cross-sectional measurement design, and reported sufficient outcome information for at least one of four major risk factors: smoking, total cholesterol, blood pressure, and body weight. Results of these studies are summarized with the effect size measure (Yi1-Yi2)-(Yr1-Yr2)Sr1 where Y = outcome measure, S = standard deviation of the outcome measure, 1 = baseline, 2 = follow-up. i = intervention, and r = reference community. This measure, which reports the net change in the intervention group in terms of the variability in the reference population before the start of the intervention, permits comparison across different outcome measures and facilitates the aggregation of effects across studies. Generalized least squares regression, which permits the incorporation of multiple, dependent effect sizes from a single study, was used to assess the impact of characteristics of the intervention (prevention strategy, type of mass communication, community organization, and environmental change), the population (setting, gender, year of follow-up measurement), and the evaluation design and implementation (the number of communities, matching of communities, the follow-up time, the response rate, and covariate adjustment in the analysis) on the effect sizes. The results of this analysis suggest that the characteristics of the evaluation method account for much of the heterogeneity in the outcome of CHHPs, though some intervention characteristics also play a role.

Blood Pressure↗
PubMed1997

Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment.

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

Age Factors↗