Biomedical subjects

John Concato

Publications and source records attributed to John Concato.

At least 37 records · Page 2Linked to original sources

PubMed2004

Informed choice and the widespread use of antiinflammatory drugs.

OBJECTIVE: To examine whether the current widespread use of antiinflammatory drugs may reflect a lack of informed choice (i.e., unawareness of adverse effects or potential treatment alternatives) among older patients with knee osteoarthritis (OA). METHODS: Consecutive patients with symptomatic knee OA (n = 100) completed a questionnaire to assess their awareness of drug toxicity. Patients also completed an Adaptive Conjoint Analysis task so that the influence of providing an additional treatment alternative on patient preferences for nonselective nonsteroidal antiinflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors could be assessed. RESULTS: Fifty-four percent of the patients surveyed were unaware of any adverse effects related to NSAIDs and 80% were unaware of any toxicity related to COX-2 inhibitors. When given a choice between NSAIDs and COX-2 inhibitors, 57% of patients preferred COX-2 inhibitors over NSAIDs. When presented with a third less effective, but safer alternative, 100% of patients switched preferences to the safer, albeit less effective, option. CONCLUSIONS: Our findings suggest that the widespread use of NSAIDs may reflect lack of informed choice among older patients with OA.

Aged↗

PubMed2004

Obstetric patient satisfaction: asking patients what they like.

OBJECTIVE: This study was undertaken to determine pertinent attributes of women's hospital experience related to the delivery of their children and to use open-ended responses from women to develop a taxonomy for classifying patient satisfaction in obstetrics. STUDY DESIGN: By using clinimetric methods, we interviewed 67 obstetric patients during their postpartum hospital stays, asking open-ended questions about their satisfaction with care. Responses were transcribed, arranged into distinct groups, and organized as a taxonomy of patient satisfaction. RESULTS: The final taxonomy derived from patient responses was divided into six main axes related to physicians, nurses, other staff, special services, hospital attributes, and personal focus; a total of 51 individual items were identified related to patient satisfaction. These items have face validity, and many are not routinely included in assessments of patient satisfaction. CONCLUSION: A simple strategy of using open-ended questions leads to a clinically relevant and easily understood classification scheme for patient satisfaction with in-hospital obstetric services.

Female↗

PubMed2004

Two measures of insulin sensitivity provided similar information in a U.S. population.

BACKGROUND AND OBJECTIVE: Two methods for measuring insulin sensitivity, fasting plasma insulin (FPI) and homeostasis model assessment (HOMA) have been proposed for use in large epidemiological research and clinical practice. This project describes the range of observed values of the HOMA and FPI in a large sample of the U.S. population. METHODS: We used fasting plasma glucose and insulin values from the Third National Health and Nutrition Survey (NHANES III) to identify the FPI and HOMA values. For both FPI and HOMA, higher values indicate lower insulin sensitivity. RESULTS: Among 6,511 participants without treated diabetes mellitus, FPI ranged from 1.8 to 175.8 microU/mL, with 25th percentile=6.7, median=9.3, 75th percentile=13.3, and mean+/-1 SD=11.2+/-7.5; HOMA ranged from 0.3 to 52.6 (mmol)(microU)/L(2), with 25th percentile=1.5, median=2.2, 75th percentile=3.3, and mean+/-SD=2.8+/-2.4. CONCLUSION: These findings describe the spectrum of insulin sensitivity and may be useful in helping physicians develop a clinical understanding of the dynamic range of both FPI and HOMA measures.

Adult↗

PubMed2004

Resilience of community-dwelling older persons.

OBJECTIVES: To assess resilience of community-dwelling older persons using a new scale based on response to a stressful life event and to identify the demographic, clinical, functional, and psychosocial factors associated with high resilience. DESIGN: Cross-sectional study. SETTING: Community. PARTICIPANTS: Five hundred forty-six nondisabled persons aged 70 and older who had experienced a stressful life event. MEASUREMENTS: Resilience (as assessed using a simple six-item scale), demographic factors, chronic conditions, medications, cognitive status, grip strength, functional status, physical activity, self-efficacy, depressive symptoms, self-rated health, and social support. RESULTS: Participants showed a wide range of resilience in response to a stressful event, with a mean score+/-standard deviation of 8.9+/-4.0 on an 18-point scale. In bivariate analyses, male sex, living with others, high grip strength, independence in instrumental activities of daily living (IADLs), having few depressive symptoms, and having good to excellent self-rated health were associated with high resilience, defined as a score in the best tertile (>10). Independence in IADLs (relative risk (RR)=1.36, 95% confidence interval (CI)=1.05-1.69), having few depressive symptoms (RR=1.59, 95% CI=1.13-2.11), and good to excellent self-rated health (RR=1.38, 95% CI=1.01-1.79) remained independently associated with high resilience in multivariate analysis. Depressive symptoms and self-rated health remained associated with high resilience after controlling for the perceived stressfulness of the event. CONCLUSION: Functional and psychosocial factors are associated with high resilience. Further research is needed to determine the relationship between resilience and future well-being.

Activities of Daily Living↗

PubMed2004

Association between functional status and use and effectiveness of beta-blocker prophylaxis in elderly survivors of acute myocardial infarction.

OBJECTIVES: To examine whether physical and cognitive impairments explain low use of beta-blockers in elderly patients and whether functionally impaired older adults have improved survival if a beta-blocker is prescribed at hospital discharge. DESIGN: Cross-sectional and retrospective cohort study. SETTING: Acute care hospitals in the United States. PARTICIPANTS: National cohort of 45,370 elderly acute myocardial infarction survivors, with no chart-documented contraindications to beta-blocker treatment. MEASUREMENTS: The main outcome measures were beta-blocker prescription at hospital discharge and 1-year survival. RESULTS: Fifty percent (n=22,683) of eligible patients were prescribed a beta-blocker at discharge. Older age and functional impairments (incontinence, mobility impairment, and cognitive impairment) were independently associated with decreased use of beta-blockers. The odds ratios for prescribing a beta-blocker at hospital discharge were 0.82 (95% confidence interval (CI)=0.77-0.86), 0.63 (95% CI=0.56-0.71), and 0.40 (95% CI=0.32-0.51) for persons with one, two, and three impairments, respectively, compared with those with no impairments. In survival analysis, patients prescribed a beta-blocker were 21% less likely than nonrecipients to die within 1 year of follow-up (relative risk=0.79, P=.0001). Similar survival benefit was observed in patients with and without functional impairments. CONCLUSION: This study shows a strong association between functional impairment and the use of beta-blockers after acute myocardial infarction in elderly patients. The results suggest that increasing use of beta-blockers in this group provides an opportunity to improve outcomes.

Activities of Daily Living↗

PubMed2004

Bathing disability in community-living older persons: common, consequential, and complex.

OBJECTIVES: To identify the specific bathing subtasks that are affected in community-living-older persons with bathing disability and to determine the self-reported reasons for bathing disability. DESIGN: Cross-sectional study. SETTING: General community of greater New Haven, Connecticut. PARTICIPANTS: A total of 626 community-living persons, aged 73 and older, who completed a comprehensive assessment, including a detailed evaluation of bathing disability. MEASUREMENTS: Trained research nurses assessed bathing disability (defined as requiring personal assistance or having difficulty washing and drying the whole body), the specific bathing subtasks that were affected, and the main reasons (up to three) for bathing disability. RESULTS: Disability in bathing was present in 195 (31%) participants; of these, 97 required personal assistance (i.e., dependence), and 98 had difficulty bathing. Participants with bathing disability reported a mean+/-standard deviation of 4.0+/-2.4 affected subtasks. The prevalence rate of disability for the eight prespecified bathing subtasks ranged from 25% for taking off clothes to 75% for leaving the bathing position. The majority of participants (59%) provided more than one reason for bathing disability. The most common reasons cited by participants for their bathing disability were balance problems (28%), arthritic complaints (26%), and fall or fear of falling (23%). CONCLUSION: For community-living older persons, disability in bathing is common, involves multiple subtasks, and is attributable to an array of physical and psychological problems. Preventive and restorative interventions for bathing disability will need to account for the inherent complexity of this essential activity of daily living.

Activities of Daily Living↗

PubMed2004

Care in the emergency department: how crowded is overcrowded?

OBJECTIVES: To examine how emergency department (ED) overcrowding has been defined in the medical literature. METHODS: Using the National Library of Medicine's PubMed and MEDLINE databases (1966 to 2002), a comprehensive review of the English-language medical literature was conducted to identify explicit criteria for defining ED overcrowding. Inclusion criteria were original articles, editorials, and reviews; news articles and letters to the editor were excluded. Using a standardized extraction form, publications were described as primary if the title or an objective statement in the introductory or methods paragraph referred to crowding or overcrowding; all other citations were categorized as secondary. Each report was then evaluated to determine whether crowding or overcrowding was defined explicitly or implicitly. Explicit definitions included phrases such as "Crowding was defined as ..." or "Overcrowding occurred when ..."; other definitions were characterized as implicit. RESULTS: A total of 231 candidate articles were identified; 91 met inclusion criteria, and 53 (58%) were primary articles about ED crowding or overcrowding. Among these primary articles, 23 (43%) had explicit definitions of crowding or overcrowding. The definitions varied widely in content and focus, including ED, hospital, or external (nonhospital) factors. CONCLUSIONS: Although ED overcrowding has been a topic of frequent investigation, current definitions of the problem are often implicit or focus on factors outside of the ED itself. A more consistent approach to defining ED overcrowding would help to clarify the distinctions between causes, characteristics, and outcomes of overcrowding.

Crowding↗

PubMed2004

Observational versus experimental studies: what's the evidence for a hierarchy?

The tenets of evidence-based medicine include an emphasis on hierarchies of research design (i.e., study architecture). Often, a single randomized, controlled trial is considered to provide "truth," whereas results from any observational study are viewed with suspicion. This paper describes information that contradicts and discourages such a rigid approach to evaluating the quality of research design. Unless a more balanced strategy evolves, new claims of methodological authority may be just as problematic as the traditional claims of medical authority that have been criticized by proponents of evidence-based medicine.

Case-Control Studies↗

PubMed2004

Are preferences for cyclooxygenase-2 inhibitors influenced by the certainty effect?

OBJECTIVE: To test whether the widespread use of cyclooxygenase-2 (COX-2) inhibitors may be mediated in part by the certainty effect, i.e., by a perception that COX-2 inhibitors eliminate the risk of serious gastrointestinal (GI) events in contrast to merely reduce their risk. METHODS: Patients' preferences for conventional nonsteroidal antiinflammatory drugs (NSAID) and COX-2 inhibitors for treatment of arthritis were predicted across a range of absolute risks of GI events using an Adaptive Conjoint Analysis survey. RESULTS: Preferences for COX-2 inhibitors were much stronger when the risk of serious GI events was eliminated in contrast to reduced, even though the absolute risk reduction (ARR) was the same. Few patients (22%) preferred COX-2 inhibitors when the risk associated with NSAID and COX-2 inhibitors was 4% and 2%, respectively (ARR = 2%). In contrast, the majority (90%) preferred COX-2 inhibitors when the risk associated with NSAID and COX-2 inhibitors was 2% and 0%, respectively (ARR = 2%). We obtained similar findings regardless of the ARR. CONCLUSION: The willingness shown by older adults to pay for COX-2 inhibitors may reflect a misperception of the risk of toxicity associated with these medications.

Aged↗

PubMed2004

Factors associated with caregiver burden among caregivers of terminally ill patients with cancer.

OBJECTIVE: To identify factors associated with caregiver burden among those caring for terminally ill patients with cancer. DESIGN: Cross-sectional study of interviews with primary caregivers (n = 206) of consecutive patients with cancer enrolled in the largest hospice in Connecticut. METHODS: Data were collected on the caregivers' sociodemographic characteristics, social network index, and number of restrictions in their own activities due to their caregiving role. The outcome was a nine-item questionnaire adapted from the Zarit Burden Inventory. RESULTS: The highest burden was reported among caregivers with more limited social networks (OR 1.38, Cl 1.02-1.87), more restrictions in their daily activities (OR 1.35, Cl 1.13-1.61), and who were younger (OR 1.46, Cl 1.10-1.93). CONCLUSIONS: Variations exist in the intensity of caregiver burden based on subjective experiences and social support, rather than on the amount of assistance provided. Clinicians should consider factors such as these when targeting caregivers for interventions to alleviate burden.

Activities of Daily Living↗

PubMed2003

Race independently predicts prostate specific antigen testing frequency following a prostate carcinoma diagnosis.

BACKGROUND: The goals of the current study were to describe patterns of prostate specific antigen (PSA) surveillance for prostate carcinoma progression in a community-based cohort of patients and to identify independent clinical and sociodemographic factors that predict the frequency of surveillance. METHODS: Patients diagnosed with localized prostate carcinoma from October 1, 1991 to December 31, 1992 in New Haven and Hartford, Connecticut, were identified. Data were collected through standardized outpatient medical record review. Multivariate statistical methods were used to determine the factors that independently predicted the frequency of surveillance. RESULTS: Six hundred fifty-eight men with localized prostate carcinoma were included in the cohort. Forty-five percent of all patients were tested at least once annually, and 69% were tested at least once every 2 years. Multivariate models indicated that African American men were half as likely as Caucasian men to receive annual testing (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24-0.97). Men diagnosed at age 70 years or older were 38% less likely to have annual testing than men diagnosed between the ages of 65 and 69 (OR, 0.62; 95% CI, 0.41-0.94). A higher Gleason score and PSA at presentation also were associated independently with higher rates of annual PSA surveillance. CONCLUSIONS: Postdiagnosis PSA surveillance is common, although not universal. African American men were at significantly greater risk for receiving less frequent testing compared with Caucasian men. This disparity in access to care may explain, in part, previously observed racial differences in survival in prostate carcinoma. Further research is needed to identify the reasons for the racial disparity in PSA surveillance and to design interventions to lessen these differences.

Adult↗

PubMed2003

Long-term mortality in cerebrovascular disease.

BACKGROUND AND PURPOSE: Stroke is the third leading cause of death in the United States, yet data are limited about the temporal pattern of mortality among patients with cerebrovascular disease. The objectives of this study were to identify predictors of 6-month mortality and to evaluate 5-year mortality in patients with cerebrovascular disease. METHODS: Our population included fee-for-service Medicare beneficiaries aged > or =65 years who were discharged with an acute ischemic stroke, transient ischemic attack (TIA), or carotid stenosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 433 to 436) from Connecticut acute care hospitals in 1995. This cohort was followed through 2000 by means of part A Medicare claims and Social Security Administration mortality data. RESULTS: Among 5123 patients, 4781 survived their hospitalization and were followed for an average of 3.4 years; 670 (14.0%) died within 6 months of discharge, and 2517 (52.6%) died within 5 years. Predictors of 6-month mortality included older age, male sex, increasing comorbidity, discharge not to home, and prior admission within a year of the index hospitalization. The annual mortality rates for year 1 after discharge differed depending on the discharge diagnosis of the index hospitalization: carotid stenosis, 10.6%; TIA, 14.8%; and acute ischemic stroke, 26.4%. The 5-year cumulative mortality rates were as follows: carotid stenosis, 38.3%; TIA, 49.6%; and acute ischemic stroke, 60.0%. CONCLUSIONS: Mortality after acute ischemic stroke, TIA, and carotid stenosis is substantial. Rates and patterns of mortality differ according to patients' discharge diagnoses.

Acute Disease↗

PubMed2003

The effect of antibiotic therapy for patients infected with Helicobacter pylori who have chronic urticaria.

BACKGROUND: Several small trails looking at antibiotic therapy targeted at Helicobacter pylori for the treatment of chronic urticaria have been published and have had conflicting results. We conducted a systematic review of existing studies to help answer the clinical question of whether this therapy has a role in the treatment of chronic urticaria. METHODS: We identified studies published in the English language with searches of MEDLINE, PREMEDLINE, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effectiveness, and Cochrane Libraries using the key words "Helicobacter pylori" and "urticaria." Relevant studies from bibliography reviews were also included. Studies included met the following criteria: (1) patients had urticaria for at least 6 weeks; (2) other known causes of urticaria were excluded by appropriate testing; (3) the initial diagnosis of H pylori infection was made by either serology, urea breath test, or upper endoscopy; and (4) an adequate trial of an antibiotic with known activity against H pylori was completed. RESULTS: In all, 10 studies met our inclusion criteria. The rate of remission of urticaria when H pylori was eradicated was 30.9% (59/191) compared with 21.7% (18/83) when H pylori was not eradicated; the background remission rate among control subjects without H pylori infection was 13.5% (10/74). When data from the 10 studies were combined, eradication of H pylori was both quantitatively and statistically associated with remission of urticaria (odds ratio 2.9; 95% confidence interval 1.4-6.8; P =.005). CONCLUSION: We found that resolution of urticaria was more likely when antibiotic therapy was successful in eradication of H pylori infection than when patients who were infected did not achieve eradication. These results suggest that clinicians, after considering other causes of urticaria, should constitute (1) testing for H pylori; (2) treating with appropriate antibiotics if H pylori is present; and (3) confirming successful eradication of infection.

Chronic Disease↗

PubMed2003

Depressive symptoms as a risk factor for disabling back pain in community-dwelling older persons.

OBJECTIVES: To determine whether the presence of depressive symptoms is an independent risk factor for disabling back pain in community-dwelling older persons. DESIGN: Prospective cohort study with a 12-month follow-up period. SETTING: General community. PARTICIPANTS: Seven hundred forty-four members of a large health plan who were aged 70 and older and independent in bathing, walking, dressing, and transferring at baseline. MEASUREMENTS: The presence of depressive symptoms, defined as a score of 16 or greater on the Center for Epidemiologic Studies-Depression Scale, was documented during a comprehensive baseline assessment that also included information regarding participants' demographic, medical, and physical/cognitive status. The occurrence of disabling back pain was ascertained during monthly telephone interviews. RESULTS: Depressive symptoms were present in 153 (20.6%) participants at baseline. Over the 12-month follow-up period, 186 participants (25.0%) reported disabling back pain during 1 to 2 months and 91 (12.2%) during 3 or more months. After adjustment for potential confounders, the presence of depressive symptoms was independently associated with the occurrence of disabling back pain (adjusted odds ratio (AOR)=2.3 (95% confidence interval (CI)=1.2-4.4) for 1 to 2 months with disabling back pain; AOR=7.8 (95% CI=3.7-16.4) for 3 or more months with disabling back pain). CONCLUSION: The presence of depressive symptoms is a strong, independent, and highly prevalent risk factor for the occurrence of disabling back pain in community-dwelling older persons.

Activities of Daily Living↗

PubMed2003

The prevalence and treatment of depression among patients starting dialysis.

BACKGROUND: Depression is common in patients with end-stage renal disease (ESRD) and is associated with increased mortality, but little is known about depression in patients just after they start dialysis therapy. We sought to assess the prevalence of depressive symptoms in patients with ESRD starting dialysis therapy, identify patient characteristics associated with depression, and determine whether patients with serious depressive symptoms were receiving treatment. METHODS: We implemented a multicenter prospective cohort study at 14 dialysis centers in Connecticut. Patients with ESRD who were 18 years and older were interviewed within 10 days of initiating dialysis therapy between November 2000 and July 2001. The Beck Depression Inventory (BDI) was used to assess depressive symptoms. Chi-square tests were used to evaluate associations between several patient characteristics and depression, and multivariable logistic regression models were used to determine odds ratios (ORs) for depression, with adjustment for baseline variables. RESULTS: Among 123 patients, 44% (54 of 123 patients) had scores above the validated cutoff value in the BDI for depression. In logistic regression analysis, depression was statistically significantly associated with Caucasian race (OR, 3.4; P = 0.02), lower self-rated quality of life (OR, 2.2; P = 0.003), and no previous acquaintances on dialysis therapy (OR, 10.2; P = 0.03). Only 16% (9 of 54 patients) of depressed patients were being treated at enrollment; 13% (5 of 38 patients) of those with mild symptoms and 25% (4 of 16 patients) with more severe symptoms were being treated. CONCLUSION: Our results show that depressive symptoms are very common at the start of dialysis therapy, and specific characteristics are associated with a greater burden of depressive symptoms. Despite a high prevalence, treatment rates are low, even among patients with moderate to severe symptoms of depression.

Connecticut↗

PubMed2003

Improving diagnostic testing and reducing overuse of antibiotics for children with pharyngitis: a useful role for the electronic medical record.

BACKGROUND: Because of rising resistance to antibiotics, appropriate use of antibiotics is an important measure of quality of care. The purpose of this study was to use an electronic medical record (EMR) to assess use of diagnostic testing and of antibiotics for pharyngitis in a pediatric outpatient setting and to target areas for improvement. METHODS: Using data retrieved from the EMR, we analyzed visits from March 1, 2001 to February 28, 2002 for children 3 to 18 years old diagnosed with pharyngitis. We determined the proportion of episodes with a diagnostic test for group A streptococci, the proportion for which a prescription for an antibiotic was dispensed and factors that predicted prescribing and testing. RESULTS: Of 391 episodes of pharyngitis, a test was ordered for 303 (78%). Antibiotics were prescribed for 90 (23%); for 76 of 90 (84%) a test was ordered. Clinicians were less likely to order tests late in the week [relative risk (RR), 0.76; 95% confidence interval (CI), 0.66, 0.87)], more likely to order tests for patients with an exudate (RR 1.2; 95% CI 1.1, 1.3) and more likely to prescribe an antibiotic for patients with an exudate (RR 1.5; 95% CI 1.1, 2.1). When prescribing an antibiotic clinicians were less likely to order tests late in the week (RR 0.1; 95% CI 0.02, 0.5) and for patients diagnosed with scarlet fever (RR 0.07; 95% CI 0.01, 0.4). CONCLUSION: Using data from the EMR, we could assess adherence to the guidelines for antibiotic use and identify areas to target for improving diagnostic testing and reducing overuse of antibiotics in our clinic.

Adolescent↗

PubMed2003

Risk communication in rheumatoid arthritis.

OBJECTIVE: Some people believe that certain issues should be protected from all trade-offs. These issues are referred to as "protected values." We investigated whether some patients with rheumatoid arthritis (RA) treat the risk of adverse effects (AE) as "protected values," i.e., as unacceptable regardless of how small the risk. METHODS: Patients with RA rated willingness to risk 17 different AE on a visual analog scale, where 0 = not willing under any circumstances and 100 = definitely willing. Participants then rated willingness to take medication as the risk of each AE was progressively decreased by 2 levels from its actual risk, using a 5 level scale ranging from 10 in 100 to 1 in 100,000. RESULTS: Between 32% and 39% of participants were not more willing to accept a risk of AE causing reversible cosmetic changes (e.g., acne), between 35% and 47% were not more willing to accept a risk of AE causing reversible discomfort (e.g., rash), and between 41% and 45% were not more willing to accept a risk of AE causing potential irreversible damage (e.g., pneumonitis) as the probability of each of these AE was substantially decreased. Unwillingness to accept risk of toxicity was especially evident for cancer, where 66% of patients refused to accept a risk of cancer occurring in 1 in 100,000 persons. CONCLUSION: Among patients particularly concerned with the risk of drug toxicity, many remain unwilling to accept the risk of AE even when their probability is decreased to levels far below their actual risk. These results suggest that patients may treat particularly worrisome AE as protected values, which may lead to poor decision-making in clinical practice.

Aged↗

PubMed2002

Utility of captopril renal scans for detecting renal artery stenosis.

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.

Angiotensin-Converting Enzyme Inhibitors↗