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Biomedical subjects

L Fraenkel

Publications and source records attributed to L Fraenkel.

18 recordsLinked to original sources
PubMed2006

Are rheumatologists' treatment decisions influenced by patients' age?

OBJECTIVES: The objective of this study was to determine whether physicians' treatment preferences are influenced by patients' age. METHODS: We mailed a survey to a random sample of rheumatologists practicing in the US. The survey included a scenario describing a hypothetical patient with rheumatoid arthritis (RA) on hydroxychloroquine, sulfasalazine and low-dose prednisolone, who presents with active disease during a follow-up appointment. The scenario was formulated in two versions that were identical except for the age of the patient. After reading the scenario, respondents were asked to rate (on a 10 cm numerical rating scale) their recommendations for each of the three options: (i) increasing the dose of prednisolone, (ii) adding a new disease-modifying anti-rheumatic drug (DMARD) and (iii) switching DMARDs. Rheumatologists who rated either adding a new DMARD or switching DMARDs higher than increasing the dose of prednisolone were classified as 'preferring aggressive treatment with DMARDs', while the others were classified as 'NOT preferring aggressive treatment with DMARDs'. RESULTS: A total of 480 rheumatologists were mailed a questionnaire; 204 responded, giving a response rate of 42.5%. Overall 163 (80%) respondents were classified as preferring aggressive treatment with DMARDs. Rheumatologists responding to this survey were more likely to prefer aggressive DMARD treatment for the young RA patient vs the older RA patient (87 vs 71%, P= 0.007). CONCLUSIONS: Our findings suggest that rheumatologists' treatment recommendations may be influenced by age. Future educational efforts should increase physician awareness of this possible bias in order to ensure equal service delivery across ages.

Adult↗
PubMed2004

Patient preferences for treatment of rheumatoid arthritis.

OBJECTIVE: To elicit treatment preferences of patients with rheumatoid arthritis (RA) for disease modifying antirheumatic drugs (DMARDs) with varying risk profiles. METHODS: Patient values for 16 DMARD characteristics were ascertained using published data about side effects, effectiveness, and cost. Patient preferences were determined by Adaptive Conjoint Analysis, an interactive computer program that predicts preferences by asking patients to make trade-offs between specific treatment characteristics. Simulations were run to derive preferences for four drugs: methotrexate, gold, leflunomide, and etanercept, under different risk-benefit scenarios. Infliximab was not included because it is given with methotrexate, and we did not include preferences for combination therapy. Based on each patient's expressed preferences, and the characteristics of the treatments available at the time of the study, the option that best fitted each patient's perspective was identified. RESULTS: 120 patients (mean age 70 years) were interviewed. For the base case scenario (which assumed the maximum benefits reported in the literature, a low probability of adverse effects, and low equal monthly "co-pays" (out of pocket costs)), 95% of the respondents preferred etanercept over the other treatment options. When all four options were described as being equally effective, 88% continued to prefer etanercept owing to its safer short term adverse effect profile. Increasing etanercept's co-pay to $30.00 decreased the percentage of patients preferring this option to 80%. CONCLUSIONS: In this study, older patients with RA, when asked to consider trade-offs between specific risk and benefits, preferred etanercept over other treatment options. Preference for etanercept is explained by older patients' risk aversion for drug toxicity.

Adult↗
PubMed2003

Risk-attitude and patient treatment preferences.

Women's treatment preferences for lupus nephritis vary widely even after adjusting for sociodemographic factors and disease severity. Attitude toward risk may partially explain interpatient variability in treatment preference. The objective of this study was to examine the association between 'risk-attitude' and patient treatment preferences in lupus nephritis. Sixty-five premenopausal women with systemic lupus erythematosus were interviewed. Patient preferences for cyclophosphamide versus azathioprine for the treatment of lupus nephritis were ascertained using an Adaptive Conjoint Analysis questionnaire. Risk-attitude was ascertained by asking patients to choose between a pair of lotteries having the same expected value but differing in spread (the difference between the worst and best outcomes). Respondents preferring the wider spread were classified as relatively more risk-seeking and those preferring the narrower spread were classified as relatively more risk-averse. Twenty-eight percent of respondents were classified as relatively more risk-seeking. Risk-seeking women were more likely to prefer cyclophosphamide for the treatment of lupus nephritis compared with risk-averse women [least square mean (+/- SD) preference for cyclophosphamide 63 +/- 3 among risk-seeking women versus 55 +/- 2 among risk-averse women (P < 0.03)]. The association between risk attitude and treatment preference persisted asthe probabilities of adverse events were varied to reflect the range of risks reported in the literature. Our results suggest that patients' relative risk-attitudes, as measured by a lottery task, are related to their treatment preferences. Differences in risk-attitude may help explain the inter-patient variability in treatment preferences.

Adult↗
PubMed2002

Unwillingness of rheumatoid arthritis patients to risk adverse effects.

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.

Adult↗
PubMed2001

Preference for disclosure of information among patients with rheumatoid arthritis.

OBJECTIVE: To quantify preference for disclosure of information among patients with rheumatoid arthritis (RA) and to examine sex-specific correlates of information preference. METHODS: We interviewed patients with RA and assessed preference for disclosure of information using 4 questions from the previously validated "Information Preference Seeking Scale." Three questions addressed preference for disclosure of side effects and 1 question addressed preference for disclosure of therapeutic options. Associations between preference for information and patient characteristics were examined using stepwise multiple linear regression. RESULTS: One hundred RA patients (mean age 68+/-12 years; 73% female) were interviewed; 89 respondents agreed or strongly agreed with all 4 statements reflecting a preference for full disclosure, and an additional 8 respondents agreed or strongly agreed with 3 of the 4 statements. The mean score (+/- SD) for information preference was 86+/-13, on a scale from 0 to 100 where 100 reflected a strong preference for full disclosure. In bivariate analyses, female sex and current employment were associated with stronger preferences for being informed (mean score for women 88+/-11, for men 80+/-15 [P = 0.02]; for employed 92+/-11, for unemployed 84+/-13 [P = 0.04]). Multivariate sex-specific analyses demonstrated that current employment and higher education level were positively associated with preference for disclosure among women and men, respectively. CONCLUSION: The results of our survey suggest that RA patients want to be fully informed about the risks associated with medications and about alternative options. The challenge remaining for rheumatologists is how to effectively communicate the risks and benefits related to the many options that are currently available for RA patients.

Adult↗
PubMed2001

Understanding patient preferences for the treatment of lupus nephritis with adaptive conjoint analysis.

BACKGROUND: Incorporation of patient preferences into treatment decisions is an essential component of medical care. Conjoint analysis is an established method of eliciting consumer preferences in market research and is being increasingly used to study patient preferences for health care. OBJECTIVE: To examine the value of Adaptive Conjoint Analysis (ACA), a unique method of performing conjoint analysis, and to evaluate patient treatment preferences. RESEARCH DESIGN: Interactive computer survey. SUBJECTS: Consecutive women (n = 103) with lupus followed in three community rheumatology practices. MEASURES: ACA was used to assess patients' relative preferences for specific cytotoxic medication characteristics, and to estimate the percentage of women preferring cyclophosphamide over azathioprine for different risk-benefit scenarios. RESULTS: All participants were able to complete the conjoint task in 14 +/-5 minutes. Of the nine medication characteristics studied, efficacy and risk for infection had the greatest impact on preference (each accounting for 20% of the variation in preferences), suggesting that patients consider differences in the risk for infection equally as important as differences in the probability of renal survival. Premenopausal women wanting more children were less likely to choose cyclophosphamide compared with their counterparts (56% vs. 80%, P = 0.04). Modest changes in the probability of renal survival or risk for major toxicity lowered the percentage of women preferring cyclophosphamide by more than 20%, irrespective of their desire for more children. CONCLUSIONS: ACA is a feasible method of assessing how patients consider specific medication characteristics and predicting treatment preferences under different risk-benefit scenarios. ACA may be a valuable tool to incorporate patient preferences into medical decision-making.

Adult↗
PubMed2001

Rheumatologists' attitudes toward routine screening for hydroxychloroquine retinopathy.

OBJECTIVE: To examine rheumatologists' attitudes toward routine ophthalmologic screening for hydroxychloroquine (HCQ) retinopathy and to estimate the acceptability of hypothetical guidelines discouraging this practice. METHODS: We E-mailed a random sample of 300 US rheumatologists listed in the American College of Rheumatology (ACR) Directory who treat adults. We asked about current screening practice, reasons for screening, and the effect of hypothetical guidelines discouraging routine screening on future practice. Associations between adherence to guidelines and clinical variables were evaluated using multiple logistic regression. RESULTS: Of 56% who responded, almost all (94%) currently screen their patients at least once per year. Seventy-five percent stated that they would continue to screen because they are unwilling to accept any risk of visual loss among their patients; 74% would continue to screen because of legal liability; and 56% felt their patients would insist on being screened regardless of their physician's opinion. Forty-four percent stated that they would continue to screen regularly, even if the ACR published guidelines discouraging routine screening. Rheumatologists unwilling to accept any risk of retinopathy were less likely to follow guidelines discouraging screening (46 vs 77%, adjusted OR 0.2, 95% CI 0.1-0.6). Patient insistence and fear of legal liability were not significantly associated with predicted adherence to guidelines. CONCLUSION: Our survey indicates that the majority of rheumatologists currently routinely screen their patients for HCQ retinopathy, and that many would not follow ACR guidelines discouraging this practice, at least in part because they are unwilling to accept any risk of visual damage.

Antirheumatic Agents↗
PubMed2000

Improving the selective use of plain radiographs in the initial evaluation of shoulder pain.

OBJECTIVE: In a previous retrospective study, we had found that shoulder radiographs were overused in the initial evaluation of patients presenting to the emergency department with shoulder pain. Our objective was to prospectively define clinical criteria that identify patients who have a low risk of radiographic findings that influence the management of the initial evaluation of shoulder pain in the emergency department. METHODS: All adult patients presenting to the emergency department of a university teaching hospital with shoulder pain were eligible to participate. Patients with deformities, penetrating wounds, referred pain, and those presenting for followup were excluded. Data were recorded prospectively using a standardized form. All radiographs were classified as therapeutically uninformative (TU) except fracture, acromioclavicular joint separation (> or =Grade 3), infection, or malignancy. A classification tree was used for analysis. RESULTS: Two hundred six patients had shoulder radiographs, of which 88% were TU. The model yielded 3 sets of low risk patients with a high percentage of TU radiographs: (1) no fall, no swelling (99% TU: 106 TU, 1 radiograph with lytic lesions in a cancer patient); (2) a fall, but no swelling, and no pain at rest (100% TU, n = 18); (3) a fall and pain at rest, but no swelling and normal range of motion (100% TU, n = 10). Not performing radiographs on these low risk patients would have decreased radiograph utilization from 52 to 18% of all shoulder patients seen. CONCLUSION: Our findings suggest that specific clinical criteria are able to identify patients who do not need radiographs as part of the initial management of shoulder pain. Prospective validation of these criteria are needed to confirm that these low risk patients can be safely evaluated without radiographs.

Adult↗
PubMed2000

Do lupus disease activity measures detect clinically important change?

OBJECTIVE: New scales for the clinical assessment of patients with systemic lupus erythematosus (SLE) are valid and reliable, and quantitate disease activity. We assessed the responsiveness to change of 2 widely used standardized multi-item lupus activity measures, the revised Systemic Lupus Activity Measure (SLAM-R) and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and their ability to detect clinically relevant changes. METHODS: Ninety-six (96) patients with definite SLE participated in this study. The group mean age was 45.0 (13.7) years, 91% were female, and the mean disease duration was 14.9 (7.5) years. Sociodemographic information, lupus activity (SLAM-R, SLEDAI), and damage were recorded at baseline. At each of the 5 monthly followup visits, the activity measures were repeated and a transition scale asked the physician if their patient's lupus activity had changed. Five different methods were used to compare the responsiveness of the activity measures studied: 1. the effect size; 2. the standardized response mean; 3. the control standardized response mean; 4. the area under the curve of a receiver operating characteristic (ROC) curve; and 5. a new multiple response modeling approach. RESULTS: Both SLAM-R and SLEDAI are responsive. SLAM-R is consistently, although moderately, more responsive than SLEDAI. All 5 methods of evaluating responsiveness yielded a consistent ranking of disease activity measures. CONCLUSION: SLAM-R and SLEDAI are responsive measures of lupus activity. SLAM-R appears to be more responsive than SLEDAI.

Activities of Daily Living↗
PubMed1999

Different factors influencing the expression of Raynaud's phenomenon in men and women.

OBJECTIVE: To determine whether the risk profile for Raynaud's phenomenon (RP) is different between men and women. METHODS: In this cross-sectional study of 800 women and 725 men participating in the Framingham Offspring Study, the association of age, marital status, smoking, alcohol use, diabetes, hypertension, and hypercholesterolemia with prevalent RP was examined in men and women separately, after adjusting for relevant confounders. RESULTS: The prevalence of RP was 9.6% (n = 77) in women and 5.8% (n = 42) in men. In women, marital status and alcohol use were each associated with prevalent RP (for marital status adjusted odds ratio [OR] 2.3, 95% confidence interval [95% CI] 1.4-3.9; for alcohol use OR 2.2, 95% CI 1.0-5.2), whereas these factors were not associated with RP in men (marital status OR 1.4, 95% CI 0.6-3.5; alcohol use OR 1.0, 95% CI 0.2-4.4). In men, older age (OR 2.3, 95% CI 1.0-5.2) and smoking (OR 2.6, 95% CI 1.1-6.3) were associated with prevalent RP; these factors were not associated with RP in women (older age OR 0.8, 95% CI 0.4-1.6; smoking OR 0.7, 95% CI 0.4-1.1). Diabetes, hypertension, and hypercholesterolemia were not associated with RP in either sex. CONCLUSION: The results indicate that risk factors for RP differ between men and women. Age and smoking were associated with RP in men only, while the associations of marital status and alcohol use with RP were observed in women only. These findings suggest that different mechanisms influence the expression of RP in men and women.

Age Factors↗
PubMed1998

The association of estrogen replacement therapy and the Raynaud phenomenon in postmenopausal women.

BACKGROUND: Hormonal factors may play an important role in the pathophysiology of the Raynaud phenomenon. Experimental studies have shown an increased vasoconstrictor response to estrogen, a response that can be prevented by the addition of progesterone. OBJECTIVE: To measure the association between estrogen replacement therapy (alone and with progesterone) and the Raynaud phenomenon. DESIGN: Cross-sectional study. SETTING: Framingham Offspring Study. PARTICIPANTS: 497 postmenopausal women. MEASUREMENTS: Prevalence of the Raynaud phenomenon according to hormone use. Covariates measured included age, body mass index, smoking, alcohol consumption, and beta-blocker use. RESULTS: Forty-nine women were classified as having the Raynaud phenomenon (9.9%). The prevalence of this phenomenon was 8.4% among women who did not receive estrogen, 19.1% among women receiving estrogen alone, and 9.8% among women receiving estrogen plus progesterone. The adjusted odds ratio for the Raynaud phenomenon was 2.5 (95% CI, 1.2 to 5.3) for unopposed estrogen and 0.9 (CI, 0.3 to 2.6) for estrogen plus progesterone, with nonusers as the reference group. CONCLUSIONS: Unopposed estrogen therapy was associated with the Raynaud phenomenon in postmenopausal women. This association was not present in women who were receiving combined hormone therapy.

Cross-Sectional Studies↗
PubMed1998

The use of radiographs to evaluate shoulder pain in the ED.

This study was conducted to describe the utilization of plain radiography in the initial evaluation of shoulder pain in the emergency department (ED) and assess the feasibility of developing guidelines for the selective use of shoulder radiographs by determining whether clinical variables are able to discriminate between subjects having therapeutically informative versus uninformative X-rays. The study was a chart review of all adult ED patients presenting to the Boston University Medical Center Hospital (Boston, MA) between January 1994 and January 1996 with a chief complaint that included shoulder pain. Subjects with X-rays were classified into two groups, those with therapeutically informative X-rays (ie, identified conditions requiring specific therapy) and those with therapeutically uninformative X-rays (ie, did not result in specific therapy). Recursive partitioning techniques were then used to identify clinical variables that best distinguished between therapeutically informative and uninformative radiographs. Three hundred twelve patients were included in the analysis, of whom 185 (59%) had shoulder X-rays performed. Thirty-seven (20%) radiographs were therapeutically informative, including 13 glenohumeral dislocations, 3 acromioclavicular joint separations, and 21 fractures. Deformity present on shoulder examination was the strongest discriminating variable and correctly classified 21 of 23 subjects as having informative X-rays. Of the remaining patients (n = 162), only those older than 43.5 years with a history of a precipitating fall (n = 40) had a high likelihood of having therapeutically informative X-rays. No patients without a deformity or precipitating fall (n = 90) had an informative X-ray. These data show that X-rays for the initial evaluation of shoulder pain in the ED are overutilized. This preliminary model suggests that clinical variables are able to distinguish between patients with informative versus uninformative X-rays. Prospective studies are needed to derive valid decision rules for selective use of shoulder radiographs in the ED.

Adolescent↗
PubMed1998

Longitudinal analysis of the relationship between serum insulin-like growth factor-I and radiographic knee osteoarthritis.

OBJECTIVE: To examine the relation between serum insulin-like growth factor I (IGF-I) levels and both incident and progressive radiographic knee osteoarthritis (OA) in the Framingham Osteoarthritis Study. DESIGN: Subjects had bilateral weight-bearing, anterior-posterior knee radiographs performed in 1983-1985 and again in 1992-1993. IGF-I levels were measured from blood specimens obtained in 1988-1989 by a competitive binding radio-immunoassay (RIA) after separation with octadecasilyl-silica cartridges of serum IGF-I from binding proteins. Participants without baseline radiographic OA [Kellgren and Lawrence grades (K&L) = 0-1] were classified as having incident disease if they had K&L > or = 2 grades at follow-up. Progressive OA was defined as an increase in K&L score of > or = 1 in knees with baseline OA (K&L > or = 2). All analyses were knee-based and sex-specific. We examined IGF-I tertiles in relation to the risk of incident and progressive radiographic OA separately, adjusting for age, body mass index (BMI), and baseline K&L score, and used generalized estimating equations to adjust for the correlation between fellow knees. RESULTS: Four hundred and forty-one participants had knee radiographs and serum IGF-I levels measured. No associations were found for serum IGF-I levels and incident [women: OR = 0.9 (0.6-1.7), men OR = 1.2 (0.6-2.6)] or progressive [women OR = 0.9 (0.6-1.6), men OR = 0.9 (0.3-3.0)] radiographic knee OA in either sex. Neither did we observe any association between IGF-I and worsening of individual radiographic features of OA (i.e., osteophyte growth and joint space loss). CONCLUSION: In summary, this longitudinal study did not demonstrate any association of serum IGF-I and incident or progressive radiographic knee OA. Further studies are needed to clarify the role of IGF-I in OA.

Case-Control Studies↗
PubMed1998

Impact of disease activity and cumulative damage on the health of lupus patients.

To test if lupus activity and damage predict physical function and general health in lupus was the objective of this study. Ninety-six patients with lupus were seen at baseline and monthly for 4 months. Sociodemographic characteristics and lupus damage (SLICC/ACR DI), were collected at baseline while lupus activity (SLAM-R, SLEDAI), health status measures (HAQ, SF-36) and immunological tests were collected at each visit. Associations of lupus activity and damage with general health and physical function were evaluated. Baseline health status measures were greatly impaired and comparable to those of severe medical illnesses. In cross-sectional analyses, baseline activity score measured by SLAM-R, but not by SLEDAI, correlated with most subscales of SF-36. Baseline damage score SLICC/ACR DI correlated only with the HAQ and the physical function subscale of SF-36. Differences in both activity measures (SLAM-R and SLEDAI) over time correlated with change in health status measures while baseline cumulative damage (SLICC/ACR DI) correlated with the average level of physical function only. Lupus activity measures, SLAM-R and SLEDAI, although differing cross-sectionally, both reflected patients' health status performance over time and lupus damage measure, SLICC/ACR DI, performed well in assessing physical function. Lupus patients scores for health are poor and comparable to those found in severe medical illnesses.

Activities of Daily Living↗
PubMed1998

The association of peripheral monocyte derived interleukin 1beta (IL-1beta), IL-1 receptor antagonist, and tumor necrosis factor-alpha with osteoarthritis in the elderly.

OBJECTIVE: To examine the association of peripheral blood mononuclear cell (PBMC) derived interleukin 1beta (IL-1beta), IL-1 receptor antagonist (IL-1Ra), tumor necrosis factor alpha (TNF-alpha), and radiographic osteoarthritis (OA) in the elderly. METHODS: A total of 703 subjects (436 women, 267 men, mean age 78.5+/-4.5 yrs) had both knee and hand radiographs, and cytokines were measured during the 22nd biennial examination of the Framingham Cohort. PBMC derived IL-1beta , IL-1Ra, and TNF-alpha production was assessed using a non-cross reacting polyclonal radioimmunoassay. Knee OA was defined as a score of > 2 using a modified Kellgren and Lawrence scale. The presence of osteophytes and joint space narrowing were scored separately on a 0-3 scale, in which disease was defined a priori as a score > 0 for each feature. Sex-specific odds ratios were calculated for knee OA after adjusting for weight, history of knee injury, and use of estrogen and nonsteroidal antiinflammatory drugs. RESULT: No uniform associations were found for IL-1beta or IL-1Ra in men, or for TNF-alpha production and radiographic OA in either sex. We found possible associations for the highest levels of IL-1beta production and the presence of knee osteophytes [OR=2.0 (1.2-3.5)] and joint space narrowing [OR=1.7 (1.1-2.8)] in women. Our data suggested a possible protective effect for IL-1Ra production and hand OA in women [OR=0.6 (0.4-1.0)]. CONCLUSION: We found no consistent association of PBMC cytokine production and radiographic OA. However, women with the highest production of IL-1beta and IL-1Ra had respectively higher rates of knee OA and lower rates of hand OA than expected.

Aged↗
PubMed1994

Response to treatment as a predictor of longterm outcome in patients with lupus nephritis.

OBJECTIVE: To evaluate response to therapy over one year as a predictor of several longterm outcomes in lupus nephritis. METHODS: Response to treatment was evaluated by comparing serum creatinine and 24 h urine protein excretion at initial renal biopsy to those obtained after one year of treatment. Response at one year was evaluated as a predictor of renal failure, death due to lupus nephritis, and total lupus mortality, using survival analysis. RESULTS: Eighty-five patients with lupus nephritis diagnosed between 1967 and 1983 and followed through 1990 were studied. Change in proteinuria was a powerful predictor of renal failure (p = 0.001) death due to lupus nephritis (p < 0.001) and overall lupus mortality (p = 0.001). In contrast to a recent study of patients selected for severe lupus nephritis, serum creatinine was not found to be of prognostic significance. CONCLUSION: Response of proteinuria to treatment over one year is a useful predictor of longterm outcomes in lupus nephritis.

Adolescent↗
PubMed1989

Relationship of body-image distortion to sex-role identifications, irrational cognitions, and body weight in eating-disordered females.

Thirty-one eating-disordered (ED) women and 11 normal women completed tests of sex-role identity, dysfunctional cognitions, and body image. Anorexics, not bulimics, exhibited body-image distortion. All EDs (distorters and nondistorters) showed "hyperfeminine" identifications. Maladaptive cognitions were present in all EDs, but more marked in "overestimators." Body weight predicted BID better than other measures of eating pathology, which suggests important effects of weight per se in producing BID.

Adult↗