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Ralph I Horwitz

Publications and source records attributed to Ralph I Horwitz.

17 recordsLinked to original sources
PubMed2006

The effectiveness of screening for prostate cancer: a nested case-control study.

BACKGROUND: Screening for prostate cancer is done commonly in clinical practice, using prostate-specific antigen (PSA) tests or digital rectal examination (DRE). Evidence is lacking, however, to confirm a survival benefit among screened patients. We evaluated the effectiveness of PSA, with or without DRE, in reducing mortality. METHODS: We conducted a multicenter nested case-control study at 10 Veterans Affairs medical centers in New England. Among 71 661 patients receiving ambulatory care between 1989 and 1990, 501 case patients were identified as men who were diagnosed as having adenocarcinoma of the prostate from 1991 through 1995 and who died sometime between 1991 and 1999. Control patients were men who were alive at the time the corresponding case patient had died, matched (1:1 ratio) for age and Veterans Affairs facility. The exposure variable (determined blind to case-control status) was whether PSA testing or DRE was performed for screening prior to the diagnosis of prostate cancer among case patients, with the same time interval for control patients. The association of screening and overall or cause-specific (prostate cancer) mortality was adjusted for race and comorbidity. RESULTS: A benefit of screening was not found in our primary analysis assessing PSA screening and all-cause mortality (adjusted odds ratio, 1.08; 95% confidence interval, 0.71-1.64; P=.72), nor in a secondary analysis of PSA and/or DRE screening and cause-specific mortality (adjusted odds ratio, 1.13; 95% confidence interval, 0.63-2.06; P=.68). CONCLUSIONS: These results do not suggest that screening with PSA or DRE is effective in reducing mortality. Recommendations for obtaining "verbal informed consent" from men regarding such screening should continue.

Adenocarcinoma↗
PubMed2005

Major risk factors for intracerebral hemorrhage in the young are modifiable.

BACKGROUND AND PURPOSE: To identify risk factors for intracerebral hemorrhage (ICH), we examined data from the Hemorrhagic Stroke Project (HSP), a case-control study of hemorrhagic stroke among men and women aged 18 to 49 years. METHODS: Case subjects for the HSP were recruited from 44 hospitals in the United States. Eligibility criteria included an ICH within 30 days preceding enrollment, no history of stroke or known brain lesion. For this report, we focused on patients with primary ICH, defined as not associated with an aneurysm, arteriovenous malformation or other structural lesion. Two control subjects were sought for each case subject. A multivariate regression analysis was performed to determine risk factors for primary ICH. RESULTS: A total of 1714 patients with hemorrhagic stroke were identified for participation in the HSP. Of these, 217 cases met the criteria for primary ICH. Cases with primary ICH were matched to 419 controls. Independent risk factors for ICH included hypertension (adjusted odds ratio [OR], 5.71; 95% CI, 3.61 to 9.05), diabetes (adjusted OR, 2.40; 95% CI, 1.15 to 5.01), menopause (adjusted OR, 2.50; 95% CI, 1.06 to 5.88), current cigarette smoking (adjusted OR, 1.58; 95% CI, 1.02 to 2.44), alcoholic drinks> or =2/day (adjusted OR, 2.23; 95% CI, 1.16 to 4.32), caffeinated drinks> or =5/day (adjusted OR, 1.73; 95% CI, 1.08 to 2.79), and caffeine in drugs (adjusted OR, 3.55; 95% CI, 1.24 to 10.20). CONCLUSIONS: Among young men and women, the major risk factors for primary ICH can be modified, suggesting that this type of stroke may be preventable. Our findings for caffeine and menopause warrant further study.

Adolescent↗
PubMed2005

Decline in physical performance among women with a recent transient ischemic attack or ischemic stroke: opportunities for functional preservation a report of the Women's Estrogen Stroke Trial.

BACKGROUND AND PURPOSE: Physical performance for walking, reaching, turning, and other common tasks is a major determinant of functional independence after stroke. Current strategies to preserve physical performance focus on prevention of recurrent stroke. Loss of physical performance, however, may occur in the absence of recurrence. To examine this possibility, we measured change in physical performance, independent of subsequent stroke, among women with a recent ischemic stroke or transient ischemic attack (TIA). METHODS: Among 664 postmenopausal women who participated in a clinical trial of estrogen therapy after stroke or TIA, we administered the Physical Performance Test (PPT) at baseline (mean 58 days from the cerebrovascular event) and annually. Women who died or had a stroke during follow-up were censored. Decline or improvement in physical performance was defined as a change in the PPT score from baseline of at least 3 points. Sustained decline or improvement was defined as 2 consecutive years during which the score had declined or improved, respectively, relative to the baseline score. RESULTS: With each year of follow-up, a smaller proportion of the cohort demonstrated improvement (16% in year 1, 6% in year 5) and a larger proportion demonstrated decline (15% in year 1, 35% in year 5). In an analysis restricted to 259 women with 3 years of follow-up, 46 (18%) experienced a nonsustained decline in physical performance, and 39 (15%) experienced a sustained decline. CONCLUSIONS: Decline in physical performance is common after an ischemic stroke or TIA even in the absence of a recurrent neurological event. Our findings suggest that specific interventions to maintain and improve physical performance may be important for reducing long-term disability.

Aged↗
PubMed2005

Estrogen therapy and risk of cognitive decline: results from the Women's Estrogen for Stroke Trial (WEST).

OBJECTIVE: This study was undertaken to assess whether estrogen therapy (ET) reduces the risk of cognitive decline in women with cerebrovascular disease. STUDY DESIGN: We conducted a randomized, double-blind trial of estradiol 17beta versus placebo for secondary stroke prevention in 664 postmenopausal women with a recent stroke or transient ischemic attack. The Mini-Mental State Examination (MMSE) and 5 domain measures were obtained at baseline and exit. RESULTS: Among 461 women withdrawn alive without stroke, ET did not have a significant effect on cognitive measures after an average of 3 years (relative risk of MMSE decline: 0.74, 95% CI, 0.49-1.13). In women with normal MMSE at entry, estrogen was associated with less decline (relative risk, 0.46, 95% CI, 0.24-0.87). CONCLUSION: In this study, estradiol did not have significant effects on cognitive measures. However, in women with normal function at baseline, there may be a benefit for ET in reducing the risk for cognitive decline.

Aged↗
PubMed2005

Altruism as a reason for participation in clinical trials was independently associated with adherence.

BACKGROUND: To determine whether altruism as reason for participation in research is independently associated with adherence to a medical regimen in a clinical trial. METHODS: Participants were 475 participants in the Women's Estrogen for Stroke Trial. Before randomization to estrogen or placebo, all women were questioned about reason for participation and baseline features that may contribute to adherence. Adherence was defined as completion of at least 80% of expected pill intake during the trial. RESULTS: Women who reported at least one altruistic reason for participation were more likely to be college educated, have a higher level of social support, and a better functional status. They were also more likely to be adherent to their study medication {155 of 212 (73%) vs. 158 of 253 (62.5%), P < .01}. On stratified analysis and multivariable regression, the relationship between altruism as reason for participation and adherence was independent of other sociodemographic, psychosocial, and clinical features (relative risk 1.17, Confidence interval 1.03-1.32). CONCLUSION: Altruism may explain a small portion of the variation in adherence among research participants. This relationship may have implications for recruitment of participants in clinical research. The possible contribution of altruism to the relationship between adherence and outcomes in clinical trials is worthy of further investigation.

Aged↗
PubMed2004

Educational disadvantage impairs functional recovery after hospitalization in older persons.

PURPOSE: To determine whether low educational level is associated with poor functional recovery after hospitalization in older adults. METHODS: We followed 862 patients (374 with low education, defined as <high school) for 6 months after hospitalization. Poor functional recovery was defined as an Activities of Daily Living score that was lower 6 months after hospitalization than 1 month before hospitalization. People who died were also considered to have poor recovery. RESULTS: Of the 862 participants, 351 (41%) experienced poor functional recovery: 124 died and 227 had declines in activities of daily living. There was a graded, statistically significant relation between level of education and poor functional recovery, regardless of impairment of activities of daily living at baseline. Poor functional recovery was more common in subjects with baseline impairment (50% [147/296]) than in those without baseline impairment (36% [204/566]). Independent predictors of poor functional recovery were low education, cognitive impairment, lack of social support, poor self-rated health, and high comorbidity. Sequential addition of demographic, economic, functional, psychosocial, and clinical factors to low education only modestly affected the association between low education and poor functional recovery. CONCLUSION: Educational disadvantage impairs functional recovery after hospitalization in older persons.

Activities of Daily Living↗
PubMed2004

The role of physician specialty board certification status in the quality movement.

The Institute of Medicine's reports and discussions on quality of medical care have focused on a systems-based approach to quality improvement. Our objective is to summarize evidence and theory about the role of a physician's current board certification status in quality improvement. The first body of evidence includes the validity of board certification demonstrated by the testing process, the relationship of examination scores with other measures of physician competence, and the relationship between certification status and clinical outcomes. The second body of evidence involves the adaptation of error prevention theory to medical care. Patient safety is enhanced when problem-solving uses readily accessed habits of behavior, the same behavior necessary to achieve board certification. The third body of evidence, obtained through a Gallup poll, demonstrates that certification and maintenance of certification are highly valued by the public. The majority of respondents thought it important for physicians to be reevaluated on their qualifications every few years and that physicians should do more to demonstrate ongoing competence than is currently required by the profession. We conclude that a physician's current certification status should be among the evidence-based measures used in the quality movement.

Physician's Role↗
PubMed2003

Major risk factors for aneurysmal subarachnoid hemorrhage in the young are modifiable.

BACKGROUND AND PURPOSE: To identify risk factors for subarachnoid hemorrhage (SAH) and intracerebral hemorrhage, we designed a case-control study of men and women 18 to 49 years of age (the Hemorrhagic Stroke Project [HSP]). This report focuses on SAH. METHODS: Patients were recruited from 44 hospitals in the United States. Cases with SAH must have had a ruptured aneurysm documented by angiography or surgery. Two controls, identified by random digit dialing and matched to each patient for age, sex, race, and telephone exchange, were sought for each case subject. RESULTS: Between 1994 and 1999, 425 patients with SAH were enrolled in HSP, and 312 cases met the criteria for aneurysmal SAH. The present analyses also included 618 matched controls. Of the 312 cases, 66% were current cigarette smokers compared with 30% of controls (adjusted odds ratio [OR], 3.73; 95% CI, 2.67 to 5.21). Cocaine use within the previous 3-day period was reported by 3% of cases and no controls (bivariate exact OR, 24.97; 95% exact CI, 3.95 to infinity; adjusted estimate not calculable). Other independent risk factors in the multivariable model included hypertension (adjusted OR, 2.21; 95% CI, 1.48 to 3.29), low body mass index (OR, 1.59; 95% CI, 1.08 to 2.35), primary family history of hemorrhagic stroke (OR, 3.83; 95% CI, 1.73 to 8.46), caffeine in pharmaceutical products (OR, 2.48; 95% CI, 1.19 to 5.20), lower educational achievement (OR, 2.36; 95% CI, 1.44 to 3.87), and nicotine in pharmaceutical products (adjusted estimate not calculable). CONCLUSIONS: Aneurysmal SAH may be largely a preventable disease among the young and middle-aged because several prevalent risk factors can be modified by medication (eg, hypertension) or behavioral change (eg, cigarette smoking, cocaine use). The association of caffeine and nicotine in pharmaceutical products and aneurysmal SAH warrants further study.

Adolescent↗
PubMed2003

Pioglitazone improves insulin sensitivity among nondiabetic patients with a recent transient ischemic attack or ischemic stroke.

BACKGROUND AND PURPOSE: The aim of this study was to determine the effectiveness of pioglitazone compared with placebo for improving insulin sensitivity among nondiabetic patients with a recent transient ischemic attack (TIA) or nondisabling ischemic stroke and impaired insulin sensitivity. METHODS: Eligible subjects were men and women >45 years of age who had no history of diabetes, fasting glucose <7.0 mmol/L, and impaired insulin sensitivity according to an index calculated from insulin and glucose blood levels obtained during an oral glucose tolerance test. Eligible subjects were randomized to pioglitazone 45 mg/d or placebo. After 3 months of therapy, the glucose tolerance test was repeated. RESULTS: Between July 2000 and June 2001, we performed oral glucose tolerance tests on 75 patients with no history of diabetes, among whom 36 (50%) were found to have impaired insulin sensitivity and fasting glucose <7.0 mmol/L. Among these 36, 20 consented to the trial. Patients assigned to pioglitazone (n=10) and placebo (n=10) were similar in insulin sensitivity, age, obesity, and index event (stroke compared with TIA), but patients assigned to pioglitazone were less likely to be male (4 compared with 9). The mean proportional increase in insulin sensitivity was 62% among patients assigned to pioglitazone compared with a -1% decline among patients assigned to placebo (P=0.0006). Mean C-reactive protein concentration declined from 0.30 to 0.20 mg/L among patients assigned to pioglitazone and increased from 0.41 to 0.45 mg/L among patients assigned to placebo (P=0.06 for comparison of mean change). CONCLUSIONS: Pioglitazone is effective for improving insulin sensitivity among patients with recent TIA or stroke and impaired insulin sensitivity.

Aged↗
PubMed2003

Effects of propranolol on recovery of heart rate variability following acute myocardial infarction and relation to outcome in the Beta-Blocker Heart Attack Trial.

This study evaluated the effects of propranolol on recovery of heart rate variability (HRV) after acute myocardial infarction and its relation to outcome in the Beta-blocker Heart Attack Trial (BHAT). Beta blockers improve mortality after acute myocardial infarction, but through an unknown mechanism. Depressed HRV, a measure of autonomic tone, predicts mortality after acute myocardial infarction. Whether beta blockers influence recovery of HRV after acute myocardial infarction, and thereby improve outcome, is unknown. We compared 24-hour HRV parameters at 1 week after acute myocardial infarction and after 6 weeks of treatment with propanolol (n = 88) or placebo (n = 96). The relation between 25-month outcome (death/acute myocardial infarction/congestive heart failure), propranolol treatment, and HRV was further analyzed. After 6 weeks, high-frequency (HF) power (log-normalized), an index of vagal tone, increased more in propranolol-treated patients (4.28 +/- 0.1 to 5.17 +/- 0.09 ms(2)) than in placebo-treated patients (4.26 +/- 0.09 to 4.77 +/- 0.1 ms(2), p <0.05). Sympathovagal balance measured by the low-frequency (LF) to HF ratio increased in placebo-treated patients (3.55 +/- 0.24 to 3.86 +/- 0.24) but decreased in those treated with propranolol (3.76 +/- 0.29 to 3.17 +/- 0.23, p <0.01). Other frequency-domain parameters increased over time but were not affected by propranolol. Propranolol blunted the morning increase in the LF/HF ratio. Recovery of HF, the strongest HRV predictor of outcome, and propranolol therapy independently predicted outcome. In summary, after acute myocardial infarction, propranolol therapy improves recovery of parasympathetic tone, which correlates with improved outcome, and decreases morning sympathetic predominance. These findings may elucidate the mechanisms by which beta blockers decrease mortality and reduce the early morning risk of sudden death after acute myocardial infarction.

Adrenergic beta-Antagonists↗
PubMed2003

Influence of race, clinical, and other socio-demographic features on trial participation.

We assessed whether sociodemographic and clinical characteristics were determinants of clinical trial participation in the Women's Estrogen for Stroke Trial (WEST) by examining data collected on women with a WEST consent visit completed after June 1996. We found no differences in consent rates by education or ethnic group (32% of white women compared with 34% of black women). Conditions associated with the intervention, such as a history of hysterectomy or previous estrogen replacement use, were strongly associated with a woman's decision to participate in this clinical trial. In multivariate models, features independently associated with consent to participate were age (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.94-0.97), hysterectomy (OR 1.78, 95% CI 1.27-2.50), no cognitive impairment (OR 1.70, 95% CI 1.10-2.63), history of volunteerism (OR 1.62, 95% CI 1.02-2.63), and previous estrogen use (RR 1.58, 95% CI 1.08-2.30).

Age Factors↗
PubMed2002

Clinical assessment of function among women with a recent cerebrovascular event: a self-reported versus performance-based measure.

BACKGROUND: Self-reported functional status is a commonly used health measure in clinical settings, yet the optimal approach for assessing function is often debated. OBJECTIVE: To examine the agreement between a self-reported and a performance-based measure of function and the relative ability of each measure to predict long-term health outcomes. DESIGN: Prospective cohort study. SETTING: 20 hospitals in Connecticut and Massachusetts. PARTICIPANTS: 620 postmenopausal women (46 to 91 years of age) who had experienced a stroke or transient ischemic attack. MEASUREMENTS: A self-reported and a performance-based measure of function were assessed at baseline (before intervention) by using the Barthel index and the Physical Performance Test. RESULTS: Disagreement between the self-reported and performance-based measure of function was common (slight disagreement, 55.0%; substantial disagreement, 19.3%). Most women (95.4%) overreported their level of function. Women who were more clinically impaired (risk ratio [RR] for more comorbid conditions, 1.52 [95% CI, 1.17 to 1.97]; RR for recent stroke, 2.33 [CI, 1.45 to 3.73]; and RR for cognitive impairment, 1.76 [CI, 1.34 to 2.32]); who were less educated (RR = 1.30 [CI, 1.02 to 1.67]); and who were of nonwhite ethnicity (RR 1.43 [CI, 1.07 to 1.91]) were more likely to overreport their level of function. An impaired performance-based measure of function predicted subsequent stroke or death (hazard ratio, 1.50, [CI, 1.06 to 2.11]); however, an impaired self-reported measure of function was not likely to predict these outcomes. CONCLUSIONS: Clinicians should be aware that results of self-reported and performance-based measures of function can differ in women who have experienced a recent cerebrovascular event. Although more difficult to collect, results of a performance-based measure may provide information about long-term health outcomes that is not available from a self-reported measure.

Activities of Daily Living↗
PubMed2002

How do women make decisions about hormone replacement therapy?

Although clinicians are often expected to include patients in medical decision making, there is little data to assist clinicians in this process. The objective of this study was to investigate how patients make decisions and the role clinicians can play in this process in the context of how women decide about hormone replacement therapy.Twenty-three women who were deciding whether to take hormone replacement therapy, but who had not begun treatment, were interviewed individually using a semistructured protocol with open-ended questions. The interviews were audiotaped, transcribed, and converted into a database. The transcripts were labeled according to their content, and the database was used to identify common themes. The content of the women's statements were organized into nine descriptive categories. A common set of processes involved in patient decision making was identified and organized into a model of patient decision making. Four areas where clinicians might influence or assist patients in making decisions include the provision of information, the process by which patients selectively pay attention to some information, the patients' perception of their own health, and the patients' development of an explanatory narrative. This new model describes some of the complexity of the patient decision-making process and contributes to our understanding of the clinician's role. To examine its generalizability, the model should be tested on other types of patients making other medical decisions.

Attitude to Health↗
PubMed2002

Social class and mortality in older women.

In middle-aged people, social class is one of the strongest predictors of mortality. However, to date, research prospectively evaluating the relationship between social class and mortality in the older persons has produced conflicting results. This may be due to the lack of clinical covariates in many analyses. The objective of this study was to determine the relationship between social class markers-education, income, husband's work history, and personal work history-and mortality in a cohort of older women, after adjusting for clinical and behavioral factors. The participants were 737 ambulatory, community-living women, age 72 and older, followed from 1989 to 1993. In addition to education attained, present income, husband's work history, and personal work history, proportional hazard models adjusted for age, race, marital status, number of chronic conditions, number of medications used, Activities of Daily Living status, Mini-Mental State Exam score, physical activity, and alcohol use. In multivariable models personal work history was the only social class marker that remained significantly associated with mortality. Compared with managers and professionals, women who never worked outside the home had a 3.5 greater risk of death (95% CI, 1.6-7.5), while women who had worked in partly/unskilled or skilled professions were over two and a half times more likely to die; the adjusted hazard ratios were 2.7 (95% CI, 1.2-6.4) and 2.7 (95% CI, 1.3-5.7), respectively. In this population of older women, personal work history was the only social class marker predictive of mortality.

Aged↗
PubMed2002

Risk for delirium tremens in patients with alcohol withdrawal syndrome.

To determine the characteristics associated with an increased risk for delirium tremens (DT) we performed a case-control study at the detoxification units of two hospitals. Cases met DSM-IV criteria for DT. For each case (n = 15), 3 controls (n = 45) were chosen. Eligibility criteria were applied equally to cases and controls. Cases were more likely than controls to report a prior complicated withdrawal (DT or alcohol withdrawal seizure) (53 vs. 27%, OR 3.1, 95% CI 0.94-10.55), have a systolic blood pressure greater than 145 mm Hg on admission (60 vs. 27%, OR 4.1, 95% CI 1.21-14.06), and have comorbidity scores of at least 1 (60 vs. 18%, OR 6.9, 95% CI 1.92-25.08). Zero cases (0%) and 15 (33%) controls had no prior complicated withdrawals and no adverse clinical features (systolic blood pressure >145 or comorbidity score >1). Compared to this group, the odds of being a case and having both prior complicated withdrawal and at least 1 adverse clinical feature was 44.8 (95% CI 4.36-460). Elevated blood pressure, prior complicated alcohol withdrawal and medical comorbidity, alone and in combination, are associated with an increased risk of delirium tremens.

Adult↗