T Heeren’s research while affiliated with Boston University and other places

Self-reported capability in physical functioning has long been considered an important focus of research for older persons. Current measures have been criticized, however, for conceptual confusion, lack of sensitivity to change, poor reproducibility, and inability to capture a wide range of upper and lower extremity functioning. Using Nagi's disablement model, we wrote physical functioning questionnaire items that assessed difficulty in 48 common daily tasks. We constructed the instrument using factor analysis and Rasch analytic techniques and evaluated its validity and test-retest reliability with 150 ethnically and racially diverse adults aged 60 years and older who had a range of functional limitations. Our analyses resulted in a 32-item function component with three dimensions--upper extremity, basic lower extremity, and advanced lower extremity functions. Expected differences in summary scores of known-functional limitation groups support its validity. Test-retest stability over a 1- to 3-week period was extremely high (intraclass correlation coefficients =.91 to.98). The Late-Life Function and Disability Instrument has potential to assess activity concepts related to upper and lower extremity functioning across a wide variety of daily physical tasks and individual levels of physical functioning.

This study assessed whether persons who begin drinking at younger ages are more likely to report drunk driving and alcohol-related crash involvement over the life course, even after controlling analytically for diagnosis of alcohol dependence, years of drinking alcohol, and other personal characteristics associated with the age respondents started drinking. A national survey asked 42,862 respondents the age that they started drinking, whether they drove after drinking too much, and whether they were in motor-vehicle crashes because of their drinking. This analysis focused on 27,081 (65%), who reported ever drinking in their lifetime. The earlier the age respondents started drinking, the more likely they were to report driving after drinking too much and being in a motor-vehicle crash because of their drinking even after adjusting for current/ever diagnosis of alcohol dependence, number of years respondents had been drinking, and other characteristics and behaviors associated with the age respondents started drinking. Particularly, among persons who were never alcohol-dependent, those who began drinking in each age group under 21, relative to those starting at age 21 or older, were more likely to report "ever" and "in the past year" being in a crash after drinking too much. The traffic safety benefits of delaying drinking may extend well beyond the legal drinking age of 21.

Background: Physician noncompliance with screening recommendations has been a major barrier to effective colorectal cancer control. The overall objectives of this study were to assess the current attitudes and screening behavior of primary care physicians in light of new efficacy data, revised guidelines, improved technology, and more widespread insurance coverage. Methods: Questionnaires inquiring about knowledge, beliefs, and practice patterns related to colorectal cancer screening were mailed in mid-1997 to 700 randomly selected Massachusetts internists. Results: The overall response rate was 63%. Nearly 60% of respondents reported an increase in screening behavior during the past 5 years. Most (80%) were aware of at least one set of screening guidelines and 90% reported utilizing one or more recommended screening strategies. Fecal occult blood testing (FOBT), alone (47%) or in combination with flexible sigmoidoscopy (50%), was the preferred strategy for most respondents. Colonoscopy was rarely utilized (5%) despite high perceived effectiveness. Concern about patient compliance was a significant determinant of FOBT utilization, whereas perceived effectiveness, concerns about time or efficacy data, prior procedural training, date of licensure, and use of instructional materials were independent determinants of sigmoidoscopy utilization. Conclusion: Massachusetts' internists report high rates of utilization of select colorectal cancer screening strategies. Future studies must validate self-reported compliance and explore barriers to screening colonoscopy.

Treatment of acute otitis media (AOM) differs worldwide. The Dutch avoid antimicrobials unless fever and pain persist; the British use them for 5 to 7 days, and Americans use them for 10 days. If effects of therapies are to be compared, it is necessary to evaluate rates of risk factors, severity of attacks, and their influence on treatment decisions. We wanted to compare the prevalence of risk factors for AOM and evaluate their association with severity of attacks and of severity with antimicrobial treatment. We undertook a prospective cohort study of 2,165 patients with AOM enrolled by primary care physicians; 895 were enrolled from North America, 571 were enrolled from the United Kingdom, and 699 were enrolled from The Netherlands. The literature was searched using the key words "acute otitis media," "severity," and "international comparisons." The prevalence of several AOM risk factors differs significantly among patients from the three country networks; these factors include race, parent smoking habits, previous episodes, previous episodes without a physician visit, tonsillectomy or adenoidectomy, frequency of upper respiratory tract infections, day care, and recumbent bottle-feeding. Dutch children have the most severe attacks as defined by fever, ear discharge, decreased hearing during the previous week, and moderate or severe ear pain. In country-adjusted univariate analyses, increasing age, exposure to tobacco smoke, day care, previous attacks of AOM, previous attacks without physician care, past prophylactic antimicrobials, ear tubes, adenoidectomy, and tonsillectomy all contribute to severity. Only country network, age, history of AOM, previous episode without physician care, and history of adenoidectomy and tympanostomy tubes are independently related to increased severity, while current breast-feeding is protective. Severity of attacks influences treatment decisions. Dutch children are least likely to receive antimicrobials, and even for severe attacks the British and Dutch physicians usually use amoxicillin or trimethoprim-sulfa; North American children with severe attacks are more likely to receive a broad-spectrum second-line antimicrobial. Dutch children have the highest ratings in all severity measures, possibly reflecting parental decisions about care seeking for earaches. When comparing groups of patients with AOM, it is necessary to adjust for baseline characteristics. Severity of episode affects physician treatment decisions. Adoption of Dutch guidelines restricting use of antimicrobials for AOM in the United States could result in annual savings of about $185 million.

Previous studies have examined the relation of endogenous estrogen levels or estrogen replacement therapy to the risk of poor cognitive function, but results have been inconclusive. Bone mineral density has been proposed as a marker for cumulative estrogen exposure. The authors studied the relation of bone mineral density to the prevalence of verbal memory impairment among 4,304 elderly subjects in the Third National Health and Nutrition Examination Survey (1988-1994). Bone mineral density was measured in five regions of the proximal femur with dual-energy x-ray absorptiometry. Verbal memory was assessed using delayed recall of a three-item word list and a six-item story. Verbal memory impairment was defined as a combined score of <4. The prevalence of verbal memory impairment for each increasing bone mineral density quintile at the femoral neck was 8.35, 5.74, 5.22, 5.00, and 3.38% in women and 11.54, 7.27, 8.47, 6.29, and 5.89% in men, respectively. With adjustment for age, sex, and other covariates, the prevalence ratios of verbal memory impairment for each increased bone mineral density quintile were 1.00, 0.64, 0.65, 0.55, and 0.44, respectively (p for trend < 0.001). These results suggest that bone mineral density in the elderly is associated with verbal memory impairment. The mechanisms underlying this relation are not understood, but cumulative exposure to estrogen may play a role.

Studies have shown that rates of liver disease are higher in persons who are coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) than they are in persons with HCV alone, but estimates of risk vary widely and are based on data for dissimilar patient populations. We performed a meta-analysis to quantify the effect of HIV coinfection on progressive liver disease in persons with HCV. Eight studies were identified that included outcomes of histological cirrhosis or decompensated liver disease. These studies yielded a combined adjusted relative risk (RR) of 2.92 (95% confidence interval [CI], 1.70–5.01). Of note, studies that examined decompensated liver disease had a combined RR of 6.14 (95% CI, 2.86–13.20), whereas studies that examined histological cirrhosis had a pooled RR of 2.07 (95% CI, 1.40–3.07). There is a significantly elevated RR of severe liver disease in persons who are coinfected with HIV and HCV. This has important implications for timely diagnosis and consideration of treatment in coinfected persons.

The objective of this investigation is to describe the health-related quality of life of Persian Gulf War (GW) veterans and to examine the effects of current chronic medical conditions and psychiatric status on physical functioning. To measure health-related quality of life, the Medical Outcomes Short Form Survey (SF36) was administered approximately 4 years after the GW to a stratified, random sample of New England-area GW-deployed veterans and a group of military personnel deployed to Germany during the GW. The SF36 scores for the GW-deployed study population (N = 141) were compared with those for the Germany-deployed group (N = 46) and with published U.S. population norms. Multiple linear regression analyses were performed to identify risk factors associated with lower physical health functioning in the GW-deployed study group. Functional health status was significantly lower in the GW-deployed group compared with the Germany-deployed group for each of the SF36 subscales and the two summary scores (Physical Component Summary [PCS] and Mental Component Summary). Compared with the general U.S. population, the GW-deployed group median was between the 25th and 50th percentile for the Physical Functioning subscale and the PCS score. Within the GW-deployed group, lower education, psychological symptomatology, and a higher number of chronic self-reported medical conditions were significant predictors of the PCS score. GW-deployed veterans report lower functional health status compared with a group of Germany-deployed veterans and published general U.S. population norms. Within the group of GW-deployed veterans, several current medical and psychological conditions predictive of lower physical functioning levels were identified.

The accuracy of data gathered by primary care clinicians in practice-based research networks (PBRNs) has been questioned. Tympanometry, recently recommended as a means of improving accuracy of diagnosing acute otitis media, was included as an objective diagnostic measure in an international PBRN study. We report the level of agreement of interpretations of tympanograms between primary care physicians in PBRNs and experts. Primary care physicians in PBRNs in the Netherlands, United Kingdom, United States, and Canada enrolled 1773 children aged 6 to 180 months who contributed 6358 tympanograms during 3179 visits. The physicians were trained in the use and interpretation of tympanometry using the Modified Jerger Classification. We determined the level of agreement between physicians and experts for interpretation of tympanograms. One comparison used the 6358 individual ear tracings. A second comparison used the 3179 office visits by children as the unit of analysis. The distribution of expert interpretation of all tympanograms was: 35.8% A, 30% B, 15.5% C1, 12% C2, and 6.8% uninterpretable; for visits, 37.8% were normal (A or C1), 55.6% abnormal (B or C2), and 6.6% could not be classified. There was a high degree of agreement in the interpretation of tympanograms between experts and primary care physicians across networks (kappa=0.70-0.77), age groups of children (kappa=0.69-0.73), and types of visits (kappa=0.66-0.77). This high degree of agreement was also found when children were used as a unit of analysis. Interpretations of tympanograms by primary care physicians using the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.

In 1997, unintentional injury was the leading cause of death for persons aged 1 to 34 years. Approximately one third of deaths due to unintentional injury in the United States are estimated to be alcohol related. Onset of drinking at an early age has been found to be associated with alcohol dependence, but whether early-onset drinking increases risk for unintentional injury while drinking is unknown. To explore whether persons who started drinking at an early age are more likely to have experienced unintentional injuries while under the influence of alcohol. The National Longitudinal Alcohol Epidemiology Survey, a cross-sectional survey conducted in 1992 of a representative sample of the US population. A total of 42,862 randomly selected adults (response rate, 90%; mean age, 44 years). Unintentional injury involvement while under the influence of alcohol by age of drinking onset (categorized as <14 years, each age from 14-20 years, or >/=21 years). Relative to respondents who began drinking at age 21 years or older, those who started before age 14 years as well as those who started at each intervening age up to 21 years were significantly more likely to have been injured while under the influence of alcohol, even after controlling for history of alcohol dependence, heavy drinking frequency during the period that they drank most, family history of alcoholism, and other characteristics associated with earlier onset of drinking. After adjusting for these variables, odds ratios for having been injured while under the influence of alcohol were as follows: for younger than 14 years, 2.98 (95% confidence interval [CI], 2.29-3.89); age 14 years, 2.96 (95% CI, 2.26-3.88); age 15 years, 3.14 (95% CI, 2.48-3.97); age 16 years, 2.38 (95% CI, 1.90-2.98); age 17 years, 2.12 (95% CI, 1.66-2.71); age 18 years, 1. 33 (95% CI, 1.08-1.64); age 19 years, 1.42 (95% CI, 1.07-1.89); and age 20 years, 1.39 (95% CI, 1.01-1.91). Drinking onset at ages younger than 21 years is associated with having experienced alcohol-related injuries. JAMA. 2000;284:1527-1533