Kleinman, Kenneth
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Kleinman
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Kenneth
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Publication Longitudinal Study of Birth Weight and Adult Body Mass Index in Predicting Risk of Coronary Heart Disease and Stroke in Women(2005-01) Kleinman, Ken; Rich-Edwards, Janet; Michels, Karin; Stampfer, Meir; Manson, JoAnn; Rexrode, Kathryn; Hibert, Eileen; Willett, WalterObjectives To determine whether birth weight and adult body size interact to predict coronary heart disease in women, as has been observed for men. To determine whether birth weight and adult body size interact to predict risk of stroke. Design Longitudinal cohort study. Setting and participants 66 111 female nurses followed since 1976 who were born of singleton, term pregnancies and reported their birth weight in 1992. Main outcome measures 1504 events of coronary heart disease (myocardial infarction or sudden cardiac death) and 1164 strokes. Results For each kilogram of higher birth weight, age adjusted hazard ratios from prospective analysis were 0.77 (95% confidence interval 0.69 to 0.87) for coronary heart disease and 0.89 (0.78 to 1.01) for total stroke. In combined prospective and retrospective analysis, hazard ratios were 0.84 (0.76 to 0.93) for total stroke, 0.83 (0.71 to 0.96) for ischaemic stroke, and 0.86 (0.66 to 1.11) for haemorrhagic stroke. Exclusion of macrosomic infants (> 4536 g) yielded stronger estimates. Risk of coronary heart disease was especially high for women who crossed from a low centile of weight at birth to a high centile of body mass index in adulthood. The association of lower birth weight with increased risk of stroke was apparent across categories of body mass index in adults and was not especially strong among heavier women. Conclusions Higher body mass index in adulthood is an especially strong risk factor for coronary heart disease among women who were small at birth. In this large cohort of women, size at birth and adiposity in adulthood interacted to predict events of coronary heart disease but not stroke events.Publication Quality and Correlates of Medical Record Documentation in the Ambulatory Care Setting(2002-01) Kleinman, Ken; Soto, Carlos; Simon, StevenBackground Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record. Methods We reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians) at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care. Results Among internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 – 2.83) but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 – 0.75). Conclusions Medical record documentation varied depending on the measure, with room for improvement in most domains. A variety of characteristics correlated with medical record documentation, but no pattern emerged. Further study could lead to targeted interventions to improve documentation.Publication Maternal Fish Consumption, Hair Mercury, and Infant Cognition in a U.S. Cohort.(2005-01) Kleinman, Ken; Oken, Emily; Wright, Robert; Bellinger, David; Amarasiriwardena, Chitra; Hu, Howard; Rich-Edwards, Janet; Gillman, MatthewFish and other seafood may contain organic mercury but also beneficial nutrients such as n-3 polyunsaturated fatty acids. We endeavored to study whether maternal fish consumption during pregnancy harms or benefits fetal brain development. We examined associations of maternal fish intake during pregnancy and maternal hair mercury at delivery with infant cognition among 135 mother–infant pairs in Project Viva, a prospective U.S. pregnancy and child cohort study. We assessed infant cognition by the percent novelty preference on visual recognition memory (VRM) testing at 6 months of age. Mothers consumed an average of 1.2 fish servings per week during the second trimester. Mean maternal hair mercury was 0.55 ppm, with 10% of samples > 1.2 ppm. Mean VRM score was 59.8 (range, 10.9–92.5). After adjusting for participant characteristics using linear regression, higher fish intake was associated with higher infant cognition. This association strengthened after adjustment for hair mercury level: For each additional weekly fish serving, offspring VRM score was 4.0 points higher [95% confidence interval (CI), 1.3 to 6.7]. However, an increase of 1 ppm in mercury was associated with a decrement in VRM score of 7.5 (95% CI, –13.7 to –1.2) points. VRM scores were highest among infants of women who consumed > 2 weekly fish servings but had mercury levels ≤1.2 ppm. Higher fish consumption in pregnancy was associated with better infant cognition, but higher mercury levels were associated with lower cognition. Women should continue to eat fish during pregnancy but choose varieties with lower mercury contamination.Publication A New Surrogate Variable for Erectile Dysfunction Status in the Massachusetts Male Aging Study(2000-01) Kleinman, Kenneth; Feldman, Henry; Johannes, Catherine; Derby, Carol; McKinlay, JohnErectile dysfunction (ED) is the subject of a vast clinical literature, but little information has been gathered from random samples of the general public. The Massachusetts Male Aging Study (MMAS) addressed this important aspect of men's health. The MMAS was conducted in two waves, with baseline data collection in 1987–1989 and follow-up in 1995–1997. Subsequent to the baseline MMAS survey, a consensus developed that subjective measures are optimal for defining ED. Unfortunately, the baseline questionnaire did not ask subjects directly about their erectile functioning. Thus, we previously assigned the MMAS subjects a degree of impotence at baseline using a series of related questions, employing a discriminant formula constructed from a separate sample of urology clinic patients. At follow-up the men classified themselves directly in addition to answering the original series of related questions. In the present article, we report the results of a new discriminant function, based on the MMAS men at follow-up. We also compare the two methods and discuss our reasons for preferring the internally calibrated method.Publication A Nearly Continuous Measure of Birth Weight for Gestational Age Using a United States National Reference(2003-01) Kleinman, Ken; Oken, Emily; Rich-Edwards, Janet; Gillman, MatthewBackground Fully understanding the determinants and sequelae of fetal growth requires a continuous measure of birth weight adjusted for gestational age. Published United States reference data, however, provide estimates only of the median and lowest and highest 5th and 10th percentiles for birth weight at each gestational age. The purpose of our analysis was to create more continuous reference measures of birth weight for gestational age for use in epidemiologic analyses. Methods We used data from the most recent nationwide United States Natality datasets to generate multiple reference percentiles of birth weight at each completed week of gestation from 22 through 44 weeks. Gestational age was determined from last menstrual period. We analyzed data from 6,690,717 singleton infants with recorded birth weight and sex born to United States resident mothers in 1999 and 2000. Results Birth weight rose with greater gestational age, with increasing slopes during the third trimester and a leveling off beyond 40 weeks. Boys had higher birth weights than girls, later born children higher weights than firstborns, and infants born to non-Hispanic white mothers higher birth weights than those born to non-Hispanic black mothers. These results correspond well with previously published estimates reporting limited percentiles. Conclusions Our method provides comprehensive reference values of birth weight at 22 through 44 completed weeks of gestation, derived from broadly based nationwide data. Other approaches require assumptions of normality or of a functional relationship between gestational age and birth weight, which may not be appropriate. These data should prove useful for researchers investigating the predictors and outcomes of altered fetal growth.Publication Using Automated Medical Records for Rapid Identification of Illness Syndromes (Syndromic Surveillance): The Example of Lower Respiratory Infection(2001-01) Kleinman, Kenneth; Lazarus, Ross; Dashevsky, Inna; DeMaria, Alfred; Platt, RichardBackground Gaps in disease surveillance capacity, particularly for emerging infections and bioterrorist attack, highlight a need for efficient, real time identification of diseases. Methods We studied automated records from 1996 through 1999 of approximately 250,000 health plan members in greater Boston. Results We identified 152,435 lower respiratory infection illness visits, comprising 106,670 episodes during 1,143,208 person-years. Three diagnoses, cough (ICD9CM 786.2), pneumonia not otherwise specified (ICD9CM 486) and acute bronchitis (ICD9CM 466.0) accounted for 91% of these visits, with expected age and sex distributions. Variation of weekly occurrences corresponded closely to national pneumonia and influenza mortality data. There was substantial variation in geographic location of the cases. Conclusion This information complements existing surveillance programs by assessing the large majority of episodes of illness for which no etiologic agents are identified. Additional advantages include: a) sensitivity, uniformity and efficiency, since detection of events does not depend on clinicians' to actively report diagnoses, b) timeliness, the data are available within a day of the clinical event; and c) ease of integration into automated surveillance systems. These features facilitate early detection of conditions of public health importance, including regularly occurring events like seasonal respiratory illness, as well as unusual occurrences, such as a bioterrorist attack that first manifests as respiratory symptoms. These methods should also be applicable to other infectious and non-infectious conditions. Knowledge of disease patterns in real time may also help clinicians to manage patients, and assist health plan administrators in allocating resources efficiently.