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Howe JA, Inness EL, Venturini A, Williams JI, Verrier MC. The Community Balance and Mobility Scale-a balance measure for individuals with traumatic brain injury. Clin Rehabil 2016; 20:885-95. [PMID: 17008340 DOI: 10.1177/0269215506072183] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To provide evidence for the validity and reliability of a new outcome measure of balance, the Community Balance and Mobility Scale, developed for the ambulatory individual with traumatic brain injury. Design: A validity and reliability study. Setting: Acute care, in- and outpatient rehabilitation and day hospital settings. Subjects: Two convenience samples ( n=36, 32) of ambulatory patients with traumatic brain injury. Main measures: The content and construct validity, test-retest, inter- and intra-rater reliability and internal consistency of the Community Balance and Mobility Scale. Results: Content validity was demonstrated by the involvement of patients with traumatic brain injury ( n=7) and clinicians ( n=17) in the process of item generation and by physical therapists’ ratings of item relevance. Further support is the correlation of the Community Balance and Mobility Scale scores with physical therapists’ global balance ratings of the patient ( r=0.62). Construct validity was supported by the ability of the measure to differentiate between patients along the continuum of care and also by comparisons with maximal walking velocity ( r=0.64). Patients who scored greater than or less than 50 on the balance measure demonstrated significantly different Community Integration Questionnaire scores ( P=0.004). The Community Balance and Mobility Scale demonstrated intraclass correlation coefficients (ICCs) of 0.977, 0.977, 0.975 and Cronbach’s alpha of 0.96 for intra-, inter-, test-retest reliability and internal consistency, respectively. Conclusion: The Community Balance and Mobility Scale is a valid and reliable outcome measure for the ambulatory individual with traumatic brain injury.
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Affiliation(s)
- J A Howe
- Toronto Rehabilitation Institute and Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada.
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2
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Carr WW, Bernstein DI, Hampel FC, Gow JA, Williams JI, Zuraw BL, Chipps BE, Miller TA, Berger WE, Carr WW, Tort MJ. Abstracts from the North American Rhinology & Allergy Conference, February 3, 2011, Puerto Rico. Am J Rhinol Allergy 2011; 25:369. [PMID: 29021069 DOI: 10.2500/ajra.2011.11.3699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION To establish the efficacy of bepotastine besilate ophthalmic solution (bepotastine) 1.5%, a dual acting histamine H1 receptor antagonist approved for treatment of ocular itching associated with allergic conjunctivitis, compared to placebo in relieving ocular itching and redness for subjects with active allergic rhinoconjunctivitis. METHODS A randomized, double-masked, placebo-controlled, confirmatory natural exposure study of bepotastine 1.5% and placebo was conducted during allergy season at 12 clinical sites throughout the U.S. Following a 7-day screening period, eligible subjects ≥12 years old were assigned in a 1:1 ratio to dosing OU b.i.d. either bepotastine 1.5% (n = 123) or placebo (n = 122). Subjects recorded instantaneous grades for their ocular symptoms prior to their next dose for 14 consecutive days. Clinically significant reduction in ocular sign or symptom grades between treatment groups required p ≤ 0.05 as determined by ANCOVA analysis. RESULTS Significant clinical effectiveness with bepotastine 1.5% was demonstrated over the 2-week treatment period in comparison to placebo in the intent-to-treat population for reducing mean instantaneous grades for both ocular itching (p = 0.007) and redness (p = 0.001). Investigator rating of efficacy over the 2-week treatment period across response categories was also superior for bepotastine 1.5% compared to placebo (p = 0.024). Only one subject discontinued participation in the study due to an adverse event. CONCLUSIONS These data support bepotastine 1.5% as an effective treatment for allergen-induced signs and symptoms in a clinical study designed to closely resemble the conditions under which patients with allergic rhinoconjunctivitis would require treatment.
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Clark JC, Williams JI, Gow JA, Abelson MB, McNamara TR, Wheeler W, Shah S, Wheeler W, Lieberman P, Meltzer EO, Tort MJ, Zilberberg MD, Jacobsen T, Tillotson G, Zilberberg MD, Jacobsen T, Tillotson G, McNamara TR, Macejko TT, Meier EJ, Bergmann MT, Williams JI, Gow JA. Research abstracts presented at the Eastern Allergy Conference, Palm Beach, Florida, May 6-9, 2010. Allergy Asthma Proc 2010; 31:361-362. [PMID: 29165186 DOI: 10.2500/108854110792379140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Eypasch E, Troidl H, Wood-Dauphinee S, Williams JI, Spangenberger W, Ure BM, Neugebauger E. Immediate improval in quality of life after laparoscopic cholecystectomy. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/13645709309152954] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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5
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Young N, McCormick A, Mills W, Barden W, Boydell K, Law M, Wedge J, Fehlings D, Mukherjee S, Rumney P, Williams JI. The transition study: a look at youth and adults with cerebral palsy, spina bifida and acquired brain injury. Phys Occup Ther Pediatr 2006; 26:25-45. [PMID: 17135068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
A group of 100 adults and 190 youth who have cerebral palsy (CP), spina bifida (SB), and acquired brain injuries from childhood (ABIc) participated in a multi-method study focused on the transition to adult health care. The results show that 95% of youth and 61% of adults were living with their parents; 23% of the youth and 55% of adults were employed; and 60% of youth and 42% of adults reported "excellent" or "very good" health. The lowest health scores were reported by adults with SB. These findings provide a starting point for examining health issues specific to youth and young adults with CP, SB, and ABIc.
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Affiliation(s)
- Nancy Young
- Laurentian University, The Hospital for Sick Children, Canada.
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6
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Davis AM, Badley EM, Beaton DE, Kopec J, Wright JG, Young NL, Williams JI. Rasch analysis of the Western Ontario McMaster (WOMAC) Osteoarthritis Index: results from community and arthroplasty samples. J Clin Epidemiol 2004; 56:1076-83. [PMID: 14614998 DOI: 10.1016/s0895-4356(03)00179-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE This study is based on secondary analysis of Western Ontario McMaster Osteoarthritis Index (WOMAC) data from a community sample over 55 years and total hip or knee arthroplasty samples presurgery and 1-year postoperative. METHODS The WOMAC data were evaluated by Rasch analysis. Data were considered to fit the Rasch mathematical model for the pain and physical dimensions of the WOMAC if unidimensionality was confirmed by principle component analysis of the subscale and the residuals from the Rasch analysis, infit and outfit statistics were in the range of 0.80 to 1.20; if there was no differential item functioning based on gender or hip vs. knee subjects; and, if there was stability of the item logits across the three data samples. RESULTS A three-item pain dimension (excluding night pain and pain on standing) and a 14-item physical dimension (excluding heavy domestic duties, getting in and out of the bath and getting on and off the toilet) fit the Rasch model based on these criteria. CONCLUSION In evaluating existing health status questionnaires using Rasch methodology, it is important to evaluate relevant patient samples and longitudinal data when the measure is intended to evaluate change in status. By these criteria, a modified WOMAC questionnaire fits the Rasch model and has interval-level scaling properties.
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Affiliation(s)
- A M Davis
- Department of Physical Therapy, Graduate Department of Rehabilitation Science and Health Policy, Management and Evaluation, Toronto Rehabilitation Institute and the University of Toronto, Toronto, ON, Canada.
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7
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Zasloff M, Williams JI, Chen Q, Anderson M, Maeder T, Holroyd K, Jones S, Kinney W, Cheshire K, McLane M. A spermine-coupled cholesterol metabolite from the shark with potent appetite suppressant and antidiabetic properties. Int J Obes (Lond) 2001; 25:689-97. [PMID: 11360152 DOI: 10.1038/sj.ijo.0801599] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2000] [Revised: 10/09/2000] [Accepted: 12/14/2000] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We describe the pharmacological properties of a novel spermine-cholesterol adduct, MSI 1436 (3beta-N-1(spermine)-7alpha, 24R-dihydroxy-5alpha-cholestane 24-sulfate), which causes reversible suppression of food and fluid intake in mammals resulting in profound weight loss, not associated with other signs or symptoms of illness, and which exhibits antidiabetic properties in genetically obese mice. METHODS Wild-type rodents and strains with genetic obesity were studied. Effects on food and fluid intake, body weight and composition were examined along with pharmacological and toxicological parameters. RESULTS MSI-1436 induces profound inhibition of food and fluid intake in rats and mice, resulting in significant weight loss. MSI-1436 is active when introduced directly into the third ventricle of the rat, suggesting the compound acts on central targets. Pair-feeding studies suggest that MSI-1436 causes weight loss by suppressing food intake. Fluid intake is also profoundly reduced but animals remain normally hydrated and defend both water and electrolyte balance from parenteral administration. MSI-1436 is active in ob/ob, db/db, agouti and MC4 receptor knockout mice. MSI-1436 has been administered to ob/ob mice over a 4 month period via a regimen that safely controls body weight, glucose homeostasis and serum cholesterol levels. Following MSI-1436 treatment, db/db mice preferentially mobilize adipose tissue and hyperglycemia is corrected. CONCLUSION A naturally occurring spermine metabolite of cholesterol, isolated from the dogfish shark, Squalus acanthias, has been identified that induces profound reduction in food and fluid intake in rodents in a setting where thirst is preserved and fluid and electrolyte homeostasis appears to be functioning normally. MSI-1436 probably acts on a central target involving neural circuits that lie downstream from the leptin and the MC4 receptors. Although long-term administration can be accomplished safely in mice, the utility of this compound as a potential human therapeutic awaits an analysis of its pharmacological properties in man.
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Affiliation(s)
- M Zasloff
- Magainin Pharmaceuticals, Plymouth Meeting, Pennsylvania 19462, USA.
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8
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Bhargava P, Marshall JL, Dahut W, Rizvi N, Trocky N, Williams JI, Hait H, Song S, Holroyd KJ, Hawkins MJ. A phase I and pharmacokinetic study of squalamine, a novel antiangiogenic agent, in patients with advanced cancers. Clin Cancer Res 2001; 7:3912-9. [PMID: 11751482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
PURPOSE A Phase I study of squalamine, a novel antiangiogenic agent originally isolated from the dogfish shark Squalus acanthias, was conducted in patients with advanced cancers to: (a) determine the maximum tolerated dose (MTD), dose-limiting toxicity (DLT) and pharmacokinetics of squalamine lactate when given as a 120-h continuous i.v. infusion every two weeks; and (b) to obtain information on prolonged (>120-h) continuous i.v. infusions in patients who have tolerated 120-h infusions. EXPERIMENTAL DESIGN A rapid dose escalation scheme was used that permitted intrapatient dose escalation. Three or more patients were treated at each dose, of which at least one patient started treatment de novo at that dose. Once DLT was encountered, the dose was decreased by one dose level, and the duration of infusion was prolonged from 10 up to 30 days in 5-day increments. RESULTS Nineteen patients were treated at eight squalamine dose levels; the number of patients/dose level who received 120-h infusions were [expressed as dose in mg/m(2)/day (number of patients initiated de novo at that dose/total number of patients treated at that dose)]: 6 (3/3), 12 (3/6), 24 (1/5), 48 (2/6), 96 (4/10), 192 (2/6), 384 (3/8), and 538 (1/5). DLT was encountered at 384 mg/m(2)/day (1/3 de novo patients, 5/8 total patients) and 538 mg/m(2)/day (1/1 de novo patients, 4/5 total patients) and consisted of hepatotoxicity, characterized by grade 3 transaminase elevations that resolved 3-11 days after ceasing squalamine infusion. Three patients did not experience hepatotoxicity when first treated at 384 mg/m(2)/day but developed DLT at the same dose when de-escalated from 538 mg/m(2)/day. Other toxicities included grade 1-3 fatigue, grade 1-2 nausea, anorexia, and neuromuscular symptoms. The maximum duration of continuous i.v. infusion was 20 days at a dose rate of 192 mg/m(2)/day in one patient without adverse effects. Pharmacokinetic calculations revealed a linear relationship between area under the curve or Cmax and squalamine dose rate up to 384 mg/m(2)/day, with a prolonged terminal squalamine persistence in patient plasma (median t(1/2) = 18 h; range, 8-48 h). Transient tumor responses were observed in a patient with synovial cell sarcoma and a patient with breast carcinoma with cutaneous metastases. CONCLUSIONS The best tolerated dose rate of squalamine when administered as a 120-h continuous i.v. infusion was 192 mg/m(2)/day; however, patients without prior exposure to squalamine appeared to tolerate a dose rate of 384 mg/m(2)/day without DLT. On the basis of preclinical evidence of synergy with cytotoxic agents and demonstration of human safety from this trial, additional clinical trials have been initiated with squalamine in combination with chemotherapy for patients with late stage lung cancer and ovarian cancer.
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Affiliation(s)
- P Bhargava
- Lombardi Cancer Center, Georgetown University Medical Center, Washington, DC 20007, USA.
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van Walraven C, Mamdani MM, Wells PS, Williams JI. Inhibition of serotonin reuptake by antidepressants and upper gastrointestinal bleeding in elderly patients: retrospective cohort study. BMJ 2001; 323:655-8. [PMID: 11566827 PMCID: PMC55923 DOI: 10.1136/bmj.323.7314.655] [Citation(s) in RCA: 171] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To determine the association between inhibition of serotonin reuptake by antidepressants and upper gastrointestinal bleeding. DESIGN Retrospective cohort study from population based databases. SETTING Ontario, Canada. PARTICIPANTS 317 824 elderly people observed for more than 130 000 person years. The patients started taking an antidepressant between 1992 and 1998 and were grouped by how much the drug inhibited serotonin reuptake. Patients were observed until they stopped the drug, had an upper gastrointestinal bleed, or died or the study ended. MAIN OUTCOME MEASURE Admission to hospital for acute upper gastrointestinal bleeding. RESULTS Overall, 974 bleeds were observed, with an overall bleeding rate of 7.3 per 1000 person years. After controlling for age or previous gastrointestinal bleeding, the risk of bleeding significantly increased by 10.7% and 9.8%, respectively, with increasing inhibition of serotonin reuptake. Absolute differences in bleeding between antidepressant groups were greatest for octogenarians (low inhibition of serotonin reuptake, 10.6 bleeds/1000 person years v high inhibition of serotonin reuptake, 14.7 bleeds/1000 person years; number needed to harm 244) and those with previous upper gastrointestinal bleeding (low, 28.6 bleeds/1000 person years v high, 40.3 bleeds/1000 person years; number needed to harm 85). CONCLUSIONS After age or previous upper gastrointestinal bleeding were controlled for, antidepressants with high inhibition of serotonin reuptake increased the risk of upper gastrointestinal bleeding. These increases are clinically important for elderly patients and those with previous gastrointestinal bleeding.
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Affiliation(s)
- C van Walraven
- Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, ON, Canada K1Y 4E9.
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Tudiver F, Brown JB, Medved W, Herbert C, Ritvo P, Guibert R, Haggerty J, Goel V, Smith P, O'Beirne M, Katz A, Moliner P, Ciampi A, Williams JI. Making decisions about cancer screening when the guidelines are unclear or conflicting. J Fam Pract 2001; 50:682-687. [PMID: 11509162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Our purpose was to determine the factors involved in the cancer screening decisions of family physicians in situations where the clinical practice guidelines are unclear or conflicting as opposed to when they are clear and uncontroversial. STUDY DESIGN We analyzed discussions with focus groups using a constant comparative approach. POPULATION A total of 73 family physicians in active practice participated in 10 focus groups (1 urban group and 1 rural group in each of 5 Canadian provinces). OUTCOME MEASURES Our main outcome measures were participants' perceptions regarding cancer screening when the guidelines were unclear or conflicting. RESULTS We propose a model of the determinants of cancer screening decision making with regard to unclear and conflicting guidelines. This model is rooted in the physician-patient relationship, and is an interactive process influenced by patient factors (anxiety, expectations, and family history) and physician factors (perception of guidelines, clinical practice experience, influence of colleagues, distinction between the screening styles of specialists and family physicians, and the amount of time and financial costs involved in performing the maneuver). CONCLUSIONS Our model is unique, because it is embedded in the physician-patient relationship. Ultimately, a modified model could be used to design interventions to assist with the implementation of preventive services guidelines.
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Affiliation(s)
- F Tudiver
- State University of New York Upstate Medical University, Suite 200, 475 Irving Ave, Syracuse, NY 13210, USA.
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Manuel DG, Goel V, Williams JI, Corey P. Health-adjusted life expectancy at the local level in ontario. Chronic Dis Can 2001; 21:73-80. [PMID: 11007658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Health expectancy measures are becoming a common method of combining information on mortality and health-related quality of life into one summary population health measure. However, health expectancy measures are infrequently measured at the local level, despite a shift toward health service planning to that level. Using a modified Sullivan method, we calculated health-adjusted life expectancy (HALE) for the 42 public health units in Ontario using life tables that were derived from mortality and population data for 1988-1992 and the Health Utilities Index from the 1990 Ontario Health Survey. There were large variations among health units in HALE at age 15 for both men (range: 51.3-58.2 years) and women (range: 56.6-62.9 years). Generally, rural and northern areas had the lowest HALE. Local differences in male HALE were greater than for life expectancy (7.1 versus 6.0 years). Despite a relatively large health survey (45,583 respondents, range: 729-1,746 per health unit), few HALE differences deviated significantly from the Ontario mean, raising concerns about the feasibility of estimating local health expectancy measures with adequate precision. Nevertheless, the wider local differences and different geographic distribution of local HALE compared with mortality measures, along with the additional benefit of being able to model the complex interaction of mortality and morbidity, suggest that HALE may be a useful population health measure.
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Affiliation(s)
- D G Manuel
- Department of Public Health Sciences, University of Toronto, Ontario, Canada.
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Abstract
BACKGROUND AND PURPOSE Several reports have linked chiropractic manipulation of the neck to dissection or occlusion of the vertebral artery. However, previous studies linking such strokes to neck manipulation consist primarily of uncontrolled case series. We designed a population-based nested case-control study to test the association. METHODS Hospitalization records were used to identify vertebrobasilar accidents (VBAs) in Ontario, Canada, during 1993-1998. Each of 582 cases was age and sex matched to 4 controls from the Ontario population with no history of stroke at the event date. Public health insurance billing records were used to document use of chiropractic services before the event date. RESULTS Results for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had >/=3 visits with a cervical diagnosis in the month before the case's VBA date (95% CI from bootstrapping, 1.34 to 18.57). No significant associations were found for those aged >/=45 years. CONCLUSIONS While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment. Because of the popularity of spinal manipulation, high-quality research on both its risks and benefits is recommended.
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Affiliation(s)
- D M Rothwell
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto,Ontario, Canada
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Williams JI, Weitman S, Gonzalez CM, Jundt CH, Marty J, Stringer SD, Holroyd KJ, Mclane MP, Chen Q, Zasloff M, Von Hoff DD. Squalamine treatment of human tumors in nu/nu mice enhances platinum-based chemotherapies. Clin Cancer Res 2001; 7:724-33. [PMID: 11297269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Squalamine, an antiangiogenic aminosterol, is presently undergoing Phase II clinical trials in cancer patients. To broaden our understanding of the clinical potential for squalamine, this agent was evaluated in nu/nu mouse xenograft models using the chemoresistant MV-522 human non-small cell lung carcinoma and the SD human neuroblastoma lines. Squalamine was studied alone and in combination with either cisplatin or paclitaxel plus carboplatin. Squalamine alone produced a modest MV-522 tumor growth inhibition (TGI) and yielded a TGI with cisplatin that was better than cisplatin alone. Squalamine also significantly enhanced the activity of paclitaxel/carboplatin combination therapy in the MV-522 tumor model. Squalamine similarly improved the effectiveness of cisplatin in producing TGI when screened against the SD human neuroblastoma xenograft. Xenograft tumor shrinkage was seen for the MV-522 tumor in combination treatments including squalamine, whereas no tumor shrinkage was seen when squalamine was omitted from the treatment regimen. To gain a greater understanding of the mechanism by which squalamine inhibited tumor growth in the xenograft studies, in vitro experiments were carried out with vascular endothelial growth factor-stimulated human umbilical vein endothelial cells in culture exposed to squalamine. Squalamine treatment was found to retard two cellular events necessary for angiogenesis, inducing disorganization of F-actin stress fibers and causing a concomitant reduction of detectable cell the surface molecular endothelial cadherin (VE-cadherin). We propose that the augmentation by squalamine of cytotoxicity from platinum-based therapies is attributable to interference by squalamine with the ability of stimuli to promote endothelial cell movement and cell-cell communication necessary for growth of new blood vessels in xenografts after chemotherapeutic injury to the tumor.
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Affiliation(s)
- J I Williams
- Magainin Pharmaceuticals Inc., Plymouth Meeting, Pennsylvania 19462, USA.
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Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier R, Wilkins A, Badley EM. Determining the need for hip and knee arthroplasty: the role of clinical severity and patients' preferences. Med Care 2001; 39:206-16. [PMID: 11242316 DOI: 10.1097/00005650-200103000-00002] [Citation(s) in RCA: 216] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Area variation in the use of surgical interventions such as arthroplasty is viewed as concerning and inappropriate. OBJECTIVES To determine whether area arthroplasty rates reflect patient-related demand factors, we estimated the need for and the willingness to undergo arthroplasty in a high- and a low-use area of Ontario, Canada. RESEARCH DESIGN Population-based mail and telephone survey. SUBJECTS All adults aged > or =55 years in a high (n = 21,925) and low (n = 26,293) arthroplasty use area. MEASURES We determined arthritis severity and comorbidity with questionnaires, established the presence of arthritis with examination and radiographs, and evaluated willingness to have arthroplasty with interviews. Potential arthroplasty need was defined as severe arthritis, no absolute contraindication for surgery, and evidence of arthritis on examination and radiographs. Estimates of need were then adjusted for patients' willingness to undergo arthroplasty. RESULTS Response rates were 72.0% for questionnaires and interviews. The potential need for arthroplasty was 36.3/1,000 respondents in the high-rate area compared with 28.5/1,000 in the low-rate area (P <0.0001). Among individuals with potential need, only 14.9% in the high-rate area and 8.5% in the low-rate area were definitely willing to undergo arthroplasty (P = 0.03), yielding adjusted estimates of need of 5.4/1,000 and 2.4/1,000 in the high- and low-rate areas, respectively. CONCLUSIONS Demonstrable need and willingness were greater in the high-rate area, suggesting these factors explain in part the observed geographic rate variations for this procedure. Among those with severe arthritis, no more than 15% were definitely willing to undergo arthroplasty, emphasizing the importance of considering both patients' preferences and surgical indications when evaluating need and appropriateness of rates for surgery.
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MESH Headings
- Activities of Daily Living
- Aged
- Arthroplasty, Replacement/psychology
- Arthroplasty, Replacement/statistics & numerical data
- Choice Behavior
- Community Health Planning
- Female
- Geriatric Assessment
- Health Care Surveys
- Humans
- Male
- Middle Aged
- Needs Assessment/organization & administration
- Ontario/epidemiology
- Osteoarthritis, Hip/classification
- Osteoarthritis, Hip/epidemiology
- Osteoarthritis, Hip/psychology
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Knee/classification
- Osteoarthritis, Knee/epidemiology
- Osteoarthritis, Knee/psychology
- Osteoarthritis, Knee/surgery
- Patient Satisfaction
- Practice Patterns, Physicians'/statistics & numerical data
- Sensitivity and Specificity
- Severity of Illness Index
- Socioeconomic Factors
- Surveys and Questionnaires
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Affiliation(s)
- G A Hawker
- Faculty of Medicine, University of Toronto, Ontario, Canada.
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Kopec JA, Williams JI, To T, Austin PC. Measuring population health: correlates of the Health Utilities Index among English and French Canadians. Can J Public Health 2001. [PMID: 11200741 DOI: 10.1007/bf03404831] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study used cross-sectional data from the 1994/95 National Population Health Survey (NPHS) in Canada. The objective of the study was to examine the relationship between several established correlates of health status in the general population and the Health Utilities Index (HUI), a multi-dimensional, preference-based measure of health status. Analyses were carried out separately for the English-speaking (n = 9,853) and French-speaking (n = 1,519) respondents. The index correlated strongly with self-ratings of health status and functional disability and varied as expected according to age, sex, and income. Subjects classified to different categories of chronic conditions reported different levels of health, as predicted. The HUI was also associated with the use of drugs and recent history of hospitalization. No major differences in the findings were observed between the two cultural groups. The results should be treated with caution due to the cross-sectional design and other methodological limitations of the study.
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Affiliation(s)
- J A Kopec
- Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC.
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Lewis SJ, Kouri D, Estabrooks CA, Dickinson H, Dutchak JJ, Williams JI, Mustard C, Hurley J. Devolution to democratic health authorities in Saskatchewan: an interim report. CMAJ 2001; 164:343-7. [PMID: 11232134 PMCID: PMC80727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND In 1995 Saskatchewan adopted a district health board structure in which two-thirds of members are elected and the rest are appointed. This study examines the opinions of board members about health care reform and devolution of authority from the province to the health districts. METHODS All 357 members of Saskatchewan district health boards were surveyed in 1997; 275 (77%) responded. Analyses included comparisons between elected and appointed members and between members with experience as health care providers and those without such experience, as well as comparisons with hypotheses about how devolution would develop, which were advanced in a 1997 report by another group. RESULTS Most respondents felt that devolution had resulted in increased local control and better quality of decisions. Ninety-two percent of respondents believed extensive reforms were necessary and 83% that changes made in the previous 5 years had been for the best. However, 56% agreed that there was no clear vision of the reformed system. A small majority (59%) perceived health care reform as having been designed to improve health rather than reduce spending, contrary to a previous hypothesis. Many respondents (76%) thought that boards were legally responsible for things over which they had insufficient control, and 63% perceived that they were too restricted by rules laid down by the provincial government, findings that confirm the expectation of tensions surrounding the division of authority. Respondents with current or former experience as health care providers were less likely than nonprovider respondents to believe that nonphysician health care providers support decisions made by the regional health boards (45% v. 63%, p = 0.02), a result that confirmed the contention that the role of health care providers on the boards would be a source of tension. INTERPRETATION Members of Saskatchewan district health boards supported the general goals of health care reform and believed that changes already undertaken had been positive. There were few major differences in views between appointed and elected members and between provider and nonprovider members. However, tensions related to authority and representation will require resolution.
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Affiliation(s)
- S J Lewis
- HEALNet Regionalization Research Centre, Saskatoon, Sask
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Abstract
OBJECTIVE The purpose of this study was to examine the differences in health status, as measured by the Health Utilities Index (HUI), among seven cultural groups in Canada defined by place of birth and language. DESIGN The study analysed cross-sectional data from the National Population Health Survey conducted by Statistics Canada in 1994-95. RESULTS Age-standardized prevalence of dysfunction, defined as HUI < 0.83, varied from 12.7% in English-speaking immigrants to 17.8% in French-speaking Canadians. Considerable differences between the groups were found in the reporting of pain, emotional function, and cognitive function. The variation in HUI scores across the cultural groups could not be explained by differences in socioeconomic status and self-reported chronic conditions. CONCLUSIONS Although the healthy immigrant effect is probably responsible for some of the variation in health status among cultural groups in Canada, considerable differences exist within the immigrant and Canadian-born populations. Cultural factors may have a substantial effect on the reporting of pain and mental health problems. Further studies are needed to determine the cross-cultural validity of the HUI.
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Affiliation(s)
- J A Kopec
- Department of Health Care and Epidemiology, University of British Columbia and Arthritis Research Centre of Canada, Vancouver, BC, Canada.
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Craig DM, Wade KE, Allison KR, Irving HM, Williams JI, Hlibka CM. Factors predictive of adolescents' intentions to use birth control pills, condoms, and birth control pills in combination with condoms. Can J Public Health 2000. [PMID: 11089290 DOI: 10.1007/bf03404808] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Using the Theory of Planned Behaviour (Ajzen, 1988) as a conceptual framework, 705 secondary school students were surveyed to identify their intentions to use birth control pills, condoms, and birth control pills in combination with condoms. Hierarchical multiple regression revealed that the theory explained between 23.5% and 45.8% of the variance in intentions. Variables external to the model such as past use, age, and ethnicity exhibited some independent effects. Attitudes were consistently predictive of intentions to use condoms, pills, and condoms in combination with pills for both male and female students. However, there were differences by gender in the degree to which subjective norms and perceived behavioural control predicted intentions. The findings suggest that programs should focus on: creation of positive attitudes regarding birth control pills and condoms; targeting important social influences, particularly regarding males' use of condoms; and developing strategies to increase students' control over the use of condoms.
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Affiliation(s)
- D M Craig
- Faculty of Nursing, University of Toronto, ON.
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Kinney WA, Zhang X, Williams JI, Johnston S, Michalak RS, Deshpande M, Dostal L, Rosazza JP. A short formal synthesis of squalamine from a microbial metabolite. Org Lett 2000; 2:2921-2. [PMID: 10986072 DOI: 10.1021/ol0059495] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A short formal synthesis of squalamine is described, utilizing the biotransformation product 2, which is available in one step from commercially available 3-keto-23,24-bisnorchol-4-en-22-ol (1). Regioselective C-22 oxidation and C-24 sulfation of the corresponding alcohols in the presence of a free C-7 alcohol make for an efficient preparation of squalamine intermediate 11.
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Affiliation(s)
- W A Kinney
- Magainin Pharmaceuticals Inc., 5110 Campus Drive, Plymouth Meeting, Pennsylvania 19462, USA.
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21
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Craig DM, Wade KE, Allison KR, Irving HM, Williams JI, Hlibka CM. Factors predictive of adolescents' intentions to use birth control pills, condoms, and birth control pills in combination with condoms. Can J Public Health 2000; 91:361-5. [PMID: 11089290 PMCID: PMC6979616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/26/1999] [Accepted: 03/06/2000] [Indexed: 02/18/2023]
Abstract
Using the Theory of Planned Behaviour (Ajzen, 1988) as a conceptual framework, 705 secondary school students were surveyed to identify their intentions to use birth control pills, condoms, and birth control pills in combination with condoms. Hierarchical multiple regression revealed that the theory explained between 23.5% and 45.8% of the variance in intentions. Variables external to the model such as past use, age, and ethnicity exhibited some independent effects. Attitudes were consistently predictive of intentions to use condoms, pills, and condoms in combination with pills for both male and female students. However, there were differences by gender in the degree to which subjective norms and perceived behavioural control predicted intentions. The findings suggest that programs should focus on: creation of positive attitudes regarding birth control pills and condoms; targeting important social influences, particularly regarding males' use of condoms; and developing strategies to increase students' control over the use of condoms.
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Affiliation(s)
- D M Craig
- Faculty of Nursing, University of Toronto, ON.
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22
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Higgins RD, Sanders RJ, Yan Y, Zasloff M, Williams JI. Squalamine improves retinal neovascularization. Invest Ophthalmol Vis Sci 2000; 41:1507-12. [PMID: 10798670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
PURPOSE Modalities for inhibiting neovascularization may be one avenue to the development of effective therapies for retinopathy. The effect of squalamine, an antiangiogenic amino sterol, on oxygen-induced retinopathy (OIR) was assessed in a mouse model. METHODS OIR was induced in C57BL6 mice by a 5-day exposure to 75% oxygen from postnatal day (P)7 through P12. Squalamine (25 mg/kg, subcutaneous)treated animals received either daily doses for five days from P12 to P16 or one dose just after removal from oxygen on P12. Each set of animals was killed at P17 to P21. Retinopathy was assessed with a retinopathy scoring system evaluation of retinal wholemounts and by quantification of neovascular nuclei on retinal sections. RESULTS Animals receiving 5 days of squalamine after a 5-day exposure to oxygen had total retinopathy scores (expressed as median score with 25th and 75th quartiles in parentheses) of 4(3, 5) versus oxygen-only-reared animals with scores of 8(7, 9; P < 0.001). Animals reared in room air and animals exposed to squalamine only had similar retinopathy scores: 1(1, 2) and 1(0, 2). Oxygen-reared animals receiving single-dose squalamine also showed improvement, with a median retinopathy score of 4(4, 6.75) versus oxygen-only-reared animals with median retinopathy score of 9(7, 10; P < 0.001). There was a decreased number of neovascular nuclei extending beyond the inner limiting membrane on retinal sections in animals treated with 5 days (P < 0.01) and 1 day (P < 0.001) of squalamine. CONCLUSIONS Squalamine significantly improved retinopathy and may be a novel agent for effective treatment of ocular neovascularization.
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Affiliation(s)
- R D Higgins
- Department of Pediatrics, Georgetown University Medical Center, Washington, DC 20007, USA.
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Abstract
BACKGROUND Previous studies suggest that, for some conditions, women receive fewer health care interventions than men. We estimated the potential need for arthroplasty and the willingness to undergo the procedure in both men and women and examined whether there were differences between the sexes. METHODS All 48,218 persons 55 years of age or older in two areas of Ontario, Canada, were surveyed by mail and telephone to identify those with hip or knee problems. In these subjects, we assessed the severity of arthritis and the presence of coexisting conditions by questionnaire, documented arthritis by examination and radiography, and conducted interviews to evaluate the subjects' willingness to undergo arthroplasty. The potential need for arthroplasty was defined by the presence of severe symptoms and disability, the absence of any absolute contraindications to surgery, and clinical and radiographic evidence of arthritis. The estimates of need were then adjusted for the subjects' willingness to undergo arthroplasty. RESULTS The overall response rates were at least 72 percent for the questionnaires and interviews. As compared with men, women had a higher prevalence of arthritis of the hip or knee (age-adjusted odds ratio, 1.76; P<0.001) and had worse symptoms and greater disability, but women were less likely to have undergone arthroplasty (adjusted odds ratio, 0.78; P<0.001). Despite their equal willingness to have the surgery, fewer women than men had discussed the possibility of arthroplasty with a physician (adjusted odds ratio, 0.63). The numbers of people with a potential need for hip or knee arthroplasty were 44.9 per 1000 among women and 20.8 per 1000 among men. After adjustment for willingness to undergo the procedure, the numbers were 5.3 per 1000 for women and 1.6 per 1000 for men. CONCLUSIONS There is underuse of arthroplasty for severe arthritis in both sexes, but the degree of underuse is more than three times as great in women as in men.
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Affiliation(s)
- G A Hawker
- Department of Medicine, Faculty of Medicine, University of Toronto, and Women's College Hospital Campus, Sunnybrook and Women's College Health Sciences Centre, ON, Canada.
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Affiliation(s)
- M M Mamdani
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Abstract
The Activities Scale for Kids (ASK) is a self-report measure of childhood physical disability, that has excellent reliability (ICC = 0.97). The purpose of this study was to assess further the ASK's measurement properties. ASK questionnaires were completed by 200 children with musculoskeletal limitations (mean age, 10.1 years). Rasch analyses confirmed that all items measured the same construct and supported aggregation of a summary score. Validity of the ASK was demonstrated by a correlation of 0.81 (P<0.0001) with parent-reported Childhood Health Assessment Questionnaire scores; a significant difference in scores according to clinicians' global ratings of disability (P<0.0001), and a correlation of 0.92 (P<0.0001) with clinician-observation. The ASK showed minimal ceiling effects, no floor effects, and changed by 1.73 standard deviation units after clinically important change. The ASK is a valid and responsive outcome measure that permits 5- to 15-year-old children physical functioning in the community to be assessed accurately by mail. The quality of this measure will enable clinical studies to measure outcome not only in a way that is relevant to patients, but also in a way that is sensitive to small amounts of change and is practical and inexpensive.
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Affiliation(s)
- N L Young
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
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26
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Williams JI. Ready, set, stop: reflections on assessing quality of life and the WHOQOL-100 (U.S. version). World Health Organization Quality of Life. J Clin Epidemiol 2000; 53:13-7. [PMID: 10693898 DOI: 10.1016/s0895-4356(99)00122-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- J I Williams
- Institute of Clinical Evaluative Sciences, University of Toronto, Department of Family & Community Medicine, Ontario, Canada.
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Affiliation(s)
- J I Williams
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Kreder HJ, Williams JI, Jaglal S, Axcell T, Stephen D. A population study in the Province of Ontario of the complications after conversion of hip or knee arthrodesis to total joint replacement. Can J Surg 1999; 42:433-9. [PMID: 10593244 PMCID: PMC3795135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
OBJECTIVE To evaluate the complication rates after conversion of hip and knee fusions to total joint replacements in the Province of Ontario. DESIGN A retrospective cohort study. PATIENTS Those who had undergone an elective conversion of a hip or knee fusion to a total joint replacement during fiscal year 1993 through 1996, as captured in the Canadian Institute for Health Information and Ontario Health Insurance Plan databases. OUTCOME MEASURES Inhospital complications and length of initial hospital stay, revision, infection, amputation and repeat fusion rates within 4 years. RESULTS Conversion of hip and knee fusion to total joint arthroplasty was generally performed by high-volume surgeons in high-volume hospital settings. Forty hip and 18 knee replacements involved conversion of a previous fusion. Conversion of a hip fusion was associated with a 10% infection rate, a 10% revision rate and a 5% resection arthroplasty rate due to infection within 4 years of the conversion. Conversion of a knee fusion was associated with an 11% infection rate, and a more than 5% revision rate at 4 years. Over 16% of patients who underwent conversion of a knee fusion required removal of the components (for various reasons) within the first 4 years. CONCLUSIONS There is a high rate of complications after conversion of a hip or knee fusion to a total joint arthroplasty. These issues must be carefully considered and discussed with the patient before any conversion procedure.
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Affiliation(s)
- H J Kreder
- Institute for Clinical Evaluative Sciences, Toronto.
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29
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Borgiel AE, Williams JI, Davis DA, Dunn EV, Hobbs N, Hutchison B, Wilson CR, Jensen J, O'Neil JJ, Bass MJ. Evaluating the effectiveness of 2 educational interventions in family practice. CMAJ 1999; 161:965-70. [PMID: 10551192 PMCID: PMC1230705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Structured feedback of information can produce change in physician behaviour. The objective of this study was to assess the effectiveness of 2 educational interventions for improving the quality of care provided by family physicians in Ontario: the Practice Assessment Report (PAR) and the Continuing Medical Education Plan (CMEP) with a follow-up visit by a mentor. METHODS The study was a randomized controlled trial. Physicians in the control group received only the PAR, whereas those in the experimental group received the PAR, CMEP and mentor interventions. The participants were 56 family physicians and general practitioners (27 in the PAR group and 29 in the CMEP group) in southern Ontario who agreed to participate in the interventions and provide data. A total of 2395 patients randomly sampled from the practices returned questionnaires and consented to have their medical records abstracted. The outcome measures were global scores in 4 areas--quality of care, charting, prevention and overall use of medications--and patient ratings of satisfaction with care and preventive practices. The measures were applied at the beginning (phase 1) and end (phase 2) of the study. RESULTS The mean global scores at the end of the study for the PAR group were 70.1% for quality of care, 84.7% for prevention, 77.7% for charting and 82.2% for overall use of medications. The corresponding scores for the CMEP group were 68.3%, 82.1%, 76.4% and 83.2%. In the patient satisfaction component, the personal care scores at phase 2 were 93.6% for the PAR group and 94.6% for the CMEP group. Examples of the scores for prevention for the PAR group were 98.3% for children's current immunization, 96.6% for blood pressure measured within the previous 5 years, 79.4% for referral of women of the appropriate age for mammography within the previous 2 years, and 58.4% for discussion about alcohol use. The corresponding scores for the CMEP group were 95.8%, 97.6%, 77.6% and 64.6%. The changes in mean scores between phase 1 and phase 2 ranged from -1.9 to 2.3 points. There were no significant differences between the 2 groups in phase 1 or phase 2 scores or in change in scores. A total of 64.3% of the physicians rated the PAR as useful, 26.5% found the CMEP to be useful, and 41.0% considered the mentor strategy to be a useful form of continuing medical education. Although changes in practice related to the PAR, CMEP or mentor were reported by some physicians, they were not related to chart audit or patient scores. INTERPRETATION Educational interventions based on quality-of-care assessments and directed to global improvements in quality of care did not result in improvements in the outcome measures. Educational interventions may have to be targeted to specific areas of the practice, with physicians being monitored and receiving ongoing feedback on their performance.
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Affiliation(s)
- A E Borgiel
- Institute for Clinical Evaluative Sciences, Toronto, Ont
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Schachter D, Kleinman I, Williams JI. Informed consent for antipsychotic medication. Can Fam Physician 1999; 45:1502-8. [PMID: 10386214 PMCID: PMC2328455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
OBJECTIVE To determine family physicians' attitudes and practices regarding documentation of informed consent for antipsychotic medication. DESIGN Pilot cross-sectional study. SETTING Teaching and non-teaching hospitals in Toronto, Ont. PARTICIPANTS Thirty family physicians were selected in equal numbers from teaching and non-teaching hospitals with no more than five physicians from a given hospital. Participants were treating at least 10 patients with antipsychotic medication. Participants' mean age was 44.3 years; 83% were men. MAIN OUTCOME MEASURES Documentation of consent and of disclosure of consent for antipsychotic medication in patients' charts. RESULTS Documentation was found in only 13% of charts. Whether it was there or not did not correlate with information disclosed, score on an attitude scale, or demographics. Physicians who found documentation time-consuming were less likely to document. Most physicians disclosed reasons for antipsychotic medication, but less than half described tardive dyskinesia, a potentially irreversible movement disorder that affects about 25% of patients on long-term treatment. CONCLUSIONS The low rate of documentation observed in this sample was consistent with reports of similar samples and might indicate that family physicians are unaware of recommendations for documentation or simply do not have time to keep abreast of current recommendations. Many physicians thought signed consent forms unnecessary for psychotic patients, and even more believed seeking consent for antipsychotic medications would increase patient anxiety.
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Affiliation(s)
- D Schachter
- Department of Psychiatry, University of Toronto, Ont.
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31
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Williams JI. The unanswered challenges in measuring quality of life. 1998. Can J Nurs Res 1999; 30:295-8. [PMID: 10603801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
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Abstract
BACKGROUND AND PURPOSE As survival following stroke improves, individuals are more likely to live with the aftermath of stroke rather than immediately die from it. The purpose of this study was to examine the consequences of stroke on the life activities of survivors in the social realm (stroke handicap) using the framework of the World Health Organization's International Classification of Impairments, Disabilities and Handicaps. METHODS Multivariate analysis of variance was applied to cross-sectional data from a clinical study to investigate the correlates of handicap in a cohort of hemispheric stroke survivors at 3 months (n = 145) and at 1 year (n = 135) after stroke onset. Handicap was assessed with the Reintegration to Normal Living Index, impairment by the Adams' Hemispheric Stroke Scale and Zung Depression Scale, and disability by the Functional Independence Measure. Environmental variables in the model included marital status and receipt of rehabilitation therapy. RESULTS Physical disability and post-stroke depressive symptoms were associated with handicap at both follow-up periods (p < 0.05). Cognitive disability and impairments from a previous stroke were also associated with handicap (p < 0.01), but only at 1 year. The presence of a spouse was found to benefit male survivors at 1 year. CONCLUSIONS Disability and depressive symptoms restrict the meaningful life activities of stroke survivors in the first year of recovery. Social supports may be influential in reducing their impact.
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Affiliation(s)
- P J Clarke
- Graduate Department of Community Health, and Institute for Human Development, Life Course and Aging, University of Toronto, Ontario, Canada.
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Bunting PS, Goel V, Williams JI, Iscoe NA. Prostate-specific antigen testing in Ontario: reasons for testing patients without diagnosed prostate cancer. CMAJ 1999; 160:70-5. [PMID: 9934349 PMCID: PMC1229953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND The use of the prostate-specific antigen (PSA) test has been increasing rapidly in Canada since its introduction in 1988. The reasons for using the PSA test in patients without known prostate cancer are unclear. This paper reports on the first study in Canada to use physician records to assess the use of PSA testing. METHODS A questionnaire was mailed to physicians attending 475 patients without diagnosed prostate cancer. The patients were randomly selected from 2 laboratory databases of PSA test records in the greater Toronto area during 1995. The physicians were asked to consult their patient records to avoid recall bias. Information obtained included physician's specialty, patient's age at time of PSA test and reason(s) for the test. RESULTS There were 264 responses (56%), of which 240 (91%) were usable. Of these 240, 63% (95% confidence interval [Cl] 58%-70%) indicated that the test was conducted to screen for prostate cancer, 40% (95% Cl 34%-47%) said it was to investigate urinary symptoms, and 33% (95% Cl 27%-40%) responded that it was a follow-up to a medical procedure or drug therapy. More than one reason was permitted. Of 151 responses indicating screening as one reason for testing, 64% (95% Cl 56%-72%) stated that it was initiated by the patient, and 73% (95% Cl 65%-80%) stated that it was part of a routine examination. For 19%, both investigation of symptoms and screening asymptomatic patients were given as reasons for testing, and for another 19% both follow-up of a medical procedure and screening were given as reasons. Screening was recorded as a reason for testing far more commonly for patients seen by family physicians and general practitioners than for patients seen by urologists (67% v. 29%, p < 0.001). In contrast, the use of PSA testing to diagnose urinary symptoms was more common for patients seen by urologists than for those seen by family physicians and general practitioners (52% v. 37%, p = 0.044). No significant difference was found between physician groups in the use of PSA testing as a follow-up of a medical procedure (42% for urologists and 31% for family physicians and general practitioners). About 24% of the PSA test records were for patients younger than 50 and older than 70 years. PSA testing initiated by patients was more common in the practices of family physicians and general practitioners than in the practices of urologists (44% v. 13%, p < 0.001). INTERPRETATION Screening for prostate cancer was the most common reason for PSA testing in our study group; it occurred most commonly in the family and general practice setting and was usually initiated by the patient. Differences in reasons for testing were identified by practice specialty. Although PSA screening for prostate cancer is sometimes recommended for men between 50 and 70 years of age, it is being conducted in men outside this age group.
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Affiliation(s)
- P S Bunting
- Department of Laboratory Medicine, Sunnybrook and Women's College Health Sciences Centre, Ont.
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Kuchler T, Henne-Bruns D, Rappat S, Graul J, Holst K, Williams JI, Wood-Dauphinee S. Impact of psychotherapeutic support on gastrointestinal cancer patients undergoing surgery: survival results of a trial. Hepatogastroenterology 1999; 46:322-35. [PMID: 10228816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
BACKGROUND/AIMS The impact of psychotherapeutic support on survival time in patients with gastrointestinal cancer undergoing surgery was studied. METHODOLOGY A randomized controlled trial was conducted in cooperation with the Departments of General Surgery and Medical Psychology, University Hospital of Hamburg, Germany. Two hundred and seventy-one consenting patients with a preliminary diagnosis of cancer of the esophagus, stomach, liver/gallbladder, pancreas or colon/rectum were stratified by gender and randomly assigned to a control group that received standard care, as provided on the surgical wards, or to an experimental group that received formal psychotherapeutic support in addition to routine care during the hospital stay. Patients in both groups completed the EORTC-Quality of Life questionnaire pre-operatively, post-operatively, and at 3, 6, 12, and 24 months following surgery. Date of death, if applicable, was also recorded. Unadjusted and adjusted survival analyses were performed. RESULTS Kaplan-Meier survival curves demonstrated better survival for the experimental group than for the control group. The unadjusted significance level for group differences was p = 0.002 for survival up to 2 years. Cox regression models that took TNM Staging or the Residual Tumor Classification into account also found significant differences at the 2-year follow-up. Secondary analyses found that most of the differences in favor of the experimental group occurred in females and in patients with stomach, pancreatic, primary liver or colorectal cancer. CONCLUSIONS The results of this study indicate that patients with gastrointestinal cancer, particularly those who are female and those who undergo surgery for stomach, pancreatic, primary liver or colorectal cancer, benefit from a formal program of psychotherapeutic support in terms of survival.
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Affiliation(s)
- T Kuchler
- Klinik fur Allgemeine und Thoraxchirurgie, Christian-Albrechts-Universitat, Kiel, Germany
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Manuel DG, Goel V, Williams JI. Life expectancy at birth at the local level in Ontario. Can J Public Health 1999; 90:52-4. [PMID: 10910567 PMCID: PMC6979687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- D G Manuel
- Community Medicine Residency Program, University of Toronto, ON
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Kreder HJ, Williams JI, Jaglal S, Hu R, Axcell T, Stephen D. Are complication rates for elective primary total hip arthroplasty in Ontario related to surgeon and hospital volumes? A preliminary investigation. Can J Surg 1998; 41:431-7. [PMID: 9854532 PMCID: PMC3949798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
OBJECTIVE To test the hypothesis that complication rates for elective total hip replacement operations are related to surgeon and hospital volumes. DESIGN Retrospective population cohort study. STUDY COHORT: Patients who had undergone elective total hip replacement in Ontario during 1992 as captured in the Canadian Institute for Health Information database. MAIN OUTCOME MEASURES In-hospital complications, 1- and 3-year revision rates, 1- and 3-year infection rates, length of hospital stay, and 3-month and 1-year death rates. RESULTS Surgeons with patient volumes above the 80th percentile (more than 27 hip replacements annually) discharged patients approximately 2.4 days earlier (p < 0.05) than surgeons with volumes below the 40th percentile (less than 9 hip replacements annually) even after adjusting for discharge disposition, hospital volume, patient age, sex, comorbidity and diagnosis. Complication rates requiring hospital readmission and death rates did not differ by surgeon or hospital volume (p > 0.05). CONCLUSIONS There is no evidence to support regionalization of elective hip replacement surgery in Ontario based on adverse clinical outcomes. Surgeons who perform a large number of total hip replacements are discharging patients earlier than less experienced surgeons, without any-demonstrable increase in complications leading to hospital readmission. The explanation for this observation remains unknown and will require further study.
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Affiliation(s)
- H J Kreder
- Division of Orthopedic Surgery, University of Toronto, Sunnybrook and Women's College Health Sciences Centre, Ont.
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Williams JI. Time, space, and motion: the unanswered challenges in measuring quality of life. Can J Nurs Res 1998; 30:119-24. [PMID: 9807291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Affiliation(s)
- J I Williams
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
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Cheung CM, Paterson JM, Gort EH, Williams JI. Ontario hospitals' purchasing practices for hip and knee prostheses: a survey. Can J Surg 1998; 41:309-15. [PMID: 9711165 PMCID: PMC3950087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES To determine the makes, models and prices of the implants provided by Ontario hospitals for hip and knee replacements and the policies and procedures governing purchases. DESIGN A questionnaire survey of hospitals with telephone follow-up. STUDY POPULATION Seventy-nine public hospitals in Ontario in which 10 or more hip or knee replacements were carried out in the fiscal year 1993/94. SURVEY RESPONSE: Seventy-six hospitals returned questionnaires (96% response rate), reporting on 4950 primary hip and 5107 primary knee implants. Sixty-two hospitals reported volumes and prices for 19 models used in 2961 hip implants. Information on price but not makes and models was available for 1989 hip implants. Model and price information was missing for 340 hip prostheses. Fifty-seven hospitals identified the models and prices for 3460 knee implants. Twenty-five hospitals provided prices but not specific models names for 1647 knee implants and hybrids. OUTCOME MEASURE The prices paid for prostheses. RESULTS The average price of hip implants was Can$2141 (range from Can$650 to Can$3559). The average price for knee implants was Can$2412 (range from Can$1178 to Can$3777). The averages and ranges were about the same for specified and unspecified models and hybrids. The variations were unrelated to hospital policies about the numbers of procedures to be provided or the procedures for making purchases from suppliers. CONCLUSIONS Savings of Can$13.7 million could have been made in Ontario during the fiscal year 1993/94 had the lowest prices been paid for the implants. Although it may be neither desirable nor possible to use the least expensive model and price in every hospital, the potential for cost reductions in the purchase of implants is substantial.
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Affiliation(s)
- C M Cheung
- Department of Medicine, Sunnybrook Health Science Centre, University of Toronto, Ontario.
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Manuel DG, Goel V, Williams JI. The derivation of life tables for local areas. Chronic Dis Can 1998; 19:52-6. [PMID: 9664025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Life tables are seldom derived at the local level, despite a shift toward health service planning to that level. We calculated life tables by sex for the 42 public health units in Ontario, using 1988 1992 mortality files. Traditional methods of life table construction were compared and validated. Data quality, particularly geographical coding of death certificates, poses the greatest difficulty in deriving accurate life tables for comparison between areas. Migration will affect estimates, but it is best considered during the interpretation of results. Except for the final age interval, methods of modelling life tables have little impact on final life expectancy estimates. It is feasible to calculate local level life tables with data and tools that are readily available. The results highlight the importance of examining such life tables, as variations within a province in life expectancy at birth may be as important as the differences between provinces.
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Affiliation(s)
- D G Manuel
- Community Medicine Residency Program, University of Toronto, Ontario, K1A 0L2, Canada
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Sills AK, Williams JI, Tyler BM, Epstein DS, Sipos EP, Davis JD, McLane MP, Pitchford S, Cheshire K, Gannon FH, Kinney WA, Chao TL, Donowitz M, Laterra J, Zasloff M, Brem H. Squalamine inhibits angiogenesis and solid tumor growth in vivo and perturbs embryonic vasculature. Cancer Res 1998; 58:2784-92. [PMID: 9661892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The novel aminosterol, squalamine, inhibits angiogenesis and tumor growth in multiple animal models. This effect is mediated, at least in part, by blocking mitogen-induced proliferation and migration of endothelial cells, thus preventing neovascularization of the tumor. Squalamine has no observable effect on unstimulated endothelial cells, is not directly cytotoxic to tumor cells, does not alter mitogen production by tumor cells, and has no obvious effects on the growth of newborn vertebrates. Squalamine was also found to have remarkable effects on the primitive vascular bed of the chick chorioallantoic membrane, which has striking similarities to tumor capillaries. Squalamine may thus be well suited for treatment of tumors and other diseases characterized by neovascularization in humans.
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Affiliation(s)
- A K Sills
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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41
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Teicher BA, Williams JI, Takeuchi H, Ara G, Herbst RS, Buxton D. Potential of the aminosterol, squalamine in combination therapy in the rat 13,762 mammary carcinoma and the murine Lewis lung carcinoma. Anticancer Res 1998; 18:2567-73. [PMID: 9703911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Squalamine, a naturally-occurring aminosterol, has demonstrated antiangiogenic activity in several experimental models. Extended treatment with other antiangiogenic agents has been shown to increase tumor oxygenation. Tumor oxygenation was measured using an Eppendorf pO2 histograph polarographic pO2 electrode system in the rat 13,762 mammary carcinoma after treatment of the tumor-bearing animals with squalamine (40 mglkg) on days 4 through 18 post tumor implantation. Under air breathing conditions, the hypoxic fraction (percent of pO2 readings < 5 mmHg) was 53% in controls and was decreased to 38% in the squalamine treated animals. While squalamine administration alone produced only a modest effect on the growth of the 13,762 tumor, there were increases in tumor growth delay of 1.9- to 2.5-fold when squalamine was administered along with cyclophosphamide, cisplatin and paclitaxel compared with the tumor growth delays observed with the chemotherapeutic agents alone. To determine the efficacy of squalamine alone and along with cytotoxic therapies against a model of primary and systemic disease, squalamine was administered to animals bearing the Lewis lung carcinoma by daily subcutaneous injection or by continuous infusion on days 4 through 18 post tumor implantation. Squalamine as a single agent had only a modest effect on the growth of the primary Lewis lung tumor but increased the tumor growth delays produced by cyclophosphamide, cisplatin, paclitaxel and 5-fluorouracil by 2.4- to 3.8-fold compared with the anticancer drugs alone. Squalamine administration alone substantially decreased the number of lung metastases found in animals bearing the Lewis lung carcinoma and further decreased the number of lung metastases when administered along with the chemotherapeutic agents.
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MESH Headings
- 9,10-Dimethyl-1,2-benzanthracene
- Animals
- Anticarcinogenic Agents/therapeutic use
- Antineoplastic Agents/therapeutic use
- Carcinoma, Lewis Lung/drug therapy
- Carcinoma, Lewis Lung/pathology
- Carcinoma, Lewis Lung/prevention & control
- Carcinoma, Lewis Lung/radiotherapy
- Cell Division/drug effects
- Cholestanols/therapeutic use
- Cisplatin/therapeutic use
- Combined Modality Therapy
- Cyclophosphamide/therapeutic use
- Doxorubicin/therapeutic use
- Drug Therapy, Combination
- Female
- Fluorouracil/therapeutic use
- Mammary Neoplasms, Experimental/drug therapy
- Mammary Neoplasms, Experimental/pathology
- Mammary Neoplasms, Experimental/prevention & control
- Mammary Neoplasms, Experimental/radiotherapy
- Mice
- Oxygen/analysis
- Oxygen Consumption/drug effects
- Paclitaxel/therapeutic use
- Partial Pressure
- Rats
- Rats, Inbred F344
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Affiliation(s)
- B A Teicher
- Dana-Farber Cancer Institute and Joint Center for Radiation Therapy, Boston, MA 02115, USA.
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42
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Flintoft VF, Williams JI, Williams RC, Basinski AS, Blackstien-Hirsch P, Naylor CD. The need for acute, subacute and nonacute care at 105 general hospital sites in Ontario. Joint Policy and Planning Committee Non-Acute Hospitalization Project Working Group. CMAJ 1998; 158:1289-96. [PMID: 9614821 PMCID: PMC1229322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Previous studies of hospital utilization have not taken into account the use of acute care beds for subacute care. The authors determined the proportion of patients who required acute, subacute and nonacute care on admission and during their hospital stay in general hospitals in Ontario. From this analysis, they identified areas where the efficiency of care delivery might be improved. METHODS Ninety-eight of 189 acute care hospitals in Ontario, at 105 sites, participated in a review that used explicit criteria for rating acuity developed by Inter-Qual Inc., Marlborough, Mass. The records of 13,242 patients who were discharged over a 9-month period in 1995 after hospital care for 1 of 8 high-volume, high-variability diagnoses or procedures were randomly selected for review. Patients were categorized on the basis of the level of care (acute, subacute or nonacute) they required on admission and during subsequent days of hospital care. RESULTS Of all admissions, 62.2% were acute, 19.7% subacute and 18.1% nonacute. The patients most likely to require acute care on admission were those with acute myocardial infarction (96.2% of 1826 patients) or cerebrovascular accident (84.0% of 1596 patients) and those admitted for elective surgery on the day of their procedure (73.4% of 3993 patients). However, 41.1% of patients awaiting hip or knee replacement were admitted the day before surgery so did not require acute care on admission. The proportion of patients who required acute care on admission and during the subsequent hospital stay declined with age; the proportion of patients needing nonacute care did not vary with age. After admission, acute care was needed on 27.5% of subsequent days, subacute care on 40.2% and nonacute care on 32.3%. The need for acute care on admission was a predictor of need for acute care during subsequent hospital stay among patients with medical conditions. The proportion of patients requiring subacute care during the subsequent hospital stay increased with age, decreased with the number of inpatient beds in each hospital and was highest among patients with congestive heart failure, chronic obstructive pulmonary disease and pneumonia. INTERPRETATION In 1995, inpatients requiring subacute care accounted for a substantial proportion of nonacute care days in Ontario's general hospitals. These findings suggest a need to evaluate the efficiencies that might be achieved by introducing a subacute category of care into the Canadian health care system. Generally, efforts are needed to reduce the proportion of admissions for nonacute care and of in-hospital days for other than acute care.
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Affiliation(s)
- V F Flintoft
- Institute for Clinical Evaluative Sciences, Toronto, Ont
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Sasso RC, Williams JI, Dimasi N, Meyer PR. Postoperative drains at the donor sites of iliac-crest bone grafts. A prospective, randomized study of morbidity at the donor site in patients who had a traumatic injury of the spine. J Bone Joint Surg Am 1998; 80:631-5. [PMID: 9611023 DOI: 10.2106/00004623-199805000-00003] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A prospective, randomized study was performed to assess the effectiveness of postoperative closed suction drainage. One hundred and twelve consecutive procedures involving autologous iliac-crest bone graft were performed, from December 29, 1992, to July 1, 1993, following a traumatic injury of the spine in 108 patients. Sixty of the sites from which the bone graft had been obtained were drained with a single large Hemovac device. The drains were maintained for two to five days postoperatively. The remaining fifty-two incisions were closed without a drainage device. All patients were evaluated clinically for problems with wound-healing. The incisions were considered to be healed when they had been asymptomatic for one year. Of eleven patients who had problems with wound-healing, six had been managed with a drain and five had not. The findings of this study do not support the routine use of drainage at the donor sites of iliac-crest bone grafts.
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Affiliation(s)
- R C Sasso
- Indianapolis Neurosurgical Group, Indiana 46260, USA
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Abstract
OBJECTIVES The authors examine the association between psychiatric morbidity and visits to general practitioners and family practitioners in Ontario, Canada. METHODS A nested set of hypotheses were posed to account for different levels of use among persons with differing levels of psychiatric morbidity. The sample of 8,116 is drawn from a comprehensive household survey of physical and mental health that included the UM-CIDI standardized diagnostic interview. RESULTS The findings suggest that persons with psychiatric disorders make more visits than can be accounted for by sociodemographic factors, medical status, access, or by intentional use of the general medical system for mental health treatment. CONCLUSIONS Psychiatric morbidity is associated with higher rates of health service use. This effect is strongest among persons with multiple psychiatric disorders.
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Affiliation(s)
- D L Tweed
- Health Systems Research Unit, Clarke Institute of Psychiatry, Toronto, Ontario, Canada
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Abstract
BACKGROUND Approximately 31 percent of cesarean deliveries in the United States and Canada are performed for dystocia. The aim of this study was to determine the effectiveness of early labor assessment to reduce cesarean birth rates for low-risk nulliparous women. METHODS Two hundred and nine low-risk nulliparous women were randomly allocated to either the early labor assessment group or the direct admission to hospital group. Women in the early labor assessment group were evaluated and, if found to be in false or latent labor, were encouraged to go home or walk before admission to the labor unit. Those in the direct admission group were admitted to the labor unit without an assessment. Data were collected and analyzed about method of delivery, duration of labor, intrapartum interventions, and neonatal well-being. Women completed an evaluation of their experience in the early postpartum period. RESULTS Significant decreases occurred in duration of labor, use of epidural analgesia for pain, and use of oxytocin to augment labor in the early labor assessment group. These women evaluated their labor and birth experience more positively than women in the direct admission group. No significant differences were found in the frequency of cesarean section or instrumental vaginal delivery for the two groups. CONCLUSIONS Early labor assessment has the potential to reduce the number of women receiving oxytocin for augmentation, the rate of epidural analgesia for pain relief, and the duration of the active and second stages of labor, and to improve women's evaluations of their labor and birth experiences.
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Affiliation(s)
- P S McNiven
- McMaster University Midwifery Education Programme, St. Joseph's Hospital, Hamilton, Ont., Canada
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Llewellyn-Thomas HA, Arshinoff R, Bell M, Williams JI, Naylor CD. In the queue for total joint replacement: patients' perspectives on waiting times. Ontario Hip and Knee Replacement Project Team. J Eval Clin Pract 1998; 4:63-74. [PMID: 9524913 DOI: 10.1046/j.1365-2753.1998.t01-1-00006.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We assessed patients on the waiting lists of a purposive sample of orthopaedic surgeons in Ontario, Canada, to determine patients' attitudes towards time waiting for hip or knee replacement. We focused on 148 patients who did not have a definite operative date, obtaining complete information on 124 (84%). Symptom severity was assessed with the Western Ontario/McMaster Osteoarthritis Index and a disease-specific standard gamble was used to elicit patients' overall utility for their arthritic state. Next, in a trade-off task, patients considered a hypothetical choice between a 1-month wait for a surgeon who could provide a 2% risk of post-operative mortality, or a 6-month wait for joint replacement with a 1% risk of post-operative mortality. Waiting times were then shifted systematically until the patient abandoned his/her initial choice, generating a conditional maximal acceptable wait time. Patients were divided in their attitudes, with 57% initially choosing a 6-month wait with a 1% mortality risk. The overall distribution of conditional maximum acceptable wait time scores ranged from 1 to 26 months, with a median of 7 months. Utility values were independently but weakly associated with patients' tolerance of waiting times (adjusted R-square = 0.059, P = 0.004). After splitting the sample along the median into subgroups with a relatively 'low' and 'high' tolerance for waiting, the subgroup with the apparently lower tolerance for waiting reported lower utility scores (z = 2.951; P = 0.004) and shorter times since their surgeon first advised them of the need for surgery (z = 3.014; P = 0.003). These results suggest that, in the establishment and monitoring of a queue management system for quality-of-life-enhancing surgery, patients' own perceptions of their overall symptomatic burden and ability to tolerate delayed relief should be considered along with information derived from clinical judgements and pre-weighted health status instruments.
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Affiliation(s)
- H A Llewellyn-Thomas
- Clinical Epidemiology Unit, Sunnybrook Health Science Centre, North York, Ontario, Canada
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Williams JI, Lloyd S. Monitoring and evaluation in primary care. Health Law Can 1997; 18:61-7. [PMID: 10178201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- J I Williams
- Institute for Clinical Evaluative Sciences in Ontario
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Sampalis JS, Tamim H, Denis R, Boukas S, Ruest SA, Nikolis A, Lavoie A, Fleiszer D, Brown R, Mulder D, Williams JI. Ineffectiveness of on-site intravenous lines: is prehospital time the culprit? J Trauma 1997; 43:608-15; discussion 615-7. [PMID: 9356056 DOI: 10.1097/00005373-199710000-00008] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The purpose of the present study was to test the association between on-site intravenous fluid replacement and mortality in patients with severe trauma. The effect of prehospital time on this association was also evaluated. The design was that of an observational quasi-experimental study comparing 217 patients who had on-site intravenous fluid replacement (IV group) with an equal number of matched patients for whom this intervention was not performed (no-IV group). The patients were individually matched on their Prehospital Index obtained at the scene and were included in the study if they had an on-site Prehospital Index score > 3 and were transported alive to the hospital. The outcome measure of interest was mortality because of injury. The patients in the IV group had a significantly lower mean age (37 vs. 45 years; p < 0.001) and higher incidence of injuries to the head or neck (46 vs. 32%; p = 0.004), chest (34 vs. 17%; p < 0.001), and abdomen (28 vs. 12%; p < 0.001). The IV group also had a higher proportion of patients injured by motor vehicle crashes (41 vs. 27%; p = 0.003), firearms (9 vs. 2%; p = 0.001), and stabbing (20 vs. 9%; p = 0.001). The rate of extremity injuries (38 vs. 59%; p < 0.001) and falls (12 vs. 40%; p < 0.001) was lower for the IV group. In addition, the mean Injury Severity Score was significantly higher for the IV group (15 vs. 9; p < 0.001). The mortality rates for the IV and no-IV groups were 23 and 6% (p < 0.001). Logistic regression analysis showed that after adjusting for patient age, gender, Injury Severity Score, mechanism of injury, and prehospital time, the use of on-site intravenous fluid replacement was associated with a significant increase in the risk of mortality (adjusted odds ratio = 2.3; 95% confidence interval = 1.02-5.28; p = 0.04). To further evaluate the effect of prehospital time on the association between on-site IV use and mortality, the analysis was repeated separately for the following time strata: 0 to 30 minutes, 31 to 60 minutes, and >60 minutes. The adjusted odds ratios (95% confidence interval) for these strata were 1.05 (0.08-14.53; p = 0.97), 3.38 (0.84-13.62; p = 0.08), and 8.40 (1.27-54.69; p = 0.03). These results show that for prehospital times of less than 30 minutes, the use of on-site intravenous fluid replacement provides no benefit, and that for longer times, this intervention is associated with significant increases in the risk of mortality. The results of this observational study have shown that the use of on-site intravenous fluid replacement is associated with an increase in mortality risk and that this association is exacerbated by, but is not solely the result of, increased prehospital times. Our findings are consistent with the hypothesis that early intravenous fluid replacement is harmful because it disrupts the normal physiologic response to severe bleeding. Although this evidence is against the implementation of on-site intravenous fluid replacement for severely injured patients, further studies including randomized controlled trials are required to provide a definitive answer to this question.
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Affiliation(s)
- J S Sampalis
- Department of Surgery, Trauma Programme, Montreal General Hospital, McGill University, Quebec, Canada
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Goel V, Iron K, Williams JI. Enthusiasm or uncertainty: small area variations in the use of mammography services in Ontario, Canada. J Epidemiol Community Health 1997; 51:378-82. [PMID: 9328542 PMCID: PMC1060504 DOI: 10.1136/jech.51.4.378] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE To examine the variation in mammography utilisation in relation to age group and indication across health planning regions in Ontario, Canada. DESIGN This study includes all women aged 30 and over in Ontario who received a mammogram between July 1, 1990 and December 31, 1991. Data from a sample of 10,000 women aged 50-69 were used to assign mammogram indication as "screening", "possible diagnostic", or "probable diagnostic" based on previous health care utilisation patterns. Age specific rates and age adjusted rates in relation to age group (30-39, 40-49, 50-69, and 70 + years) and region were derived. MAIN RESULTS Overall, 572,762 women received one or more mammograms. Rates increased from 30-54 years and decreased thereafter. Similar variations were seen in the 40-49 and 50-69 age groups. The ranking in the area specific rates remained consistent for all ages except the 30-39 year range. In relation to indication, the largest variation across regions occurred in the screening group. CONCLUSIONS Mammography utilisation varies across age groups. The greatest variability is for screening, probably because of physician referral patterns, patient uptake, and perhaps access to mammography. The extent of variation was similar when compared between groups where recommendations were consistent (ages 50-59) and where they were inconsistent (ages 40-49) suggesting that perhaps enthusiasm rather than uncertainty is related to regional variation for this procedure.
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Affiliation(s)
- V Goel
- Department of Preventive Medicine and Biostatistics, University of Toronto, Canada
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Abstract
BACKGROUND We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program. METHODS Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS, n = 350). RESULTS Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%). Length of stay and disability were statistically significantly decreased post-PHTLS. Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre-PHTLS mortality. CONCLUSIONS Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome.
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Affiliation(s)
- J Ali
- Department of Surgery, St. Michael's Hospital, University of Toronto, Ontario, Canada
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