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Biomedical subjects

A Laupacis

Publications and source records attributed to A Laupacis.

At least 109 records · Page 6Linked to original sources
PubMed1995

Association of drug therapy with survival in cardiac arrest: limited role of advanced cardiac life support drugs.

OBJECTIVE: To generate hypotheses regarding the association of standard Advanced Cardiac Life Support (ACLS) drugs with human cardiac arrest survival. METHODS: This observational cohort study was conducted over a two-year period in the wards, intensive care units, and EDs of two tertiary care hospitals. Included werc adult patients who suffered cardiac arrest either inside or outside the hospital and who required epinephrine according to standard ACLS guidelines. Six standard ACLS drugs (given while CPR was in progress) were assessed for association with survival from resuscitation to one hour and to hospital discharge by univariate and multivariate logistic regression analyses. RESULTS: In the 529 patients studied, initial cardiac rhythm had no impact on the association between drug administration and survival. The time of drug administration (quartile of ACLS period) was associated with resuscitation for atropine (p < 0.05) and lidocaine (p < 0.01). The odds ratios (95% CIs) for successful resuscitation, after multivariate adjustment for potential confounders, were: a respiratory initiating cause, 3.7 (2.1 -6.4); each 5-minute increase in CPR-ACLS interval, 0.5 (0.4-0.7); each 5-minute duration of ACLS. 0.9 (()1.8- 1.0; atropine, 1.2 (1.0-1.3); bretylium. (0.4 (0.1-1.1); calcium 0.8 (0.2-2.4); lidocaine, 0.9 (0.7-1.1); procainamide. 21.0 (5.2-84.0) d sodium bicarbonate 1.2 (1.0-1.6). All other potential confounding variables entered into the model were not significantly associated with resuscitation. CONCLUSION: Initiating cause of arrest, time to ACLS, and duration of ACLS were important correlates of survival. Other than procainaimide, standard ACLS drugs had relatively little association with survival, but timing of administration may be an important factor. Further research using definitive large randomized controlled trials is warranted to assess the role of drug therapy in improving cardiac arrest survival.

Adult↗
PubMed1995

The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation.

PURPOSE: To develop a conceptual tool for the systematic development of cancer treatment practice guidelines. MATERIALS AND METHODS: The guidelines development tool, the Practice Guidelines Development Cycle, was derived from observing an evidence-based practice guidelines initiative at a comprehensive cancer center in Ontario, Canada, and from a literature review that uncovered barriers to guidelines development and implementation. Based on the literature findings and direct observations of how clinicians struggled with evidence-based guidelines development, we evolved a framework to incorporate clinical and administrative factors (eg, costs) into evidence-based guidelines. Use of the Practice Guidelines Development Cycle is illustrated with a clinical example (the use of adjuvant systemic therapy in good-risk, node-negative premenopausal breast cancer patients). RESULTS: The result is the Practice Guidelines Development Cycle, which consists of eight sequential steps, from topic selection to policy formulation. Independent validation of guidelines is included. The cycle products are the evidence-based recommendation, the practice guideline, and the practice policy. The main features of the cycle are emphasis on scientific evidence, acknowledgment of the roles of clinical experience and nonclinical (administrative) factors through consensus, and explicit separation of clinical and cost considerations in guidelines development. Twenty guidelines are currently in development. CONCLUSION: Attention to the barriers of guidelines development and the sociocultural nature of clinical practice, and respect for clinical experience, can lead to improved strategies for guidelines development.

Cancer Care Facilities↗
PubMed1995

Total hip replacement: the case for noncemented femoral fixation because of age.

Both noncemented fixation and improved cemented fixation of total hip replacements emerged to counteract the clinical and radiographic failures of early cemented procedures. A randomized clinical trial comparing a second-generation cemented with a second-generation noncemented total hip replacement demonstrated that in the medium term both implants allow excellent, disease-specific, global and functional capacity outcome measures. No significant differences existed between the cemented and noncemented implants in terms of these parameters or revision rate. Cost-to-utility analyses of both types of replacements revealed that total hip replacement is one of the most cost-effective medical interventions. Noncemented total hip replacements seem as efficacious as cemented devices in patients younger than 70 years.

Adolescent↗
PubMed1994

Low-dose cyclosporine for the treatment of Crohn's disease. The Canadian Crohn's Relapse Prevention Trial Investigators.

BACKGROUND: Long-term corticosteroid therapy for Crohn's disease is associated with important types of morbidity, such as osteoporosis. Safe and effective alternative treatments are required. Although a short-term benefit of cyclosporine in active Crohn's disease has been suggested, the long-term safety and efficacy of this treatment have not been established. METHODS: We conducted a randomized, double-blind, placebo-controlled evaluation of the effect of 18 months of low-dose cyclosporine treatment on the course of Crohn's disease. Adult patients whose disease had been active within the previous two years were randomly assigned to receive cyclosporine (151 patients) or placebo (154 patients) in addition to their usual therapy. Randomization was stratified according to center and score on the Crohn's Disease Activity Index (193 patients had scores of 150 or less, and 112 had scores greater than 150). The primary outcome measure was clinically important worsening of Crohn's disease, defined as a 100-point increase in the Crohn's Disease Activity Index from the patient's base-line value. Secondary outcomes were the use of prednisone and 5-amino-salicylates, mean score on the Crohn's Disease Activity Index and mean quality-of-life score, and the need for surgery. RESULTS: The condition of more patients worsened with cyclosporine than with placebo (91 of 151, or 60.3 percent, vs. 80 of 154, or 51.9 percent; P = 0.10). The median time to worsening of disease in patients receiving cyclosporine was 338 days, as compared with 492 days in patients receiving placebo (P = 0.25; relative risk, 1.22; 95 percent confidence interval, 0.86 to 1.72). Analyses of the mean Crohn's Disease Activity Index and quality-of-life scores and of the use of prednisone and 5-aminosalicylates also failed to demonstrate benefit. CONCLUSIONS: In our patient population, the addition of low-dose cyclosporine to conventional treatment for Crohn's disease did not improve symptoms or reduce requirements for other forms of therapy.

Adult↗
PubMed1994

Hard to swallow test.

Explore the source record for details and available documents.

Cerebrovascular Disorders↗
PubMed1994

Costs of elective total hip arthroplasty during the first year. Cemented versus noncemented.

The cost-effectiveness of the Mallory Head (Biomet, Warsaw, IN) cemented versus noncemented total hip arthroplasty was determined as part of a randomized trial. Costs were assessed during the first postoperative year. In-hospital resource use was determined using a chart review of 60 randomly selected patients. Costs were determined using a fully allocated costing model. Outpatient resource use was determined using patient diaries, and appropriate costs were allocated for outpatient visits, admissions to hospital, and patient-borne costs. There was no difference in costs between the cemented and noncemented prostheses. The average cost of the initial hospitalization was $9,990 (1988 Canadian dollars), and outpatient costs during the first year were $1,137 (total cost during the first year was $11,127). The cost per quality adjusted life year was $27,139 during the first year and $8,031 during the first 3 years.

Ambulatory Care↗
PubMed1994

A meta-analysis of prophylactic endoscopic sclerotherapy for esophageal varices.

OBJECTIVES: A number of randomized clinical trials of prophylactic sclerotherapy have been carried out with different results. The main objective of this study was to determine if the literature provides evidence that prophylactic sclerotherapy increases the survival rate of patients with esophageal varices. METHODS: Meta-analysis was used to evaluate the effect of prophylactic sclerotherapy on the survival of patients with esophageal varices. Only randomized controlled trials that compared prophylactic sclerotherapy to placebo were included. RESULTS: Fourteen fully published randomized controlled trials, as well as six trials published as abstracts, were identified in the English literature. Pooling of the 14 fully published trials yielded an odds ratio of death in the treatment group compared with the control group of 0.74 (95% confidence interval, 0.60-0.93) in favor of prophylactic sclerotherapy. There was statistically significant heterogeneity that resolved when the trials were pooled in subgroups based on the sclerosant used. Pooling of trials using polidocanol showed a highly significant benefit for prophylactic sclerotherapy in terms of overall mortality, particularly when those trials that selected subjects at high risk of bleeding were pooled, yielding an odds ratio of 0.51 (95% confidence interval, 0.36-0.73). When trials using sodium tetradecyl sulfate were pooled, a detrimental effect for prophylactic sclerotherapy was seen, with an odds ratio of 1.86 (95% confidence interval, 1.15-3.00). Subgroup analysis by Child's class showed no benefit for patients in Child's class A. CONCLUSION: These results suggest that prophylactic sclerotherapy with polidocanol is effective, particularly in high-risk patients.

Endoscopy, Gastrointestinal↗
PubMed1994

A double-blind study of 250 cases comparing cemented with cementless total hip arthroplasty. Cost-effectiveness and its impact on health-related quality of life.

The success of a total hip arthroplasty (THA) is dependent on many more parameters than simply the prosthesis used. This study has demonstrated that a randomized controlled clinical trial of 250 patients comparing two types of hip prostheses (cemented versus cementless) with virtually complete follow-up examination is feasible. It also demonstrates that patients are willing to answer extensive quality-of-life questionnaires that allow complete assessment of the impact of hip arthroplasty on the patient's overall health-related quality of life. This study has also demonstrated that THA is an extremely effective intervention when one assesses its ability to impact on patients health-related quality of life with no difference between cement versus cementless at two years' follow-up examination.

Activities of Daily Living↗
PubMed1993

A comparison of aspirin with placebo in patients treated with warfarin after heart-valve replacement.

BACKGROUND: Despite the use of warfarin, major systemic embolism remains an important complication in patients with heart-valve replacement. Although the addition of antiplatelet agents has the potential to reduce this complication, their efficacy and safety when given in combination with warfarin are uncertain. METHODS: In a randomized, double-blind, placebo-controlled trial, we assessed the efficacy and safety of adding aspirin (100 mg per day) to warfarin treatment (target international normalized ratio, 3.0 to 4.5) in 370 patients with mechanical heart valves or with tissue valves plus atrial fibrillation or a history of thromboembolism. RESULTS: A total of 186 patients were randomly assigned to aspirin and 184 to placebo, and they were followed for up to 4 years (average, 2.5). Major systemic embolism or death from vascular causes occurred in 6 aspirin-treated patients (1.9 percent per year) and 24 placebo-treated patients (8.5 percent per year) (risk reduction with aspirin, 77 percent; 95 percent confidence interval, 44 to 91 percent; P < 0.001). Major systemic embolism, nonfatal intracranial hemorrhage, or death from hemorrhage or vascular causes occurred in 12 patients assigned to aspirin (3.9 percent per year) and 28 patients assigned to placebo (9.9 percent per year) (risk reduction, 61 per cent; 95 percent confidence interval, 24 to 80 percent; P = 0.005); major systemic embolism or death from any cause occurred in 13 patients (4.2 percent) and 33 patients (11.7 percent), respectively (risk reduction, 65 percent; 95 percent confidence interval, 33 to 82 percent; P < 0.001); and death from all causes occurred in 9 patients (2.8 percent) and 22 patients (7.4 percent), respectively (risk reduction, 63 percent; 95 percent confidence interval, 19 to 83 percent; P = 0.01). Bleeding occurred in 71 patients in the aspirin group (35.0 percent), as compared with 49 patients in the placebo group (22.0 percent) (increase in risk, 55 percent; 95 percent confidence interval, 8 to 124 percent; P = 0.02); major bleeding occurred in 24 and 19 patients, respectively (increase in risk, 27 percent; 95 percent confidence interval, -30 to 132 percent; P = 0.43). CONCLUSIONS: In patients with mechanical heart valves and high-risk patients with prosthetic tissue valves, the addition of aspirin to warfarin therapy reduced mortality, particularly mortality from vascular causes, together with major systemic embolism. Although there was some increase in bleeding, the risk of the combined treatment was more than offset by the considerable benefit.

Adult↗