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D A Grimes

Publications and source records attributed to D A Grimes.

At least 73 records · Page 4Linked to original sources
PubMed1999

Clinical features differentiating patients with postmortem confirmed progressive supranuclear palsy and corticobasal degeneration.

Progressive supranuclear palsy (PSP) and cortocobasal degeneration (CBD) are often clinically confused with each other because they share a rapid disease progression, parkinsonism that responds poorly or transiently to levodopa therapy, and associated signs (e.g., ocular abnormalities, pyramidal signs and cognitive involvement). To improve the accuracy in diagnosing these disorders, this study examined the clinical features of 51 patients pathologically diagnosed with PSP and CBD. Logistic regression analysis identified two sets of predictors (models) for CBD patients, one consisting of asymmetric parkinsonism, cognitive disturbances at onset and instability and falls at first clinic visit, and the other one of asymmetric parkinsonism, cognitive disturbances at symptom onset and speech disturbances. While PSP patients often had severe postural instability at onset, symmetric parkinsonism, vertical supranuclear gaze palsy, speech and frontal lobe-type features, CBD patients presented with lateralized motor (e.g., parkinsonism, dystonia or myoclonus) and cognitive signs (e.g., ideomotor apraxia, aphasia or alien limb). On the other hand, CBD patients presenting with an alternate phenotype characterized by early severe frontal dementia and bilateral parkinsonism were generally misdiagnosed. PSP patients without vertical supranuclear gaze palsy were misdiagnosed. Recognizing the features which differentiate these disorders and the less obvious disease presentations as well as developing an increased index of suspicion will improve the diagnostic accuracy of these disorders.

Aged↗
PubMed1999

Prophylactic antibiotics for intrauterine device insertion: a metaanalysis of the randomized controlled trials.

We evaluated the effectiveness of prophylactic antibiotic administration before IUD insertion in reducing the incidence of pelvic inflammatory disease, unscheduled visits back to the clinician, and IUD discontinuations within 3 months of insertion. We performed a metaanalysis of all known randomized controlled trials comparing an antibiotic (either oral doxycycline or azithromycin) versus a placebo or no treatment. Use of prophylaxis significantly reduced the frequency of unscheduled return visits (odds ratio 0.82; 95% CI 0.70, 0.98). The protection against pelvic inflammatory disease was smaller and not statistically significant 0.89 (95% CI 0.53, 1.51). No significant effect on premature IUD discontinuation was evident. Use of either doxycycline or azithromycin before IUD insertion offered little observable benefit in the US. Prophylaxis reduced unscheduled visits and possibly PID in developing countries, which have higher rates of sexually transmitted diseases than in the US. A more important finding in these trials is the low incidence of pelvic inflammatory disease with or without prophylactic antibiotics.

Adult↗
PubMed1999

Patients' understanding of medical risks: implications for genetic counseling.

OBJECTIVE: To assess patients' ability to compare magnitudes of Down syndrome risk at maternal ages of 35 and 40 years, expressed as rates or as proportions. METHODS: We used a self-administered, anonymous questionnaire that posed the same comparison in two different formats: 2.6 versus 8.9 per 1000 women (rates) and one in 384 versus one in 112 women (proportions). The study setting included several university-affiliated obstetrics and gynecology outpatient clinics in San Francisco, California. A total of 633 women, whose primary languages were English, Spanish, or Chinese, participated. The main outcome measure was correct identification of the larger of two risks. RESULTS: Women were more successful with rates (463 of 633 respondents, 73%) than with proportions (353 of 633 respondents, 56%). A paired analysis, in which each woman served as her own control, found risk assessment to be significantly better with rates than with proportions (P < .001). Women with little formal education had difficulty understanding risks framed either way. CONCLUSION: The traditional use of proportions to express risk in genetic counseling lacks scientific basis. Rates were easier to understand than proportions, regardless of respondents' age, language, and education.

Adult↗
PubMed1999

New technologies in cervical cytology screening: a word of caution.

Nearly 5000 women in the United States will die of cervical cancer this year and many of those deaths could be prevented. Most incident cases (60%) are associated with absent or deficient screening. Approximately 25% of screening failures are due to errors in cervical sampling or smear interpretation. New techniques for cytology screening such as liquid-based smears and computerized rescreening of slides are being promoted to physicians and the lay public despite limited scientific evaluation. Improving the validity of screening tests is important, but shifting resources for this purpose might cause net harm if the result is fewer screening opportunities for high-risk women. New screening technologies do not address this utilization gap and might widen it by driving the cost of screening out of the reach of high-risk women. Greater decreases in cervical cancer morbidity and mortality would likely result if the same resources were invested in a comprehensive national screening program that targeted women at highest risk.

Female↗
PubMed1999

Bundling a pregnancy test with the Yuzpe regimen of emergency contraception.

The recent United States Food and Drug Administration approval of a commercial kit containing the Yuzpe regimen for emergency contraception is a welcome event. Unlike emergency contraceptive pills sold in other countries, however, the United States product has a pregnancy test bundled with the pills. The test could identify existing pregnancies and avoid unnecessary use of the pills, although any protection against lawsuits alleging injury to an embryo is speculative. Conversely, no major medical organization recommends routine pregnancy testing before using emergency contraceptive pills. The test might stigmatize the Yuzpe regimen as being dangerous to an embryo. Difficulty in understanding the pregnancy test instructions could, paradoxically, deter some women from using the pills after having bought them. The bulky size of the pregnancy test reagent stick makes the package indiscreet, and the test adds unnecessary cost to emergency contraception. The greatest usefulness of the test could be to confirm or exclude a pregnancy several weeks after taking the pills, rather than before. If bundling an unnecessary test with emergency contraception is the only way to bring this useful product to the United States market, then the public health benefits could outweigh the disadvantages. However, this approach sets a worrisome precedent and further isolates the United States from the international medical community.

Contraceptives, Postcoital↗
PubMed1999

Treatment of early Parkinson's disease.

The early treatment of Parkinson's disease continues to be controversial as our understanding of the etiology of the disease remains incomplete. Ideally an intervention that reverses or protects against further damage to dopaminergic neurons would be initiated once the symptoms of the disease are recognized. Unfortunately, there are no currently available therapies that have been shown to have a major impact on the progression of the disease. However, delaying effective symptomatic therapy beyond a point of significant disability does result in increased mortality. Concerns have been raised regarding the potential toxicity of levodopa on remaining nigral neurons. Although there is little support for this concept, levodopa is associated with important complications. The development of new symptomatic treatments has made the management of early Parkinson's disease even more complex and requires that many different factors be considered prior to initiating therapy in an attempt to minimize current and future disability caused by the disease and its treatment.

Antiparkinson Agents↗
PubMed1998

The case against using ordinal numbers for gestational age.

OBJECTIVE: Use of ordinal numbers (eg, twelfth) instead of cardinal numbers (eg, twelve) to measure gestational age often leads to clinical confusion. We conducted this study to document the prevalence of ambiguous or contradictory use of ordinal numbers for gestational age and to discuss some clinical implications. MATERIALS AND METHODS: We reviewed a convenience sample of standard texts in obstetrics and in abortion and examined a random sample of articles on abortion. RESULTS: Imprecise or incorrect use of ordinal numbers for gestational age was common: Eight of nine (89%) obstetrics texts and all six abortion texts had this problem. The corresponding figure for the abortion articles was 32 of 88 (36%). CONCLUSION: Use of ordinal numbers for gestational age introduces information bias (misclassification) into the scientific literature. More importantly, it may lead to clinical errors related to the timing of administration of antenatal corticosteroids and the upper limit for induced abortions. Gestational age measurements should use only cardinal numbers (eg, twelve) of completed days or weeks from the last menstrual period. Clinicians should abandon use of ordinal numbers for gestational age.

Bias↗
PubMed1998

Teaching critical appraisal to medical students in obstetrics and gynecology.

Critical appraisal might be the most important skill to acquire in medical school. Despite its importance, this issue has received little attention in obstetrics and gynecology training. This article describes the approach used at San Francisco General Hospital. We teach critical appraisal in several ways. We provide a series of student seminars that foster critical reading of the literature. Topics range from technology assessment to contraception to sexually transmitted diseases. Evidence-based ward rounds complement the experience. During the rotation, each student formally reviews one topic in women's health using the US Preventive Services Task Force rating system. Although we lack a quantitative assessment of this approach, student feedback has been enthusiastic. Critical appraisal skills enable students to continue their medical education after completion of their formal training.

Clinical Competence↗
PubMed1998

Vasculitic basilar artery thrombosis in chronic Candida albicans meningitis.

BACKGROUND: Cerebrovascular complications of meningitis have been most extensively documented in the setting of acute bacterial or chronic tuberculous meningitis. Involvement of major cerebral vessels is rare and basilar artery thrombosis has not been reported in fungal meningitis secondary to candida infection. METHODS: We describe the clinical course and neuropathological findings in a woman with chronic meningitis due to Candida albicans. RESULTS: The diagnosis remained elusive antemortem despite analysis of 7 large volume CSF samples and examination of a meningeal and cortical biopsy. Death followed extensive brainstem and temporo-occipital infarction secondary to basilar artery thrombosis. The basilar artery occlusion was secondary to an intense, granulomatous and necrotizing basal meningitis focally extending to the media and intima. CONCLUSIONS: This paroxysmal and devastating complication of untreated chronic candida meningitis reinforces that a trial of empirical therapy with both antituberculous and antifungal agents should be considered in most cases of chronic culture-negative lymphocytic meningitis.

Adult↗
PubMed1998

The U.S. Preventive Services Task Force: putting evidence-based medicine to work.

The U.S. Preventive Services Task Force is a prominent example of evidence-based medicine put to work. The Guide to Clinical Preventive Services and its Canadian counterpart distill thousands of articles into easily understood guidelines for the busy clinician. Rather than dictating practice, it provides the scientific base for prevention services. The second fundamental part of evidence-based medicine is the filtering of that evidence through the clinical skill of the clinician. Only the clinician can judge the applicability of the evidence and the preferences of the woman and her family. Some common preventive practices in women's health lack a scientific basis. Others clearly work. To maximize benefit, clinicians should emphasize and encourage prevention strategies that are effective. These include cervical cytology screening, blood pressure screening, urine cultures in early pregnancy, testing for phenylketonuria, and discouraging smoking. No health program can be reviewed in a vacuum. This is especially true in the managed care era. Clinicians must ask what benefit would have accrued had the same amount of time and money been spent on alternative programs. If practices with only a class C recommendation draw money and resources from other programs of proven worth (e.g., class A recommendations), then the former have a net negative impact on women's health. The Task Force report helps women, clinicians, payers, and policymakers make these important decisions.

Breast Neoplasms↗
PubMed1998

The alleged association between induced abortion and risk of breast cancer: biology or bias?

The alleged association between induced abortion and breast cancer is one of the most controversial and important questions in women's health today. To help clinicians provide appropriate counseling, we reviewed both the primary data and review articles on this topic. We identified the studies and reviews by using Medline and the reference lists of articles and texts. We then used the U.S. Preventive Services Task Force rating system to evaluate the evidence. Many case-control studies have addressed this question, but their results have been inconsistent. Persistent problems in the case-control studies include selection of an appropriate control group, recall bias (under-reporting of induced abortion by controls), and confounding by other risk factors. Two recent, large cohort studies, which are less susceptible to bias, showed either protection or no effect on breast cancer risk from an induced abortion. At present, level II-2 evidence (cohort and case-control studies) supports a class B recommendation (fair evidence) that induced abortion does not increase a woman's risk of breast cancer later in life.

Abortion, Induced↗
PubMed1997

The safety of early postpartum discharge: a review and critique.

OBJECTIVE: To determine the effect of early postpartum discharge (less than 48 hours after vaginal birth or 96 hours after cesarean delivery) on maternal and neonatal complications, maternal concerns, patient satisfaction, and cost savings. DATA SOURCES: We performed a MEDLINE search of English-language journals for pertinent articles published from 1966 through January 1997. We also reviewed reference lists in all the articles retrieved in the search as well as those of major obstetric texts. METHODS OF STUDY SELECTION: We included all studies describing early postpartum discharge. TABULATION, INTEGRATION, AND RESULTS: Studies included five randomized controlled trials, ten cohort studies, one case-control study, and 12 case-series reports. We classified the data using the rating system of the U.S. Preventive Services Task Force. We calculated relative risks and 95% confidence intervals for maternal and neonatal readmission and outpatient treatment after early postpartum discharge. Most studies did not show an increase in maternal or neonatal morbidity after early discharge. The five randomized controlled studies did not meet criteria for properly designed trials. Most evidence consists of cohort studies and case-series (class II-2 and III evidence) of highly selected patients with extensive supplemental antepartum and postpartum care and education. CONCLUSION: The current data do not support or condemn widespread use of early postpartum discharge in the general population (class C recommendation). Early postpartum discharge appears safe for carefully selected, consenting patients. Whether these data can be extrapolated to the general population of pregnant women remains unknown.

Cesarean Section↗
PubMed1997

Medical abortion in early pregnancy: a review of the evidence.

OBJECTIVE: To review the literature on medical abortion in early pregnancy. DATA SOURCES: I performed a MEDLINE search, supplemented by bibliographies of articles and textbooks. In addition, investigators in the field were consulted to identify other sources. The review was limited to reports in English or French concerning antiprogestins or methotrexate used either alone or in combination with a prostaglandin. METHODS OF STUDY SELECTION: Only those mifepristone studies with 100 or more participants were included. Those participants who received the prostaglandin sulprostone were excluded because this drug is no longer used with mifepristone. Methotrexate studies of any size were included. All reports were categorized by study type, and the evidence was evaluated using the U.S. Preventive Services Task Force rating system. TABULATION, INTEGRATION, AND RESULTS: Both mifepristone and methotrexate, when used with a prostaglandin, can induce abortion safely in early pregnancy. Class I evidence supports a class A (good) recommendation that oral, single mifepristone doses of 200 mg and 600 mg have similar efficacy when used with a prostaglandin. Sequential and single-dose regimens have comparable efficacy. Vaginal misoprostol at 800 micrograms as an augmenting agent appears superior to the same dose given orally. With methotrexate abortion, 800 micrograms of misoprostol given vaginally 7 days after methotrexate is superior to the same dose given 3 days after. In addition, methotrexate in combination with misoprostol is more effective than misoprostol alone. CONCLUSION: Medical abortion with mifepristone or methotrexate in combination with a prostaglandin is safe and effective. However, the risk of hemorrhage and gastrointestinal side effects is greater with medical abortion than with suction curettage. Further research should be done to compare mifepristone and methotrexate abortions, to determine the upper gestational age limit, and to find the best way to provide this service in the U.S. health care system.

Abortifacient Agents, Steroidal↗