Patients' interests or resource allocation?
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Decision Making↗
Biomedical subjects
D J Hunter
Publications and source records attributed to D J Hunter.
Antioxidant micronutrients and breast cancer.
We reviewed epidemiologic evidence on the relationship between four antioxidant micronutrients (vitamin A, vitamin C, vitamin E, and selenium) and breast cancer risk. Available data support a modest protective effect of vitamin A, although more studies are needed to examine further this association and to assess the relative contributions of preformed vitamin A (retinol) and carotenoids. In addition, the possibility that some other component of vitamin A-rich foods may account for this observed association should be explored. Data on the relationship between vitamins C and E and breast cancer risk are limited and inconsistent, and further information is necessary. A substantial body of evidence indicates a lack of any appreciable effect of selenium intake on breast cancer risk, at least within the range of human diets. Future observational studies should ideally be prospective in design, as prospective studies are less prone to selection and recall bias than are case-control studies, and should address methodologic issues such as confounding by other micronutrients and appropriate storage conditions of blood specimens. Although hypotheses relating micronutrient intake to risk of breast cancer should be tested in randomized trials, ethical and logistical constraints make these studies difficult to perform.
Antioxidants↗
Validity of contraceptive histories in a rural community in Kenya.
To determine the validity of self-reported contraceptive histories obtained from rural Kenyan women, we interviewed 122 women participants in a long-term study during which their contraceptive use had been recorded regularly at clinics. Interview information was compared with each woman's clinic record. In all 71 women (58%) reported ever use of oral contraceptives, while 76 (62%) of the clinic records documented ever use. The agreement between the records and interview was reasonable (Kappa = 0.54, P < 0.001). The sensitivity of self-report of use compared to clinic records was 79%, specificity was 76%, positive and negative predictive values were 85% and 69% respectively. Ever use of injectable contraceptives (Depo-Provera) was reported by 78 (63%) women while the records showed use by 80 (65%) women (Kappa = 0.87, P < 0.001). The sensitivity, specificity, positive and negative predictive values were 94%, 93%, 96%, and 89% respectively. For the intrauterine contraceptive device, ever use was reported by 18 (14.8%) women while the records showed 19 (15.6%) (Kappa = 0.90, P < 0.001). The associated sensitivity, specificity, positive and negative predictive values were 90%, 99%, 94% and 98% respectively. The validity of reported duration of use of each method showed a similar pattern to that of the history of ever use. The Spearman's rank correlations for the duration of use calculated from interview compared with the clinic records were for oral contraceptives r = 0.68 (P < 0.001), injectables r = 0.81 (P < 0.001) and intrauterine devices r = 0.82 (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Diet, body size, and breast cancer.
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Animals↗
The relationship between HIV infection and cervical intraepithelial neoplasia among women attending two family planning clinics in Nairobi, Kenya.
OBJECTIVE: To determine the relationship between HIV-1 infection and cervical intraepithelial neoplasia (IN) among women at relatively low risk for both conditions. DESIGN: A case-control study comparing women with cytological evidence of IN (cases) with those without IN (controls) and HIV-1 serostatus as the principal exposure of interest. METHODS: A total of 4058 women attending two family planning clinics in Nairobi, Kenya between October 1989 and May 1991 were enrolled following HIV pretest counseling and informed consent. Structured interviews by trained nurses and medical students were used to obtain data on social, demographic, contraceptive practice and sexual behavior variables. A Papanicolaou smear specimen for cervical cytology and an endocervical swab for gonorrhea culture were obtained. HIV-1 serostatus was determined by enzyme-linked immunosorbent assay and confirmed by Western blot; syphilis serostatus was determined by the rapid plasma reagin test. RESULTS: Eighty-two of the 4058 (2.02%) women had cytological evidence of IN. We observed a significant positive association between HIV-1 infection and IN that remained after controlling for sexual behavior, contraceptive practices and other potential confounding variables (odds ratio, 2.78; 95% confidence interval 1.32-5.85). clinical symptoms and signs were uncommon among the HIV-1-seropositive women, suggesting that they were still in the early stages of the infection. CONCLUSION: The risk of IN among women even in the early stages of HIV-1 infection is increased.
Adolescent↗
Desperately seeking solutions: rationing dilemmas in health care.
Rationing health care is high on the policy agenda in many countries as the demand for care apparently outstrips supply. There are calls for the public to become more actively involved in determining priorities along the lines of the Oregon experiment in the United States. In Britain rationing has always been a feature of the National Health Service (NHS) although it has become implicit rather than explicit. The NHS reforms, principally the purchaser-provider separation, is making rationing much more explicit. The paper reviews the debate in Britain and concludes that there are no quick fixes or simple panaceas to a complex issue. It questions the extent to which the public can or should be involved in deciding who should or who should not get treated and argues that doctors have a central role to play in finding a better way of allocating resources effectively.
Community Participation↗
Association of immune activation with intravenous heroin use and methadone treatment in HIV-1 seropositive and seronegative subjects.
This study evaluated the effect of continued heroin use during methadone treatment on serum neopterin levels in 40 human immunodeficiency virus (HIV) type 1 seropositive (HIV+) and 70 seronegative (HIV-) intravenous drug users (IVDUs). Persistent drug use, determined by urinary evidence of opiates, was more common in HIV+ than in HIV- IVDUs (p = 0.01). Serum neopterin concentration, an indicator of increased probability of progression to AIDS, was elevated in HIV+ IVDUs, p < 0.0001 (mean 16.0 nmol/L) compared to that of HIV- IVDUs (mean 10.0 nmol/L) and in persistent IV drug users compared with abstainers, p < 0.0001. The effect of drug use and HIV status on serum neopterin was not explained by differences in methadone treatment, age, sex, or total years of i.v. drug use. Neopterin decreased in 25 IVDUs, regardless of HIV serostatus, treated with methadone for an average of 1.5 years.
Adult↗
AIDS in sub-Saharan Africa: the epidemiology of heterosexual transmission and the prospects for prevention.
As the epidemic of the acquired immunodeficiency syndrome (AIDS) in sub-Saharan Africa enters its second decade, much has been learned about the distribution and determinants of the disease and its causative agent, the human immunodeficiency virus (HIV). Over 6 million people, or 2.5% of the adult population, are thought to be infected with HIV. The distribution of HIV is largely determined by sexual behavior; as for other sexually transmitted diseases, the characteristics of sexual networks determine the extent and rate of spread of HIV. Female sex workers and their male clients are at high risk for HIV and have been important in initiating the epidemic in many African countries. The dynamics of HIV in the rest of the population are complex; men with multiple sexual partners are largely responsible for transmission of HIV to women in the general population. Other sexually transmitted diseases and lack of male circumcision may increase the probability of transmission of HIV during sexual intercourse and probably are partially responsible for the rapid diffusion of HIV in Africa. Interventions among high-risk groups are needed, but they must be accompanied by attempts to induce behavior change among men and women in the general population. Epidemiologic studies of the determinants of sexual behavior and sexual contact patterns, as well the design and evaluation of interventions, are urgently needed. Key areas for development are the study of behavioral exposures and outcomes, the evaluation of interventions, developing new methods for conducting interventions in resource-poor environments, and increasing the number of African scientists with the skills and resources to conduct epidemiologic studies.
Acquired Immunodeficiency Syndrome↗
Dietary fat and fiber in relation to risk of breast cancer. An 8-year follow-up.
OBJECTIVE: To address the hypotheses that dietary fat increases and fiber decreases the risk of breast cancer. DESIGN: Prospective cohort study with dietary assessment at baseline, using a validated, self-administered food frequency questionnaire. SETTING/PARTICIPANTS: 89,494 women in the Nurses' Health Study who were 34 through 59 years of age in 1980 and who were followed up for 8 years (> 95% complete). RESULTS: 1439 incident cases of breast cancer were diagnosed, including 774 among postmenopausal women. After adjustment for age, established risk factors, and total energy intake, we observed no evidence of any positive association between total fat intake and breast cancer incidence (relative risks [RRs] for increasing quintiles of fat intake were 1.0, 0.85, 0.96, 0.91, and 0.90; 95% confidence interval for highest vs lowest quintile, 0.77 to 1.07). Among postmenopausal women alone, corresponding RRs were 1.0, 0.89, 1.00, 0.95, and 0.91. Comparing extreme deciles of total fat intake (> or = 49% vs < 29% of total energy intake), the RR was 0.86 (95% confidence interval, 0.67 to 1.08). A similar absence of any positive association was observed without adjustment for energy intake; for tumors less than 2 cm as well as 2 cm or greater in diameter; for saturated, monounsaturated, and polyunsaturated fat; and after excluding the first 4 years of follow-up. Also, we found no suggestion of any positive association when using a more detailed and precise dietary questionnaire completed in 1984 (666 subsequent cases), even when women consuming less than 25% of energy from fat were used as the comparison group. No suggestion of a protective effect of dietary fiber was observed (RRs for increasing quintiles were 1.0, 0.95, 0.93, 1.02, and 1.02). CONCLUSIONS: These data provide evidence against both an adverse influence of fat intake and a protective effect of fiber consumption by middle-aged women on breast cancer incidence over 8 years. Nevertheless, the positive association between intake of animal fat and risk of colon cancer observed in many studies provides ample reason to limit this source of energy.
Adult↗
What cervical dilatation rate during active labour should be considered abnormal?
The present study tested the common notion of slow labour that only dilatation rates of 1 cm/h and above lead to normal (intervention free) delivery. We examined all primiparous spontaneous term labours cared for in our hospital over a 1 year period when a protocol for intervention in the case of slow dilation rate was not in place. Of 505 consecutive singleton labours, 105 (20.6%) progressed at an overall cervical dilatation rate of less than 1 cm/h. However, only those progressing at 0.5 cm/h and less (n = 52 or 10.3% of the total) had significantly increased rates of oxytocin usage and of caesarean section. The data suggest that there may be a more conservative definition of slow labour.
Cervix Uteri↗
Comparison of measures of fatty acid intake by subcutaneous fat aspirate, food frequency questionnaire, and diet records in a free-living population of US men.
In 1986-1987, the authors assessed the fatty acid intake of 118 Boston-area men, aged 40-75 years, by a semiquantitative food frequency questionnaire administered twice, by two 7-day diet records, and by capillary gas chromatography of subcutaneous fat samples obtained by needle aspirate from the lateral buttock. Spearman correlation coefficients between diet record estimates of fatty acid intake (as a percentage of total fat) and fat aspirate measures (as a percentage of total peak area) were as follows: saturated fat, r = 0.16 (p = 0.09); monounsaturated fat, r = 0.22 (p = 0.01); and polyunsaturated fat, r = 0.49 (p = 0.0001). Spearman correlation coefficients between estimates derived from the food frequency questionnaire were as follows: saturated fat, r = 0.18 ( p = 0.05); monounsaturated fat, r = 0.14 (p = 0.14); polyunsaturated fat, r = 0.50 (p = 0.0001); and eicosapentaenoic acid, r = 0.47 (p = 0.0001). These data confirm that the polyunsaturated and eicosapentaenoic fatty acid content of subcutaneous fat is a measure of dietary intake of these fats. Although diet records are commonly thought to be the "gold standard" method of dietary assessment, the similar correlations observed between the fatty acid composition of adipose tissue and estimates of intake from the food frequency questionnaire and from diet records suggest that these two dietary assessment methods have similar validity in the measurement of polyunsaturated fatty acid intake.
Adipose Tissue↗
Accountability and the NHS.
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Government↗
Type of postmenopausal hormone use and risk of breast cancer: 12-year follow-up from the Nurses' Health Study.
We prospectively examined the use of hormone replacement therapy in relation to breast cancer incidence in a cohort of women 30 to 55 years of age in 1976. During 12 years of follow-up (480,665 person-years) among postmenopausal women, 1,050 incident cases of breast cancer were documented. Overall, past users of replacement estrogen were not at increased risk. After adjustment for established risk factors, type of menopause, age at menopause, and current age, the rate ratio (RR) was 0.91, 95 percent confidence interval (CI) = 0.78-1.07. The risk of breast cancer was elevated significantly among current users (RR = 1.33, CI = 1.12-1.57); after adjusting for age, we observed no evidence of increasing risk with increasing duration of use among current users (P trend = 0.41), or among past users (P trend = 0.46). Women currently using unopposed estrogen (RR = 1.42, CI = 1.19-1.70), estrogen and progesterone (RR = 1.54, CI = 0.99-2.39), or progesterone alone (RR = 2.52, CI = 0.66-9.63), were all at increased risk of breast cancer compared with never users. These data suggest that long-term past use of estrogen replacement therapy is not related to risk, that current estrogen use increases risk of breast cancer to a modest degree, and that the addition of progesterone does not remove the increased risk observed with current use of unopposed estrogen.
Adult↗
Ethnicity, morbidity and health service utilization in two Labrador communities.
This paper compares total outpatient health care utilization of residents of the Labrador community of Sheshatshit, a predominantly native Innu settlement, with those for the adjacent and predominantly caucasian community of Northwest River for 1986. In lieu of a community survey, these data provide an approximation of the morbidity patterns within the populations. Findings indicate that the native population experiences proportionately more infectious diseases (39.3% of all visits compared to 12.5% of all visits for the non-native community). While residents of the Innu community utilize health services primarily for curative care, residents of Northwest River sought services for both curative and preventive care. It is concluded that inequalities in material wellbeing may underlie the morbidity in Sheshatshit. While desirable in light of the WHO Ottawa Charter, any modification of the health services on account of these morbidity patterns will have only modest effect until policy-based initiatives to reduce material inequalities are implemented.
Adolescent↗
Doctors as managers: poachers turned gamekeepers?
Doctors in health care systems of different types are coming under increasing pressure to take on active roles in management. Mounting concern among governments over the escalating costs of health care, coupled with a desire to improve the quality of care and render services more responsive to user preferences has resulted in management being viewed as offering an effective means of tackling these issues. Until recently, the favoured strategy was to strengthen management in order to curb doctors' discretionary decision-making. There is now a shift towards creating managers out of doctors with all that this implies for the future shape of health services. There are also issues about the training and development required for a management role, the stratification of roles within the medical profession, and the future status of lay, or non-medical managers. The paper reviews the debate about doctors and managers and their distinctive value bases. It suggests that doctors can be involved in management as managers at two levels--meso and micro--and considers the issues raised at each level. The paper presents an analysis of the wider context in which the debate about doctors as managers is taking place. The main thesis put forward is that far from managers incorporating doctors, the end result may prove to be the other way round with 'provider capture' of the management agenda in health services a distinct possibility. In contrast to managers, doctors retain enormous public respect and support. As long as it is so doctors will remain powerful stakeholders in defining and controlling the shape and range of health services available. Their active involvement in management could lead to a strengthening of their position. It is argued that, paradoxically, this could make it more difficult for governments to challenge doctors' work practices. Medicine's traditional preoccupations and its resilience to change are likely to remain as strong as ever thereby disappointing advocates of a health and social care system located in a broader policy framework which emphasises health gain and a holistic approach to health.
Attitude of Health Personnel↗
Diet and risk of basal cell carcinoma of the skin in a prospective cohort of women.
We conducted a prospective study of diet in relation to the incidence of basal cell carcinoma of the skin in a cohort of 73,366 women who were 34 to 59 years old in 1980 and without previous skin or other cancer. During 4 years of follow-up, 771 incident cases of basal cell carcinoma were diagnosed. When adjusted for other risk factors, women in the highest quintile of energy intake were at higher risk of basal cell carcinoma compared with those in the lowest quintile (relative risk, 1.28; 95% confidence interval, 1.02 to 1.60). No significant associations were observed between risk of basal cell carcinoma and energy-adjusted intake of dietary fat, carotenoids with vitamin A activity, and retinol, vitamin C, vitamin D, and vitamin E, either with or without supplements. Use of specific vitamin A, C, D, or E supplements, or multivitamins, did not materially alter risk. Although the period of follow-up was relatively short, these data are most consistent with no major role for these nutrients in the etiology of basal cell carcinoma.
Adult↗
Effect of carbetocin, a long-acting oxytocin analog on the postpartum uterus.
Carbetocin, a long-acting oxytocin analog, was administered by intravenous and intramuscular injection to 40 women 24 to 48 hours postpartum. Intravenous injection of 8 to 30 micrograms produced a tetanic uterine contraction within 2 minutes, lasting about 6 minutes, followed by rhythmic contractions for a further 60 +/- 18 minutes. Intramuscular injection of 10 to 70 micrograms also produced tetanic contraction in less than 2 minutes, lasting about 11 minutes, and followed by rhythmic contractions for an additional 119 +/- 69 minutes. The prolonged duration of activity after intramuscular compared with the intravenous carbetocin was significant (p = 0.020). Carbetocin produced mild lower abdominal cramping in most patients and severe pain in three patients who received 50 or 100 micrograms intravenously or 70 micrograms intramuscularly. Approximately half of the patients also experienced flushing and warmth. Although carbetocin has not yet been studied immediately postpartum, its prolonged uterine activity suggests that carbetocin may offer advantages over oxytocin in management of the third stage of labor.
Adult↗
Reproductive knowledge, and contraceptive awareness and practice among secondary school pupils in Bagamoyo and Dar-es-Salaam, Tanzania.
Reproductive knowledge, and contraceptive awareness and practice were assessed among secondary school pupils in Bagamoyo and Dar-es-Salaam, Tanzania. Four classes from four government secondary schools were randomly selected within strata of year of schooling, and students were interviewed using a structured questionnaire. All 490 pupils in selected classes participated in the study. Of 481 respondents with complete data, 315 (65.5 pc) were males and 166 (34.5 pc) were females; 256 (53.2 pc) were from Dar-es-Salaam while 225 (46.8 pc) were from Bagamoyo. Two hundred and ninety three (60.9 pc) respondents reported they were sexually active. However, only 77 (17.0 pc) pupils knew the "safe period" within the menstrual cycle and 329 (68.4 pc) pupils were able to spontaneously mention at least one method of contraception. Less contraceptive awareness was noted among respondents below 18 years of age particularly among females in both study areas. Only 45 (15.4 pc) pupils had ever used a contraceptive method. Despite a reasonable level of awareness and a positive attitude towards contraception, only a small proportion of sexually active pupils had ever used contraceptives. More research is required to identify the barriers to contraceptive use in the presence of knowledge.
Adolescent↗