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Biomedical subjects

G Rubin

Publications and source records attributed to G Rubin.

At least 37 records · Page 2Linked to original sources
PubMed2001

Validation of self-reported hearing loss. The Blue Mountains Hearing Study.

PURPOSE: Large-scale epidemiological studies have often used self-report to estimate prevalence of age-related hearing loss. However, few large population-based studies have validated self-report against measured hearing loss. Our study aimed to assess the performance of a single question and a brief hearing handicap questionnaire in identifying individuals with hearing loss, against the gold standard of pure-tone audiometry. METHODS: We examined 2015 residents, aged 55-99 years, living in the west of Sydney, Australia, who participated in the Blue Mountains Hearing Study during 1997-1999. Audiologists administered a comprehensive questionnaire, including the question: 'Do you feel you have a hearing loss?' The Shortened Hearing Handicap Inventory for Elderly (HHIE-S) was also administered during the hearing examination, which included pure-tone audiometry. The single question and HHIE-S were compared with measured losses at levels >25, >40 and >60 decibels hearing level (dBHL) to indicate mild, moderate and marked hearing impairment, for pure-tone averages (PTA) of responses to 500, 1000, 2000 and 4000 Hz. RESULTS: The single question yielded reasonable sensitivity and specificity for hearing impairment, and was minimally affected by age and gender. HHIE-S scores >8 had lower sensitivity but higher specificity and positive predictive value. The HHIE-S performed slightly better in younger than older subjects and performed better for moderate hearing impairment. CONCLUSIONS: In this older population with a high prevalence of hearing loss (39.4%), both a question about hearing and the HHIE-S appeared sufficiently sensitive and specific to provide reasonable estimates of hearing loss prevalence. Both could be recommended for use in epidemiological studies that aim to assess the magnitude of the burden caused by age-related sensory impairment but cannot measure hearing loss by audiometry.

Aged↗
PubMed2001

Modelling strategies for reducing pharmaceutical costs in hospital.

OBJECTIVE: To describe drug utilization and cost in a large hospital and to compare the impact of different strategies on cost associated with drug prescribing. DESIGN: Retrospective data on drug utilization and cost, linked to patient clinical data and prescriber data from November 1998 were analyzed and modelled. MAIN OUTCOME MEASURES: Impact of different strategies for cost control. SETTING: A large hospital in Sydney, Australia. RESULTS: The mean cost of drugs per episode of care was 28 Australian dollars. Of all drug costs, 79% was incurred by medical units and 14% by surgical units. Oncology accounted for 42% and inpatients for 91% of drug costs. Although section-100 (S-100) drugs incurred a high cost (640 dollars) per episode of care, there were only 41 episodes where S-100 drugs (expensive, restricted drugs) were used, and the total cost of S-100 drugs was only 3.7% of the total cost to the hospital. Antibiotics were the most commonly prescribed drug category, prescribed in 14% of all hospital episodes, and accounting for 14% of total drug costs. Anti-ulcer drugs were the next most costly group, accounting for 7% of total drug costs. A 20% reduction in use of antibiotics would save four times that (233,832 dollars pa) of a 20% reduction in use of S-100 drugs (61,392 dollars pa). DISCUSSION: Our study suggests that reducing inappropriate use of high volume drugs such as antibiotics could be more effective in optimising health facility drug budgets than attempts concentrating solely on reducing use of high cost drugs alone. Moreover our study suggests that systematic measurement of drug utilisation patterns is a key element of drug cost control strategies.

Cost Allocation↗
PubMed2001

Tissue-specific estrogen biosynthesis and metabolism.

While the ovaries are the principal source of systemic estrogen in the premenopausal nonpregnant woman, other sites of estrogen biosynthesis are present throughout the body and these become the major sources of estrogen beyond menopause. These extragonadal sources of estrogen are small, but may play an important, though hitherto largely unrecognized, physiological and pathophysiological role. Aromatase activity in extragonadal sites contributes to this source of estrogen and may contribute to breast tumor development and/or growth. Selective aromatase modulators (SAMs) may have a role to play in the treatment of estrogen-dependent diseases, such as breast cancer.

Animals↗
PubMed2000

Rethinking patient satisfaction: patient experiences of an open access flexible sigmoidoscopy service.

The high morbidity and mortality rates for colo-rectal cancer in Teesside, UK, have led to the initiation of an open access service in two local National Health Service Trust hospitals. This paper reports the results of a pilot patient satisfaction study of the service using a combination of participant-observation, in-depth interviews and questionnaire methods. Although offering a standardised service, ethnographic study revealed interesting differences in practice and follow-up procedures between the two hospitals. Patients, both verbally and on paper, expressed high levels of satisfaction with the services offered at both hospitals, yet in-depth, qualitative research revealed a more complex picture. The evidence from this research will be used to argue that standard consumer satisfaction questionnaires of health provision are inadequate indicators of patients' experience of health care delivery.

Adult↗
PubMed2000

Measuring client clinical progress in therapeutic community treatment. The therapeutic community Client Assessment Inventory, Client Assessment Summary, and Staff Assessment Summary.

The therapeutic community (TC) Client Assessment Inventory (CAI), Client Assessment Summary (CAS), and Staff Assessment Summary (SAS) are instruments developed from a comprehensive theory of TC treatment and recovery. They measure client self-report and staff evaluation of client progress along 14 domains of behavior, attitude, and cognitive change. The present article reports on the development of the instruments and findings from an analysis of data on 346 clients in TC treatment; including scale properties and cross-sectional client differences by treatment tenure. The instruments were administered over a 1-year period at two residential TC facilities. Findings indicate that both client and staff instruments reliably differentiate client clinical changes during treatment and client self-ratings are initially consistently higher than staff ratings. Clarifying and measuring changes in the individual during treatment is the first step in the effort to understand the change process and what steps can be taken to improve treatment effectiveness.

Adult↗
PubMed2000

The role of local estrogen biosynthesis in males and females.

Natural (human) and experimental (mouse) models of estrogen insufficiency have revealed hitherto unexpected roles for estrogens in both males and females. In postmenopausal women, and in men, estrogen no longer has a major role as a circulating hormone, but rather it functions locally as a paracrine or even 'intracrine' factor in tissue sites where it is formed. As a consequence, the tissue-specific nature of aromatase production assumes physiological and pathophysiological significance. The availability of circulating precursors is also important in sites where there is no local supply of C19 precursors, particularly in elderly women. The potential clinical significance of these findings in terms of the development of new therapeutic modalities is discussed.

Adipose Tissue↗
PubMed2000

Introduction

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Journal Article↗
PubMed2000

Tests for Helicobacter pylori infection: a critical appraisal from primary care.

BACKGROUND: Testing of patients for Helicobacter pylori infection is common in primary care settings. The accuracy of such tests has been assessed and critical appraisal of this literature can inform the clinical management of patients suspected of being infected with H. pylori METHODS: Literature evaluating the accuracy of diagnostic tests for H.pylori infection was sought as part of a systematic review of literature concerning the management of patients infected with H.pylori Studies were appraised and estimates of sensitivity and specificity were extracted. Positive and negative likelihood ratios (LRs) were calculated and the implications for post-test probabilities are reported. RESULTS: The sensitivity, specificity, LR+ and LR- for H.pylori infection tests ar: [(13)C]urea breath test (UBT), 96.5, 96, 24 and 0.04; [(14)C]UBT, 97.5, 95.5, 21 and 0.03; serology, 91, 89.5, 8 and 0.11; near patient tests, 77, 74, 3 and 0. 31; and meta-analysis of serology, 85, 79, 4 and 0.19. The range of pre-test probabilities of H.pylori infection in which the diagnostic tests were useful, estimated from primary studies, wer: [(13)C]UBT, 20-90%; [(14)C]UBT, 20-99%; serology, 30-80%; and near patient tests, 50-60%. CONCLUSIONS: Tests for H.pylori infection are useful in primary care when the pre-test probability of infection is neither too high nor too low. This indicates that the tests may not be useful for screening purposes but may help with differential diagnosis. Outside moderate pre-test probability ranges, the chances of a result being false is high, and such patients should either receive eradication without prior testing (if the probability of infection is sufficiently high) or the test result should be reconfirmed. When the pre-test probability falls below approximately 20%, a positive test result is unreliable. If the pre-test probability is above approximately 80%, a negative test result is unreliable. Clinical selection of patients needing testing should be used to limit testing to individuals with pre-test probabilities within these ranges. The choice of diagnostic H.pylori test should be influenced by the H.pylori infection rate in the population being tested and the test characteristics. Recommendations for the use of tests, especially near patient tests, should be reconsidered. This critical appraisal supports the recommendations of the European Society for Primary Care Gastroenterology guidelines, arrived at by consensus, for testing for H.pylori infection in primary care.

Bias↗
PubMed2000

Helicobacter pylori infection: a comparative review of existing management guidelines.

A central feature of general practice is the use of time in the management of patients and their illnesses. The use of active interventions such as investigations or therapies within the context of this dimension has implications for the development of clinical guidelines for primary care. Importantly, their recommendations of best practice must be compatible with the complexities of the holistic relationship between GP and patient. Many existing guidelines adopt a reductionist, algorithmic approach, losing applicability and relevance to primary care in the process. Here we identify the key features in the primary care management of the patient with dyspepsia, and examine the utility of existing guidelines for the management of Helicobacter pylori infection. Through this comparative analysis, the scope and nature of primary care-centred management guidelines are identified.

Algorithms↗
PubMed2000

The use of consensus to develop guidelines for the management of Helicobacter pylori infection in primary care. European Society for Primary Care Gastroenterology.

BACKGROUND: Guidelines are an increasingly important feature of clinical practice and have proliferated over the past decade. When the evidence base for effective practice is limited, guidelines have to derive from the opinions and experience of those with knowledge of the subject. The manner in which a group synthesizes its individual opinions, the consensus process, is central to the validity and applicability of the resulting recommendations. This paper considers the theoretical issues in consensus development and describes the consensus process used in developing the European Society for Primary Care Gastroenterology guidelines for the management of Helicobacter pylori in primary care. METHODS: A consensus development conference of 48 GPs from nine European countries used case scenarios to define clinical management strategies in dyspepsia and H.pylori infection. Structured data collection from this meeting allowed a quantitative measure of the extent of consensus to be produced. RESULTS: Specific recommendations were produced for 15 decision points relevant to the management of H.pylori infection in primary care. DISCUSSION: Consensus development is often utilized in the production of guidelines for clinical practice. Guideline appraisal instruments fail to examine in depth the methods used for this important part of the development process. We describe an approach to consensus development which contains a simple measure of the strength of consensus underlying each recommendation.

Anti-Bacterial Agents↗
PubMed2000

Guidelines on the management of H.pylori in primary care: development of an implementation strategy.

BACKGROUND: Clinical guideline programmes as being developed in many European countries contribute to quality of care in general practice. The applicability of multicountry guidelines will depend on country-specific circumstances. Implementation programmes are required for optimal compliance with guidelines. OBJECTIVE: In order to achieve optimal follow-up of the European Society for Primary Care Gastroenterology (ESPCG) Helicobacter pylori guidelines in general practice, we analysed factors that might obstruct compliance at national level, and integrated this in implementation programmes. METHOD: Discussion groups in eight participating countries reviewed epidemiological characteristics and diagnostic and therapeutic resources that would hinder applicability. The groups also indicated potential constraints to optimal compliance and developed a national implementation programme. RESULTS: Helicobacter pylori infection rates and peptic ulcer incidence vary widely across Europe, as do the availability, access and reimbursement of diagnostic test facilities for H.pylori Minor adaptation of the ESPCG guidelines is required in some countries. Implementation programmes have been developed and partially carried out in all countries. CONCLUSION: A pan-European approach to H.pylori guideline development should result in a framework of best practice into which nationally specific details can be incorporated, thus guaranteeing optimal follow-up of the guidelines and true improvement of dyspepsia management in primary care.

Benchmarking↗
PubMed2000

The management of Helicobacter pylori infection in primary care: a systematic review of the literature.

OBJECTIVE: The aim of the present study was to provide evidence from the literature to inform the production of guidelines by the European Society for Primary Care Gastroenterology (ESPCG) for the management of Helicobacter pylori infection in primary care. METHODS: A systematic review was conducted, searching MEDLINE, EMBASE and the Cochrane Library. The systematic review was designed to answer a number of question: the role of H.pylori in the aetiology of peptic ulcer disease (PUD), gastric cancer (GC), non-ulcer dyspepsia (NUD) and oesophagitis; non-invasive testing for H.pylori and post-treatment testing; eradication therapy; and cost issues. Selection of records concentrated on the highest quality studies, i.e. systematic reviews, meta-analyses and cost analyses. RESULTS: Helicobacter pylori infection is a causal factor in PUD and GC but not in NUD or oesophagitis. Serological tests and urea breath tests (UBTs) can be used for the detection of H.pylori, but UBT is the preferred choice for post-treatment testing. Proton pump inhibitor (PPI)-based triple regimens are the preferred eradication therapy. Eradication therapy is more cost-effective than long-term maintenance therapy. CONCLUSIONS: Strong evidence is available for answering questions on the aetiology of stomach ulcers and GU, eradication therapies and cost issues. Weaker evidence is available for answering the questions on the aetiology of NUD and non-invasive testing. No evidence is available for answering the question on the role of H.pylori in the aetiology of oesophagitis.

Anti-Bacterial Agents↗
PubMed2000

Budd-Chiari syndrome in a patient with ulcerative colitis: association with anticardiolipin antibodies.

This is the first reported case of a young patient with ulcerative colitis who developed acute Budd-Chiari syndrome and was found positive for anticardiolipin antibodies. Although an association between ulcerative colitis and Budd-Chiari syndrome, and between the latter and antiphospholipid antibodies, has been shown in the literature, the coexistence of these three conditions has never been reported. The patient we describe did poorly and was considered as a candidate for liver transplantation in spite of prompt heparin therapy, probably because of the presence of multiple risk factors.

Adult↗
PubMed1999

Development of obstructive hydrocephalus with lumboperitoneal shunting following subarachnoid hemorrhage.

Hydrocephalus is a frequent complication of subarachnoid hemorrhage (SAH). The optimum method of treating hydrocephalus in this setting has not been determined. We review our experience with patients developing communicating hydrocephalus secondary to SAH and subsequently treated with lumboperitoneal (LP) shunts. Following hospitalization for the treatment of SAH, patients who developed clinical symptoms and radiologic signs of hydrocephalus were treated with (ventriculoperitoneal) VP or LP shunting. Eighteen patients received an LP shunt, of which seven (28%) developed a non-communicating or obstructive hydrocephalus. These seven patients underwent replacement with a VP shunt and have not had further complications. In the setting of post-SAH communicating hydrocephalus, obstructive hydrocephalus may develop after LP shunt placement. Patients who develop this complication and have their LP shunts converted to VP shunts have a favorable prognosis.

Adult↗
PubMed1999

Factors affecting survival rates for acute vertebrobasilar artery occlusions treated with intra-arterial thrombolytic therapy: a meta-analytical approach.

OBJECTIVE: To determine whether recanalization, coma at presentation, or clot location in the basilar artery influences the relative mortality risk after intra-arterial thrombolytic therapy for acute vertebrobasilar artery occlusions. METHODS: Studies were identified using the MEDLINE database for January 1987 to November 1997. Series were included if they involved 10 or more patients with basilar or vertebrobasilar artery occlusions, used urokinase and/or recombinant tissue plasminogen activator, and were written in English. A fixed-effect meta-analysis approach was used to estimate the risk of death with the aforementioned risk factors. Each study was weighted according to sample size. Relative risks were calculated with 95% confidence intervals. RESULTS: As calculated from peer-reviewed published data, the relative mortality risk for patients for whom recanalization was attempted but not achieved was 2.34 (95% confidence interval, 1.48-3.71; n = 126). Coma at presentation was associated with a relative mortality risk of 1.95 (95% confidence interval, 1.26-2.99; n = 145). Clot locations in the distal one-third of the basilar artery were shown to favor survival, compared with clots located in the proximal and/or middle portions of the basilar artery (relative risk, 0.52; 95% confidence interval, 0.31-0.86; n = 126). CONCLUSION: The combined data suggest that coma at presentation has an independent and adverse effect on survival rates. Complete recanalization, distal clot location, and responsiveness at the time of presentation are statistically significant factors for increased patient survival rates.

Adolescent↗
PubMed1999

Local estrogen biosynthesis in males and females.

It is now apparent that in men and in postmenopausal women, estrogens have important physiological and pathophysiological roles. However, importantly, these actions are at a local level, namely paracrine, autocrine, and even 'intracrine' rather than endocrine in the classical sense. Thus for example local estrogen biosynthesis in the bones of men plays a hitherto unsuspected role in the maintenance of bone mineralization and in epiphyseal fusion; and in the testes, estrogen is essential for male germ cell development. On the other hand, in postmenopausal women, the mesenchymal cells of the breast are the major source of estrogen responsible for breast cancer development. This realization points to the importance of circulating C19 precursors in the maintenance of adequate estrogen biosynthesis in extragonadal sites and suggests the possibility of new therapies to block estrogen synthesis in a tissue-specific fashion.

Adipose Tissue↗
PubMed1999

Factors influencing compliance in long-term proton pump inhibitor therapy in general practice.

Long-term proton pump inhibitor (PPI) prescribing in general practice is common, but only a minority of patients request their prescriptions regularly. This study determined factors linked with compliance using questionnaires and diary cards. The chief factors determining whether or not patients took their PPIs were the presence or severity of symptoms and the desire to remain in personal control, together with a fear of side-effects and lack of knowledge about the drugs. As most such prescribing is for uncomplicated gastro-oesophageal reflux disease, on-demand therapy should now be formally advocated.

Adolescent↗