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Biomedical subjects

J B Brown

Publications and source records attributed to J B Brown.

At least 55 records · Page 3Linked to original sources
PubMed1999

First 20 months' experience with use of metformin for type 2 diabetes in a large health maintenance organization.

OBJECTIVE: To assess adherence to prescribing guidelines, continuation rates, population effects on glycemic control, and occurrence of lactic acidosis during the first 20 months of the availability of metformin in a large health maintenance organization. RESEARCH DESIGN AND METHODS: A retrospective cohort study was performed in the 90,000-member diabetes registry of Kaiser Permanente, northern California. Principal study measures were the proportions of patients started on metformin who met prescribing guidelines (previously on sulfonylureas, HbA1c, obesity, creatinine), the change in HbA1c at 6 months after starting metformin, and hospitalization rates for lactic acidosis. RESULTS: A total of 9,875 patients received metformin during this interval. At least 74% were previously treated with sulfonylureas alone, 81% had baseline HbA1c > or = 8.5%, 71% were obese, and 99% had a serum creatinine < or = 1.5 mg/dl. Among patients on sulfonylureas at baseline, those starting metformin had significantly lower HbA1c levels 6 months later than those not started, after adjustment for age, sex, and the higher baseline levels in those started (adjusted difference: 0.5%, P < 0.0001). Patients starting metformin as initial monotherapy also improved significantly, but patients previously treated with insulin (with or without sulfonyl-ureas) had slightly higher follow-up HbA1c levels than similar patients not starting metformin. Continuation of metformin at 12 months was significantly higher for patients previously treated with sulfonylureas than other groups. One probable case of lactic acidosis was identified during 4,502 person-years on metformin. CONCLUSIONS: Adherence to prescribing guidelines was relatively high during metformin's first 20 months of availability. Glycemic control improved substantially for patients previously treated with sulfonylureas. Lactic acidosis was rare.

Adolescent↗
PubMed1999

Type 2 diabetes: incremental medical care costs during the first 8 years after diagnosis.

OBJECTIVE: To describe and analyze the time course of medical care costs caused by type 2 diabetes, from the time of diagnosis through the first 8 postdiagnostic years. RESEARCH DESIGN AND METHODS: From electronic health maintenance organization (HMO) records, we ascertained the ongoing medical care costs for all members with type 2 diabetes who were newly diagnosed between 1988 and 1995. To isolate incremental costs (costs caused by the diagnosis of diabetes), we subtracted the costs of individually matched HMO members without diabetes from costs of members with diabetes. RESULTS: The economic burden of diabetes is immediately apparent from the time of diagnosis. In year 1, total medical costs were 2.1 times higher for patients with diabetes compared with those without diabetes. Diabetes-associated incremental costs (type 2 diabetic costs minus matched costs for people without diabetes) averaged $2,257 per type 2 diabetic patient per year during the first 8 postdiagnostic years. Annual incremental costs varied relatively little over the period but were higher during years 1, 7, and 8 because of higher-cost hospitalizations for causes other than diabetes or its complications. CONCLUSIONS: For the first 8 years after diabetes diagnosis, patients with type 2 diabetes incurred substantially higher costs than matched nondiabetic patients, but those high costs remained largely flat. Once the growth in costs due to general aging is controlled for, it appears that diabetic complications do not increase incremental costs as early as is commonly believed. Additional research is needed to better understand how diabetes and its diagnosis affect medical care costs over longer periods of time.

Antihypertensive Agents↗
PubMed1999

Peer consultation reflection exercise.

OBJECTIVE: To explore participants' overall perception of the value of the Peer Consultation Reflection Exercise (PCRE); of barriers and facilitators to participation and learning during a PCRE; and of the transferability of the experience to participants' own settings. DESIGN: This study used the qualitative techniques of key informant interviews and a focus group. SETTING: Focus group and key informant interviews at the 1996 Annual Meeting of the College of Family Physicians of Canada's Section of Teachers. PARTICIPANTS: Family medicine teachers attending a PCRE. METHOD: Five key informant interviews and one focus group composed of five participants were conducted to explore participants' experience of participating and learning during a PCRE. MAIN FINDINGS: Participants viewed the PCRE as a valuable opportunity to interact and learn from colleagues a were especially impressed with the opportunity to listen. Confidentiality and the important role of the facilitator were identified as key components. The greatest perceived barrier was the formal structure of the PCRE. CONCLUSIONS: The PCRE is an innovative strategy for personal and professional development. It could be used in other settings.

Adult↗
PubMed1999

Evidence on patient-doctor communication.

This chapter covers important and well-studied aspects of patient-doctor communication. First the paper describes the lessons learned from studies about patients' satisfactions or dissatisfactions related to patient-doctor communication, making the point that complaints about doctors are usually due to communication problems and not technical competency issues. The next section of the chapter deals with time. It is often assumed that effective communication is inefficient. While this is not necessarily the case, the research results are complex and very interesting. The third part of the chapter covers communication in relation to patient adherence with the management plan recommended by the doctor. There is strong evidence that communication affects patient adherence and that there are four key aspects of communication that can enhance the patients' co-operation with the management plan. The final topic is patients' health. Twenty-two studies indicate the generally positive effect of key dimensions of communication on actual patient health outcomes such as pain, recovery from symptom, anxiety, functional status, and physiologic measures of blood pressure and blood glucose.

Attitude to Health↗
PubMed1998

Definition of the potentially fertile period from urinary steroid excretion rates. Part II. A threshold value for pregnanediol glucuronide as a marker for the end of the potentially fertile period in the human menstrual cycle.

Application of time series analysis to a database containing serial pregnanediol data from 113 complete ovulatory menstrual cycles contributed by 83 women of proven fertility and 68 cycles for which pregnanediol values were available over the ovulatory period, detected the first statistically significant risk in pregnanediol excretion for all cycles for which a baseline was available (n = 170). However, even at the 99% confidence level, for 22% of cycles a rise was observed before the presumed day of ovulation. Therefore, a threshold value for pregnanediol was sought from the database as a better marker for the end of fertility. A value of 1.4 mg per 24 h was not reached before day 2 after the pre-ovulatory estrogen peak day for 96% of the cycles. In the remaining 4% of cycles it was reached one day after the total estrogen peak day. The validity of this threshold was confirmed in extensive studies using the Ovarian Monitor where the equivalent is 6.3 mumol per 24 h of pregnanediol glucuronide and measurements are performed on timed urine specimens with a minimum collection time of three hours. These studies were as follows: 1) a World Health Organization study on the use of the Ovarian Monitor as a fertility self test in the home (108 cycles), 2) a multicenter study on returning fertility during breast feeding conducted by Family Health International (73 women), and 3) the general application of the Ovarian Monitor for pregnancy achievement and avoidance during the past ten years (over 250,000 PdG assays performed in ten countries). With rare exceptions, the use of these threshold values is applicable for all women provided correction is made for urine volume.

Biomarkers↗
PubMed1998

Hormone replacement therapy: determinants of women's decisions.

Hormone replacement therapy: determinants of women's decisions. The purpose of this qualitative study was to explore the decision-making process used by menopausal women initiating or remaining on hormone replacement therapy (HRT), stopping HRT, or never starting HRT. Eight focus groups, composed of women reflecting these categories, were conducted. Four major themes or spheres of influence emerged as important in the women's decision-making process: the woman's internal influence--the interface between her perceptions and feelings including the symptoms of menopause, the benefits realized by HRT usage, and the experiences of negative side effects; interpersonal relationships, including the patient-physician relationship, family, friends and information networks; external influences, such as ageism and sexism; and consequences resulting from whichever treatment decision was chosen. A new concept was elucidated called "weighted influence" to underscore the dynamic interplay among the spheres. As information about HRT continues to grow and change, an understanding and application of these spheres of influence can assist physicians in engaging in a dialogue with their patients that allows individual evaluation and application of this new information.

Adult↗
PubMed1998

Gender differences in FFM accumulation and architectural characteristics of muscle.

PURPOSE: The purpose of this study was to gain insight into the skeletal muscle development potential in women and to evaluate the contribution of muscle pennation angle (PANG) and fascicle length to gender differences in muscle size or FFM accumulation. METHODS: Skeletal muscle architectural characteristics and FFM were studied in 29 strength-trained female and 22 age- and height-matched male college athletes. Muscle thickness (MTH) was measured by B-mode ultrasound at 13 anatomical sites. Isolated MTH and PANG of the triceps long head (TL), vastus lateralis (VL), and gastrocnemius medialis (MG) muscles were measured in vivo, and fascicle length was estimated. RESULTS: Six female athletes had more than 60 kg of FFM, with the largest being 82.1 kg. In general, male athletes had a significantly greater FFM and MTH at all sites except for the anterior thigh. Isolated MTH and PANG of the TL, VL, and MG were greater in males. There were no gender differences in limb length or fascicle length of the three isolated muscles. A significant correlation was observed between MTH and PANG for TL (r = 0.84) and MG (r = 0.41), but not for VL. CONCLUSIONS: In contrast to previous estimates, we conclude that the theoretical upper limit of FFM accumulation and FFM-to-height ratio in women is greater than 80 kg and 0.44 kg.cm-1, respectively. Gender differences in PANG appear to be related to differences in muscle size (MTH) and do not appear to contribute independently to the gender difference in FFM.

Adipose Tissue↗
PubMed1998

Lactic acidosis rates in type 2 diabetes.

OBJECTIVE: To provide a context for the interpretation of lactic acidosis risk among patients using metformin, we measured rates of lactic acidosis in patients with type 2 diabetes before metformin was approved for use in the U.S. RESEARCH DESIGN AND METHODS: Using electronic databases of hospital discharge diagnoses and laboratory results maintained by a large, nonprofit health maintenance organization (HMO). we identified possible lactic acidosis events in three geographically and racially diverse populations with type 2 diabetes. We then reviewed hard-copy clinical records to confirm and describe each event and determine its likely cause(s). RESULTS: From >41.000 person-years of experience, we found four confirmed, three possible, and three borderline cases of lactic acidosis. In each case, we identified at least one severe medical condition that could have caused the acidosis. The annual confirmed event rate is similar to published rates of metformin-associated lactic acidosis. CONCLUSIONS: Lactic acidosis occurs regularly, although infrequently, among persons with type 2 diabetes, at rates similar to its occurrence among metformin users. The medical conditions with which both metformin-associated and naturally occurring lactic acidosis co-occur are also its potential causes. The observed association between metformin and lactic acidosis may be coincidental rather than causal. This possibility merits further study

Acidosis, Lactic↗
PubMed1998

Factors influencing palliative care. Qualitative study of family physicians' practices.

OBJECTIVE: To examine factors that influence family physicians' decisions to practise palliative care. DESIGN: Qualitative method of in-depth interviews. SETTING: Southwestern Ontario. PARTICIPANTS: Family physicians who practise palliative care on a full-time basis, who practise on a part-time basis, or who have retired from active involvement in palliative care. METHOD: Eleven in-depth interviews were conducted to explore factors that influence family physicians' decisions to practise palliative care and factors that sustain their interest in palliative care. All interviews were audiotaped and transcribed verbatim. The analysis strategy used a phenomenological approach and occurred concurrently rather than sequentially. All interview transcriptions were read independently by the researchers, who then compared and combined their analyses. Final analysis involved examining all interviews collectively, thus permitting relationships between and among central themes to emerge. MAIN OUTCOME FINDINGS: The overriding theme was a common philosophy of palliative care focusing on acceptance of death, whole person care, compassion, communication, and teamwork. Participants' philosophies were shaped by their education and by professional and personal experiences. In addition, participants articulated personal and systemic factors currently affecting their practice of palliative care. CONCLUSIONS: Participants observed that primary care physicians should be responsible for their patients' palliative care within the context of interdisciplinary teams. For medical students to be knowledgeable and sensitive to the needs of dying patients, palliative care should be given higher priority in the curriculum. Finally, participants argued compellingly for transferring the philosophy of palliative care to the overall practice of medicine.

Adult↗
PubMed1998

Understanding and preventing osteoporosis.

1. Osteoporosis is a condition in which the amount of bone tissue is so low that the bones easily fracture in response to minimal force. 2. Osteoporosis affects more than 25 million Americans, 80% of whom are women. Because osteoporosis is a "silent disease" that can progress undetected for decades, early screening can identify women at risk which may help avert the escalation of this health problem. 3. Risk factors include older age; female; white or Asian ethnicity; normal or early menopause; lifestyle factors including smoking, excessive alcohol intake, little or no exercise, taking inadequate amounts of calcium; medications and disease; and heredity. 4. Prevention efforts need to be directed toward education related to the need for adequate dietary calcium and the need for weight bearing exercise. Health care providers should develop methods for screening clients to determine whether they are at risk and need a bone density test.

Aged↗
PubMed1998

Roles and influence of people who accompany patients on visits to the doctor.

OBJECTIVES: To determine the proportion of patients who are accompanied by another person (ie, partner, child, relative, friend) during visits to their doctors; to describe the demographic characteristics and role(s) assumed by the main accompanying person and the nature of the presenting dyads; and to describe the influence of the main accompanying person on the patient-doctor interaction. DESIGN: Prospective observational survey. SETTING: Family practices in London, Ont, and surrounding area. PARTICIPANTS: Eight family physicians completed surveys on 100 consecutive patients attending for both regularly scheduled and emergency visits. MAIN OUTCOME MEASURES: Roles and influence of the main accompanying person. RESULTS: Approximately one third (30.4%) of patients were accompanied during visits to their doctors. Children and patients older than 75 years most frequently had another person with them. Most patients (74.1%) were accompanied by one person who most often was female (72.6%) and between the ages of 21 and 40 years (53.6%). The accompanying person's role was most frequently described by doctors as an advocate for the patient (n = 235, 68.5%). If the accompanying person was a child, however, the role was most often described as a silent observer (n = 36, 68.6%). The influence of the main accompanying person on the patient-doctor encounter was usually described as positive (95.1%). CONCLUSIONS: Physicians report that people accompanying patients usually have a positive influence on medical encounters. Future studies need to include patients' and accompanying persons' perspectives.

Adolescent↗
PubMed1997

Fertility of fully breast-feeding women in the early postpartum period.

OBJECTIVE: To examine bleeding between 6 and 8 weeks postpartum in fully breast-feeding women and its association with fertility as assessed by hormone analysis. METHODS: Seventy-two fully breast-feeding women were followed prospectively from 42 days postpartum. Vaginal bleeding was recorded daily. Women who experienced bleeding were compared with women who did not with respect to time of ovulation and time of first menses. RESULTS: Nearly half of the women experienced some vaginal bleeding or spotting between 6 and 8 weeks postpartum. These women eventually menstruated and ovulated earlier than the women who did not bleed, but the differences were not significant. The study had 34% and 45% power to detect a 20% difference in the proportion menstruating and ovulating, respectively, at 6 months postpartum, and 10% and 16% power to detect the same differences at 1 year. Seven women experienced ovarian follicular development before day 56, but neither bleeding nor follicular development was associated with ovulation in any woman in the first 8 weeks postpartum. CONCLUSIONS: It is unlikely that vaginal bleeding in fully breast-feeding women in the first 8 weeks postpartum represents a return to fertility.

Female↗
PubMed1997

Effects of age and non-hormonal contraception on menstrual cycle characteristics.

The objective of this study was to investigate the effects of age and non-hormonal contraceptive method on menstrual cycle parameters. The menstrual cycle data were collected prospectively, and the study was cross-sectional with regard to age. The subjects were 142 women, including 14 asymptomatic volunteers and 128 women who presented to a premenstrual tension (PMT) clinic. The age range was 20-45 years. Contraceptive methods used were intrauterine device (IUD) (n = 12), tubal ligation (n = 61) and non-intensive methods (n = 69). Daily menstrual cycle diaries were used to calculate cycle length and number of days of menstruation. Daily 24-h urine collections were used to calculate the day of the preovulatory estrogen peak. Pearson correlations found significant relationships between age and preovulatory estrogen peak day (p < 0.001) and length of cycle (p < 0.002), but not between age and length of menstruation or luteal phase. Analysis of variance was highly significant for age and contraceptive method, for both cycle length and preovulatory estrogen peak day. Non-intrusive contraception users aged 30 years and younger had significantly longer follicular phases than did women with tubal ligation (p < 0.05). It was concluded that cycle length decreases with age due to shortening of the follicular phase. Further research on whether tubal ligation affects ovulation and follicular phase length in young women is needed.

Adult↗
PubMed1997

Barriers and facilitators to seniors' independence. Perceptions of seniors, caregivers, and health care providers.

OBJECTIVE: To identify barriers and facilitators to independence as perceived by seniors with chronic health problems and their caregivers. In particular, researchers sought insights into seniors' experience of medical, home-based, and public health services. DESIGN: This study used the qualitative method of focus groups. SETTING: London, Ont, and surrounding area. PARTICIPANTS: Seniors with chronic health problems and informal and formal caregivers were purposefully selected to participate. METHOD: Seven focus groups composed of seniors, informal caregivers, and health care providers representing each of the three primary care areas (medical, home-based, and public health) explored the barriers and facilitators to seniors' independence. MAIN FINDINGS: Four main themes characterized the barriers and facilitators to seniors' independence: attitudes and attributes, service accessibility, communication and coordination, and continuity of care. CONCLUSIONS: Knowledge of barriers and facilitators to seniors' independence in the context of the health care system provides insight into how seniors can be empowered to remain independent. Health care providers need to communicate better, to foster more positive attitudes toward aging, and to participate in refining service access, coordination of services, and continuity of care.

Activities of Daily Living↗
PubMed1997

Long-term attendance at a family practice teaching unit. Qualitative study of patients' views.

OBJECTIVE: To identify the factors that contribute to patients' long-term attendance at a family practice teaching unit. DESIGN: Qualitative method of focus groups. SETTING: A community-based family practice teaching unit in southwestern Ontario. PARTICIPANTS: Patients who had been coming to St Joseph's Family Medical Centre for more than 15 years were purposefully selected to participate. METHOD: Five focus groups composed of patients who had been affiliated with one of the three practices at the Centre for more than 15 years explored factors contributing to long-term attendance. MAIN FINDINGS: Four key themes were identified as the primary factors contributing to long-term attendance: the relationship context, the team concept, professional responsibility and attitudes, and comprehensive and convenient care. CONCLUSION: The resource-rich era of medical care, during which participants formulated their views and opinions about the factors contributing to their long-term attendance at a family practice teaching unit, has come to a close. The findings of this study provide important information that could help maintain one of the basic tenets of family medicine-continuity of care.

Adult↗
PubMed1996

A prospective study of urinary oestrogen excretion and breast cancer risk.

To test the hypothesis that high levels of endogenous oestrogens increase the risk for developing breast cancer, concentrations of oestrone, oestradiol and oestriol were measured in 24 h urine samples from 1000 women participants in a prospective study of breast cancer on the island of Guernsey. Sixty-nine subjects were diagnosed with breast cancer subsequent to urine collection. Among women who were premenopausal at the time of urine collection, cases excreted less oestrogen than controls; the odds ratios (95% CI) for breast cancer in the middle and upper thirds of the distribution of oestrogen excretion, in comparison with the lower third (reference group, assigned odds ratio = 1.0), were 0.5(0.2-1.2) and 0.4(0.2-1.1) respectively for oestrone, 0.8(0.4-1.8 and 0.4(0.2-1.1) for oestradiol, 0.7(0.3-1.6) and 0.7(0.3-1.6) for oestriol and 0.9(0.4-2.0) and 0.5(0.2-1.3) for total oestrogens. Among women who were post-menopausal at the time of urine collection, the trend was in the opposite direction, with an increase in risk associated with increased oestrogen excretion; the odds ratios were 0.9(0.3-2.2) and 1.1(0.5-2.8) for oestrone, 0.8(0.3-2.3) and 1.9(0.8-4.6) for oestradiol, 1.5(0.6-3.9) and 1.8(0.7-4.6) for oestriol and 0.9(0.4-2.6) and 1.9(0.7-4.7) for total oestrogens. The trends of increasing risk with increasing oestrogen excretion among post-menopausal women were statistically significant for oestradiol (P = 0.022) and for total oestrogens (P = 0.016). We conclude that high levels of endogenous oestrogens in post-menopausal women are associated with increased breast cancer risk, but that the relationship of oestrogens in premenopausal women with risk is unclear.

Adult↗