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Biomedical subjects

J Forbes

Publications and source records attributed to J Forbes.

At least 37 records · Page 2Linked to original sources
PubMed1998

Routine prenatal screening for HIV in a low-prevalence setting.

BACKGROUND: The objectives of this study were to assess the effect of British Columbia's June 1994 guidelines for prenatal HIV screening on the rate of maternal-fetal HIV transmission and to estimate the cost-effectiveness of such screening. METHODS: The authors conducted a retrospective review of pregnancy and delivery statistics, HIV screening practices, laboratory testing volume, prenatal and labour management decisions of HIV-positive women, maternal-fetal transmission rates and associated costs. RESULTS: Over 1995 and 1996, 135,681 women were pregnant and 92,645 carried to term. The rate of HIV testing increased from 55% to 76% of pregnancies on chart review at one hospital between November 1995 and November 1996. On the basis of seroprevalence studies, an estimated 50.2 pregnancies and 34.3 (95% confidence interval 17.6 to 51.0) live births to HIV-positive women were expected. Of 42 identified mother-infant pairs with an estimated date of delivery during 1995 or 1996, 25 were known only through screening. Of these 25 cases, there were 10 terminations, 1 spontaneous abortion and 14 cases in which the woman elected to carry the pregnancy to term with antiretroviral therapy. There was one stillbirth. One instance of maternal-fetal HIV transmission occurred among the 13 live births. The net savings attributable to prevented infections among babies carried to term were $165,586, with a saving per prevented case of $75,266. INTERPRETATION: A routine offer of pregnancy screening for HIV in a low-prevalence setting reduces the rate of maternal-fetal HIV transmission and may rival other widely accepted health care expenditures in terms of cost-effectiveness.

British Columbia↗
PubMed1998

Split thickness buccal mucous membrane grafts and beta irradiation in the treatment of recurrent pterygium.

BACKGROUND: Pterygium is a common problem and after surgical removal may recur in up to 80% of cases, depending on the technique of primary excision. Recurrent pterygia can be aggressive and repeated excision may result in severe conjunctival scarring and shortening, resulting in insufficient conjunctiva to perform further grafting and lid surgery. When there is insufficient autologous conjunctiva, mucous membrane must be obtained from other sites. Full thickness buccal mucous membrane grafts have been described, but they may result in a beefy red appearance, with graft contraction and a poor tear film. METHOD: The use of split thickness buccal mucous membrane grafts is described in three patients with recurrent pterygium, two in combination with lamellar keratoplasty. beta Irradiation was used as adjuvant therapy in all cases. RESULTS: In all three cases an acceptable cosmetic appearance was achieved, with no recurrence of the pterygium, and a good range of eye movements. CONCLUSIONS: It is recommended that split thickness buccal mucosal grafts, combined with beta irradiation, should be considered in complex cases of pterygium recurrence when there is insufficient autologous conjunctiva and conjunctival shortening with restricted eye movements.

Adult↗
PubMed1997

A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices.

The aim of this study was to compare transjugular intrahepatic portosystemic stent-shunt (TIPSS) with variceal band ligation (VBL) in the secondary prophylaxis of esophageal variceal hemorrhage in patients with cirrhosis. Fifty-eight patients with cirrhosis who presented with the first episode of esophageal variceal hemorrhage were randomized to TIPSS (31) or VBL (27), 24 hours after control of bleeding. Shunt function was assessed after 1 month and then at 6 monthly intervals thereafter. VBL was performed weekly until variceal eradication, and then at 3 months, 6 months, and yearly thereafter. Mean follow-up in the TIPSS group was 15.7 (+/-10.2) months; in the VBL group, it was 16.8 (+/-10.9) months. Results for rebleeding and mortality were analyzed on an intention-to-treat basis and using the Kaplan-Meier method. The frequency and the severity of variceal rebleeding was significantly lower in the TIPSS group (9.8%), compared with the VBL group (51.9%) (P < .0006). Although mortality rates were not significantly different, 8 of the patients who rebled in the VBL group required TIPSS therapy for uncontrolled bleeding. No significant differences were found in the frequency of other complications such as encephalopathy and sepsis. Patients in the VBL group required significantly greater time in the intensive care unit during the period of this study (<0.03). The total direct cost of treatment incurred was pound sterling 1,373 ($2,200) per patient, the cost being less in the patients treated with TIPSS compared with VBL. The results of this study show that TIPSS is superior to VBL for the secondary prophylaxis of variceal hemorrhage in patients with cirrhosis.

Adolescent↗
PubMed1997

An individual patient-based meta-analysis of tamoxifen versus ovarian ablation as first line endocrine therapy for premenopausal women with metastatic breast cancer.

We performed a meta-analysis of randomized trials comparing tamoxifen to ovarian ablation carried out either by surgery or irradiation as first-line hormonal therapy for pre-menopausal women with metastatic breast cancer. Patients in all trials included were required to have measurable disease and to be currently menstruating or within 1 year of cessation of menses, and to have estrogen receptor (ER) positive or unknown disease (ER negative women were admitted to one of the studies). Individual patient data were obtained from the four studies identified and the results updated to June 1992. A total of 220 eligible patients were enrolled in the four trials. There was no difference in overall response rate between tamoxifen and oophorectomy across the four trials (p = 0.94, Mantel-Haenszel test). The odds reduction for progression was 14% +/- 12% and for mortality 6% +/- 13% in favour of tamoxifen, results which were not statistically significant (p = 0.32 and 0.72, respectively). Although the design of all four studies included a cross-over to the other therapy, only 54/111 patients receiving ovarian ablation and 34/109 patients receiving tamoxifen as primary therapy actually crossed over to the other arm at the time of disease progression. Response to initial treatment with tamoxifen was predictive of subsequent response to ovarian ablation (p < 0.05), and response to initial therapy with ovarian ablation was predictive of subsequent response to tamoxifen (p < 0.05). Support curves based on log-likelihood ratios revealed that this meta-analysis provides moderate evidence rejecting a 14% advantage for ovarian ablation compared to tamoxifen in terms of odds of disease progression. A 25% advantage for ovarian ablation with respect to odds of death is also rejected with moderate evidence. We conclude that the efficacy of tamoxifen appears to be similar to that of ovarian ablation by surgery or irradiation as first-line therapy for premenopausal, ER positive metastatic breast cancer, and is unlikely to be substantially inferior.

Adult↗
PubMed1997

Menstrual cycle and timing of breast surgery in premenopausal node-positive breast cancer: results of the International Breast Cancer Study Group (IBCSG) Trial VI.

PURPOSE: It has been postulated that breast cancer surgery performed during the follicular phase of the menstrual cycle is associated with poorer outcome. PATIENTS AND METHODS: We tested this hypothesis by evaluating disease-free survival (DFS) for 1033 premenopausal patients who received definitive surgery either during the follicular phase (n = 358) or the luteal phase (n = 675). All patients were enrolled in a randomized trial conducted between July 1986 and April 1993. All had node positive breast cancer and randomization was stratified by estrogen receptor (ER) status. All patients received at least three cycles of adjuvant cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). The median follow-up was 60 months. RESULTS: Patients who underwent definitive surgery for breast cancer in the follicular phase had a slightly worse disease-free survival than those operated on during the luteal phase (five-year DFS percentage: 53% versus 58%; hazard ratio, 1.13; 95% confidence interval (CI), 0.94-1.38; P = 0.20). The effect was significantly greater for the subpopulation of 300 patients with ER-negative primaries (P = 0.02 interaction effect; five-year DFS percentages 42% vs. 59%; hazard ratio 1.60; 95% CI, 1.12-2.25; P = 0.008). The effect of timing of surgery diminished for analyses based on lesser surgical procedures, e.g., excisional biopsies. In particular, no effect of timing was observed for fine needle aspiration procedures. CONCLUSIONS: Surgical procedures which are more extensive than a fine needle aspiration biopsy might be associated with worse prognosis if conducted during the follicular phase of the menstrual cycle. This phenomenon was seen predominantly for high risk breast cancer with low levels or no estrogen receptors in the primary tumor.

Breast Neoplasms↗
PubMed1997

Quantification of human immunodeficiency virus type 1 RNA from dried plasma spots collected on filter paper.

To assess dried plasma spots (DPSs) as a source of material for virus quantification, human immunodeficiency virus type 1 (HIV-1) RNA levels were quantified in matched DPS and liquid plasma samples from 73 infected patients, including 5 neonates and 4 adult patients with acute HIV-1 infection. Quantifications were performed by commercially available assays (NASBA [nucleic acid sequence-based amplification] or Amplicor, or both). There was a strong correlation between HIV-1 RNA levels in plasma and DPSs. More importantly, there was no decline in HIV-1 RNA levels in DPSs stored for as long as 2 weeks at 20 degrees C. Similarly, storage of DPSs for 3 days at 37 degrees C resulted in no decrease in viral RNA levels. For patients with primary infection, the DPS method allowed for the measurement of RNA levels in plasma during the initial spike in the level of viremia and in the subsequent period of suppressed viral replication. DPS quantification was equally informative in the neonatal setting, with all five newborns showing HIV-1 RNA loads of greater than 4.991 log10 copies/ml. We conclude that the viral RNA levels in DPSs are equivalent to those measured in fresh-frozen plasma. The ease and economy of DPS sampling, the minute volumes required, and the unexpected stability of dried RNA suggest that the use of DPSs will be particularly valuable for small-volume neonatal samples and large, population-based studies in which cold storage and transportation present special problems, as is often the case in developing countries. The ability to measure viral changes during primary infection suggests that the method will be useful for assessing vaccine efficacy in large field trials.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Medroxyprogesterone acetate addition or substitution for tamoxifen in advanced tamoxifen-resistant breast cancer: a phase III randomized trial. Australian-New Zealand Breast Cancer Trials Group.

PURPOSE: To determine whether a strategy of adding medroxyprogesterone acetate (MPA) to tamoxifen (TAM) is superior to the substitution of MPA for TAM among women with advanced breast cancer and disease progressing on TAM. To assess the patterns or response and subsequent progression in sites and tissues according to prior involvement and treatment. PATIENTS AND METHODS: Two-hundred-fifteen postmenopausal women with advanced breast cancer progressing on TAM after receiving TAM for at least six months were randomized: 109 to add MPA 500 mg/day orally (TAM + MPA), and 106 to stop TAM and to substitute MPA. RESULTS: There were no significant differences between the groups with respect to complete plus partial response rates: TAM + MPA 10%, MPA 9%, median time to progression TAM + MPA 3.0 months, MPA 4.5 months, or median overall survival, TAM + MPA 17.2 months, MPA 18.4 months. In a multivariate model, prognostic factors significant for a shorter time to disease progression were worse for performance status, involvement of more than one tissue, prior radiotherapy, and shorter time from recurrence after primary therapy to randomization. Adjusting for these factors, treatment with TAM + MPA was associated with a higher relative risk for disease progression, with a hazards ratio of 1.31, but this was not significant (95% confidence interval, 0.98 to 1.74; P = .067). However, in an exploratory analysis, the time to disease progression, among patients with progesterone receptor positive (PR+) tumors, was 6.3 months with MPA versus 2.9 months with TAM + MPA, with a hazards ratio of 1.92 (95% confidence interval, 1.12 to 3.32; P = .02). There was a significant interaction, P = .04, between PR status and treatment, indicating an advantage to treatment substitution for those who have PR+ tumors. Tumor response occurred in 14% of assessed metastatic sites. Subsequent progression occurred in a new tissue alone in 13% of patients, in both new and previously involved (old) tissues in 76%, and in old tissues only in 11%. In 23% of patients, progression occurred only at a new site, in 50% at both old and new sites, and in 27% only at old sites. No significant differences in the patterns of response or progression were seen in the different treatment groups. CONCLUSION: Among women with breast cancer whose disease is progressing after at least six months of treatment with TAM, there is no advantage to maintaining TAM when MPA is to be given. An overall effect of treatment on the pattern of failure at old sites or at new sites or tissues cannot be discerned.

Aged↗
PubMed1997

A journey of recovery.

Explore the source record for details and available documents.

Attitude of Health Personnel↗
PubMed1996

Can different patient satisfaction survey methods yield consistent results? Comparison of three surveys.

OBJECTIVE: To examine the consistency of survey estimates of patient satisfaction with interpersonal aspects of hospital experience. DESIGN: Interview and postal surveys, evidence from three independent population surveys being compared. SETTING: Scotland and Lothian. SUBJECTS: Randomly selected members of the general adult population who had received hospital care in the past 12 months. MAIN OUTCOME MEASURES: Percentages of respondents dissatisfied with aspects of patient care. RESULTS: For items covering respect for privacy, treatment with dignity, sensitivity to feelings, treatment as an individual, and clear explanation of care there was good agreement among the surveys despite differences in wording. But for items to do with being encouraged and given time to ask questions and being listened to by doctors there was substantial disagreement. CONCLUSIONS: Evidence regarding levels of patient dissatisfaction from national or local surveys should be calibrated against evidence from other surveys to improve reliability. Some important aspects of patient satisfaction seem to have been reliably estimated by surveys of all Scottish NHS users commissioned by the management executive, but certain questions may have underestimated the extent of dissatisfaction, possibly as a result of choice of wording.

Adolescent↗
PubMed1996

Deciding to move home: a preliminary analysis of household migration behaviour in Scotland.

"This paper examines data from a mainland Scotland survey of household migration into owner-occupied properties identified from the Register of Sasines. Plotting of movements reveals migration patterns, but of arguably greater interest are the increasingly segmented and largely unexplored household decisions which drive migration. The purpose of the survey was to reveal something of these migration processes. Overview results presented here confirm that most moves are short distance, reasons for moving differ according to distance travelled, and although employment remains important for long-distance moves, its significance has declined in favour of quality of life considerations."

Demography↗
PubMed1995

Interpreting self reported limiting long term illness.

OBJECTIVE: To examine the association between self reported limiting long term illness and other dimensions of self reported health. DESIGN: Stratified random sample of general population. SETTING: Lothian region, Scotland, in 1993. SUBJECTS: 6212 men and women aged 16 and over. MAIN OUTCOME MEASURES: Limiting long term illness was assessed by the same question as used in the 1991 United Kingdom census. The short form 36 health survey was used to assess other dimensions of health. RESULTS: Rates of limiting long term illness were much higher than reported in the census. Scores on general and physical health scales had strong associations with limiting long term illness, but after adjustment for these associations psychosocial health measures had little influence on limiting long term illness. Being at the lower rather than the upper quartile on the physical functioning scale more than doubled the odds of having limiting long term illness. Reported prevalence of many common illnesses was between two and three times higher among those with limiting long term illness. CONCLUSIONS: A positive response to the question used by the census to define limiting long term illness was strongly associated with physical limitations on activity and less strongly influenced by scores on scales of mental and social wellbeing. Socioeconomic effects on limiting long term illness seem largely mediated through measures of general health and physical limitations on health.

Activities of Daily Living↗
PubMed1994

The International (Ludwig) Breast Cancer Study Group Trials I-IV: 15 years follow-up.

BACKGROUND: Adjuvant systemic therapy prolongs disease-free and overall survival in both pre- and postmenopausal patients. Available data shown benefit from multi-agent chemotherapy, prolonged tamoxifen treatment, and ovarian ablation, and that the combination of chemo- and endocrine therapy might be advantageous. In 1978 the International (Ludwig) Breast Cancer Study Group (IBCSG) initiated four complementary randomized controlled clinical trials to evaluate the roles of chemo-endocrine combinations or endocrine therapy alone in specific populations defined by risk (for pre- and perimenopausal patients) or by age (for postmenopausal patients). The results at 10 and 13 years' median follow-up for these trials are summarized in this report and are compared to those of the Overview meta-analysis with regard to chemo-endocrine or endocrine therapy combinations. Furthermore, types of first relapses by sites and second malignant diseases are reported. PATIENTS AND METHODS: 1601 evaluable patients with node positive disease were included into the studies I-IV. In Trial I (491 premenopausal patients with 1-3 positive axillary nodes) we studied the addition of low-dose continuous prednisone (p) to a cyclophosphamide-methotrexate-fluorouracil (CMF) combination. In Trial II 327 premenopausal patients with four or more positive axillary nodes were randomized to one year CMFp or to a surgical oophorectomy followed by CMFp. In Trial III (463 postmenopausal patients 65 years old or younger), combined chemoendocrine therapy (one year of CMFp plus tamoxifen (T)) was compared to endocrine therapy (1 year of p + T) or to surgery alone. In Trial IV 320 postmenopausal patients 66 to 80 years old were treated either by surgery alone or by surgery followed by 1 year prednisone and tamoxifen. RESULTS: In Trial I the addition of prednisone allowed a higher dose of cytotoxics to be administered compared with CMF alone. Despite this increased dose intensity, 13-year disease-free survival (DFS) and overall survival (OS) were similar for the two treatment groups (49% vs. 52% DFS, 59% vs. 65% OS for CMFp vs. CMF). In Trial II the addition of surgical oophorectomy to CMFp yielded an improved outcome which approached statistical significance for the subset of 107 patients known to have estrogen receptor-positive tumors (DFS, 23% vs. 15%, p = 0.13; OS, 41% vs. 30%, p = 0.12). In Trial III combined chemoendocrine therapy improved DFS and OS compared with endocrine therapy alone (p + T) given for the same duration, or no adjuvant treatment (DFS, 35% vs. 25% vs. 14%, p < 0.0001; OS, 48% vs. 36% vs. 32%, p = 0.01). In Trial IV p + T improved DFS compared with no adjuvant therapy (27% vs. 15%, p = 0.004). Despite competing risks for this elderly population, OS was also improved but the result was not statistically significant (34% vs. 22%, p = 0.08). CONCLUSIONS: The overall results of these four trials indicate that the continuation of investigations on combined chemo-endocrine therapies is warranted. The prognosis of the patients, all node-positive, treated with the most effective adjuvant treatment is such that there is a large potential for improvement.

Aged↗
PubMed1994

A pilot study of the economic cost and clinical outcome of day patient vs inpatient management of active rheumatoid arthritis.

The aims of this pilot study, which compares day patient with inpatient care for management of active RA were (i) to test the feasibility of a trial protocol design including the method of randomization and the practicality of data collection, and (ii) to obtain preliminary information on economic cost and clinical outcome of these two methods of management. Twenty consecutive patients requiring admission for management of active RA were randomized to receive either day patient or inpatient care. All hospital, transport, community and indirect costs incurred over a 6-month period from recruitment were collected for each patient. Disease activity and clinical outcome were assessed using the Ritchie articular index, ESR, Health Assessment Questionnaire, Functional Independence Measure and Hospital Anxiety and Depression Scale. The trial protocol was found to be feasible and no patient allocated to the day patient group requested or required to be transferred to inpatient care. Day care was significantly cheaper than inpatient care despite higher transport costs; the total cost of treating 10 day patients was UK 10,272 pounds compared with 14,528 pounds for 10 inpatients. Clinical outcome was comparable in both groups for all parameters studied and there was no obvious detrimental effect on patients receiving day care. This pilot study demonstrates that day care is feasible and acceptable to patients with active RA. The preliminary data suggest that day care is substantially cheaper than inpatient care and does not apparently compromise clinical outcome.

Ambulatory Care↗
PubMed1993

Visual performance and objectively measured grades of cataract. A correlation of methods designed for use in longitudinal trials.

Objective quantification of cataract and subjective assessment of visual performance are essential features of anticataract or cataractogenic drug trials. The constrains of a longitudinal trial require a compromise in contrast sensitivity measurement between sensitivity and speed. Such a system has been developed for use in longitudinal anticataract trials. An objective cataract assessment system has also been developed for these trials. Visual performance parameters and objectively measured grades of cataract using these systems were correlated in a group of patients with early lens opacities. Overall the correlation was poor in all three morphological types of cataract. Possible reasons for this and implications for future anticataract trials are discussed.

Aged↗