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Biomedical subjects

J I Williams

Publications and source records attributed to J I Williams.

At least 37 records · Page 2Linked to original sources
PubMed2000

Squalamine improves retinal neovascularization.

PURPOSE: Modalities for inhibiting neovascularization may be one avenue to the development of effective therapies for retinopathy. The effect of squalamine, an antiangiogenic amino sterol, on oxygen-induced retinopathy (OIR) was assessed in a mouse model. METHODS: OIR was induced in C57BL6 mice by a 5-day exposure to 75% oxygen from postnatal day (P)7 through P12. Squalamine (25 mg/kg, subcutaneous)treated animals received either daily doses for five days from P12 to P16 or one dose just after removal from oxygen on P12. Each set of animals was killed at P17 to P21. Retinopathy was assessed with a retinopathy scoring system evaluation of retinal wholemounts and by quantification of neovascular nuclei on retinal sections. RESULTS: Animals receiving 5 days of squalamine after a 5-day exposure to oxygen had total retinopathy scores (expressed as median score with 25th and 75th quartiles in parentheses) of 4(3, 5) versus oxygen-only-reared animals with scores of 8(7, 9; P < 0.001). Animals reared in room air and animals exposed to squalamine only had similar retinopathy scores: 1(1, 2) and 1(0, 2). Oxygen-reared animals receiving single-dose squalamine also showed improvement, with a median retinopathy score of 4(4, 6.75) versus oxygen-only-reared animals with median retinopathy score of 9(7, 10; P < 0.001). There was a decreased number of neovascular nuclei extending beyond the inner limiting membrane on retinal sections in animals treated with 5 days (P < 0.01) and 1 day (P < 0.001) of squalamine. CONCLUSIONS: Squalamine significantly improved retinopathy and may be a novel agent for effective treatment of ocular neovascularization.

Animals↗
PubMed2000

Health-adjusted life expectancy at the local level in ontario.

Health expectancy measures are becoming a common method of combining information on mortality and health-related quality of life into one summary population health measure. However, health expectancy measures are infrequently measured at the local level, despite a shift toward health service planning to that level. Using a modified Sullivan method, we calculated health-adjusted life expectancy (HALE) for the 42 public health units in Ontario using life tables that were derived from mortality and population data for 1988-1992 and the Health Utilities Index from the 1990 Ontario Health Survey. There were large variations among health units in HALE at age 15 for both men (range: 51.3-58.2 years) and women (range: 56.6-62.9 years). Generally, rural and northern areas had the lowest HALE. Local differences in male HALE were greater than for life expectancy (7.1 versus 6.0 years). Despite a relatively large health survey (45,583 respondents, range: 729-1,746 per health unit), few HALE differences deviated significantly from the Ontario mean, raising concerns about the feasibility of estimating local health expectancy measures with adequate precision. Nevertheless, the wider local differences and different geographic distribution of local HALE compared with mortality measures, along with the additional benefit of being able to model the complex interaction of mortality and morbidity, suggest that HALE may be a useful population health measure.

Adolescent↗
PubMed1999

Evaluating the effectiveness of 2 educational interventions in family practice.

BACKGROUND: Structured feedback of information can produce change in physician behaviour. The objective of this study was to assess the effectiveness of 2 educational interventions for improving the quality of care provided by family physicians in Ontario: the Practice Assessment Report (PAR) and the Continuing Medical Education Plan (CMEP) with a follow-up visit by a mentor. METHODS: The study was a randomized controlled trial. Physicians in the control group received only the PAR, whereas those in the experimental group received the PAR, CMEP and mentor interventions. The participants were 56 family physicians and general practitioners (27 in the PAR group and 29 in the CMEP group) in southern Ontario who agreed to participate in the interventions and provide data. A total of 2395 patients randomly sampled from the practices returned questionnaires and consented to have their medical records abstracted. The outcome measures were global scores in 4 areas--quality of care, charting, prevention and overall use of medications--and patient ratings of satisfaction with care and preventive practices. The measures were applied at the beginning (phase 1) and end (phase 2) of the study. RESULTS: The mean global scores at the end of the study for the PAR group were 70.1% for quality of care, 84.7% for prevention, 77.7% for charting and 82.2% for overall use of medications. The corresponding scores for the CMEP group were 68.3%, 82.1%, 76.4% and 83.2%. In the patient satisfaction component, the personal care scores at phase 2 were 93.6% for the PAR group and 94.6% for the CMEP group. Examples of the scores for prevention for the PAR group were 98.3% for children's current immunization, 96.6% for blood pressure measured within the previous 5 years, 79.4% for referral of women of the appropriate age for mammography within the previous 2 years, and 58.4% for discussion about alcohol use. The corresponding scores for the CMEP group were 95.8%, 97.6%, 77.6% and 64.6%. The changes in mean scores between phase 1 and phase 2 ranged from -1.9 to 2.3 points. There were no significant differences between the 2 groups in phase 1 or phase 2 scores or in change in scores. A total of 64.3% of the physicians rated the PAR as useful, 26.5% found the CMEP to be useful, and 41.0% considered the mentor strategy to be a useful form of continuing medical education. Although changes in practice related to the PAR, CMEP or mentor were reported by some physicians, they were not related to chart audit or patient scores. INTERPRETATION: Educational interventions based on quality-of-care assessments and directed to global improvements in quality of care did not result in improvements in the outcome measures. Educational interventions may have to be targeted to specific areas of the practice, with physicians being monitored and receiving ongoing feedback on their performance.

Education, Medical, Continuing↗
PubMed1999

Prostate-specific antigen testing in Ontario: reasons for testing patients without diagnosed prostate cancer.

BACKGROUND: The use of the prostate-specific antigen (PSA) test has been increasing rapidly in Canada since its introduction in 1988. The reasons for using the PSA test in patients without known prostate cancer are unclear. This paper reports on the first study in Canada to use physician records to assess the use of PSA testing. METHODS: A questionnaire was mailed to physicians attending 475 patients without diagnosed prostate cancer. The patients were randomly selected from 2 laboratory databases of PSA test records in the greater Toronto area during 1995. The physicians were asked to consult their patient records to avoid recall bias. Information obtained included physician's specialty, patient's age at time of PSA test and reason(s) for the test. RESULTS: There were 264 responses (56%), of which 240 (91%) were usable. Of these 240, 63% (95% confidence interval [Cl] 58%-70%) indicated that the test was conducted to screen for prostate cancer, 40% (95% Cl 34%-47%) said it was to investigate urinary symptoms, and 33% (95% Cl 27%-40%) responded that it was a follow-up to a medical procedure or drug therapy. More than one reason was permitted. Of 151 responses indicating screening as one reason for testing, 64% (95% Cl 56%-72%) stated that it was initiated by the patient, and 73% (95% Cl 65%-80%) stated that it was part of a routine examination. For 19%, both investigation of symptoms and screening asymptomatic patients were given as reasons for testing, and for another 19% both follow-up of a medical procedure and screening were given as reasons. Screening was recorded as a reason for testing far more commonly for patients seen by family physicians and general practitioners than for patients seen by urologists (67% v. 29%, p < 0.001). In contrast, the use of PSA testing to diagnose urinary symptoms was more common for patients seen by urologists than for those seen by family physicians and general practitioners (52% v. 37%, p = 0.044). No significant difference was found between physician groups in the use of PSA testing as a follow-up of a medical procedure (42% for urologists and 31% for family physicians and general practitioners). About 24% of the PSA test records were for patients younger than 50 and older than 70 years. PSA testing initiated by patients was more common in the practices of family physicians and general practitioners than in the practices of urologists (44% v. 13%, p < 0.001). INTERPRETATION: Screening for prostate cancer was the most common reason for PSA testing in our study group; it occurred most commonly in the family and general practice setting and was usually initiated by the patient. Differences in reasons for testing were identified by practice specialty. Although PSA screening for prostate cancer is sometimes recommended for men between 50 and 70 years of age, it is being conducted in men outside this age group.

Adult↗
PubMed1999

Handicap in stroke survivors.

BACKGROUND AND PURPOSE: As survival following stroke improves, individuals are more likely to live with the aftermath of stroke rather than immediately die from it. The purpose of this study was to examine the consequences of stroke on the life activities of survivors in the social realm (stroke handicap) using the framework of the World Health Organization's International Classification of Impairments, Disabilities and Handicaps. METHODS: Multivariate analysis of variance was applied to cross-sectional data from a clinical study to investigate the correlates of handicap in a cohort of hemispheric stroke survivors at 3 months (n = 145) and at 1 year (n = 135) after stroke onset. Handicap was assessed with the Reintegration to Normal Living Index, impairment by the Adams' Hemispheric Stroke Scale and Zung Depression Scale, and disability by the Functional Independence Measure. Environmental variables in the model included marital status and receipt of rehabilitation therapy. RESULTS: Physical disability and post-stroke depressive symptoms were associated with handicap at both follow-up periods (p < 0.05). Cognitive disability and impairments from a previous stroke were also associated with handicap (p < 0.01), but only at 1 year. The presence of a spouse was found to benefit male survivors at 1 year. CONCLUSIONS: Disability and depressive symptoms restrict the meaningful life activities of stroke survivors in the first year of recovery. Social supports may be influential in reducing their impact.

Activities of Daily Living↗
PubMed1999

Informed consent for antipsychotic medication.

OBJECTIVE: To determine family physicians' attitudes and practices regarding documentation of informed consent for antipsychotic medication. DESIGN: Pilot cross-sectional study. SETTING: Teaching and non-teaching hospitals in Toronto, Ont. PARTICIPANTS: Thirty family physicians were selected in equal numbers from teaching and non-teaching hospitals with no more than five physicians from a given hospital. Participants were treating at least 10 patients with antipsychotic medication. Participants' mean age was 44.3 years; 83% were men. MAIN OUTCOME MEASURES: Documentation of consent and of disclosure of consent for antipsychotic medication in patients' charts. RESULTS: Documentation was found in only 13% of charts. Whether it was there or not did not correlate with information disclosed, score on an attitude scale, or demographics. Physicians who found documentation time-consuming were less likely to document. Most physicians disclosed reasons for antipsychotic medication, but less than half described tardive dyskinesia, a potentially irreversible movement disorder that affects about 25% of patients on long-term treatment. CONCLUSIONS: The low rate of documentation observed in this sample was consistent with reports of similar samples and might indicate that family physicians are unaware of recommendations for documentation or simply do not have time to keep abreast of current recommendations. Many physicians thought signed consent forms unnecessary for psychotic patients, and even more believed seeking consent for antipsychotic medications would increase patient anxiety.

Adult↗
PubMed1999

A population study in the Province of Ontario of the complications after conversion of hip or knee arthrodesis to total joint replacement.

OBJECTIVE: To evaluate the complication rates after conversion of hip and knee fusions to total joint replacements in the Province of Ontario. DESIGN: A retrospective cohort study. PATIENTS: Those who had undergone an elective conversion of a hip or knee fusion to a total joint replacement during fiscal year 1993 through 1996, as captured in the Canadian Institute for Health Information and Ontario Health Insurance Plan databases. OUTCOME MEASURES: Inhospital complications and length of initial hospital stay, revision, infection, amputation and repeat fusion rates within 4 years. RESULTS: Conversion of hip and knee fusion to total joint arthroplasty was generally performed by high-volume surgeons in high-volume hospital settings. Forty hip and 18 knee replacements involved conversion of a previous fusion. Conversion of a hip fusion was associated with a 10% infection rate, a 10% revision rate and a 5% resection arthroplasty rate due to infection within 4 years of the conversion. Conversion of a knee fusion was associated with an 11% infection rate, and a more than 5% revision rate at 4 years. Over 16% of patients who underwent conversion of a knee fusion required removal of the components (for various reasons) within the first 4 years. CONCLUSIONS: There is a high rate of complications after conversion of a hip or knee fusion to a total joint arthroplasty. These issues must be carefully considered and discussed with the patient before any conversion procedure.

Aged↗
PubMed1999

Evaluating functional outcome in patients with lower extremity sarcoma.

The Short Form 36, The Toronto Extremity Salvage Score, and the 1987 and 1993 Musculoskeletal Tumor Society Rating Scales were compared as measures of functional status for patients with lower extremity sarcoma. The study included 97 patients with lower extremity sarcoma and evaluated each measure on the following measurement properties: conceptual framework; statement of the purpose; feasibility; breadth of content; depth of measurement; cross sectional and longitudinal reliability; and validity and responsiveness. The Short Form 36 represents patients' perceptions of their physical and mental health and is practical to use. However, the validity of the measure is questionable for the patients with sarcoma because the subscale structure could not be reproduced in the current data. The Toronto Extremity Salvage Score meets all standards of measurement with the exception of breadth of content as it measures only physical function. The 1987 and 1993 Musculoskeletal Tumor Society scales do not meet the standards of measurement. In choosing an outcome measure for the extremity sarcoma population, the Toronto Extremity Salvage Score has superior measurement properties when compared with the Short Form 36 or the 1987 and 1993 Musculoskeletal Tumor Society scales. The Toronto Extremity Salvage Score is a reliable and efficient measure for monitoring patients and for use in clinical trials.

Adolescent↗
PubMed1998

Squalamine inhibits angiogenesis and solid tumor growth in vivo and perturbs embryonic vasculature.

The novel aminosterol, squalamine, inhibits angiogenesis and tumor growth in multiple animal models. This effect is mediated, at least in part, by blocking mitogen-induced proliferation and migration of endothelial cells, thus preventing neovascularization of the tumor. Squalamine has no observable effect on unstimulated endothelial cells, is not directly cytotoxic to tumor cells, does not alter mitogen production by tumor cells, and has no obvious effects on the growth of newborn vertebrates. Squalamine was also found to have remarkable effects on the primitive vascular bed of the chick chorioallantoic membrane, which has striking similarities to tumor capillaries. Squalamine may thus be well suited for treatment of tumors and other diseases characterized by neovascularization in humans.

Animals↗
PubMed1998

The need for acute, subacute and nonacute care at 105 general hospital sites in Ontario. Joint Policy and Planning Committee Non-Acute Hospitalization Project Working Group.

BACKGROUND: Previous studies of hospital utilization have not taken into account the use of acute care beds for subacute care. The authors determined the proportion of patients who required acute, subacute and nonacute care on admission and during their hospital stay in general hospitals in Ontario. From this analysis, they identified areas where the efficiency of care delivery might be improved. METHODS: Ninety-eight of 189 acute care hospitals in Ontario, at 105 sites, participated in a review that used explicit criteria for rating acuity developed by Inter-Qual Inc., Marlborough, Mass. The records of 13,242 patients who were discharged over a 9-month period in 1995 after hospital care for 1 of 8 high-volume, high-variability diagnoses or procedures were randomly selected for review. Patients were categorized on the basis of the level of care (acute, subacute or nonacute) they required on admission and during subsequent days of hospital care. RESULTS: Of all admissions, 62.2% were acute, 19.7% subacute and 18.1% nonacute. The patients most likely to require acute care on admission were those with acute myocardial infarction (96.2% of 1826 patients) or cerebrovascular accident (84.0% of 1596 patients) and those admitted for elective surgery on the day of their procedure (73.4% of 3993 patients). However, 41.1% of patients awaiting hip or knee replacement were admitted the day before surgery so did not require acute care on admission. The proportion of patients who required acute care on admission and during the subsequent hospital stay declined with age; the proportion of patients needing nonacute care did not vary with age. After admission, acute care was needed on 27.5% of subsequent days, subacute care on 40.2% and nonacute care on 32.3%. The need for acute care on admission was a predictor of need for acute care during subsequent hospital stay among patients with medical conditions. The proportion of patients requiring subacute care during the subsequent hospital stay increased with age, decreased with the number of inpatient beds in each hospital and was highest among patients with congestive heart failure, chronic obstructive pulmonary disease and pneumonia. INTERPRETATION: In 1995, inpatients requiring subacute care accounted for a substantial proportion of nonacute care days in Ontario's general hospitals. These findings suggest a need to evaluate the efficiencies that might be achieved by introducing a subacute category of care into the Canadian health care system. Generally, efforts are needed to reduce the proportion of admissions for nonacute care and of in-hospital days for other than acute care.

Acute Disease↗
PubMed1998

In the queue for total joint replacement: patients' perspectives on waiting times. Ontario Hip and Knee Replacement Project Team.

We assessed patients on the waiting lists of a purposive sample of orthopaedic surgeons in Ontario, Canada, to determine patients' attitudes towards time waiting for hip or knee replacement. We focused on 148 patients who did not have a definite operative date, obtaining complete information on 124 (84%). Symptom severity was assessed with the Western Ontario/McMaster Osteoarthritis Index and a disease-specific standard gamble was used to elicit patients' overall utility for their arthritic state. Next, in a trade-off task, patients considered a hypothetical choice between a 1-month wait for a surgeon who could provide a 2% risk of post-operative mortality, or a 6-month wait for joint replacement with a 1% risk of post-operative mortality. Waiting times were then shifted systematically until the patient abandoned his/her initial choice, generating a conditional maximal acceptable wait time. Patients were divided in their attitudes, with 57% initially choosing a 6-month wait with a 1% mortality risk. The overall distribution of conditional maximum acceptable wait time scores ranged from 1 to 26 months, with a median of 7 months. Utility values were independently but weakly associated with patients' tolerance of waiting times (adjusted R-square = 0.059, P = 0.004). After splitting the sample along the median into subgroups with a relatively 'low' and 'high' tolerance for waiting, the subgroup with the apparently lower tolerance for waiting reported lower utility scores (z = 2.951; P = 0.004) and shorter times since their surgeon first advised them of the need for surgery (z = 3.014; P = 0.003). These results suggest that, in the establishment and monitoring of a queue management system for quality-of-life-enhancing surgery, patients' own perceptions of their overall symptomatic burden and ability to tolerate delayed relief should be considered along with information derived from clinical judgements and pre-weighted health status instruments.

Adult↗
PubMed1998

An early labor assessment program: a randomized, controlled trial.

BACKGROUND: Approximately 31 percent of cesarean deliveries in the United States and Canada are performed for dystocia. The aim of this study was to determine the effectiveness of early labor assessment to reduce cesarean birth rates for low-risk nulliparous women. METHODS: Two hundred and nine low-risk nulliparous women were randomly allocated to either the early labor assessment group or the direct admission to hospital group. Women in the early labor assessment group were evaluated and, if found to be in false or latent labor, were encouraged to go home or walk before admission to the labor unit. Those in the direct admission group were admitted to the labor unit without an assessment. Data were collected and analyzed about method of delivery, duration of labor, intrapartum interventions, and neonatal well-being. Women completed an evaluation of their experience in the early postpartum period. RESULTS: Significant decreases occurred in duration of labor, use of epidural analgesia for pain, and use of oxytocin to augment labor in the early labor assessment group. These women evaluated their labor and birth experience more positively than women in the direct admission group. No significant differences were found in the frequency of cesarean section or instrumental vaginal delivery for the two groups. CONCLUSIONS: Early labor assessment has the potential to reduce the number of women receiving oxytocin for augmentation, the rate of epidural analgesia for pain relief, and the duration of the active and second stages of labor, and to improve women's evaluations of their labor and birth experiences.

Adult↗
PubMed1998

Psychiatric morbidity and physician visits: lessons from Ontario.

OBJECTIVES: The authors examine the association between psychiatric morbidity and visits to general practitioners and family practitioners in Ontario, Canada. METHODS: A nested set of hypotheses were posed to account for different levels of use among persons with differing levels of psychiatric morbidity. The sample of 8,116 is drawn from a comprehensive household survey of physical and mental health that included the UM-CIDI standardized diagnostic interview. RESULTS: The findings suggest that persons with psychiatric disorders make more visits than can be accounted for by sociodemographic factors, medical status, access, or by intentional use of the general medical system for mental health treatment. CONCLUSIONS: Psychiatric morbidity is associated with higher rates of health service use. This effect is strongest among persons with multiple psychiatric disorders.

Adolescent↗
PubMed1998

Postoperative drains at the donor sites of iliac-crest bone grafts. A prospective, randomized study of morbidity at the donor site in patients who had a traumatic injury of the spine.

A prospective, randomized study was performed to assess the effectiveness of postoperative closed suction drainage. One hundred and twelve consecutive procedures involving autologous iliac-crest bone graft were performed, from December 29, 1992, to July 1, 1993, following a traumatic injury of the spine in 108 patients. Sixty of the sites from which the bone graft had been obtained were drained with a single large Hemovac device. The drains were maintained for two to five days postoperatively. The remaining fifty-two incisions were closed without a drainage device. All patients were evaluated clinically for problems with wound-healing. The incisions were considered to be healed when they had been asymptomatic for one year. Of eleven patients who had problems with wound-healing, six had been managed with a drain and five had not. The findings of this study do not support the routine use of drainage at the donor sites of iliac-crest bone grafts.

Adolescent↗
PubMed1998

The derivation of life tables for local areas.

Life tables are seldom derived at the local level, despite a shift toward health service planning to that level. We calculated life tables by sex for the 42 public health units in Ontario, using 1988 1992 mortality files. Traditional methods of life table construction were compared and validated. Data quality, particularly geographical coding of death certificates, poses the greatest difficulty in deriving accurate life tables for comparison between areas. Migration will affect estimates, but it is best considered during the interpretation of results. Except for the final age interval, methods of modelling life tables have little impact on final life expectancy estimates. It is feasible to calculate local level life tables with data and tools that are readily available. The results highlight the importance of examining such life tables, as variations within a province in life expectancy at birth may be as important as the differences between provinces.

Adolescent↗
PubMed1998

Ontario hospitals' purchasing practices for hip and knee prostheses: a survey.

OBJECTIVES: To determine the makes, models and prices of the implants provided by Ontario hospitals for hip and knee replacements and the policies and procedures governing purchases. DESIGN: A questionnaire survey of hospitals with telephone follow-up. STUDY POPULATION: Seventy-nine public hospitals in Ontario in which 10 or more hip or knee replacements were carried out in the fiscal year 1993/94. SURVEY RESPONSE: Seventy-six hospitals returned questionnaires (96% response rate), reporting on 4950 primary hip and 5107 primary knee implants. Sixty-two hospitals reported volumes and prices for 19 models used in 2961 hip implants. Information on price but not makes and models was available for 1989 hip implants. Model and price information was missing for 340 hip prostheses. Fifty-seven hospitals identified the models and prices for 3460 knee implants. Twenty-five hospitals provided prices but not specific models names for 1647 knee implants and hybrids. OUTCOME MEASURE: The prices paid for prostheses. RESULTS: The average price of hip implants was Can$2141 (range from Can$650 to Can$3559). The average price for knee implants was Can$2412 (range from Can$1178 to Can$3777). The averages and ranges were about the same for specified and unspecified models and hybrids. The variations were unrelated to hospital policies about the numbers of procedures to be provided or the procedures for making purchases from suppliers. CONCLUSIONS: Savings of Can$13.7 million could have been made in Ontario during the fiscal year 1993/94 had the lowest prices been paid for the implants. Although it may be neither desirable nor possible to use the least expensive model and price in every hospital, the potential for cost reductions in the purchase of implants is substantial.

Cost Savings↗