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Biomedical subjects

S H Woolf

Publications and source records attributed to S H Woolf.

At least 19 recordsLinked to original sources
PubMed1999

An evidence-based analysis of the effect of busulfan, hydroxyurea, interferon, and allogeneic bone marrow transplantation in treating the chronic phase of chronic myeloid leukemia: developed for the American Society of Hematology.

Because there are differing opinions regarding treatment of patients in the chronic phase of chronic myeloid leukemia (CML), the American Society of Hematology convened an expert panel to review and document evidence-based benefits and harms of treatment of CML with busulfan (BUS), hydroxyurea (HU), recombinant interferon-alpha (rIFN-alpha), and bone marrow transplantation (BMT). The primary measure for defining efficacy was survival. Analysis indicated a survival advantage for HU over BUS. Observational studies of rIFN-alpha suffer from numerous biases including sample size, variations in study populations, definitions of hematologic and cytogenetic remissions, and dose. That rIFN-alpha is more efficacious than chemotherapy is demonstrated by 6 prospective randomized trials. For patients with favorable clinical features in chronic phase, compared to HU and BUS, rIFN-alpha improves survival by a median of about 20 months. Most evidence suggests that rIFN-alpha is most effective when combined with other drugs and when given during the earliest stage of the chronic phase. Adding cytarabine to rIFN-alpha adds further survival benefit but increases toxicity. Limitations for evaluating the long-term benefits of allogeneic BMT include the retrospective nature of most studies, incomplete documentation of the clinical characteristics of the patients, paucity of the details on patient selection, lack of control groups, and limitations of survival calculations. Survival curves for BMT show that at least half of the patients transplanted remain alive 5 to 10 years after treatment, whereas similar curves for rIFN-alpha show a continuous relapse rate over time with the curves crossing at about 7 to 8 years. Estimates of long-term survival may be confounded by the selection biases mentioned and the analytic methods used. The magnitude of the incremental increase in benefit with BMT must be weighed against the potential serious harm and death that may accompany the procedure in the short term. The best results with BMT have been obtained when it is performed within 1 to 2 years from diagnosis. Since each treatment option involves tradeoffs between benefit and harm, patient choice must be based on the examination of facts presented in an unbiased fashion. Newly diagnosed younger patients and older patients who are candidates for BMT should also be offered information about IFN-based regimens, the tradeoffs involved, and, if possible, share in the treatment decision. Hopefully this analysis will provide the stimulus for evaluation of other important aspects of CML.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1999

Is cigarette smoking associated with impaired physical and mental functional status? An office-based survey of primary care patients.

OBJECTIVE: To examine the relationship between cigarette smoking and self-reported physical and mental functional status. DESIGN: Cross-sectional survey of 837 patients visiting 2 family-practice centers. Patients completed a self-administered survey about functional status, tobacco use, and demographic characteristics while waiting to be called back for their appointments. SETTING: An inner-city family practice clinic in Richmond, Virginia, and a more affluent suburban practice outside Washington, DC. MAIN OUTCOME MEASURES: Physical and mental functional status, as measured by the SF-36 (Medical Outcomes Trust, Boston, MA); current and former cigarette use; and demographic variables (age, gender, education, income). RESULTS: Among current smokers, self-reported functional status scores were significantly lower than those of nonsmokers in all SF-36 domains (p < or = 0.02), a pattern that was more dramatic for mental functional status domains (social function, vitality, emotional role limitations, mental health). In several SF-36 domains, a dose-response relationship between smoking and functional status was noted. After multivariate adjustment for demographic confounders and practice site, the statistical significance of these differences diminished considerably, but it remained significant for certain domains and for the overall difference across all domains (MANCOVA p = 0.017). CONCLUSIONS: Current smokers report lower functional status than nonsmokers, in physical and especially in mental domains. The meaning of this cross-sectional relationship is unclear without further longitudinal study. Smoking may be associated with other variables that have a causal role.

Adolescent↗
PubMed1999

Screening for prostate cancer: the roles of science, policy, and opinion in determining what is best for patients.

Controversy over screening for prostate cancer involves both scientific and policy considerations. The principal scientific questions are whether tumors detected by screening are clinically significant, whether screening generates too many false-positive results, and whether early detection lowers morbidity or mortality. Both screening and treatment of prostate cancer can be harmful, making the tradeoff between benefits and risks especially relevant. Studies suggest that this judgment is highly personal, depending on the relative importance that individuals assign to potential outcomes. Opinions and policy considerations also influence views about the appropriateness of screening. Chief among these are personal beliefs about benefits and harms, medicolegal concerns, patient expectations, resource constraints, and opportunity costs. Appropriate policy must discriminate between what is best for populations and for individual patients. The lack of evidence of benefit and the potential harms argue against a societal policy of routine screening. Individual patients who could benefit from screening should be informed about the potential benefits and harms and invited to make a personal choice based on their priorities and concerns.

Attitude to Health↗
PubMed1998

Do clinical practice guidelines define good medical care? The need for good science and the disclosure of uncertainty when defining 'best practices'.

Practice guidelines, although important in promoting quality, can also be harmful if they do not advocate the best options for patients. The latter can occur because of uncertainties in scientific evidence, biases in guideline development, and patient heterogeneity. Guidelines must therefore accurately describe the quality of the evidence and the degree of uncertainty that underlie recommendations. Proper methods for developing practice guidelines are reviewed.

Decision Support Techniques↗
PubMed1998

Idiopathic thrombocytopenic purpura: a guideline for diagnosis and management of children and adults. American Society of Hematology.

Idiopathic thrombocytopenic purpura (ITP, also known as immune thrombocytopenic purpura) affects both children and adults. In childhood, the peak age is 2-4 years, girls and boys are equally affected, and in most children, the disease is self-limited with spontaneous recovery occurring in several weeks to several months. In adults, ITP is most common among young women, and the disease is more insidious in its onset and chronic in its course. In both children and adults, there are important unresolved issues in diagnosis and management that have major cost implications. For this reason, the American Society of Hematology chose ITP as the disease topic for its initial practice guideline in 1993. In 1996, the practice guideline was published in Blood, the Journal of the American Society of Hematology. This review describes the principle features of ITP in children and adults, the process of development of the practice guideline for ITP, and the implications of the guideline for the diagnosis and management of patients with ITP.

Adult↗
PubMed1998

The functional status of inner-city primary care patients. Diminished function in a family practice population and its potential determinants.

BACKGROUND: Research on health care quality and effectiveness often relies on global health status measures, such as functional status, but little is known about the functional status of patients in the primary care setting (without limitation to specific diseases) and even less about the function of the poor or ethnic minorities. In preparation for a planned practice-based research network, we administered a functional-status survey to patients visiting an inner-city family practice center. METHODS: Over 9 weeks, 555 established patients older than 18 years, as well as adolescents accompanied by a parent or guardian, completed a survey that included the SF-36 Health Survey and questions about demographic variables and cigarette use. The survey was self-administered in the waiting area and examination room, and patients received no assistance from staff. RESULTS: Functional-status scores reported by this primary care cohort were significantly lower than those of the general population (P < .001) and comparable with those reported nationally for patients with chronic diseases (e.g., congestive heart failure, diabetes). Functional-status scores were associated with age, sex, and, most strikingly, socioeconomic status. For example, patients with a yearly income of less than $15,000 had lower mean physical function scores than those reported nationally for patients with hypertension, diabetes, depression, recent myocardial infarction, or hypertension (P < .05). Patients who currently smoked reported lower physical function (P = .004) and strikingly lower mental function (P < .001) than nonsmokers. CONCLUSIONS: Although patients completing the survey included healthy persons seeking preventive care and sick patients with acute and chronic illnesses, their overall functional status resembled that reported nationally for patients with chronic disease, perhaps reflecting the influence of poverty. Few studies have reported the association we observed between smoking and lower functional status. Further longitudinal studies in the primary care setting are necessary to fully interpret these associations and to evaluate the true impact of interventions on outcomes.

Adolescent↗
PubMed1998

Care of adults with type 2 diabetes mellitus. A review of the evidence.

BACKGROUND: The purpose of this study was to provide primary care physicians with a concise review of the evidence that guides selected aspects of type 2 diabetes care, including glycemic control, macrovascular risk reduction, and screening for microvascular complications of diabetes. METHODS: We identified randomized clinical trials that addressed selected aspects of the care of adults with type 2 diabetes using systematic literature review, review of existing clinical guidelines, and other sources. The results of these trials were interpreted as absolute risk reduction, and the number of patients that need to be treated to obtain a specific clinical outcome was calculated. RESULTS: Good glycemic control with metformin may reduce overall mortality in obese patients with type 2 diabetes (number need to treat [NNT] = 14 for 10 years), and improved blood pressure control reduced diabetes-related mortality (NNT = 15 for 10 years); improved glycemic control with agents other than metformin, or with combinations including metformin, does not reduce diabetes-related or overall mortality. Major cardiovascular events (CVE) in type 2 diabetes can be prevented by control of blood pressure with low-dose diuretics, atenolol, or angiotensin-converting enzyme inhibitors (NNT = 10 to 20 for 5 to 10 years for primary prevention of one CVE); by use of aspirin (NNT = 45 for 5 years for primary prevention of one CVE); and by use of simvastatin to lower low-density lipoprotein (LDL) cholesterol (NNT = 6 for 5 years for secondary prevention of one CVE). Glycemic control (NNT = 19 for 10 years) and hypertension control (NNT = 6 for 10 years) slow the progression of complications in patients with type 2 diabetes. Retinopathy and nephropathy are more preventable than neuropathy. The benefits of glycemic control are less for patients with shorter life expectancy and are greater for those with the highest levels of Hb A1c because larger Hb A1c improvements can be achieved in such patients. Periodic screening of patients for eye, kidney, and foot complications is supported because effective early treatment of these complications is available. CONCLUSIONS: In patients with type 2 diabetes, control of hypertension reduces microvascular and macrovascular complications more than glycemic control does. Control of LDL cholesterol with statins, aspirin, and smoking cessation reduce major cardiovascular events. Metformin reduces overall mortality in obese patients with creatinine levels < 1.5 mg/dL. Glycemic control reduces microvascular complications. The evidence supports angiotensin-converting enzyme inhibitors, atenolol, or low-dose diuretics for blood pressure control. Effective treatment of eye, kidney, and foot complications is available, and regular screening for these complications is justified.

Adult↗