Efficacy and cost effectiveness of current therapies in Guillain Barre syndrome.
Explore the source record for details and available documents.
Adrenal Cortex Hormones↗
Biomedical subjects
V Goel
Publications and source records attributed to V Goel.
The validity of a sore throat score in family practice.
BACKGROUND: Reducing the number of antibiotic prescriptions given for common respiratory infections has been recommended as a way to limit bacterial resistance. This study assessed the validity of a previously published clinical score for the management of infections of the upper respiratory tract accompanied by sore throat. The study also examined the potential impact of this clinical score on the prescribing of antibiotics in community-based family practice. METHODS: A total of 97 family physicians in 49 Ontario communities assessed 621 children and adults with a new infection of the upper respiratory tract accompanied by sore throat and recorded their prescribing decisions. A throat swab was obtained for culture. The sensitivity and specificity of the score approach in this population were compared with previously published results for patients seen at an academic family medicine centre. In addition, physicians' prescribing practices and their recommendations for obtaining throat swabs were compared with score-based recommendations. RESULTS: Of the 621 cases of new upper respiratory tract infection and sore throat, information about prescriptions given was available for only 619; physicians prescribed antibiotics in 173 (27.9%) of these cases. Of the 173 prescriptions, 109 (63.0%) were given to patients with culture-negative results for group A Streptococcus. Using the score to determine management would have reduced prescriptions to culture-negative patients by 63.7% and overall antibiotic prescriptions by 52.3% (both p < 0.01). Culturing of throat samples would have been reduced by 35.8% (p < 0.01). There was no statistically significant difference in the sensitivity or specificity of the score approach between this community-based population (sensitivity 85.0%, specificity 92.1%) and an academic family medicine centre (sensitivity 83.1%, specificity 94.3%). INTERPRETATION: An explicit clinical score approach to the management of patients presenting with an upper respiratory tract infection and sore throat is valid in community-based family practice and could substantially reduce the unnecessary prescribing of antibiotics for these conditions.
Adolescent↗
Dissociation of mechanisms underlying syllogistic reasoning.
A key question for cognitive theories of reasoning is whether logical reasoning is inherently a sentential linguistic process or a process requiring spatial manipulation and search. We addressed this question in an event-related fMRI study of syllogistic reasoning, using sentences with and without semantic content. Our findings indicate involvement of two dissociable networks in deductive reasoning. During content-based reasoning a left hemisphere temporal system was recruited. By contrast, a formally identical reasoning task, which lacked semantic content, activated a parietal system. The two systems share common components in bilateral basal ganglia nuclei, right cerebellum, bilateral fusiform gyri, and left prefrontal cortex. We conclude that syllogistic reasoning is implemented in two distinct systems whose engagement is primarily a function of the presence or absence of semantic content. Furthermore, when a logical argument results in a belief-logic conflict, the nature of the reasoning process is changed by recruitment of the right prefrontal cortex.
Basal Ganglia↗
Utilization of professional supportive care services by women with breast cancer.
This paper reports on the results of a survey of utilization of professional supportive care services by women with breast cancer, and on patterns of differential service utilization by sub-groups of patients. Study participants were women with invasive breast cancer diagnosed 23-36 months prior to contact about the study, and randomly selected from the Ontario Cancer Registry. From among 1,119 eligible women sent survey questionnaires, 731 returned completed questionnaires (65%). A total of 31% of respondents reported accessing one or more of the following professionals: social worker, psychologist, psychiatrist, dietitian, physiotherapist. Among those who responded to a question about whether they would have liked specific services, 34% reported that there was at least one professional supportive care service they would have liked to use, but were unable to access. Factors shown to be related to greater utilization of services included: younger age, higher household income, employed or student status, private health insurance coverage, and having received chemotherapy. Overall, there was a surprisingly low utilization of professional specialized supportive care services among women with breast cancer. Policy implications include finding strategies to better inform cancer patients about existing services, and ensuring that a core set of services are available to all patients.
Aged↗
Why are investigations not recommended by practice guidelines ordered at the periodic health examination?
Evidence-based guidelines recommend few routine investigations for healthy adults at the periodic health examination (PHE). However, small studies indicate that laboratory tests are commonly ordered at the PHE. This study examined PHE laboratory testing that is not recommended by recognized guidelines ('discretionary'). Using administrative data from the universal health care system in Ontario, Canada, we studied 792,844 adults having a PHE in 1996 and the 3,727 physicians who administered them. We measured the number of discretionary laboratory tests per PHE along with the patient and physician factors potentially influencing laboratory testing. A multilevel, multivariate model was used to examine the association between the number of discretionary laboratory tests at the PHE with patient and physician characteristics. A mean of 7.1 discretionary tests (SD 7.1) was ordered per PHE. Renal, haematological, glucose and lipid tests each were conducted in more than a third of PHEs. Testing varied extensively between physicians and was more common in healthy patients. With the exception of age, patient factors had little effect on discretionary testing. However, each physician factor we examined was independently associated with the number of discretionary tests. Physician specialty, practice volume and previous testing patterns had the strongest influence on discretionary testing. Discretionary investigations are common at the PHE. Testing varies extensively between physicians and seems to be driven more by physician than by patient factors. Interventions to modify discretionary test utilization at the PHE should consider these physician factors.
Adult↗
Infective discitis as an uncommon but important cause of back pain in older people.
CASE REPORTS: two elderly patients (aged 70 and 80 years) presented with severe back pain and restriction of spinal movements. Inflammatory markers were raised and in each case computed tomography findings confirmed infective discitis. One patient improved with antibiotics but the second developed paraplegia, a recognized complication of discitis. CONCLUSION: the association of back pain, restricted spinal movements and raised inflammatory markers should act as 'red flags', alerting the clinician to the presence of serious, but potentially treatable pathology.
Age Factors↗
Quality of hospital discharge and physician data for type of breast cancer surgery.
OBJECTIVE: The quality of coding for breast surgical procedures was examined by comparing hospital discharge abstracts and physician claims with data abstracted from records of women diagnosed with node-negative breast cancer from April 1, 1991, to December 31, 1991. METHODS: The node-negative breast cancer cohort was linked with a population registry file. Hospital discharge abstracts and physician billing claims were retrieved for matched subjects. Overall agreement between two data sets was defined as the number of cases for which there was a match by specific type of procedure out of all eligible cases that were matched with the health care utilization file. Specific agreement was assessed by the kappa statistic, using only those records in the administrative data set that were coded for mastectomy or breast-conserving surgery. RESULTS: Of 735 eligible cases in the node-negative breast cancer cohort, 655 (89.1%) were linked to a health care utilization file. Overall agreement between surgeon billing claims and charts was 95.4% (CI = 93.5, 96.9) for most definitive procedure. Agreement for breast surgery type was 98.1% (kappa = 0.96; CI = 0.87,1.0) for cases coded as breast-conserving surgery or mastectomy. When hospital discharge and chart data were compared, overall agreement was 86.2% (CI = 83.4, 88.8), whereas agreement for breast surgery type was 93.2% (kappa = 0.86; CI = 0.77, 0.94). CONCLUSION: Overall, definitive surgical procedure in the two administrative databases accurately reflected information recorded in patients' charts. Physician claims appeared to provide more accurate information than did hospital discharge data.
Abstracting and Indexing↗
Anatomical segregation of component processes in an inductive inference task.
Inductive inference underlies much of human cognition. The essential component of induction is hypothesis selection based on some criterion of relevance. The purpose of this study was to determine the neural substrate of inductive inference, particularly hypothesis selection, using fMRI. Ten volunteers were shown stimuli consisting of novel animals under two task conditions, and asked to judge whether all the animals in the set were the same type of animal. In one condition, subjects were given a rule that specified the criteria for "same type of animal". In the other condition, subjects had to infer the rule without instruction. The two conditions were further factored into easy and difficult components. Rule inference was specifically associated with bilateral hippocampal activation while the task by difficulty interaction was associated with activation in right lateral orbital prefrontal cortex. We interpret the former in terms of semantic encoding of novel stimuli and the latter in terms of hypothesis selection. Thus, we show an anatomical dissociation between task implementation and task difficulty that may correspond to a critical psychological distinction in the processes necessary for inductive inference.
Adult↗
Spinal stability with anterior or posterior ray threaded fusion cages.
OBJECT: The authors conducted a study to determine if the rigidity supplied to the spine by posterior placement of the Ray threaded fusion cage (TFC) is further enhanced by the placement of pedicle screws and, additionally, if bilateral anteriorly placed TFCs render the spine more rigid than a single anteriorly placed TFC. METHODS: Ten human cadaveric spinal specimens (L2-S1) were affixed within a testing frame. Loads of 1.5, 3, 4.5, and 6 Nm were applied to the spine in six degrees of freedom: flexion-extension, right and left lateral bending, and right and left axial rotation. Motion in an x, y, and z cartesian axis system was tracked using dual video cameras following light-emitting diodes attached to the spine and base plate. Load testing of the spines was performed in the intact mode, following which the spinal segments were randomized to receive anterior or posterior instrumentation. In five spine specimens we performed posterior discectomy, posterior lumbar interbody fusion (PLIF) with placement of femoral rings and pedicle screws, PLIF with bilateral TFCs, and bilateral TFCs with pedicle screws. Five other spines underwent anterior-approach discectomy, followed by implantation of a unilateral cage and bilateral cages. Load testing was performed after each step. CONCLUSION: Spines in which PLIF with pedicle screws and TFCs with pedicle screws were placed were more rigid than after discectomy in all directions of motion except flexion. Anterior discectomy provided significantly (p < or = 0.05) less stability in left and right axial rotation than the intact spines and following posterior discectomy. Following anterior implantation of bilateral TFCs, spines were significantly more rigid than after discectomy in all directions except extension.
Bone Screws↗
Comparing angiographic coronary revascularization strategies: a 'natural' experiment.
OBJECTIVE: To study the impact of intracoronary stents on clinical restenosis in the 'real world'. DESIGN: Retrospective comparison of the rates of clinical restenosis between two cohorts exposed to different strategies for percutaneous transcatheter intervention. The endpoint was the first of death, myocardial infarction, coronary artery bypass grafting, repeat percutaneous transluminal coronary angioplasty (PTCA) or repeat coronary angiography within nine months. SETTING: Tertiary care cardiac referral centre serving a large, metropolitan population. PATIENTS: Patients undergoing angiographic revascularization from January 1 to February 28, 1996 (the 'restricted' group [R], n=147) were compared with a before and after cohort (the 'usual' group [U], n=232, divided into those who underwent revascularization between November 1 and November 30, 1995, and those who underwent revascularization between April 1 and May 31, 1996). INTERVENTIONS: The R group was revascularized during a period of economic constraint, which imposed a shortage on stent availability. The U cohort underwent revascularization before and after the shortage (an 'unrestricted' environment for stent usage). MAIN RESULTS: There was no difference in clinical restenosis rates between the R (34.7%) and U (37.9%) groups (P=0.524, OR R/U=0.915, 95% CI 0.694 to 1.206). Also, the rate of clinical restenosis was the same among patients who underwent PTCA without stent insertion (34.8%) and those who received a stent (39.4%) (P=0.368, OR=1.13, 95% CI 0.87 to 1.44). CONCLUSIONS: At the authors' institution, a restricted stenting policy did not result in a higher clinical restenosis rate than that of usual practice.
Angioplasty, Balloon, Coronary↗
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↗
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↗
Time-series analysis of the relation between influenza virus and hospital admissions of the elderly in Ontario, Canada, for pneumonia, chronic lung disease, and congestive heart failure.
This study examined the relation between the presence of circulating influenza virus and all hospital admissions of people over age 65 years in Ontario, Canada, for pneumonia, congestive heart failure, and chronic lung disease in 1988-1993. Autoregressive integrated moving average (ARIMA) transfer function models were used to perform a time-series analysis. These models were compared with simple cross correlations by using Pearson's product moment correlation. The results showed statistically significant correlations between the presence of influenza virus and admissions of the elderly for pneumonia (in all 5 years under study) and chronic lung disease (in 4 of the 5 years under study). The relation between circulation of influenza virus and admissions for congestive heart failure was inconsistent. The simple cross correlation tended to overestimate the association between the presence of circulating influenza strains and hospital admissions. Measures of the impact of influenza should include chronic lung disease as an outcome. Further studies, with greater covariate control, are required to delineate more precisely the relation between influenza and hospital morbidity in the elderly. This study demonstrates the power and utility of using time-series methods in the epidemiologic study of communicable diseases.
Aged↗
Development of a knowledge scale about breast cancer and heredity (BCHK).
An 11-item questionnaire, the Breast Cancer and Heredity Knowledge Scale (BCHK), was developed to test general knowledge about breast cancer and hereditary breast cancer (HBC) among women at low to moderate risk of HBC. The BCHK measures knowledge about breast cancer incidence and prognosis, risk factors, screening, disease presentation and treatment, and HBC. Scale items were generated from focus group interviews, previously published breast cancer knowledge scales, and consultation with a multidisciplinary research team, including health professionals and women with breast cancer or a family history of breast cancer. A 27-item draft scale was tested on 36 breast clinic patients and 17 women from the general public. Results were used to develop the final 11-item scale. Development of the scale and its potential uses are discussed.
Adult↗
Dietary rhubarb (Rheum rhaponticum) stalk fibre stimulates cholesterol 7 alpha-hydroxylase gene expression and bile acid excretion in cholesterol-fed C57BL/6J mice.
Both experimental and clinical studies have indicated that a novel source of dietary fibre, produced from rhubarb (Rheum rhaponticum) stalks, is potentially hypolipidaemic. The present study, using C57BL/6J mice, was undertaken to examine if this fibre source affects cholesterol degradation. Mice were maintained on semi-purified diets containing 50 g rhubarb fibre or cellulose/kg with or without 5 g cholesterol/kg for 4 weeks. In cholesterol-supplemented mice, rhubarb fibre caused significant lowering of plasma cholesterol (-13%) and the hepatic concentrations of total cholesterol (-34%) and cholesteryl esters (-34%). In parallel to the reduction of hepatic cholesteryl ester content, animals fed on rhubarb fibre had significantly lower activity of acyl CoA: cholesterol acyltransferase (EC 2.3.1.26) than the mice maintained on a diet containing cellulose and cholesterol. Rhubarb-fibre feeding accelerated the faecal bile-acid loss and diminished the gall-bladder bile-acid pool in both the normal and the cholesterol-fed mice. The increase in the bile-acid excretion was positively correlated with an increased activity as well as mRNA abundance of cholesterol 7 alpha-hydroxylase (EC 1.14.13.17). The increased excretion of bile acids and induction of cholesterol 7 alpha-hydroxylase activity may account for the hypocholesterolaemic effect of rhubarb fibre.
Animals↗
Biotyping of Acinetobacter species isolated from clinical samples.
We used the biotyping scheme using carbohydrate substrate utilization test with 14 carbon sources to speciate Acinetobacter isolates from blood and cerebrospinal fluid cultures of patients admitted to the postoperative neurosurgery ICU during January to November 1996. Sixty one patients culture positive for Acinetobacter sp. from blood or cerebrospinal fluid were followed up prospectively. Among these patients, 40 patients had clinically diagnosed infections like bacteriemia or meningitis while in 21 patients the isolation was regarded as contaminants. A. baumanniii was the most common isolate associated with clinical infections while A. lwoffii was more likely to be an environmental contaminant.
Acinetobacter↗
Hereditary breast cancer. Risk assessment of patients with a family history of breast cancer.
OBJECTIVES: To assist family physicians in stratifying women with a family history of breast cancer as being at low, moderate, or high risk of hereditary breast cancer (HBC). To present guidelines for managing each of these risk groups. QUALITY OF EVIDENCE: A MEDLINE search was conducted from January 1976 to December 1997 using key words related to breast cancer risk factors, risk assessment, prevention, and screening. Risk stratification criteria were derived empirically and assessed using retrospective chart review. MAIN FINDINGS: Although up to 20% of women in the general population have a family history of breast cancer, less than 5% are at high risk for HBC. Certain features in a family history suggest increased risk. Women with none of these features are at low risk for HBC and should have annual clinical breast examinations and mammography at least every 2 years starting at age 50. Women with one or more features of increased risk who do not meet criteria for referral to a familial cancer clinic are at moderate risk for HBC and should begin annual mammography and clinical breast examination at age 40. Women who meet referral criteria are at high risk for HBC and should be counseled regarding referral to a familial cancer clinic for more detailed risk assessment and consideration for genetic testing. All women should be taught proper breast self-examination technique and encouraged but not pressured to practise it monthly for life. CONCLUSION: A simple algorithm can assist physicians in stratifying women into low, moderate, and high HBC risk groups. Management strategies for each group are given in this article and the two following (Heisey et al page 114 and Carroll et al page 126).
Adult↗
Hereditary breast cancer. Identifying and managing BRCA1 and BRCA2 carriers.
OBJECTIVES: To present a strategy for identifying candidates for consideration of BRCA1 and BRCA2 mutation testing. To discuss the implications of identifying patients as BRCA1 or BRCA2 mutation carriers, and to provide recommendations for managing them. QUALITY OF EVIDENCE: A MEDLINE search from January 1990 to May 1998 was performed using the terms genetic breast screening, BRCA1, and BRCA2. The bibliographies of articles found were searched for further relevant titles. There are no published, randomized controlled clinical trials of management strategies for known BRCA carriers. Many recommendations for management are based on expert opinion only. MAIN FINDINGS: About 5% of women with breast cancer are carriers of genetic mutations. An accurate and detailed family history is the most important tool for identifying potential BRCA1 and BRCA2 mutation carriers. Women identified as carriers have a substantially increased risk of breast and ovarian cancer. Male carriers have a moderately increased risk of prostate cancer. Management strategies for carriers are not well studied but include increased surveillance, preventive surgery, chemoprevention, and lifestyle modification. CONCLUSION: Family physicians must be able to identify people at risk, to discuss management strategies, and when appropriate, to offer referral for consideration of genetic testing. There is an urgent need for research to determine the effectiveness of surveillance strategies, preventive surgery, chemoprevention, and lifestyle modification for BRCA1 and BRCA2 mutation carriers.
Adult↗