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Biomedical subjects

A Willan

Publications and source records attributed to A Willan.

50 records · Page 3Linked to original sources
PubMed1992

Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group.

BACKGROUND: The rates of perinatal mortality and neonatal morbidity are higher for post-term pregnancies than for term pregnancies. It is not known, however, whether the induction of labor results in better outcomes than does serial fetal monitoring while awaiting spontaneous labor. METHODS: We studied 3407 women with uncomplicated pregnancies of 41 or more weeks' duration. The women were randomly assigned to undergo induction of labor or to have serial antenatal monitoring and spontaneous labor unless there was evidence of fetal or maternal compromise, in which case labor was induced or cesarean section was performed. In the induction group, labor was induced by the intracervical application of prostaglandin E2. Serial antenatal monitoring consisted of counts of fetal kicks, nonstress tests, and assessments of amniotic-fluid volume. The outcomes we measured were the rates of perinatal mortality, neonatal morbidity, and delivery by cesarean section. RESULTS: Among the 1701 women in the induction group, 360 (21.2 percent) underwent cesarean section, as compared with 418 (24.5 percent) of the 1706 women in the monitoring group (P = 0.03). This difference resulted from a lower rate of cesarean section performed because of fetal distress among the women in the induction group (5.7 percent vs. 8.3 percent, P = 0.003). When two infants with lethal congenital anomalies were excluded, there were no perinatal deaths in the induction group and two stillbirths in the monitoring group (P not significant). The frequency of neonatal morbidity was similar in the two groups. CONCLUSIONS: In post-term pregnancy, the induction of labor results in a lower rate of cesarean section than serial antenatal monitoring; the rates of perinatal mortality and neonatal morbidity are similar with the two approaches to management.

Adult↗
PubMed1991

Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study.

OBJECTIVES: To determine what treatment decisions physicians will make when faced with a hypothetical incompetent elderly patient with life-threatening gastrointestinal bleeding and to examine the relative importance of physician characteristics and factors (legal and ethical concerns, hospital costs, level of dementia, patient's age, physician's religion, patient's wishes and family's wishes) in making those decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. MAIN OUTCOME MEASURES: A self-administered questionnaire describing the elderly patient. Respondents were asked to choose one of four levels of care and to identify the level of importance factors had in making that decision. Older physicians, those less concerned about litigation, those for whom the level of dementia was important and those for whom the patient's age was important were expected to give less aggressive care than the other physicians. MAIN RESULTS: Supportive care was chosen by 8.1% of the respondents, limited therapeutic care by 41.5%, maximum therapeutic care without admission to the intensive care unit (ICU) by 32.2% and maximum care with admission to the ICU by 18.2%. The patient's wishes were reported by 91.0% as being extremely or very important in choosing the treatment. Stepwise logistic regression analysis revealed that the following variables independently predicted the level of treatment: level of dementia, country of residence, duration of practice, legal concerns, patient's age and ethical concerns. These factors were significantly correlated with the physicians' treatment choices (p less than 0.05). CONCLUSIONS: The importance that the physicians placed on the level of dementia was the strongest predictor of the level of care that would be provided. A societal consensus on the influence of cognitive function on the appropriate level of care as well as training of physicians in ethical issues are required.

Adult↗
PubMed1991

Superiority of granisetron to dexamethasone plus prochlorperazine in the prevention of chemotherapy-induced emesis.

Trials of selective 5-hydroxytryptamine3 receptor antagonists have shown excellent antiemetic activity for chemotherapy containing cisplatin when compared with high-dose metoclopramide. There is little information about the efficacy of these new agents for chemotherapy other than for high-dose cisplatin. We performed a double-blind, randomized trial comparing a single dose of the 5-hydroxytryptamine3 receptor antagonist granisetron (BRL 43694A) as a single intravenous dose with dexamethasone plus prochlorperazine in 152 patients receiving their first course of moderately emetogenic chemotherapy (mainly doxorubicin- and cyclophosphamide-containing combinations). During the first 24 hours, there was a statistically significant advantage for the granisetron group in terms of the prevention of both nausea and emesis. There was no difference in the frequency of reported adverse events. We conclude that granisetron is more effective than dexamethasone plus prochlorperazine in patients who are receiving moderately emetogenic cytotoxic agents.

Antiemetics↗
PubMed1988

A randomized trial of maintenance versus no maintenance melphalan and prednisone in responding multiple myeloma patients.

In order to assess the role of maintenance melphalan and prednisone (MP) in responding multiple myeloma patients, 185 eligible patients who responded to initial MP with stabilization for at least 4 months were randomized to either stop treatment and resume therapy at relapse or to continue MP until relapse. Time to first relapse was significantly shorter in the no maintenance group (P = 0.0011), however 57% of the no maintenance patients had a second response when MP was restarted and others had minor improvement. The time to final progression on MP, which reflects the duration of disease control by MP, was therefore longer for the no maintenance group (median = 39 months) compared to the maintenance group (median = 31 months) although the observed difference was not statistically significant (P = 0.086). Median survival from start of MP in the maintenance group (46 months) was also not significantly different than the no maintenance group (51 months) (P = 0.587). Multifactor analysis of the randomized patients demonstrated shorter total remission duration and shorter survival in patients who had an initially rapid response to therapy or a lesser reduction in serum M-protein concentration.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1988

Chemotherapy can prolong survival in patients with advanced non-small-cell lung cancer--report of a Canadian multicenter randomized trial.

The survival benefit of combination chemotherapy to patients with advanced non-small-cell carcinoma of the lung (NSCLC) is controversial. To study this question, the National Cancer Institute of Canada (NCIC) Clinical Trials Group conducted a prospective randomized trial comparing best supportive care (BSC) to two chemotherapy regimens, vindesine and cisplatin (VP), and cyclophosphamide, doxorubicin, and cisplatin (CAP). Between February 1983 and January 1986, 23 centers across Canada entered 251 patients on study. Eighteen centers participated in the three-arm schema (150 patients); centers choosing not to participate in a study with a no-chemotherapy arm followed a two-arm schema comparing VP with CAP (101 additional patients). Altogether, 233 patients were eligible. Patients had measurable or evaluable disease, with either distant metastases (82.5%) or bulky limited disease considered inoperable or unsuitable for radical radiotherapy. The treatment groups were comparable in terms of age, sex, performance status, histology, disease extent, and weight loss. The overall response rates (complete response [CR] plus partial response [PR]) on the chemotherapy arms were CAP, 15.3%, and VP, 25.3% (P = .06). Patients on the three-arm portion of the trial had a median survival of 32.6 weeks when treated with VP, 24.7 weeks with CAP, and 17 weeks with BSC. The significance of the differences in survival, adjusted for prognostic factors, is as follows: chemotherapy v BSC, P = .02; VP v BSC, P = .01; and CAP v BSC, P = .05. Toxicity on the chemotherapy arms was significant, with leukopenia of severe or greater degree occurring in 37.8% (CAP) and 40.0% (VP), severe vomiting in 12.2% (CAP) and 23.3% (VP), and severe neurotoxicity in 15.6% (VP).

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1987

Superiority of alternating non-cross-resistant chemotherapy in extensive small cell lung cancer. A multicenter, randomized clinical trial by the National Cancer Institute of Canada.

The National Cancer Institute of Canada Clinical Trials Group conducted a prospective randomized study comparing standard chemotherapy with alternating chemotherapy in patients with extensive small cell lung cancer. "Standard" treatment consisted of cyclophosphamide (1000 mg/m2 body surface area); doxorubicin (50 mg/m2), and vincristine (2 mg) every 3 weeks for six courses. Alternating chemotherapy was cyclophosphamide, doxorubicin, and vincristine alternating with etoposide (100 mg/m2 on days 1 to 3) and cisplatin (25 mg/m2 on days 1 to 3) every 3 weeks for six treatment cycles. Two hundred eighty-nine patients were eligible and evaluable for response to therapy and survival. Best response was higher in patients on alternating chemotherapy (complete plus partial response, 80% compared with 63.2%; p less than 0.002). Progression-free survival for patients on alternating chemotherapy was superior (p less than 0.0001) as was overall survival (p = 0.03). Major toxicities were equally frequent in both treatment groups. These results show a modest superiority of alternating chemotherapy over standard therapy in extensive small cell lung cancer.

Adult↗
PubMed1987

Weekly cyclophosphamide and alternate-day prednisone: an effective secondary therapy in multiple myeloma.

Intravenous or oral cyclophosphamide, 150-250 mg/m2 (500 mg maximum), once per week with alternate-day oral prednisone, 100 mg, was given to 57 myeloma patients resistant to melphalan and prednisone (MP). Seven responses in 28 primary MP-resistant patients and ten responses in 29 secondary MP-resistant patients were observed. Previous response to MP was not a significant factor in predicting response to weekly cyclophosphamide and alternate-day prednisone. The results suggest that the regimen of weekly cyclophosphamide and alternate-day prednisone may be as effective as more aggressive regimens in the treatment of patients with myeloma who have failed MP therapy. However, a randomized trial would be required to determine the relative contributions of cyclophosphamide and prednisone to the effectiveness of this regimen.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1986

The use of VP-16 plus cisplatin during induction chemotherapy for small-cell lung cancer.

In an attempt to circumvent innate or acquired tumor-cell resistance to chemotherapy, patients with small-cell lung cancer (SCLC) were treated with induction therapy that incorporated two active and potentially non-cross-resistant chemotherapy regimens on two National Cancer Institute of Canada (NCI-C) trials. Patients with limited disease (LD) SCLC were treated with cyclophosphamide, doxorubicin (Adriamycin [Adria Laboratories, Columbus, Ohio]) and vincristine (CAV) and VP-16 plus cisplatin in two different sequences. One arm was randomized to receive CAV alternating with VP-16 plus cisplatin for a total of six treatment cycles, and the other arm received three courses of CAV followed by three courses of VP-16 plus cisplatin. Both treatment strategies produced similar response rates and survival curves, and each treatment group has a projected 2-year survival of 20%. Patients with extensive disease (ED) were treated with either six cycles of CAV (standard regimen) or CAV alternating with VP-16 plus cisplatin for a total of six treatment cycles. In this study, the alternating regimen produced a higher complete response (CR) rate (40% v 27%) and overall response rate (61% v 39%; P less than .01). The progression-free survival was also superior for the alternating arm (P = .001), as was overall survival (P less than .05). The frequency of thrombocytopenia and severe gastrointestinal toxicity was slightly greater in the alternating arm, but the frequency of neutropenia and infection was less. The alternation of CAV and VP-16 plus cisplatin during induction therapy is an effective treatment strategy in the management of SCLC and superior to CAV alone in extensive SCLC.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1984

Marijuana use during pregnancy and decreased length of gestation.

In a prospective study the relationship of marijuana use during pregnancy to infant birth weight and length of gestation was examined in 583 women who delivered single live infants. Eighty-four women used marijuana to varying degrees during pregnancy. Marijuana, alcohol, smoking, and nutritional habits were estimated by repeated interviews. Compared to nonuse, an average use of marijuana six or more times per week during pregnancy was associated with a statistically significant reduction of 0.8 weeks in the length of gestation after consideration of the effects of nicotine, alcohol, parity, mother's prepregnancy weight, and the sex of the infant. With similar adjustments no reduction in birth weight was noted. Among the heavy marijuana users the effect of gestation length was does dependent.

Adult↗
PubMedDate not supplied

Health care professionals' familiarity with non-pharmacological strategies for managing cancer pain.

Many studies have confirmed unnecessary suffering among cancer patients, due to the inadequate use of analgesic medication and other effective interventions. While pharmacological treatments are appropriately the central component of cancer pain management, the under-utilization of effective nonpharmacological strategies (NPS) may contribute to the problem of pain and suffering among cancer patients. The purpose of this study was to determine health care professionals' familiarity with, and perceptions regarding, NPS for managing cancer pain, and to assess their interest in learning more about NPS as adjuncts to pharmacological analgesics. Two-hundred and fourteen health care professionals were surveyed at two cancer treatment centres in Ontario, Canada. The self-report questionnaire included questions regarding 11 psychological strategies (e.g. imagery) and eight other NPS (e.g. acupuncture). The response rate was 67% (141/214). Subjects were found to be the least familiar with autogenic training, operant conditioning, and cognitive therapy. Other than radiation and surgery, subjects most commonly reported recommending support groups (67%), imagery (54%), music or art therapy (49%) and meditation (43%) for managing cancer pain. Participants were most interested in learning more about acupuncture, massage therapy, therapeutic touch, hypnosis, and biofeedback. Participants were somewhat familiar with most of the 19 NPS presented; however, they use or recommend few NPS for managing cancer pain. Health professionals' interest in NPS has important implications for the supportive care of cancer patients.

Adult↗
PubMedDate not supplied

Laboratory diagnosis of iron-deficiency anemia: an overview.

BACKGROUND AND METHODS: To determine the diagnostic values of laboratory tests used in the diagnosis of iron-deficiency anemia, the authors conducted a systematic overview of the relevant literature. Computerized searches of the MEDLINE database yielded 1,179 potentially relevant citations. Fifty-five studies included the results of laboratory tests and histologic examination of the bone marrow for at least 50% of an identifiable patient group. In these 55 studies, quality was assessed and descriptive information concerning the study populations, the tests conducted, and the results was extracted, all in duplicate. RESULTS: Serum ferritin radioimmunoassay was by far the most powerful test, with an area under the receiver operating characteristic curve of 0.95. Test properties differed for populations of patients with inflammatory, liver, or neoplastic disease and patients without these conditions. Likelihood ratio lines, which allow precise interpretation of results across the entire range of ferritin concentration values, were constructed for the individual populations. CONCLUSION: Serum ferritin radioimmunoassay is an extremely powerful test for the diagnosis of iron-deficiency anemia and, appropriately interpreted, can be applied to the complete range of patients.

Anemia, Hypochromic↗
PubMedDate not supplied

Prognostic variables for survival of neonatal foals under intensive care.

The costly nature of intensive care for neonatal foals prompted a study of predictive variables for survival in a referral hospital. Applying stepforward logistic regression to parameters that differed significantly (P less than 0.10) between survivors (S) and nonsurvivors (NS) in a retrospective study (n = 56), two variables retained statistical significance [anion gap (AG, P = 0.0047) and venous PO2 (PvO2, P = 0.0342)], thus forming the basis for a predictive equation for survival: the Pn (probability of NS) = eA/(1 + eA) where A = -1.46 - 0.107 (PvO2) + 0.213 (AG). The predictive equation was evaluated prospectively in foals (n = 48), irrespective of diagnosis, that underwent intensive care. Sepsis was the most common medical problem identified in both groups of foals (51/104). In the prospective study, a Pn less than or equal to 0.5 predicted S (positive test) and Pn greater than 0.5 predicted NS (negative test). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the predictive equation were 100%, 40%, 62%, and 100%, respectively. All foals with Pn greater than 0.4 (n = 14) did not survive. Erroneous predictions were consistently false positives (predicted S, outcome NS). The predictive equation for survival may aid in identification of high risk neonates, i.e., unlikely to survive. The prognostic merits of anion gap and PvO2 imply that tissue oxygen debt was a significant problem for these critically ill foals.

Acid-Base Equilibrium↗