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Biomedical subjects

D Wilkinson

Publications and source records attributed to D Wilkinson.

At least 37 records · Page 2Linked to original sources
PubMed2001

Population-based interventions for reducing sexually transmitted infections, including HIV infection.

BACKGROUND: Sexually transmitted infections (STI) are common in developing countries. The World Health Organisation (WHO) estimates that in 1995, 333 million new cases of syphilis, gonorrhoea, chlamydial infection and trichomoniasis occurred. Human immunodeficiency virus (HIV) infection is also common in developing countries. UNAIDS estimates that over 90% of the 33 million people infected with HIV by December 1999 live in developing countries (UNAIDS 1999). The STI and HIV epidemics are interdependent. Similar behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of both infections, and there is clear evidence that conventional STIs increase the likelihood of HIV transmission. Several studies have demonstrated a strong association between both ulcerative and non-ulcerative STIs, and HIV infection (Cameron 1989, Laga 1993) and there is biological evidence that the presence of an STI increases shedding of HIV and that STI treatment reduces HIV shedding (Cohen 1997, Robinson 1997). Therefore, STI control may have the potential to contribute substantially to HIV prevention. OBJECTIVES: To determine the impact of population-based STI interventions on the frequency of HIV infection, frequency of STIs and quality of STI management. SEARCH STRATEGY: The following electronic databases were searched for relevant randomised trials or reviews: 1) MEDLINE for the years 1966 to current using the search terms sexually transmitted diseases and human immunodeficiency virus infection 2) The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness and the Cochrane Clinical Trials Register in the most recent issue of the Cochrane Library 3) The specialist register of trials maintained by the Cochrane Infectious Diseases Group. 4) EMBASE The abstracts of relevant conferences were searched and reference lists of all review articles and primary studies were scanned. Finally, authors of included trials and other experts in the field were contacted as appropriate. SELECTION CRITERIA: Randomised controlled trials in which the unit of randomisation is either a community or a treatment facility. Studies where individuals are randomised were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied the inclusion criteria to potential studies with any disagreements resolved by discussion. Trials were examined for completeness of reporting. The methodological quality of each trial was assessed by the same two reviewers with details recorded of randomisation method, blinding, use of intention-to-treat analysis and the number of patients lost to follow-up using standard guidelines of the Cochrane Infectious Diseases Group. MAIN RESULTS: Four trials were included. Frequency of HIV infection: In Rakai, after 3 rounds of treatment of all community members for STIs the rate ratio of incident HIV infection was 0.97 (95%CI 0.81 to 1.16), indicating no effect of the intervention. In Mwanza, the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (OR=0.58, 95% CI 0.42-0.70), corresponding to a 38% reduction (95%CI 15% to 55%) in HIV incidence in the intervention group. Frequency of STIs: In both Mwanza and Rakai, there was no significant reduction in gonorrhoea, chlamydia, urethritis, or reported STI symptoms among intervention communities. The prevalence ratio of syphilis between intervention and control groups in Rakai was 0.8 (95%CI 0.71-0.89), of trichmoniasis was 0.59 (0.38-0.91), and of bacterial vaginosis was 0.87 (0.74-1.02). In Mwanza, the prevalence of serologically diagnosed syphilis in the intervention community was 5% compared with 7% in the control community at the end of the trial (adjusted relative risk 0.71 (95%CI 0.54-0.93). Quality of treatment: In Lima, following training of pharmacy assistants in STI syndromic management, symptoms were recognised as being due to an STI in 65% of standardised simulated patients (SSPs) visiting intervention and 60% of SSPs visiting control pharmacies (p=0.35). Medication was offered without referral to a doctor in most cases (83% intervention and 78% control, p=0.61). Of those SSPs offered medication, only 1.4% that visited intervention pharmacies and only 0.7% of those that visited control pharmacies (p=0.57) were offered a recommended regimen. Similarly in only 15% and 16% of SSP visits respectively was any recommended drug offered. However, education and counseling were more likely to be given to SSPs visiting intervention pharmacies (40% vs 27%, p=0.01). No SSPs were given partner cards or condoms. In Hlabisa, following the intervention targeting primary care clinic nurses (strengthened STI syndromic management and provision of STI syndrome packets containing recommended drugs, condom, partner cards and patient information leaflets), SSPs were more likely to be given recommended drugs in intervention clinics (83% vs 12%, p <0.005) and more likely to be correctly case managed [given correct drugs, partner cards and condoms] (88% vs 50%, p <0.005). There were no significant difference in the proportions adequately counseled (68% vs 46%, p=0.06), experiencing good staff attitude (84% vs 58%, p=0.07), and being consulted in privacy (92% vs 86%, p=0.4). There was no strong evidence of any impact on treatment seeking behaviour, utilisation of services, or sexual behaviour in any of the four trials. REVIEWERS' CONCLUSIONS: There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. There are however other compelling reasons why STI treatment services should be strengthened and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. Further community based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment as well as HIV, STI and other biological endpoints.

Developing Countries↗
PubMed2001

Galantamine: a randomized, double-blind, dose comparison in patients with Alzheimer's disease.

OBJECTIVES: To investigate whether Galantamine significantly improves the core symptoms of Alzheimer's disease (AD). BACKGROUND: Galantamine is a reversible, competitive, selective inhibitor of acetylcholinesterase (AChE) that also allosterically modulates nicotinic acetylcholine receptors. This dual mechanism of action provided the rationale for a phase II trial of galantamine in AD. METHOD: A multicentre, randomized, parallel, double-blind, placebo-controlled trial was carried out to evaluate the efficacy and tolerability of galantamine 18, 24 and 36 mg/day administered for 3 months in 285 patients with mild-to-moderate probable AD. The primary outcome measure was the Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog); secondary outcome measures were the Clinical Global Impression of Change (CGIC) and the Progressive Deterioration Scale (PDS). RESULTS: Patients treated with galantamine 24 mg/day had a significantly better outcome than placebo on ADAS-cog; the treatment difference was 3 points on the intention-to-treat (ITT) analysis ( p = 0.01) and 4.2 points on per protocol analysis ( p = 0.001). Per protocol analysis showed that galantamine had a significantly better outcome than placebo on PDS ( 24-mg/day dose, p < 0.05) and CGIC (36-mg/day dose, p < 0.05). Galantamine was well tolerated at the lower doses of 18 and 24 mg/day where it produced mild, transient effects typical of cholinomimetic agents. CONCLUSION: This study shows that, relative to placebo, galantamine significantly improves the core symptoms of Alzheimer's disease.

Aged↗
PubMed2001

Pharmacotherapy of Alzheimer's disease: is there a need to redefine treatment success?

The traditional aim of Alzheimer's disease treatment in clinical trials has been to improve cognitive abilities. It has become increasingly clear, however, that other aspects are important in assessing treatment responses. A group of 10 physicians recently gathered to review the current criteria for assessing treatment success in Alzheimer's disease. While cognition has been previously viewed as the primary measure of efficacy, areas such as functional abilities, behaviour, caregiver burden, quality of life and resource utilization all need to be comprehensively assessed to fully evaluate treatment effects in patients with Alzheimer's disease, as well as their impacts on caregivers and society. Postponing or slowing decline in any of these areas may represent an important benefit and should be considered as an outcome measure in clinical trials, clinical practice and decision-making about healthcare budgets. Accepted instruments are available for assessing outcomes in each aspect of Alzheimer's disease, but they need to be selected carefully to provide valid, meaningful data. Some of the most frequently used outcome measures in Alzheimer's disease are reviewed. Using expanded criteria for treatment success and clinically relevant outcome measures, data from currently available studies show that cholinesterase inhibitors produce clinically meaningful long-term benefits in multiple domains in patients with Alzheimer's disease.

Activities of Daily Living↗
PubMed2001

Long-Term use of rivastigmine in patients with dementia with Lewy bodies: an open-label trial.

Patients with dementia with Lewy bodies (DLB) have progressive deficits in cognition, parkinsonism, and neuropsychiatric symptoms. Cholinesterase inhibitors have been used to ameliorate cognitive decline and neuropsychiatric symptoms in short-term trials. In this study, patients with DLB were treated with rivastigmine up to 96 weeks. Improvement from baseline was seen in cognitive function as measured by the Mini-Mental State Examination (MMSE), and neuropsychiatric symptoms as measured by the Neuropsychiatric Inventory (NPI) over the first 24 weeks of treatment. By 96 weeks, neither the MMSE scores nor the NPI scores were significantly worse than at baseline.

Aged↗
PubMed2001

Patient-controlled analgesia and intra-operative suggestion.

In a double-blind randomised study, we investigated the influence of positive intra-operative suggestions, presented to anaesthetised patients undergoing total abdominal hysterectomy, on postoperative pain, nausea and vomiting. One hundred and forty patients were randomly allocated to listen to one of four tapes containing either white noise or positive suggestions. The positive suggestions related to pain, postoperative nausea and vomiting, or both. We found that the positive intra-operative suggestions had no beneficial effects in reducing postoperative pain or nausea scores, nor was the consumption of morphine or anti-emetics reduced.

Adult↗
PubMed2001

Epidemiology of abdominal aortic aneurysms in the Asian community.

BACKGROUND: Studies relating to the ethnic origin of patients with an abdominal aortic aneurysm (AAA) are few and are mainly concerned with the differences between black and white Americans. The purpose of this study was to determine whether the incidence of AAA among the Asian population of Bradford is different from that in the Caucasian population. METHODS: A retrospective study of patients with an AAA was carried out between 1990 and 1997 using data collected by the Patient Administrative Service, personal databases of the vascular consultants and theatre records. Information about the ethnic composition of the population of Bradford was obtained from the 1991 national census. Demographic data, including ethnic origin and clinical details, were obtained from patient notes. RESULTS: Two hundred and thirty-three patients with an AAA were identified during the study interval. The Asian population comprised 14.0 per cent of the total population of Bradford. Twenty-eight AAAs would be expected per year. All of the aneurysms identified occurred in the Caucasian population and none in the Asian community. CONCLUSION: These early results suggest that AAA is rare among the Asian population.

Age Distribution↗
PubMed2001

Enumeration of non-communicable disease in rural South Africa by electronic data linkage and capture-recapture techniques.

Non-communicable diseases (NCDs) are becoming increasingly common and important in developing countries, yet their enumeration is problematic. We have attempted to enumerate NCD patients in a rural district of KwazuluNatal, South Africa, using the techniques of electronic data linkage and capture-recapture (CR). We examined four major NCDs (hypertension, diabetes, asthma and epilepsy). Basic patient details were recorded onto EpiInfo software over a 6-week period, from the main hospital clinic at Hlabisa, as well as the 10 outlying peripheral health clinics. Using electronic data linkage of lists from the main hospital, the peripheral clinics, and repeat prescription cards, a district NCD register was produced of 2455 patients. The mean age was 51 +/- 16 years (1 SD) and 76% were female. Of the total NCD patients, 62% had hypertension (age 57 +/- 12 years, 82% female), 16% epilepsy (age 35 +/- 17 years, 49% female), 13% asthma (age 45 +/- 19 years, 60% female) and 12% diabetes (age 54 +/- 13 years, 61% female). Estimated population crude prevalence rates for known NCD cases on the register were 7.4% for hypertension, epilepsy 0.2%, asthma 0.2% and diabetes 0.2%. We also attempted a CR analysis to assess completeness of data, by comparing overlap between patients attending peripheral clinics, and the central Hlabisa Hospital clinic. Matching by name, age, and diagnosis proved feasible, but there was little overlap, and CR calculations were invalid because of the relative independence of sources. We conclude that NCDs are common in rural Africa, and that a simple NCD district register is a potentially feasible and inexpensive option. Capture-recapture analysis is feasible, but requires suitable lists with acceptable overlap of patients.

Adolescent↗
PubMed2001

Positive impact of rural academic family practices on rural medical recruitment and retention in South Australia.

Difficulty recruiting and retaining doctors in rural and remote Australia is well recognised. Here, we describe the positive impact on recruitment and retention of general practitioners of a network of university-linked rural family practices in South Australia. Between August 1995 and October 1999, 17 doctors were recruited; eight (47%) were female and six (35%) worked part time. Four doctors left the practices after an average of 20 months service (annual turnover of 6%). Of the two general practice registrars placed in the single accredited practice, one has since joined the practice and the other will do so in 2000. Five doctors are overseas-trained (24%) and four are expected to stay permanently. Rural academic family practices have successfully recruited and retained medical staff in this setting over the past few years. This model of practice may be a useful recruitment and retention strategy for other parts of Australia.

Academic Medical Centers↗
PubMed2001

Amalgamation and collaboration in rural general practices: early experience with the GP links program in rural South Australia.

The GP Links program aims to promote the amalgamation of smaller general practices into larger group practices and is one of several strategies being used to modernise Australian family practice. GP Links provides financial incentives to practices willing to amalgamate. The focus of the program has been on urban practices to date and indeed some of the requirements of the program mean that rural practices are less likely to access the scheme. We report our positive and negative experiences of practice amalgamation through the GP Links program in a regional setting of South Australia. From our experience we suggest that for rural practices, a staged approach of increasing collaboration that may lead to amalgamation, which focuses on rural practices developing a supportive network and alliances with others such as Divisions and University Departments of Rural Health might be a positive way ahead.

Cooperative Behavior↗
PubMed2001

Contemporary management issues for Aboriginal Community Controlled Health Services.

Aboriginal Community Controlled Health Services face particular management issues as they adjust to the dominant Western paradigm of managerialism and the market model of health service provision. Their cultural orientation leads to distinctive organisational features which both advantage and disadvantages them in this environment. The holistic model of health used and community control enable the delivery of integrated, culturally appropriate health care. However, effective community control is difficult to achieve. Services may benefit from partnerships with collaborators such as hospitals, regional health services and university departments of rural health if the partnerships are based on mutual respect and ensure that community control is retained.

Community Health Services↗
PubMed2001

A multi-sectorial committee in directing HIV/AIDS-specific interventions in the occupational setting: an example from South Africa.

We present a descriptive analysis of a mechanism to coordinate and implement human immunodeficiency virus (HIV) prevention and care in the occupational setting. The mechanism we describe is a multidisciplinary committee composed of stakeholders in the occupational health environment including unions, management, medical researchers, and medical personnel. The site chosen for the analysis was a South African sugar mill in rural KwaZulu-Natal. The factory is situated in an area of high HIV seroprevalence and has a workforce of 400 employees. The committee was initiated to coordinate a combined prevention-care initiative. The issues that were important in the formation of the committee included confidentiality, trust, and the traditional roles of the stakeholder relationships. When these points were addressed through the focus on a common goal, the committee was able to function in its role as a coordinating body. Central to this success was the inclusion of all stakeholders in the process, including those with traditionally opposing interests and legitimacy conferred by the stakeholders. This committee was functionally effective and demonstrated the benefit of a freestanding committee dedicated to addressing HIV/acquired immune deficiency syndrome (AIDS) issues. We describe the implementation and feasibility of a multisectoral committee in directing HIV/AIDS initiatives in the occupational setting in rural South Africa.

Feasibility Studies↗
PubMed2001

Variation in mortality rates in Australia: correlation with Indigenous status, remoteness and socio-economic deprivation.

BACKGROUND: The aim of this study was to study ecological correlations between age-adjusted all-cause mortality rates in Australian statistical divisions and (1) the proportion of residents that self-identify as Indigenous, (2) remoteness, and (3) socio-economic deprivation. METHODS: All-cause mortality rates for 57 statistical divisions were calculated and directly standardized to the 1997 Australian population in 5-year age groups using Australian Bureau of Statistics (ABS) data. The proportion of residents who self-identified as Indigenous was obtained from the 1996 Census. Remoteness was measured using ARIA (Accessibility and Remoteness Index for Australia) values. Socioeconomic deprivation was measured using SEIFA (Socio-Economic Index for Australia) values from the ABS. RESULTS: Age-standardized all-cause mortality varies two-fold from 5.7 to 11.3 per 1,000 across Australian statistical divisions. Strongest correlation was between Indigenous status and mortality (r = 0.69, p < 0.001). Correlation between remoteness and mortality was modest (r = 0.39, p = 0.002) as was correlation between socio-economic deprivation and mortality (r = -0.42, p = 0.001). Excluding the three divisions with the highest mortality, a multiple regression model using the logarithm of the adjusted mortality rate as the dependent variable showed that the partial correlation (and hence proportion of the variance explained) for Indigenous status was 0.03 (9 per cent; p = 0.03), for SEIFA score was -0.17 (3 per cent; p = 0.22); and for remoteness was -0.22 (5 per cent; p = 0.13). Collectively, the three variables studied explain 13 per cent of the variability in mortality. CONCLUSIONS: Ecological correlation exists between all-cause mortality, Indigenous status, remoteness and disadvantage across Australia. The strongest correlation is with Indigenous status, and correlation with all three characteristics is weak when the three statistical divisions with the highest mortality rates are excluded. Intervention targeted at these three statistical divisions could reduce much of the variability in mortality in Australia.

Australia↗
PubMed2001

Increasingly inequitable distribution of general practitioners in Australia, 1986-96.

OBJECTIVE: To document trends in the distribution of general practitioners (GPs) in Australia between 1986 and 1996, adjusted for community need. METHODS: Data on the location of GPs, population size and crude mortality in statistical divisions (SD) were obtained from the Australian Bureau of Statistics Census of Population and Housing in 1986 and 1996. From these data, we calculated measures of distribution equality (number of people sharing each GP in each SD) and distribution equity (number of people sharing each GP divided by the crude mortality rate; the Robin Hood Index), and analysed temporal changes in the distribution of GPs. RESULTS: Nationally, the number of people sharing each GP fell 11% from 1,038 in 1986 to 921 in 1996. However, in 41 of 57 SDs (72%, p=0.01) the number of people sharing a GP actually increased over this time, and the average Robin Hood Index across SDs fell from 0.943 to 0.783 (p=0.004), indicating increasingly inequitable distribution. Comparing the Robin Hood Index values of all SDs ranked in pairs, the value fell in 53 of 57 (93%, p<0.001) paired SDs over the decade. These patterns demonstrate increasing inequity over the decade. The number of people sharing each GP was consistently and substantially lower in the capital city SDs and the Robin Hood Index values were consistently and substantially higher (overserved) compared with country SDs. CONCLUSIONS: Despite there being more GPs per capita in Australia, their distribution became increasingly unequal and inequitable between 1986 and 1996, such that rural and remote areas became increasingly poorly served.

Australia↗
PubMed2001

Effects of a flexible galantamine dose in Alzheimer's disease: a randomised, controlled trial.

OBJECTIVE: To assess the efficacy and safety of galantamine in Alzheimer's disease at 3 months using flexible dose escalation. METHODS: A randomised, double blind, placebo controlled trial in 43 centres in the United States, Canada, Great Britain, South Africa, Australia, and New Zealand. Patients with probable Alzheimer's disease (n=386; 171 women) with a score of 11-24 on the mini mental state examination, and a score> or =12 on the cognitive subscale of the Alzheimer's disease assessment scale (ADAS-cog) were randomised to placebo, or galantamine escalated over 4 weeks to a maintenance dose of 24 or 32 mg/day. The primary outcome measures were the change in ADAS-cog score and the clinician's interview based impression of change plus caregiver input (CIBIC-plus) score. Activities of daily living (ADL) and behavioural symptoms were secondary outcomes. To compare the effects of highest levels of dosing, an observed cases (OC) analysis was undertaken, with classic intention to treat (ITT) and ITT with last observation carried forward (LOCF) as confirmatory analyses. RESULTS: At 3 months, galantamine (24-32 mg/day) produced a significantly better outcome on cognitive function than placebo (treatment difference=1.9 points on ADAS-cog, p=0.002) and a significantly better global response than placebo, as measured by CIBIC-plus (deterioration in 21% of patients on galantamine v 37% on placebo; p<0.001). Galantamine produced significant benefits on basic and instrumental ADL. Behavioural symptoms did not change significantly from baseline levels in either group. Adverse events (primarily gastrointestinal) were of mild to moderate intensity. There were no important differences between the OC, ITT, and ITT/LOCF analyses. Most patients (82%) who were maintained on the higher dose of galantamine completed the study. CONCLUSIONS: Patients on galantamine, compared with those on placebo, experienced benefits in cognitive function and instrumental and basic activities of daily living. Flexible dose escalation of galantamine was well tolerated.

Activities of Daily Living↗
PubMed2001

Does the extract of the plant Echinacea purpurea influence the clinical course of recurrent genital herpes?

An increasing proportion of the population perceive complementary medicine as a safer alternative for non-life threatening conditions such as genital herpes. The extract of the plant Echinacea purpurea (Echinaforce) has been shown to have immunomodulating properties and has been advocated in the lay press for the treatment of genital herpes. This study, a single centre, prospective, double blind, placebo-controlled cross-over trial set out to assess whether an extract of the plant and root of E. purpurea can prevent or decrease the frequency and severity of genital herpes recurrences. These were assessed using a detailed history and clinical review of symptoms. Visual analogue scales were used for documentation and haematological and immunological parameters were measured. Over a one-year period, 50 patients took part in the study receiving 6 months' placebo and 6 months' Echinaforce each. No statistically significant benefit could be detected in this study comparing placebo versus Echinaforce in the treatment of frequently recurrent genital herpes.

Adult↗
PubMed2001

The K-Four bandage system: evaluating its effectiveness on recalcitrant venous leg ulcers.

This evaluation examined the effectiveness of the K-Four (Parema) high compression bandage system on 50 patients with recalcitrant 'hard-to-heal' venous leg ulcers and relates the outcome to an earlier randomised study which compared three other four-layer bandage systems. Twelve-week healing rates were 53.2% in the current series, which included patients with poor mobility, large ulcers and long pretreatment ulcer duration, rising to 69.5% at 20 weeks. When account was taken of known risk factors for delayed ulcer healing, no significant difference could be identified between between either K-Four or the earlier evaluated bandages, which included the original Charing Cross system, where the overall healing rates were 64.5% and 80%, respectively, at 12 and 20 weeks. It would seem more likely that treatment outcome is related to patient risk factors for delayed healing and bandaging expertise than to the bandage system employed.

Activities of Daily Living↗