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Biomedical subjects

Joel G Ray

Publications and source records attributed to Joel G Ray.

At least 19 recordsLinked to original sources
PubMed2006

Bias in published cost effectiveness studies: systematic review.

OBJECTIVE: To investigate if published studies tend to report favourable cost effectiveness ratios (below 20,000 dollars, 50,000 dollars, and 100,000 dollars per quality adjusted life year (QALY) gained) and evaluate study characteristics associated with this phenomenon. DESIGN: Systematic review. Studies reviewed 494 English language studies measuring health effects in QALYs published up to December 2001 identified using Medline, HealthSTAR, CancerLit, Current Content, and EconLit databases. MAIN OUTCOME MEASURES: Incremental cost effectiveness ratios measured in dollars set to the year of publication. RESULTS: Approximately half the reported incremental cost effectiveness ratios (712 of 1433) were below 20,000 dollars/QALY. Studies funded by industry were more likely to report cost effectiveness ratios below 20,000 dollars/QALY (adjusted odds ratio 2.1, 95% confidence interval 1.3 to 3.3), 50,000 dollars/QALY (3.2, 1.8 to 5.7), and 100,000 dollars/QALY (3.3, 1.6 to 6.8). Studies of higher methodological quality (adjusted odds ratio 0.58, 0.37 to 0.91) and those conducted in Europe (0.59, 0.33 to 1.1) and the United States (0.44, 0.26 to 0.76) rather than elsewhere were less likely to report ratios below 20,000 dollars/QALY. CONCLUSION: Most published analyses report favourable incremental cost effectiveness ratios. Studies funded by industry were more likely to report ratios below the three thresholds. Studies of higher methodological quality and those conducted in Europe and the US rather than elsewhere were less likely to report ratios below 20,000 dollars/QALY.

Conflict of Interest↗
PubMed2006

Primary and secondary prevention of heart failure with statins.

Statins are effective in the prevention of coronary heart disease (CHD), a leading cause of heart failure (HF). Secondary analyses from 11 randomized clinical trials of patients with high-risk acute or stable coronary heart disease, but without HF, suggest that statins may prevent new-onset HF or HF-related hospitalization. In persons with established HF, several cohort studies found an approximate 35% relative risk reduction in all-cause mortality. While ongoing randomized clinical trials will help to determine the efficacy of statins in persons with established HF, it is reasonable to consider this class of medications in patients with a history of cardiovascular disease, dyslipidemia or diabetes mellitus, and who have either developed, or who remain at risk of, HF.

Dyslipidemias↗
PubMed2005

Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study.

BACKGROUND: Maternal placental syndromes, including the hypertensive disorders of pregnancy and abruption or infarction of the placenta, probably originate from diseased placental vessels. The syndromes arise most often in women who have metabolic risk factors for cardiovascular disease, including obesity, pre-pregnancy hypertension, diabetes mellitus, and dyslipidaemia. Our aim was to assess the risk of premature vascular disease in women who had had a pregnancy affected by maternal placental syndromes. METHODS: We did a population-based retrospective cohort study in Ontario, Canada, of 1.03 million women who were free from cardiovascular disease before their first documented delivery. We defined the following as maternal placental syndromes: pre-eclampsia, gestational hypertension, placental abruption, and placental infarction. Our primary endpoint was a composite of cardiovascular disease, defined as hospital admission or revascularisation for coronary artery, cerebrovascular, or peripheral artery disease at least 90 days after the delivery discharge date. FINDINGS: The mean (SD) age of participants was 28.2 (5.5) years at the index delivery, and 75 380 (7%) women were diagnosed with a maternal placental syndrome. The incidence of cardiovascular disease was 500 per million person-years in women who had had a maternal placental syndrome compared with 200 per million in women who had not (adjusted hazard ratio [HR] 2.0, 95 CI 1.7-2.2). This risk was higher in the combined presence of a maternal placental syndrome and poor fetal growth (3.1, 2.2-4.5) or a maternal placental syndrome and intrauterine fetal death (4.4, 2.4-7.9), relative to neither. INTERPRETATION: The risk of premature cardiovascular disease is higher after a maternal placental syndrome, especially in the presence of fetal compromise. Affected women should have their blood pressure and weight assessed about 6 months postpartum, and a healthy lifestyle should be emphasised.

Adolescent↗
PubMed2005

Adverse perinatal outcomes associated with homelessness and substance use in pregnancy.

BACKGROUND: Women who are homeless during pregnancy may be exposed to poor nutrition, violence and substance use, yet the health status of their newborn infants has not been systematically evaluated. We undertook a study to provide preliminary estimates of the risk of adverse perinatal outcomes among Canadian women who are homeless or marginally housed during pregnancy, and the effect of concomitant substance use. METHODS: We conducted a retrospective cohort study at a single downtown hospital from October 2002 to December 2004, involving women who, during pregnancy, were homeless or underhoused (n = 80), substance users (n = 59) or neither (n = 3756). We noted neonatal measures such as birth weight and gestational age; the main study outcomes were preterm birth before 37 weeks' gestation, birth weight less than 2000 g and small for gestational age at birth. RESULTS: Homelessness or inadequate housing was associated with an odds ratio (adjusted for maternal age, gravidity and being a current smoker of tobacco) of 2.9 (95% confidence interval [CI] 1.4-6.1) for preterm delivery, 6.9 (95% CI 2.4- 20.0) for infant birth weight under 2000 g and 3.3 (95% CI 1.1- 10.3) for delivery of a newborn small for gestational age. Adjusted odds ratios for substance use during pregnancy were similar. In the combined presence of an underhoused or homeless state and maternal substance use, the adjusted risk estimates were 5.9 (95% CI 1.9-18.5), 16.6 (95% CI 3.5-79.3) and 5.6 (95% CI 1.1-28.7), respectively. INTERPRETATION: Homelessness and maternal substance use may reduce neonatal well-being through prematurity and low birth weight.

Adult↗
PubMed2005

Statin use and survival outcomes in elderly patients with heart failure.

BACKGROUND: Coronary artery disease is a leading cause of heart failure. Statins are efficacious drugs for the primary and secondary prevention of coronary heart disease, but their value in persons with heart failure remains unknown. METHODS: We performed a population-based retrospective cohort study involving the entire province of Ontario, Canada, restricting participants to those aged 66 to 85 years who were free of cancer and who survived at least 90 days following hospitalization for newly diagnosed heart failure. The primary study outcome was the risk of death from all causes, nonfatal acute myocardial infarction, or nonfatal stroke among persons newly dispensed statins (n = 1,146) relative to those who were not (n = 27,682). RESULTS: The mean age of all participants was 76.5 years, and half were women. During the 7-year study period, death, acute myocardial infarction, or stroke occurred in 217 statin recipients (13.6 per 100 person-years) vs 12,299 nonrecipients (21.8 per 100 person-years; adjusted hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.63-0.83). Most of the benefit from statins was related to a reduction in all-cause mortality (adjusted HR, 0.67; 95% CI, 0.57-0.78). No significant reduction was seen for subsequent myocardial infarction (adjusted HR, 0.81; 95% CI, 0.63-1.03) or stroke (adjusted HR, 0.81; 95% CI, 0.53-1.25). CONCLUSIONS: Statin use is associated with a lower risk of death among seniors newly diagnosed as having congestive heart failure. While statin use has been previously shown to be efficacious in patients with coronary heart disease and stroke, we could not control for all prognostic risk factors in the present study, including left ventricular ejection fraction and serum lipid levels. Better evidence can direct clinicians about which patients with heart failure might benefit from these drugs.

Aged↗
PubMed2005

Metabolic syndrome and the risk of placental dysfunction.

BACKGROUND: Placental dysfunction (PD), which may manifest partly as the hypertensive disorders of pregnancy and abruption or infarction of the placenta, occurs more commonly in women with obesity, chronic hypertension, diabetes mellitus, and dyslipidemia-each a major feature of the metabolic syndrome. However, the relationship between the metabolic syndrome and the future risk of PD or fetal demise is unknown. METHODS: We completed a retrospective cohort study of 1.03 million women who had a first documented delivery in the province of Ontario between 1990 and 2002. Using linked administrative databases, we categorized women as having zero, one, two, or three to four features of the metabolic syndrome up to 24 months before their index delivery hospitalization. Women were considered to have placental dysfunction if they had a diagnosis of preeclampsia, gestational hypertension, placental abruption, or placental infarction during their first hospitalization for delivery in the period of study. RESULTS: At the time of delivery, 75 380 women (7.3%) were diagnosed as having PD. There was a progressive increase in the risk of PD in women with one (adjusted odds ratio [OR] 3.1; 95% confidence interval [CI] 3.0-3.1), two (OR 5.5; 95% CI 5.2-5.8), or three to four (OR 7.7; 95% CI 6.7-8.9) features of the metabolic syndrome, compared with none. A similar gradient effect was seen for the combined outcome of PD with poor fetal growth, or of PD with concomitant fetal death. CONCLUSIONS: Women who exhibit features of the metabolic syndrome before pregnancy have a higher graded risk of PD and fetal demise. Studies are needed to determine whether modifying a woman's metabolic profile before pregnancy, through modest caloric restriction and increased physical activity, can lower her future risk of PD.

Abruptio Placentae↗
PubMed2005

Greater maternal weight and the ongoing risk of neural tube defects after folic acid flour fortification.

OBJECTIVE: Maternal obesity is likely a risk factor for neural tube defects (NTDs). By late 1997, it became mandatory in Canada that all refined wheat flour be fortified with folic acid. Because overweight women may consume greater quantities of refined wheat flour, we questioned whether their risk of NTD changed after flour fortification. METHODS: A retrospective population-based study was conducted between 1994 and late 2000. We included all Ontarian women who underwent antenatal maternal screening at 15 to 20 weeks of gestation. Self-declared maternal date of birth, ethnicity, current weight, and the presence of pregestational diabetes mellitus were recorded in a standardized fashion on the maternal screening requisition sheet. The presence of NTDs was systematically detected both antenatally and postnatally. The risk of open NTD was evaluated across maternal weight quartiles and deciles, and an interaction between greater maternal weight and the presence of flour fortification was tested using multiple logistic regression analysis. RESULTS: A total of 292 open NTDs were detected among 420,362 women. The adjusted odds ratio (OR) for NTD was 1.2 (95% confidence interval [CI] 1.1-1.3) per 10-kg incremental rise in maternal weight. Comparing the highest with the lowest quartile of maternal weight, the adjusted OR for NTD was 2.6 (95% CI 1.8-4.0). A similar finding was observed for the highest compared with lowest weight deciles (adjusted OR 3.3, 95% CI 1.7-6.2). The interaction between elevated maternal weight and the presence of folic acid flour fortification was of borderline significance (P = .09). Before fortification, greater maternal weight was associated with a modestly increased risk of NTD (adjusted OR 1.4, 95% CI 1.0-1.8); after flour fortification, this effect was more pronounced (adjusted OR 2.8, 95% CI 1.2-6.6). CONCLUSION: These data emphasize the higher risk of NTD associated with increased maternal weight, even after universal folic acid flour fortification. Beyond periconceptional folic acid use, consideration should be given to testing whether prepregnancy weight reduction is an independent means of preventing NTD. LEVEL OF EVIDENCE: II-2.

Body Constitution↗
PubMed2004

Maternal ethnicity and risk of neural tube defects: a population-based study.

BACKGROUND: Maternal body mass and the presence of diabetes mellitus are probable risk factors for neural tube defects (NTDs). The association between maternal ethnicity and the risk of NTDs remains poorly understood, however. METHODS: We performed a retrospective population-based study and included all women in Ontario who underwent antenatal maternal screening (MSS) at 15 to 20 weeks' gestation between 1994 and late 2000. Self-declared maternal date of birth, ethnicity and weight and the presence of pregestational diabetes mellitus were recorded in a standardized fashion on the MSS requisition sheet. NTDs were detected antenatally by ultrasonography or fetal autopsy and postnatally by considering all live and stillborn affected infants beyond 20 weeks' gestation. The risk of open NTD was evaluated across the 5 broad ethnic groups used for MSS, with white ethnicity as the referent. RESULTS: Compared with white women (n = 290 799), women of First Nations origin (n = 1551) were at increased associated risk of an NTD-affected pregnancy (adjusted odds ratio [OR] 5.2, 95% confidence interval [CI] 2.1-12.9). Women of other ethnic origins were not at increased associated risk compared with white women (women of Asian origin [n = 75 590]: adjusted OR 0.9, 95% CI 0.6-1.3; black women [n = 25 966]: adjusted OR 0.6, 95% CI 0.3-1.1; women of "other" ethnic origin [n = 10 009]: adjusted OR 0.1, 95% CI 0.02-0.9). INTERPRETATION: The associated risk of NTD-affected pregnancies was higher among women of First Nations origin than among women of other ethnic origins. The mechanisms for this discrepancy should be explored.

Adult↗
PubMed2004

In vitro analysis of human transplacental transport of desmopressin.

OBJECTIVE: Desmopressin (DDAVP) therapy may be required during pregnancy, but there are limited data about its safety. We wished to verify whether DDAVP is transported across the human placenta. METHODS: Using the in vitro human placental cotyledon perfusion model, we performed serial measurements of maternal and fetal DDAVP concentrations. After introducing the drug into the maternal circulation at estimated baseline therapeutic (30 pg/ml) and supratherapeutic (16,000 and 60,000 pg/ml) concentrations, we measured the rate of transplacental drug transfer up to 2 h. RESULTS: There was no detectable transport of DDAVP at a 30 pg/ml concentration, and the maternal drug concentration remained stable over time. At a much higher maternal concentration of 60,000 pg/ml, the mean peak fetal DDAVP concentration was 2990 pg/ml, equivalent to 4.8% of the baseline maternal concentration. CONCLUSION: At a therapeutic maternal drug concentration, DDAVP does not appear to cross the placenta within detectable limits. At much higher drug concentrations, DDAVP may cross the placenta in a small amount. Future in vitro clinical studies should attempt to reproduce these findings.

Biological Transport↗
PubMed2004

Evidence for suboptimal use of periconceptional folic acid supplements globally.

OBJECTIVE: To systematically summarise the available evidence concerning the rate of folic acid supplement use pre- and periconceptionally, to identify those characteristics associated with low rates of use and to assess whether folic acid public awareness campaigns are associated with higher folic acid use. DESIGN: Systematic overview. SETTING: Survey studies. POPULATION: Women of reproductive age, most of whom were currently or recently pregnant. METHODS: Two investigators searched MEDLINE, Embase and Nutriotiongate databases between 1990 and 2003. Bibliographies of retrieved references were scanned for other relevant publications, and authors were contacted if necessary. Studies were included that evaluated the rate of folic acid supplement use either before conception or in early pregnancy. MAIN OUTCOME MEASURES: Rate of preconceptional and/or periconceptional folic acid use, rate of planned pregnancy in each study, as well as significant characteristics differentiating non-users from users of folic acid, including the effect of folic acid awareness campaigns. RESULTS: A total of 52 studies were included. In 34 studies, reported preconceptional folic acid use varied from 0.9% to 50%. In 49 studies, the reported rate of periconceptional supplement use ranged from 0.5% to 52%. Significant predictors of reduced periconceptional folic acid use were a low level of formal education, immigrant status, young maternal age, lack of a partner and an unplanned pregnancy. Four studies examined the effect of mass media campaigns on periconceptional folic acid use; the reported rates increased significantly, by a factor of 1.7 to 7.2, but in no study was the post-campaign rate above 50%. CONCLUSIONS: In many countries, fewer than 50% of women take periconceptional folic acid supplements. Consideration should be given to the practical advantages of folic acid fortification of centrally processed foods, such as wheat, corn and rice flour, while further promoting vitamin tablet supplement use and planned pregnancy.

Dietary Supplements↗
PubMed2004

Estimating the prevalence of renal insufficiency in seniors requiring long-term care.

BACKGROUND: Renal function declines with age, but little is known about the extent of renal insufficiency among the institutionalized elderly. The objective of this study was to estimate the prevalence of low glomerular filtration rate (GFR) in a large sample of elderly adults living in long-term care facilities, and to compare two commonly used methods for estimating GFR. METHODS: A total of 9931 residents aged 65 years and older participated in a retrospective cross-sectional study of 87 long-term care facilities in Ontario. GFR was estimated by the Cockcroft-Gault and Modification of Diet in Renal Disease Study (MDRD) equations. The prevalence of low GFR, using the Cockcroft-Gault equation (<30 mL/min), was compared with the MDRD equation (<30 mL/min/1.73 m2). RESULTS: A total of 17.0% (95% CI 15.6 to 18.5) of men and 14.4% (95% CI 13.6 to 15.3) of women had a serum creatinine concentration above the laboratory reported upper reference limit of normal. The prevalence of both elevated serum creatinine and low GFR were observed to increase with age (P < 0.0001). The Cockcroft-Gault equation produced a consistently lower estimate of GFR than did the MDRD equation, a discrepancy most pronounced in the oldest residents. Among all men, a low GFR was more prevalent using the Cockcroft-Gault (10.3%, 95% CI 9.2 to 11.5) than MDRD (3.5%, 95% CI 2.8 to 4.2) equation, with a similar difference also seen in women (23.3%, 95% CI 22.4 to 24.3 versus 4.0%, 95% CI 3.6 to 4.5, respectively). Of all residents whose Cockcroft-Gault estimated GFR was under 30 mL/min, 14.7% (95% CI 13.2 to 16.3) were found to have GFR greater than 60 mL/min/1.73 m2 according to the MDRD equation. CONCLUSION: Age-associated renal impairment is common among elderly long-term care residents, but there exists a clear discrepancy between the Cockcroft-Gault and MDRD equations in predicting GFR. Consideration should be given to medication dose adjustment, based on a practical estimate of GFR. However clarification is needed about which method, if either, is most valid among the frail elderly. Complex patient and societal issues surrounding advanced care directives, treatments associated with renal insufficiency, and, if and when to initiate dialysis, require further attention.

Aged↗
PubMed2004

Folic acid food fortification in Canada.

By January 1998, most Canadian cereal grains (e.g., white flour) were being fortified with folic acid, with a large percentage being fortified by mid-1997. This was in compliance with both American and Canadian mandatory fortification deadlines of January and November 1998, respectively. It was estimated that between 0.1 to 0.2 mg of additional synthetic folic acid per day would be provided through this initiative, the goal of which was to lower the rate of neural tube defects (NTD). The current report outlines some of the changes to the health status of Canadians in relation to its folic acid food fortification initiative.

Canada↗