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Biomedical subjects

John Sellors

Publications and source records attributed to John Sellors.

16 recordsLinked to original sources
PubMed2006

Preliminary report of a gas conditioner to improve operational reliability of cryotherapy in developing countries.

BACKGROUND: Cryotherapy is a safe, affordable, and effective method of treatment for cervical intraepithelial neoplasia. In some low-resource settings, environmental conditions or qualities of the refrigerant gas can lead to blockage of cryotherapy equipment, terminating treatment. A prototype of a gas conditioner to prevent operational failure was designed, built, and field tested. METHODS: The prototype conditioner device consists of an expansion chamber that filters and dries the refrigerant gas. Users in Peru and Kenya reported on their experience with the prototype conditioner. In Ghana, simulated cryotherapy procedures were used to test the effects of the prototype conditioner, as well as the commonly used "cough technique." RESULTS: Anecdotal reports from field use of the device were favorable. During simulated cryotherapy, the prevalence of blockage during freezing were 0% (0/25) with the device alone, 23.3% (7/30) with the cough technique alone, 5.9% (1/17) with both, and 55.2% (16/29) with neither (Pearson's Chi square = 26.6, df = 3, p < 0.001 (comparison amongst all groups)). CONCLUSION: This prototype design of a cryotherapy gas conditioner is a potential solution for low-resource settings that are experiencing cryotherapy device malfunction.

Journal Article↗
PubMed2004

Prescribing of potentially inappropriate medications to elderly people.

OBJECTIVE: To estimate the prevalence and predictors of medications deemed potentially inappropriate for the elderly among family physicians' patients aged 65 and older (seniors) taking multiple prescribed medications. METHODS: Forty-eight randomly selected family practices in 16 towns and cities in Southern Ontario, Canada and 889 of their senior patients were recruited into a randomized trial. We conducted a cross-sectional analysis of prescription insurance data from the provincial universal prescription insurance database over 12 months, from the 777 seniors who completed the trial and agreed to have their data released. The prevalence and patient and physician predictors of use of a potentially inappropriate medication (PIM), as defined by published widely accepted criteria, were examined. RESULTS: The median number of prescriptions filled was 24. Nearly one-fifth (16.3%) of the seniors received at least one prescription for a PIM, with short-acting benzodiazepine prescriptions for longer than 30 days (6.4%) and oxybutynin (3.7%) being the types prescribed most frequently. In univariate and multiple variable analyses, women were found to be statistically significantly more likely to be prescribed a PIM (adjusted OR = 1.6; 95% confidence interval = 1.0-2.4). Age, education, self-rated health, number of health conditions, and number of prescriptions were not associated with PIM use. Physician gender, family medicine certification status, and time since graduation were not significantly associated with PIM prescribing. CONCLUSIONS: Prescribing of PIMs, especially of short-acting benzodiazepines was common in seniors taking multiple medications. Interventions to reduce use of PIM, especially long-term benzodiazepines, are important in primary care.

Aged↗
PubMed2004

Optimal cutoff of the hybrid capture II human papillomavirus test for self-collected vaginal, vulvar, and urine specimens in a colposcopy referral population.

OBJECTIVE: To estimate the optimal relative light unit ratio, as a measure of viral load, of the Hybrid Capture II human papillomavirus (HPV) test in self-collected specimens for detecting cervical intraepithelial neoplasia (CIN). METHODS: Two hundred women referred for colposcopy with abnormal cytologic, self-collected vaginal and vulvar swabs and urine for HPV testing. The receiver operating characteristic (ROC) curve method was used to estimate optimal cutoffs for the Hybrid Capture II test. The reference standard was colposcopy, with directed biopsy as required. RESULTS: The estimated optimal cutoffs of the relative light unit ratio for detecting CIN 2 or higher for urine, vulvar, and vaginal samples gave sensitivities of 72.4%, 82.8%, and 89.0% and specificities of 57.0%, 52.1%, and 55.9%, respectively. At the manufacturer's recommended 1.0 cutoff, sensitivities were 44.8%, 62.1%, and 86.2% for urine, vulvar, and vaginal samples, with specificities of 69.7%, 62.7%, and 53.5%, respectively. The likelihood ratios (likelihood of being truly positive after a positive test result) were similar for the optimal and the 1.0 cutoff. CONCLUSIONS: The ROC curve methods did not improve the overall diagnostic accuracy of the Hybrid Capture II test compared with the 1.0 relative light unit ratio cutoff.

Journal Article↗
PubMed2004

Systematic review of the literature on postpartum care: methodology and literature search results.

BACKGROUND: The postpartum period is a time for multiple clinical interventions. To date, no critical review of these interventions exists. This systematic review examined evidence for the effectiveness of postpartum interventions that have been reported in the literature. METHODS: MEDLINE, Cinahl, PsycINFO, and the Cochrane Library were searched for randomized controlled trials of interventions initiated from immediately after birth to 1 year in postnatal women that were conducted in North America, Europe, Australia, or New Zealand. The initial literature search was done in 1999, using postpartum content search terms, and was enhanced in 2003. In both years, bibliographic databases were searched from their inception. Studies were categorized into key topic areas. Data extraction forms were developed and completed for each study, and the quality of each study was systematically reviewed. Groups of studies in a topic area were reviewed together, and clinically relevant questions emanating from the studies were identified to determine whether the studies, alone or together, provided evidence to support the clinical intervention. RESULTS: In the 1999 search, of 671 studies identified, 140 studies were randomized controlled trials that met the selection criteria: 41 studies related to breastfeeding, 33 to postpartum perineal pain management, and 63 to 11 other key topic areas (Papanicolaou test, rubella immunization, contraception, postpartum support, early discharge, postpartum depression and anxiety, postpartum medical disorders, smoking cessation, nutrition supplements other than breastfeeding, effects of pelvic floor exercise, and effects of early newborn contact). The results of the systematic review of each topic will be summarized in separate papers as they are completed. CONCLUSIONS: This systematic search has identified key topic areas in postpartum care for which randomized controlled trials have been conducted. Our ultimate goal is to provide evidence-based guidelines on the use of routine postpartum interventions.

Breast Feeding↗
PubMed2004

Systematic review of the literature on postpartum care: selected contraception methods, postpartum Papanicolaou test, and rubella immunization.

BACKGROUND: The postpartum period is a time when many routine interventions are provided to mothers. This review examined the published evidence for the effectiveness of selected contraceptive methods, Papanicolaou (Pap) tests, and rubella immunization. METHODS: MEDLINE, Cinahl, PsycINFO, and the Cochrane Library were searched for randomized controlled trials of interventions initiated from immediately after birth to 1 year in postnatal women. The initial literature search was done in 1999, and was enhanced in 2003. Studies were categorized and reviewed by topic areas. Data were extracted in a systematic method, and the quality of each study was reviewed. RESULTS: In the 1999 search, 140 studies were randomized controlled trials that met the selection criteria: 5 related to postpartum contraception, 1 to timing of the postpartum Pap test, and 2 to postpartum rubella immunization. In the 2003 searches, 1 additional study related to postpartum contraception was identified. From the published literature on selected contraceptive methods, the intrauterine devices examined were effective in preventing pregnancy and had comparable side effect profiles. No clear recommendation can be made because insertion timing was not randomized in the included trials. Although delaying the postpartum Pap smear until 8 weeks reduces the proportion of inflammatory smears, it is uncertain whether a Pap smear is of benefit to postpartum women. The RA 27/3 postpartum rubella vaccine appears to be more effective than the Cendehill vaccine, but a small proportion of women may develop acute and chronic joint manifestations. CONCLUSIONS: Some evidence is available to support selected postpartum contraceptive methods and the postpartum rubella vaccine, but data are lacking on the effectiveness and optimal timing of the postpartum Pap smear.

Contraception↗
PubMed2003

A randomized controlled trial of a pharmacist consultation program for family physicians and their elderly patients.

BACKGROUND: Pharmacists can improve patient outcomes in institutional and pharmacy settings, but little is known about their effectiveness as consultants to primary care physicians. We examined whether an intervention by a specially trained pharmacist could reduce the number of daily medication units taken by elderly patients, as well as costs and health care use. METHODS: We conducted a randomized controlled trial in family practices in 24 sites in Ontario. We randomly allocated 48 randomly selected family physicians (69.6% participation rate) to the intervention or the control arm, along with 889 (69.5% participation rate) of their randomly selected community-dwelling, elderly patients who were taking 5 or more medications daily. In the intervention group, pharmacists conducted face-to-face medication reviews with the patients and then gave written recommendations to the physicians to resolve any drug-related problems. Process outcomes included the number of drug-related problems identified among the senior citizens in the intervention arm and the proportion of recommendations implemented by the physicians. RESULTS: After 5 months, seniors in the intervention and control groups were taking a mean of 12.4 and 12.2 medication units per day respectively (p = 0.50). There were no statistically significant differences in health care use or costs between groups. A mean of 2.5 drug-related problems per senior was identified in the intervention arm. Physicians implemented or attempted to implement 72.3% (790/1093) of the recommendations. INTERPRETATION: The intervention did not have a significant effect on patient outcomes. However, physicians were receptive to the recommendations to resolve drug-related problems, suggesting that collaboration between physicians and pharmacists is feasible.

Aged↗
PubMed2003

Observer agreement with laparoscopic diagnosis of pelvic inflammatory disease using photographs.

OBJECTIVE: To test the intraobserver (are observers likely to agree between themselves?) and interobserver (are observers likely to agree with other observers?) reproducibility and the overall diagnostic accuracy of laparoscopic diagnosis of pelvic inflammatory disease (PID). METHODS: Three senior consultants and three residents in training in obstetrics and gynecology scored the four laparoscopic images (adnexa, cul-de-sac, and pelvic panoramic view) from each of 40 patients and repeated the process 2 days later after the order of presentation had been randomized. A standardized predesigned scoring form was used. Histopathologically proven PID was used as the gold standard. RESULTS: The overall accuracy of the laparoscopic diagnosis of PID was 78%, the sensitivity was 27%, and the specificity was 92%. The overall intraobserver reproducibility of the diagnosis of PID was only fair (kappa = 0.58), and it was clearly better among the consultants than among the residents (kappa = 0.76 and 0.39, respectively). The overall interobserver reproducibility was poor to fair (kappa = 0.43), and it was again better among the consultants than among the residents (kappa = 0.48 and 0.38, respectively). When specific diagnostic features (including tubal erythema, edema, adhesions, cul-de-sac fluid) were separately analyzed, the results were no different suggesting only poor-to-fair reproducibility. CONCLUSION: Based on photographic images, the observer reproducibility and the overall diagnostic accuracy of the laparoscopic diagnosis of PID are unsatisfactory when histopathologically proven PID is used as the gold standard.

Female↗
PubMed2003

Prospective evaluation of colposcopic features in predicting cervical intraepithelial neoplasia: degree of acetowhite change most important.

OBJECTIVE.: To prospectively evaluate the contribution of three colposcopic features-degree of acetowhite change, blood vessel pattern, and lesion margin-to the diagnosis of cervical intraepithelial neoplasia. MATERIALS AND METHODS.: A total of 301 women, who participated in two randomized controlled trials and a cross-sectional study of human papillomavirus testing and who were referred to a regional colposcopy center, were studied. Women were examined by colposcopists, who prospectively scored all abnormal transformation zones using three features. The site with the highest score (the most abnormal site) was biopsied and histology reviewed by two pathologists. RESULTS.: In multivariate analysis, degree of acetowhite change was the only feature significantly associated with cervical intraepithelial neoplasia. CONCLUSIONS.: Grading lesion severity using degree of acetowhite change alone gave comparable results to grading using the three combined features.

Journal Article↗
PubMed2003

Prenatal HIV tests. Routine testing or informed choice?

OBJECTIVE: To examine how prenatal care providers responded to a new provincial policy of offering HIV testing to all prenatal patients, and to determine factors associated with self-reported high testing rates. DESIGN: Cross-sectional mailed survey. SETTING: Outpatient practices in three Ontario health-planning regions. PARTICIPANTS: Prenatal care providers: 784 family physicians, 200 obstetricians, and 103 midwives were sent questionnaires and were eligible to participate. MAIN OUTCOME MEASURES: Self-reported testing of 80% or more prenatal patients ("high testers") and associated practice characteristics, attitudes, and counseling practices. RESULTS: Response rate was 57% (622/1087): 43% of respondents were high testers. Family physicians were most likely and midwives least likely to be high testers. High testers tended to report that they had adequate knowledge of HIV testing, that HIV risk among their patients warranted testing all of them, and that testing should be routine. Encouraging women to test and not providing written information or choice were independently associated with high testing rates. CONCLUSION: Strongest predictors of high prenatal HIV testing rates were attitudes and practices that favoured a routine approach to testing and that placed little emphasis on informed consent.

AIDS Serodiagnosis↗
PubMed2002

Optimizing the hybrid capture II human papillomavirus test to detect cervical intraepithelial neoplasia.

OBJECTIVE: To estimate the optimal relative light unit ratio, and correspondingly viral load, of the hybrid capture II oncogenic human papillomavirus deoxyribonucleic acid test for detecting cervical intraepithelial neoplasia (CIN). METHODS: Women with abnormal cytology were referred for colposcopy, and a cervical swab or brush specimen was obtained for human papillomavirus testing. Sensitivities, specificities, and likelihood ratios of different relative light unit ratio cutoffs were calculated using a reference standard of colposcopy or biopsy of either CIN II+ (CIN II, III, or carcinoma), or CIN I+ (CIN I, CIN II+). The receiver operating characteristic curve was used to estimate optimal test-positive cutoff points for the hybrid capture II test. RESULTS: CIN II+ was found in 18.7% (98 of 524) and CIN I in 10.5% (55 of 524) of the women. The optimal relative light unit ratio was 15.56, giving a sensitivity and specificity of 82.7% and 73.2% for CIN II+, and 74.2% and 77.8% for CIN I+. In a stratified analysis, a higher relative light unit cutoff (15.19) optimized sensitivity and specificity for CIN II+ (sensitivity 81.8%, specificity 51.5%) for women with low-grade squamous intraepithelial lesions cytology, whereas the optimal cutoff was 2.36 (sensitivity 100%, specificity 73.0%) for women with atypical squamous cells of undetermined significance, yielding referral rates of 53.3% and 28.7%, respectively. Use of a swab or brush was not associated with the level of human papillomavirus detected (P >.05). CONCLUSION: Use of a higher cutoff for the relative light unit ratio (higher viral load) of the hybrid capture II test may improve the management of women, especially those with low-grade squamous intraepithelial lesions cytology.

Adolescent↗
PubMed2002

Recruiting family physicians and patients for a clinical trial: lessons learned.

BACKGROUND: The randomized controlled trial (RCT) is the most definitive tool for evaluating an intervention. However, methodological deficiencies may limit the internal or external validity of the RCT. OBJECTIVE: Our aim was to describe the tactics used and the resources required randomly to select and recruit family physicians (FPs) and their patients aged 65 and older (seniors) for a community-based cluster RCT in primary care. METHODS: We randomly selected 48 FPs in 24 urban and rural sites in Southern Ontario, and 889 of their community-dwelling seniors (approximately 20 per FP) taking five or more medications daily. To accomplish this, the principal investigator (an FP) contacted the eligible FPs. The participating FPs' office staff then generated and contacted the roster of eligible seniors, with support provided by the research staff. RESULTS: Of the 163 randomly selected FPs telephoned, 94 were ineligible and 48 (69.6%) of the remaining 69 participated. The rosters were generated with the assistance of the research staff (taking 1.5-8.0 hours) in each of the 48 practices, using electronic appointment records (n = 26), electronic billing records (n = 17), electronic medical records (n = 2) or written charts or file cards (n = 3). Of the 2078 seniors approached, 799 were ineligible and 889 (69.5%) of the remaining 1279 participated. Seniors' refusal rates among practices ranged from 4.8 to 62.3%. CONCLUSIONS: Recruitment of a representative sample and generalizability of results are possible in RCTs in primary care. Involvement of an FP in physician recruitment and clinical research nurses who provided assistance to office staff were keys to success.

Aged↗
PubMed2002

Medical abortion and family physicians. Survey of residents and practitioners in two Ontario settings.

OBJECTIVE: To determine the knowledge, attitudes, and interest in providing medical abortion reported by family physicians and residents in rural and urban settings. DESIGN: A self-administered mailed survey using the modified Dillman method. SETTING: Hamilton and Thunder Bay County in Ontario. PARTICIPANTS: Family medicine residents (n = 93) and physicians (n = 234) in predominantly urban (Hamilton) and rural (Thunder Bay) settings. All faculty family physicians at McMaster University practising general family medicine and all family physicians in Thunder Bay County were surveyed. MAIN OUTCOME MEASURES: Knowledge of, attitudes toward, and interest in providing medical abortion. RESULTS: Overall response rate to the survey was 62.7% (n = 327); 74.2% (69/93) of residents responded; 58.1% (136/234) of physicians responded. Physicians and residents rated their knowledge about medical abortion as poor, but most were interested in receiving more information and training in this area. Many (83.1%, 157/189) reported that medical abortion was an acceptable procedure for family physicians to perform, and 52.0% (64/123) of the physicians would consider providing medical abortions for their patients. Residents training in the more rural Thunder Bay program were less likely to support first-trimester abortions for both medical and nonmedical reasons than those training in Hamilton (P < .05). Male respondents were significantly less supportive of abortion for nonmedical reasons and were less likely to consider providing medical abortions for their patients (P < .05). CONCLUSION: Most family physicians and residents showed interest in receiving more information about and training in medical abortion.

Abortion, Induced↗
PubMedDate not supplied

Collaboration between community pharmacists and family physicians: lessons learned from the Seniors Medication Assessment Research Trial.

OBJECTIVES: To learn about the experiences of specially trained expanded role pharmacists (ERPs) and family physicians in a program in which they worked together to optimize drug therapy for elderly patients (aged 65 and older) and to identify shortcomings of the program, obstacles to its implementation, and strategies to overcome these obstacles. DESIGN: Qualitative opinion analysis. PARTICIPANTS: Six family physicians and six community-based ERPs who had participated in a randomized controlled trial (Seniors Medication Assessment Research Trial [SMART]). INTERVENTION: In-depth interviews. MAIN OUTCOME MEASURES: Themes that emerged from the interviews regarding the strengths and weaknesses of and ways to improve the program. RESULTS: ERPs and physicians differed in their perceptions of appropriate roles for ERPs. ERPs saw the program as an opportunity to take on new professional roles. Physicians appreciated the information they received from ERPs about their patients' adherence and use of nonprescription medications, but they did not want ERPs to directly counsel their patients. Some physicians questioned the value of the program for some patients, since the inclusion criteria for patients were broad and not all patients meeting the criteria needed intense interventions by ERPs. Both ERPs and physicians identified the need to refine the referral process and to work out professional role relationships and ongoing collaboration more fully. If the program were to be implemented as a routine service, physicians were concerned about the demands on their staff and office space and the need for an external compensation mechanism. CONCLUSION: Issues to be addressed for future programs include clarification of the roles of pharmacist and physician when the professionals work together, targeting of appropriate patients for the program, identification of a more efficient way to deliver recommendations, and development of an appropriate compensation mechanism.

Aged↗
PubMedDate not supplied

Prenatal HIV testing in Ontario: knowledge, attitudes and practices of prenatal care providers in a province with low testing rates.

OBJECTIVE: To describe the knowledge, attitudes and practices of prenatal care providers in relation to prenatal HIV testing. METHODS: A stratified random sample of 784 family physicians, 200 obstetricians and 103 midwives providing prenatal care in 3 health planning regions in Ontario received a questionnaire. RESULTS: Response was 622/1087 (57%). Almost half of participants (43%) were not aware of Ontario's prenatal HIV testing policy. Eighty-five percent of participants reported that they offered or ordered HIV testing for all pregnant women. Sixty-six percent agreed that women should have a choice about whether to test or not, and midwives were more supportive of having an informed consent process than were physicians. CONCLUSION: Knowledge about the risks and benefits of prenatal HIV testing needs to be improved, and standards for informed consent should be re-evaluated to achieve the most ethical process with the least complexity.

AIDS Serodiagnosis↗
PubMedDate not supplied

Screening and management of precancerous lesions to prevent cervical cancer in low-resource settings.

Cervical cancer is a leading cause of cancer death among women in low-resource settings, but it is completely preventable by screening for and treating precancerous lesions. In this article, the current approaches to screening, confirmation, and treatment of precancerous lesions of the cervix are reviewed from the perspective of low-resource settings. Cervical cytology is compared to visual inspection with acetic acid (VIA) for screening women to detect precancerous lesions. The use of colposcopy to confirm findings in women with positive screening test results and various treatment methods are discussed. With one examination, cytology appears to detect fewer precancerous lesions than VIA, but VIA has a lower specificity and labels proportionately more women falsely positive. When available, colposcopy may be used to obtain directed biopsies from abnormal areas of the cervix to pathologically confirm the findings in women with positive screening tests. Treatment with cryotherapy appears to be a safe, acceptable, and effective procedure for the majority of precancerous lesions. Lesions that are not suitable for cryotherapy because of endocervical canal involvement or large size are amenable to outpatient treatment by loop electrical excision procedure (LEEP). HIV/AIDS and immune system suppression are associated with more rapid CIN progression and HIV-positive women generally have high recurrence rates of CIN after treatment. Women tempora may more readily transmit the virus after cryotherapy and, therefore, they require counseling regarding abstinence and condom use. Highly active antiretroviral therapy (HAART) may cause CIN to regress and may decrease the risk of cervical cancer in HIV-infected women. Cost-effectiveness modeling using South African data shows that use of a single lifetime VIA test and immediate cryotherapy saves costs compared to cytology or to no screening. VIA and cryotherapy are appropriate services for low-resource settings. Colposcopy and LEEP services should be available on a referral basis.

Adult↗