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Biomedical subjects

P Garner

Publications and source records attributed to P Garner.

At least 19 recordsLinked to original sources
PubMed1998

Effect of preventive treatment for tuberculosis in adults infected with HIV: systematic review of randomised placebo controlled trials.

OBJECTIVE: To determine whether preventive treatment for tuberculosis in adults infected with HIV reduces the frequency of tuberculosis and overall mortality. DESIGN: Systematic review and data synthesis of randomised placebo controlled trials. MAIN OUTCOME MEASURES: Active tuberculosis, mortality, and adverse drug reaction requiring cessation of the study regimen. Outcomes stratified by status of purified protein derivative skin test. RESULTS: Four trials comprising 4055 adults from Haiti, Kenya, the United States, and Uganda were included. All compared isoniazid (6-12 months) with placebo, and one trial also compared multidrug treatment for 3 months with placebo. Mean follow up was 15-33 months. Overall, frequency of tuberculosis (relative risk 0.57, 95% confidence interval 0.41 to 0.79) was reduced in those receiving preventive treatment compared with placebo: mortality was not significantly reduced (0.93, 0.83 to 1.05). In subjects positive for purified protein derivative receiving preventive treatment, the risk of tuberculosis was reduced substantially (0.32, 0.19 to 0.51) and the risk of death was reduced moderately (0.73, 0.57 to 0.95) compared with those taking placebo. In adults negative for purified protein derivative receiving preventive treatment, the risk of tuberculosis (0.82, 0.50 to 1.36) and the risk of death (1.02, 0.89 to 1.17) were not reduced significantly. Adverse drug reactions were more frequent, but not significantly so, in patients receiving drug compared with placebo (1.45, 0.98 to 2.14). CONCLUSIONS: Preventive treatment given for 3-12 months protects against tuberculosis in adults infected with HIV, at least in the short to medium term. Protection is greatest in subjects positive for purified protein derivative, in whom death is also less frequent. Long term benefits remain to be shown.

AIDS-Related Opportunistic Infections↗
PubMed1998

Private practitioners in the slums of Karachi: what quality of care do they offer?

Private health services have expanded in many developing countries over the last 10 yr. Qualified private practitioners provide basic health care for poorer groups in urban areas, although health care planners frequently criticize them for providing poor quality of care, charging high fees and failing to provide preventive health advice. In Karachi, a large city with more than 400 slums, private practitioners are important providers of care to the poor. This study assessed the nature and quality of care provided by 201 practitioners selected from four districts of the city. Vignettes of specific medical problems were used to assess their knowledge and their practice was measured by observing 658 doctor-patient contacts. The results show that knowledge was closer to accepted medical management than was their actual prescribing practice. On the other hand, their manners and interpersonal behaviour were good. Thus poor prescribing practice, which might equally stem from market influences as lack of knowledge, is the cause of low standards of care. In these circumstances, didactic in-service training to improve prescribing practice is unlikely to be successful.

Adult↗
PubMed1998

Trichomoniasis treatment in women: a systematic review.

OBJECTIVE: To compare the effectiveness of various treatment strategies for trichomoniasis in women. DATA SOURCES: Medline from 1966 to 1996, Embase from 1986 to 1996, Science Citation Index from 1990 to 1996; reference lists of existing reviews; through the manufacturers of metronidazole and tinidazole in the UK, the Cochrane Controlled Trials Register until October 1997 and informal discovery. STUDY SELECTION: Any randomized or quasi-randomized trial in nonpregnant women with trichomoniasis where different treatment strategies were compared. 45 of the 124 identified studies met the criteria and were included in the review. DATA EXTRACTION: Settings, diagnostic methods, exclusions, loss to follow-up and partner treatment strategies were extracted. Outcomes sought were parasitological cure, clinical cure and side-effects of treatment. RESULTS: Most trials were small, with only two trials containing more than 100 women in each comparison group. Only 11 trials followed up women for more than one month. Oral nitroimidazoles were effective in achieving parasitological cure. Fourteen trials compared different treatment strategies with the remainder comparing different doses or different drugs. Partner treatment was effective in decreasing longer-term re-infection rates in the one trial testing this. CONCLUSIONS: Parasitological cure can be achieved by a single oral dose of nitroimidazoles. There is, however, very little data on partner treatment strategies and long-term cure rates after initial treatment. Further research should test various partner treatment strategies to prevent re-infections and reduce trichomoniasis prevalence.

Antitrichomonal Agents↗
PubMed1998

Episiotomy in Burkina Faso.

Episiotomy is a common obstetric intervention in many countries of the world, although little is known about rates in African countries. In recent years, the effectiveness of routine episiotomy to prevent severe tears and neonatal asphyxia has been questioned, and evidence shows that the procedure results in considerable maternal morbidity. This study estimates episiotomy rates in Burkina Faso. A high proportion of primigravidae (46%) received an episiotomy when trained midwives attended the delivery; a level which indicates the procedure has to be regarded as routine practice. The episiotomy rate was lower (26%) in primigravidae delivered by auxillary midwives. This proportion is closer to recommended selective approaches derived from good research summaries. The tear rate in women assisted by midwife and auxiliary staff was similar, suggesting that women tear even when the procedure is performed. These results indicate that obstetricians and midwives in Burkina Faso should critically appraise whether routine episiotomy should be abandoned. The introduction of a labour chart is a good vehicle to introduce a policy on avoiding episiotomies.

Adolescent↗
PubMed1998

Putting evidence into practice.

A training module is described in which experienced health care managers from developing countries explore the challenges to be faced when attempting to use the results of systematic reviews of scientific studies on health care interventions in policy and practice.

Decision Making↗
PubMed1997

Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatment.

OBJECTIVE: To determine the effectiveness of strategies to promote adherence to treatment for tuberculosis. IDENTIFICATION: Searches in Medline (1966 to August 1996), the Cochrane trials register (up to October 1996), and LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud) (1982 to September 1996); screening of references in articles on compliance and adherence; contact with experts in research on tuberculosis and adherence. INCLUSION CRITERIA: Randomised or pseudorandomised controlled trials of interventions to promote adherence with curative or preventive treatment for tuberculosis, with at least one measure of adherence. MAIN OUTCOME MEASURE: Relative risks and 95% confidence intervals for estimates of effect for categorical outcomes. RESULTS: Five trials met the inclusion criteria. The relative risk for tested reminder cards sent to patients who defaulted on treatment was 1.2 (95% confidence interval 1.1 to 1.4), for help given to patients by lay health workers 1.4 (1.1 to 1.8), for monetary incentives offered to patients 1.6 (1.3 to 2.0), for health education 1.2 (1.1 to 1.4), for a combination of a patient incentive and health education 2.4 (1.5 to 3.7) or 1.1 (1.0 to 1.2), and for intensive supervision of staff in tuberculosis clinics 1.2 (1.1 to 1.3). There were no completed trials of directly observed treatment. All of the interventions tested improved adherence. On current evidence it is unclear whether health education by itself leads to better adherence to treatment. CONCLUSIONS: Reliable evidence is available to show some specific strategies improve adherence to tuberculosis treatment, and these should be adopted in health systems, depending on their appropriateness to practice circumstances. Further innovations require testing to help find specific approaches that will be useful in low income countries. Randomised controlled trials evaluating the independent effects of directly observed treatment are awaited.

Attitude to Health↗
PubMed1997

Mefloquine to prevent malaria: a systematic review of trials.

OBJECTIVE: To evaluate the research evidence on the efficacy and tolerability of mefloquine chemoprophylaxis. SEARCH STRATEGY: Any potentially relevant trial from the Cochrane Infectious Disease Group's register of controlled trials; systematic searches of Medline, Embase, Lilacs and Science Citation Index; scanning citations; and consulting drug companies and key investigators. We considered studies in all languages. INCLUSION CRITERIA: Trials carried out in non-immune adult travellers, and in non-travelling volunteers, where an attempt had been made to conduct a randomised comparison of mefloquine against placebo or against alternative standard prophylaxis. RESULTS: 37 potentially eligible trials of mefloquine prophylaxis were identified, and 10 met the inclusion criteria. These 10 trials comprised a total of 2750 non-immune adult participants randomised to mefloquine or to a control. One placebo controlled trial examined malaria incidence directly and showed mefloquine to be highly effective in preventing malaria in an area of drug resistance. However, four placebo controlled trials showed that mefloquine was not well tolerated, and withdrawals were consistently higher in mefloquine treatment arms than in placebo arms (odds ratio 3.49 (95% confidence interval 1.42 to 8.56)). Five field trials compared mefloquine with other chemoprophylaxis. Mefloquine was no worse tolerated than other chemoprophylaxis, although there was possibly a trend towards higher withdrawals in mefloquine arms (odds ratio 1.33 (0.75 to 2.36)). CONCLUSION: One trial showed mefloquine to be effective in preventing malaria, but withdrawal rates, presumably from side effects, were high across most studies. This is likely to impair mefloquine's effectiveness in general travellers, and it may therefore not be useful for routine prophylaxis. Mefloquine may be useful in specific situations such as for groups travelling to regions with a high risk of chloroquine resistant malaria and only limited access to effective medical care.

Adult↗
PubMed1997

A randomized controlled trial of strict glycemic control and tertiary level obstetric care versus routine obstetric care in the management of gestational diabetes: a pilot study.

OBJECTIVES: The purpose of this study was to determine whether strict maternal glycemic control for the treatment of gestational diabetes lessened the risk of fetal macrosomia, birth trauma, neonatal hypoglycemia, and operative delivery. The aim of the pilot study was to prepare for a multicenter trial by assessing patient acceptance of the study, by determining realistic accrual rates, and by detecting any major adverse outcomes in the control group that received routine obstetric care. STUDY DESIGN: The study was a prospective randomized controlled trial comparing fetal-neonatal and maternal outcomes in 300 women with gestational diabetes. Women randomized to the treatment arm were managed by strict glycemic control and tertiary level obstetric care, and women in the control arm received routine obstetric care. RESULTS: Three hundred women with gestational diabetes mellitus were studied. There was no difference in maternal age, weight, or length of gestation between groups. The treatment mean birth weight was 3437 +/- 575 gm compared with 3544 +/- 601 gm in the control group, a difference of 107 gm (not significant). Macrosomia rates were similar. There was no birth trauma in either group. The frequency of neonatal hypoglycemia and other metabolic complications was the same. The mode of delivery also showed similar patterns. The treatment group had significantly lower preprandial and postprandial glucose levels by 32 weeks' gestation, which continued to term. CONCLUSION: This pilot study suggests that intensive treatment of gestational diabetes mellitus may have little effect on birth weight, birth trauma, operative delivery, or neonatal metabolic disorders. It has demonstrated the safety of proceeding to a multicenter trial of sufficient sample size to confirm these findings.

Adult↗