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Biomedical subjects

R D Remington

Publications and source records attributed to R D Remington.

At least 19 recordsLinked to original sources
PubMed1990

From preventive policy to preventive practice.

Characteristics of the relationship of preventive policy to preventive practice are reviewed. The relatively low emphasis on prevention compared with treatment programs is discussed and the particular problem of the "anonymity" of prevention is defined. Prevention programs suffer in part because of the lack of identity of the specific individuals benefited. Examples from the cardiovascular diseases are used to illustrate the general points. The contrast between community- and patient-oriented prevention is important. Adequate levels of disease prevention and health promotion will never be attained one case at a time. Interactions among individuals are determinants of environmental behavioral factors relevant to health. The policy forming process is intrinsically interactive in nature. The Institute of Medicine's 1988 study of the future of public health is reviewed with respect to its emphasis on professional participation in the health policy process. Prevention is an essentially multidisciplinary area requiring the participation of many professions and disciplines. This property of prevention will be enhanced in the future. Ten principles which can be useful in translating preventive policy into preventive practice are presented.

Cardiovascular Diseases↗
PubMed1989

Potential impact of exclusion criteria on results of hypertension trials.

Recent trials of antihypertensive therapy, including the Veterans Administration trials, the Hypertension Detection and Follow-up Program, the Multiple Risk Factor Intervention Trial, the Australian Mild Hypertension Trial, and the British Medical Research Council Trial, are reviewed with a particular emphasis on the criteria leading to the exclusion of potentially eligible participants. The observation of all-cause and cause-specific mortality rates in the group ultimately selected to participate in the trial is suggested as an index to the general applicability of trial results. Because end-point rates are fundamental for determining sample size, substantial reduction in these end-point rates by patient exclusion should be taken into account by the trial design. Some recent trials may have generated end-point-event rates so low that the power of the trial to detect reasonable treatment effects was substantially reduced. Future trials should attempt to take this important factor into account at the design stage.

Antihypertensive Agents↗
PubMed1984

Who should code cause of death in a clinical trial?

Clinical trials of intervention in chronic disease often use cause-specific mortality as a principal outcome variable. Surprisingly, there has been little standardization of the approach to determining cause of death. Some studies use standard nosological coding based on the International Statistical Classification of Diseases while others rely on panels of physicians. Some studies utilize autopsy findings; others do not. There is a clear need for standardization, and a unified approach is suggested. In this approach, panels of physicians prepare death certificates and are trained and standardized to generate reproducible information. A system for adjudication of differences is a part of the trial's design. Death certificates are then transmitted to panels of nosologists who assign cause of death. Again, the nosologists are standardized, and an adjudication system for resolving differences is developed. This two-stage system takes advantage of strengths of the two types of cause of death coding now in use in clinical trials and should produce results permitting cross-trial and cross-time comparisons.

Adult↗
PubMed1983

Nosological coding of cause of death.

Death certificates representing 766 decedents who had participated in the Hypertension Detection and Follow-up Program (1973-1979) at one of 14 US centers were given to three nosologists for purposes of coding underlying cause of death. Analyses examined interobserver variability among the three nosologists as well as intraobserver variability for each of the three nosologists. All three nosologists agreed on a three-digit International Classification of Diseases, Adapted (ICDA) code in 90.2% of the cases and at least two out of three agreed in 99.7% of the death certificates examined. Agreement rates improved when disease codes were collapsed into broader categories utilized in the Hypertension Detection and Follow-up Program. When particular disease classifications (e.g., cerebrovascular, ischemic heart disease, myocardial infarction, and neoplasms) were examined, three out of three agreement rates were highest for neoplasms (97.8%) and lowest for myocardial infarction (86.5%). Similarly, two out of three agreement was highest for neoplasms (98.5%) and lowest for myocardial infarction (88.0%). Intranosologist agreement rates were based on a recoded 20% sample of death certificates. Agreement rates for three-digit ICDA codes ranged from 94.8% to 96.1% for the three nosologists. The agreement rates for the general disease categories ranged from 96.7% to 97.4%.

Cardiovascular Diseases↗
PubMed1982

Lewis A. Conner Memorial Lecture. Choices that must not be made.

Throughout our professional lifetimes, we are conditioned by the need to choose; among careers, among treatments for our patients, among health habits and lifestyles. After detailing the extent to which a choice-making orientation has dominated our lives, our society, our health system, our science, this paper describes areas in which it is crucial that choices not be made. These include the choice between basic and applied research, between targeted and investigator-initiated research, between prevention and treatment of cardiovascular disease, and between the need to know (research on mechanisms of disease) and the need to take action (intervention in the individual and the community to control disease). In each of these areas, a decision to emphasize either alternative at the expense of the other is undesirable and defeats the basic goals of understanding and controlling heart and vascular disease. In discussing these sets of alternatives, the three major cardiovascular risk factors are discussed: cigarette smoking, high blood pressure and diet. Examples are chosen from research investigations on risk, intervention, treatment, prevention and community control.

Cardiovascular Diseases↗
PubMed1979

Problems of university-based scientists associated with clinical trials.

University faculty members who participate in clinical trials face a number of difficulties in connection with this association. Publication opportunities are often limited, and individual scholarship is difficult to express and evaluate within the context of a cooperative trial. Merit increases, promotion, and the award of tenure will usually require evidence of scholarly achievement outside the trial setting. For this reason, it seems inadvisable to recommend that a young investigator devote a major portion of his scholarly and research time to such an activity. A possible exception may be a full-time appointment for 1 to 2 years. Nonetheless, cooperative clinical trials are an important investigative tool and they should continue to be associated with academic centers. If appropriate administrative arrangements can be made, it should be possible to solve the academic problems of the young investigator associated with such trials.

Clinical Trials as Topic↗
PubMed1979

Research related to validation of treatment modalities by large-scale clinical trials.

The history of randomized, controlled, clinical trials is reviewed. Cooperative clinical trials are reviewed and summarized, and specific needs for future trials are identified. Improved policy on resource allocation decisions for clinical trials vs other forms of research is necessary, particularly as such trials begin to translate improved therapeutic knowledge into community level disease control.

American Heart Association↗
PubMed1978

A method for assessing volunteer bias and its application to a cardiovascular disease prevention progamme involving physical activity.

Studies of chronic disease may require long-term observation of volunteer participants. This is a characteristic of investigations of primary or secondary prevention of cardiovascular disease by increased level of physical activity. Activation of sedentary, middle-aged, high risk men requires a substantial personal commitment on their part to a long-term programme. Because of self-selection, individuals who volunteer for such programmes cannot be assumed to be representative of the populations from which they come. To the best of our knowledge, there has been no systematic investigation of such self-selection based upon a study designed for that purpose. We found little consistent tendency for vouunteering behaviour to be associated with serum cholesterol, blood pressure, relative weight, level of activity at work, or Type A hehaviour variables.

Adult↗