Biomedical subjects
V Goel
Publications and source records attributed to V Goel.
Pitfalls of absent or faint kidney sign on bone scan.
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Long-term contraception by a single silastic implant-D containing norethindrone acetate in women: a clinical evaluation.
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Neurilemmoma of the greater omentum.
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Squamous cell carcinoma of the renal pelvis.
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Intrapulmonary stromal mesothelioma.
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The role of group support technology in developing the HEALNet research agenda.
HEALNet, a Canadian Network of Centres of Excellence Program, has undergone a building exercise to focus and consolidate its research program for the 1998 to 2002 funding period. A number of challenges were identified while trying to develop this research agenda within a short time frame. These included how to bring together a diverse group of researchers, ensuring that everyone's voice was heard, and ensuring that the collective interests were placed ahead of individual interests. Furthermore, as three separate workshops were being held, a method for quickly capturing the workshop output and preparing reports was required. A Group Support System (GSS) was used to facilitate this work and to help meet these challenges. This report describes how the GSS was used. While the GSS supported brainstorming activities, it was less useful in assisting the group in developing the details of research programs. It did facilitate the timely production of reports from the workshops. Such systems have a role to play in supporting group work at the idea generation stage, but further work is required in order for them to be useful in the development of detailed research programs.
The rate of breast-conserving surgery for early breast cancer is not influenced by the surgical strategy of excisional biopsy followed by the definitive procedure.
Increased emphasis on breast conservation and the primacy of the patient's preferences has led to the promotion and increased use of a two-step surgical strategy (definitive operation only after a final tissue diagnosis from a biopsy done on a previous visit) in the treatment of early breast cancer, with the assumption being that this is more conducive to the performance of breast-conserving surgery (BCS). We sought to test this by examining the effect of the surgical strategy (one-step versus two-step) on the operation performed (BCS versus mastectomy). A random sample of women with node-negative breast cancer diagnosed in 1991 in Ontario was drawn from the Ontario Cancer Registry database and matched to the Canadian Institute of Health Information and Ontario Health Insurance Plan databases (n = 643). This provided information on the timing and nature of all surgical procedures performed as well as patient, tumor, hospital, and surgeon characteristics. The surgical strategy was defined as either a one-step procedure (biopsy and definitive surgery performed at the same time) or a two-step procedure (surgical biopsy and pathologic diagnosis, followed by definitive surgery at a later date). The axillary lymph node dissection was used to define the definitive procedure. BCS was employed in 68% of patients, and this did not differ significantly between the one-step and two-step groups (66% versus 70%). Patients with palpable lesions had a significantly lower rate of breast conservation than those with nonpalpable lesions. Other variables associated with a lower rate of BCS were larger tumor size, presence of extensive ductal carcinoma in situ (DCIS), and central or multifocal tumors. The use of a one-step procedure was associated with a patient age of more than 50 years, a palpable mass, tumor size larger than 1 cm, previous fine needle aspiration (FNA) biopsy, absence of extensive DCIS, and surgery in an academic setting. Breast conservation was not affected by the surgical strategy used or the timing of the decision, but was associated with several accepted tumor factors. This study shows that, contrary to the opinion of some, there is a group of breast cancer patients in whom treatment in a one-step manner is appropriate.
Blood lead levels in Toronto children and abatement of lead-contaminated soil and house dust.
South Riverdale in Toronto, Canada, underwent a lead-abatement program. In 1988, lead-contaminated soil was replaced at 970 properties, and in 1989, professional housecleaning for lead removal was conducted in 717 households. The effect of "abatement" on blood lead levels in young children was investigated. Data were analyzed from 12 cross-sectional blood-screening surveys that were conducted during an 8-y period in South Riverdale and in two comparison areas. Responses regarding behavioral, household, lifestyle, neighborhood, and environmental factors, all of which were gleaned from associated questionnaires, were also analyzed. Response rates varied between 32% and 75%. During the years between 1984 and 1992, blood lead decreased in all study areas. There appeared to be a minimal blood lead level of 2-3 micrograms/dl for urban Ontario children who were less than 6 y of age. The significant difference between South Riverdale and the control areas disappeared by 1992. Although abatement activity in South Riverdale was associated with an accelerated decline in blood lead levels, it was difficult to distinguish this from effects of decreased Toronto air lead levels or decreased smelter emissions. Within South Riverdale, abatement appeared to be associated with a slower decline in blood lead levels over time, likely the result of selection bias, soil mixing, or recontamination from the smelter. No difference was observed between the separate effects of housecleaning or soil replacement. The findings could neither strongly support nor refute beneficial effects of abatement.
Randomized trial of a patient decision aid for choice of surgical treatment for breast cancer.
A decision aid for the surgical treatment of early breast cancer was evaluated in a randomized controlled trial. The decision aid, a tape and workbook, includes explicit presentation of probabilities, photographs and graphics, and a values clarification exercise. Community surgeons were randomized to use the decision aid or a control pamphlet. Patients completed a questionnaire prior to using the decision aid, after reviewing it but prior to surgery, and 6 months after enrollment. There was no difference in anxiety, knowledge, or decisional regret across the 2 groups. There was a nonsignificant trend toward lower decisional conflict in the decision aid group. A subgroup of women who were initially leaning toward mastectomy or were unsure had lower decisional conflict. Although the decision aid had minimal impact on the main study outcomes, a subgroup may have benefited. Such subgroups should be identified, and appropriate decision support interventions should be developed and evaluated.
Using explicit decision rules to manage issues of justice, risk, and ethics in decision analysis: when is it not rational to maximize expected utility?
Concepts of justice, risk, and ethics can be merged with decision analysis by requiring the analyst to specify explicity a decision rule or sequence of rules. Decision rules are categorized by whether they consider: 1) aspects of outcome distributions beyond central tendencies; 2) probabilities as well as utilities of outcomes; and 3) means as well as ends. This formulation suggests that distribution-based decision rules could address both risk (for an individual) and justice (for the population). Rational choice under risk if choices are one-time only (vs. repeated events) or if one branch contains unlikely but disastrous outcomes might ignore probability information. Incorporating risk attitude into decision rules rather than utilities could facilitate use of multiattribute approaches to measuring outcomes. Certain ethical concerns could be addressed by prior specification of rules for allowing particular branches. Examples, including selection of polio vaccine strategies, are discussed, and theoretical and practical implications of a decision rule approach noted.
Effect of an explicit decision-support tool on decisions to prescribe antibiotics for sore throat.
Studies of scoring rules for sore throat have failed to show that they lower antibiotic prescription rates. The authors studied the effect of an explicit decision-support tool, incorporating a modified score, on antibiotic-prescription decisions. Four hundred and fifty family physicians received an information package, a score card, and a recording form to use during one sore-throat encounter. The physicians randomly received either a control form or an intervention form that required them to interact with the score during the clinical recording process. There was a trend towards a reduction in antibiotic prescriptions (21%, p=0.09) in the physicians using the intervention form. A greater reduction (45%, p=0.06) was observed for patients whose probabilities of infection with group A streptococcus were low. Sore-throat-scoring rules may reduce unnecessary antibiotic prescriptions if physicians are specifically cued to use them during clinical encounters and appropriate management responses are linked to score estimates for the likelihood of group A streptococcus infection.
Paratyphoid fever in India: An emerging problem.
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One stop swallowing clinic may be more effective than a new cancer clinic.
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Measuring the impact of influenza on the hospital admission rates of the elderly in Ontario: a five-year admission rate analysis, 1988-1993.
OBJECTIVE: A retrospective study was conducted to compare age- and sex-specific rates of hospital admission of the elderly in Ontario for five influenza seasons from 1988-1993 for pneumonia, congestive heart failure and chronic respiratory disease. RESULTS: Significant increases in admissions were found for pneumonia in each influenza season for both sexes. Admissions were significantly increased for congestive heart failure for the oldest males in all years; and for four of five years for the youngest two age groups of males. For females significant increases in admissions occurred in the oldest two age groups in each influenza season; and for three of five seasons for the youngest age group. For chronic respiratory disease, significant increases in admissions were found for each influenza season for all years for the two youngest age groups of males and females. CONCLUSION: The impact of influenza is substantial in terms of morbidity in the elderly.
Life expectancy at birth at the local level in Ontario.
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An introduction to multilevel regression models.
Data in health research are frequently structured hierarchically. For example, data may consist of patients nested within physicians, who in turn may be nested in hospitals or geographic regions. Fitting regression models that ignore the hierarchical structure of the data can lead to false inferences being drawn from the data. Implementing a statistical analysis that takes into account the hierarchical structure of the data requires special methodologies. In this paper, we introduce the concept of hierarchically structured data, and present an introduction to hierarchical regression models. We then compare the performance of a traditional regression model with that of a hierarchical regression model on a dataset relating test utilization at the annual health exam with patient and physician characteristics. In comparing the resultant models, we see that false inferences can be drawn by ignoring the structure of the data.
Health informatics education: an opportunity for public health in Canada.
Health information infrastructure is being developed across Canada, and health informatics education should be a component of the emerging infrastructure. However, educational opportunities do not appear to be developing in pace with infrastructure. This study characterizes the required education, and describes specific issues facing the development of health informatics education. Twenty-six key informants were interviewed, and responses were analyzed to identify major themes. Subjects agreed that the current capacity for health informatics education is inadequate. Also, limited expertise could adversely affect health infostructure implementation and health system performance. A need was identified for both advanced and basic education. Four issues facing the development of health informatics education in Canada were consistently identified: awareness, collaboration, funding, and human resources. Public health is well positioned to play a central role in health informatics education due to its historical basis in handling health information, and its developing expertise in health informatics applications.