Evidence-based Answers Research Articles

Värdefulla, meningsfulla lärare. Ett slag för otillräcklighetens etik och utbildningsvetenskapens olika ansikten

One issue in the current school debate concerns the scientific basis of teaching and the question, what kind of scientific research should be central to the everyday work of teachers? A leading thought in this debate seems to relate to the need for research that provides evidence-based answers to the question “what works” in teaching. However, there are risks with allowing a one-sided notion of what kind of scientific basis teachers need. I therefore argue that we need to highlight the importance of other types of research that rather than seeking answers, seek to raise questions. This is important not least in relation to the ethical dimensions of the teaching profession. In a retrospective summary of my own research, I advocate what I would like to refer to as “ethics of incertitude”, while critically examining several of my own contributions. The question in focus is how the everyday practices of teachers serve as the basis for the theoretical work I present.

Are online surgical discussion boards a safe and useful venue for surgeons to ask for advice? A review of the International Hernia Collaboration Facebook Group

Social media is a growing medium for disseminating information among surgeons. The International Hernia Collaboration Facebook Group (IHC) is a widely utilized social media platform to share ideas and advice on managing patients with hernia-related diseases. Our objective was to assess the safety and utility of advice provided. Overall, 60 consecutive de-identified clinical threads were extracted from the IHC in reverse chronological order. A group of three hernia specialists evaluated all threads for unsafe posts, unhelpful comments, and if an established evidence-based management strategy was provided. Positive and negative controls for safe and unsafe answers were included in seven threads and reviewers were blinded to their presence. Reviewers were free to access all online and professional resources (except the IHC). There were 598 unique responses (median 10, 1-26 responses per thread) to the 60 clinical threads/scenarios. The review team correctly identified all seven positive and negative controls. Most responses were safe (96.6%) but some were unhelpful (28.4%). For sixteen threads, the reviewers believed there was an established evidence-based answer; however, only six were provided. In addition, 14 responses were considered unsafe, but only four were corrected. The vast majority of responses were considered helpful; however, evidence-based management is typically not provided and unsafe recommendations often go uncontested. While the IHC allows wide dissemination of hernia-related surgical advice/discussions, surgeons should be cautious when using the IHC for clinical advice. Mechanisms to provide evidence-based management strategies and to identify unsafe advice are needed to improve quality within online forums and to prevent patient harm.

Chinese Physicians' Perspectives on the 2017 American College of Cardiology/American Heart Association Hypertension Guideline: A Mobile App-Based Survey.

Hypertension is a leading global risk factor for death and disability. Seeking new ways to prevent and treat hypertension is a priority for scientists and healthcare professionals worldwide. In November 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) issued a new hypertension guideline shifting the definition of hypertension from 140/90mmHg to 130/80mmHg for systolic/diastolic blood pressure. This new diagnostic threshold of hypertension has sparked a lively discussion worldwide over whether it should be applied in clinical settings to diagnose and treat hypertension. China, the world's most populous country, is facing a hypertension crisis. According to the 140/90mmHg guideline, China has an estimated 244.5 million population aged ≥18 years with hypertension, and another 435.3 million with pre-hypertension. If the new guideline is adopted, the prevalence of hypertension in China would double. This change would significantly impact patients, healthcare professionals, scientists, and policy makers in terms of the delivery of care and needed resources. This study aims to investigate whether Chinese physicians will use the 130/80mmHg threshold to diagnose hypertension in clinical practice. In March 2018, we launched a mobile app-based survey to study 253 Chinese physicians' perspectives on the ACC/AHA Guideline. A total of 253 physicians from 21 Chinese provinces completed the survey. Nearly 80% of the participants had already noticed the ACC/AHA guideline change. The proportion of participants who said they would use the new threshold to diagnoses hypertension was 41%, while 59% said they would not use the new threshold. The primary reason for those who said "yes" was that they believed early diagnosis of hypertension can trigger early actions to prevent the increasing blood pressure. For those who said "no", they argued that their decision was based on the fact that the Chinese Hypertension Prevention Guideline had not yet changed the diagnostic threshold from 140/90 to 130/80mmHg. Different understanding of hypertension prevention and treatment exists among Chinese physicians. It is an emergent need to form an evidence-based authoritative answer to guide Chinese physicians' future clinical practice.

Evidence Based Medicine IV: how to find an evidence-based answer to a clinical question? Make a critically appraised topic!

This manuscript is the fourth in a five part series related to evidence based medicine (EBM) provided by the European society of pediatric urology (ESPU) research committee. It will present a way to come to a quick and critical appraisal of available evidence on a specific topic: a CAT (critically appraised topic). The way how to write a cat is described for interventions to be compared to a control group, and for other, more generalized clinical questions. While systematic reviews provide a throughout overview of all evidence available, a CAT provides a shorter way to come to quick insights based on EBM.

Does Despair Really Kill? A Roadmap for an Evidence-Based Answer.

Two seemingly associated demographic trends have generated considerable interest: income stagnation and rising premature mortality from suicides, drug poisoning, and alcoholic liver disease among US non-Hispanic Whites with low education. Economists interpret these population-level trends to indicate that despair induced by financial stressors is a shared pathway to these causes of death. Although we now have the catchy term "deaths of despair," we have yet to study its central empirical claim: that conceptually defined and empirically assessed "despair" is indeed a common pathway to several causes of death. At the level of the person, despair consists of cognitive, emotional, behavioral, and biological domains. Despair can also permeate social relationships, networks, institutions, and communities. Extant longitudinal data sets feature repeated measures of despair-before, during, and after the Great Recession-offering resources to test the role that despair induced by economic decline plays in premature morbidity and mortality. Such tests must also focus on protective factors that could shield individuals. Deaths of despair is more than a phrase; it constitutes a hypothesis that deserves conceptual mapping and empirical study with longitudinal, multilevel data.

Mediterranean Diet and Cardiodiabesity: A Systematic Review through Evidence-Based Answers to Key Clinical Questions.

The Mediterranean Diet (MedDiet) has been promoted as a means of preventing and treating cardiodiabesity. The aim of this study was to answer a number of key clinical questions (CQs) about the role of the MedDiet in cardiodiabesity in order to provide a framework for the development of clinical practice guidelines. A systematic review was conducted to answer five CQs formulated using the Patient, Intervention, Comparison, and Outcome (PICO) criteria. Twenty articles published between September 2013 and July 2016 were included, adding to the 37 articles from the previous review. There is a high level of evidence showing that MedDiet adherence plays a role in the primary and secondary prevention of cardiovascular disease (CVD) and improves health in overweight and obese patients. There is moderate-to-high evidence that the MedDiet prevents increases in weight and waist circumference in non-obese individuals, and improves metabolic syndrome (MetS) and reduces its incidence. Finally, there is moderate evidence that the MedDiet plays primary and secondary roles in the prevention of type 2 diabetes mellitus (T2DM). The MedDiet is effective in preventing obesity and MetS in healthy and at-risk individuals, in reducing mortality risk in overweight or obese individuals, in decreasing the incidence of T2DM and CVD in healthy individuals, and in reducing symptom severity in individuals with T2DM or CVD.

Prevention and Management of Severe Obstetric Anal Sphincter Injuries (OASIs): a National Survey of Nurse- Midwives.

There are no data on midwives' knowledge and management of obstetric anal sphincter injuries (OASIs) in the USA. We performed a cross-sectional national survey characterizing OASI practice by certified nurse midwives (CNMs), hypothesizing that few midwives personally repair OASIs and that there are gaps in CNM OASI training/education. We emailed a REDCap internet-based survey to 6909 American College of Nurse Midwives members (ACNM). We analyzed responses from active clinicians performing at least one delivery per month, asking about OASI risks, prevention, repair, and management. We summarized descriptive data then evaluated OASI knowledge by patient and provider characteristics. We received 1070 (15.5%) completed surveys, and 832 (77.8%) met the inclusion/exclusion criteria. Participants were similar to ACNM membership. Respondents most frequently identified prior OASI (87%) and nutrition (71%) as antepartum OASI risk factors and, less frequently, nulliparity (36%) and race (22%). Identified intrapartum risks included forceps delivery (94%) and midline episiotomy (88%). When obstetric laceration is suspected, 13.6% of respondents perform a rectal examination routinely. Only 15% of participants personally perform OASI repair. Overall, participants matched 64% of evidence-based answers. OASI education/training courses were attended by 30% of respondents, and 44% knew of OASI protocols within their group/institution. Of all factors evaluated, the percent of evidence-based responses was only different for respondent education/CME and protocols. Quality initiatives regarding OASI prevention and management may improve care. Our data suggest OASI training for midwives may improve delivery care in the US. Further studies of other obstetric providers are needed.

훈민정음 창제자와 관련한 제설

This article presents all views put forward so far about the identity of the inventor of Hunminjeongeum and seeks to find an evidence-based answer to this question by examining each of these views. The debate as to who is the inventor of Hunminjeongeum arose from the intuitive doubt about the possibility of a King creating an elaborate writing system alone and the lacking records about the from the process of the creation of Hunminjeongeum from beginning to end in the Annals of the Joseon Dynasty. Seong Hyeon’s Yongjaechonghwa substantially contributed to the birth of the myths that Hunminjeongeum was invented by the collaboration of Munjong and Jiphyeonjeon scholars. Seong Hyeon influenced many scholars of his time and later the scholars of the School of Practical Learning. Writings that deny the sole inventorship of King Sejong without presenting reliable evidence cannot be accepted as reliable resources. There are a number of reliable historical documents that prove that King Sejong invented Hunminjeongeum alone. Denying the sole invention of Hunminjeongeum by King Sejong without presenting any evidence that can override the veracity of the historical resources of the official records and publications can be defined as the results of unscientific imagination.

Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement)

BackgroundFor the diagnosis of prosthetic joint infection, real evidence-based guidelines to aid clinicians in choosing the most accurate diagnostic strategy are lacking.Aim and MethodsTo address this need, we performed a multidisciplinary systematic review of relevant nuclear medicine, radiological, orthopaedic, infectious, and microbiological literature to define the diagnostic accuracy of each diagnostic technique and to address and provide evidence-based answers on uniform statements for each topic that was found to be important to develop a commonly agreed upon diagnostic flowchart.Results and ConclusionThe approach used to prepare this set of multidisciplinary guidelines was to define statements of interest and follow the procedure indicated by the Oxford Centre for Evidence-based Medicine (OCEBM).

Revenue Implications of Alternative Personal Income Tax Structures in Illinois

This report provides background information and evidence-based answers in response to questions posed by an Illinois legislator. The questions are: (1) Can you describe the income distribution in Illinois and how this has evolved over the recent past? (2) Can you project out the income distribution in Illinois for the next five years and project personal income tax revenue with: (a) Illinois’ current personal income tax system? (b) a graduated rate personal income tax system comparable to other Midwestern states (i.e. Wisconsin, Minnesota, Iowa or Missouri)? (3) What personal income tax revenue would Illinois’ economy generate if it adopted the personal income tax structure of Wisconsin, Minnesota, Iowa or Missouri? (4) How are tax burdens distributed in the current tax system and how would they be different under alternative tax systems in the question above? Our empirical analyses suggest that, compared to the four neighboring states, Illinois’ tax system collects less revenue and the revenue that Illinois does collect comes disproportionately from the lowest income categories compared to the other states. Allowing for behavioral change in response to tax-policy changes does not alter, and under some assumptions reinforces, this conclusion.

Reflexiones sobre la Declaración de Cancún 2008: el derecho a la nutrición en los hospitales

Overview: Ten years after the Declaration of Cancun, I am doing a critical analysis to evaluate if what was expressed in it has had repercussions on the improvement of the quality of in-hospital nutritional care in Latin America.The question is: Does the patient receive optimal nutrition based on quality criteria (timeliness, efficiency, effectiveness and safety)? The evidence-based answer is a “significant” no. We can divide in 2 big sections the failures that nutritionally damage patients; the so-called latent failures that are failures in the system and the active ones that are those made by the different people that act directly on the patient’s attention. Therefore, actions to improve the nutritional security of the hospitalized patient should be focused on proactive and preventive change at both the systemic (system) and individual (people) levels. These actions may be regulated or self-regulated; however, our vision is that nutritional security in the health system will mean nothing without the collaboration and commitment of medical professionals. A cultural change is a precondition for focusing on actions to improve the safety of the patient’s nutritional care and also on a policy of outcomes. Secure patient nutrition care must be put on the political agenda. Simultaneously finding quality of nutritional care, operational efficiency and financial incentive linked to the outcome must be the goal. Trying to solve the problem independently is a waste of time and effort.

Should parents share medical information with their young children? A prospective study

BackgroundAs psychiatric consultants to pediatric wards, we are often asked whether to disclose to young children full information about the invasive medical procedures they face. To date, no studies have been published offering an evidence-based answer to this question. This prospective study examined whether sharing medical information with young children regarding invasive interventions correlates with the development of chronic post-traumatic stress three to five months after hospitalization. MethodThe participants in this prospective study were parents of 151 children aged 3–13 who were hospitalized in a pediatric surgery ward. The sample was representative of the population hospitalized in this ward during that year. Independent of the study, parents of 104 children chose to share with them information regarding the procedure they were about to undergo, while parents of 47 children chose not to do so. t-Tests were used to assess the correlation between the children's exposure to medical information and their level of long-term post-intervention stress. ResultsFindings show an inverse correlation between the children's exposure to medical information and their level of post-traumatic stress several months after their medical episode. The correlation is significant in both preschool children and school-aged children. ConclusionsWe suggest the implementation of psychoeducation programs among both medical staff and parents in order to increase awareness of the importance of sharing medical information with young children facing medical challenges.

TEACH Cards: Teaching Evidence-Based Medicine and Clinical Topics in the Hospital.

Inpatient training and evidence-based medicine (EBM) curricula are fundamental components of medical education. Teaching EBM And Clinical topics in the Hospital (TEACH) Cards is an inpatient curricular tool developed to help guide efficient, discussion-based teaching sessions. TEACH Cards aims to increase frequency of inpatient teaching, improve exposure to the breadth of inpatient topics, advance EBM skills, and improve efficiency in answering clinical questions. TEACH Cards is a set of 25 topic-based cards, each addressing an adult inpatient medicine topic by asking background questions and encouraging learners to write and answer foreground questions. Residents and faculty from a family medicine residency rotating on an adult inpatient medicine service during the 6-month study period were invited to complete a prerotation survey, use the TEACH Cards, and then complete a postrotation survey. Out of 54 potential participants, 35% completed both the pre- and postrotation surveys. Respondents used TEACH Cards on average three times per week, reporting significantly stronger agreement that they were both learning (P=0.034) and teaching (P=0.006) core inpatient topics. Respondents reported greater confidence in using EBM resources ( P=0.006) and significantly shorter time to find an evidence-based answer to a clinical question (pretest median=6-10 minutes vs posttest median=2-5 minutes, P=0.002). Use of TEACH Cards increased self-reported exposure to the breadth of core inpatient topics, confidence with EBM skills, and efficiency in finding answers to clinical questions.

Promoting Research with Organ Transplant Patients

Given the numerous questions related to patient selection, surgical technique, and posttransplant care requiring evidence-based answers, transplantation programs should be conducting research with patients waiting to receive an organ and those who have undergone organ transplantation. Yet, there continues to be a dearth of human subjects research in the field of transplantation medicine. Here, we discuss challenges that may deter transplantation programs from engaging in transplant-related research. Taking liver transplantation as our illustrative example, we explain the vulnerabilities of patients with end-stage organ failure and the complex ethical issues of decisional capacity, coercion, and the timing of study enrollment. Ultimately, we argue that all transplant candidates should be invited and encouraged to participate in research. We maintain that clinical care should be provided in the context of active research so that clinicians can further their understanding of transplantation medicine while also providing high-quality patient care. We suggest that early discussion with patients about participating in research and about a research advance directive may help to overcome reluctance about and the ethical challenges of transplantation research with human subjects.

Contraception following pregnancy: FAQs

Practice nurses may be at the frontline of delivering contraception to women following pregnancy. Carol Marilyn Ann Robinson provides the answers to some frequently asked questions in clinical practice The aim of this paper is to address questions frequently asked by practice nurses, midwives and health visitors during contraception training programmes in relation to the provision of contraception to women following childbirth, abortion, miscarriage or ectopic pregnancy. In order to formulate evidence-based answers to the questions electronic sources were routinely searched including clinical guidance from the Faculty of Sexual and Reproductive Healthcare; the World Health Organization publications; UK Medical Eligibility Recommendations for Contraceptive Use; the Cochrane library; and Medline, as well as manufacturers' Summaries of Product Characteristics.

Four Questions for Every Clinician Diagnosing and Monitoring Glaucoma.

We pose 4 questions for the clinician diagnosing and monitoring glaucoma, and supply evidence-based answers. The first question is: "When do you perform a 10-2 (2-degree grid) visual field (VF) test?" We argue the best answer is: anyone you would do, or have done, a 24-2 (6-degree grid) VF on should have both a 24-2 and a 10-2 VF within the first 2 visits. Second, "When do you perform an optical coherence tomography (OCT) scan of the macula?" We argue that, if you are performing an OCT test, then it should include both the macula and disc, either as a single scan or as 2 scans, one centered on the macula and the other on the disc. Third, "How do you know if the VF and OCT tests agree?" The poor answer is, "I use summary statistics such as 24-2 mean deviation and global or quadrant average of retinal nerve fiber layer (RNFL) thickness." It is much better to topographically compare abnormal regions on the OCT to abnormal regions on the VF. Finally, the fourth question is: "When do you look at OCT images?" We argue that, at a minimum, the clinician should be directly examining an image of the circumpapillary RNFL, and this image should be sufficiently large and with sufficient resolution so that local damage can be seen, and the segmentation evaluated.

In which individuals should aspirin be used for primary prevention of cardiovascular disease?

EVIDENCE-BASED ANSWER In patients older than 40 years without cardiovascular disease (CVD), aspirin use decreases the risk of nonfatal myocardial infarction (MI) by 22% and allcause mortality by 6%. However, aspirin has no effect on stroke or all-cause mortality and may increase the risk of hemorrhage and other nontrivial bleeding (SOR: B, meta-analysis of heterogeneous RCTs). Low-dose aspirin should be given to adults 50 to 69 years old with a 10% or higher 10-year risk of CVD who are not at increased risk of bleeding and have a life expectancy of at least 10 years. The decision should be individualized for adults 60 to 69 years old (SOR: C, expert opinion).

Are rapid group B Streptococcus (GBS) tests accurate in determining GBS colonization status in laboring women?

EVIDENCE-BASED ANSWER Yes, intrapartum rapid nucleic acid amplification test (NAAT) results are accurate and timely in identifying women with GBS colonization during labor, with negative predictive values of 97% or more (SOR: A, consistent prospective cohort studies).

How accurate is C-reactive protein in diagnosing rheumatoid arthritis?

EVIDENCE-BASED ANSWER In patients with clinical findings consistent with rheumatoid arthritis (RA), a C-reactive protein (CRP) level of more than 0.06 mg/dL is modestly useful for ruling in, but is not useful for ruling out RA when obtained within 3 and 24 months of symptoms onset (SOR: B, prospective cohort study). CRP measurements in the years prior to diagnosis of RA do not accurately predict progression to RA (SOR: B, prospective cohort study). Elevated CRP is more sensitive but less specific than rheumatoid factor, anti-cyclic citrullinated protein (anti-CCP), and erythrocyte sedimentation rate (ESR) for the diagnosis of RA (SOR: B, cross-sectional survey).

How effective is exercise training in improving symptoms in adults with obstructive sleep apnea?

EVIDENCE-BASED ANSWER Overall, exercise (aerobic, resistance, and oropharyngeal exercise training) slightly reduces obstructive sleep apnea (OSA) severity and daytime sleepiness (SOR: B, meta-analysis of RCTs and case series). Myofunctional therapy alone may produce more substantial reductions in OSA severity and daytime sleepiness (SOR: B, metaanalysis of RCTs and case series).