Evidence-based Medical Practice Research Articles

The worldview of pre-service and in-service teachers about health education

Health is coconsidered as goodness; therefore, schools should be places where healthy habits, along with evidence-based medical knowledge and practices, are taught and practised. The key persons in education are teachers, so their opinions and worldviews should not be neglected. The objective of this work was to identify opinions about health education among Slovenian teachers. We investigated the worldviews of and differences between pre-service and in-service Biology teachers about health education. The questionnaires were delivered to 163 Sloveian participants. Most differences in opinion occurred in the nutrition field between younger and older participants. The majority of participants (85%) agree that “Providing knowledge or developing behavior that is respectful of one´s own health” is the main goal of health education.

Changing Trends in the Landscape of Patients Hospitalized With Acute Myocardial Infarction (2001 to 2011) (from the Worcester Heart Attack Study)

During the past several decades, new diagnostic tools, interventional approaches, and population-wide changes in the major coronary risk factors have taken place. However, few studies have examined relatively recent trends in the demographic characteristics, clinical profile, and the short-term outcomes of patients hospitalized for acute myocardial infarction (AMI) from the more generalizable perspective of a population-based investigation. We examined decade long trends (2001 to 2011) in patient's demographic and clinical characteristics, treatment practices, and hospital outcomes among residents of the Worcester metropolitan area hospitalized with an initial AMI (n = 3,730) at all 11 greater Worcester medical centers during 2001, 2003, 2005, 2007, 2009, and 2011. The average age of the study population was 68.5 years and 56.9% were men. Patients hospitalized with a first AMI during the most recent study years were significantly younger (mean age = 69.9 years in 2001/2003; 65.2 years in 2009/2011), had lower serum troponin levels, and experienced a shorter hospital stay compared with patients hospitalized during the earliest study years. Hospitalized patients were more likely to received evidence-based medical management practices over the decade long period under study. Multivariable-adjusted regression models showed a considerable decline over time in the hospital death rate and a significant reduction in the proportion of patients who developed atrial fibrillation, heart failure, and ventricular fibrillation during their acute hospitalization. These results highlight the changing nature of patients hospitalized with an incident AMI, and reinforce the need for surveillance of AMI at the community level.

Lithium and the Woozle effect.

Lithium is the oldest and most-studied treatment for bipolar depression. Many treatment guidelines place lithium as a top treatment recommendation for bipolar depression; yet some guidelines do not recommend lithium at all. These discrepancies were explored by examining the following errors: the Woozle effect (evidence by citation), reference inflation (overreporting the findings of cited studies) and belief perseverance (maintaining a belief despite new contradictory evidence) as possible causes for these discrepancies. Various search engines were used to find treatment guidelines for bipolar depression. The references cited in these guidelines were examined and analyzed in-depth. Ten guidelines recommend lithium as a first-line treatment for bipolar depression. Five did not recommend lithium at all for the treatment of bipolar depression. These discrepancies are remarkable. The references cited in the treatment guidelines were examined and do not favor lithium as a treatment for bipolar depression. The guidelines that favored lithium for the treatment of bipolar depression suffered numerous Woozle effects, reference inflation and belief perseverance are prevalent in guidelines that recommend lithium as a first-line treatment. All three errors are principally slippery slopes. These errors do not involve a deliberate attempt to mislead and may reflect failures of the peer review process. These errors may be common, as demonstrated in the case of lithium, interfering with our understanding and practice of evidence-based medicine. Both authors and journals need to guard against these types of errors in order to achieve sound evidence-based medical practices.

Comprehensive pressure profiling to develop next-generation compression treatment for lymphedema: Testing efficacy of high resolution sensors

Evidence for the use and effectiveness of compression garments (sleeves, stockings) for medical conditions including lymphedema and deep vein thrombosis remains empirical. The contemporary mandate for evidence-based medical practices, i.e. the delivery of care based on objective, effective measurements (efficacy), gives impetus for the establishment of both standardized testing protocols and tools enabling accurate spatial and temporal measurements of pressures delivered by compression garments. This study proposes the establishment of Gage Linearity and Bias study protocols to assess efficacy of pressure testing sensors within and between studies. While several such sensors are commercially available, they have not been tested in clinically relevant pressure ranges or contexts. The efficacy of a current commercial, high-resolution and compliance pressure sensor (Tekscan 9833E Medical Sensor) was assessed using Gage Linearity and Bias methods. The Tekscan sensor proved insufficient for the accurate measurement of target pressure ranges applied by lymphedema compression sleeves. The study demonstrates that standardization, and the use of protocol techniques such as the adapted Gage Linearity and Bias methods presented here, lend themselves well for efficacy testing of pressure sensing technologies. Further, this study highlights efforts underway to develop customized sensors and technologies enabling efficacy testing of compression treatments in situ in patients and in age-matched, healthy control subjects. Effective high resolution pressure sensors will enable comprehensive pressure profiling for establishment of efficacy-based compression treatments. Ultimately, effective high resolution pressure sensors will pave the way to elucidate mechanisms underpinning compression treatment and the etiology of lymphedema per se, a poorly understood condition with no current cure.

A survey of Paediatricians on evidence-based medical practice in Nigeria

Background: The increasing need for a uniform standard of medical practice necessitates an examination of the impediments to the use of evidencebased medicine.Objective: To examine the knowledge, perceived barriers to the use of evidence-based medicine and the associated profession-related factors among paediatricians in Nigeria.Methods: A cross-sectional survey of paediatricians in Nigeria was conducted between March and April 2013 by Email. The knowledge about evidence-based medicine and systematic reviews was tested using a structured questionnaire and the responses were provided on three-item Likert scale.Results: The response rate in the survey was 56.5% (65/115). Almost 37% of the participants had postgraduate qualification in or before year 1999 (Group I). Majority (93.8%) of the respondents believed that EBM should form the basis for decision making in clinical practice while 53.9% believed that EBM is more suitable for the developed world. The overall mean knowledge score was 77.6%. Knowledge about EBM was rated high among 80% of the participants and the proportion with high knowledge was not significantly associated with EBM use in routine practice or prior EBM training. Some of the perceived barriers to EBM use included lack of skills for understanding statistics (81.6%), lack of incentives for the use of EBM (64.7%), lack of time (44.6%) and lack of conclusive evidences (44.6%).Conclusion: The knowledge of EBM among Nigerian paediatricians was good but a high proportion regarded lack of skills to perform statistical analysis required for EBM as a major barrier to the practice of EBM.Keywords: Evidence-based medicine, Systematic review, Research, Paediatricians

Joining a Multicenter Clinical Trial.

During the past several decades, stroke care delivery has transformed from experience-based to evidence-based practice. The rapid development of thrombolysis, endovascular therapy, and secondary prevention treatment has led to an increase in the number of clinical research studies and thus, an increased need for multicenter clinical trials. Although clinical trials with multiple sites are labor intensive, they are necessary for studying large samples of patients to determine what therapeutic, preventative, and diagnostic products or interventions are best across multiple settings and will be effective in actual practice. In addition to the scientific contribution of multicenter trials, they also help build capacity for research at individual centers. Each participating site needs a local principal investigator (PI), creating an exciting leadership opportunity for early career stroke physicians and researchers. This article will focus on the opportunities, advantages, challenges, and potential pitfalls of becoming a local PI for a large multicenter clinical trial. Clinical research, especially multicenter randomized controlled trials, is the cornerstone of evidence-based medical practice. Rigorous and well-conducted clinical trials are the foundation of scientific knowledge for guidelines that shape clinical practice of acute stroke management and secondary prevention.1 A site PI is defined as a person who is responsible for trial selection, site activation, and study conduct in a local site to maximize enrollment, optimize data quality, and ensure patient retention. Site PIs play an important role in the development of evidence. Serving as site PI involves leading discussions for which trials to participate in, developing or implementing a strategy to maximize enrollment, reinforcing data quality and ensuring patient retention, and providing regulatory, financial, and scientific oversight. Becoming an early career site PI brings a level of responsibility and recognition beyond every day clinical practice. Stroke physicians may choose research that combines their area of clinical practice, scientific curiosity, …

The realisation of evidence-based medicine

The new model of evidence-based medicine (EBM) that appeared in last century has experienced the global development of nearly 30 years, which praise and question all have. How to develop this medical model scientifically? This article will talk about personal thinking about this from three aspects. I. Looking back and relearning evidence-based medicine; II. What is the current misunderstanding of evidence-based medicine? Ⅲ. Medical ethics to be reaffirmed in evidence-based medical practice. Key words: Evidence-based medicine; Ethics, medical

Towards a standardized protocol for conducting randomized clinical trial for software

In the last decade, evidence-based medical practice has been aided on a large scale by computerized decision support tools, aimed at reducing diagnostic and therapeutic uncertainty, complementing the actions of the health professional. With the technological evolution, it is already possible to consider these systems as part of the clinical intervention, both for the diagnostic stage and for the treatment of diseases. This article proposes the creation of a specific clinical trial protocol to evaluate the effects of the software as clinical intervention in different medical settings. The proposal is unprecedented and extremely relevant in the scientific literature and able to standardize from the development stage to the application of the software aiding in the treatment of diseases.

Trip Database: Turning Research into Practice for Evidence-Based Care

ABSTRACTTrip Database is a freely available search engine based in the United Kingdom. Trip directs users to journal articles, practice guidelines, and other research to support evidence-based medical practice. This column includes sample searches in both the free version and in the subscription Pro version.

Medical research and audit skills training for undergraduates: an international analysis and student-focused needs assessment

IntroductionInterpreting, performing and applying research is a key part of evidence-based medical practice, however, incorporating these within curricula is challenging. This study aimed to explore current provision of research skills...

A call to action for data definition standardisation and core outcome sets.

Systematic reviews, which form the pinnacle of the ‘levels of evidence pyramid’, synthesise knowledge and serve to evolve evidence-based medical practice. Duffy and colleagues present a systematic review of maternal and offspring outcome reporting across 79 randomised controlled trials (RCTs) evaluating 55 various therapeutic interventions for pre-eclampsia. These RCTs reported 119 different outcomes (72 maternal and 47 offspring outcomes) for 31 615 maternal and 28 172 offspring participants. Surprisingly, some critical yet easily acquirable outcomes were often not reported: for example, maternal mortality and offspring mortality were reported in 14% and 35% of RCTs, respectively. Fewer than half of all RCTs reported maternal and offspring harm, only six RCTs reported childhood outcomes (with the longest duration of follow-up being 2 years), and three RCTs performed economic evaluations. Relatively recently, it has become apparent to researchers and clinicians that variation and heterogeneity in reported outcomes among related RCTs create impediments to aggregating data. This problem stems from several sources, including multiple potential definitions for a single outcome and from wide variations in reporting from the panoply of potential outcomes. For example, an RCT on the treatment of postpartum haemorrhage may define it as 500 mL for vaginal delivery and 1000 mL for caesarean delivery, whereas another may use a definition of 1000 mL in the first 24 hours, regardless of delivery mode. A study on interventions for pre-eclampsia may base the definition of severe pre-eclampsia upon the American Congress of Obstetricians and Gynecologists (ACOG), the UK National Institute for Health and Care Excellence (NICE), the International Society for the Study of Hypertension in Pregnancy (ISSHP), or other recognised, but essentially different, guidelines. Concerted efforts to standardize clinical definitions, such as ACOG's reVITALize campaign, are needed to improve outcome reporting and aggregate analysis in subsequent systematic reviews (Menard et al. Obstet Gynecol 2014;124:150–3). The COMET Initiative (Core Outcome Measures in Effectiveness Trials), formed in Liverpool in 2010, is a database focused on studies for the development and implementation of standardised core outcomes sets (COSs), which are determined by consensus methodology involving multiple stakeholders and contain the minimum number of variables deemed critically important to a topic (Williamson & Clarke Cochrane Database Syst Rev 2012;5:ED000041). The CROWN Initiative (Core Outcomes in Women's Health) aims to form a consortium to promote the development of COSs in our specialty (Khan BJOG 2014;121:1181–2). At present, three COSs are endorsed by CROWN (epilepsy in pregnancy, preterm birth prevention, and maternity care), with many others in development. One significant limitation of systematic reviews is the potentially short shelf life: one study reported that 23% of systematic reviews needed updating within 2 years of publication (Shojania et al. Ann Intern Med 2007;147:224–33). Data definition standardisation, implementation of COSs, and data sharing via repositories (Coady et al. N Engl J Med 2017;376:1849–58) should accelerate our ability to make timely systematic review updates and changes to best practice. So, let this be a call to action for collaborative efforts among researchers, publishers, guideline makers, grant-making agencies, insurers, and patient advocacy groups for a further focus on the development of data definition standardisation and COSs in obstetrics and gynecology research. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Setting Boundaries: Public Views on Limiting Patient and Physician Autonomy in Health Care Decisions.

We obtained and qualitatively analyzed input from more than nine hundred citizens during seventy-six public deliberation sessions about patient and physician autonomy in decision making, setting health care boundaries, and the tensions among competing social values. Generally, participants resisted interference with the patient-physician relationship and believed strongly in the freedom of patient and physician to control individual medical decisions. However, during deliberation participants identified two situations where boundaries and regulations in health care were more acceptable: protecting people from harm and allocating limited resources. The core value of individual freedom was tempered in varying degrees by the values of concern for the greater good and fairness in allocating resources. Where tensions between values emerged, participants used different concepts-including accountability, transparency, trust, personal responsibility, and moral obligation-to navigate trade-offs. Fairly balancing the public's desire to protect individual freedom with their sense of responsibility for protecting the common good may be the key to developing acceptable, workable policies that promote evidence-based medical practice.

Training the next generation of Canadian Clinician-Scientists: charting a path to success.

Clinician-scientists are physicians with training in both clinical medicine and research that enables them to occupy a unique niche as specialists in basic and translational biomedical research. While there is widespread acknowledgement of the importance of clinician-scientists in today's landscape of evidence-based medical practice, training of clinician-scientists in Canada has been on the decline, with fewer opportunities to obtain funding. With the increasing length of training and lower financial compensation, fewer medical graduates are choosing to pursue such a career. MD-PhD programs, in which trainees receive both medical and research training, have the potential to be an important tool in training the next generation of clinician-scientists; however, MD-PhD trainees in Canada face barriers that include an increase in medical school tuition and a decrease in the amount of financial support. We examined the available data on MD-PhD training in Canada and identified a lack of oversight, a lack of funding and poor mentorship as barriers experienced by MD-PhD trainees. Specific recommendations are provided to begin the process of addressing these challenges, starting with the establishment of an overseeing national body that would track long-term outcome data for MD-PhD trainees. This national body could then function to implement best practices from individual programs across the country and to provide further mentorship and support for early-career physician-scientists. MD-PhD programs have the potential to address Canada's growing shortage of clinician-scientists, and strengthening MD-PhD programs will help to effect positive change.

'Involve Me and I Learn': Development of an Assessment Program for Research and Critical Analysis.

Evidence-based medical practice is best achieved by developing research understanding in medical practitioners. To this end, medical councils worldwide increasingly recognise the importance of medical schools graduating students with well-developed research skills and research capacity. To meet this need, the principles of programmatic assessment were implemented in designing a research and critical analysis curriculum and assessment program that aimed to enhance the research and critical analysis skills of medical students. The program was developed by mapping assessment tasks to a research capabilities framework that was in turn scaffolded to different levels of Miler’s pyramid. The curriculum and assessments were integrated with the science, clinical, and professional aspects of the medical course. The progressive longitudinal development of research skills, with feedback and academic mentoring, culminated in the students’ capacity to undertake an independent research project. Designing an assessment program for learning encouraged students to develop their research capacity by involving them in their learning.

Future Perspectives in Sleep Surgery.

Over the past few decades there has been a significant increase in research focusing on the pathophysiology, diagnosis, and treatment of sleep apnea. However, there is still a long way to go in creating standard evidence-based medical practice for the diagnosis, evaluation, and treatment of sleep apnea patients. Current and future directions of sleep surgery and other treatments are discussed here.

Turkish Final Year Medical Students' Exposure to and Attitudes Concerning Drug Company Interactions: A Perspective from a Minimally Regulated Environment for Medical Students.

Interactions between drug companies and medical students may affect evidence-based medical practice and patient safety. The aim of this study was to assess drug company–medical student interactions in a medical faculty where limited specific national or institutional regulations apply between drug companies and medical students. The objectives of the study were to determine the exposure and attitudes of final year medical students in terms of drug company–medical student and physician interactions, to identify factors affecting those attitudes and to provide data for policymakers working on the regulation of interactions between drug companies and medical students. This anonymous questionnaire-based study of 154 medical final year medical students at the Karadeniz Technical University Medical Faculty, Trabzon, Turkey, in April and May 2015 attracted a response rate of 92.2% (n/N, 154/164). Exposure to interaction with a pharmaceutical representative was reported by 90.3% (139/154) of students, and 68.8% (106/154) reported experiencing such interaction alongside a resident. In addition, 83.7% (128/153) of students reported an interaction during internship. Furthermore, 69.9% (107/153) of students agreed that interactions influence physicians’ prescription preferences, while 33.1% (51/154) thought that a medical student should never accept a gift from a drug company and 24.7% (38/154) agreed with the proposition that “drug companies should not hold activities in medical faculties”. Students with rational prescription training expressed greater agreement with the statement “I am skeptical concerning the information provided by drug companies during interactions” than those who had not received such training, and this finding was supported by logistic regression [O.R.(C.I), p -3.7(1.2–11.5), p = 0.022]. Acceptance of advertisement brochures was found to significantly reduce the level of agreement with the proposition that “A physician should not accept any gift from a drug company.” (0.3[0.1–0.9], p = 0.030). In summary, exposure to drug companies was widespread among our final year medical students who, like students in both Western and non-Western societies, hold permissive attitudes concerning accepting gifts, and drug advertising brochures may relax those permissive attitudes still further. Rational prescription training was useful in generating rational attitudes. Policies concerning drug company–medical student relationships should be developed in Turkey as well as internationally.

A comparative analysis of semi-supervised learning: The case of article selection for medical systematic reviews

While systematic reviews are positioned as an essential element of modern evidence-based medical practice, the creation of these reviews is resource intensive. To mitigate this problem, there have been some attempts to leverage supervised machine learning to automate the article triage procedure. This approach has been proved to be helpful for updating existing systematic reviews. However, this technique holds very little promise for creating new reviews because training data is rarely available when it comes to systematic creation. In this research we assess and compare the applicability of semi-supervised learning to overcome this labeling bottleneck and support the creation of systematic reviews. The results indicated that semi-supervised learning could significantly reduce the human effort and is a viable technique for automating medical systematic review creation with a small-sized training dataset.

Utilization of smart phones related medical applications among medical students at King Abdulaziz University, Jeddah: A cross-sectional study.

The present study explored the utility, attitude, and trends regarding Smartphone related Medical Applications (Apps) among medical students of King Abdulaziz University (KAU) Jeddah, Saudi Arabia (SA) and their perceptions of the impact of Medical Apps in their training activities. This survey was conducted at the Faculty of Medicine, Jeddah, and Rabigh campuses, KAU, Jeddah, SA. All participants were medical students of 2nd to 6th year. The data was collected by using an anonymous questionnaire regarding the perception of medical students about Medical Apps on the smart devices and the purpose of installation of the Apps. Additionally examined was the use of different Medical Apps by the students to investigate the impact of Medical Apps on the clinical training/practice. Data was analyzed on SPSS 21. The opinion of 330/460 medical students from all academic years was included in the study with a response rate of 72%. There were 170 (51.5%) males and 160 (48.5%) females with a mean age of 21.26±1.86 years. Almost all participating students 320 (97%) were well aware of Medical Apps for smart devices and 89.1% had installed different applications on their smart devices. The main usage was for either revision of courses (62.4%) or for looking up of medical information (67.3%), followed by preparing for a presentation (34.5%) and getting the medical news (32.1%). Regarding the impact of Medical Apps, most of the students considered these helpful in clinical decision-making, assisting in differential diagnosis, allowing faster access to Evidence-Based Medical practice, saving time and others. The practical use of these Apps was found to be minimal in medical students. Around 73% were occasional users of Medical Apps, and only 27% were using Medical Apps at least once a day. The regular use of Medical Apps on mobile devices is not common among medical students of KAU.

Overlap in drug-disease associations between clinical practice guidelines and drug structured product label indications.

BackgroundClinical practice guidelines (CPGs) recommend pharmacologic treatments for clinical conditions, and drug structured product labels (SPLs) summarize approved treatment indications. Both resources are intended to promote evidence-based medical practices and guide clinicians’ prescribing decisions. However, it is unclear how well CPG recommendations about pharmacologic therapies match SPL indications for recommended drugs. In this study, we perform text mining of CPG summaries to examine drug-disease associations in CPG recommendations and in SPL treatment indications for 15 common chronic conditions.MethodsWe constructed an initial text corpus of guideline summaries from the National Guideline Clearinghouse (NGC) from a set of manually selected ICD-9 codes for each of the 15 conditions. We obtained 377 relevant guideline summaries and their Major Recommendations section, which excludes guidelines for pediatric patients, pregnant or breastfeeding women, or for medical diagnoses not meeting inclusion criteria. A vocabulary of drug terms was derived from five medical taxonomies. We used named entity recognition, in combination with dictionary-based and ontology-based methods, to identify drug term occurrences in the text corpus and construct drug-disease associations. The ATC (Anatomical Therapeutic Chemical Classification) was utilized to perform drug name and drug class matching to construct the drug-disease associations from CPGs. We then obtained drug-disease associations from SPLs using conditions mentioned in their Indications section in SIDER. The primary outcomes were the frequency of drug-disease associations in CPGs and SPLs, and the frequency of overlap between the two sets of drug-disease associations, with and without using taxonomic information from ATC.ResultsWithout taxonomic information, we identified 1444 drug-disease associations across CPGs and SPLs for 15 common chronic conditions. Of these, 195 drug-disease associations overlapped between CPGs and SPLs, 917 associations occurred in CPGs only and 332 associations occurred in SPLs only. With taxonomic information, 859 unique drug-disease associations were identified, of which 152 of these drug-disease associations overlapped between CPGs and SPLs, 541 associations occurred in CPGs only, and 166 associations occurred in SPLs only.ConclusionsOur results suggest that CPG-recommended pharmacologic therapies and SPL indications do not overlap frequently when identifying drug-disease associations using named entity recognition, although incorporating taxonomic relationships between drug names and drug classes into the approach improves the overlap. This has important implications in practice because conflicting or inconsistent evidence may complicate clinical decision making and implementation or measurement of best practices.

The Importance Of Integrating Narrative Into Health Care Decision Making.

When making health care decisions, patients and consumers use data but also gather stories from family and friends. When advising patients, clinicians consult the medical evidence but also use professional judgment. These stories and judgments, as well as other forms of narrative, shape decision making but remain poorly understood. Furthermore, qualitative research methods to examine narrative are rarely included in health science research. We illustrate how narratives shape decision making and explain why it is difficult but necessary to integrate qualitative research on narrative into the health sciences. We draw on social-scientific insights on rigorous qualitative research and our ongoing studies of decision making by patients with cancer, and we describe new tools and approaches that link qualitative research findings with the predominantly quantitative health science scholarship. Finally, we highlight the benefits of more fully integrating qualitative research and narrative analysis into the medical evidence base and into evidence-based medical practice.