Importance Of Evidence-based Medicine Research Articles

Why is it Important for Family Physicians to Identify Reliable Sources of Information in the Digital Age?

Dear Editor, Accessing reliable information in the 21st century can be challenging, particularly with the ease of access to data through technology. For both society and health professionals, the integrity of information is of utmost importance. Evidence-based medicine (EBM) offers a framework for evaluating the reliability of sources through rigorous scientific methods, including experimentation, falsification, and data accumulation (1). Medical knowledge has historically evolved through continuous refinement, with evidence being established via repeated experiments and analyses. Reliable information stems from multiple confirmations rather than isolated findings. EBM uses a hierarchy of evidence to categorize research by its reliability, facilitating informed clinical decision-making. It presents a structured approach to medical diagnosis, treatment, and follow-up strategies based on evidence levels (Grade Practice Recommendations, A-D) (2). The importance of EBM is emphasized in the digital era, promoting a systematic and reliable presentation of information. To combat misinformation, it is important to exercise critical thinking and skepticism toward information sources. Accessing reliable medical information is of crucial importance, especially in times of crisis such as the COVID-19 pandemic (3). Primary sources, including peer-reviewed journals, respected international guidelines, scientific reports, and reputable textbooks play a pivotal role in providing accurate and trustworthy information. For example, The National Institute for Health and Clinical Excellence (NICE) and the Cochrane Library offer evidence-based information that has undergone peer review (5,6). The pandemic has highlighted the significance of open access to scientific publications, which has facilitated global information sharing and accelerated vaccine development, ultimately reducing morbidity and mortality rates. This event has underscored the necessity of reliable information sources and the importance of continued collaboration and cooperation in the scientific community. Misinformation, particularly on social media, can pose significant challenges when it comes to verifying the accuracy of online information. To differentiate between truth and falsehood, it is crucial to employ critical evaluation methods, such as cross-referencing multiple sources and examining evidence consistency. Educational initiatives on media and health literacy from a young age, as well as platforms dedicated to verifying claims, can play a vital role in countering misinformation (6). In the digital age, family physicians face both opportunities and challenges due to the abundance of online information. It is very important to acknowledge that quick access to a wide range of data is invaluable for informed decision-making in patient care. However, the vast amount of information available also poses the risk of encountering unreliable or outdated sources. Therefore, it is crucial to utilize reputable medical literature and evidence-based resources (7). For family physicians, it is important to remain up-to-date with the latest research and guidelines through respected indexes such as Web of Science, PubMed, and Scopus. This practice not only helps in delivering high-quality patient care but also supports lifelong learning and professional development (8). Additionally, recent global health crises have emphasized the need for quick access to accurate and reliable medical information to effectively address public health emergencies (6). Therefore, discerning and accessing reliable information sources are indispensable skills for family physicians in the digital age. Keywords: evidence-based medicine, information sources, family practice, practice guideline, resource guides

Common Bias and Challenges in Physical and Rehabilitation Medicine Research: How to Tackle Them.

The importance of evidence-based medicine is crucial, especially in physical and rehabilitation medicine (PRM), where there is a need to conduct rigorous experimental protocols, as in any medical field. Currently, in clinical practice, therapeutic approaches are often based on empirical data rather than evidence-based medicine. However, the field of PRM faces several challenges that may complicate scientific research. In addition, there is often a lack of appropriate research training in educational programs. In this context, we aim to review the methodological challenges in PRM and provide clear examples for each of them as well as potential solutions when possible. This article will cover the following themes: (1) Choosing the right study design and conducting randomized and benchmarking controlled trials; (2). Selecting the appropriate controlled, placebo or sham condition and the issue of blinding in non-pharmacological trials; (3) The impact of populations' heterogeneity and multi-comorbidities; (4). The challenge of recruitment and adherence; (5). The importance of homogeneity and proper quantification of rehabilitative strategies; and (6). Ethical issues. We are convinced that teaching the basics of scientific research in PRM could help physicians and therapists to choose a treatment based on (novel) scientific evidence. It may also promote scientific research in PRM to develop novel and personalized rehabilitation strategies using rigorous methodologies and randomized or benchmarking controlled trials in order to improve patients' management.

Keeping up with the literature: A current practice survey and qualitative needs assessment among emergency physicians.

Physicians face the challenge of staying current with a rapidly growing body of evidence and applying it to their practice. How emergency physicians (EPs) do so is unknown. The authors sought to describe and assess needs around EP patterns of evidence-based medicine (EBM) and continuing medical education (CME) resource use. The authors conducted a multicenter, cross-sectional study in 2019 across 12 tertiary care, community, and suburban emergency department (ED) sites in the greater area of Edmonton. Information on EBM/CME resource use along with barriers and facilitators to staying current was gathered using a rigorously developed survey tool, distributed electronically and by mail. Responses were tabulated and subgroups analyzed using MANOVA and ANOVA tests. Thematic analysis of comments used a phenomenological lens. A total of 118 EPs (40.1%) completed the survey. Listening to podcasts, attending EM conferences, and subscription-based resources were preferred for staying current. Resource use differed by years in practice but not by age, sex, training background, or site type. EBM had an important impact on respondents' practice (average rating 3.8 out of 5, with 5 indicating "practice changing"). Time was an important barrier. Most (62.7%) felt that they did not spend enough time, despite spending a median of 4 to 5h monthly on EBM. Facilitators (including journal club summaries or lists of practice-relevant papers) had only moderate impacts. Thematic analysis found three themes (importance of EBM, implementation challenges, and dissemination of EBM) and 13subthemes. EPs preferentially chose podcasts, conferences, and subscription-based resources to stay current with EBM; time was the biggest barrier. These findings help ED leads and educators tailor CME to physician learning preferences to maximize application of EBM to clinical practice. The next steps include developing/curating resources and disseminating the survey on a larger scale to identify opportunities for shared virtual resources.

EVIDENCE-BASED MEDICINE IN THE TIMES OF COVID-19: A CROSS-SECTIONAL SURVEY TO UNDERSTAND THE INDIAN PERSPECTIVE

Introduction: During the COVID-19 pandemic, there is a tremendous amount of literature published regularly. In a country like India, historically, where there is a paternalistic approach to practicing medicine, there is a lot of hindrance to evidence-based medicine (EBM). Doctors have always weighed one's clinical experience superior over any other form of decision-making. This system of practice has made decision-making difficult for the physicians during this pandemic as COVID-19 is a reasonably new disease entity and the physicians lack enough 'prior experience' dealing with such a situation. Our survey tries to address the common barriers to evidence-based medical practices especially during the COVID-19 pandemic in India. We also try to explore the various source of information used by the doctors.
 Methods: It is a descriptive cross-sectional survey. The questions were provided in multiple-choice question format. An online survey comprising of 10 questions entitled “Hurdles faced by physicians to assimilate evidence-based guidelines on COVID-19” was made using Google Forms (Google Inc, California, US) and circulated through email to medical practitioners in the Ghatkopar (Mumbai, India) Medical Association's register from 17th June 2020 to 1st September 2020.
 Results: Our survey collected 213 responses, out of which 80.3% (n=171) of doctors were involved in care, counseling, or management of COVID-19 patients. The most opted primary sources for evidence-based information during this pandemic were teachings of/discussions with medical colleagues (71.4%, n=152), followed by online webinars (59.6%, n= 127) and social media (41.8%, n=89).
 When questioned about the main obstacles faced by them to obtain evidence-based information, the responses were as follows: Overload of medical literature (53.5%, n=114), limited access to quality resources (40.8%, n=87), unfamiliarity with the bio-statistics analysis (39%, n= 83), difficulty in locating relevant medical literature (38%, n=81), unfamiliarity with the research methodology (37.1%, n=79), lack of time (30%, n=64). 
 Our respondents' perspective concerning EBM attributes: 57.3% (n=122) think evidence-based practice takes their clinical experience into account. 93.4% (n=199) of them have shown an interest in broadening their skills. There was no significant difference between doctors' attitudes with less than 10 years and more than 10 years of experience (chi-square value = 0.857, p = 0.65).
 Conclusion: Our survey results highlight the balance maintained between evidence-based medicine and experience-based medicine by Indian physicians. They identify the importance of EBM while acknowledging its shortcomings. They realize the significance of developing their repertoire to understand, appraise, and practice EBM.
 Keywords: EBM, COVID-19

25. WHAT'S THE EVIDENCE? EVALUATING THE IMPACT OF A RESIDENT EVIDENCE-BASED MEDICINE CURRICULUM

Background The ability to incorporate evidence-based medicine (EBM) into clinical practice is an ACGME competency, yet many pediatric residents have limited knowledge, comfort, and skill in this area. In addition, there is a lack of data regarding how residents apply EBM curricula to clinical practice. Objective: Describe the effect of an EBM curriculum on resident attitudes and clinical use of EBM. Methods We implemented a twice-weekly EBM curriculum to review key literature and guidelines. In this IRB-exempt mixed methods study, we surveyed residents, fellows, and faculty about use of EBM at baseline and 6 months later. Results were compared using Mann-Whitney U tests. We surveyed faculty twice weekly about residents’ EBM use on rounds. Residents participated in focus groups, which were audio-recorded, transcribed and coded using conventional content analysis to develop themes. Results Residents (N=61 pre- and 41 post-curriculum) reported increased: satisfaction with conferences (p=0.0037), importance of EBM (p = 0.0041), comfort generating a search question (p= 0.0001), and citation of evidence on rounds (p Conclusion As a result of this EBM curriculum, trainees described increased use of EBM in clinical practice and better understanding of research methodology. Additionally, resident use of EBM reinforced plans, taught faculty, and at times, changed management. Ongoing work is needed to create a culture that promotes EBM.

The Importance of Evidence-Based Medicine and Clinical Guidelines: Meaningful and Clinically Actionable Information Cannot be Compromised for the Convenience of Consumer Sleep Data.

The Importance of Evidence-Based Medicine and Clinical Guidelines: Meaningful and Clinically Actionable Information Cannot be Compromised for the Convenience of Consumer Sleep Data.

The history of Distilbène® (Diethylstilbestrol) told to grandchildren – the transgenerational effect

The Distilbène® story is a dramatic episode which belongs to the history of medicine. It provided several useful lessons such as the importance of evidence-based medicine and the hazard to develop treatments during pregnancy without careful animal verifications. However, this experience has also provided unexpected progress by suggesting new pathophysiological concepts: fetal programming of adult diseases and/or transgenerational transmission of environmental effects through epigenetic modifications.

Overview and recent trends of systematic reviews and meta-analyses in hepatology.

A systematic review (SR) is a research methodology that involves a comprehensive search for and analysis of relevant studies on a specific topic. A strict and objective research process is conducted that comprises a systematic and comprehensive literature search in accordance with predetermined inclusion/exclusion criteria, and an assessment of the risk of bias of the selected literature. SRs require a multidisciplinary approach that necessitates cooperation with clinical experts, methodologists, other experts, and statisticians. A meta-analysis (MA) is a statistical method of quantitatively synthesizing data, where possible, from the primary literature selected for the SR. Review articles differ from SRs in that they lack a systematic methodology such as a literature search, selection of studies according to strict criteria, assessment of risk bias, and synthesis of the study results. The importance of evidence-based medicine (EBM) in the decision-making for public policy has recently been increasing thanks to the realization that it should be based on scientific research data. SRs and MAs are essential for EBM strategy and evidence-based clinical practice guidelines. This review addresses the current trends in SRs and MAs in the field of hepatology via a search of recently published articles in the Cochrane Library and Ovid-MEDLINE.

Global health: the importance of evidence-based medicine

Global health is a varied field that comprises research, evaluation and policy that, by its definition, also occurs in disparate locations across the world. This forum article is introduced by our guest editor of the Medicine for Global Health article collection, Gretchen Birbeck. Here, experts based across different settings describe their personal experiences of global health, discussing how evidence-based medicine in resource-limited settings can be translated into improved health outcomes.

Levels of evidence and quality of randomized controlled trials in hand and wrist surgery: an analysis of two major hand surgery journals

Dear Sir,The importance of evidence-based medicine has been emphasized for many years. Levels of evidence range from I to V, where level I studies are most rigorously designed and represent the ‘best evidence’. Randomized controlled trials (RCTs) are recognized as the ‘gold standard’ for evaluating interventions. However, there is a paucity of high level evidence in surgical literature. The quality of hand surgery publications has not been fully reported. Our study evaluated levels of evidence and quality of RCTs in hand and wrist surgery publica-tions in

The Level of Evidence Presented at Plastic Surgery Meetings

Internationally, plastic surgery societies have placed an increasing emphasis on the importance of evidence-based medicine. The authors aimed to categorize levels of evidence of podium presentations at three major North American plastic surgical meetings, and to assess the factors associated with a higher level evidence. Presentations at the 2010/2011 meetings of three of the largest societies of plastic surgeons in North America were evaluated for the area of research, number and origin of authors, subdomain of plastic surgery, number of centers of collaboration, number of subjects, study subtype, and level of evidence. One hundred eighty-eight presentations were screened, and 126 met eligibility criteria. The American Society of Plastic Surgeons was the largest meeting with 74 presentations (58.7 percent). Breast (23.8 percent) and craniofacial (21.4 percent) topics were most frequently covered. Most studies had five or fewer authors (76.4 percent), were conducted at a single center (84.3 percent), were therapeutic (89.7 percent), and had 50 or fewer subjects (36.8 percent). Two studies (1.6 percent) were level I, 11 (8.7 percent) were level II, 54 (42.9 percent) were level III, 46 (36.5 percent) were level IV, and 13 (10.3 percent) were level V. Overall, the mean level of evidence was 3.45, and one of every 10 presentations was of higher level of evidence (level I or II). Higher level evidence presentations were found to be associated with multicenter studies. Evidence presented at major plastic surgical meetings is rarely level I and infrequently level II. Opportunities to create greater awareness of the need for prospective high-level studies are needed.

Levels of Evidence in the Neurosurgical Literature

The importance of evidence-based medicine has been well documented and supported across various surgical subspecialties. To quantify the levels of evidence across publications in the neurosurgical literature, to assess the change in evidence over time, and to indicate predictive factors of higher-level evidence. We reviewed the levels of evidence across published clinical studies in 3 neurosurgical journals from 2009 to 2010. Randomized trials were evaluated by use of the Detsky quality of reporting scale. Levels-of-evidence data for the same journals in 1999 were obtained from the literature, and regression analysis was performed to identify predictive factors for higher-level evidence. Of 660 eligible articles, 14 (2.1%) were Level I, 54 (8.2%) were level II, 73 (11.1%) were Level III, 287 (43.5%) were level IV, and 232 (35.2%) were level V. The number of level I studies decreased significantly between 1999 and 2010 (3.4% vs. 2.1%, respectively; P = .01). Seven randomized clinical trials were identified, and 1 trial had significant methodological limitations (mean Detsky index = 16.3; SD = 1.8). Publications with larger sample size were significantly associated with higher levels of evidence (levels I and II; odds ratio, 1.7; 95% confidence interval, 1.45-2.05; P = .001). The ratio of higher levels of evidence to lower levels was 0.11. Higher levels of evidence (levels I and II) represent only 1 in 10 neurosurgical clinical papers in the top neurosurgical journals. Increased awareness of the need for better evidence in the field through education and adoption of the levels of evidence may improve the conduct and publication of prospective studies.

ADDIS: A decision support system for evidence-based medicine

Clinical trials are the main source of information for the efficacy and safety evaluation of medical treatments. Although they are of pivotal importance in evidence-based medicine, there is a lack of usable information systems providing data-analysis and decision support capabilities for aggregate clinical trial results. This is partly caused by unavailability (i) of trial data in a structured format suitable for re-analysis, and (ii) of a complete data model for aggregate level results. In this paper, we develop a unifying data model that enables the development of evidence-based decision support in the absence of a complete data model. We describe the supported decision processes and show how these are implemented in the open source ADDIS software. ADDIS enables semi-automated construction of meta-analyses, network meta-analyses and benefit–risk decision models, and provides visualization of all results.

Evidence-based medicine: The Canadian Journal of Plastic Surgery's future

Over the past few decades, evidence-based medicine has been rated as one of the most significant medical advances in patient care (1). The ability to systematically rate research evidence should direct patient care so that the most beneficial interventions for patients are implemented. In the absence of intervention evaluation, significant portions of our health care dollars continue to be wasted on care that does not benefit the patient or has never been appraised for its supporting evidence. In the Spring 2012 issue of the Canadian Journal of Plastic Surgery (CJPS), the article by Thoma et al (2) provided a brief history and detailed the importance of evidence-based medicine. Currently, more and more scientific journals are focusing on evidence-based medicine and level of evidence (LOE) rating scales when evaluating journal articles. These scales enable researchers and authors to produce better articles, and enable readers to easily understand the LOE for each published article. There are many LOE rating scales in the literature. The CJPS has decided to use the rating system and standardized icons currently used by Plastic and Reconstructive Surgery. The editorial by Sullivan et al (3) highlights the importance of evidence-based medicine and the need for journals to embrace LOE rating scales. The LOE tables to be implemented by the CJPS were developed by the American Society of Plastic Surgeons and are presented here. It is with their full support and encouragement that we begin duplicating their requirements for authors to rate their articles based on the LOE in one of three categories: THERAPEUTIC, DIAGNOSTIC or PROGNOSTIC/RISK. Each article will have its level rated based on the set criteria established by the American Society of Plastic Surgeons. The CJPS’s Editorial Board will then confirm the level and publish the level with the article. The same triangular rating logo will be used in a similar manner to what is currently published in Plastic and Reconstructive Surgery (Figure 1). Figure 1 The level of evidence pyramid, showing level of evidence (I through V) and clinical question addressed by the article. Left Diagnostic clinical question addressed, with a level of evidence of II. Centre Therapeutic clinical question addressed, with a ... Hopefully, this new initiative will enhance the quality of the work published in the CJPS and enhance the educational experience of our readers.

Are neurologists really data driven in selecting epilepsy treatment?

Neurology is considered a cognitive field, with thoughtful practitioners who are driven by empiric data. With the development of guidelines, practice parameters, and now a review of how physicians practice, this notion could be called into question. There is no doubt that evidence-based medicine (EBM) should be and is the basis for the practice of modern medicine. Medical school curricula worldwide have recognized the importance of EBM, incorporating it into standard medical student education. The American Academy of Neurology (AAN), recognizing the need to supplement this type of thinking, developed a resident education program covering the basics of EBM.1 So how do we as neurologists fare in the practice of EBM? Our track record is mixed. We hear our colleagues utter, “there is no evidence to support that.” That statement is more an editorial comment than a valid conclusion. EBM is built on the principle that there exists a hierarchy of evidence, some of which is strong and other weak, with the rest falling somewhere in between. Data, properly collected, should not be considered valid or invalid, but rather strong or weak. Similarly, an individual's opinion should not be thought of as valid …

Evidence-based medicine in urology

“Evidence-based medicine” refers to a set of principles and methods to ensure that, to the greatest extent possible, individual decisions and population-based policies are consistent with the evidence of their eVectiveness and beneWt [1]. The term that was coined less than 20 years ago by Gordon Guyatt at McMaster University has grown from a Xedging concept to the fundamental basis of clinical practice that reaches into all aspects of medical practice [2]. The importance of evidence-based medicine and evidence-based clinical practice is highlighted by the fact that statements encouraging adherence to these principles are included in the landmark health care reform legislation enacted in the United States in 2010 and is guiding health care policy in countries such as the United Kingdom. With increasing recognition that greater adherence to evidencebased practice can improve quality of care and reduce costs, it is critically important that all practitioners in urology understand the underpinnings of the concepts of evidencebased medicine as well as its applicability and limitations. This issue of the World Journal of Urology pays tribute to the remarkable and growing impact that evidence-based medicine has had on the practice of urology. It includes eleven articles written by recognized experts in the Weld that provide in-depth analyses of the inXuence of evidencebased medicine on key areas of clinical practice, education, publishing, health policy, and clinical research. Lavallee et al. explore the current and future role of randomized controlled trials—recognized as leading the “hierarchy of evidence” as the best original study design to provide high quality evidence for questions of therapeutic eVectiveness—in guiding the clinical practice of urology. It is followed by studies by Porten et al. and Yu et al. that provide similar analyses of the roles of observational study designs/registries and health services research, respectively, in addressing the most important evidence gaps in urology. The following two articles by Wang et al. and Shelton et al. put these Wndings into perspective by discussing the growing importance of comparative eVectiveness research as well as their implications for health policy decision-making. Recognizing the critical role of clinical practice guidelines to guide evidence-based clinical practice, MacLennan et al. discuss the value of clinical pathways as a guide to their development; an approach that is being promoted by the European Association of Urology and The British Association of Urological Surgeons guideline developer groups. Wolf et al. analyze the considerable eVorts of the American Urological Association (AUA) as an example of how rigorous methodology can feasibly be applied to the development of evidence-based recommendations. A review by CanWeld et al. then discusses the GRADE approach for rating the quality of evidence and strengths of recommendations. It provides a transparent and methodologically rigorous framework for developing clinical practice guidelines that has been adopted by over Wfty professional organizations all over the globe (http://www.gradeworkinggroup.org). GRADE holds the promise of becoming the unifying methodological framework for guideline developers, which would allow enhanced collaboration and improved resource utilization for professional urological organizations. P. Dahm (&) Department of Urology, College of Medicine, Health Science Center, University of Florida, Box 100247, Room N-203, Gainesville, FL 32610-0247, USA e-mail: p.dahm@urology.ufl.edu

Evidence‐based medicine training in a resource‐poor country, the importance of leveraging personal and institutional relationships

Efforts to implement evidence-based medicine (EBM) training in developing countries are limited. We describe the results of an international effort to improve research capacity in a developing country; we conducted a course aimed at improving basic EBM attitudes and identified challenges. Between 2005 and 2009, we conducted an annual 3-day course in Perú consisting of interactive lectures and case-based workshops. We assessed self-reported competence and importance in EBM using a Likert scale (1 = low, 5 = high). Totally 220 clinicians participated. For phase I (2005-2007), self-reported EBM competence increased from a median of 2 to 3 (P < 0.001) and the perceived importance of EBM did not change (median = 5). For phase II (2008-2009), before the course, 8-72% graded their competence very low (score of 1-2). After the course, 67-92% of subjects graded their increase in knowledge very high (score of 4-5). The challenges included limited availability of studies relevant to the local reality written in Spanish, participants' limited time and lack of long-term follow-up on practice change. Informal discussion and written evaluation from participants were universally in agreement that more training in EBM is needed. In an EBM course in a resource-poor country, the baseline self-reported competence and experience on EBM were low, and the course had measurable improvements of self-reported competence, perceived utility and readiness to incorporate EBM into their practices. Similar to developed countries, translational research and building the research capacity in developing countries is critical for translating best available evidence into practice.

The proof of efficacy in psychopharmacology: clinical studies, metaanalysis and evidence-based medicine

Evidence-based medicine (EBM) becomes more prominent in everyday clinical practice since treatment guidelines are available for different diseases and clinical situations. However, in daily clinical practice it is quite often apparent that the type of studies which we wish to have for the specific and individual situation in which the patient is situated is not available. EBM is only possible when sound studies are conducted and additionally meta-analyses help to guide us through the plethora of available data. The critical reflections of recent meta-analyses substantiated that they are not the highest level of evidence as sometimes suggested since meta-analyses can only be as good as the selected and included studies and furthermore depend on the methodology used. These three topics, the importance of EBM, the methodology of meta-analyses as well as the principle standards and problems in proving efficacy in clinical psychopharmacology, are dealt with in this special issue by wellknown European authorities in psychopharmacology and clinical psychiatry. The literature on the above mentioned topics is discussed and reflected critically including the possibilities, problems and limitations. It is apparent that meta-analyses can be helpful in one way, but also can be problematic when certain standards are not set and met sufficiently. This special issue should be a guidance not only for researchers and clinicians, but also for health regulatory authorities who have to judge the available studies on clinical efficacy as well as meta-analyses. Furthermore, the contents of these papers are important for the judgement of treatment guidelines and how recommendations can be implemented in everyday clinical practice.

How do doctors use information in real‐time? A qualitative study of internal medicine resident precepting

Despite the importance of evidence-based medicine in medical education, little observational research exists on how doctors-in-training seek and use evidence from information resources in ambulatory care. To describe information exchange behaviour by internal medicine residents and attendings in ambulatory resident clinic precepting rooms. We observed resident behaviour and audiotaped resident-attending doctor interactions during precepting sessions. Participating residents included 70 of an eligible 89 residents and 28 of 34 eligible attendings from one large academic internal medicine residency programme in the Midwestern USA. Residents were observed during 95 separate precepting interactions at four ambulatory sites. Using a qualitative approach, we analysed transcripts and field notes of observed behaviours and interactions looking for themes of information exchange. Coders discussed themes which were refined using feedback from an interdisciplinary panel. Four themes of information exchange behaviour emerged: (i) questioning behaviours that were used as part of the communication process in which the resident and attending doctor could reason together; (ii) searching behaviour of non-human knowledge sources occurred in a minority of precepting interations; (iii) unsolicited knowledge offering and (iv) answering behaviours were important means of exchanging information. Most clinic interactions between resident and attending doctors relied heavily on spoken deliberation without resorting to the scientific literature or other published information resources. These observations suggest a range of factors that may moderate information exchange behaviour in the precepting context including relationships, space and efficiency. Future research should aim to more readily adapt information resources to the relationships and practice context of precepting.

Heparin use in acute ischaemic stroke: does evidence change practice?

There has been much discussion in recent years about the importance of evidence-based medicine and, although the discipline has received broad acceptance, it is not without its critics. An important question that has received relatively little attention is: what is the evidence that evidence-based medicine has had any effect on practice? In this article, I shall try to answer this question with respect to the use of heparin in the management of acute ischaemic stroke. I will not consider the unusual instances of extra-cranial arterial dissection, cerebral venous thrombosis and crescendo transient ischaemic attacks, but will instead focus on the more common causes of acute ischaemic stroke for which heparin anticoagulation is still frequently used. Acute ischaemic stroke is a common problem that carries a significant risk of death and disability. There are approximately 600 000 new cases diagnosed each year in the USA with about 150 000 deaths and a further 300 000 survivors left with substantial disability. The use of heparin in the management of acute ischaemic stroke has been the subject of many studies, including a number of randomized controlled trials. Low-molecular-weight heparin, administered subcutaneously, was used in most studies, although a few have examined the use of intravenous unfractionated heparin. For the most part, these studies (Table 1) have shown no benefit from heparin, with the small decrease in the risk of stroke progression or recurrence being offset by an increase in the risk of hemorrhagic complications. What has been the impact of these results? Has there been a decline in the usage of heparin since publication of these results? If not, why not? These are the questions that are considered in this paper. View this table: Table 1 Randomized trials of heparin use in acute ischaemic stroke There are limited data upon which to base an answer to this question. A few studies …