Medicine In Oxford Research Articles

„EUebm“ – Integration einer europaweit harmonisierten Aus- und Fortbildung zu Evidenzbasierter Medizin (EbM) in die Krankenversorgung

Integrative concepts of teaching and learning with close reference to individual work routines are better suited to bring about attitudinal and behavioural modification--apart from a gain in knowledge and skills--than traditional educational approaches. All the same, the vast majority of continuing training courses in Evidence-based Medicine takes place during weekend courses or evening classes, outside the work environment. To counteract this deficit a modular curriculum framework for Evidence-based Medicine was developed within the scope of the European research project EUebm which aims to achieve both a harmonisation of EbM education and training in Europe and a better integration of education and training with everyday clinical practice. The modules of this curriculum are intended to seamlessly fit into our day-to-day clinical work for and with patients and thus facilitate close interaction between the actual clinical work and the learning of EbM techniques and their implementation into our own patients' care. On the basis of a survey conducted among all the project partners in Austria, England, Germany, Hungary, Italy, The Netherlands, Poland, Spain and Switzerland the demand for training and continuing education in EbM in the individual countries was identified. Taking into account the results of this survey as well as previous work such as, for example, the curriculum of the German Network for Evidence-based Medicine or material provided by the Centre for Evidence-based Medicine in Oxford, an Internet-based teaching and learning module on systematic reviews and meta-analyses was developed and tested in five of the participating countries. The test demonstrated that in this way harmonisation of EbM education and training and a better integration of training with our everyday clinical work becomes feasible.

Life after the EBM workshop

The Centre for Evidence-Based Medicine in Oxford offers workshops on practising and teaching evidence-based medicine (EBM). Having attended 2 of these and co-tutored in a third, I thought I would...

Why is evidence-based medicine important?

I’m sure readers of the Evidence-Based Medicine journal have a variety of reasons for subscribing. But most of you would assume evidence-based medicine (EBM) is important to clinicians. Recently Olive...

Using critically appraised topics to inform nursing practice in DVT prevention using graduated compression stockings

Summary This article describes how critically appraised topics (CATS) were adapted to support clinicians and managers in evidence-based decision making and how clinical uncertainty can be reduced using this system. The critically appraised topic has been adapted from the original CATS developed in Canada in 1995 [Sauve, et al., 1995. The critically appraised topic: a practical approach to learning critical appraisal. Ann. Roy. Soc. Phys. Surg. Canada. 28, 396–398] and from the centre for evidence-based medicine in Oxford. Our illustrative example relates to the use of anti-embolic stockings in reducing the risk of Deep Vein Thrombosis (DVT), now more usually called venous thromboembolism, in a range of patient groups including orthopaedic patients.

Verletzungen der ableitenden Harnwege bei polytraumatisierten Patienten

Within the S3 Guideline Project of the European Association of Urology (EAU) an expert committee was set up to develop guidelines for the appropriate management of genitourinary trauma. These European guidelines were accepted in principle as national guidelines by the German Urological Society. Therefore, they also became the basis of the contribution of the German Urological Society to the S3 Guideline Project "Polytrauma" of the German Society for Trauma Surgery. For the guideline "management of genitourinary trauma" all the requirements for classification as S3 guidelines were full-filled. The guideline itself was developed in accordance with the principles of "evidence-based medicine". A systematic analysis of literature published between 1966 and 2004 was carried out. The articles retrieved were assessed in respect of study design and clinical relevance and classified following the scheme of the Centre for Evidence-Based Medicine in Oxford. In suspected renal injuries the hemodynamic situation of the patient is the benchmark for the diagnostic and therapeutic algorithm. The diagnostic gold standard for the assessment of haemodynamically stable patients is CT scanning. Uncontrolled haemodynamic instability is an indication for immediate explorative laparotomy. Partial ureteral tears are managed by stenting; complete tears by immediate surgical repair. Pelvic fractures are often associated with bladder ruptures. Extraperitoneal bladder ruptures, identified by retrograde cystography, are in most cases safely managed by simple catheter drainage. Intraperitoneal ruptures require surgical intervention. Blood at the meatus may suggest a urethral lesion-blind urethral catheterization should not be attempted. Suprapubic cystostomy and delayed urethroplasty are recommended.

Searching for evidence-based medicine in the literature. Part 3: Assessment.

After composing a pointed question for an evidence-based medicine (EBM) search and then selecting appropriate resources for its execution, the final step requires an assessment of the information gleaned: what is substantive material and what is not? Unless one is especially adept at statistics and/or EBM methodology, it may appear that one study is as good as another and, consequently, the researcher can feel muddled by the retrieval. Critical appraisal in EBM generally centers around three questions: 1) is it valid?, 2) what are the results?, and 3) is it applicable to the patient? One is trying to determine if the study’s evidence demonstrates enough rigor within its methodology to impact the course of a particular patient’s care. It may be tempting to view critical appraisal as an invitation to negate or castigate clinical study efforts but, in a real world, no study can be perfectly designed or executed. The main purpose of critical appraisal is to “assess not whether a paper is ‘rubbish’, but whether there is so much potential bias that the results are no longer valid”.1 While the determination of validity is not easy and relevance to patient care is sometimes obscured, two resources that can assist in the evaluation of good, better, and best EBM information can be accessed electronically. At the Critical Appraisal Skills Programme (CASP) section of the United Kingdom’s National Health Service web site (http://www.phru.nhs.uk/casp/appraisa.htm), a wealth of resources provides a rich repository. Especially useful are forms described as critical appraisal tools for various types of articles including systematic reviews, randomized controlled trials, cohort studies, case control studies, diagnostic test studies and economic evaluation studies. Each form consists of ten questions about each specific type of article, which are supplemented with prompts that assist in the assessment of each question topic. The questions derive from a notable series titled “Users’ Guides to the Medical Literature,” which appeared in the Journal of the American Medical Association (JAMA) from 1993 through 20002 – 34 and, as such, constitute a solid approach to evidence-based assessment. In terms of function, the forms demonstrate attention to clarity in font size, strong contrast in design, and an efficient screening section in each article type that determines whether one should proceed through all ten questions or stop. While the roomy, clear forms may be used only for an individual’s personal use, the web site also provides a method to obtaining copyright permission if one wanted to use them in a group practice or other setting. Another useful web site that offers a step-by-step approach to critical appraisal can be found at the Centre for Evidence-Based Medicine in Oxford, England (http://www.cebm.net/critical_appraisal.asp). Worksheets provided for the assessment of articles relating to diagnosis, harm, etiology, therapy and systematic reviews of therapy can be accessed separately or downloaded as a group. Each type of article evaluation requires a different approach to determination of validity; critical questions and demonstrations of specific calculations are customized for each worksheet set. The addition of statistics can be daunting, but the authors supply understandable sample calculations and then provide a practice section for the user’s skill development. The last section of the form consists of patient-related questions to focus the results of the inquiry and, as such, cinches the usefulness of the worksheets. The aim of the worksheet exercise is to determine the article’s relevance to an individual patient’s care, and these worksheets provide an effective and cogent methodology to do so. While there are many evidence-based medicine resources, it is more difficult to find those with an easy and efficient approach to a rather complex area. Without compromising quality or exhausting time, one can find respectable EBM web resources to compose a suitable question, execute a viable literature search, and then assess the trustworthiness of the materials gleaned. Certainly more time and resources are needed for extended systematic assessments, but the busy practitioner can use evidence-based medicine in daily practice and still feel comfortable about the results for specific patient care.

Dirty Nails

42-YR-OLD MAN presented with symptoms and signs of hyperthyroidism, including a large symmetrical goiter with a bruit, tachycardia, brisk reflexes, and fingernail changes consistent with onycholysis (Plummer’s nails), shown in Fig. 1. After thyroidectomy, he has remained well with normal thyroid function tests. A photograph of his fingernails after 18 months of follow-up is shown in Fig. 2. The patient’s fingernails are examples of Plummer’s nails, first described by Henry Stanley Plummer in 1918 (1), in a patientwithhyperthyroidism.Hisfindingswerefirstdescribed in Oxford Medicine by Boothby and Plummer in 1937 (1, 2). Plummer’s nails represent a separation of the distal nail body from the nail bed. This separation, or onycholysis, is characteristically concave, and the hyponichium commonly traps dirt, giving the nail a dark appearance. The detachment isprobablyaresultofthyrotoxiccatabolismand/ortherapid growth of the nail body (3). For unknown reasons, onycholysis most commonly occurs on the fourth finger (3). With progressive disease, most other fingernails become affected (1). One study reported a 5.2% prevalence of onycholysis in hyperthyroidism (4). Onycholysis is not specific to thyrotoxicosis. Thedifferentialdiagnosisofonycholysisincludespsoriatic arthritis, lung cancer, sarcoidosis, bronchiectasis, trauma,

Mary P Sutphen and Bridie Andrews (eds), Medicine and colonial identity, Routledge Studies in the Social History of Medicine, vol. 17London and New York, Routledge, 2003, pp. xi, 147, £55.00 (hardback 0-415-28880-0).

Mary P Sutphen and Bridie Andrews (eds), Medicine and colonial identity, Routledge Studies in the Social History of Medicine, vol. 17London and New York, Routledge, 2003, pp. xi, 147, £55.00 (hardback 0-415-28880-0). - Volume 49 Issue 1

Rave reviews?

Rave reviews?

Führt Laufsport vorzeitig zu degenerativen Veränderungen am Hüftgelenk?

The study was performed to investigated correlations between running and degenerative arthritis of the hip, according to the principles of evidence-based medicine. The database Medline, the Cochrane Library, the centre for Evidence Based Medicine in Oxford and the sports science database Spolit, Spofor and Spowis were scanned systematically for the keywords "arthritis, osteoarthritis, degenerative, hip, sports, running, jogging, walking". 10 retrospective case control studies and 3 prospective studies were included for further analysis. The clinical examinations reported in the prospective studies did not reveal a significant difference between runners and non-runners. In one study a slightly increased risk for signs of arthritis at the X-ray was found in runners below 50 years with a very high mileage. No increased risk for degenerative arthritis was reported in most of the retrospective studies. A few authors of retrospective studies reported a slightly to moderately increased risk. The pooled estimate of the included studies showed a slightly increased risk for degenerative arthritis in runners (pooled OR 1.24 95 % CI 0.87-1.85). However, the increased risk did not reach a level of statistical significance. The graphic analysis of the data with the technique of the funnel plot gives an OR of 1.04. There is no evidence that running is associated with an increased risk for degenerative arthritis of the hip. There is no evidence for a different risk in men and women.

The Centre for Evidence-Based Medicine 9th UK workshop

The 2003 workshop was held at a new venue: Oriel College—part of Oxford University, in the centre of Oxford City, adjacent to the High Street, and one of the oldest...

Book of the Month Universities in the Future

Book of the Month Universities in the Future

The origins of AIDS

“Chimpanzee meat blamed for AIDS epidemic” was the headline of a front page article in the Times on 1 February, which began: “Chimpanzees slaughtered for food in west central Africa were the original source of AIDS.” The Daily Telegraph flagged the story in a similar way: “AIDS started by humans eating chimps.”Strengthened by the UK's recent climate of concern over food safety issues such as Salmonella, Escherichia coli 0157 and bovine spongiform encephalopathy (BSE), the implication was clear. Humans had first contracted AIDS by eating chimpanzee meat containing the virus. The television programme Newsnight on BBC2 continued the theme by comparing AIDS with BSE, and asking “What's next?”A paper given the previous day at a conference in Chicago by Beatrice Hahn from the University of Alabama at Birmingham, USA, was the trigger for these and many similar media stories. Previewing a paper in that week's Nature showing the close sequence similarity between strains of human immunodeficiency virus-1 (HIV-1) and a simian immunodeficiency virus strain (SIVcpz) isolated from a captive chimp belonging to a subspecies of Pan troglodytes troglodytes, Hahn had argued that close contact between people and chimps had probably allowed an ancestor of HIV-1 to cross the species barrier into humans. The bushmeat trade, associated with logging and deforestation, was under keen suspicion.But the suggested route of infection was, of course, exposure to blood during hunting and butchering, not ingestion through the gut. This crucial point did not come out strongly in any of the newspaper stories and was absent from some altogether. It appeared more than halfway through a lengthy account in the Daily Telegraph, near the very end of an equally prominent report in the Guardian, and nowhere at all in the Daily Mail's story.Most radio and television news bulletins, despite severe limits on time, provided more balanced coverage. Variously using interviews with the authors of the paper and with Andrew McMichael and Sarah Rowland-Jones of the Institute of Molecular Medicine in Oxford — who are working on boosting immune responses to the virus — they were effective in explaining the implications of the discovery for our understanding of AIDS and the development of vaccines.A live interview on Newsnight with Hilton Whittle, Deputy Director of the Medical Research Council Laboratories in The Gambia, was less successful. There is no reason why Whittle should be a charismatic TV personality: he is not, and that is not what the MRC pays him to be. The real problem was the interviewer's bizarre steering of the story line. At one point, immediately after Whittle had explained that viruses probably moved frequently from animals to humans without causing illness, he was asked why the consequences were “always catastrophic.”Even on the following day, when the Times published a second substantial piece, it failed to mention blood as the vehicle of infection. “The pace of destruction of African rainforests by logging companies and their employees, who poach hundreds of tonnes of primate meat, means that mass infections would be difficult to control,” the article said.Yet it was also on the second day that the most illuminating article of all appeared. Writing in the Guardian, Paul Brown and Hilary Bower linked the new finding with the puzzle of Nairobi prostitutes who are repeatedly infected with HIV-1 yet do not develop AIDS, and explored the implications of this resistance for the inherently difficult task of immunisation against the disease. The work of McMichael and Rowland-Jones was again used to illuminate the issues.This is by no means the first time that a national newspaper has produced a more thoughtful, more fully researched feature with the benefit of a further day's work. The fierceness of the current circulation war makes the argument seem unrealistic at present, yet many readers would surely prefer a definitive piece later to an imperfect piece sooner.To make this point is not to overlook the considerable skill that goes into the composition of newspaper articles which journalists are obliged to complete within a few hours of receiving the ‘breaking news’. Nevertheless, it is significant that on this occasion arguably the best of the first crop of reports, headlined “AIDS virus is thousands of years old,” was co-authored by Steve Connor in the Independent.Connor has previously written not only a highly regarded book on AIDS but also many articles on the origin of HIV-1. He was thus ideally placed to put the development in context and highlight its key implications.Describing the newspaper magnate Lord Northcliffe in My Northcliffe Diary (Victor Gollancz, 1931), Tom Clark recalled that he insisted on “experts” for everything — “an electrical engineer to criticise the telephones, an American to describe baseball, a sailor to report yachting…” Sounds quaint — but not a bad principle?

Haematologists in district general hospitals practise evidence based medicine.

A study published by the Centre for Evidence Based Medicine in Oxford, demonstrated that 82% of primary interventions offered by a general medical team in a 1 month period were evidence based. This contrasted with the traditional view that only 10-20% of medical interventions offered to patients have any scientific foundation. We have carried out a prospective study to determine if the primary interventions we offer to patients are evidence based. In June 1996 all therapeutic decisions which were made in one clinical haematology practice were studied. We included in the analysis the primary haematological diagnosis and the primary intervention offered. Interventions were classified as evidence based if the intervention was based on either evidence from randomized controlled trials, or evidence from well-designed non-randomized prospective or retrospective controlled studies or other convincing non-experimental evidence. In our study 70% of the primary therapeutic decisions made in the 83 patients studied were evidence based. This study reinforces the view that earlier assessments of the degree to which medicine is evidence based were too pessimistic. It is clear from our study that randomized controlled trials need to be developed in areas which are a relatively common clinical problem.

Sir William Osler's gown returns home.

At a ceremony at 13 Norham Gardens, Oxford, on 31 May 1984 Professor Michael Brain of McMaster University, Hamilton, Ontario, and Professor Charles Fletcher formally presented William Osier's former DSc gown to Sir John Walton, warden of Green College. The gown will be displayed permanently in Osier's old home and made available for use by any future regius professor of medicine in Oxford or by any warden of Green College holding the degree of DM (Oxon).

Oxford Medicine Edited by Kenneth Dewhurst (review)

BOOK REVIEWS Oxford Medicine. Edited by Kenneth Dewhurst. Oxford: Sandford Publications, 1970. Pp. 212. $6.00. Kenneth Dewhurst, distinguished physician and medical historian, has written notable biographies of Thomas Dover, John Locke, Thomas Willis, and Thomas Sydenham. He has contributed many papers of his studies on Oxford greats. The occasion of the printing of the collection of essays on Oxford medicine, which Kenneth Dewhurst edited, was the two hundredth birthday of the Radcliffe Infirmary , one of the many monuments to John Radcliffe's shrewdness, popularity, and generosity. Hugh Sinclair begins with a discourse of the seesaw ups and downs of medicine and science at Oxford. Dewhurst himself contributes an essay expanded from one he had previously published on "An Oxford Medical Quartet: Sydenham, Willis, Locke and Lower," but perhaps even more apposite to his fine sketch of John Radcliffe. Despite the fact that he has had several biographers, by far the most sympathetic sketch of Radcliffe is in MacMichael's The Gold Headed Cane. Included is an interesting symposium on the relationship of Oxford University and the Radcliffe Infirmary. Medicine, as a training for poetry, is discussed in John Potter's essay on Robert Bridges. It is surprising that no mention is made of the famous Daniel Press of Oxford, where some dozens of Robert Bridges's early poems were published in separate booklets, and whose present director, Dr. Bent Jewel Jensen, is on the staff of Radcliffe Infirmary. A number of essays deal quite naturally with Osier, who certainly added luster and distinction to medicine at Oxford during his tenure of the Regius Professorship from 1905 until his death in 1919. The reprinting of Sir Geoffrey Jefferson's "Memories of Hugh Cairns" gives a vivid account of one of the important people in Oxford's more recent medical history. This is brought right up to date in L. J. Witts's essay on "Twenty-seven Years a Nuffield Professor," which is autobiographical , and his scholarly essay, entitled "On Running a Department of Medicine ," as well as his perceptive discourse on "Success in Medicine." Although this collection represents largely an ingathering of earlier papers and essays, it makes an admirable volume to celebrate the bicentenary of the establishment of the Radcliffe Infirmary, probably the most productive and useful, if not the most satisfying from the architectural point of view, of the many Radcliffe buildings in Oxford. It should not be forgotten that fundamental contributions to medicine were made at Oxford by physicians and scientists; for example, Sir Archibald Garrod who introduced the fundamental concept of inborn errors of metabolism. The Radcliffe Infirmary saw the first clinical use of penicillin in human disease and, indeed, much fundamental work on its development and production. Sherrington illuminated an epoch at Oxford, and Charles Singer advanced his reputation for scholarly work in the history of science at Oxford. Despite the fact that he made no single great or unique contribution to medical science or clinical medicine, the sum total of Osier's influence and its happy 478 I Book Reviews longevity makes him the beacon light in a brilliant galaxy of physicians and scientists who have added luster to the Radcliffe Infirmary while lighting up the whole field of medicine. William B. Bean, M.D. Department of Internal Medicine University of Iowa, Iowa City A Notable Career in Finding Out: Peyton Rous, 1879-1970. By James S. Hknderson, Phillip D. McMaster, John G. Kidd, and Charles Huggins. New York: Rockefeller University Press, 1971. Pp. 48. J5.00. This beautiful brochure would have pleased Peyton Rous. Its frontispiece shows his quizzical features in the laboratory that he loved and in which he worked for more than sixty years. Frederick Seitz, president of the Rockefeller University, introduces this charming booklet, indicating that it contains the reminiscences of four close friends of Peyton Rous who spoke in tribute to him at a gathering shortly after his death. James S. Henderson, of the University of Manitoba, offers "a view from the center of the world." This short comment has the sharp observation that Peyton Rous's laboratory was a playroom. The view from his laboratory truly came from the center of the world of virus research. The "sparkling...

Medicine in Oxford

Medicine in Oxford

Two Hundred Years of Medicine

Oxford Medicine . (Essays on the evolution of the Oxford Clinical School to commemorate the Bicentenary of the Radcliffe Infirmary, 1770–1970.) Edited by Kenneth Dewhurst. Pp. viii + 212. (Sandford: Oxford, 1970.) 50s.

The Basal Ganglia and Their Relation to Disorders of Movements

The second of a series of Oxford Neurological Monographs, this book contains the material presented as the Croonian Lectures in November, 1960, by Professor Denny-Brown. The previous paper on the basal ganglia published in<i>Oxford Medicine</i>in 1945, and as a separate monograph in 1946 has long been a classic in its field. The material presented in this book will become one of the landmarks in the field of neurology and will serve as a taking off point for much work and discussion by others in the future. In this monograph the author presents his concepts of the pertinent clinical anatomy of these nuclei. Of especial interest is his emphasis on the presence of corticostriate fibers which play an important role in the hypothesis he presents and which have not been emphasized before. An interpretative description of pathology in relation to the various "basal ganglia disease" and their syndromes is

The role of posture in cardiovascular disease.

Excerpt The cardiologist is frequently confronted with disturbances associated with posture. Angina decubitus and postural hypotension are familiar examples. The physiologic mechanism controlling t...