Patient-Oriented Evidence That Matters Research Articles

Top 4 Research Studies of the month for Italian Primary Care Physicians: April 2024.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) In children and adults with acute conjunctivitis, antibiotic drops increase the likelihood that a patient will experience clinical recovery. Damage appears to be minimal for all agents other than fusidic acid (therefore, fusidic acid should be avoided). Since most patients improve without antibiotics, the benefit is modest, and there is a risk of antibiotic resistance, we would avoid them for patients with milder symptoms, especially immunocompetent adults. 2) A high quality randomized controlled trial was recently conducted on more than 4000 adult patients with recurrent episodes of subclinical atrial fibrillation. Trialists found that there was approximately 1 fewer ischemic stroke and 1 more major bleed for every 250 persons treated with apixaban instead of aspirin, but in people treated with apixaban major bleeding was also significantly more likely. This seems like a decision that requires an informed patient and shared decision-making. 3) In an intriguing but somewhat limited network meta-analysis, probiotics were equally or more effective than treatment with any antidepressant except escitalopram. Given the low advantage of standard treatments over placebo, probiotic treatment might be offered to patients who are reluctant to use antidepressants. 4) A recent meta-analysis showed that amyloid-targeting monoclonal antibodies do not provide any clinical meaningful benefits for patients with Alzheimer disease. Instead, they are associated with concerning risks of harm, most notably cerebral hemorrhage identified on imaging studies. The balance of risk versus benefit demonstrated thus far doesn't justify the use of these costly (over US$ 20,000 annually) drugs.

Top 5 Research Studies of the month for Italian Primary Care Physicians: March 2024.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) A simple, well-validated risk score can help clinicians counsel patients with atrial fibrillation regarding the use of DOACs to prevent stroke. The score shares its name with the drug class (the "DOAC" score). 2) Presumably by perturbing the intestinal microbiome, antibiotic treatment is associated with an increase in the likelihood of the development of irritable bowel disease; this is especially true with multiple courses of antibiotics. 3) Patients with uncomplicated gallstones can be managed over time with analgesia and monitoring, though approximately 25% will eventually undergo cholecystectomy over the next 18 months. Still, there appears to be no need to rush to surgery without evidence of common bile duct blockage or acute pancreatitis. 4) Delivering bad news (e.g. a cancer diagnosis) by telephone does not affect levels of anxiety, depression, or satisfaction with care as compared with delivering the news in person. 5) An updated high quality systematic review found that, in conjunction with psychosocial interventions, oral naltrexone (50 mg/day) and oral acamprosate have the strongest evidence for being effective in the treatment of alcohol use disorder.

Top 4 Research Studies of the month for Italian Primary Care Physicians: February 2024.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) For patients with severe fatigue at least 3 months after Covid-19 infection, cognitive behavioral therapy offers significant improvement in symptoms over care as usual. 2) Key changes in the US chronic coronary disease guideline recommendations include the following. Shortening the duration of dual antiplatelet therapy, the use of beta-blockers in patients with chronic coronary disease, not recommending fish oil or omega-3 fatty acids for secondary prevention, not using e-cigarettes as first-line agents (but as secondary agents) for smoking cessation, and incorporating sodium-glucose transport protein 2 inhibitors (Sglt-2i) and glucagon-like peptide-1 (GLP-1) receptor agonists for some patients with chronic coronary disease, including those without comorbid diabetes mellitus. 3) People with irritable bowel syndrome can try various probiotic-containing products to lessen their symptoms, but on the whole, most people will not experience a significant reduction. Products containing Escherichia strains were the most likely to provide a benefit, but these are not widely available. 4) Framing weight loss in terms of its positive effects, rather than by listing the risks of excess weight, increased patients' participation in a weight-loss program and increased their eventual weight loss.

Top 4 Research Studies of the month for Italian Primary Care Physicians: June 2024.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) Although bleeding risk scores such as HAS-BLED and HEMORR2HAGE are widely recommended by guidelines for decision-making regarding long-term anticoagulation, their accuracy in primary care patients seems to be pretty terrible. Studies in the primary care setting that derive and then externally validate simple, pragmatic risk scores are needed. 2) Point-of-care ultrasound is increasingly finding a role at the bedside, and this study adds to that evidence base. In the patient with acute abdominal pain, point-of-care ultrasound has been shown to be highly accurate for diagnosis of appendicitis, small bowel obstruction, aneurysm - and now, acute diverticulitis. 3) According to a recent meta-analysis, rhythm control is associated with a lower risk of dementia and cognitive dysfunction than rate control. Most of the data come from middling quality studies, which likely overestimate the purported protective effects. 4) Limited quality research finds no difference in outcomes among common treatments for acute otitis externa, including antibiotic, steroid, antiseptic, or nonpharmacologic treatment. Given the low quality of trials conducted so far, it remains to be seen if larger, better studies will find out a difference, but for now the existing literature gives us little guidance.

Top 5 Research Studies of the month for Italian Primary Care Physicians: January 2024.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) A recent high-quality systematic review (SR) of 76 SRs found that, compared to all other lipid-lowering medications, for overall, primary, and secondary prevention the best balance of benefits, harms, and costs is provided by statins. 2) To our surprise, a network meta-analysis of 12 randomized controlled trials (RCTs) concluded that acetaminophen and ketorolac were more effective than morphine in alleviating pain from renal colic and were less likely than morphine to cause adverse effects and the need for rescue analgesia. 3) Proton pump inbibitors (PPI) use in children is associated with an increased risk of developing serious infections as compared with the use other acid-suppressing therapy. It seems prudent to use antacids and histamine 2 receptor antagonists first and reserve PPIs for nonresponders. 4) Overdiagnosis - the identification of, in this case, breast cancer, that would not have caused symptoms in a person's lifetime - seems to increase with age. In a study including more than 50.000 women aged above 70 who underwent mammography screening, the overdiagnosis rate was 31%, 47% and 51% for women aged 70 to 74 years, 75 to 84 years and over age 85, respectively. 5) An RCT among community-dwelling adults conducted in the US found that using a regular cuff on larger-than-average arms can falsely raise blood pressure readings by almost 5 mmHg, and a regular cuff on an especially thin arm can lower readings by 3.6 mmHg.

Top 4 Research Studies of the month for Italian Primary Care Physicians: December 2023.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) According to a high-quality network meta-analysis, oral isotretinoin is the most effective therapy for decreasing the number of inflammatory and non-inflammatory skin lesions in patients with acne vulgaris. 2) Non-steroidal anti-inflammatory drug (Nsaid) use is associated with a small increase (0.004%) in the risk of venous thromboembolism. Combining Nsaid use with a medium-risk hormonal contraceptive increases the risk to 0.011%; the addition of a high-risk hormonal contraceptive increases the risk to 0.023%. 3) For adults who wish to quit smoking, nicotine delivery via e-cigarettes, plus counseling, may be more effective than other means of nicotine replacement, or counseling alone for long-term smoking cessation. 4) We can reassure our patients that nonerosive gastroesophageal reflux disease (Gerd) does not increase the likelihood of esophageal cancer. Erosive Gerd, however, is associated with a doubled - but still low - risk of developing cancer, with the likelihood increasing over time.

Top 4 Research Studies of the month for Italian Primary Care Physicians: November 2023.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) Based on efficacy, safety, and cost, a regimen of terbinafine 250 mg once daily for 12 weeks, followed by a 12-week period of no therapy, and then a 4-week booster of terbinafine 250 mg is preferred for onychomycosis in adults for the outcome of complete cure at 1 year. 2) A high-quality randomized trial found that standard-course antibiotic therapy for children with uncomplicated urinary tract infection was superior to short-course therapy. However, the number needed to treat of 28 suggests that offering short-course therapy is not unreasonable, especially if there is good follow-up in the subsequent weeks. 3) An updated guideline of the American College of Physicians on screening of colorectal cancer adds 2 new recommendations. One is to consider not screening patients aged 45 to 49 years. The other recommendation is against screening using stool Dna, computed tomography colonography, capsule endoscopy, urine, or serum screening tests for colorectal cancer. 4) The US Preventive Services Task Force found additional evidence on the benefit of folic acid supplementation for preventing neural tube defects. Since the critical period starts at least 1 month before conception, the task force recommends a daily supplement of 0.4 mg to 0.8 mg folic acid for all women who plan to or could become pregnant.

Focusing on patient-oriented evidence that matters: a practical approach to keeping up with new research.

One of the challenges of medical practice, especially primary care because of its breadth, is keeping up with the latest research findings. As physicians, how can we select, among hundreds of thousands of research studies published each year, those worth knowing about? Since 1996, a group of American primary care physicians have been systematically reviewing over 100 journals every month to identify new Patient-Oriented Evidence that Matters (POEMs). To be a POEM, a research study must have the potential to change clinical practice by addressing hard, patient-oriented outcomes, such as mortality, intensity or duration of symptoms, or quality of life, as opposed to disease-oriented (surrogate) outcomes, such as laboratory parameters. In addition, it must be methodologically valid, i.e., reasonably free of bias, with its validity evaluated through objective criteria by experts in evidence-based medicine with no conflicts of interest with the industry. To be useful at the point of care, these studies must be easy to retrieve and require little work to review. Starting from this issue, a selection of POEMs most likely to change and improve Italian primary care practice will be published monthly in Recenti Progressi in Medicina as brief evidence summaries. In addition, yearly, we will present an article summarizing the 20 most important research studies for primary care of the previous year.

Top 5 Research Studies of the month for Italian Primary Care Physicians: October 2023.

This monthly article provides a selection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. Amoxicillin is no more likely to cause a rash than any other antibiotic in children with infectious mononucleosis. According to a good quality systematic review and network meta-analysis, only a small number of randomized controlled trials, disappointing in overall quality, suggest that for managing neuropsychiatric symptoms in adults with dementia, risperidone has the best balance of effectiveness and adverse effects. In a rigorously conducted double-blind randomized controlled trial, adults with acute low back or neck pain treated with opioids had no benefit in pain relief as those treated with placebo. In a large study of more than 21,000 participants aged 60 to 84 years, taking 60,000 IU vitamin D each month slightly reduced their likelihood of experiencing a major cardiovascular event (number needed to treat = 172 over 5 years). A single screening colonoscopy had higher rates of participation than 5 years of fecal occult blood testing in a high-quality study in which patients were offered free screening with these two methods (84% vs 73%; p<0.001).

Renal function in patients with chronic kidney disease and hypertension degree 1–2 against the background of SARS-CoV-2

Renal function in patients with chronic kidney disease and hypertension degree 1–2 against the background of SARS-CoV-2

Top POEMs of 2022 for choosing wisely in practice.

Since 2005, members of the Canadian Medical Association (CMA) have been rating daily synopses of research studies or clinical practice guidelines, called POEMs (Patient-Oriented Evidence that Matters), which raise awareness of the most relevant research studies and guidelines for improving clinical

Final results of BIRCOV trial (ARB, ACEI, DRi in COVID-19)

Background. The question of the possible effect of the inhibitors of the renin-angiotensin system (iRAS) on hypertensive subjects who fell ill with COVID-19 has been discussed in the literature. SARS-CoV-2 is well-known to use an angiotensin-converting enzyme 2 receptors facilitating virus entry into host cells. There are three possible mechanisms of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) effect in COVID-19 in clinical practice: with worsening, neutral, or helpful function. Considering the different mechanisms of blood pressure reduction by iRAS, one can expect differences in people with COVID-19 receiving these drugs. The purpose of the BIRCOV study is to pinpoint possible clinical and laboratory differences in hypertensive people who received iRAS and suffered from coronavirus infection. Materials and methods. Patient-Oriented Evidence that Matters (POEM) intervention was designed as an open prospective randomized two medical centers trial in subjects suffering from COVID-19 who have been receiving iRAS, either ACEi, ARB, or direct renin inhibitor (DRi) as basic antihypertensive therapy. One hundred and twenty people with stage 1–2 hypertension have been screened, 108 subjects were enrolled in the BIRCOV study. COVID-19 was confirmed by a PCR test; the disease follow-up was divided into 2 periods: up to 12 weeks and up to 24 weeks. The primary outcome measure was as follows: blood pressure (BP) was known one week before COVID-19 onset and was measured during the disease on weeks 2, 4, 12, 24. The secondary outcome measures were clinical features. Subanalysis in patients with chronic kidney disease (CKD) was performed. Results. All patients were randomized into 3 groups who received: ACEi — 42 (39%), ARB — 35 (32%), or DRi — 31 (29%). The BIRCOV trial documented the trend of BP lowering in the first two weeks of the COVID-19 disease with its gradual return to baseline values up to the 12th week. Twenty-three (21%) patients have withdrawn medicine for up to 2 weeks due to severe hypotension. However, the BP values after COVID-19 in most subjects remained lower than the baseline ones for 4 weeks. The use of ACE inhibitors significantly increased the risk of withdrawal compared to DRi (RR 1.648; 95% CI 0.772–3.519; NNT 7.0) and ARB (RR 13.023; 95% CI 1.815–93.426; NNT 2.9) due to COVID-19. The synchronous decline of estimated glomerular filtration rate (eGFR) and systolic BP was more pronounced in CKD patients. The greatest decrease in eGFR was noted in people who have been taking ACEi. The drop in eGFR ranged from 23% in CKD stage 1 to 45% in CKD stage 4. Two people required short-term dialysis. The analysis of secondary outcome points demonstrated that in 23% of people without preceding albuminuria it developed in the A2 range. During 12 weeks of observation, 81% of patients had spontaneous albuminuria reduction. Post-COVID-19 (above 12 weeks) albuminuria remained in 19% of patients, 90% of them had a history of CKD. Patients with preceding CKD had an increase in albuminuria in 78% of cases, and its return to the baseline was observed only in 24% of patients by the 12th week and in 49% of individuals in 24 weeks. Conclusions. People with stage 1–2 hypertension who are receiving chronic iRAS and suffer from COVID-19 may develop hypotension with ACE inhibitors. COVID-19 leads to transient albuminuria and decreased glomerular filtration rate, which is especially dangerous for people with CKD.

Physician Perspectives on Mammography Screening for Average-Risk Women: "Like a Double-Edged Sword".

On balance, the benefits and harms of mammography screening put systematic screening for average-risk women into question. Since screening decisions frequently occur in primary care, it is important to understand what family physicians think of the evidence on mammography screening, and how they intend to use this information in practice. Using a cross-sectional design, we obtained data from a group of physician participants who rated the daily Patient-Oriented Evidence that Matters (POEM), which is a short, research-based synopsis. Physicians responded to closed and open-ended questions, based on the validated Information Assessment Method. Quantitative data were assessed with descriptive statistics. The qualitative data were subjected to inductive and deductive iterative thematic analysis. These data were organized into subthemes, and then grouped into major themes. Four relevant POEMs were identified. Each of these POEMs was rated by 1243 to 1351 physicians, and these ratings provided 310 comments. Three major themes emerged across all 4 POEMs: 1) perspectives on information presented in POEMs, 2) applying this information in practice, and 3) confronting clinical and cultural realities. Our findings highlight important differences in the ways physicians value research-based information on mammography screening and use this information in their practice. Although POEMs about mammography screening raise awareness of harms and benefits, deeply rooted ideas illustrate how any change process is complex. In sum, rethinking breast cancer screening for average-risk women is challenging.

Top 20 POEMs of the Past 20 Years: A Survey of Practice-Changing Research for Family Physicians.

POEMs (patient-oriented evidence that matters) are studies that address a relevant clinical question, demonstrate improved patient-oriented outcomes, and have the potential to change practice. For 20 years the authors of this article have reviewed more than 100 English language clinical journals monthly to identify POEMs in the medical literature relevant to primary care practice. This article identifies the POEMs in each of the last 20 years that were highest ranked for having recommended a major and persistent change in practice that year. They include POEMs that recommend a novel, effective intervention, a second group that recommends abandoning an ineffective practice, and a third group that recommends abandoning a potentially harmful practice. The top POEMs of the past 20 years illustrate the breadth of practice change in primary care and the need for family physicians to have a systematic approach to keeping up with the medical literature, such as that in POEMs, especially because many of these important articles did not appear in the primary care literature.

Comparison of Reading Levels of Pharmacy Students and Reading Level of Primary Literature

Objectives: The project purpose was to evaluate pharmacy students’ reading levels using the Nelson-Denney Reading Test (NDRT) and compare these results with the reading level of primary literature to investigate incongruities between student’s comprehension ability and the readability level of assigned reading in the curriculum.&#x0D; Methods: The NDRT was administered to first- through third-year student pharmacists to determine grade equivalents (GE) for vocabulary and reading comprehension. Twenty articles previously identified as Patient-Oriented Evidence that Matters (POEMs) were analyzed to determine the Flesch-Kincaid Grade Level and Gunning-Fog Score. Student demographics, information regarding language spoken, and reading habits, were also assessed. Pearson product moment correlations, t-tests, ANOVA, and descriptive statistics were used to assess relationships between demographic data and NDRT scores.&#x0D; Results: One hundred students participated. The mean NDRT total grade equivalent (±SD) was 16.95 ± 2.1 (median = 17.3). NDRT grade equivalents were statistically different for students with different racial or ethnic backgrounds (t(98)=3.74, p=0.026), English as a second language (ESL) students (t(98)=5.19, p=0.021), and students that read works of fiction for pleasure (t(98)=4.31, p=0.002). The average Gunning-Fog Score for all primary literature articles was 11.48, with the introduction section being the most complex. The average Flesch-Kincaid Grade Level was 17.04, with the results section scoring the lowest average grade level.&#x0D; Implications: While the overall reading grade level of our pharmacy students suggests that they are capable of comprehending reading assigned in the pharmacy curriculum, minority students and students for whom English is a second language may struggle with comprehending complex text.&#x0D; Conflict of Interest&#x0D; We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties.&#x0D; &#x0D; Type: Original Research

Patient-oriented evidence that matters (POEMs)™ suggest potential clinical topics for the Choosing Wisely™ campaign.

We propose a method of identifying clinical topics for campaigns like Choosing Wisely. In the context of an ongoing continuing medication education program, we analyzed ratings on every patient-oriented evidence that matters (POEM) synopsis delivered in 2012 and 2013. Given the objective of the Choosing Wisely campaign, we focused this analysis on 1 specific item in the validated questionnaire used by physicians to rate POEMs. This questionnaire item is about "avoiding an unnecessary diagnostic test or treatment." For each POEM, we calculated frequencies and proportions for this item, then we identified the 20 POEMs that were most commonly associated with this item in 2012 and 2013. Finally, we determined whether the clinical topic of each of these POEMs was mentioned in the Choosing Wisely master list. In 2012 and 2013 we received 506,809 completed questionnaires (or ratings) linked to 530 POEMs, for an average of 956 ratings per POEM. In 59% of these POEMs (n = 312), the most commonly expected type of health benefit was "avoiding an unnecessary diagnostic test or treatment." We then identified the top 20 POEMs most commonly associated with this item in each year by ranking all 312 POEMs from the top down. The clinical topic addressed by 29 of these 40 POEMs was not addressed in the Choosing Wisely master list. These topics fell into 3 categories: diagnostic tests, medical interventions, and surgical interventions. "Big data" can identify clinical topics relevant to campaigns such as Choosing Wisely. This process represents a new way to inform the expert panel approach.

Time to say goodbye

Dear reader,Since 2009, when Prof. Dr. Alvaro Nagib Atallah and I accepted the challenge of leading the Scientific Department of Associacao Paulista de Medicina (APM), I have had the privilege of also taking on the function of editor of the journals of this entity: Sao Paulo Medical Journal and Diagnostico & Tratamento.From the outset, this was seen to be an arduous task that would certainly be greater than any prediction that we might have made. We discovered that fulfilling this task with the deserved quality was only saved from being impossible thanks to the support and collaboration of a mul -tiprofessional team that dedicated itself to the APM every day. This team became ever more professional as time went by, with the aim of providing our association with the best resources available in all areas. After completing six years of leading this undertaking (three years as Adjunct Director and three years as Director), the time has come to “pass the baton”, by handing over this posi -tion that I have served with pride and dedication. Nonetheless, this is not just a moment of farewell but, rather, a moment of renewal, and for this reason I would like to reflect on what has been achieved.Specifically with regard to the Sao Paulo Medical Journal, the most important objective was to raise the relevance of the journal within the international scenario, without losing its focus on dissemination of general medical knowledge. In other words, we sought articles for the jour -nal that would have high quality and scientific rigor, but without transforming the journal into something very specialized or that might cause habitual readers of the journal to drift away. The crowning moment of this work was certainly when, for the first time, the Sao Paulo Medical Journal obtained a designated impact factor from Thompson Reuters.In relation to Diagnostico & Tratamento, we maintained the premise of disseminating medical knowledge in a wide-ranging manner through sections dedicated to specialties (gyne-cology, dermatology, nutrology etc.) and the sections Patient-Oriented Evidence that Matters (POEMs), Evidence-Based Medicine, Language, Residency and Medical Teaching, General Interest, Opinion and Cochrane Highlights.At the helm of the Scientific Department, where I initially held the position of Adjunct Scientific Director until 2012 and then Scientific Director until the present date, I sought to encourage initiatives that would bring greater dynamism and penetration for the APM. One successful example of this is the Student Medical Congress, which was first held in 2009 and translated very well our intention to interact with physicians from the time of their graduation onwards, by stimulating them and assisting them in their technical and scientific development.Other activities of the Scientific Department that deserve highlighting are the interaction and partnerships with health departments and universities that have had the aim of developing medical teaching and scientific updating. Building ties with specialty societies was a partially achieved objective, and this will certainly end up being consolidated through the work of the next board of directors.

Evidence-based medicine: The pearls in the medical literature

Physician assistants are continuously inundated with new pharmacologic agents, management techniques, questions from their patients, and information from the media. Primary care providers develop 2.4 questions for every 10 patient encounters1 and up to 2 questions for every 3 patient encounters;2 of these, approximately two-thirds go unanswered.2 How can PAs stay current with the medical literature, provide useful information to patients, and maintain productivity? Evidence-based medicine (EBM), a method of applying current, proven practices to patient care,1 can be used to quickly obtain information for clinical decision making. Lack of time and perceived loss of clinical judgment are two of the most common arguments against using EBM. PAs have a limited amount of time to filter through all the information that may be relevant to a patient or case. In addition, information is disseminated at a rapid rate, and a comprehensive critical analysis of an article is time-consuming.1,3 The goal is to learn to use and apply EBM rather than become an expert in the analysis process.1 Rapid-access resources and up-to-date databases help avoid the need to critically analyze every study related to a clinical question. Practice guidelines are one example of how to integrate EBM into busy practice routines.4 POEMs (patient-oriented evidence that matters) answer common clinical questions based on original research and systematic reviews and can be found relatively quickly through select databases.1JAAPA publishes POEMs in each issue. The most specific clinical questions are constructed using the PICO method.5 Questions are formulated within one of four EBM domains: harm, diagnosis, treatment, and prognosis (eg, What is the most appropriate treatment for premenopausal symptoms?). Awareness of each domain becomes more relevant when completing analyses of original literature. Step 1 Formulate a clinical question. Patient population. The clinical question needs to define the patient as specifically as possible. The search can be more refined if relevant medical history is included in the question (eg, 54-year-old perimenopausal female with hot flashes). Intervention. A new treatment method, diagnostic study, or physical examination maneuver that is being considered in the care of the patient (eg, soy protein). Comparison. An established treatment method, diagnostic study, or physical examination maneuver. In some cases, the new intervention is being compared with the standard of care (eg, does the new intervention achieve the same results as established interventions). Outcome. The question should define the desired outcome (for example, a decrease in the frequency and/or severity of hot flashes). Step 2 Search the medical literature through reputable databases. Essential Evidence Plus is a Web site that allows PAs to search for POEMs based on subject area (www.essentialevidenceplus.com). Step 3 Evaluate whether the search results are relevant to your patient and practice. Critical appraisal worksheets from the Centre for Evidence-Based Medicine are available online to help PAs who want to hone their literature-analysis skills (www.cebm.utoronto.ca/teach/materials/caworksheets). A common misconception about EBM is that it is algorithmic, limits clinical judgment, or does not account for patient variability. However, study results clearly demonstrate that EBM complements clinical experience and judgment and allows for the integration of patient values.1 The patient and his or her family should be included when integrating your analysis into the clinical decision-making process.4 Finally, evidence to support whether patients have benefitted from the integration of EBM into clinical practice is limited because EBM is not being integrated sufficiently or broadly enough to confidently assess patient outcomes.1,6 Utilizing the various EBM resources can help PAs integrate EBM into daily clinical practice (see "Table. Evidence-based medicine resources," in the online version of this article). EBM provides PAs with a valuable tool with which to answer patient-oriented questions.

Transitioning toward Evidence-Based Research in the Health Sciences for the XXI Century

This article discusses some of the misconceptions of evidence-based research in the health sciences. It proposes that since not all treatments in medicine and dentistry can be evidence-based, clinical applications of the evidence-based process should become a specialty. The case is particularly evident in dentistry. Therefore dentistry is taken in this article as a model for discussion. We propose that to approach dentistry from the viewpoint of the patient-oriented evidence that matters (POEM) is perfectly acceptable so far as we also engage in the process of research evaluation and appraisal in dentistry (READ). We distinguish between dentistry based on the evidence, and evidence-based dentistry. We argue that when invoking an evidence-based approach to dentistry or medicine, it is not sufficient to establish the ‘levels of evidence’, but rather that all evidence-based clinical intervention must undergo the stringent process of evidence-based research so that clinical practice guidelines be revised based on the best available evidence.

Randomized Trial of the Effect of Research Design and Publication Characteristics on Physician Change

The primary barrier to translation of research into practice relates to physician use of research. If we are to succeed at translating research into practice, we must understand to which research characteristics and publication formats practitioners attend. To determine which characteristics of research design (sample characteristics, study design) and publication (type of publication) are most influential on the acquisition of knowledge and change in behavior of family practitioners. This randomized clinical trial was conducted in family practice offices on the 305 family physicians who scored lowest on a survey of knowledge about management of major depressive disorder (MDD), panic disorder, and generalized anxiety disorder (GAD). Subjects were randomly assigned to receive 1 of 3 MDD abstracts differing in study site, 1 of 3 panic disorder abstracts differing in study design, and 1 of 3 GAD communications differing in format. The main outcome measures (knowledge and management strategies) were assessed immediately following the intervention and again 6 months later. Data for the intervention survey were gathered in November 2002. This study found significant increases in knowledge level and use of first-line agents with all interventions; however, knowledge declined again after 6 months for both panic disorder and GAD. The only statistically significant interoption difference was that the POEM (patient-oriented evidence that matters) was associated with better retention of knowledge of the treatment of GAD. In conclusion, all interventions were associated with immediate increases in knowledge and use of first-line treatments. However, such gains were not retained for panic disorder and GAD. Except for better knowledge retention associated with POEM use, no consistent differences between intervention options were noted.