Physicians In Routine Practice Research Articles

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

Impact of Decipher on use of post-operative radiotherapy: Individual patient analysis of two prospective registries.

ObjectiveTo assess the association between Genomic Classifier (GC)‐risk group and post‐radical prostatectomy treatment in clinical practice.MethodsTwo prospective observational cohorts of men with prostate cancer (PCa) who underwent RP in two referral centers and had GC testing post‐prostatectomy between 2013 and 2018 were included. The primary endpoint of the study was to assess the association between GC‐risk group and time to secondary therapy. Univariable (UVA) and multivariable (MVA) Cox proportional hazards models were constructed to assess the association between GC‐risk group and time to receipt of secondary therapy after RP, where secondary therapy is defined as receiving either RT or ADT after RP.ResultsA total of 398 patients are included in the analysis. Patients with high‐GC risk were more likely to receive any secondary therapy (OR: 6.84) compared to patients with low/intermediate‐GC risk. The proportion of high‐GC risk patients receiving RT at 2 years post‐RP was 31.5%, compared to only 6.3% among the low/intermediate‐GC risk patients.ConclusionThis study demonstrates that physicians in routine practice used GC to identify high risk patients who might benefit the most from secondary treatment. As such, GC score was independent predictor of receipt of secondary treatment.

Study patients and routine practice patients

Dear Sir, The road to acceptance in routine practice of important results from clinical trials is sometimes very long. It may be shorter in countries where fear of litigation is a reality and where physicians are aware of the necessity to provide evidence-based medicine. However, in my own country I have experienced a reluctance, or perhaps only a lack of interest, in adopting the conclusions from repeated trials demonstrating that the duration of anticoagulation after venous thromboembolism needs to be prolonged [1, 2]. In the majority of patients the duration of secondary prophylaxis should be about 6 months, in some maybe a year, whereas in those with a distal deep vein thrombosis and a temporary cause 6 weeks will suffice. It is not acceptable to state that patients in clinical practice are different from study patients and therefore cannot be given the same treatment. A large number of the patients in routine practice could very well have been study patients if they were diagnosed at the time when a suitable trial was going on and if they had the time to participate. This large group, which does not have contraindications to standard therapy, is entitled to the optimum therapy, as demonstrated in multicentre randomized clinical trials. It may be possible that family practitioners are unable to provide the same quality of anticoagulation as the study centres at major hospitals [3-6]. But should patients suffer for that reason? Would it not be more appropriate in that case to centralize the care to anticoagulation clinics with more than just a few patients on vitamin K antagonists and with improved outcome? If that is not possible, the use of computer assisted dosing has also been beneficial [7, 8]. It is not necessarily true that study patients are monitored more often than those in routine practice. In the DURAC trials it was stipulated that prothrombin times (PTs) ought to be performed at least once a month [1]. In fact many of the patients were only monitored once every 3–4 weeks. On the other hand, ever so often I see patients who are managed by their family physicians with PT-tests every week, when there is no need for it, because the levels are actually quite stable, but the dosing was not always optimal. Thus, I believe that it is time for the physicians in routine practice to adopt the evidence that has been produced and published lately in this field! Received 24 August 2000; accepted 24 August 2000.

Safety and Yield of Ultrasound-Assisted Transthoracic Biopsy Performed by Pulmonologists

Background: Transthoracic ultrasound (US) has gained popularity as a tool for visualizing pleural effusions and assisting thoracentesis or chest drain placement. In the absence of effusion, US just as well demonstrates solid masses involving or abutting the pleura, yet biopsy of such lesions is not widely performed by chest physicians. Objective: To assess the feasibility and the safety of US-assisted cutting needle biopsy performed by chest physicians in routine practice. Methods: Lesions involving or abutting the pleura ≧20 mm in diameter on US were sampled with a 14-gauge cutting needle under local anesthesia. Biopsy site, needle direction and depth of penetration were determined with US. The procedure was performed without direct US guidance in ‘free-hand’ technique. Results: Ninety-one patients underwent 96 cutting-needle biopsies for suspected peripheral lung tumors (n = 44, 46%), pleural-based (n = 39, 41%), mediastinal (n = 10, 10%), or chest wall lesions (n = 3, 3%), which were single in 71%, multiple in 6% and diffuse in 23%. Sensitivity for malignant neoplasms (n = 65) was 85.5% and 100% for mesothelioma (n = 10). Pneumothorax occurred in 4%. Conclusions: US-assisted cutting-needle biopsy of lesions ≧20 mm in diameter is safe in the hands of pulmonologists. The yield for neoplastic disease including mesothelioma is high.

Trends in the use of pharmacotherapies for acute myocardial infarction among physicians who design and/or implement randomized trials versus physicians in routine clinical practice: the MILIS-TIMI experience

Background Although studies have documented that randomized, controlled trials (RCTs) have a measurable influence on clinical practice, investigators have uncovered important deficiencies in the application of RCT findings to the management of acute myocardial infarction (AMI). Little is known about the extent to which physicians who design and/or implement clinical trials differ from physicians in routine practice in their translation of the literature. Methods Our aims were to (1) evaluate recent trends in selected treatments of AMI in relation to the publication of RCTs, statistical overviews, and task-force guidelines, and (2) compare prescribing practices in AMI management between physicians in routine clinical practice and physicians who design and/or implement RCTs. We reviewed the use of aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers on entry and at discharge in patients enrolled in the MILIS, TIMI 1, 2, 4, 5, 6, and 9B trials with ST-elevation (and depression in MILIS) myocardial infarction for a period approaching 2 decades (August 1978 to September 1995). We hypothesized that physicians who participate in RCTs apply the findings of the published literature more promptly and thoroughly than physicians in routine practice. Results Use of aspirin, β-blockers, and angiotensin converting enzyme inhibitors exhibited a statistically significant time-related increase at discharge and, excepting β-blockers, at enrollment across the trials. Prescription of calcium channel blockers showed a statistically significant decrease at discharge only. For all medications under study, increases and decreases in use associated with publication of clinical data occurred earlier and more steeply for the discharge cohort (prescriptions by physicians participating in RCTs) than for the enrollment cohort (prescriptions by physicians in routine practice). Recent prescribing practices (1994 to 1995) among RCT investigators and their colleagues have higher concordance with published findings than those of physicians in routine practice. Conclusions Physicians who design and/or implement RCTs translate the results of the medical literature more promptly and to a greater extent than physicians in routine clinical practice. Differences between different physician classes need to be studied further amid efforts to reconfigure health care delivery that currently favor more dominant roles for primary care physicians. (Am Heart J 1999;137:79-92.)