Case study : a patient-clinician collaboration that identified and prioritized evidence gaps and stimulated research development

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Five year prognosis in patients with angina identified in primary care : incident cohort study

Peer reviewedPublisher PD

Service organisation for the secondary prevention of ischaemic heart disease in primary care.

BACKGROUND: Ischaemic heart disease (IHD) is a major cause of mortality and morbidity and its prevalence is set to increase. Secondary prevention aims to prevent subsequent acute events in people with established IHD. While the benefits of individual medical and lifestyle interventions is established, the effectiveness of interventions which seek to improve the way secondary preventive care is delivered in primary care or community settings is less so. OBJECTIVES: To assess the effectiveness of service organisation interventions, identifying which types and elements of service change are associated with most improvement in clinician and patient adherence to secondary prevention recommendations relating to risk factor levels and monitoring (blood pressure, cholesterol and lifestyle factors such as diet, exercise, smoking and obesity) and appropriate prophylactic medication. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2007, Issue 4), MEDLINE (1966 to Feb 2008), EMBASE (1980 to Feb 2008), and CINAHL (1981 to Feb 2008). Bibliographies were checked. No language restrictions were applied. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials of service organisation interventions in primary care or community settings in populations with established IHD. DATA COLLECTION AND ANALYSIS: Analyses were conducted according to Cochrane recommendations and Odds Ratios (with 95% confidence intervals) reported for dichotomous outcomes, mean differences (with 95% CIs) for continuous outcomes. MAIN RESULTS: Eleven studies involving 12,074 people with IHD were included. Increased proportions of patients with total cholesterol levels within recommended levels at 12 months, OR 1.90 (1.04 to 3.48), were associated with interventions that included regular planned appointments, patient education and structured monitoring of medication and risk factors, but significant heterogeneity was apparent. Results relating to blood pressure within target levels bordered on statistical significance. There were no significant effects of interventions on mean blood pressure or cholesterol levels, prescribing, smoking status or body mass index. Few data were available on the effect on diet. There was some suggestion of a \u22ceiling effect\u22 whereby interventions have a diminishing beneficial effect once certain levels of risk factor management are reached. AUTHORS\u27 CONCLUSIONS: There is weak evidence that regular planned recall of patients for appointments, structured monitoring of risk factors and prescribing, and education for patients can be effective in increasing the proportions of patients within target levels for cholesterol control and blood pressure. Further research in this area would benefit from greater standardisation of the outcomes measured

Risk of prostate cancer associated with benign prostate disease:a primary care case-control study

BACKGROUND: Benign diseases of the prostate are common in the general male population, and prostate cancer is the most common cancer in men. Uncertaintyastothe nature of the association between benign and malignant disease is a source of concern for patients and clinicians. AIM: To determine the likelihood of men with benign prostate disease developing prostate cancer compared with men without disease. DESIGN: Incident matched case-control study METHOD: All incident cases of prostate cancer (n = 984) were identified in a nationally representative community-based population, and each was matched by age with two controls with no prostate cancer (n = 1968). Participants' records of the previous 5 years were searched for diagnoses of benign prostate disease. Analyses investigated an a priori hypothesis that clinicians may record disease as benign until proven to be malignant, causing misleading significant associations between benign and malignant diagnoses. RESULTS: There was a significant association between a diagnosis of prostate cancer and a benign diagnosis at any time in the previous 5 years: odds ratio (OR) 1.57 (95% confidence interval [CI] = 1.32 to 1.88). However, there was no significant association when benign diagnoses within 6 months and within 12 months of cancer diagnoses were excluded: OR 1.19 (95% CI = 0.97 to 1.46) and OR 1.00 (95% CI = 0.79 to 1.27) respectively. CONCLUSION: Findings from this study suggest that unless prostate cancer is detected within 6 months, men diagnosed for the first time with benign disease are at no greater risk of prostate cancer than those with no recorded prostate disease

Woodland Type and Spatial Distribution of Nymphal Ixodes scapularis (Acari: Ixodidae)

Spatial distribution patterns of black-legged ticks, Ixodes scapularis, in deciduous and coniferous woodlands were studied by sampling ticks in different woodland types and at sites from which deer had been excluded and by quantifying movement patterns of tick host animals (mammals and birds) at the Lighthouse Tract, Fire Island, NY, from 1994 to 2000. Densities of nymphal ticks were greater in deciduous than coniferous woods in 3 of 7 yr. Only engorged ticks survived the winter, and overwintering survival of engorged larvae in experimental enclosures did not differ between deciduous and coniferous woods. Nymphs were not always most abundant in the same forest type as they had been as larvae, and the habitat shift between life stages differed in direction in different years. Therefore, forest type by itself did not account for tick distribution patterns. Nymphal densities were lower where deer had been excluded compared with areas with deer present for 3 yr after exclusion, suggesting that movement patterns of vertebrate hosts influenced tick distribution, but nymphal densities increased dramatically in one of the enclosures in the fourth year. Therefore, movements of ticks on animal hosts apparently contribute substantially to tick spatial distribution among woodland types, but the factor(s) that determine spatial distribution of nymphal I. scapularis shift from year to year

Five-Year Prognosis in an Incident Cohort of People Presenting with Acute Myocardial Infarction

Peer reviewedPublisher PD

Medical interns' knowledge and training regarding urethral catheter insertion and insertion-related urethral injury in male patients

<p>Abstract</p> <p>Background</p> <p>Improper catheterization can lead to urethral injury. Yet research from four continents suggests training of junior doctors in catheterization is insufficient. European research suggests a majority of catheterization related morbidities occur when the procedure is performed by interns.</p> <p>Methods</p> <p>To assess the knowledge and practices of medical interns relating to urethral catheterization and iatrogenic urethral injury secondary to traumatic catheter insertion, a questionnaire survey was conducted of all first year medical interns at a tertiary national university hospital in the Philippines. The questionnaire contained 17 items covering 4 areas: methods of training in catheterization and level of experience; perceived adequacy of training; theoretical knowledge of catheterization; the mechanisms of catheter-related urethral injury.</p> <p>Results</p> <p>225/240 interns (94%) completed the survey (130 (57.8%) female). 125 (55.6%) responded that they had adequate theoretical training and 150 (66.7%) adequate practical training. All had performed more than 10 catheterizations and 204 (90%) were supervised when they first performed catheterization. Despite relatively high levels of experience and confidence, deficits were identified in detailed knowledge of correct catheterization procedures and of risks associated with urethral injury.</p> <p>Conclusions</p> <p>More thorough training of incoming medical interns in urinary catheterization may help to reduce the risk of complications and injury. Training should be universal and thought given to its timing within the curriculum. Training should include step by step instruction in the process, emphasis on history taking and awareness of factors associated with increased risk of urethral injury.</p

Mobile technologies to support healthcare provider to healthcare provider communication and management of care

Background: The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes. Objectives: To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers' performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties. Search methods: We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts. Selection criteria: Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care. Data collection and analysis: We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. Main results: We included 19 trials (5766 participants when reported), most were conducted in high-income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties. Mobile technologies used by primary care providers to consult with hospital specialists. We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies:. - probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants);. - probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants);. - may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported);. - probably make little or no difference to patient-reported quality of life and health-related quality of life (2 trials, 622 participants) or to clinician-assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions;. - may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists;. - may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants). Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department. We assessed the certainty of evidence for this group of trials as moderate. Mobile technologies:. - probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference −12 minutes, 95% CI −19 to −7; 1 trial, 345 participants);. - probably reduce participants’ length of stay in the emergency department by a few minutes (median difference −30 minutes, 95% CI −37 to −25; 1 trial, 345 participants). We did not identify trials that reported on providers' adherence, participants’ health status and well-being, healthcare provider and participant acceptability and satisfaction, or costs. Mobile technologies used by community health workers or home-care workers to consult with clinic staff. We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies:. - probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants);. - may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants);. - may make little or no difference to participants' disease activity or health-related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants);. - probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants). We did not identify any trials that reported on providers' adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs. Authors' conclusions: Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants' health status and well-being, satisfaction, or costs.publishersversionpublishe

Discrete seasonal hydroclimate reconstructions over northern Vietnam for the past three and a half centuries

We present a 350-year hydroclimatic year (HY) index for northern Vietnam derived from three discrete seasonal reconstructions from tree rings: an index of autumn rainfall from the earlywood widths of Chinese Douglas fir (Pseudotsuga sinensis), the first such record from this species, and two nearby published Palmer Drought Severity Index (PDSI) reconstructions from cypress (Fokienia hodginsii) tree rings for spring and summer, respectively. Autumn rainfall over the study region constitutes only around 9% of the annual total, but its variability is strongly linked to the strength of the atmospheric gradient over Asia during the transition from the boreal summer to winter monsoons. Deficit or surplus of autumn rainfall enhances or mitigates, respectively, the impact of the annual winter dry season on trees growing on porous karst hillsides. The most protracted HY drought (dry across all seasons) occurred at the turn of the twentieth century at a time of relative quiet, but a mid-to-late eighteenth century multi-year HY drought coincided with a period of great societal turmoil across mainland Southeast Asia and the Tay Son Rebellion in northern Vietnam. A mid-nineteenth century uprising accompanied by a smallpox epidemic, crop failure and famine, occurred during the worst autumn drought of the past two and a half centuries but only moderate drought in spring and summer. The “Great Vietnamese Famine” of the mid-twentieth century was dry only in autumn, with a wet spring and an average summer