Teaching and learning evidence-based medicine: cross-sectional survey investigating knowledge and attitudes of teachers and learners in primary and secondary care

Evidence-based medicine (EBM) is an important component of quality healthcare and a key part of the curriculum for doctors in training. There have been no previous studies comparing attitudes and knowledge of doctors in primary and secondary care towards EBM practice and teaching and this study sets out to investigate this area. We asked participants, a stratified sample of general practitioners, hospital consultants, GP registrars and junior hospital doctors in Leicester, Northamptonshire and Rutland, UK, to complete a self-administered survey questionnaire and written knowledge test which provided ‘positive to evidence based practice’ (PEP) attitude scores and Manchester Short EBM Questionnaire Education for Primary Care (2007) 18: 45–57 # 2007 Radcliffe Publishing Limited WHAT IS ALREADY KNOWN IN THIS AREA. There is little evidence on the relationship between attitudes and knowledge in relation to evidence-based medicine (EBM) in family doctors, consultants and doctors intraining. WHAT THIS WORK ADDS. This study showed that, although general practitioners and general practitioner trainers were significantly less positive in attitude to EBM compared to GP registrars, junior hospital doctors and consultant respondents, they had significantly higher knowledge scores. This study demonstrated that the attitude (PEP) score and knowledge questionnaire(MANSEBMQ) have high reliability but require further research to demonstrate validity. SUGGESTIONS FOR FURTHER RESEARCH. There remain opportunities for refinement of the MANSEBMQ, validation against existing tools and further application in a larger study, including assessment of EBM knowledge and skills, before and after an educational process, involving students in clinically relevant and integrated EBM learning. Keywords: attitudes, evidence-based practice, general practice registrars, general practitioners, hospital doctors, primary care, secondary care(MANSEBMQ) knowledge scores of participants. The response rate was low which may have led to volunteer bias but there were sufficient responses to explore attitude scores and knowledge scores. Attitude(PEP) scores were highest in hospital consultants, intermediate in doctors in training and lowest in general practitioner (GP)respondents (mean score 71.7 vs 70.5 vs 67.2; P = 0.006). PEP scores were also highest in respondents with higher degrees (MD, PhD, MSc), intermediate in those with higher professional qualifications (MRCP, FRCS, MRCGP or equivalent) and lowest in those with none of these (mean score 72.9 vs 70.6 vs 67.2; P = 0.005). PEP scores were significantly higher(P = 0.002) in respondents who taught EBM (mean score 71.7, 95% CI 70.3 to 73.2, n=109, missing=5) compared with those who did not (mean score 68.6, 95% CI 67.3 to 69.9, n = 105, missing = 12) and in respondents with research experience (P < 0.001), research training (P < 0.001) and training in EBM (P = 0.001). There was a positive correlation between PEP score and MANSEBMQ score (P = 0.013). In contrast, and paradoxically opposite to the pattern of attitudes, knowledge scores were highest in GPs, intermediate in junior hospital doctors and lowest in consultant respondents (mean score 63.5 vs 61.9 vs 54.5, P=0.005). Although GPs and GP trainers were significantly less positive in attitude to EBM compared to GP registrars, junior hospital doctors and consultant respondents, they had significantly higher knowledge scores. This study demonstrated that the attitude(PEP) score and knowledge questionnaire (MANSEBMQ) have good reliability but require further research to demonstrate validity

Modelling the Kinetics, Thermodynamic and Physical Properties of Coconut (Cocos nucifera L.) during Convective Drying

The drying kinetics, thermodynamic properties, and energy consumption of five potential coconut cultivars identified by Ghana's CSIR-Oil Palm Research Institute were studied. Drying was carried out in a convectional dryer using four temperatures (70, 80, 90 and 100oC) and 2.0 m/s air velocity. The asymptotic model was adjudged the best fit model in predicting moisture content based on the highest coefficient of determination (0.9589-0.9998) and lowest residual sum of squares (8.427-252.61), chi-square (0.52671-16.8409) and root mean square error (2.8744-3.4421). Temperature caused between 66.8-96.5% variations in moisture diffusivity. Thermodynamic study revealed endothermic and non-spontaneous reactions in the drying system resulting from enthalpy change and Gibbs free energy change. Meanwhile, a direct relation was established among higher spontaneity and higher temperature. Despite the high drying temperatures used for the experiment, internal cellular composition was not affected as a result of excellent rehydration capacity. In effect, the Vanuatu TThe drying kinetics, thermodynamic properties, and energy consumption of five potential coconut cultivars identified by Ghana's CSIR-Oil Palm Research Institute were studied. Drying was carried out in a convectional dryer using four temperatures (70, 80, 90 and 100oC) and 2.0 m/s air velocity. The asymptotic model was adjudged the best fit model in predicting moisture content based on the highest coefficient of determination (0.9589-0.9998) and lowest residual sum of squares (8.427-252.61), chi-square (0.52671-16.8409) and root mean square error (2.8744-3.4421). Temperature caused between 66.8-96.5% variations in moisture diffusivity. Thermodynamic study revealed endothermic and non-spontaneous reaction in the drying system resulting from enthalpy change and Gibbs free energy change. Meanwhile, a direct relation was established among higher spontaneity and higher temperature. Despite the high drying temperatures used for the experiment, internal cellular composition was not affected as a result of excellent rehydration capacity. In effect, the Vanuatu Tall was adjudged as the best coconut variety based on its lower energy consumption and activation energy, shorter drying time and higher moisture diffusivity. All was adjudged as the best coconut variety based on its lower energy consumption and activation energy, shorter drying time and higher moisture diffusivity

An integrated care pathway for menorrhagia across the primary–secondary interface : patients' experience, clinical outcomes, and service utilisation

Background: ‘‘Referral’’ characterises a significant area of interaction between primary and secondary care. Despite advantages, it can be inflexible, and may lead to duplication. Objective: To examine the outcomes of an integrated model that lends weight to general practitioner (GP)-led evidence based care. Design: A prospective, non-random comparison of two services: women attending the new (Bridges) pathway compared with those attending a consultant-led one-stop menstrual clinic (OSMC). Patients’ views were examined using patient career diaries, health and clinical outcomes, and resource utilisation. Follow-up was for 8 months. Setting: A large teaching hospital and general practices within one primary care trust (PCT). Results: Between March 2002 and June 2004, 99 women in the Bridges pathway were compared with 94 women referred to the OSMC by GPs from non-participating PCTs. The patient career diary demonstrated a significant improvement in the Bridges group for patient information, fitting in at the point of arrangements made for the patient to attend hospital (ease of access) (p,0.001), choice of doctor (p = 0.020), waiting time for an appointment (p,0.001), and less ‘‘limbo’’ (patient experience of non-coordination between primary and secondary care) (p,0.001). At 8 months there were no significant differences between the two groups in surgical and medical treatment rates or in the use of GP clinic appointments. Significantly fewer (traditional) hospital outpatient appointments were made in the Bridges group than in the OSMC group (p,0.001). Conclusion: A general practice-led model of integrated care can significantly reduce outpatient attendance while improving patient experience, and maintaining the quality of care

SCIA: GIS-based software for assessing the impacts from chemical industrial accidents

This study is performed to develop a comprehensive software package entitled “simulation of chemical industrial accident (SCIA).” The SCIA can be integrated with geographical information system (GIS) to predict and display the risk and consequence of chemical hazards from two categories of hazardous materials, namely toxic and flammable materials. This paper describes how the existing models are used for predicting accident scenarios and their impact to humans and the environment. The technique for assessing the consequences from chemical accidents is developed by integrating the models in the system with the help of the GIS tools. The software is coded in Visual Basic, and is compatible with Windows working environments. The validity of the software has been confirmed by comparing the results of several applications with other commercial software. The software is a user-friendly and effective tool for evaluating the consequences of major chemical accidents, process decision making for land-use planning namely locating suitable hazardous installations, hazardous waste disposal areas and emergency response plan

Application of Stabilized Cefixime-AgNPs-GO Thin Films as Corrosion Inhibitors for Mild Steel Alloy

In this work, the corrosion inhibition of mild steel at ambient conditions by an antibiotic in a solution that contains silver nanoparticles (AgNPs) and graphene oxide (GO) was studied. GO and AGNPs were prepared by one-step simple and ecofriendly method and characterized by different techniques. Different concentrations of the inhibitor were prepared and their inhibition efficiency in acidic media was investigated. The adsorption characteristics of the inhibitor were studied and it was found that the antibiotic (Cefixime) alone and with GO combined with AgNPs inhibit the corrosion of mild steel by being adsorbed on the surface of mild steel by a physical adsorption mechanism. The adsorption of Cefixime and GO with AgNPs on the mild steel surface was found to be spontaneous. Incorporating AgNPs and GO with Cefixime showed an additional inhibition efficiency when compared with using only Cefixime. This indicates the strong inhibition efficiency offered by incorporating the antibiotic with AgNPs and GO

Awareness of stroke risk factors, signs and treatment in a Pakistani population

OBJECTIVE: To assess the level of awareness in the general public on risk factors, symptomatology and immediate treatment of stroke.METHOD: A cross sectional study was conducted in a sample of subjects visiting a tertiary care university hospital by means of a self-designed questionnaire. The study period extended between May and June, 2007.RESULTS: A total of 398 individuals were surveyed. Hypertension (69.1%) and stress (55.8%) were identified as two major risk factors for stroke. Among them 50.8% identified Brain as the principal organ involved in stroke out of which 78.2% of the response came from people whose level of education was intermediate-and-above. Around 13% of the study respondents did not know of any risk factor for stroke, while 11.6% of the study respondents didn\u27t know about the alarming signs of stroke. The most frequent response (26.16%) to immediate management of stroke was to take the individual to Emergency Department/hospital. In all 56% reported that basic information about stroke was given to them by friend/relative.CONCLUSIONS: The overall awareness of the study population regarding stroke was shown to be inadequate by this study. Knowledge was significantly greater in participants of younger age and a higher level of education

Global mortality associated with 33 bacterial pathogens in 2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: Reducing the burden of death due to infection is an urgent global public health priority. Previous studies have estimated the number of deaths associated with drug-resistant infections and sepsis and found that infections remain a leading cause of death globally. Understanding the global burden of common bacterial pathogens (both susceptible and resistant to antimicrobials) is essential to identify the greatest threats to public health. To our knowledge, this is the first study to present global comprehensive estimates of deaths associated with 33 bacterial pathogens across 11 major infectious syndromes. Methods: We estimated deaths associated with 33 bacterial genera or species across 11 infectious syndromes in 2019 using methods from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, in addition to a subset of the input data described in the Global Burden of Antimicrobial Resistance 2019 study. This study included 343 million individual records or isolates covering 11 361 study-location-years. We used three modelling steps to estimate the number of deaths associated with each pathogen: deaths in which infection had a role, the fraction of deaths due to infection that are attributable to a given infectious syndrome, and the fraction of deaths due to an infectious syndrome that are attributable to a given pathogen. Estimates were produced for all ages and for males and females across 204 countries and territories in 2019. 95% uncertainty intervals (UIs) were calculated for final estimates of deaths and infections associated with the 33 bacterial pathogens following standard GBD methods by taking the 2·5th and 97·5th percentiles across 1000 posterior draws for each quantity of interest. Findings: From an estimated 13·7 million (95% UI 10·9–17·1) infection-related deaths in 2019, there were 7·7 million deaths (5·7–10·2) associated with the 33 bacterial pathogens (both resistant and susceptible to antimicrobials) across the 11 infectious syndromes estimated in this study. We estimated deaths associated with the 33 bacterial pathogens to comprise 13·6% (10·2–18·1) of all global deaths and 56·2% (52·1–60·1) of all sepsis-related deaths in 2019. Five leading pathogens—Staphylococcus aureus, Escherichia coli, Streptococcus pneumoniae, Klebsiella pneumoniae, and Pseudomonas aeruginosa—were responsible for 54·9% (52·9–56·9) of deaths among the investigated bacteria. The deadliest infectious syndromes and pathogens varied by location and age. The age-standardised mortality rate associated with these bacterial pathogens was highest in the sub-Saharan Africa super-region, with 230 deaths (185–285) per 100 000 population, and lowest in the high-income super-region, with 52·2 deaths (37·4–71·5) per 100 000 population. S aureus was the leading bacterial cause of death in 135 countries and was also associated with the most deaths in individuals older than 15 years, globally. Among children younger than 5 years, S pneumoniae was the pathogen associated with the most deaths. In 2019, more than 6 million deaths occurred as a result of three bacterial infectious syndromes, with lower respiratory infections and bloodstream infections each causing more than 2 million deaths and peritoneal and intra-abdominal infections causing more than 1 million deaths. Interpretation: The 33 bacterial pathogens that we investigated in this study are a substantial source of health loss globally, with considerable variation in their distribution across infectious syndromes and locations. Compared with GBD Level 3 underlying causes of death, deaths associated with these bacteria would rank as the second leading cause of death globally in 2019; hence, they should be considered an urgent priority for intervention within the global health community. Strategies to address the burden of bacterial infections include infection prevention, optimised use of antibiotics, improved capacity for microbiological analysis, vaccine development, and improved and more pervasive use of available vaccines. These estimates can be used to help set priorities for vaccine need, demand, and development. Funding: Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care, using UK aid funding managed by the Fleming Fund

Subnational mapping of HIV incidence and mortality among individuals aged 15–49 years in sub-Saharan Africa, 2000–18 : a modelling study

Background: High-resolution estimates of HIV burden across space and time provide an important tool for tracking and monitoring the progress of prevention and control efforts and assist with improving the precision and efficiency of targeting efforts. We aimed to assess HIV incidence and HIV mortality for all second-level administrative units across sub-Saharan Africa. Methods: In this modelling study, we developed a framework that used the geographically specific HIV prevalence data collected in seroprevalence surveys and antenatal care clinics to train a model that estimates HIV incidence and mortality among individuals aged 15–49 years. We used a model-based geostatistical framework to estimate HIV prevalence at the second administrative level in 44 countries in sub-Saharan Africa for 2000–18 and sought data on the number of individuals on antiretroviral therapy (ART) by second-level administrative unit. We then modified the Estimation and Projection Package (EPP) to use these HIV prevalence and treatment estimates to estimate HIV incidence and mortality by second-level administrative unit. Findings: The estimates suggest substantial variation in HIV incidence and mortality rates both between and within countries in sub-Saharan Africa, with 15 countries having a ten-times or greater difference in estimated HIV incidence between the second-level administrative units with the lowest and highest estimated incidence levels. Across all 44 countries in 2018, HIV incidence ranged from 2 ·8 (95% uncertainty interval 2·1–3·8) in Mauritania to 1585·9 (1369·4–1824·8) cases per 100 000 people in Lesotho and HIV mortality ranged from 0·8 (0·7–0·9) in Mauritania to 676· 5 (513· 6–888·0) deaths per 100 000 people in Lesotho. Variation in both incidence and mortality was substantially greater at the subnational level than at the national level and the highest estimated rates were accordingly higher. Among second-level administrative units, Guijá District, Gaza Province, Mozambique, had the highest estimated HIV incidence (4661·7 [2544·8–8120·3]) cases per 100000 people in 2018 and Inhassunge District, Zambezia Province, Mozambique, had the highest estimated HIV mortality rate (1163·0 [679·0–1866·8]) deaths per 100 000 people. Further, the rate of reduction in HIV incidence and mortality from 2000 to 2018, as well as the ratio of new infections to the number of people living with HIV was highly variable. Although most second-level administrative units had declines in the number of new cases (3316 [81· 1%] of 4087 units) and number of deaths (3325 [81·4%]), nearly all appeared well short of the targeted 75% reduction in new cases and deaths between 2010 and 2020. Interpretation: Our estimates suggest that most second-level administrative units in sub-Saharan Africa are falling short of the targeted 75% reduction in new cases and deaths by 2020, which is further compounded by substantial within-country variability. These estimates will help decision makers and programme implementers expand access to ART and better target health resources to higher burden subnational areas

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10&nbsp;years; 78.2% included were male with a median age of 37&nbsp;years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112