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Chatzimichail T, Hatjimihail AT. A Software Tool for Estimating Uncertainty of Bayesian Posterior Probability for Disease. Diagnostics (Basel) 2024; 14:402. [PMID: 38396440 PMCID: PMC10887534 DOI: 10.3390/diagnostics14040402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
The role of medical diagnosis is essential in patient care and healthcare. Established diagnostic practices typically rely on predetermined clinical criteria and numerical thresholds. In contrast, Bayesian inference provides an advanced framework that supports diagnosis via in-depth probabilistic analysis. This study's aim is to introduce a software tool dedicated to the quantification of uncertainty in Bayesian diagnosis, a field that has seen minimal exploration to date. The presented tool, a freely available specialized software program, utilizes uncertainty propagation techniques to estimate the sampling, measurement, and combined uncertainty of the posterior probability for disease. It features two primary modules and fifteen submodules, all designed to facilitate the estimation and graphical representation of the standard uncertainty of the posterior probability estimates for diseased and non-diseased population samples, incorporating parameters such as the mean and standard deviation of the test measurand, the size of the samples, and the standard measurement uncertainty inherent in screening and diagnostic tests. Our study showcases the practical application of the program by examining the fasting plasma glucose data sourced from the National Health and Nutrition Examination Survey. Parametric distribution models are explored to assess the uncertainty of Bayesian posterior probability for diabetes mellitus, using the oral glucose tolerance test as the reference diagnostic method.
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Jurkovic D. Conservative management of adnexal tumors: how to tell good from bad. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:149-151. [PMID: 36722429 DOI: 10.1002/uog.26158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 05/27/2023]
Affiliation(s)
- D Jurkovic
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
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Tugwell P. Farewell to André Knottnerus and welcome to David Tovey. J Clin Epidemiol 2021; 129:A8-A9. [PMID: 33422269 DOI: 10.1016/j.jclinepi.2020.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Falzer PR. Evidence-based medicine's curious path: From clinical epidemiology to patient-centered care through decision analysis. J Eval Clin Pract 2021; 27:631-637. [PMID: 32844571 DOI: 10.1111/jep.13466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/29/2020] [Indexed: 11/28/2022]
Abstract
Evidence-based medicine (EBM), one of the most important movements in health care, has been a lightning rod for controversy. Conflicts about the meaning and value of EBM are owing in part to lack of clarity about basic questions regarding its development, the importance of expertise and intuition, and the role of evidence in clinical decision making. These issues have persisted in part because of unclarity at the outset, but also because of how EBM evolved, why it was introduced when it was, and how it was modified following its introduction. This paper traces the evolution of EBM from clinical epidemiology (CE) and the internal dispute that precipitated the developers to establish EBM as a distinct approach to clinical practice. The paper proposes that health care industrialization also had a significant role in EBM's emergence and that industrialization influenced the decision to merge EBM with the method of normative decision making known as decision analysis (DA). The paper discusses the impact of this merger, in particular how it led to EBM's identification with managed care and has added momentum to the effort at forging a connection between a normative decision model and clinical judgement. This effort would turn clinical decision making into a conduit for bringing administrative rules and regulations into the consulting room and would result in expertise becoming a surplus skill. The paper closes by discussing a challenge yet unmet by EBM's advocates and critics-to chronicle the dangers that EBM in the framework of DA during the current era of industrialization poses to health and health care, and discover ways of unhinging the relationship between model and judgement.
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Affiliation(s)
- Paul R Falzer
- Retired, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Knottnerus JA, Tugwell P. Research methods must find ways of accommodating clinical reality, not ignoring it: the need for pragmatic trials. J Clin Epidemiol 2019; 88:1-3. [PMID: 28867146 DOI: 10.1016/j.jclinepi.2017.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
In individuals with coronary artery disease and concurrent depressive symptomatology, the evidence on the beneficial and harmful effects of antidepressants is very limited. Recently, a study was carried out to describe depressive symptoms and the treatments provided under real-world circumstances to cardiac patients who entered the Mayo Clinic cardiac rehabilitation program. Antidepressant use was associated with reductions in depressive symptoms, but also with poorer cardiovascular outcomes. In this commentary, the results of this study are discussed in view of their clinical implications for everyday clinical practice and for the production of knowledge.
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Nunes N, Ambler G, Foo X, Widschwendter M, Jurkovic D. Prospective evaluation of IOTA logistic regression models LR1 and LR2 in comparison with subjective pattern recognition for diagnosis of ovarian cancer in an outpatient setting. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:829-835. [PMID: 28976616 DOI: 10.1002/uog.18918] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/08/2017] [Accepted: 09/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To determine whether International Ovarian Tumor Analysis (IOTA) logistic regression models LR1 and LR2 developed for the preoperative diagnosis of ovarian cancer could also be used to differentiate between benign and malignant adnexal tumors in the population of women attending gynecology outpatient clinics. METHODS This was a single-center prospective observational study of consecutive women attending our gynecological diagnostic outpatient unit, recruited between May 2009 and January 2012. All the women were first examined by a Level-II ultrasound operator. In those diagnosed with adnexal tumors, the IOTA-LR1/2 protocol was used to evaluate the masses. The LR1 and LR2 models were then used to assess the risk of malignancy. Subsequently, the women were also examined by a Level-III examiner, who used pattern recognition to differentiate between benign and malignant tumors. Women with an ultrasound diagnosis of malignancy were offered surgery, while asymptomatic women with presumed benign lesions were offered conservative management with a minimum follow-up of 12 months. The initial diagnosis was compared with two reference standards: histological findings and/or a comparative assessment of tumor morphology on follow-up ultrasound scans. All women for whom the tumor classification on follow-up changed from benign to malignant were offered surgery. RESULTS In the final analysis, 489 women who had either or both of the reference standards were included. Their mean age was 50 years (range, 16-91 years) and 45% were postmenopausal. Of the included women, 342/489 (69.9%) had surgery and 147/489 (30.1%) were managed conservatively. The malignancy rate was 137/489 (28.0%). Overall, sensitivities of LR1 and LR2 for the diagnosis of malignancy were 97.1% (95% CI, 92.7-99.2%) and 94.9% (95% CI, 89.8-97.9%) and specificities were 77.3% (95% CI, 72.5-81.5%) and 76.7% (95% CI, 71.9-81.0%), respectively (P > 0.05). In comparison with pattern recognition (sensitivity 94.2% (95% CI, 88.8-97.4%), specificity 96.3% (95% CI, 93.8-98.0%)), the specificities of the IOTA models were significantly lower (P < 0.0001). A significantly higher number of women would have been offered surgery for suspected cancer if the women had been assessed using the IOTA models instead of pattern recognition (213/489 (43.6%) vs 142/489 (29.0%); P < 0.001). CONCLUSIONS The IOTA models maintained their high sensitivity when used in an outpatient setting. Specificity was relatively low, which indicates that a significant proportion of the women would have been offered unnecessary surgery for suspected ovarian cancer. These findings show that the IOTA models could be used as a first-stage test to diagnose ovarian cancer in an outpatient setting, but a different second-stage test is required to minimize the number of false-positive findings. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N Nunes
- Gynaecological Diagnostic Outpatient Treatment Unit, University College Hospital, London, UK
| | - G Ambler
- Department of Statistical Science, University College London, London, UK
| | - X Foo
- Gynaecological Diagnostic Outpatient Treatment Unit, University College Hospital, London, UK
| | - M Widschwendter
- Department of Women's Cancer, University College London, Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - D Jurkovic
- Gynaecological Diagnostic Outpatient Treatment Unit, University College Hospital, London, UK
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Concato J, Horwitz RI. Randomized trials and evidence in medicine: A commentary on Deaton and Cartwright. Soc Sci Med 2018; 210:32-36. [PMID: 29685451 DOI: 10.1016/j.socscimed.2018.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/10/2018] [Indexed: 11/16/2022]
Affiliation(s)
- John Concato
- Director, Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, and Professor of Medicine, Yale University School of Medicine, 950 Campbell Ave., West Haven, CT 06516, USA.
| | - Ralph I Horwitz
- Professor of Medicine, Lewis Katz School of Medicine, Temple University, 3500 N. Broad St., Philadelphia, PA 19140, USA
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Sacristán JA, Dilla T. Pragmatic trials revisited: applicability is about individualization. J Clin Epidemiol 2018; 99:164-166. [PMID: 29432859 DOI: 10.1016/j.jclinepi.2018.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/01/2018] [Accepted: 02/04/2018] [Indexed: 10/18/2022]
Affiliation(s)
- José A Sacristán
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Medical Department, Lilly, Madrid, Spain.
| | - Tatiana Dilla
- Health Evaluation and Market Access Program, Universidad Carlos III, Madrid, Spain; Medical Department, Lilly, Madrid, Spain
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El-Khayat R, Baldwin DS. Antipsychotic drugs for non-psychotic patients. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.23.7.416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and methodThe aim of this study was to examine the pattern and basis of use of psychotropic drug prescriptions by psychiatrists to relieve anxiety symptoms arising from non-psychotic disorders. A questionnaire survey was conducted among senior psychiatrists in the Wessex region.ResultsThe response rate was 74%. A range of psychotropic drugs was used to treat non-psychotic anxiety symptoms, most commonly selective serotonin re-uptake inhibitors, tricyclic antidepressants and antipsychotic drugs. Antipsychotic drugs are reserved for second- and third-line treatments, mainly in low doses but sometimes in high doses and for long periods. The use of antipsychotic drugs as anxiolytics was seen by the majority of responders as reasonable practice, and they are considered suitable alternatives to benzodiazepines. This practice was based mainly on personal experience.Clinical implicationsAnxiety symptoms arising from non-psychotic disorders are common in the out-patient population. Although antipsychotics are used by psychiatrists to relieve these symptoms, the ‘evidence base’ for such practice is flimsy and mainly based on clinical experience. The benefit/risk ratio should be considered carefully before prescribing antipsychotics for non-psychotic anxiety. Further research is needed in this area, contributing towards general guidelines.
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Norbruis OF, Escher JC, Walhout LC, Kindermann A, de Rijke YB, van Rheenen PF, Berger MY. Diagnostic test strategies in children at increased risk of inflammatory bowel disease in primary care. PLoS One 2017; 12:e0189111. [PMID: 29211800 PMCID: PMC5718464 DOI: 10.1371/journal.pone.0189111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 11/20/2017] [Indexed: 01/13/2023] Open
Abstract
Background In children with symptoms suggestive of inflammatory bowel disease (IBD) who present in primary care, the optimal test strategy for identifying those who require specialist care is unclear. We evaluated the following three test strategies to determine which was optimal for referring children with suspected IBD to specialist care: 1) alarm symptoms alone, 2) alarm symptoms plus c-reactive protein, and 3) alarm symptoms plus fecal calprotectin. Methods A prospective cohort study was conducted, including children with chronic gastrointestinal symptoms referred to pediatric gastroenterology. Outcome was defined as IBD confirmed by endoscopy, or IBD ruled out by either endoscopy or unremarkable clinical 12 month follow-up with no indication for endoscopy. Test strategy probabilities were generated by logistic regression analyses and compared by area under the receiver operating characteristic curves (AUC) and decision curves. Results We included 90 children, of whom 17 (19%) had IBD (n = 65 from primary care physicians, n = 25 from general pediatricians). Adding fecal calprotectin to alarm symptoms increased the AUC significantly from 0.80 (0.67–0.92) to 0.97 (0.93–1.00), but adding c-reactive protein to alarm symptoms did not increase the AUC significantly (p > 0.05). Decision curves confirmed these patterns, showing that alarm symptoms combined with fecal calprotectin produced the diagnostic test strategy with the highest net benefit at reasonable threshold probabilities. Conclusion In primary care, when children are identified as being at high risk for IBD, adding fecal calprotectin testing to alarm symptoms was the optimal strategy for improving risk stratification.
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Affiliation(s)
- Gea A. Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- * E-mail:
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Boudewijn J. Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Obbe F. Norbruis
- Department of Pediatrics, Isala Hospital, Zwolle, The Netherlands
| | - Johanna C. Escher
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Laurence C. Walhout
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children’s Hospital ⁄ Academic Medical Center, Amsterdam, the Netherlands
| | - Yolanda B. de Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Patrick F. van Rheenen
- Department of Pediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marjolein Y. Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Holtman GA, Lisman-van Leeuwen Y, van Rheenen PF, Kollen BJ, Escher JC, Kindermann A, de Rijke YB, Berger MY. Evaluation of point-of-care test calprotectin and lactoferrin for inflammatory bowel disease among children with chronic gastrointestinal symptoms. Fam Pract 2017; 34:400-406. [PMID: 27535331 DOI: 10.1093/fampra/cmw079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Faecal calprotectin is considered to be a valid test for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms in specialist care. In contrast, faecal lactoferrin has higher specificity. The recent availability of both as point-of-care tests (POCTs) makes them attractive for use in primary care. OBJECTIVE To evaluate the test characteristics of calprotectin and lactoferrin POCTs for diagnosing IBD in symptomatic children. METHODS We defined two prospective cohorts of children with chronic gastrointestinal symptoms: (i) children presenting to primary care (primary care cohort); (ii) children referred for specialist care (referred cohort). Baseline POCT results were compared with the outcome of either endoscopic assessment or 12 months follow-up. Clinicians were blinded to the POCT results. RESULTS In the primary care cohort, none of the 114 children had IBD, and the calprotectin and lactoferrin POCTs had specificities of 0.95 (0.89-0.98) and 0.98 (0.93-0.99), respectively. In the referred cohort, 17 of the 90 children had IBD: the sensitivity of POCT calprotectin and POCT lactoferrin were both 0.94 (0.72-0.99); and the specificity was 0.93 (0.84-0.97) and 0.99 (0.92-1.00), respectively. The POCT calprotectin could reduce the referral rate by 76% and POCT lactoferrin by 81%, while missing one child with IBD (6%). CONCLUSION A diagnostic test strategy in primary care using a simple POCT calprotectin or lactoferrin has the potential to reduce the need for referral for further diagnostic work-up in specialist care, with a low risk of missing a child with IBD.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Boudewijn J Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Angelika Kindermann
- Department of Paediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, PO Box 22700, 1100 DE Amsterdam, The Netherlands
| | - Yolanda B de Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Centre, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
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Horwitz RI, Singer BH. Why evidence-based medicine failed in patient care and medicine-based evidence will succeed. J Clin Epidemiol 2017; 84:14-17. [DOI: 10.1016/j.jclinepi.2017.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kowalski CJ, Hutchinson RJ, Mrdjenovich AJ. The Ethics of Clinical Care and the Ethics of Clinical Research: Yin and Yang. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2017; 42:7-32. [DOI: 10.1093/jmp/jhw032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Norbruis OF, Escher JC, Kindermann A, de Rijke YB, van Rheenen PF, Berger MY. Diagnostic Accuracy of Fecal Calprotectin for Pediatric Inflammatory Bowel Disease in Primary Care: A Prospective Cohort Study. Ann Fam Med 2016; 14:437-45. [PMID: 27621160 PMCID: PMC5394359 DOI: 10.1370/afm.1949] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/16/2016] [Indexed: 02/03/2023] Open
Abstract
PURPOSE In specialist care, fecal calprotectin (FCal) is a commonly used noninvasive diagnostic test for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms. The aim of this study was to evaluate the diagnostic accuracy of FCal for IBD in symptomatic children in primary care. METHODS We studied 2 prospective cohorts of children with chronic diarrhea, recurrent abdominal pain, or both: children initially seen in primary care (primary care cohort) and children referred to specialist care (referred cohort). FCal (index test) was measured at baseline and compared with 1 of the 2 reference standards for IBD: endoscopic assessment or 1-year follow-up. Physicians were blinded to FCal results, and values greater than 50 μg/g feces were considered positive. We determined specificity in the primary care cohort and sensitivity in the referred cohort. RESULTS None of the 114 children in the primary care cohort ultimately received a diagnosis of IBD. The specificity of FCal in the primary care cohort was 0.87 (95% CI, 0.80-0.92). Among the 90 children in the referred cohort, 17 (19%) ultimately received a diagnosis of IBD. The sensitivity of FCal in the referred cohort was 0.99 (95% CI, 0.81-1.00). CONCLUSIONS The findings of this study suggest that a positive FCal result in children with chronic gastrointestinal symptoms seen in primary care is not likely to be indicative of IBD. A negative FCal result is likely to be a true negative, which safely rules out IBD in children in whom a primary care physician considers referral to specialist care.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Boudewijn J Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Obbe F Norbruis
- Department of Pediatrics, Isala Hospital, Zwolle, The Netherlands
| | - Johanna C Escher
- Department of Pediatric Gastroenterology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital ⁄ Academic Medical Center, Amsterdam, The Netherlands
| | - Yolanda B de Rijke
- Department of Clinical Chemistry, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Beatrix Children's Hospital ⁄ University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Petrou P. Failed Attempts to Reduce Inappropriate Laboratory Utilization in an Emergency Department Setting in Cyprus: Lessons Learned. J Emerg Med 2016; 50:510-7. [DOI: 10.1016/j.jemermed.2015.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 07/03/2015] [Accepted: 07/25/2015] [Indexed: 11/30/2022]
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de Leon J, Stephens DB. Pathophysiology and clinical trials have limitations in some areas of medicine: focus on psychiatry (letter commenting: J Clin Epidemiol. 2014;67(4):361-363.). J Clin Epidemiol 2016; 75:126-7. [PMID: 26808819 DOI: 10.1016/j.jclinepi.2016.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Room 3A15A, 1350 Bull Lea Road, Lexington, KY 40511, USA.
| | - Dustin B Stephens
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Room 3A15A, 1350 Bull Lea Road, Lexington, KY 40511, USA
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Burda MHF, van den Akker M, van der Horst F, Lemmens P, Knottnerus JA. Collecting and validating experiential expertise is doable but poses methodological challenges. J Clin Epidemiol 2016; 72:10-5. [PMID: 26769258 DOI: 10.1016/j.jclinepi.2015.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 09/09/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To give an overview of important methodological challenges in collecting, validating, and further processing experiential expertise and how to address these challenges. STUDY DESIGN AND SETTING Based on our own experiences in studying the concept, operationalization, and contents of experiential expertise, we have formulated methodological issues regarding the inventory and application of experiential expertise. RESULTS The methodological challenges can be categorized in six developmental research stages, comprising the conceptualization of experiential expertise, methods to harvest experiential expertise, the validation of experiential expertise, evaluation of the effectiveness, how to translate experiential expertise into acceptable guidelines, and how to implement these. The description of methodological challenges and ways to handle those are illustrated using diabetes mellitus as an example. CONCLUSION Experiential expertise can be defined and operationalized in terms of successful illness-related behaviors and translated into recommendations regarding life domains. Pathways have been identified to bridge the gaps between the world of patients' daily lives and the medical world.
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Affiliation(s)
- Marika H F Burda
- Department of Family Medicine, School CAPHRI, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Marjan van den Akker
- Department of Family Medicine, School CAPHRI, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands; Department of General Practice, KU Leuven, Kapucijnenvoer 33 blok J-bus 7001, 3000 Leuven, Belgium.
| | - Frans van der Horst
- Department of Family Medicine, School CAPHRI, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Paul Lemmens
- Department of Health Education, School CAPHRI, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - J André Knottnerus
- Department of Family Medicine, School CAPHRI, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
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Moons KGM, Altman DG, Reitsma JB, Ioannidis JPA, Macaskill P, Steyerberg EW, Vickers AJ, Ransohoff DF, Collins GS. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med 2015; 162:W1-73. [PMID: 25560730 DOI: 10.7326/m14-0698] [Citation(s) in RCA: 2928] [Impact Index Per Article: 325.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.
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Lurie F, Vaidya V, Comerota AJ. Clinical outcomes and cost-effectiveness of initial treatment strategies for nonembolic acute limb ischemia in real-life clinical settings. J Vasc Surg 2014; 61:138-46. [PMID: 25154566 DOI: 10.1016/j.jvs.2014.07.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The optimal initial treatment for patients with acute limb ischemia (ALI) remains undefined. Although clinical outcome data are inconsistent, catheter-directed thrombolysis (CDT) with tissue plasminogen activator is increasingly used. Patient-level analysis combining clinical and economic data in a real-life setting is lacking. This study compared clinical outcomes and cost-effectiveness of initial treatment strategies for nonembolic ALI using real-life patient-level data. METHODS Medical records and data for hospital costs were analyzed for nonembolic ALI patients treated in four hospitals over 3 years. A cost-effectiveness analysis was performed using a decision tree analytic model. All costs were valued based on cost-to-charge ratios. RESULTS In 205 patients, initial treatments were CDT alone in 68 or with angioplasty in 16, open surgery in 60, endovascular in 33, and hybrid in 28. Although clinical outcomes did not differ significantly among the groups, reintervention rates during hospital stay, readmission rates, and costs were highest in the CDT group. Reintervention was required in 62% of patients after CDT compared with 7% after open surgery, and 16% of the CDT patients needed more than one reintervention. The mean total hospital cost was $34,800 per patient in CDT group compared with $10,677 in open surgery group. CONCLUSIONS In this real-life study, initial treatment of nonembolic ALI with currently available CDT options was associated with greater health care resource consumption and cost compared with other initial treatment options.
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Affiliation(s)
| | - Varun Vaidya
- College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, Ohio
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Abstract
The frail elderly populations of nursing homes frequently use drugs and suffer from considerable comorbidities. Medication reviews are intended to support evidence based prescribing and optimise therapy. However, literature is still ambiguous regarding the optimal method and the effects of medication reviews. Innovative computerised systems may support the medication reviews in the future. We are developing a clinical decision support system (CDSS) that, independently of the prescribing software, continuously monitors all prescribed drugs while taking into account co-medication, laboratory-data and co-morbidities. The CDSS will be developed in five phases: (1) development of the computerised system, (2) development of the clinical rules, (3) validation of the CDSS, (4) randomised controlled trial, and (5) feasibility for implementation in different nursing homes. The clinical decision support system aims at supporting the traditional medication review.
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Buyyounouski MK, Viswanathan AN, Prestidge BR. Examining the evidence in pursuit of the highest possible brachytherapy standards. Brachytherapy 2014; 13:15-6. [DOI: 10.1016/j.brachy.2013.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 07/13/2013] [Indexed: 10/26/2022]
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Affiliation(s)
- Charles Safran
- Division of Clinical Informatics, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1330 Beacon Street Suite 400, Brookline, MA, 02446, USA,
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Escher JC, Kindermann A, Rheenen PFV, Berger MY. Challenges in diagnostic accuracy studies in primary care: the fecal calprotectin example. BMC FAMILY PRACTICE 2013; 14:179. [PMID: 24274463 PMCID: PMC4222604 DOI: 10.1186/1471-2296-14-179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 11/21/2013] [Indexed: 01/02/2023]
Abstract
Background Low disease prevalence and lack of uniform reference standards in primary care induce methodological challenges for investigating the diagnostic accuracy of a test. We present a study design that copes with these methodological challenges and discuss the methodological implications of our choices, using a quality assessment tool for diagnostic accuracy studies (QUADAS-2). Design The study investigates the diagnostic value of fecal calprotectin for detecting inflammatory bowel disease in children presenting with chronic gastrointestinal symptoms in primary care. It is a prospective cohort study including two cohorts of children: one cohort will be recruited in primary care and the other in secondary/tertiary care. Test results of fecal calprotectin will be compared to one of the two reference standards for inflammatory bowel disease: endoscopy with histopathological examination of mucosal biopsies or assessment of clinical symptoms at 1-year follow-up. Discussion According to QUADAS-2 the use of two reference standards and the recruitment of patients in two populations may cause differential verification bias and spectrum bias, respectively. The clinical relevance of this potential bias and methods to adjust for this are presented. This study illustrates the importance of awareness of the different kinds of bias that result from choices in the design phase of a diagnostic study in a low prevalence setting. This approach is exemplary for other diagnostic research in primary care.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, FA21, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands.
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Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med 2013; 41:2108-15. [PMID: 23782969 DOI: 10.1097/ccm.0b013e31828a42c5] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The vast majority of ICU patients require some form of venous access. There are no evidenced-based guidelines concerning the use of either central or peripheral venous catheters, despite very different complications. It remains unknown which to insert in ICU patients. We investigated the rate of catheter-related insertion or maintenance complications in two strategies: one favoring the central venous catheters and the other peripheral venous catheters. DESIGN Multicenter, controlled, parallel-group, open-label randomized trial. SETTING Three French ICUs. PATIENTS Adult ICU patients with equal central or peripheral venous access requirement. INTERVENTION Patients were randomized to receive central venous catheters or peripheral venous catheters as initial venous access. MEASUREMENTS AND RESULTS The primary endpoint was the rate of major catheter-related complications within 28 days. Secondary endpoints were the rate of minor catheter-related complications and a composite score-assessing staff utilization and time spent to manage catheter insertions. Analysis was intention to treat. We randomly assigned 135 patients to receive a central venous catheter and 128 patients to receive a peripheral venous catheter. Major catheter-related complications were greater in the peripheral venous catheter than in the central venous catheter group (133 vs 87, respectively, p=0.02) although none of those was life threatening. Minor catheter-related complications were 201 with central venous catheters and 248 with peripheral venous catheters (p=0.06). 46% (60/128) patients were managed throughout their ICU stay with peripheral venous catheters only. There were significantly more peripheral venous catheter-related complications per patient in patients managed solely with peripheral venous catheter than in patients that received peripheral venous catheter and at least one central venous catheter: 1.92 (121/63) versus 1.13 (226/200), p<0.005. There was no difference in central venous catheter-related complications per patient between patients initially randomized to peripheral venous catheters but subsequently crossed-over to central venous catheter and patients randomized to the central venous catheter group. Kaplan-Meier estimates of survival probability did not differ between the two groups. CONCLUSION In ICU patients with equal central or peripheral venous access requirement, central venous catheters should preferably be inserted: a strategy associated with less major complications.
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Rashidbeygi M, Sayehmiri K. Knowledge and attitudes of physicians towards evidence based medicine in ilam, iran. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:798-803. [PMID: 24616789 PMCID: PMC3929814 DOI: 10.5812/ircmj.7204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 01/10/2013] [Accepted: 06/11/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Evidence based medicine (EBM) is very important in the process of decision making, diagnosis and treatment of patients. For years, medical schools have developed instructions for EBM to determine the attitude and knowledge of physicians towards EBM and their related educational needs. MATERIALS AND METHODS This study was a questionnaire study among physicians. One hundred twenty physicians were selected using stratified random sampling in Ilam. A main outcome measure was attitudes and knowledge of physicians toward EBM, ability to access and interpret evidence, and best method of moving from opinion based to EBM. RESULTS Of the 120 questionnaires we have sent, 94 (78.3%) were answered. 56.6% were using the internet to answer their patients questions and 23.8% used the internet to obtain clinical evidence. Mean and standard deviation (SD) of knowledge and attitude scores were 24% ± 23% and 72% ± 10%, respectively. Pearson correlation shows a significant relation between knowledge of physicians and years of graduation (r = -0.37, P = 0.00). There was a significant difference between mean of knowledge score of general practitioners, specialist and subspecialist (P = 0.026). CONCLUSIONS Knowledge and attitude of young physicians were more based on EBM compare to old physicians. A significant difference in knowledge mean score of physician shows that the EBM is still new in Iran, the future physician's critical need to learn EBM and necessity of entering EMB at all medical levels.
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Affiliation(s)
- Milad Rashidbeygi
- Medical Student, Student Research Committee, Ilam University of Medical Sciences, Ilam, IR Iran
| | - Kourosh Sayehmiri
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, IR Iran
- Social Medicine Department, Medicine faculty, Ilam University of Medical Sciences, Ilam, IR Iran
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Cals JWL, Ament AJHA, Hood K, Butler CC, Hopstaken RM, Wassink GF, Dinant GJ. C-reactive protein point of care testing and physician communication skills training for lower respiratory tract infections in general practice: economic evaluation of a cluster randomized trial. J Eval Clin Pract 2011; 17:1059-69. [PMID: 20666881 DOI: 10.1111/j.1365-2753.2010.01472.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES An economic evaluation of general practitioner (GP) use of C-reactive protein (CRP) point of care test, GP communication skills training, and both GP use of CRP and communication skills training on antibiotic use for lower respiratory tract infections (LRTIs) in general practice. METHODS Cost-effectiveness analysis with a time horizon of 28 days alongside a factorial, cluster randomized trial in 431 patients with LRTIs recruited by 40 GPs. INTERVENTIONS usual care (control group), GP use of CRP point of care test, GP communication skills training, and both CRP use and communication skills training. MAIN OUTCOME MEASURE health care costs. Cost-effectiveness, using the primary outcome measure antibiotic prescribing at index consultation, was assessed by incremental cost-effectiveness ratios (ICER). To adjust for skewed data and clustering, we used non-parametric bootstrapping re-sampling to derive percentile intervals for the mean difference in total costs and the mean difference in effectiveness between the groups. Various implementation scenarios according to GP preference were modelled with corresponding net monetary benefit (NMB) curves based on a given willingness-to-pay (λ) for a 1% lower antibiotic prescribing rate. RESULTS The total mean cost per patient in the usual care group was €35.96 with antibiotic prescribing of 68%, €37.58 per patient managed by GPs using CRP tests (antibiotic prescribing 39%, ICER €5.79), €25.61 per patient managed by GPs trained in enhanced communication skills (antibiotic prescribing 33%, dominant) and €37.78 per patient managed by GPs using both interventions (antibiotic prescribing 23%, ICER €4.15). The interventions are cost-effective in any combination (yielding NMB at no willingness-to-pay), taking into account GPs' preferences where at least 15% of GPs chose to implement the communication skills training. CONCLUSIONS The two strategies, both singly and combined, are cost-effective interventions to reduce antibiotic prescribing for LRTI, at no, or low willingness-to-pay. Taking GP preferences into account will optimize investment in strategies to reduce antibiotic prescribing for LRTI.
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Affiliation(s)
- Jochen W L Cals
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, the Netherlands.
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Abstract
SUMMARYBackground – The patterns of antidepressant and antipsychotìc drag prescribing have rarely been studied in large and geographically defined catchment areas. In the present study we examined the prevalence and distribution of antidepressant and antipsychotic prescribing in Lombardy, a northern Italy region of nine million inhabitants. Methods – This study used the Regional Administrative Database of Lombardy. This database includes all prescriptions reimbursed by the National Health System in the population living in this region. All antidepressant and antipsychotic prescriptions dispensed from the 1st January to the 31st December 2001 were extracted and prevalence data calculated by dividing antidepressant and antipsychotic users by the total number of male and female residents in each age group. In addition, from the Regional database of hospital admissions we extracted all patients aged 65 or above with cerebrovascular-related outcomes for the year 2002. The two databases were linked anonymously with the aim of investigating the relationship between exposure to psychotropics and occurrence of cerebrovascular accidents in the elderly. Results – During the study period 404, 238 individuals were dispensed antidepressants, yielding a prevalence of use of 2.85 (95% CI 2.84, 2.87) per 100 males and 5.92 (95% CI 5.90, 5.94) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old individuals. The majority of individuals received a pharmacological treatment with selective-serotonin reuptake inhibitors only, slightly more than 12% received a treatment with tricyclic antidepressants. A total of 86, 187 subjects were dispensed antipsychotic agents, yielding a prevalence of use of 0.87 (95% CI 0.86, 0.88) per 100 males and 1.01 (95% CI 1.00, 1.02) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old subjects. Concerning the relationship between exposure to second-generation antipsychotics (SGAs) and occurrence of cerebrovascular (CBV) accidents, the analysis showed a significantly increased risk of CBV events in elderly subjects exposed to SGAs in comparison with those exposed to first-generation antipsychotics (FGAs) (3, 31%, 95% CI 2, 95–3, 69 vs. 2, 37%, 95% CI 2, 19–2, 57). Finally the analysis indicated no differences in the proportion of cerebrovascular events in elderly subjects exposed to TCAs and SSRIs. Conclusions – The very high rates of antidepressant and antipsychotic drug prescribing detected in late life suggest the need of characterising these individuals in terms of medical and psychiatric characteristics, needs and quality of life. It also suggests the need for pragmatic clinical trials, carried out in the general practice, with the aim of assessing whether antidepressants are effective in these conditions. The data provide preliminary epidemiological evidence that exposure to SGAs, in comparison with exposure to FGAs, significantly increased the risk of cerebrovascular accidents in the elderly.Declaration of Interest: none.
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Kjelgaard-Hansen M, Jacobsen S. Assay validation and diagnostic applications of major acute-phase protein testing in companion animals. Clin Lab Med 2010; 31:51-70. [PMID: 21295722 DOI: 10.1016/j.cll.2010.10.002] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The use of major acute-phase proteins (APPs) for assessment of health and disease in companion animals has increased within the last decade because of increased knowledge in the field and increased access to appropriate assay systems for detection of relevant APPs, which are highly species specific. Despite evidence being restricted almost solely to proven excellent overlap performance of these markers in detecting inflammatory activity, clinically relevant studies at higher evidence levels do exist. The available body of literature shows a clear, but seemingly untapped, potential for more extended routine clinical use of major APP testing in companion animal medicine.
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Affiliation(s)
- Mads Kjelgaard-Hansen
- Department of Small Animal Clinical Sciences, Faculty of LIFE Sciences, University of Copenhagen, Frederiksberg C, Denmark.
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Abstract
RÉSUMÉCet article cherche à établir le potentiel d'évaluation des programmes d'une base de données sur les soins de longue durée dans la communauté. Les données proviennent d'un projet-pilote sur la qualité et la clientèle du Health Care Financing Administration, incluant tous les établissements couverts par Medicare/ Medicaid de cinq états américains entre 1992 et 1994. À l'aide du Minimum Data Set, 70 000 résidents de plus de 65 ans souffrant d'insuffisance cardiaque globale ont été identifiés. L'analyse préliminaire de la pharmacothérapie de l'insuffisance cardiaque globale et de ses effets sur le déclin des fonctions physiques est présentée. L'état des fonctions physiques, mesuré par le taux de déclin des activités instrumentales de la vie quotidienne des patients qui suivent une thérapie combinée s'améliore par rapport à ceux qui prennent seulement de la digoxine ou des inhibiteurs de l'enzyme convertissant l'angiotensine. La disponibilité d'un ensemble de donnees sur la population fournit done une méthode d'évaluation des politiques et des pratiques courantes.
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Knottnerus JA, Tugwell P. Evidence-based quality of care. J Clin Epidemiol 2010; 63:1279-80. [PMID: 20971421 DOI: 10.1016/j.jclinepi.2010.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Challenges in using evidence to inform your clinical practice in low back pain. Best Pract Res Clin Rheumatol 2010; 24:281-9. [PMID: 20227648 DOI: 10.1016/j.berh.2009.12.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of evidence-based medicine (EBM) from its early days was to provide the appropriate means for making effective clinical decisions, not only for avoiding habitual practice but also for enhancing clinical performance. It is, however, unrealistic to simply assume that the results of research will soon evolve into practice. In this article, when aiming to translate results from research into practice, we focus on certain challenges, which can be broadly categorised into two: how the evidence is generated, and how the evidence is implemented. When focussing on generating evidence, a major barrier to the rapid passage of research into clinical practice is that the 'practice' in trials or research settings could be a long way from the setting, circumstances, patient groups and resources available in the daily practice of many clinicians. This is the consequence of the several choices that researchers have to make in designing a trial regarding population, measurement tools and interventions. For implementing the evidence, clinical guidelines appear to be one of the most promising and effective tools for improving the quality of care. Although the importance of implementing clinical guidelines is widely recognised, little is known about the optimal implementation strategy. We present two examples of implementing low back pain guidelines, illustrating that it remains difficult to develop effective implementation strategies. Finally, we discuss some future directions that have been proposed for EBM, which aim to overcome the essential tension between internal validity and external validity (generalisability), specifically in fields where complex syndromes and complex interventions are the focus of attention.
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Bloomrosen M, Detmer DE. Informatics, evidence-based care, and research; implications for national policy: a report of an American Medical Informatics Association health policy conference. J Am Med Inform Assoc 2010; 17:115-23. [PMID: 20190052 PMCID: PMC3000781 DOI: 10.1136/jamia.2009.001370] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 12/21/2009] [Indexed: 11/04/2022] Open
Abstract
There is an increased level of activity in the biomedical and health informatics world (e-prescribing, electronic health records, personal health records) that, in the near future, will yield a wealth of available data that we can exploit meaningfully to strengthen knowledge building and evidence creation, and ultimately improve clinical and preventive care. The American Medical Informatics Association (AMIA) 2008 Health Policy Conference was convened to focus and propel discussions about informatics-enabled evidence-based care, clinical research, and knowledge management. Conference participants explored the potential of informatics tools and technologies to improve the evidence base on which providers and patients can draw to diagnose and treat health problems. The paper presents a model of an evidence continuum that is dynamic, collaborative, and powered by health informatics technologies. The conference's findings are described, and recommendations on terminology harmonization, facilitation of the evidence continuum in a "wired" world, development and dissemination of clinical practice guidelines and other knowledge support strategies, and the role of diverse stakeholders in the generation and adoption of evidence are presented.
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Affiliation(s)
- Meryl Bloomrosen
- American Medical Informatics Association, Bethesda, Maryland 20814, USA.
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de Leon J, Greenlee B, Barber J, Sabaawi M, Singh NN. Practical guidelines for the use of new generation antipsychotic drugs (except clozapine) in adult individuals with intellectual disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2009; 30:613-669. [PMID: 19084370 DOI: 10.1016/j.ridd.2008.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 10/16/2008] [Indexed: 05/27/2023]
Abstract
New generation antipsychotic (NGA) drugs introduced to the US market after clozapine (aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone) are frequently used in individuals with intellectual disabilities (ID). However, there is very limited research to fully establish evidence-based or personalized medicine approaches for their use in this population. These guidelines take a pragmatic approach to establishing frameworks for their use by utilizing the prescribing information and reviewing the available literature on other relevant neuropsychiatric disorders. In the absence of expert consensus guidance and well-controlled comparison trials, we present a set of guidelines to inform initiation, dosing and monitoring of use in adults. Further, in these guidelines we provide practical information on drug-drug interactions and adverse drug reactions, and a brief review of discontinuation syndromes, potential for abuse, use during pregnancy and cost considerations. We also provide drug utilization review forms for each NGA to facilitate implementation of these guidelines, these guidelines provide a practical and necessary resource for practitioners treating psychiatric disorders and challenging behaviors in adult individuals with ID.
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Affiliation(s)
- Jose de Leon
- University of Kentucky Mental Health Research Center, Lexington, KY 40508, USA.
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Sim K, Su HC, Fujii S, Yang SY, Chong MY, Ungvari G, Si T, He YL, Chung EK, Chan YH, Shinfuku N, Kua EH, Tan CH, Sartorius N. High-dose antipsychotic use in schizophrenia: a comparison between the 2001 and 2004 Research on East Asia Psychotropic Prescription (REAP) studies. Br J Clin Pharmacol 2009; 67:110-7. [PMID: 19133060 DOI: 10.1111/j.1365-2125.2008.03304.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIMS We aimed to examine the frequency of high-dose (defined as mean chlorpromazine mg equivalent doses above 1000) antipsychotic prescriptions in schizophrenia and their clinical correlates in the context of a comparison between studies in 2001 and 2004 within six East Asian countries and territories. METHODS Prescriptions of high-dose antipsychotic for a sample of 2136 patients with schizophrenia from six countries and territories (mainland China, Hong Kong, Korea, Japan, Taiwan and Singapore) were evaluated in 2004 and compared with data obtained for 2399 patients in 2001. RESULTS Overall, the comparison between 2001 and 2004 showed a significant decrease in high-dose antipsychotic use from 17.9 to 6.5% [odds ratio (OR) 0.32, 95% confidence interval (CI) 0.26, 0.39, P < 0.001]. Patients who received high-dose antipsychotics were significantly more likely to have multiple admissions (OR 1.96, 95% CI 1.16, 3.33, P = 0.009), more positive psychotic symptoms such as delusions (OR 2.05, 95% CI 1.38, 3.05, P < 0.001) and hallucinations (OR 1.85, 95% CI 1.30, 2.64, P = 0.001), but less likely to have negative symptoms (OR 0.58, 95% CI 0.40, 0.82, P = 0.002). Multivariate regression analyses revealed that prescription of high-dose antipsychotics was also predicted by younger age (P < 0.001), time period of study (2001; P < 0.001), use of first-generation antipsychotic (P < 0.001) and depot antipsychotics (P < 0.001) as well as antipsychotic polytherapy (P < 0.001). CONCLUSIONS We identified the clinical profile and treatment characteristics of patients who are at risk of receiving high antipsychotic doses. These findings should provide impetus for clinicians to constantly monitor the drug regimes and to foster rational, evidence-based prescribing practices.
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Affiliation(s)
- Kang Sim
- Institute of Mental Health/Woodbridge Hospital, Singapore.
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Lapaige V. Evidence-based decision-making within the context of globalization: A "Why-What-How" for leaders and managers of health care organizations. Risk Manag Healthc Policy 2009; 2:35-46. [PMID: 22312206 PMCID: PMC3270906 DOI: 10.2147/rmhp.s4845] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
In the globalized knowledge economy, the challenge of translating knowledge into policy and practice is universal. At the dawn of the 21st century, the clinicians, leaders, and managers of health care organizations are increasingly required to bridge the research-practice gap. A shift from moving evidence to solving problems is due. However, despite a vast literature on the burgeoning field of knowledge translation research, the "evidence-based" issue remains for many health care professionals a day-to-day debate leading to unresolved questions. On one hand, many clinicians still resist to the implementation of evidence-based clinical practice, asking themselves why their current practice should be changed or expanded. On the other hand, many leaders and managers of health care organizations are searching how to keep pace with the demand of actionable knowledge. For example, they are wondering: (a) if managerial and policy innovations are subjected to the same evidentiary standards as clinical innovations, and (b) how they can adapt the scope of evidence-based medicine to the culture, context, and content of health policy and management. This paper focuses on evidence-based health care management within the context of contemporary globalization. In this paper, our heuristic hypothesis is that decision-making process related changes within clinical/managerial/policy environments must be given a socio-historical backdrop. We argue that the relationship between research on the transfer of knowledge and its uptake by clinical, managerial and policy target audiences has undergone a shift, resulting in increasing pressures in health care for intense researcher-practitioner collaboration and the development of "integrative KT platforms" at the crossroads of different fields (the field of knowledge management and the field of knowledge translation). The objectives of this paper are: (a) to provide an answer to the questions that health professionals ask most frequently about "Why" and "How" to bridge the know-do gap, (b) to illustrate by a Canadian example how the PRO-ACTIVE program helps in closing the evidence-based practice gap.
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Affiliation(s)
- Véronique Lapaige
- Canadian Health Services Research Foundation Fellow; PRO-ACTIVE Research Program (Participatory and Evaluative Research Program to Optimize Workplace Management: Application of Knowledge, Transfer of Expertise, Innovative Interventions, Training Transformational Leaders) Pavillon Ferdinand-Vandry, CIFSS (Centre intégré de formation en sciences de la santé), Laval University, Quebec City, Quebec Canada
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Freedman J. Healing, Hype Or Harm? A Critical Analysis of Complementary Or Alternative Medicine. Acupunct Med 2009. [DOI: 10.1136/aim.2008.000109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kroese MEAL, Schulpen GJC, Bessems MCM, Severens JL, Nijhuis FJ, Geusens PP, Landewé RB. Substitution of specialized rheumatology nurses for rheumatologists in the diagnostic process of fibromyalgia: a randomized controlled trial. ACTA ACUST UNITED AC 2008; 59:1299-305. [PMID: 18759317 DOI: 10.1002/art.24018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the substitution of specialized rheumatology nurses for rheumatologists in diagnosing fibromyalgia (FM). METHODS Referred patients with FM symptoms (n = 193) were randomized to a study group diagnosed by a specialized rheumatology nurse (SRN group, n = 97) or to a control group diagnosed by a rheumatologist (RMT group, n = 96). SRN patients were seen within 3 weeks by a nurse who took structured history and initiated routine laboratory tests. During a 5-minute supervision session, the rheumatologist was informed by the nurse about medical history, performed a brief physical examination, and confirmed or rejected the nurse's diagnosis. RMT patients were seen by a rheumatologist after a regular waiting period of 3 months. Outcome measures were initial agreement between the nurse and rheumatologist in the SRN group, final diagnosis after 12-24 months of followup, patient satisfaction, and diagnostic costs. RESULTS The mean waiting time after randomization was 2.8 and 12.1 weeks in the SRN and RMT groups, respectively. Eight RMT patients cancelled their appointments because of the waiting time. Excellent agreement (kappa = 0.91) between rheumatologists and nurses was found. After 12-24 months of followup, none of the initial diagnoses were recalled in either group. SRN patients were significantly more satisfied than RMT patients. Mean diagnostic costs were lower in the SRN group (euro219) than in the RMT group (euro281) (95% uncertainty interval euro-103, euro-20). CONCLUSION Substituting specialized nurses for rheumatologists in the diagnostic process of FM is a trustworthy and successful approach that saves waiting time, provides greater patient satisfaction, and is cost-effective.
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Affiliation(s)
- M E A L Kroese
- University Hospital Maastricht, Maastricht, The Netherlands.
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Mollo V, Falzon P. The development of collective reliability: a study of therapeutic decision-making. THEORETICAL ISSUES IN ERGONOMICS SCIENCE 2008. [DOI: 10.1080/14639220701195186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Special methodological challenges when studying the diagnosis of unexplained complaints in primary care. J Clin Epidemiol 2008; 61:318-22. [DOI: 10.1016/j.jclinepi.2007.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Revised: 05/25/2007] [Accepted: 05/25/2007] [Indexed: 11/23/2022]
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Dinant GJGJ, Buntinx FF, Butler CCC. The necessary shift from diagnostic to prognostic research. BMC FAMILY PRACTICE 2007; 8:53. [PMID: 17854488 PMCID: PMC2034563 DOI: 10.1186/1471-2296-8-53] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Accepted: 09/13/2007] [Indexed: 11/27/2022]
Abstract
Background Do doctors really need to establish an etiological diagnosis each time a patient presents? Or might it often be more effective to treat simply on the basis of symptoms and signs alone, relying on research and on our experience of outcomes for patients who presented in similar ways in the past? Discussion At a time of increase health care costs especially in pharmaceuticals and expensive diagnostic tests, this article uses examples from recent research to address this question. Our examples come from general practice, because that is where doctors frequently see patients presenting with a yet undifferentiated disease which is consequently difficult to diagnose. The examples include respiratory tract infections, low back pain and shoulder pain. Finally we discuss the 'something is wrong' feeling. Summary We conclude that, in addition to diagnostic research, a renewed focus on prognostic research is needed.
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Affiliation(s)
- Geert-Jan GJ Dinant
- Department of General Practice, School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
| | - Frank F Buntinx
- Academic Centre for General Practice, Catholic University Leuven, Leuven, Belgium
| | - Chris CC Butler
- Department of General Practice, Cardiff University, Cardiff, UK
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Falzon P, Mollo V. Managing patients’ demands: the practitioners’ point of view. THEORETICAL ISSUES IN ERGONOMICS SCIENCE 2007. [DOI: 10.1080/14639220701193249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Yousefi-Nooraie R, Shakiba B, Mortaz-Hedjri S, Soroush AR. Sources of knowledge in clinical practice in postgraduate medical students and faculty members: a conceptual map. J Eval Clin Pract 2007; 13:564-8. [PMID: 17683297 DOI: 10.1111/j.1365-2753.2007.00755.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the most important knowledge sources that can influence clinical practice and to cluster them in conceptual groups based on their relative importance. METHODS Faculty members, fellows and residents of a large teaching tertiary care hospital were asked to rate the importance of different resources in their daily clinical practice and their understanding of some common terms from evidence-based medicine. The knowledge sources were distributed in a two-dimensional map using multidimensional scaling and hierarchical cluster analysis. RESULTS A total of 250 of 320 recruited hospital staff returned the questionnaires. The most important resources in daily practice were English journals, text books and literature searching for faculty members, experience, text books and English journals for fellows and text books, experience and peers for residents. Regional journals were the least important resources for all study groups. About 62.7% of residents did not know the meaning of 'number needed to treat', 36.8%'confidence interval', 54.9%'confounding factor' and 44.6%'meta-analysis'. The percentages for faculty members were 41.3%, 37%, 42.2% and 39.1%. The knowledge sources were placed in four clusters in a point map derived from the multidimensional scaling process. CONCLUSION The dominance of the traditional information resources and experience-based medicine debate which is the consequence of traditional approaches to medical education may be one of the considerable barriers to the dissemination of evidence-based medicine in developing countries. The evidence-based clinical practice guidelines could be used as a useful passive-predigested source for busy clinicians to make informed decisions. A considerable Western bias may undermine the local research in developing world.
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Affiliation(s)
- Reza Yousefi-Nooraie
- Center for Research Development, Sariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Amin M, Saunders JA, Fenton JE. Pilot study of the knowledge and attitude towards evidence based medicine of otolaryngology higher surgical trainees. Clin Otolaryngol 2007; 32:133-5. [PMID: 17403235 DOI: 10.1111/j.1365-2273.2007.01369.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The objective of this survey is to provide an insight into the knowledge and attitude of the higher surgical trainees in Otolaryngology towards evidence based medicine and evaluate their understanding of medical statistics and use of evidence based medicine in patient management. A self administered anonymous questionnaire was distributed to twenty Specialist Registrars in Otolaryngology in Ireland during an annual National Otolaryngology Meeting. Of these, nineteen attempted the questionnaire and eighteen completed it. Three previously published questionnaires [Meserve et al. (2005) Med. Educ. Online.10, 1; McColl et al. (1998) BMJ.316, 361; Khan et al. (1999) J. Obst. Gynaecol.19, 231] were used in this survey. In general, there was a moderately welcoming attitude towards evidence based medicine. However, the survey findings indicate the need for incorporation of formal teaching of critical appraisal skills into medical education with a greater emphasis on involvement and dissemination of evidence based medicine in day to day practice.
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Affiliation(s)
- M Amin
- Department of Otolaryngology, Head and Neck Surgery, University of Limerick, Limerick, Ireland.
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