Evidence Based Medicine

The mild traumatic brain injury (MTBI) is one of the most frequent diseases treated in emergency departments. Extensive studies addressing evidence-based treatment criteria have been published, the indication for CT scans depending on clinical symptoms appeared to be one of the critical issues. In this study, the question was raised whether or not the developed evidence-based criteria may be transferred to the patients of a German level 1 trauma centre. Within 2 years (2004/05) 1841 patients with a traumatic brain injury were treated, 1042 patients with a mild traumatic brain injury and with an age over 14 years were included in the study. The indication for a head CT scan was checked by criteria of a phase 3 study (New Orleans Criteria - NOC). Furthermore, the length of hospitalisation, number and character of secondary aggravation, and kind of inpatient care were analysed. 69.5 % of our patients were diagnosed with the help of a CT scan, according to the evidence criteria 98.8 % o...

This article summarizes the findings of a study of community-wide strategies for preventing homelessness among families and single adults with serious mental illness, conducted for the US Department of Housing and Urban Development. The study involved six communities, of which this article focuses on five. A major finding of this study was that it was difficult to identify sites with communitywide strategies, and even harder to find any that maintained data capable of documenting prevention success. However, the five communities selected for this study presented key elements of successful strategies including mechanisms for accurate targeting, a high level of jurisdictional commitment, significant mainstream agency involvement, and mechanisms for continuous system improvement.

People migrate to improve their well-being, whether through an expansion of economic and social opportunities or a reduction in persecution. Yet a large literature suggests that migration can be a very stressful process, with potentially negative impacts on mental health reducing the net benefits of migration. However, to truly understand the effect of migration on mental health one must compare the mental health of migrants to what their mental health would have been had they stayed in their home country. The existing literature is not able to do this and typically settles for comparing the mental health of migrants to that of natives in the destination country,which takes no account of any pre-existing differences between these groups. This paper overcomes the selection problems affecting previous studies of the effect of migration on mental health by examining a migrant lottery program. New Zealand allows a quota of Tongans to immigrate each year with a lottery used to choose amo...

Ankle Foot Orthoses (AFOs) to promote walking ability are a common treatment in patients with neurological or muscular diseases. However, guidelines on the prescription of AFOs are currently based on a low level of evidence regarding their efficacy. Recent studies aiming to demonstrate the efficacy of wearing an AFO in respect to walking ability are not always conclusive. In this paper it is argued to recognize two levels of evidence related to the ICF levels. Activity level evidence expresses the gain in walking ability for the patient, while mechanical evidence expresses the correct functioning of the AFO. Used in combination for the purpose of evaluating the efficacy of orthotic treatment, a conjunct improvement at both levels reinforces the treatment algorithm that is used. Conversely, conflicting outcomes will challenge current treatment algorithms and the supposed working mechanism of the AFO. A treatment algorithm must use relevant information as an input, derived from measur...

Getting evidence into practice: the role and function of facilitation Aim of paper. This paper presents the findings of a concept analysis of facilitation in relation to successful implementation of evidence into practice. Background. In 1998, we presented a conceptual framework that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice. One of the three elements of the framework was facilitation, alongside the nature of evidence and context. It was proposed that facilitators had a key role in helping individuals and teams understand what they needed to change and how they needed to change it. As part of the on-going development and refinement of the framework, the elements within it have undergone a concept analysis in order to provide theoretical and conceptual clarity. Methods. The concept analysis approach was used as a framework to review critically the research literature and seminal texts in order to establish the conceptual clarity and maturity of facilitation in relation to its role in the implementation of evidence-based practice.

As healthcare delivery changes in critical care, nursing continues to extend its practice base. Nursing practice is expanding to incorporate skills once seen as the remit of the medical profession. Critical care nurses are equipping themselves with evidence-based knowledge and skills that can enhance the care they provide to their patients. Assessment of patients is a major role in nursing and, by expanding assessment techniques, nurses can ensure patients receive the care most appropriate to their needs. Nurses in critical care are well placed to perform a more detailed assessment which can help to focus nursing care. This article describes the step-by-step process of undertaking a full and comprehensive respiratory assessment in critical care settings. It identifies many of the problems that patients may have and the signs and symptoms that a nurse may note whilst undertaking the assessment and preparing to prescribe care.

Objective: To extract and to validate a brief version of the DISCERN which could identify mental healthrelated websites with good content quality. Method: The present study is based on the analysis of data issued from six previous studies which used DISCERN and a standardized tool for the evaluation of content quality (evidence-based health information) of 388 mental health-related websites.

Multicultural professional psychologists routinely assert that psychotherapeutic interventions require culturally competent delivery for ethnoracial minority clients to protect the distinctive cultural orientations of these clients. Dominant disciplinary conceptualizations of cultural competence are "kind of person" models that emphasize specialized awareness, knowledge, and skills on the part of the practitioner. Even within psychology, this approach to cultural competence is controversial owing to professional misgivings concerning its culturally essentialist assumptions. Unfortunately, alternative "process-oriented" models of cultural competence emphasize such generic aspects of therapeutic interaction that they remain in danger of losing sight of culture altogether. Thus, for cultural competence to persist as a meaningful construct, an alternative approach that avoids both essentialism and generalism must be recovered. One means to capture this alternative is...

Evidence-based medicine (EBM) is the combination of the best available research evidence with clinical experience and patient needs. The concept of EBM as a part of clinical decision making has become increasingly popular over the last decade. In the hierarchy of studies meta-analysis and systematic reviews occupy the highest levels. A systematic review of a clinical question can be performed by following a relatively standard form. These techniques as described here can be performed without formal training. Systematic reviews conducted in this fashion can be used as a higher form of current concepts or as review articles and replace the traditional expert opinion narrative review.

In the last years the field of research and practice in psychotherapy has been deeply influenced by two different approaches: the so-called Empirically Supported Treatments (ESTs) movement, due to the development of Evidence Based Medicine (EBM) attitude in the mental health field too, and the Common Factors perspective, supported by who sustain the "Dodo Bird Verdict" and the importance of common features in the explanation of therapeutic process. The major aim of this paper is to provide a critical review of these two different approaches pointing out possible criticisms from epistemological and methodological perspectives not avoiding to consider economic and practical issues. Possible solutions to go beyond this debate are indicated in the last part of the article.

Objectives: To evaluate positron emission tomography-computed tomography (PET-CT) for the preoperative management of early-stage intermediate-and high-risk endometrial cancer (EC). Study design: Data of patients with intermediate-and high-risk early-stage EC were retrieved from a prospectively collected database. Patients with preoperative PET-CT followed by surgical staging including pelvic lymphadenectomy were analyzed. Diagnostic performance for lymph node (LN) metastasis was evaluated. Results: Overall, 45 patients were included: 27 (60%) and 18 (40%) with intermediate-and highrisk EC, respectively. Four patients (8.8%) had LN metastasis, three correctly identified at PET-CT, yielding a sensitivity of 75% (95% CI 21.9-98.7). Among 41 patients (91.2%) without LN metastasis, 38 had negative PET-CT with specificity of 92.7% (95% CI 78.9-98.1). The negative predictive value (NPV) was 97.4% (95% CI 84.9-99.9) and the positive predictive value was 50% (95% CI 13.9-86.1). Conclusions: The utility of PET-CT is limited by the low sensitivity for LN metastasis in intermediate-and high-risk early-stage EC, that may impede to consider PET-CT alone an adequate alternative to surgical retroperitoneal staging by lymphadenectomy or sentinel LN biopsy. However, the high diagnostic accuracy, specificity and NPV might support its adoption to improve the diagnostic accuracy of the sentinel LN algorithm.

Approximately 10% of patients following a variety of surgeries develop chronic postsurgical pain. Reducing chronic postoperative pain is especially important to reconstructive surgeons because common operations such as breast and limb reconstruction have even higher risk for developing chronic postsurgical pain. Animal studies of posttraumatic nerve injury pain demonstrate that there is a critical time frame before and immediately after nerve injury in which specific interventions can reduce the incidence and intensity of chronic neuropathic pain behaviors-so called "preventative analgesia." In animal models, perineural local anesthetic, systemic intravenous local anesthetic, perineural clonidine, systemic gabapentin, systemic tricyclic antidepressants, and minocycline have each been shown to reduce pain behaviors days to weeks after treatment. The translation of this work to humans also suggests that brief perioperative interventions may protect patients from developing new chronic postsurgical pain. Recent clinical trial data show that there is an opportunity during the perioperative period to dramatically reduce the incidence and severity of chronic postsurgical pain. The surgeon, working with the anesthesiologist, has the ability to modify both early and chronic postoperative pain by implementing an evidence-based preventative analgesia plan. Keywords pain; neuropathic pain; preventative analgesia Chronic postoperative surgical pain presents a continuing clinical problem.

Evidence on the value of some cur rent physiotherapeutic practices and the in - effectiveness of others is accumulating . This paper addresses the best evidence available on the efficacy and effective - ness of physiotherapeutic modalities in ankylosing spondylitis. General issues in the assessment of physiother apy in this disease are briefly discussed. Core sets for assessments are nowa

Renal anemia is the result of chronic kidney disease (CKD) and deteriorates with disease progression. Anemia may be the first sign of kidney disease. In all patients with anemia and CKD, diagnostic evaluation is required. Prior to diagnosing renal anemia, it is necessary to eliminate the other possible causes. Direct correlation between the concentration of hemoglobin and the stage of renal failure is well known. Early development of anemia is common in diabetic patients. Correction of anemia may slow the progression of CKD. Anemia is an independent risk factor for developing cardiovascular disease in patients with CKD. Treatment of anemia in patients with CKD is based on current guidelines. Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anemia in CKD patients and ERBP (European Renal Best Practice) group its position statement and comments on the KDIGO guidelines. The Croatian Socie...

Developing the best care for clients and patients is a paramount aim of all health care practices, which therefore, should be based on best evidence. This is also crucial for care during the childbearing period here defined as pregnancy, childbirth, and infancy. However, due to dominance of the evidence-based medicine (EBM) model, health care practice has encountered problems especially regarding its relationship to qualitative research. In this article, we analyze and discuss how research based on a lifeworld perspective fits with evidence-based care (EBC), and how a circular model instead of a hierarchy is suitable when attributing value to knowledge for EBC. The article focuses on the history of EBM and EBC, the power of the evidence concept, and EBC from a narrow to a broad view. Further qualitative research and its use for developing EBC is discussed and examples are presented from the authors' own lifeworld research in the Nordic childbearing context. Finally, an alternative circular model of knowledge for EBC is presented. In order to develop evidence-based care, there is need for multiple types of scientific knowledge with equal strength of evidence, integrated with clinical experience, setting, circumstances and health care resources, and incorporating the experiences and clinical state of the childbearing woman and her family.

Background: Practitioners and policymakers need credible evidence of effectiveness to justify allocating resources to complex, expensive health programs. Investigators, however, face challenges in designing sound effectiveness and translation research with relevance for "real-world" settings.

Peter Urbach has argued, on Bayesian grounds, that experimental randomization serves no useful purpose in testing causal hypotheses. I maintain that he fails to distinguish general issues of statistical inference from specific problems involved in identifying causes. I concede the general Bayesian thesis that random sampling is inessential to sound statistical inference. But experimental randomization is a different matter, and often plays an essential role in our route to causal conclusions.

Deep vein thromboses (DVTs) cause significant morbidity and mortality in the general population. Oral anticoagulation therapy may reduce thrombus propagation but does not cause clot lysis and therefore does not prevent postthrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) can be used to treat DVTs as an adjunct to medical therapy, but there is no consensus defining exact indications. Current evidence suggests that CDT can reduce clot burden and DVT recurrence and consequently prevents the formation of PTS compared with systemic anticoagulation. Appropriate indications include younger individuals with acute proximal thromboses, a long life expectancy, and relatively few comorbidities. Limbthreatening thromboses may also be treated with CDT, although the subsequent mortality remains high. A number of randomized controlled trials are currently under way comparing the longer-term outcomes of CDT compared with anticoagulation alone. Initial reports suggest that venous patency and valvular function are better maintained after CDT. The effectiveness of combined pharmacomechanical thrombectomy and the role of vena cava filters need to be investigated further before strong recommendations can be made. The reported short-term outcomes following catheter-based intervention for DVT are encouraging in selected patients. Further evidence is required to establish long-term benefits and cost-effectiveness. (Arterioscler Thromb Vasc Biol. 2010;30:669-674.)

In the Western world, calcified aortic valve stenosis is the most common form of valvular heart disease, affecting up to 3% of adults over the age of 75 years. It is a gradually progressive disease, characterized by a long asymptomatic phase that may last for several decades, followed by a short symptomatic phase associated with severe restriction of the valve orifice. Investigations on treatments for aortic valve stenosis are still in progress. Thus, it is believed that calcification of aortic valve stenosis is similar to the process of atherosclerosis that occurs in coronary artery disease. Recent studies have suggested that cholesterol lowering through the use of statins may have a salutary effect on the progression of aortic valve stenosis

Background: Departing from the hypotheses that over the past decades patients have become more active participants and physicians have become more task-oriented, this study tries to identify shifts in GP and patient communication patterns between 1986 and 2002. Methods: A repeated cross-sectional observation study was carried out in 1986 and 2002, using the same methodology. From two existing datasets of videotaped routine General Practice consultations, a selection was made of consultations with hypertension patients (102 in 1986; 108 in 2002). GP and patient communication was coded with RIAS (Roter Interaction Analysis System). The data were analysed, using multilevel techniques. Results: No gender or age differences were found between the patient groups in either study period. Contrary to expectations, patients were less active in recent consultations, talking less, asking fewer questions and showing less concerns or worries. GPs provided more medical information, but expressed also less often their concern about the patients' medical conditions. In addition, they were less involved in process-oriented behaviour and partnership building. Overall, these results suggest that consultations in 2002 were more task-oriented and businesslike than sixteen years earlier. Conclusion: The existence of a more equal relationship in General Practice, with patients as active and critical consumers, is not reflected in this sample of hypertension patients. The most important shift that could be observed over the years was a shift towards a more businesslike, task-oriented GP communication pattern, reflecting the recent emphasis on evidence-based medicine and protocolized care. The entrance of the computer in the consultation room could play a role. Some concerns may be raised about the effectiveness of modern medicine in helping patients to voice their worries.

A large proportion of non-communicable disease can be attributed to modifiable risk factors such as poor nutrition and physical inactivity. We present data on planning and transport practitioners' perceptions and responses to government public health guidance aimed at ...

The aim of this study was to validate a French version of the Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski, N., Kraaij, V., & Spinhoven, P., 2001. Negative life events, cognitive emotion regulation and emotional problems. Personality and Individual Differences, 30, 1311-1327) and to explore its relationships with impulsivity and depression. Teenagers from a junior secondary (n ¼ 107, 13-16 years) and a secondary school (n ¼ 110, 15-19 years) completed the CERQ, which assesses regulation strategies in response to negative events. The secondary school adolescents also completed the

The purpose is to provide an update the Bone Metastases Guideline published in 2011 based on evidence complemented by expert opinion. The update will discuss new high-quality literature for the 8 key questions from the original guideline and implications for practice. Methods and materials: A systematic PubMed search from the last date included in the original Guideline yielded 414 relevant articles. Ultimately, 20 randomized controlled trials, 32 prospective nonrandomized studies, and 4 meta-analyses/pooled analyses were selected and abstracted into evidence tables. The authors synthesized the evidence and reached consensus on the included recommendations. Results: Available literature continues to support pain relief equivalency between single and multiple fraction regimens for bone metastases. High-quality data confirm single fraction radiation therapy may be delivered to spine lesions with acceptable late toxicity. One prospective, randomized trial confirms both peripheral and spine-based painful metastases can be successfully and safely palliated with retreatment for recurrence pain with adherence to published dosing constraints. Advanced radiation therapy techniques such as stereotactic body radiation therapy lack high-quality data, leading the panel to favor its use on a clinical trial or when results will be collected in a registry. The panel's conclusion remains that surgery, radionuclides, bisphosphonates, and kyphoplasty/vertebroplasty do not obviate the need for Supplementary material for this article (http://dx.doi.org/10.1016/j.prro.2016.08.001) can be found at www.practicalradonc.org. Conflicts of interest. Before initiating work on this guideline, all panelists completed disclosure statements and pertinent disclosures are published within this report. Where potential conflicts are detected, remedial measures to address them are taken and noted here. TB received research funding from Templeton Foundation and leads ongoing bone metastases study. S.Lo. participated in international oligometastases consortium partially funded by Elekta and received honoraria and travel expenses from Accuray and Varian. These disclosures were shared with the panel. The panel and guideline subcommittee chair reviewed these relationships and determined that the disclosure here is sufficient to manage potential conflicts.

Research has shown that numerous dietary bioactive components that are not considered essential may still be beneficial to health. The dietary reference intake (DRI) process has been applied to nonessential nutrients, such as fiber, yet the majority of bioactive components await a recommended intake. Despite a plethora of new research over the past several years on the health effects of bioactives, it is possible that the field may never reach a point where the current DRI framework is suitable for these food components. If bioactives are to move toward dietary guidance, they will likely require an alternative path to get there.

There are few data on the practice of evidence based medicine in the developing world, nor on the actual sources of evidence that clinicians use in practice. To test the hypothesis that there was variation between and within developing countries in the proposed management of a patient with hospital acquired pneumonia, and that part of the variation can be explained by the sources of evidence used. Questionnaire responses to hypothetical case history. Investigators from 6 centres within the International Clinical Epidemiology Network (INCLEN) in China, Thailand, India, Egypt, and Kenya. Doctors chosen to represent primary and secondary hospital practice in the regions of the study centres. Investigations and initial treatments which would be ordered for a hypothetical 60-year-old woman who develops pneumonia 5 days after hospital admission, whether local data on antibiotic sensitivities are available and where information would be obtained to guide management. Chest x-ray and sputum gram stain/culture were consistently the most commonly ordered investigations, there being much greater variation in the initial treatment choices with either penicillin, a third-generation cephalosporin or aminoglycoside being the most popular choice. Textbooks were the commonest form of information source, and access to a library, textbooks and journals were statistically significantly associated with appropriate choice of investigations, but not treatment. Access to local antibiotic sensitivities was associated with appropriate initial treatment choice. Improving access to information in the literature and to local data may increase the practice of evidence-based medicine in the developing world.

Een intensieve vijfdaagse training Evidence-Based Medicine (EBM) leidt tot betere kennis en vaardigheden in de EBM-methode bij verzekeringsartsen. De training zorgt ook voor een betere onderbouwing van arbeidsongeschiktheidsbeoordelingen. In EBM getrainde verzekeringsartsen blijken gemotiveerd en empowered te zijn om EBM te blijven gebruiken. Zij zien de invoering van evidence-based werken als een verbetering van de kwaliteit van hun werk en als een factor die hun werk aantrekkelijker maakt. Voor het op grotere schaal invoeren van evidence-based werken, zien we bevordering van (EBM-)casuïstiekgroepen als de meest veelbelovende aanpak. Vooral wanneer deze casuïstiekbesprekingen ertoe leiden dat ook andere verzekeringsartsen profiteren van de opgedane kennis, bijvoorbeeld door middel van verzekeringsgeneeskundige mediprudentie, richtlijnen of protocollen.
- Een intensieve vijfdaagse EBM-training leidt tot een betere onderbouwing van arbeidsongeschiktheidsbeoordelingen.
- Verzekeringsartsen geven aan empowered te worden door het leren van deze methodiek, waardoor ook de communicatie met medisch specialisten en collega’s verbetert.
- Een zoekstrategie voor het identificeren van artikelen over de prognose van arbeidsongeschiktheid helpt verzekeringsartsen om sneller en beter deze onderzoeksinformatie te vinden.
- Het toepassen van EBM vereist het continu up-to-date houden van opgedane kennis en vaardigheden door middel van EBM-casuïstiekgroepen, EBM-onderwijs, en beschikbaarheid van EBM-tools en bibliotheekfaciliteiten.

Au début des années 1990, les approches d'« evidencebased medicine » ont commencé à être formalisées pour permettre l'usage le plus judicieux possible des connaissances disponibles par les praticiens, le mot « evidence » renvoyant à la fois aux idées de corroboration empirique et de preuve. Ces approches se sont étendues à d'autres sphères de la décision publique (lutte contre la pauvreté, éducation, justice, environnement...), donnant naissance à la notion d'« evidence-based policy » (EBP). Dans le monde francophone, ces approches sont souvent assimilées à un simple effet de rhétorique ou à une tentative de dépolitiser les débats. L'analyse de leur genèse invite à plus de nuances et montre plutôt la volonté de renouveler les démarches positives d'aide à la décision publique en proposant des méthodes ad hoc offrant une alternative au recours croissant à des modèles de connaissances reposant trop exclusivement sur des opinions ou des simulations qui s'exonèrent de tests de validation empiriques.