Patient-detected diurnal changes in spleen volume.
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Adult↗
Biomedical subjects
C Silagy
Publications and source records attributed to C Silagy.
A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult.
OBJECTIVE: To review effectiveness of screening for colorectal cancer with faecal occult blood test, Hemoccult, and to consider benefits and harms of screening. DESIGN: Systematic review of trials of Hemoccult screening, with meta-analysis of results from the randomised controlled trials. SUBJECTS: Four randomised controlled trials and two non-randomised trials of about 330 000 and 113 000 people respectively aged >=40 years in five countries. MAIN OUTCOME MEASURES: Meta-analysis of effects of screening on mortality from colorectal cancer. RESULTS: Quality of trial design was generally high, and screening resulted in a favourable shift in the stage distribution of colorectal cancers in the screening groups. Meta-analysis of mortality results from the four randomised controlled trials showed that those allocated to screening had a reduction in mortality from colorectal cancer of 16% (relative risk 0.84 (95% confidence interval 0.77 to 0.93)). When adjusted for attendance for screening, this reduction was 23% (relative risk 0.77 (0.57 to 0.89)) for people actually screened. If a biennial Hemoccult screening programme were offered to 10 000 people and about two thirds attended for at least one Hemoccult test, 8.5 (3.6 to 13.5) deaths from colorectal cancer would be prevented over a period of 10 years. CONCLUSION: Although benefits of screening are likely to outweigh harms for populations at high risk of colorectal cancer, more information is needed about the harmful effects of screening, the community's responses to screening, and costs of screening for different healthcare systems before widespread screening can be recommended.
Adult↗
A prospective randomized trial of an urban general practice attachment for medical students.
A randomized controlled trial was undertaken to evaluate the effectiveness of a new model for providing urban general practice attachments for final-year medical students at the Flinders University of South Australia. All the student groups in that year were randomized prospectively to either the standard student attachment, as run by the university, or to an attachment organized by a project team from a local network of general practitioners. Students in the intervention group had their personal learning goals assessed and matched with their general practice preceptors, and the students were set a task that developed their contact with other health resources in the community. Results from an evaluation questionnaire completed by the students at the end of their terms showed that the students in the intervention group rated their general practice preceptors more highly, had more contact with allied health and community organizations, felt that they had met their own learning goals to a greater extent, and enjoyed their term more. Student examination results showed that the students in the intervention group did not perform as well in one of the four areas of their end of term examination as did the students in the standard attachment. The additional cost of providing the intervention was estimated to be A$340 per student. We conclude that long-term decisions about adopting this new model of organizing general practice attachments on a wider scale will need to balance the apparent benefits against the increased resources required.
Education, Medical, Undergraduate↗
Prostate cancer testing in SA men: influence of sociodemographic factors, health beliefs and LUTS.
This study investigates the prevalence and determinants of prostate cancer screening in the South Australian community. An interview-based survey of a probability sample of the SA population (N = 3,016) in 1995 addressed previous PSA testing, beliefs about vulnerability to prostate cancer and efficacy of screening, presence of uncomplicated lower urinary tract symptoms (LUTS) and sociodemographic variables. Of 736 men, 40 years and over with no history of prostate cancer, 24.7% (182/736) reported ever having had a test and 53.9% (397) reported an intention to test; 74% (547) agreed that prostate cancer could be cured if detected early, while only 14.9% (109) believed they were unlikely to suffer from prostate cancer. In a logistic regression model, visit to a doctor for (but not presence of) LUTS was a strong, independent predictor of participation in PSA testing (OR 9.0, 95% CI 5.0, 16.0). Beliefs, occupation and education were not. In a similar model examining intention to test, belief in vulnerability to prostate cancer was the strongest predictor (OR 3.32, 95% CI 1.9, 5.9), followed by doctor visit for urinary symptoms. These data are consistent with widespread PSA testing and with seeking treatment for LUTS being a major determinant of previous testing. NHMRC Clinical Guidelines for LUTS recommend against PSA testing for investigation of uncomplicated LUTS. Implementation of those guidelines may therefore have a significant effect on PSA testing rates. Belief in personal vulnerability to prostate cancer remains a significant component of reported future testing, suggesting a focus for community education.
Adult↗
How should we research unconventional therapies? A panel report from the Conference on Complementary and Alternative Medicine Research Methodology, National Institutes of Health.
Research in unconventional medicine requires a number of different questions to build up a "mosaic" of evidence. Choice of research design depends on the question being asked and is independent of the therapy under investigation. Despite the doubts of some practitioners, randomized trials are of value for determining certain questions in alternative medicine.
Complementary Therapies↗
A systematic review of the effectiveness of promoting lifestyle change in general practice.
BACKGROUND: There is increasing evidence that particular lifestyle behaviours increase the risk of disease and it is widely argued that GPs are ideally placed to encourage patients to modify their behaviour in these areas and thereby reduce their disease risk. There is therefore a need for evidence that GP-based lifestyle interventions are effective in eliciting behaviour change. As there has been no comprehensive attempt to review the literature on this subject, we chose to conduct a systematic review, incorporating meta-analytic techniques where possible, to address this need. OBJECTIVES: This study aimed to examine how effective lifestyle advice provided by GPs is in changing patient behaviour. The following four areas of behaviour were examined: smoking, alcohol consumption, diet, and exercise. METHOD: The review was restricted to English-language reports of trials which investigated the effectiveness of lifestyle advice provided in a general practice setting. Studies were included where it could be established that subjects were randomly allocated to experimental groups and where a comparison was made between either a "no intervention' or "usual care' control group, or between advice of differing intensities. Six electronic databases were searched and a total of 37 trials were selected for inclusion in the review. Meta-analytic techniques were employed to analyse the data from the smoking advice trials. The results form the trials concerned with the other three behaviours did not lend themselves to this form of analysis. Outcome data were extracted from these trials and summarized in tabular form. RESULTS: The results of this review suggest that whilst many of the general practice-based lifestyle interventions show promise in effecting small changes in behaviour, none appears to produce substantial changes. CONCLUSION: There is a need for more extensive and rigorous research in this area before substantial public funds are committed to general practice-based health promotion. Furthermore, it is clear that if general practice-based interventions are to be effective in a public health sense, a greater number of GPs will need to become involved in promoting behaviour change than the literature suggests is currently occurring.
Alcohol Drinking↗
Systematic reviews.
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Data Interpretation, Statistical↗
Evidence-based cardiac practice.
Increasing attention is being placed on using an evidence-based approach within health care decision making. In order to apply this approach to a particular clinical scenario, the relevant clinical evidence must be available, accessible, accepted, applied, and audited. Cardiovascular medicine is a discipline in which a large body of evidence is available. The development of the Cochrane Library, as a source of systematic reviews concerning the effects of health care, will make this evidence more accessible. However, caution is required in interpreting systematic reviews, particularly when meta-analytic techniques are used, to ensure that potential sources of bias in the identification and synthesis of the primary studies are minimised. A further challenge is to develop strategies to ensure the evidence is accepted and applied in clinical practice. Although there are no magic bullets to change behaviour of positions, there are a number of strategies which have been shown to influence change positively in clinical practice.
Australia↗
Attitudes of rural general practitioners towards undergraduate medical student attachments.
OBJECTIVE: Increasing exposure of undergraduate medical students to rural practice is a key component of the national effort in Australia to redress the rural workforce shortage. For this exposure to be successful, willing cooperation of current rural general practitioners is essential. To date there has been no formal assessment of rural general practitioners' attitudes to having undergraduate medical students attached to their practice. METHOD: A descriptive survey, using a mailed questionnaire was sent to all 316 general practitioners currently practising in rural areas of South Australia, as identified from the database maintained by the South Australian Rural Practice Training Unit. RESULTS: A 71.5% response rate (n = 225) was achieved, of which 203 were eligible for inclusion. Of these, 176 doctors had medical student attachments in their practice on at least one occasion; 74.4% of whom (n = 131) perceived the attachments to have a positive experience on their continuing medical education experience, and 81.1% (n = 142) described a positive experience on their professional development. However, 52.6% (n = 92) felt the attachments had a negative effect on their income. Almost all the doctors who were included in the survey (94.6%, n = 192) were willing to have students attached to their practice in the future for between one to two weeks. Of these, 169 wanted quality assurance points, 112 wanted financial reimbursement, and 108 wanted 'academic status' with a university. CONCLUSION: The results suggest that rural general practitioners are willing to have students attached to their practice for periods between one to two weeks, providing they receive quality assurance points, and to a lesser extent, financial reimbursement and academic status.
Attitude of Health Personnel↗
The Cochrane Collaboration: New Zealand gets involved.
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Humans↗
Development of a prospective register of smoking cessation trials.
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Clinical Trials as Topic↗
Can resource use be extracted from randomized controlled trials to calculate costs? A review of smoking cessation interventions in general practice.
The ability to extract information on resource use from randomized controlled trials can provide the groundwork for systematically compiling health economic reviews of health interventions. A review of the brief smoking interventions in general practice demonstrates that not all the necessary information can be extrapolated from these trials, and cost data will have to be supplemented from other sources.
Cost-Benefit Analysis↗
Treatments for postherpetic neuralgia--a systematic review of randomized controlled trials.
BACKGROUND: A number of different therapies have been used for postherpetic neuralgia. We decided to conduct a systematic review of existing randomized controlled trials. OBJECTIVE: To determine the efficacy of available therapies for relieving the pain of established postherpetic neuralgia. METHODS: We performed a systematic review, including meta-analysis, of existing randomized controlled trials. Eleven published trials and one unpublished trial were identified which met the inclusion criteria and were included in the current review. RESULTS: Pooled analysis of the effect of tricyclic antidepressants demonstrate statistically significant pain relief (OR 0.15, CI 0.08-0.27). Pooling of the results of the three trials comparing the effects of capsaicin and placebo could not be done due to heterogeneity. This heterogeneity was mainly attributable to an unpublished trial which differed in terms of the dose and duration of treatment. When this study was omitted, no heterogeneity was found and the pooled analysis revealed a statistically significant benefit (OR 0.29, 95% CI 0.16-0.54). However, problems with blinding in patients using capsaicin may have accounted for the positive effect. One small study of vincristine iontophoresis compared to placebo also yielded a favourable result (OR 0.05, 95% CI 0.01-0.26). Other treatment evaluated include lorazepam, acyclovir, topical benzydamine, and acupuncture. We found no evidence that these are effective in relieving pain associated with postherpetic neuralgia. CONCLUSION: Based on evidence from randomized trials, tricyclic anti-depressants appear to be the only agents of proven benefit for established postherpetic neuralgia.
Analgesics↗
Health economic reviews. Are they compiled systematically?
Attempts to perform economic reviews of randomized controlled trials frequently lack a systematic approach. This conclusion is consistent with the findings of previous analyses of review articles in other fields, which have highlighted the failure to apply the same degree of rigor to this type of research synthesis that the scientific community has come to expect from primary research articles.
Bibliometrics↗
Cochrane collaboration in primary health care--implications for general practice.
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Australia↗
The move towards evidence-based medicine.
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Clinical Medicine↗
Strategies for reducing coronary risk factors in primary care: which is most cost effective?
OBJECTIVE: To examine the relative cost effectiveness of a range of screening and intervention strategies for preventing coronary heart disease in primary care. SUBJECTS: 7840 patients aged 35-64 years who were participants in a trial of modifying coronary heart disease risk factors in primary care. DESIGN: Effectiveness of interventions assumed and the potential years of life gained estimated from a risk equation calculated from Framingham study data. MAIN OUTCOME MEASURE: The cost per year of life gained. RESULTS: The most cost effective strategy was minimal screening of blood pressure and personal history of vascular disease, which cost 310 pounds-930 pounds per year of life gained for men and 1100 pounds-3460 pounds for women excluding treatment of raised blood pressure. The extra cost per life year gained by adding smoking history to the screening was 400 pounds-6300 pounds in men. All strategies were more cost effective in men than in women and more cost effective in older age groups. Lipid lowering drugs accounted for at least 70% of the estimated costs of all strategies. Cost effectiveness was greatest when drug treatment was limited to those with cholesterol concentrations above 9.5 mmol/l. CONCLUSIONS: Universal screening and intervention strategies are an inefficient approach to reducing the coronary heart disease burden. A basic strategy for screening and intervention, targeted at older men with raised blood pressure and limiting the use of cholesterol lowering drugs to those with very high cholesterol concentrations would be most cost effective.
Adult↗
The Cochrane Collaboration in Primary Care: an international resource for evidence-based practice of family medicine.
In recent years, promoting the use of evidence-based decision making in health care has been gaining popularity. This method of decision making requires that the results of primary research be compiled in a systematic manner and made accessible to those involved in the decision-making process. Failure to do this may result in a considerable lag period before therapies of proven effectiveness are implemented in medical practice or ineffective therapies are withdrawn from practice. The Cochrane Collaboration in Primary Health Care was established as part of an international effort to facilitate the preparation, maintenance, and dissemination of systematic reviews of the effects of health care provided in, or relevant to family practice. This paper describes the progress made in establishing the Cochrane Collaboration as an international register of randomized controlled trials in family medicine that will subsequently be used for undertaking systematic reviews in the discipline.
Clinical Trials as Topic↗