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Biomedical subjects

I Graham

Publications and source records attributed to I Graham.

At least 19 recordsLinked to original sources
PubMed1999

Evidence-based medicine and the practicing clinician.

OBJECTIVE: To assess the attitudes of practicing general internists toward evidence-based medicine (EBM-defined as the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions) and their perceived barriers to its use. DESIGN: Cross-sectional, self-administered mail questionnaire conducted between June and October 1997. SETTING: Canada. PARTICIPANTS: Questionnaires were sent to all 521 physician members of the Canadian Society of Internal Medicine with Canadian mailing addresses; 296 (60%) of 495 eligible physicians responded. Exclusion of two incomplete surveys resulted in a final sample size of 294. MAIN RESULTS: Mean age of respondents was 46 years, 80% were male, and 52% worked in large urban medical centers. Participants reported using EBM in their clinical practice always (33, 11%), often (173, 59%), sometimes (80, 27%), or rarely/never (8, 3%). There were no significant differences in demographics, training, or practice types or locales on univariate or multivariate analyses between those who reported using EBM often or always and those who did not. Both groups reported high usage of traditional (non-EBM) information sources: clinical experience (93%), review articles (73%), the opinion of colleagues (61%), and textbooks (45%). Only a minority used EBM-related information sources such as primary research studies (45%), clinical practice guidelines (27%), or Cochrane Collaboration Reviews (5%) on a regular basis. Barriers to the use of EBM cited by respondents included lack of relevant evidence (26%), newness of the concept (25%), impracticality for use in day-to-day practice (14%), and negative impact on traditional medical skills and "the art of medicine" (11%). Less than half of respondents were confident in basic skills of EBM such as conducting a literature search (46%) or evaluating the methodology of published studies (34%). However, respondents demonstrated a high level of interest in further education about these tasks. CONCLUSIONS: The likelihood that physicians will incorporate EBM into their practice cannot be predicted by any demographic or practice-related factors. Even those physicians who are most enthusiastic about EBM rely more on traditional information sources than EBM-related sources. The most important barriers to increased use of EBM by practicing clinicians appear to be lack of knowledge and familiarity with the basic skills, rather than skepticism about the concept.

Adult↗
PubMed1998

Low circulating folate and vitamin B6 concentrations: risk factors for stroke, peripheral vascular disease, and coronary artery disease. European COMAC Group.

BACKGROUND: A high plasma homocysteine concentration is a risk factor for atherosclerosis, and circulating concentrations of homocysteine are related to levels of folate and vitamin B6. This study was performed to explore the interrelationships between homocysteine, B vitamins, and vascular diseases and to evaluate the role of these vitamins as risk factors for atherosclerosis. METHODS: In a multicenter case-control study in Europe, 750 patients with documented vascular disease and 800 control subjects frequency-matched for age and sex were compared. Plasma levels of total homocysteine (before and after methionine loading) were determined, as were those of red cell folate, vitamin B12, and vitamin B6. RESULTS: In a conditional logistic regression model, homocysteine concentrations greater than the 80th percentile for control subjects either fasting (12.1 micromol/L) or after a methionine load (38.0 micromol/L) were associated with an elevated risk of vascular disease independent of all traditional risk factors. In addition, concentrations of red cell folate below the lowest 10th percentile (<513 nmol/L) and concentrations of vitamin B6 below the lowest 20th percentile (<23.3 nmol/L) for control subjects were also associated with increased risk. This risk was independent of conventional risk factors and for folate was explained in part by increased homocysteine levels. In contrast, the relationship between vitamin B6 and atherosclerosis was independent of homocysteine levels both before and after methionine loading. CONCLUSIONS: Lower levels of folate and vitamin B6 confer an increased risk of atherosclerosis. Clinical trials are now required to evaluate the effect of treatment with these vitamins in the primary and secondary prevention of vascular diseases.

Adult↗
PubMed1998

A prospective endoscopic study of scalloped folds and grooves in the mucosa of the duodenum as signs of villous atrophy.

BACKGROUND: Scalloping of the valvulae conniventes visible at endoscopy may predict the presence of villous atrophy. This prospective study was designed to discover how commonly duodenal mucosal scallops and grooves occurred and to delineate their relationship to villous atrophy. METHODS: All patients undergoing upper gastrointestinal endoscopy by a single observer over 5 years were included. After inspection of the duodenal mucosa, biopsy samples were taken from those in whom the mucosa was abnormal (n = 26) and from those in whom it was not, but where biopsy was indicated (n = 100). RESULTS: None of the 100 endoscopically normal controls had subtotal villous atrophy: 94 had normal histology, 2 had non-atrophic change, and 4 had partial villous atrophy; 14 of the 26 individuals (54%) with abnormal duodena had subtotal villous atrophy, 7 having both scallops and grooves. Four had scallops alone, and three had grooves only. All patients with both scallops and grooves had subtotal villous atrophy (100%), the positive predictive value of which was 36% for scallops alone and 38% for grooves alone. CONCLUSIONS: Scallops and grooves together indicate that subtotal villous atrophy is very likely histologically, even when that diagnosis has not been suspected. A normal duodenum excludes it.

Adult↗
PubMed1998

A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation.

Although postmenopausal women are advised to consider their values when deliberating about potential benefits and risks of hormone therapy (HRT), feasible, effective methods of decision support in primary care have yet to be established. Using an explicit decision support framework, we developed a self-administered HRT decision aid and evaluated it in a before/after study of 94 women from six family practices. An audiotape guided women through an illustrated booklet including: detailed information about HRT benefits and risks tailored to a woman's clinical risk, and a values clarification exercise to promote informed decision making consistent with personal values. After using the decision aid participants: had better general knowledge and more realistic personal expectations of HRT benefits and risks; and, felt more certain, informed, clear about values, and supported in decision making. Women's values elicited in the clarification exercise were 84% accurate in discriminating between decisions. Women with polarized preferences at baseline did not change their minds, but were better informed. Changes in preferences occurred in the uncertain group, with equal numbers accepting or declining HRT. Most participants found the decision aid comprehensible, acceptable in length and pace, and balanced. Decision aids are useful in preparing women for decision making about this complex, personal issue.

Aged↗
PubMed1997

Lung cancer practice guidelines: lessons learned and issues addressed by the Ontario Lung Cancer Disease Site Group.

PURPOSE: The primary objective was to identify the lessons learned and issues addressed by the Disease Site Group (DSG) developing guidelines on lung cancer for practitioners in the province of Ontario. METHODS: The minutes of the Ontario Lung Cancer Disease Site Group (LCDSG) and the meeting notes of a medical sociologist who attended all LCDSG meetings were reviewed to identify the disease-specific and generic issues addressed by the LCDSG during guideline development. RESULTS AND CONCLUSION: The Ontario LCDSG has completed three practice guidelines and has five evidence-based recommendations (EBRs) in production. Topics for guideline development were selected on the basis of known practice variability (eg, advanced-stage non-small-cell lung cancer [NSCLC]); the size of the patient population that could potentially be affected by the guideline; results of phase II trials of new and potentially expensive agents (vinorelbine, paclitaxel, and docetaxel); and randomized controlled clinical trials that support new practice standards (combined modality therapy for unresectable stage III NSCLC). The wording of each EBR reflects the strength and quality of the evidence in support of the treatment option, the primary outcome(s), and the individual physician and discipline values concerning treatment outcomes in the absence of known patient values.

Canada↗
PubMed1996

A presentation of a conceptual framework and its use in the definition of nursing development within a number of nursing development units.

This paper provides a conceptual framework upon which action plans can be built to enable registered nurses to reflect upon their work and practice activities. This conceptual framework has been used by the author in his work with various nursing development units within Yorkshire, England, in his role as their academic nurse advisor. The framework has been useful in helping nurses not only to reflect upon current work and practice activities but also as a guideline for future development. The paper provides examples of such nursing development activities and includes a personal view of how nursing development units can act as catalysts for change.

Clinical Nursing Research↗
PubMed1995

Hyperhomocysteinemia in premature arterial disease: examination of cystathionine beta-synthase alleles at the molecular level.

Hyperhomocysteinemia occurs in approximately 30% of the patients with premature occlusive arterial disease (POAD). Some of these exhibit significantly reduced fibroblast cystathionine beta-synthase (CBS) activities, suggesting that they may be heterozygous for CBS deficiency. To test this possibility, we studied cDNA derived from four well characterized patients with POAD, exhibiting hyperhomocysteinemia and reduced CBS activities, from four normal controls, and from four obligatory heterozygotes for CBS deficiency. Lysates of individual colonies of E.coli, containing full-length PCR-amplification products in the expression vector, pKK388.1, were tested for CBS activity. cDNA from at least seven of the eight possible independent POAD alleles encoded catalytically active, stable CBS which exhibited normal response to both PLP and AdoMet. The sequences of all 3'-untranslated regions of all seven isolated POAD alleles were identical to the normal, 'wild-type' CBS sequences. The results of the expression studies were confirmed for one POAD patient by determining the full-length cDNA sequences for both alleles; these were entirely normal over the complete length of the cDNA. In contrast, the screening method correctly distinguished mutant from normal alleles in all four obligatory heterozygotes studied. We conclude that CBS mRNAs from POAD individuals are free from inactivating mutations, including all 33 previously identified in heterozygous carriers and homocystinuric patients.

Alleles↗