What have new efforts to change professional practice achieved? Cochrane Effective Practice and Organization of Care Group.
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Diffusion of Innovation↗
Biomedical subjects
M A Thomson
Publications and source records attributed to M A Thomson.
Resting energy expenditure, pulmonary inflammation, and genotype in the early course of cystic fibrosis.
To further investigate the early course of cystic fibrosis (CF), specifically to examine factors contributing to energy imbalance, we examined resting energy expenditure (REE) (by indirect calorimetry) per unit body weight and metabolically active body cell mass (by total body potassium), in relation to CF genotype (by genomic DNA analysis), CF pancreatic phenotype, and markers of pulmonary inflammation (from bronchoalveolar lavage fluid). Eighteen subjects with presymptomatic CF who were less than 2 years of age (n = 11, delta F508/ delta F508 genotype; n = 15, pancreatic insufficiency phenotype), identified by newborn screening, were compared with age-, sex-, and length-matched control subjects (n = 13). Those with the delta F508/ delta F508 genotype had significantly higher mean REE expressed per unit body weight (125%) and body cell mass (115%; p < 0.03). Those with other genotypes (n = 7) did not, as a group, have significantly different mean REEs, but individuals with known "severe" genotypes had REEs in the high range and those with a pancreatic-sufficient phenotype had significantly lower REE than those with a pancreatic-insufficient phenotype (p < 0.05), and REEs were in the normal range. Examination of bronchoalveolar lavage fluid revealed positive culture results (7/10) but variable colony counts, neutrophil percentages, and concentrations of interleukin-8 and interleukin-1 beta equally in both CF genotype groups. These markers of pulmonary inflammation were not correlated, individually or collectively, with REE or genotype. We conclude that genotypic variations in energy balance are detectable early in CF unrelated to lung inflammation. Subclinical defects in body composition and pulmonary integrity occur early in CF and, in combination with increased cellular metabolic activity, have important clinical implications with respect to early diagnosis and management.
Body Composition↗
Treatment of traveller's diarrhoea. Economic aspects.
Traveller's diarrhoea (TD) is an enteric infective disease seen in 30 to 50% of the 30 million people who travel annually from the developed world to developing countries. It is the commonest disorder affecting international travellers. Although usually trivial, a significant minority of patients may develop a more protracted disease with an attendant increase in morbidity. This may then incur financial costs to the travellers themselves and to the healthcare systems of the host and origin countries. Advice regarding risk avoidance has so far proved ineffective in altering the behaviour of travellers and consequently the incidence of TD among them. Hard data are lacking on the cost effectiveness and cost benefit of prophylaxis and treatment of TD. Thus, we have attempted to quantify, as far as is possible, the total cost of TD and to set this against the potential savings from avoiding TD if prophylaxis or treatment options were universally employed. It must be noted that the financial benefit-cost ratio of an intervention may not be the most suitable measure of its desirability. However, such concepts as the success of travel are inherently difficult to quantify in economic terms. This analysis applies to travellers from the UK and economic variations between countries will after the outcomes obtained. Nevertheless, given these necessary constraints, all possible treatment options have a more favourable benefit-cost ratio than prophylaxis. In conclusion, the case for prophylaxis is not strong except in selected high risk groups, and limited self-treatment seems economically justified.
Diarrhea↗
No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.
OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.
Humans↗
Changing physician performance. A systematic review of the effect of continuing medical education strategies.
OBJECTIVE: To review the literature relating to the effectiveness of education strategies designed to change physician performance and health care outcomes. DATA SOURCES: We searched MEDLINE, ERIC, NTIS, the Research and Development Resource Base in Continuing Medical Education, and other relevant data sources from 1975 to 1994, using continuing medical education (CME) and related terms as keywords. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts. STUDY SELECTION: We reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes. These intervention strategies included (alone and in combination) educational materials, formal CME activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders. Studies were selected only if more than 50% of the subjects were either practicing physicians or medical residents. DATA EXTRACTION: We extracted the specialty of the physicians targeted by the interventions and the clinical domain and setting of the trial. We also determined the details of the educational intervention, the extent to which needs or barriers to change had been ascertained prior to the intervention, and the main outcome measure(s). DATA SYNTHESIS: We found 99 trials, containing 160 interventions, that met our criteria. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact. CONCLUSION: Widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers.
Decision Making↗
Abnormal ipsilateral functional vibrissae projection onto Purkinje cells multiply innervated by climbing fibers in the rat.
We have previously shown that synapse elimination occurring in the climbing fiber (CF)-Purkinje cell (PC) relationships during normal postnatal development is likely involved in the refinement of vibrissae projections onto the cerebellar cortex. In normal adult rats, CF-mediated vibrissae projections onto cerebellar Purkinje cells of the vermis of lobule VII are strictly contralateral and located in a narrow microzone whereas they are widely distributed in rats whose PCs remained multiply innervated by CFs due to postnatal irradiation. Given the proximity of this microzone to the midline, the question arose as to whether this synapse elimination process could participate in the segregation of ipsilateral and contralateral projections. In the present study, we compared the topographical map of the ipsilateral and contralateral CF-mediated projections of the third row of vibrissae onto the vermal PCs of lobule VII in adult normal rats and in polyinnervated rats. Using intracellular electrophysiological recordings, we examined the responsiveness of PCs to mechanical stimulation of vibrissae, and positioned responsive cells on an averaged planar map of lobule VII. In normal rats no ipsilateral responses were found, while in irradiated rats ipsilateral responses were distributed evenly from the midline to 700 microns apart. These results suggest that synapse elimination participates in the segregation of ipsi and contralateral mystacial inputs to the vermis.
Animals↗
Measured versus predicted resting energy expenditure in infants: a need for reappraisal.
The reliability of commonly used predictive equations for estimating energy expenditure in infants in both health and disease was assessed by comparing resting energy expenditure (REE, measured by indirect calorimetry) in relation to weight, height, and body cell mass (by total body potassium analysis) with predictive equations (Harris-Benedict, Food and Agriculture Organization/World Health Organization/United Nations University (FAO/WHO/UNU), Schofield weight-only, and Schofield weight-and-height equations) in 36 healthy infants (age 0.43 +/- 0.27 years; 19 male) and in 9 infants with cystic fibrosis (age 0.41 +/- 0.30 years; 4 male). Mean +/- SD REE for healthy boys was 0.205 +/- 0.019 MJ kg-1 day-1 and for healthy girls 0.217 +/- 0.026 MJ kg-1 day-1. Infants with cystic fibrosis had a significantly higher REE (0.258 +/- 0.034 vs 0.210 +/- 0.024 MJ kg-1 day-1; p < 0.005). Compared with measured values, predicted REE values varied markedly among equations, overestimating REE in healthy infants (Harris-Benedict equation, 182% +/- 63% (SD) of measured values; FAO/WHO/UNU equation, 104% +/- 14%; Schofield weight-only equation, 107.5% +/- 14%; and Schofield weight-and-height equation, 106% +/- 11%) and underestimating REE in those with cystic fibrosis (84% to 88% for the FAO/WHO/UNU, Schofield weight-only, and Schofield weight-and-height equations) except the Harris-Benedict equation (152%). On regression analysis both weight and body cell mass were related significantly to REE (r2 = 0.87 and r2 = 0.61, respectively) for normal infants and (r2 = 0.92 and r2 = 0.94) for those with cystic fibrosis. Using a generalized linear model of variance, we saw a significant (p < 0.001) variability among all REE measures. Thus we could rely on none of the predictive equations to give an accurate estimate of REE, and hence energy and fluid requirements, in individual infants. We suggest that when accurate estimates are needed, measurement of REE in individual infants should be attempted, especially in disease states, and that the continued use of current formulas should be reexamined.
Body Composition↗
Canine-human transmission of Gastrospirillum hominis.
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Animals↗
Canine-human transmission of Gastrospirillum hominis.
We report electron microscopic evidence of transmission from a pet dog to a 12-year-girl of Gastrospirillum hominis which caused gastric disease in both that was eradicable with treatment.
Animals↗
Enlargement of olivo-cerebellar microzones in the agranular cerebellum of adult rats.
Previous work on normal adult rat showed that the vibrissae project, through the climbing fiber (CF) system, onto the Purkinje cells (PCs) of the contralateral cerebellar hemivermis of lobule VII. The highly elaborated CF projections from a given row of vibrissae delimit a narrow parasagittal zone which can be regarded as a functional olivo-cerebellar microzone. Interestingly, the adult one-to-one relationship between PCs and CFs is preceded by a transient phase during which each PC receives synaptic inputs from several CF collaterals which will be eliminated but one, when granule cells begin to establish synapses on PCs. Therefore, the question arose as to whether this synaptic elimination process could participate in the refinement of the topographical organization of CF projections and could contribute to the formation of such precise peripheral maps onto the cerebellum. In the present study, the topographical map of the CF-mediated projection of mystacial vibrissae onto the vermal PCs of lobule VII was determined in adult rats whose cerebellar PCs remain polyinnervated by olivary CFs due to degranulation by postnatal X-irradiation. Using intracellular recordings, we examined the responsiveness of PCs in lobule VII during mechanical stimulation of the 3rd row of contralateral vibrissae, and positioned cells responding to the stimulation on an averaged planar map of lobule VII. Comparison of the results to those obtained in our previous work on normal rats showed that the activated cells were more numerous and more diffusely distributed.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Persistent wheezing and gastroesophageal reflux in infants.
We have evaluated the presence of gastroesophageal reflux (GER) and the effect of its treatment in 12 infants (mean age, 7 months; range, 4-11 months) with persistent wheezing not responding to bronchodilators and anti-inflammatory asthma medications. All patients had GER on cineradiography and significant acid reflux on 24 hour pH monitoring (percentage of time pH < 4 ranged from 6.1 to 47%). All infants were initially treated with prokinetic agents and with receptor histamine antagonists in addition to aggressive pulmonary therapy. Six patients treated medically had substantially decreased use of asthma medications, completely discontinuing them within 2-4 months. Two patients, though significantly improved, require intermittent asthma therapy. Four patients responding poorly to GER and asthma treatment for 2 months to 2 years had fundoplications. These had an excellent outcome over 1-4.5 years follow-up; only one patient required further asthma medications. Pulmonary function testing was done in six patients before and after 6-8 weeks of therapy indicating significant improvement in peripheral airflow: terminal flow/peak tidal expiratory flow (TEF25/PTEF), and percentage of total expiratory time to reach peak tidal expiratory flow (Tp/Te or Tme/Te). Our experience suggests that evaluation for GER should be considered in infants with persistent wheezing. Aggressive medical and possibly surgical therapy for GER may resolve persistent wheezing.
Anti-Inflammatory Agents↗
Efficacy of electromyographic biofeedback compared with conventional physical therapy for upper-extremity function in patients following stroke: a research overview and meta-analysis.
BACKGROUND AND PURPOSE: The purpose of this study was to examine the efficacy of electromyographic biofeedback compared with conventional physical therapy for improving upper-extremity function in patients following a stroke. SUBJECTS AND METHODS: A literature search was done for the years 1976 to 1992. The selection criteria included single-blinded randomized control trials. Study quality was assessed for nine criteria. For functional (disability index or stage of recovery) and impairment outcomes, meta-analyses were performed on odds ratios for improvement versus no improvement. Mann-Whitney U-Test probability values were combined across studies. RESULTS: Six studies were selected, and outcome data were obtained for five studies. The common odds ratio was 2.2 for function and 1.1 for impairments in favor of biofeedback. The estimate of the number needed to treat to prevent a nonresponder was 11 for function and 22 for impairments. None of the meta-analyses were statistically significant. CONCLUSIONS AND DISCUSSION: The results do not conclusively indicate superiority of either form of therapy. Although there is a chance of Type II error, the estimated size of the effect is small. Given this estimate of little or no difference, therapists need to consider cost, ease of application, and patient preference when selecting these therapies.
Activities of Daily Living↗
Antenatal assessment of neurological impairment.
An unreactive cardiotocograph late in the mid-trimester led to a sequence of investigations that revealed an appropriately grown fetus, with hepatic calcification, and evidence of intrauterine infection. Ultrasound observation and stimulation of the fetus with vibration and glucose revealed altered neurophysiological responses. The profound neurological impairment was confirmed by detailed neonatal investigations.
Adult↗
Evidence for the effectiveness of CME. A review of 50 randomized controlled trials.
OBJECTIVE: To assess the impact of diverse continuing medical education (CME) interventions on physician performance and health care outcomes. DATA SOURCES: Using continuing medical education and related phrases, we performed regular searches of the indexed literature (MEDLINE, Social Science Index, the National Technical Information Service, and Educational Research Information Clearinghouse) from 1975 through 1991. In addition, for these years, we used manual searches, key informants, and requests to authors to locate other indexed articles and the nonindexed literature of adult and continuing professional education. STUDY SELECTION: From the resulting database we selected studies that met the following criteria: randomized controlled trials; educational programs, activities, or other interventions; studies that included 50% or more physicians; follow-up assessments of at least 75% of study subjects; and objective assessments of either physician performance or health care outcomes. DATA EXTRACTION: Studies were reviewed for data related to physician specialty and setting. Continuing medical education interventions were classified by their mode(s) of activity as being predisposing, enabling, or facilitating. Using the statistical tests supplied by the original investigators, physician performance outcomes and patient outcomes were classified as positive, negative, or inconclusive. DATA SYNTHESIS: We located 777 CME studies, of which 50 met all criteria. Thirty-two of these analyzed physician performance; seven evaluated patient outcomes; 11 examined both measures. The majority of the 43 studies of physician performance showed positive results in some important measures of resource utilization, counseling strategies, and preventive medicine. Of the 18 studies of health care outcomes, eight demonstrated positive changes in patients' health care outcomes. CONCLUSION: Broadly defined CME interventions using practice-enabling or reinforcing strategies consistently improve physician performance and, in some instances, health care outcomes.
Clinical Competence↗
[Does synaptic elimination contribute to the organization of cerebellar microzones of climbing fiber projection?].
In adult rats whose cerebellar Purkinje cells (PCs) remain polyinnervated by olivary climbing fibres (CFs) after postnatal irradiation, topographical maps of responsive PCs to mechanical stimulation of the third row of contralateral vibrissae show that these cells are more numerous and more diffusely distributed than in the normal rat. PCs responding with the "best responses" are distributed evenly from the midline to 400 microns lateral in the contralateral hemivermis of lobule VII, and not in a parasagittal microzone centred on the plane 200 microns as in the normal rat. Thus it seems likely that synaptic elimination should contribute to microzone formation during postnatal development of the normal cerebellum.
Action Potentials↗
Extent of multiple innervation of cerebellar Purkinje cells by climbing fibers in adult X-irradiated rats. Comparison of different schedules of irradiation during the first postnatal week.
The multiple innervation of cerebellar Purkinje cells (PCs) by climbing fibers (CFs) that is transient in normal developing rats can be experimentally maintained in cerebella which have been degranulated by repetitive postnatal X-irradiation restricted to the first postnatal week. Since the involution of redundant CFs occurs essentially between postnatal days 5 and 10, and given that postirradiation effects last 2-3 days, the question arose to know whether it is possible to further delimit a 'critical period' of irradiation within the first week. An estimate of the extent of multiple innervation of PCs by CFs was made in adult rats that had been irradiated according to 5 different schedules: in two groups, rats received X-rays applied repetitively during the first postnatal week (PN0-7 groups); in the 3 other groups, X-rays were delivered either during the first part of the week (early group PN1-3) or during the last part of the week (late groups PN4-7). In addition, two daily doses were tested (150 and 200 r). The CF pathway was electrically stimulated in anesthetized rats at the level of the inferior olive or in the cerebellar white matter. Intracellular recordings of spontaneous and evoked CF responses in PCs allowed to estimate the number of afferent CFs and to calculate the mean value (m) per PC for each group. The majority of recorded cells was located in lobules VII and VIII and similar results were obtained in these two lobules.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Effect of station examination item sampling on generalizability of student performance.
This article may be of interest to physical therapy educators who are responsible for structuring station or practical examinations used to evaluate physical therapy students. The global intent of the article is to provide information that may be useful in selecting test items. Specifically, the purposes of this study were 1) to examine how two item-sampling strategies (one based on different diagnostic concepts, or diagnostic probes, and the other based on different anatomical sites) influenced the generalizability of a station examination, 2) to determine the interrater reliability during the station examination, and 3) to determine whether the status of the rater (that of observer or simulated patient) influenced the rating. Using a nested study design, 24 physical therapy students were assessed by eight raters. The raters were randomly and equally assigned to four teams. Each team assessed six students. One rater acted as the simulated patient for the first three students in each group, and the other rater acted as observer. This order was reversed for the last three students. Each student performed nine mini-diagnostic patient cases consisting of three diagnostic probes reproduced at three different anatomical sites. The results demonstrate that 1) similar diagnostic concepts can be generalized across anatomical sites, although different concepts or skills cannot be generalized at a given anatomical site or across sites; 2) interrater reliability was excellent; and 3) the status of the raters (ie, simulated patient or observer) did not bias the ratings.(ABSTRACT TRUNCATED AT 250 WORDS)
Clinical Competence↗
Dexamethasone and infection in preterm babies: a controlled study.
To find out if the use of steroids affected the incidence of infection in babies who were nursed in the neonatal intensive care unit for nine weeks or more, 24 preterm babies who had received a three weeks course of dexamethasone (0.6 mg/kg/day, reducing to 0.3 mg/kg/day after a week, and 0.15 mg/kg/day after two weeks) were compared with 18 preterm babies who had not been so treated. No differences were found in the incidence or pattern of septicaemia or other bacteriologically proved infections between the groups. Of 57 episodes of septicaemia, 44 (77%) were caused by coagulase negative staphylococci.
Bacterial Infections↗