Biomedical subjects
Martin Dawes
Publications and source records attributed to Martin Dawes.
The Bug Buster kit was better than single dose pediculicides for head lice.
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Colorectal cancer screening: physicians' knowledge of risk assessment and guidelines, practice, and description of barriers and facilitators.
BACKGROUND: Physician nonadherence to colorectal cancer (CRC) screening recommendations contributes to underuse of screening. OBJECTIVE: To assess physicians' knowledge of CRC screening guidelines for average-risk individuals, perceived barriers to screening and practice behaviours. METHODS: Between October 2004 and March 2005, staff physicians working in three university-affiliated hospitals in Montreal, Quebec, were surveyed. Self-administered questionnaires assessed knowledge of risk classification and current guidelines for average-risk individuals, as well as perceptions of barriers to screening and practice behaviours. RESULTS: All 65 invited physicians participated in the survey, including 46 (70.8%) family medicine physicians and 19 (29.2%) general internists. Most physicians knew that screening should begin at 50 years of age, all knew to screen men and women and 92% said they screened average-risk patients. Fifty-seven (87.7%) physicians correctly identified three common characteristics associated with high risk for developing CRC. Physicians who screened average-risk patients preferred fecal occult blood testing (88.3%) and colonoscopy (88.3%) to flexible sigmoidoscopy (10.0%) and double-contrast barium enema (30.0%). Most physicians knew the correct screening periodicity for fecal occult blood testing (87.6%), but only 40% or fewer could identify correct screening periodicities for the other modalities. Barriers and facilitators focused on health care delivery system improvements, better evidence on which to base recommendations and development of practical screening modalities. CONCLUSIONS: Physicians lacked knowledge of the recommended screening modalities and periodicities to appropriately screen average-risk individuals. Because CRC screening can reduce mortality, efforts to improve physician delivery should focus on physician knowledge and changes to the health care delivery system.
The development and evaluation of an integrated electronic prescribing and drug management system for primary care.
OBJECTIVE: To develop and evaluate the acceptability and use of an integrated electronic prescribing and drug management system (MOXXI) for primary care physicians. DESIGN: A 20-month follow-up study of MOXXI (Medical Office of the XXIst Century) implementation in 28 primary care physicians and 13,515 consenting patients. MEASUREMENT: MOXXI was developed to enhance patient safety by integrating patient demographics, retrieving active drugs from pharmacy systems, generating an automated problem list, and providing electronic prescription, stop order, automated prescribing problem alerts, and compliance monitoring functions. Evaluation of technical performance, acceptability, and use was conducted using audit trails, questionnaires, standardized tasks, and information from comprehensive health insurance databases. RESULTS: Perceived improvements in continuity of care and professional autonomy were associated with physicians' expected use of MOXXI. Physician speed in using MOXXI improved substantially in the first three months; however, only the represcribing function was faster using MOXXI than by handwritten prescription. Physicians wrote electronic prescriptions in 36.9 per 100 visits and reviewed the patient's drug profile in 12.6 per 100 visits. Physicians rated printed prescriptions, the current drug list, and the represcribing function as the most beneficial aspects of the system. Physicians were more likely to use the drug profile for patients who used more medication, made more emergency department visits, had more prescribing physicians, and lower continuity of care. CONCLUSION: Primary care physicians believed an integrated electronic prescribing and drug management system would improve continuity of care, and they were more likely to use the system for patients with more complex, fragmented care.
Combing and combating head lice.
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Sicily statement on evidence-based practice.
BACKGROUND: A variety of definitions of evidence-based practice (EBP) exist. However, definitions are in themselves insufficient to explain the underlying processes of EBP and to differentiate between an evidence-based process and evidence-based outcome. There is a need for a clear statement of what Evidence-Based Practice (EBP) means, a description of the skills required to practise in an evidence-based manner and a curriculum that outlines the minimum requirements for training health professionals in EBP. This consensus statement is based on current literature and incorporating the experience of delegates attending the 2003 Conference of Evidence-Based Health Care Teachers and Developers ("Signposting the future of EBHC"). DISCUSSION: Evidence-Based Practice has evolved in both scope and definition. Evidence-Based Practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources. Health care professionals must be able to gain, assess, apply and integrate new knowledge and have the ability to adapt to changing circumstances throughout their professional life. Curricula to deliver these aptitudes need to be grounded in the five-step model of EBP, and informed by ongoing research. Core assessment tools for each of the steps should continue to be developed, validated, and made freely available. SUMMARY: All health care professionals need to understand the principles of EBP, recognise EBP in action, implement evidence-based policies, and have a critical attitude to their own practice and to evidence. Without these skills, professionals and organisations will find it difficult to provide 'best practice'.
Surgical margins in cutaneous melanoma (2 cm versus 5 cm for lesions measuring less than 2.1-mm thick).
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Intra-articular steroid injections for painful knees. Systematic review with meta-analysis.
OBJECTIVE: Do intra-articular steroid injections relieve the pain of osteoarthritis (OA) of the knee? DATA SOURCES: MEDLINE, Cochrane, and Internet databases were searched for randomized controlled trials. STUDY SELECTION: Five randomized controlled trials involving 312 patients were found. SYNTHESIS: One week after injection, treated patients were less likely to have continuing pain and had significantly lower scores on a visual analogue scale (VAS) for pain. Three to 4 weeks after injection, treated patients still had significantly less pain, but their VAS scores were no longer significantly lower than scores in the control group. Six to 8 weeks after injection, neither pain reduction nor VAS scores were significantly different between groups. CONCLUSION: Intra-articular corticosteroid injection results in clinically and statistically significant reduction in osteoarthritic knee pain 1 week after injection. The beneficial effect could last for 3 to 4 weeks, but is unlikely to continue beyond that.
Introduction to research in cardiology. Evidence-based medicine--stratification of the evidence.
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Knowledge management in clinical practice: a systematic review of information seeking behavior in physicians.
OBJECTIVES: To determine information seeking behavior of physicians. DATA SOURCES: Systematic review of 19 studies that described information seeking behavior in a number of different settings using differing methodologies. Analysis was limited to quantitative studies describing sources of information sought by physicians. RESULTS: Investigators have used questionnaires, interviews and observation to identify the information seeking behavior of clinicians. The results were mainly obtained from trials in the United States and showed a wide variation in primary information sources used by physicians. The most frequent source for information used are text sources, second is asking colleagues and only one study found electronic databases to be the primary resource. Physician's desk reference is the commonest cited printed resource. Convenience of access, habit, reliability, high quality, speed of use, and applicability makes information seeking likely to be successful and to occur. The lack of time to search, the huge amount of material, forgetfulness, the belief that there is likely to be no answer, and the lack of urgency all hinder the process of answering questions. CONCLUSIONS: The wide variation in information seeking behavior implies a need for further categorization of information need and information sources. Careful planning of information delivery to physicians is required to enable them to keep up to date and to improve knowledge transfer.
Isolated limb perfusion with melphalan in the treatment of malignant melanoma of the extremities: a systematic review of randomised controlled trials.
Isolated limb perfusion is a surgical procedure for delivering a high dose of chemotherapeutic or immunochemotherapeutic agent to a localised area, thus avoiding the severity of side-effects caused by systemic administration. This technique is generally used for treatment of patients with tumours of the limbs and extremities. We have done a systematic review of randomised controlled trials assessing the effectiveness of this treatment in patients with melanoma of the extremities. Four trials of 1038 patients met our inclusion criteria and were analysed. Although our analysis confirmed the reported increase in survival in two of the trials, neither had sufficient power to detect significant benefit for perfusion. Results from the trials showed that prophylactic perfusion has an equivocal effect on survival in patients with limb melanoma. Therefore, current evidence suggests that prophylactic isolated limb perfusion cannot be recommended as a routine adjunct to standard surgery in patients with high-risk primary limb melanoma, but only as a treatment for local disease control if other forms of locoregional therapy are not available.
Interferon alfa therapy for malignant melanoma: a systematic review of randomized controlled trials.
PURPOSE: No standard systemic adjuvant therapy has been proven to increase overall survival in melanoma patients. The effect of interferon alfa (IFNalpha) as a single agent or in combination has been widely explored in clinical trials. The purpose of this study was to assess the benefit of IFNalpha therapy in malignant melanoma. METHODS: We performed a systematic review of randomized controlled trials comparing regimens with or without IFNalpha adjuvant therapy in melanoma patients. We assessed the effect of IFNalpha therapy on overall survival (OS), disease-free survival (DFS), melanoma recurrences, and toxicity. The quality of each trial was systematically evaluated. RESULTS: Nine randomized controlled trials (RCTs) of IFNalpha therapy in melanoma patients were identified. Eight were published and one was unpublished. Eight trials comprising 3,178 patients fulfilled our inclusion criteria and were analyzed. Quality assessment scores ranged from 22 to 71, with a mean score of 55.4 (95% confidence interval, 53.8 to 57.0). For OS, only one trial reported a statistically significant benefit for IFNalpha, but our analysis did not confirm it. Two trials reported statistically significant benefit in DFS for the patients treated with IFNalpha, but our analysis confirmed it in only one trial. There was a wide clinical heterogeneity between included trials, making meta-analysis inappropriate. CONCLUSION: In our review, results from included RCTs demonstrated no clear benefit of IFNalpha therapy on OS in melanoma patients. A large RCT is required to answer whether a full regimen of IFNalpha therapy is effective and to identify the subgroups of patients who might benefit from IFNalpha treatment.
Excision margins in the treatment of primary cutaneous melanoma: a systematic review of randomized controlled trials comparing narrow vs wide excision.
BACKGROUND: The optimal excision margin for primary cutaneous melanoma remains controversial, although several clinical studies have suggested that wide local excision is unnecessary. HYPOTHESIS: Wide excision margins do not improve survival in patients with melanoma. OBJECTIVES: To describe the published evidence and determine the effectiveness of wide surgical margins compared with narrow surgical margins. DESIGN: Systematic review of randomized controlled trials that compared narrow margins with wide excision margins for cutaneous melanoma. SETTING: Randomized controlled trials available by March 2001. SUBJECTS: The included trials comprised 2406 participants. INTERVENTION: Surgical excision of melanoma using narrow excision margins compared with excision using wide excision margins. MAIN OUTCOME MEASURE: Effect of width of excision margin on melanoma recurrences, disease-free survival, and overall survival. RESULTS: We identified and analyzed 4 randomized controlled trials. All 4 trials failed to demonstrate statistically significant differences in overall survival and disease-free survival when comparing wide vs narrow excision. Peto pooled odds ratio for overall survival was 0.79 (95% confidence interval, 0.61-1.04) and for disease-free survival was 0.89 (95% confidence interval, 0.69-1.13), indicating a statistically nonsignificant improvement with wide excision. CONCLUSIONS: Not one of the included studies showed any statistically significant difference between the 2 groups treated with narrow or wide excision margins with regard to recurrences and survival. However, current evidence is not sufficient to address the optimal surgical margins for all melanomas, and further research is required.
Elective lymph node dissection in patients with melanoma: systematic review and meta-analysis of randomized controlled trials.
HYPOTHESIS: Elective lymph node dissection does not improve survival in patients with melanoma without clinically detectable lymph node metastases. OBJECTIVE: To determine whether elective lymph node dissection in patients with melanoma without clinically detectable regional metastases decreases overall mortality. DESIGN: Systematic review and meta-analysis of randomized controlled trials comparing elective lymph node dissection with delayed lymphadenectomy at the time of clinical recurrence. SETTING: Randomized controlled trials available by February 2001. SUBJECTS: The included trials comprised 1533 participants. INTERVENTION: Elective lymph node dissection compared with delayed lymphadenectomy or no lymphadenectomy in patients with melanoma without clinically detectable regional metastases. MAIN OUTCOME MEASURE: Overall mortality in treatment groups as compared with control groups at the end of a 5-year follow-up period. RESULTS: Three randomized controlled trials met the inclusion criteria. The pooled odds ratio for overall mortality for the 3 trials was 0.86 (95% confidence interval, 0.68-1.09). Results are statistically nonsignificant, but they have potential clinical significance. CONCLUSIONS: This systematic review of randomized controlled trials comparing elective lymph node dissection with surgery delayed until the time of clinical recurrence shows no significant overall survival benefit for patients undergoing elective lymph node dissection. Trials included in this review, however, contain significant bias. The question is not answered for all patients, and the results do not exclude the possibility that some subgroups may benefit from elective lymph node dissection. Further research is required.
Economic evaluation in evidence-based practice.
The economic evaluation of health care interventions and technologies is an essential part of any modern healthcare system. In recent years a growing demand for information about the economic benefits of healthcare technologies has seen a significant increase in the number of published economic evaluations of healthcare. Economic evaluation reviews have demonstrated considerable methodological flaws in a significant number of analyses in health care. Widely accepted guidance regarding the manner in which multinational economic evaluations should be designed, analysed and presented is still awaited. The main types of economic analyses are described in this article, providing a framework along which to evaluate them.
Effect of a PDA-assisted evidence-based medicine course on knowledge of common clinical problems.
BACKGROUND AND OBJECTIVES: It is not yet known if personal digital assistant (PDA)-assisted evidence-based medicine (EBM) courses in postgraduate training enhance knowledge of common clinical problems. This study's objective was to determine if PDA-assisted EBM training would improve clinical knowledge. METHODS: In a controlled trial, intervention group residents received InfoRetriever on a PDA coupled with an EBM course integrated within clinical rotations in family medicine. The effect of the intervention and the rate of use of InfoRetriever on a written test of knowledge were evaluated after adjusting for baseline knowledge scores. The test measured knowledge of primary care management of hypertension and diabetes as well as estimation of disease probability. RESULTS: There was no effect on first posttest knowledge scores of the intervention overall or of the rate with which participants had used InfoRetriever during the intervention. However, when intervention group residents retook the test with access to InfoRetriever while taking the knowledge test, scores increased 7.4% (+2.4 correct test questions). Access to InfoRetriever Clinical Prediction Rules on a PDA, however, had an unclear effect on residents' ability to estimate disease probability. CONCLUSIONS: There was no effect of a PDA-assisted EBM course on knowledge test scores, although using the PDA during the test results in higher scores. It is unclear if using PDA Clinical Prediction Rules can improve residents' estimates of disease probability.