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Contents of a core library in continuing medical education: a Delphi study.
INTRODUCTION: In developing their professional competence, those who are interested in the practice of continuing medical education (CME) should recognize the knowledge base that defines their field. This study systematically identifies and organizes a list of books and journals comprising a core library (100 books/15 journals) for CME professionals. METHODS: The Delphi method was applied to elicit and combine the judgments of a fifty member panel considered knowledgeable about the CME field. The panelists participated in three iterations of the survey to first identify and then rank order nominated works. Separate ranked lists were created for books and journals. RESULTS: Forty-four participants completed the study (88% response rate). 268 books and 34 journals were identified. Mean ratings ranged from 4.78 (high) to 1.50 (low). DISCUSSION: The results of the study reflect the panel's judgment. The list is not definitive; instead, it describes what a select group of individuals knowledgeable about the CME field considered important. The list should therefore be seen as a general guide and a resource to facilitate decision-making, not as a prescription for creating a library.
Delphi Technique↗
Recent advances in the management of depression and psychopharmacology.
OBJECTIVE: To review the recent advances in the management of depression and psychopharmacology. DATA SOURCES: Medline and non-Medline literature search. STUDY SELECTION: The following key words were used: depression/therapy, depressive disorders, antidepressant, psychopharmacology, and mental health services. Years of study: 1988 to 1998. DATA EXTRACTION: Original articles, review papers, meta-analyses, and relevant book chapters were reviewed. DATA SYNTHESIS: Recent advances in research on depression have confirmed that it is a common, recurrent, and disabling medical disorder. The latest epidemiological studies from the United States suggest that its lifetime prevalence is more than 17%, while a lower, but still substantial, proportion of Chinese people have the same disorder. The highly recurrent nature and conspicuous morbidity of depression call for the continuation of antidepressant treatment beyond the initial resolution of symptoms. For the first episode of depression, 6 to 9 months of adequate antidepressant treatment is indicated. For patients with recurrent depression, maintenance therapy for several years is needed. The increasingly widespread use of selective serotonin re-uptake inhibitors and other newer antidepressants has increased the direct drug cost, but the total health care expenditure may not be raised and may even be reduced. CONCLUSION: Proper recognition and management of depression at both the clinical and health care policy levels are urgently needed.
Antidepressive Agents↗
Specificity of 192 IgG-saporin for NGF receptor-positive cholinergic basal forebrain neurons in the rat.
A monoclonal antibody to the rat nerve growth factor (NGF) receptor, 192 IgG, accumulates bilaterally and specifically in cholinergic basal forebrain (CBF) cells following intraventricular injection. An immunotoxin composed of 192 IgG linked to saporin (192 IgG-saporin) has been shown to destroy cholinergic neurons in the basal forebrain. We sought to determine if intraventricular 192 IgG-saporin affected choline acetyltransferase (ChAT) enzyme activity in the CBF terminal projection fields. ChAT assays from 192 IgG-saporin-treated animals showed significant time-dependent decreases in ChAT activity in the neocortex, olfactory bulb and hippocampus, compared to PBS- or OKT1-saporin-injected controls. ChAT and tyrosine hydroxylase activity in the striatum was always unchanged by 192 IgG-saporin. ChAT immunohistochemistry was confirmative of major cell loss in the CBF, while other cholinergic nuclei appeared unremarkable. The data provide further evidence of the selectivity of 192 IgG-saporin in abolishing cholinergic, NGF receptor-positive CNS neurons.
Acetylcholine↗
A medieval casebook: hand cures documented in the Icelandic Sagas of bishops.
The Sagas of Icelandic bishops composed in and around the 13th century reveal something of the incidence and treatment of various hand conditions in the medieval period. A selection from the relevant material is translated and discussed.
Books↗
Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women.
BACKGROUND: Urinary tract infections are common in elderly patients. Authors of non systematic literature reviews often recommend longer treatment durations (7-14 days) for older patients than for younger women, but the scientific evidence for such recommendations is not clear. OBJECTIVES: To determine the optimal duration of antibiotic treatment for uncomplicated symptomatic lower urinary tract infections in elderly women. SEARCH STRATEGY: We contacted known investigators and pharmaceutical companies marketing antibiotics used to treat urinary tract infections, screened the reference list of identified articles, reviews and books, and searched the following data bases: MEDLINE, EMBASE, CINAHL, Healthstar, Popline, Gerolit, Bioethics Line, The Cochrane Library, Dissertation Abstracts International, Index to Scientific & Technical Proceedings. SELECTION CRITERIA: All randomized controlled trials in which different treatment durations of oral antibiotics for uncomplicated symptomatic lower urinary tract infections in elderly women were compared. We excluded patients with fever or flank pain and those with complicating factors. Trials with treatment durations longer than 14 days or designed for prevention of urinary tract infection were also excluded. No language restriction was applied. DATA COLLECTION AND ANALYSIS: The quality of all selected trials was assessed and data extracted by the reviewers. Main outcome measures were persistence of urinary symptoms (short-term and long-term efficacy), effect on mental and functional status and adverse drug reactions. To compare the different treatment durations, we defined the following categories of duration: single dose, short course (3-6 days) and long course (7-14 days). Relative risk (RR) and 95% confidence intervals (CI) were calculated for each trial and outcome and were then combined using a random effects model. MAIN RESULTS: Thirteen trials were included in this review. Six trials compared single dose with short-term treatment (3-6 days), three studies single dose with long-term treatment (7-14 days) and four trials short-term with long term treatment. Eight trials also included younger patients, but provided a subgroup analysis for elderly women. The methodological quality of all trials was low. All trials reported results of bacteriological cure rate; less often clinical outcomes (e.g. improvement or cure of symptoms) were analyzed. Only five trials compared the same antibiotic given for a different length of time. We performed a separate analysis for these trials. The rate of persistent bacteriuria rate at short-term (two weeks post-treatment) was better in the longer treatment group (3-14 days) than in the single dose group (RR 1.84, 95% CI 1.18 to 2.86). However, the rate of persistent bacteria at long term and the clinical cure rate showed no statistically significant difference between the two groups. Patients showed a preference for single dose treatment (RR 0.73, 95% CI 0.66 to 0.88), however this was based on only one trial comparing the same antibiotic. The comparison of short (3-6 days) and longer treatments (7-14 days) did not show any significant difference, but the number of included studies and sample size were low. REVIEWER'S CONCLUSIONS: This review suggests that single dose antibiotic treatment is less effective but may be better accepted by the patients than longer treatment durations (3-14 days). In addition there was no significant difference between short course (3-6 days) versus longer course (7-14 days) antibiotics. The methodological quality of the identified trials was poor and the optimal treatment duration could not be determined. We therefore need more appropriately designed randomized controlled trials testing the effect, - on clinical relevant outcomes -, of different treatment durations of a given antibiotic in a strictly defined population of elderly women.
Aged↗
Treatments for priapism in boys and men with sickle cell disease.
BACKGROUND: Sickle cell disease comprises a group of genetic haemoglobin disorders. The predominant symptom associated with sickle cell disease is pain resulting from the occlusion of small blood vessels by abnormally 'sickle-shaped' red blood cells. There are other complications, including chronic organ damage and prolonged painful erection of the penis, known as priapism. Severity of sickle cell disease is variable, and treatment is usually symptomatic. Priapism affects up to half of all men with sickle cell disease, however there is no consistency in treatment. We therefore need to know the best way of treating this complication in order to offer an effective interventional approach to all affected individuals. OBJECTIVES: To assess the benefits and risks of different treatments for stuttering (repeated short episodes) and fulminant (lasting for six hours or more) priapism in sickle cell disease. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register, which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched the internet for further references. Date of the most recent search of the Group's trials register: August 2004. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing non-surgical or surgical treatment with placebo or no treatment, or with another intervention for stuttering or fulminant priapism. DATA COLLECTION AND ANALYSIS: The reviewers independently extracted data and assessed study quality. MAIN RESULTS: Only one study of 11 participants was identified and met the criteria for inclusion in this review. This study compared stilboestrol to placebo. The only outcome specified in this review, which was assessed in the study, was reduction in frequency of stuttering priapism and there was no difference between the groups, relative risk 0.18 (95%CI 0.01 to 2.54). REVIEWERS' CONCLUSIONS: There is no evidence for the benefits or risks of the different treatments for both stuttering and fulminant priapism in sickle cell disease. This systematic review has clearly identified the need for well-designed, adequately-powered, multicentre randomised controlled trials assessing the effectiveness of specific interventions for priapism in sickle cell disease.
Anemia, Sickle Cell↗
Dietary habits during adolescence--results of the Belgian Adolux Study.
UNLABELLED: OBJECTIVE OF THE PRESENT STUDY: To analyse the usual dietary habits of Belgian adolescents from a high cardiovascular risk population. METHODS: A food frequency questionnaire (57 items) was administered to the whole sample. Complementary questions specified some types of food (eg fat content). A subgroup of 234 adolescents gave detailed information on portion size (picture book and food samples). SETTING: Twenty-four secondary schools in the Belgian province of Luxembourg. SUBJECTS: A total of 1,526 adolescents (12-17y) selected by a multiclustered stage sampling (participation: 83.6%). RESULTS: Respectively 46% and 60% of the adolescents did not eat fruit and vegetables daily. Most of the adolescents (72%) consumed at least one dairy product daily. The frequent consumption of chocolate and French fries indicated the strong cultural influence on dietary habits while imported foods (like hamburgers) had little success. One-third of the adolescents (33%, n = 509) drank alcohol at least once a week and this proportion rose to 57% in the oldest age group. Boys and girls differed significantly in their diet, with girls choosing healthier foods. Dietary habits, in particular drinking habits, differed also significantly between education levels, assessed by the learning option of the participants. The semi-quantitative questionnaire showed that two-thirds of the adolescents had a lipid intake (mainly saturated fatty acids) which exceeded 35% of the total caloric intake. Complex carbohydrates represented less than half of the total carbohydrates intake. CONCLUSION: The study of the diet of Belgian adolescents confirmed the strong influence of tradition, in particular on the consumption of high fat content foods. The promotion of healthy diet in adolescents should consider the cultural influence, even for this young age group.
Adolescent↗
Tracing our roots: the first clinical laboratory scientist.
OBJECTIVE: To trace the roots of clinical laboratory science by discussing the development of the role of the "laboratory technician", and describing selected early training programs for clinical laboratory personnel. DESIGN: A survey of literature on the history of clinical laboratory science was conducted. References consulted include various books and professional journals. CONCLUSION: The first clinical laboratory scientists began working in clinical laboratories shortly before World War I. During the war, and in the years that followed, a critical shortage of trained laboratory personnel developed. To alleviate this shortage, pathologists began to hire young women, training them on the job to perform simple laboratory tests. However, there were no established training standards, and few institutions offered a systematic method for instruction. During this same period, three educational programs were established that did offer high quality training that provided systematic instruction to their students.
History, 20th Century↗
[On the history of French eugenics].
The French Eugenical Society was founded in 1913, but eugenics had been actively discussed already much earlier, although under varing names. The main protagonists of early French eugenics were Georges Vacher de Lapouge, who was inspired by Galton and socialism, Adolphe Pinard, who propagated the "puericulture", and Paul Robin, who represented neo-malthusianism in his country. Alexis Carrel's ideas on improving the human race became widespread especially through his book "Man, the Unknown", published simultaneously in French and English in 1935. In general, the French eugenicists were more in favour of positive eugenics than negative selection, including sterilization, but their general influence was weaker than in several other countries.
Eugenics↗
An update on the management of nephropathy in type 2 diabetes.
BACKGROUND: To provide an update on the latest evidence-based management of nephropathy in type 2 diabetes. METHODS: A literature search (MEDLINE 1966 to 2002) was performed using the key words "diabetic nephropathy," and relevant book chapters were also reviewed, to identify well-controlled, prospective landmark studies and expert review articles on diabetic nephropathy (DN). Data and conclusions from the selected articles that provided solid evidence regarding the optimal management of DN were extracted and interpreted in light of clinical and research experience with Chinese patients. RESULTS: DN is the leading cause of end-stage renal disease worldwide. High blood pressure, dyslipidemia, long duration of diabetes, poor glycemic control and central obesity are important risk factors. Microalbuminuria is a practical marker to predict the development of overt nephropathy in type 2 diabetic patients. Risk factor modification, renal function monitoring and combined therapies are the current integrated approaches to manage patients with diabetic kidney disease. Optimal glycemic control is a fundamental goal, but effective antihypertensive and possibly lipid-lowering therapy delay the progression of DN. Recent large clinical trials support the earlier experimental data that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have important renoprotective actions independent of their blood pressure lowering actions. CONCLUSIONS: Screening for microalbuminuria and monitoring renal function will identify patients with DN at an early stage and allow for intervention. Tight glycemic control and aggressive antihypertensive treatment as well as the use of renin-angiotensin system inhibitors should substantially delay the progression of nephropathy.
Diabetes Mellitus, Type 2↗
Disease pattern and prescribing at the University of Zimbabwe students health service, 1987-1991.
The trends in drug use, expenditure and disease pattern at the University of Zimbabwe students' health facility over a period of five years (1987-1991), were analysed retrospectively. The study also analysed the use of the essential drugs concept and the drug situation in Zimbabwe. A total of 1,500 cases which were randomly selected were studied. The total student population over this period was 44,030. Data collection sheets where utilised to extract information from patients' cards. Requisition order books and budgets for drugs and medical appliances and student population statistical data were analysed. Males accounted for 75.7 pc of the cases and the average age at the time of the visit was 22.04 years. The percentage of cases involving married students was 2.53 pc of which 94.74 pc were males. The total expenditure of drugs and medical appliances for the study period was $412,413.55 and most of the items were supplied by the Government Medical Stores. The most prevalent disease conditions were respiratory tract infections (35 pc) and urinary tract infections (16.3 pc). The disease pattern differed from that at district, general and provincial hospitals. The total number of drugs dispensed for the 1,500 students was 2,600, giving an average of 1.7 drugs per case. Analgesics were the most widely used drugs (28.5 pc), followed by anti-infectives (28.2 pc). The most popular analgesic used was paracetamol which accounted for 66.6 pc of the analgesics. Antibiotics accounted for 88.1 pc of the anti-infectives and 24.9 pc of the total number of drugs dispensed.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Early postpartum discharge in the postpartum].
OBJECTIVE: To assess a policy of early discharge from hospital after a vaginal birth. DATA SOURCES: Reports of studies on this topic were identified in Medline and Cochrane Collaboration database (from 1985 to the beginning of 1995, in english or latin publications). This search was supplemented by referenced studies in book chapters and in other published bibliographies. Key words were: early discharge or ambulatory care and mother or infant or post-partum or obstetrics. STUDY SELECTION: One hundred and ten articles have been retrieved. We have included in the meta-analyse the randomized clinical trials comparing a group of women discharged early (less than 48-72 hours after delivery) with a control group leaving hospital after an usual stay (more than 48-72 hours). Quality of the studies was analysed through the Chalmers et al. recommendations. DATA EXTRACTION: Data were retrieved independently by two authors, and results were compared. Selected outcomes were: hyperbilirubinemia, infant feeding problems and skin rashes; breast feeding; maternal satisfaction on the hospital stay; readmission and non-routine clinics for both the mother and her child. DATA SYNTHESIS: Data from five included studies were pooled by the Peto method. There are no significant modifications of the risks of re-admission to hospital. The frequency of non-routine clinics and the risk of skin rash are not different in the two groups. The risk of hyperbilirubinemia and infant food problems are not different. The frequency of breastfeeding one month after delivery was higher in the early discharge group (OR = 1.88; 95% CI: 1.09-3.23), but this difference decreased over time. Women satisfaction on hospital stay was lower in case of early discharge (OR = 0.56; 95% IC: 0.44-0.72). CONCLUSION: The meta-analysis suggests an advantage of early discharge policy on breastfeeding at one month after the delivery, but mothers seem to prefer longer hospital stays. These results must be cautiously interpreted as included studies are of small sample size or rather old. This policy remains to be evaluated more thoroughly before recommendations could be made.
Attitude to Health↗
A pilot study to establish a randomized trial methodology to test the efficacy of a behavioural intervention.
How can pregnant women be helped to stop smoking? This was a pilot study of midwife home-based motivational interviewing. Clients were 100 consecutive self-reported smokers booking at clinics in Glasgow from March to May 1997. Smoking guidance is routinely given at booking. In addition, intervention clients received a median of four home-based motivational interviewing sessions from one specially trained midwife. All sessions (n = 171) were audio-taped and interviews (n = 49) from 13 randomly selected clients were transcribed for content analysis. Three 'experts' assessed intervention quality using a recognized rating scale. Cotinine measurement on routine blood samples confirmed self-reported smoking change from late pregnancy telephone interview. Postnatal telephone questionnaire measured client satisfaction. Focus groups of routine midwives explored acceptability, problems and disruption of normal care. Fisher exact, chi 2 and Mann-Whitney tests compared enrolment characteristics. Two-sample t-tests assessed outcome between groups. Motivational interviewing was satisfactory in more than 75% of transcribed interviews. In this pilot study, self-reported smoking at booking (100 of 100 available) corroborated by cotinine (93 of 100) compared with late pregnancy self-reports (intervention 47 of 48; control 49 of 49) and cotinine (intervention 46 of 48; control 47 of 49) showed no significant difference between groups. Tools have been developed to answer the question: 'Can proactive opportunistic home-based motivational interviewing help pregnant smokers reduce their habit?'.
Adult↗
The selective disruption of spatial working memory by eye movements.
In the late 1970s/early 1980s, Baddeley and colleagues conducted a series of experiments investigating the role of eye movements in visual working memory. Although only described briefly in a book, these studies have influenced a remarkable number of empirical and theoretical developments in fields ranging from experimental psychology to human neuropsychology to nonhuman primate electrophysiology. This paper presents, in full detail, three critical studies from this series, together with a recently performed study that includes a level of eye movement measurement and control that was not available for the older studies. Together, the results demonstrate several facts about the sensitivity of visuospatial working memory to eye movements. First, it is eye movement control, not movement per se, that produces the disruptive effects. Second, these effects are limited to working memory for locations and do not generalize to visual working memory for shapes. Third, they can be isolated to the storage/maintenance components of working memory (e.g., to the delay period of the delayed-recognition task). These facts have important implications for models of visual working memory.
Adolescent↗
Cultural competence models in nursing: a selected annotated bibliography.
Since the early 1990s, along with a phenomenal growth of nursing literature published on cultural competence, an array of cultural competence and cultural assessment models has been developed. This annotated bibliography provides bibliographic entries to books, book chapters, and journal articles that deal with the construction, development, or conceptualization of cultural competence and cultural assessment models. It also includes entries to books dealing with cultural assessment guides.
Bibliometrics↗
Preoperative evaluation for epilepsy surgery (Bonn Algorithm).
SUMMARY: Epilepsy surgery has been established as a successful treatment in patients with drug-resistant focal epilepsies. Different standardized surgical approaches were developed for resective or functional treatment. Successful surgical treatment, however, necessitates a careful presurgical evaluation. Although there are international standards for non invasive and invasive presurgical procedures most centers differ in their diagnostic strategy. This article gives a survey of the Bonn Epilepsy surgery program within which more than 1300 patients have been treated. After the method of patient selection different we describe tools of non invasive and invasive evaluation. This article serves only as a description of current practice in one center with a relatively large volume of cases. It presents just one opinion of a specific group within a wide spectrum of possible algorithms for presurgical evaluation that have briefly been outlined for 33 centers in Engels book [4].
Electroencephalography↗
Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment.
BACKGROUND: Delirium is common in hospitalized elderly people. In the frail elderly, delirium may occur in 60% of those hospitalized. In the cognitively impaired, 45% have been shown to develop delirium and these patients have longer lengths of stay and a higher rate of complications which, amongst other things, together contribute to an increase in cost of care. The combination of being elderly and chronically cognitively impaired leads to a high risk of delirium with the associated increased risk of prolonged hospital stay, complications, and poor outcomes. The management of delirium has commonly been multifaceted - the primary emphasis has always been on the diagnosis and therapy of the precipitating factors, but as this may not be immediately resolved, symptomatic and supportive care may become of major importance. OBJECTIVES: The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of patients with delirium superimposed on an underlying chronic cognitive impairment compared with the usual care of older cognitively impaired patients. SEARCH STRATEGY: The Cochrane Controlled Trials Register (Cochrane Library, up to and including Issue 1, 1998) was searched using the terms 'delirium, controlled trial, cognitive'. MEDLINE, EMBASE and Psychlit (Ovid via Winspirs up to Feb 1998) were also searched with the same terms. Other sources including personal communications, ongoing trials, conference proceedings, handsearching and reference lists of published papers and books were all searched for relevant randomized controlled trials. The total yield from searching was 157 from which 8 (eight) were retained for consideration in the review. SELECTION CRITERIA: From the initial search yields, all randomised controlled trials involving the management of elderly patients with delirium were identified. A single reviewer (AMB) discarded irrelevant publications based on the title of the publication and its abstract. In the event that the article could possibly be relevant, it was retrieved for further assessment. All references were compiled in a list with a commentary on type of article, eg review, prospective study etc and this was independently considered by the second reviewer (RR) who agreed to review all randomised controlled studies reported on patients with delirium. Selection for possible inclusion in this review was then made on the basis of the participants reported as having chronic cognitive impairment, who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care. The outcomes of interest were length of stay in hospital, morbidity (including complications), patient distress & impact on care environment, mortality, discharge arrangements and follow-up including assessment of cognitive function at 6 months. Studies in which patients with chronic cognitive impairment or dementia, managed for incident delirium, according to ICD 9 criteria (see note) were considered eligible for inclusion in the review. Studies of risk factors and non-randomized studies were excluded. Note: this classification has been widely utilised throughout the English speaking medical literature over the past 20 years: ICD 10 is still being incorporated into clinical coding systems and has not been utilised in studies published in 1996. (ABSTRACT TRUNCATED)
Delirium↗