[Growing pains of cochranology].
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Doctors always seek to base their decisions on the best available evidence. Often this evidence represents extrapolations of pathophysiological principles and logic rather than established facts based on data derived from patients. The advent and proliferation of randomized controlled trials have led to a rapid increase in the quantity and quality of clinically valid evidence concerning clinical history taking and physical examination, issues of diagnosis, prognosis, therapy and other important health care issues. As a result it is becoming possible to make explicit much of the implicit non-verbal reasoning of expert clinicians, making their clinical reasoning more comprehensible and accessible to trainees. The ability to track down, critically appraise and incorporate evidence into clinical practice has been named 'evidence-based medicine'. As the quantity of valid evidence increases so does the requirement for each of us to develop the skills necessary to assimilate, evaluate and make best use of that evidence for patients. Often we fail to identify or address our daily needs for clinically important knowledge, leading to a progressive decline in our clinical competency. When we do seek knowledge traditional sources of information such as journals and text-books are often either too disorganized or out of date and we often resort to asking colleagues. The need to maintain and expand clinically important knowledge has been partially addressed by increasing demands for continuing medical education but how might this be best achieved? Recent evaluations suggest that three evidence-based medicine strategies help fulfill these goals. They include; learning evidence-based medicine, seeking and applying evidence-based medical summaries generated by others, and accepting evidence-based protocols developed by others.
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In this article the authors show the correct method to gather together clinical data. First they explain how to compile clinical files (five cards) and how to maintain the centres and monitor them. The initial quality of the data is increased by the creating of a structure with "regional" and "central" monitors. Thirdly the authors explain data management: how to code and enter data, how to check its correctness and lastly data base authorization.
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The use of insurance claims databases in drug therapy outcomes research holds great promise as a cost-effective alternative to post-marketing clinical trials. Claims databases uniquely capture information about episodes of care across healthcare services and settings. They also facilitate the examination of drug therapy effects on cohorts of patients and specific patient subpopulations. However, there are limitations to the use of insurance claims databases including incomplete diagnostic and provider identification data. The characteristics of the population included in the insurance plan, the plan benefit design, and the variables of the database itself can influence the research results. Given the current concerns regarding the completeness of insurance claims databases, and the validity of their data, outcomes research usually requires original data to validate claims data or to obtain additional information. Improvements to claims databases such as standardisation of claims information reporting, addition of pertinent clinical and economic variables, and inclusion of information relative to patient severity of illness, quality of life, and satisfaction with provided care will enhance the benefit of such databases for outcomes research.
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PURPOSE: To assess the quality of information in the literature regarding the benefits of prophylactic treatment of asymptomatic retinal tears and lattice degeneration. CLINICAL RELEVANCE: Asymptomatic retinal breaks occur in approximately 7% of patients over age 40, and lattice degeneration is present in approximately 8% of the general population. Because retinal breaks cause retinal detachment and lattice degeneration is associated with approximately 30% of retinal detachments, prophylactic treatment of these lesions has sometimes been recommended. LITERATURE REVIEWED: A panel of vitreoretinal experts performed a literature review of all publications regarding prevention of retinal detachment that have been published in English. These articles were then used to prepare recommendations for patient care in an American Academy of Ophthalmology Preferred Practice Pattern (PPP). Each recommendation was rated according to: (1) its importance in the care process and (2) the strength of evidence supporting the given recommendation. RESULTS: Most recommendations were rated as A (most important to patient care). Only a single publication was graded as I (providing strong evidence in support of a recommendation), and this was not a prospective trial. Of the few publications rated as II (substantial evidence), most were studies documenting a lack of treatment benefit. Because of an absence of level I and level II studies in the literature, level III (consensus of expert opinion) was the basis for most recommendations in the PPP. CONCLUSIONS: The current literature regarding prevention of retinal detachment does not provide sufficient information to support strongly prophylactic treatment of lesions other than symptomatic flap tears. Prospective randomized trials of prophylactic therapy are indicated. Eyes highly predisposed to retinal detachment should be considered for such studies.
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The information on therapeutics is moving at a high path for various causes. Now, tools for informing correctly the prescriber do exist. However, they require the operation of suitable structures. The mainstem of the system consists of an intermediary which should comply with appropriate rules. It will work from an exhaustive collection of pertinent information. This will allowed by the extensive use of literature data banks and clinical trial registries kept with the help of international collaboration. It will rank the strength of evidence of the collected data according to their internal validity. It will elaborate overviews from validated data obtained from meta-analysis, and messages readily readable by the users, and accessible whenever needed. Overviews will be used to set up guidelines, references, editorials... Data banks will be accessible to researchers, teachers, officers concerned by health care.
Medical practice is most strongly founded when based on the results of well conducted clinical trials. Clinical trial results normally enter the domain of medical knowledge and practice through their publication in scientific journals. This in itself poses problems of accessibility and selection. The results of this is a slow and selective diffusion of new medical facts which has a consequent cost in human lives and human suffering. In an attempt to shorten this information path initiatives such as the Cochrane collaboration produce and maintain systematic reviews by speciality of the current state of knowledge. The ability to store a representation of a clinical trial in a standard form seems to us to be a necessary condition for the efficient and reproducible preparation of systematic reviews. Furthermore the consequent increased accessibility of research results due to the existence of the summaries would itself be of great use. In this aim a relational database client server system was developed and we publish here the results of our preliminary findings, including the data model, which we feel is an important contribution to the future discussion and development of computer based representations of clinical trial protocols and results and their use in clinical decision making.
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Problem 1 of Genetic Analysis Workshop 11 consists of data from a family study of the genetics of alcoholism and related traits contributed by the six centers making up the National Institute for Alcohol Abuse and Alcoholism sponsored by the Collaborative Study on the Genetics of Alcoholism (COGA). The family data included 1,214 members of 105 pedigrees ascertained for having three or more individuals affected with alcoholism. Data available to workshop participants included clinical phenotypes, personality measures, smoking behavior, event-related potentials, platelet monamine oxidase B activity, and a genome scan of 296 markers.