A critical mass of Internet users is leading to a wide diffusion of electronic communications within medical practice. Unless implemented with substantial forethought, these new technological linkages could disturb delicate balances in the doctor-patient relationship, threaten the privacy of medical information, widen social disparity in health outcomes, and even function as barriers to access. The American Medical Informatics Association (AMIA) recently published recommendations to guide computer-based communications between clinicians and patients. This paper describes the motivations for and the design of HealthConnect, a web-based patient-doctor communications tool currently in use at Children's Hospital, Boston. Structural and process-oriented features of HealthConnect, as they relate to promotion of adherence with the Guidelines, are discussed. (+info)
Creating your own medical Internet library.
(74/2665)
Many physicians struggle to keep up with new developments in their fields. The internet can provide a solution to this problem by allowing rapid access to a broad spectrum of reliable information. Becoming familiar with a few clinically relevant and freely available medical resources on the World Wide Web may enhance a physician's efforts to provide evidence-based care on a daily basis. This article outlines a simple strategy for physicians to make the internet a useful tool. (+info)
The clinical utility of the Revised European-American Lymphoma (R.E.A.L.) Classification: preliminary results of a prospective study in patients with non-Hodgkin's lymphoma from a single centre.
(75/2665)
BACKGROUND: The clinical applicability of the Revised European-American Lymphoma (R.E.A.L.) Classification has been demonstrated in several retrospective studies. The present, ongoing study was initiated to evaluate the clinical and pathological utility of the R.E.A.L. Classification compared with the Working Formulation (WF) in a prospective fashion, in an unselected patient population treated at a single institution. PATIENTS AND METHODS: Prospective data were collected on 596 biopsies from 557 patients referred with an initial diagnosis of lymphoma. After initial histologic review, 465 biopsies from 441 patients were confirmed as non-Hodgkin's lyphoma (NHL), 412 of which could be classified in R.E.A.L. and WF. RESULTS: According to WF criteria, 25% were low grade, 58% intermediate grade and 2% high grade, 14% could not be allocated to a WF subtype. According to R.E.A.L., 46% were diffuse large B cell, 19% follicle centre lymphoma, 6% marginal zone, 6% small lymphocytic, 4% mantle cell, and 3% T-cell anaplastic large cell. For those with B-cell NHL, 7% were unclassifiable in WF compared with 1% in R.E.A.L. Corresponding figures for T-cell NHL were 68% and 3%, respectively. CONCLUSIONS: Preliminary results confirm the clinical utility of the R.E.A.L. Classification in a single institution setting, demonstrating that cases were more readily sub-typed in R.E.A.L. compared with WF. Frequencies are comparable with I.L.S.G. data. Further follow up with large patient numbers is on-going to analyse survival data with reference to clinical prognostic factors. (+info)
Recommendations for standards regarding preclinical neuroprotective and restorative drug development.
(76/2665)
The plethora of failed clinical trials with neuroprotective drugs for acute ischemic stroke have raised justifiable concerns about how best to proceed for the future development of such interventions. Preclinical testing of neuroprotective drugs is an important aspect of assessing their therapeutic potential, but guidelines concerning how to perform preclinical development of purported neuroprotective drugs for acute ischemic stroke are lacking. This conference of academicians and industry representatives was convened to suggest such guidelines for the preclinical evaluation of neuroprotective drugs and to recommend to potential clinical investigators the data they should review to reassure themselves that a particular neuroprotective drug has a reasonable chance to succeed in an appropriately designed clinical trial. Without rigorous, robust, and detailed preclinical evaluation, it is unlikely that novel neuroprotective drugs will prove to be effective when tested in large, time-consuming, and expensive clinical trials. Additionally, similar recommendations are provided for drugs with the potential to enhance recovery after acute ischemic stroke, a burgeoning new field with great potential but little currently available data. The suggestions contained in this document are meant to serve as overall guidelines that must be adapted to the individual characteristics related to particular drugs and their preclinical and clinical development needs. (+info)
Familial gastric cancer: overview and guidelines for management.
(77/2665)
Families with autosomal dominant inherited predisposition to gastric cancer have been described. More recently, germline E-cadherin/CDH1 mutations have been identified in hereditary diffuse gastric cancer kindred. The need to have protocols to manage and counsel these families in the clinic led a group of geneticists, gastroenterologists, surgeons, oncologists, pathologists, and molecular biologists to convene a workshop to produce consensus statements and guidelines for familial gastric cancer. Review of the available cancer pathology from people belonging to families with documented germline E-cadherin/CDH1 mutations confirmed that the gastric cancers were all of the diffuse type. Criteria to define the different types of familial gastric cancer syndromes were agreed. Foremost among these criteria was that review of histopathology should be part of the evaluation of any family with aggregation of gastric cancer cases. Guidelines for genetic testing and counselling in hereditary diffuse gastric cancer were produced. Finally, a proposed strategy for clinical management in families with high penetrance autosomal dominant predisposition to gastric cancer was defined. (+info)
Experiences of general practitioners and practice nurses of training courses in evidence-based health care: a qualitative study.
(78/2665)
BACKGROUND: Clinical governance will require general practitioners (GPs) and practice nurses (PNs) to become competent in finding, appraising, and implementing research evidence--the skills of evidence-based health care (EBHC). AIM: To report the experiences of GPs and PNs in training in this area. METHOD: We held 30 in-depth, semi-structured interviews throughout North Thames region with three groups of informants: primary care practitioners recruited from the mailing lists of established EBHC courses; organizers and teachers on these courses; and educational advisers from Royal Colleges, universities, and postgraduate departments. Detailed qualitative analysis was undertaken to identify themes from each of these interview groups. RESULTS: At the time of the fieldwork for this study (late 1997), remarkably few GPs or PNs had attended any formal EBHC courses in our region. Perceived barriers to attendance on courses included inconsistency in marketing terminology, cultural issues (e.g. EBHC being perceived as one aspect of rapid and unwanted change in the workplace), lack of confidence in the subject matter (especially mathematics and statistics), lack of time, and practical and financial constraints. Our interviews suggested, however, that the principles and philosophy of EBHC are beginning to permeate traditional lecture-based continuing medical education courses, and consultant colleagues increasingly seek to make their advice 'evidence based'. CONCLUSION: We offer some preliminary recommendations for the organizers of EBHC courses for primary care. These include offering a range of flexible training, being explicit about course content, recognizing differences in professional culture between primary and secondary care and between doctors and nurses, and addressing issues of funding and accreditation at national level. Introducing EBHC through traditional topic-based postgraduate teaching programmes may be more acceptable and more effective than providing dedicated courses in its theoretical principles. (+info)
The attitudes of Australian GPs to evidence-based medicine: a focus group study.
(79/2665)
BACKGROUND: Over the last 6 years there has been an exponential increase in the publication of medical literature on evidence-based medicine. In Australia, as in many other parts of the world, there have been calls for an increase in the practice of evidence-based medicine. In general practice, two major themes of criticism have been the lack of relevant research evidence in primary care and the failure of evidence-based medicine to take into account the complexity of the consultation. OBJECTIVE: We aimed to explore the attitudes of Australian GPs to evidence-based medicine. METHODS: We conducted a qualitative study using evidence-based guidelines as a model to explore attitudes within focus group interviews. Focus group data were analysed using grounded theory methodology. The study was set in the Australian cities Melbourne, Adelaide and Darwin. The subjects were 27 GPs in five focus groups. RESULTS: Data were used to generate a model illustrating factors affecting the consideration and use of evidence within consultations. Prior beliefs and experience had a strong influence on decision-making. Overall, the GPs had a positive attitude to evidence-based medicine and stated that this could be a helpful strategy for meeting their information needs. These needs arose during the consultation and were frequently generated by patients. The evidence-based approach was regarded as particularly useful when patients required validation of their management or had specific queries. However, the GPs also expressed some concerns, such as the application of evidence from clinical trials to individuals, and the appropriateness of using research evidence with certain patients. They also feared a move away from the 'art of medicine'. None of the GPs expressed a need for critical appraisal skills. CONCLUSIONS: The Australian GPs in this study had mixed views about the increasing profile of evidence-based medicine, and the use of this paradigm in practice. Acceptability was more likely to be influenced by relevance to general practice and local contextual and patient factors than by the strength, or critical quality of the evidence. (+info)
Ethical review of regulatory toxicology guidelines involving experiments on animals: the example of endocrine disrupters.
(80/2665)
The safety assessment of new chemicals (including medicines, pesticides, food additives, and industrial chemicals) relies on the results of animal experiments. Because the safety of those exposed to these products and the welfare of the experimental animals used are considered critically important, both testing requirements and the welfare of experimental animals are controlled by law. In the U.K., projects that propose to use animals for experimental purposes, including for the testing of chemicals, have been controlled by law for over a century, with the most recent legislation (Animals [Scientific Procedures] Act of 1986) requiring a cost/benefit assessment before it may proceed. New regulations introduced in 1998 will require an ethical review process for all projects from April 1999. Such ethical review will have to take account of the toxicity testing methods and schemes that are required by the legislation aimed at protecting human health. Neither national nor international proposals for toxicity testing methods and schemes are generally subjected to ethical review from the point of protecting animal welfare. The international nature of the chemical and pharmaceutical industry means that testing requirements from one of the major national regulatory agencies (USA, EU, or Japan) or the international organizations (Organization for Economic Co-operation and Development [OECD]or the International Conference on Harmonization [ICH]) have an impact on the testing carried out by industrial organizations in all countries. The recent proposals for screening and testing chemicals to identify endocrine disrupters (ED) from the Endocrine Disrupter Screening and Testing Advisory Committee (EDSTAC) of the U.S. Environmental Protection Agency (EPA) are used as an example of the interaction between regulatory proposals and animal welfare issues. The current proposals are the most extravagant in the use of animals. Between 0.6 and 1.2 million animals would be required for each 1000 chemicals tested. The EPA, before incorporating them into regulation, is subjecting the recommendations to further review. This will undoubtedly moderate the number of animals actually used from the worst-case calculation. The variables that have the greatest impact on the number of animals required for testing are the prevalence of ED chemicals in the chemicals to be tested, and the sensitivity and specificity of the testing methods. The modeling demonstrates, for example, that increasing the prevalence from 10 to 50% reduces the number of animals used to detect one ED from 10,000 to 2700. Knowledge of the prevalence of EDs in the chemicals to be tested would allow rational selection of tier one screening based on the sensitivity and specificity of the screening tests. The EDSTAC proposals are difficult to justify from an ethical perspective, as equally effective detection rates may be achieved with fewer animals. National and international regulatory testing proposals should be subjected to formal independent ethical review before they are finalized, with a view to improving animal welfare. (+info)