bluuebunny/crossref_metadata_2025 huggingface dataset:
Review of antithrombotic drug usage in atrial fibrillation
Authors: Ang  , Peterson  , Friesen  , Vial
Published: March 2003

Background:
The important prophylactic role of antithrombotic therapy against stroke in nonrheumatic atrial fibrillation (AF) has been clearly established in recent clinical trials. There have been suggestions, however, that practice has been slow to change in light of the findings of these trials

Aim:
To review cases of AF at the major teaching hospital in Tasmania, Australia, to determine whether the recommendations from the results of the trials had been translated into local clinical practice

Methods:
A retrospective review of the medical records for consecutive patients who had AF documented on ECG between 1 January and 30 June 1997 was performed. An extensive range of demographic and clinical variables were recorded for patients with chronic or paroxysmal nonrheumatic AF. These included antithrombotic and other drug therapy at admission and discharge from hospital care, risk factors for stroke, contraindications to antithrombotic use, and incidents of ischaemic stroke and bleeding complications that occurred during the period from January 1996 up to 3 months after the hospital admission that was studied

Results: The 228 patients included in the study had a mean (±SD) age of 75·3±10·9 years. Sixty‐eight per cent had chronic AF and 32% had paroxysmal AF. According to two risk stratification criteria, 91% and 86% of the patients with previously diagnosed chronic or paroxysmal nonrheumatic AF (
n=186) had a high risk of developing stroke at the time of admission to hospital care. However, less than one‐third of these patients were receiving warfarin (or warfarin plus aspirin), with almost another one‐third receiving no antithrombotic agent. Of those who were not taking warfarin, about 60% had no apparent contraindication to warfarin. For those high risk patients who had a possible contraindication to warfarin, only approximately one‐third had been prescribed aspirin. Only a slight increase in the use of antithrombotic agents had occurred by the time of discharge from hospital care. The majority of international normalized ratio (INR) values on admission for patients who had been taking warfarin were subtherapeutic. The estimated annual incidence of bleeding complications in patients taking warfarin was 15·0% overall, 5·0% for major bleeds and 3·8% for intracranial haemorrhages

Conclusions:
While a number of published trials have demonstrated that antithrombotic agents confer substantial protection against stroke in patients with nonrheumatic AF, the drugs were underused in our setting. There is a need to improve antithrombotic use and to develop a better monitoring system for the provision of safer and more effective antithrombotic therapy.
Sustaining computer‐mediated communication in university courses
Authors: Lewis R. , Warren K.J. , Rada R.
Published: March 2003

Abstract In the second of two graduate classes with the same title and content, the volume of on‐line messages per person, in the four weeks sampled, was more than seven times higher than in the first. Between weeks l‐2 and weeks 5‐6, the total number of messages per person dropped in the first class and rose in the second. Each class had a different computer‐mediated communication (CMC) system and was given different guidelines for use. This paper analyses differences in volume and hypothesises a relationship between system characteristics, guidelines for use, and the perpetuation of verbal interaction in settings where CMC is mandated.
Fostering superficial learning
Authors: Ramberg R. , Karlgren K.
Published: March 2003

Abstract Different views of learning and what it means to follow rules are discussed. The activities, the language and context of expertise and knowledge have traditionally often been neglected and underestimated as something ancillary to the real knowledge which lies ‘beyond’ such surface manifestations. The primacy of ‘superficial’ aspects are argued for. It is further argued that these should be more emphasis and fully appreciated. The goal of fostering ‘superficial’ learning is suggested, i.e. an emphasis on practical activities, the use of the language of the domain to be learned and getting familiar with the new culture. A case study is presented and discussed in terms of this theoretical viewpoint.
Training for strategic decision making in professional contexts
Authors: Leclet D. , Weidenfeld G.
Published: March 2003

Abstract The main new result reported in this paper is a computer‐based approach for training strategic competences in practical jobs such as salesmen or waiters. The environment represents job situations in which the students may act from basic principles. The interaction is similar to that in simulations or microworlds, but there is no underlying model of the activity. In order to provide feedback to the learner, a model has been built which is based on the analysis of a large set of cases provided by experts. This model uses formal knowledge and contextual knowledge in order to build an explanation mechanism providing textual comments and multimedia illustrations.
A knowledge‐based system for postgraduate engineering courses
Authors: Day A. J. , Suri A. K.
Published: March 2003

This paper describes a novel approach to the development and implementation of an educational tool based on knowledge‐based technology employing an expert system shell. Software has been developed which, after providing basic background information, proceeds to analyse the student’s learning pattern to establish which next question, explanation, or topic to propound in order to aid the learning process and ensure that fundamental knowledge is gained by the student at his/her own pace. While the system described has been designed and implemented specifically to supplement, rather than supplant, the taught part of an MSc. course in Manufacturing Systems Engineering and Management, the methodology formulated can be used to develop similar knowledge‐based systems for other technical as well as non‐technical subjects at both undergraduate and postgraduate levels in Higher Education.
Problem solving, planning ability and sharing processes with LOGO
Authors: Kapa E.
Published: March 2003

The present research examined the impact of a Logo environment on the level of problem solving control, modification of planning ability and sharing processes in pairs and individual learners. Forty‐five fifth‐grade students (ranging in age from 10 to 11 years old, who studied in four classes), participated in the study. The subjects were randomly divided into fifteen pairs and fifteen individuals. Results showed significant differences in problem solving control between the Logo environment group and the comparison group. At the end of the treatment the degree of cooperative learning increased in the pairs groups. There was an effective modification of the subjects’ planning ability in both pairs and individuals.
Coding categories to record student talk at a multimedia interface
Authors: Klinger S.
Published: March 2003

Multimedia CD‐ROMs carry enormous quantities of textual, video and graphical information, connected by numbers of hypertext links. With no clear, linear narrative, this mass of information can be baffling for novice users. Using case study methodology, this paper examines how pairs of first time student users navigated through a multimedia geography disc together. The students and their on‐screen actions were videotaped and their discussions analysed to reveal three initial categories of talk, entitled route, function and content. These categories describe the students’ overall comprehension of the content design, the functionality of the individual screen, and its relevance to the set task. In conclusion, recommendations are made for teachers wishing to introduce similar materials to their classrooms.
Students at the centre: non‐lineal narratives and self‐conscious learning
Authors: Pink S.
Published: March 2003

This paper reflects on the design and evaluation of a multimedia learning tool developed for students of qualitative research. Two issues are explored which are pertinent to the introduction of multimedia networked learning tools into existing teaching and learning cultures. First, the concept of the non‐lineal — in multimedia narratives, in the ethnographic research process, in the learning process and in relation to teaching strategies. Second, drawing from evaluations of the multimedia tool the idea of self‐conscious multilineal learning, and continuities between hypermedia learning and conventional teaching and learning practices are discussed. Finally the theoretical and practical implications of these discussions are related to the question of developing ‘student‐centred learning’.
The effects of training wheels and self‐learning materials in software training
Authors: Bannert M
Published: March 2003

Abstract The role of software training is becoming increasingly important due to the growing variety and complexity of modern software products. This paper focuses on the effectiveness and feasibility of two different kinds of individual learners' support in software training in classroom settings. This research question was investigated by analysing 11 text‐processing courses which were conducted on the basis of a quasi‐experimental research design. Firstly, the user interface was varied, i.e. half of the courses used the regular standard user interface of the software, whereas the other half used a training wheels interface in which all irrelevant functions were blocked. Secondly, in half of the courses all instruction was given by a human tutor whereas the participants in the other half received written self‐learning material. A total of 72 university students majoring in different fields participated. Dependent measures were learning time, learning outcome, and learner satisfaction.
Policy and practice in Germany
Authors: Metz Rainer
Published: March 2003

Abstract: In Germany, EU directives have been the primary source of consumer protection legislation in banking and financial services, especially legislation on consumer credit and investment services. Otherwise, there is little significant statute law, either at federal or provincial (Länder) level, apart from a recent Consumer Bankruptcy Law. Most consumer problems have to be solved within the framework of the very general Civil Code or the law on unfair contract terms. This means that there is strong emphasis on the role of the courts in interpreting the law in specific cases. In recent years consumer organizations have played an important part in bringing class action cases in the courts – notably on issues concerned with value dating, bank charges and the early termination of mortgage and insurance contracts. There is virtually no tradition of securing consumer protection through codes of conduct. Banking ombudsman schemes have been set up in recent years, but are subject to some criticisms by consumer organizations.
An investigation into the effects of domestic cleaning on upholstery covering materials backcoated with fire retardants
Authors: Yates Karen , Peel Robert , Farmer Nigel
Published: March 2003

Abstract: The purpose of this research was to investigate the effects of domestic cleaning on upholstery covering materials backcoated with fire retardants. The results are an indicator of the effectiveness of legislative controls for upholstery. A questionnaire and pilot study were used to devise standard treatment procedures reflecting popular domestic cleaning methods. Samples of material were subjected to each treatment procedure followed by testing to the match test in BS 5852:Pt 1: 1979, over filling material specified in Part 1 of Schedule 5 of the Furniture and Furnishings (Fire) (Safety) Regulations 1988. To provide a standard, materials were also subjected to the water soak procedure in BS 5651: 1978, followed by testing to the match test. The results indicate that domestic cleaning methods affect backcoated fire retardants in such a way that current furniture legislation does not adequately provide for the level of durability required in practice. In addition, evidence was gained via a retail survey which suggests that consumers are not provided with sufficient aftercare information when purchasing new furniture.
Back to the well: the hidden costs of service exclusion for the network poor
Authors: Speak Suzanne
Published: March 2003

This paper discusses the consumption of the everyday services that sustain living in contemporary Britain, many of which are now provided by private sector organizations operating in the global marketplace. It aims to highlight the differential access to and cost of those services to people living stressed and disadvantaged lives in marginalized neighbourhoods. Drawing on recent empirical research, it highlights the way in which the exclusion and marginalization of some customers exacerbates both their financial poverty and the stress associated with it.
Using social and consumer values to predict market‐place behaviour: questions of congruency
Authors: McGregor Sue L.T.
Published: March 2003

Social values and consumption values, although intricately linked, are not exactly the same. Nonetheless, marketers contend that the central premise of social value monitoring is that, if one understands people’s values, one can better predict how they will behave in the market‐place. This paper challenges this assumption because policy analysts and industries are relying on both the consumer and social value profiles at a time when society and the market‐place are undergoing a profound transition. Using Canada as a case study, the general societal values of consumers identified by pollsters are discussed relative to nine consumer values espoused by marketers. This comparative analysis suggests that many of Canadians’ alleged consumer values seem to be in direct conflict with their espoused social values. This conclusion implies that the validity of using social values as a proxy variable or predictor for consumer values needs to be examined by researchers and policy analysts. Also, future dialogue needs to occur about adhering to the convention of monitoring social and consumer values using public opinion polls while not marrying this process with public judgement dialogues. Finally, other countries are urged to examine the situation in their market‐place so as to facilitate cross‐cultural comparative analysis of consumer market‐place values.
Trade‐offs between phlorotannin production and annual growth in natural populations of the brown seaweedAscophyllum nodosum
Authors: Pavia Henrik , Toth Gunilla , Åberg Per
Published: March 2003

1 The potential cost of polyphenolic (phlorotannin) production in the brown seaweedAscophyllum nodosumwas investigated by testing for phenotypic trade‐offs between phlorotannin content and annual growth. Relationships between tissue nitrogen and phlorotannin content, as well as between tissue nitrogen content and annual growth, were also examined to evaluate the importance of the carbon–nutrient balance in explaining intraspecific variation in phlorotannins.

2 Annual shoots were collected from a total of 300 A. nodosumindividuals in natural populations at three sites in each of two study areas, in 2 consecutive years.

3 Data were analysed using analyses of covariance (ancovas), which showed that there was a significant negative relationship between phlorotannins and growth in both study areas in both years. Shoots with a relatively high phlorotannin content (> 9% dry weight) had a mean reduction in growth that varied from 25% to 54%, compared with shoots with relatively low concentrations (< 6% dry weight) of phlorotannins.

4 Predictions about variation in the cost of carbon‐based chemical defences were supported by regression analyses with subsampled data sets that revealed that the trade‐off between phlorotannins and growth was most pronounced in individuals with relatively high tissue nitrogen levels.

5 The relationship between tissue nitrogen and phlorotannin content, as well as between nitrogen content and growth, was weak and variable.

6 Production of phlorotannins inA. nodosumunder natural conditions appears to involve a substantial cost in terms of individual growth. This cost varies spatially and temporally, at least partly as a consequence of variation in nutrient availability.

7 Tissue nitrogen content is not strongly related to phlorotannin concentration ofA. nodosumindividuals, in contrast with findings for a few other seaweed species.
Comparison of post‐fire seedling establishment between scrub communities in mediterranean and non‐mediterranean climate ecosystems
Authors: Carrington M.E. , Keeley J. E.
Published: March 2003

1 Both fire regimes and the conditions under which fires occur vary widely. Abiotic conditions (such as climate) in combination with fire season, frequency and intensity could influence vegetation responses to fire. A variety of adaptations facilitate post‐fire recruitment in mediterranean climate ecosystems, but responses of other communities are less well known. We evaluated the importance of climate by comparing sites with mediterranean and subtropical climates.

2 We used paired burned and mature sites in chamise chaparral, mixed chaparral and coastal sage scrub (California), and rosemary scrub, sand pine scrub and sandhill (Florida), to test whether (i) patterns of pre‐fire and post‐fire seedling recruitment are more similar between communities within a region than between regions, and (ii) post‐fire stimulation of seedling establishment is greater in regions with marked fire‐induced contrasts in abiotic site characteristics.

3 Post‐fire seedling densities were more similar among sites within climatic regions than between regions. Both seedling densities and proportions of species represented by seedlings after fires were generally higher in California.

4 The only site characteristic showing a pre‐fire–post‐fire contrast was percentage open canopy, and the effect was greater in California than in Florida. Soil properties were unaffected by fire.

5 Mediterranean climate ecosystems in other regions have nutrient‐poor soils similar to our subtropical Florida sites, but show post‐fire seedling recruitment patterns more similar to the nutrient‐rich sites in California. Climate therefore appears to play a more major role than soil characteristics.
Detection of delayed density dependence in an orchid population
Authors: Gillman M. P. , Dodd M.
Published: March 2003

1 Annual censuses of Orchis morio (green‐winged orchid) flowering spikes have been taken over a 27‐year period in a replicated factorial experiment on the effects of fertilizer application. Census data, combined by block or treatment, were used in time–series analyses to test for density dependence.

2 Partial autocorrelation functions revealed the importance of positive correlations at lag 1 and negative correlations at lag 5. Stepwise multiple regressions provided evidence of delayed density dependence, again with a delay of about 5 years, with no evidence of direct (first‐order) density dependence.

3 First‐order autocorrelations and delayed density dependence were considered in the light of the known stage structure and generation time of the plant and the possibility of density dependence at different points in the life history.

4 Model structure affects the detection of density dependence, increasing the propensity for type I errors.
Effects of low and high nutrients on the competitive hierarchy of 26 shoreline plants
Authors: Keddy Paul , Gaudet Connie , Fraser Lauchlan H.
Published: March 2003

1 We tested the hypothesis that competitive hierarchies are invariant with respect to changing nutrient supply.

2 The competitive performance of 26 shoreline plant species was determined experimentally as the relative ability to suppress the growth of a common indicator (phytometer) species, Penthorum sedoides. Each species was grown with the phytometer under each of two nutrient treatments created with different concentrations of a modified Hoagland’s solution (n = 5 replicates per species/treatment), for two growing seasons.

3 Although shifts in ranking of relative competitive performance were apparent between nutrient levels, competitive performance under high and low nutrient conditions was significantly correlated in both year 1 (r = 0.65) and year 2 (r = 0.76), when all species were considered.

4 At the broad community scale, the outcome of competitive interactions thus appears to be relatively predictable and independent of the environment, and therefore provides a useful tool for exploring and understanding community pattern. These results cannot address questions related to the outcome of competitive interactions between similar species or the effects of fine‐scale pattern.
Below‐ground ectomycorrhizal community structure in a recently burned bishop pine forest
Authors: Grogan P. , Baar J. , Bruns T.D.
Published: March 2003

1 The effects of wildfire ash on ectomycorrhizal (EM) associations were investigated by sampling bishop pine (Pinus muricata,D. Don) seedlings from control and ash‐removed plots 1.5 years after a severe fire in a northern CalifornianP. muricataforest. The below‐ground community composition of EM at the site was characterized using molecular techniques (PCR‐RFLP and nucleotide sequencing).

2 A total of 30 fungal taxa were observed, many of which differed in their distribution between treatment and control seedlings. However, most of the taxa that were distinctive to either treatment or control seedlings occurred only once across the site, precluding statistical detection of potential ash effects on EM community composition. There were no significant effects of ash removal on plot‐level mycorrhizal community richness or diversity, and there were no distinct treatment‐related clusters in a principal components analysis.

3 Analysis of the combined data indicated that numbers of fungal taxa per seedling, numbers of successive root depth increments colonized by the same taxon, and distances to neighbouring seedlings colonized by the same taxon, were randomly distributed across the site for the majority of mycorrhizal fungi. These distributional patterns suggest that the post‐fire mycorrhizal community structure onP. muricataarose primarily from successful colonization by randomly distributed point‐source fungal inocula within the upper mineral soil layer of the forest floor.

4 By comparison with pre‐fire studies from similarP. muricatasites nearby, our data indicate that severe wildfire disturbance resulted in marked changes in mycorrhizal community composition, and a sharp increase in the relative biomass of ascomycetous fungi.
Nutritional constraints onSphagnum‐growth and potential decay in northern peatlands
Authors: Aerts Rien , Wallén Bo , Malmer Nils , De Caluwe Hannie
Published: March 2003

In a 4‐year fertilization experiment we studied the effects of increased nitrogen (N) or phosphorus (P) supply on productivity and potential decay in the acrotelm ofSphagnum‐dominated Swedish peatlands at northern (low atmospheric N input: low‐N site) and southern (high atmospheric N input: high‐N site) sites.

 During the experimental period, there was a severe summer drought at the high‐N site which led to strong limitations onSphagnumgrowth, especially in the fertilized treatments. There were no significant effects of the nutrient treatments on cumulative length growth and productivity at either site. There were, however, significant effects of site and nutrient treatment on nutritional variables of theSphagnumspecies.

 Nitrogen concentration in living capitula was lower, but P concentration was higher at the low‐N site than at the high‐N site. However, at both sites N and P concentration in the living capitula showed only minor responses to the nutrient additions.

 Litter chemistry variables differed significantly among sites and treatments.Sphagnumlitter had lower N concentration, higher P concentration, a higher C : N ratio, a lower C : P ratio and a lower N : P ratio at the low‐N site. Litter chemistry was significantly affected by the nutrient treatments only at the high‐N site, where litter P concentrations increased significantly in the P‐fertilized treatment, whereas C : P and N : P ratios showed a significant reduction.

 Although potential rates of decay ofSphagnumlitter were higher at the high‐N site than at the low‐N site, they were not significantly affected by nutrient additions. Potential decay rates did, however, show significant relations with all the litter chemistry variables we had determined.

 An increase in nitrogen input toSphagnum‐dominated bogs appears to lead to higher N concentrations in litter and, as a result of dilution, to lower P concentrations. This change in litter chemistry leads to a higher potential decay rate of the litter and this may seriously affect the carbon balance in the acrotelm of these systems.

 Our results also show that carbon balance characteristics ofSphagnumbogs can be strongly affected by unpredictable extreme climatic conditions. This suggests that the occurrence and consequences of these events need more attention when long‐term responses of ecosystems to global change are studied.
Forest herb colonization of postagricultural forests in central New York State, USA
Authors: Singleton Rhine , Gardescu Sana , Marks P. L. , Geber Monica A.
Published: March 2003

The recovery of forest vegetation following abandonment of agriculture was followed by surveying forest herbs in central New York State at 25 sites where postagricultural forest occurred directly adjacent to old‐woods (forest that has never been ploughed).

 The abundance, richness and diversity of 50 forest herbs were on average lower in postagricultural forests than in old‐woods.

 Thirty of 39 forest herbs that were found in at least four stands were less frequent (number of plots present out of 60) in postagricultural forests than in old‐woods. Three species (Aster divaricatus,Dryopteris intermediaandPolystichum acrostichoides) had significantly higher frequency in old‐woods, while none was significantly more common in postagricultural forests.

 Although differences among species in their frequency in the two forest types were not strongly related to dispersal mode, species with rapid clonal expansion were significantly more frequent in postagricultural stands.

 Several species that were less frequent in postagricultural forests than in old‐woods showed decreases in density in postagricultural forests with increasing distance from the adjacent old‐woods.
Challenges in evaluating primary health care for teenagers
Authors: Jacobson Lionel D. , Matthews Sarah J. , Robling Michael R. , Donovan Chris , Mellanby A. , Donovan C. , Parry‐Langdon N. , Kramer T.
Published: March 2003

This paper concerns the evaluation of health care for teenagers and examines the role of primary care and its interaction with the teenage users of this service. It recognizes that the majority of health care for teenagers takes place within general practice. The challenge posed is to identify and put in place suitable evaluation tools. There are government targets to improve the health of teenagers by reducing teenage pregnancy, drug use, smoking rates and suicides. It is an assumption of this paper that improvements in experiences of primary care will lead to improvements in more population‐based outcomes of care, although this link needs investigation. The paper shows that there are few measures of generic outcome which are available for use in experiments to assess teenage health care as a baseline now. This has implications for conducting future research projects. Such measures are important and it is a necessary feature of research into teenage health that these measures are devised, tested and validated as a priority.
GUEST EDITORIAL: Evaluation: beyond the rhetoric
Authors: Cantillon P.
Published: March 2003

Evaluation does not generally command a high priority during either the design or the subsequent dissemination of new educational interventions in medical education (Rolfe 1997). New courses and programs are often initiated in the firm and sometimes arrogant belief that all or most of the objectives will be achieved. The publicity associated with the introduction of a new course or curriculum is rarely matched by an adequate assessment of either the costs or effects of the educational innovation (Gonella 1982). Within the undergraduate institutions, spared the cold eye of peer review, courses and curricula rumble on. Students graduate, become doctors and appear to perform well enough. In recent years regulatory bodies such as the General Medical Council of the United Kingdom (GMC) have questioned the traditional Flexnerian medical school curricula (Towle 1998b) and suggested radical changes to both content and structure (GMC Tomorrow’s Doctors 1993). This has led to widescale changes in medical school curricula with the introduction of integration between the basic and clinical sciences and elements of choice around a core curriculum. There is little evidence in the literature to suggest that these changes have been accompanied by associated evaluative measures. Thus there appears to have been an almost unquestioning acceptance of the GMC recommendations, with few if any assessments of the effects of these changes on the individual medical schools or their students. It would be informative to establish whether undergraduates who are experiencing the GMC initiated curricular changes differ from their predecessors in their ability to apply their knowledge to clinical problems. If there are differences, it is only by formal evaluation that we can determine which aspects of the curriculum and its delivery were foundational to these differences? I would like to consider, in this editorial, why educational evaluation in medicine should happen and yet in so many cases why it does not.
The Clinical Oncology Information Network (COIN) Project: background, purpose and products
Authors: Karp Stephen J.
Published: March 2003

The Clinical Oncology Information Network (COIN) Project of The Royal College of Radiologists is developing evidence‐based practice guidelines, clinical core data sets to audit compliance and a dedicated clinical workstation with a client‐server architecture that will collect the data sets as an automatic by‐product of the routine delivery of care. Guidelines for the treatment of breast, colorectal, lung and prostate cancer and for the delivery of chemotherapy and radiotherapy will be published in 1999. Version 2 of a demonstrator workstation is in use at the North Middlesex Hospital, London.
A method for guideline development: assessing practical feasibility and adaptation of thyroid nodule guidelines
Authors: Vidal‐Trécan G. M. , Pazart L. H. , Massol J. A.
Published: March 2003

The objective of this study was to assess adaptation and feasibility of practice guidelines for thyroid nodule management. For one month physicians completed a self‐administered semi‐structured questionnaire concerning a draft version of the guidelines for each consecutive patient. A sample group of 20 endocrinologists, 20 surgeons and 120 general practitioners from all parts of France took part in this study. The main outcome measures were whether the case description was found by the physicians, and whether recommendations were found and agreement with these recommendations were assessed. We found that two hundred and fifty‐three patients (of whom 85% were women) were included in the study: 52% were seen for a surgical decision; 20% for diagnosis or screening and 28% for follow‐up. Four percent of the women were pregnant; 2% of the patients had a large nodule; and 2%, a retrosternal nodule. These last three situations had not been well identified in the draft guidelines. The patient’s case description was appropriately identified in 75% of the responses. Most cases reported as being not found were, however, covered by the guidelines. Physicians in private practice were less likely than the others to identify their patient’s cases. Physicians agreed with the recommendation in 77% of cases. General practitioners were more likely and endocrinologists less likely than surgeons to disagree. Most disagreements and alternative proposals were not evidence‐based. Our conclusion is that this study shows that the draft guidelines were applicable, and allowed minor improvements of the final version. Adapting guidelines to practice could improve their use and, consequently, the quality of health care.
Implementing best practice guidelines: the influence of personal characteristics
Authors: Sturmberg J. P.
Published: March 2003

Clinical practice guidelines (CPGs) have not been widely adopted by general practitioners despite their obvious benefits of improving health care. Personal characteristics have been identified as one factor influencing doctors’ attitudes towards guidelines. This study examined the impact of personal characteristics of Australian general practitioners on their attitudes towards guidelines. Favouring a fee‐for‐service remuneration system is highly associated with a negative view towards guidelines. This finding needs to be taken into account when developing strategies for the implementation of guidelines in the Australian context.
Health policy directions for evidence‐based decision making in Canada
Authors: Noseworthy Tom , Watanabe Mamoru
Published: March 2003

The topic, evidence‐based decision making, may be seen from many perspectives and levels of policy consideration. Canada has been actively pursuing policy macro‐level directions for health information and evidence‐based decision making through the National Forum on Health and the Advisory Council on Health Infostructure, together with changes in the federal health ministry, Health Canada, and other important national health organizations such as the Canadian Institute for Health Information. It remains to be determined how these initiatives will fundamentally influence a culture of evidence‐based decision making and health information availability and quality for the average Canadian. Canada has, nonetheless, recognized that our health care delivery system has fallen behind in terms of using information management and technology to enable and facilitate the ever‐growing information needs of the system. Policy direction provided by the National Forum on Health and the Advisory Council on Health Information offer an agenda for action and strategic direction drawn from two broadly based, highly iterative processes.
Performance: a multi‐disciplinary and conceptual model
Authors: Lied Terry R. , Kazandjian Vahé A.
Published: March 2003

We contend that the scientific study of performance requires a model or paradigm. We propose a performance model with an underlying mathematical basis that is well defined, has explicit assumptions and has the potential to be both heuristic and scientifically testable. The model is based on an integration of concepts from health sciences and psychology that have been adapted to performance measurement in health care. The proposed performance model consists of a combination of four primary elements: quality of care, cost of care, access to care and satisfaction. Satisfaction is defined as a function of perceived and expected outcomes of care and perceived and expected input. This performance model can serve as both a tool for understanding and as a vehicle for comparing performance within and between health care organizations. We believe that this model can be used to develop a performance profile report and the future report card.
From the life‐cycles of clinical evidence to the learning curve of clinical experience
Authors: Maisonneuve Hervé. , Ojasoo Tiiu
Published: March 2003

Treatments on offer to an individual with suspected disease are based on concepts which, like products, go through life‐cycles (introduction, growth, maturity, decline). We argue that randomized controlled trials, meta‐analyses, and guidelines have reached maturity and/or are already on the decline and note renewed interest in case reports and qualitative medicine. The latter emphasize individual rather than ‘average’ patients. Moreover, we point out that scientific evidence relates not only to variables that can be measured but also to categorical variables that are often neglected. An appropriate treatment strategy is probably one which is indicated by several methods based on different concepts rather than by a single standard method. The doctor’s role is to use his critical judgement and experience to appraise evidence from formal trials and from analyses of observational data and to share his views with the patient.
Monitoring the care of lung cancer patients: linking audit and care pathways
Authors: Kaltenthaler E. , McDonnell A. , Tech J. Peters B.
Published: March 2003

Clinical audit plays an important role in monitoring the provision of care for patients whatever their condition. Care pathways define the steps and expected course of events in the care of patients with a specific clinical problem over a set time scale. This paper describes a study undertaken in a multisite cancer unit to develop a tool for monitoring the progress of lung cancer patients through a care pathway and auditing key standards within the pathway. Important issues associated with the development of this tool are highlighted. The process of developing this tool involved the following steps: a review of the literature dealing with the management of lung cancer patients; interviews with key personnel in primary, secondary, tertiary and palliative care; development of a paper‐based series of forms representing key steps in the patient’s care pathway; 3‐month trial of the paper‐based tool; analysis of completion rates and interviews with form users to evaluate effectiveness; and recommendations for creating an electronic record using the experience and lessons learned from the paper version. The paper forms developed through this multistage process were found to be acceptable to users and have the potential to provide accurate information at key points for audit throughout the patient’s time within the health‐care system for their lung cancer condition. The flexibility of this methodology allows it to be adapted readily to a variety of clinical situations and conditions.
National sentinel clinical audit of evidence‐based prescribing for older people: methodology and development
Authors: Grant R. L. , Batty G. M. , Aggarwal R. , Lowe D. , Potter J. M. , Pearson M. G. , Oborne A. , Jackson S. H. D.
Published: March 2003

Rationale, aims and objectives This national clinical audit aimed
to develop and implement a methodology to assess the appropriateness of prescribing
for patients over the age of 65 in hospitals, general practice and nursing homes.
Methods Organizations providing health care in the National Health
Service in these three sectors were recruited into multi‐disciplinary and inter‐organizational
local coalition teams. Prescription data and relevant clinical data were collected
electronically on a customized database. The appropriateness of prescribing for specific
conditions among the patients sampled was assessed by simple computerized algorithms,
and users were provided with feedback to stimulate discussion and change. Use of
the software tool was demonstrated to be feasible and its data reliable. Participants
were re‐audited, after a period of nationally guided and locally driven intervention,
to evaluate levels of change. Local efforts to stimulate change and barriers to change
were collected qualitatively. Results and conclusions The investigation revealed encouraging results and demonstrated the ability of audit to improve the quality of clinical services in given circumstances, although a multiplicity of questions relating to cost and methodology remain to be addressed.
Prescribing pattern of antihypertensive drugs by family physicians and general practitioners in the primary care setting in Bahrain
Authors: Sequeira Reginald P. , Jassim Khalid A. , Damanhori Awatif H. H. , Mathur Vijay S.
Published: March 2003

The aim was to determine whether there are differences among family physicians (FPs) and general practitioners (GPs) in terms of their preference for different classes of antihypertensives, either alone or in combinations, in uncomplicated cases of hypertension and to determine the extent of adherence to WHO/ISH guidelines. We have analysed prescribing of antihypertensives by qualified family physicians (FPs) (n=77) and compared this with that of general practitioners (GPs) (n =41) by auditing 1791 prescriptions of FPs and 914 prescriptions of GPs, issued to patients with uncomplicated hypertension, at 15 out of 20 health centres in Bahrain. The choice of antihypertensive(s) by FPs and GPs was comparable and conformed with the WHO/ISH guidelines as regards preference for: (i) β‐blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers (CCBs) as monotherapy; (ii) two‐drug combinations (diuretic–β‐blocker; β‐blocker–CCB); (iii) three‐drug combinations (diuretic–β‐blocker–CCB; diuretic–β‐blocker–ACE inhibitor; β‐blocker– ACE inhibitor–CCBs), and (iv) choice of drug used for the elderly either alone (CCBs) or as combinations (diuretic–β‐blocker; β‐blocker–CCB and diuretic–β‐blocker–ACE inhibitor; diuretic–β‐blocker–CCB). In several instances prescribing by both FPs and GPs was not in accordance with the WHO/ISH guidelines: reluctance to prescribe diuretics as monotherapy; use of suboptimal combinations (β‐blocker–ACE inhibitor); and extensive use of β‐blockers and irrational use of immediate‐release nifedipine in elderly. A statistically significant prescribing difference between FPs and GPs was evident in the following: β‐blockers as monotherapy (P =0.01), diuretic–CCB (P=0.046), and diuretic–CCB–methyldopa (P=0.01) combination, and immediate‐release nifedipine monotherapy in the elderly (P=0.027), were prescribed more often by the GPs. However, β‐blocker–ACE inhibitor–CCB combination was more often prescribed by FPs (P=0.046). Remarkable differences in prescribing pattern of antihypertensives between the FPs and GPs were evident. Although the general pattern supported a superior prescribing profile of the FPs as expected, there is a need for improved prescribing by both GPs and FPs. Educational programmes, both graduate and residency training, and continuing professional education, should specifically address these deficiencies in order to assure quality primary health care.
Dietary salt and hypertension: a scientific issue or a matter of faith?
Authors: Robertson J. Ian S.
Published: March 2003

Many workers have an overly simplistic view of the relationship between salt intake and hypertension. This article attempts a critical evaluation of some of the evidence.
Hafnia alvei as an opportunistic pathogen causing mortality in brown trout, Salmo trutta L.
Authors: Rodríguez L. A. , Gallardo C. S. , Acosta F. , Nieto T. P. , Acosta B. , Real F.
Published: March 2003

Strains of Hafnia alvei caused mortalities in brown trout, Salmo trutta L., following intraperitoneal injection with LD50 values ranging between 1.3 × 104 and 2.5 × 107 bacteria fish−−1. These values are considered to represent a high to moderate degree of virulence. Virulent strains were isolated from non‐fish sources. Fish surviving the LD50 values continued to harbour the organism in the kidney, suggesting the establishment of a carrier state.
Epizootics in farm‐raised channel catfish, Ictalurus punctatus (Rafinesque), caused by the enteric redmouth bacterium Yersinia ruckeri
Authors: Danley M L. , Goodwin A E. , Killian H S.
Published: March 2003

In the winters of 1995 and 1996, unusual disease outbreaks occurred on two separate channel catfish farms in Arkansas, USA. Affected fish exhibited extraordinary haemorrhaged rings around the eyes and raised haemorrhaged areas overlying the frontal foramens. Other signs included abnormal swimming, lethargy, loss of equilibrium, and exophthalmia. Bacterial isolates from the moribund fish were identified as Yersinia ruckeri by biochemical tests, no lysis by the Hafnia‐specific bacteriophage 1672, and Y. ruckeri‐specific growth patterns on Shotts‐Waltman media. Fingerling catfish injected intraperitoneally with the bacterial isolate at 7.8 × 106 bacteria fish−1 developed lesions characteristic of the epizootics at 13, 18, and 22 °C and a biochemically identical isolate was recovered. Fingerling rainbow trout injected with the channel catfish isolate at 1 × 105 bacteria fish−1 and held at 20 °C developed signs typical of enteric redmouth by 4 days post‐inoculation and were moribund by 5 days post‐inoculation. Some differences of clinical signs occurred between experimentally infected rainbow trout and channel catfish. Clinical and biochemical similarities between infections of Y. ruckeri and many warmwater pathogens in affected catfish may lead to incorrect diagnosis of ERM infections.
Characterization of the adhesion of Flavobacterium columnare (Flexibacter columnaris) to gill tissue
Authors: Decostere A. , Haesebrouck F. , Van Driessche E. , Charlier G. , Ducatelle R.
Published: March 2003

Flavobacterium columnare (Flexibacter columnaris) is an important cause of gill and skin disease in freshwater fish species, often causing high mortality. In previous studies, virulence of F. columnare was correlated with the ability to adhere to the gill tissue. To gain insight into the factors responsible for adherence, a gill perfusion model was used. The bacterial cells of the high virulence strain AJS 1 were exposed to various treatments, after which they were added to the organ bath of an isolated gill arch and adherence to the gill tissue assessed. Adherence capabilities were significantly reduced following treatment of the bacteria with sodium metaperiodate or incubating them with d‐glucose, N‐acetyl‐d‐glucosamine, d‐galactose and d‐sucrose. Incubation of the bacteria with trypsin and pronase did not significantly inhibit adherence. The binding sites for F. columnare on the gill tissue were also partially characterised. Treatment of the gill with sodium metaperiodate reduced adhesion, but treatment with pronase or trypsin did not cause any significant reduction, indicating that the major component of the receptor is of carbohydrate nature. Adherence ability of the bacteria correlated well with their haemagglutination capacity using chicken and guinea pig erythrocytes. Higher haemagglutination titres were obtained with the highly virulent strain AJS 1 than with strain AJS 4, a strain with low virulence and adherence capacity. Haemagglutination was partially inhibited after incubation of the bacteria with d‐glucose and N‐acetyl‐d‐glucosamine and after treatment of the bacteria at 41_°C for 10_min (minor heat treatment). It was completely abolished following incubation of the bacterial cells with sodium metaperiodate and intensive heat treatment (65_°C, 25_min). Haemagglutination was also in‐sensitive to pronase and trypsin treatment. Transmission electron microscopy (TEM) revealed that the high virulence strain had a thick capsule (120–130_nm) with a regular, dense appearance, whereas the capsule of the low virulence strain was much thinner (80–90_nm) and less dense. TEM also demonstrated the loss of the capsule of the high virulence strain after treatment of the bacterial cells with minor heat and sodium metaperiodate. These results indicate that a lectin‐like carbohydrate‐binding substance incorporated in the capsule is responsible for the attachment of F. columnare to the gill tissue.