bluuebunny/crossref_metadata_2025_split huggingface dataset:
Errors: can indicators measure the magnitude?
Authors: Kazandjian Vahé A. , Matthes Nikolas , Thomas Tom 
Published: March 2003

AbstractErrors in medicine, especially medication errors, have long been recognized as a dimension of quality of care and organizational performance. Recently, however, the magnitude of the issue, or its potential impact on cost, quality of care and patient safety have catapulted this issue to the forefront of national debate on the appropriateness of patient care management. There are still fundamental issues associated with the measurement of errors. Should errors that do not cause patient harm receive much attention? Could there be organizational or system issues that predispose to errors? Are there acceptable measurement models that allow comparative analysis and trending of institutional error rate profiles? This paper presents a systematic review of the measurement aspects for errors in medicine, emphasizing the medication errors’ dimension. An indicator‐based, epidemiological model of measurement is proposed which will allow a systematic inquiry into the issues of both preventable and non‐preventable errors and their potential for patient harm.
An illustrated guide to the methods of meta‐analysis
Authors: Sutton Alexander J. , Abrams Keith R. , Jones David R. 
Published: March 2003

AbstractMeta‐analysis is now accepted as a necessary tool for the evaluation of health care. Such analyses have been carried out in virtually every area of medicine to evaluate a wide spectrum of health care interventions and policies. This paper has three broad aims: (1) to describe the basic principles of meta‐analysis, using a meta‐analysis of interventions intended to reduce hospital re‐admission rates for illustration; (2) to consider threats to the internal validity of meta‐analysis, and the measures which can be taken to minimize their impact; and (3) to present an overview of more specialist and developing methods for synthesizing data, with the intention of outlining the directions meta‐analysis may take in the future. The methods used to synthesize studies, which take ‘weighted averages’ of effect sizes have been refined to a high degree, while the methods for dealing with threats to the validity of meta‐analyses such as publication bias, and variations in quality of the primary studies, are at a less advanced stage. However, many consider this standard ‘weighted average’ approach to meta‐analysis not to be ‘state of the art’ in at least some situations, where the use of more sophisticated methods, generally to explain variation in estimates from different studies and synthesize a broader base of evidence, would be advantageous. Currently, approaches which attempt to do this are mainly still in the experimental stage and, unfortunately, ideas which sound natural and appealing are often difficult to implement in practice. Clearly, it will be some time before they are used routinely, but significant steps have been made.
Structuring student learning in the primary care setting: where is the evidence?
Authors: Kurth Rebecca J. , Irigoyen Matilde M. , Schmidt Hilary J. 
Published: March 2003

AbstractOver the past two decades, the majority of medical schools in the USA have embarked upon curricular initiatives to enhance the teaching of ambulatory or office‐based primary care. Identifying characteristics of these primary care experiences that make for the most effective learning is a top priority in medical education research. In this paper we examine what is known about the influence of variability in the structure of primary care experiences on student learning outcomes. We examine the questions of how rotations are scheduled, who does the teaching and where the teaching takes place. Given the variability in curricula across the 125 accredited medical schools in the USA and the absence of agreed‐upon objectives, outcomes or assessment measures for primary care education, it is not surprising that the current literature has fallen short in providing definitive answers. There is much debate about the benefits of community vs. campus sites, longitudinal vs. block experiences, and the influence of specialty training of the preceptor, but little in the current literature to guide and substantiate a programme's choice. What can be concluded with relative confidence is that clinics currently offer more active student experiences than do private offices, that students may be more satisfied with rural experiences than with urban or suburban experiences, and that longitudinal and block experiences have different learning advantages. Research in primary care medical education will benefit from the current movement towards a cross‐institutional consensus on educational objectives and outcome measures and on the general application of a more rigorous research methodology.
Applying Prochaska’s model of change to needs assessment, programme planning and outcome measurement
Authors: Parker Kathryn , Parikh Sagar V. 
Published: March 2003

AbstractA major goal of continuing medical education (CME) is to enhance the performance of the learner. In order to accomplish this goal, careful consideration and expertise must be applied to the three primary ingredients of CME planning: assessing learner needs, programme design and outcome measurement. Traditional methods used to address these three components seldom result in CME initiatives that change performance, even in the presence of sophisticated CME formats and capable learners. In part, performance may not change because the learner is not ‘ready to change’. Planners of CME are aware of this concept but have been unable to measure ‘readiness to change’ or employ it in assessing learner needs, and planning and evaluating CME. One theory that focuses on an individual’s readiness to change is Prochaska’s model, which postulates that change is a gradual process proceeding through specific stages, each of which has key characteristics. This paper examines the applicability of this model to all components of CME planning. To illustrate the importance of this model, this paper provides examples of these three components conducted both with and without implementation of this model.
Improving general practitioner records in France by a two‐round medical audit
Authors: Brami Jean , Doumenc Michel 
Published: March 2003

AbstractRationale, aims and objectives The effectiveness of clinical audits in
changing the practice of health care professionals is a moot point. Methods of implementation
impinge directly upon outcomes. We investigated whether a network of local opinion
leaders could contribute towards a successful audit. Our objectives were to: (i)
bring about an improvement in record keeping in general practice; and (ii) increase
GPs’ awareness of medical evaluation. Methods The GPs were recruited
by local opinion leaders who had been briefed by the French National Agency for Accreditation
and Evaluation in Health Care (ANAES, formerly ANDEM). On a given day (first round
of the audit) they were invited to examine whether the medical records of their 10
first patients met 13 set criteria. Overall results were analysed by ANAES. Each
GP was informed of how well they had fared compared with the regional and national
averages and was provided with a standard set of recommendations. Anonymity was ensured
by the local leaders. A second round was conducted 6 months later. Results A
total of 244 GPs took part in both rounds of the audit; 32 dropped out after the
first round. Their results were of a significantly lower standard. A significant
improvement in results (P < 0.025) was recorded between the
two rounds for all 13 criteria of the questionnaire. Overall scores improved between
the two rounds for 69% of the GPs and improved above average for 49%.
The greatest scatter in results was noted for items relating to medical history rather
than to personal identity (administrative data). Conclusions Self‐assessment can help improve general standards of medical record keeping. A network of local opinion leaders, briefed by a national agency whose mission is to promote quality improvement in health care, seems to be an effective means of inducing participation in self‐assessment.
Fitting dietary advice for oral health into the roles of food for elderly, mentally ill people
Authors: Fiske J. , Zhang W. 
Published: March 2003

Summary Aim: To identify the roles of food in a day‐centre for elderly, mentally ill people, so that dietary recommendations for optimal oral health are made within the overall philosophies of the day‐centre. Method: A qualitative approach was adopted. It comprised an observational study of the daily routine and a semistructured interview to examine the attitudes, beliefs and knowledge of the care‐staff related to diet, general health and oral health. Results: The use of food was pivotal to the functioning of the centre. Food was used for nutrition, as a focus for communal activities, to express love and caring, and to maintain cognitive, daily living and social skills. All staff considered oral health important and appreciated the link between oral health, general health and diet (primarily sugar consumption). Despite this, one‐third of carers considered tooth loss an inevitable consequence of ageing. Sugar was generally regarded as detrimental to general health, but attitudes towards use of sweeteners as an alternative were mixed. However, it was believed that elderly people can adapt to dietary changes. Conclusion: Dietary advice for oral health would be acceptable if put in the context of general health and the changes take account of the overall philosophies of the centre. To this end a ‘Healthy Eating Resource Pack’ was produced for use in the centre.
Assessing the dietetic needs of different patient groups receiving enteral tube feeding in primary care
Authors: Madigan S. M. , O'Neill S. , Clarke J. , L'Estrange F. , MacAuley D. C. 
Published: March 2003

AbstractAimTo examine the nature of all contacts between adult tube‐fed patients and the dietetic service and to refine the current dietetic protocols to reflect the findings of the study with a view to improving patient care.MethodsAll adult patients referred to the Community Nutrition and Dietetic Service within a 6‐month period were included in the study. Using a proforma developed from a retrospective case‐note analysis, data were collected on the complications that prompted more frequent contacts than the department protocol. Data were analysed using the Statistical Package for the Social Sciences.ResultsThe most common indication for home enteral feeding in this group of adult patients was a swallowing disorder resulting from a cerebrovascular accident (59.5%) followed by cancer (21.5%). There was a trend for cancer patients to need more intervention compared with those patients with other medical conditions. A significant difference was observed in the total contacts and telephone calls given to those patients in there own homes (P=0.019) and there was a trend towards more domicilary visits with this group.ConclusionsThe department protocols have been revised to include a planned review within 2–6 weeks of initial dietetic assessment in the community for those patients who were identified to have the greatest need. More intensive dietetic monitoring has clear implications for dietetic services in the community.
Ethical issues involved in the implementation of a differential reinforcement of inappropriate behaviour programme for the treatment of social isolation and ritualistic behaviour in an individual with intellectual disabilities
Authors: Iqbal Z 
Published: March 2003

AbstractThe present case study describes an adult male with a 28‐year history of institutional care underpinned by a moderate intellectual disability (ID), and ritualistic behaviour congruent with features of autism or obsessive‐compulsive disorder. The subject's ID was recognized early in life and he was provided with a special educational placement at 6 years of age, although his increasingly disturbed behaviour had resulted in several psychiatric admissions by early adolescence, and by the age of 20, his presentation necessitated long‐term secure psychiatric care. The present report describes the application and ethical issues pertaining to a differential reinforcement of inappropriate behaviour (DRI) programme for the reduction of ritualistic behaviour and social isolation, the latter being a direct consequence of the former, one year after the subject was admitted to a medium‐secure assessment and treatment residential facility. The results suggest that, although the treatment was successful in targeting ritualization and reducing social isolation, ethical concerns extended to care staff concerns about the reinforcer adopted for the programme and the lack of informed consent from the subject. The former resulted in inconsistent application of the programme and its eventual termination. A follow‐up assessment of the subject's extent of social isolation and ritualistic behaviour suggested a return to a pre‐DRI level of morbidity. Limitations and suggestions for the future treatment of such cases are outlined.
Informing patients and relatives about do‐not‐resuscitate decisions. Attitudes of cardiologists and nurses in Sweden
Authors: lÖfmark  , nilstun  
Published: March 2003

Löfmark R, Nilstun T (Länssjukhuset Gävle and Lund University, Lund, Sweden). Informing patient and relatives about do‐not‐resuscitate decisions. Attitudes of cardiologists and nurses in Sweden. J Intern Med 1998; 243: 191–95.ObjectivesTo survey the attitudes of Swedish cardiologists and nurses regarding information given to patients and relatives concerning do‐not‐resuscitate (DNR) status.MethodQuestionnaire.SettingNationwide, 2 years after the publication of a proposal of guidelines on DNR.Subjects10% random sample of members of the Swedish Cardiac Society, 104 physicians and 196 nurses. Response rate 73%.ResultsAccording to most Swedish cardiologists and cardiac nurses, patients and relatives should be honestly informed about a patient's DNR status if they ask for information. Almost all (97%) answered that the relatives of a noncompetent patient should be informed when they ask and (67%) believe that the relatives should be informed even if they do not ask. Most of the respondents (61%) stated that the patient, if mentally competent, should be informed about the DNR status first and decide if the information should be passed on to relatives. Only 12% of the respondents were of the opinion that if the relatives asked for this information to be withheld from the patient, this should be respected even if the patient asked for information, and 45% believed it should be respected if the patient did not ask. With reference to the latter, many (31%) were uncertain. The cardiologists and cardiac nurses expressed almost identical opinions in the matter of informing patients and relatives about DNR status.ConclusionsCurrent guidelines recommend honest answers to questions and that priority should be given to the autonomy of the patient. However the guidelines do not offer any assistance when no questions are asked. In such cases, there may be an ethical conflict between two requirements: respect for the person and do not harm. Many health care professionals believe that the information could, in some cases, harm the patient. This conflict can hardly be solved by referring to more basic ethical values. More training in informing patients and relatives about delicate matters is probably required, together with more knowledge about the wishes of very ill patients.
Haemangioblastoma of the central nervous system in von Hippel–Lindau disease
Authors: Richard  , Campello  , Taillandier  , Parker  , Resche  
Published: March 2003

Richard S, Campello C, Taillandier L, Parker F, Resche F (Hôpital Necker, Paris, CHU Hôpital Caremeau, Nîmes, CHU Hôpital Saint‐Julien, Nancy, CHU Hôpital de Bic tre, Le Kremlin‐Bic tre, Hôpital Laennec, Nantes, France). Haemangioblastoma of the central nervous system in von Hippel–Lindau disease (Minisymposium: MEN & VHL). J Intern Med 1998; 243: 547–53.Haemangioblastoma of the central nervous system (CNS) is the most characteristic lesion and the most common presenting manifestation of von Hippel–Lindau (VHL) disease and has a striking tendency to multiple occurrence. Its sites of predilection are the posterior fossa (cerebellum++), and the spinal cord. Haemangioblastoma may cause increased intracranial pressure and/or neurological deficits and remains the main cause of morbidity and mortality in VHL. Treatment of symptomatic haemangioblastoma remains neurosurgical and is often in emergency. Haemangioblastoma appears to be more commonly associated with VHL than previously reported and suggests that all patients with ‘sporadic’ haemangioblastoma should be investigated for evidence of VHL disease. From a fundamental point of view, haemangioblastoma is a benign neoplastic entity with a double, vascular and cellular differentiation. Mutational inactivation of both copies of the VHL gene plays a major role in the pathogenesis of haemangioblastoma. Over‐expression of vascular endothelial growth factor (VEGF) and VEGF‐receptors has been recently demonstrated in these tumours, raising the possibility of angioblastic origin, and is of very great interest in view of the direct implication of the VHL gene in negative regulation of VEGF.
Deoxycholic acid treatment in patients with cholesterol gallstones: failure to detect a suppression of cholesterol 7α‐hydroxylase activity
Authors: Hillebrant C.‐G. , Nyberg B. , Angelin B. , Axelson M. , Björkhem I. , Rudling M. , Einarsson C. 
Published: March 2003

Abstract. Hillebrant C‐G, Nyberg B, Angelin B, Axelson M, Björkhem I, Rudling M, Einarsson C (Huddinge University Hospital and Karolinska Hospital, Karolinska Institute, Stockholm, Sweden). Deoxycholic acid treatment in patients with cholesterol gallstones: failure to detect a suppression of cholesterol 7α‐hydroxylase activity. J Intern Med 1999; 246: 399–407.Objectives. Based on animal studies, hydrophobic bile acids have been postulated to be particularly strong inhibitors of bile acid synthesis. The present study was undertaken to characterize in humans the effects of one of the most hydrophobic of the common bile acids, deoxycholic acid (DCA), on the transcriptional regulation and activity of the cholesterol 7α‐hydroxylase, on hepatic cholesterol metabolism and on biliary lipid metabolism and plasma lipids.Design, subjects and settings. Thirteen patients with cholesterol gallstone disease were treated with DCA (750 mg day–1) for 3 weeks prior to cholecystectomy. Blood samples were collected before and during treatment. At operation, a liver biopsy and gallbladder bile were obtained. Twenty‐eight untreated gallstone patients undergoing cholecystectomy served as controls. The study was carried out at a university hospital.Results. Deoxycholic acid comprised 72 ± 6% (mean ± SEM) of total biliary bile acids in DCA‐treated patients (n = 8), and 21 ± 2% in the controls (n = 16; P < 0.001). Cholesterol saturation of gallbladder bile averaged 102% in both treated (n = 7) and untreated (n = 16) patients. Cholesterol 7α‐hydroxylase and HMG CoA reductase activities and mRNA levels were not different between DCA‐treated and untreated gallstone patients. The LDL receptor mRNA levels were similar in both groups of patients. Plasma levels of total cholesterol were lowered by 10% upon DCA treatment (P < 0.05).Conclusions. Treatment with DCA did not significantly affect mRNA levels and activity of hepatic cholesterol 7α‐hydroxylase or HMG CoA reductase in patients with cholesterol gallstones. There was no effect on the saturation of gallbladder bile, Thus, the present study could not verify that the hydrophobicity of the bile acid pool is a major factor regulating human hepatic cholesterol 7α‐hydroxylase activity.
Randomized controlled trials and consensus as a basis for interventions in internal medicine
Authors: Nordin‐Johansson A. , Asplund K. 
Published: March 2003

Abstract. Nordin‐Johansson A, Asplund K (Department of Medicine, University Hospital, Umeå, Sweden). Randomized controlled trials and consensus as a basis for interventions in internal medicine. J Intern Med 2000; 247: 94–104.Objectives. To estimate the proportion of routine clinical interventions in internal medicine that are supported by the results of randomized controlled trials or consensus amongst experienced internists.Design. Retrospective review of case records allowed one or more major diagnosis–intervention combination(s) to be identified for each patient. The scientific literature was searched for metaanalyses and randomized controlled trials in electronic databases that supported the specific intervention used. When support from randomized trials was lacking, possible consensus on management was sought by asking national expert panels of experienced clinicians.Setting. Department of Medicine at a Swedish teaching hospital.Subjects. At total of 197 consecutively admitted medical inpatients.Results. Fifty per cent of the diagnosis–intervention combinations (186/369) were supported by results from randomized controlled trial evidence and 34% (125/369) were supported by consensus amongst experienced clinicians. The proportion of interventions based on randomised controlled trials was highest in patients with cardiac (64%) and other circulatory diagnoses (73%). There were no important differences between sexes or between age groups.Conclusions. Half of the interventions used in routine clinical practice amongst medical inpatients are supported by results from randomized controlled trials. These results refute popular claims that only a small proportion of medical interventions are supported by scientific evidence.
Resting energy expenditure, growth hormone indices, body composition and adipose tissue distribution in premenopausal women
Authors: Armellini F. , Zamboni M. , De Pergola G. , Bissoli L. , Turcato E. , Giorgino R. , Bosello O. 
Published: March 2003

Abstract. Armellini F, Zamboni M, De Pergola G, Bissoli L, Turcato E, Giorgino R, Bosello O (San Lorenzo Hospital, Valdagno; University of Verona, Verona; and University of Bari, Bari, Italy). Resting energy expenditure, growth hormone indices, body composition and adipose tissue distribution in premenopausal women. J Intern Med 2000; 247: 709–714.Objectives. A significant growth hormone (GH) contribution to interindividual variance in energy expenditure (REE) in women can be hypothesized. The present study examines the independent association between physiological levels of GH function indices and REE.Setting. All subjects were hospitalized in the Institute of Internal Medicine of the University of Verona.Subjects. Twenty‐four premenopausal overweight (BMI = 28–55 kg m–2) women aged 18–49 years.Interventions. REE was estimated by indirect calorimetry and body composition and fat distribution by single slice computed tomography method. GH activity and GH status were determined by measuring serum levels of insulin‐like growth factor I (IGF‐I) and insulin‐like growth factor binding protein‐3 (IGFBP‐3).Results. GH indices did not show any significant correlation with REE. The relation between GH indices and REE was also examined by multiple regression analysis to account for possible confounders such as body composition, adipose tissue distribution and age. When body composition was considered, body fat and fat‐free mass were the only significant predictors of REE (R2 = 0.699, P = 0.0001). The contributions of GH indices were not significant.Conclusions. Our findings do not support the hypothesis that GH in physiological conditions could be an independent determinant of REE in women with obesity.