Web-based distance continuing education: a new way of thinking for students and instructors

As people have more difficulty taking time away from work to attend conferences and workshops, the idea of offering courses via the Web has become more desirable. Addressing a need voiced by Medical Library Association membership, the authors developed a Web-based continuing-education course on the subject of the librarian's role in evidence-based medicine. The aim of the course was to provide medical librarians with a well-constructed, content-rich learning experience available to them at their convenience via the Web. This paper includes a discussion of the considerations that need to be taken into account when developing Web-based courses, the issues that arise when the information delivery changes from face-to-face to online, the changing role of the instructor, and the pros and cons of offering Web-based versus traditional courses. The results of the beta test and future plans for the course are also discussed.

Expediting the transfer of evidence into practice: building clinical partnerships*

A librarian/clinician partnership was fostered in one hospital through the formation of the Evidence-based Practice Committee, with an ulterior goal of facilitating the transfer of evidence into practice. The paper will describe barriers to evidence-based practice and outline the committee's strategies for overcoming these barriers, including the development and promotion of a Web-based guide to evidence-based practice specifically designed for clinicians (health professionals). Educational strategies for use of the Web-based guide will also be addressed. Advantages of this partnership are that the skills of librarians in meeting the needs of clinicians are maximized. The evidence-based practice skills of clinicians are honed and librarians make a valuable contribution to the knowledgebase of the clinical staff. The knowledge acquired through the partnership by both clinicians and librarians will increase the sophistication of the dialogue between the two groups and in turn will expedite the transfer of evidence into practice.

A Meta-analytic Review of Acceptance-Based Behavioral Interventions for the Treatment of Anxiety

The relative popularity of acceptance and commitment therapy (ACT) has grown in recent years, and inspired the development of contemporary acceptance-based treatment approaches. Acceptance-based therapies differ from traditional cognitive- behavior therapy (CBT) on pragmatic grounds, the import of which implicates the purpose of therapy. CBT utilizes exposure and cognitive change techniques primarily in service of symptom change outcomes; whereas, ACT utilizes exposure and acceptance for purposes of promoting psychological flexibility in the pursuit of personal values. The purpose of this meta-analytic study was to determine the relative efficacy of acceptance- based versus symptom-change behavioral approaches with anxiety disorders and to quantify this impact. A comprehensive literature search turned up 18 studies that met inclusion criteria for this analysis. An effect size was calculated using the standardized mean gain procedure for both the acceptance-based and symptom-change approaches, along with the waitlist control groups. The results demonstrate a large effect size for the acceptance-based approach (Weighted mean ES = .83) and a medium effect size for symptom-change approach (Weighted mean ES = .60). The waitlist control groups demonstrated a small effect size (Weighted mean ES = .24). Based on this review, it is suggested that graduate and internship programs in Clinical Psychology should promote evidence-based training in the use of acceptance-inspired behavioral therapies.

Evidencia científica y recomendaciones sobre cribado de agudeza visual: revisión bibliográfica

Fundamentos: En los ámbitos científico e institucional existe controversia sobre cuándo recomendar la práctica del cribado visual en la población. El objetivo de este trabajo es valorar el nivel de evidencia científica que existe sobre el cribado visual para determinar si las recomendaciones existentes son o no adecuadas. Métodos: Revisión sistemática de artículos científicos consultando las bases de datos MedLine y The Cochranre Library Plus, sin restricción de fecha, en los idiomas español e inglés. Se incluyó literatura gris mediante búsqueda manual. No se hicieron restricciones respecto al tipo de estudio. Se revisaron los abstracts y en los casos necesarios los artículos completos, teniéndose en cuenta finalmente todos los artículos que incluían recomendaciones sobre cribado de agudeza visual y eliminando el resto. Resultados: Se seleccionaron 6 artículos. La mayoría de las recomendaciones realizadas por las sociedades fueron a través de guías de práctica clínica o artículos de opinión. Respecto a los diseños de los artículos científicos localizados hubo 2 ensayos aleatorios controlados, 3 ensayos no controlados y 1 estudio transversal. Conclusiones: Los estudios sobre adultos no permiten determinar que las recomendaciones realizadas por las sociedades científicas tengan una base científica sólida. En el caso de los niños, los estudios y las sociedades científicas no aclaran cuál es la edad más idónea para realizar cribado visual.

Does the scientific evidence support the advertising claims made for products containing Lactobacillus casei and Bifidobacterium lactis? A systematic review

Background To analyse the scientific evidence that exists for the advertising claims made for two products containing Lactobacillus casei and Bifidobacterium lactis and to conduct a comparison between the published literature and what is presented in the corporate website. Methods Systematic review, using Medline through Pubmed and Embase. We included human clinical trials that exclusively measured the effect of Lactobacillus casei or Bifidobacterium lactis on a healthy population, and where the objective was related to the health claims made for certain products in advertising. We assessed the levels of evidence and the strength of the recommendation according to the classification criteria established by the Oxford Centre for Evidence Based Medicine (CEBM). We also assessed the outcomes of the studies published on the website that did not appear in the search. Results Of the 440 articles identified, 16 met the inclusion criteria. Only four (25%) of these presented a level of evidence of 1b and a recommendation grade of A, all corresponding to studies on product containing Bifidobacterium lactis, and only 12 of the 16 studies were published on the corporate website (47). Conclusions There is insufficient scientific evidence to support the health claims made for these products, especially in the case of product containing Lactobacillus casei.

Determinantes de efetividade de intervenção clínica na obesidade : perspetiva de um painel de peritos

Tese de mestrado, Nutrição Clínica, Faculdade de Medicina, Universidade de Lisboa, 2014

Overtreatment of asymptomatic bacteriuria: a qualitative study

BACKGROUND Overtreatment of asymptomatic bacteriuria (ASB) is widespread and may result in antibiotic side-effects, excess costs to the healthcare system, and may potentially trigger antimicrobial resistance. According to international management guidelines, ASB is not an indication for antibiotic treatment (with few exceptions). AIM To determine reasons for using antibiotics to treat ASB in the absence of a treatment indication. METHODS A qualitative study was conducted at a tertiary care hospital in Switzerland during 2011. We interviewed 21 internal medicine residents and attending physicians selected by purposive sampling, using a semi-structured questionnaire. Responses were analysed in an inductive thematic content approach using dedicated software (MAXQDA(®)). FINDINGS In the 21 interviews, the following thematic rationales for antibiotic overtreatment of ASB were reported (in order of reporting frequency): (i) treating laboratory findings without taking the clinical picture into account (N = 17); (ii) psychological factors such as anxiety, overcautiousness, or anticipated positive impact on patient outcomes (N = 13); (iii) external pressors such as institutional culture, peer pressure, patient expectation, and excessive workload that interferes with proper decision-making (N = 9); (iv) difficulty with interpreting clinical signs and symptoms (N = 8). CONCLUSION In this qualitative study we identified both physician-centred factors (e.g. overcautiousness) and external pressors (e.g. excessive workload) as motivators for prescribing unnecessary antibiotics. Also, we interpreted the frequently cited practice of treating asymptomatic patients based on laboratory findings alone as lack of awareness of evidence-based best practices.

Promoting better use of the PSA test in general practice: Randomized controlled trial of educational strategies based on outreach visits and mailout

Background. Prostate-specific antigen (PSA) testing for prostate cancer is controversial. Demand for PSA testing is likely to rise in the UK, Australia and other western countries. Primary care needs to develop appropriate strategies to respond to this demand. Objectives. Our aim was to compare the effectiveness of educational outreach visits (EOVs) and mailout strategies targeting PSA testing in Australian primary care. Methods. A randomized controlled trial was conducted in general practices in southern Adelaide. The main outcome measures at baseline, 6 months and 12 months post-intervention were PSA testing rates and GP knowledge in key areas relating to prostate cancer and PSA testing. Results. The interventions were able to demonstrate a change in clinical practice. In the 6 months post-intervention, median PSA testing rate in the EOV group was significantly lower than in the postal group, which in turn was significantly lower than the control group (P < 0.001). Statistically significant differences were not, however, maintained in the 6-12 month post-intervention period. The EOV group, at 6 months follow-up, had a significantly greater proportion of 'correct' responses than the control group to questions about prostate cancer treatment effectiveness (P = 0.004) and endorsement of PSA screening by professional bodies (P = 0.041). Conclusions. Primary care has a central role in PSA testing for prostate cancer. Clinical practice in this area is receptive to evidence-based interventions.

"Only a GP?'': is the solution to the general practice crisis intellectual?

General practice is suffering a crisis of status, as shown by financial, power and intellectual markers. This is serious as a strong general-practice workforce is important to deliver cost-effective, high-quality healthcare. We argue that strengthening the intellectual aspects of general practice (particularly critical thinking) is essential. Most strategies to achieve this centre on research, with many initiatives in Australia and overseas to enhance research by general practitioners; there is still insufficient clinical research in general practice. Other ways to improve critical thinking include promoting use of evidence-based medicine, provided it is not implemented only via cook-book guidelines. Other innovations are desperately needed.

Improving supportive care for women with breast cancer in Australia: The challenge of modifying health systems

Although the benefits of many psychosocial support strategies in improving well being in women with breast cancer have been demonstrated, few women receive these programs as part of routine care. This paper provides some recommendations, based on experience in Australia, about how access to evidence-based supportive care strategies might be improved through modification of health systems. It demonstrates the paucity of research about the costs and health service implications of psychosocial support strategies, which is vital to health planning and service delivery change. It outlines the systematic approach taken in Australia to improving psychosocial support nationally by: the development of research reviews; preparation of guidelines about supportive care, implementation of programs to foster the adoption of guidelines through modification of policy, health service delivery and clinician training; and monitoring programs. Coalitions of government, health care professionals and consumers are key to effective lobbying for change. If all women with breast cancer are to receive better supportive care, there is a need for approaches which: refocus the research effort in psycho-oncology; develop more strategic approaches to generating change in health systems and health policy and foster partnerships to advocate for improved resources. Copyright (C) 2003 John Wiley Sons, Ltd.

Academic medicine: The evidence base

The International Campaign to Revitalise Academic Medicine recognises that an evidence based approach is important in discussing the problems of academic medicine. A preliminary exploration of the evidence on academic medicine has led to a research agenda for examining and proposing realistic solutions. Copyright © 2004, BMJ Publishing Group Ltd.

Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive-behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness - Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression. Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods. Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold. Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Intensive case management: A critical re-appraisal of the scientific evidence for effectiveness

Intensive Case Management (ICM) is widely claimed to be an evidence-based and cost effective program for people with high levels of disability as a result of mental illness. However, the findings of recent randomized controlled trials comparing ICM with 'usual services' suggest that both clinical and cost effectiveness of ICM may be weakening. Possible reasons for this, including fidelity of implementation, researcher allegiance effects and changes in the wider service environment within which ICM is provided, are considered. The implications for service delivery and research are discussed.

A framework for systematically improving occupational therapy expert opinions on work capacity

Aim: To present an evidence-based framework to improve the quality of occupational therapy expert opinions on work capacity for litigation, compensation and insurance purposes. Methods: Grounded theory methodology was used to collect and analyse data from a sample of 31 participants, comprising 19 occupational therapists, 6 medical specialists and 6 lawyers. A focused semistructured interview was completed with each participant. In addition, 20 participants verified the key findings. Results: The framework is contextualised within a medicolegal system requiring increasing expertise. The framework consists of (i) broad professional development strategies and principles, and (ii) specific strategies and principles for improving opinions through reporting and assessment practices. Conclusions: The synthesis of the participants' recommendations provides systematic guidelines for improving occupational therapy expert opinion on work capacity.

Dissemination of a community-based physical activity project: The case of 10,000 steps

This paper describes the use of a web-site for the dissemination of the community-based '10,000 steps' program which was originally developed and evaluated in Rockhampton, Queensland in 2001-2003. The website provides information and interactive activities for individuals, and promotes resources and programs for health promotion professionals. The dissemination activity was assessed in terms of program adoption and implementation. In a 2-year period (May 2004-March 2006) more than 18,000 people registered as users of the web-site (togging more than 8.5 billion steps) and almost 100 workplaces and 13 communities implemented aspects of the 10,000 steps program. These data support the use of the internet as an effective means of disseminating ideas and resources beyond the geographical borders of the original project. Following this preliminary dissemination, there remains a need for the systematic study of different dissemination strategies, so that evidence-based physical activity programs can be translated into more widespread public health practice. (c) 2006 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.