Michael A Crilly

Evidence-based medicine teaching in UK medical schools.

Background: It is recognized that clinicians need training in evidence-based medicine (EBM), however there is considerable variation in the content and methods of the EBM curriculum in UK medical schools. Aims: To determine current practice and variation in EBM undergraduate teaching in UK medical schools and inform the strategy of medical schools and the National Knowledge Service. Methods: We contacted all 32 medical schools in the UK and requested that the person primarily responsible for EBM undergraduate teaching complete a short online survey and provide their EBM curriculum. Results: The survey was completed by representatives from 20 (63%) medical schools and curriculum details were received from 5 (16%). There is considerable variation in the methods and content of the EBM curriculum. Although the majority of schools teach core EBM topics, relatively few allow students to practice the skills or assess such skills. EBM teaching is restricted by lack of curriculum time, trained tutors and teaching materials. Conclusions: Key elements to progress include the integration of EBM with clinical specialties, tutor training and the availability of high-quality teaching resources. The development of a national undergraduate EBM curriculum may help in promoting progress in EBM teaching and assessment in UK medical schools.

Arterial stiffness and cumulative inflammatory burden in rheumatoid arthritis: a dose-response relationship independent of established cardiovascular risk factors.

OBJECTIVE To quantify the relationship between arterial stiffness and cumulative inflammatory burden in patients with RA. METHODS We recruited RA patients without overt arterial disease aged 40-65 years, attending hospital rheumatology outpatient clinics. Standardized research nurse assessment included blood pressure (BP), pulse wave analysis (PWA, SphygmoCor), BMI, fasting blood sample (lipids, glucose, RF and ESR), patient questionnaire (smoking, alcohol, diet, exercise, family history of premature coronary heart disease and Stanford HAQ), current medication and medical record review. Cumulative inflammatory burden was measured as ESR area-under-the-curve (ESR-years) extracted from medical records. Arterial stiffness was measured using PWA [aortic augmentation index (AIX@75)]. Multiple linear regression was used to adjust for age, sex and nine other cardiovascular risk factors. RESULTS We recruited 114 RA patients (mean age 54 years, female 81%, current DMARD 90%, current NSAID 70%, ACR criteria 56%) comprising 1040 RA person-years. Cholesterol, glucose and BMI were similar in women and men. Women had a longer duration of arthritis (10 vs 7 years) and were more likely to be seropositive (85 vs 71%). BP, smoking and alcohol consumption were lower for women. On fully adjusted analysis, an increase of 100 ESR-years was associated with an increase in AIX@75 of 0.51 (95% CI 0.13, 0.88). On fully adjusted analysis restricted to women the increase was 0.43 (95% CI 0.01, 0.85). CONCLUSIONS In RA patients free of overt arterial disease, a dose-response relationship exists between cumulative inflammatory burden and arterial stiffness. This relationship is independent of established CV risk factors.

Repeatability of the measurement of augmentation index in the clinical assessment of arterial stiffness using radial applanation tonometry

Objective. Aortic augmentation index (AIx) measured using applanation tonometry is a non‐invasive indicator of arterial stiffness. The objective of this study was to assess its repeatability when used by nurses with limited experience of the technique. Material and methods. Blood pressure/augmentation index (BP/AIx) was measured 4 times in 20 consecutive ambulant patients (16 male) after they rested supine for 15 min. Two nurses independently and alternately measured BP/AIx using the same equipment (Omron HEM‐757; SphygmoCor with Millar hand‐held tonometer). Nurses were blinded to patient medical records and their colleagues AIx/BP. ‘Within’ and ‘between’ observer differences were assessed using intra‐class correlation coefficients (rI) and 95 % limits of agreement (95 % LoA) derived from Bland‐Altman plots. Results. Mean age was 56 (mean BP 136/79; mean pulse 64). Mean AIx was 24.1 (range 2.8 to 41.0). Both ‘between’ and ‘within’ observer repeatability was very high, with intra‐class correlation coefficients ranging from 0.92 to 0.98. Mean AIx readings ‘between’ observers differed by only 0.68 (95 % CI −0.24 to 1.59) with a high rI (0.98; 95 % CI 0.95 to 0.99) and a narrow 95 % LoA (−3.22 to 4.57). The 95 % LoA for ‘within’ observer repeatability was −6.75 to 7.95. Differences in AIx measurement did not vary over time or with increasing levels of AIx. Conclusions. Even when undertaken by relatively inexperienced operators, both ‘within’ and ‘between’ observer repeatability of AIx measurement is very high. Such non‐invasive assessment of arterial stiffness has the potential to be included in the clinical assessment of ambulant patients.

Physical Disease and Resilient Outcomes: A Systematic Review of Resilience Definitions and Study Methods

Background Findings from physical disease resilience research may be used to develop approaches to reduce the burden of disease. However, there is no consensus on the definition and measurement of resilience in the context of physical disease. Objective The aim was to summarize the range of definitions of physical disease resilience and the approaches taken to study it in studies examining physical disease and its relationship to resilient outcomes. Methods Electronic databases were searched from inception to March 2013 for studies in which physical disease was assessed for its association with resilient outcomes. Article screening, data extraction, and quality assessment were carried out independently by 2 reviewers, with disagreements being resolved by a third reviewer. The results were combined using a narrative technique. Results Of 2280 articles, 12 met the inclusion criteria. Of these studies, 1 was of high quality, 9 were of moderate quality, and 2 were low quality. The common findings were that resilience involves maintaining healthy levels of functioning following adversity and that it is a dynamic process not a personality trait. Studies either assessed resilience based on observed outcomes or via resilience measurement scales. They either considered physical disease as an adversity leading to resilience or as a variable modifying the relationship between adversity and resilience. Conclusion This work begins building consensus as to the approach to take when defining and measuring physical disease resilience. Resilience should be considered as a dynamic process that varies across the life-course and across different domains, therefore the choice of a resilience measure should reflect this.

Hypertensive disorders of pregnancy and adult offspring cardiometabolic outcomes: a systematic review of the literature and meta-analysis

Hypertensive disorders of pregnancy include eclampsia, pre-eclampsia, gestational hypertension, pre-existing chronic hypertension and pre-eclampsia superimposed on chronic hypertension.1 ,2 They affect up to 8% of pregnancies and are a major cause of maternal and fetal morbidity and mortality.1 Chronic hypertension is associated with a much higher risk of pre-eclampsia and, in a subset of women, worsening of hypertension during pregnancy (without development of pre-eclampsia).3 ,4 Women with pre-eclampsia have an adverse cardiovascular risk profile in later life.5 ,6 Cardiovascular risk factors in the childhood and early adulthood of offspring of pregnancies affected by pre-eclampsia have been examined in two earlier systematic reviews. These found evidence of raised blood pressure (BP) and body mass index (BMI) in the offspring born to pre-eclamptic pregnancies.7 ,8 Less is known about the later life cardiovascular risk in offspring affected by maternal pre-eclampsia or other maternal hypertensive disorders of pregnancy, although some studies suggest a higher risk of cardiovascular disease, including hypertension9 and stroke10 in adulthood. The associations between hypertensive disorders of pregnancy and subsequent cardiovascular disease in the offspring are complex. Hypertensive disorders of pregnancy are associated with prematurity (which may be iatrogenic) and low birth weight even when corrected for gestation.11 Small for gestational age and gestation have been inversely associated with risk of cardiovascular disease.12 ,13 Furthermore, the strength of these associations varies by hypertensive disorder and severity of condition. We have systematically reviewed published papers of the association between maternal hypertensive disorders of pregnancy, and cardiovascular risk factors and disease in adult offspring. A systematic review of the published literature was undertaken. Inclusion criteria were: ### Types of study Observational epidemiological studies of offspring exposed in utero to a maternal hypertensive disorder of pregnancy. ### Types of participant Offspring aged at least 18 years at last …

Influence of rurality, deprivation and distance from clinic on uptake in men invited for abdominal aortic aneurysm screening.

Effective abdominal aortic aneurysm (AAA) screening requires high uptake. The aim was to assess the independent association of screening uptake with rurality, social deprivation, clinic type, distance to clinic and season.

Relationship Between Arterial Stiffness and Stanford Health Assessment Questionnaire Disability in Rheumatoid Arthritis Patients without Overt Arterial Disease

Objective. To quantify the relationship between Stanford Health Assessment Questionnaire (HAQ) disability and arterial stiffness in patients with rheumatoid arthritis (RA). Methods. A consecutive series of 114 patients with RA but without overt arterial disease, aged 40–65 years, were recruited from rheumatology clinics. A research nurse measured blood pressure (BP), arterial stiffness (heart rate-adjusted augmentation index), fasting lipids, glucose, erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF). A self-completed patient questionnaire included HAQ, damaged joint count, EuroQol measure of health outcome, and Godin physical activity score. Multiple linear regression (MLR) adjusted for age, sex, smoking pack-years, cholesterol, mean arterial BP, physical activity, daily fruit and vegetable consumption, arthritis duration, ESR, and RA criteria. Results. Mean age was 54 years (81% women) with a median HAQ of 1.13 (interquartile range 0.50; 1.75). Median RA duration was 10 years, 83% were RF-positive, and median ESR was 16 mm/h. Mean arterial stiffness was 31.5 (SD 7.7), BP 125/82 mm Hg, cholesterol 5.3 mmol/l, and 24% were current smokers. Current therapy included RA disease-modifying agents (90%), prednisolone (11%), and antihypertensive therapy (18%). Arterial stiffness was positively correlated with HAQ (r = 0.42; 95% CI 0.25 to 0.56). On MLR, a 1-point increase in HAQ disability was associated with a 2.8 increase (95% CI 1.1 to 4.4; p = 0.001) in arterial stiffness. Each additional damaged joint was associated with a 0.17 point increase (95% CI 0.04 to 0.29; p = 0.009) in arterial stiffness. The relationship between EuroQol and arterial stiffness was not statistically significant. Conclusion. In patients with RA who are free of overt arterial disease, higher RA disability is associated with increased arterial stiffness independently of traditional cardiovascular risk factors and RA characteristics.

Does the current version of 'Tomorrow's Doctors' adequately support the role of evidence-based medicine in the undergraduate curriculum

Background: The evidence-based medicine (EBM) approach to clinical practice has been incorporated into medical training around the world. Whilst EBM is a component of the ‘foundation years’ (FY) programme, it appears to lack a firm foundation in the UK undergraduate curriculum. Aim: To identify whether the teaching of EBM is adequately supported by the guideline ‘Tomorrows Doctors’ (TD-2003). Methods: We mapped TD-2003 against the five steps of EBM and also reviewed the literature for reports concerning the introduction of EBM into undergraduate curricula. Results: Whilst all five steps of EBM can be mapped against TD-2003, the guidance makes no explicit reference to EBM and a coherent framework is lacking. The focus of undergraduate EBM teaching should be on ‘using’ research evidence (rather than undertaking research). The current emphasis on ‘therapy’ should be expanded to include the EBM-related issues of ‘diagnosis, prognosis and harm’. UK medical schools also need to exploit the NHS investment in ‘national electronic libraries’.

Routine pharmacological venous thromboembolism prophylaxis in frail older hospitalised patients: where is the evidence?

It has been claimed that there are over 25,000 preventable in-hospital deaths from venous thromboembolism annually in the UK. NICE and SIGN guidelines therefore recommend that all hospitalised patients are risk assessed for venous thromboembolism. The guidelines would recommend using pharmacological thromboprophylaxis for all patients aged 60 and above with reduced mobility and acute medical illness unless obvious contra-indications exist. Meta-analysis data regarding pharmacological thromboprophylaxis for medical patients demonstrate reductions in asymptomatic deep vein thrombosis (DVT) rather than fatal pulmonary embolism and mortality. There is also the potential for increased bleeding risk with this approach. Evidence for older medical in-patients, particularly those aged over 75, is more limited being derived from subgroup analyses of larger clinical trials. In addition, based on exclusion criteria such as increased bleeding risk, frailer older adults were unlikely to have been included within such trials. This commentary will (i) critically appraise available data on the incidence of DVT and PE in older hospitalised patients; (ii) review the evidence available from meta-analyses and subgroup analyses in older medical in-patients for the use of venous thromboembolism prophylaxis; (iii) discuss those situations out-with the guidelines where venous thromboprophylaxis may not be appropriate and even potentially harmful in this patient group and (iv) suggest future research directions.

Charlson index scores from administrative data and case-note review compared favourably in a renal disease cohort

BACKGROUND The Charlson index is a widely used measure of comorbidity. The objective was to compare Charlson index scores calculated using administrative data to those calculated using case-note review (CNR) in relation to all-cause mortality and initiation of renal replacement therapy (RRT) in the Grampian Laboratory Outcomes Mortality and Morbidity Study (GLOMMS-1) chronic kidney disease cohort. METHODS Modified Charlson index scores were calculated using both data sources in the GLOMMS-1 cohort. Agreement between scores was assessed using the weighted Kappa. The association with outcomes was assessed using Poisson regression, and the performance of each was compared using net reclassification improvement. RESULTS Of 3382 individuals, median age 78.5 years, 56% female, there was moderate agreement between scores derived from the two data sources (weighted kappa 0.41). Both scores were associated with mortality independent of a number of confounding factors. Administrative data Charlson scores were more strongly associated with death than CNR scores using net reclassification improvement. Neither score was associated with commencing RRT. CONCLUSION Despite only moderate agreement, modified Charlson index scores from both data sources were associated with mortality. Neither was associated with commencing RRT. Administrative data compared favourably and may be superior to CNR when used in the Charlson index to predict mortality.