Paul Ewings

A systematic review of the effectiveness of critical appraisal skills training for clinicians

The aim of this paper is to undertake a descriptive systematic review of the effectiveness of critical appraisal skills training for clinicians. Of the 10 controlled studies which examined this issue and were found to meet the eligibility criteria of this review, all used a study population of either medical students or doctors in training. The studies used a variety of different intervention ‘dosages’ and reported a range of outcomes. These included participants’ knowledge of epidemiology/biostatistics, their attitudes towards medical literature, their ability to appraise medical literature, and medical literature reading behaviour. An overall improvement in assessed outcomes of 68% was reported after critical appraisal skills training, particularly in knowledge relating to epidemiology and biostatistics. This review appears to provide some evidence of the benefit of teaching critical appraisal skills to clinicians, in terms of both knowledge of methodological/statistical issues in clinical research and attitudes to medical literature. However, these findings should be considered with caution as the methodological quality of studies was generally poor, with only one study employing a randomized controlled design. There is a need for educators within the field of evidence‐based health to consider the implications of this review.

An exercise intervention to prevent falls in people with Parkinson's disease: a pragmatic randomised controlled trial

Objectives To compare the effectiveness of an exercise programme with usual care in people with Parkinsons disease (PD) who have a history of falls. Design Pragmatic randomised controlled trial. Setting Recruitment was from three primary and four secondary care organisations, and PD support groups in South West England. The intervention was delivered in community settings. Participants People with PD, with a history of two or more falls in the previous year, who were able to mobilise independently. Intervention 10 week, physiotherapy led, group delivered strength and balance training programme with supplementary home exercises (intervention) or usual care (control). Main outcome measure Number of falls during the (a) 10 week intervention period and (b) the 10 week follow-up period. Results 130 people were recruited and randomised (64 to the intervention; 66 to usual care). Seven participants (5.4%) did not complete the study. The incidence rate ratio for falls was 0.68 (95% CI 0.43 to 1.07, p=0.10) during the intervention period and 0.74 (95% CI 0.41 to 1.33, p=0.31) during the follow-up period. Statistically significant between group differences were observed in Berg balance, Falls Efficacy Scale-International scores and recreational physical activity levels. Conclusions The study did not demonstrate a statistically significant between group difference in falls although the difference could be considered clinically significant. However, a type 2 error cannot be ruled out. The findings from this trial add to the evidence base for physiotherapy and exercise in the management of people with PD. Trial registration ISRCTN50793425.

Development and validation of a questionnaire to evaluate the effectiveness of evidence-based practice teaching

The aim of this study was to develop and validate a questionnaire to evaluate the effectiveness of evidence‐based practice (EBP) teaching.

Accessing out-of-hours care following implementation of the GMS contract: an observational study

BACKGROUND There is widespread concern that the quality of out-of-hours primary care for patients with complex needs may be at risk now that the new general medical services contract (GMS) has been implemented. AIM To explore changes in the use of out-of-hours services around the time of implementation of the new contract for patients with complex needs, using patients with cancer as an example. DESIGN OF STUDY Longitudinal observational study. SETTING Out-of-hours primary care provider covering Devon (adult population 900,000), UK. METHOD Two, 1-year periods corresponding to pre- (April 2003 to March 2004) and post-contract implementation (October 2004 to September 2005) were sampled. Call rates per 1000 of the adult population (age>or=16 years) were calculated for all calls (any cause) and cancer-related calls. Anonymised outcome and process measures data were extracted. RESULTS Although overall call rates per 1000 population had increased by 26% (185 pre-contract to 233 post-contract), the proportion of cancer-related calls remained relatively constant (2.08% versus 1.96%). Around half (56%) of these callers had advanced cancer needs (including palliative care). By post-contract, the time taken to triage had significantly increased (P<0.001). Although the proportions admitted to hospital or receiving a home visit remained constant, calls where a special message was sent by the out-of-hours clinician to the in-hours team had decreased (P<0.001). CONCLUSION The demand for out-of-hours care for patients with cancer did not alter disproportionately after implementation of the contract. While potential quality indicators (for example, hospital admissions, home visiting rates) remained constant, potentially adverse changes to triage time and communication between out-of-hours and in-hours clinicians were observed. Quality standards and provider databases require further refinement to capture elements of care relevant to patients with complex needs.

Ear discharge in children presenting with acute otitis media: observational study from UK general practice

BACKGROUND National Institute for Health and Clinical Excellence (NICE) guidance to treat otitis media in older children immediately with antibiotics only if they have ear discharge is based on limited evidence. AIM To determine the clinical significance and outcome of ear discharge in children with acute otitis media, in routine clinical practice. DESIGN OF STUDY Observational cohort study of children with acute otitis media comparing those with and without ear discharge at presentation. SETTING Primary care in East Somerset. METHOD Two hundred and fifty-six children aged 6 months to 10 years were recruited from primary care. Clinical features and other characteristics were recorded at presentation. Follow-up was undertaken at 2 weeks and 3 months. RESULTS Children with otitis media who present with ear discharge are much more likely to be treated with antibiotics irrespective of age (adjusted odds ratio 15, 95% confidence interval [CI] = 3 to 66). Most with discharge have proven bacterial infection (58%, 95% CI = 42 to 72%). They have a more severe systemic illness, with higher axillary temperature (80% increase in odds of ear discharge for each additional degree centigrade, P = 0.02), pulse rate (9% increase in odds for each extra beat, P<0.001), and Yale score (mean 10.5 versus 9.0, P = 0.003). They may also have an increased likelihood of adverse outcome (adjusted odds ratio of pain at 1 week 2.9; further episodes of acute otitis media 3.3; hearing difficulty at 3 months 4.7; all P<0.10). CONCLUSION Ear discharge defines a group of children with otitis media who are sicker and may be at higher risk of adverse outcome. NICE guidance to treat them with antibiotics is supported.

Refractive outcomes after cataract surgery with primary lens implantation in infants

Aims: To show the refractive outcomes, accuracy of intraocular lens power selection, and visual outcomes and complications in infants undergoing cataract surgery. Methods: The refraction (spherical equivalent) of 14 operated eyes in 8 children aged <1 year was plotted over time. Preoperative and final recorded visual acuities were assessed. Results: The median follow-up was 37.25 months. The median initial postoperative refraction was +6.75 dioptres. Conclusions: Refractive outcomes for each eye were not entirely predictable and were variable between infants. However, there was a consistent pattern in each infant who underwent bilateral surgery, with both eyes following a similar pattern of refractive change with time: a decreasing myopic shift was seen in 8 eyes, possibly demonstrating emmetropisation. The two unilateral cases appeared to show a linear myopic shift. 4 eyes in 2 patients did not follow a myopic shift curve and one of these patients showed an early trend towards increased hyperopia. Definite causes for this erratic refractive change were not identified. A postoperative refraction >4.5 dioptres avoided early onset myopia. The range of difference between postoperative and predicted refraction using SRK-T was −2.85 to 2.97 dioptres. Most of the visual results are encouraging compared with historical data in older children.

What affects anticoagulation control in patients taking warfarin

BACKGROUND The ageing population is taking an increasing number of both prescribed and non-prescribed medication. Little is known of the potential for adverse drug reactions between these. Warfarin is a commonly prescribed medication, well known for its potential to cause serious adverse reactions in combination with many prescription medicines. It has been suggested that herbal medicines such as garlic, either as a dietary supplement or in cooking, may also interact with warfarin, resulting in poor international normalised ratio (INR) control. AIM To determine whether, for patients who take garlic as well as warfarin, the proportion of the INR tests in range is lower than in comparable patients who do not take garlic. DESIGN OF THE STUDY Retrospective study of patients taking prescribed warfarin. SETTING Primary care practices in Somerset and Devon. METHOD Three controls (not taking garlic) matched for age, sex, and general practice were compared with each patient self-reporting taking garlic as a supplement. INR results were assessed for the preceding 12 months. Potentially confounding factors were considered, for example diabetes mellitus; all prescribed medication; any bleeding episodes. RESULTS No evidence was found to suggest that garlic consumption either as a supplement or in cooking is associated with more frequent haemorrhagic complications or less control of INR. Poor INR control may, however, be associated with taking larger numbers of prescription medicines, particularly during prescription changes. CONCLUSION Further research would be warranted into whether increased INR monitoring is needed when drug changes are made. These data render clinically significant interactions between warfarin and garlic intake unlikely.

To what extent does a lack of refrigeration of generic chloramphenicol eye-drops used in India decrease their purity and what are the implications for Europe?

Background/aims: Thermal degradation of chloramphenicol occurs at a faster rate when stored in unrefrigerated conditions. This study measures the concentration of the principal thermal breakdown product of generic chloramphenicol eye-drops being sold over the counter in chemists in different locations in India. Methods: Forty-eight samples of generic chloramphenicol eye-drops were collected form Delhi and Chennai (Madras) in India. Conditions of storage of chloramphenicol eye-drops were recorded at the time of purchase. Concentrations of a hydrolytic degradation product of chloramphenicol were measured using validated high-pressure liquid chromatography. Results were compared with accepted UK standards. Results: Significantly higher levels of chloramphenicol thermal breakdown product were found in collected samples. All samples purchased were being stored in unrefrigerated conditions in the chemists sampled. Shelf lives exceeded UK equivalents, varying considerably between manufacturers. Conclusion: Inadequate refrigeration and prolonged shelf lives of chloramphenicol generics collected from Delhi and Chennai are associated with very high levels of chloramphenicol thermal breakdown product. These levels substantially exceed UK quality-assurance standards undermining product reliability, possibly contributing to the positive selection of resistant organisms and product toxicity effects. The principals of quality-assurance breakdown described are particularly relevant to Europe, following recent deregulation of chloramphenicol eye-drops purchased over the counter.