Professional competence--can it be accurately measured or defined?

In addition to Good Clinical Trial Practice for the study of experimental drugs, regulations are also needed for good practice in the assessment of medicines after approval (Good PMS Practice, GPP). GPP has to protect the interests of public health at large as well as those of individual patients, investigators and pharmaceutical companies. GPP may be the natural way to solve threatening conflicts between privacy legislation and the public interest.     

NCI? What is it? What do they do?

BACKGROUND: Omeprazole, a H+/K+ ATPase inhibitor, has been shown to reduce gastric bicarbonate secretion in cats. However, there has been no study on the effect of omeprazole on bicarbonate secretion in patients with duodenal ulcer (DU). METHODS: Fifteen men with duodenal ulcer (mean age 38 years, range 22-57) were included. Baseline gastric acid output, bicarbonate secretion, and parietal and nonparietal secretions were estimated before and after omeprazole therapy (20 mg/day) for four weeks. RESULTS: Omeprazole administration did not significantly alter bicarbonate secretion (3.3 [1.2] vs 2.4 [0.4] mmol/h), though there was significant reduction in gastric acidity (44.2 [6.6] vs 20.7 [4.6] mmol/L, p < 0.01). CONCLUSION: Omeprazole reduces acid secretion but does not affect gastric bicarbonate secretion in patients with DU.     

Skin biopsy: how to do it

This article explains how to perform a skin biopsy with details about instruments and equipment. The patient's consent should always be obtained for the procedure. The wound margins should be marked out along the skin crease lines. The specimen should always be sent for analysis.     

Alcohol counseling: physicians will do it

OBJECTIVE: To assess the use of a brief provider-delivered alcohol counseling intervention of 5 to 10 minutes with high-risk drinking patients by primary care provider* trained in the counseling intervention and provided with an office support system. DESIGN: A group randomized study design was used. Office sites were randomized to either a usual care or special intervention condition, within which physicians and patients were nested. The unit of analysis was the patient. SETTING: Primary care internal medicine practices affiliated with an academic medical center. PARTICIPANTS: Twenty-nine providers were randomized by practice site to receive training and an office support system to provide an alcohol counseling special intervention or to continue to provide usual care. INTERVENTION: Special intervention providers received 2 1/2 hours of training in a brief alcohol-counseling intervention and were then supported by an office system that screened patients, cued providers to intervene, and made patient education materials available as tip sheets. MEASUREMENTS AND MAIN RESULTS: Implementation of the counseling steps was measured by patient exit interviews (PEI) immediately following the patient visit. The interval between the date of training and the date of the PEI ranged from 6 to 32 months. Special intervention providers were twice as likely as usual care providers to discuss alcohol use with their patients. They carried out every step of the counseling sequence significantly more often than did usual care providers (p < .001). This intervention effect persisted over the 32 months of follow-up. CONCLUSIONS: Physicians and other health-care providers trained in a brief provider-delivered alcohol intervention will counsel their high-risk drinking patients when cued to do so and supported by a primary care office system.     

ECLS in pertussis: does it have a role?

OBJECTIVES: To investigate the value of extracorporeal circulatory life support (ECLS) in paediatric patients with severe Bordetella pertussis infection. DESIGN: Single case report and a review of the ECLS database. SETTING: Tertiary referral hospital paediatric intensive care unit. PATIENTS AND PARTICIPANTS: A single case report of an infant with B. pertussis infection is described. Despite receiving ECLS, this infant died from overwhelming cardiac and cerebral insults. Outcome for children receiving ECLS registered on the Extracorporeal Life Support Organization database is reviewed. MEASUREMENTS AND RESULTS: The mortality of infants receiving ECLS for B. pertussis infection is high, with only 5 survivors reported among 22 registered cases. The majority of nonsurvivors had evidence of circulatory collapse in addition to severe respiratory failure, and these patients commonly died of hypoxic-ischaemic cerebral insult. These data suggest the existence of a subgroup of patients with respiratory failure only, who may benefit from ECLS, and a larger subgroup who suffer ischaemic cardiac and cerebral insults which are unlikely to be improved by ECLS. CONCLUSIONS: The value of ECLS in patients with B. pertussis infection who present with major cardiac dysfunction is questionable. Such patients almost invariably have a poor outcome despite maximal therapy.     

Did I do it or did I only imagine doing it?

Conducted 5 experiments with 180 undergraduates to investigate the memory and decision process involved in distinguishing between memories of doing and imagining doing. Ss were presented with items (typically line drawings) and told to trace or imagine tracing the outline or simply look at them. Ss were then tested for their ability to recognize the item and to identify the activity performed on it. Selected findings indicate that, although the accuracy of activity identification varied, type of activity did not affect item recognition. Tracing and imagining were more confusable in memory than were tracing and looking. The pattern of item recognition and activity identification remained the same whether or not Ss expected to be tested for their memory of the activity performed. Memory for imagining was more susceptible to confusion or multiple interpretation than was memory for tracing or looking, suggesting that accuracy of image identifications is affected by the number and the nature of the alternative activities under consideration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sperm factor: what is it and what does it do?

There are two current hypotheses as to how the spermatozoon triggers the oocyte into activity; a transmembrane receptor mechanism involving G-proteins and a soluble sperm-factor mechanism. In this short review we show that the present data favours the idea of a soluble factor diffusing from the spermatozoon into the oocyte following plasma membrane fusion of the two gametes that triggers calcium release in the oocyte. Two categories of calcium release mechanisms, inositol-1,4,5-triphosphate-induced calcium release (IICR) and calcium induced calcium release (CICR) are found in oocytes from a variety of species and both appear to be activated at fertilization. Since these calcium release pathways are distinct it is possible that sperm cytosol contains more that one activating factor. Finally, the fact that sperm extracts 'activate' oocytes from different phyla and trigger calcium oscillations in somatic cells infers calcium releasing agents common to other cell types.     

Retrospective estimates of act frequencies: How accurately do they reflect reality?

Several authors have argued that memory-based reports about dispositional characteristics of people exhibit a correlational structure that is unrelated to the co-occurrences of pertinent on-line recorded behaviors. We hypothesize, however, that the empirical evidence, deemed to be in favor of this challenging hypothesis, is due to the neglect of act overlap among the behavior classes under investigation. The present study was conducted in order to examine this hypothesis. Eight groups, each composed of 6 male actors, were videotaped while discussing controversial topics. The tapes were later shown to five judges who retrospectively estimated, with respect to 16 behavior categories, the individual act frequencies after viewing each discussion in its entirety. Four other judges classified each activity, immediately after observing it, by using one of two coding schemes. Two judges made forced choices; that is, they assigned a given behavior to exactly one category. Two other judges rated the prototypicalities of each activity with respect to each of the 16 behavior categories. The latter coding scheme led to substantially higher correspondences between the correlational structures of the retrospectively estimated and the on-line recorded act frequencies. The results support a systematic overlap hypothesis rather than a systematic distortion hypothesis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Working 61 plus hours a week: Why do managers do it?

The authors investigated why some managers work extreme hours, defined as 61 or more hours per week. The authors, tested explanations drawn from theories including the work-leisure tradeoff, work as an emotional respite, social contagion, and work as its own reward. In a demographically homogeneous sample of male managers, the best explanations for why some worked 61 or more hours per week were the financial and psychological rewards they, received from doing so. The hypothesis derived from A. Hochschild's (1997) research that managers who work long hours seek relief at work from pressures at home was not supported. Findings in a small sample of managerial women were consistent with the work-leisure trade-off hypothesis, the social contagion hypothesis, and the work as its own reward hypothesis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How to do it: making audit work

The orthodontic Audit Working Party of the Faculty of Dental Surgery, Royal College of Surgeons of England, in collaboration with the Centre for Medical Education, Ninewells Hospital and Medical School, Dundee developed an audit project entitled 'Clinical Audit: Scenarios for Evaluation and Study'. The aim of the project was to contribute to the construction of clinical guidelines for orthodontists. This article, the first of a short series, describes the background to and general results of the study. Further articles will study individual aspects of the project.     

Central venous cannulation: how to do it

Central venous cannulation is an important clinical tool for the hospital doctor. A sound knowledge of applied anatomy, relative contraindications and possible complications is required to decrease morbidity and mortality. This article seeks to provide the working knowledge required to perform and use central venous cannulation safely.     

Interpretation of prospective trials in hypertension: do treatment guidelines accurately reflect current evidence?

OBJECTIVE: To review the findings of prospective controlled trials of antihypertensive treatment and determine whether the evidence they have provided is embodied satisfactorily in current national and international guidelines for hypertension management. MANAGEMENT GUIDELINES: Conventional guidelines all advise prompt treatment of moderate-to-severe hypertension and treatment of even mild hypertension in subjects with cardiovascular disease, target organ damage or diabetes, and in the elderly; and treatment of isolated systolic hypertension in the elderly. All acknowledge that evidence for efficacy and safety of treatment is strongest for thiazide diuretics and beta-blockers. UNCOMPLICATED MILD HYPERTENSION: Conventional guidelines all emphasize the importance of long-term blood pressure, measured over some months, for treatment decisions. However the blood pressure for routine treatment varies from 160/100 mmHg (British Hypertension Society) to 140/90 mmHg (Joint National Committee V). This dictates very large differences in the number of patients to be treated to prevent a cardiovascular disease event and in the proportion of the population to be treated, yet the reasons for these differences are not explicit. None of the conventional guidelines is entirely satisfactory. The more conservative British Hypertension Society policy may leave untreated some middle-aged men who ought to be treated. The more aggressive Joint National Committee V policy will lead to treatment of some young subjects who have only a remote chance of benefit, at very high cost, and possibly with adverse harm-benefit consequences. RISK-BASED GUIDELINES: Guidelines developed in New Zealand target absolute cardiovascular disease risk in mild hypertension and have the potential to correct this shortcoming of conventional guidelines. However they require further consideration as regards the number needed to treat which is acceptable to well-informed patients, the appropriate estimate of relative cardiovascular disease risk reduction by treatment in mild hypertension, the pattern of treatment which will emerge and their acceptability in ordinary practice. CONCLUSION: Comparative evaluation will be needed to determine whether the outcome is better with conventional guidelines, which are simple but at the expense of accuracy, or with risk-targeted guidelines, which are more accurate but at the expense of simplicity.