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evidence-based medicine

Evidence-Based Medicine Guidelines

Evidence-Based Medicine Guidelines

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Editor-in-Chief: Ilkka Kunnamo
Publisher: Duodecim Medical Publications (March 2005)
Reviewer: Meteb Al-Foheidi, Medical Resident, University of Toronto


When I was originally asked to review this book, I anticipated examining a pocket-sized guide, but I was surprised to receive a textbook-sized volume running1,311 pages.

When I started to review this book, I tried to cover some topics that I knew and others that I had little knowledge about. At the time I delved in I was doing my emergency medicine rotation, where I was exposed to a wide variety of surgical and medical emergencies in an urban academic hospital. I planned to check every case that I encountered in the Emergency Room with the information contained in the book. For instance, I had an allergic rhinitis case, and I went looking for this in the book. In this and other cases, the text proved to be a good resource: the material was informative and clear, and it provided me with the ARIA guidelines and classifications.

The guide is further enhanced by its thorough forward, preface, and list of abbreviations. It also features good-quality cover design and material.
However, readers should be aware of a few flaws. First, I noted several spelling mistakes (for example, the word “Pheo” was written as “feo”). Second, main chapters were not categorized properly for easy searching. Generally, each chapter dealt with a specialty (e.g., cardiology or pediatrics). But there were some chapters that should have been subchapters within specific specialties: diabetes should fall under endocrinology and birth control under obstetrics and gynecology. While they were likely allotted their own chapters because they are extensively studied conditions or categories, I found it poor on the level of organization.

Furthermore, sections under chapters were improperly categorized. This may cause confusion or even make it difficult to find the information easily without going through all of the contents’ subsections. For instance, page 89 featured material about Hospital Investigations. The first point referred readers to a page still further ahead, page 100, which was about “Secondary Hypertension.” Sending readers back and forth to read about one subject should be avoided.
Other examples of poor organization included chapter content. Some chapters were diseases and others were symptoms. For example, Pulmonary Diseases started with Hemoptysis. Etiologies such as infections, tumours, cardiovascular disease, trauma, etc., were discussed. Then under Differential Diagnosis, the authors addressed the importance of the patient’s history, clinical examinations, and chest x-ray, which are essential for differential diagnosis. As another example of disorganization, the writers opted to explore specific diseases of the respiratory system within a chapter dealing with a symptom.

Some chapters were not evidence-based such as Occupational Health and Pollution—a concern in a text devoted to evidence-based guidelines.
Regarding references: the textbook mentioned only grading references, but no tables or summary and references were listed at the end of each section. In my opinion, this kind of book should contain tables, easy-to-follow flow charts, and summaries that are specific to that section.

The book should have been devoted to guidelines only, based on the title, but the authors/editors went beyond that and added information that one would only find in general medical textbooks and reference guides, such as adding detailed definitions, epidemiology, clinical presentations, and investigations that lacked connection to either guidelines or to evidence-based medicine. Thus the book deviates from its title and is a hybrid of evidence-based guidelines and a standard textbook.

My overall assessment of this book: I believe it will be helpful for the generalists for whom this book was intended. As for me, I will keep this copy on my shelf and I will use it for topics outside my specialty, internal medicine. It will be more useful as a general reference for me in other areas such as surgery, pediatrics, and so forth.

Hypertension in the Older Adult: An Update on Canadian Hypertension Education Program Recommendations

Hypertension in the Older Adult: An Update on Canadian Hypertension Education Program Recommendations

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Norm R.C. Campbell, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
J. George Fodor, MD, FRCPS, PhD, Ottawa Heart Institute, Ottawa, ON.
Robert Herman, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
Pavel Hamet, MD, FRCPC, PhD, Research Center, CHUM, Montréal, QC (for the Canadian Hypertension Education Program).

Hypertension is a leading risk for morbidity and mortality in Canada. The older population is at greater risk from hypertension and has a greater reduction in cardiovascular risk with treatment than young patients. Frequent screening for hypertension is prudent as the estimated risk of developing hypertension is about 90%, even in normotensive 65-year-olds. Systolic blood pressure is a more relevant risk factor than diastolic blood pressure in older patients and is more difficult to treat to target. Most hypertensive patients will have multiple cardiovascular risks that require screening and management to reduce cardiovascular risk optimally. Lifestyle therapy is efficacious. Effective first-line drug therapies that reduce hypertension complications include thiazide-type diuretics, ACE inhibitors, long-acting calcium-channel blockers, and angiotensin-receptor blockers. Most patients require two or more drugs to achieve current blood pressure targets.
Key words: high blood pressure, hypertension, guidelines, recommendations, evidence-based medicine.

The Experience of Implementing Nursing Best Practice Guidelines for the Screening of Delirium, Dementia and Depression in the Older Adult

The Experience of Implementing Nursing Best Practice Guidelines for the Screening of Delirium, Dementia and Depression in the Older Adult

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Rola Moghabghab, RN, MN,1 Lori Adler, RN, MHSc,2 Carol Banez, RN, MAN,1 Faith Boutcher RN, MSc,3 Athina Perivolaris, RN, MN,3 Donna-Michelle Rancoeur, RN, MSc(A),3 Donna Spevakow, RN, MSN,3 Sandra Tully, RN, MAEd,1 Susan Wallace, RN, MSc3 and Kevin Woo, RN, MSc.4

1Advanced Practice Nurse, University Health Network; 2Administrative Director, Regional Geriatric Program, Toronto Rehabilitation Institute; 3Advanced Practice Nurse, Toronto Rehabilitation Institute; 4Advanced Practice Nurse, Mount Sinai Hospital; Toronto, ON.

Confusion related to dementia, delirium and/or depression is a common concern in the older adult. The Registered Nurses Association of Ontario Best Practice Guideline (BPG),"Screening for Delirium, Dementia and Depression in the Older Adult", was implemented as a pilot project by Advanced Practice Nurses on eight different units at Toronto Rehabilitation Institute, University Health Network and Mount Sinai Hospital. This article describes the development of the BPG and its implementation, including the design of an education program and a screening process to assist nurses. Discussion focuses on the facilitators and barriers to BPG implementation and effecting sustainable change in practice.

Research, Evaluation, and Evidence-Based Medicine

Research, Evaluation, and Evidence-Based Medicine

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Christine Oyugi, BSc
Managing Editor,
Geriatrics & Aging

On Friday, January 19th, the Baycrest Centre for Geriatric Care presented the first webcast of its continuing medical education (CME) accredited Grand Rounds program. The webcast featured an exhilarating one-hour talk on research, evaluation, and evidence-based medicine presented by Dr. David Streiner, Director of the Kunin-Lunenfeld Applied Research Unit.

Dr. Streiner began his presentation by providing a definition of the terms, research and evaluation. He defined research as the search for knowledge, where the emphasis is on the outcome and the underlying intention of the research is publication. The results from research are usually peer-reviewed and the recommendations from the study can be generalized to other patients and other institutions. Evaluations, in contrast, are not generalizable; usually they are targeted to local clinicians and administrators who use the results of the evaluation to change clinical programs within the given institution. The results in an evaluation are usually not peer-reviewed, but are vetted internally by the organization where the study took place. Often, the distinguishing factor between research and evaluation is that, in the latter case, there is no intention to publish the results of the study.

Part of EBM is integrating individual clinical practice experience, with the best available evidence and the values and expectations that each patient brings to a clinical encounter.

Since the 1940's, journals have reported an exponential increase in published research. In the field of mental health, for example, there are about 4,500 potentially relevant scientific papers published each year. A physician would have to read at least 12 articles a day to keep up with all the research. With the time constraints on clinicians, it would be difficult for them to read all published papers that are relevant to their particular field and those in other areas. However, the unfortunate consequence of clinicians not keeping up with the latest research is that clinical practice lags behind research, and is then based on the opinion of experts rather than on evidence. The incorporation of new interventions into clinical practice is chaotic, resulting in unnecessary variations in clinical practice.

The idea of evidence-based medicine (EBM) has been around for some time, but recently, there appears to be surge of interest in this topic. EBM is the conscious, explicit, and judicious use of the current best evidence for making patient care decisions. Part of EBM is integrating individual clinical practice experience, with the best available evidence and the values and expectations that each patient brings to a clinical encounter. Individual clinical experience should rely on the clinical skill and judgement of the clinician. This is vital in determining if the evidence applies to the patient being treated and, if it does, in determining how to apply it to that patient. Best evidence should always come from clinical research done with patients.

Physicians need a way to quickly evaluate studies and understand the potential applications of high-quality research to their clinical practice. This involves tracking down the best evidence by using electronic searches (e.g. medline). If judiciously used, EBM can replace currently accepted diagnostic tests and treatments with ones that are more accurate, effective, and better tolerated.

The Baycrest Centre for Geriatric Care is one of the leading institutions in the field of Geriatrics and Gerontology. The webcast is part of an ongoing health information strategy that aims to create and share knowledge to a broad spectrum of individuals and groups. To this end, Baycrest offers a number of on-line resources to facilitate your clinical practice. For more information on CME accredited courses, as well as other useful resources provided at Baycrest, please contact Mariana Catz, Chief Information Officer, at the Baycrest Centre for Geriatrics Care at (416) 785-2500 ext. 2503.

Acknowledgements
We would like to thank Mariana Catz and Stephen Tucker, from the Baycrest Centre for Geriatrics Care, for taking the time to be interviewed for this article.