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Actual Clinical Practice (actual + clinical_practice)
Selected AbstractsRole of the Clinical Breast Examination in Breast Cancer ScreeningJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2001Does This Patient Have Breast Cancer? QUESTION: The authors, in an article for the JAMA section on the rational clinical examination, consider the evidence on whether and how to use clinical breast examination as a cancer screening technique. BACKGROUND: Breast cancer is a common disease, particularly in older women. The authors note that by age 70 the annual incidence of breast cancer is one in 200 women. Breast cancer survival is strongly influenced by the stage of the disease at the time of diagnosis. As a result, it is important to consider how best to screen for this disease. In recent years there has been considerable attention in the clinical literature and in the popular media paid to the screening strategies of breast self-examination and of screening mammography, but somewhat less to the potential role of the breast examination by the healthcare provider. In actual clinical practice, the same woman may be the recipient of any, none, or all of these screening modalities. The best way to combine these screening strategies, particularly in the case of the older woman, remains a subject of some uncertainty and controversy. DATA SOURCES: Data were obtained from a MEDLINE search of the English-language literature for 1966 through 1997 and additional articles as identified by the authors. STUDY SELECTION CRITERIA: In their evaluation of the effectiveness of clinical breast examination, the authors included both controlled trials and case-controlled studies in which clinical breast examination was used as a component of the screening. Study of breast examination technique considered both clinical studies and studies using silicone breast models. DATA EXTRACTION: The combined data from the trials included information on approximately 200,000 women who received a breast cancer screening intervention (mammography and/or clinical breast examination). However, none of the studies made the direct comparison of a group receiving clinical breast examination as a sole intervention with a control group that did not receive any screening. Data on the utility of clinical breast examination were partially derived from studies where that screening modality was used in combination with mammography. MAIN RESULTS: A number of trials of cancer screening have demonstrated a reduction in mortality from the use of mammography and clinical breast examination as combined screening strategies compared with no screening, with the inference that the reduction in mortality comes from the earlier detection of breast cancer. The percentage of the detected cancers that are detected in the trials by clinical breast examination despite having been missed on mammography varies across the trials from a low of 3% of the detected cancers to a high of 45%. It is speculative whether the marginal contribution of clinical breast examination to the mortality reduction in these screening trials corresponds to the percentage of cancers detected by clinical breast examination alone. In most of the clinical trials, the technique of breast examination reportedly was not well described. It is unclear therefore how much the technique of breast examination used varied within and among the clinical trials. Data from studies using examinations of breast models made of silicone demonstrated that test performance accuracy correlated with a lengthier breast examination, better breast examination technique, and perhaps with examiner experience. The report includes data from six comparator studies and from two demonstration projects. Of the six comparator studies, four compared a screened population with an unscreened population and two compared different intensities of screening strategies. None of the eight clinical trials was directed to a geriatric population and in fact older women were excluded by upper age entry criteria from the six comparator studies. (The upper age limit for study entry in the six comparator studies varied from 49 to 64.) CONCLUSION: The authors drew on the pooled results of these eight studies to conclude that clinical breast examination has a sensitivity of 54% (95% confidence interval, 48.3,59.8) and a specificity of 94% (95% confidence interval, 90.2,96.9). The authors conclude that screening clinical breast examination should be done for women age older than 40. [source] Evidence-based medicine: Review of guidelines and trials in the prevention of secondary stroke,JOURNAL OF HOSPITAL MEDICINE, Issue S4 2008David J. Likosky MD Abstract Transient ischemic attack (TIA) carries a substantial short-term risk for stroke, which is a leading cause of disability and death in the United States. Despite the existing evidence-based guidelines for secondary prevention of stroke, variability in the assessment, diagnostic testing, and treatment of patients with TIA in actual clinical practice remains. Identification of stroke etiology via radiological examination is of paramount importance for the appropriate treatment of patients after TIA or stroke. Management of ischemic stroke or TIA includes lifestyle modifications, reduction of modifiable risk factors (eg, hypertension, diabetes, and elevated cholesterol), and appropriate therapeutic treatments. Antiplatelet therapy is the cornerstone of secondary prevention of stroke; guidelines for its use for noncardioembolic cases have been developed from a solid evidence base. Additional therapeutic approaches include HMG-CoA reductase inhibitors (statins), antihypertensives, and anticoagulants. The results of ongoing large trials will further clarify the role of specific antiplatelet agents for the secondary prevention of stroke in patients with noncardioembolic ischemic stroke or TIA. Journal of Hospital Medicine 2008;3(4 Suppl):S6,S19. © 2008 Society of Hospital Medicine. [source] Diagnosis and treatment of gastroesophageal reflux disease in Ohio Medicaid patients: practice patterns and temporal trends,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 1 2004Gregory S. Cooper MD Abstract Purpose There is a paucity of data about the use of procedures and prescription medications in the treatment of gastroesophageal reflux disease (GERD) in actual clinical practice. Methods Outpatient Ohio Medicaid claims from 1994 to 1998 were searched to identify patients with an initial diagnosis of GERD along with associated prescriptions and gastrointestinal procedures. Complications of GERD and comorbid illnesses were also determined. Results A total of 5579 patients were identified. Histamine-2 receptor antagonists (H2RA') were prescribed in 59%, followed by proton pump inhibitors (PPI's) (30%) and prokinetic drugs (17%). PPI's were more frequently prescribed to patients with GERD-related complications, peptic ulcer disease and major comorbidities, and patients who received PPI's were also more likely to undergo upper gastrointestinal endoscopy. The frequencies of upper endoscopy and barium studies were 20% and 11% respectively, with no change over the study period. There was an increased frequency of PPI therapy (17,43%) and decreased frequency of H2RA therapy (72,47%) from 1994 to 1998 which persisted after adjusting for potential differences in case mix. Conclusions In this population-based study, prescription of PPI's increased over time which likely reflected changes in clinician practice rather than patient mix. Despite a greater awareness of GERD complications, use of upper endoscopy did not increase. Although the cohort consists of predominantly low socioeconomic status, female patients, further studies should be conducted in other populations to confirm these findings. Copyright © 2003 John Wiley & Sons, Ltd. [source] Study Designs and Evaluation Models for Emergency Department Public Health ResearchACADEMIC EMERGENCY MEDICINE, Issue 11 2009Kerry B. Broderick MD Abstract Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. This article is the product of a breakout session from the 2009 Academic Emergency Medicine consensus conference entitled "Public Health in the ED: Screening, Surveillance, and Intervention" and serves to describe in detail aspects of performing emergency department (ED)-based public health research, while serving as a resource for current and future researchers. In doing so, the authors describe methodologic features of study design, participant selection and retention, and measurements and analyses pertinent to public health research. In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation. [source] Remission induction therapy containing rituximab markedly improved the outcome of untreated mature B cell lymphomaBRITISH JOURNAL OF HAEMATOLOGY, Issue 5 2008Hirokazu Nagai Summary Many controlled clinical trials have proven that rituximab improves the clinical outcome of patients with mature B cell lymphoma. This study was conducted to assess the contribution of rituximab in the actual clinical practice. Patients with newly diagnosed mature B cell lymphoma treated at 20 National Hospital Organization hospitals from January 2000 to December 2004 were consecutively registered. Rituximab was approved in September 2002 for indolent B cell lymphoma and in September 2003 for aggressive B cell lymphoma in Japan. The patients were divided into two groups depending on whether they received induction therapy containing rituximab. The endpoint was to evaluate the rituximab benefit based on 2-year progression-free survival (PFS) and 2-year overall survival (OS). A total 1126 patients received chemotherapies. Of these, 762 were diagnosed as diffuse large B cell lymphoma (DLBCL) and 215 as follicular lymphoma (FL). PFS and OS were markedly improved in the rituximab group compared with the non-rituximab group in patients with DLBCL (both P < 0·001) and in patients with FL (P < 0·001 and P = 0·003 respectively). Rituximab, when used for remission induction therapy, significantly improved the clinical outcome of the mature B cell lymphoma patient in actual clinical practice. [source] | ||||||||||