An interprofessional clinic for adults with Turner syndrome: the patient perspective.

OBJECTIVES: This qualitative study assessed the value of a primary care-based interprofessional clinical team for adults with Turner syndrome (TS) utilizing patient perspectives. METHODS: Ten patients within one institution's interprofessional adult TS clinic participated in one of two semi-structured focus groups. Content analysis was used to classify content provided by participants into themes and sub-themes using Dedoose software. RESULTS: Participants found that their quality of care and life were both improved due to the presence of the interprofessional Adults with TS Clinic. Specifically, participants reported that the clinic helped address problems with finding knowledgeable providers and care gaps, made appointments more convenient and improved interprofessional communication. Participants also reported that the clinic helped them find a sense of community and increased personal confidence. Study participants suggested improvements to the clinic by expanding the scope of practice further, simplifying processes to schedule appointments, and potentially creating interprofessional clinics for other rare diseases as well. CONCLUSION: Pursuing avenues to create interprofessional clinics for adults with rare diseases has value from the patient perspective. This value can translate to improved patient outcomes through improvements in patient knowledge of their diagnosis, adherence to evidence-based care and quality of life.

The effectiveness of implementing a reminder system into routine clinical practice: does it increase postpartum screening in women with gestational diabetes?

INTRODUCTION: During regular care, women with previous gestational diabetes mellitus (GDM) rarely receive the recommended screening test for type 2 diabetes, a 2-hour oral glucose tolerance test (OGTT), in the postpartum period. The current study examined whether the implementation of a reminder system improved screening rates. METHODS: Based on our previous randomized control trial, we implemented a postpartum reminder (letter or phone call) protocol into routine care at two of three clinical sites. We verified postpartum testing by searching hospital laboratory databases and by linking to the provincial physician service claims database. The primary outcome was the proportion of patients who underwent an OGTT within 6 months of delivery. RESULTS: Women who received care in a setting using a reminder system were more likely to receive an OGTT within 6 months postpartum (28%) compared with usual care (14%). The OGTT rates for both reminder groups were lower than that found in our randomized control trial (28% vs. 60%). CONCLUSION: Although the screening rates remain low, postpartum reminders doubled screening rates using the recommended test, the OGTT.

The medical review article revisited: has the science improved?

BACKGROUND: The validity of a review depends on its methodologic quality. OBJECTIVE: To determine the methodologic quality of recently published review articles. DESIGN: Critical appraisal. SETTING: All reviews of clinical topics published in six general medical journals in 1996. MEASUREMENTS: Explicit criteria that have been published and validated were used. RESULTS: Of 158 review articles, only 2 satisfied all 10 methodologic criteria (median number of criteria satisfied, 1). Less than a quarter of the articles described how evidence was identified, evaluated, or integrated; 34% addressed a focused clinical question; and 39% identified gaps in existing knowledge. Of the 111 reviews that made treatment recommendations, 48% provided an estimate of the magnitude of potential benefits (and 34%, the potential adverse effects) of the treatment options, 45% cited randomized clinical trials to support their recommendations, and only 6% made any reference to costs. CONCLUSIONS: The methodologic quality of clinical review articles is highly variable, and many of these articles do not specify systematic methods.

Assessing the quality of randomized trials: reliability of the Jadad scale.

An instrument was developed and validated by Jadad, et al. to assess the quality of clinical trials using studies from the pain literature. Our study determined the reliability of the Jadad scale and the effect of blinding on interrater agreement in another group of primary studies. Four raters independently assessed blinded and unblinded versions of 76 randomized trials. Interrater agreement was calculated among combinations of four raters for blinded and unblinded versions of the studies. A 4 x 2 x 2 repeated measures design was employed to evaluate the effect of blinding. The interrater agreement for the Jadad scale was poor (kappa 0.37 to 0.39), but agreement improved substantially (kappa 0.53 to 0.59) with removal of the third item (an explanation of withdrawals). Blinding did not significantly affect the Jadad scale scores. A more precise description of how to score the withdrawal item and careful conduct of a practice set of articles might improve interrater agreement. In contrast with the conclusions reached by Jadad, we were unable to demonstrate a significant effect of blinding on the quality scores.

Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies.

BACKGROUND: There is controversy over whether perioperative allogeneic red blood cell transfusions are associated with an increased risk of cancer recurrence, postoperative infection or death in patients with cancer undergoing surgery. METHODS: A systematic meta-analysis was performed to answer this question. Studies were identified from electronic databases (Medline 1966-1997, Cancerlit 1983-1997, Current Contents, Cinahl 1982-1996, Healthstar 1990-1997, Bioabstracts 1990-1996 and Embase), by hand search of the bibliographies of identified studies and relevant journals, and by contact with experts in the field. All randomized controlled trials or prospective cohort studies with active comparator controls (autologous or leucocyte-depleted allogeneic blood) were eligible for inclusion if they reported on mortality, infection or recurrence rate in patients with cancer undergoing potentially curative surgical resection. The validity of the identified studies was assessed by means of a standardized scale, and data abstraction was carried out by two investigators independently. A random effects model was used for data synthesis. RESULTS: Of the 2172 references identified, only 17 studies fulfilled the inclusion criteria. After exclusion of duplicate publications, six randomized controlled trials and two prospective cohort studies with appropriate concurrent controls were included in the analysis. The summary risk ratios were 0.95 (95 per cent confidence interval (c.i.) 0.79-1.15) for all-cause mortality and 1.06 (95 per cent c.i. 0.88-1.28) for cancer recurrence, the two endpoints that were appropriate to combine statistically. There was significant heterogeneity (explainable by differences in study design and patient characteristics) in the postoperative infection data and the summary risk ratio was 1.00 (95 per cent c.i. 0.76-1.32) for the four studies that were appropriate to subject to meta-analysis. Given the sample sizes of these eight studies, this meta-analysis had insufficient power to detect a relative difference of less than 20 per cent in the frequency of death, cancer recurrence or infection between the allogeneic and control transfusion arms. CONCLUSION: Although more studies are required before a definitive statement can be made, at this time there is no evidence that allogeneic blood transfusion increases the risk of clinically important adverse sequelae in patients with cancer undergoing surgery.

Reappraisal of the resting metabolic rate of normal young men.

The Harris-Benedict (HB) equation, widely used to estimate the resting metabolic rate (RMR), has been disputed by Owen et al who reported that it overestimates the RMR of men aged less than 50 y by approximately 9%. We measured the RMR of 29 healthy, nonsmoking men aged 18-33 y by direct oxygen consumption with a closed-circuit technique similar to that used by Harris and Benedict (respirometer), as well as by a ventilated-hood technique. RMR determined by the ventilated-hood technique was 5.6% lower than when determined by the respirometer (1643 +/- 148 vs 1721 +/- 145 kcal/d, respectively, means +/- SD; P less than 0.001). RMRs by both these methods were lower than the value of 1813 +/- 164 kcal/d predicted by the HB equation; the 95% confidence intervals (CIs) for RMR were 92.4-98.1% (respirometer) and 88.5-91.1% (ventilated hood) of the value predicted by the HB equation. The 95% CI for RMR determined by ventilated hood was 98.4-103.5% of the value predicted by using a new equation proposed by Owen et al. We conclude that the HB equation overestimates RMR by 9.2% in normal young men. This could be due in part to the inherent discomfort experienced by subjects when the original technique was used.