https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(00)02816-6.pdf

A risk score to predict need for treatment for upper-gastrointestinal haemorrhage.

The chronic toxicity of aluminium, cadmium, mercury, and lead in birds: a review.

Background Limited resources coupled with unlimited demand for healthcare mean that decisions have to be made regarding the allocation of scarce resources across competing interventions. Policy documents have advocated the importance of public views as one such criterion. In principle, the elicitation of public values represents a big step forward. However, for the exercise to be worthwhile, useful information must be obtained that is scientifically defensible, whilst decision-makers must be able and willing to use it. Aims and objectives The aim was to identify techniques that could be reasonably used to elicit public views on the provision of healthcare. Hence, the objectives were: (1) to identify research methods with the potential to take account of public views on the delivery of healthcare; (2) to identify criteria for assessing these methods; (3) to assess the methods identified according to the predefined criteria; (4) to assess the importance of public views vis-a-vis other criteria for setting priorities, as judged by a sample of decision-makers; (5) to make recommendations regarding the use of methods and future research. Methods A systematic literature review was carried out to identify methods for eliciting public views. Criteria currently used to evaluate such methods were identified. The methods identified were then evaluated according to predefined criteria. A questionnaire-based survey assessed the relative importance of public views vis-a-vis five other criteria for setting priorities: potential health gain; evidence of clinical effectiveness; budgetary impact; equity of access and health status inequalities; and quality of service. Two techniques were used: choice-based conjoint analysis and allocation of points technique. The questionnaire was sent to 143 participants. A subsample was followed up with a telephone interview. Results The methods identified were classified as quantitative or qualitative. RESULTS - QUANTITATIVE TECHNIQUES: Quantitative techniques, classified as ranking, rating or choice-based approaches, were evaluated according to eight criteria: validity; reproducibility; internal consistency; acceptability to respondents; cost (financial and administrative); theoretical basis; whether the technique offered a constrained choice; and whether the technique provided a strength of preference measure. Regarding ranking exercises, simple ranking exercises have proved popular, but their results are of limited use. The qualitative discriminant process has not been used to date in healthcare, but may be useful. Conjoint analysis ranking exercises did well against the above criteria. A number of rating scales were identified. The visual analogue scale has proved popular within the quality-adjusted life-year paradigm, but lacks constrained choice and may not measure strength of preference. However, conjoint analysis rating scales performed well. Methods identified for eliciting attitudes include Likert scales, the semantic differential technique, and the Guttman scale. These methods provide useful information, but do not consider strength of preference or the importance of different components within a total score. Satisfaction surveys have been frequently used to elicit public opinion. Researchers should ensure that they construct sensitive techniques, despite their limited use, or else use generic techniques where validity has already been established. Service quality (SERVQUAL) appears to be a potentially useful technique and its application should be researched. Three choice-based techniques with a limited application in healthcare are measure of value, the analytical hierarchical process and the allocation of points technique, while those more widely used, and which did well against the predefined criteria, include standard gamble, time trade-off, discrete choice conjoint analysis and willingness to pay. Little methodological work is currently available on the person trade-off. RESULTS - QUALITATIVE TECHNIQUES: Qualitative techniques were classified as either individual or group-based approaches. Individual approaches included one-to-one interviews, dyadic interviews, case study analyses, the Delphi technique and complaints procedures. Group-based methods included focus groups, concept mapping, citizens' juries, consensus panels, public meetings and nominal group techniques. Six assessment criteria were identified: validity; reliability; generalisability; objectivity; acceptability to respondents; and cost. Whilst all the methods have distinct strengths and weaknesses, there is a lot of ambiguity in the literature. Whether to use individual or group methods depends on the specific topic being discussed and the people being asked, but for both it is crucial that the interviewer/moderator remains as objective as possible. The most popular and widely used such methods were one-to-one interviews and focus groups. (ABSTRACT TRUNCATED)

Eliciting public preferences for healthcare: a systematic review of techniques.

This brief review focuses on calcium balance and homeostasis and their relationship to dietary calcium intake and calcium supplementation in healthy subjects and patients with chronic kidney disease and mineral bone disorders (CKD-MBD). Calcium balance refers to the state of the calcium body stores, primarily in bone, which are largely a function of dietary intake, intestinal absorption, renal excretion, and bone remodeling. Bone calcium balance can be positive, neutral, or negative, depending on a number of factors, including growth, aging, and acquired or inherited disorders. Calcium homeostasis refers to the hormonal regulation of serum ionized calcium by parathyroid hormone, 1,25-dihydroxyvitamin D, and serum ionized calcium itself, which together regulate calcium transport at the gut, kidney, and bone. Hypercalcemia and hypocalcemia indicate serious disruption of calcium homeostasis but do not reflect calcium balance on their own. Calcium balance studies have determined the dietary and supplemental calcium requirements needed to optimize bone mass in healthy subjects. However, similar studies are needed in CKD-MBD, which disrupts both calcium balance and homeostasis, because these data in healthy subjects may not be generalizable to this patient group. Importantly, increasing evidence suggests that calcium supplementation may enhance soft tissue calcification and cardiovascular disease in CKD-MBD. Further research is needed to elucidate the risks and mechanisms of soft tissue calcification with calcium supplementation in both healthy subjects and CKD-MBD patients.

/pdf/calcium-metabolism-in-health-and-disease-4cqws7jq7h.pdf

Calcium Metabolism in Health and Disease

These guidelines provide evidence-based recommendations for the management of patients with acute nonvariceal upper gastrointestinal bleeding. The recommendations emphasize early action to improve ...

https://www.cag-acg.org/images/publications/AIM_2003_GIBleed_Consensus_Guidelines.pdf

Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding.

The Association of Program Directors in Internal Medicine (APDIM) Council has developed a strategy for redesigning residency training The Council’s recommendations were reviewed and approved by the APDIM membership and form the basis of this official position paper The Association of Program Directors in Internal Medicine comprises more than 400 internal medicine training programs throughout the United States and Canada The redesign process will require substantial changes to the educational environment, oversight, curriculum, faculty reward system, and funding of graduate medical education in internal medicine The Association of Program Directors in Internal Medicine proposes immediate, shortterm, and long-term solutions There is a growing consensus that residency education in internal medicine urgently needs redesign The educa

/pdf/redesigning-residency-education-in-internal-medicine-a-kzfmuw6sqy.pdf

Redesigning residency education in internal medicine: A position paper from the Association of Program Directors in Internal Medicine

The degree of consensus and the accuracy of subjective prior probability estimates made by 104 clinicians were examined. The clinicians' estimates were compared with objective prior probabilities obtained from published sources and actual patient outcomes. Each cli nician made seven estimates based upon written case summaries abstracted from patient records. Consensus was measured by calculating estimate ranges and standard deviations. The clinicians' estimates varied widely: the smallest range was 80 (2%-82%); four of the seven probability ranges were greater than 90. The average standard deviation was 19.5. Using these prior probabilities and Bayes' theorem, widely varying posttest probabilities would result after many common diagnostic tests. Accuracy was measured using the Brier score, which ranges from 0 to 1; a score of 0 indicates perfect accuracy. The clinicians' Brier scores ranged from 0.05 to 0.57. The objectively determined probabilities achieved a Brier score of 0.11, better than that of 96% ...

An Eualuation of Clinicians' Subjective Prior Probability Estimates

Early identification of patients at low risk for poor outcome after acute upper gastrointestinal hemorrhage would allow reduction of diagnostic and therapeutic interventions. We identified six early predictors of good outcome: age less than 75 years, no unstable comorbid illness, no ascites found on physical examination, normal prothrombin time, and, within an hour after presentation, systolic blood pressure of 100 mm Hg or greater and nasogastric aspirate free of fresh blood. Presence of all six predictors defined the low-risk population. Among 162 patients in the development and retrospective validation phases of our study, all 74 low-risk patients had good outcomes. A prospective validation study of 111 patients further established the accuracy of our predictive method; only two of 52 low-risk patients had poor outcomes. Application of our method should allow more selective management of patients with acute upper gastrointestinal hemorrhage. (JAMA1985;253:3282-3285)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=jama&articleId=398927&pdfFileName=jama_253_22_026.pdf

Early clinical signs identify low-risk patients with acute upper gastrointestinal hemorrhage.

PURPOSE To implement an evidence-based medicine (EBM) curriculum for Year 1 and 2 medical students, and to develop a method to evaluate their practice of EBM in discrete and relevant worksteps. METHODS For the 100 students entering Year 1 of their medical education in 2000, we implemented a curriculum with 25–30 student contact hours of EBM instruction which used a variety of teaching formats and spanned the first and second years of their training. We developed an evaluation module that assessed the following 5 steps in the practice of EBM: generating well built questions; searching for evidence; critical appraisal; applying the evidence, and self-evaluation. We tested 2 different versions of the test module 3-months apart with the same cohort of second year students, and correlated their scores on the second module with examination components of a comprehensive assessment. We obtained feedback from the students regarding the EBM curriculum and evaluation method. RESULTS Each test module took 2–4 hours to complete and 5–8 minutes to grade. There was moderate test)retest reliability for the total test scores (r ¼ 0.35, P < 0.001). Step 1 scores correlated with the mock board examination scores (r ¼ 0.23, P ¼ 0.05). Step 2 scores correlated with the peer assessment factor work habits (r ¼ 0.24, P ¼ 0.02), and Step 3 scores correlated with clinical reasoning exercises (r ¼ 0.31, P ¼ 0.002). Step 4 scores lacked test)retest reliability and did not correlate with components of the comprehensive assessment. The majority of students felt there was too much focus on EBM during the first 2 years of the curriculum and they rated the EBM test module the lowest rated component of the comprehensive assessment. CONCLUSIONS Although we have demonstrated preliminary reliability and validity of a new evaluation instrument that assess the domains of scientific knowledge, work habits and reasoning skills required in the practice of EBM, many of the correlations were weak, and we remain in the very early stages of determining if, when and how EBM instruction should occur in medical education.

Teaching and evaluating first and second year medical students' practice of evidence-based medicine.

A 60-year-old woman was evaluated for bone pain and incapacitating weakness. Initial laboratory studies showed a serum calcium level of 10.1 mg/dL, severe hypophosphatemia (1.1 mg/dL), and an elevated alkaline phosphatase level. X-ray films showed changes consistent with osteomalacia. Further studies revealed hypercalciuria (448 mg/24 hr) but absent urinary phosphorus. These data indicated phosphate malabsorption. Excessive use of an aluminum hydroxide—containing antacid was the cause of this patient's failure to absorb dietary phosphate. The features of this syndrome are reviewed to increase physicians' awareness of this illness, which occurs particularly in the elderly and is easily treated. (JAMA1980;244:2544-2546)

https://jamanetwork.com/journals/JAMA/articlepdf/372790/jama_244_22_025.pdf

Donald R. Bordley

Papers

Redesigning residency education in internal medicine: A position paper from the Association of Program Directors in Internal Medicine

An Eualuation of Clinicians' Subjective Prior Probability Estimates

Early clinical signs identify low-risk patients with acute upper gastrointestinal hemorrhage.

Teaching and evaluating first and second year medical students' practice of evidence-based medicine.

Osteomalacia and Weakness From Excessive Antacid Ingestion