Showing papers by "Gordon H. Guyatt published in 1994"
TL;DR: The patient is a 28-year-old man whose acute onset of shortness of breath and vague chest pain began shortly after completing a 10-hour auto trip, and the physician is very apprehensive about his symptoms.
Abstract: CLINICAL SCENARIO You are back where we put you in the previous article1on diagnostic tests in this series on how to use the medical literature: in the library studying an article that will guide you in interpreting ventilation-perfusion (V/Q) lung scans. Using the criteria in Table 1, you have decided that the Prospective Investigation of Pulmonary Diagnosis (PIOPED) study2will provide you with valid information. Just then, another physician comes looking for an article to help with the interpretation of V/Q scanning. Her patient is a 28-year-old man whose acute onset of shortness of breath and vague chest pain began shortly after completing a 10-hour auto trip. He experienced several episodes of similar discomfort in the past, but none this severe, and is very apprehensive about his symptoms. After a normal physical examination, electrocardiogram and chest radiograph, and blood gas measurements that show a Pco2of
2,084 citations
TL;DR: You are back where you were in the previous article1 on diagnostic tests: in the library studying an article that will guide you in interpreting ventilation-perfusion (V/Q) lung scans.
Abstract: You are back where we put you in the previous article1 on diagnostic tests in this series on how to use the medical literature: in the library studying an article that will guide you in interpreting ventilation-perfusion (V/Q) lung scans. Using the criteria in Table 1, you have decided that the Prospective Investigation of Pulmonary Diagnosis (PIOPED) study2 will provide you with valid information. Just then, another physician
1,963 citations
TL;DR: The observation that the minimal important difference is consistent across domains and for both improvement and deterioration will facilitate interpretation of results of studies examining quality of life.
1,780 citations
Journal Article•
TL;DR: In this paper, a 78-year-old woman who had abdominal surgery was seen by a medical consultant, who was asked by a surgical colleague to see a 78 year old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours.
Abstract: CLINICAL SCENARIO You are a medical consultant asked by a surgical colleague to see a 78-year-old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours. She has also been experiencing what she describes as chest discomfort, which is sometimes made worse by taking a deep breath (but sometimes not). Abnormal findings on physical examination are restricted to residual tenderness in the abdomen and scattered crackles at both lung bases. Chest roentgenogram reveals a small right pleural effusion, but this is the first roentgenogram since the operation. Arterial blood gases show a Po 2 of 70 mm Hg, with a saturation of 92%. The electrocardiogram shows only nonspecific changes. You suspect that the patient, despite receiving 5000 U of heparin twice a day,
936 citations
TL;DR: A 78-year-old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours, is seen by a medical consultant asked by a surgical colleague to see her.
Abstract: CLINICAL SCENARIO You are a medical consultant asked by a surgical colleague to see a 78-year-old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours. She has also been experiencing what she describes as chest discomfort, which is sometimes made worse by taking a deep breath (but sometimes not). Abnormal findings on physical examination are restricted to residual tenderness in the abdomen and scattered crackles at both lung bases. Chest roentgenogram reveals a small right pleural effusion, but this is the first roentgenogram since the operation. Arterial blood gases show a Po 2 of 70 mm Hg, with a saturation of 92%. The electrocardiogram shows only nonspecific changes. You suspect that the patient, despite receiving 5000 U of heparin twice a day,
929 citations
TL;DR: A 55-year-old man has had his serum cholesterol level measured at a shopping mall 2 months ago and his cholesterol level was elevated, but before deciding on a treatment recommendation, you elect to find out just how big a reduction in the risk of CHD this patient could expect from a cholesterollowering diet or drug therapy.
Abstract: CLINICAL SCENARIO A 55-year-old man had his serum cholesterol level measured at a shopping mall 2 months ago. His cholesterol level was elevated and he comes to you, his primary care physician, for advice. He does not smoke, is not obese, and does not have hypertension, diabetes mellitus, or any first-order relatives with premature coronary heart disease (CHD). You repeat his cholesterol test and schedule a follow-up appointment. The test confirms an elevated cholesterol level (7.9 mmol/L [305 mg/dL]), but before deciding on a treatment recommendation, you elect to find out just how big a reduction in the risk of CHD this patient could expect from a cholesterollowering diet or drug therapy. THE SEARCH There are a number of cholesterol-lowering trials, and instead of trying to find and review all of the original studies yourself, you use Grateful Med to find a recent overview. On the first subject line you
816 citations
712 citations
TL;DR: A general internist is asked to see a 65-year-old man with controlled hypertension and a 6-month history of atrial fibrillation resistant to cardioversion, who has no evidence for valvular or coronary heart disease, and who shares concerns about the benefits of long-term anticoagulant therapy.
Abstract: CLINICAL SCENARIO You are a general internist who is asked to see a 65-year-old man with controlled hypertension and a 6-month history of atrial fibrillation resistant to cardioversion. Although he has no evidence for valvular or coronary heart disease, the family physician who referred him to you wants your advice on whether the benefits of long-term anticoagulants (to reduce the risk of embolic stroke) outweigh their risks (of hemorrhage from anticoagulant therapy). The patient shares these concerns and doesn't want to receive a treatment that would do more harm than good. You know that there have been randomized trials of warfarin for nonvalvular atrial fibrillation and decide that you'd better review one of them.
678 citations
624 citations
TL;DR: Improvements in exercise tolerance and quality of life can be achieved and sustained for 6 months in patients undergoing respiratory rehabilitation compared with those receiving conventional care.
517 citations
TL;DR: A 76-year-old retired schoolteacher who has lived with her son since her husband died 6 years ago has become increasingly agitated and paranoid during the last year and you feel she has probable Alzheimer's disease.
Abstract: CLINICAL SCENARIO You are about to see a 76-year-old retired schoolteacher for the second time. You first saw her in the clinic a month ago because of cognitive problems. Your evaluation at that time included a Standardized Mini-Mental State Examination,1on which she scored 18 out of a possible 30 points, and a physical examination that was normal including no focal neurological signs. You arranged investigations for the treatable causes of dementia that were negative, and you thus feel she has probable Alzheimer's disease. The patient has lived with her son since her husband died 6 years ago. Her son thinks that she first developed significant problems with her memory about 3 years ago. However, she has become increasingly agitated and paranoid during the last year. She has refused to allow him to look after her financial affairs, despite the fact that she owns three pieces of property and
TL;DR: Impairment of quality of life may not be the same in the two groups and that it is appropriate to have a questionnaire specifically designed for adolescent rhinoconjunctivitis clinical trials.
Abstract: Background: The objectives of the study were to evaluate impairment in quality of life in 12- to 17-year-old patients with seasonal allergic rhinoconjunctivitis and to develop and test a questionnaire suitable for evaluating change in quality of life during clinical trials. Methods: Patients were asked to identify physical and emotional impairments associated with allergic rhinoconjunctivitis. The resultant questionnaire was tested for responsiveness and validity in a clinical trial in which fluticasone nasal spray and loratadine were compared for treatment of ragweed pollen—induced rhinoconjunctivitis. Eighty-three patients, 12 to 17 years of age, with grass- or ragweed-induced hayfever participated in the instrument development phase. They were recruited for the study from an allergy clinic and local schools and recreational organizations. Two hundred forty patients with ragweed hayfever participated in the clinical trial and provided quality of life data. Results: The survey showed that in addition to local symptoms, patients experienced impairment of quality of life because of systemic symptoms, activity limitations, and emotional and practical problems. The resultant questionnaire has 25 items in six domains. In the clinical trial responsiveness was demonstrated by the questionnaire's ability to detect change over time and differences between treatments. Construct validity was demonstrated by moderate to strong relationships between changes in diary symptom scores and quality of life. Conclusions: The items identified by 12- to 17-year-old patients were not identical to those previously identified by adults. This suggests that impairment of quality of life may not be the same in the two groups and that it is appropriate to have a questionnaire specifically designed for adolescent rhinoconjunctivitis clinical trials.
TL;DR: A search for a key article on the safety of β-adrenergic agonists in the treatment of asthma and how to respond to patients asking him about media reports of an increased risk of death associated with these medications.
Abstract: CLINICAL SCENARIO You are having lunch in the hospital cafeteria when one of your colleagues raises the issue of the safety of β-adrenergic agonists in the treatment of asthma. Your colleague feels uncertain about how to respond to patients asking him about media reports of an increased risk of death associated with these medications. Another colleague mentions a key article on this topic that generated much of the publicity, but she cannot recall the details. You all agree that this is an issue that arises frequently enough in your practices that you should become familiar with the evidence contained in the article that your patients have heard about. You volunteer to search the literature for the key article and report back to your colleagues in the next few days. THE SEARCH The next day you do a MEDLINE search using the following terms: asthma (MH) (MH stands for MeSH heading,
TL;DR: Prophylaxis against stress ulcers can be safely withheld from critically ill patients unless they have coagulopathy or require mechanical ventilation, according to this prospective multicenter cohort study.
Abstract: BACKGROUND
The efficacy of prophylaxis against stress ulcers in preventing gastrointestinal bleeding in critically ill patients has led to its widespread use. The side effects and cost of prophylaxis, however, necessitate targeting preventive therapy to those patients most likely to benefit.
METHODS
We conducted a prospective multicenter cohort study in which we evaluated potential risk factors for stress ulceration in patients admitted to intensive care units and documented the occurrence of clinically important gastrointestinal bleeding (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion).
RESULTS
Of 2252 patients, 33 (1.5 percent; 95 percent confidence interval, 1.0 to 2.1 percent) had clinically important bleeding. Two strong independent risk factors for bleeding were identified: respiratory failure (odds ratio, 15.6) and coagulopathy (odds ratio, 4.3). Of 847 patients who had one or both of these risk factors, 31 (3.7 percent; 95 percent confidence interval, 2.5 to 5.2 percent) had clinically important bleeding. Of 1405 patients without these risk factors, 2 (0.1 percent; 95 percent confidence interval, 0.02 to 0.5 percent) had clinically important bleeding. The mortality rate was 48.5 percent in the group with bleeding and 9.1 percent in the group without bleeding (P < 0.001).
CONCLUSIONS
Few critically ill patients have clinically important gastrointestinal bleeding, and therefore prophylaxis against stress ulcers can be safely withheld from critically ill patients unless they have coagulopathy or require mechanical ventilation.
TL;DR: In this issue of JAMA, Gill and Feinstein take the philosophical position that only the individual can rate quality of life, and if the individual says that it is excellent, that is what it is.
Abstract: FROM time to time, a terrible event happens to someone, and yet the survivor finds herself or himself better off. Through injury, a person is rendered paraplegic, or even quadriplegic; cancer strikes, requiring debilitating chemotherapy and raising the specter of a shortened life. The person suffering the calamity transcends the suffering and loss and finds new meaning in life. Living becomes a richer, more satisfying experience and, in extreme instances, people feel that they never really appreciated life until their tragedy. See also p 619. If one had to rate the quality of life of a quadriplegic whose life experience is dominated by well-being and joy, what would one say? In this issue of JAMA , Gill and Feinstein 1 take the philosophical position that only the individual can rate quality of life, and if the individual says that it is excellent, that is what it is. From this perspective, they
TL;DR: Relations between the QLMI and other measures provide moderate to strong evidence of its validity in discriminating between patients following AMI according to their health- related quality of life, and in measuring changes in health-related quality oflife over time.
TL;DR: Evidence is provided that brief cardiac rehabilitation initiated soon after acute myocardial infarction for patients with mild to moderate anxiety or depression, or both, is an efficient use of health-care resources and may be economically justified.
Abstract: Although there are extensive clinical evaluations of cardiac rehabilitation after acute myocardial infarction (AMI), no full economic evaluation is available. Patients with AMI and mild to moderate anxiety or depression, or both, while still in hospital were randomized to either an 8-week rehabilitation intervention (n = 99) or usual care (n = 102). Comprehensive costs and health-related quality of life, measured with the time trade-off preference score, were obtained in a 12-month trial, and together with survival data derived from published meta-analyses, cost-utility and cost-effectiveness of early cardiac rehabilitation were estimated. The best estimate of the incremental net direct 12-month costs for patients randomized to rehabilitation was $480 (United States, 1991)/patient. During 1-year follow-up, rehabilitation patients had fewer \"other rehabilitation visits\" (p < 0.0001) and gained 0.052 quality-adjusted life-year more than did the group with usual care. The cost-utility ratio was $9,200/quality-adjusted life-year gained with cardiac rehabilitation during the year of follow-up. This economic evaluation of cardiac rehabilitation does not consider the important distinctions between affordability and worth of alternative health-care services. The data provide evidence that brief cardiac rehabilitation initiated soon after AMI for patients with mild to moderate anxiety or depression, or both, is an efficient use of health-care resources and may be economically justified.
TL;DR: Establishing the wide variety of patient-specific complaints associated with Hypothyroidism provides guidance for clinicians dealing with hypothyroid patients, and investigators interested in HRQOL impairment in these patients.
Abstract: The aim of this study is to evaluate the frequency and relative importance of different aspects of health related quality of life (HRQOL) impairment in patients with hypothyroidism. A survey of 200 patients with treated hypothyroidism was undertaken. Patients were identified and questionnaires distributed through family physicians, endocrinologists, and regional branches of the Thyroid Foundation of Canada. Frequency of importance of patients' symptoms attributed to hypothyroidism and resolved or improved with treatment were measured. Establishing the wide variety of patient-specific complaints associated with hypothyroidism provides guidance for clinicians dealing with hypothyroid patients, and investigators interested in HRQOL impairment in these patients.
TL;DR: Insufficient experimental data exist to permit conclusions that enteral nutrition formulations or supplements reduce infectious morbidity and mortality rates, but results are promising enough to warrant further research.
Abstract: ObjectiveTo examine the relationship between the formulation of enteral nutrition and nosocomial infection in critical illness.Data SourcesComputerized search of published research and reference list review.Study SelectionReview of 151 citations. Included are 31 primary studies in which the authors
TL;DR: Criteria to aid intensive care workers in the assessment of diagnostic technologies is presented, using the example of bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia.
Abstract: Objective To present criteria to aid intensive care workers in the assessment of diagnostic technologies, using the example of bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia. Data sources MEDLINE was used to search for articles published from 1969 to the present that concerned diagnostic tests, diagnostic technology, pneumonia, and critically ill patients. Study selection Clinical investigations, case control studies, case series, and experimental data on the use of bronchoalveolar lavage. Studies of diagnostic technology were also included. Data extraction We extracted relevant data in duplicate, independently. Data synthesis Diagnostic technology assessment should begin by establishing the capability of the technology under ideal or laboratory conditions, followed by an exploration of the range of possible uses as well as the accuracy of the test. Bronchoalveolar lavage is a well-established technology for the diagnosis of pneumonia in immunocompromised patients. Studies of the accuracy of bronchoalveolar lavage in ventilator-dependent but nonimmunocompromised patients have shown promising diagnostic accuracy. Accuracy, however, is insufficient for dissemination of a test; an evaluation of the impact of a test on management decisions and, most importantly, on patient outcome, is required. Investigators have not addressed the full impact of bronchoalveolar lavage, and, even if the test is accurate, there are reasons to doubt whether patients will be better off if the test becomes part of routine clinical practice. Conclusions We present guidelines for the assessment of diagnostic technology, and apply them to bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia. Bronchoalveolar lavage has been studied in both the laboratory and clinical setting, and the diagnostic sensitivity and specificity of this technique are high. Further randomized trials evaluating management decisions and patient benefit would facilitate decisions regarding the appropriate dissemination of bronchoalveolar lavage.
TL;DR: In this paper, the authors compared the efficacy and side effects of salt cromoglycate eye drops (Opticrom 2%) used regularly versus as needed in the treatment of seasonal (ragweed) allergic conjunctivitis.
Abstract: Objective: The objective of this study was to compare the efficacy and side effects of sodium cromoglycate eye drops (Opticrom 2%) used regularly versus as needed in the treatment of seasonal (ragweed) allergic conjunctivitis. Methods: A randomized, unblinded, parallel group comparison was performed during the 6 weeks of the ragweed pollen season. Sixty-two adults with ragweed pollen–induced conjunctivitis were recruited for the study from previous ragweed studies and notices in the local media. Two drops of sodium cromoglycate were placed in each eye either four times daily (regular treatment group) or when needed, up to four times daily (prn group), from 1 week before and throughout the ragweed pollen season. Uncontrolled eye symptoms were treated with terfenadine 60 mg as needed, up to 120 mg daily. Subjects kept daily diaries for symptoms and medication requirements throughout the 6 weeks of treatment. The Rhinoconjunctivitis Quality of Life Questionnaire was administered and adverse experiences were reported after 1, 3, and 6 weeks of treatment. Results: Diary eye symptoms were similar in the two treatment groups, but quality of life was better in the regular treatment group. There was a trend for the prn group to require more terfenadine for uncontrolled eye symptoms. Conclusions: There may be some additional therapeutic benefit from using sodium cromoglycate eye drops regularly throughout the ragweed pollen season. (J ALLERGY CLIN IMMUNOL 1994;94:36-43.)
TL;DR: The curricular determinants of success require institutional commitment to an educational philosophy that embraces the generalist disciplines, a core curriculum that provides education and training that are correlated with the demands of clinical practice, and generalist faculty who serve as role models, mentors, and teachers.
Abstract: The authors analyzed the educational content of the curricula developed for teaching in the generalist disciplines of pediatrics, family medicine, and general internal medicine. Fifteen educational components that constitute the core content shared by the three generalist disciplines are identified, described, and referenced. Tailoring the generalist curriculum for students and residents at the different stages of learning is reviewed, along with the refinement of the curriculum to meet the special needs of each generalist discipline. The success of a generalist curriculum will ultimately be measured by generalist career choices, quality of care, and both patient and professional satisfaction. The curricular determinants of success require institutional commitment to an educational philosophy that embraces the generalist disciplines, a core curriculum that provides education and training that are correlated with the demands of clinical practice, and generalist faculty who serve as role models, mentors, and teachers.
TL;DR: In this article, two basic approaches to health-related quality of life measurement are available: gene-based and gene-assisted methods, which are used in controlled clinical trials to measure the quality of human life.
Abstract: Measurement of health-related quality of life is becoming increasingly relevant to controlled clinical trials. Two basic approaches to health-related quality of life measurement are available: gene...