Summary

Evidence-based medicine (EBM) is the clinical use of current best available evidence from relevant, valid research. Provision of evidence-based healthcare is the most ethical way to practise as it integrates up-to-date patient-oriented research into the clinical decision-making to improve patients' outcomes. This article provides tips for teachers to teach clinical trainees the final two steps of EBM: integrating evidence with clinical judgement and bringing about change.

Summary

Evidence-based medicine (EBM) is an indispensable tool in clinical practice. Teaching and training of EBM to trainee clinicians is patchy and fragmented at its best. Clinically integrated teaching of EBM is more likely to bring about changes in skills, attitudes and behaviour. Provision of evidence-based health care is the most ethical way to practice, as it integrates up-to-date, patient-oriented research into the clinical decision making process, thus improving patients' outcomes. In this article, we aim to dispel the myth that EBM is an academic and statistical exercise removed from practice by providing practical tips for teaching the minimum skills required to ask questions and critically identify and appraise the evidence and presenting an approach to teaching EBM within the existing clinical and educational training infrastructure.

Hepatitis B virus (HBV) strains isolated from members of the primitive Paharia ethnic community of Eastern India were studied to gain insight into the genetic diversity and evolution of the virus. The Paharia tribe has remained quite separate from the rest of the Indians and differs culturally, genetically, and linguistically from the mainstream East Indian population, whose HBV strains were previously characterized. Full-length HBV DNA was PCR amplified, cloned, and sequenced. Phylogenetic relationships between the tribal sequences and reference sequences from the mainstream population were assessed, and divergence times of subgenotypes of HBV genotype D were estimated. HBV was found in 2% of the Paharias participating in the study. A predominance of hepatitis B e antigen-negative infection (73%) was observed among the Paharias, and the genome sequences of the HBV strains exhibited relative homogeneity, with a very low prevalence of mutations. The novel feature of Paharia HBV was the exclusive presence of the D5 subgenotype, which was recently identified in Eastern India. Analysis of the four open reading frames (ORFs) of these tribal HBV D5 sequences and comparison with previously reported D1 to D7 sequences enabled the identification of 27 specific amino acid residues, including 6 unique ones, that could be considered D5 signatures. The estimated divergence times among subgenotypes D1 to D5 suggest that D5 was the first to diverge and hence is the most ancient of the D subgenotypes. The presence of a specific, ancient subgenotype of HBV within an ethnically primitive, endogamous population highlights the importance of studies of HBV genetics in well-separated human populations to understand viral transmission between communities and genome evolution.

Introduction

Spontaneous intraperitoneal rupture with biliary peritonitis in a case of hepatic hydatid cyst is extremely rare but serious complication. It is a surgical emergency with high morbidity and mortality rates. Very few cases have been reported in the literature.

Case presentation

We report an unusual case of a biliary peritonitis due to spontaneous rupture of hepatic hydatid cyst in a male patient of 34 years of age. He presented with acute peritonitis. Contrast enhanced computed tomography 2 days prior to laparotomy showed a dumbbell shaped hydatid cyst of right lobe of the liver with perihepatic fluid collection. At operation 1.5 L bile was found in the peritoneal cavity with rupture of the anterior wall of the cyst and large cystobiliary communication. He was managed with deroofing of the cyst, cholecystectomy, and placement of T tube in the cystobiliary communication and in the extrahepatic bile duct. He developed biliary fistula which was closed over a period of 34 days with conservative therapy. At 6 months follow up patient is well and free of recurrence.

Conclusion

Though rare, ruptured hydatid cyst should be considered in the differential diagnosis of acute abdomen in a patient residing in the endemic zone.

Calix[4]arenes constrained to 1,3-alternate conformation and functionalized at the upper rim with four and two nitronyl nitroxides have been synthesized, and characterized by X-ray crystallography, magnetic resonance (EPR and 1H NMR) spectroscopy, and magnetic studies. Such calix[4]arene tetraradicals and diradicals provide scaffolds for through-bond and through-space intramolecular exchange couplings.

Background

To evaluate the educational effects of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduates compared to a traditional lecture-based course of equivalent content.

Methods

We conducted a cluster randomised controlled trial in the Netherlands and the UK involving postgraduate trainees in six obstetrics and gynaecology departments. Outcomes (knowledge gain and change in attitude towards EBM) were compared between the clinically integrated e-learning course (intervention) and the traditional lecture based course (control). We measured change from pre- to post-intervention scores using a validated questionnaire assessing knowledge (primary outcome) and attitudes (secondary outcome).

Results

There were six clusters involving teaching of 61 postgraduate trainees (28 in the intervention and 33 in the control group). The intervention group achieved slightly higher scores for knowledge gain compared to the control, but these results were not statistically significant (difference in knowledge gain: 3.5 points, 95% CI -2.7 to 9.8, p = 0.27). The attitudinal changes were similar for both groups.

Conclusion

A clinically integrated e-learning course was at least as effective as a traditional lecture based course and was well accepted. Being less costly than traditional teaching and allowing for more independent learning through materials that can be easily updated, there is a place for incorporating e-learning into postgraduate EBM curricula that offer on-the-job training for just-in-time learning.

Trial registration

Trial registration number: ACTRN12609000022268.