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1.  The Saudi clinical practice guideline for the diagnosis of the first deep venous thrombosis of the lower extremity 
Annals of Thoracic Medicine  2015;10(1):3-15.
The diagnosis of deep venous thrombosis (DVT) may be challenging due to the inaccuracy of clinical assessment and diversity of diagnostic tests. On one hand, missed diagnosis may result in life-threatening conditions. On the other hand, unnecessary treatment may lead to serious complications. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia (KSA), an expert panel led by the Saudi Association for Venous Thrombo-Embolism (SAVTE; a subsidiary of the Saudi Thoracic Society) with the methodological support of the McMaster University Working Group, produced this clinical practice guideline to assist healthcare providers in evidence-based clinical decision-making for the diagnosis of a suspected first DVT of the lower extremity. Twenty-four questions were identified and corresponding recommendations were made following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. These recommendations included assessing the clinical probability of DVT using Wells criteria before requesting any test and undergoing a sequential diagnostic evaluation, mainly using highly sensitive D-dimer by enzyme-linked immunosorbent assay (ELISA) and compression ultrasound. Although venography is the reference standard test for the diagnosis of DVT, its use was not recommended.
doi:10.4103/1817-1737.146849
PMCID: PMC4286842  PMID: 25593601
Clinical practice guideline; deep venous thrombosis; diagnosis; Saudi Arabia; venous thromboembolism
2.  Impact of missing participant data for dichotomous outcomes on pooled effect estimates in systematic reviews: a protocol for a methodological study 
Systematic Reviews  2014;3(1):137.
Background
There is no consensus on how authors conducting meta-analysis should deal with trial participants with missing outcome data. The objectives of this study are to assess in Cochrane and non-Cochrane systematic reviews: (1) which categories of trial participants the systematic review authors consider as having missing participant data (MPD), (2) how trialists reported on participants with missing outcome data in trials, (3) whether systematic reviewer authors actually dealt with MPD in their meta-analyses of dichotomous outcomes consistently with their reported methods, and (4) the impact of different methods of dealing with MPD on pooled effect estimates in meta-analyses of dichotomous outcomes.
Methods/Design
We will conduct a methodological study of Cochrane and non-Cochrane systematic reviews. Eligible systematic reviews will include a group-level meta-analysis of a patient-important dichotomous efficacy outcome, with a statistically significant effect estimate. Teams of two reviewers will determine eligibility and subsequently extract information from each eligible systematic review in duplicate and independently, using standardized, pre-piloted forms. The teams will then use a similar process to extract information from the trials included in the meta-analyses of interest. We will assess first which categories of trial participants the systematic reviewers consider as having MPD. Second, we will assess how trialists reported on participants with missing outcome data in trials. Third, we will compare what systematic reviewers report having done, and what they actually did, in dealing with MPD in their meta-analysis. Fourth, we will conduct imputation studies to assess the effects of different methods of dealing with MPD on the pooled effect estimates of meta-analyses. We will specifically calculate for each method (1) the percentage of systematic reviews that lose statistical significance and (2) the mean change of effect estimates across systematic reviews.
Discussion
The impact of different methods of dealing with MPD on pooled effect estimates will help judge the associated risk of bias in systematic reviews. Our findings will inform recommendations regarding what assumptions for MPD should be used to test the robustness of meta-analytical results.
Electronic supplementary material
The online version of this article (doi:10.1186/2046-4053-3-137) contains supplementary material, which is available to authorized users.
doi:10.1186/2046-4053-3-137
PMCID: PMC4285551  PMID: 25423894
Missing participant data; Imputation; Risk of bias; Trials; Systematic reviews; Meta-analysis
4.  Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise 
Background:
Although several tools to evaluate the credibility of health care guidelines exist, guidance on practical steps for developing guidelines is lacking. We systematically compiled a comprehensive checklist of items linked to relevant resources and tools that guideline developers could consider, without the expectation that every guideline would address each item.
Methods:
We searched data sources, including manuals of international guideline developers, literature on guidelines for guidelines (with a focus on methodology reports from international and national agencies, and professional societies) and recent articles providing systematic guidance. We reviewed these sources in duplicate, extracted items for the checklist using a sensitive approach and developed overarching topics relevant to guidelines. In an iterative process, we reviewed items for duplication and omissions and involved experts in guideline development for revisions and suggestions for items to be added.
Results:
We developed a checklist with 18 topics and 146 items and a webpage to facilitate its use by guideline developers. The topics and included items cover all stages of the guideline enterprise, from the planning and formulation of guidelines, to their implementation and evaluation. The final checklist includes links to training materials as well as resources with suggested methodology for applying the items.
Interpretation:
The checklist will serve as a resource for guideline developers. Consideration of items on the checklist will support the development, implementation and evaluation of guidelines. We will use crowdsourcing to revise the checklist and keep it up to date.
doi:10.1503/cmaj.131237
PMCID: PMC3928232  PMID: 24344144
5.  Methodological survey of designed uneven randomization trials (DU-RANDOM): a protocol 
Trials  2014;15:33.
Background
Although even randomization (that is, approximately 1:1 randomization ratio in study arms) provides the greatest statistical power, designed uneven randomization (DUR), (for example, 1:2 or 1:3) is used to increase participation rates. Until now, no convincing data exists addressing the impact of DUR on participation rates in trials. The objective of this study is to evaluate the epidemiology and to explore factors associated with DUR.
Methods
We will search for reports of RCTs published within two years in 25 general medical journals with the highest impact factor according to the Journal Citation Report (JCR)-2010. Teams of two reviewers will determine eligibility and extract relevant information from eligible RCTs in duplicate and using standardized forms. We will report the prevalence of DUR trials, the reported reasons for using DUR, and perform a linear regression analysis to estimate the association between the randomization ratio and the associated factors, including participation rate, type of informed consent, clinical area, and so on.
Discussion
A clearer understanding of RCTs with DUR and its association with factors in trials, for example, participation rate, can optimize trial design and may have important implications for both researchers and users of the medical literature.
doi:10.1186/1745-6215-15-33
PMCID: PMC3902027  PMID: 24456965
Participation rate; Designed uneven randomization trials; Trial participation
6.  A methodological survey of the analysis, reporting and interpretation of Absolute Risk ReductiOn in systematic revieWs (ARROW): a study protocol 
Systematic Reviews  2013;2:113.
Background
Clinicians, providers and guideline panels use absolute effects to weigh the advantages and downsides of treatment alternatives. Relative measures have the potential to mislead readers. However, little is known about the reporting of absolute measures in systematic reviews. The objectives of our study are to determine the proportion of systematic reviews that report absolute measures of effect for the most important outcomes, and ascertain how they are analyzed, reported and interpreted.
Methods/design
We will conduct a methodological survey of systematic reviews published in 2010. We will conduct a 1:1 stratified random sampling of Cochrane vs. non-Cochrane systematic reviews. We will calculate the proportion of systematic reviews reporting at least one absolute estimate of effect for the most patient-important outcome for the comparison of interest. We will conduct multivariable logistic regression analyses with the reporting of an absolute estimate of effect as the dependent variable and pre-specified study characteristics as the independent variables. For systematic reviews reporting an absolute estimate of effect, we will document the methods used for the analysis, reporting and interpretation of the absolute estimate.
Discussion
Our methodological survey will inform current practices regarding reporting of absolute estimates in systematic reviews. Our findings may influence recommendations on reporting, conduct and interpretation of absolute estimates. Our results are likely to be of interest to systematic review authors, funding agencies, clinicians, guideline developers and journal editors.
doi:10.1186/2046-4053-2-113
PMCID: PMC3867670  PMID: 24330779
Systematic reviews; Meta-analysis; Statistical data; Evidence-based medicine; Numbers needed to treat; Data reporting; Absolute effect measures
7.  A Comprehensive Review of Hypertension in Pregnancy 
Journal of Pregnancy  2012;2012:105918.
Hypertension is the most common medical disorder encountered during pregnancy. Hypertensive disorders are one of the major causes of pregnancy-related maternal deaths in the United States. We will present a comprehensive update of the literature pertinent to hypertension in pregnancy. The paper begins by defining and classifying hypertensive disorders in pregnancy. The normal vascular and renal physiological changes which occur during pregnancy are detailed. We will summarize the intriguing aspects of pathophysiology of preeclampsia, emphasizing on recent advances in this field. The existing diagnostic tools and the tests which have been proposed for screening preeclampsia are comprehensively described. We also highlight the short- and long-term implications of preeclampsia. Finally, we review the current management guidelines, goals of treatment and describe the potential risks and benefits associated with various antihypertensive drug classes. Preeclampsia still remains an enigma, and the present management focuses on monitoring and treatment of its manifestations. We are hopeful that this in depth critique will stimulate the blossoming research in the field and assist practitioners to identify women at risk and more effectively treat affected individuals.
doi:10.1155/2012/105918
PMCID: PMC3366228  PMID: 22685661
8.  The Effects of Tracking Responses and the Day of Mailing on Physician Survey Response Rate: Three Randomized Trials 
PLoS ONE  2011;6(2):e16942.
Background
The response rates to physician postal surveys remain modest. The primary objective of this study was to assess the effect of tracking responses on physician survey response rate (i.e., determining whether each potential participant has responded or not). A secondary objective was to assess the effects of day of mailing (Monday vs. Friday) on physician survey response rate.
Methods
We conducted 3 randomized controlled trials. The first 2 trials had a 2×2 factorial design and tested the effect of day of mailing (Monday vs. Friday) and of tracking vs. no tracking responses. The third trial tested the effect of day of mailing (Monday vs. Friday). We meta-analyzed these 3 trials using a random effects model.
Results
The total number of participants in the 3 trials was 1339. The response rate with tracked mailing was not statistically different from that with non-tracked mailing by the time of the first reminder (RR = 1.01 95% CI 0.84, 1.22; I2 = 0%). There was a trend towards lower response rate with tracked mailing by the time of the second reminder (RR = 0.91; 95% CI 0.78, 1.06; I2 = 0%). The response rate with mailing on Mondays was not statistically different from that with Friday mailing by the time of first reminder (RR = 1.01; 95% CI 0.87, 1.17; I2 = 0%), and by the time of the 2nd reminder (RR = 1.08; 95% CI 0.84, 1.39; I2 = 77%).
Conclusions
Tracking response may negatively affect physicians' response rate. The day of mailing does not appear to affect physicians' response rate.
doi:10.1371/journal.pone.0016942
PMCID: PMC3044144  PMID: 21373197
9.  Support for and aspects of use of educational games in family medicine and internal medicine residency programs in the US: a survey 
BMC Medical Education  2010;10:26.
Background
The evidence supporting the effectiveness of educational games in graduate medical education is limited. Anecdotal reports suggest their popularity in that setting. The objective of this study was to explore the support for and the different aspects of use of educational games in family medicine and internal medicine residency programs in the United States.
Methods
We conducted a survey of family medicine and internal medicine residency program directors in the United States. The questionnaire asked the program directors whether they supported the use of educational games, their actual use of games, and the type of games being used and the purpose of that use.
Results
Of 434 responding program directors (52% response rate), 92% were in support of the use of games as an educational strategy, and 80% reported already using them in their programs. Jeopardy like games were the most frequently used games (78%). The use of games was equally popular in family medicine and internal medicine residency programs and popularity was inversely associated with more than 75% of residents in the program being International Medical Graduates. The percentage of program directors who reported using educational games as teaching tools, review tools, and evaluation tools were 62%, 47%, and 4% respectively.
Conclusions
Given a widespread use of educational games in the training of medical residents, in spite of limited evidence for efficacy, further evaluation of the best approaches to education games should be explored.
doi:10.1186/1472-6920-10-26
PMCID: PMC2851700  PMID: 20338034
10.  Curricula for teaching the content of clinical practice guidelines to family medicine and internal medicine residents in the US: a survey study 
Background
Teaching the content of clinical practice guidelines (CPGs) is important to both clinical care and graduate medical education. The objective of this study was to determine the characteristics of curricula for teaching the content of CPGs in family medicine and internal medicine residency programs in the United States.
Methods
We surveyed the directors of family medicine and internal medicine residency programs in the United States. The questionnaire included questions about the characteristics of the teaching of CPGs: goals and objectives, educational activities, evaluation, aspects of CPGs that the program teaches, the methods of making texts of CPGs available to residents, and the major barriers to teaching CPGs.
Results
Of 434 programs responding (out of 839, 52%), 14% percent reported having written goals and objectives related to teaching CPGs. The most frequently taught aspect was the content of specific CPGs (76%). The top two educational strategies used were didactic sessions (76%) and journal clubs (64%). Auditing for adherence by residents was the primary evaluation strategy (44%), although 36% of program directors conducted no evaluation. Programs made texts of CPGs available to residents most commonly in the form of paper copies (54%) while the most important barrier was time constraints on faculty (56%).
Conclusion
Residency programs teach different aspects of CPGs to varying degrees, and the majority uses educational strategies not supported by research evidence.
doi:10.1186/1748-5908-4-59
PMCID: PMC2753632  PMID: 19772570
11.  An educational game for teaching clinical practice guidelines to Internal Medicine residents: development, feasibility and acceptability 
Background
Adherence to Clinical Practice Guidelines (CPGs) remains suboptimal among internal medicine trainees. Educational games are of growing interest and have the potential to improve adherence to CPGs. The objectives of this study were to develop an educational game to teach CPGs in Internal Medicine residency programs and to evaluate its feasibility and acceptability.
Methods
We developed the Guide-O-Game© in the format of a TV game show with questions based on recommendations of CPGs. The development of the Guide-O-Game© consisted of the creation of a multimedia interactive tool, the development of recommendation-based questions, and the definition of the game's rules. We evaluated its feasibility through pilot testing and its acceptability through a qualitative process.
Results
The multimedia interactive tool uses a Macromedia Flash web application and consists of a manager interface and a user interface. The user interface allows the choice of two game styles. We created so far 16 sets of questions relating to 9 CPGs. The pilot testing proved that the game was feasible. The qualitative evaluation showed that residents considered the game to be acceptable.
Conclusion
We developed an educational game to teach CPGs to Internal Medicine residents that is both feasible and acceptable. Future work should evaluate its impact on educational outcomes.
doi:10.1186/1472-6920-8-50
PMCID: PMC2631007  PMID: 19017400
12.  The United States Physician Workforce and International Medical Graduates: Trends and Characteristics 
Background
International medical graduates (IMGs) have been a valuable resource for the United States physician workforce, and their contribution to the United States workforce is likely to increase.
Objective
To describe the historical trends and compare the characteristics of IMGs to United States medical graduates (USMGs) in the United States.
Design
Longitudinal analysis of the American Medical Association Physicians’ Professional Data (AMA-PPD) database using the 1978–2004 files and a comparative analysis of the characteristics of a random sample of 1,000 IMGs and a random sample of 1,000 USMGs using the 2004 file.
Measurements
Historical trends and characteristics of IMGs in the United States.
Results
Over the last 26 years, the number of IMGs in the United States grew by 4,873 per year reaching a total of 215,576 in 2004, about 2.4 times its size in 1978. The proportion of IMGs increased 0.12% per year, from 22.2% in 1978 to 25.6% in 2004. In 2004, compared with USMGs, IMGs were older, less likely to be board certified [Odds ratio (OR), 0.68; 95% CI, 0.53 to 0.86], less likely to work in group practice (OR, 0.60; 95% CI, 0.37 to 0.98), more likely to have Internal Medicine as practice specialty (OR, 2.10; 95% CI, 1.62 to 2.71) and more likely to be residents (OR, 1.52; 95% CI, 1.07 to 2.16).
Conclusions
Over the last quarter century, the IMGs provided a significant and steady supply for the United States physician workforce that continues to grow. Policymakers should consider the consequences for both the United States and source countries.
doi:10.1007/s11606-006-0022-2
PMCID: PMC1824721  PMID: 17356997
foreign medical graduates; health manpower; internship and residency
13.  The United States Physician Workforce and International Medical Graduates: Trends and Characteristics 
Background
International medical graduates (IMGs) have been a valuable resource for the United States physician workforce, and their contribution to the United States workforce is likely to increase.
Objective
To describe the historical trends and compare the characteristics of IMGs to United States medical graduates (USMGs) in the United States.
Design
Longitudinal analysis of the American Medical Association Physicians’ Professional Data (AMA-PPD) database using the 1978–2004 files and a comparative analysis of the characteristics of a random sample of 1,000 IMGs and a random sample of 1,000 USMGs using the 2004 file.
Measurements
Historical trends and characteristics of IMGs in the United States.
Results
Over the last 26 years, the number of IMGs in the United States grew by 4,873 per year reaching a total of 215,576 in 2004, about 2.4 times its size in 1978. The proportion of IMGs increased 0.12% per year, from 22.2% in 1978 to 25.6% in 2004. In 2004, compared with USMGs, IMGs were older, less likely to be board certified [Odds ratio (OR), 0.68; 95% CI, 0.53 to 0.86], less likely to work in group practice (OR, 0.60; 95% CI, 0.37 to 0.98), more likely to have Internal Medicine as practice specialty (OR, 2.10; 95% CI, 1.62 to 2.71) and more likely to be residents (OR, 1.52; 95% CI, 1.07 to 2.16).
Conclusions
Over the last quarter century, the IMGs provided a significant and steady supply for the United States physician workforce that continues to grow. Policymakers should consider the consequences for both the United States and source countries.
doi:10.1007/s11606-006-0022-2
PMCID: PMC1824721  PMID: 17356997
foreign medical graduates; health manpower; internship and residency

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