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Stayner C, Poole CA, McGlashan SR, Pilanthananond M, Brauning R, Markie D, Lett B, Slobbe L, Chae A, Johnstone AC, Jensen CG, McEwan JC, Dittmer K, Parker K, Wiles A, Blackburne W, Leichter A, Leask M, Pinnapureddy A, Jennings M, Horsfield JA, Walker RJ, Eccles MR. An ovine hepatorenal fibrocystic model of a Meckel-like syndrome associated with dysmorphic primary cilia and TMEM67 mutations. Sci Rep 2017; 7:1601. [PMID: 28487520 PMCID: PMC5431643 DOI: 10.1038/s41598-017-01519-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 03/29/2017] [Indexed: 01/20/2023] Open
Abstract
Meckel syndrome (MKS) is an inherited autosomal recessive hepatorenal fibrocystic syndrome, caused by mutations in TMEM67, characterized by occipital encephalocoele, renal cysts, hepatic fibrosis, and polydactyly. Here we describe an ovine model of MKS, with kidney and liver abnormalities, without polydactyly or occipital encephalocoele. Homozygous missense p.(Ile681Asn; Ile687Ser) mutations identified in ovine TMEM67 were pathogenic in zebrafish phenotype rescue assays. Meckelin protein was expressed in affected and unaffected kidney epithelial cells by immunoblotting, and in primary cilia of lamb kidney cyst epithelial cells by immunofluorescence. In contrast to primary cilia of relatively consistent length and morphology in unaffected kidney cells, those of affected cyst-lining cells displayed a range of short and extremely long cilia, as well as abnormal morphologies, such as bulbous regions along the axoneme. Putative cilia fragments were also consistently located within the cyst luminal contents. The abnormal ciliary phenotype was further confirmed in cultured interstitial fibroblasts from affected kidneys. These primary cilia dysmorphologies and length control defects were significantly greater in affected cells compared to unaffected controls. In conclusion, we describe abnormalities involving primary cilia length and morphology in the first reported example of a large animal model of MKS, in which we have identified TMEM67 mutations.
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Affiliation(s)
- C Stayner
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - C A Poole
- Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand.,150 Warren Street, Wanaka, 9305, New Zealand
| | - S R McGlashan
- Department of Anatomy and Medical Imaging, The University of Auckland 1142, Private Bag, 92019, Auckland, New Zealand
| | - M Pilanthananond
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - R Brauning
- AgResearch Invermay Agricultural Centre, Mosgiel, 9053, New Zealand
| | - D Markie
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - B Lett
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - L Slobbe
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - A Chae
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - A C Johnstone
- Institute of Veterinary, Animal and Biomedical Sciences, Massey University, Tennant Drive, Palmerston North, 4472, New Zealand
| | - C G Jensen
- Department of Anatomy and Medical Imaging, The University of Auckland 1142, Private Bag, 92019, Auckland, New Zealand
| | - J C McEwan
- AgResearch Invermay Agricultural Centre, Mosgiel, 9053, New Zealand
| | - K Dittmer
- Institute of Veterinary, Animal and Biomedical Sciences, Massey University, Tennant Drive, Palmerston North, 4472, New Zealand
| | - K Parker
- Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - A Wiles
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - W Blackburne
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - A Leichter
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - M Leask
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - A Pinnapureddy
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - M Jennings
- Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - J A Horsfield
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - R J Walker
- Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - M R Eccles
- Department of Pathology, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand.
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Warnell I, Chincholkar M, Eccles M. Predicting perioperative mortality after oesophagectomy: a systematic review of performance and methods of multivariate models. Br J Anaesth 2015; 114:32-43. [DOI: 10.1093/bja/aeu294] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Dasgupta T, Antony J, Rhodes J, McEwan M, Eccles M, Horsfield J. 172 Modulation of estrogen-dependent transcription by cohesin in MCF7 human breast adenocarcinoma cells. Eur J Cancer 2014. [DOI: 10.1016/s0959-8049(14)70298-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bussières A, Francis J, Patey A, Gagnon M, Sales A, Eccles M, Lemyre L, Godin G, Grimshaw J. 047 Identifying Factors Predictive of Managing Patients with Low Back Pain without Using X-Rays Among North American Chiropractors: Applying Psychological Theories to Evidence-Based Clinical Practice. BMJ Qual Saf 2013. [DOI: 10.1136/bmjqs-2013-002293.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wu MK, Sabbaghian N, Xu B, Addidou-Kalucki S, Bernard C, Zou D, Reeve AE, Eccles MR, Cole C, Choong CS, Charles A, Tan TY, Iglesias DM, Goodyer PR, Foulkes WD. Biallelic DICER1 mutations occur in Wilms tumours. J Pathol 2013; 230:154-64. [PMID: 23620094 DOI: 10.1002/path.4196] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 03/20/2013] [Accepted: 03/29/2013] [Indexed: 12/21/2022]
Abstract
DICER1 is an endoribonuclease central to the generation of microRNAs (miRNAs) and short interfering RNAs (siRNAs). Germline mutations in DICER1 have been associated with a pleiotropic tumour predisposition syndrome and Wilms tumour (WT) is a rare manifestation of this syndrome. Three WTs, each in a child with a deleterious germline DICER1 mutation, were screened for somatic DICER1 mutations and were found to bear specific mutations in either the RNase IIIa (n = 1) or the RNase IIIb domain (n = 2). In the two latter cases, we demonstrate that the germline and somatic DICER1 mutations were in trans, suggesting that the two-hit hypothesis of tumour formation applies for these examples of WT. Among 191 apparently sporadic WTs, we identified five different missense or deletion somatic DICER1 mutations (2.6%) in four individual WTs; one tumour had two very likely deleterious somatic mutations in trans in the RNase IIIb domain (c.5438A>G and c.5452G>A). In vitro studies of two somatic single-base substitutions (c.5429A>G and c.5438A>G) demonstrated exon 25 skipping from the transcript, a phenomenon not previously reported in DICER1. Further we show that DICER1 transcripts lacking exon 25 can be translated in vitro. This study has demonstrated that a subset of WTs exhibits two 'hits' in DICER1, suggesting that these mutations could be key events in the pathogenesis of these tumours.
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Affiliation(s)
- M K Wu
- Department of Medical Genetics, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, QC, Canada
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Poole T, Stayner C, McGlashan SR, Parker K, Wiles A, Jennings M, Jensen CG, Johnstone AC, Walker RJ, Eccles MR. Primary cilia defects in the polycystic kidneys from an ovine model of Meckel Gruber syndrome. Cilia 2012. [PMCID: PMC3555837 DOI: 10.1186/2046-2530-1-s1-p97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- T Poole
- University of Otago, New Zealand
| | | | | | - K Parker
- University of Otago, New Zealand
| | - A Wiles
- University of Otago, New Zealand
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Burger MC, Brucker DP, Baumgarten P, Ronellenfitsch MW, Wanka C, Hasselblatt M, Eccles MR, Klingebiel T, Weller M, Rieger J, Mittelbronn M, Steinbach JP. PAX2 is an antiapoptotic molecule with deregulated expression in medulloblastoma. Int J Oncol 2012; 41:235-41. [PMID: 22552444 DOI: 10.3892/ijo.2012.1446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 02/06/2012] [Indexed: 11/06/2022] Open
Abstract
PAX2 is a paired box transcription factor possessing a fundamental role in the embryogenesis of hindbrain and urinary tract. PAX genes are proto-oncogenes, PAX2 expression may contribute to the pathogenesis of renal cell carcinoma. Because of the expression of PAX2 in the developing hindbrain and its essential role in cerebellar development, it has been hypothesized that PAX2 may also be involved in medulloblastoma tumorigenesis. We investigated the expression pattern of PAX2 and various genes of the neuronal lineage in medulloblastoma and glioma cell lines. We found high expression of PAX2 mRNA and PAX2 protein in medulloblastoma cells and some glioma cell lines independent of their neuronal lineage gene expression signature. Gene suppression of PAX2 decreased the expression of the PAX2 transcriptional target GDNF in Daoy cells and had a profound cytotoxic effect in vitro on Daoy medulloblastoma and T98G glioma cells. Expression of PAX2 was then assessed in two separate medulloblastoma tissue microarrays with a total of 61 patient samples by immunohistochemistry. PAX2 expression was detected in the majority of medulloblastoma samples and correlated with less differentiated histology. Therefore, PAX2 is a biomarker for a more aggressive medulloblastoma phenotype and may represent a novel therapeutic target.
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Affiliation(s)
- M C Burger
- Dr Senckenberg Institute of Neurooncology, Goethe-University Hospital Frankfurt, Frankfurt, Germany.
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Abstract
The collocation of software development teams is common, specially in agile software development environments. However little is known about the impact of collocation on the team’s effectiveness. This paper explores the impact of collocating agile software development teams on a number of team effectiveness factors. The study focused on South African software development teams and gathered data through the use of questionnaires and interviews.
The key finding was that collocation has a positive impact on a number of team effectiveness factors which can be categorised under team composition, team support, team management and structure and team communication. Some of the negative impact collocation had on team effectiveness relate to the fact that team members perceived that less emphasis was placed on roles, that morale of the group was influenced by individuals, and that collocation was invasive, reduced level of privacy and increased frequency of interruptions. Overall through it is proposed that companies should consider collocating their agile software development teams, as collocation might leverage overall team effectiveness.
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Lock C, Wilson J, Steen N, Eccles M, Mason H, Carrie S, Clarke R, Kubba H, Raine C, Zarod A, Brittain K, Vanoli A, Bond J. North of England and Scotland Study of Tonsillectomy and Adeno-tonsillectomy in Children(NESSTAC): a pragmatic randomised controlled trial with a parallel non-randomised preference study. Health Technol Assess 2010; 14:1-164, iii-iv. [PMID: 20302811 DOI: 10.3310/hta14130] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To examine the clinical effectiveness and cost-effectiveness of tonsillectomy/adeno-tonsillectomy in children aged 4-15 years with recurrent sore throats in comparison with standard non-surgical management. DESIGN A pragmatic randomised controlled trial with economic analysis comparing surgical intervention with conventional medical treatment in children with recurrent sore throats (trial) and a parallel non-randomised cohort study (cohort study). SETTING Five secondary care otolaryngology departments located in the north of England or west of Scotland. PARTICIPANTS 268 (trial: 131 allocated to surgical management; 137 allocated to medical management) and 461 (cohort study: 387 elected to have surgical management; 74 elected to have medical management) children aged between 4 and 15 years on their last birthday with recurrent sore throats. Participants were stratified by age (4-7 years, 8-11 years, 12-15 years). INTERVENTIONS Treatment was tonsillectomy and adeno-tonsillectomy with adenoid curettage and tonsillectomy by dissection or bipolar diathermy according to surgical preference within 12 weeks of randomisation. The control was non-surgical conventional medical treatment only. MAIN OUTCOME MEASURES The primary clinical outcome was the reported number of episodes of sore throat in the 2 years after entry into the study. Secondary clinical outcomes included: the reported number of episodes of sore throat; number of sore throat-related GP consultations; reported number of symptom-free days; reported severity of sore throats; and surgical and anaesthetic morbidity. In addition to the measurement of these clinical outcomes, the impact of the treatment on costs and quality of life was assessed. RESULTS Of the 1546 children assessed for eligibility, 817 were excluded (531 not meeting inclusion criteria, 286 refused) and 729 enrolled to the trial (268) or cohort study (461). The mean (standard deviation) episode of sore throats per month was in year 1 - cohort medical 0.59 (0.44), cohort surgical 0.71 (0.50), trial medical 0.64 (0.49), trial surgical 0.50 (0.43); and in year 2 - cohort medical 0.38 (0.34), cohort surgical 0.19 (0.36), trial medical 0.33 (0.43), trial surgical 0.13 (0.21). During both years of follow-up, children randomised to surgical management were less likely to record episodes of sore throat than those randomised to medical management; the incidence rate ratios in years 1 and 2 were 0.70 [95% confidence interval (CI) 0.61 to 0.80] and 0.54 (95% CI 0.42 to 0.70) respectively. The incremental cost-effectiveness ratio was estimated as 261 pounds per sore throat avoided (95% confidence interval 161 pounds to 586 pounds). Parents were willing to pay for the successful treatment of their child's recurrent sore throat (mean 8059 pounds). The estimated incremental cost per quality-adjusted life-year (QALY) ranged from 3129 pounds to 6904 pounds per QALY gained. CONCLUSIONS Children and parents exhibited strong preferences for the surgical management of recurrent sore throats. The health of all children with recurrent sore throat improves over time, but trial participants randomised to surgical management tended to experience better outcomes than those randomised to medical management. The limitations of the study due to poor response at follow-up support the continuing careful use of 'watchful waiting' and medical management in both primary and secondary care in line with current clinical guidelines until clear-cut evidence of clinical effectiveness and cost-effectiveness is available. TRIAL REGISTRATION Current Controlled Trials ISRCTN47891548.
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Affiliation(s)
- C Lock
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Collerton J, Davies K, Jagger C, Kingston A, Eccles M, James O, Bond J, Robinson L, Von Zglinicki T, Martin-Ruiz C, Kirkwood T. Health and disease in a UK cohort of 85-year-olds: the Newcastle 85+ study. Br J Soc Med 2009. [DOI: 10.1136/jech.2009.096727t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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11
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Abstract
BACKGROUND Systematic reviews are most helpful if they are up-to-date. We did a systematic review of strategies and methods describing when and how to update systematic reviews. OBJECTIVES To identify, describe and assess strategies and methods addressing: 1) when to update systematic reviews and 2) how to update systematic reviews. SEARCH STRATEGY We searched MEDLINE (1966 to December 2005), PsycINFO, the Cochrane Methodology Register (Issue 1, 2006), and hand searched the 2005 Cochrane Colloquium proceedings. SELECTION CRITERIA We included methodology reports, updated systematic reviews, commentaries, editorials, or other short reports describing the development, use, or comparison of strategies and methods for determining the need for updating or updating systematic reviews in healthcare. DATA COLLECTION AND ANALYSIS We abstracted information from each included report using a 15-item questionnaire. The strategies and methods for updating systematic reviews were assessed and compared descriptively with respect to their usefulness, comprehensiveness, advantages, and disadvantages. MAIN RESULTS Four updating strategies, one technique, and two statistical methods were identified. Three strategies addressed steps for updating and one strategy presented a model for assessing the need to update. One technique discussed the use of the "entry date" field in bibliographic searching. Statistical methods were cumulative meta-analysis and predicting when meta-analyses are outdated. AUTHORS' CONCLUSIONS Little research has been conducted on when and how to update systematic reviews and the feasibility and efficiency of the identified approaches is uncertain. These shortcomings should be addressed in future research.
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Affiliation(s)
- D Moher
- Chalmers Research Group, Children's Hospital of Eastern Ontario, 401 Smyth Road, Room R226, Ottawa, Ontario, Canada, K1H 8L1.
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Chen YJ, Eccles M, Braithwaite A, Royds J. 335 POSTER Silencing of pax8 transcription factor reduced the viability of glioma cells. EJC Suppl 2006. [DOI: 10.1016/s1359-6349(06)70340-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Moher D, Barrowman N, Daniel R, Eccles M, Grimshaw J, Sampson M, Tricco A, Tsertsvadze A. When and how to update systematic reviews. Hippokratia 2006. [DOI: 10.1002/14651858.mr000023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Renal cell carcinoma (RCC) is the most common kidney malignancy and has a poor prognosis owing to its resistance to chemotherapy. RCC cells overexpress the transcription factor, PAX2, normally expressed in fetal kidney but downregulated at birth. Since Pax2 suppresses apoptosis during renal development, we reasoned that PAX2 may confer resistance to cisplatin-induced apoptosis in RCC. Here, we show that PAX2 confers resistance to cisplatin-induced apoptosis in normal kidney cells and fetal kidney explants. Human embryonic kidney 293 cells transfected with a PAX2 expression vector and exposed to cisplatin (40 microM) exhibited 45 +/- 15% as much caspase-3 cleavage compared to control cells. Conversely, murine collecting duct cells stably transfected with PAX2 antisense cDNA had twofold increase in cisplatin-induced apoptosis. Murine fetal (embryonic day 15) kidney explants from PAX2(1Neu)+/- mice exposed to cisplatin (25 microM x 24 h) had 50% increased apoptosis (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling staining). We then show that RCC cells (CAKI-1 (human, Caucasian, kidney, carcinoma) and ACHN (human, Caucasian, kidney, adenocarcinoma)) express PAX2 protein. PAX2-small interfering RNA (100 nM) reduces endogenous PAX2 protein (10% of baseline) and induces apoptosis (Annexin-V staining). Pax2 knockdown sensitized RCC cells to cisplatin-induced apoptosis, killing 50-60% of cisplatin-resistant ACHN and CAKI-1 cells. These findings suggest that PAX2 confers resistance to cisplatin-induced apoptosis in non-transformed kidney cells and fetal kidney explants. Similarly, Pax2 overexpression in RCC cells contributes to cisplatin resistance. Conceivably, a therapeutic strategy that inactivates Pax2 in vivo might enhance the efficacy of conventional cytotoxic drugs against RCC.
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Affiliation(s)
- P-A Hueber
- Experimental Medicine McGill University, Montreal, QC, Canada H3A 1A3
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Abstract
AIM To describe the pathology and inheritance of a congenital polycystic kidney disease (PKD) of sheep. METHODS Mode of inheritance of PKD was investigated by evaluation of results of the disorder from planned matings in two consecutive years within subsets of a flock that had a high prevalence of PKD in lambs. Gross pathological and histopathological studies were based on tissues derived from this study. Haematoxylin and eosin (H&E)-stained paraffin sections of kidney, liver, extrahepatic biliary and pancreatic ducts, pancreas and epididymis were used to describe the lesions. RESULTS Twenty-five lambs affected by PKD, of both sexes, were born, numbers in accord with those expected for an autosomal recessive disorder in the population studied. In all cases for which tissues were available, the renal, bile ductal (intrahepatic and extrahepatic), pancreatic and epididymal tissues had widespread dysplastic changes and associated cyst formation. CONCLUSIONS The findings of renal cysts in conjunction with cysts in other organs are unifying features in many of the human and animal forms of PKD and suggest a related pathogenic and genetic base consistent with an autosomal recessive disorder.
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Affiliation(s)
- A C Johnstone
- Institute of Veterinary, Animal and Biomedical Sciences, Massey University, Private Bag 11222, Palmerston North, New Zealand.
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Silverman MS, Aronson L, Eccles M, Eisenstat J, Gottesman M, Rowsell R, Ferron M, Scolnik D. Leptospirosis in febrile men ingesting Agouti paca in South America. Ann Trop Med Parasitol 2005; 98:851-9. [PMID: 15667717 DOI: 10.1179/000349804x3216] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To explore the relationship between the ingestion of Agouti paca (AP) and human leptospirosis in Guyana, 19 febrile men who said they had hunted and eaten A. paca were screened for malaria, using bloodsmears, and for leptospirosis, using an enzyme immuno-assay that detects Leptospira -specific IgM. Those found positive for anti-Leptospira IgM were then evaluated further, with a microscopical agglutination test based on a limited panel of serovars from three pathogenic species of Leptospira. Although six of the 18 patients who provided suitable samples for the serology were found seropositive for acute leptospirosis, only three of the 19 patients were found smear-positive for malaria. A clinical-decision model, based on medical histories, the results of physical examinations, and the use of routine urine dipsticks, and enabling prediction of the serological results, was developed. This model, which had 83% sensitivity and 100% specificity for leptospirosis, indicated that, in the absence of serology, most febrile patients reporting AP ingestion could be correctly treated if each was checked for malaria using traditional bloodsmears. The smear-positives should be treated with antimalarial drugs whereas the smear-negatives should be treated for leptospirosis if they had any of the following: a skin rash; lymphadenopathy; abnormal urine sediment (proteinuria or haematuria); and/or no previous history of malaria. In the present study, the relative risk of leptospirosis among the patients who were smear-negative for malaria and fulfilled at least one of these four criteria was 13 (P = 0.0007). In Guyana at least, leptospirosis appears to be common among men who hunt, prepare and ingest AP. Vaccines may be the best, practical form of protection among such men.
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Affiliation(s)
- M Eccles
- Centre for Health Services Research, School of Health Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4AA, UK.
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Littlejohns P, Eccles M, Leng G. NICE cancer guidance: a description of the institute's clinical guideline programme. Br J Cancer 2003; 89 Suppl 1:S9-S11. [PMID: 12915897 PMCID: PMC2753002 DOI: 10.1038/sj.bjc.6601078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- P Littlejohns
- National Institute for Clinical Excellence, 11 Strand, London WC2N 5HR, UK
- National Institute for Clinical Excellence, 11 Strand, London WC2N 5HR, UK. E-mail: ; http://www.nice.org.uk
| | - M Eccles
- National Institute for Clinical Excellence, 11 Strand, London WC2N 5HR, UK
| | - G Leng
- National Institute for Clinical Excellence, 11 Strand, London WC2N 5HR, UK
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Abstract
AIM To investigate whether the effect of educational reminder messages for knee and lumbar spine radiographs varied over a 12 month period. MATERIALS AND METHODS In a previous randomized, controlled trial, educational reminder messages attached to x-ray reports were shown to be effective in reducing the number of radiograph requests by general practitioners for knee and lumbar spine radiographs. In this study, all radiology departments from the previous trial were asked for monthly referral records for the 12 month intervention period for knee and lumbar spine radiographs for each general practice. Poisson regression was used to test for a change over time in the number of referrals between control and intervention practices. RESULTS Data were obtained for 66% of the general practices in the main trial. The number of referrals for both knee and lumbar spine radiographs remained consistently and statistically significantly lower in the educational reminder messages group compared with the control group (relative risk=0.65 and 0.64, respectively). There was no evidence that this difference increased or decreased throughout the 12 month period. CONCLUSIONS The effect of educational reminder messages was produced as soon as the intervention was delivered and maintained throughout the intervention period. There was no evidence of the effect of the intervention wearing off.
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Affiliation(s)
- C R Ramsay
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, UK.
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Abstract
The methods of evaluating change and improvement strategies are not well described. The design and conduct of a range of experimental and non-experimental quantitative designs are considered. Such study designs should usually be used in a context where they build on appropriate theoretical, qualitative and modelling work, particularly in the development of appropriate interventions. A range of experimental designs are discussed including single and multiple arm randomised controlled trials and the use of more complex factorial and block designs. The impact of randomisation at both group and individual levels and three non-experimental designs (uncontrolled before and after, controlled before and after, and time series analysis) are also considered. The design chosen will reflect both the needs (and resources) in any particular circumstances and also the purpose of the evaluation. The general principle underlying the choice of evaluative design is, however, simple-those conducting such evaluations should use the most robust design possible to minimise bias and maximise generalisability.
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Affiliation(s)
- M Eccles
- Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne, UK.
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Abstract
Because of the workings of health care systems, new, important, and cost-effective treatments sometimes do not become routine care while well-marketed products of equivocal value achieve widespread adoption. Should policymakers attempt to influence clinical behavior and correct for these inefficiencies? Implementation methods achieve a certain level of behavioral change but cost money to enact. These factors can be combined with the cost-effectiveness of treatments to estimate an overall policy cost-effectiveness. In general, policy cost-effectiveness is always less attractive than treatment cost-effectiveness. Consequently trying to improve the uptake of underused cost-effective care or reduce the overuse of new and expensive treatments may not always make economic sense. In this article, we present a method for calculating policy cost-effectiveness and illustrate it with examples from a recent trial, conducted during 1997 and 1998, of educational outreach by community pharmacists to influence physician prescribing in England.
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Affiliation(s)
- J Mason
- Centre for Health Services Research, University of Newcastle Upon Tyne, Newcastle Upon Tyne, England.
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Gus PI, de Souza CF, Porteous S, Eccles M, Giugliani R. Renal-coloboma syndrome in a Brazilian family. Arch Ophthalmol 2001; 119:1563-5. [PMID: 11594973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Abstract
To help patients to fully participate in shared decision making is becoming an important goal in clinical practice and one which is receiving increasing attention in terms of the requisite skills and technological development. We discuss the potential application of decision analysis-a specific technology that has been introduced into clinical practice but to date only within research contexts-and examine the usefulness and feasibility of the technique for patients, particularly in settings where clinical presentations are diverse and characterised by uncertainty.
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Affiliation(s)
- G Elwyn
- Department of General Practice, University of Wales College of Medicine, Canolfan Iechyd Llanedeyrn Health Centre, CF23 9PN, Cardiff, UK.
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Abstract
BACKGROUND Clinical guidelines, defined as 'systematically developed statements to assist both practitioner and patient decisions in specific circumstances', have become an increasingly familiar part of clinical care. Guidelines are viewed as useful tools for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. Interest in clinical guidelines is international and has its origin in issues faced by most healthcare systems: rising healthcare costs; variations in service delivery with the presumption that at least some of this variation stems from inappropriate care; the intrinsic desire of healthcare professionals to offer, and patients to receive, the best care possible. Within the UK, there is ongoing interest in the development of guidelines and a fast-developing clinical-effectiveness agenda within which guidelines figure prominently. Over the last decade, the methods of developing guidelines have steadily improved, moving from solely consensus methods to methods that take explicit account of relevant evidence. However, UK guidelines have tended to focus on issues of effectiveness and have not explicitly considered broader issues, particularly cost. This report describes the methods developed to handle benefit, harm and cost concepts in clinical guidelines. It reports a series of case studies, each describing the development of a clinical guideline; each case study illustrates different issues in incorporating these different types of evidence. HEALTH ECONOMICS AND CLINICAL GUIDELINES There has been no widely accepted successful way of incorporating economic considerations into guidelines. Unlike other areas of guideline development, there is little practical or theoretical experience to direct the incorporation of cost issues within clinical guidelines. However, the reasons for considering costs are clearly stated: "health interventions are not free, people are not infinitely rich, and the budgets of [health care] programmes are limited. For every dollar's worth of health care that is consumed, a dollar will be paid. While these payments can be laundered, disguised or hidden, they will not go away" (Eddy DM. A manual for assessing health practices and designing practice policies: the explicit approach. Philadelphia: American College of Physicians; 1992). Such opportunity costs are a universal phenomenon. In the USA it has been recommended that every set of clinical guidelines should include information on the cost implications of the alternative preventive, diagnostic, and management strategies for each clinical situation. The stated rationale was that this information would help potential users to evaluate better the potential consequences of different practices. However, it was acknowledged that "the reality is that this recommendation poses major methodological and practical challenges" (Institute of Medicine. Guidelines for clinical practice: from development to use. Washington: National Academy Press; 1992). METHODS OF DEVELOPING CLINICAL GUIDELINES A guideline development process summarises the technical information about the value of treatments in a manner that makes them accessible and ready for use in clinical practice, alongside information on contextual issues. The requirement is that the presentation of costs and benefits of treatments is methodologically sound, robust and accessible. This report includes a summary of the current best practice in evidence-based guideline development, including recent methodological advances. The manner in which cost and cost-effectiveness concepts have been successfully incorporated into the guideline process is introduced. GUIDELINE DEVELOPMENT CASE STUDIES The 'cost-effectiveness' sections of 11 guidelines are reported to illustrate both the range of methods used and the nature of the recommendations reached by the guideline development groups when considering the profile of consequences of treatments including costs. These guidelines are broadly grouped as: (1) those using qualitative evidence summary methods; (2) those using quantitative evidence summary methods and addressing relatively narrow clinical questions; (3) those using quantitative evidence summary methods and addressing a broad clinical area; (4) a guideline based upon a decision analysis model. CONCLUSIONS The focus of this project was to explore the methods of incorporating cost issues within clinical guidelines. However, the process of reviewing evidence in guideline development groups is becoming increasingly sophisticated, not only in considerations of cost but also in review techniques and group process. At the outset of the project it was unclear how narrowly or broadly the concept of 'cost' could be considered. (ABSTRACT TRUNCATED)
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Affiliation(s)
- M Eccles
- Centre for Health Services Research, University of Newcastle, Newcastle upon Tyne, UK
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Robinson A, Thomson R, Parkin D, Sudlow M, Eccles M. How patients with atrial fibrillation value different health outcomes: a standard gamble study. J Health Serv Res Policy 2001; 6:92-8. [PMID: 11357250 DOI: 10.1258/1355819011927288] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE The assessment of any health care intervention should consider both risks and benefits and take patients' preferences about these into account. The study reported in this paper aimed to elicit patient valuations of health states relevant to assessment of the prevention of stroke by warfarin anticoagulation therapy for patients with atrial fibrillation. METHODS A sample of patients over the age of 60 years with atrial fibrillation from three family practices in North-East England was interviewed. Their health state values were elicited using the standard gamble method for general practitioner (GP)-managed warfarin treatment, hospital-managed warfarin treatment, major bleed, mild stroke and severe stroke. RESULTS Of 180 patients, 69 (38%) agreed to participate, of whom 57 (83%) completed interviews. Median (mean) utility values were for GP-managed warfarin treatment 0.986 (0.948), hospital-managed warfarin treatment 0.984 (0.941), major bleed 0.880 (0.841), mild stroke 0.675 (0.641) and severe stroke 0 (0.189). There was wide variation in values between patients and the distributions were highly skewed. CONCLUSIONS The results are of value in applying decision analysis to groups of patients. They should be used with caution in reaching decisions about appropriate treatment for individual patients, but may provide a starting point for necessary further exploration of those patients' individual preferences.
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Affiliation(s)
- A Robinson
- Department of Epidemiology and Public Health, University of Newcastle upon Tyne, UK
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28
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Chen F, Collin GB, Liu KC, Beier DR, Eccles M, Nishina PM, Moshang T, Epstein JA. Characterization of the murine Lbx2 promoter, identification of the human homologue, and evaluation as a candidate for Alström syndrome. Genomics 2001; 74:219-27. [PMID: 11386758 DOI: 10.1006/geno.2001.6539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The murine Lbx2 gene is a member of the ladybird family of homeobox genes, which is expressed in the developing urogenital system, eye, and brain. Using transgenic mice, we demonstrate that 9 kb of the 5' flanking region of mouse Lbx2 is able to direct expression of a reporter gene in a tissue-specific manner recapitulating the endogenous expression pattern. This regulatory region provides a novel reagent allowing for transgenic expression in the developing urogenital ridge. In addition, we describe the identification of the human homologue, LBX2. Comparison of the human LBX2 and mouse Lbx2 sequences upstream of the coding regions reveals sequence conservation suggesting conserved regulatory regions. Both the human LBX2 and the mouse Lbx2 genes have similar genomic structures and are composed of two exons separated by an intron. We mapped the mouse Lbx2 gene to 35 cM on chromosome 6 and the human LBX2 gene to a homologous region of chromosome 2p13. This is a candidate region for several inherited disorders, including Alström syndrome, a disorder that includes ocular, urogenital, and renal abnormalities. Given the expression pattern of Lbx2, the chromosomal location in humans, and the potential function of mammalian ladybird genes, we have begun to analyze patients with ocular disorders and those with Alström syndrome for mutations in LBX2. Although polymorphisms were identified, our results indicate that mutations in the coding region of LBX2 do not account for Alström syndrome in the six kindreds analyzed.
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Affiliation(s)
- F Chen
- Cardiology Division, Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania 19104, USA
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29
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Hall L, Eccles M, Barton R, Steen N, Campbell M. Is untargeted outreach visiting in primary care effective? A pragmatic randomized controlled trial. J Public Health Med 2001; 23:109-13. [PMID: 11450926 DOI: 10.1093/pubmed/23.2.109] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND There is increasing evidence that clinical guidelines can lead to improvements in clinical care. However, they are not self-implementing. Outreach visits may improve prescribing behaviour. METHODS Within a before-and-after pragmatic randomized controlled trial, involving all general practices in one health district, routine methods were used to distribute guidelines for management of Helicobacter pylori eradication. Intervention practices were offered a visit and the conduct of an audit by a pharmacist trained in the techniques of outreach visiting. The intervention was evaluated using level three Prescribing Analysis and Cost (PACT) data for metronidazole and omeprazole for the two 12 month periods around the introduction of the guidelines. RESULTS Of the 38 intervention practices 19 accepted an outreach visit and three accepted the offer of an audit. There was a significant increase in omeprazole use during the study of 0.24 [95 per cent confidence interval (CI) +0.19 to +0.29] dose units per year but no effect from the offer [-0.02 (95 per cent CI -0.12 to +0.08) dose units] or acceptance of a visit [-0.03 (95 per cent CI -0.15 to +0.08) dose units]. The results for metronidazole were similar, with an increase in use of 0.028 (95 per cent CI +0.018 to +0.038) dose units per year. The effect of the intervention was a non-significant change in prescribing of -0.005 (95 per cent CI -0.025 to +0.015) dose units. Accepting a visit had little effect on prescribing: a change of 0.003 (95 per cent CI -0.021 to +0.027) dose units. CONCLUSIONS The routine use of untargeted outreach visiting is probably not a worthwhile strategy.
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Affiliation(s)
- L Hall
- Centre for Health Services Research, University of Newcastle upon Tyne
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30
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Eccles M, Steen N, Grimshaw J, Thomas L, McNamee P, Soutter J, Wilsdon J, Matowe L, Needham G, Gilbert F, Bond S. Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial. Lancet 2001; 357:1406-9. [PMID: 11356439 DOI: 10.1016/s0140-6736(00)04564-5] [Citation(s) in RCA: 157] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Radiological tests are often used by general practitioners (GPs). These tests can be overused and contribute little to clinical management. We aimed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists' guidelines on lumbar spine and knee radiographs. METHODS We assessed audit and feedback, and educational reminder messages in six radiology departments and 244 general practices that they served. The study was a before-and-after, pragmatic, cluster randomised controlled trial with a 232 factorial design. A random subset of GP patients' records were examined for concordance with the guidelines. The main outcome measure was number of radiograph requests per 1000 patients per year. Analysis was by intention to treat. FINDINGS The effect of educational reminder messages (ie, the change in request rate after intervention) was an absolute change of -1.53 (95% CI -2.5 to -0.57) for lumbar spine and of -1.61 (-2.6 to -0.62) for knee radiographs, both relative reductions of about 20%. The effect of audit and feedback was an absolute change of -0.07 (-1.3 to 0.9) for lumbar spine of 0.04 (-0.95 to 1.03) for knee radiograph requests, both relative reductions of about 1%. Concordance between groups did not differ significantly. INTERPRETATION 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals. Any department of radiology that handles referrals from primary care could deliver this intervention to good effect.
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Affiliation(s)
- M Eccles
- Centre for Health Services Research, University of Newcastle upon Tyne, NE2 4AA, Newcastle upon Tyne, UK.
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Abstract
The authors discuss the important and often neglected role of psychosocial factors in guideline development. Such factors can influence the process by which guideline development groups interact, make decisions and achieve consensus, which may have important implications for the validity and reliability of the recommendations they produce. Particular attention is paid to the role of social influence within multidisciplinary groups and the importance of good chairmanship. Recommendations for participants, chairmen and guideline development bodies are given.
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Affiliation(s)
- C Pagliari
- Health Services Research Unit, University of Aberdeen, UK
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32
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Abstract
This is an updated version of the first North of England Asthma Guideline (1,2) and summarizes the full guideline. (3) This paper presents all the recommendations within the guideline and, where these are new or substantially altered from the original version, it also presents a summary of the supporting evidence. The aims and methods of development (summarized in Box 1) of this guideline are unchanged from the original version, to which readers are directed for more detail. The research questions raised during the development of this guideline are shown in Box 2.
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Affiliation(s)
- M Eccles
- Centre for Health Services Research, University of Newcastle Upon Tyne, 21 Claremont Place, Newcastle Upon Tyne NE2 4AA, UK
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33
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Abstract
This is an updated version of the first North of England Stable Angina Guideline (1,2) and summarizes the full guideline. (3) This paper presents all the recommendations within the guideline; and where these are new or substantially altered from the original version, it also presents a summary of the supporting evidence. The aims and methods of development (summarized in Box 1) of this guideline are unchanged from the original version, to which readers are directed for more detail. The research questions raised during the development of this guideline are shown in Box 2.
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Affiliation(s)
- M Eccles
- Centre for Health Services Research, University of Newcastle Upon Tyne, 21 Claremont Place, Newcastle Upon Tyne NE2 4AA, UK
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van Wersch A, Eccles M. Involvement of consumers in the development of evidence based clinical guidelines: practical experiences from the North of England evidence based guideline development programme. Qual Health Care 2001; 10:10-6. [PMID: 11239138 PMCID: PMC1743421 DOI: 10.1136/qhc.10.1.10] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Consumer involvement in clinical guidelines has long been advocated although there are few empirical accounts of attempts to do so. It is therefore not surprising that there is a lack of clarity about how and when to involve consumers and what to expect from them within the process of guideline development. METHODS The North of England evidence based guideline development programme has used four different methods of consumer involvement. RESULTS When individual patients were included in a guideline development group they contributed infrequently and had problems with the use of technical language. Although they contributed most in discussions of patient education, their contributions were not subsequently acted on. In a "one off" meeting with a group of patients there were again reported problems with medical terminology and the group were most interested in sections on patient education and self management. However, their understanding of the use of scientific evidence in order to contribute to a more cost effective health care remained unclear. In a workshop it was possible to explain the technical elements of guideline development to patients who could then engage with such a process and make relevant suggestions as a consequence. However, this was relatively resource intensive. A patient advocate within a guideline development group felt confidence to speak, was used to having discussions with health professionals, and was familiar with the medical terminology. CONCLUSIONS Consumers should be involved in all stages of guideline development. While this is possible, it is not straightforward. There is no one right way to accomplish this and there is a clear need for further work on how best to achieve it.
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Affiliation(s)
- A van Wersch
- Centre for Health Services Research, School of Health Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4AA, UK
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35
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Hall L, Eccles M. Case study of an inter-professional and inter-organisational programme to adapt, implement and evaluate clinical guidelines in secondary care. Clin Perform Qual Health Care 2001; 8:72-82. [PMID: 11184054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
This paper describes the implementation of a clinical guideline across three acute Trusts. A Clinical Effectiveness Steering Group identified prevention of venous thromboembolism as a health priority. A local guideline development group adapted the recommendations of an existing review and produced a local guideline. Then, a multidisciplinary implementation group developed the practical aspects of implementing guidelines into routine daily practice. They identified appropriate staff to carry out risk assessment and to administer appropriate prophylaxis, as necessary. They also produced a "guideline pack" containing a training resource manual and implementation aids. Following this a multiple strategy implementation programme was used to introduce the guidelines, and an evaluation was carried out eight to ten months after the introduction of the guidelines. The evaluation identified a number of areas for improving current practice. Guideline implementation is a complex, time-consuming process.
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Affiliation(s)
- L Hall
- Centre for Health Services Research, University of Newcastle upon Tyne, UK
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36
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Amiel J, Audollent S, Joly D, Dureau P, Salomon R, Tellier AL, Augé J, Bouissou F, Antignac C, Gubler MC, Eccles MR, Munnich A, Vekemans M, Lyonnet S, Attié-Bitach T. PAX2 mutations in renal-coloboma syndrome: mutational hotspot and germline mosaicism. Eur J Hum Genet 2000; 8:820-6. [PMID: 11093271 DOI: 10.1038/sj.ejhg.5200539] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The renal-coloboma syndrome (RCS, MIM 120330) is an autosomal dominant disorder caused by PAX2 gene mutations. We screened the entire coding sequence of the PAX2 gene for mutations in nine patients with RCS. We found five heterozygous PAX2 gene mutations: a dinucleotide insertion (2G) at position 619 in one sporadic RCS case, a single nucleotide insertion (619 + G) in three unrelated cases, and a single nucleotide deletion in a familial case. In this familial case, three affected sibs showed a striking ocular phenotypic variability. Each of the sibs carried a 619insG mutation, whilst unaffected parents did not, suggesting the presence of germline mosaicism. Interestingly, the 619insG mutation has been previously reported in several patients and is also responsible for the Pax21Neu mouse mutant, an animal model of human RCS. This study confirms the critical role of the PAX2 gene in human renal and ocular development. In addition, it emphasises the high variability of ocular defects associated with PAX2 mutations ranging from subtle optic disc anomalies to microphthalmia. Finally, the presence of PAX2 germline mosaicism highlights the difficulties associated with genetic counselling for PAX2 mutations.
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Affiliation(s)
- J Amiel
- Département de Génétique et Unité INSERM U-393, Paris, France
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Morison IM, Eccles MR, Reeve AE. Imprinting of insulin-like growth factor 2 is modulated during hematopoiesis. Blood 2000; 96:3023-8. [PMID: 11049980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
The transcription of insulin-like growth factor 2 (IGF-2) is affected by genomic imprinting, a multistep process through which the parental origin of a gene influences its transcription. The maternal copy of IGF-2 is silenced in most human tissues, but in the choroid plexus and the adult liver both alleles of IGF-2 are expressed. This study shows that though in peripheral blood mononuclear cells IGF-2 shows paternal allele-specific expression, in total bone marrow both alleles are transcribed. This modulation of imprinting is not attributable to use of the P1 promoter, because transcription from the P3 promoter occurred from both alleles. These results suggest that transcriptional recognition of the IGF-2 imprint can be modulated during hematopoiesis and may facilitate the development of in vitro model systems to study the transcriptional recognition of a genomic imprint.
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Affiliation(s)
- I M Morison
- Cancer Genetics Laboratory, Department of Biochemistry, University of Otago, Dunedin, New Zealand.
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Abstract
PAX2 is a transcription factor belonging to the evolutionarily conserved paired box family and is required during development of the central nervous system and genitourinary axis. Mutations in the PAX2 gene cause a rare autosomal dominant renal-coloboma syndrome, characterized by optic nerve colobomas and renal hypoplasia. Recent analysis of a spontaneous PAX2 mutant mouse model (1Neu) revealed that the major cause of renal hypoplasia is reduced branching of the ureteric bud (UB) and fewer nephrons. We have observed that this abnormality is associated with a striking increase in the number of UB cells undergoing programmed cell death during nephrogenesis. To ascertain whether apoptosis is directly linked to the level of PAX2 expression, we have studied the role of PAX2 in cultured renal cells. We show that mIMCD-3 cells, a murine collecting duct cell line with high endogenous PAX2 expression, undergo apoptosis when transfected with anti-sense PAX2. In contrast, HEK293 cells expressing exogenous PAX2 are protected against apoptotic death induced by caspase-2. PAX2 has no effect on proliferation of embryonic kidney or in cultured kidney cells. Our observations imply a direct role for PAX2 in survival of ureteric bud cells.
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Affiliation(s)
- E Torban
- Department of Pediatrics and Experimental Medicine, McGill University, Montreal, Quebec, Canada
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39
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Eccles M, Mason J, Freemantle N. Developing valid cost effectiveness guidelines: a methodological report from the north of England evidence based guideline development project. Qual Health Care 2000; 9:127-32. [PMID: 11067251 PMCID: PMC1743508 DOI: 10.1136/qhc.9.2.127] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- M Eccles
- Centre for Health Services Research, University of Newcastle upon Tyne, UK.
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Elovainio M, Mäkelä M, Sinervo T, Kivimäki M, Eccles M, Kahan J. Effects of job characteristics, team climate, and attitudes towards clinical guidelines. Scand J Public Health 2000; 28:117-22. [PMID: 10954138 DOI: 10.1177/140349480002800207] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to form and test a model of the antecedents and possible moderators of the use of clinical guidelines among healthcare professionals. A postal questionnaire survey of all workers in six health centres around Finland. was carried out in April 1996. The health centres were selected to represent all different areas of Finland. A total of 748 (65.5%) of the healthcare workers completed and returned the questionnaire. Of the respondents 95% were women, 16% physicians or dentists, 31% registered nurses, and 27% practical nurses. It was hypothesized that besides positive attitudes towards guidelines, job characteristics and team climate affect the use of guidelines. Three alternative models of possible main and moderating effects of attitudes, job characteristics, and team climate were formed and tested. These models were tested using hierarchical regression analysis and structural equation modelling (LISREL8). All of the hypothesized main effects and the moderating effect of job characteristics between attitudes towards and the use of guidelines were supported. According to our results important factors behind the general positive or negative attitudes towards guidelines are the usefulness, reliability, practicality, and availability of the guidelines. Also, the overall individual, team, and organizational competence to follow the procedures recommended, seemed to be vital. Moreover, those whose job motivation potential was high were more ready to use clinical guidelines even when their attitudes towards guidelines were the same.
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Affiliation(s)
- M Elovainio
- National Research and Development Centre for Welfare and Health, Helsinki, Finland
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41
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Eccles MR, Jacobs GH. The genetics of primary vesico-ureteric reflux. Ann Acad Med Singap 2000; 29:337-45. [PMID: 10976387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Vesico-ureteric reflux (VUR), reflux of urine from the bladder into the ureter and towards the kidney, is an important cause of end-stage renal failure in both children and adults. Primary VUR is considered to be a result of a disruption of the normal anti-reflux mechanism of the ureterovesical junction (UVJ). VUR is common, occurring in approximately 1% to 2% of newborns in Caucasian populations. The aetiology of VUR is thought to involve a substantial genetic component, supported by the observation that VUR frequently occurs in multiple members of the same family. The purpose of this article is to review the literature supporting a genetic cause of VUR, and to draw together observations and make suggestions regarding differential diagnosis of VUR, which might help in future studies on the genetic aetiology of VUR. RESULTS A common theme arising was the notion that VUR may be caused by multiple genes in the population. However, any one individual with VUR may carry a single dominant mutant allele. Overall, progress has been made in mapping putative VUR loci in both humans and mice, although the mode(s) of inheritance and the exact nature of the underlying defect are still poorly understood. CONCLUSIONS It is likely that over the next few years VUR genes will be mapped and, once identified, the challenge will be to understand how changes in the expression of these genes lead to the underlying defect in VUR.
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Affiliation(s)
- M R Eccles
- Department of Biochemistry, University of Otago, New Zealand
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42
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Mason J, Freemantle N, Eccles M. Fatal toxicity associated with antidepressant use in primary care. Br J Gen Pract 2000; 50:366-70. [PMID: 10897532 PMCID: PMC1313699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND New selective serotonin reuptake inhibitors (SSRIs) are perceived to be much safer in use than older tricyclic antidepressants (TCAs). However, previous assessments of association with fatal toxicity were made too soon after the introduction of the new drugs to permit accurate estimation. AIM To determine the level of association of antidepressant drugs with fatal poisoning in the treatment of depression. METHOD National data for England and Wales for three years (1993 to 1995) for fatal poisonings associated with antidepressants were obtained and, together with national primary care data on prescribing, were used to calculate fatality association by antidepressant drug. RESULTS There were substantial variations between drugs in the level of association with fatal poisoning. Assuming an average treatment episode lasted three months, one fatality is associated with 11,800 treatment episodes of antidepressant use (95% CI = 11,120 to 12,580) when only single substance fatalities are considered. For SSRIs as a group the association was one in 411,800 (95% CI = 243,300 to 1.34 million) and for TCAs one in 8130 (95% CI = 7650 to 8670). However, for one of the newer TCAs, lofepramine, the single substance fatality rate associated with its use was one in 233,700 (95% CI = 124,500 to 1.89 million), which is not statistically significantly different from the SSRIs (P = 0.35). CONCLUSIONS Estimated death rates associated with specific antidepressants should be compared with caution because drugs may be used selectively in patients with differing severity of depression. The proportion of these fatalities that could be prevented by switching to safer antidepressants is unclear when so few deaths are recorded as accidental; when there is intent to do self-harm the potential for switching to other means is unknown. However, this approach to relative toxicity may remain the best available since it is unlikely that a randomised trial will ever be conducted with a large enough sample size to obtain experimental data. Fatalities from antidepressant poisoning are very rare but if safety is paramount then lofepramine or an SSRI are justifiable treatment choices.
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Affiliation(s)
- J Mason
- Centre for Health Economics, University of York
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43
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Abstract
BACKGROUND Cluster randomized trials increasingly are being used in health services research and in primary care, yet the majority of these trials do not account appropriately for the clustering in their analysis. OBJECTIVES We review the main implications of adopting a cluster randomized design in primary care and highlight the practical application of appropriate analytical techniques. METHODS The application of different analytical techniques is demonstrated through the use of empirical data from a primary care-based case study. CONCLUSION Inappropriate analysis of cluster trials can lead to the presentation of inaccurate results and hence potentially misleading conclusions. We have demonstrated that adjustment for clustering can be applied to real-life data and we encourage more routine adoption of appropriate analytical techniques.
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Affiliation(s)
- M K Campbell
- Health Services Research Unit, University of Aberdeen, Department of Public Health, University of Aberdeen, Aberdeen, UK
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Eccles M, Grimshaw J, Steen N, Parkin D, Purves I, McColl E, Rousseau N. The design and analysis of a randomized controlled trial to evaluate computerized decision support in primary care: the COGENT study. Fam Pract 2000; 17:180-6. [PMID: 10758083 DOI: 10.1093/fampra/17.2.180] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Eccles
- Centre for Health Services Research, University of Newcastle Upon Tyne, Newcastle Upon Tyne NE2 4AA, UK
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Abstract
BACKGROUND Clinical guidelines are needed on whether or not to use anticoagulant therapy to prevent stroke in patients with non-valvular atrial fibrillation. We did a Markov decision analysis to model decision-making with regard to warfarin treatment in patients with atrial fibrillation, and used the model to develop evaluative guidelines. METHODS The decision analysis involved a systematic literature review supplemented by patients' estimates of the quality of life associated with different states of health, secondary analysis of stroke-registry data, and estimation of service costs; it also incorporated a sensitivity analysis. The derived guidelines were subsequently applied to a cohort of patients with atrial fibrillation. FINDINGS We constructed decision tables for 12 age and sex groups. For most risk combinations, warfarin treatment would have decreased health-care costs and increased quality-of-life years, although the clinical decision was sensitive to patients' preferences and to the estimate of warfarin's effectiveness. 97% of women with atrial fibrillation older than 75 years, and 69% aged 65-74 would have been recommended for treatment; for men, the corresponding figures would have been 75% and 53%. With the upper quartile for the loss of quality of life associated with being on warfarin treatment (1.00), all but two of the 116 patients without contraindications would have been treated, whereas with the lower quartile (0.92), only 27 of 116 would have been treated. INTERPRETATION Decision analysis is useful in the incorporation of complex probabilistic data into informed decision-making, the identification of factors influencing such decisions, and the subsequent development of evaluative guidelines.
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Affiliation(s)
- R Thomson
- Department of Epidemiology and Public Health, School of Health Sciences, Newcastle Medical School, Newcastle Upon Tyne, UK.
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Abstract
The choice of study design for guideline implementation studies will determine the confidence with which the observed effects can be attributed to the interventions under study. In general, cluster randomized trials, of which there are different types, provide the most robust design. However, the use of these designs has implications for the power, conduct and analysis of studies. Wherever possible, designs allowing head-to-head comparisons, which incorporate baseline measures of performance, should be used.
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Affiliation(s)
- J Grimshaw
- Health Services Research Unit, University of Aberdeen, UK
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Porteous S, Torban E, Cho NP, Cunliffe H, Chua L, McNoe L, Ward T, Souza C, Gus P, Giugliani R, Sato T, Yun K, Favor J, Sicotte M, Goodyer P, Eccles M. Primary renal hypoplasia in humans and mice with PAX2 mutations: evidence of increased apoptosis in fetal kidneys of Pax2(1Neu) +/- mutant mice. Hum Mol Genet 2000; 9:1-11. [PMID: 10587573 DOI: 10.1093/hmg/9.1.1] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PAX2 mutations cause renal-coloboma syndrome (RCS), a rare multi-system developmental abnormality involving optic nerve colobomas and renal abnormalities. End-stage renal failure is common in RCS, but the mechanism by which PAX2 mutations lead to renal failure is unknown. PAX2 is a member of a family of developmental genes containing a highly conserved 'paired box' DNA-binding domain, and encodes a transcription factor expressed primarily during fetal development in the central nervous system, eye, ear and urogenital tract. Presently, the role of PAX2 during kidney development is poorly understood. To gain insight into the cause of renal abnormalities in patients with PAX2 mutations, kidney anomalies were analyzed in patients with RCS, including a large Brazilian kindred in whom a new PAX2 mutation was identified. In a total of 29 patients, renal hypoplasia was the most common congenital renal abnormality. To determine the direct effects of PAX2 mutations on kidney development fetal kidneys of mice carrying a Pax2 (1Neu)mutation were examined. At E15, heterozygous mutant kidneys were approximately 60% of the size of wild-type littermates, and the number of nephrons was strikingly reduced. Heterozygous 1Neu mice showed increased apoptotic cell death during fetal kidney development, but the increased apoptosis was not associated with random stochastic inactivation of Pax2 expression in mutant kidneys; Pax2 was shown to be biallelically expressed during kidney development. These findings support the notion that heterozygous mutations of PAX2 are associated with increased apoptosis and reduced branching of the ureteric bud, due to reduced PAX2 dosage during a critical window in kidney development.
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Affiliation(s)
- S Porteous
- Cancer Genetics Laboratory, Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Freemantle N, Mason J, Eccles M. Deriving treatment recommendations from evidence within randomized trials. The role and limitation of meta-analysis. Int J Technol Assess Health Care 1999; 15:304-15. [PMID: 10507190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Meta-analysis is commonly used in reviews of the effectiveness of medical technologies, but this approach has not been used in direct support of guidelines development groups. This paper describes the approach of the North of England Guidelines Development Project in describing the evidence using meta-analyses that were conducted explicitly to address questions on the choice of therapy raised by the guidelines development groups. Particular emphasis is placed on the context within which the contributing trials were conducted and the extent to which systematic differences between trials (heterogeneity) was observed, described, and explained. There is a trade-off between internal and external validity for different metrics when presenting the results of trials. More interpretable metrics, such as risk differences or weighted mean differences, are confounded by study design issues and strong assumptions. More robust measures such as odds ratios or standardized weighted mean differences are difficult to interpret physically. Individual patient data may prove particularly helpful in addressing pivotal questions on the magnitude of effects of interventions, though accessing and reanalyzing these data requires a substantial investment in time and other resources.
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Freemantle N, Eccles M, Wood J, Mason J, Nazareth I, Duggan C, Young P, Haines A, Drummond M, Russell I, Walley T. A randomized trial of Evidence-based OutReach (EBOR): rationale and design. Control Clin Trials 1999; 20:479-92. [PMID: 10503808 DOI: 10.1016/s0197-2456(99)00023-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
There is increasing interest in evaluating the methods used to implement the findings from medical research. This paper describes the Evidence-based OutReach (EBOR) trial, which is the first large randomized study in the United Kingdom that will evaluate the effectiveness and efficiency of educational outreach visits by trained pharmacists who are delivering messages derived from four evidence-based clinical practice guidelines. General practices form the unit of allocation and analysis. The study design addresses important factors that may influence the effectiveness of the intervention, such as the pharmacist who delivers the messages, the health authority in which practices are located, and the size of a practice.
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Affiliation(s)
- N Freemantle
- Centre for Health Economics, University of York, Heslington, United Kingdom.
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50
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Adès LC, Davies R, Haan EA, Holman KJ, Watson KC, Sreetharan D, Cao SN, Milewicz DM, Bateman JF, Chiodo AA, Eccles M, McNoe L, Harbord M. Aortic dissection, patent ductus arteriosus, iris hypoplasia and brachytelephalangy in a male adolescent. Clin Dysmorphol 1999; 8:269-76. [PMID: 10532176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
We describe a 14-year-old male with dissection of the descending aorta, bilateral iris hypoplasia, striae distensae and brachytelephalangy, the latter being most marked in the thumbs. Inguinal herniae and a patent ductus arteriosus were surgically repaired in infancy. The pattern of abnormalities may constitute a previously undescribed syndrome. The proband died suddenly at the age of 17 years.
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Affiliation(s)
- L C Adès
- Department of Clinical Genetics, Royal Alexandra Hospital for Children, Parramatta, New South Wales, Australia.
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