Do clinicians want recommendations? A multicenter study comparing evidence summaries with and without GRADE recommendations.

OBJECTIVES: Evidence-based clinical practice guidelines provide recommendations to assist clinicians in decision-making and to reduce the gap between best current research evidence and clinical practice. However, some argue that providing preappraised evidence summaries alone, rather than recommendations, is more appropriate. The objective of the study is to evaluate clinicians' preferences, and understanding of the evidence and intended course of action in response to evidence summaries with and without recommendations. STUDY DESIGN SETTING: We included practicing clinicians attending educational sessions across 10 countries. Clinicians were randomized to receive relevant clinical scenarios supported by research evidence of low or very low certainty and accompanied by either strong or weak recommendations developed with the GRADE system. Within each group, participants were further randomized to receive the recommendation plus the corresponding evidence summary or the evidence summary alone. We evaluated participants' preferences and understanding for the presentation strategy, as well as their intended course of action. RESULTS: One hundred eighty-nine of 219 (86%) and 201 of 248 (81%) participants preferred having recommendations accompanying evidence summaries for both strong and weak recommendations, respectively. Across all scenarios, less than half of participants correctly interpreted information provided in the evidences summaries (e.g., estimates of effect, certainty in the research evidence). The presence of a recommendation resulted in a more appropriate intended course of action for two scenarios involving strong recommendations. CONCLUSION: Evidence summaries alone are not enough to impact clinicians' course of action. Clinicians clearly prefer having recommendations accompanying evidence summaries in the context of low or very low certainty of evidence (Trial registration NCT02006017).

Effect of Lowering the Dialysate Temperature in Chronic Hemodialysis: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Lowering the dialysate temperature may improve outcomes for patients undergoing chronic hemodialysis. We reviewed the reported benefits and harms of lower temperature dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We searched the Cochrane Central Register, OVID MEDLINE, EMBASE, and Pubmed until April 15, 2015. We reviewed the reference lists of relevant reviews, registered trials, and relevant conference proceedings. We included all randomized, controlled trials that evaluated the effect of reduced temperature dialysis versus standard temperature dialysis in adult patients receiving chronic hemodialysis. We followed the Grading of Recommendations Assessment, Development and Evaluation approach to assess confidence in the estimates of effect (i.e., the quality of evidence). We conducted meta-analyses using random effects models. RESULTS: Twenty-six trials were included, consisting of a total of 484 patients. Compared with standard temperature dialysis, reduced temperature dialysis significantly reduced the rate of intradialytic hypotension by 70% (95% confidence interval, 49% to 89%) and significantly increased intradialytic mean arterial pressure by 12 mmHg (95% confidence interval, 8 to 16 mmHg). Symptoms of discomfort occurred 2.95 (95% confidence interval, 0.88 to 9.82) times more often with reduced temperature compared with standard temperature dialysis. The effect on dialysis adequacy was not significantly different, with a Kt/V mean difference of -0.05 (95% confidence interval, -0.09 to 0.01). Small sample sizes, loss to follow-up, and a lack of appropriate blinding in some trials reduced confidence in the estimates of effect. None of the trials reported long-term outcomes. CONCLUSIONS: In patients receiving chronic hemodialysis, reduced temperature dialysis may reduce the rate of intradialytic hypotension and increase intradialytic mean arterial pressure. High-quality, large, multicenter, randomized trials are needed to determine whether reduced temperature dialysis affects patient mortality and major adverse cardiovascular events.

Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer: a systematic review.

BACKGROUND: The authors compared the relative efficacy and safety of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) for the initial treatment of venous thromboembolism (VTE) between patients with and without cancer. METHODS: By using Cochrane methodology for systematic reviews, separate meta-analyses were conducted for subgroups of patients with and without cancer, and relative risks (RRs) were compared for statistical significance. The methodologic quality for each outcome was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS: LMWH reduced mortality significantly compared with UFH in patients with cancer (RR of 0.71; 95% confidence interval [95% CI], 0.52-0.98 [moderate-quality evidence]) but not in patients without cancer (RR of 0.97; 95% CI, 0.65-1.46 [low-quality evidence]). However, the difference in the RR for the 2 subgroups did not reach statistical significance (P = .113). The difference between LMWH and UFH in the effect on recurrent VTE was not statistically significant in the subgroup with cancer (RR of 0.78; 95% CI, 0.29-2.08 [low-quality evidence]), in the subgroup without cancer (RR of 0.94; 95% CI, 0.60-1.46 [low-quality evidence]), or between the 2 subgroups (P = .367). No data were available for bleeding outcomes, thrombocytopenia, or postphlebitic syndrome. CONCLUSIONS: The current results indicated that LMWH most likely is superior to UFH in reducing mortality in the initial treatment of VTE for patients with cancer. There is a need for more and better designed trials to confirm these findings.

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.

Gemcitabine and acute myocardial infarction--a case report.

The objective of this paper is to report a case of acute, non-q-wave myocardial infarction, presumably secondary to gemcitabine chemotherapy for nonsmall cell lung cancer. A 43-year-old woman with postpartum cardiomyopathy and ischemic heart disease was treated with gemcitabine for metastatic nonsmall cell lung cancer. Three days after her 5th treatment with gemcitabine, she developed chest pain and was diagnosed as having acute, non-q-wave myocardial infarction. She made an uneventful recovery. An objective causality assessment revealed that the adverse event was possible. Gemcitabine has been previously reported to be causative of acute myocardial infarction. Ischemic complications of chemotherapeutic agents are discussed. A review of literature on this subject is presented. Gemcitabine should be administered with caution in patients with underlying cardiac disease.