An instrument to assess the quality of clinical guidelines was developed and tested on guidelines for asthma, breast cancer, depression, and coronary heart disease. The instrument assesses the rigor of guideline development, clarity of presentation and implementation planning. It was found to have acceptable reliability and validity. Most guidelines did not achieve a majority of criteria in each assessment dimension, indicating variability and room for improvement in guideline quality. The instrument can help encourage rigorous guideline development and help users choose which guidelines to follow.
A systematic review of the challenges to implementation of the patient-centre...Paul Grundy
review the available literature to identify the major challenges and barriers to implementation and adoption of the patient-centred medical home (PCMH) model, topical in current Australian primary care reforms. documents the key challenges and barriers to implementing the PCMH model in United States family practice. It provides valuable
evidence for Australian clinicians, policymakers, and
organisations approaching adoption of PCMH elements
within reform initiatives in Australia.
A systematic review of the challenges to implementation of the patient-centre...Paul Grundy
review the available literature to identify the major challenges and barriers to implementation and adoption of the patient-centred medical home (PCMH) model, topical in current Australian primary care reforms. documents the key challenges and barriers to implementing the PCMH model in United States family practice. It provides valuable
evidence for Australian clinicians, policymakers, and
organisations approaching adoption of PCMH elements
within reform initiatives in Australia.
Abstract
To address the growing need for information on a therapeutic, besides information on safety and efficacy, and the increasing trend to extrapolate data from traditional randomized control trials (RCT’s) to influence clinical practice; an in-depth evaluation of the utility and practicability of RCT’s in influencing real-world clinical practice is evaluated. The pragmatic clinical trial (PCT) is discussed and introduced as a potentially viable means to influence clinical practice. The regulatory impact of this new adaptation is also explored. Concepts of study design, including concepts such as validity, generalizability, efficacy and effectiveness are discussed for both RCT’s and PCT’s.
Understanding applicability, also referred to as relevance, the extent to which published results are likely to reflect expected outcomes when an intervention is applied broadly across populations.
The best of clinical pathway redesign - practical examples of delivering bene...NHS Improvement
The examples here showcase just some of the innovations that have enabled thousands of patients to enjoy better health and well-being thanks to practicalservice improvements implemented on various clinical pathways
The Importance of measuring outcomes, including Patient Reported Outcome Measures (PROMS)
BAOT Lifelong Learning Event
10 November 2010
Dr Alison Laver-Fawcett
Head of Programme, BHSC(Hons) Occupational Therapy
York St John University
Evidence based nursing practice is one of most important for perfect and accurate in terms of saving a life.this presentation covers almost all aspect of EBD
Clinical Audit is a method of confirming the quality of clinical services and identify the need for improvement. A skill hospital administrator should learn and practice.
Real effectiveness medicine pursuing best effectiveness in the ordinary care ...Malmivaara Antti
These slides present a new concept of Real-Effectiveness Medicine (REM), which pursues the best effectiveness of patient care in the real-world setting. In order to reach the goal, four layers of information are needed: 1) expertise or the health care personnel, 2) use of up-to-date scientific evidence, 3) continuous documentation of performance and quality improvement, and 4) benchmarking between providers. The new framework is suggested for clinicians, organizations, policy-makers, and researchers.
OHE’s Professor Nancy Devlin has researched, written and spoken widely on the use of the EQ-5D, and related measures, both in her capacity as the Director of Research at the OHE and as Chair of the Executive Committee of the EuroQol Group.
In May, Nancy was invited to participate in the “Workshop on measuring patient-reported outcomes using the EQ-5D”, which was organised by the Swedish National Board of Health and Welfare in collaboration with the EuroQol Group. The workshop brought together policy makers and researchers in Sweden interested in measuring patients’ health outcomes.
Sweden has included the EQ-5D in some of its quality registries and in population health surveys for many years. The Swedish National Board of Health and Welfare now is exploring whether and how to extend use of patient reported outcomes measures in the health care system, including the EQ-5D, to both monitor the quality of providers and services and to facilitate health technology appraisal.
Nancy’s talk, shown below, introduced the EQ-5D instrument; discussed how data from it can be analysed; identified some of the challenges in analysis; and commented on the future of outcomes measurement.
Abstract
To address the growing need for information on a therapeutic, besides information on safety and efficacy, and the increasing trend to extrapolate data from traditional randomized control trials (RCT’s) to influence clinical practice; an in-depth evaluation of the utility and practicability of RCT’s in influencing real-world clinical practice is evaluated. The pragmatic clinical trial (PCT) is discussed and introduced as a potentially viable means to influence clinical practice. The regulatory impact of this new adaptation is also explored. Concepts of study design, including concepts such as validity, generalizability, efficacy and effectiveness are discussed for both RCT’s and PCT’s.
Understanding applicability, also referred to as relevance, the extent to which published results are likely to reflect expected outcomes when an intervention is applied broadly across populations.
The best of clinical pathway redesign - practical examples of delivering bene...NHS Improvement
The examples here showcase just some of the innovations that have enabled thousands of patients to enjoy better health and well-being thanks to practicalservice improvements implemented on various clinical pathways
The Importance of measuring outcomes, including Patient Reported Outcome Measures (PROMS)
BAOT Lifelong Learning Event
10 November 2010
Dr Alison Laver-Fawcett
Head of Programme, BHSC(Hons) Occupational Therapy
York St John University
Evidence based nursing practice is one of most important for perfect and accurate in terms of saving a life.this presentation covers almost all aspect of EBD
Clinical Audit is a method of confirming the quality of clinical services and identify the need for improvement. A skill hospital administrator should learn and practice.
Real effectiveness medicine pursuing best effectiveness in the ordinary care ...Malmivaara Antti
These slides present a new concept of Real-Effectiveness Medicine (REM), which pursues the best effectiveness of patient care in the real-world setting. In order to reach the goal, four layers of information are needed: 1) expertise or the health care personnel, 2) use of up-to-date scientific evidence, 3) continuous documentation of performance and quality improvement, and 4) benchmarking between providers. The new framework is suggested for clinicians, organizations, policy-makers, and researchers.
OHE’s Professor Nancy Devlin has researched, written and spoken widely on the use of the EQ-5D, and related measures, both in her capacity as the Director of Research at the OHE and as Chair of the Executive Committee of the EuroQol Group.
In May, Nancy was invited to participate in the “Workshop on measuring patient-reported outcomes using the EQ-5D”, which was organised by the Swedish National Board of Health and Welfare in collaboration with the EuroQol Group. The workshop brought together policy makers and researchers in Sweden interested in measuring patients’ health outcomes.
Sweden has included the EQ-5D in some of its quality registries and in population health surveys for many years. The Swedish National Board of Health and Welfare now is exploring whether and how to extend use of patient reported outcomes measures in the health care system, including the EQ-5D, to both monitor the quality of providers and services and to facilitate health technology appraisal.
Nancy’s talk, shown below, introduced the EQ-5D instrument; discussed how data from it can be analysed; identified some of the challenges in analysis; and commented on the future of outcomes measurement.
RESEARCH Open AccessA methodological review of resilience.docxverad6
RESEARCH Open Access
A methodological review of resilience
measurement scales
Gill Windle1*, Kate M Bennett2, Jane Noyes3
Abstract
Background: The evaluation of interventions and policies designed to promote resilience, and research to
understand the determinants and associations, require reliable and valid measures to ensure data quality. This
paper systematically reviews the psychometric rigour of resilience measurement scales developed for use in
general and clinical populations.
Methods: Eight electronic abstract databases and the internet were searched and reference lists of all identified
papers were hand searched. The focus was to identify peer reviewed journal articles where resilience was a key
focus and/or is assessed. Two authors independently extracted data and performed a quality assessment of the
scale psychometric properties.
Results: Nineteen resilience measures were reviewed; four of these were refinements of the original measure. All
the measures had some missing information regarding the psychometric properties. Overall, the Connor-Davidson
Resilience Scale, the Resilience Scale for Adults and the Brief Resilience Scale received the best psychometric
ratings. The conceptual and theoretical adequacy of a number of the scales was questionable.
Conclusion: We found no current ‘gold standard’ amongst 15 measures of resilience. A number of the scales are
in the early stages of development, and all require further validation work. Given increasing interest in resilience
from major international funders, key policy makers and practice, researchers are urged to report relevant validation
statistics when using the measures.
Background
International research on resilience has increased substan-
tially over the past two decades [1], following dissatisfac-
tion with ‘deficit’ models of illness and psychopathology
[2]. Resilience is now also receiving increasing interest
from policy and practice [3,4] in relation to its poten-
tial influence on health, well-being and quality of life
and how people respond to the various challenges of
the ageing process. Major international funders, such
as the Medical Research Council and the Economic
and Social Research Council in the UK [5] have identi-
fied resilience as an important factor for lifelong health
and well-being.
Resilience could be the key to explaining resistance to
risk across the lifespan and how people ‘bounce back’
and deal with various challenges presented from child-
hood to older age, such as ill-health. Evaluation of inter-
ventions and policies designed to promote resilience
require reliable and valid measures. However the com-
plexity of defining the construct of resilience has been
widely recognised [6-8] which has created considerable
challenges when developing an operational definition of
resilience.
Different approaches to measuring resilience across
studies have lead to inconsistencies relating to the nat-
ure of potential risk factors and protective processes,.
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxspoonerneddy
Chapter 7. The Evidence for Evidence-Based Practice
Implementation
Marita G. Titler
Background
Overview of Evidence-Based Practice
Evidence-based health care practices are available for a number of conditions such as asthma,
heart failure, and diabetes. However, these practices are not always implemented in care
delivery, and variation in practices abound.1–4 Traditionally, patient safety research has focused
on data analyses to identify patient safety issues and to demonstrate that a new practice will lead
to improved quality and patient safety.5 Much less research attention has been paid to how to
implement practices. Yet, only by putting into practice what is learned from research will care be
made safer.5 Implementing evidence-based safety practices are difficult and need strategies that
address the complexity of systems of care, individual practitioners, senior leadership, and—
ultimately—changing health care cultures to be evidence-based safety practice environments.5
Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.6–
9 Although during the early and mid-1900s, few nurses contributed to this foundation initiated
by Nightingale,10 the nursing profession has more recently provided major leadership for
improving care through application of research findings in practice.11
Evidence-based practice (EBP) is the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care
decisions.12–15 Best evidence includes empirical evidence from randomized controlled trials;
evidence from other scientific methods such as descriptive and qualitative research; as well as
use of information from case reports, scientific principles, and expert opinion. When enough
research evidence is available, the practice should be guided by research evidence in conjunction
with clinical expertise and patient values. In some cases, however, a sufficient research base may
not be available, and health care decisionmaking is derived principally from nonresearch
evidence sources such as expert opinion and scientific principles.16 As more research is done in a
specific area, the research evidence must be incorporated into the EBP.15
Models of Evidence-Based Practice
Multiple models of EBP are available and have been used in a variety of clinical settings.16–36
Although review of these models is beyond the scope of this chapter, common elements of these
models are selecting a practice topic (e.g., discharge instructions for individuals with heart
failure), critique and syntheses of evidence, implementation, evaluation of the impact on patient
care and provider performance, and consideration of the context/setting in which the practice is
implemented.15, 17 The learning that occurs during the process of translating research into
practice is valuable information to capture and feed back into the process, so that.
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxmccormicknadine86
Chapter 7. The Evidence for Evidence-Based Practice
Implementation
Marita G. Titler
Background
Overview of Evidence-Based Practice
Evidence-based health care practices are available for a number of conditions such as asthma,
heart failure, and diabetes. However, these practices are not always implemented in care
delivery, and variation in practices abound.1–4 Traditionally, patient safety research has focused
on data analyses to identify patient safety issues and to demonstrate that a new practice will lead
to improved quality and patient safety.5 Much less research attention has been paid to how to
implement practices. Yet, only by putting into practice what is learned from research will care be
made safer.5 Implementing evidence-based safety practices are difficult and need strategies that
address the complexity of systems of care, individual practitioners, senior leadership, and—
ultimately—changing health care cultures to be evidence-based safety practice environments.5
Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.6–
9 Although during the early and mid-1900s, few nurses contributed to this foundation initiated
by Nightingale,10 the nursing profession has more recently provided major leadership for
improving care through application of research findings in practice.11
Evidence-based practice (EBP) is the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care
decisions.12–15 Best evidence includes empirical evidence from randomized controlled trials;
evidence from other scientific methods such as descriptive and qualitative research; as well as
use of information from case reports, scientific principles, and expert opinion. When enough
research evidence is available, the practice should be guided by research evidence in conjunction
with clinical expertise and patient values. In some cases, however, a sufficient research base may
not be available, and health care decisionmaking is derived principally from nonresearch
evidence sources such as expert opinion and scientific principles.16 As more research is done in a
specific area, the research evidence must be incorporated into the EBP.15
Models of Evidence-Based Practice
Multiple models of EBP are available and have been used in a variety of clinical settings.16–36
Although review of these models is beyond the scope of this chapter, common elements of these
models are selecting a practice topic (e.g., discharge instructions for individuals with heart
failure), critique and syntheses of evidence, implementation, evaluation of the impact on patient
care and provider performance, and consideration of the context/setting in which the practice is
implemented.15, 17 The learning that occurs during the process of translating research into
practice is valuable information to capture and feed back into the process, so that ...
RESEARCH ARTICLE Open AccessDelivering an evidence-based o.docxrgladys1
RESEARCH ARTICLE Open Access
Delivering an evidence-based outdoor journey
intervention to people with stroke: Barriers and
enablers experienced by community
rehabilitation teams
Annie McCluskey1*†, Sandy Middleton2,3*†
Abstract
Background: Transferring knowledge from research into practice can be challenging, partly because the process
involves a change in attitudes, roles and behaviour by individuals and teams. Helping teams to identify then target
potential barriers may aid the knowledge transfer process. The aim of this study was to identify barriers and
enablers, as perceived by allied health professionals, to delivering an evidence-based (Level 1) outdoor journey
intervention for people with stroke.
Methods: A qualitative design and semi-structured interviews were used. Allied health professionals (n = 13) from two
community rehabilitation teams were interviewed, before and after receiving feedback from a medical record audit and
attending a training workshop. Interviews allowed participants to identify potential and actual barriers, as well as enablers to
delivering the intervention. Qualitative data were analysed using theoretical domains described by Michie and colleagues.
Results: Two barriers to delivery of the intervention were the social influence of people with stroke and their
family, and professionals’ beliefs about their capabilities. Other barriers included professionals’ knowledge and skills,
their role identity, availability of resources, whether professionals remembered to provide the intervention, and
how they felt about delivering the intervention. Enablers to delivering the intervention included a belief that they
could deliver the intervention, a willingness to expand and share professional roles, procedures that reminded
them what to do, and feeling good about helping people with stroke to participate.
Conclusions: This study represents one step in the quality improvement process. The interviews encouraged
reflection by staff. We obtained valuable data which have been used to plan behaviour change interventions
addressing identified barriers. Our methods may assist other researchers who need to design similar behaviour
change interventions.
Background
Translating Evidence into Practice
Translating evidence into practice, or implementation is
an active process involving individuals, teams and orga-
nisations [1]. Knowledge translation is an important
final step in the process of evidence-based practice. This
step is challenging and involves changes in attitude and
behaviour. Researchers cannot assume that an interven-
tion which demonstrates a positive effect and has been
described in a high impact journal will be translated in
practice [2]. Nor should researchers assume that the
majority of people with a health condition will receive
that intervention [3].
Barrier identification is an important first step in the
process of knowledge translation [4]. Failure to anticipate
problems and barriers may lead to disa.
'Demystifying Knowledge Transfer- an introduction to Implementation Science M...NEQOS
Powerpoint presentation from 'Demystifying Knowledge Transfer: an introduction to Implementation Science' - 28th May 2014.
Facilitated by Professor Jeremy Grimshaw and Dr Justin Presseau
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. F. A. Cluzeau et al.
to bring about the anticipated health outcomes when adhered contains 20 items and assesses responsibility and endorsement
to (defined as validity [10]) would be available; in reality there for the guidelines, the composition of the development group,
is a virtual absence of this type of outcome data for most identification and interpretation of evidence, the link between
guidelines. Moreover when results from carefully controlled evidence and main recommendation, peer review and up-
randomized trials of guidelines implementation strategies are dating. The second dimension, context and content, contains
available they may not necessarily be generalizable to a routine 12 items addressing the attributes of guideline reliability,
clinical setting [11]. In the absence of appropriate outcome applicability, flexibility and clarity. It assesses the aims of the
indicators on which to judge effectiveness, most assessments guidelines, the target population, circumstances for applying
of clinical quality substitute process and structural criteria the recommendations, presentation and format of the guide-
[12]. Indeed this is often the most practical way to assess lines and estimated benefits–harms and costs. The third
quality of care on a routine basis [13]. Using this approach dimension, application, contains five items addressing the
to the assessment of guidelines requires the determination of implementation, dissemination and monitoring strategies. All
whether guideline developers have been rigorous in min- three dimensions assess the adequacy of documentation.
imizing the potential biases in creating the guideline [14], in Each item inquires whether information is present and
essence, critically appraising guidelines. then requires a judgement about the quality of the information.
There is increasing published work on how to critically The specific questions demand ‘yes’, ‘no’, ‘not sure’ answers.
appraise primary research and reviews [15–17]. This work An option for ‘not applicable’ answers is available for some
has been stimulated by the Cochrane Collaboration [18]. items. To ensure that the questions were interpreted con-
However, the application of this approach to guidelines is in sistently and to minimize the need for judgement a user
its infancy. In 1992 the Institute of Medicine (IOM) started manual was designed; this contained a detailed explanation
the process by developing a provisional, if unwieldy, appraisal of the meaning of each question [23], and suggested cir-
instrument based on ‘desirable attributes’ of good guidelines cumstances where a ‘yes’ answer may be appropriate. In the
[19]. Subsequently, shorter checklists were produced in study a global assessment of the guidelines was asked for, as
Canada [20] and Australia [21] but their usefulness has never a measure of overall quality: ‘strongly recommended’ (for use
been formally assessed. in practice without modifications); ‘recommended’ (for use
In June 1993, The UK National Health Service Man- in practice on condition of some alterations or with provisos);
agement Executive organized a workshop to explore the or ‘not recommended’ (not suitable for use in practice).
issues around assessing the quality of guidelines. A research
programme was initiated to produce a generic instrument to
Selection of guidelines for appraisal
appraise guidelines. The instrument should be capable of
being applied by anyone (general or specialist clinicians, Sixty guidelines were selected from a national survey of
health care managers, and researchers) interested in assessing UK guidelines between January 1991 and January 1996 on
guidelines and should allow comparison between guidelines. coronary heart disease, asthma, breast cancer and depression
This paper describes the creation of the instrument, an (15 guidelines per disease group) [24]. The size of the
assessment of its validity and reliability, and a description of sample was based on Nunnally’s recommendation that at
the quantity and quality of UK guidelines for the management least 300 observations are needed for inter-rater test of
of coronary artery disease, depression, breast cancer and reliability [25]. We hypothesized that national guidelines
asthma. would be more systematically developed than local ones.
All 12 guidelines produced by nationally recognized or-
ganizations or commissioned by the NHS Executive were
Methods selected. Forty-eight local guidelines were drawn through
a random sample. Guideline authors were asked to provide
Appraisal instrument copies of their guidelines and information on how their
guidelines had been developed.
The purpose of the appraisal instrument is to assess the extent
to which clinical guidelines are ‘systematically developed’ Appraisers
[22], and take into account known determinants of effective
strategies for dissemination and implementation. Initially the Each guideline was assessed independently by six appraisers
reliability and face validity of the IOM instrument was tested (120 in total). Each assessed three guidelines. Each block of
on five UK guidelines with seven appraisers in a pilot study three guidelines (20 blocks altogether) was assessed by the
[7]. Based on these results potential questions for a simplified same six appraisers (Figure 1). These included a national
appraisal tool were circulated to individuals interested in expert in the disease area, a general practitioner, a public
guideline development for comments. The revised list con- health physician, a hospital consultant physician, a nurse
tained 37 items (see Appendix). These address different specializing in the disease area, and a researcher on guideline
aspects and are categorized into three conceptual dimensions methodology. They were recruited through UK cardiac units,
which could be mapped to the IOM attributes. The first asthma centres, the Royal College of General Practitioners,
dimension, rigour of development, reflects the attributes respondents to the survey, the Royal College of Nursing and
necessary to enhance guideline validity and reproducibility. It research institutions and were randomly allocated guidelines.
22
3. Guidelines appraisal methodology
Guidelines calculating Pearson’s correlation coefficients between ap-
praisers’ dimension scores and their global assessment of a
Appraisers 1 2 3
1
guideline. We predicted that dimension scores for national
2
3
guidelines would be higher than those for local guidelines.
4
5
In an attempt to investigate validity further, analysis of
6 4 5 6
7
variance (ANOVA) was used to test this hypothesis. ANOVA
8
9 was also used to examine the effect of year of publication,
10
11 disease area and level of background information on guideline
12 7 8 9
13 dimension scores. Year of publication was classified into three
14
15 categories: pre 1994, 1994–1996 and unknown. These were
16
17 chosen because a number of influential papers and re-
18 10 11 12
19 commendations had been published about the development
20
21 of guidelines in 1993 [29,30]. A zero skewness log trans-
22
23
13 14 15
formation was used in the ANOVA for dimensions one and
24
25 three because the scores were not normally distributed.
26
27 Mann–Whitney tests were used on individual appraisers’
28
29 scores to examine differences between professional groups.
30
Appraisers who omitted at least one question in a di-
mension were excluded from calculations of the ICCs and
Figure 1 Design for the assessment of coronary heart disease Pearson’s correlation coefficients for that dimension.
guidelines (design repeated for other three disease areas:
asthma, breast cancer and depression).
Results
Analysis
Background information was received for 53 guidelines. Five
In order to allow comparison of guideline performance, guidelines (three national and two local) had a background
dimension scores for each guideline were calculated. A ‘yes’ document with details of their development process. Com-
response was given a value of 1 and other responses ( ‘no’, pleted structured questionnaires were available for 46 guide-
‘not sure’ and ‘not applicable’) a value of zero. Individual lines and two authors provided information in a letter. No
appraisers’ dimension scores were calculated by summing additional information was available for seven local guidelines.
their scores for each item within a dimension. A guideline Thirty-eight guidelines had been published between 1994 and
dimension score was obtained by calculating the mean of the 1996, 14 between 1992 and 1993 and eight documents were
appraisers’ scores. This was then expressed as a percentage undated. One appraiser had been closely associated with the
of the maximum possible score for that dimension in order development of one of the guidelines and therefore assessed
to compare scores across the three dimensions. only two guidelines.
Figure 2 shows the distribution of guideline scores for
Item dimension
each dimension. Over two-thirds of guidelines scored less
We calculated Pearson’s correlation coefficients between each than 50 on dimension one, which means that less than 50%
item and dimension scores, omitting the index item, to check of criteria for rigorous development were met. The median
that each item was in the appropriate dimension [26]. for dimension one was 30.4 with a wide range of 0.8–85.
The median score was higher for dimension two (47.9).
Reliability Performance was poorest on dimension three (median 24.2).
Reliability of the instrument was assessed in two ways: The distribution for this dimension was very skewed with
first, internal consistency was measured by calculating the scores ranging from 0 to 95.
correlation between all items within a dimension to test to
what extent they measured the same underlying concept, Item dimension
using Cronbach’s coefficient [27]. Second, inter-rater agree-
Items were in the appropriate dimension as all but two
ment was measured by calculating the intra-class correlation
correlated more highly with their dimension scores than with
coefficient (ICC) for the dimension scores according to the
the other two dimensions’ scores (table of results available
criteria of Shrout and Fleiss [28]. Calculations were based on
from the authors).
the assumption that each guideline was assessed by a different
set of appraisers.
Reliability
Validity
All three dimensions had good internal consistency (Cron-
In the absence of a gold standard or a validated measure of bach’s , 0.68–0.84) and excellent inter-rater agreement (ICCs,
guideline quality, evidence of criterion validity was sought by 0.82–0.90) and narrow confidence intervals [31] (Table 1).
23
4. F. A. Cluzeau et al.
Validity
The Pearson’s correlation coefficients between appraisers’
dimension scores and their global assessment were 0.49 (n=
311) for dimension one, 0.63 (n=319) for dimension two
and 0.40 (n=315) for dimension three. All coefficients were
highly significant (P<0.0001), providing evidence of criterion
validity. However it should be noted that the appraisers made
their global assessment after completing the instrument, so
a significant correlation would be expected.
Mean standardized guideline scores are presented in Table
2. National guidelines had a significantly higher score than
local guidelines for the three dimensions (dimension one
P<0.001, dimension two P=0.0008, dimension three P=
0.04), confirming our a priori hypothesis, and hence providing
some further evidence of validity. Guidelines with a back-
ground document or a form performed significantly better
than others on dimension one (P<0.001), although numbers
were small and confidence intervals were wide.
Median scores for researchers was significantly lower than
that for the nurses in all dimensions. The median scores for
consultant physicians, general practitioners and public health
physicians were significantly higher than those of the re-
searchers for dimension two (table of results available from
the authors).
Discussion
This study has shown that it is feasible to develop an
instrument that can be used for appraising the methodological
quality of clinical guidelines. The instrument has good re-
liability and there is suggestion of validity. Assessing the
quality of any health care intervention is complex because of
the multidimensional nature of the concept [32], and guide-
lines are no exception [33]. Although the linear separation
of the creation process into development, dissemination, and
implementation provides a useful framework [3], interactions
between these stages and differing perceptions by the various
Figure 2 Frequency distribution of guidelines’ standardized participants (developer, user, patient and payer) of what are
scores by dimension. satisfactory outcomes creates a more complicated picture. It
is possible to use randomized controlled trials to assess
whether guidelines can change practice in the required dir-
ection [34,35], but observational studies can also provide
useful information on the performance of a guideline in
practice [36]. However, even this level of evaluative data is
rarely available for newly developed guidelines. Furthermore,
Table 1 Cronbach’s correlation coefficient and intraclass
researchers require reassurance that they have a ‘good enough’
correlation coefficient
guideline before embarking on a long and expensive evalu-
ation. The development of a useable, valid and reliable generic
Dimension Cronbach’s ICC (95% CI∗)
............................................................................................................ instrument to assess the rigour with which guidelines are
1. Rigour of 0.84 0.90 (0.85–0.93) created provides an essential first step in the evaluative
development process. Aside from the use of guidelines in research, potential
2. Context and content 0.78 0.82 (0.74–0.89) users of the guidelines (either for direct patient care or
3. Application 0.68 0.84 (0.77–0.90) commissioning of health care) and groups adapting guidelines
for local use, need to make systematic and reliable judgements
∗ Confidence intervals (CI) were calculated using Wald’s Method of their quality. This instrument provides a basis for these
[28]. judgements.
24
5. Guidelines appraisal methodology
Table 2 Mean standardized guidelines scores and their confidence intervals (CI) for each dimension according to type of
guideline, level of information, disease area and year of production
Dimension 1 Dimension 2 Dimension 3
.................................................... .................................................... ......................................................
Mean 95% CI Mean 95% CI Mean 95% CI
.............................................................................................................................................................................................................................
All guidelines (n=60) 34.0 29.6–38.3 46.2 41.8–50.7 29.0 22.9–35.1
Type of guideline
Local (n=48)1 29.2 25.3–33.1 42.3 37.5–47.0 26.5 19.9–33.2
National (n=12) 52.93 42.7–63.1 62.03 55.0–68.9 38.82 23.0–54.7
Level of information
Nothing (n= 7)1 12.4 3.0–21.9 40.4 19.9–60.9 14.3 −4.6–33.1
Letter (n=2) 28.8 2.3–55.2 58.3 40.7–76.0 20.6 −88.5–129.6
Form (n=46) 35.83 31.3–40.3 45.9 41.0–50.8 31.1 24.1–38.1
Document (n=5) 49.13 27.7–70.5 52.5 29.5–75.5 34.0 −2.0–70.0
Disease area
Cancer (n=15)1 33.6 25.3–42.0 48.1 40.0–56.2 29.6 16.5–42.7
Depression (n=15) 33.1 26.8–39.3 46.2 35.2–57.2 29.5 20.4–38.6
Asthma (n=15) 34.1 21.4–46.8 46.0 35.6–56.3 27.3 13.7–40.9
Coronary heart 35.1 25.3–44.9 44.5 35.2–53.8 29.6 12.8–46.4
disease (n=15)
Year of publication
Unknown (n=8)1 23.0 8.6–37.4 33.9 22.9–44.9 12.8 1.9–23.7
1994–1996 (n=38) 36.5 30.9–42.2 47.5 42.1–53.0 34.32 26.0–42.5
Pre-1994 (n=14) 33.3 25.4–41.1 49.6 38.8–60.5 24.0 12.9–35.1
1
Reference category.
2
0.001< P<0.05.
3
PΖ0.001.
To our knowledge this is the first time a study of its kind Executive in the UK to help to decide which guidelines are
has been undertaken and there are a number of method- to be recommended to the NHS (a dichotomous outcome
ological issued that need to be addressed. First, the de- for each guideline) [39]. It has formed the basis of a BIOMED-
velopment of appraisal criteria is conceptually similar to the 2 research project involving 10 European countries and
development of instruments or checklists for assessing the Canada to identify the reasons for differences in guideline
quality of randomized controlled trials [15,37]. This means recommendations across countries [40]; this will provide a
that the instrument will require regular testing and revision. further test of validity by assessing the usefulness of the
Further work on the instrument will need to be undertaken scoring system in explaining inconsistencies of guidelines
to examine issues of validity, item refinement and weighting recommendations.
of items. Second, an apparently rigorous development process In practice, a key indicator of its value will be whether
can still hide aberrant clinical recommendations. Therefore it is perceived to be useful in helping developers to address
detailed analysis and comparison of the clinical content of the issues necessary to produce good quality guidelines
guidelines is also necessary to ensure that the re- and potential users (individuals and organizations) to decide
commendations are clinically sound before they can be ad- on which guidelines to use. The progression from a
opted. For example, we will need to test the instrument qualitative to quantitative assessment of guidelines should
against guidelines that have been shown to have predictive facilitate this process. Rather than splitting guidelines into
validity, such as the Ottawa ankle rules [38]. Third, it remains good or bad, the instrument provides a numerical description
an assumption that the structural and process factors that of a guideline in three key dimensions. This allows potential
are assessed by the instrument are true determinants of valid users to relate a guideline to the whole population of
and effective guidelines. It would be reassuring if the validity guidelines and then to decide on the basis of their
of this approach itself (as opposed to the validity of the requirements. For example, a hospital wishing to introduce
instrument) could be subjected to a formal evaluation. How- a guideline for the management of asthma may want to
ever this can only happen if the instrument is widely used look at guideline X because of its rigour of development
and the performance of the guidelines as described by the but also to review guideline Y because it scores high on
instrument is compared to an external standard. This is clarity. This approach could provide a quality dimension
beginning to happen as the instrument has been translated to the databases of guidelines that are now emerging in
into Italian and French and is being used by the NHS Canada [41], America [42] and Germany [43].
25
6. F. A. Cluzeau et al.
Acknowledgements 17. Moher D, Jadad AR, Nichol G et al. Assessing the quality of
randomised controlled trials: an annotated bibliography of scales
and checklists. Controlled Clin Trials 1995; 16: 62–73.
The authors thank the guidelines authors for making their
documents available, the Royal College of General Prac- 18. Chalmers I, Haynes B. Reporting, updating, and correcting
titioners for recruiting the general practitioners, Professor systematic reviews of the effects of health care. Br Med J 1994;
Martin Bland for his helpful comments on earlier drafts, and 309: 862–865.
the appraisers. 19. Lohr KN, Field MJ. A Provisional Instrument for Assessing Clinical
Practice Guidelines. In Institute of Medicine, Field MJ, Lohr K,
eds, Guidelines: from Practice to Use. Washington DC: National
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26
7. Guidelines appraisal methodology
guidelines on patients outcomes in primary care: a systematic
review. Can Med Assoc J 1997; 156: 1705–1712. 9. If so, is (are) the method(s) for rating the evidence adequate?
36. Steinhoff MC, Abd El Khalek MK, Khallaf N et al. Effectiveness 10. Is there a description of the methods used to formulate the
of clinical guidelines for the presumptive treatment of strep- recommendations?
tococcal pharyngitis in Egyptian children. Lancet 1997; 350: 11. If so, are the methods satisfactory?
918–921.
12. Is there an indication of how the views of interested parties
37. Jadad AR, Moore RA, Carroll D et al. Assessing the quality of not on the panel were taken into account?
reports of randomized clinical trials: is blinding necessary?
Control Clin Trials 1996; 17: 1–12. 13. Is there an explicit link between the major recommendations
and the level of supporting evidence?
38. Stiell IG, Greenberg GH, McKnight RD et al. Decision rules
for the use of radiography in acute ankle injuries. Refinement and 14. Were the guidelines independently reviewed prior to pub-
prospective validation. J Am Med Assoc 1993; 269: 1127–1132. lication/release?
39. CMO Update 16. 1997: Number 8. 15. If so, is explicit information given about the methods and how
comments were addressed?
40. Littlejohns P, Cluzeau F. Promoting the rigorous development
16. Were the guidelines piloted?
of clinical guidelines in Europe through the creation of a
common appraisal instrument. Scientific Basis for Health Services, 17. If so, is explicit information given about the methods used and
Amsterdam, 1997 (abstract). the results adopted?
41. Graham I, Beardall S, Carter A, Laupacis A. The state of 18. Is there a mention of a date for reviewing or updating the
the art of practice guidelines development, dissemination, and guidelines?
evaluation in Canada. Scientific Basis for Health Services, Amsterdam,
1997. 19. Is the body responsible for the reviewing and updating clearly
identified?
42. Stephenson J. Revitalized AHCPR pursues Research on Quality.
J Am Med Assoc 1997; 278: 1557. 20. Overall, have the potential biases of guideline development
been adequately dealt with?
43. Lauterbach KW, Lubecki P, Oesingmann U et al. A concept for
a clearing procedure for guidelines in Germany (in German). Dimension two: context and content
Zeitschrift Fur Arztliche Fortbildung Und Qualitatssicherung 1997; 91:
21. Are the reasons for developing the guidelines clearly stated?
283–288.
22. Are the objectives of the guidelines clearly defined?
23. Is there a satisfactory description of the patients to which the
Appendix. Appraisal instrument guidelines are meant to apply?
Dimension one: rigour of development process 24. Is there a description of the circumstances (clinical or non-
clinical) in which exceptions might be made in using the
1. Is the agency responsible for the development of the guidelines guidelines?
clearly identified?
25. Is there an explicit statement of how the patient’s preferences
2. Was external funding or other support received for developing should be taken into account in applying the guidelines?
the guidelines?
26. Do the guidelines describe the condition to be detected, treated,
3. If external funding or support was received, is there evidence or prevented in unambiguous terms?
that the potential biases of the funding body(ies) were taken
into account? 27. Are the different possible options for the management of the
condition clearly stated in the guidelines?
4. Is there a description of the individuals (e.g. professionals,
interest groups – including patients) who were involved in the 28. Are the recommendations clearly presented?
guidelines development group?
29. Is there an adequate description of the health benefits that are
likely to be gained from the recommended management?
5. If so, did the group contain representatives of all key disciplines?
30. Is there an adequate description of the potential harms or risks
6. Is there a description of the sources of information used to that may occur as a result of the recommended management?
select the evidence on which the recommendations are based?
31. Is there an estimate of the costs or expenditures likely to incur
7. If so, are the sources of information adequate? from the recommended management?
8. Is there a description of the method(s) used to interpret and 32. Are the recommendations supported by the estimated benefits,
assess the strength of evidence? harms and costs of the intervention?
27
8. F. A. Cluzeau et al.
Dimension three: application of guidelines 36. Does the guideline document identify clear standards or targets?
33. Does the guideline document suggest possible methods for 37. Does the guideline document define measurable outcomes that
dissemination and implementation? can be monitored?
34. (National guidelines only) Does the guideline document identify
key elements which need to be considered by local guideline
groups?
35. Does the guideline document specify criteria for monitoring
compliance? Accepted for publication 28 September 1998
28