Twenty-five years of progress: Twenty-five more?

This address outlines important steps for ensuring the future of biofeedback and applied psychophysiology. These steps are contained in the acronym PHUTRE, wherein PH stands for Political activism of the Hard and fast variety, U represents United front, T encompasses Transfer of knowledge (from clinician to researcher, researcher to clinician, and from both to students in training), R refers to our Research base, and E represents the Excitement that our field has the potential to generate.This paper is based on the Presidential Address delivered at the annual meeting of AAPB, Atlanta, Georgia, March, 1994. Please address correspondence to Frank Andrasik, Ph.D., Center for Behavioral Medicine, The University of West Florida, 11000 University Parkway, Pensacola, Florida 32514.     

The retreat of the less fit allele in a population-controlled model for population genetics

It is shown that the solutions of a single-locus diploid model with population control for the spatial and temporal interaction of the three genotypes approach a constant-density equilibrium in which only the more fit allele is present, provided the density dependent birth rate and fitnesses have certain properties. The speed at which this phenomenon spreads is at least as great as that of the linearization of the corresponding Fisher equation. A larger upper bound for this speed is also obtained.     

One hundred years ago: Presents from patient

ObjectiveTo compare rates of upper gastrointestinal haemorrhage among elderly patients given selective cyclo-oxygenase-2 (COX 2) inhibitors and non-selective non-steroidal anti-inflammatory drugs (NSAIDs).DesignObservational cohort study.SettingAdministrative data from Ontario, Canada, used from 17 April 2000 to 31 March 2001 to identify population based, NSAID-naive cohorts of patients.PatientsSubjects aged ⩾66 years who started taking non-selective NSAIDs (n=5391), diclofenac plus misoprostol (n=5087), rofecoxib (n=14 583), or celecoxib (n=18 908) and a randomly selected control cohort not exposed to NSAIDs (n=100 000).ResultsRelative to controls, the multivariate model revealed an increased short term risk of upper gastrointestinal haemorrhage for users of non-selective NSAIDs (adjusted rate ratio 4.0 (95% confidence intervals 2.3 to 6.9)), diclofenac plus misoprostol (3.0 (1.7 to 5.6)), and rofecoxib (1.9 (1.3 to 2.8)) but not celecoxib (1.0 (0.7 to 1.6)). Relative to celecoxib, significantly higher risks of upper gastrointestinal haemorrhage were observed for non-selective NSAIDs (4.4 (2.3 to 8.5)), diclofenac plus misoprostol (3.2 (1.6 to 6.5)), and rofecoxib (1.9 (1.2 to 2.8)). Relative to rofecoxib, non-selective NSAID users were at significantly higher risk of upper gastrointestinal haemorrhage (1.9 (1.0 to 3.5)).ConclusionsThis population based observational study found a lower short term risk of upper gastrointestinal haemorrhage for selective COX-2 inhibitors compared with non-selective NSAIDs.

What is already known on this topic

Long term NSAID use is associated with the development of peptic and duodenal ulcersSelective COX 2 inhibitors are claimed to cause fewer gastrointestinal problems than conventional, non-selective NSAIDsIt is unclear to what degree COX 2 inhibitors increase gastrointestinal risk relative to not using NSAIDs, and the relative gastrointestinal safety of the different COX 2 inhibitors is uncertain

What this study adds

The risk of upper gastrointestinal haemorrhage with the COX 2 inhibitors rofecoxib and celecoxib was significantly lower than with conventional NSAIDs, but the risk with rofecoxib was significantly higher than that with celecoxibThe risk of gastrointestinal haemorrhage with celecoxib was similar to that in controls not using NSAIDs     

One hundred years ago : Fashion and medicine

Objective: To determine which attributes of clinical practice guidelines influence the use of guidelines in decision making in clinical practice. Design: Observational study relating the use of 47 different recommendations from 10 national clinical guidelines to 12 different attributes of clinical guidelines—for example, evidence based, controversial, concrete. Setting: General practice in the Netherlands. Subjects: 61 general practitioners who made 12 880 decisions in their contacts with patients. Main outcome measures: Compliance of decisions with clinical guidelines according to the attribute of the guideline. Results: Recommendations were followed in, on average, 61% (7915/12 880) of the decisions. Controversial recommendations were followed in 35% (886/2497) of decisions and non-controversial recommendations in 68% (7029/10 383) of decisions. Vague and non-specific recommendations were followed in 36% (826/2280) of decisions and clear recommendations in 67% (7089/10 600) of decisions. Recommendations that demanded a change in existing practice routines were followed in 44% (1278/2912) of decisions and those that did not in 67% (6637/9968) of decisions. Evidence based recommendations were used more than recommendations for practice that were not based on research evidence (71% (2745/3841) v 57% (5170/9039)). Conclusions: People and organisations setting evidence based clinical practice guidelines should take into account some of the other important attributes of effective recommendations for clinical practice.

Key messages

• Specific attributes of clinical practice guidelines determine whether they are used in practice
• Evidence based recommendations are better followed in practice than recommendations not based on scientific evidence
• Precise definitions of recommended performance improve the use of guidelines
• Testing the feasibility and acceptance of clinical guidelines among the target group is important for effective implementation
• People setting evidence based guidelines need to understand the attributes of effective guidelines