A Clinically Integrated Post-Graduate Training Programme in Evidence-Based Medicine versus ‘No Intervention’ for Improving Disability Evaluations: A Cluster Randomised Clinical Trial

Background

Although several studies have shown that teaching EBM is effective in improving knowledge, at present, there is no convincing evidence that teaching EBM also changes professional behaviour in practice. Therefore, the primary aim of this study was to evaluate the effectiveness of a clinically integrated post-graduate training programme in EBM on evidence-based disability evaluation.

Methods and Findings

In a cluster randomised controlled trial, fifty-four case-based learning groups consisting of 132 physicians and 1680 patients were randomly assigned to the intervention or control groups. A clinically integrated, post-graduate, 5-day training programme in evidence-based medicine, consisting of (home) assignments, peer teaching, interactive training in searching databases, lectures and brainstorming sessions was provided to the intervention group. The control group received no training. The primary outcome was evidence-based disability evaluation, as indicated by the frequency in use of evidence of sufficient quality in disability evaluation reports. There are no general EBM behaviour outcome measures available. Therefore, we followed general guidelines for constructing performance indicators and defined an a priori cut-off for determination of sufficient quality as recommended for evaluating EB training. Physicians trained in EBM performed more evidence-based disability evaluations compared to physicians in the control group (difference in absolute proportion 9.7%, 95% CI 3.5 to 15.9). The primary outcome differences between groups remained significant after both cluster-adjusted analysis and additional sensitivity analyses accounting for subjects lost to follow-up.

Conclusions

A EBM programme successfully improved the use of evidence in a non-hospital based medical specialty. Our findings support the general recommendations to use multiple educational methods to change physician behaviour. In addition, it appeared important that the professional context of the intervention was very supportive in the sense that searches in databases, using and applying guidelines and other forms of evidence are considered standard practice and are encouraged by colleagues and management.     

Oral but Not Intravenous Glucose Acutely Decreases Circulating Interleukin-6 Concentrations in Overweight Individuals

Background

Plasma interleukin-6 (IL-6) concentrations decrease acutely 1 h after ingestion of a glucose load or mixed meals and this may be mediated by an anti-inflammatory effect of insulin. The aim of the present study was to compare the effect of higher versus lower insulin levels on plasma IL-6 concentrations following oral compared with intravenous glucose administration in overweight/obese subjects.

Methods and Findings

Fifteen subjects (12 women and 3 men) with BMI >28 kg/m² were given an oral glucose load (75g) followed a week later by an intravenous infusion of glucose aimed at matching plasma glucose concentrations during the oral glucose load. A week later, they drank a volume of water equivalent to the volume consumed with the oral glucose load. Plasma glucose, insulin, nonesterified fatty acids, and IL-6 concentrations and blood hematocrit were measured at 30 minute intervals for 2 h following each intervention. Plasma IL-6 decreased (13–20%) significantly (P = 0.009) at 30 min to 90 min following the oral glucose load and did not change significantly following the other two interventions. The incremental area under the curve for plasma IL-6 concentrations following oral intake of glucose was significantly lower compared with concentrations following intravenous glucose (P = 0.005) and water control (P = 0.02). Circulating insulin concentrations were significantly (P<0.001) and 2.8 fold higher following oral compared with intravenous glucose administration.

Conclusions

These data show that plasma IL-6 concentrations did not decrease during isoglycemic, intravenous glucose administration suggesting that the markedly higher circulating insulin levels and/or gut-related factors may mediate the acute decrease in plasma IL-6 after oral glucose intake in overweight/obese subjects.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12612000491864     

Low Hepcidin Levels in Severely Anemic Malawian Children with High Incidence of Infectious Diseases and Bone Marrow Iron Deficiency

Introduction

A reliable diagnostic biomarker of iron status is required for severely anemic children living in malarious areas because presumptive treatment with iron may increase their infection risk if they are not iron deficient. Current biomarkers are limited because they are altered by host inflammation. In this study hepcidin concentrations were assessed in severely anemic children living in a highly malarious area of Malawi and evaluated against bone marrow iron in order to determine the usefulness of hepcidin as a point of care test.

Methods

207 severely anemic children were assessed for levels of hepcidin, ferritin, serum transferrin receptor, erythropoietin, hematological indices, C-reactive protein, interleukin-6, malaria parasites and HIV infection. Deficiency of bone marrow iron stores was graded and erythroblast iron incorporation estimated. Interaction of covariates was assessed by structural-equation-modeling.

Results and Conclusion

Hepcidin was a poor predictor of bone marrow iron deficiency (sensitivity 66.7%; specificity 48.5%), and of iron incorporation (sensitivity 54.2%; specificity 61.8%), and therefore would have limitations as a point of care test in this category of children. As upregulation of hepcidin by inflammation and iron status was blunted by erythropoietin in this population, enhanced iron absorption through the low hepcidin values may increase infection risk. Current recommendations to treat all severely anemic children living in malarious areas with iron should therefore be reconsidered.     

First genetic evidence that invasive bullhead (Cottus L. 1758) in Scotland is of English origin and the difficulty of resolving the European Cottus species taxonomy

The European bullhead (Cottus gobio) is widely distributed across Europe, and within the UK is native to England and Wales, where it is protected under the Habitats Directive. In Scotland, however, the species is considered invasive and thriving populations are recorded in the Forth and Clyde river catchments, and the Ale Water in the Scottish Borders. The genetic identity of the Scottish populations has not been established. There is also debate about the status of the European bullhead and its validity as single species, a species complex with several unresolved species, or distinct different species in its European distribution range. There is therefore a need to determine the taxonomy and likely source of the novel Scottish populations. Genetic analyses using cytochrome oxidase 1 (COI) mitochondrial DNA sequences were undertaken on specimens from the Forth and Clyde catchments, and combined with the results of morphological characteristics to provide a comprehensive assessment of the taxonomic classification for Scottish bullheads. There was considerable variation in morphological characteristics between populations within Scotland and a wider range of variability than previously recorded for English populations. Genetically the Scottish populations were very closely related to English specimens, supporting the hypothesis of introduction directly from England to Scotland. In terms of broader relationships, Scottish specimens are genetically more closely related to the ostensible species Chabot fluviatile Cottus perifretum, which has been suggested as one of a complex of species across Europe. Morphologically they exhibit characteristics on the spectrum between C. perifretum and C. gobio. There is an urgent need for the clarification of the taxonomy of Cottus sp(p). to avoid confusion in future publications, legislation and management practices relating to bullheads throughout the UK and Europe.     

Quantifying the recent expansion of native invasive rush species in a UK upland environment

Rushes, such as soft rush (Juncus effusus L.), hard rush (Juncus inflexus L.), and compact rush (Juncus conglomeratus L.) have become problem species within upland grasslands across the United Kingdom and the coastal grasslands of western Norway. Indeed, being largely unpalatable to livestock and having a vigorous reproductive ecology means that they can rapidly come to dominate swards. However, rush dominance results in a reduction in grassland biodiversity and farm productivity. Anecdotal evidence from the United Kingdom suggests that rush cover within marginal upland grasslands has increased considerably in recent decades. Yet, there is currently no published evidence to support this observation. Here, we use recent and historical Google Earth imagery to measure changes in rush frequency over a 13-year period within four survey years: 2005, 2009, 2015, and 2018. During each survey year, we quantified rush presence or absence using a series of quadrats located within 300 upland grassland plots in the West Pennine Moors, United Kingdom. Data were analysed in two stages, first, by calculating mean rush frequencies per sample year using all the available plot-year combinations (the full dataset), and second by examining differences in rush frequency using only the plots for which rush frequency data were available in every sample year (the continuous dataset). The full dataset indicated that rush frequency has increased by 82% between 2005 and 2018. Similarly, the continuous dataset suggested that rush frequency has increased by 174% over the same period, with the increases in frequency being statistically significant (p < .05) between 2005–2018 and 2009–2018. We discuss the potential drivers of rush expansion in the West Pennine Moors, the ecological and agronomic implications of grassland rush infestations, and priorities for future research.     

Spatio-temporal history of the disjunct family Tecophilaeaceae: a tale involving the colonization of three Mediterranean-type ecosystems

Background and Aims

Tecophilaeaceae (27 species distributed in eight genera) have a disjunct distribution in California, Chile and southern and tropical mainland Africa. Moreover, although the family mainly occurs in arid ecosystems, it has colonized three Mediterranean-type ecosystems. In this study, the spatio-temporal history of the family is examined using DNA sequence data from six plastid regions.

Methods

Modern methods in divergence time estimation (BEAST), diversification (LTT and GeoSSE) and biogeography (LAGRANGE) are applied to infer the evolutionary history of Tecophilaeaceae. To take into account dating and phylogenetic uncertainty, the biogeographical inferences were run over a set of dated Bayesian trees and the analyses were constrained according to palaeogeographical evidence.

Key Results

The analyses showed that the current distribution and diversification of the family were influenced primarily by the break up of Gondwana, separating the family into two main clades, and the establishment of a Mediterranean climate in Chile, coinciding with the radiation of Conanthera. Finally, unlike many other groups, no shifts in diversification rates were observed associated with the dispersals in the Cape region of South Africa.

Conclusions

Although modest in size, Tecophilaeaceae have a complex spatio-temporal history. The family is now most diverse in arid ecosystems in southern Africa, but is expected to have originated in sub-tropical Africa. It has subsequently colonized Mediterranean-type ecosystems in both the Northern and Southern Hemispheres, but well before the onset of the Mediterranean climate in these regions. Only one lineage, genus Conanthera, has apparently diversified to any extent under the impetus of a Mediterranean climate.     

Book review

Oral Biofilms and Plaque Control. Edited by H J Busscher and L V Evans. Harwood Academic Publishers, The Netherlands, 1998; 348 pp, US$ 125.00; £80.00; ISBN 90–5702–391–1     

Age differences in tactile pattern recognition at the fingertip

Young (21–26 years, n?=?20) and old (55–86 years, n?=?25) participants were tested for their ability to recognize raised letters (6-mm high, 1-mm relief) by touch. Spatial resolution thresholds were also measured with grating domes to derive an index of the degree of afferent innervation at the fingertip. Letter recognition in the young group was very consistent and highly accurate (mean, 86% correct), contrasting with the performance of the old group, which was more variable and comparatively low in accuracy (mean, 53% correct). In both groups, spatial resolution thresholds accounted for a substantial portion of the variance in the performance, suggesting a strong link between age-dependent variations in tactile innervation and recognition accuracy. The patterns of errors in the old group showed that an inability to encode internal elements specific to certain letters was at the source of most confusion among letters. Whether this inability reflected only deficient peripheral encoding mechanisms or some other alterations at the central level is discussed.