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Evidence-based medicine (EBM) has been the subject of controversy since it was introduced in 1992. However, it has yet to be critically examined as an alternative paradigm for medical education, which is how it was proposed. This commentary examines EBM on the terms on which it was originally advanced and within the context that gave rise to it, the problem-based learning (PBL) environment at McMaster University in the 1970s and 80s. The EBM educational prescription is revealed to be aligned with the information processing psychology (IPP) model of learning through acquisition of general problem solving skills that characterized the early McMaster version of PBL. The IPP model has been identified in the literature as discordant with an alternative, constructivist, model that emerged at Maastricht University in the Netherlands over the subsequent period. Strengths and weaknesses of EBM are identified from the standpoint of the underlying cognitive theories. Principles are proposed with which to guide an educationally viable approach to learning and teaching the valuable skills included within the original EBM formula.

Evidence-based practice (EBP) requires practitioners to identify and formulate questions in response to patient encounters, and to seek, select, and appraise applicable clinical research. A standardized workshop format serves as the model for training of medical educators in these skills. We developed an evaluation exercise to assess the ability to identify and solve a problem requiring the use of targeted skills and administered it to 47 North American junior faculty and residents in various specialties at the close of two short workshops in EBP. Prior to the workshop, subjects reported prior training in EBP and completed a previously validated knowledge test. Our post-workshop exercise differed from the baseline measures and required participants to spontaneously identify a suitable question in response to a simulated clinical encounter, followed by a description of a stepwise approach to answering it. They then responded to successively more explicitly prompted queries relevant to their question. We analyzed responses to identify areas of skill deficiency and potential reasons for these deficiencies. Twelve respondents (26%) initially failed to identify a suitable question in response to the clinical scenario. Ability to choose a suitable question correlated with the ability to connect an original question to an appropriate study design. Prior EBP training correlated with the pretest score but not with performance on our exercise. Overall performance correlated with ability to correctly classify their questions as pertaining to therapy, diagnosis, prognosis, or harm. We conclude that faculty and residents completing standard workshops in EBP may still lack the ability to initiate and investigate original clinical inquiries using EBP skills.

Innovative teaching techniques and more instructional time required for licensing are changing the kind of accounting instruction offered in colleges and universities. The changes also create uncertainty about accounting firms' recruitment practices, cohesion within the discipline, and the ability of colleges to meet these new imperatives. (MSE)

Liberal arts trends include: a return to core curriculum, focus on outcomes, emphasis on process over content, interest in the whole student, moral education, a new relationship with the professions in undergraduate study, and new degree forms and delivery systems. (MSE)

Issues in the question of a college or university hiring its own graduates as faculty are considered: productivity, inbreeding as a way of building specialty, occupational mobility, and overall contribution to institutional vitality. (MSE)

Study objective: US regulatory authorities mandate delivery of antibiotics within 4 hours of arrival for patients being admitted to the hospital with community-acquired pneumonia. This evidence-based emergency medicine review examines the scientific evidence pertaining to this requirement. Methods: We searched MEDLINE, EMBASE, the Cochrane Library, other databases, and bibliographies. We selected articles allowing comparison of inpatient or 30-day mortality among patients receiving early versus delayed antibiotics. We prospectively categorized studies according to whether they were retrospective or prospective and whether they adjusted for severity with the Pneumonia Severity Index. We evaluated the precision with which the interval to initiation of antibiotic therapy was defined and the compliance of retrospective studies with standard reporting criteria for chart reviews. Results: We identified 13 observational studies reporting comparative outcomes in patients receiving early versus delayed antibiotic initiation, of which 10 allowed calculation of our primary outcome. Of the 4 prospective studies, 1 allowed severity adjustment using the Pneumonia Severity Index score. Among the retrospective studies, definition of time to antibiotic therapy was frequently imprecisely defined, and compliance with standard reporting criteria for chart review was scanty in the subgroup lacking severity adjustment. Odds ratios (ORs) for mortality varied widely. One methodologically weak study reported a large benefit of early antibiotics (OR for mortality antibiotics <4 hours versus >4 hours 0.24; 95% confidence interval [CI] 0.08 to 0.71). The one study that used prospective enrollment and severity adjustment using the Pneumonia Severity Index observed a contrary result (adjusted OR for mortality, antibiotics <4 hours versus >4 hours 1.99; 95% CI 1.22 to 13.45). Results from studies reporting an 8-hour cutoff also varied in magnitude and direction of effect. Conclusion: Evidence from observational studies fails to confirm decreased mortality with early administration of antibiotics in stable patients with community-acquired pneumonia. Although timely administration of antibiotics to patients with confirmed community-acquired pneumonia should be encouraged, an inflated sense of priority of the 4-hour time frame is not justified by the evidence. [Copyright &y& Elsevier]

Knowledge translation describes any activity or process that facilitates the transfer of high-quality evidence from research into effective changes in health policy, clinical practice, or products. This increasingly important discipline attempts to conceptually combine elements of research, education, quality improvement, and electronic systems development to create a seamless linkage between interventions that improve patient care and their routine implementation in daily clinical practice. We outline the gap between research and practice and present a case study of an emergency medicine example of validated evidence that has failed to achieve widespread implementation. The authors describe a model of organization of evidence and its relationship with the process that links research from the scientific endeavor to changes in practice that affect patient outcomes. Obstacles to evidence uptake are explored, as well as the limitations of current educational strategies. Innovative strategies in realms such as computerized decision support systems designed to enhance evidence uptake are also described. The potential interface between knowledge translation and continuous quality improvement, as well as the role for bedside tools, is also presented. Research in knowledge translation includes studies that attempt to quantify and understand the discrepancies between what is known and what is done, as well as those that examine the impact and acceptability of interventions designed to narrow or close these gaps. Sentinel examples in this line of research conducted in the emergency department setting are described. [Copyright &y& Elsevier]

Study objective: The use of vasopressin in patients with cardiac arrest presenting with specific rhythms is controversial. We performed an evidence-based emergency medicine review of evidence comparing vasopressin to epinephrine in structured cardiac arrest protocols. Methods: We searched MEDLINE, EMBASE, the Cochrane Library, and other databases for randomized trials or systematic reviews comparing vasopressin to epinephrine for adults with cardiac arrest and measuring survival to hospital discharge and neurologic function in survivors. We used standard criteria to appraise the quality of published trials and systematic reviews. We used the random effects model in supplementary analyses to summarize results and to test for significant differences across subgroups of patients presenting with different arrest rhythms. Results: We found 3 high-quality well-reported randomized trials and 1 rigorous meta-analysis. The evidence does not confirm a consistent benefit of vasopressin over epinephrine in increasing survival or improving neurologic outcome in survivors. Subgroup analysis reveals a large difference in effect of vasopressin over epinephrine in cardiac arrest patients with asystole, compared to other arrest rhythms, coming from within-trial comparisons. The difference is not consistent across otherwise similar trials, is not statistically significant, may reflect the application of multiple unplanned subgroup analyses, and is not supported by a plausible biological hypothesis. Conclusion: Evidence from randomized trials does not establish a benefit of vasopressin over epinephrine in increasing survival to discharge or improving neurologic outcomes in adult patients with nontraumatic cardiac arrest. [Copyright &y& Elsevier]

Clinical experience provides clinicians with an intuitive sense of which findings on history, physical examination, and investigation are critical in making an accurate diagnosis, or an accurate assessment of a patient's fate. A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. Three steps are involved in the development and testing of a CDR: creation of the rule, testing or validating the rule, and assessing the impact of the rule on clinical behavior. Clinicians evaluating CDRs for possible clinical use should assess the following components: the method of derivation; the validation of the CDR to ensure that its repeated use leads to the same results; and its predictive power. We consider CDRs that have been validated in a new clinical setting to be level 1 CDRs and most appropriate for implementation. Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction. JAMA. 2000;284:79-84 [ABSTRACT FROM AUTHOR]

The effect of endotracheal tubes (ETTs) impregnated with chlorhexidine (CHX) and silver carbonate (antiseptic ETTs) against Staphylococcus aureus, methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacter aerogenes [organisms associated with ventilator-associated pneumonia (VAP)], was evaluated in a laboratory airway model. Antiseptic ETTs and control ETTs (unimpregnated) were inserted in culture tubes half-filled with agar media (airway model) previously contaminated at the surface with 10(8) cfu/mL of the selected test organism. After five days of incubation, bacterial colony counts on all ETT segments were determined. Swabs of proximal and distal ends of the agar tract in antiseptic and control models were subcultured. The initial and residual CHX levels, (five days post-implantation in the model) were determined. Cultures of antiseptic ETTs revealed colonization by the tested pathogens ranging from 1-100 cfu/tube, compared with approximately 10(6) cfu/tube for the control ETTs (P < 0.001). Subcultures from proximal and distal ends of the agar tract showed minimal or no growth in the antiseptic ETTs compared with the control ETTs (P < 0.001). The amount of CHX retained in the antiseptic ETTs after five days of implantation was an average of 45% of the initial level. Antiseptic ETTs prevented bacterial colonization in the airway model and also retained significant amounts of the antiseptic. These results indicate that the effectiveness of antiseptic-impregnated ETTs in preventing the growth of bacterial pathogens associated with VAP may vary with different organisms., (Copyright 2004 The Hospital Infection Society)

Introduction: Emergency departments (EDs) provide an opportunity to initiate preventive services for millions of Americans who have no other source for these services., Objectives: To identify primary and secondary preventive interventions appropriate for inclusion in routine emergency care and, secondarily, to recommend areas in which research into the efficacy and cost-effectiveness of interventions is needed., Methods: Systematic reviews were performed on 17 candidate preventive interventions with potential applicability in the ED. All but one was selected from those reviewed by the U.S. Preventive Services Task Force (USPSTF). Each two-person review team followed a template that provided a uniform approach to search strategy, selection criteria, methodology appraisal, and analysis of the results of primary studies bearing on ED cost-effectiveness. Assigned proctors provided methodological guidance to the review teams throughout the review process. A grading scheme was developed that took into account the evidence and recommendations of the USPSTF supporting primary efficacy of the intervention and the level of evidence supporting ED application identified by the Society for Academic Emergency Medicine Public Health and Education Task Force (PHTF) review teams., Results: Seventeen reviews were completed. The following interventions received an alpha rating, indicating that evidence is sufficient to support offering these services in the ED setting, assuming sufficient resources are available: alcohol screening and intervention, HIV screening and referral (in high-risk, high-prevalence populations), hypertension screening and referral, adult pneumococcal immunizations (age >/=65 years), referral of children without primary care physicians to a continuing source of care, and smoking cessation counseling. Interventions receiving a beta or gamma rating, indicating that existing research is not sufficient to recommend for or against instituting them routinely in the ED, include: identification and counseling of geriatric patients at risk of falls, Pap tests in women having a pelvic exam in the ED, counseling for smoke detector use, routine social service screening, depression screening, domestic violence screening, safe firearm storage counseling, motorcycle helmet use counseling, and youth violence counseling programs in the ED. Interventions not recommended for ED implementation (omega rating) include Pap test screening for women not having a routine pelvic exam, diabetes screening, and pediatric immunizations., Conclusions: A set of recommendations for prevention, screening, and counseling activities in the ED based on systematic reviews of selected interventions is presented. The applicability of these primary and secondary preventive services will vary with the different clinical environments and resources available in EDs. The PHTF recommendations should not be used as the basis of curtailing currently available services. This review makes clear the need for further research in this important area.