St. René: the patron saint of anaesthetists and a patron saint of canada

René Goupil, the Patron Saint of Anaesthetists, and a Patron Saint of Canada, was born in Angers, France in 1608 and studied surgery. He joined the Jesuits as a donné or volunteer worker in 1640 and served in the then tiny colony of Quebec as one of the first medical workers of Canada. After earning meritorious praise for his skills, he again volunteered to attend the Hurons at Sainte Marie, a mission far beyond the frontiers. René’s canoe party was ambushed. He was captured by the Mohawks and endured eight weeks of cruel torture before being killed on September 29, 1642. René was the first of eight North American martyrs whose dedication was recognized by canonization in 1930. St. René was appointed Patron Saint of Anaesthetists in 1951. Rod K. Calverley, M.D., F.R.C.P.(C), Associate Clinical Professor, Department of Anaesthesiology, University of California, San Diego. Address reprint requests to: Rod K. Calverley, M.D., Department of Anaesthesia, VA Medical Center, 3360 La Jolla Village Drive, San Diego, California 92161, U.S.A.     

Industry and evidence-based medicine: Believable or conflicted? A systematic review of the surgical literature

Background

Over the last few decades medical research and development has come to depend more heavily on the financial support of industry. However, there is concern that financial relations between the medical community and medical industry could unduly influence medical research and therefore patient care. Our objective was to determine whether conflict of interest owing to authors’/investigators’ financial affiliation with industry associated with their academic research has been identified in the surgical literature. In particular, we sought to answer the following questions: What is the extent of such conflict of interest? Does conflict of interest bias the results of academic surgical research in favour of industry? What are the potential causes of this proindustry bias?

Methods

We conducted a systematic review of the literature in May 2008 using the OVID SP search engine of MEDLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, DARE and Health Technology Assessment. Quantitative studies that included a methods section and reported on conflict of interest as a result of industry funding in surgery-related research specifically were included in our analysis.

Results

The search identified 190 studies that met our criteria. Author/investigator conflict of interest owing to financial affiliation with industry associated with their academic research is well documented in the surgical literature. Six studies demonstrated that authors with such conflicts of interest were significantly more likely to report a positive outcome than authors without industry funding, which demonstrates a proindustry bias. Two studies found that the proindustry bias could not be explained by variations in study quality or sample size.

Conclusion

The conflict of interest that exists when surgical research is sponsored by industry is a genuine concern.     

Stage classification and prognosis: an intersection of medicine, quantum physics and religion?

Estimating prognosis is an important part of caring for patients with cancer. However, predicting prognosis is complicated and depends on many factors. Simply amassing more data alone is not the answer; we have to learn to intellectually manage the inherent complexity and uncertainty if we are to make progress.     

Critical care and perioperative medicine. How goes the flow?

The specialty of anesthesiology is at a crossroad. Do anesthesiologists stay in the illusionary safe harbor of the operating room and allow critical care anesthesiologists to float alone? How can in-fighting with other medical and nonmedical providers be avoided, while maintaining or expanding the historic and hopefully future roles of anesthesiologists as hospital-based physicians? A different tact is required to redefine the scope of the practice with broadened training to provide increased expertise in the evolving medical marketplace. This approach would include solid training in business, informatics, data management, and critical thinking on outcomes. This paradigm shift may be challenging, and requires redirection, reallocation of assets, re-education, and a new mindset. If successfully applied, however, it presents a means to strengthen the respected position of the specialty and to promote the medical care and practice of perioperative specialists in the rapidly changing landscape of modern medicine. Regarding the question of turf and ownership of the ICU, the authors suggest pursuing the higher ground of an excellent scope of practice, which facilitates the care and activities of surgical and primary care colleagues. These colleagues, administrators, and governmental agencies will have to be re-educated to support training and provide equitable remuneration. Appropriately trained anesthesiologist-intensivists can complement many other care providers, while providing a wide range of services with an economy of care, whether in a semiclosed or closed ICU setting.     

Evidence-based medicine and the management of the chronic wound: is it enough?

Evidence-based medicine has become ubiquitous in modern-day medicine, including wound care. However, the application of evidence-based medicine into the arena of chronic wounds has not been uniformly performed and measured. Most wound care studies are plagued by inconsistencies in inclusion criteria, data measurements, and endpoint reporting. Furthermore, the small sample sizes prohibit drawing effective conclusions. However, that does not imply that the current guidelines of treatment are substandard. Instead, one must rely more heavily on current evidence and experts in the field until larger, more consistent studies can establish good practice patterns.     

Perceptions and competence in evidence-based medicine: Are surgeons getting better? A questionnaire survey of members of the Dutch Orthopaedic Association

BACKGROUND: The Journal of Bone and Joint Surgery, American Volume (The Journal) recently initiated a section called "Evidence-Based Orthopaedics." Furthermore, a level-of-evidence rating is now used in The Journal to help readers in clinical decision-making. Little is known about whether this recent emphasis has influenced surgeons' perceptions about and competence in evidence-based medicine. Therefore, we examined perceptions and competence in evidence-based medicine among Dutch orthopaedic surgeons. METHODS: Members of the Dutch Orthopaedic Association were surveyed to examine their attitudes toward evidence-based medicine and their competence in evidence-based medicine. We evaluated competences using a newly developed instrument tailored to surgical practice. RESULTS: Of the 611 members, 367 surgeons (60%) responded. Orthopaedic surgeons welcomed evidence-based medicine. Practical evidence-based medicine resources were perceived as the best method to move from opinion-based or experience-based to evidence-based practice. Four variables were significantly and positively associated with the competence instrument: (1) a younger age, particularly between thirty-six and forty-five years (p = 0.007), (2) experience of less than ten years (p = 0.032), (3) having a PhD degree (p < 0.001), and (4) working in an academic or teaching setting (p = 0.004). The majority of the respondents were aware of The Journal's evidence-based medicine section (84%) and level-of-evidence ratings (65%), and 20% used The Journal's evidence-based medicine abstracts in clinical decision-making. This increased awareness of evidence-based medicine was also reflected in the frequent use of Cochrane reviews in clinical decision-making (27% of the respondents). Surgeons who used and those who were aware of but did not use The Journal's evidence-based medicine abstracts or Cochrane reviews in clinical decision-making had significantly higher competence instrument scores than those who were unaware of these resources (p = 0.03 and p < 0.001, respectively). CONCLUSIONS: Evidence-based medicine is welcomed by Dutch orthopaedic surgeons. The recent emphasis on evidence-based medicine is reflected in an increased awareness about The Journal's evidence-based medicine section, levels of evidence, and the largest evidence-based medicine resource: the Cochrane reviews. Younger orthopaedic surgeons had better knowledge about evidence-based medicine. The development and use of evidence-based resources as well as preappraised summaries such as The Journal's evidence-based medicine abstracts and Cochrane reviews were perceived as the best way to move from opinion-based to evidence-based orthopaedic practice.     

Is there evidence in evidence-based medicine? A comparison of common gradation systems and critical evaluation

AIM: Evidence-based medicine is still discussed controversially. The current literature offers a huge amount of tables, recommendations and modifications for the levels of evidence and degrees of recommendations. The scientist who is critical of new techniques and who wants to continue his education might be confused by the different recommendations. Unfortunately, the gradation of the recommendations is not always cited which has led to the controversially held discussion about evidence-based medicine. It was, therefore, the aim of the current article to present the most often used gradations and to discuss them critically. METHOD: In the current study we performed an analysis of the currently used recommendations and gradations in evidence-based medicine and discussed them critically. RESULTS: The great number of the available divisions to evidence-based medicine are often technical and partially differ considerably. An unambiguous assignment of the evidence classes and of recommendation degrees can only succeed if the source is indicated clearly. CONCLUSION: As far as the authors are concerned, the confusing status of evidence-based medicine makes one gradation necessary, which should be accepted and used worldwide.     

The adolescent varicocele: diagnostic and treatment patterns of pediatricians. A public health concern?

PURPOSE: We determine whether practice patterns of pediatricians contribute to delays in diagnosing and treating adolescents with varicoceles. MATERIALS AND METHODS: A survey consisting of 11 multiple-choice questions was mailed to 5,000 pediatricians selected by zip code in New York State. Zip codes were chosen to reflect urban, suburban and rural counties. RESULTS: A total of 544 of the 5000 (10.9%) surveys were returned, and 92 (16.9%) pediatricians acknowledged that they did not routinely perform physical examinations of the genitalia of adolescent males patients. Of 497 pediatricians who routinely or occasionally examine the genitalia 54 (10.9%) did not examine for the presence of varicoceles. When pediatricians were asked how they assess for the presence of varicoceles, 13 of 521 (2.5%) only used visual inspection, 50 (9.6%) only examined patients in the supine position and 379 (72.7%) of these pediatricians never used Valsalva maneuvers. Of 517 respondents 442 (85.5%) referred patients with varicoceles to a urologist for followup and 72 (13.9%) did no further evaluation. When asked to indicate what they thought was the greatest concern regarding the pediatric varicocele, 327 of 497 (65.0%) pediatricians indicated deterioration of future infertility, 120 (30.0%) indicated testicular growth retardation, 105 (24.2%) indicated pain and 18 (4.3%) indicated cosmesis. CONCLUSIONS: A significant percentage of pediatricians do not routinely perform physical examinations for varicoceles or appropriately examine for varicoceles, despite the majority being aware of the potential significance of varicoceles. This study demonstrates the need for increased educational efforts among pediatricians regarding the need for physical examination of the genitalia, the techniques for appropriate physical examination, and the need for appropriate referral and followup of adolescents with varicoceles.