Evidence-based policy-making: The implications of globally-applicable research for context-specific problem-solving in developing countries

In the past 15 or so years, the “evidence-based medicine” (EBM) framework has become increasingly institutionalized, facilitating its transfer across the globe. In the late 1990s, the basic principles of EBM began to have a marked influence in a number of non-clinical public policy arenas. Policy-makers working in these areas are now being urged to move away from developing policies according to political ideologies to a more legitimate approach based on “scientific fact,” a process termed “evidence-based policy-making” (EBPM). The conceptual diffusion of EBM to non-clinical arenas has exposed epistemologically destabilizing views regarding the definition of “science,” particularly as it relates to the demands of global versus national/sub-national policy-making. Using the maternal and neonatal subfield as an ethnographic case-study, this paper explores the effects of these divergences on EBPM in 5 developing countries (Bangladesh, Burkina Faso, Ghana, Malawi and Nepal). In doing so, our analysis aims to explain why EBPM has thus far had a limited impact in the area of context-specific programmatic policy-development and implementation at the national and sub-national levels. Results highlight that the political contexts in which EBPM is played out promote uniformity of methodological and policy approaches, despite the fact that disciplinary diversity is being called for repeatedly in the public health literature. Even in situations where national EBPM diverges from international priorities, national evidence-based policies are found to hold little weight in countering global policy interests, which some informants claim are themselves legitimated, rather than informed, by evidence. Informants also highlight the way interpretations of research findings are shaped by the broader political context within which donors set priorities and distribute limited resources – contexts that are driven by the need to provide generalisable research recommendations based on scientifically replicable methods. Added to this are clear rifts between senior and junior-level experts within countries that constrain national and sub-national research agendas from serving as tools for empowered knowledge production and problem-solving. We conclude by arguing for diverse forms of research that can more effectively address context-specific problems. While such diversity may render EBPM more conflict-ridden, debate is by no means an undesirable characteristic in any evolving system of knowledge, for it has the potential to foster critical insight and localized change.     

Effects of multi-source feedback on developmental plans for leaders of postgraduate medical education

Objectives  Multi-source feedback (MSF) is a widely used developmental tool for leaders in organisations including those dealing with health care. This study was performed to examine the effects of an MSF process on developmental plans made by leaders of postgraduate medical education (PGME) in clinical departments.
Methods  An MSF instrument was developed based on literature on the subject and previous investigations. The instrument was used by consultants responsible for PGME in clinical departments (CREs). Apart from CREs' self-ratings, MSF responses were collected from heads of departments, consultants and young doctors-in-training. The MSF process included individual feedback as well as guidance on drafting developmental plans for both the department and the CREs. Themes emerging in the developmental plans were analysed and compared with the areas in need of improvement identified by the MSF process.
Results  The MSF instrument was found to be feasible, valid and reliable (Cronbach's α = 0.98). The study included 52 CREs from various specialties and 498 MSF respondents. The response rate was 84%. Low ratings and negative gaps between others' ratings and self-ratings were identified for both management and leadership performance areas. The developmental plans mainly focused on management initiatives, whereas plans for the development of leadership performance were few. Areas rated low by all respondents were scarcely represented in CREs' developmental plans.
Conclusions  An MSF process might in itself lead to development in administrative areas. However, MSF carried through as a single stand-alone procedure was not sufficient to foster plans for the development of leadership performance.     

Schizophrenia: From genes to phenes to disease

This article provides an overview of the past year’s literature on schizophrenia genetics. Quantitative genetics continues to be an important foundation in which family and twin studies have been used to evaluate potential endophenotypes. Research in molecular genetics has focused on detecting multiple genes of small effect, and developments relating to key positional and functional candidate genes are reviewed. Large-scale, multicenter studies are proving to be important in this quest. Research using neuroimaging and animal modeling studies continues to link genotype with phenotype. It is increasingly apparent that some candidate genes considered important in schizophrenia are likely to be relevant to the etiology of other psychotic disorders, including bipolar disorder. This notion may challenge traditional disease classifications, not only in research but potentially in clinical practice.     

The Impact of Roux Limb Length on Weight Loss After Gastric Bypass

Background Extending the length of the Roux limb (RL) in gastric bypass (GBP) may improve weight loss in super obese patients (body mass index [BMI] > 50 kg/m²), but no consensus exists about the optimal length of the RL. We sought to determine the impact of RL length on weight loss in super obese patients 1 year after GBP. Materials and Methods One-year weight loss outcomes were analyzed in all super obese patients who underwent consecutive and primary laparoscopic or open GBP between January 2003 and June 2006. Patients were divided into two groups according to RL length (100 vs. 150 cm). The RL length was at the discretion of the attending surgeon. Baseline and follow-up data were collected prospectively. Multiple linear regression was used to adjust for potential confounders in the weight loss outcomes. Results Twelve-month follow-up data were available in 137 (85%) of 161 patients with a BMI ≥ 50 who underwent GBP during the study period. An RL of 100 or 150 cm was used in 102 (74.5%) and 35 patients (25.5%), respectively. In multivariate analysis, patients with the 150-cm RL lost more weight (68.5 vs. 55.3 kg, p < 0.01), had a greater change in BMI (25 vs. 21 kg/m², p = 0.01), and had greater excess weight loss (64 vs. 53%, p < 0.01). Conclusion A 150-cm RL provides better weight loss outcomes in super obese patients at 1-year follow-up.     

Roller coaster marathon: being a live liver donor

The purpose of this phenomenological study was to examine the meaning of being a live liver donor. Six people between ages 27 and 53 years participated. A qualitative, in-depth, semistructured interview format was used to explore donors' thoughts and feelings about being an organ donor. Five themes were identified: (1) no turning back--how do I live without you? (2) roller coaster marathon, (3) donor network, (4) the scar, and (5) reflections--time to think. At the center of the experience was the donor's commitment to the recipient. Once donors began the process, they were determined to see it through. The process was complex, and donors received various levels of support from family, friends, health care professionals, and others. After donation, as donors recovered and were able to resume their usual daily responsibilities, they reflected on the impact of the experience and how it changed their view of life.     

Initial laparoscopic access using an optical trocar without pneumoperitoneum is safe and effective in the morbidly obese

Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in morbidly obese people. The aim of this study was to examine the safety and efficacy of accessing the peritoneal cavity using an optical, bladeless trocar without previous pneumoperitoneum in morbidly obese patients. The patients' characteristics and outcomes with consecutive and preferential use of an optical, bladeless, first trocar insertion without previous pneumoperitoneum in morbidly obese patients (body mass index > 35 kg/m2) was reviewed. A total of 208 morbidly obese patients were included. The trocar insertion technique was used in 196 patients. No bowel or major abdominal vessel injuries occurred. Ninety-eight patients (50%) had previous abdominal operations. Trocar-related injuries occurred in 3 patients: a superficial mesenteric laceration in 2 and a laceration of a greater omentum vessel in 1. The direct first trocar insertion technique provides safe entry into the peritoneal cavity in morbidly obese patients.     

Community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infections at a public hospital: do public housing and incarceration amplify transmission?

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections have emerged among patients without health care-associated risk factors. Understanding the epidemiology of CA-MRSA is critical for developing control measures. METHODS: At a 464-bed public hospital in Chicago and its more than 100 associated clinics, surveillance of soft tissue, abscess fluid, joint fluid, and bone cultures for S aureus was performed. We estimated rates of infection and geographic and other risks for CA-MRSA through laboratory-based surveillance and a case-control study. RESULTS: The incidence of CA-MRSA skin and soft tissue infections increased from 24.0 cases per 100,000 people in 2000 to 164.2 cases per 100,000 people in 2005 (relative risk, 6.84 [2005 vs 2000]). Risk factors were incarceration (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.00-3.67), African American race/ethnicity (OR, 1.91; 95% CI, 1.28-2.87), and residence at a group of geographically proximate public housing complexes (OR, 2.50; 95% CI, 1.25-4.98); older age was inversely related (OR, 0.89; 95% CI, 0.82-0.96 [for each decade increase]). Of 73 strains tested, 79% were pulsed-field gel electrophoresis type USA300. CONCLUSIONS: Clonal CA-MRSA infection has emerged among Chicago's urban poor. It has occurred in addition to, not in place of, methicillin-susceptible S aureus infection. Epidemiological analysis suggests that control measures could focus initially on core groups that have contributed disproportionately to risk, although CA-MRSA becomes endemic as it disseminates within communities.     

Mesenteric artery occlusion secondary to activated protein C resistance: a life-threatening combination

We present a case of mesenteric ischemia in a 32-year-old woman. The rarity of this potentially fatal condition in this age group, the diagnostic and therapeutic challenges associated with such a condition, and secondary causes that must always be investigated are highlighted. In this case, activated protein C resistance resulted in thrombosis of the superior mesenteric artery and subsequent bowel ischemia.