Promoting clinically effective practice: general practitioners' awareness of sources of research evidence

BACKGROUND: Practitioners are being encouraged to base their clinical practice on research evidence. In order to do this, they must be aware of and use the sources of evidence. METHODS: A questionnaire survey was undertaken to establish GPs' awareness of research evidence in their clinical practice and, in fundholding practices, its influence on purchasing plans. Questionnaires were sent to 360 lead fundholders in North Thames Region and 440 of a random sample of the remaining general practitioners in the region for comparison. RESULTS: Questionnaires were returned by 62% of lead fundholders and 63% of GPs in the random sample. There was limited use of the electronic sources of clinical effectiveness. There was greater reported awareness of published sources of research evidence and fundholding GPs were significantly more likely to have referred to publications summarizing research evidence. CONCLUSIONS: GPs seem to make more use of published clinical effectiveness sources than the electronic databases. Consequently, they need educational and technical support if they are to make full use of the available sources of research evidence available in other media.      

The endoscopic spectrum of primary non-Hodgkin's lymphoma of the stomach

Thirty-one consecutive patients with primary non-Hodgkin's lymphoma of the stomach were studied to outline the spectrum of endoscopic abnormalities. The 17 men and 14 women had a median age of 65 years. There were 22 patients in stage I and 9 in stage II. Three endoscopic patterns were recognized: diffuse infiltration (9), ulceration (9) and polypoid lesions (13). There was no apparent correlation between the endoscopic appearance and the grading or subtype of the malignancy. Local recurrence did not occur once complete remission was obtained. The disease-free 5-year survival rate was 45%. Recognition of these endoscopic patterns may lead to earlier detection and, hopefully, improved survival.     

Liver-infiltrating T helper cells in autoimmune chronic active hepatitis stimulate the production of autoantibodies against the human asialoglycoprotein receptor in vitro.

Autoantibodies against the human asialoglycoprotein receptor (ASGPR) occur in the sera of patients with autoimmune liver disorders. Liver-infiltrating T cell clones that specifically recognize the ASGPR have been described in patients with autoimmune chronic active hepatitis (AI-CAH) and primary biliary cirrhosis (PBC). Recently, we have shown that peripheral blood mononuclear cells (PBMC) from patients with AI-CAH or PBC but not chronic viral hepatitis secreted anti-ASGPR antibodies in vitro. In this study we characterized the influence of liver-infiltrating T cells on the secretion of ASGPR-specific autoantibodies by autologous B cells in cell culture supernatants. T cell clones from liver biopsies of three patients with chronic autoimmune liver disorders (one with AI-CAH, two with PBC) were isolated and investigated for their proliferative response to soluble ASGPR and their helper function provided to autoantibody-secreting B lymphocytes. PBMC from these patients secreted autoantibodies spontaneously in their cell culture supernatants and showed a proliferative response to ASGPR. T cell-depleted PBMC, however, lacked spontaneous antibody secretion. Four CD4+CD8- liver-infiltrating T cell clones showed a proliferative response to ASGPR and also induced spontaneous anti-ASGPR antibody production in cell culture supernatants when added to autologous T cell depleted PBMC. Activated supernatants of these T cell clones failed to induce antibody production. None of seven CD4+CD8- and two CD4-CD8+ T cell clones non-responding to ASGPR provided this help for antibody secretion. Anti-ASGPR secretion in vitro could not be inhibited by the addition of MoAbs raised against monomorphic determinants on HLA class II molecules. The addition of purified ASGPR or polyclonal-activating pokeweed mitogen showed no influence on the production of autoantibodies in these cultures. These data show that B lymphocytes require T cell help for the production of ASGPR-specific antibodies. This help can be provided by ASGPR-responsive T helper cells via cellular interactions.     

Health status, adherence with health recommendations, self-efficacy and social support in patients with rheumatoid arthritis

A study was performed in 86 patients with rheumatoid arthritis (RA) to assess their health problems, the problems they experience in adhering to health recommendations and the relationships of these problems with self-efficacy and social support. Feeling dependent, disability and pain were the most important health related problems. The results showed self-efficacy to be related to the subjective experience of health status as measured by DUTCH-AIMS. Social emotional support was not related to health status and contrary to what we expected social instrumental support was positively related to health status. The majority of the patients (55%) experienced adherence problems with health recommendations. These problems were not related to functional incapacity, pain or other aspects of health status but to the patient's self-efficacy expectations about coping with arthritis. Our conclusion is that to improve the self-management of disability and pain and adherence to health recommendations, patient education should be aimed at strengthening self-efficacy expectations in which social emotional support might be a motivating factor.     

Periodic colonoscopic examinations of persons with a positive family history for colorectal cancer. Work Group 'Hereditary non-polyposis- colon-rectum cancers']

Individuals with one first-degree relative with colorectal cancer diagnosed before age 45 years and those with two first-degree relatives with colorectal cancer run a significantly increased risk (relative risk: 4-6) of developing colorectal cancer. Based on calculation of the mortality due to colorectal cancer for the age group 50-70 years (which is higher than the mortality due to breast cancer) surveillance may be justified, e.g. by colonoscopy at 5-year intervals from the age of 45-50. The total number of people in the Netherlands in this high risk group is estimated at 10,000. The authors conclude that prospective studies are needed to assess the cost-effectiveness of such a programme.