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  • Gruen, Russell L.  (101)
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  • 1
    Language: English
    In: JAMA, 07 January 2004, Vol.291(1), pp.94-8
    Description: Although leaders and other commentators have called for the medical profession's greater engagement in improving systems of care and population health, neither medical education nor the practice environment has fostered such engagement. Missing have been a clear definition of physicians' public roles, reasonable limits to what can be expected, and familiarity with tasks that are compatible with busy medical practices. We address these issues by proposing a definition and a conceptual model of public roles that require evidence of disease causation and are guided by the feasibility and efficacy of physician involvement. We then frame a public agenda for individual physicians and physician organizations that focuses on advocacy and community participation. By doing so, we aim to stimulate dialogue about the appropriateness of such roles and promote physician engagement with pressing health issues in the public arena.
    Keywords: Bioethics and Professional Ethics ; Health Care and Public Health ; Delivery of Health Care ; Ethics, Medical ; Goals ; Physician'S Role ; Social Responsibility
    ISSN: 00987484
    E-ISSN: 1538-3598
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  • 2
    Language: English
    In: The Lancet, 22 September 2012, Vol.380(9847), pp.1099-1108
    Description: Most surgeons have adopted damage control surgery for severely injured patients, in which the initial operation is abbreviated after control of bleeding and contamination to allow ongoing resuscitation in the intensive-care unit. Developments in early resuscitation that emphasise rapid control of bleeding, restrictive volume replacement, and prevention or early management of coagulopathy are making definitive surgery during the first operation possible for many patients. Improved topical haemostatic agents and interventional radiology are becoming increasingly useful adjuncts to surgical control of bleeding. Better understanding of trauma-induced coagulopathy is paving the way for the replacement of blind, unguided protocols for blood component therapy with systemic treatments targeting specific deficiencies in coagulation. Similarly, treatments targeting dysregulated inflammatory responses to severe injury are under investigation. As point-of-care diagnostics become more suited to emergency environments, timely targeted intervention for haemorrhage control will result in better patient outcomes and reduced demand for blood products. Our Series paper describes how our understanding of the roles of the microcirculation, inflammation, and coagulation has shaped new and emerging treatment strategies.
    Keywords: Medicine
    ISSN: 0140-6736
    E-ISSN: 1474-547X
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  • 3
    Language: English
    In: The Lancet, 2011, Vol.377(9771), pp.1052-1054
    Description: Unlike coagulopathy that is secondary to haemodilution, hypothermia, or acidosis, acute traumatic coagulopathy is a hyperacute process in which systemic fibrinolysis releases D-dimers that are detectable within 30 min of injury.5 While the mechanisms are poorly understood, shock and tissue injury seem...
    Keywords: Medicine
    ISSN: 0140-6736
    E-ISSN: 1474-547X
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  • 4
    Language: English
    In: The Lancet, 22 September 2012, Vol.380(9847), pp.1033-1034
    Description: By 2030, road traffic injuries are predicted to be the world's fifth leading cause of death and the third leading cause of disability.1 The Lancet's accompanying Series on trauma surgery updates present knowledge of three broad aspects of acute trauma care: haemorrhagic shock (responsible for most preventable...
    Keywords: Medicine
    ISSN: 0140-6736
    E-ISSN: 1474-547X
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  • 5
    Language: English
    In: The Lancet, 22 September 2012, Vol.380(9847), pp.1088-1098
    Description: Severe traumatic brain injury remains a major health-care problem worldwide. Although major progress has been made in understanding of the pathophysiology of this injury, this has not yet led to substantial improvements in outcome. In this report, we address present knowledge and its limitations, research innovations, and clinical implications. Improved outcomes for patients with severe traumatic brain injury could result from progress in pharmacological and other treatments, neural repair and regeneration, optimisation of surgical indications and techniques, and combination and individually targeted treatments. Expanded classification of traumatic brain injury and innovations in research design will underpin these advances. We are optimistic that further gains in outcome for patients with severe traumatic brain injury will be achieved in the next decade.
    Keywords: Medicine
    ISSN: 0140-6736
    E-ISSN: 1474-547X
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  • 6
    Language: English
    In: Journal of Clinical Epidemiology, May 2013, Vol.66(5), pp.496-502.e2
    Description: We present a multistep process for identifying priority research areas in rehabilitation and long-term care of traumatic brain-injured (TBI) patients. In particular, we aimed to (1) identify which stakeholders should be involved; (2) identify what methods are appropriate; (3) examine different criteria for the generation of research priority areas; and (4) test the feasibility of linkage and exchange among researchers, decision makers, and other potential users of the research. Potential research questions were identified and developed using an initial scoping meeting and preliminary literature search, followed by a facilitated mapping workshop and an online survey. Identified research questions were then prioritized against specific criteria (clinical importance, novelty, and controversy). Existing evidence was then mapped to the high-priority questions using usual processes for search, screening, and selection. A broad range of stakeholders were then brought together at a forum to identify priority research themes for future research investment. Using clinical and research leaders, smaller targeted planning workshops prioritized specific research projects for each of the identified themes. Twenty-six specific questions about TBI rehabilitation were generated, 14 of which were high priority. No one method identified all high-priority questions. Methods that relied solely on the views of clinicians and researchers identified fewer high-priority questions compared with methods that used broader stakeholder engagement. Evidence maps of these high-priority questions yielded a number of evidence gaps. Priority questions and evidence maps were then used to inform a research forum, which identified 12 priority themes for future research. Our research demonstrates the value of a multistep and multimethod process involving many different types of stakeholders for prioritizing research to improve the rehabilitation outcomes of people who have suffered TBI. Enhancing stakeholder representation can be augmented using a combination of methods and a process of linkage and exchange. This process can inform decisions about prioritization of research areas.
    Keywords: Prioritization ; Traumatic Brain Injury ; Research Funding ; Evidence Mapping ; Research Gaps ; Rehabilitation ; Medicine
    ISSN: 0895-4356
    E-ISSN: 1878-5921
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  • 7
    Language: English
    In: Journal of Clinical Epidemiology, May 2013, Vol.66(5), pp.503-510.e4
    Description: To identify high-priority research questions for osteoarthritis systematic reviews with consideration of health equity and the social determinants of health (SDH). We consulted with experts and conducted a literature search to identify a priority-setting method that could be adapted to address the health equity and SDH. We selected the Global Evidence Mapping priority-setting method, and through consultations and consensus, we adapted the method to meet our objectives. This involves developing an evidence map of the existing systematic reviews on osteoarthritis; conducting one face-to-face workshop with patients and another one with clinicians, researchers, and patients; and conducting an online survey of patients to rank the top 10 research questions. We piloted the adapted method with the Cochrane Musculoskeletal Review Group to set research priorities for osteoarthritis. Our focus was on systematic reviews: we identified 34 high-priority research questions for osteoarthritis systematic reviews. Prevention and self-management interventions, mainly diet and exercise, are top priorities for osteoarthritis systematic reviews. Evaluation against our predefined objectives showed that this method did prioritize SDH (50% of the research questions considered SDH). There were marked gaps: no high-priority topics were identified for access to care until patients had advanced disease–lifestyle changes once the disease was diagnosed. This method was felt feasible if conducted annually. We confirmed the utility of an adapted priority-setting method that is feasible and considers SDH. Further testing of this method is needed to assess whether considerations of health equity are prioritized and involve disadvantaged groups of the population.
    Keywords: Priority Setting ; Health Equity ; Osteoarthritis ; Social Determinants of Health ; Systematic Reviews ; Methods ; Methodology ; Research Priorities ; Medicine
    ISSN: 0895-4356
    E-ISSN: 1878-5921
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  • 8
    In: PLoS ONE, 2016, Vol.11(2)
    Description: Background The Neurotrauma Evidence Translation (NET) Trial aims to design and evaluate the effectiveness of a targeted theory-and evidence-informed intervention to increase the uptake of evidence-based recommended practices for the management of patients who present to an emergency department (ED) with mild head injuries. When designing interventions to bring about change in organisational settings such as the ED, it is important to understand the impact of the context to ensure successful implementation of practice change. Few studies explicitly use organisational theory to study which factors are likely to be most important to address when planning change processes in the ED. Yet, this setting may have a unique set of organisational pressures that need to be taken into account when implementing new clinical practices. This paper aims to provide an in depth analysis of the organisational context in which ED management of mild head injuries and implementation of new practices occurs, drawing upon organisational level theory. Methods Semi-structured interviews were conducted with ED staff in Australia. The interviews explored the organisational context in relation to change and organisational factors influencing the management of patients presenting with mild head injuries. Two researchers coded the interview transcripts using thematic content analysis. The “model of diffusion in service organisations” was used to guide analyses and organisation of the results. Results Nine directors, 20 doctors and 13 nurses of 13 hospitals were interviewed. With regard to characteristics of the innovation (i.e. the recommended practices) the most important factor was whether they were perceived as being in line with values and needs. Tension for change (the degree to which stakeholders perceive the current situation as intolerable or needing change) was relatively low for managing acute mild head injury symptoms, and mixed for managing longer-term symptoms (higher change commitment, but relatively low change efficacy). Regarding implementation processes, the importance of (visible) senior leadership for all professions involved was identified as a critical factor. An unpredictable and hectic environment brings challenges in creating an environment in which team-based and organisational learning can thrive (system antecedents for innovation). In addition, the position of the ED as the entry-point of the hospital points to the relevance of securing buy-in from other units. Conclusions We identified several organisational factors relevant to realising change in ED management of patients who present with mild head injuries. These factors will inform the intervention design and process evaluation in a trial evaluating the effectiveness of our implementation intervention.
    Keywords: Research Article ; Medicine And Health Sciences ; Medicine And Health Sciences ; People And Places ; Medicine And Health Sciences ; Medicine And Health Sciences ; People And Places ; People And Places ; Biology And Life Sciences ; Biology And Life Sciences ; Social Sciences ; Biology And Life Sciences ; Computer And Information Sciences ; Social Sciences ; Medicine And Health Sciences ; Medicine And Health Sciences
    E-ISSN: 1932-6203
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  • 9
    Language: English
    In: Injury, 2012, Vol.43(1), pp.33-37
    Description: A high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) is currently recognised as the standard of care in some centres during massive transfusion post trauma. The aim of this study was to test whether the presumption of benefit held true for severely injured patients who received a massive transfusion, but did not present with acute traumatic coagulopathy. Data collected in The Alfred Trauma Registry over a 6 year period were reviewed. Included patients were sub-grouped by a high FFP:PRBC ratio (≥1:2) in the first 4 h and compared to patients receiving a lower ratio. Outcomes studied were associations with mortality, hours in the intensive care unit and hours of mechanical ventilation. Of 4164 eligible patients, 374 received a massive transfusion and 179 (49.7%) patients who did not have coagulopathy were included for analysis. There were 66 patients who received a high ratio of FFP:PRBC, and were similar in demographics and presentation to 113 patients who received a lower ratio. There was no significant difference in mortality between the two groups ( = 0.80), and the FFP:PRBC ratio was not significantly associated with mortality, ICU length of stay or mechanically ventilated hours. A small proportion of major trauma patients received a massive blood transfusion in the absence of acute traumatic coagulopathy. Aggressive FFP transfusion in this group of patients was not associated with significantly improved outcomes. FFP transfusion carries inherent risks with substantial costs and the population most likely to benefit from a high FFP:PRBC ratio needs to be clearly defined.
    Keywords: Wounds and Injuries ; Blood Coagulation Disorders ; Blood Transfusion ; Resuscitation
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 10
    In: Journal of Evaluation in Clinical Practice, August 2011, Vol.17(4), pp.819-826
    Description: This qualitative study identifies cultural factors that influence the effective implementation of evidence‐based medicine (EBM) in surgical practice among Australian surgeons. In‐depth interviews ( = 22) were conducted with surgeons from a variety of specialties within a large hospital system in Victoria, Australia. The interviews explored the surgeons' understanding of EBM; and challenges to the adoption of EBM. The canons and procedures of the Miles and Huberman's Matrix Analyses approach to qualitative research guided the coding and organization of the data derived from the semi‐structured interviews. Surgeons had a good understanding of EBM, but viewed it as little more than a system of evidence, which was often divorced from actual clinical practice. The data also suggested that surgical culture(s) and typologies of surgical style were important variables in the implementation of EBM. The results suggest that the ideal method of EBM implementation is workplace instruction led by surgeons, who exhibit scientist and/or clinician styles of surgical practice; EBM training should occur early in the surgeons' careers; and EBM practice should be role modelled in the presence of trainees by surgeons who exhibit either a scientist and/or clinician style of surgical practice. The study findings suggest that using pre‐existing surgical culture(s) and styles is an important component in the implementation of EBM in surgery. The effective use of the scientist and/or clinician surgeon within the apprenticeship model and the context‐specific collegial networks of the surgical profession appear to be key elements in ensuring the successful implementation of EBM in surgery.
    Keywords: Ebm Training ; Epistemic Culture ; Implementation ; Hidden Curriculum ; Surgery
    ISSN: 1356-1294
    E-ISSN: 1365-2753
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