Critical Analysis of a Randomized Controlled Trial

In the era of evidence-based medicine, healthcare professionals are bombarded with plenty of trials and articles of which randomized control trial is considered as the epitome of all in terms of level of evidence. It is very crucial to learn the skill of balancing knowledge of randomized control trial and to avoid misinterpretation of trial result in clinical practice. There are various methods and steps to critically appraise the randomized control trial, but those are overly complex to interpret. There should be more simplified and pragmatic approach for analysis of randomized controlled trial. In this article, we like to summarize few of the practical points under 5 headings: "5 'Rs' of critical analysis of randomized control trial" which encompass Right Question, Right Population, Right Study Design, Right Data, and Right Interpretation. This article gives us insight that analysis of randomized control trial should not only based on statistical findings or results but also on systematically reviewing its core question, relevant population selection, robustness of study design, and right interpretation of outcome. How to cite this article: Nimavat BD, Zirpe KG, Gurav SK. Critical Analysis of a Randomized Controlled Trial. Indian J Crit Care Med 2020;24(Suppl 4):S215-S222.

A systematic review on COVID-19 pandemic with special emphasis on curative potentials of Nigeria based medicinal plants

Despite the frightening mortality rate associated with COVID-19, there is no known approved drug to effectively combat the pandemic. COVID-19 clinical manifestations include fever, fatigue, cough, shortness of breath, and other complications. At present, there is no known effective treatment or vaccine that can mitigate/inhibit SARS-CoV-2. Available clinical intervention for COVID-19 is only palliative and limited to support. Thus, there is an exigent need for effective and non-invasive treatment. This article evaluates the possible mechanism of actions of SARS-CoV-2 and present Nigeria based medicinal plants which have pharmacological and biological activities that can mitigate the hallmarks of the pathogenesis of COVID-19. SARS-CoV-2 mode of actions includes hyper-inflammation characterized by a severe and fatal hyper-cytokinaemia with multi-organ failure; immunosuppression; reduction of angiotensin-converting enzyme 2 (ACE2) to enhance pulmonary vascular permeability causing damage to the alveoli; and further activated by open reading frame (ORF)3a, ORF3b, and ORF7a via c-Jun N- terminal kinase (JNK) pathway which induces lung damage. These mechanisms of action of SARS-CoV-2 can be mitigated by a combination therapy of medicinal herbs based on their pharmacological activities. Since the clinical manifestations of COVID-19 are multifactorial with co-morbidities, we strongly recommend the use of combined therapy such that two or more herbs with specific therapeutic actions are administered to combat the mediators of the disease.

Opioid prescribing patterns and usage after rhinologic surgery: A systematic review

OBJECTIVE

Judicious management of analgesics following rhinologic surgery is important for curtailing over-prescription of opioids. Limited data exists defining expected pain levels and appropriate opioid requirements after rhinologic surgery.

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Embase, Ovid MEDLINE, Cochrane Library databases were queried, and relevant articles were identified.

RESULTS

A total of 405 articles were identified, of which 13 met final inclusion criteria. Significant heterogeneity existed regarding type and quantity of opioid medication prescribed. Eight studies utilized a subjective patient-reported pain score as an outcome measure and reported mild to moderate postoperative pain that diminished over the first 3-6 days. Eight studies reported over-prescription of opioid medications with inappropriate storage of excess pills at home. Several factors were associated with an increased opioid requirement, including concurrent septoplasty, younger age, and current smoking status.

CONCLUSION

Rhinologic surgery is well tolerated with mild to moderate, short-lived postoperative pain. A limited amount and duration of opioid medications is required for routine management. Patients are frequently prescribed more opioids than is necessary for expected pain level, resulting in the potential for opioid misuse, abuse, and diversion. Current evidence is limited by a predominance of level 4 studies. Larger, higher quality studies with standardized reporting of pain score and opioid prescription quantity are needed.

COVID-19: Off-label therapies based on mechanism of action while waiting for evidence-based medicine recommendations

The world pandemic due to coronavirus disease 2019, known as COVID-19, embodies a high rate of disease transmission that causes a critical hospitalization overload. As of May 15, 2020, the disease has been the cause of more than 4 million infections and more than 280000 deaths all over the world. At the beginning, we underestimated the disease; now, we have sufficient information and it is clear that it is not just a respiratory disease. In fact, if a prompt treatment is not initiated, the disease may evolve towards an abnormal immune response and cytokine storm with an important thrombophilic pattern. Therefore, we think that while waiting for certainties to be established by evidence-based medicine, it is not ethical to not try off-label therapies for some of the well-known drugs, as they could have some efficacy based on their mechanisms of action.

The mystery of the COVID toes - turning evidence-based medicine on its head

The recent and rapid emergence of COVID-19 infection has led to a flood of publications describing all aspects of the disease and its presentation. The appearance of chilblain-like lesions, in children and young adults has particularly caught the attention of healthcare professionals with an interest in the foot. With such a novel infection, demand for information is high at a time when evidence is scarce. Consequently, there has been a renaissance in the publication of case studies. This type of research, previously relegated from many mainstream journals, as a low level source of evidence, has permitted the rapid reporting, publication and dissemination of much needed clinical data which can be used as a foundation to inform further research and investigations about a new global infection.

A Systematic Review of Tracheostomy Modifications and Swallowing in Adults

Dysphagia occurs in 11% to 93% of patients following tracheostomy. Despite its benefits, the tracheostomy often co-exists with dysphagia given its anatomical location, the shared pathway of the respiratory and alimentary systems, and the medical complexities necessitating the need for the artificial airway. When tracheostomy weaning commences, it is often debated whether the methods used facilitate swallowing recovery. We conducted a systematic review to determine whether tracheostomy modifications alter swallowing physiology in adults. We searched eight electronic databases, nine grey literature repositories and conducted handsearching. We included studies that reported on oropharyngeal dysphagia as identified by instrumentation in adults with a tracheostomy. We accepted case series (n > 10), prospective or retrospective observational studies, and randomized control trials. We excluded patients with head and neck cancer and/or neurodegenerative disease. Two independent and blinded reviewers rated abstracts and articles for study inclusion. Data abstraction and risk of bias assessment was conducted on included studies. Discrepancies were resolved by consensus. A total of 7079 citations were identified, of which, 639 articles were reviewed, with ten articles meeting our inclusion criteria. The studies were heterogeneous in study design, patient population, and outcome measures. For these reasons, we presented our findings descriptively. All studies were limited by bias risk. This study highlights the limitations of the evidence and therefore the inability to conclude whether tracheostomy modifications alter swallowing physiology.

Latex and synthetic rubber glove usage in UK general dental practice: changing trends

Objectives

To evaluate the current routine use of latex gloves and latex containing dental dam in UK general dental practice.

Methods

A questionnaire was disseminated to 89 general dental practitioners (GDPs) in June 2017. The survey concerned their current, routine use of latex gloves and latex-containing dental dam in general dental practice. In addition, monthly sales figures of gloves classified by material, were obtained from a UK dental supply company, for 2015–2017.

Results

The questionnaire response rate was 84 (94%), of whom 90% reported using non-latex (non-sterile examination) gloves for their routine dentistry. The majority were using nitrile gloves. All GDPs surveyed would use examination gloves for routine extractions, and 76% would use examination gloves for surgical extractions. The majority (75%) reported using non-latex dental dam. Sales of nitrile gloves were significantly higher than for latex gloves, with a continuing trend in the reduction in volume of sales of latex gloves.

Conclusion

The majority of GDP's now routinely use non-latex containing gloves and dental dam in their clinical dentistry. Nitrile gloves are predominantly used. Examination gloves are used for straightforward extractions, with many practitioners also using them for minor oral surgery. Sales of latex containing gloves are continuing to decrease.

Clinical significance

The routine use of latex-containing products in UK dental practice is low and likely to reduce further, with on-going benefit for the dental practitioner, latex allergic patients and prevalence of latex allergy in the general population.

Which study outcomes change practice

The use of evidence based medicine to guide treatment decision making is widely supported by clinicians as a method to improve patient care and outcomes. Surgeons and physicians play a key role in both the design of clinical and translational research studies, as well as the implementation of the results. With the massive volume of published studies, it is increasingly difficult for clinicians to evaluate the literature and appropriately integrate novel findings into practice. With a focus on research studies in the field of orthopaedic surgery, the purpose of this review is to discuss which factors lead to impactful conclusions and clinical change, including the role of outcome selection, study design, presentation of results, and stakeholder involvement.

The Prospective Lynch Syndrome Database reports enable evidence-based personal precision health care

The aims of the Prospective Lynch Syndrome Database (PLSD) are to provide empirical prospectively observed data on the incidences of cancer in different organs, survival following cancer and the effects of interventions in carriers of pathogenic variants of the mismatch repair genes (path_MMR) categorized by age, gene and gender. Although PLSD is assumption-free, as with any study the ascertainment procedures used to identify the study cohort will introduce selection biases which have to be declared and considered in detail in order to provide robust and valid results. This paper provides a commentary on the methods used and considers how results from the PLSD reports should be interpreted. A number of the results from PLSD were novel and some in conflict with previous assumptions. Notably, colonoscopic surveillance did not prevent colo-rectal cancer, survival after colo-rectal, endometrial and ovarian cancer was good, no survival gain was observed with more frequent colonoscopy, new causes of cancer-related death were observed in survivors of first cancers due to later cancers in other organs, variants in the different MMR genes caused distinct multi-cancer syndromes characterized by different penetrance and phenotypes. The www.PLSD.eu website together with the InSiGHT database website (https://www.insight-group.org/variants/databases/) now facilitate evidence-based personalized precision health care for individual carriers at increased risk of cancer. The arguments are summarized in a final discussion on how to conceptualize current knowledge for the different practical purposes of treating cancers, genetic counselling and prevention, and for understanding /research on carcinogenetic mechanisms.

[S2k guidelines of the PEG on calculated parenteral initial treatment of bacterial diseases in adults : Focussed summary and supplementary information on antibiotic treatment of critically ill patients]

In January 2018 the recent revision of the S2k guidelines on calculated parenteral initial treatment of bacterial diseases in adults-update 2018 (Editor: Paul Ehrlich Society for Chemotherapy, PEG) was realized. It is a helpful tool for the complex infectious disease setting in an intensive care unit. The present summary of the guidelines focuses on the topics of anti-infective agents, including new substances, pharmacokinetics and pharmacodynamics as well as on microbiology, resistance development and recommendations for calculated drug therapy in septic patients. As in past revisions the recent resistance situation and results of new clinical studies are considered and anti-infective agents are summarized in a table.

Patient-focused outcomes are infrequently reported in pediatric health information technology trials: a systematic review

OBJECTIVES

Billions of dollars have been invested in Health Information Technologies (HITs), and randomized controlled trials (RCTs) have been conducted to identify the effects of these interventions. Our objective was to identify the types of outcomes that were measured and reported in these RCTs.

STUDY DESIGN AND SETTING

We completed a systematic review (Medline, EMBASE, and CENTRAL databases) of RCTs involving children (<18 years) and utilizing HIT interventions.

RESULTS

We identified 45 RCTs involving 323,945 children. Most studies reported process outcomes (n = 40/45 (88.9%)) but did not include patient-focused outcomes such as patient/carer functioning (n = 12/45 (26.7%)), clinical/physiological health (n = 10/45, 22.2%), quality of life (n = 3/45, 6.7%), or mortality (n = 1/45, 2.2%). Only 3 of 45 (6.7%) studies reported an evaluation of adverse events. In only 14 of 45 (31.1%) studies was it clear that all outcomes that were measured were reported.

CONCLUSION

It is difficult to use RCTs to fully evaluate the benefits and risks of using HIT interventions in pediatric health care settings because patient-focused outcomes and adverse events are rarely reported. Measures to improve the quality of future trials may include the publication of study protocols and the development of an outcome reporting framework or core outcome set.

The future of publishing

This is the first Journal of Pediatric Surgery lecture at the Pacific Association of Pediatric Surgeons (PAPS) meeting.

Evidence-based medicine and problem based learning a critical re-evaluation

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.

Quantifying semantic similarity of clinical evidence in the biomedical literature to facilitate related evidence synthesis

OBJECTIVE

Published clinical trials and high quality peer reviewed medical publications are considered as the main sources of evidence used for synthesizing systematic reviews or practicing Evidence Based Medicine (EBM). Finding all relevant published evidence for a particular medical case is a time and labour intensive task, given the breadth of the biomedical literature. Automatic quantification of conceptual relationships between key clinical evidence within and across publications, despite variations in the expression of clinically-relevant concepts, can help to facilitate synthesis of evidence. In this study, we aim to provide an approach towards expediting evidence synthesis by quantifying semantic similarity of key evidence as expressed in the form of individual sentences. Such semantic textual similarity can be applied as a key approach for supporting selection of related studies.

MATERIAL AND METHODS

We propose a generalisable approach for quantifying semantic similarity of clinical evidence in the biomedical literature, specifically considering the similarity of sentences corresponding to a given type of evidence, such as clinical interventions, population information, clinical findings, etc. We develop three sets of generic, ontology-based, and vector-space models of similarity measures that make use of a variety of lexical, conceptual, and contextual information to quantify the similarity of full sentences containing clinical evidence. To understand the impact of different similarity measures on the overall evidence semantic similarity quantification, we provide a comparative analysis of these measures when used as input to an unsupervised linear interpolation and a supervised regression ensemble. In order to provide a reliable test-bed for this experiment, we generate a dataset of 1000 pairs of sentences from biomedical publications that are annotated by ten human experts. We also extend the experiments on an external dataset for further generalisability testing.

RESULTS

The combination of all diverse similarity measures showed stronger correlations with the gold standard similarity scores in the dataset than any individual kind of measure. Our approach reached near 0.80 average Pearson correlation across different clinical evidence types using the devised similarity measures. Although they were more effective when combined together, individual generic and vector-space measures also resulted in strong similarity quantification when used in both unsupervised and supervised models. On the external dataset, our similarity measures were highly competitive with the state-of-the-art approaches developed and trained specifically on that dataset for predicting semantic similarity.

CONCLUSION

Experimental results showed that the proposed semantic similarity quantification approach can effectively identify related clinical evidence that is reported in the literature. The comparison with a state-of-the-art method demonstrated the effectiveness of the approach, and experiments with an external dataset support its generalisability.

Measuring the impact of screening automation on meta-analyses of diagnostic test accuracy

BACKGROUND

The large and increasing number of new studies published each year is making literature identification in systematic reviews ever more time-consuming and costly. Technological assistance has been suggested as an alternative to the conventional, manual study identification to mitigate the cost, but previous literature has mainly evaluated methods in terms of recall (search sensitivity) and workload reduction. There is a need to also evaluate whether screening prioritization methods leads to the same results and conclusions as exhaustive manual screening. In this study, we examined the impact of one screening prioritization method based on active learning on sensitivity and specificity estimates in systematic reviews of diagnostic test accuracy.

METHODS

We simulated the screening process in 48 Cochrane reviews of diagnostic test accuracy and re-run 400 meta-analyses based on a least 3 studies. We compared screening prioritization (with technological assistance) and screening in randomized order (standard practice without technology assistance). We examined if the screening could have been stopped before identifying all relevant studies while still producing reliable summary estimates. For all meta-analyses, we also examined the relationship between the number of relevant studies and the reliability of the final estimates.

RESULTS

The main meta-analysis in each systematic review could have been performed after screening an average of 30% of the candidate articles (range 0.07 to 100%). No systematic review would have required screening more than 2308 studies, whereas manual screening would have required screening up to 43,363 studies. Despite an average 70% recall, the estimation error would have been 1.3% on average, compared to an average 2% estimation error expected when replicating summary estimate calculations.

CONCLUSION

Screening prioritization coupled with stopping criteria in diagnostic test accuracy reviews can reliably detect when the screening process has identified a sufficient number of studies to perform the main meta-analysis with an accuracy within pre-specified tolerance limits. However, many of the systematic reviews did not identify a sufficient number of studies that the meta-analyses were accurate within a 2% limit even with exhaustive manual screening, i.e., using current practice.

[The development of vaccination policy]

THE DEVELOPMENT OF VACCINATION POLICY

In France, the minister of health is responsible for vaccination policy. Its development is based on the expertise of a Technical Committee on Vaccinations, attached to the High Authority of Health (HAS). The Committee's main missions are to issue recommendations and propose updates to the vaccination calendar. Its composition guarantees multidisciplinary expertise by integrating professionals interested in vaccination who must not have any conflict of interest. A response to referrals, usually from the Directorate-General for Health, is made according to different procedures depending on whether it is proposed to introduce a new vaccination strategy, to determine the place of a vaccine in an existing strategy, or to respond to emergency referrals. The epidemiology of the relevant disease as well as the efficacy and tolerance of vaccines are the essential elements taken into consideration. The production of evidence-based recommendations requires a systematic review of the literature with gradation of the level of evidence. Medico-economic studies are required for the introduction of new vaccine strategies. The draft opinion prepared by a working group is discussed and voted in plenary session. The project can be submitted to public consultation before validation by the college of the HAS. Downstream of this are the Transparency Commission which decides on reimbursement and the Public Health Economic Evaluation Commission which gives an opinion on efficiency which serves as a basis for discussions on price. Links established between these three commissions of the HAS are intended to ensure policy coherence.

Awareness of population regarding the effects of diabetes on dental implant treatment in Jeddah, Saudi Arabia

OBJECTIVE

Diabetes mellitus (DM) has several complications. Delayed wound healing, microvascular disease and an impaired response to infections are complications that can have a direct bearing on dental implant therapy. This paper studies the awareness of the population with regard to the effect of DM on dental implant treatment.

MATERIALS AND METHODS

A validated, close-ended questionnaire was distributed to 506 randomly selected mall-goers in the city of Jeddah. Responses were coded and entered into spreadsheet software (SPSS, IBM). The frequency distribution of the responses was calculated, and inferences were drawn.

RESULTS

The study revealed that the majority of the sample were females (62.8%), did not have diabetes (80.4%) and reported a positive family history of diabetes (87.4%). Most of the respondents (56%) believed that uncontrolled diabetes can lead to implant loss and that diabetes affects the healing process (91.6%). Many patients (42%) responded that diabetes could be treated with dental implants if the blood sugar level was controlled.

CONCLUSION

The studied sample revealed a satisfactory level of awareness regarding the association of diabetes and oral hygiene in dental implant therapy. However, there is less than adequate knowledge about the effects of diabetes on dental implants, as the majority of the respondents believe that only controlled diabetics can avail dental implant treatment.

Results From a Randomized Controlled Trial to Address Balance Deficits After Traumatic Brain Injury

OBJECTIVE

To evaluate the efficacy of an in-home 12-week physical therapy (PT) intervention that utilized a virtual reality (VR) gaming system to improve balance in individuals with traumatic brain injury (TBI).

SETTING

Home-based exercise program (HEP).

PARTICIPANTS

Individuals (N=63; traditional HEP n=32; VR n=31) at least 1 year post-TBI, ambulating independently within the home, not currently receiving PT services.

MAIN OUTCOME MEASURES

Primary: Community Balance and Mobility Scale (CB&M); Secondary: Balance Evaluation Systems Test (BESTest), Activities-Specific Balance Confidence Scale (ABC), Participation Assessment with Recombined Tools-Objective (PART-O).

RESULTS

No significant between-group differences were observed in the CB&M over the study duration (P=.9983) for individuals who received VR compared to those who received a HEP to address balance deficits after chronic TBI nor in any of the secondary outcomes: BESTest (P=.8822); ABC (P=.4343) and PART-O (P=.8822). However, both groups demonstrated significant improvements in CB&M and BESTest from baseline to 6, 12, and at 12 weeks follow-up (all P's <.001). Regardless of treatment group, 52% of participants met or exceeded the minimal detectable change of 8 points on the CB&M at 24 weeks and 38% met or exceeded the minimal detectable change of 7.81 points on the BESTest.

CONCLUSION

This study did not find that VR training was more beneficial than a traditional HEP for improving balance. However, individuals with chronic TBI in both treatment groups demonstrated improvements in balance in response to these interventions which were completed independently in the home environment.

Science and fiction in critical care: established concepts with or without evidence?

In the absence of evidence, therapies are often based on intuition, belief, common sense or gut feeling. Over the years, some treatment strategies may become dogmas that are eventually considered as state-of-the-art and not questioned any longer. This might be a reason why there are many examples of "strange" treatments in medical history that have been applied in the absence of evidence and later abandoned for good reasons.In this article, five dogmas relevant to critical care medicine are discussed and reviewed in the light of the available evidence. Dogma #1 relates to the treatment of oliguria with fluids, diuretics, and vasopressors. In this context, it should be considered that oliguria is a symptom rather than a disease. Thus, once hypovolaemia can be excluded as the underlying reason, there is no justification for giving fluids, which may do more harm than good in euvolaemic or hypervolaemic patients. Similarly, there is no solid evidence for forcing diuresis by administering vasopressors and loop diuretics. Dogma #2 addresses the treatment of crush syndrome patients with aggressive fluid therapy using NaCl 0.9%. In fact, this treatment may aggravate renal injury by iatrogenic metabolic acidosis and subsequent renal hypoperfusion. Dogma #3 concerns the administration of NaCl 0.9% to patients undergoing kidney transplantation. Since these patients are usually characterised by hyperkalaemia, the potassium-free solution NaCl 0.9%, containing exclusively 154 mmol/l of sodium and chloride ions each, is often considered as the fluid of choice. However, large volumes of chloride-rich solutions cause hyperchloraemic acidosis in a dose-dependent manner and induce a potassium shift to the extracellular space, thereby increasing serum potassium levels. Thus, balanced electrolyte solutions are to be preferred in this setting. Dogma #4 relates to the fact that enteral nutrition is often withheld for patients with high residual gastric volume due to the theoretical risk of gastro-oesophageal reflux, potentially resulting in aspiration pneumonitis. Despite controversial discussions, there is no clinical data supporting that residual gastric volume should be generally measured, especially not in patients without a gastro-intestinal surgery and/or motility disorders. Clinical evidence rather suggests that abandoning residual gastric volume monitoring does not increase the incidence of pneumonia, but may benefit patients by facilitating adequate enteral feeding. Finally, dogma #5 is about sedating all mechanically ventilated patients because "fighting" against the respirator may cause insufficient ventilation. This concern needs to be balanced against the unwanted consequences of sedation, such as prolonged mechanical ventilation and intensive care unit length of stay as well as increased risk of delirium. Modern concepts based on adequate analgesia and moderate to no sedation appear to be more suitable.In conclusion, dogmas are still common in clinical practice. Since science rather than fiction should govern our actions in intensive care medicine, it is important to remain critical and challenge long established concepts, especially when the underlying evidence is weak or non-existing.

Pharmacy student perceptions regarding understanding of and confidence in literature evaluation following a student-led journal club

BACKGROUND

Journal clubs are commonly used by healthcare professionals, including pharmacists, as a means of analyzing and applying research to clinical practice. The purpose of this research is to determine if participation in student-led journal clubs impacts students' understanding of and confidence in literature evaluation.

METHODS

First- through third-year pharmacy students attended co-curricular journal club sessions. Students attending these sessions completed a questionnaire (Journal Club Comprehension and Confidence Instrument [JCCCI]) immediately prior to [pre-survey] and following [post-survey] the journal club session (journal club group). The JCCCI was also delivered to student pharmacists not attending the co-curricular journal club sessions (control group). Wilcoxon Signed-Rank tests were used to compare the responses to the JCCCI questionnaire. Analysis was conducted using SPSS. This research was approved by the University's Institutional Review Board.

RESULTS

A total of 182 student pharmacists completed the survey (journal club group, n = 52; control group, n = 130). There were significant differences in the pre- and post-survey of the journal club group in eight of the 10 competencies; "process", "background", "methods", "intervention/treatment", "statistical analysis", "results", "clinical significance" and "strengths/limitations". There were significant differences discovered between the journal club group (post-survey) and control group in three of the 10 competencies; "process", "importance", and "intervention/treatment".

CONCLUSIONS

This study demonstrates that participation in a journal club yielded significant improvements in how students self-rated their confidence in and understanding of literature evaluation. Based on students' self-assessed understanding of and confidence in literature evaluation, student-led journal club sessions conducted outside of the traditional pharmacy curriculum offer a perceived benefit to students.

Structured decision-making drives guidelines panels' recommendations "for" but not "against" health interventions

BACKGROUND AND OBJECTIVES

The determinants of guideline panels' recommendations remain uncertain. The objective of this study was to investigate factors considered by members of 8 panels convened by the American Society of Hematology (ASH) to develop guidelines using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

STUDY DESIGN AND SETTING

Web-based survey of the participants in the ASH guidelines panels.

ANALYSIS

two-level hierarchical, random-effect, multivariable regression analysis to explore the relation between GRADE and non-GRADE factors and strength of recommendations (SOR).

RESULTS

In the primary analysis, certainty in evidence [OR = 1.83; (95CI% 1.45-2.31)], balance of benefits and harms [OR = 1.49 (95CI% 1.30-1.69)] and variability in patients' values and preferences [OR = 1.47 (95CI% 1.15-1.88)] proved the strongest predictors of SOR. In a secondary analysis, certainty of evidence was associated with a strong recommendation [OR = 3.60 (95% CI 2.16-6.00)] when panel members recommended "for" interventions but not when they made recommendations "against" interventions [OR = 0.98 (95%CI: 0.57-1.8)] consistent with "yes" bias. Agreement between individual members and the group in rating SOR varied (kappa ranged from -0.01 to 0.64).

CONCLUSION

GRADE's conceptual framework proved, in general, to be highly associated with SOR. Failure of certainty of evidence to be associated with SOR against an intervention, suggest the need for improvements in the process.

Ethics, Evidence Based Sports Medicine, and the Use of Platelet Rich Plasma in the English Premier League

The use of platelet rich plasma (PRP) as a novel treatment is discussed in the context of a qualitative research study comprising 38 interviews with sports medicine practitioners and other stakeholders working within the English Premier League during the 2013-16 seasons. Analysis of the data produced several overarching themes: conservatism versus experimentalism in medical attitudes; therapy perspectives divergence; conflicting versions of appropriate evidence; subcultures; community beliefs/practices; and negotiation of medical decision-making. The contested evidence base for the efficacy of PRP is presented in the context of a broader professional shift towards evidence based medicine within sports medicine. Many of the participants while accepting this shift are still committed to casuistic practices where clinical judgment is flexible and does not recognize a context-free hierarchy of evidentiary standards to ethically justifiable practice. We also discuss a tendency in the data collected to consider the use of deceptive, placebo-like, practices among the clinician participants that challenge dominant understandings of informed consent in medical ethics. We conclude that the complex relation between evidence and ethics requires greater critical scrutiny for this emerging specialism within the medical community.

An analysis of the literature addressing tonsillectomy knowledge gaps

IMPORTANCE

The ability of clinical practice guidelines to improve patient outcomes depends on the quality of evidence that they are built upon. Research into tonsillectomy in children is lacking, and the gaps in evidence were identified by guideline authors.

OBJECTIVE

The objective of this study is to evaluate the extent that new research is addressing the gaps identified in the AAO-HNS Tonsillectomy in Children Guideline.

DESIGN

For each recommendation in the AAO-HNS guideline Tonsillectomy In Children, we created PICO (Participants, Intervention, Comparator, Outcome) questions and search strings. PubMed was searched to locate studies undertaken after the final literature search performed by the AAO-HNS work group. These studies were then extracted and analyzed.

SETTING

This study is relevant to all invested in focusing otolaryngological research on questions which currently lack strong evidence.

PARTICIPANTS

Trials in tonsillectomy that started after the development of the AAO-HNS clinical practice guidelines.

MAIN OUTCOME MEASURES

The main outcome measures of this study is the extent to which tonsillectomy research is addressing the evidence gaps listed in the clinical practice guideline.

RESULTS

Of the 2519 studies included in our sample, 276 (11%) were relevant to the 18 recommendations made within the Tonsillectomy in Pediatric Patients clinical practice guideline. All but one of the recommendations was met by at least one study.

CONCLUSIONS

and Relevance: Our findings indicate that knowledge gaps within the guideline at publication may have since been addressed and a guideline update may thus be warranted.

LEVEL OF EVIDENCE

NA.

Conversion of Skeletal Society of Radiology annual meeting abstracts to publications in 2010-2015

Background

Material presented at conferences is meant to provide exposure to ongoing research that could affect medical decision making based on future outcomes. It is important then to evaluate the rates of publication from conference presentations as a measure of academic quality as such research has undergone peer review and journal acceptance. The purpose of this study is to evaluate the fate of abstracts presented at the Skeletal Society of Radiology Annual Meetings from 2010-2015.

Materials and Methods

Conference abstracts were searched using Google, Google Scholar, and PubMed (which includes Medline) to locate the corresponding published reports. The data recorded for published studies included date published online, in print, or both; the journal in which it was published; and the 5-year journal impact factor. When an abstract was not confirmed as published, authors were contacted by email to verify its publication status or, if not published, the reason for nonpublication.

Results

A total of 162 abstracts were published out of 320 presented (50.6%) at the SSR conferences from 2010 to 2015 with 59.9% (85/142) of publications occurring within two years of the conference date (not counting abstracts published prior to conference). Mean time to publication was 19 months and is calculated by excluding the 20 (12.3%) abstracts that were published prior to the conference date. The median time to publication is 13 months (25th-75th percentile: 6.25-21.75). The top two journals publishing research studies from this conference were Skeletal Radiology and The American Journal of Roentgenology. These journals accepted 72 of the 162 (44.4%) studies for publication. Of the 14 authors who responded with 17 reasons for not publishing, the most common reasons were lack of time (7-41.2%), results not important enough (4-23.5%), publication not an aim (3-17.6%), and lack of resources (3-17.6%).

Discussion

At least half of the abstracts presented at the annual meeting for the Society of Skeletal Radiology are accepted for publication in a peer-reviewed journal. The majority (59.9%) of these publications were achieved within two years of the conference presentation. The rate at which presentations are published and the journals that accept the abstracts can potentially be used to compare the importance and quality of information at conferences.

Clinical reasoning in unimodal interventions in patients with non-specific neck pain in daily physiotherapy practice, a Delphi study

BACKGROUND

Neck pain is the fourth major cause of disability worldwide but sufficient evidence regarding treatment is not available. This study is a first exploratory attempt to gain insight into and consensus on the clinical reasoning of experts in patients with non-specific neck pain.

OBJECTIVE

First, we aimed to inventory expert opinions regarding the indication for physiotherapy when, other than neck pain, no positive signs and symptoms and no positive diagnostic tests are present. Secondly, we aimed to determine which measurement instruments are being used and when they are used to support and objectify the clinical reasoning process. Finally, we wanted to establish consensus among experts regarding the use of unimodal interventions in patients with non-specific neck pain, i.e. their sequential linear clinical reasoning.

STUDY DESIGN

A Delphi study.

METHODS

A Web-based Delphi study was conducted. Fifteen experts (teachers and researchers) participated.

RESULTS

Pain alone was deemed not be an indication for physiotherapy treatment. PROMs are mainly used for evaluative purposes and physical tests for diagnostic and evaluative purposes. Eighteen different variants of sequential linear clinical reasoning were investigated within our Delphi study. Only 6 out of 18 variants of sequential linear clinical reasoning reached more than 50% consensus.

CONCLUSION

Pain alone is not an indication for physiotherapy. Insight has been obtained into which measurement instruments are used and when they are used. Consensus about sequential linear lines of clinical reasoning was poor.

Valuing Healthcare Improvement: Implicit Norms, Explicit Normativity, and Human Agency

I argue that greater attention to human agency and normativity in both researching and practicing service improvement may be one strategy for enhancing improvement science, illustrating with examples from cancer screening. Improvement science tends to deliberately avoid explicit normativity, for paradigmatically coherent reasons. But there are good reasons to consider including explicit normativity in thinking about improvement. Values and moral judgements are central to social life, so an adequate account of social life must include these elements. And improvement itself is unavoidably normative: it assumes that things could and should be better than they are. I seek to show that normativity will always be implicated in the creation of evidence, the design of programs, the practice of healthcare, and in citizens' judgements about that care, and to make a case that engaging with this normativity is worthwhile.

Barriers for nurses' participation in and utilisation of clinical research in three hospitals within the Kumasi Metropolis, Ghana

Introduction

Scientific research results are a necessary base for high quality nursing practice. The level of implementation of research in the clinical setting, including nurses' participation in and knowledge of research results, have gained considerable attention internationally. However, the remarkable international increase of such studies does not apply to the Ghanaian context. We therefore set out to evaluate the degree of involvement of nurses in research, as well as their utilization patterns of research findings in Ghana. Objectives: the study sought to investigate the proportion of nurses involved in clinical research as well as barriers for nurses' participation and utilization of research findings, within the Kumasi Metropolis area, Ghana.

Methods

A descriptive and analytical cross-sectional study design was used in this study. A 47 item questionnaire elicited data on 158 participants' demographics, the proportion and the barriers to participation, which was then analyzed using SSPS version 17 software. Qualitative interviews with key informants complemented quantitative survey data. In-depth interviews with nurse managers at the hospitals in focus was conducted and analyzed thematically.

Results

The study shows that 36.1% of the nurses, included in the study, had participated in research and only 25.3% of these had (knowingly) used specific research results in clinical practice. However, the level of research participation differed greatly between nurses working at different hospitals. Nurses' participation in clinical research was shown to be associated with their perception of benefit of research to practice as well as their understanding of time as a factor for them engaging in reading scientific articles. In addition, barriers associated with nurses' integration of research findings into the daily practice was their perceived lack of support from the collegium and their perception of research as not part of the nursing role.

Conclusion

Findings from the study suggest that there is a need to create institutional support to facilitate and encourage nurses' participation in research, yet also to formalize nurses' continuous professional development. This, could change nurses' attitudes towards research, and contribute to improving health care as it would increase nurses' role as agents for evidence based clinical practice.

A thematic analysis assessing clinical decision-making in antipsychotic prescribing for schizophrenia

BACKGROUND

In recent decades atypical antipsychotics have increased treatment options available for schizophrenia, however there is conflicting evidence concerning the trade-off between clinical efficacy and side effects for the different classes of antipsychotics. There has been a consistent increase in atypical antipsychotic prescribing compared to typical, despite evidence showing that neither class is superior. This leads to the question of whether prescribers are selective in their uptake of research evidence and clinical guidelines and if so, what influences their choice.. This study aims to identify the factors that contribute to the prescribing choice and how these can be used to aid knowledge translation and guideline implementation.

METHODS

A thematic analysis study was conducted using data from 11 semi-structured interviews with clinicians with experience in prescribing for schizophrenia.

RESULTS

The analysis identified five themes underpinning prescribing behaviour: (1) ownership and collaboration; (2) compromise; (3) patient involvement; (4) integrating research evidence; and (5) experience.

CONCLUSION

The themes mapped to various degrees onto current models of evidence-based decision making and suggest that there is scope to re-think the guideline implementation frameworks to incorporate recurring themes salient to clinicians who ultimately use the guidelines. This will further translation of future evidence into clinical practice, accelerating clinical progress.

Application of Bayesian evidence synthesis to modelling the effect of ketogenic therapy on survival of high grade glioma patients

Background

Ketogenic therapy in the form of ketogenic diets or calorie restriction has been proposed as a metabolic treatment of high grade glioma (HGG) brain tumors based on mechanistic reasoning obtained mainly from animal experiments. Given the paucity of clinical studies of this relatively new approach, our goal is to extrapolate evidence from the greater number of animal studies and synthesize it with the available human data in order to estimate the expected effects of ketogenic therapy on survival in HGG patients. At the same time we are using this analysis as an example for demonstrating how Bayesianism can be applied in the spirit of a circular view of evidence.

Results

A Bayesian hierarchical model was developed. Data from three human cohort studies and 17 animal experiments were included to estimate the effects of four ketogenic interventions (calorie restriction/ketogenic diets as monotherapy/combination therapy) on the restricted mean survival time ratio in humans using various assumptions for the relationships between humans, rats and mice. The impact of different biological assumptions about the relevance of animal data for humans as well as external information based on mechanistic reasoning or case studies was evaluated by specifying appropriate priors. We provide statistical and philosophical arguments for why our approach is an improvement over existing (frequentist) methods for evidence synthesis as it is able to utilize evidence from a variety of sources. Depending on the prior assumptions, a 30–70% restricted mean survival time prolongation in HGG patients was predicted by the models. The highest probability of a benefit (> 90%) for all four ketogenic interventions was obtained when adopting an enthusiastic prior based on previous case reports together with assuming synergism between ketogenic therapies with other forms of treatment. Combinations with other treatments were generally found more effective than ketogenic monotherapy.

Conclusions

Combining evidence from both human and animal studies is statistically possible using a Bayesian approach. We found an overall survival-prolonging effect of ketogenic therapy in HGG patients. Our approach is best compatible with a circular instead of hierarchical view of evidence and easy to update once more data become available.

Electronic supplementary material

The online version of this article (10.1186/s12976-018-0084-y) contains supplementary material, which is available to authorized users.

The clinical reasoning process in randomized clinical trials with patients with non-specific neck pain is incomplete: A systematic review

OBJECTIVE

Primarily to evaluate the completeness of the description of the clinical reasoning process in RCTs with patients with non-specific neck pain with an argued or diagnosed cause i.e. an impairment or activity limitation. Secondly, to determine the association between the completeness of the clinical reasoning process and the degree of risk of bias.

DATA SOURCES

Pubmed, Cinahl and PEDro were systematically searched from inception to July 2016.

STUDY SELECTION

RCTs (n = 122) with patients with non-specific neck pain receiving physiotherapy treatment published in English were included.

DATA EXTRACTION

Data extraction included study characteristics and important features of the clinical reasoning process based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)].

DATA SYNTHESIS

Thirty-seven studies (30%) had a complete clinical reasoning process of which 8 (6%) had a 'diagnosed cause' and 29 (24%) had an 'argued cause'. The Spearmans rho association between the extent of the clinical reasoning process and the risk of bias was -0.2.

CONCLUSIONS

In the majority of studies (70%) the described clinical reasoning process was incomplete. A very small proportion (6%) had a 'diagnosed cause'. Therefore, a better methodological quality does not necessarily imply a better described clinical reasoning process.

¿Es tiempo de exigir publicidad basada en la evidencia?

Claims made in current advertising for medical products is not necessarily scientifically proven, yet at the same time clinicians are required to adopt evidence-based practices and undergo periodic certifications. This is a clear contradiction. It is crucial to begin to reflect on the need to regulate information presented in the media and to place greater emphasis on patient well-being and safety instead of on third-party interests. The medical community must demand stricter regulations and evidence-based advertising policies.

[Pioneering surgical innovations in Germany : Part 1: generation of medical evidence]

BACKGROUND

In recent years research which conforms to evidence-based medicine (EBM) has been required even in surgery. Prospective, randomized studies are carried out in order to provide justification for the benefits of new procedures.

OBJECTIVE

The acquisition of special features in surgery with respect to the application of EBM.

MATERIAL AND METHODS

The investigation period selected was from1933 to 2013; therefore, all disciplines within the German Society of Surgery were questioned on the achievement of revolutionary innovations. The investigation was carried out utilizing personal interviews and a questionnaire. Only novel methods which were developed in Germany were considered. The survey was completed by carrying out research in database files.

RESULTS

During the past 80 years 15 pioneering innovations have been published in surgical research, although the prerequisites of EBM were only partly met. They appear to be based on the lowest level of evidence as these methods were mostly published as case reports or case series in journals with a low impact factor.

DISCUSSION

In general, innovative surgical procedures through top level research are still being published in the form of case reports or case series. This allows a rapid distribution of research results to the surgical community. Controlled studies still do not represent an alternative for the introduction of pioneering surgical innovations.

Assessing the evidence based medicine educational needs of community pharmacy preceptors within an experiential program in Qatar

INTRODUCTION

Observations have shown a lack of evidence-based medicine (EBM) knowledge and skills among community pharmacy preceptors in Qatar. These skills are important when delivering evidence-based recommendations to healthcare providers and patients. The aim of this study was to explore the community pharmacy preceptors' knowledge and understanding of EBM and to identify challenges in applying this approach to community practice.

METHODS

A survey instrument was developed to assess the knowledge of community pharmacy preceptors related to EBM. Knowledge-based questions were mapped according to National Association of Pharmacy Regulatory Authorities professional competencies for practicing pharmacists. The survey tool was administered to community pharmacy preceptors involved in mentoring Qatar University College of Pharmacy students.

RESULTS

Twenty-six community pharmacy preceptors completed the survey with a response rate of 65%. The knowledge-based questions linked to drug information resulted in 18%, 36%, and 46% of correct, incorrect, and unsure responses respectively while the critical appraisal questions showed 18%, 27%, 55% of correct, incorrect, and unsure responses respectively. Major barriers to practicing EBM included lack of EBM training (81%) and interpreting study results (80%).

CONCLUSIONS

Community pharmacy preceptors showed poor knowledge and understanding of EBM. These results and expressed needs by pharmacists support the development of a supplementary course to improve EBM skills.

The development of CHAMP: a checklist for the appraisal of moderators and predictors

Background

Personalized healthcare relies on the identification of factors explaining why individuals respond differently to the same intervention. Analyses identifying such factors, so called predictors and moderators, have their own set of assumptions and limitations which, when violated, can result in misleading claims, and incorrect actions. The aim of this study was to develop a checklist for critically appraising the results of predictor and moderator analyses by combining recommendations from published guidelines and experts in the field.

Methods

Candidate criteria for the checklist were retrieved through systematic searches of the literature. These criteria were evaluated for appropriateness using a Delphi procedure. Two Delphi rounds yielded a pilot checklist, which was tested on a set of papers included in a systematic review on reinforced home-based palliative care. The results of the pilot informed a third Delphi round, which served to finalize the checklist.

Results

Forty-nine appraisal criteria were identified in the literature. Feedback was obtained from fourteen experts from (bio)statistics, epidemiology and other associated fields elicited via three Delphi rounds. Additional feedback from other researchers was collected in a pilot test. The final version of our checklist included seventeen criteria, covering the design (e.g. a priori plausibility), analysis (e.g. use of interaction tests) and results (e.g. complete reporting) of moderator and predictor analysis, together with the transferability of the results (e.g. clinical importance). There are criteria both for individual papers and for bodies of evidence.

Conclusions

The proposed checklist can be used for critical appraisal of reported moderator and predictor effects, as assessed in randomized or non-randomized studies using individual participant or aggregate data. This checklist is accompanied by a user’s guide to facilitate implementation. Its future use across a wide variety of research domains and study types will provide insights about its usability and feasibility.

Electronic supplementary material

The online version of this article (10.1186/s12874-017-0451-0) contains supplementary material, which is available to authorized users.

SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax

This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group.

Building on evidence to improve patient care

Evidence-based medicine (EBM) is gaining importance in the current paediatric healthcare landscape. Improvement of paediatric health status is its major aim. However, for EBM to be successful, all stakeholders involved should understand what EBM really is, why and how EBM should or should not be practiced, and have the necessary skills to distinguish methodologically sound papers from biased opinion papers, and understand how and why guidelines are different from systematic reviews. Improving patient outcome requires attention to high-quality evidence and understanding of the processes of medical decision-making. Rigorous methodology is the cornerstone of guideline production, but in cases where quality evidence cannot be produced, as is often the case in paediatric nephrology because of low patient numbers, consensus-based guidance may be suitable to assist the practitioner at the bedside, as long as the underlying process is transparent. Most importantly, EBM should support patient involvement in a shared decision-making process. The more consistent and accurately predictable the effect of certain interventions is, clinically relevant to patients rather than affecting surrogate outcomes, and a priority for patients and other stakeholders, the more likely it is that adherence to the guidance provided will improve the outcome of patients.

Medicine Based Evidence for Individualized Decision Making: Case Study of Systemic Lupus Erythematosus

BACKGROUND

To guide management decisions for an index patient, evidence is required from comparisons between approximate matches to the profile of the index case, where some matches contain responses to treatment and others act as controls.

METHODS

We describe a method for constructing clinically relevant histories/profiles using data collected but unreported from 2 recent phase 3 randomized controlled trials assessing belimumab in subjects with clinically active and serologically positive systemic lupus erythematosus. Outcome was the Systemic lupus erythematosus Responder Index (SRI) measured at 52 weeks.

RESULTS

Among 1175 subjects, we constructed an algorithm utilizing 11 trajectory variables including 4 biological, 2 clinical, and 5 social/behavioral. Across all biological and social/behavioral variables, the proportion of responders based on the SRI whose value indicated clinical worsening or no improvement ranged from 27.5% to 42.3%. Kappa values suggested poor agreement, indicating that each biological and patient-reported outcome provides different information than gleaned from the SRI.

CONCLUSION

The richly detailed patient profiles needed to guide decision-making in clinical practice are sharply at odds with the limited information utilized in conventional randomized controlled trial analyses.

Evaluation of the current guidelines for resection of hepatocellular carcinoma using the Appraisal of Guidelines for Research and Evaluation II instrument

BACKGROUND & AIMS

Numerous guidelines for the management of hepatocellular carcinoma (HCC) have been developed. The Appraisal of Guidelines for Research & Evaluation (AGREE II) is the only validated instrument to assess the methodological quality of guidelines. We aim to appraise the methodological quality of existing guidelines for the resection of HCC using the AGREE II instrument.

METHODS

Cochrane, Medline, Google Scholar and Embase were searched using both PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria and free text. The assessment of the included clinical practice guidelines and consensuses were performed using the AGREE II instrument, version 2013. Guidelines with a score ⩾80% for the overall appraisal item were considered as applicable without modifications.

RESULTS

Literature searches identified 22 clinical practice guidelines. Five out of 22 guidelines passed the 70% mark on overall assessment, 11 out of 22 had shortcomings on indications, contraindications, side effects, key recommendations, technical aspects, transparency and health economics. Ten of 22 scored below the 50% mark showing that the guideline had low methodological and overall quality. Only 3/22 clinical practice guidelines were considered applicable without modifications.

CONCLUSIONS

The methodological quality of guidelines for the surgical management of HCC is generally poor. Future guideline development should be informed by the use of the AGREE II instrument. Guidelines based upon high quality evidence could improve stratification of patients and individualized treatment strategies. Lay summary: The methodology of clinical practice guidelines for resection for hepatocellular carcinoma (HCC) evaluated with the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument is generally poor. However, there are some clinical practice guidelines that are based upon higher quality evidence and can form the framework within which patients with HCC can be selected for surgical resection. Future guideline development should be informed by the use of the AGREE II instrument.

Shared decision making: relevant concepts and facilitating strategies

As the paradigm in healthcare nowadays is the evidence-based, patient-centered decision making, the issue of shared decision making (SDM) is highlighted. The aims of this manuscript were to look at the relevant concepts and suggest the facilitating strategies for overcoming barriers of conducting SDM. While the definitions of SDM were discordant, several concepts such as good communication, individual autonomy, patient participants, and patient-centered decision-making were involved. Further, the facilitating strategies of SDM were to educate and train physician, to apply clinical practice guidelines and patient decision aids, to develop valid measurement tools for evaluation of SDM processes, and to investigate the impact of SDM.

Factors influencing the clinical decision-making of midwives: a qualitative study

Background

Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives’ decisions are based on more than the evidence based medicine (EBM) model – i.e. clinical evidence, midwife’s expertise, and woman’s values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently.

Methods

We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives’ clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts.

Results

We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives’ clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged.

Conclusion

Midwives’ clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are actually made.

Sample size and number of outcome measures of veterinary randomised controlled trials of pharmaceutical interventions funded by different sources, a cross-sectional study

Background

Randomised controlled trials (RCTs) are a key component of the veterinary evidence base. Sample sizes and defined outcome measures are crucial components of RCTs.

To describe the sample size and number of outcome measures of veterinary RCTs either funded by the pharmaceutical industry or not, published in 2011.

Methods

A structured search of PubMed identified RCTs examining the efficacy of pharmaceutical interventions. Number of outcome measures, number of animals enrolled per trial, whether a primary outcome was identified, and the presence of a sample size calculation were extracted from the RCTs. The source of funding was identified for each trial and groups compared on the above parameters.

Results

Literature searches returned 972 papers; 86 papers comprising 126 individual trials were analysed. The median number of outcomes per trial was 5.0; there were no significant differences across funding groups (p = 0.133). The median number of animals enrolled per trial was 30.0; this was similar across funding groups (p = 0.302). A primary outcome was identified in 40.5% of trials and was significantly more likely to be stated in trials funded by a pharmaceutical company. A very low percentage of trials reported a sample size calculation (14.3%).

Conclusions

Failure to report primary outcomes, justify sample sizes and the reporting of multiple outcome measures was a common feature in all of the clinical trials examined in this study. It is possible some of these factors may be affected by the source of funding of the studies, but the influence of funding needs to be explored with a larger number of trials. Some veterinary RCTs provide a weak evidence base and targeted strategies are required to improve the quality of veterinary RCTs to ensure there is reliable evidence on which to base clinical decisions.

Electronic supplementary material

The online version of this article (10.1186/s12917-017-1207-0) contains supplementary material, which is available to authorized users.

An Australian general practice based strategy to improve chronic disease prevention, and its impact on patient reported outcomes: evaluation of the preventive evidence into practice cluster randomised controlled trial

BACKGROUND

Implementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care.

METHODS

PEP Intervention practices received education, clinical audit and feedback and practice facilitation. Patients (40‑69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires. Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar's test and multilevel analysis was used to determine the effect of the intervention on follow-up scores.

RESULTS

Five hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes.

CONCLUSIONS

The lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.

Support for reporting guidelines in surgical journals needs improvement: A systematic review

INTRODUCTION

Evidence-based medicine works best if the evidence is reported well. Past studies have shown reporting quality to be lacking in the field of surgery. Reporting guidelines are an important tool for authors to optimize the reporting of their research. The objective of this study was to analyse the frequency and strength of recommendation for such reporting guidelines within surgical journals.

METHODS

A systematic review of the 198 journals within the Journal Citation Report 2014 (surgery category) published by Thomson Reuters was undertaken. The online guide for authors for each journal was screened by two independent groups and results compared. Data regarding the presence and strength of recommendation to use reporting guidelines was extracted.

RESULTS

193 journals were included (as five appeared twice having changed their name). These had a median impact factor of 1.526 (range 0.047-8.327), with a median of 145 articles published per journal (range 29-659), with 34,036 articles published in total over the two-year window 2012-2013. The majority (62%) of surgical journals made no mention of reporting guidelines within their guidelines for authors. Of the 73 (38%) that did mention them, only 14% (10/73) required the use of all relevant reporting guidelines. The most frequently mentioned reporting guideline was CONSORT (46 journals).

CONCLUSIONS

The mention of reporting guidelines within the guide for authors of surgical journals needs improvement. Authors, reviewers and editors should work to ensure that research is reported in line with the relevant reporting guidelines. Journals should consider hard-wiring adherence to them.

Missed opportunities in the evaluation of public health interventions: a case study of physical activity programmes

BACKGROUND

Evidence-based approaches are requisite in evaluating public health programmes. Nowhere are they more necessary than physical activity interventions where evidence of effectiveness is often poor, especially within hard to reach groups. Our study reports on the quality of the evaluation of a government funded walking programme in five 'Walking Cities' in England. Cities were required to undertake a simple but robust evaluation using the Standard Evaluation Framework (SEF) for physical activity interventions to enable high quality, consistent evaluation. Our aim was not to evaluate the outcomes of this programme but to evaluate whether the evaluation process had been effective in generating new and reliable evidence on intervention design and what had worked in 'real world' circumstances.

METHODS

Funding applications and final reports produced by the funder and the five walking cities were obtained. These totalled 16 documents which were systematically analysed against the 52 criteria in the SEF. Data were cross checked between the documents at the bid and reporting stage with reference to the SEF guidance notes.

RESULTS

Generally, the SEF reporting requirements were not followed well. The rationale for the interventions was badly described, the target population was not precisely specified, and neither was the method of recruitment. Demographics of individual participants, including socio-economic status were reported poorly, despite being a key criterion for funding.

CONCLUSIONS

Our study of the evaluations demonstrated a missed opportunity to confidently establish what worked and what did not work in walking programmes with particular populations. This limited the potential for evidence synthesis and to highlight innovative practice warranting further investigation. Our findings suggest a mandate for evaluability assessment. Used at the planning stage this may have ensured the development of realistic objectives and crucially may have identified innovative practice to implement and evaluate. Logic models may also have helped in the development of the intervention and its means of capturing evidence prior to implementation. It may be that research-practice partnerships between universities and practitioners could enhance this process. A lack of conceptual clarity means that replicability and scaling-up of effective interventions is difficult and the opportunity to learn from failure lost.

Sponsorship bias and quality of randomised controlled trials in veterinary medicine

BACKGROUND

Randomised controlled trials (RCTs) are considered the gold standard form of evidence for assessing treatment efficacy, but many factors can influence their reliability including methodological quality, reporting quality and funding source. The aim of this study was to examine the relationship between funding source and positive outcome reporting in veterinary RCTs published in 2011 and to assess the risk of bias in the RCTs identified.

METHODS

A structured search of PubMed was used to identify feline, canine, equine, bovine and ovine clinical trials examining the efficacy of pharmaceutical interventions published in 2011. Funding source and outcomes were extracted from each RCT and an assessment of risk of bias made using the Cochrane risk of bias tool.

RESULTS

Literature searches returned 972 papers, with 86 papers (comprising 126 individual RCTs) included in the analysis. There was found to be a significantly higher proportion of positive outcomes reported in the pharmaceutical funding group (P) compared to the non-pharmaceutical (NP) and 'no funding source stated' (NF) groups (P = 56.9%, NP = 34.9%, NF = 29.1%, p < 0.05). A high proportion of trials had an unclear risk of bias across the five criteria examined.

CONCLUSIONS

We found evidence that veterinary RCTs were more likely to report positive outcomes if they have pharmaceutical industry funding or involvement. Consistently poor reporting of trials, including non-identification of funding source, was found which hinders the use of the available evidence.

Barriers to the conduct of randomised clinical trials within all disease areas

Background

Randomised clinical trials are key to advancing medical knowledge and to enhancing patient care, but major barriers to their conduct exist. The present paper presents some of these barriers.

Methods

We performed systematic literature searches and internal European Clinical Research Infrastructure Network (ECRIN) communications during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project.

Results

The following barriers to randomised clinical trials were identified: inadequate knowledge of clinical research and trial methodology; lack of funding; excessive monitoring; restrictive privacy law and lack of transparency; complex regulatory requirements; and inadequate infrastructures. There is a need for more pragmatic randomised clinical trials conducted with low risks of systematic and random errors, and multinational cooperation is essential.

Conclusions

The present paper presents major barriers to randomised clinical trials. It also underlines the value of using a pan-European-distributed infrastructure to help investigators overcome barriers for multi-country trials in any disease area.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2099-9) contains supplementary material, which is available to authorized users.

Improving the healthcare response to domestic violence and abuse in sexual health clinics: feasibility study of a training, support and referral intervention

Objectives

Sexual health and gynaecological problems are the most consistent and largest physical health differences between abused and non-abused female populations. Sexual health services are well placed to identify and support patients experiencing domestic violence and abuse (DVA). Most sexual health professionals have had minimal DVA training despite English National Institute for Health and Care Excellence recommendations. We sought to determine the feasibility of an evidence-based complex DVA training intervention in female sexual health walk-in services (IRIS ADViSE: Identification and Referral to Improve Safety whilst Assessing Domestic Violence in Sexual Health Environments).

Methods

An adaptive mixed method pilot study in the female walk-in service of two sexual health clinics. Following implementation and evaluation at site 1, the intervention was refined before implementation at site 2. The intervention comprised electronic prompts, multidisciplinary training sessions, clinic materials and simple referral pathways to IRIS ADViSE advocate-educators (AEs). The pilot lasted 7 weeks at site 1 and 12 weeks at site 2. Feasibility outcomes were to assign a supportive DVA clinical lead, an IRIS ADViSE AE employed by a local DVA service provider, adapt electronic records, develop local referral pathways, assess whether enquiry, identification and referral rates were measurable.

Results

Both sites achieved all feasibility outcomes: appointing a supportive DVA clinical lead and IRIS ADViSE AE, establishing links with a local DVA provider, adapting electronic records, developing local referral pathways and rates of enquiry, identification and referral were found to be measurable. Site 1: 10% enquiry rate (n=267), 4% identification rate (n=16) and eight AE referrals. Site 2: 61% enquiry rate (n=1090), a 7% identification rate (n=79) and eight AE referrals.

Conclusions

IRIS ADViSE can be successfully developed and implemented in sexual health clinics. It fulfils the unmet need for DVA training. Longer-term evaluation is recommended.

Anthropologists in Global Health Experiments

Can global health experiments be part of more flexible systems of knowledge generation, where different bodies of knowledge come together to provide understanding not only of the outcomes of new interventions but also of the mechanisms through which they affect people's well-being and health? Building past work in which they tried to transform how global health experiments are carried out and inspired by the articles in this special issue, the authors of this commentary argue that strategic collaboration is needed to break the hegemony of randomized controlled trials in designing global health technologies. More open-ended experiments are possible if anthropologists team up with innovative researchers in biomedicine to develop new conceptual models and to adopt novel observational techniques and 'smart' trials that incorporate ethnography to unravel complex interactions between local biologies, attributes of health systems, social infrastructures, and users' everyday lives.