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Evidence-Based Medicine current issue



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What evidence affects clinical practice? An analysis of Evidence-Based Medicine commentaries

2017-11-24T05:51:09-08:00

Evidence-Based Medicine (EBM) published by BMJ aims to alert clinicians to significant advances in healthcare by selecting original and systematic review articles, from 100 candidate journals, whose results are likely to be both reliable and useful.1 We select articles if they concern topics relevant to internal medicine, general and family practice, surgery, emergency and critical care, psychiatry, paediatrics or obstetrics and gynaecology. Articles are summarised in value-added abstracts and commented on by clinical experts in the field.

To better understand the impact our choices may have on clinical practice, we audited 1 year’s worth of the journal’s commentaries, asking what journals we select from, what types of studies we choose and whether we identify articles likely to change practice.

To do this, we surveyed EBM commentaries published between December 2016 and September 2017 and extracted the following information: study type, original journal, setting and type of intervention. We...




Controversies in PSA screening

2017-11-24T05:51:09-08:00

Forty years after its discovery, a reanalysis of the two largest trials to date, controversially suggests that prostate-specific antigen (PSA) screening may actually be beneficial.

Most healthcare organisations do not recommend PSA screening for prostate cancer,1 2 mainly in response to conflicting evidence about the benefits and clear evidence of harms. PSA can lead to false positive or ‘overdiagnosed’ cancer (detecting prostate cells that histologically represent cancer, but will never grow to cause a patient harm).

Evidence regarding efficacy has been based on two large randomised controlled trials: The European Randomised Study of Screening for Prostate Cancer (ERSPC)3 and Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO).4 These trials are both considered to be of high quality, but the trials came to substantially different conclusions. The ERSPC showed a significant decrease in mortality in men screened with PSA compared with those...




Interpreting diagnostic tests with continuous results and no gold standard: a common scenario explained using the tuberculin skin test

2017-11-24T05:51:09-08:00

Practitioners of evidence-based medicine commonly encounter diagnostic tests with continuous results and no gold standard. In contrast, the traditional critical appraisal teachings assume a binary test (2x2 table) with a gold standard. In this guide, we use the example of the tuberculin skin test to illustrate a simple approach facilitated by using stratum-specific likelihood ratios and odds of developing future patient-important events. This approach can aid practitioners in the interpretation and application of diagnostic tests to patient care.




Ten essential papers for the practice of evidence-based medicine

2017-11-24T05:51:09-08:00

In this article we signpost readers to 10 papers we consider essential reading for anyone starting out on an evidence-based medicine journey. We have considered papers consisting a mix of old and new, seminal and cutting-edge that offer insight into what evidence-based medicine is, where it came from, why it matters and what it has achieved. This is balanced against some of the common criticisms of evidence-based medicine and efforts to tackle them. We have also highlighted papers acknowledging the importance of teaching and learning of the principles of evidence-based medicine and how health professionals can better use evidence in clinical decisions with patients.




What data sources do ophthalmologists trust?

2017-11-24T05:51:09-08:00

To survey ophthalmologists regarding sources they trust when incorporating new medical knowledge into their practice. The survey was distributed primarily to US-based ophthalmologists. Questions were derived based on the lead author’s research experience from congresses and discussions and from mentions in the medical literature. In total, 77 physicians completed the survey of 1886 sent (4% response rate). Regarding study design, physicians preferred a well-controlled, randomised, double-masked trial (99%) with multicentred investigational site across a wide geographical area (80%). Authorship of a research article was most desired from a well-known key opinion leader (KOL) (75%) or any KOL leader at a university (75%). The most selected journal type was a subspecialty publication (86%) and second a multispecialty high impact journal (77%). Study sponsorship was most desired from the NIH or other government agencies (71%) or a university (71%). Doctors preferred clinical opinions from an ophthalmic medical society (75%). For the source of new clinical data, physicians indicated an unsponsored peer-reviewed journal article (77%) or a lecture at a large ophthalmic congress (74%) as the preferred source. Ophthalmologists generally desire sponsors, study designs and opinions that appear free of bias on which to base their clinical practice decisions.




Routine prophylaxis is not necessary to prevent renal scarring in children with urinary tract infection

2017-11-24T05:51:09-08:00

Commentary on: Hewitt IK, Pennesi M, Morello W, et al. Antibiotic prophylaxis for urinary tract infection-related renal scarring: a systematic review. Pediatrics 2017;139:e20163145.

Context

Renal scarring is a potentially serious long-term complication of acute pyelonephritis, and the risk increases significantly in children with high-grade vesicoureteral reflux (VUR) and recurrent urinary tract infection (UTI).1 For decades it has been a common practice to use antimicrobial prophylaxis or surgical correction to prevent recurrent UTI and renal scarring in children with VUR. Some recent studies have shown that antimicrobial prophylaxis significantly decreases the risk of UTI recurrence in children with VUR but does not significantly impact the risk of renal scarring when compared with placebo or no treatment.2 3

Methods

A review of the literature and a meta-analysis were done to evaluate the effect of antibiotic prophylaxis on UTI-related renal scarring. Medline, Embase and the Cochrane Controlled...




Supplementary antimicrobials for patients with HIV and <100 CD4 cells/{micro}L are associated with improved survival

2017-11-24T05:51:09-08:00

Commentary on: Hakim J, Musiime V, Szubert AJ, et al. Enhanced Prophylaxis plus Antiretroviral Therapy for Advanced HIV Infection in Africa. N Engl J Med 2017;377:233–45.

Context

Despite expansion of HIV testing and recommendations to start antiretroviral therapy (ART) immediately, people living with HIV (PLWH) often present late in the disease. In poorer countries, 30%–40% of PLWH starting ART have CD4 counts <200 cells/µL and 20% have a CD4 count <100 cells/µL.1 PLWH with advanced immunosuppression are at greater risk for complications and death, and their care is more complex than those with early disease.

The WHO promotes differentiated service delivery2—a strategy that varies the intensity, frequency and location of treatment. To date, this has focused on deintensifying treatment for patients with higher CD4 counts. Hakim and colleagues offer a strategy for PLWH presenting with advanced disease.3

Methods

The Reduction of Early Mortality in HIV-Infected Adults...




Unblinded ASCOT study results do not rule out that muscle symptoms are an adverse effect of statins

2017-11-24T05:51:09-08:00

Commentary on: Gupta A and ASCOT investigators. Adverse events associated with unblinded, but not with blinded, statin therapy in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial and its non-randomised non-blind extension phase. Lancet 2017;389:2473–81.

Context

Several studies suggest that the low adherence rates with statin therapy are related to adverse events, particularly statin-associated muscle symptoms (SAMS).1 Rates of SAMS are found to be much higher in observational studies (10%–20%) compared with randomised controlled trials (RCTs) (1%–3%), which often find little difference in adverse events between statin and placebo groups.2 3 This study, having both blinded and unblinded phases, offers a unique perspective in looking at adverse events with statin therapy.

Methods

The first trial phase was a randomised, blinded phase that included 10 180 patients aged 40–79 years with hypertension, at least three cardiovascular risk factors, total...




SOFA criteria predict infection-related in-hospital mortality in ICU patients better than SIRS criteria and the qSOFA score

2017-11-24T05:51:09-08:00

Commentary on: Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. JAMA 2017;317:290–300.

Context

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) has redefined sepsis, now defining sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection, with organ failure defined as a two-or-more-point change in the Sequential Organ Failure Assessment (SOFA) score.1 The new sepsis definition was determined in a retrospective cohort of both intensive care unit (ICU) and non-ICU encounters.2 The quick SOFA (qSOFA) score (altered mentation, systolic blood pressure ≤100 mm Hg and respiratory rate ≥22/min) was also introduced as a possible useful predictive tool among patients outside the ICU.

Methods

This external validation study compares the discrimination of three measures in the...




Prescribing antibiotics to hospitalised patients increases the risk of Clostridium difficile infection for the next bed occupant

2017-11-24T05:51:09-08:00

Commentary on: Freedberg DE, Salmasian H, Cohen B, et al. Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed. JAMA Intern Med 2016;176:1801–8.

Context

Patients are at heightened risk of Clostridium difficile-associated disease when they are exposed to both the organism and to antibiotic treatments, which deplete their normal, diverse, protective gastrointestinal flora. Both of these factors are prevalent in healthcare facilities, and thus C. difficile is the most common and most burdensome hospital-acquired pathogen.1 The hazards of antibiotic use may extend beyond the individual patient. As ward-level antibiotic use increases, so too does an individual patient’s risk of C. difficile infection, even when he or she has not directly received antibiotics.2 In this study, Freedberg et al aim to provide perhaps the most direct evidence of the indirect hazards of antibiotic use on the...




Cephalexin plus trimethoprim-sulfamethoxazole was not superior to cephalexin alone for the treatment of outpatient non-purulent cellulitis

2017-11-24T05:51:09-08:00

Commentary on: Moran GJ, Krishnadasan A, Mower WR, et al. Effect of cephalexin plus trimethoprim-sulfamethoxazole vs cephalexin alone on clinical cure of uncomplicated cellulitis: a randomised clinical trial. JAMA 2017;317:2088–96.

Context

Skin infections are one of the most common infections in ambulatory medicine. Yet, despite the high incidence of these infections, there remain questions about optimal treatment of cellulitis without abscess. Cellulitis without abscess is particularly challenging, as the aetiology of this infection remains relatively elusive. Studies employing molecular diagnostic techniques for bacteria from needle biopsies of cellulitis have failed to determine the aetiology of cellulitis without abscess. Current thinking is that cellulitis is usually caused by Group A Streptococcus and occasionally Staphylococcus aureus, possibly including methicillin-resistant S. aureus (MRSA). However, the relative contribution of these pathogens is unclear and the need to include anti-MRSA therapy as part of treatment for cellulitis without abscess is unclear. A small clinical trial found no...




Adjunctive antibiotics for drained skin abscesses improve clinical cure rate

2017-11-24T05:51:09-08:00

Commentary on: Daum RS, Miller LG, Immergluck LA, et al. Placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med 2017;376:2545–55.

Context

The primary treatment of a skin abscess is drainage. Past studies of adjunctive antibiotic treatment conducted before and after the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) in the USA and other parts of the world were small and did not clearly demonstrate benefit. In 2016, Talan et al1 reported a US randomised placebo-controlled trial (RCT) among 1265 mostly adults, including some with co-morbidities, which demonstrated that treatment with an antibiotic possessing in vitro activity against MRSA, trimethoprim–sulfamethoxazole (TMP-SMX), was associated with a significantly higher short-term cure rate among patients with a drained skin abscess ≥2 cm in diameter. TMP-SMX-treated participants also had fewer additional drainage procedures and new site skin infections through 4–6 post-treatment. Overall adverse event rates were similar, with slightly more mostly...




Ocrelizumab appears to reduce relapse and disability in multiple sclerosis but quality of evidence is moderate

2017-11-24T05:51:09-08:00

Commentary on: Hauser SL, Bar-Or A, Comi G, et al. Ocrelizumab versus interferon Beta-1a in relapsing multiple sclerosis. N Engl J Med 2017;376:221–34. Montalban X, Hauser SL, Kappos L, et al. Ocrelizumab versus placebo in primary progressive multiple sclerosis. N Engl J Med 2017;376:209–20.

Context

Multiple sclerosis (MS) is a chronic, immune-mediated disorder of the central nervous system, and one of the most common causes of disability in young people, with an annual incidence ranging from 2 to 10 cases/100 000 persons/year. The disease is classified as either relapsing-remitting MS (RRMS) or primary progressive MS (PPMS) based on the initial disease course.1 People with RRMS have recurrent episodes of neurological deficit (relapses) followed by periods of remission and over time an accumulation of residual deficits and a slow progression of fixed disability supervene in about 80% of them (secondary progressive MS). Approximately, 15% of people with PPMS have a slowly progressive course from...




In patients with localised prostate cancer, active surveillance is associated with better sexual function, urinary symptoms and bowel symptoms

2017-11-24T05:51:09-08:00

Commentary on: Chen RC, Basak R, Meyer AM, et al. Association between choice of radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance and patient-reported quality of life among men with localised prostate cancer. JAMA 2017;317:1141–50.

Context

Many patients with prostate cancer are diagnosed with low-risk disease only, for whom the benefit of surgery or radiation on life expectancy may be very limited, while still bringing the risk of side effects.1 2 Therefore, patients with low-risk prostate cancer are currently offered the option of active surveillance. This strategy delays therapy with curative intent until progression occurs, or it may completely avoid radical treatment.3 As a result, in the treatment decision-making process of patients newly diagnosed with prostate cancer, up-to-date and preferably personalised information about the possible positive and negative effects of the treatment options is vital.

Methods

Chen and colleagues conducted a US...




A meta-analysis of positive airway pressure treatment for cardiovascular prevention: why mix apples and pears?

2017-11-24T05:51:09-08:00

Commentary on: Yu J, Zhou Z, McEvoy RD, et al. Association of positive airway pressure with cardiovascular events and death in adults with sleep apnea: a systematic review and meta-analysis. JAMA 2017;318:156–66.

Context

Despite an increasing body of evidence supporting an independent association between sleep apnoea and cardiovascular outcomes, there is still a lack of convincing data to suggest that treating this disorder reduces the cardiovascular risk. Sleep apnoea may be either obstructive (OSA) or central (CSA), or of a combination of both types, especially in patients with concomitant cardiovascular disease (CVD). Randomised controlled trials (RCT) have shown that continuous positive airway pressure (CPAP) treatment reduces excessive daytime sleepiness and improves quality of life in sleepy patients with OSA.1 Randomisation of patients with this phenotype to no treatment has been considered unethical. Thus, the long-term RCTs during the last decade have been focused on asymptomatic or minimally symptomatic...




Intensive glucose control in patients with diabetes prevents onset and progression of microalbuminuria, but effects on end-stage kidney disease are still uncertain

2017-11-24T05:51:09-08:00

Commentary on: Ruospo M, Saglimbe VM, Palmer SC, et al. Glucose targets for preventing diabetic kidney disease and its progression. Cochrane Database Syst Rev 2017;6:CD010137.

Context

Diabetic kidney disease (DKD) is the leading cause of end-stage kidney disease (ESKD). Randomised controlled trials (RCTs) suggest that intensive glycaemic control reduces progression of albuminuria, but effects on later DKD stages and cardiovascular outcomes are less clear. This systematic review evaluated the benefits and harms of intensive versus standard glycaemic control on the onset and progression of DKD and mortality.

Methods

This meta-analysis of published tabular data included RCTs assigning patients with diabetes (type 1 or 2) with and without kidney disease to intensive (glycated haemoglobin (HbA1c) <7% or fasting blood glucose (FBG) <6.6 mmol/L) or standard glycaemic control (HbA1c ≥7% or FBG ≥6.6 mmol/L). Primary outcomes were doubling of serum creatinine, ESKD, and death or non-fatal myocardial infarction or stroke. Secondary outcomes included measures of albuminuria, serum creatinine,...




Dont put off until tomorrow what you can do today: Early cholecystectomy is cost-effective in symptomatic cholelithiasis requiring hospitalization

2017-11-24T05:51:09-08:00

Commentary on: Sutton AJ, Vohra RS, Hollyman M, et al. Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology. Br J Surg 2016;104:98–107.

Context

Randomised trial and population-based data support the clinical benefit of early over delayed laparoscopic cholecystectomy for acute cholecystitis.1 Concern of increased risk of major bile duct injury or death with early surgery in the setting of acute inflammation has been refuted and there is 20%–30% risk of recurrent gallstone symptoms if surgery is delayed.2 Early and delayed surgery have also been previously compared with economic models informed by randomised controlled trial and population-based data. While most studies have focused on acute cholecystitis, Sutton and colleagues have considered patients across the spectrum of symptomatic cholelithiasis—biliary colic and cholecystitis—requiring hospitalisation.

Methods

This study is a model-based cost-utility analysis. An economic model, with a time horizon of 1 year, compared early versus delayed...




Minimal difference in survival between radical prostatectomy and observation in men with modest life expectancy

2017-11-24T05:51:09-08:00

Commentary on: Wilt TJ, Jones KM, Barry MJ, et al. Follow-up of prostatectomy versus observation for early prostate cancer. N Engl J Med 2017;377:132–42.

Context

Screening, diagnosis and management of localised prostate cancer remains controversial.

Methods

Prostate Cancer Intervention Versus Observation Trial (PIVOT) was a randomised controlled trial that accrued 731 men with prostate cancer (PCa) between 1994 and 2002 from Veterans Affairs hospitals. Patients were randomised to radical prostatectomy (n=364) or observation (n=367). Inclusion criteria was clinical stage T1–T2 (organ confined), prostate-specific antigen (PSA) <50 ng/mL, age ≤75 years and estimated life expectancy >10 years. Primary and secondary outcomes were all-cause and prostate-cancer mortality.

Findings

Median age was 67 years, median PSA 7.8 ng/mL and 45% of patients were clinical stage T2 (palpable on exam). After 19.5 years follow-up (median 12.7 years), cumulative all-cause mortality was similar between surgery and observation (61.3% vs 66.8%; HR 0.84; 95% CI 0.70 to 1.01, P=0.06)....




Protocolised early goal-directed therapy in patients with sepsis/septic shock does not result in improved survival compared with usual care with less invasive resuscitation strategies

2017-11-24T05:51:09-08:00

Commentary on: Rowan KM, Angus DC, Bailey M, et al. Early, goal-directed therapy for septic shock – a patient-level meta-analysis. N Engl J Med 2017;376:2223–34.

Context

Early goal-directed therapy for sepsis/septic shock became the standard of care as advocated by the 2004 Surviving Sepsis Campaign Guidelines.1 This guidance was based on a single-centre randomised controlled trial (RCT) by Rivers et al2 involving 263 patients with sepsis/septic shock admitted to emergency departments. However, three recent multicentre, early goal-directed therapy RCTs3–5 were unable to replicate the treatment effects observed by Rivers et al.2 The current Surviving Sepsis Campaign Guidelines revised the resuscitation recommendations to administering at least 30 mL/kg of intravenous crystalloids in the first 3 hours of sepsis management.1 This commentary reviews the Protocolised Resuscitation in Sepsis Meta-Analysis (PRISM) study,6 which reports the preplanned individual...




Stent choice in cardiogenic shock complicating acute myocardial infarction likely does not affect mortality or reinfarction

2017-11-24T05:51:09-08:00

Commentary on: Ledwoch J, Fuernau G, Desch S, et al. Drug-eluting stents versus bare-metal stents in acute myocardial infarction with cardiogenic shock. Heart 2017;103:1177–84.

Context

Early revascularisation improves acute and long-term outcomes of patients presenting with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). However, which type of stent to use for revascularisation remains controversial. Earlier small single-centre non-randomised study and registry data concluded that a drug-eluting stent (DES) is superior to a bare metal stent (BMS) as it improved clinical outcomes in these patients.1 2 Current European Society Guidelines recommend the use of DES, while American Society guidelines do not. This study examined the impact of BMS versus DES use on clinical outcomes in patients who had participated in the previously reported the Intra-aortic Balloon Pump (IABP) in Cardiogenic Shock II Trial (IABP-SHOCK II) which showed that IABP use did not reduce mortality.3




Prophylactic platelet transfusion does not reduce risk of clinical bleeding in adults with dengue and thrombocytopaenia

2017-11-24T05:51:09-08:00

Commentary on: Lye DC, Archuleta S, Syed-Omar SF, et al. Prophylactic platelet transfusion plus supportive care versus supportive care alone in adults with dengue and thrombocytopenia: a multicentre, open-label, randomised, superiority trial. Lancet 2017;389:1611–18.

Context

Dengue is the fastest growing vector-borne viral disease worldwide afflicting nearly 390 million people in 2010 with 96 million having clinically apparent infection.1 The clinical spectrum of dengue infection can vary from asymptomatic infection to life-threatening dengue shock syndrome.2 3 Thrombocytopaenia is a common manifestation of dengue infection. However, a correlation between platelet count and risk of clinical bleeding in dengue has not been established. A number of observational studies4 and a small randomised trial5 have shown lack of effectiveness of prophylactic platelet transfusion in preventing clinical bleeding in adults with dengue and thrombocytopaenia. This larger randomised trial compared prophylactic platelet transfusion plus supportive care...




Acute myocardial infarction can be ruled out with a single high-sensitivity cardiac troponin T level

2017-11-24T05:51:09-08:00

Commentary on: Pickering JW, Than P, Cullen L, et al. Rapid rule-out of acute myocardial infarction with a single high-sensitivity cardiac troponin T measurement below the limit of detection. Ann Intern Med 2017;166:715–24.

Context

Historically, it has been regarded that at least two measurements of cardiac biomarkers, with 6 hours in between, are needed in order to rule out acute myocardial infarction (AMI). With the introduction of high-sensitivity cardiac troponin (hs-cTn) assays, the time it takes to detect signs of myocyte necrosis has shortened considerably.1 In an observational cohort study published in 2014, it was found that the risk of AMI within 30 days was 0.2% if the first high-sensitivity cardiac troponin T (hs-cTnT) measurement was <5 ng/L.2 The authors suggested that it was safe to discharge all patients with chest pain with a non-ischaemic ECG, if the first hs-cTnT was <5 ng/L. However, the safety of this strategy has been questioned. Therefore,...




Early invasive strategy should be performed within 72 hours in high-risk patients with non-ST-elevation myocardial infarction

2017-11-24T05:51:09-08:00

Commentary on: Jobs A, Mehta SR, Montalescot G, et al. Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet 2017;390:737–46.

Context

The mainstay of treatment for patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) is medical therapy, early coronary angiography and revascularisation. A routine invasive strategy has been shown to reduce all-cause death and myocardial infarction  compared with a conservative approach at 5 years.1 Therefore, an early invasive strategy with intent to perform revascularisation is advocated in the 2014 American and European guidelines with a class I recommendation.2 3 While immediate angiography is recommended for extremely high-risk patients (eg, haemodynamic or electrical instability, persistent angina, heart failure or worsening mitral regurgitation), the optimal timing for an invasive approach in patients without the aforementioned risk characteristics remains undefined.

Methods

Jobs and colleagues performed...




Long-acting reversible contraception acceptability and satisfaction is high among adolescents

2017-11-24T05:51:09-08:00

Commentary on: Diedrich JT, Klein DA, Peipert JF, et al. Long-acting reversible contraception in adolescents: a systematic review and meta-analysis. Am J Obstet Gynecol 2017;216:364.e1-364.e12.

Context

Long-acting reversible contraception (LARC) consists of intrauterine devices and subdermal implants. LARC is in the highest tier of effectiveness and once started, most women tend to be satisfied and use it for long durations. Historically, LARC use has been concentrated in older, higher parity populations. Dissatisfaction or weariness with shorter-term contraceptives often leads women to try LARC; in addition, LARC retention (continued use) may be linked to stage of life and more resolute, long-term intentions. Thus, most of what we know about LARC effectiveness is biased by self-selection, user characteristics and needs.

Women aged 15–19 are not typical LARC users; among those on contraception, 4% use LARC.1 Difficult-to-use, short-term products are the mainstay and it is this situation that often leads to...




Acupuncture is not as effective as infertility treatment in women with PCOS

2017-11-24T05:51:09-08:00

Commentary on: Wu XK, Stener-Victorin E, Kuang HY, et al. Effect of acupuncture and clomiphene in Chinese women with polycystic ovary syndrome: a randomised clinical trial. JAMA 2017;317:2502–14.

Context

Ovulatory dysfunction is considered to be one of the major characteristics of polycystic ovary syndrome (PCOS), which affects 5%–10% of women of reproductive age and leads to 70%–80% of anovulatory infertility. Many ovulation induction treatments, including clomiphene citrate, letrozole, exogenous gonadotropin and laparoscopic ovarian drilling, have limited effectiveness, safety and negative side effects. Acupuncture has been used in eastern Asian countries for thousands of years, and the use of acupuncture in reproductive endocrinology and infertility is becoming popular in research and clinical practice. Several clinical and animal experimental studies indicate that acupuncture may improve ovulation frequency by improving endocrine profile and normalising insulin sensitivity.1 2 However, evidence is of very low quality. Many studies have limitations, including failure...




Journal Clubs: 1. Origins

2017-11-24T05:51:09-08:00

A journal club is a group of individuals who meet regularly to discuss publications that are relevant to their professional interests; the term is also used to describe such a meeting.

The earliest mention of a journal club that I have found is in an 1854 paper by Sir John Forbes in The Association Medical Journal, which was published between 1853 and 1856, and was a forerunner of the BMJ. The Association was in financial straits, as Forbes discussed1: ‘Our dear old ASSOCIATION is in rather a bad plight; but I hope and trust she is not in any risk of death or decay, but is merely passing through a dangerous crisis, to come out of it more vivacious and more vigorous than ever.’ He was mainly concerned about the future of the journal: ‘The Association, if it exists at all, must retain as part of its...




Journal Clubs: 2. Why and how to run them and how to publish them

2017-11-24T05:51:09-08:00

Journal clubs have many functions, including the provision of a forum for developing skills in critical appraisal, an essential part of being a competent clinician.

From early on, journal clubs reported their proceedings in academic journals. The Zoological Journal Club of Michigan, for example, regularly reported its activities in the journal Science (see figure 1). Table 1 lists a selection of other journals that publish journal club articles, showing the wide range of topics covered. Modern methods of conducting journal clubs include the use of online media to encourage interactive discussion,1 including blogs,2 twitter,3 and virtual journal clubs.4

It is therefore appropriate that Evidence-Based Medicine (EBM) should feature a regular journal club report.

In order to find out how others run journal clubs and the effects that they have, I searched PubMed for articles on journal clubs, using the...




Evaluation of a 0-hour/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin T1

2017-11-24T05:51:09-08:00

Using a highly sensitive assay of serum troponin T in patients with suspected myocardial infarction might help in early diagnosis, but the method needs thorough clinical assessment before implementation.

Summary box

  • A highly sensitive serum troponin T assay has been claimed to be useful in ruling a myocardial infarction in or out soon after presentation.

  • However, performance measures for diagnostic tests should be thought of in terms of real patients, and not taken at face value.

  • Changes in biomarker concentrations over time may be superior to single cut-off values.

  • Summary of evidence

    The High Sensitivity Cardiac Troponin T Assay for Rapid Rule-out of Acute Myocardial Infarction trial was a prospective, multicentre, diagnostic study done at 12 sites, across three continents to validate the diagnostic accuracy of the troponin T 0-hour/1-hour algorithm for rule-in and rule-out of acute myocardial infarction.1

    Current...