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Evidence-Based Medicine recent issues



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Join the editorial board

2017-07-26T03:21:32-07:00

We are changing the way the journal looks, feels and operates. In order to do this well, we would very much like your help in delivering relevant, trustworthy and impactful evidence-based content to as wide a range of frontline health professionals as possible.

We are planning to publish original evidence-based research, insights and opinions on what matters for healthcare, while focusing on the tools, methods and concepts that are basic and central to practising evidence-based medicine. Our plan includes exciting developments in the types of articles that debate the uncertainties and controversies in evidence, and the research methods that educate and inform practice. Our new clinical spotlight section will strive to disseminate relevant research: saving you time and improving your practice.

We are looking for health professionals and EBM researchers who are interested, and motivated, to enhance the practice and understanding of evidence-based healthcare.

We want BMJ Evidence-Based Medicine...




Evidence based medicine manifesto for better healthcare: A response to systematic bias, wastage, error and fraud in research underpinning patient care

2017-07-26T03:21:32-07:00

Informed decision-making requires clinicians and patients to identify and integrate relevant evidence. But with the questionable integrity of much of today's evidence, the lack of research answering questions that matter to patients and the lack of evidence to inform shared decision-making how are they expected to do this?

Too many research studies are poorly designed or executed. Too much of the resulting research evidence is withheld or disseminated piecemeal.1 As the volume of clinical research activity has grown,2 the quality of evidence has often worsened,3 which has compromised the ability of all health professionals to provide affordable, effective, high value care for patients.

The BMJ...




Mental health literacy in primary care: Canadian Research and Education for the Advancement of Child Health (CanREACH)

2017-07-26T03:21:32-07:00

The effectiveness of a continuing education programme in paediatric psychopharmacology designed for primary healthcare providers was objectively measured based on the assumption that training would lead to measurable changes in referral patterns and established clinical measures of referred patients. Using established, valid and reliable measures of clinical urgency embedded in to a regional healthcare system since 2002, the referrals to child and adolescent psychiatric services of physicians who participated in the training (n=99) were compared pretraining and post-training, and to non-participating/untrained referring physicians (n=7753) making referrals over the same time period. Referrals were analysed for evidence of change based on frequencies and measures of clinical urgency. Participants of the training programme also completed standardised baseline and outcome self-evaluations. Congruent with participants self-reported evaluative reports of improved knowledge and practice, analysis of referral frequency and the clinical urgency of referrals to paediatric psychiatric services over the study period indicated that trained physicians made more appropriate referrals (clinically more severe) and reduced referrals to emergency services. Quantitative clinical differences as completed by intake clinicians blind to referrals from the study group designations were observed within the trained physician group pretraining and post-training, and between the trained physician group and the unexposed physician group. The results illustrate a novel model for objectively measuring change among physicians based on training in paediatric mental health management.




Determining clinical decision thresholds for HIV-positive patients suspected of having tuberculosis

2017-07-26T03:21:32-07:00

Clinical decision thresholds may aid the evaluation of diagnostic tests but have rarely been determined for tuberculosis (TB). We presented clinicians with six web-based clinical scenarios, describing patients with HIV and possible TB at various sites and with a range of clinical stability. The probability of disease was varied randomly and clinicians asked to make treatment decisions; threshold curves and therapeutic thresholds were calculated. Test and treatment thresholds were calculated using Bayes theorem and the diagnostic accuracy of Xpert MTB/RIF. We received 165 replies to our survey. Therapeutic thresholds vary depending on the clinical stability and site of suspected disease. For inpatients, it ranges from 3.4% in unstable to 79.6% in stable patients. For TB meningitis, it ranges from 0% in unstable to 51.4% in stable patients and for pulmonary TB in outpatients it ranges from 29.1% in unstable to 74.5% in the stable patients. Test and treatment thresholds vary in a similar way with test thresholds ranging from 0 in unstable patients with suspected meningitis to 8.2% for stable inpatients. Treatment thresholds vary from 0 for unstable patients with suspected meningitis to 97% for stable inpatients. Therapeutic thresholds for TB can be determined by presenting clinicians with patient scenarios with random probabilities of disease and can be used to calculate test and treatment thresholds using Bayes theorem. Thresholds are lower when patients are more clinically unstable and when the implications of inappropriately withholding therapy are more serious. These results can be used to improve use and evaluation of diagnostic tests.




Guidelines for reporting meta-epidemiological methodology research

2017-07-26T03:21:32-07:00

Published research should be reported to evidence users with clarity and transparency that facilitate optimal appraisal and use of evidence and allow replication by other researchers. Guidelines for such reporting are available for several types of studies but not for meta-epidemiological methodology studies. Meta-epidemiological studies adopt a systematic review or meta-analysis approach to examine the impact of certain characteristics of clinical studies on the observed effect and provide empirical evidence for hypothesised associations. The unit of analysis in meta-epidemiological studies is a study, not a patient. The outcomes of meta-epidemiological studies are usually not clinical outcomes. In this guideline, we adapt items from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) to fit the context of meta-epidemiological studies.




The Cochrane Collaboration withdraws a review on methylphenidate for adults with attention deficit hyperactivity disorder

2017-07-26T03:21:32-07:00

A Cochrane systematic review on immediate-release methylphenidate for adults with attention deficit hyperactivity disorder (ADHD) was withdrawn from the Cochrane Library on 26 May 2016 after substantial criticism of its methods and flawed conclusions. Retraction of scientific papers on this basis is unusual but can be necessary. We provide a summary of the criticism that led to the withdrawal. We detail the methodological flaws of the withdrawn Cochrane systematic review and general issues of bias and shortcomings of the included ADHD trials: cross-over designs compared with parallel-group designs, exclusion of participants with psychiatric comorbidity, absence of ‘functional outcomes’ and use of clinical outcomes with limited relevance, short trial duration and small trial populations, broken blinding caused by easily recognisable side effects, combining outcome assessments by trial investigators and participants, outcome reporting bias, poor evaluation of cardiovascular and psychiatric harms and conflicts of interest of trialists and systematic reviewers. The withdrawal of the Cochrane systematic review signals recognition of previous unreliable clinical ADHD research. We conclude that clinical trials of immediate-release methylphenidate in adults with ADHD are of very low quality. We urgently need well-conducted long-term trials free of bias to assess the benefits and harms of central stimulant treatment in adult ADHD.




Induction of labour at 37 weeks for suspected fetal macrosomia may reduce birth trauma

2017-07-26T03:21:32-07:00

Citation: Magro-Malosso ER, Saccone G, Chen M, et al. Induction of labour for suspected macrosomia at term in non-diabetic women: a systematic review and meta-analysis of randomised controlled trials. BJOG 2017;124:414-21.

Context

Mothers with big babies tend to have longer labours and more difficult births. They may require caesarean section, or instrumental vaginal delivery. They may also sustain perineal injury or more seriously the head may deliver and the shoulders get stuck, so-called shoulder dystocia. This severe complication may cause birth injury, including brachial plexus injury (2%–16%) which may be permanent and disabling. Finally, the baby may suffer bony fractures or birth asphyxia with risk of neurological damage or death. Obstetricians have wondered whether inducing labour early might make birth easier and reduce injury, but have been cautious to implement this policy due to concerns that induced labour may be longer or increase caesareans, and because the diagnosis of...




Second trimester levothyroxine treatment for subclinical hypothyroidism or hypothyroxinaemia of pregnancy does not improve cognitive outcomes of children

2017-07-26T03:21:32-07:00

Context

Overt thyroid disease, be it overt hypothyroidism or overt hyperthyroidism, is associated with a multitude of adverse outcomes during pregnancy including miscarriage, gestational hypertension, gestational diabetes, preterm delivery and decreased IQ in the offspring.1 In its most severe form, overt hypothyroidism results in cretinism. The impact of subclinical hypothyroidism (SCH) on pregnancy outcomes is complex. Observational and retrospective studies have shown a correlation with adverse maternal and fetal events.2 In 1999, Pop et al3 and Haddow et al4 reported a correlation between hypothyroidism and isolated hypothyroxinaemia (IH) with decreased neurocognitive function in the offspring. However, only two prospective randomised studies have evaluated the impact of levothyroxine therapy for SCH or IH on pregnancy outcomes. In an Italian study, levothyroxine therapy for SCH in thyroid antibody-positive women in the first trimester of pregnancy resulted in a decrease in overall adverse...




Clinicians should assess the benefits and risks of using bezlotoxumab for reducing the risk of recurrent Clostridium difficile infection

2017-07-26T03:21:32-07:00

Commentry on: Wilcox MH, Gerding DN, Poxton IR, et al. Bezlotoxumab for Prevention of Recurrent Clostridium difficile Infection. N Engl J Med 2017;376:305–317.

Context

Clostridium difficile is an anaerobic gram-positive spore-forming bacillus that plays a major role in healthcare antibiotic-associated diarrhoea. A continued rise in antibiotic use, specifically, cephalosporins and fluoroquinolones, has been linked to the development of more resistant strains of this toxin-forming pathogen, triggering more recurrences and severe manifestations of the disease across USA and Europe.1 The high burden of recurrence and increased healthcare costs associated with C. difficile infection (CDI) have encouraged the development of new treatments to prevent recurrence including the use of pulsed/tapered oral vancomycin, fidaxomicin and faecal microbiota transplantation (FMT).2

Methods

Monoclonal antibodies for C. difficile therapy (MODIFY) trials I and II are two global phase 3 trials aimed at examining the efficacy and safety of a single...




Percutaneous coronary intervention has similar 5-year survival rates to coronary artery bypass grafting surgery for patients with unprotected left main artery disease

2017-07-26T03:21:32-07:00

Commentary on: Mäkikallio T, Holm NR, Lindsay M, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet 2016;388:2743–2752.

Context

An on-going debate is whether percutaneous coronary intervention (PCI) offers similar clinical results compared with coronary artery bypass grafting surgery (CABG) for patients with unprotected left main artery disease (ULMAD). Previously, the SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery  (SYNTAX) trial scrutinized the benefit of the first generation of drug-eluting stents in patients with multivessel disease and ULMAD. At 5 years, CABG was associated with improved clinical outcomes compared with PCI. Nonetheless, in patients with ULMAD and SYNTAX score <33, similar results were observed.1 The European and American guidelines agree upon the fact that in patients with ULMAD, CABG is the preferred treatment whereas PCI might be an alternative when the...




Placebo might be superior to antipsychotics in management of delirium in the palliative care setting

2017-07-26T03:21:32-07:00

Commentary on: Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med 2017;177:34–42.

Context

The need for controlled trials evaluating the efficacy of antipsychotics in the management of delirium has been recognised since the Practice Guidelines for the treatment of patients with delirium were introduced in 1999.1 Since then, only few relevant studies have been published. In contrast to the Practice Guidelines, which favoured psychopharmacological management, the National Institute for Health and Care Excellence Guidelines solely recommend psychopharmacological management for distress.2 To date, it has not yet been clearly defined what the distressing symptoms of delirium are. Considering this controversy and the necessity of further studies in this domain, the most beneficial approach for delirious patients remains unclear.3 4

...



Apixaban may have lower risk of GI bleeding compared with dabigatran and rivaroxaban in patients with atrial fibrillation

2017-07-26T03:21:32-07:00

Commentary on: Abraham NS, Noseworthy PA, Yao X, et al. Gastrointestinal safety of direct oral anticoagulants: a large population-based study. Gastroenterology 2017;152:1014–1022.e1.

Context

Oral anticoagulation (OAC) reduces the risk of stroke and mortality in atrial fibrillation (AF). The known limitations of vitamin K antagonists (VKAs) have led to the development of non-vitamin K oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban and edoxaban. These anticoagulants are at least as effective as VKAs for prevention of stroke in patients with AF and safer in terms of serious bleeding events.1–3 Given that high rates of gastrointestinal (GI) bleeding have been observed in NOACs,1 Abraham et al report a ‘real world’ study of the GI safety profile comparing the various NOACs head-to-head.

Methods

Abraham et al enrolled both inpatients and outpatients with non-valvular AF who started dabigatran, apixaban or rivaroxaban during 1 October 2010 to 28 February...




Use of the M-CHAT follow-up interview (M-CHAT/F) by paediatricians during well-child care visits is feasible, valid and reliable

2017-07-26T03:21:32-07:00

Citation: Sturner R, Howard B, Bergmann P, et al. Autism screening with online decision support by primary care pediatricians aided by M-CHAT/F. Pediatrics. 2016 Sep;138: e20153036.

Context

Early identification of children with autism spectrum disorders (ASDs) leads to early intervention and improved outcomes.1 The American Academy of Pediatrics (AAP) recommends universal screening with a validated tool such as the Modified Checklist for Autism in Toddlers (M-CHAT) at well-child care visits.2 The M-CHAT/R (original M-CHAT and its revised version) includes a follow-up interview (the M-CHAT/R-F) designed to clarify positive responses. Use of the M-CHAT/R-F significantly improves the positive predictive value (PPV) of the tool,3 but questions remain regarding the feasibility of using the interview in routine clinical care.

Methods

The study investigated the feasibility of using the follow-up interview in routine practice and the validity of the results from paediatricians compared with...