Evid Based Med
· 2017 Apr · PMID 28073867
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A sad little story about a maimed Martian astronaut is used to illustrate a method of improving confidence interval (CI) calculations. CIs in medical statistics are currently calculated from the data available in a clini...A sad little story about a maimed Martian astronaut is used to illustrate a method of improving confidence interval (CI) calculations. CIs in medical statistics are currently calculated from the data available in a clinical trial or meta-analysis considered in isolation from all other information available on earth. Likewise, the Martian in the story uses only information available to it, in isolation from further information from earth. However, there is further objective knowledge available to people on earth to improve the Martian's estimate. In the same way, we have objective prior knowledge available to us outside of the current clinical trial results which we can use to improve CI calculations. This prior knowledge is incorporated into the CI calculations using Bayesian methods. The objective prior knowledge that is available is the fact that there were researchers who felt it worthwhile to conduct the trial and journal editors who felt it worthwhile publishing the results. It is shown here that the use of this information contracts the width of the log CI by a factor of about three quarters on average. Unlike standard CIs, these new intervals also have the advantage of being directly interpretable in terms of probabilities. These probabilities also enable calculation of improved point estimates. These calculations are applied to 100 randomly selected Cochrane systematic reviews and show serious problems in assessing medical treatments. For treatments not involving new drugs or devices, it is shown that there is evidence of a bias towards a negative assessment. The calculations here make a quantitative adjustment for publication bias. They show that the proportion of negative assessments do not reflect an appropriate adjustment for publication bias.
Evid Based Med
· 2017 Mar · PMID 27998881
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The global campaign to lower cholesterol by diet and drugs has failed to thwart the developing pandemic of coronary heart disease around the world. Some experts believe this failure is due to the explosive rise in obesit...The global campaign to lower cholesterol by diet and drugs has failed to thwart the developing pandemic of coronary heart disease around the world. Some experts believe this failure is due to the explosive rise in obesity and diabetes, but it is equally plausible that the cholesterol hypothesis, which posits that lowering cholesterol prevents cardiovascular disease, is incorrect. The recently presented ACCELERATE trial dumbfounded many experts by failing to demonstrate any cardiovascular benefit of evacetrapib despite dramatically lowering low-density lipoprotein cholesterol and raising high-density lipoprotein cholesterol in high-risk patients with coronary disease. This clinical trial adds to a growing volume of knowledge that challenges the validity of the cholesterol hypothesis and the utility of cholesterol as a surrogate end point. Inadvertently, the cholesterol hypothesis may have even contributed to this pandemic. This perspective critically reviews this evidence and our reluctance to acknowledge contradictory information.
Evid Based Med
· 2017 Mar · PMID 27993941
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BACKGROUND: Effective education of relevant professionals underpins provision of quality eye healthcare. OBJECTIVES: This scoping systematic review had 2 aims: first to investigate the extent and nature of scholarly outp...BACKGROUND: Effective education of relevant professionals underpins provision of quality eye healthcare. OBJECTIVES: This scoping systematic review had 2 aims: first to investigate the extent and nature of scholarly output published on ophthalmic and paraophthalmic education, and second to focus on the quality of reporting of randomised controlled trials (RCTs) identified. STUDY SELECTION: A search strategy was created and applied to PubMed. Any scholarly publications on any aspect of education of those involved in the care of patients with visual problems as the main theme or context was selected. Predefined data were extracted. FINDINGS: Of 255 studies included, the most common type of scholarly publications were descriptions of an educational innovation, opinion pieces and descriptive studies. RCTs made up 5.5% of the sample. Most of the 14 RCTs failed to report most of the items recommended in the CONSORT guidelines. CONCLUSIONS: This review highlights the need for investigators, ethical committees and journals to insist on a better quality of RCT conduct than is presently apparent, but also that clinicians should not be blind to the strengths of non-RCT-based studies in the field of education.
Iannone P, Costantino G, Montano N
… +4 more, Podda GM, Minardi M, Doyle J, Cartabellotta A
Evid Based Med
· 2017 Mar · PMID 27986816
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Any evidence-based recommendation needs careful assessment of its methodological background as well as of its content trustworthiness, especially given that following it will not necessarily produce the intended clinical...Any evidence-based recommendation needs careful assessment of its methodological background as well as of its content trustworthiness, especially given that following it will not necessarily produce the intended clinical outcomes. There are no established instruments to evaluate guidelines for their content, while useful tools assessing the quality of methods followed are well recognised and adopted. We suggest a 'safety bundle' considering methodological aspects and content trustworthiness of guidelines, by adopting the GRADE method in a backward fashion. Sharing the critical analysis of the guidelines with patients, including any eventual uncertainty about them, is of key importance in order to avoid the possible adverse effects derived from following the wrong guidelines. Such critical approach is also helpful and beneficial in producing better care pathways, health policy decisions and more relevant and ethical research.
Evid Based Med
· 2017 Mar · PMID 27986815
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Evidence from randomised trials and their meta-analyses is typically formed of head-to-head comparisons of a couple of treatments; multiarm trials are infrequent. However, in real-life healthcare, there are many more tha...Evidence from randomised trials and their meta-analyses is typically formed of head-to-head comparisons of a couple of treatments; multiarm trials are infrequent. However, in real-life healthcare, there are many more than two treatment options for a particular condition. To be relevant for the shop-floor of practice, evidence-based medicine requires the use a comprehensive approach to compile, compare and contrast evidence on all options in one synthesis. Network meta-analysis (NMA) offers exactly such a solution. It generates a rank order of the available treatments for practitioners and policymakers that has the merit of objectivity. However, reviewers should make transparent the limitations of NMA as it uses direct and indirect comparisons, inevitably collating data with a certain degree of heterogeneity. This approach is increasingly being deployed to underpin evidence syntheses for incorporating research into practice.
Iannone P, Montano N, Minardi M
… +3 more, Doyle J, Cavagnaro P, Cartabellotta A
Evid Based Med
· 2017 Mar · PMID 27986814
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Evidence-based guidelines are considered an essential tool in assisting physicians, policymakers and patients when choosing among alternative care options and are considered unbiased standards of care. Unfortunately, dep...Evidence-based guidelines are considered an essential tool in assisting physicians, policymakers and patients when choosing among alternative care options and are considered unbiased standards of care. Unfortunately, depending on how their reliability is measured, up to 50% of guidelines can be considered untrustworthy. This carries serious consequences for patients' safety, resource use and health economics burden. Although conflict of interests, panel composition and methodological flaws are traditionally thought to be the main reasons undermining their untrustworthiness, corruption and waste of biomedical research also contribute. We discuss these issues in the hope for a wider awareness of the limits of guidelines.
Alahdab F, Alabed S, Al-Moujahed A
… +5 more, Al Sallakh MA, Alyousef T, Alsharif U, Fares M, Murad MH
Evid Based Med
· 2017 Mar · PMID 27965267
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Healthcare infrastructure and medical schools in Syria have been greatly compromised by military conflict and humanitarian disaster. Medical students and healthcare professionals reached out for remote learning opportuni...Healthcare infrastructure and medical schools in Syria have been greatly compromised by military conflict and humanitarian disaster. Medical students and healthcare professionals reached out for remote learning opportunities. Surprisingly, they desired a curriculum in evidence-based medicine. We report on a curriculum that was delivered to 126 learners using an online remote delivery platform. This experience demonstrates the feasibility of this approach in disaster-stricken areas and underscores the importance of evidence-based medicine even under such conditions.
Evid Based Med
· 2017 Mar · PMID 27932400
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Evidence-based practitioners who want to apply evidence from complex interventions to the care of their patients are often challenged by the difficulty of grading the quality of this evidence. Using the GRADE (Grading of...Evidence-based practitioners who want to apply evidence from complex interventions to the care of their patients are often challenged by the difficulty of grading the quality of this evidence. Using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and an illustrative example, we propose a framework for evaluating the quality of evidence that depends on obtaining feedback from the evidence user (eg, guideline panel) to inform: (1) proper framing of the question, (2) judgements about directness and consistency of evidence and (3) the need for additional contextual and qualitative evidence. Using this framework, different evidence users and based on their needs would consider the same evidence as high, moderate, low or very low.