I’ve got Good News and I’ve got Bad News

26 01 2010

If someone tells you: “I’ve got Good News and I’ve got Bad News”, you probably ask this person: “Well, tell me the bad news first!”

Laika’s MedLibLog has good and bad news for you.

The Bad News is, that this blog didn’t make it to the Finals of the sixth annual Medical Weblog Awards, organized by Medgadget. (see earlier post)

The Good news is that this keeps me from the stress that inevitably comes with following the stats and seeing how your blog is lagging more and more behind. Plus you don’t have to waste time desperately trying to mobilize your husband to just press the *$%# vote button (choosing the right person: me), no matter how many times he says he doesn’t care a bit – (“and wouldn’t it be better to spend less time on blogging anyway?”)

This reminds me of something I’ve tried to suppress, namely that this blog didn’t make it to the shortlists of the Dutch Bloggies 2009 either (see Laika’s MedLibLog on the Longlist of the DutchBloggies!)

The Good news is that many high quality blogs did make it to the finals. Including The Blog that Ate Manhattan, Clinical Cases and Images, Musings of a Distractible Mind (Best Medical Weblog) , other things amanzi (Best Literary Medical Weblog), Allergy Notes, Clinical Cases and Images, Life in the Fast Lane (Best Clinical Sciences Weblog), ScienceRoll (Best Medical Technologies/Informatics Weblog).

Best of all, the superb blog I nominated for Best Medical WeblogDr Shock MD PhD made it to the finals as well!!

But it is hard to understand that blogs like EverythingHealth and Body in Mind with many nominations are not among the finalists. That underlines that contests are very subjective, but so are individual preferences for blogs. It is all in the game.

Anyway you can start voting for your favorite blogs tomorrow. Please have a look at the finalists here at Medgadget, so you can decide who deserves your votes.

Finally I would like to conclude with positive news concerning this blog. This week’s “Cochrane in the news” features the post on Cochrane Evidence Aid. It is on the Cochrane homepage today.

Photo Credit

Best Literary Medical Weblog
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Cochrane Evidence Aid for Catastrophes like Haiti’s Earthquake. “Helping by doing what we do best”

24 01 2010

How it started [1]
2005. December 26th. Someone* working for the Cochrane Collaboration was on the Internet when he accidentally saw the AOL’s home page mentioning a powerful earthquake in the Indian Ocean, triggering a powerful tsunami that swept the coasts of neighboring countries. The story and the horror unfolded over the next hours and days. From the first reports of a few thousand dead to, within a day, a few thousand dead and tens of thousands missing in one part of Indonesia alone.

“What can we do?” he thought “Aid needs evidence on what works and what doesn’t work. It is no good and, worse, might be harmful, to deliver health care that is ineffective. The Cochrane Library already contains several reviews of relevance. There are Cochrane reviews on overcoming the effects of dehydration and the treatment of injuries, both physical and psychological. Those of us who work in the production of evidence can, therefore, deliver our own form of aid: information. The provision of reliable information on the effects of health care is the way that many of us can contribute to alleviating its effects. We need to recognize the privileged position that we are in: we can help by doing what we do best.”[1]

As reader of this blog, you probably know that the Cochrane Collaboration (http://www.cochrane.org/) is an international not-for-profit and independent organization, dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide. It produces and disseminates systematic reviews of healthcare interventions  in the Cochrane Library, which is available through subscription. The information on which these are based is drawn together collaboratively by a global network of dedicated volunteers, supported by a small staff.

Evidence Aid: what it is and what it does. [2, 3, 4, 5]
That Christmas, the idea was born to set up “Evidence Aid”.
A working party was established early January 2005 of people in the region and elsewhere.  Emails were send to people from the affected countries to express sympathy and support, and to ask for suggestions on how The Cochrane Collaboration might help.

Then, a list of over 200 interventions relevant to health care in the aftermath of the tsunami was made in consultation with all Cochrane entities, Cochrane members from affected countries, and members of other agencies such as the World Health Organization, Oxfam (one of the main UK charities working in the region), and the publishers of BMJ’s Clinical Evidence (http://clinicalevidence.com).

A prioritization was made, and subsequently lists were made of topics for which up-to-date Cochrane reviews were available and lists for which reviews were not yet available (see updated lists of  available and not currently available topics).

Concise summaries of evidence on the priority topics were offered in one place with “one-click” access to all contents, available free of charge (http://www.cochrane.org/docs/tsunamiresp​onse, now changed into http://www.cochrane.org/evidenceaid/index.htm)

The summaries link to the full evidence, which is already available on the Cochrane Library. If a summary is not currently available but there is a relevant Cochrane review in the Cochrane Library, a link takes people straight to that review. If a suitable Cochrane review is not available, links are included to other identified sources of evidence, in particular, to topics in Clinical Evidence .

In addition The Cochrane Library (http://www.thecochranelibrary.org) was made freely available in the effected countries for a six-month period. (This was before the Cochrane Library became freely available in India through funding)

Evidence matters, an example [4,5,6]
One helpful Cochrane Review was the Cochrane systematic review on the effects of brief “debriefing” [6], which is a procedure aimed to reduce immediate psychological distress and to prevent the subsequent development of psychological disorders, notably Post Traumatic Stress Disorder (PTSD). The review shows that this strategy is unlikely to be helpful and may even be harmful and cause an increase in PTSD.
After the tsunami, many teams of well-meaning people rushed to one of the worst hit areas in India, offering brief debriefing to survivors in each village, and then rushing on to the next of the 93 tsunami-affected villages in the district. Prathap Tharyan, Professor of Psychiatry and Coordinator of the South Asian Cochrane Network, found the relevant Cochrane review on debriefing and urged that this type of single session debriefing should not be provided. This message was incorporated into the content of counselor training workshops, along with evidence for interventions supported by the results of systematic reviews and other high quality research.[5]

Evidence Aid for Haiti [7]
After the tsunami it was decided to continue with Evidence Aid in natural disasters and other healthcare emergencies, drawing on knowledge gathered.

Tweets of @cochranecollab about various Evidence Aid Reviews for Haiti

Following the devastating earthquake in Haiti, The Cochrane Collaboration is working with colleagues in the World Health Organization (WHO), Pan American Health Organization (PAHO), the Centre for Reviews & Dissemination (UK), Cochrane Review Groups and others to identify Cochrane reviews and other systematic reviews of immediate importance. These, along with available Evidence Update summaries, were made available in a special Evidence Aid collection on Cochrane.org on 15 January, and have been shared with WHO and PAHO.

The information has been translated into French (thanks to the Cochrane Francophone Network) and Spanish (thanks to the Iberoamerican Cochrane Centre). At the moment, the collection includes reviews from several Cochrane Review Groups, including the Bone, Joint and Muscle Trauma Group; Depression, Anxiety and Neurosis Group; Infectious Diseases Group; Injuries Group; Renal Group and Wounds Group. [7]

Access to Evidence Aid resources for Haiti: The summaries are available at http://www.cochrane.org/evidenceaid/haiti/index.html and The Cochrane Library is freely available in the region through a variety of means. One is the Biblioteca Cochrane Plus via the Virtual Health Library BIREME interface (in English, Spanish or Portuguese).  Also, the PDF versions of all the highlighted Cochrane reviews are now available free to all on The Cochrane Library website.[7]

Is this enough?[4]
A PLOS article on Evidence Aids in 2005 already concluded: “No, not nearly enough”.[4]

Not all topics on the list have been covered by an up-to-date, good-quality systematic review. And, similar as in 2005, not all reviews have conclusions that can guide practice, because of a lack of relevant good-quality studies. After all, reviews are only as good as the studies they review. Therefore it is important to fill the gaps with good quality reviews and new practical trials on the most urgent topics.
Although things have certainly changed, i.e. more topics are now covered, there still remains room for further improvement.

If you would like to suggest additional material not yet covered, please contact Mike Clarke (mclarke@cochrane.ac.uk). You can also contribute to Evidence aid in other ways.

* This person signed the Gem [1] with “Insider”. It is not difficult to gather that the Insider is Mike Clarke, professor of clinical epidemiology at the University of Oxford, director of the UK Cochrane Centre and convenor of the working group which has set up the initiative.

Afterword: Last Monday, tweets mentioning Cochrane Evidence Aid topics appeared in my twitterstream (see Fig). As I was not profoundly familiar with this initiative, I wanted to gain more knowledge about it and summarize my findings in a post. I’m thankful to Mike Clarke and Nick Royle for instantly responding to my request for more information and Mike in particular for sending me the draft he compiled for CC-info [7] and an older cochrane gem [1], that explained how Evidence Aid arose.
Disclaimer: I’m employed as a Trial Search Coordinator of the Dutch Cochrane Centre for one day per week. The opinions expressed at this blog, however, are my own.

References:

  1. Cochrane Gem for week commencing 4 January 2005, written by “Insider”. Gems are weekly highlights one of new reviews or sometimes important news. Gems are available at the CKS database here.
  2. http://news.cochrane.org/view/item/review_one.jsp?j=177 assessed 24-01-2010
  3. Lynn Eaton (2005) Evidence based research for coping in emergencies goes online BMJ 330(7497):926 (23 April), doi:10.1136/bmj.330.7497.926-a
  4. Tharyan P, Clarke M, Green S (2005) How the Cochrane Collaboration Is Responding to the Asian Tsunami. PLoS Med 2(6): e169. doi:10.1371/journal.pmed.0020169
  5. World Health Organization (2005) Three months after the Indian Ocean earthquake-tsunami: Health consequences and WHO’s response. Available: http://www.who.int/hac/crises/internatio​nal/asia_tsunami/3months/en/index.html . Accessed 24-01-2010.
  6. Rose SC, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000560. DOI: 10.1002/14651858.CD000560. Edited (no change to conclusions), published in Issue 1, 2009.
  7. Draft written for CC-INFO (January 21, 2010) by Mike Clarke. It will become available at the CC-info archive.
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Role of Consumer Networks in Evidence Based Health Information

11 11 2009

Guest author: Janet Wale
member of the Cochrane Consumer Network

People are still struggling with evidence or modern medicine – clinicians, patients, health consumers, carers and the public alike. Part of this is because we always thought medicine was based on quality research, or evidence. It is not only that. For evidence to be used most effectively in healthcare systems researchers, clinicians and ‘the existing or potential patients and carers’ have to communicate and resonate with each other – to share knowledge and responsibilities both in developing the evidence and in individual decision making. On the broader population level, this may include consultation but is best achieved by developing partnerships.

The Cochrane Collaboration develops a large number of the published systematic reviews of best evidence on healthcare interventions, available electronically on The Cochrane Library. Systematic reviews are integral to the collation of evidence to inform clinical practice guidelines. They are also an integral part of health technology assessments, where the cost-effectiveness of healthcare interventions is determined for a particular health system.

With the availability of the Internet we are able to readily share information. We are also acutely aware of disadvantage for many of the World’s populations. What this has meant is pooled efforts. Now we have not only the World Health Organization but also The Cochrane Collaboration, Guidelines International Network, and Health Technology Assessment International. What is common among these organizations? They involve the users of health care, including patients, consumers and carers. The latter three organizations have a formal consumer/patient and citizen group that informs their work. In this way we work to make the evidence relevant, accessible and being used. We all have to be discerning whatever knowledge we are given and apply it to ourselves.

This is  a short post on request.
It also appeared as a comment at:
http://e-patients.net/archives/2009/11/tell-the-fda-the-whole-story-please.html

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#Cochrane Colloquium 2009: Better Working Relationship between Cochrane and Guideline Developers

19 10 2009

singapore CCLast week I attended the annual Cochrane Colloquium in Singapore. I will summarize some of the meetings.

Here is a summary of an interesting (parallel) special session: Creating a closer working relationship between Cochrane and Guideline Developers. This session was brought together as a partnership between the Guidelines International Network (G-I-N) and The Cochrane Collaboration to look at the current experience of guideline developers and their use of Cochrane reviews (see abstract).

Emma Tavender of the EPOC Australian Satellite, Australia reported on the survey carried out by the UK Cochrane Centre to identify the use of Cochrane reviews in guidelines produced in the UK ) (not attended this presentation) .

Pwee Keng Ho, Ministry of Health, Singapore, is leading the Health Technology Assessment (HTA) and guideline development program of the Singapore Ministry of Health. He spoke about the issues faced as a guideline developer using Cochrane reviews or -in his own words- his task was: “to summarize whether guideline developers like Cochrane Systematic reviews or not” .

Keng Ho presented the results of 3 surveys of different guideline developers. Most surveys had very few respondents: 12-29 if I remember it well.

Each survey had approximately the same questions, but in a different order. On the face of it, the 3 surveys gave the same picture.

Main points:

  • some guideline developers are not familiar with Cochrane Systematic Reviews
  • others have no access to it.
  • of those who are familiar with the Cochrane Reviews and do have access to it, most found the Cochrane reviews useful and reliable. (in one survey half of the respondents were neutral)
  • most importantly they actually did use the Cochrane reviews for most of their guidelines.
  • these guideline developers also used the Cochrane methodology to make their guidelines (whereas most physicians are not inclined to use the exhaustive search strategies and systematic approach of the Cochrane Collaboration)
  • An often heard critique of Guideline developers concerned the non-comprehensive coverage of topics by Cochrane Reviews. However, unlike in Western countries, the Singapore minister of Health mentioned acupuncture and herbs as missing topics (for certain diseases).

This incomplete coverage caused by a not-demand driven choice of subjects was a recurrent topic at this meeting and a main issue recognized by the entire Cochrane Community. Therefore priority setting of Cochrane Systematic reviews is one of the main topics addressed at this Colloquium and in the Cochrane Strategic review.

Kay Dickersin of the US Cochrane Center, USA, reported on the issues raised at the stakeholders meeting held in June 2009 in the US (see here for agenda) on whether systematic reviews can effectively inform guideline development, with a particular focus on areas of controversy and debate.

The Stakeholder summit concentrated on using quality SR’s for guidelines. This is different from effectiveness research, for which the Institute of Medicine (IOM) sets the standards: local and specialist guidelines require a different expertise and approach.

All kinds of people are involved in the development of guidelines, i.e. nurses, consumers, physicians.
Important issues to address, point by point:

  • Some may not understand the need to be systematic
  • How to get physicians on board: they are not very comfortable with extensive searching and systematic work
  • Ongoing education, like how-to workshops, is essential
  • What to do if there is no evidence?
  • More transparency; handling conflicts of interest
  • Guidelines differ, including the rating of the evidence. Almost everyone in the Stakeholders meeting used GRADE to grade the evidence, but not as it was originally described. There were numerous variations on the same theme. One question is whether there should be one system or not.
  • Another -recurrent- issue was that Guidelines should be made actionable.

Here are podcasts covering the meeting

Gordon Guyatt, McMaster University, Canada, gave  an outline of the GRADE approach and the purpose of ‘Summary of Findings’ tables, and how both are perceived by Cochrane review authors and guideline developers.

Gordon Guyatt, whose magnificent book ” Users’ Guide to the Medical Literature”  (JAMA-Evidence) lies at my desk, was clearly in favor of adherence to the original Grade-guidelines. Forty organizations have adopted these Grade Guidelines.

Grade stands for “Grading of Recommendations Assessment, Development and Evaluation”  system. It is used for grading evidence when submitting a clinical guidelines article. Six articles in the BMJ are specifically devoted to GRADE (see here for one (full text); and 2 (PubMed)). GRADE not only takes the rigor of the methods  into account, but also the balance between the benefits and the risks, burdens, and costs.

Suppose  a guideline would recommend  to use thrombolysis to treat disease X, because a good quality small RCTs show thrombolysis to be slightly but significantly more effective than heparin in this disease. However by relying on only direct evidence from the RCT’s it isn’t taken into account that observational studies have long shown that thrombolysis enhances the risk of massive bleeding in diseases Y and Z. Clearly the risk of harm is the same in disease X: both benefits and harms should be weighted.
Guyatt gave several other examples illustrating the importance of grading the evidence and the understandable overview presented in the Summary of Findings Table.

Another issue is that guideline makers are distressingly ready to embrace surrogate endpoints instead of outcomes that are more relevant to the patient. For instance it is not very meaningful if angiographic outcomes are improved, but mortality or the recurrence of cardiovascular disease are not.
GRADE takes into account if indirect evidence is used: It downgrades the evidence rating.  Downgrading also occurs in case of low quality RCT’s or the non-trade off of benefits versus harms.

Guyatt pleaded for uniform use of GRADE, and advised everybody to get comfortable with it.

Although I must say that it can feel somewhat uncomfortable to give absolute rates to non-absolute differences. These are really man-made formulas, people agreed upon. On the other hand it is a good thing that it is not only the outcome of the RCT’s with respect to benefits (of sometimes surrogate markers) that count.

A final remark of Guyatt: ” Everybody makes the claim they are following evidence based approach, but you have to learn them what that really means.”
Indeed, many people talk about their findings and/or recommendations being evidence based, because “EBM sells well”, but upon closer examination many reports are hardly worth the name.

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Cochrane 2.0 Workshop at the Cochrane Colloquium #CC2009

12 10 2009

Today Chris Mavergames and I held a workshop at the Cochrane Colloquium, entitled:  Web 2.0 for Cochrane (see previous post and abstract of the workshop)

First I gave an introduction into Medicine 2.0 and (thus) Web 2.0. Chris, Web Operations Manager and Information Architect of the Cochrane Collaboration, talked more about which Web 2.0 tools were already used by the Cochrane Collaboration and which Web 2.0 might be useful as such.

We had half an hour for discussion which was easily filled. There was no doubt about the usefulness of Web 2.0 for the Cochrane in this group. Therefore, there was ample room for discussing technical aspects, like:

  • Can you load your RSS feed of a PubMed search in Reference Manager? (According to Chris you can)
  • How can you deal with this lot of information (by following a specific subject, or not too much people – not many updates on a daily basis; you don’t have to follow it all, just pick up the headlines, when you can)
  • Are you involved in a Wiki that is successful? (it appears very difficult to involve people)
  • What happens if people comment or upload picture on facebook (of the Cochrane collaboration) in an appropriate way (Chris: didn’t happen, but you have to check and remove them)
  • How do you follow tweets (we showed Tweetdeckhashtags # and #followfridays)
  • What is the worst thing that happened to you (regarding web 2.0)? Chris and I thought a long time. Chris: that I revealed something that wasn’t officially public yet (though appeared to be o.k.). Me: spam (but I remove it/don’t approve it).
    Later I remembered two better (worse) examples, like the “Clinical Reader” social misbehaviour, a good example of how “branding” should not be done, and sites that publish top 50 and 100 list of bloggers just to get more traffic to their spam websites

Below is my presentation on Slideshare.

The (awful) green blackgound color indicates I went “live” on the web. As a reminder of what I did, I included some screendumps.

The current workshop was just meant to introduce and discuss Medicine 2.0 and Cochrane 2.0.

I hope we have a vivid discussion Wednesday when the plenary lectures deal with Cochrane 2.0.

The answers to my question on Twitter

  1. Why Web 2.0 is useful? (or not)
  2. Why we need Cochrane 2.0? (or not)

can be found on Visibletweets (temporary) and saved as: Quoteurl.com/sggq0 (permanent selection).

I think it would be good when these points are taken into account during the Cochrane 2.0 plenary discussions.

* possible WIKI (+ links) might appear at http://medicine20.wetpaint.com/page/Cochrane+2.0

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This week I will blog from…..

10 10 2009

35167809 singapore colloquiumPicture taken by Chris Mavergames http://twitpic.com/kxrnl

Chris and I will facilitate a web 2.0 workshop for the Cochrane (see here, for all workshops see here).
The entire program can be viewed at the Cochrane Colloquium site.

Chris Mavergames, Web Operations Manager and Information Architect of the Cochrane Collaboration will also give a plenary presentation entitled:
Cochrane for the Twitter generation:
inserting ourselves into the ‘conversation
‘”.

The session has the promising title: The Cochrane Library – brave new world?

Here is the introductory text of the session:

The Cochrane Collaboration is not unique in facing a considerable challenge to the way it packages and disseminates healthcare information. The proliferation of communication platforms and social networking sites provides opportunities to reach new audiences, but how far can or should the Collaboration go in embracing these new media? In this session we hear from speakers who are at the heart of the discussions about The Cochrane Library’s future direction, including the Library’s Editor in Chief. We finish the session with reflections on the week’s discussions with respect to the Strategic Review (…)

Request (for the workshop, not the plenary session):
If you ‘re on Twitter, could you please tell the participants of the (small) web 2.0 workshop  your opinion on the following, using the hashtag #CC20.
*

  1. Why Web 2.0 is useful? (or not)
  2. Why we need Cochrane 2.0? (or not)

An example of such an answer (from @Berci):

#CC20 Web 2.0 opens up the world and eases communication. Cochrane 2.0 is needed bc such an important database should have a modern platform

If you don’t have Twitter you can add your comment here and I will post it for you (if you leave a name).

Thanks for all who have contributed so far.

—–

*this is only for our small-scaled workshop, I propose to use #CC2009 for the conference itself.

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#CECEM David Tovey -the Cochrane Library’s First Editor in Chief

13 06 2009

cochrane-symbolThis week I was attending another congress, the Continental European Cochrane Entities Meeting (CECEM).

This annual meeting is meant for staff from Cochrane Entities, thus Centre Staff, RGC’s (Review Group Coordinators), TSC’s (Trial Search Coordinators) and other staff members of the Cochrane Collaboration based in Continental Europe.

CECEM 2009 was held in Maastricht, the beautiful old Roman city in the South of the Netherlands. The city where my father was born and where I spend many holidays.

One interesting presentation was by Cochranes’ 1st Editor in chief, David Tovey, previously GP in an urban practice in London for 14 years and  Editorial Director of the BMJ Group’s ‘Knowledge’ division (responsible for BMJ Clinical Evidence and its sister product Best Treatments, see announcement in Medical News Today)

David began with saying that the end user is really the key person and that the impact of the Cochrane Reviews is most important.

“How is it that a Senior health manager in the UK may shrug his shoulders when you ask him if he has ever heard of Cochrane?”

“How do we make sure that our work had impact? Should we make use of user generated content?”

Quality is central, but quality depends on four pillars. Cochrane reviews should be reliable, timely, relevant and accessible.

Cochrane Tovey wit

How quality is perceived is dependent on the end users. There are several kinds of end users, each with his own priorities.

  1. doctor: wants comprehensive and up-to-date info, wants to understand and get answers quickly.
  2. patient: trustworthiness, up-to-date, wants to be able to make sense of it.
  3. scientist: wants to see how the conclusions are derived.
  4. policy and guideline-makers.

Reliable: Several articles have shown Cochrane Systematic Reviews to be more reliable then other systematic reviews  (Moher, PLOS BMJ)*

Timely: First it takes time to submit a title of a Cochrane Review and then it takes at least 2 years before a protocol becomes a review. Some reviews take even longer than 2 years. So there is room for improvement.

Patients are also very important as end user. Strikingly, the systematic review about the use of cranberry to prevent recurrent urinary tract infection is the most frequently viewed article,- and this is not because the doctors are most interested in this particular treatment….

Doctors: Doctors often rely on their colleagues for a quick and trustworthy answer. Challenge: “can we make consulting the Cochrane Library as easy as asking a colleague: thus timely and easy?”

Solutions?

  • making plain language summaries more understandable
  • Summary of Findings
  • podcasts of systematic reviews (very successful till now), .e. see an earlier post.
  • Web 2.0 innovations

Key challenges:

  • ensure and develop consistent quality
  • (timely) updating
  • putting the customer first: applicability & prioritization
  • web delivery
  • resources (not every group has the same resources)
  • make clear what an update means and how important this update is: are there new studies found? are these likely to change conclusions or not? When was the last amendment to the search?

I found the presentation very interesting. What I also liked is that David stayed with us for two days -also during the social program- and was easy approachable. I support the idea of a user-centric approach very much. However, I had expected the emphasis to be less on the timeliness (of updates for instance), but more on how users (patients, doctors) can get more involved and how we review the subjects that are most urgently needed. Indeed, when I twittered that Tovey suggested that we “make consulting the Cochrane Library as easy as asking a colleague”, Jon Brassey of TRIP answered that a lot has to be done to fulfill this, as the Cochrane only answers 2 out of 350+ questions asked by GPs in the UK, a statement that appeared to be based on his own experience (Jon is founder of the TRIP-database).

But in principle I think that Jon is correct. Right now too few questions (in the field of interventions) are directly answered by Cochrane Systematic Reviews and too little is done to reach and involve the Cochrane Library users.

13-6-2009 15-43-17 twitter CECEM discussion

click to enlarge

During the CECEM other speakers addressed some of these issues in more detail. André Knottnerus, Chair of the Dutch Health Council, discussed “the impact of Cochrane Reviews”, and Rob the Bie of the Rehabilitation & Related Therapies field discussed “Bridging the  gap between evidenced based practice and practice based evidence”, while Dave Brooker launched ideas about how to implement Web 2.0 tools. I hope to summarize these (and other) presentations in a blogpost later on.

*have to look this up

NOTE (2009-11-10).

I had forgotten about this blank “citation” till this post was cited quite in another context (see comment: http://e-patients.net/archives/2009/11/tell-the-fda-the-whole-story-please.html) and someone commented that the asterisk to the “the amazing statement” had still to be looked up,  indirectly arguing that this statement thus was not reliable- and continuing by giving an example of a typically flawed Cochrane Review that hit the headlines 4 years ago, a typical exception to the rule that “Cochrane systematic reviews are more reliable than other systematic reviews”. Of course when it is said that A is more trustworthy than B it is meant on average. I’m a searcher, and on average the Cochrane searchers are excellent, but when I do my best I surely can find some that are not good at all. Without doubt that also pertains to other parts of Cochrane Systematic Reviews.
In addition -and that was the topic of the presentation- there is room for improvement.

Now about the asterisk, which according to Susannah should have been (YIKES!) 100 times bigger. This was a post based on a live presentation and I couldn’t pick up all the references on the slides while making notes. I had hoped that David Tovey would have made his ppt public, so I could have checked the references he gave. But he didn’t and so I forgot about it. Now I’ve looked some references up, and, although they might not be identical to the references that David mentioned, they are in line with what he said:

  1. Moher D, Tetzlaff J, Tricco AC, Sampson M, Altman DG, 2007. Epidemiology and Reporting Characteristics of Systematic Reviews. PLoS Med 4(3): e78. doi:10.1371/journal.pmed.0040078 (free full text)
  2. The PLoS Medicine Editors 2007 Many Reviews Are Systematic but Some Are More Transparent and Completely Reported than Others. PLoS Med 4(3): e147. doi:10.1371/journal.pmed.0040147 (free full text; editorial coment on [1]
  3. Tricco AC, Tetzlaff J, Pham B, Brehaut J, Moher D, 2009. Non-Cochrane vs. Cochrane reviews were twice as likely to have positive conclusion statements: cross-sectional study. J Clin Epidemiol. Apr;62(4):380-386.e1. Epub 2009 Jan 6. [PubMed -citation]
  4. Anders W Jørgensen, Jørgen Hilden, Peter C Gøtzsche, 2006. Cochrane reviews compared with industry supported meta-analyses and other meta-analyses of the same drugs: systematic review BMJ  2006;333:782, doi: 10.1136/bmj.38973.444699.0B (free full text)
  5. Alejandro R Jadad, Michael Moher, George P Browman, Lynda Booker, Christopher Sigouin, Mario Fuentes, Robert Stevens (2000) Systematic reviews and meta-analyses on treatment of asthma: critical evaluation BMJ 2000;320:537-540, doi: 10.1136/bmj.320.7234.537 (free full text)

In previous posts I regularly discussed that (Merck’s Ghostwriters, Haunted Papers and Fake Elsevier Journals and One Third of the Clinical Cancer Studies Report Conflict of Interest) that pharma-sponsored trials rarely produce results that are unfavorable to the companies’ products [e.g. see here for an overview, and many papers of Lisa Bero].

Also pertinent to the abovementioned discussion at E-patient-Net is my earlier post: The Trouble with Wikipedia as a Source for Medical Information. (references still not in the correct order. Yikes!)

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New Cochrane Handbook: altered search policies

14 11 2008

cochrane-symbolThe Cochrane Handbook for Systematic Reviews of Interventions is the official document that describes in detail the process of preparing and maintaining Cochrane systematic reviews on the effects of healthcare interventions.

The current version of the Handbook is 5.0.1 (updated September 2008) is available either for purchase from John Wiley & Sons, Ltd or for download only to members of The Cochrane Collaboration (via the Collaboration’s information management system, Archie).
Version 5.0.0, updated February 2008, is freely available in browseable format, here. It should be noted however, that this version is not as up to date as version 5.0.1. The methodological search filters, for instance, are not1989 visual 6 completely identical.

As an information specialist I will concentrate on Chapter 6: Searching for studies.

This chapter consist of the following paragraphs:

  • 6.1 Introduction
  • 6.2 Sources to search
  • 6.3 Planning the search process
  • 6.4 Designing search strategies
  • 6.5 Managing references
  • 6.6 Documenting and reporting the search process
  • 6.7 Chapter information
  • 6.8 References

As the previous versions the essence of the Cochrane searches is to perform a comprehensive (sensitive) search for relevant studies (RCTs) to minimize bias. The most prominent changes are:

1. More emphasis on the central role of the Trial Search Coordinator (TSC) in the search process.
Practically each paragraph summary begins with an advice to consult the TSC, i.e. in 6.1: Cochrane review authors should seek advice from the Trials Search Co-ordinator of their Cochrane Review Group (CRG) before starting a search.

One of the main roles of TSC’s is the assisting of authors with searching, although the range of assistance may vary from advise on to how run searches to designing, running and sending the searches to authors.

I know from experience that most authors have not enough search literacy to be able to satisfactory complete the entire search on their own. Not even all librarians may be equipped to perform such exhaustive searches. That is why the handbook says: “If a CRG is currently without a Trials Search Co-ordinator authors should seek the guidance of a local healthcare librarian or information specialist, where possible one with experience of conducting searches for systematic reviews.”

Another essential core function of the TSC is the development and maintenance of the Specialized Register, containing all relevant studies in their area of interest, and submit this to CENTRAL (The Cochrane Central Register of Controlled Trials) on a quarterly basis”. CENTRAL is the most comprehensive source of reports of controlled trials (~500,000 records), available in “The Cochrane Library” (there it is called CLINICAL TRIALS). CENTRAL is available to all Cochrane Library subscribers, whereas the Specialized Register is only available via the TSC.

central-middle

Redrawn from the Handbook Fig. 6.3.a: The contents of CENTRAL

2. Therefore Trials registers are an increasingly important source of information. CENTRAL is considered to be the best single source of reports of trials that might be eligible for inclusion in Cochrane reviews. However, other than would be expected (at least by many authors) a search of MEDLINE (PubMed) alone is not considered adequate.

The approach now is: Specialized Registers/CENTRAL and MEDLINE should be searched as a minimum, together with EMBASE if it is available (apart from topic specific databases, snowballing). MEDLINE should be searched from 2005 onwards, since CENTRAL contains all records from MEDLINE indexed with the Publication Type term ‘Randomized Controlled Trial’ or ‘Controlled Clinical Trial’ (a substantial proportion of theses MEDLINE records have been retagged as a result of the work of The Cochrane Collaboration (Dickersin 2002)).

Personally, for non-Cochrane searches, I would rather search the other way around, MEDLINE (OVID) first, than EMBASE (OVID) and finally CENTRAL, and deduplicate the searches afterwards (in Reference Manager for instance). The (Wiley) Cochrane Library is not easy to search (for non-experienced users, i.e. you have to know the MESH beforehand, there is (yet) no mapping). If you start your search in MEDLINE (OVID) you can easily transform it in EMBASE and subsequently CENTRAL (using both MESH and EMBASE keywords as well as textwords)

3. The full search strategies for each database searched need to be included in an Appendix with the total number of hits retrieved by the electronic searches included in the Results section. Indeed the reporting has been very variable, some authors only referring to the general search strategy of the group. This made the searching part less transparent.

4. Two new Cochrane Highly Sensitive Search Strategies for identifying randomized trials in MEDLINE strategies have been developed: a sensitivity-maximizing version and a sensitivity- and precision-maximizing version. These filters (that are to be combined with the subject search) were designed for MEDLINE-indexed records. Therefore, a separate search is needed to find non-indexed records as well. An EMBASE RCT filter is still under development.

These methodological filters will be exhaustively discussed in another post.





CC (2) Duodecim: Connecting patients (and doctors) to the best-evidence

5 10 2008

This is the second post in the series Cochrane Colloquium (CC) 2008.

In the previous post, I mentioned a very interesting opening session.

Here I will summarize one of the presentations in that opening session, i.e. the presentation by Pekka Mustonen, called:

Connecting patients to the best-evidence through technology: An effective solution or “the great seduction”?

Pekka essentially showed us what the Finnish have achieved with their Duodecim database.

Duodecim was started as a health portal for professionals only. It is a database (a decision support system) made by doctors for doctors. It contains Evidence Base (EBM) Guidelines with:

  • regularly updated recommendations
  • links to evidence, including guidelines and Cochrane Systematic Reviews
  • commentaries

Busy Clinicians don’t have the time to perform an extensive search to find the best available evidence each time they have a clinical question. Ideally, they only would have to carry out one search, taking not more than one minute to find the right information.

This demand seems to be reasonably met by Duodecim.

Notably, Duodecim is not only very popular as a source for clinicians ànd nurses, the guidelines are also read and followed by them. Those familiar with healthcare know that this is the main obstacle: getting doctors and nurses to actually use the guidelines.

According to Pekka, patients are even more important than doctors to implement guidelines: Half of the patients don’t seem to follow their doctor’s advice. If the advice is to keep on inhaled steroids for long-term management for asthma, many patients won’t follow that advice, for instance. “When you reach patients, small changes can have large benefits”, he said.

However, although many patients rely on internet to find health information, formal health information sites face fierce competition on Internet. It is difficult for consumers to separate chaff from wheat:

Still, Duodecim has managed to make a website for the general public that is now as popular as the original physicians database is for doctors, the only difference being that doctors use the database continuously, whereas the general public just consults the database when they are confronted with a health problem.
The database contains 1000 EBM key articles, where the content is integrated with personal health records. The site looks rather straightforward, not glitzy nor flashy. Intentionally, in order to look like a serious and trustworthy professional health care site.

A survey revealed that Duodecim performed a lot better than Google in answering health care questions, and does lead to more people either deciding NOT to consult a physician (because they are reassured), or deciding to consult one (because the symptoms might be more serious than thought). Thus it can make a difference!

The results are communicated differently to patients compared to doctors. For instance, whether it is useful to wear stockings during long-haul flights to prevent deep venous thrombosis in patients that have either a low or a high risk for thrombosis is explained to the physician in terms of RR, ARR, RRR and NNT.
Patients see a table with red (high risk patients) and green columns (low risk patients). Conclusions will be translated as follows:

If 1000 patients with a low risk for DVT wear stockings on long-haul flights

  • 9 will avoid it
  • 1 will get it
  • 1 out of 1000 (will get it)
  • 990 use stocking in vain

If 1000 patients at high risk for DVT wear stockings on long-haul flights:

  • 27 will avoid it
  • 3 will get it
  • 1 out of 333 (will get it)
  • 970 use stocking in vain

This database will be integrated with permanent health records and virtual health checks. It is also linked to a tv program with the aim of changing the way of living. Online you can do a life expectancy test to see what age you would reach if you continue your life style as you do (compare “je echte leeftijd”, “your real age”[dutch]).

“What young people don’t realize”, Pekka said, is that most older people find that the best of life starts at the age of 60(?!) Thus, it doesn’t end at 30, as most youngsters think. But young people will only notice, when they reach old age in good health. To do this, they must change their habits already when young.

The Finnish database is for free for Finnish people.

Quite coincidentally (asking for a free usb-stick at the Wiley stand ;) ) I found out that Wiley’s database EBM Guidelines links to the Duodecim platform (see below). Quite interesting to take a trial, I think.

(Although this presumably is only the professional part of Duodecim, thus not the patient oriented database.)





Attend the virtual Cochrane Colloquium

5 10 2008

The annual Cochrane Colloquium is now ongoing in Freiburg, Germany. The theme is “Evidence in the Era of Globalisation.”

As many readers may already know, the Cochrane (CC, Cochrane Collaboration) is an international not-for-profit and independent organization, dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide. It produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions (see Glossary).

The yearly Cochrane Colloquium is meant for members of the CC, and those interested in the organization.

For those that cannot attend the meeting, there is an opportunity to virtually view the following items:

To go to the individual virtual items you can click one of the items above.

You can also go to “Welcome” by following this link and go to the Virtual Colloquium. It is easier to switch to another item from there.

It should be noted that there is also a lot uncovered by the virtual media: the meetings and workshops (of course), as well as the (non plenary) oral sessions and even the very interesting opening session with the following speakers: Gerd Antes (German Congres Centre), Tikki Pang (WHO) and Pekka Mustonen (Duodecim).

An overview of the colloquium program can be found here.





The (un)usefulness of regular breast exam

7 09 2008

Regular breast exam, either by women theirselves (BSE, breast self exam) or a doctor or nurse, has been promoted for many years, because this would help to detect breast cancer earlier, and “when breast cancer is found earlier, it’s easier to treat and cure” . At least that is what most people believe and what has been advocated by organizations and Internet companies (i.e. selling special gloves) (see figure).

The idea that regular breast exam is truly beneficial, however, has recently been challenged by a Cochrane Systematic Review, conducted by Kösters and Gøtzsche.[1] This review has stirred up quite a debate among doctors, guideline-makers, patients and women. Many major organizations and advocacy groups have stopped recommending routine BSE. Reactions of patients vary from ‘reluctant’ to ‘confused that it is no longer needed’ or even a bit angry (‘it is my body and I decide whether I check it or not’). See for instance these reactions: 1, 2, 3. Coverage in the media is sometimes misleading, but reactions of (some) doctors or “experts in the field” also do not always help to convey a clear message to the public either. Some seize the opportunity to rant against EBM (Evidence Based Medicine) in general, which makes things even less transparent, see for instance this post by Dr Rich (although he has some good points as well), this story in the Herald and this one in Medcape.

In a question-answer like way I try to cover the story.

1. What is the conclusion from the study?
The authors conclude that regular breast examination (BE) does more harm than good and is therefore not recommended.

2. Which harm, which good?
Breast examination didn’t lower mortality (not beneficial), whereas it led to more unnecessary biopsies (harm).

3. Why did they look at mortality only?
They didn’t, they also scored the number and stage of cancers identified. However mortality (or really survival) is an outcome that matters most for patients. Suppose the screening finds more breast cancers, but early intervention does not lead to any cure, than the early recognition of the cancer is of no real value to the patient.

4. Why are more unnecessary biopsies considered as harm?
Biopsies are an invasive procedure and lead to unnecessary anxiety, that can have a long-lasting effect on psychological well-being. Extra tests to rule out that it is not cancer also cost a lot of money. Whether it is ‘worth it’ depends on whether -and to which extent- people’s lives are saved (or quality of life improved).

5. What kind of study is it?
It is a systematic review (of controlled clinical trials) made by the Cochrane Collaboration (see glossary). Generally these systematic reviews are of high methodological quality, because of the systematic and explicit methods used to identify, select and critically appraise relevant research. After extensively searching for all trials, only controlled clinical trials (studies of the highest evidence) with predefined characteristics are included. Thus authors are really looking for all the high level evidence there is, instead of grabbing some papers from the drawer or looking at the core English language journals only.

6. Is this new information?
No, not really. In fact this systematic review is an update of a previous version, published in 2003. The studies included and the conclusions remain the same. As shown from the scheme below (taken from a figure in a very interesting opinion paper entitled “Challenges to cancer control by screening” (see abstract here), the attitude towards breast self examination already changed soon after the original trials were published.

Nature Reviews Cancer 3, 297 (2003)

M.N. Pollak and W.D. Foulkes: Nature Reviews Cancer 3, 297 (2003)

7. Omg? ….
All Cochrane Systematic have to be regularly updated to see if there isn’t any new evidence that could alter the conclusions. In this case, after updating the search, no new studies of good quality were found. However, there are still some trials ongoing.

8. Can we rely on these conclusions? Is the Cochrane Review of good enough quality?
The Cochrane Review itself is of high quality, but the two randomized studies included, one from Russia (1999: ~122,500 participants) and one from Shanghai (2002: ~266,000 participants) have some serious flaws. For instance, both studies did not have an adequate allocation concealment (keeping clinicians and participants unaware of the assignments). An inadequate concealment undermines the validity of a trial (see for instance this 2002 Lancet paper). Also, description of statistical methods was lacking. Furthermore, data from the Moscow-branch of the Russian study were incomplete (these are excluded), mammography might have been used additionally and in the Shanghai trial there was a large difference in all-cause mortality in favor of the control group, suggesting that the two groups were imbalanced from the start.

9. Can the results of these rather old trials from countries as China and Russia be directly translated to the situation in Western Countries with a high standard of care?
Intuitively I would say ‘probably not’. However, we still don’t know whether the current western quality of care would actually lead to a better outcome after early detection, because it has never be tested in a well performed controlled trial.

10. Is this outcome applicable to anyone?
No, the studies are applicable to healthy, middle-aged woman without any particular risk. Screening methods might be more useful or even required for woman at high risk (i.e. familiar predisposition, previous ovarian or breast cancer).

11. Still, in recent interviews experts in the field say they do know that BSE is beneficial. One doctor for instance referred (in this Medscape paper) to a recent trial, that concluded that breast self-examination should be promoted for early detection of breast cancer (see here).
Either these doctors/experts give their personal opinion, refer to unpublished data or to studies with a lower evidence level. For instance the study referred to by Dr. Goldstein above was a retrospective study looking at how accurately woman could detect a breast tumor. Retrospective studies are more biased (see previous post on levels of evidence for dummies). Furthermore this study didn’t evaluate a hard outcome (survival, better prognosis) and there are just as many retrospective studies that claim the opposite, i.e. this article of Newcomb et al in J Natl Cancer Inst. 1991(abstract).

12. Should woman refrain from breast self examination then?
I found a short article (half A4) in the Dutch woman’s magazine (!) Viva very clear and concise.
Four woman gave their opinion.

A patient who had had a previous breast tumor kept on checking it (high risk group).

The director of a patient association said: “there is no evidence that BSE is beneficial: don’t feel quilty if you don’t check your breasts. But it might have a reassuring effect if you do”.
The spokeswoman of the Dutch association “struggle against cancer” (KWF) said that they didn’t promote structural breast exam any longer, but they advised to “know your body” and know the alarm signals (retracting nipple etc), much the same way as you check for alterations in nevi. Most woman find small alterations anyway, said another, for instance when taking a shower.
Indeed, exemplified by my own experience: 18 years ago my mother detected breast cancer when feeling a lump in her breast under the shower (malignant, but curable).

The Cochrane authors are also very clear in their review about the necessity of women noticing changes to their breast.

“Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision.
It would be wrong, however, to conclude that women need not be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.”

Listen to this Podcast featuring the Cochrane authors to learn more about their findings

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Periodieke borstcontrole, uitgevoerd door vrouwen zelf of door artsen/verplegers, is jarenlang gepromoot, omdat je hierdoor eerder borstkanker zou ontdekken, waardoor het beter te genezen is. Deze gedachte wordt actief uitgedragen door verschillende organisaties en Internetbedrijven (die bijvoorbeeld speciale handschoenen verkopen, zie figuur).

Dat regelmatige borstcontrole zinvol zou zijn, wordt echter tegengesproken door een recent Cochrane Systematisch Review, uitgevoerd door Kösters and Gøtzsche.[1] Dit review heeft heel wat losgemaakt bij dokters, makers van richtlijnen, patienten en vrouwen in het algemeen. Veel belangrijke organisaties bevelen niet langer het maandelijks controleren van de borsten aan. De reacties van (engelstalige) patienten varieert van ‘opgelucht’ tot ‘in verwarring gebracht’ of lichtelijk boos (‘ik maak verdorie zelf nog wel even uit wat ik doe’). Zie bijv. enige reacties hier: 1, 2, 3. De berichtgeving door sommige media is soms misleidend. Dat is vaker zo, maar vervelender is het dat reacties van sommige artsen of ‘experts’ heel gekleurd zijn, waardoor de boodschap niet goed overkomt bij het publiek. Sommigen grijpen de gelegenheid aan om even goed op EBM (Evidence Based Medicine) af te geven, zie bijv. deze post van Dr Rich (die overigens ook zinnige dingen opmerkt), dit bericht in de Herald and dit in Medcape (zie onder).

Ik zal proberen om dit onderwerp in een vraag-en antwoord-vorm te bespreken.

1. Wat zijn de conclusies uit de studie?
Dat structureel borstonderzoek door vrouwen zelf of door artsen/verplegers meer kwaad dan goed doet, en dus niet langer aanbevolen kan worden.

2. Welk kwaad, welk goed?
Maandelijkse controle van de borsten leidt niet tot minder sterfte (niet ‘beter’), maar wel tot 2x zoveel biopsies (kwaad, ‘harm’).

3. Waarom kijken ze alleen naar sterfte?
Ze keken ook naar het aantal ontdekte kankers en hun stadia, maar sterfte (of eigenlijk overleving) is veel belangrijker voor de patient. Stel dàt je eerder borstkanker vindt door screening, maar dit leidt niet tot genezing en/of een betere kwaliteit van leven, dan schiet de patient daar niets mee op, integendeel (zij weet het langer).

4. Waarom worden biopsies als ‘schadelijk’ gezien?
Een biopsie is een medische ingreep, die -zeker in het geval van vermoede kanker-, een langdurig negatief kan effect hebben op iemand’s psychische gesteldheid. Biopsies en andere testen, die nodig
zijn om kanker uit te sluiten kosten veel geld. Of dit het ‘waard’ is hangt af van hoe nuttig die testen werkelijk zijn, dus of ze de kans op overleving of een betere kwaliteit van leven verhogen.

5. Wat voor een studie is het?
Het is een systematisch review (van “gecontrolleerde” klinische studies), gemaakt door auteurs van de Cochrane Collaboration (zie Glossary). Over het algemeen zijn deze reviews van uitstekende methodologische kwaliteit, omdat studies volgens een vast stramien gezocht, geselecteerd, beoordeeld en samengevat worden. Van te voren worden alle criteria vastgelegd. Dus de auteurs proberen echt alle evidence (positief of negatief, zonder taalbeperking) boven water te krijgen in plaats van wat artikelen uit de kast te trekken of alleen maar de top-tijdschriften te selecteren.

6. Is deze informatie nieuw?
Nee, niet echt. Dit systematische review is in feite een update van een vorige versie uit 2003. De geincludeerde studies en de conclusies zijn hetzelfde. Zoals te zien in het schema hieronder (Nature Reviews Cancer 2003, samenvatting hier), is de houding ten opzichte van borstzelfcontrole al sinds de publicaties van de oorspronkelijke studies (die in het Cochrane Review opgenomen zijn) veranderd. De Amerikaanse Cancer Society beveelt bijvoorbeeld al sindsdien maandelijks zelfonderzoek niet meer aan.

Nature Reviews Cancer 3, 297 (2003)

M.N. Pollak et al: Nature Reviews Cancer 3, 297 (2003)

7. Huh? ….
Alle Cochrane Systematische Reviews behoren regelmatig ge-update te worden om te kijken of er geen nieuwe evidence is die tot een andere conclusie leidt. In dit geval werden er geen nieuwe studies van goede kwaliteit gevonden. Wel lopen er nog enkele studies.

8. Kunnen we van deze conclusies op aan? Zijn Cochrane Reviews van een voldoende kwaliteit?
Het Cochrane Review zelf is van een goede kwaliteit, maar op de 2 studies die opgenomen zijn in het review (een uit Rusland uit 1999 met ca. 122.500 deelnemers en een uit Shanghai uit 2002 met ca. 266.000 deelnemers) is wel het een en het ander aan te merken. In beide studies was de blindering van de patienten en de behandelaars voor de toewijzing van de behandeling (concealment of allocation) onvoldoende. Daarmee wordt zo’n studie minder valide (zie bijv. dit artikel uit de Lancet van 2002). Verder was de beschrijving van de statistische methoden onvolledig, waren gegevens van de Moskouse tak van de studie Russische studie niet compleet (zijn wel uitgesloten) , en was er in de Shanghai studie een groot verschil in algehele sterfte (dus niet alleen borstkanker), wat een duidelijke aanwijzing is dat de 2 groepen al vanaf het begin niet gelijkwaardig waren.

9. Zijn de resultaten uit deze oudere studies uit landen als China en Rusland zondermeer op Westerse landen van toepassing?
Intuitief zou ik zeggen van niet. De zorg in Westerse landen en de hedendaagse behandelingen zijn mogelijk beter. Alleen weten we niet of screening door zelfonderzoek hier wel tot een betere uitkomst zou leiden, omdat dat nooit in goede gecontroleerde studies is bestudeerd.

10. Gelden de conclusies voor alle vrouwen?
Nee, de studies zijn allen gedaan -en daarom alleen van toepassing op gezonde vrouwen van zo’n 35 tot 65 jaar. Screeningsmethoden, waaronder borstzelfonderzoek, zijn wel aan te bevelen voor vrouwen, die tot de risicogroep behoren (vrouwen die erfelijk belast zijn of die eerder al borst- of eierstokkanker hebben gehad).

11. Toch stellen bepaalde deskundigen dat zelfonderzoek wel gunstig is. Een dokter (Dr. Goldstein) verwees daarbij in een interview in Medscape (zie hier) naar een heel recente studie (zie hier).
Deze artsen/deskundigen geven hun persoonlijke mening, verwijzen naar niet-gepubliceerde studies of naar studies met een lagere bewijskracht. De studie waar Dr. Goldstein naar verwijst is bijvoorbeeld een retrospectieve studie, die alleen onderzoekt hoe goed vrouwen borstkanker kunnen vaststellen. Retrospectieve studies hebben altijd meer vertekening (zie een vorig bericht over het beste studietype… voor dummies). Verder keek deze studie niet naar harde uitkomsten (overleving, betere prognose). Daarnaast zijn er evengoed retrospectieve studies die het tegenovergestelde beweren, zie bijvoorbeeld dit artikel van Newcomb PA et al in J Natl Cancer Inst. 1991(abstract).

http://breastselfexam.ca/section1slide2.html

12. Moeten vrouwen dan helemaal geen borstcontrole meer doen?
Ik kwam toevallig ergens op een terrasje een klein stukje in de Viva (1-7 aug 2008) tegen dat ik heel duidelijk vond.
4 Vrouwen gaven hun mening.

Een vrouw die eerder borstkanker had gehad bleef maandelijks controleren (risicogroep).
De directeur van de Borstkankervereniging zei: “Wetenschappelijk is aangetoond dat borstcontrole niet zorgt voor minder sterfte door borstkanker. Voel je niet schuldig als je het niet doet. Doe je het wel om zo je borsten goed te leren kennen, dan heeft dat vooral een psychologisch effect”. De woordvoerdster van de KWF Kankerbestrijding zei dat ze periodieke zelfcontrole niet langer promoten, maar dat ze ook niet zeggen dat het zinloos is. Het is net als bij moedervlekken, die controleer je ook niet gestructureerd, maar als je een verandering ziet ga je wel naar de huisarts. Daarmee in overeenstemming zei de directeur van Pink Ribbon dat 90% van de vrouwen borstkanker zelf opmerkt: als er iets zit merk je het toch wel, bijvoorbeeld tijdens het douchen. Inderdaad kan ik dat uit eigen ervaring bevestigen. Mijn moeder voelde jaren geleden een knobbeltje terwijl ze zich aan het douchen was (kwaardaardig, maar genezen).

De Cochrane auteurs zeggen in hun review ook heel expliciet dat het absoluut noodzakelijk is om naar de dokter te gaan als vrouwen veranderingen aan hun borst opmerken.

“Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision.
It would be wrong, however, to conclude that women need not be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.”

Hier is de Podcast waarin de Cochrane auteurs over hun studie vertellen.

zie Engels gedeelte hierboven





Thesis Mariska Leeflang: Systematic Reviews of Diagnostic Test Accuracy.

22 08 2008

While I was on vacation Mariska Leeflang got her PhD. The ceremony was July 1st 2008.

Her thesis is entitled: Systematic Reviews of Diagnostic Test Accuracy.

Mariska is a colleague working (part time) at the Dutch Cochrane Centre (DCC). She studied veterinarian science in Utrecht, but gradually noticed that she was more interested in research than in veterinary practice. Four years ago she applied for a job at the dept. of Clinical Epidemiology, Biostatistics and Bioinformatics (KEBB) at the Amsterdam Academic Medical Centre (AMC). Having a cv with all kinds of odd subjects like livestock and courses delivering anesthetic drugs from a distance, she thought she would never make it, but she did.

Those 4 years have been very fruitful. She did research on diagnostic accuracy, is member of the Cochrane Diagnostic Test Accuracy Working Group and first author of one of the Cochrane pilot reviews of diagnostic test accuracy (chapter 7 of thesis). [Note: Cochrane Diagnostic Test Accuracy Reviews are a new initiative; till recently all Cochrane Systematic reviews were about health care interventions].
Mariska also supports authors of Cochrane systematic reviews, gave many presentations and led many workshops. In fact, she also gave in-service training to our group of Clinical Librarians in diagnostic studies and together we have given several courses on Evidence Based Medicine and Systematic Reviews. In leisure time she is Chair of “Stichting DIO” (Vet Science & Development Cooperation)

She will continue to work for the Cochrane Collaboration, including the DCC, but has also accepted a job at the Royal Tropical Institute (http://www.kit.nl).

Because of her backgound Mariska often gives her work a light “vet” touch.

“The cover of her thesis for instance is inspired by Celtic artwork and reflects the process of a systematic review: parts become a whole. The anthropomorphic (human-like) and zoomorphic (animal-like) creatures represent the background of the author. The stethoscopes and the corners refer specifically to diagnostic test accuracy reviews.The snakes eating their own tail stand in Celtic mythology for longevity and the ever-lasting life cycle.”

Also, she often closes her presentations with a slide showing swimming pigs, the pig being symbolic for “luck”.

So I would like to close this post in turn by wishing Mariska: “Good Luck”

Thesis: ISBN: 978-90-9023139-6
Digital Version at : http://dare.uva.nl
Index: (I’ll come back to chapter 1 and 2 another time)
Chapter 1: Systematic Reviews of Diagnostic Test Accuracy – New Developments within The Cochrane Collaboration – Submitted
Chapter 2: The use of methodological search filters to identify diagnostic accuracy studies can lead to the omission of relevant studies – J Clin Epidemiol. 2006;59(3):234-40
Chapter 3: Impact of adjustment for quality on results of meta-analyses of diagnostic accuracy – Clin Chem. 2007;53(2):164-72
Chapter 4: Bias in sensitivity and specificity caused by data driven selection of optimal cut-off values: mechanisms, magnitude and solutions – Clin Chem. 2008; 54(4):729-37
Chapter 5: Diagnostic accuracy may vary with prevalence: Implications for evidence-based diagnosis – Accepted by J Clin Epidemiol
Chapter 6: Accuracy of fibronectin tests for the prediction of pre-eclampsia: a systematic review – Eur J Obstet Gynecol Reprod Biol. 2007;133(1):12-9
Chapter 7: Galactomannan detection for the diagnosis of invasive aspergillosis in immunocompromized patients. A Cochrane Review of Diagnostic Test Accuracy – Conducted as a pilot Cochrane Diagnostic Test Accuracy review

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Mariska Leeflang is op 1 juli 2008 aan de Universiteit van Amsterdam gepromoveerd op het onderwerp:“Systematische Reviews van de Diagnostische Accurratesse”.

Mariska is eigenlijk een collega van mij. We werken samen part time op het Dutch Cochrane Centre (DCC). Zij heeft diergeneeskunde gestudeerd in Utrecht, maar kwam er gaandeweg toch achter dat ze liever onderzoeker dan practiserend dierenarts wilde zijn. Toen ze vier jaar geleden ging solliciteren bij de afdeling Klinische Epidemiologie, Biostatistiek en Bioinfomatica (KEBB) van het AMC gaf ze zichzelf weinig kans met vakken als graslandbeheer en een cursus ‘verdoven op afstand’ op haar cv. Maar ze werd wel aangenomen. En terecht!

Die 4 jaar zijn zeer vruchtbaar geweest. Ze deed diagnostisch onderzoek, is lid van de Cochrane Diagnostic Test Accuracy Working Group en eerste auteur van een pilot diagnostisch accuratesse review (H 7 van proefschrift). Cochrane Systematische Reviews van Diagnostische Accuratessestudies zijn een nieuw type Systematisch Review, naast de bestaande Cochrane Reviews van interventies.
Mariska heeft veel presentaties en workshops gegeven, ook in Cochrane verband. Ze heeft zelfs ons clinical librarians bijgeschoold op het gebied van diagnostische stusies. Samen geef ik met haar EBM-cursussen en de cursus “Systematische Reviews” voor Cochrane auteurs. In haar vrije tijd is ze voorzitter van de Stichting DIO ( Diergeneeskunde in Ontwikkelingssamenwerking).

Ze zal voor de Cochrane Collaboration blijven werken, maar werkt sinds kort ook 2 dagen per week op het Koninklijk Tropeninstituut (KIT).

Vaak zie je dat Mariska vanwege haar achtergrond als diergeneeskundige vaak een link maakt naar dieren.

Op de omslag van haar boekje dat gebaseerd is op Keltisch kunstwerk wordt het proces van een systematisch review als volgt weergegeven: Alle delen worden samen een geheel. The mensachtige en dierlijke wezens vormen Mariska’s achtergrond. De stethoscoop en de hoeken staan voor de diagnostische accuratessereviews. De slangen, die hun eigen staart opeten staan in de Keltische mythologie voor een lang leven en de eeuwigdurende levenscyclus.

Ook sluit ze haar presentatie vaak af met een plaatje met zwemmende biggetjes, die voor “geluk” staan.

Dat lijkt me ook hier een passend slot: Veel geluk Mariska!!





Two new Cochrane Groups

8 05 2008

Two groups have officially joined the Cochrane Collaboration: the Cochrane Public Health Review Group and the Cochrane Prognosis Methods Group.

The Cochrane Public Health Review group belongs to the Cochrane Review Groups, i.e. groups that produce Cochrane Reviews in specific medical topic areas.

The Cochrane Prognosis Methods group will be the 13th Cochrane Method Group. This group will have two primary roles: 1. Work with existing Cochrane entities, including Methods Groups to ensure the best use of prognostic evidence in Cochrane reviews 2. Conduct research to advance the methods of prognosis reviews and other types of reviews, where similar methods apply.

By calling into existence Method Groups like the Cochrane Prognosis, Cochrane Adverse Effects, Cochrane Screening and Diagnostic Tests and the Cochrane Qualitative Research Methods Group, the Cochrane Collaboration will no longer fully concentrate on Systematic Reviews of Randomized Controlled Trials / interventions. That has been a major criticism of the Cochrane Systematic Reviews.

For people not familiar with the structure of the Cochrane Collaboration, see the schematic picture below or follow this link

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De Cochrane Collaboration heeft er 2 nieuwe groepen bij, de Cochrane Public Health Review Group en de Cochrane Prognosis Methods Group.

Zoals de naam al zegt is de Cochrane Public Health Review Group een Cochrane Review Group, d.w.z. een groep die Cochrane Reviews schrijft over een bepaald medisch onderwerp, in dit geval dus volksgezondheid.

De Cochrane Prognosis Methods Group is de 13e Cochrane Method Group. Deze groep ondersteunt andere Cochrane groepen zodat ze evidence op het gebied van prognose goed implementeren en voert onderzoek uit om de de methodologie van prognostische reviews te verbeteren.

Het is een goede zaak dat de Cochrane Collaboration de Prognosis Method Group alsmede enkele andere groepen als de Cochrane Adverse Effects, Cochrane Screening and Diagnostic Tests en de Cochrane Qualitative Research Methods Group in het leven heeft geroepen. Hiermee komt zij tegemoet aan de vaak geuite kritiek dat Cochrane Systematic Reviews zich teveel op het nut van interventies richten en zich ‘alleen’ baseren op (randomized) controlled trials.

Voor wie niet bekend is met de structuur van de Cochrane Collaboration, zie bovenstaand plaatje en deze link








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