#CECEM Bridging the Gap between Evidence Based Practice and Practice Based Evidence

15 06 2009

cochrane-symbol A very interesting presentation at the CECEM was given by the organizer of this continental Cochrane meeting, Rob de Bie. De Bie is Professor of Physiotherapy Research and director of Education of the Faculty of Health within the dept. of Epidemiology of the Maastricht University. He is both a certified physiotherapist and an epidemiologist. Luckily he kept the epidemiologic theory to a minimum. In fact he is a very engaging speaker who keeps your attention to the end.


While guidelines were already present in the Middle Ages in the form of formalized treatment of daily practice, more recently clinical guidelines have emerged. These are systematically developed statements which assists clinicians and patients in making decisions about appropriate treatement for specific conditions.

Currently, there are 3 kinds of guidelines, each with its own shortcomings.

  • Consensus based. Consensus may be largely influenced by group dynamics
    Consensus = non-sensus and Consensus guidelines are guidelies.
  • Expert based. Might be even worse than consensus. It can have all kind of biases, like expert and opinion bias or external financing.
  • Evidence based. Guideline recommendations are based on best available evidence, deals with specific interventions for specific populations and are based on a systematic approach.

The quality of Evidence Based Guidelines depends on whether the evidence is good enough, transparent, credible, available, applied and not ‘muddled’ by health care insurers.
It is good to realize that some trials are never done, for instance because of ethical considerations. It is also true that only part of what you read (in the conclusions) has actually be done and some trials are republished several times, each time with a better outcome…

Systematic reviews and qualitatively good trials that don’t give answers.

Next Rob showed us the results of a study ( Jadad and McQuay in J. Clin. Epidemiol. ,1996) with efficacy as stated in the review plotted on the X-axis and the Quality score on the Y-axis. Surprisingly meta-analysis of high quality were less likely to produce positive results. Similar results were also obtained by Suttorp et al in 2006. (see Figure below)

12066264  rob de bie CECEM

Photo made by Chris Mavergames

There may be several reasons why good trials not always give good answers. Well known reasons are  the lack of randomization or blinding. However Rob focused on a less obvious reason. Despite its high level of evidence, a Randomized Controlled Trial (RCT) may not always be suitable to provide good answers applicable to all patients, because RCT’s often fail to reflect the true clinical practice. Often, the inclusion of patients in RCT’s is selective: middle-aged men with exclusion of co-morbidity. Whereas co-morbidity occurs in > 20% of the people of 60 years and older and in >40% of the people of 80 years and older (André Knottnerus in his speech).

Usefulness of a Nested Trial Cohort Study coupled to an EHR to study interventions.

Next, Rob showed that a nested Trial cohort study can be useful to study the effectiveness of  interventions. He used this in conjunction with an EHR (electronic health record), which could be accessed by practitioner and patient.

One of the diseases studied in this way, was Intermittent Claudication. Most commonly Intermittent Claudication is a manifestation of  peripheral arterial disease in the legs, causing pain and cramps in the legs while walking (hence the name). The mortality is high: the 5 year mortality rates are in between those of colorectal cancer and Non-Hodgkin Lymphoma. This is related to the underlying atherosclerosis.

There are several risk factors, some of which cannot be modified, like hereditary factors, age and gender. Other factors, like smoking, diet, physical inactivity and obesity can be tackled. These factors are interrelated.

Rob showed that, whereas there may be an overall null effect of exercise in the whole population, the effect may differ per subgroup.

15-6-2009 3-06-19 CI 1

  • Patients with mild disease and no co-morbidity may directly benefit from exercise-therapy (blue area).
  • Exercise has no effect on smokers, probably because smoking is the main causative factor.
  • People with unstable diabetes first show an improvement, which stabilized after a few weeks due to hypo- or hyperglycaemia induced by the exercise,
  • A similar effect is seen in COPD patients, the exercise becoming less effective because the patients become short of breath.

It is important to first regulate diabetes or COPD before continuing the exercise therapy. By individually optimizing the intervention(s) a far greater overall effect is achieved: 191% improval in the maximal (pain-free) walking distance compared to for instance <35% according to a Cochrane Systematic Review (2007).

Another striking effect: exercise therapy affects some of the prognostic factors: whereas there is no effect on BMI (this stays an important risk factor), age and diabetes become less important risk factors.

15-6-2009 3-35-10 shift in prognostic factors

Because guidelines are quickly outdated, the findings are directly implemented in the existing guidelines.

Another astonishing fact: the physiotherapists pay for the system, not the patient nor the government.

More information can be found on https://www.cebp.nl/. Although the presentation is not (yet?) available on the net, I found a comparable presentation here.

** (2009-06-15) Good news: the program and all presentations can now be viewed at: https://www.cebp.nl/?NODE=239


#EAHIL2009 Web 2.0 and Health Information – Chris Mavergames

4 06 2009

2-6-2009 23-11-41 EAHIL 2009

I’m in Dublin to attend the EAHIL workshop 2009.
The EAHIL is the European Association for Health Information and Libraries.

The EAHIL -workshop 2009 really started Wednesday afternoon. Tuesday morning, as a foretaste of the official program I attended a Continuing Education Course, namely the Web 2.0 and Health Information course by Chris Mavergames.

Chris Mavergames is currently the Web Operation Manager/Information Architect for the Cochrane Collaboration. Before, he worked in the field of information and library science.

So Chris and I are really colleagues, but we didn’t realize until we “met” on Twitter.

On this hot day in June I was pleased that the workshop was held in the cool Berkeley Library of Trinity College.
They have chosen real good locations for this EAHIL workshop. Most presentations are in the Dublin Castle, another place at the Heart of the Irish History.

The workshop took approximately 3 hours and consisted of two presentations, followed by short Q&A’s and an open forum afterwards.

The presentations:

  • Web 2.0 and Health Information“,
  • A case study of the experiences of implementing and using these technologies in a large, non-profit organization (Cochrane Collaboration).

Eighteen people could attend. Each of us had a computer, which raised expectations that they were needed during the workshop. They were not, but they were handy anyway to look up things and to draft a post. And.. I could post this message on Twitter before Chris loaded a photo of his class on TwitPic.  LOL.

4-6-2009 9-46-55 chris is making a photo

10848362 class chriss mavergames

Web 2.0 versus web 1.0
Chris began with asking the audience how many people either have used ..or at least have heard of Facebook, LinkedIn or any other social networking service. And then he asked which tools were being used. Afterwards he admitted he had checked everyone’s presence on various social bookmarking sites. Hilarious.

To my surprise, quite a number of people were familiar with most of the web 2.0 services and sources. Indeed, weren’t librarians the first to embrace web 2.0?

I got the impression Twitter was the least well known/appreciated tools. Most people were either on Facebook or Linkedin, not on both. This presumably has to do with separation of professional and personal things.

Chris first explained the difference between Web 1.0 and Web 2.0: Web 1.0 is a one way interaction, static. Web 2.0 is: “more finding or receiving, less searching”. It has a dynamic aspect: there is more interaction, the possibility to ‘comment, subscribe, post, add, share or as Chris puts it: “Web 2.0 allows you to have information “pushed” at you vs. you having to “pull”.

Another characteristic of web 2.0 is that technology has become easier. It is now more about content.

As an example he showed the Cochrane website from 2004 (web 1.0) and the current website. The first was just a plain web site where you could search, browse and email, the second has social bookmarking tools and is more dynamic and active: you can add comments, post on websites etc.. In addition the Cochrane Collaboration is now on Twitter and Facebook and produces podcasts of a selection of systematic reviews.

Another example of web 2.0 interfaces are MyNCBI of PubMed (for saving your searches) and i-Google.

Social Networking services
These services allow you to create an online profile so that you can interact with others, share and integrate.

Examples are Facebook, LinkedIn and 2 Collab. What is used most, differs around the world. Linkedin is more a professional site, an “online resume” and Facebook is for more general stuff. “You’re mother is on facebook too, so..”. Most young people don’t realize what others can read. However, Facebook offers the possibility to select precisely who can see exactly what.

Twitter is a microblogging system, that allows a 140 chracter message (tweet). At first, Chris wasn’t very much interested. He only knew Twitter through the automatic updates on Facebook, but “wasn’t really interested in a  friend in New York eating a scrambled egg.”

It is as easy to subscribe to one’s updates as it is to unsubscribe. Chris uses Tweetdeck to filter for keywords that are of interest. But as he showed me later, he uses the i-phone to easily catch what people (he follows) are tweeting.

Although Twitter was created as a social tool it is now much more than that. It creates a so called “ambient awareness” and as such it is a perfect example of “push” technology: you won‘t see every tweet, but you will l be ambiently aware of the conversation (of your “friends” or the subject you follow). Twitter is also very useful for getting a real fast answer to your question. This is how Chris learned the value of Twitter. He had a question at a meeting. Someone said: just put it on Twitter with the hashtag of the congress (an agreed upon keyword with #in front, like #EAHIL2009). He did it and within 3 minutes he got an answer. Twitter is also very useful for sharing and finding links.
There are many “Twitter apps” around. Just search Google for it.

For professional use within a company the twitter look-alike Yammer can be a useful alternative, because only people in the company are able to follow the updates.

My personal experience is also very positive. Twitter and other web 2.0 tools can work synergistically, dependent on your Twitter community and how you use it.

Social bookmarking:
Although librarians aren’t always very happy with user generated tagging, social bookmarking tools are and easy way of allowing users to share a collections of links.
Links used (directly or indirectly) for his presentation are available at del.icio.us/mavergames under the tag EAHIL.

Blogs, Wiki’s
A blog can give a good summary of interesting articles in a particular field. Chris began a blog 2 months ago (http://mavergames.net) about  a very specific subject he is involved in: Drupal. For him is it just an open notebook: a platform to share your ideas with others.
It is possible receiving updates via RSS (push).

Wiki’s are a very powerful knowledge gathering tool,  a way to collaboratively create a resource, based on the principle of “Crowd sourcing” (The Wisdom of Crowds).

Examples of the two are:

  1. https://laikaspoetnik.wordpress.com/ (this blog)
  2. http://scienceroll.com/ (of the Hungarian Medical Student Bertalan Mesko)
  3. http://www.medpedia.com/ (not yet fully developped medical wiki)
  4. http://twictionary.pbwiki.com/ (a fun wiki with the Twitter Vocabulary)
  5. cochrane.org/ideas
  6. http://mavergames.net (Chris’s blog on Drupal)

Subscription services: RSS
Via RSS Really Simple Syndication you can push information from a variety of sources:

  • Podcasts, for instance cochrane.org/podcasts
  • Saved searches, like in PubMed
  • News feeds cochrane.org/news
  • Updates to sites
  • Updates to collections of bookmarks
  • Updates to flickr photos
  • Etcetera

Platforms can vary from Google Reader, Yahoo, Bloglines, but you can also use i-Google or a specilized medical page where you can find links to all kinds of sources, like blogs, podcasts and journals. Perssonalized Medicine (http://www.webicina.com/rss_feeds/) is especially recommended.

Somebody from the audience added that Medworm is a good (and free) medical RSS feed provider as well. For an overview of several of such platforms, including Medworm, i-Google and www.webicina.com see an earlier post on this blog:  Perssonalized Medicine and its alternatives (2009-02-27).

A typical Web 2.0 scenario:

  1. Chris visits Laika’s MedlibLog and reads Cochrane PodCasts are available.
  2. He finds it interesting , goes to the Cochrane website and subscribes to the Cochrane podcasts with RSS.
  3. He want to share this finding with others, so he decides to tweet that Cochrane podcasts are available.
  4. He gets a response: Hé do you know the Cochrane is on Facebook, so he visits Facebook joins and posts the news on facebook again. And so on.

Not only did Chris give a nice overview of Web 2.0 tools, but there was ample opportunity for discussions and remarks.

The two most common questions were: [1] When can you find time for this? and [2] what can you do when the IT-departments don’t allow access to web 2.0 tools like YouTube, Facebook, RSS? It really seamed the main barrier for librarians from many countries to the use of web 2.0. Nevertheless, Chris engaging presentation seemed to encourage many people to try the tools that were new to them at home. Afterwards I only heard positive comments on this workshop.

The slidecasts of the two presentations are now online on http://www.slideshare.net/mavergames.

The slidecast I’ve reviewed is below.

#Sciblog – a bird-eye’s view from the camera

2 09 2008

Last Saturday I learned from @AJCann and @Jobadge (Twitter) that there was a Science Blogging Conference going on in London, that you could virtually attend.

Although I planned to do something else (banking for my mom, pick up my daughter from her overnight stay; Saturday is my-shopping-&-bodyshape-sauna- & blogging-if-I-have-some-spare-time-day), I decided to follow it. In the meantime I tried to blog about something else, which didn’t work.

I largely followed Cameron Neylon’s streamed video on Mogulus. It’s main value was the audio-stream, as well as the candid-camera function peeping at the audience from behind.

I came in late (back from banking) and unfortunately missed the Keynote lecture of Ben Goldacre from Badscience.

The next session didn’t do it for me, partly because the 3 blogging ladies ( Jenny Rohn, Grrl Scientist, Anna Kushnir) were almost inaudible and what they had to say about the bridging function of blogs between scientists and the general public (also figuratively) didn’t catch my ears. In the meantime the virtual attendents including, Fang (Mike Seyfang) from Australia, AJCann, some other guys and me, chatted in Cameron Neylon’s room.

In between I followed Twitter-messages having the hashtag #sciblog (see here). I was not familiar with hashtags, but it is a predefined tag you can add to you microblogging post to easily tract what is being said about a subject (even when you don’t actually follow the persons themselves, so as a spin off you can get acquainted with some real interesting people).

Example of a twitter message on #sciblog:

#sciblog matt woods: friendfeed encourages discussion and closes feedback loop 9 minutes ago from TwitKit

However, Hashtags is an opt-in service. You must follow @hashtags -and it has to follow you- for the service to index your tweets, so it took me some time to get it done (For more information, see this twitter wiki.) Althoug the procedure in itself was very effective, the twitter messages didn’t add much value for people already attending.

Another online backchannel, the Friendfeed room appeared more lively, but I soon stopped following the threads. Furthermore I ‘m so old-fashioned that I think speakers do deserve my attention while they’re talking (but perhaps that is because I’m not yet used to chatting at the back-scene). Checking my notes afterwards with the Friendfeed comments was useful however.

Next I followed Matt Wood’s introduction to microblogging and aggregation services and Breakout 6 “Communicating Primary Research Publicly” by Heather Etchevers (Human in Science), Jean-Claude Bradley (Useful Chemistry) and Bob O’Hara (Deep Thoughts and Silliness).

I found these presentations interesting, but tracking my notes back I couldn’t see where Matt ended and the others began.

During his lively presentation with a lot of gesturing, the heavy “sequencer” Matt Wood from “Green is Good” told us he had decided not to worry to be open and just send the message out to the public. You could use blogs to communicate your scientific findings, but blogposts do not handle versioning, although you can sometimes manipulate the post’s date (WordPress blog). Another tool is microblogging services. Twitter is more of a social platform, whereas Friendfeed is more apt for more information-exchange (no 140 character-limit). A new microblogging service is identi.ca. (see for instance this readwriteweb post)

Labnote books (and wiki’s) were a recurrent subject through the 4 presentations. They are very useful to blog primary research. People should write their motives, use it as a diary (writing down all details and circumstances), recording the results (videorecording, freehand sketches, figures, prints, text), followed by periodic summing up.

Why this is useful?

  • You don’t have to remember it (people tend to forget) (although some lab-scientists don’t like to take the notebook along to the bench)
  • Archive of ideas, (to share with people in the lab, collaborators or even ‘the world’
  • (If open) some results may be available direct outside the lab, which may be very useful for cooperation and exchange of thoughts or help (why did my blot fail?-how to proceed?)
  • It may help as a bridge to the public, i.e. by showing if public money is being spent well or for direct communication of your data to the public.
  • The info is verifiable if you link to the real data
  • Science is far more efficient this way and results are revealed instantly. Why wait till everything is distilled out? The scientist’s approach is as Hans Ricke quoted Richard Feyman from his Nobel Lecture 1966 (at Bob o’Hara ‘s blog) :

“We have a habit in writing articles published in scientific journals to make the work as finished as possible, to cover up all the tracks, to not worry about the blind alleys or describe how you had the wrong idea first, and so on. So there isn’t any place to publish, in a dignified manner,what you actually did in order to get to do the work.”

As Hans said blogs may fill that hole, because they are the place to publish this!

Major Pitfall may be that journals may not accept data reported on a wiki. And another that some people may run away with your ideas. By writing it all down you make it very easy on them. Still if everybody would become open…. For Science that would be a great good.

What I liked most of these presentations is the openness and the creativity of the presenters.
As a (medical) librarian and a scientist these thoughts came to my mind:

  • I’m a bit jealous that I worked as a scientist in the web 1.0 era. This way of approaching science looks very stimulating to me, but maybe that’s only a romantic look from the outside?
  • How do we as librarians step in? Can we play a facilitating role? Should these primary findings be aggregated and made available in a searchable way?
    We should at least keep more in pace with the new scientific developments and the way researchers exchange and find their information. It’s entirely different to what we are used to. (we= most librarians I know, including myself)
  • I wonder if such an approach could also be used in medicine and/or in EBM. Are wiki’s like this useful for CATs for instance? Question, PICO + domain, best study type, search, critical appraisal, summary, power point presentation, pdf-files, video of CAT etc??? link to video of casus perhaps?

To get an impression of the great features of such a wiki/open notebook, take a look at http://usefulchem.wikispaces.com/ (Jean Claude Bradley). You can also go to the Useful Chemistry blog and click at “UsefulChem wiki”. Note for instance the links to the notebooks of the individual scientists. Really impressive.

Below you also find the (short) presentation of Heather. Hope the others will follow soon and share their presentations

Vodpod videos no longer available.

more about “Sciblog2008 Etchevers“, posted with vodpod
Other Info

Nature science blogging conference

30 08 2008

There is official forum for Science Blogging in London, today. The event is organized by Nature Networks.

You can find the program and the attendees here.

AJCann of Science of the Invisible has summarized in this post how you can virtually follow this conference.

At this moment (saturday 11.45 am) you can follow the forum live here

HATTIP: Twitter : @AJCann, @Jobadge


Vandaag is er een conferentie voor ‘wetenschapsbloggers’ in Londen.

het wordt georganiseerd door Nature Networks

Hier kunt u het programma bekijken.

Op dit moment (zaterdag 11.45 uur) kunt u het programma hier live volgen.

AJCann van Science of the Invisible heeft hier samengevat hoe u deze conferentie kunt volgen.

HATTIP: Twitter : @AJCann, @Jobadge