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Which O for PICO?

31 Aug, 14 | by Bob Phillips


We’ve mentioned before about the COMET initiative, that was born from lots of work in rheumatology, and seeks to standardise a core set of outcomes collected in clinical trials so that the trial

  1. Measures things of importance to patients, clinicians and researchers and
  2. Provides a degree of homogeneity that makes systematic reviews more powerful

Well, those clever rheumatologists have done it again, conceptualising the whole of it into two major areas, and breaking them up into manageable parts.


A picture paints a thousand words

20 Aug, 14 | by Bob Phillips


Pretty much sure that you’ve all hit something complicated and, after trying to explain it, have grabbed pencil, paper and said something like “Look, you see, it’s …”


And your picture may be completely unlike the thing you’re describing.


Well, hot on the tails of our Archi blog about the challenges with ‘standard care’ as a comparator comes a really nice way of thinking about complex variations in studies included in systematic reviews. Admittedly, the title is a tad off putting “Evidence-based mapping of design heterogeneity prior to meta-analysis: a systematic review and evidence synthesis” but the idea – along with it’s beautiful execution in examples – is that we can use a rather neat tabular design to outline where studies vary and how this might explain differences and need to be understood in our translation / incorporation of the outputs into clinical practice.


There’s a wealth of stuff written about visual display, and of course, an entire industry dedicated to it, but we docs do tend to ignore all that sort of stuff, don’t we?

What’s your ‘best’ example of great graphical representation making something terribly complicated enlightened? Comment, FB us, or tweet it to @ADC_BMJ #NowIsee




No Numbers Required: Qualitative research

17 Aug, 14 | by Bob Phillips

Hello everyone.

Holidays are lovely things, and I would greatly advise everyone to take one. A proper one, where you switch off your emails (?perhaps even deleting those that arrive?), ignore your work texts and generally hide in a work-free hole for a while. You might think about doing this every weekend you’re not working, or instituting your own digital sabbath, perhaps, to keep topped up with the goodness that isn’t work.

It’s always good to look at things with fresh eyes, and I would encourage you to have a think about research that doesn’t centre around assumptions of normality, stochastic thinking and positivist ideologies. Instead of ‘what happens when ..’ ask the ‘how & why do people ..’ questions. more…

What stops us getting more people into clinical trials?

1 Aug, 14 | by Bob Phillips

It may not have escaped your notice as you travel between different areas of the hospitals in which you work that there appear to be some things that have more clinical trial activity going on than others. There have been many things written on why this might be, including a very persuasive paper* that argues for the reduction in health waste by the better integration of clinical care and clinical trials, and a claim that trials are an ethical imperative.

Yet not an awful lot of folk are on-trial. Why?


Words, listening, and the art of applying the general to the specific

24 Jul, 14 | by Bob Phillips

A little bit of a swirl around a decade-old paper by @iona_heath on the trouble with turning a patient’s experience into something that might require medically fixing that was floated about twitter recently.

The paper, which is densely written and has lots of lovely quotes from proper writers, and speak of many aspects of doctoring, holds to a thesis that the truth of the patient’s condition is their living of it, and as doctors, we mould and warp and misrepresent it to fit into a diagnosis, reject a diagnosis, or hold as an uncertainty. more…

StatsMiniBlog: Kappa

16 Jul, 14 | by Bob Phillips

After a short pause while brain cells were diverted elsewhere, we’re returning with the critically acclaimed (well, slightly positively tweeted) StatsMiniBlog series.

(As an aside – do let me know via comments, Facebook or Twitter if there’s an issue you’d like to see covered)

Kappa (κ) is a measure of agreement, usually between two observers of a dichotomous outcome although there are variants for multiple observers.  It gives you a measure of what agreement you see that is ‘beyond chance’


“Compared to standard care”

9 Jul, 14 | by Bob Phillips

There’s a decent argument in the analysis of quantitative studies of therapies, particularly using RCT designs, that says that we should be looking at the totality of unbiased evidence (systematic reviews) rather than looking at individual, cherry-picked, studies. The best estimate from this come from a pooling of all the results: meta-analysis.

There’s a challenge to this, though, when the comparisons are not quite the same. In the case of trials of drug A vs. B, C, D and E it can be quite easy to spot (and then perhaps undertake a network meta-analysis to address the issue). When the trials are A vs. standard care it’s a greater challenge to see if & how “standard care” varies.  more…

A Message To Paediatricians

6 Jul, 14 | by Bob Phillips

The Children and Young People’s Health Outcomes Forum, an “expert group” formed to advise the English governmental agencies on improving heath outcomes for folk from before their birth to 25 years old, held a summit in June and were addressed by a number of young people who had used health services in different ways.

One of those people, Lucy Watts, has taken us up on an offer to speak to an audience of paediatricians, phamacists and others involved in the care of young people through this blog site. She writes:

I would like Paediatricians to know that not all parents that challenge you or disagree with you are neurotic parents, and I think parents should be appreciated and used as an important pool of knowledge: you have the medical training, but they are the experts in their children. They know their patterns, behaviour, routines, diet, and they know when their child is sick. You get the odd neurotic parent, but that doesn’t mean all parents should be treated that way (especially mothers).When a child/teenager becomes sick, and needs care, it’s the parents who step up and fill that role. For example, my mum, who never wanted to be a nurse, has learned so many procedures she could rival any qualified nurse.  She’s the one who gives me my medicine, runs round getting medications and supplies, does all the phoning around and chasing up appointments, gets up with me at night, sleeps on my floor when I am poorly, empties my bags round the clock, she does my TPN – something many nurses do not know how to do – as well as IV medication, central line care, PEGs, injections, mixing medications, catheterising, dressing, stoma bags, can catheterise a blocked stoma….many things a parent should never have to do. Some doctors do not appreciate how far a parent goes to keep their child alive, many give up their lives, like my mum has, to keep us alive.

This is hauntingly familiar to me, an oncologist. If we listen, we hear this message from many parents, young people and children, and while we need to balance it with the truth that there is “the odd neurotic parent” the appreciation of how we make people feel while they are seeking explanations for them feeling unwell is very important.

(I appreciate that nearly all the hard work of filtering the non-malignant diagnoses has been done before folk get to me – and that I benefit hugely from this.)

I also know that I fail to recognise the massive effort that families put into caring, often, as I emerge from just 5 days of QDS medication to be delivered.

How do you respond to this piece?

- Bob Phillips


The despair of the box-ticking paediatrican

1 Jul, 14 | by Bob Phillips

So, as the annual assessment of learning by paediatric trainees reached fever pitch in many ares of the UK, a question rang out across Twitter:

In (trainees approaching ARCP), does (shoehorning logbook to curriculum) compared to (reflecting on clinical experiences) improve outcomes?

And while this, I feel, is more of an emotional outpouring to garner peer support, love and recognition of the need for coffee rather than an evidence request, there are some data supporting the use of work based assessments and e-portfolios


Naming of Reviewers

29 Jun, 14 | by Ian Wacogne

Peer review has controversies. There are numerous criticisms, but when it comes down to it, to paraphrase Churchill on democracy, it’s the worst way of doing it, except for all the others. I don’t want to discuss the whole process of peer review here, except to state that when we publish something, because we’re not always experts in that field, we ensure that there has been peer review.  The question I want to pose here is around the degree of anonymity.


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