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Stopping Rules

24 Jul, 15 | by Bob Phillips

If you were cycling or driving, you’d probably know what the stopping rules were. Traffic not moving, big red sign, large goose with malevolent glare (Lincolnshire speciality).

What if you’re doing a clinical trial?

There are a variety of things what have been described, some of them are qualitative (SUSAR – sudden, unexpected, serious adverse reactions) and some statistical. The latter have with them a set of maths that leads to reasons to discontinue, either for proven benefit or futility.


There are many ways to truss a duck

21 Jul, 15 | by Bob Phillips

28bd690e07e27d7dfba01e0fc55a63f4And there are lots of ways to do ‘synthesis’ of evidence within a systematic review. We’ve gone on – at length – about meta-analysis and described qualitative synthesis with meta-ethnography, but in a new paper in the Archives we see how a narrative combination of quantitative research studies with a qualitative framework to understand them can allow us to see where the trees lie in the wood [insert alternative forestry based metaphor if preferred].

This group of authors decided to examine the safety netting tools after discharge from the paediatric emergency / urgent care department. more…

Why are you measuring it like that?

14 Jul, 15 | by Bob Phillips

We measure, monitor and assess lots of things in our jobs. We frequently try hard not to think about poorly reproducible some things are – take breathlessness in children as discussed in a recent blog – and the whole literature is methodologically far weaker than that of intervention research. Sometimes we’re really like to assess something, but find it hard to work out exactly how to make that measurement: for example, what should we be measuring when looking at “time to antibiotics” in sepsis – door to ‘needle’ time? proportion less then one hour? first fever to antibiotic duration?

Sometimes it can help to take a completely different idea, to think about what elements might be important.

Say – “home field advantage” in competitive team sports


Is breathlessness worth reporting at all?

26 Jun, 15 | by Bob Phillips

6za74k736pc03j9fp8h5gialh.500x223x11Again, deliberate bait in the title which I do hope you’re all used to by now …

But the question arose when I started to look at this paper published in the Archives, addressing the question of observer variation in clinical assessment of wheezy kids. Mostly, I think wheeze = mediastinal mass (fast onset -> T-cell lymphoma, slow onset -> Hodgkin’s lymphoma) or wheeze = aspergillus infection, if hot & leukaemic,  but I do recognise that asthma is, occasionally, the correct answer.

But how breathless are wheezers and do different clinicians agree?


Guest Blog: The trials and tribulations of answering clinical questions

23 Jun, 15 | by Bob Phillips

 For a recent evidence based paediatrics assignment we had to answer and present a clinical question. I’m sure you are well acquainted with the process; construct your question in standard PICO format, search your secondary and primary sources, critically appraise the evidence and draw your conclusions.

Having noted a trend towards starting lamotrigine rather than valproate in adolescent girls, because of the concerns of teratogenicity, and wondering if this is at the expense of good seizure control, my question was:“In adolescent girls with newly diagnosed generalised epilepsy (population) is lamotrigine (intervention) as effective as sodium valproate (comparison) at achieving seizure control (outcome)?”


Basics: Another way to look at it all

19 Jun, 15 | by Bob Phillips

While the theory of different styles of learning (kinetic, verbal, visual etc etc ) may be thoroughly garbage it’s pretty much true that folk often prefer one way of getting their learning. Some like listening – catch our podcasts for that – others doing – so we have #ADC_JC – and many readers of this blog will like, well, reading.

Anyone particularly value pictures?


Basics: Are you worrying about stuff?

22 May, 15 | by Bob Phillips

I spend quite a lot of time fairly unsure that I really know enough about the stuff I should know about. Sometimes I think we could benefit from reflecting on this a bit:

Are there known uncertainties – things which we have a good estimate, based on good research, but gives us an answer which isn’t clearly one way or another (like early discharge for low-risk febrile neutropenia)?

Are there clear ignorances – things where we know that we don’t know about that stuff (for me … acute ataxia that isn’t a cerebellar tumour or recent removal from a merry-go-round)

Are their nibbling unconvincings – things where you know what you have always done, and probably will do again, but aren’t sure it’s really right (e.g. using 0.45% saline for IV maintenance fluid)?

Are there blasts of amazing newness – where someone slaps you with something you have had no idea was a thing or what to do about the thing (I heard about something called “Mauriac syndrome” the other month ?!??)?

These types of unsureness can be resolved with very different approaches. The first line – the known uncertainty – can only really get better if there are more studies, or if the decision is shared one-to-one with the patient and family to whom it applies. The clear ignorance is relatively straighforward to fill: find a good background article that can supply the necessary gap-filling. For this, I’d heartily recommend the “15 minute consultation” section of the (green) Education and Practice section of the ADC. Nibbling unconvincingness is (obviously!) best addressed by you looking at the evidence, and summarising it if necessary … via an Archimedes perhaps?

The final lot – the unknown unknowns – are most dangerous and most unfillable. You just need to keep you ears and eyes open, and constantly taste the air for areas in which you are shockingly ignorant. An open mind – let call it #ThingsIdidntKnow – is the best way out of this. We need to support each other in letting this happen and celebrate the gaps in our knowing.

– Archi

Critical interventions

5 May, 15 | by Bob Phillips

There are considerable numbers of interventions which are undertaken at points of emergency; severe head injury, severe septic shock, myocardial infarction, admissions to intensive care units… In these situations it can be extremely tricky to get the critically ill, often unconscious, individual to agree to being randomised in a clinical trial. Yet without that, we won’t know what treatment to give. Or not give.

But surely we should just use common sense?

Like oxygen for myocardial infarction?

Or can we undertake “deferred consent” – a rather odd phrase which means seeking consent for the data collected after a patient has been, because of a critical care emergency, entered into a randomised trial.  more…

Parents on NICU rounds

1 May, 15 | by Bob Phillips

Does your neonatal unit have parents present when you’re doing medical rounds? Would that be a good thing? (Or if you already do it, is that a bad, limiting thing?) Could the presence of parents inhibit honest medical discussion? Could it compromise confidentiality? May the opportunities for bedside teaching be severely reduced? Could the stress of hearing the discussions be excruciating to the parents? Will the inclusion of parents into a ward round discussion bring about a greater trust, and make it truly inclusive? Will it allow for a deeper understanding of the dilemmas faced on both sides? And how much will it vary between parents?

Thinking about all those possibilities makes the idea of trying to investigate the question “Should parents be present on neonatal ward rounds?” rather difficult to frame. For instance, what outcomes are important, and how could they be measured?


Basics: Rapid Reviews

28 Apr, 15 | by Bob Phillips

Systematic reviews in health care aim to answer a specific, highly structured, clinical question by extensive searching, careful sifting and appraisal of the studies, a considered synthesis and well tempered conclusions. They can take very many months – 18 or more – to complete.

Where we undertake and use systematic reviews to provide the very best estimates of effect, we’ll also be waiting a long time to get there. What we might be – practically – better doing is a ‘good enough’ review; still focussed, still symptomatic and still synthetic, but quicker.

This is the realm of the rapid review, a not-quite defined type of systematic review that’s quicker, perhaps a little more focussed, sets clearer boundaries and is well prepared to make every piece fall into place one after another. It turns around an answer fast enough to bring answers about more quickly but still good enough to make a difference.

Of course, you might recognise this type of description when you think about Archimedes reports…But Archimedes reports are a bit briefer in searching, and rarely undertake a formal synthesis, so not quite in this category.

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