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Moral conflict and paternalistic thinking

8 Dec, 15 | by Bob Phillips

Doctor-Who-Day-of-the-Doctor-Forbidden-RegenerationI’ve been reading, Tweeting, FaceBooking and thinking about self-asphyxial behaviours (SAB) for the best part of two weeks, and have driven myself partly potty worrying about the moral implications of my actions and a desire to parent the world.

(I should emphasise – very very clearly – that this relates to a systematic review published by the journal before anyone becomes concerned for me personally. Particularly as this follows a blog on burnout.)

The review scoured eight databases and supplemented this with contacts to seek grey literature to find out what it could on research on the epidemiology of non-erotic self-asphyxial behaviours (SAB); it developed and applied risk of bias assessments based on established criteria for the different types of study sub-question that were being answered; it performed a sensible synthesis that drew the quantitative data together then threaded them with an intelligent thematic overview; and it writes thoughtfully about how this study needs to taken on in research, policy, education and clinical practice.

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What’s stopping you?

24 Nov, 15 | by Bob Phillips

Bovril_250gActually turning the fascinating discussions you all have (I’m sure) over breakfast, beer or bovril about the latest systematic reviews, touching on all elements of critical appraisal from their complex search to their use of mixed logistic regression meta-analysis into action is, sometimes, difficult. We all stop on our course from asking questions, through acquiring information, and appraising that evidence, before we hit the application of our knowledge in practice. But why and does it vary?

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Interventions without evidence should not be undertaken. Discuss.

17 Nov, 15 | by Bob Phillips

1024px-Debate_Logo.svgIt’s been a ‘debate topic’ from a number of conferences, medical student societies and online fora.

Should an intervention without evidence ever be undertaken?

There’s a couple of key elements here: one – the idea that there can be an intervention ‘with no evidence’, and two – that an absence of evidence should be interpreted an evidence of absence of effect. Both are straw men.

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Re-building pyramids

13 Nov, 15 | by Bob Phillips

TradEBMPyramidThe idea of the pyramid of evidence – where a systematic review, or even better, a meta-analysis, trumps all below it – is something that’s passed into mythical status in evidence based practice. Actually, mythical is probably a good way of thinking about it. It’s not real, not really real. But it’s not quite truthless either. The levels of evidence, like so many other ways of understanding the world, are useful to give us a skeleton, but the meat on the skeleton is what makes it more interesting, fun & cuddly.

Images are powerful though, so when the latest issue of the Evidence Based Health Care Newsletter* came out and showed a dramatic re-imagining of the pyramid – I was hooked

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Messed up references

10 Nov, 15 | by Bob Phillips

gold-522369_640Those who are writing a thesis, have just upgraded from one bibliographic manager to another, or have spend a week flying around your (ex) region collecting printed forms to tell a prospective employer you are not a danger to their staff, patients or cutlery may read the title one way.

Those who have been pondering the value of diagnostic test accuracy studies with imperfect “gold standards” may have another.

Take the situation of serious infection in children. We know someone’s got a serious infection because they a) look poorly and b) have a blood, urine or CSF culture that grows a Nasty Bug That Fits The Picture.

We also know that not all bugs that cause problems grown in culture bottles.

So how do we evaluate a new technology, such as PCR-based Bug Detectors; with what do we compare them?

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Triple targets

6 Nov, 15 | by Bob Phillips

EBP triadThere’s a triple target that I often splurge about evidence based medicine being the ‘combination of patient preference, clinical expertise and best-available research’ which in context addresses an EBM-is-copying-the-trial critique. The #RealEBM hashtag (go on … give it a go ..) is addressing this quite eloquently and has been graven in stone by the superb @RichardLehman1 in Ten Commandments*

There’s another triple target too, that I bumped into quite recently while doing more work on transition from child into adult health services. This is the aim for transition services to

  • improve patient experience
  • increase community health
  • have an appropriate and affordable cost

Why on earth have I not considered before that these three aims are core to EVERY health care system that we undertake?

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Nice and easy doesn’t do it.

3 Nov, 15 | by Bob Phillips

CF3wv0AWEAA-16e

With very little need to comment – this model of getting research into practice by dr prof Trish Greenhalsh – can be used to slap down anyone who turns to you and claims all you need to get X, Y or Z working is just

You’re welcome.

 

Collecting patients’ views

20 Oct, 15 | by Bob Phillips

There’s a hugely understandable drive to make health care centre around the person with the health condition and include them in their care, rather than place the focus on the operator of the health machinery or the accountant that balances the cash flows. There’s the recent launch of the Me First! initiative from the UK, for example, and a drive to patient-led safety campaigns (Have you washed your hands?) But is there any evidence that such approaches make a difference, and how can a systems effectively and efficiently measure such approaches, in order to check that Good Things are happening?

Well, there have been a nice pair of contrasting systematic reviews recently that deal with the topics of patient participation, and patient experience of quality, in healthcare systems. more…

The Emperor’s New Biomarker

13 Oct, 15 | by Bob Phillips

Please tell me that I’m not the only one, who hearing about the magical properties of S100, CD64, microbiomology or ILx (where x >8, probably prime, and is instantly forgettable) recalls the scam of the century as told by Hans Christian Andersen in 1837.

Well. There may be more to biomarkers of disease than just a tailor wanting to get away with an awful lot of cash for a very little work.

In a really nice review article by Pak Cheung Ng and colleagues in the F&N edition, they describe the ideal properties of a biomarker for detecting neonatal sepsis or necrotising enterocolitis. Even if you don’t ‘do’ neonates, if you’re involved with acute paediatrics of any or no subspeciality the themes they bring out are worth thinking on:

  1. Your biomarker should be able to be done on a TINY bit of blood/fluid
  2. That blood shouldn’t mind if it’s venous or capillary
  3. It should probably be interpreted in the light of the clinical setting (with prognostic scoring)
  4. It might be a diagnostic / early warning marker, or an organ specific damage marker, or a response to treatment marker – or ideally all of those – but your interpretation should involve understanding what the biomarker is doing
  5. It should ideally be able to be done without the lab (point of care)

It’s worth thinking about the biomarkers you probably do request … I’d class a full blood count, serum albumin, lactate level or CRP in this gang … and work out what they actually do, rather than what you want them to do, and how well they do it … and then when you see the next paper declaiming F64z-soluble-activation-factor-subunit-B as the perfect marker for lupus renalitis (or whatever), you’ll have an idea of what questions need to be asked of that study.

– Archi

Getting from the diamond to the drug chart

9 Oct, 15 | by Bob Phillips

“Come out of the dark and into the light – use systematic reviews in your clinical practice.” (OK, so that’s probably NOT a direct quote.)

It’s been battered on about for a while in this blog that systematic reviews give you – probably – the best idea of if a treatment, diagnostic test or prognostic factor is real/effective/truthful.

But it’s also true that the same, wonderful, complex and sometimes frankly unreadable pieces of research don’t tell you how to take that Truth and get the pharmacy to dispense it, or the physio team to do it, or the lab to tell you the answer.

The answer might be here, beautifully written by Paul Glasziou, an enormously wise practical theorist on evidence-based practice, and colleagues.

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