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How do health care teams talk about very-low-success interventions?

2 Feb, 16 | by Bob Phillips

The_ScreamThe situation is clear. The child has an illness which is very likely to end their life – and soon – in days, not months or years. They may be hooked to a ventilator, drizzled with inotropes, or osmosed. The health care team is talking – once again – about the outcomes and what we can, should or will do.

Do you recognise this?

Do you recall how people spoke – not the ~mab, the pressor or the particular hospice name – but what the emotional and moral content of the discussions were? Can you recall if that varied between professional groups & experience of those folk? And if there were clashes between how people felt the actions should flow, against how they were made to act?

This is the question that has been investigated by a new systematic review in the ADC, drawing together original papers who have enquired about ‘moral distress’ in NICU / PICU


Getting the message across

29 Jan, 16 | by Bob Phillips

NewEBMPyramidThere’s a rather neat editorial in BMC Medicine that discusses how academics might better write their papers to inform and influence policy makers. I was taken with how much the tone of this, and the excellent mini-series of blogs on presentation skills by @ffolliett, were similar and applied to all sorts of layers of ‘policy’ making.

Take the ‘policy’ being made on your unit – guideline implementation, the ‘how we do stuff’ of everyday practice, the business case for a new ‘Where’s Wally?’ book pre-cannulation – and think how you might want to be given the evidence that underpins the actions. more…

Steroids are bad for you. Lifesavingly so.

19 Jan, 16 | by Bob Phillips

Dexamethasone_structureThere are two newish articles on steroids in the Archives – one is a systematic review of adverse drug reactions (ADRs) from short-course use, and one the initial creation of a quality of life tool intended to be used to look at how steroids, particularly dexamathasone, affect the life of those children and young people who get it.

It’s reminded me that steroids are really quite bad for you. But lifesaving too.

Quick poll then: which of these are common (>5%) side effects of short course steroids?


Realist reviews

15 Jan, 16 | by Bob Phillips

ramses2There’s a not-so-new kid on the systematic review block that seeks to cogently and comprehensive look at if, why (or why not) an intervention ‘package’ works in practice. They are ‘realist reviews‘ which, in brief, take a slightly different idea to how things work than the standard medical researchers might.

The reviews aim to unpick the relationships between a programme of intervention (e.g. approaches to substance misusing parents of younger children), the mechanisms of action (e.g. how people think, act and believe stuff when they are approached by programme elements, the choices made), how they are contextual (e.g alter if you’re in or out of a house you can stay in), and the outcomes (e.g. school attendance, child growth, police involvement). They undertake this by following a structure similar to many systematic reviews; they define a clear question, seek widely for appropriate evidence, weigh the potential strengths and weaknesses of the evidence, synthesise it into an understanding of stuff and provide messages for using the research. The synthesis comes from a stated theory, often rough-cut, about how the intervention might work; what the mechanisms may be and how contexts may alter that.


Well I never thought of that …

12 Jan, 16 | by Bob Phillips

Urinary_catheterFor no particular reason I can think of I bumped into this RCT of “Intraurethral Lidocaine for Urethral Catheterization in Children: A Randomized Controlled Trial” and thought, initially, “Well that’s a waste of money and effort and quite unreasonably uncomfortable for the poor little things that got un-anesthetised”. (My very first job was on an adult urology firm, and after popping in a few more three-way irrigation catheters than anyone should need to do I came to the vicarious experiential position that anaesthetic would be a good thing for catheterisation.)

But I read on.

Turns out that compared with just plain, un-medicated lubrication, popping in some anaesthetic doesn’t make it better. Indeed, it might make it worse – as it stings when the lidocaine goes down – and the catheter is equally as uncomfortable.

Which makes me wonder – what have you turned up in your reading / learning that made you question perfectly sensible assumptions?

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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.


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?


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.


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


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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