{"id":1231,"date":"2016-01-22T21:06:40","date_gmt":"2016-01-22T20:06:40","guid":{"rendered":"https:\/\/blogs.bmj.com\/adc\/?p=1231"},"modified":"2015-12-31T13:34:38","modified_gmt":"2015-12-31T12:34:38","slug":"guest-blog-do-all-roads-lead-to-rome","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/adc\/2016\/01\/22\/guest-blog-do-all-roads-lead-to-rome\/","title":{"rendered":"Guest Blog: Do All Roads Lead to Rome?"},"content":{"rendered":"

\"EBP<\/a>Back in the mists of time,\u00a0you may recall we described EBM as the combination of best evidence, clinical expertise and\u00a0patient values<\/a>. Which is pretty straightforward. But how to tell you have the best evidence might be a bit tricky – the RAMBo <\/a>and FAST <\/a>routes can appraise what you’ve got, but how to tell if you’ve actually got the right papers? As our guest blogger Sheeraz Khan\u00a0asks – do all (search) roads lead to Rome?<\/p>\n

<\/p>\n

Sometimes critically appraising search results and incorporating them into your practice might not be as challenging as finding the best evidence. Which could either be because there is no evidence, poor search techniques or unpublished data.<\/p>\n

Searching the evidence: An example<\/h4>\n

Let us see how different search strategies come up with different results using just one search engine i.e. OVID Medline.
\nClinical question: Is cycling CPAP a better strategy for the weaning of CPAP in preterm babies then reducing CPAP pressure?<\/p>\n

Strategy 1.<\/h4>\n

The initial search done using OVID Medline 1996 to October week 3, 2015 using key words. CPAP, continuous positive pressure, cycling, intermittent, weaning, neonate, newborn, and preterm.
\nOnly two articles were relevant from total of 35 results:
\n1. (A) CeasIng Cpap At standarD criteriA (CICADA): Impact on weight gain, time to full feeds and caffeine use.<\/p>\n

2. (B) CPAP review.<\/p>\n

Strategy 2.<\/h4>\n

The new search strategy included the key words of CPAP, Continuous positive airway pressure, positive expiratory pressure, infant, newborn neonate, preterm, premature, weaning, ceasing, cessation, decreasing, pressure, stop, stopping, time off, cycling and intermittent.
\nOnly two articles appeared and both were relevant and different from the above results
\n1. (C) Methods of weaning preterm babies<\/p>\n

2. (D) Withdrawal of neonatal continuous positive airway pressure: current practice in Australia.<\/p>\n

I did a search on Google Scholar with my clinical question and picked up two systematic reviews to study their search strategies.<\/p>\n

Strategy 3.<\/h4>\n

Using search strategy of the systematic review \u201cWeaning of nasal CPAP in preterm infants: who, when and how? Amatya S. World J Pediatr, Vol 11 No 1. February 15, 2015\u201d and got 82 articles however only seven were relevant. Four as above i.e. A, B, C and D with other three as below.
\n5. (E) Strategies to accelerate weaning from respiratory support. [Review]<\/p>\n

6. (F) Gradual versus sudden weaning from nasal CPAP in preterm infants: a pilot randomized controlled trial.<\/p>\n

7. (G) Strategies for the withdrawal of nasal continuous positive airway pressure in preterm infants.<\/p>\n

Strategy 4.<\/h4>\n

Let us take a look at the strategies (key and text words) used by the Cochrane group in the systematic review.
\n\u201cStrategies for the withdrawal of nasal continuous positive airway pressure (NCPAP) in preterm infants The Cochrane Library 2011.\u201d
\nSeven articles were selected out of 554 results. The relevant articles were the same as in the previous search strategy 3 with the only difference of one missing (article E above) and one extra related article which is.
\n(H) Randomized controlled trial of discontinuation of nasal-CPAP in stable preterm infants breathing room air.<\/p>\n

We can see the diversity of results with just a little change in the key and or the text words.<\/p>\n

Cochrane Library<\/h4>\n

I searched Cochrane with the same clinical question however there were no results found after a search done with key words of \u201cweaning of nasal CPAP\u201d \u201cwithdrawal of CPAP\u201d \u201cwithdrawal of CPAP\u201d \u201cweaning of CPAP in preterm babies\u201d
\nBut I do get the systematic review on a little change in the search words \u201cweaning of NCPAP\u201d \u201cwithdrawal of nasal continuous airway pressure\u201d or \u201cwithdrawal of NCPAP\u201d so just the letter \u201cN\u201d in this case can make your life easy!!<\/p>\n

Anything else? – Unpublished data<\/h4>\n

After getting all the appropriate search results and applying it into the practice can we call it \u201cJob done\u201d?
\nHowever there is something still missing or hidden. We have the \u201cBest Published Evidence\u201d but still probably not the \u201cBest Evidence\u201d. There are thousands of clinical trials who have not reported their results. AllTrials campaign<\/a> is a project advocating that clinical research adopt the principles of open research.
\nSince 2008 in the USA the FDA has required results of all trials to be posted within a year of completion of the trial. However an audit published in 2012 has shown that 80% of trials failed to comply with this law.
\nIt is not very easy to say we are practicing evidence based medicine. For example, prescribing a new drug while more than half of the trial results were not published by the manufacturer.
\nRegistering trials<\/a> (tracking\u00a0completed but unpublished studies) will help clinicians who prescribe new treatments and researchers publishing their results avoiding publication bias.<\/p>\n

Conclusion.<\/h4>\n

Obtaining the evidence to make decisions can often be complicated. Performing a comprehensive and well thought out search can lead to differing amounts of evidence obtained and often missing information. This can be because of variability in the availability of papers on different databases. Differing search algorithms leading to differing results or simply data that was never published in the first place. AllTrials will help to ensure that all data is available to be searched for. However, to ensure this can be found a more systematic, less variable and more comprehensive search formula should be found to obtain results.<\/p>\n

References:<\/h4>\n

1. Weaning of nasal CPAP in preterm infants: who, when and how? A systematic review of the literature. Amatya S., Rastogi D., Bhutada A., Rastogi S. World J Pediatr, Vol 11 No 1. February 15, 2015
\n2. Strategies for the withdrawal of nasal continuous positive airway pressure (NCPAP) in preterm infants (Review). Jardine LA, Inglis GDT, Davies MW. The Cochrane Library 2011.
\n3. Principles of evidence based medicine
\nA K Akobeng. Arch Dis Child 2005;90:837\u2013840
\n4. AllTrials Compaign.
\n5. Compliance with mandatory reporting of clinical trial results on ClinicalTrials.gov: cross sectional study BMJ 2012; 344
\n6. \u201cThere is nothing like looking, if you want to find something\u201d \u2013 asking questions and searching for answers \u2013 the evidence based approach.\u00a0Munib Haroon Robert Philips. ADC ed prct ed 2010; 95; 34-39<\/p>\n","protected":false},"excerpt":{"rendered":"

Back in the mists of time,\u00a0you may recall we described EBM as the combination of best evidence, clinical expertise and\u00a0patient values. Which is pretty straightforward. But how to tell you have the best evidence might be a bit tricky – the RAMBo and FAST routes can appraise what you’ve got, but how to tell if […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2675],"tags":[],"class_list":["post-1231","post","type-post","status-publish","format-standard","hentry","category-guest-post"],"yoast_head":"\nGuest Blog: Do All Roads Lead to Rome? - ADC Online Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/adc\/2016\/01\/22\/guest-blog-do-all-roads-lead-to-rome\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Guest Blog: Do All Roads Lead to Rome? - ADC Online Blog\" \/>\n<meta property=\"og:description\" content=\"Back in the mists of time,\u00a0you may recall we described EBM as the combination of best evidence, clinical expertise and\u00a0patient values. 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