Helping you to practise evidence-based medicine

The effects of the swine flu pandemic have, so far, been less severe than many had feared, raising the question as to whether this infection has in fact reached pandemic proportions. But when is the right time to declare a pandemic? The WHO have recently revised their own criteria, but predicting how much harm a virus strain will cause is notoriously difficult and often controversial. In his editorial, Peter Gross examines the impact of influenza over the last century, and discusses whether refining the pandemic criteria put forward by the WHO might reduce the risk of a false alarm.

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by Peter A Gross, November 2nd, 2009

With the threat from swine flu seemingly on the wane, the run up to the flu season could see influenza once again making the headlines on a daily basis. But is the influenza virus as widespread and virulent as portrayed in the media? As Tom Jefferson proposes in his Editorial, misrepresentation of the syndrome of influenza-like illness (which cannot be clinically distinguished from influenza) as influenza could inflate the incidence and gravity of the disease.

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by Tom Jefferson, October 5th, 2009

Despite recommendations that mild hypothermia be considered a treatment option for people who are mechanically ventilated post-cardiac arrest, implementation of hypothermia as a therapeutic treatment has been slow. In their Editorial, Vinny Ramiah and Peadar Gilligan review the evidence in support of therapeutic hypothermia, and consider the potential reasons behind reticence to incorporate this treatment into usual care for comatose patients post-cardiac arrest. In addition, the authors discuss how uptake of therapeutic hypothermia could potentially be developed, and ultimately lead to further improvements in prognosis, through the implementation of an internationally recognised post-cardiac arrest protocol.

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by Vinny Ramiah and Peadar Gilligan, September 7th, 2009

There is currently no curative treatment for dementia, and new therapies are urgently needed to ease the demands on people and resources arising from long-term management of this condition. Considering Alzheimer’s disease, the most common form of dementia, immunotherapies that target amyloid-beta have shown encouraging results: two small pilot studies found that intravenous immunoglobulin increased serum amyloid-beta and reduced amyloid-beta in cerebrospinal fluid in people with Alzheimer’s. Here, we discuss the findings from a retrospective case–control study that investigated whether prior treatment with intravenous immunoglobulin for conditions other than Alzheimer’s and related disorders was associated with a reduced risk of Alzheimer’s disease.

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by Samantha Barton, August 10th, 2009

Augmentation of the information available in clinical trial registries through more widespread trial registration would benefit all sectors involved in public health care, and particularly those in resource-constrained settings. The multi-national Pan-African Clinical Trials Registry was established to actively promote prospective clinical trial registration across the continent. But, as Amber Abrams and Nandi Siegfried contemplate in our Guest Editorial, promotion of trial registration alone may not suffice for this initiative to achieve its goal. Changes at the legislative level, and integration of ethics, regulation, and registration, may be essential in the success of such registries in resource-constrained settings.

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by Amber Abrams and Nandi Siegfried, July 13th, 2009

Drug-eluting stents seem to have recently fallen out of favour, being the subject of controversy surrounding their long-term safety. Past examples of drugs placed on the shelf after identification of adverse effects subsequent to initial enthusiasm suggest that drug-eluting stents have entered an established cycle. If they follow this pattern, after setting limitations to their use, a return to popularity could be next. But, as we contemplate in our Editorial, could this cycle have been avoided by actively seeking potential adverse effects at an earlier stage?

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by Vijay Sharma, June 17th, 2009

With an expanding evidence base of RCTs and guidelines, it could be assumed that, in some areas, there would be no doubt about the most appropriate treatment for a particular patient. But is it feasible to assume that uncertainty on the part of the clinician can be eliminated? Or is it more realistic to accept uncertainty, and for each clinician to find a level of uncertainty that they feel comfortable with? As Philip Clatworthy contemplates in our Guest Editorial, uncertainty in decision making does not a fallible clinician make.

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by Philip Clatworthy, May 16th, 2009

Heralded as the next big breakthrough in the treatment of schizophrenia, second-generation antipsychotics were thought to offer superior efficacy and more favourable adverse-effect profiles than available treatments. But does the evidence gathered since their arrival over 10 years ago support the early hype? As Robin Emsley discusses in our Guest Editorial, it may be that the distinction between SGAs and FGAs is a redundant one.

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by Robin Emsley, April 20th, 2009

When the evidence suggests a change to clinical practice is warranted, at what point should doubts that contradictory evidence will emerge be put aside, and the decision taken to push ahead? Over-eagerness to accept new evidence can be as damaging as over-caution. As we contemplate here, when it comes to changing clinical practice, is there ever sufficient evidence to state categorically that the change is the right thing to do?

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by Rowena Pease, March 25th, 2009

With clinicians under constant pressure to treat more patients more quickly, high-quality, disease-specific guidance is more important than ever. In February the BMJ Evidence Centre launched Best Practice (http://bestpractice.bmj.com), a product designed to deliver precisely such a service. In our Editorial, Zara Quail and Maria Kouimtzi discuss the stringent processes that ensure that the guidance from world experts is fully supported by a strong evidence base.

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by Zara Quail and Maria Kouimtzi, March 2nd, 2009

Poor organisation and partial or inaccurate completion of clinical notes can cause problems ranging from frustration to litigation. Despite this, no country has processes in place to regulate record-keeping across medical facilities. In our Guest Editorial, Iain Carpenter, Mala Bridgelal Ram, and John G. Williams contemplate how new initiatives in the UK to standardise recording of clinical details could not only improve patient health care but also perhaps fill the gaps in the evidence not answered by RCTs.

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by Iain Carpenter, Mala Bridgelal Ram, and John G. Williams, February 9th, 2009

To treat, or not to treat? Clinicians and patients face this question daily. However, recent guidance from the GMC makes it explicit that, rather than making treatment decisions independently, doctors must endeavour to equip patients with the information necessary to decide which treatment, if any, they want. But imparting the subtleties of absolute and relative risk is not easy. In our Editorial, we contemplate approaches to improving communication of risk to patients to empower them to direct their own treatment.

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by Iain Marshall, January 26th, 2009

The uniform implementation of clinical recommendations is not always successful on a nationwide level, even when the clinical evidence is convincing. So is the global application of such principles possible? Or is this an unachievable goal? In the first of a series of editorials touching on international health issues, Chandrakanth Are focuses on the field of surgical oncology to examine some of the obstacles that must be overcome before evidence-based guidelines developed in resource-rich countries can be applied effectively in resource-poor countries.

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by Chandrakanth Are, January 12th, 2009

There is consensus that glycaemic control helps to prevent microvascular complications of diabetes, but its role in prevention of cardiovascular complications has been less clear. Several recent studies shed light on this issue, and our Editorial looks at how this research has prompted reconsideration of how, when, and why to use antihyperglycaemic drugs.

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by Sheila Feit, December 15th, 2008

Original research articles usually report an extensive range of information and data — much of it not essential for decision making in clinical practice. Filtering out facts and figures that are relevant to a specific clinical question can be difficult. As discussed by Jin-Ling Tang and Shan Wang in our Guest Editorial, the lack of a clear definition of what constitutes key research-derived information for practice, as well as ineffective dissemination of this information, may limit the large-scale effectiveness of evidence-based medicine.

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by Jin-Ling Tang & Shan Wang, November 17th, 2008

In an ideal world, patients presenting to a clinician for treatment would tick the same set of boxes as patients included in the key RCTs in that clinical area. But, in real-life settings, clinicians have to treat the person facing them at that moment. Here, we consider the potential differences between RCTs undertaken in research-based settings and routine clinical practice, and go on to highlight the need to identify, evaluate, and account for these differences when interpreting study results to inform practice in real-life settings.

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by Mike Bedford, November 5th, 2008

All systematic reviews are not created equal, and a poor-quality systematic review is of limited usefulness to a busy clinician. Improving the reporting of systematic reviews is an evolving process, as highlighted by the soon-to-be-published expansion of the definitive QUORUM statement. But, as David Moher deliberates in our Guest Editorial, there are core standards that, if met by a systematic review, set it apart from other reviews in terms of dependability and quality.

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by David Moher, October 20th, 2008

Given that normal growth in a child is considered a marker of good health, child growth monitoring programmes are considered good practice. But, until recently, there was little evidence to support their use. In our Guest Editorial, Ameeta Mehta and Peter Hindmarsh sum up new evidence suggesting that monitoring growth in children is useful; and, in light of the recently published WHO standards, they discuss the controversies regarding their applicability as a gauge of abnormal growth in individual populations.

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by Ameeta Mehta & Peter Hindmarsh, September 23rd, 2008

Like any organisation, the NHS needs to evolve to meet the needs of its customers. But how does a large service provider like the NHS identify areas in which it could improve, as well as gaps in its knowledge? The National Institute for Health Research Health Technology Assessment programme plays a key role in this process, as outlined in our Editorial by Nicholas Hicks, Pamela Young, and Naomi Stockley.

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by Nicholas Hicks, Pamela Young & Naomi Stockley, September 10th, 2008

Are all treatments equal in the eyes of EBM? In terms of systematic reviews and RCTs — perceived as the cornerstones of EBM today — the answer is no. But, as Helen Barnett and Ike Iheanacho discuss in their Editorial, systematic reviews and RCTs are not necessarily the best sources for identifying clinically useful treatments. Moves to implement a different type of research strategy for long-established interventions return to the spirit of EBM — building on the best available evidence and clinical expertise, while considering patients’ experiences and values.

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by Helen Barnett & Ike Iheanacho, August 28, 2008

Is a mild adverse effect of a drug treatment always an undesirable event? Or can an adverse effect be exploited to elicit a beneficial effect in another condition? In our Editorial, we touch on this question using a recent study of amitriptyline in the treatment of diarrhoea-predominant irritable bowel syndrome. As we highlight, the distinction between contributions from beneficial and adverse effect is not always clear.

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by Sam Love, August 18, 2008

Caffeine is probably the most commonly consumed stimulant worldwide. Four years ago, before the Athens Olympics, the World Anti-Doping Agency (WADA) took this substance off its list of drugs prohibited in sport. With the Beijing Olympics beginning next month, we contemplate how the change in WADA's thinking on the performance-enhancing effects of caffeine has influenced elite athletes' perceptions of the powers of this stimulant.

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by Mark Stuart, July 28, 2008

In resource-rich countries, chronic paediatric illnesses are rare. But this low prevalence has contributed to the lack of an evidence base for children as comprehensive as that available for adults. It may be that, as discussed by Michael Silverstein and Howard Bauchner, considering children with chronic conditions separately from those without them could help to remedy this gap in the evidence.

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by Michael Silverstein & Howard Bauchner, July 14, 2008

Strategies to reduce morbidity and mortality from postpartum haemorrhage in resource-poor settings are determined by the resources available to a community. But does the evidence support the strategies implemented? In our Guest Editorial, Metin Gülmezoglu and Justus Hofmeyr review gaps in the evidence, and suggest that focusing on community interventions could be the way forward.

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by A. Metin Gülmezoglu & G. Justus Hofmeyr, June 16, 2008

All reviewers need to make the best of their time and resources. But can restricting the search still best serve the needs of the review? In our editorial, Alan Thomas compares two reviews on low-cost public health interventions in the prevention of diarrhoea (our review of diarrhoea in adults has been recently updated). He contemplates that consideration of the impact of the results of the review on people's lives is perhaps just as important as the choice of the search methods and outcomes assessed.

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by Alan Thomas, May 27, 2008

How much can blood pressure tell us about a treatment for stroke? Or bone mineral density about fracture-prevention strategies? Using surrogate outcomes as a substitute for clinical events may not always give us the complete picture of treatment effectiveness. In our Editorial, Samantha Barton discusses how their use can raise more questions than answers, and contemplates what makes an ideal surrogate outcome.

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by Samantha Barton, May 05, 2008

New evidence on complementary medicine is now regularly being included in high-quality systematic reviews. EBM practitioners' opinions in this area and the evidence behind it are famously divided and often low. They range from the point of view that there is virtually no usable evidence to the conclusion that traditional scientific evidence is just not well-suited to complementary medicine. In our Guest Editorial, Professor Edzard Ernst discusses the reasons behind these doubts, and what can be done to strengthen confidence in this therapeutic area.

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by Edzard Ernst, April 21, 2008

Multidrug-resistant tuberculosis (MDR-TB) has been reported across the world, and its incidence is rising: according to the WHO, there were 500,000 cases of MDR-TB in 2006. Population heterogeneity, the wide array of available treatment regimens, and characterisation of resistance all complicate the development of evidence-based treatment guidelines. But, as Philip Hopewell and Ernesto Jaramillo highlight, combining data from the available scientific literature with clinical expertise and experience from MDR-TB treatment programmes can create a foundation on which a management scheme for this infection can be built.

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by Philip C. Hopewell & Ernesto Jaramillo, March 24, 2008

Subarachnoid haemorrhage is challenging to diagnose. Evidence-based guidelines are lacking, but computed tomography followed by lumbar puncture is recommended as the appropriate strategy. Negative results for both tests have been found to be sufficient to rule out diagnosis. However, although this combination is sensitive, it has been reported to lack specificity. There is encouraging evidence that diagnosis of this condition will be easier in the future, but, as highlighted in our Editorial by Alastair Newton and Andrew Parfitt, sometimes clinical experience makes the difference.

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by Alastair Newton & Andrew Parfitt, March 10, 2008

Consensus treatment, based on expert opinion, for early stages of Bell's palsy comprises a corticosteroid plus an antiviral agent. However, recent evidence suggests that although corticosteroids have a small, but significant, benefit when started within 72 hours of onset, antivirals confer no more benefit than placebo. Should clinical practice for the treatment of this condition be revised on the basis of this finding? In our Editorial, a critical appraisal by Karen Pettersen suggests that perhaps combination treatment should not be abandoned just yet.

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Karen Petterson, February 25, 2008

Many health questions are important to clinicians and patients, but cannot be answered by research evidence available today. In a guest editorial, Iain Chalmers, coordinator of the James Lind initiative, asks whether researchers are making sufficient effort to respond to clinician and patient need when designing research protocols.

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Iain Chalmers, January 28, 2008

2007 has been an outstanding year for Clinical Evidence. In addition to producing new systematic reviews and updating those already published, we have introduced a method based on the work of the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working party for assessing the quality of the research we review, and have also published an amazing variety of Letters from the Editor. In the latest Letter, we explain more about how we have implemented the GRADE evaluation process for Clinical Evidence reviews, and revisit two Letters which have encouraged us reconsider our editorial approach.

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Charles Young & Alison Martin, January 02, 2008

Sub-Saharan Africa is home to more than two thirds of all people infected with HIV: a grim statistic considering that most people in this region do not have access to antiretroviral therapy. Preventing HIV infection in Africa is therefore a global health care priority. This month, Nandi Siegfried and Don Operario discuss the challenges ahead for those charged with developing and implementing evidence-based HIV-preventative strategies in Africa. For further information on HIV in resource poor countries, please see our reviews on Managing HIV/AIDS in resource poor settings.

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Nandi Siegfried & Don Operario, December 03, 2007

It’s always exciting to read about promising new anti-cancer drugs, and physicians are naturally eager to make use of these therapies in everyday practice. Justin Stebbing, George Dranitsaris and Mark Vincent highlight how the toxicity of drugs tested in the ideal settings of clinical trials can sometimes be underestimated. They discuss strategies to minimise the risks of using new chemotherapies in the community, including a website that can help clinicians predict the chances of adverse effects in individual patients.

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Justin Stebbing, George Dranitsaris & Mark Vincent, November 19, 2007

The mainstream media love to report good news about miracle cures that often turn out to be not so wonderful when the absolute benefit to an individual is known. In her editorial, Cherrill Hicks discusses the problem of overenthusiastic reporting, and how a new service from BMJ BestTreatments will help healthcare professionals and patients get beneath the hype to develop realistic expectations about new interventions.

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Cherrill Hicks, November 05, 2007

Routine screening mammography is recommended for all UK women aged 50 to 70 years, as there is general consensus that screening women for breast cancer in middle age saves lives. Recently, the UK Government announced an extension of the age range for screening to include women aged 47 to 73 years, reviving the dispute about the value of routine mammography for younger women. In her editorial, Professor Valerie Beral considers this debate as she reviews the challenges facing today's breast cancer screening programmes. To read about interventions for breast cancer, see the Clinical Evidence Reviews: Breast cancer (metastatic) and Breast cancer (non-metastatic).

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Valerie Beral, October 15, 2007

One of the most important tenets of evidence-based medicine is recognition of the importance of patients’ values and preferences in determining the use of evidence within the consultation. In practice, the ways in which trials are constructed, conducted and reported frequently cause problems for clinicians and patients who wish to implement research evidence from clinical studies in practice. In his editorial, David Tovey reports from the James Lind Alliance/Lancet conference held at the Royal Society in London, which brought together a panel of experts to discuss the challenges of personalising evidence.

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David Tovey, September 17, 2007

The role of vitamins in preventing cardiovascular disease (CVD) has recently been addressed in several interesting papers. An RCT just published in Archives of Internal Medicine has shown that vitamins C, E and beta carotene do not protect women at high risk of CVD. Similarly, two recent studies have investigated the link between vitamin D and CVD. Here, we discuss the findings from the vitamin D trials, illustrating how researchers can best use different types of trial design to effectively answer important clinical questions.

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Mark Stuart, September 03, 2007

Emerging data in clinical trials are often previewed to ensure the safety of participants and to optimise the benefits derived from trials. Recently, an interim analysis of the RECORD trial — a large RCT assessing the cardiovascular effects of rosiglitazone — was published in the New England Journal of Medicine in response to a meta-analysis that cast doubt on rosiglitazone’s cardiovascular safety. Here, Dirk Bassler, Victor Montori, and Gordon Guyatt discuss whether the RECORD interim analysis has exonerated rosiglitazone, and outline the uses and limitations of data preview.

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Dirk Bassler, Victor M. Montori & Gordon Guyatt, August 15, 2007

There are now many treatment options for people with depressive disorders (see our recently updated review on Depression in adults — drug and other physical treatments. But despite the rapid pace of drug development in mental health, one important question about antidepressant drugs remains unanswered: how long do people usually take to respond to these agents? Here, Andrea Cipriani, Corrado Barbui, and John Geddes discuss the challenges of designing trials to investigate the timing of onset of action of antidepressant drugs.

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Andrea Cipriani, Corrado Barbui & John R. Geddes, July 16, 2007

On July 1 2007, England became officially "smoke-free" with smoking forbidden in virtually all enclosed public places. The ban was enforced because of the risk of smoking-related diseases, particularly lung cancer, in people working in smoky venues, such as pubs and bars. In our letter from the editor, we discuss the evidence base behind the smoking ban, focusing on a recent meta-analysis that has investigated the link between passive smoking at work and lung cancer.

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Damian Pattinson, July 02, 2007

This month, we launch the Clinical Evidence Supportive and palliative care section, which systematically reviews the evidence base behind these two distinct, but complementary, medical specialities. Here, Sam Ahmedzai and Paul Keeley explain the challenges of finding and collating evidence for supportive and palliative care. In line with the inclusive remit of today's supportive care physicians, our new section will include reviews covering a broad range of clinical problems, initially Constipation in people prescribed opioids, Delirium at the end of life, and Nausea and vomiting in people with cancer and other chronic diseases.

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Sam H Ahmedzai & Paul W Keeley, June 18, 2007

Although the Women’s Health Initiative Study suggested that hormone replacement therapy (HRT) may increase the risk of coronary heart disease in postmenopausal women, the effects of HRT on cardiovascular disease, particularly in women in early menopause, remain controversial. A recent study in JAMA tackles this issue, asking if the cardiovascular effects of HRT vary with age or with proximity to menopause. In our Letter from the Editor we discuss whether the JAMA study brings us any closer to resolving this controversy.

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Shannon Amoils, June 04, 2007

Childhood obesity is a growing health problem in resource rich countries. Government imperatives to tackle childhood obesity place a burden on clinical and public health professionals, especially as information on the effectiveness and costs of interventions has been difficult to find. The new BMJ Health Intelligence website provides information on management of childhood obesity from a public health and commissioning perspective, while the new Clinical Evidence review on childhood obesity presents the evidence on interventions for use with individual patients.

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Alison Walker, May 15, 2007

Clinical Evidence provides clinicians with the best available evidence in the face of rapidly evolving clinical practice. To achieve this, we regularly reappraise the evidence for our systematic reviews. But does such a rigorous and intensive approach to updating reviews result in increased knowledge? Or should updating be more selective and driven by the likelihood of finding new evidence? See the Letter from the Editor where we present our research into how much actually changes when we update our systematic reviews.

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Alex McNeil & Alan Thomas, May 01, 2007

Although resource poor countries bear the greatest burden of HIV disease, little research into HIV/AIDS has actually been conducted in these settings. Considering the differences in demographic distribution, co-morbidities and care infrastructure, it cannot be assumed that conclusions drawn from resource rich countries can be applied to resource poor settings. Commissioned by Johnson and Johnson, and in association with the Liverpool School of Tropical Medicine, Clinical Evidence presents a series of systematic reviews focusing on the challenges of managing HIV/AIDS in resource limited settings.

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Angela Obasi, April 16, 2007

The increasing availability of sophisticated information resources that identify and appraise high-quality evidence from the medical literature has meant that today’s clinicians can practice evidence-based medicine (EBM) without necessarily acquiring critical appraisal skills. But, as Brian Haynes and Charles Young discuss in the Letter from the Editor, there is no room for complacency — the term EBM is often misused and clinicians must retain the ability to distinguish between true and spurious evidence-based resources.

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Brian Haynes & Charles Young, April 02, 2007

Organophosphorus pesticides are possibly the most widely used means of deliberate self harm and occupational poisoning in Asia and Central America. Until recently there has been little evidence of benefit from any intervention designed to treat organophosphorus poisoning, and mortality rates have remained high (see our recently updated systematic review on acute organophosphorus poisoning). We now appraise a key study, published after our review, which shows that a continuous infusion of high dose pralidoxime may reduce mortality compared with standard treatment regimens.

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Alison Martin & Charles Young, March 19, 2007

The treatment of adolescents with major depressive disorder is fraught with challenges and uncertainties. Concerns about adverse effects of antidepressants in this group have discouraged physicians from prescribing drug therapy and, in addition, relatively little is known about the efficacy of cognitive and other psychological therapies. We have recently updated our review on depression in children and adolescents and we now appraise the Treatment for Adolescents with Depression Study (TADS), a large RCT which provides evidence that combined drug and psychological treatment may be the best treatment strategy.

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Alison Martin, Charles Young & David Tovey, March 05, 2007

Clinical Evidence identifies important clinical questions, produces systematic reviews of valid research data which answer these questions, and presents the reviews in a way that is accessible and informative for clinicians. We aim to fully update each of our systematic reviews annually and, in addition, we provide new links on a continuous basis to important research papers published prior to each update. In considering how best to use the Letter from the Editor section on the homepage we felt that, in addition to publishing occasional editorial views on aspects of evidence based practice, we would also highlight interesting publications identified by our continuous updating service such as the paper by Chubak and colleagues about exercise & the common cold.

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Shannon Amoils, Karen Pettersen & Charles Young, February 19, 2007