to identify, using predefined criteria, the best original and review articles on the cause, course, diagnosis, prevention, treatment, quality of care, or economics of disorders in the foregoing fields
to provide a description and expert commentary on the context of each article, its methods, and the clinical applications that its findings warrant
to disseminate the summaries in a timely fashion
The BMJ Publishing Group publishes Evidence-Based Medicine.
All articles in a...]]>
Sickle cell anaemia (SCA) is a disorder of haemoglobin polymerisation that results in vaso-occlusion and haemolytic anaemia, culminating in organ injury and early mortality. Elevated fetal haemoglobin has been associated with a less severe phenotype leading to an interest in hydroxycarbamide (also known as hydroxyurea) use. The MSH study
Data comparing surgery versus watchful waiting for prostate cancer are important, and the results are also relevant when evaluating whether and when screening for prostate cancer is effective.
This randomised trial seeks to determine whether mortality from prostate cancer is lower after radical prostatectomy than with primary expectant management. As an ongoing project for more than 20 years, prior major reports appeared in 2002,
In summary, 695 men with localised and well-differentiated or moderately differentiated prostate cancer (mean age 65...]]>
Proton pump inhibitors (PPIs) were initially considered to be potentially beneficial for bone as they were perceived to be able to inhibit acidic degradation by osteoclasts and thus have antiresorptive potential.
The present study examines whether a relationship exists between the use of PPIs and histamine-2-receptor antagonists (H2RAs) and adverse effects on the skeleton. The question raised is important from an epidemiological point of view as antacid drugs are widely prescribed and available over-the-counter in some locales.
Yu and colleagues applied standard meta-analytic techniques...]]>
Although supplemental oxygen (SupplO2) has been shown to prolong survival in chronic obstructive pulmonary disease (COPD) patients with severe hypoxaemia (ie, PaO2<55 mm Hg or PaO2 55–59 mm Hg with cor pulmonale or polycythaemia), benefits in non-hypoxaemic COPD patients are less clear. Prescribing SupplO2 for such patients is highly variable, and it is common and very costly. As such, there is a strong rationale to clarify the indications.
The article follows the standard Cochrane review approach, that is, considers all (and only) randomised controlled trials, irrespective of blinding (ie, of inhaling oxygen vs medical air) in this case; specifies the intervention (ie, oxygen or medical air as administered through...]]>
A single course of antenatal corticosteroids (ACS) is an unusual example of an intervention which leads to a cost savings and an improved health outcome for infants born before 34-week gestational age (GA).
A single-centre, double-blind, randomised controlled trial of a single course of antenatal corticosteroids versus placebo in women at high risk of preterm birth between 34 and 36 6/7 weeks GA. Between April 2008 and June 2010, 320 women were randomised, 163 to ACS and 157 to placebo, at a large tertiary hospital in Recife, Brazil. Women randomised to the ACS group received two doses of 12 mg of β-methasone intramuscularly every 24 h, and those randomised to placebo received a placebo of similar appearance. Women were...]]>
Cardiac resynchronisation therapy (CRT) is now a well-established therapy for certain subgroups of patients with heart failure, with a large body of evidence demonstrating improvement in symptoms and beneficial changes in cardiac structure and function. American and European guidelines support its use in patients with New York Heart Association (NYHA) class III and IV heart failure, prolonged QRS duration and left ventricular ejection fraction <35%. The COMPANION trial
Asthma is a common condition for which there are robust evidence-based guidelines.
In two parallel, multicentre open-labelled pragmatic trials, Price and colleagues evaluated the effectiveness of inhaled corticosteroids (ICS) versus leukotriene receptor antagonists (LTRAs) as initial asthma therapy (in trial 1) and the addition of an LTRA or a long-acting β agonist (LABA), by random allocation, for participants who remained uncontrolled after 12 weeks of ICS (in trail 2). Participants with physician-diagnosed asthma were recruited from 53 primary care practices in the UK. The study was not funded...]]>
For many patients, the worst part of a procedure, such as a tooth extraction or a carpal tunnel decompression, is likely to be the initial pain following the insertion of a needle and the injection of local anaesthetic. There are reports that warming local anaesthetics before injection can reduce pain, but the effectiveness of this approach has not been accurately determined. The purpose of this systematic review was to examine whether the strategy of warming local anaesthetic prior to injection reduces self-report of pain.
The authors used an accepted search strategy and analysis of randomised or pseudo-randomised studies that compared warmed local anaesthetics with those not warmed before injection. Some of the studies involved volunteers while others involved subjects receiving injections for different indications such as surgery in the head and neck region, closure of lacerations, venipuncture, carpal tunnel decompression or dental anaesthesia in...]]>
Ovarian cancer is the leading cause of death from gynaecological malignancies in developed countries. The majority of the deaths occur in women with invasive epithelial ovarian cancer, most of whom present with advanced disease. This has led to a huge effort in early detection. Buys and colleagues report on the first adequately powered trial to assess the impact of screening on mortality.
Between November 1993 and December 2001, the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial randomised 34 253 women aged 55–74 to ovarian cancer screening (OCS) and 34 304 to control. Women in the screen arm were offered annual serum CA125 interpreted using a cut-off of 35 U/ml and transvaginal ultrasound for 4 years. Those still eligible in 1999 had two further screens of CA125 alone. The evaluation and management of positive screening tests was at the discretion of the participants'...]]>
The aim of this study was to evaluate the long-term effects of early childhood stimulation and/or nutritional supplementation on growth-retarded children in Jamaica, a developing country.
Children (N=129) between 9 and 24 months with growth retardation were randomly allocated to four groups for a 2-year trial: (1) control, (2) nutritional supplementation (1 kg milk-based formula per week), (3) psychosocial stimulation (weekly play sessions to improve mother–child interaction) or (4), nutritional supplementation and psychosocial stimulation. The long-term effects of the intervention were assessed at 7, 11, 17 and 22 years.
Walker and colleagues reported educational, cognitive, social and health outcomes at 22 years for 105 participants. No significant effects were observed for those who received only nutritional supplementation. However, compared with other participants, those who received the psychosocial stimulation programme had higher IQ (p=0.004), higher educational attainment (p=0.033), better general knowledge (p=0.005),...]]>
Screening for breast, colorectal and prostate cancer is recommended to begin at an earlier age for individuals at increased risk because of their family history, compared with individuals at average risk. Some clinical guidelines have also suggested using more sensitive screening modalities for individuals with family histories of cancer, such as MRI for breast cancer screening. Since screening recommendations are different based on family history characteristics, it is important to know how family cancer history might change over time. Most family cancer history information is collected from patients on their initial visit and no evidence exists to help guide the clinician on how often family history information should be updated.
This study reviewed family cancer history information reported from individuals with either a personal or family history of cancer who had enrolled in the Cancer Genetics Network (CGN). Family cancer history information was assessed...]]>
Pneumonia develops when pathogens invading the sterile lower respiratory tract activate the innate immune response to generate local and systemic inflammation.
The two components of an infection are pathogens and inflammation. Current treatment is directed...]]>
In 2001 the FDA approved nesiritide for the treatment of acutely decompensated heart failure. As a potent intravenous vasodilator, nesiritide reduces cardiac filling pressures leading to symptomatic improvement in patients with acutely decompensated heart failure.
The randomised placebo-controlled trial was conducted in Europe and the US. Patients were eligible to participate if they had...]]>
Treatment of venous thromboembolism has evolved considerably over the last twenty years. The use of subcutaneous low molecular weight heparin without a requirement for monitoring has lessened the burden of treatment and opened the door for outpatient therapy.
Some of the reluctance to treat as an outpatient is emotional, given that many patients with DVT already have an asymptomatic pulmonary embolism.
Evidence suggests that the health benefits of statin therapy may extend beyond its cholesterol-lowering properties, potentially including favourable effects on systemic inflammation, endothelial function and oxidative stress – important mechanisms involved in the aetiology of cardiometabolic diseases.
The authors identified statin trials using MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (January 1996 through March 2011). Inclusion criteria for the trials included comparison of intensive-dose versus moderate-dose statin therapy, sample...]]>
Albert Einstein defined insanity as "doing the same thing over and over again and expecting different results". Such is the state of detecting congenital heart defects (CHD) in newborns. For years, clinicians have been taught that a careful physical examination of the newborn can detect CHD while witnessing cases of failed detection of newborns with critical CHD (CCHD). Despite these failures, we never critically addressed our strategy. The recent study by Ewer et al on the accuracy of pulse oximetry as a screening tool for CHD adds more credence to a new strategy to improve detection.
This prospective study was performed in six obstetric units in the West Midlands, UK. The main aim was evaluation of sensitivity and specificity of pulse oximetry for detection of CCHD (causing death or requiring invasive intervention before 28 days). Pulse oximetry was measured in the upper and lower...]]>
A rapid and accurate, yet inexpensive test to diagnose active pulmonary tuberculosis (TB) would increase detection of cases, and might diagnose patients at an earlier stage of disease reducing morbidity and mortality, as well as transmission. Currently the most widely used rapid test is acid fast bacilli (AFB) smear microscopy. AFB smears are inexpensive, and can provide results within hours. However, they are insensitive, detecting approximately half of all pulmonary TB cases, albeit those who are sicker and more contagious with more advanced disease. TB cultures are considered the gold standard for diagnosis but are more expensive and complex, and only provide results after weeks to months. The potential alternatives are serologic tests that use ELISA techniques to detect a humoral response (ie, detect antibodies) to TB. Many different tests have been developed, tested and marketed, and in many countries are widely used to diagnose TB. However,...]]>
Chronic obstructive pulmonary disease (COPD) affects 1 in 10 individuals more than 40 years of age.
This was a population-based nested case-control study from Ontario, Canada, in which the risk of AUR was compared between users and non-users of IACs in a group of older patients (defined as 66 years of age or older) with COPD (defined as those with a previous hospitalisation or office...]]>
Non-steroidal anti-inflammatory drugs (NSAIDs) have been implicated in causing negative cardiovascular outcomes, particularly in coronary artery disease (CAD) patients who have had a prior myocardial infarction (MI). In fact, as Schjerning Olsen and colleagues point out, current guidelines give the rather nebulous recommendation that duration of NSAID therapy should be as short as possible in CAD patients.
The study by Schjerning Olsen and colleagues seeks to characterise the association between NSAID treatment duration and risk of cardiovascular disease. Although selective cyclooxygenase 2 inhibitors (COX-2) such as rofecoxib and valdecoxib have received notoriety and media attention,
Death and/or recurrent MI associated with NSAID use in patients admitted from 1997 to 2006 with first-time MI are studied in...]]>
A key function of palliative care is to provide accurate information about prognosis with a level of specificity that patients and their families want. However, a large evidence base indicates that healthcare providers are often not able to make an accurate prognostic assessment and that prognostic predictions tend to be overly optimistic.
This optimism bias is not homogeneous. In fact, providers working in specialised settings such as the intensive care unit may be able to make more accurate predictions.
Gwilliam...]]>
The Framingham Risk Score is a widely used prediction model for the assessment of risk for coronary heart disease (CHD), which contains traditional risk factors (age, sex, blood pressure, cholesterol, diabetes and smoking status).
The authors used a prospective cohort of British civil servants enrolled in the Whitehall II study, which examines health behaviour, work environment and socioeconomic status as they pertain to clinical disease.
Almost 3 million babies are born with no signs of life worldwide every year.
Although 98% of stillbirths occur in low- and middle-income countries, they also occur in high-income countries in approximately 1 out of every 300 births, and many are preventable.
The authors studied factors related to maternal demographics and lifestyle, medical disorders and pregnancy complications that could potentially be...]]>
In the last few years, more information has been published regarding birth defects associated with the use of the new generation of antiepileptic drugs (AEDs). Some recent reports from different registries have shown a lower rate of major birth defects associated with the use of new generation AEDs compared with some of the first-generation AEDs. For example, an Australian registry showed no increase in major birth defects with the use of lamotrigine in the first trimester.