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Nicola Pidduck

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Richard Stevens

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Jason Oke

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Annette Pluddemann

Annette Pluddemann joined MaDOx in January 2009 and is the director of the Diagnostic Horizon Scanning Programme. Her research aims to identify innovations in diagnostic technologies likely to have a significant impact in primary care.

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Alice Fuller

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Dr Matthew Thompson

Matthew is a General Practitioner who has trained and worked in both the United Kingdom and the USA. He is currently a Senior Clinical Scientist in the Department, and also works as a family doctor in Oxford.

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Rafael Perera

Rafael is a University Lecturer in Medical Statistics, Co-director and the Head of Statistics for MaDOX. His general interests include: monitoring in primary care, meta-analysis methods, methodology for studying infectious diseases in children, and assessing complex interventions.

MaDOx Blog

Lancet paper podcast

Children’s heart and breathing rates are not accurate and not based on evidence

Latest Lancet Publication - Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies

This latest publication from the MaDOx group has led to lots of media attention from around the globe. Listen to Dr Matthew Thompsons Podcast discussing the latest Lancet publication on Talk Radio 702 - The Midday Report
Click here for a pdf version of the paper.

A mole-hill or a mountain: time to bring out the dermatoscope

Annette Pluddemann

On spotting a mole in the garden, some people smile and marvel at the ability of these little creatures to live underground, but if you are particularly proud of your finely manicured lawn, you are probably rather annoyed and may go to considerable lengths to be rid of it.
In much the same way we have mixed feelings about the moles on our skin. On the one hand we call them beauty spots and in some ways they make us feel unique. And if your name is Cindy Crawford you make millions by sporting one on your upper lip. But with skin cancer (melanoma) on the rise, we should view moles with suspicion. According to Cancer Research UK, around 2000 people die from melanoma each year in the UK.
When they suddenly change shape or colour, this could spell trouble, prompting a visit to the local GP. Not all moles lead to skin cancer and doctors need to identify which ones are dangerous.
At the moment, the only course of action for the GP is to refer you to a specialist dermatologist. However, in the future your GP may have a dermatoscope to hand in his practice. This is a device much like a magnifying glass with a light, which allows the doctor to analyse the mole more closely to identify whether it has any of the elements that suggest it could spell trouble. The GP could more easily identify which moles may be cause for concern and if they are not worrying, you could go home reassured the day of your visit to the GP, rather than having to wait for an appointment with a specialist. Our horizon scan report illustrates that several studies on dermoscopy have shown that GPs using dermatoscopes miss fewer cancerous moles (melanomas) than those that don’t. Although it remains to be seen how well this works when it is adopted more widely, how useful GPs will find it and how cost-effective it is, it seems like quite a simple way to improve diagnosis of skin cancer. What we need right now is a large study looking at using dermoscopy in general practice in the UK. The sooner the better.

Can anyone understand Evidence in Health Care Anymore?

Carl Heneghan (CEBM)

Imagine you woke up today, and I told you, over the next week read all the available health information that is published and tell me what we should invest in and equally what we should disinvest in: what choices should you make, on an individual basis and at the public health level to maximise your health and others.

My thoughts are this is now such a complex question it may be impossible to answer. One reason for this is the exponential growth of health care information on the worldwide web. Google search for health currently generates 844,000,000 pages.

In the US, 80% of internet users, 113 million adults, have searched for information on at least one of seventeen health topics. Yet, just 15% of health seekers say they “always” check the source and date of the health information they find online, whilst 3/4 say they check the source and date “only sometimes,” “hardly ever,” or “never,” which translates to about 85 million Americans gathering health advice online without asking whether the information is based on credible sources.

Now, imagine if I made it even more complicated, by telling you over the next year you have to come up with a credible plan for rational disinvestment in health care. Now you’re in trouble, for instance the number of randomized trials has gone from 39 RCTs in 1965 to 26,017 in 2008. At current rates we can expect to see 50,000 RCTs per year published by 2018-9.

Now you’ve managed to wade through all this health information and find the articles you need, you are faced with research which is not always transparent. For instance, the so-called “Sunshine Act”, is currently going through the US legislature, aiming to completely overhaul the interactions between physicians and the pharmaceutical industry. Yet, Fiona Godlee tells us in her editorial today that ‘articles that gave a favourable view on the risks were significantly more likely to have authors with financial ties to the manufacturers’. Even if you can locate the evidence that makes a difference, you are often left wondering can you believe it.

You’ve located the studies you’ve got beyond the vested interests and maybe feeling slightly smug but now you have to intepret the statistics. Do people understand statistics, do they trust statistics?

Most of the concepts are foreign to most individuals, even those with advanced degrees and most of us get through education, including university, without ever taking any kind of class in stats. Many surveys show heaps of people lack basic numerical skills that are essential to maintain health and make informed medical decisions. Yet, low numeracy distorts perceptions of risks and benefits of screening, reduces medication compliance, impedes access to treatments, impairs risk communication, limiting prevention efforts among the most vulnerable.

Based on what I have said do you feel equipped to understand the major evidence in healthcare? Well, I haven’t even mentioned the ten major biases that lead to mis-information and the role the media has in all this in relaying the final message. I’ll leave the last of these to the excellent Bad Science

Let me know, is there anyone out there who can understand Evidence in Health Care Anymore?

Flu vaccines in the elderly-40 years of expensive policy with no evidence?

Ami Banerjee (CEBM)

“Vaccine” is a medical term that is part of the vernacular. They are our childhood immunizations and the backbone of public health programmes at national and international level, in both rich and poor countries. They are the holy grail of research against the biggest infectious disease killers of our time, from malaria and HIV/AIDS to influenza, and, more recently swine flu. They are multi-billion dollar business to drug companies. The World Health Organisation defines a vaccine as “any preparation intended to produce immunity to a disease by stimulating the production of antibodies…..The most common method of administering vaccines is by injection.”

Vaccines have been used in the elderly for over 40 years to reduce the impact of influenza (or flu) in this part of the population that is at higher risk of complications and death from flu. In 2000, 40 out of 51 high-income or middle-income countries recommended flu vaccination for all persons aged 60 or 65 or older, with over 290 million doses of vaccine distributed worldwide in 2003. You would think that a health policy of that scale would be firmly grounded on scientific evidence. Well think again.

Because influenza vaccines are produced and tested using surrogate outcomes (antibody stimulation) ahead of each influenza "season", past performance is probably the only reliable way to predict future performance. A new Cochrane systematic review looked through over 40 years of experimental and non-experimental studies of effectiveness of flu vaccines, and found very poor evidence for effectiveness of flu vaccination in the elderly. Of the 75 studies included in their analysis, they found only one recent randomised controlled trial which used “real” outcomes (e.g. actual flu cases or deaths from flu), as opposed to surrogate outcomes (e.g. influenza antibodies). All other studies were of low quality and open to bias. Current flu vaccines prevented 45% of pneumonia cases, hospital admissions and flu-related deaths in long-term care facilities (for example, nursing homes), compared to 25% vaccine efficacy in community settings. Tom Jefferson, lead author of the review, said, “Our estimates are consistently below those usually quoted by economists and in decision making." He calls for “an adequately powered publicly-funded randomised placebo-controlled trial run over several seasons”, and emphasis on “strategies to complement vaccinations”, such as personal hygiene, food and water.

The current swine flu pandemic has caused renewed interest in influenza vaccines and their performance, and this timely review surely gives us lessons on why we should base global health policy on evidence, before spending billions of pounds, dollars and many other currencies. Perhaps the most cautionary part of this review is the analysis of study funding and quality. High quality studies were 16 times more likely to make conclusions that agreed with the presented results, and less likely to favour effectiveness of vaccines. Government-funded studies were less likely to have conclusions favouring vaccines. Studies published in prestigious journals that were most frequently cited were associated with partial or complete industry funding. How much more evidence do we need that profits are trumping public health and evidence when it comes to flu?

Research into physical education activity in children: please sir can I have some more?

Carl Heneghan (CEBM)

The 1968 version of Oliver Twist in my mind is a classic. Anyone who has seen the film will remember that classic seen where Oliver asks for more:

The evening arrived; the boys took their places. The master, in his cook's uniform, stationed himself at the copper; his pauper assistants ranged themselves behind him; the gruel was served out; and a long grace was said over the short commons. The gruel disappeared; the boys whispered each other, and winked at Oliver; while his next neighbours nudged him. Child as he was, he was desperate with hunger, and reckless with misery. He rose from the table; and advancing to the master, basin and spoon in hand, said: somewhat alarmed at his own temerity:

'Please, sir, I want some more.'

The master was a fat, healthy man; but he turned very pale. He gazed in stupified astonishment on the small rebel for some seconds, and then clung for support to the copper. The assistants were paralysed with wonder; the boys with fear.

'What!' said the master at length, in a faint voice.

'Please, sir,' replied Oliver, 'I want some more.'

The master aimed a blow at Oliver's head with the ladle; pinioned him in his arm; and shrieked aloud for the beadle.

Condensed from Oliver Twist chapter 2

So, upon reading Susi Kriemler, trial in the BMJ on the Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren all I could think of was surely we need more of this type of research in our preventive strategies and less of the poly-pill mentality.

In the study children received a programme that included adding two additional physical activity lessons a week, daily short activity breaks, and physical activity homework. Overall, physical activity and fitness improved and led to reduced adiposity in children.

'Mr. Limbkins, I beg your pardon, sir! Oliver Twist has asked for more!

There was a general start. Horror was depicted on every countenance.

'For MORE!' said Mr. Limbkins. 'Compose yourself, Bumble, and answer me distinctly. Do I understand that he asked for more, after he had eaten the supper allotted by the dietary?'

'He did, sir,' replied Bumble.

'That boy will be hung,' said the gentleman in the white waistcoat. 'I know that boy will be hung.'

Condensed from Oliver Twist chapter 2

What do you think will happen if we ask: physical activity research, please sir can we have some more?