Reporting systematic review strategies

tablet-blister-2-1307761-mA group of medical librarians (including yours truly) have been meeting once a month after work to discuss an article of interest. This is a very informal group which has just got off the ground, but we are all having a good time so far.

The article we discussed last month was Golder S, Lake, Y.K, Zorzela L. Comparison of search strategies in systematic reviews of adverse effects to other systematic reviews. Health Information & Libraries Journal 31(2) 92-105. The main points of the article is reporting of search strategies needs to improve. Having more librarians on board will help to achieve this goal. This survey found that only 9% of librarians were involved. Compared to other systematic reviews, reviews of adverse effects searched a range of databases including Medline. What is concerning though is that surveys of other reviews found that 56% of reviews only searched Medline. This is very concerning. This might be for a number of reasons: cost, access, or expertise. The most popular databases to search are free to search. These databases (not including Medline) are: Cochrane Database of Systematic Reviews (paid for by govt in some countries), Database of Abstracts of Reviews of Effectiveness (free via the CRD), FDA website (free), the internet (free but type of browser not mentioned), citation searches (some free) and clinicaltrials.gov (free).

We talked about floating subheadings (I remember learning about them when an undergrad), which allows you to pair a subheading with a subject that doesn’t include the subheading you want to use. This is useful in looking for reports of adverse effects, but could bring up lots of other unrelated reports. One of the librarians showed us a form she uses for systematic reviews. It included the strategy (plus database name and platform used), total numbers and numbers after deduplication, plus a flowchart. Very nice and something I’d like to use in my own practice. We also talked about a blog called PubMed Search Strategies (a blog for sharing strategies), which is a very useful resource, especially if you find a good strategy for a topic you are searching for – no reinventing the wheel!

We might not meet next month because next week is the two workshops led by Julie Glanville, and then there is the holidays. My next post will be writing about those workshops.

Homeopathy is bunkum

Homeopathy is bunkum. That’s the conclusion that the final NHMRC report into the evidence base of homeopathy has reached. They didn’t quite say bunkum though. What they did say was: “Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective”. You can read the full statement by clicking here. Nicely worded, to the point and very polite.

SBS featured a news segment about the  findings on Wednesday evening and the first person to be interviewed about it was a homeopath. The homeopath disagreed of course, and the Australian Homoeopathic Association is going to publish an official response soon. If they are serious about criticising the report, what they should do is include a critical appraisal of the report. It is no good to just say ‘oh, they didn’t look at all the evidence’ (btw, the AHA submitted papers to the NHMRC as part of the public submission process and these papers were critically appraised using SIGN methodology). You have to do more work than that. Your response is also more likely to be respected if you do. There was a piece in the  Guardian mid-week about the report ( Homeopathy not effective for treating any condition, Australian report finds) and the comments from readers are interesting (and funny) to read.  Some of the comments are revealing. Some object to the reductionist approach taken by the evidence appraisal method and some highly regard first hand and anecdotal evidence, rejecting the paternalistic tone that the NHMRC has. There are quite a few people skeptical about how independent the NHMRC is (btw, the evidence review was undertaken by a third party).

The NHMRC is not in the business of telling consumers what health products they should or should not purchase. What they are doing is in the interest of the consumer – do these health products act in the way they are advertised? The final report indicates that they don’t. It is fine to use homeopathic remedies as a placebo – if it makes you feel good, then do so. Just tell your medical practitioner everything you are taking or doing.

Occult Medicine

There is occult medicine amongst us. I’m not talking about witchdoctors, faith healers, crystals or miracle cures. I’m talking about Big Pharma.

The definition of occult from the OED is occultare ‘secrete’, frequentative of occulere ‘conceal’, based on celare ‘to hide'; the adjective and noun from occult- ‘covered over’, from the verb occulere. Occult is also used in medicine to describe conditions not readily diagnosed by manifest symptoms meaning that other options will have to be used e.g. blood tests.

Big Pharma regularly occults data, refusing to let the biomedical community access its full store of information. Select information is released, mostly putting AllTrials – What does all trials registered and reported mean? 2015-02-23 17-19-57positive spins on trials. Negative results are occulted. It is hard to determine how much information revealed to Big Pharma is occult. Is it a bigger percentage than the percentage Big Pharma have published? Who can say. What is known though that governments down to individuals have practiced unknown or secret medicine.

The AllTrials campaign is trying to turn the situation around by forcing Big Pharma to register and report the results of all trials, past, present and future. The Declaration of Helsinki recognised the ethical importance of releasing all clinical trial data but Big Pharma (and other research groups) still resist or ignore it. Efforts such as that of Peter Doshi and Tom Jefferson in wresting information about Tamiflu demonstrate the extent to which Big Pharma resist releasing information.

All results from any sort of clinical trial must be released, be it negative, indifferent or positive. Otherwise, clinicians practice occult medicine and lose the scientific and moral upper-hand when it comes to fighting quack medicine.