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The last couple of weeks have taught me a lot about how clinical research gets published and disseminated. On 1st February, our article, titled, “Familial History of Stroke Is Associated with Acute Coronary Syndromes in Women”, was published online by Circulation Cardiovascular Genetics prior to print. This is one of the subspeciality journals of “Circulation”, a publication aimed at scientists generally interested in cardiovascular medicine and research. Over the last few years, several of the major journals have increasingly multiplied into “sub-speciality journals”. For example, “Lancet” has spawned “Lancet Neurology”, “Lancet Infectious Diseases” and “Lancet Oncology”. Not only are the journals able to publish more specialised research that might have been rejected by the parent, general journal; they can also charge more for subscriptions, reprints and so on.

Interestingly, even as an author, I did not receive a copy of my manuscript and do not have access to the journal article, unless I pay for access or buy a reprint. So I will tell you what the gist of the research is. Basically, within the Oxford Vascular Study, a much studied cohort of 90 000 patients from the Oxfordshire general practice population, we looked at about 1000 patients with stroke and about 1000 patients with heart attacks.

Previous analyses from the same study have shown that women with stroke are twice as likely to have female relatives with stroke as male relatives with stroke. In addition, young women with heart attacks are twice as likely as young men with heart attacks to have mothers with heart attacks. Therefore, mother-to-daughter transmission seems to be important. For this reason we looked at family history of stroke in detail among patients with acute coronary syndromes (heart attacks and “unstable angina”).

Firstly, we found that family history of stroke is as common in heart attack patients as stroke patients. Secondly, women with heart attacks were twice as likely to have history of stroke in their mother as in their father. Thirdly, when we looked at the coronary arteries (which supply the heart) directly using coronary angiography, family history did not predict the location of the coronary artery disease or how severe it was. We concluded that family history of stroke needs to be studied in more detail and may well be important in better identifying women most at risk of heart attack, since women are less likely to be picked up by current risk prediction tools used by doctors. Also family history probably has its effect via influences on clotting rather than on arteries directly, given our lack of correlation with disease on angiography.

I spoke with only 1 freelance American journalist and helped write 2 press releases in the week before the article went online. On 1st February, I received an e-mail from the University that the article had been picked up by news brokering websites from Reuters to Yahoo, newspapers and TV from Canada and the Phillippines to India, South Africa and the UK tabloids. I don’t mind telling you I was surprised by all the interest! Even BBC Radio 4 contacted me to go on Woman’s Hour.

I have taken three lessons from this experience. First, a journal article will probably be read by almost nobody, primarily because it is published in a journal, and secondly because access to that journal requires money. Second, although research is published in journals, the immense speed and penetration of the global media/internet machine (based in this case on 3 interviews or press releases!) have led to the devolution of the dissemination of research findings away from journals, even though journals may be the trusted source of the original research. Third, as scientists, if we want our research to be understood by the broader public, then we need to do more than publish articles in journals, we must engage with the media and with the public. Both doctors and patients are more likely to use internet search engines than journals so we have to make sure that Google is well-informed, otherwise a great opportunity for health communication will be missed.

Highlights of the year in Evidence-Based Medicine

Carl Heneghan
Last edited 1st January 2011

The 1st of January saw the year start with a retweet from @david_colquhoun on a scary story on Big Pharma and US healthcare. We learnt authors of BMJ articles are reluctant to respond to criticisms. Reluctant in medical speak, to cebmblog, translates in to ‘can’t be bothered’. A linked editorial highlighted ‘that all aspects of post-publication review are wanting in medical research.’ Whislt the peer review process continued to create fuss, and may finally be broken.

Shriger and Altman in a linked editorial state ‘the majority of research articles receive no critique, and, for the minority that do, authors often do not reply or reply but do not respond to the criticism.’ Will we see more criticism in 2011, probably not.

In May, Isabelle Boutron, highlighted in JAMA the reporting and interpretation of randomized controlled trials with statistically nonsignificant results for primary outcomes. Guess what? Previous studies indicate the interpretation of trial results can be distorted by authors of published reports. Spin was identified in the conclusions sections for 58% of reports. Hold your hand up if you are guilty.

In terms of what drives health costs? You are twice as likely to have an x-ray, ultrasound or imaging after seeing a self-employed urologist as opposed to a salaried urologist Staying on the diagnostic theme, we learnt we should not be pooling diagnostic likelihood ratios in systematic reviews.

Small studies gave us the wrong answers, and Docs suggested women were hitting the pause button on osteoporosis drugs, which sounded very much like the HRT story.

On the drug front, we managed to give out 300,000 prescriptions for sibutramine in the UK in the last yr. Put me in charge of the drug budget, I’ll show you some cuts. Yet, nearly 1 in 10 prescribed meds were not taken by hospital inpatients. Hard to know what is the point of being in hospital but one of the major reasons was drugs were not available.

A pretty sobering statistic from 2010 is one-third of world's population is without access to surgical services

In contrast, a 10-year stroke prevention study after successful carotid endarterectomy had no surrogate, no early stopping, proper research for a change. But, bad news in that adherence statistics showed ¼ of stroke patients stopped taking their meds within 3 months and useful stroke studies remained unpublished: 1 in 5 studies were not published.

Jamie Oliver waded into the health debate @jamie_oliver: "not a day goes by I dont see a patient who could stop one med if they ate healthier." He needs to get out more, as he doesn’t see enough patients. Although his TED Prize wish: Teach every child about food was a great watch for Easter.

However, good news arrived by Xmas, despite all the snow, the FDA was aiming to keep us safe from harmful diet supplements which contain deceptively labeled ingredients, whilst the media was easily fooled by the Xmas BMJ edition. The BBC, at times, continued to produce shocking maths –why most research findings are false and, highlights for cebmblog were the prostate 'magic drug', the case of the changing headline

It’s a good job NHS choices continued to make sense of the news in 2010 : Put your feet up to slim down?

Oh, and Docs continue to be outed @ProPublicafor being paid by pharma despite government sanctions. However, they take fewer freebies, but disclosure is poor: really, 71% still accept gifts.

In addition, we learnt a bit more about ghost writers from @bengoldacre: Worst of all is the complicity of the academics And we became aware we had to be careful what you tweet ; when Bad Science clashed with Gillian McKeith.

Whilst the biggest problem may be consumer organizations: in 2010 2/3rds working with European Medicines Agency (the drug regulators) received partial or significant funding. Or is it Drug company study results are the major problem: drug company studies 85% positive, Government 50% positive. Must do more drug trials, if I want to get ahead. Or should I join the WHO: WHO admits to "inconsistencies" in its policy on conflicts of interest, whillt the BMJ editor pulled no punches WHO leadership may need to resign.

Finally the biggest change of the year saw the Avandia saga come to an end, well nearly, and four years to late. The recorded meeting between GSK and Dr Nissen in 2007 was published due to a subpoena, whilst Panorama ran the Avandia story asking why a million prescriptions were still issued in the UK.

And, after 16 yrs cebmblog thought he knew everything on calculating NNTs. Read this neat piece by Smeeth, I don't. Still more EBM to learn then for 2011, and my final thought for 2010 is: you better watch out, you better not lie. Here’s the reason I’m telling you why

Cheers cebmblog

Medicine and media - do they have to be awkward bedfellows?

Ami Banerjee
Last edited 17th March 2010

My Monday evening was spent at an event organised by the London Business School' Healthcare Club, called "Challenging the Status Quo". Andrew Witty, CEO of GlaxoSmithkline, spoke passionately about why drug development and profits do not have to be at the expense of access to medicines in poor countries. His company has been the first global pharmaceutical company to pledge to pool its patents to allow generic manufacture of its drugs in poor countries, and to enforce differential pricing between rich and poor countries. The take home message was that it is possible to change the prevailing practice or norms, even in an industry like pharma.

Sanjay Gupta is a neurosurgeon with a difference and he is changing the norms in a totally different arena. He is most famous for being CNN's chief medical correspondent and his TV programmes and writings are hugely popular in the US for their new angles on healthcare problems around the world. For example, he has followed medics in war zones, and was filmed meeting the Mexican boy, who was thought to be the index case of swine flu, amid global hysteria about the disease. He recently turned down the job to be Surgeon-General in President Obama's staff.

Gupta made two important points. Firstly peer review, the process used by journals to accept and then publish scientific articles, takes too long and is too slow at delivering up-to-date information for mass consumption. Moreover, one study showed that "... although recommendations made by reviewers have considerable influence on the fate of both papers submitted to journals and abstracts submitted to conferences, agreement between reviewers ... was little greater than would be expected by chance alone". In other words, peer review is far from perfect. Therefore, many people (including health professionals) are increasingly gaining their knowledge from alternative sources such as the internet, blogs and Twitter. Secondly, the pressure for news headlines from mass media corporations does not necessarily have to conflict with the need for good quality, science and health information. There is a plethora of health-related news and advice and so there is plenty of room for health professionals to work innovatively with new media to ensure quality of that information. We wholeheartedly agree at trusttheevidence.net. Are you thinking enough about where you get your up-to-date health information from?

Twitter TrustTheEvidence.net


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