What an interesting audit. Why not select the whole series for 1 year and
publish the report in BMJ or Lancet, which may be more accepting of your
letter.

-----Original Message-----
From: [log in to unmask]
[mailto:[log in to unmask]]On Behalf Of
padmanabhan badrinath
Sent: Saturday, October 30, 1999 5:26 AM
To: [log in to unmask]
Subject: Audit of Authors Evidence (NEJM)


Dear All,
Greetings from Al-Ain, the Oasis city of the Middle East.

Few weeks ago, on one of the week ends while I was scanning the journals for
compilation of JSCAN, our professional news letter for local circulation, I
came across this (1) clinical problem solving series in the NEJM. As the
authors were dealing with diagnostic and management issues on a clinical
scenario I wanted to look at the evidence they quoted to support their
material. I initially proposed to undertake this exercise and share it with
the list. Then I had a brain wave! Why can't I submit it as a letter to the
Journal. The journal has come back to me saying that due to the tremendous
pressure on the limited space available in NEJM, they regret that many
worthwhile communications like mine cannot be printed. So I am keen to share
this worthwhile communication with the audience to whom it was originally
intended for.

If you are not interested in this any more please delete the message. If you
think it is ineresting and may be worthwhile then, here is the letter I sent
to the NEJM. Any comments and criticisms will be gratefully received.

As I cannot fit Table 1 in the mail I am sending it as an attachment.
Though you have just begun your week end our week has just commenced.

Cheers & warm regards,

Badri


Clinical problem – solving: Back to the basics – a reader’s audit on the
authors’ evidence.

To the Editor,

In the recent article by Fisk et al(1)information about a real paraplegia
patient with general and abdominal symptoms was presented in stages to an
expert clinician, who responded sharing his/her reasoning with the reader.
The authors’ commentary, which followed attempted to provide evidence for
the various steps, involved in diagnosing the patient’s condition. As the
case with NEJM other front line journals have introduced sections(2)that try
to bring together the external clinical evidence in individual patient care.
Evidence based medicine (EBM) has been defined as the conscientious,
explicit and judicious use of current best evidence in making decisions
about the care of individual patients(3. Hierarchy of evidence and the
research methods through which evidence is generated form a part of this new
paradigm(4).

As a self-commissioned auditor I attempted to analyze the evidence presented
by the authors for this article and classify them based on study designs and
levels of evidence wherever appropriate. I went through all the references
provided by the authors through Internet grateful Med(5)and accessed the
abstracts and in some cases the full texts of the articles. Using the MeSH
(Medical subject heading) terms of the key word in the references and
applying the various limit functions, I also attempted to identify any
higher level of evidence other than that provided by the authors (for e.g.,
meta-analysis, randomized controlled trials etc)

There were 17 references in the articles of which one referred to a book and
another was a paper in press by the second author. The remaining 15 were
articles in journals. Apart from a 1975 paper, others were published between
1985-1999 (mean 1994, SD 4.05). Table 1 shows the types of studies and their
probable levels of evidence for the references.

It is interesting that only 3 references could be classified as level I
evidence (meta-analysis, evidence-based synthesis and a diagnostic study)
and 40% were reviews (6/15). Though the attempt to classify the authors’
commentary (the references provided) by levels of evidence was crude in
nature, it is apparent that narrative reviews are still the main source of
evidence in this example. One possible explanation could be due to the
specific (narrow) nature of this clinical problem and it remains to be seen
whether a commoner clinical problem would produce better quality evidence.
[381 words]


                       References

1) Fisk DT, Saint S, Tierney LM. Back to the basics. N Engl J Med 1999;
341:747-750.

2) Sackett DL, Rosenberg WMC, Gray JAM, Haynes BR, Richardson WS. Evidence
based medicine: what it is and what it isn't. BMJ 1996; 312: 71-72.

3) http://cebm.jr2.ox.ac.uk/docs/levels.html visited on 05.09.99

4) Vause S, Macintosh M. Evidence based case report: Use of prostaglandins
to induce labor in women with a caesarian section scar. BMJ
1999;318:1056-1058.

5) http://igm.nlm.nih.gov   visited on 05.09.99



Dr.P.Badrinath M.D.,M.Phil.,(Epid) PhD(Cantab)
Assistant Professor and Epidemiologist,
Department of Community Medicine,
UAE University, PO Box 17666, Al Ain,
United Arab Emirates.
Tel: 00 971 3 5039 652
Fax: 00 971 3 672022.
[log in to unmask]
[log in to unmask]


______________________________________________________
Get Your Private, Free Email at http://www.hotmail.com



%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%