Objectives To identify and appraise empirical studies on publication and related biases published since 1998; to assess methods to deal with publication and related biases; and to examine, in a random sample of published systematic reviews, measures taken to prevent, reduce and detect dissemination bias. Data sources The main literature search, in August 2008, covered the Cochrane Methodology Register Database, MEDLINE, EMBASE, AMED and CINAHL. In May 2009, PubMed, PsycINFO and OpenSIGLE were also searched. Reference lists of retrieved studies were also examined. Review methods In Part I, studies were classified as evidence or method studies and data were extracted according to types of dissemination bias or methods for dealing with it. Evidence from empirical studies was summarised narratively. In Part II, 300 systematic reviews were randomly selected from MEDLINE and the methods used to deal with publication and related biases were assessed. Results Studies with significant or positive results were more likely to be published than those with non-significant or negative results, thereby confirming findings from a previous HTA report. There was convincing evidence that outcome reporting bias exists and has an impact on the pooled summary in systematic reviews. Studies with significant results tended to be published earlier than studies with non-significant results, and empirical evidence suggests that published studies tended to report a greater treatment effect than those from the grey literature. Exclusion of non-English-language studies appeared to result in a high risk of bias in some areas of research such as complementary and alternative medicine. In a few cases, publication and related biases had a potentially detrimental impact on patients or resource use. Publication bias can be prevented before a literature review (e.g. by prospective registration of trials), or detected during a literature review (e.g. by locating unpublished studies, funnel plot and related tests, sensitivity analysis modelling), or its impact can be minimised after a literature review (e.g. by confirmatory large-scale trials, updating the systematic review). The interpretation of funnel plot and related statistical tests, often used to assess publication bias, was often too simplistic and likely misleading. More sophisticated modelling methods have not been widely used. Compared with systematic reviews published in 1996, recent reviews of health-care interventions were more likely to locate and include non-English-language studies and grey literature or unpublished studies, and to test for publication bias. Conclusions Dissemination of research findings is likely to be a biased process, although the actual impact of such bias depends on specific circumstances. The prospective registration of clinical trials and the endorsement of reporting guidelines may reduce research dissemination bias in clinical research. In systematic reviews, measures can be taken to minimise the impact of dissemination bias by systematically searching for and including relevant studies that are difficult to access. Statistical methods can be useful for sensitivity analyses. Further research is needed to develop methods for qualitatively assessing the risk of publication bias in systematic reviews, and to evaluate the effect of prospective registration of studies, open access policy and improved publication guidelines.

Dissemination and publication of research findings: an updated review of related biases.

In this article, we review some of the key methodologic points that should be considered with regard to clinical evaluation of artificial intelligence tools for use in medical diagnosis and prediction.

Methodologic Guide for Evaluating Clinical Performance and Effect of Artificial Intelligence Technology for Medical Diagnosis and Prediction

The purpose of this review is to present a guide to help readers critically appraise the methodologic quality of an article or articles describing a clinical decision rule. This guide will also be useful to clinical researchers who wish to answer 1 or more questions detailed in this article. We consider the 6 major stages in the development and testing of a new clinical decision rule and discuss a number of standards within each stage. We use examples from emergency medicine and, in particular, examples from our own research on clinical decisions rules for radiography in trauma.

Iconographies supplémentaires de l'article : Methodologic Standards for the Development of Clinical Decision Rules in Emergency Medicine

This systematic review provides detailed supporting evidence for the American College of Physicians' recommendations on competency in electrocardiogram interpretation. The authors found no evidence...

Competency in interpretation of 12-lead electrocardiograms: a summary and appraisal of published evidence.

Computer decision support as a source of interpretation error: the case of electrocardiograms.

Background: Plethysmography and rheography techniques have been widely studied as diagnostic tests for deep vein thrombosis (DVT). This study aimed to systematically review the accuracy of these tests for diagnosing clinically suspected DVT. Methods: The following databases were searched: Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews , Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club (1966 to 2004), and citation lists of retrieved articles. Studies that compared plethysmography or rheography to a reference standard of ultrasound or contrast venography were selected. Standardised data were extracted and study quality determined against validated criteria. Data were analysed by random effects meta-analysis and meta-regression. Results: The meta-analysis included 78 studies, reporting 82 patient cohorts. Sensitivity and specificity (95% CI) were: 75% (73% to 77%) and 90% (89% to 91%) for impedance plethysmography, 83% (81% to 85%) and 81% (79% to 82%) for strain-gauge plethysmography, 85% (79% to 90%) and 91% (81% to 95%) for air plethysmography, 91% (87% to 94%) and 71% (66% to 75%) for light-reflex rheography, and 86% (83% to 89%) and 93% (91% to 95%) for phleborheography. Meta-regression was limited by poor reporting of studies. There was some evidence that diagnostic performance depended on the proportion of males in the cohort and reporting of study setting. Conclusions: Although plethysmography and rheography techniques add diagnostic value, they have inadequate diagnostic performance to act as a stand-alone test in DVT diagnosis. Evaluation of their role in combination with other tests, or standardised clinical assessment, is required.

/pdf/meta-analysis-of-plethysmography-and-rheography-in-the-37ajh6m0zo.pdf

Meta‐analysis of plethysmography and rheography in the diagnosis of deep vein thrombosis

Background: Increases in emergency medical admissions are placing a strain upon hospitals throughout the world. The aim of the study was to evaluate the effect of a new post, the "A&E physician", upon emergency medical admissions to a hospital. 

Methods: For six months the A&E physician workload was audited and a randomised controlled comparison undertaken. Days were randomised to "A&E physician present" or "A&E physician absent". The A&E physician recorded details of all patients referred for medical admission, any intervention made, and their disposal from A&E. Routine hospital data compared the mean daily number of medical admissions, non-medical admissions, and referrals to other hospitals. 

Results: 124 days were randomised: 59 to A&E physician present, 65 to A&E physician absent. The A&E physician received 581 referrals and intervened in the management of 142 (24%). Of these, 80 were discharged home, apparently saving 1.4 admissions per day. However, randomised comparison showed that presence of the A&E physician was associated with a reduction of only 0.7 medical admissions per day (95% CI -1.7 to 3.2, p = 0.561), and an increase of 1.1 non-medical admissions (95% CI -0.2 to 2.3, p = 0.09) and 0.3 transfers to other hospitals per day (95% CI zero to 0.6, p = 0.09). Overall, hospital admissions were increased by 0.9 per day when the A&E physician was present (95% CI -1.8 to 3.6, p = 0.5). 

Conclusion: Despite receiving many referrals and discharging a substantial proportion of these patients home, the A&E physician did not significantly change emergency medical admissions and may have increased admissions to other specialties.

https://emj.bmj.com/content/emermed/21/1/51.full.pdf

Can additional experienced staff reduce emergency medical admissions

OBJECTIVES—To determine whether access to a computer generated electrocardiogram (ECG) report can reduce errors of interpretation by senior house officers (SHOs) in an accident and emergency department.
METHODS—Ten SHOs were asked to interpret 50 ECGs each: 25 with computer generated reports, 25 without. Their answers, and the computer generated reports, were compared with a "gold standard" produced by two experienced clinicians. The primary outcome measure was the proportion of major errors of interpretation.
RESULTS—The computer reading system made two major errors (4%, 95% confidence interval (CI) 1.1% to 13.5%) compared with the gold standard. Access to the computer report did not significantly reduce major errors among SHOs (46 (18.4%) with report v 56 (22.4%) without, odds ratio 0.64, 95% CI 0.36% to 1.14%, p=0.13) or improve the proportion completely correct (104 (41.6%) with report v 91 (36.4%) without, odds ratio 1.43, 95% CI 0.88 to 2.33, p=0.15).
CONCLUSIONS—SHOs have a high error rate when interpreting ECGs, which is not significantly reduced by access to a computer generated report. Junior doctors should continue to seek expert senior help when they have to interpret a difficult ECG.


Keywords: electrocardiogram; computer reading systems; accident and emergency

https://pmj.bmj.com/content/postgradmedj/77/909/455.full.pdf

Do computer generated ECG reports improve interpretation by accident and emergency senior house officers

Objective: Wrist injuries are a common presentation to the emergency department (ED). There are no validated decision rules to help clinicians evaluate paediatric wrist trauma. This study aimed to identify which clinical features are diagnostically useful in deciding the need for a wrist radiograph, and then to develop a clinical decision rule. Methods: This prospective cohort study was carried out in the ED of Sheffield Children’s Hospital. Eligible patients were recruited if presenting within 72 hours following blunt wrist trauma. A standardised data collection form was completed for all patients. The outcome measure was the presence or absence of a fracture. Univariate analysis was performed with the χ 2 test. Associated variables (p Results: In total, 227 patients were recruited and 106 children were diagnosed with fractures (47%). Of 10 clinical features analysed, six were found by univariate analysis to be associated with a fracture. CART analysis identified the presence of radial tenderness, focal swelling, or an abnormal supination/pronation as the best discriminatory features. Cross fold validation of this decision rule had a sensitivity of 99.1% (95% confidence interval 94.8% to 100%) and a specificity of 24.0% (17.2% to 32.3%). The radiography rate would be 87%. Conclusions: Radial tenderness, focal swelling, and abnormal supination/pronation are associated with wrist fractures in children. The clinical decision rule derived from these features had a high sensitivity, but low specificity, and would not substantially alter our current radiography rate. The potential for a clinical decision rule for paediatric wrist trauma appears limited.

/pdf/how-do-clinical-features-help-identify-paediatric-patients-2vc345w9re.pdf

How do clinical features help identify paediatric patients with fractures following blunt wrist trauma

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Meta‐analysis of plethysmography and rheography in the diagnosis of deep vein thrombosis

Can additional experienced staff reduce emergency medical admissions

Do computer generated ECG reports improve interpretation by accident and emergency senior house officers

How do clinical features help identify paediatric patients with fractures following blunt wrist trauma