- Email: [email protected]
Commentary on “The role of evidence based medicine in neurotrauma”
Journal of Clinical Neuroscience 22 (2015) 617–618
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Commentary
Commentary on ‘‘The role of evidence based medicine in neurotrauma’’ J.V. Rosenfeld a,⇑, D.J. Cooper b a b
Department of Neurosurgery, The Alfred, Department of Surgery, Monash University, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia Department of Intensive Care, School of Public Health and Preventive Medicine, Monash University, Australia
High level evidence to guide clinicians in the management of severe traumatic brain injury (TBI) is scarce. Honeybul and Ho propose a step ‘‘forward’’ by promoting the status of ‘‘expert opinion’’ [1]. In other words, and in their view, personal bias should be elevated. Their proposed revision of the pyramid of levels of evidence is distantly based on the Bayesian approach of integrating prior knowledge into a complex evidence framework. The new thought is to place ‘‘background information’’ and ‘‘expert opinion’’ as pillars that support all tiers of evidence in the pyramid, rather than as the lowest tier of quality of evidence where they currently reside. Further, Honeybul and Ho label the highest category of evidence as ‘‘systematic reviews’’. Clearly this is only true when the reviews themselves contain quality randomised trials, and to clarify, the National Health and Medical Research Council of Australia specifically states that Level I evidence is ‘‘A systematic review of Level II studies which are randomised controlled trials’’ [2]. The process of clinical judgement has always been a complex integration of evidence and experience. Clinicians make informed decisions based on their weighting of the levels of evidence available for a particular clinical question or management problem. The evidence pyramid will not benefit from the proposed redesign, and the individual clinician’s experience (expert opinion and context) will continue to guide clinicians in management of individual patients as it always has. A critical appraisal of evidence is an essential skill for all medical practitioners, including surgeons. That is why medical course curricula include evaluation of the scientific literature and the Royal Australasian College of Surgeons has developed the Critical Literature Evaluation and Research course for surgical trainees. Published critical reviews, systematic reviews and editorials also influence medical opinion, as they should. Specifically, Honeybul and Ho use decompressive craniectomy for diffuse TBI and for middle cerebral artery infarction to support their ‘‘novel’’ proposal. The logic appears to be that if one study is less than perfect, then a whole new evidence paradigm is required. No trial is perfect, especially in the complex clinical world of neurotrauma. Detailed responses to criticism of the Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury trial
DOI of original article: http://dx.doi.org/10.1016/j.jocn.2014.08.035
⇑ Corresponding author. Tel.: +61 3 9903 0190.
E-mail address: [email protected] (J.V. Rosenfeld). http://dx.doi.org/10.1016/j.jocn.2014.10.006 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
have been exhaustively discussed previously, and are hardly relevant here [3,4]. We have previously reviewed evidence-based guidelines in neurosurgery in the Journal of Clinical Neuroscience [5]. Neurosurgeons currently have excellent evidence-based guidelines such as the Brain Trauma Foundation Guidelines for the management of severe TBI [6]. In these guidelines, there has been a weighting of the literature by multiple experts to advise on the various elements of the management of TBI. Bias is probably still present, but has been actively minimised, leading to valuable Guidelines. However, an update of these Guidelines is overdue, and we understand it is forthcoming. We do not agree with the statement of Honeybul and Ho that for many years randomised controlled trials have been seen to be the only way to advance clinical practice. Medicine has always advanced with all tiers of evidence being utilised. Randomised controlled trials cannot be applied to many clinical questions in neurosurgery because they are often not feasible. Partly in response, there has been a recent upsurge in interest in comparative effectiveness research in neurosurgery [7]. A recent review of case-control studies found them also to be useful and recommended that the Strengthening the Reporting of Observational Studies in Epidemiology checklist be followed and that careful design and data analysis can minimise bias and confounding [8]. Honeybul and Ho do not present a persuasive case for redesigning the traditional pyramid of evidence. Instead, they highlight the ever present need for critical appraisal of literature by clinicians. Evidence appraisal then informs patient management, together with clinical experience and a solid knowledge of pathophysiology. It has always been this way.
Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
References [1] Honeybul S, Ho KM. The role of evidence based medicine in neurotrauma. J Clin Neurosci 2015;22:611–6. http://dx.doi.org/10.1016/j.jocn.2014.08.035. [2] National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009. Available from: https://www.
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J.V. Rosenfeld, D.J. Cooper / Journal of Clinical Neuroscience 22 (2015) 617–618
nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_ evidence_120423.pdf. [3] Cooper DJ, Rosenfeld JV. Craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;365:376. [4] Cooper DJ, Rosenfeld JV, Wolfe R. DECRA investigators’ response to ‘‘The future of decompressive craniectomy for diffuse traumatic brain injury’’ by Honeybul et al. J Neurotrauma 2012;29:2595–6. http://dx.doi.org/10.1089/neu.2011. 2279. [5] Bandopadhayay P, Goldschlager T, Rosenfeld JV. The role of evidence based medicine with neurosurgery: a personal view. J Clin Neurosci 2008;15:373–8.
[6] Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. J Neurotrauma 2007;24:S1–S106. [7] Hartings JA, Vidgeon S, Strong AJ. Surgical management of traumatic brain injury: a comparative effectiveness study of 2 centers. J Neurosurg 2014;120:434–46. [8] Nesvick CL, Thompson CJ, Boop FA, et al. Case-controlled studies in neurosurgery. A review. J Neurosurg 2014;121:285–96.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Commentary
Commentary on ‘‘The role of evidence based medicine in neurotrauma’’ J.V. Rosenfeld a,⇑, D.J. Cooper b a b
Department of Neurosurgery, The Alfred, Department of Surgery, Monash University, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia Department of Intensive Care, School of Public Health and Preventive Medicine, Monash University, Australia
High level evidence to guide clinicians in the management of severe traumatic brain injury (TBI) is scarce. Honeybul and Ho propose a step ‘‘forward’’ by promoting the status of ‘‘expert opinion’’ [1]. In other words, and in their view, personal bias should be elevated. Their proposed revision of the pyramid of levels of evidence is distantly based on the Bayesian approach of integrating prior knowledge into a complex evidence framework. The new thought is to place ‘‘background information’’ and ‘‘expert opinion’’ as pillars that support all tiers of evidence in the pyramid, rather than as the lowest tier of quality of evidence where they currently reside. Further, Honeybul and Ho label the highest category of evidence as ‘‘systematic reviews’’. Clearly this is only true when the reviews themselves contain quality randomised trials, and to clarify, the National Health and Medical Research Council of Australia specifically states that Level I evidence is ‘‘A systematic review of Level II studies which are randomised controlled trials’’ [2]. The process of clinical judgement has always been a complex integration of evidence and experience. Clinicians make informed decisions based on their weighting of the levels of evidence available for a particular clinical question or management problem. The evidence pyramid will not benefit from the proposed redesign, and the individual clinician’s experience (expert opinion and context) will continue to guide clinicians in management of individual patients as it always has. A critical appraisal of evidence is an essential skill for all medical practitioners, including surgeons. That is why medical course curricula include evaluation of the scientific literature and the Royal Australasian College of Surgeons has developed the Critical Literature Evaluation and Research course for surgical trainees. Published critical reviews, systematic reviews and editorials also influence medical opinion, as they should. Specifically, Honeybul and Ho use decompressive craniectomy for diffuse TBI and for middle cerebral artery infarction to support their ‘‘novel’’ proposal. The logic appears to be that if one study is less than perfect, then a whole new evidence paradigm is required. No trial is perfect, especially in the complex clinical world of neurotrauma. Detailed responses to criticism of the Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury trial
DOI of original article: http://dx.doi.org/10.1016/j.jocn.2014.08.035
⇑ Corresponding author. Tel.: +61 3 9903 0190.
E-mail address: [email protected] (J.V. Rosenfeld). http://dx.doi.org/10.1016/j.jocn.2014.10.006 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
have been exhaustively discussed previously, and are hardly relevant here [3,4]. We have previously reviewed evidence-based guidelines in neurosurgery in the Journal of Clinical Neuroscience [5]. Neurosurgeons currently have excellent evidence-based guidelines such as the Brain Trauma Foundation Guidelines for the management of severe TBI [6]. In these guidelines, there has been a weighting of the literature by multiple experts to advise on the various elements of the management of TBI. Bias is probably still present, but has been actively minimised, leading to valuable Guidelines. However, an update of these Guidelines is overdue, and we understand it is forthcoming. We do not agree with the statement of Honeybul and Ho that for many years randomised controlled trials have been seen to be the only way to advance clinical practice. Medicine has always advanced with all tiers of evidence being utilised. Randomised controlled trials cannot be applied to many clinical questions in neurosurgery because they are often not feasible. Partly in response, there has been a recent upsurge in interest in comparative effectiveness research in neurosurgery [7]. A recent review of case-control studies found them also to be useful and recommended that the Strengthening the Reporting of Observational Studies in Epidemiology checklist be followed and that careful design and data analysis can minimise bias and confounding [8]. Honeybul and Ho do not present a persuasive case for redesigning the traditional pyramid of evidence. Instead, they highlight the ever present need for critical appraisal of literature by clinicians. Evidence appraisal then informs patient management, together with clinical experience and a solid knowledge of pathophysiology. It has always been this way.
Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
References [1] Honeybul S, Ho KM. The role of evidence based medicine in neurotrauma. J Clin Neurosci 2015;22:611–6. http://dx.doi.org/10.1016/j.jocn.2014.08.035. [2] National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009. Available from: https://www.
618
J.V. Rosenfeld, D.J. Cooper / Journal of Clinical Neuroscience 22 (2015) 617–618
nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_ evidence_120423.pdf. [3] Cooper DJ, Rosenfeld JV. Craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;365:376. [4] Cooper DJ, Rosenfeld JV, Wolfe R. DECRA investigators’ response to ‘‘The future of decompressive craniectomy for diffuse traumatic brain injury’’ by Honeybul et al. J Neurotrauma 2012;29:2595–6. http://dx.doi.org/10.1089/neu.2011. 2279. [5] Bandopadhayay P, Goldschlager T, Rosenfeld JV. The role of evidence based medicine with neurosurgery: a personal view. J Clin Neurosci 2008;15:373–8.
[6] Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. J Neurotrauma 2007;24:S1–S106. [7] Hartings JA, Vidgeon S, Strong AJ. Surgical management of traumatic brain injury: a comparative effectiveness study of 2 centers. J Neurosurg 2014;120:434–46. [8] Nesvick CL, Thompson CJ, Boop FA, et al. Case-controlled studies in neurosurgery. A review. J Neurosurg 2014;121:285–96.