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EDITORIALS: Trish Groves and Fiona Godlee Innovations in publishing BMJ research BMJ 2008; 337: a3123 [Full text]

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Short Cuts and Pico (with layout modification)

Babatunde A. Gbolade   (2 January 2009)

Both abstracts omit vital data

John S Garrow, 93 Uxbridge Road, Rickmansworth, WD3 7DQ   (4 January 2009)

PICO - a window into the future?

Tom Jefferson, Luca De Fiore   (30 January 2009)

Can journal abstracts alone be used for clinical decision making?

Paul Fontelo, Alvin A. Marcelo National Telehealth Center, University of the Philippines, Manila, Philippines   (11 June 2009)

Short Cuts and Pico (with layout modification) 2 January 2009
Babatunde A. Gbolade, Consultant Gynaecologist & Director of Fertility Control Unit Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Beckett Street, Leeds LS9 7TF Send response to journal: Re: Short Cuts and Pico (with layout modification)	As a busy reader, I would read the Short Cuts first as it is in plain language and provides a summary of the research in a rapidly digestible format without much cerebral exercise. If my interest is aroused enough, I would then go on to Pico for more detail. As a researcher, I would still read the Short Cuts first, but will always read the Pico. As an author, I prefer the Pico, but would like the layout modified so that the answer to the question posed at the beginning is right at the bottom as outlined below. In that way, readers, researchers and authors can follow the same path from the question to the answer in an orderly manner. Study question, Study design, Source of effectiveness, Data, Main results, Results of sensitivity analysis, Limitations of study, Answer. Competing interests: None declared
Both abstracts omit vital data 4 January 2009
John S Garrow, retired physician The Dial House,, 93 Uxbridge Road, Rickmansworth, WD3 7DQ Send response to journal: Re: Both abstracts omit vital data	Obviously abstracts must omit some data which are given in the full article, but not facts that should be mentioned in the "Limitations of study" section of the abstact. On this criterion the abstracts in both formats are unsatisfactory. The study was done on 579 volunteers (3.2%) out of 18,342 patients with back pain who were invited to participate. It is reasonable to assume that this select group were hoping to receive Alexander technique therapy. This group was then randomised into those who did, or did not, receive the hoped-for therapy. The trial is therefore a comparison of the reported relief of back pain among those who did, or did not, receive the treatment they wanted. The volunteers were not in any way binded: everyone knew exactly what treatment they were having. With this information it would be obvious to the reader that the trial was done on a highly selected group of volunteers (who therefore may not reflect the reponse of typical patients with back pain) and that this group were not blind to the treatment they were receiving, and therefore at risk of biasing their reported relief of pain in favour of Alexander treatment. Both abstracts are flawed because they do not alert the reader to this very important "limitation of the study". Competing interests: None declared
PICO - a window into the future? 30 January 2009
Tom Jefferson, HTA advisor Agency for Regional Health Services, Via Puglie 23, 00187 Roma, Italy, Luca De Fiore Send response to journal: Re: PICO - a window into the future?	Editor - One of us (TJ) has recently been invited (as first author of a manuscript in the copy editor’s queue) to join the PICO pilot. TJ debated with his co-authors the pros and cons but at the time of writing they are still undecided whether to accept the offer. Some of the group were dubious about doing more work on a paper which has already cost the group dearly (four re-writes). Others were fearful that just publishing an abstract would diminish visibility of our work (which is exactly the opposite of the PICO aims as stated by Groves and Godlee). We have some additional observations to make on the PICO initiative. Personally we were aware of the PICO idea after reading the editorial by Groves and Godlee and were wondering about the motives behind the move to reduce the paper research content while retaining the full electronic version of papers (de facto pushing the BMJ’s ELPS policy further towards the E). Our first reaction was one of surprise as one of the foreseeable effects of PICO and the publishing of more research would be decreasing the BMJ's impact factor (IF) by increasing the denominator. This may or may not be compensated by a possible increase in readership, circulation and citation (the IF numerator). Then we started wondering whether you have seen further than most or all editors and can see the end of the current publishing business model based largely on the IF. Are you trying to develop the BMJ into an archive of publicly accessible electronic research (such as RoMEO and ArXiV) albeit with editing and peer review? Is the paper version of the BMJ then going to be devoted to debates, education, correspondence and comments? This would be the way forward to transform the publishing world from a business into a service and a resource, de-coupling the circulation wars and business aspects from the health science. The underlying idea of such a move would be to recognize that research and health are not a business but a shared asset. If this is the ultimate aim of PICO then you have our whole-hearted support. On other consideration may be that as journals push the E further, the context of the journal, its history and traditions may be lost especially if access is through a search engine (the so-called single article economy). This may provide stimulus to develop critical skills in readers or it may be taken as a blank check to enfranchise anything which is published in a certain format on the web. Tom Jefferson Luca De Fiore Competing interests: TJ produces research and his capacity to do so could be enhanced or be damaged by international publishers’ strategies. LDF works in the medical communication industry and his business could improve or be damaged by international publishers’ strategies.
Can journal abstracts alone be used for clinical decision making? 11 June 2009
Paul Fontelo, Research physician National Library of Medicine, Bethesda MD 20894, Alvin A. Marcelo National Telehealth Center, University of the Philippines, Manila, Philippines Send response to journal: Re: Can journal abstracts alone be used for clinical decision making?	The Medline abstract, originally intended only as an indexing tool, has become the sole information source for many. It has its advantages -- easy to read, structured and informative, and it is now available almost everywhere through mobile phones and other wireless handheld devices. It can even be retrieved by text messaging or e-mail. Wireless networks, so pervasive worldwide, raise the possibility that it might be useful in the practice of evidence-based medicine. Are journal abstracts alone adequate for clinical decision-making? Is it better to use abstracts from current clinical journals to guide clinical decisions than not to have any guide at all? Clinicians and medical librarians are wary because evidence-based medicine (EBM) calls for a comprehensive review and critical assessment of full- text journal articles and, together with information from the patient and laboratory tests, develop a guide to patient management [1]. But, it is not easy to practice -- many clinicians, because of lack of time, access to full- text articles and expertise in critical appraisal skills, rely solely on abstracts for clinical decisions [2-3]. Could abstracts alone be used instead? Will multiple abstracts from highly regarded clinical journals comprise a ‘consensus’ opinion to provide the clinician the confidence to make a treatment decision or diagnostic approach? Concurring abstracts might provide validation needed for formulating a management strategy. If clinicians are unable to make use of clinical research they could miss out on research that can potentially benefit their patients Clinical evidence has to be easily accessible to be most useful -- if it is not convenient, clinicians will not use it even if the need is high [4]. The more effort is required to use it, the less likely it will be used [5-7]. In a recent survey of 1900 U.S. physicians, Manhattan Research found that nearly 50% of US physicians use Wikipedia for professional health and medical information purposes, especially condition information [8]. Yet, only about 10% created new entries or edited existing information. Convenience trumps need and knowledge all the time. Most highly accessed journals today use structured abstracts. Since the adoption of the IMRAD (Introduction, Methods, Results and Discussion) format, abstracts like BMJ’s pico have become more systematic, detailed, and informative to the point of becoming ‘mini papers’ [9]. Sometimes, the abstract does not accurately represent or completely summarize the article [10]. However, many of the errors were minor and unlikely to lead to serious misinterpretation. A journal-based effort to improve abstract quality seemed to be effective [11]. A more recent review of BMJ, CMAJ and JAMA showed that the conclusions in 27 articles had a mean quality score of 100%, meaning that were consistent with the results [12]. Could several concurring abstracts from distinct journals provide a “consensus” clinical bottom line? Will this compensate for the deficiencies in abstracts and provide the clinician greater confidence? The availability of open access journal articles is on the rise. Today, full-text versions of research papers of many highly read journals are immediately available or within a year of publication. Additionally, some organizations and publishers provide totally free, or low cost, online access to biomedical journals for readers in developing countries. [13-15]. Furthermore, papers generated through research funded by the NIH, other government agencies and participating organizations, are now required by law to be deposited in PubMed Central. Nevertheless, access to online full-text articles is still a challenge in developing countries: the lack of Internet access, low bandwidth and shortage of computers for reading and printing journal articles are still making full- text access difficult. Most healthcare workers in developing countries use public computers like Internet cafes and libraries. [16]. Many countries (more than 70) with GNI (gross national income) per capita that do not qualify for free access are eligible for reduced subscription, but for most, the cost is still unaffordable. Moreover, these programs are intended for government and non-profit health care organizations only -– physicians practicing independently or in a group cannot avail of these programs. We recently asked some physicians practicing mostly in developing countries whether Medline abstracts are adequate for clinical decisions: 28% (15/54) categorically stated they are. Forty three percent (23/54) said no, but that they had no access to full-text journals and another 28% also said no, but they had no time to read full-text articles. One respondent did not use Medline abstracts at all. This preliminary study confirms access issues in these countries, but also the potential value for abstracts if these could be made available easily through their existing infrastructure. Wireless communications is a success story far exceeding the UN’s goal of 50% coverage by 2015. GSMA reports that there are now more than four billion connections worldwide with more than 80% of the world’s population accessible by mobile phones [17]. Among U.S. physicians, 64% now use smartphones [18]. Furthermore, mobile phones are getting better -- processes previously associated only with desktop or laptop computers are now in smartphones. The mobile phone, available in countries with minimal Internet access or low bandwidth and poor computer resources enables healthcare personnel to access the Internet. It creates an environment where updated medical information such as Medline journal abstracts is accessible. An added benefit is that expert consultation through camera phones is possible. For example, a search for randomized controlled trials using the PICO strategy (http://pubmedhh.nlm.nih.gov/nlme/pico/piconew.html) P “postpartum haemorrhage”; I “misoprostol”; C “placebo”; O “low resource area” will retrieve an abstract of a three-year clinical trial [19]. Even though EBM teaches that full-text journals be reviewed, with more informative abstracts such as above, Medline abstracts alone might be a useful tool for making clinical decisions especially in places where no other resource is available. If journal abstracts are accepted as ‘current evidence’ suitable for evidence-based practice, then all who are involved in the publication process -- authors, journal reviewers and editors, need to ensure that the abstract is indeed an accurate summary of the full paper. References: 1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996;312: 71-2. 2. Read MEDLINE abstracts with a pinch of salt. Lancet 2006, 368(9545): 1394. 3. Barry HC, Ebell MH, Shaughnessy AF, Slawson DC, Nietzke F. Family physicians' use of medical abstracts to guide decision making: style or substance? J Am Board Fam Pract 2001;14:437-42. 4. Sackett DL, Straus SE.Finding and applying evidence during clinical rounds: the "evidence cart". JAMA; 1998 Oct 21 ; 280(15):1336-8. 5. Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract 1994;39:489-99. 6. Slawson DC, Shaughnessy AF.Obtaining useful information from expert based sources. BMJ 1997;314:947-9. 7. Smith R. What clinical information do doctors need? BMJ 1996;313:1062- 8. 8. Docs look to Wikipedia for condition info: Manhattan Research. Ben Comer April 21, 2009. http://www.mmm-online.com/Docs-look-to-Wikipedia- for-condition-info-Manhattan-Research/article/131038/ 9. Editorial - Innovations in publishing BMJ research. BMJ 2008; 337: a3123 10. Pitkin RM, Branagan MA, Burmeister LF. Accuracy of data in abstracts of published research articles. JAMA 1999;281:1110-1. 11. Winker MA. The need for concrete improvement in abstract quality (editorial). JAMA 1999;281:1129-30. 12. Wong HL, Truong D, Mahamed A, Davidian C, Rana Z, Einarson TR. Quality of structured abstracts of original research articles in the British Medical Journal, the Canadian Medical Association Journal and the Journal of the American Medical Association: a 10-year follow-up study. Curr Med Res Opin; 2005 Apr ; 21(4):467-73. 13. http://journals.bmj.com/subscriptions/countries.shtml 14. Access to Research Initiative (HINARI) http://www.who.int/hinari/eligibility/en/ 15. Full-text e-journals. http://www.healthnet.org/essential- links/fulltext- e-journals.html 16. Villafuerte-Gálvez J, Curioso WH, Gayoso O (2007) Biomedical Journals and Global Poverty: Is HINARI a Step Backwards? PLoS Med 4(6): e220 doi:10.1371/journal.pmed.0040220 17. Mobile World Celebrates Four Billion Connections. http://www.gsmworld.com/newsroom/press-releases/2009/2521.htm 18. What Percentage of U.S. Physicians Use a Smart Phone? http://www.ihealthbeat.org/Data-Points/2009/What-Percentage-of-US- Physicians-Use-a-Smart-Phone.aspx 19. Oral misoprostol in preventing postpartum haemorrhage in resource- poor communities: a randomised controlled trial. Derman RJ, Kodkany BS, Goudar SS, Geller SE, Naik VA, Bellad MB, Patted SS, Patel A, Edlavitch SA, Hartwell T, Chakraborty H, Moss N. Lancet; 2006 Oct 7; 368(9543):1248-53. The views and opinions of authors expressed herein do not necessarily state or reflect those of the National Library of Medicine, National Institutes of Health or the US Department of Health and Human Services. Acknowledgements: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Library of Medicine (NLM), and Lister Hill National Center for Biomedical Communications (LHNCBC). Competing interests: None declared