How can clinicians choose between conflicting and discordant systematic reviews? A replication study of the Jadad algorithm.

INTRODUCTION: The exponential growth of published systematic reviews (SRs) presents challenges for decision makers seeking to answer clinical, public health or policy questions. In 1997, an algorithm was created by Jadad et al. to choose the best SR across multiple. Our study aims to replicate author assessments using the Jadad algorithm to determine: (i) if we chose the same SR as the authors; and (ii) if we reach the same results. METHODS: We searched MEDLINE, Epistemonikos, and Cochrane Database of SRs. We included any study using the Jadad algorithm. We used consensus building strategies to operationalise the algorithm and to ensure a consistent approach to interpretation. RESULTS: We identified 21 studies that used the Jadad algorithm to choose one or more SRs. In 62% (13/21) of cases, we were unable to replicate the Jadad assessment and ultimately chose a different SR than the authors. Overall, 18 out of the 21 (86%) independent Jadad assessments agreed in direction of the findings despite 13 having chosen a different SR. CONCLUSIONS: Our results suggest that the Jadad algorithm is not reproducible between users as there are no prescriptive instructions about how to operationalise the algorithm. In the absence of a validated algorithm, we recommend that healthcare providers, policy makers, patients and researchers address conflicts between review findings by choosing the SR(s) with meta-analysis of RCTs that most closely resemble their clinical, public health, or policy question, are the most recent, comprehensive (i.e. number of included RCTs), and at the lowest risk of bias.

An ancestral Ashkenazi haplotype at the HMPS/CRAC1 locus on 15q13-q14 is associated with hereditary mixed polyposis syndrome.

The putative locus for hereditary mixed polyposis syndrome (HMPS) in a large family of Ashkenazi descent (SM96) was previously reported to map to chromosome sub-bands 6q16-q21. However, new clinical data, together with molecular data from additional family members, have shown 6q linkage to be incorrect. A high-density genomewide screen for the HMPS gene was therefore performed on SM96, using stringent criteria for assignment of affection status to minimize phenocopy rates. Significant evidence of linkage was found only on a region on chromosome 15q13-q14. Since this region encompassed CRAC1, a locus involved in inherited susceptibility to colorectal adenomas and carcinomas in another Ashkenazi family (SM1311), we determined whether HMPS and CRAC1 might be the same. We found that affected individuals from both families shared a haplotype between D15S1031 and D15S118; the haplotype was rare in the general Ashkenazi population. A third informative family, SM2952, showed linkage of disease to HMPS/CRAC1 and shared the putative ancestral haplotype, as did a further two families, SMU and RF. Although there are probably multiple causes of the multiple colorectal adenoma and cancer phenotype in Ashkenazim, an important one is the HMPS/CRAC1 locus on 15q13-q14.

'Settings' based health promotion: a review.

Over the past 10 years, 'settings' based health promotion has become a central feature of efforts to promote health that recognize the significance of context. Emerging in part from a perception of an over-reliance on individualistic methods, the approach was built on a profound belief in its value and deployed a range of novel theoretical resources, mainly from organizational sociology and psychology. This initial enthusiasm has been maintained within policy directives, in the published literature and, from our own experience, amongst health promotion practitioners. At the same time, with the maturing of the approach, has come a healthy element of critical review. Drawing upon the literature and based upon our experiences within the Health Education Board for Scotland, this paper seeks to bring together a range of perspectives, casting a critical yet constructive eye on current settings theory and practice. The paper first reviews the nature of settings based work, highlighting the varied bases and expectations that underpin it. Similarly, the many factors that influence the ability of health promoters to deliver such activities are considered. In relation to the construction and delivery of such activity, the paper suggests that there needs to be an explicit and detailed assessment of the nature of the setting, the skills of the health promoter and the associated expectations.

The status of evidence and outcomes in Stages of Change research.

The Stages of Change model has become a prominent feature within health promotion and most of the literature associated with the model portrays it as being 'effective'. Based on an extensive review of the literature, this paper suggests that contrary to this view, there exist a relative paucity of sufficiently strong supportive evidence. The paper describes the features of the existing evidence base, and highlights problems in relation to various aspects of design and execution. Two wider issues relating to the core nature of the model and the evidence associated with it are identified as important and discussed. Two main conclusions are drawn. First, better quality quantitative outcome studies are needed. These should be complemented with significant qualitative case studies with a focus on practitioner and organizational utilization of the model. Second, the disproportionate popularity of the model may be skewing the practical and conceptual nature of health promotion. Stages of Change activities are seen to equate to 'health promotion' at the expense of other activities and approaches.

Global health promotion models: enlightenment or entrapment?

This paper suggests that there is a tendency for health promotion to be located within models that consider health to be a product of a range of forces, with practice itself assumed to comprise a similarly wide range of activities. This paper develops a critique of this tendency that is essentially accommodating, all embracing and 'neutral'. It is argued that this leads to the masking of tensions between the conflicting values contained within the different elements of the models. We suggest that for health promoters, this is neither conceptually appropriate nor practically sensible. These notions are developed in five main stages. We start by defining some of the key concepts in the piece, e.g. the nature of a 'model' and examples of 'global' models. We then examine some of the general reasons why global models are favoured, with respect to the emergence of the UK's strategy for health, The Health of the Nation. The third stage of the discussion identifies and considers, within the British context, professional and governmental factors perceived to have driven this choice. The fourth aspect of the paper will introduce a critique of the use of global modelling. The paper concludes by critically questioning this evolving relationship, and suggests that it will be essentially conservative and unproductive. We end by reviewing the implications for practice and suggesting a useful way forward.

PIP: One paradigm of health promotion directs efforts at individuals through formal biomedical service provision or education, while the other suggests that more profound outcomes can be achieved through broad social and political change. Recent policy statements in the UK seem to embrace these potentially incompatible views. This paper, on the other hand, argues that the creation of "global" health promotion models can impede constructive debate about alternative perspectives on health. This argument is developed in five stages. First, the key concepts of global models are defined. Second, some of the general reasons why global models are favored are presented and related to the UK's strategy for health as presented in "The Health of the Nation." Third, the factors that enhance the attractiveness of global models are described as being the formal aspirations and expectations of health promoters and the governmental expectations, or political context, that governs manifestation of the former expectations. Fourth, the critique of the use of global models in the literature is reviewed. The next section of the paper questions the evolving new policy of accommodating both views and determines that this accommodation requires a degree of compromise that will stifle debate on particular health promotion approaches and, thus, foster apathy. The paper concludes by suggesting that health promoters should adopt a more cautious relationship with global modeling and maintain their tradition of critical analysis.

Clinical and molecular features of the hereditary mixed polyposis syndrome.

BACKGROUND & AIMS: Various inherited syndromes predispose to the development of colonic juvenile polyps and colorectal cancer, with potential importance for sporadic tumorigenesis. This study describes features of a possibly new syndrome of atypical juvenile polyps and other colonic tumors and compares these features with those of known gastrointestinal tumor syndromes. METHODS: A large family, St. Mark's family 96, with a tendency to develop colonic polyps of mixed histological types is described. Genetic linkage to known polyposis syndromes has been tested. RESULTS: Adenomatous and hyperplastic polyps occur in affected members of the family, although the characteristic lesion is an atypical juvenile polyp. Some affected individuals have developed polyps of more than one type, and individual polyps may contain features of more than one histological type. Polyps can undergo malignant change. Typically, fewer than 15 polyps are found at colonoscopy and there is no extracolonic disease associated with the development of polyps. The family's polyps seem to be inherited in an autosomal-dominant fashion, but the disease is probably unlinked to candidate loci with importance in colorectal tumorigenesis, such as APC, hMSH2, and hMLH1. CONCLUSIONS: We term this family's disease hereditary mixed polyposis syndrome (HMPS). Although mutations in the putative HMPS gene may be responsible for syndromes such as juvenile and Peutz-Jeghers polyposes, HMPS may also be a distinct disease.

Attitudes to predictive DNA testing in familial adenomatous polyposis.

Attitudes to predictive DNA testing for familial adenomatous polyposis were documented in 62 affected adults. Patient views on prenatal testing and termination of pregnancy for this disorder were sought, as were opinions on the most suitable age to offer predictive testing for at risk children and the most appropriate age to begin screening. While 15 (24%) of those questioned stated that they would proceed to termination of pregnancy if a prenatal test indicated that the unborn baby was affected, in clinical practice no one has yet requested this option. Six (10%) people who had refrained from having children for fear of passing on the polyposis gene felt that the arrival of prenatal testing would enable them to consider planning a family. The majority of patients (93%) said they would like their children tested by DNA analysis at birth or in infancy, but felt that 10 to 12 years was the most appropriate time to discuss the diagnosis with the child.

Genetic mapping of hereditary mixed polyposis syndrome to chromosome 6q.

Hereditary mixed polyposis syndrome (HMPS) is characterized by atypical juvenile polyps, colonic adenomas, and colorectal carcinomas. HMPS appears to be inherited in an autosomal dominant manner. Genetic linkage analysis has been performed on a large family with HMPS. Data did not support linkage to the APC locus or to any of the loci for hereditary nonpolyposis colorectal cancer. Evidence that the HMPS locus lies on chromosome 6q was, however, provided by significant two-point LOD scores for linkage between HMPS and the D6S283 locus. Analysis of recombinants and multipoint linkage analysis suggested that the HMPS locus lies in a 4-cM interval containing the D6S283 locus and flanked by markers D6S468 and D6S301.

Market testing specialist health promotion services--a test case for an imaginative public health presence in purchasing.

This paper focuses on the current pressure being imposed upon health promotion services in the 'North West' Region in the form of 'market testing'. It suggests that this is not only of concern to those services themselves, but may also act as a 'test case' for the examination of the range of competing perspectives that inform a purchasing function. The tensions between the views that respectively support or question the application of market values is thus examined in relation to the role of public health specialists within purchasing organizations. The paper concludes that although there is some potential to 'sharpen up' services, caution is required in avoiding unrestricted market values leading to superficial and fragmented health promotion provision. It is admitted that there are consequences relating to health promotion specialists. However, because of the close affinity between promotion and public health, failure to protect health promotion from the harshness of the market and ensure a broad-based approach will not only be a set-back for health promotion but will also harm the status of 'public health perspectives' in the broader purchasing context.

Variables associated with the risk of colorectal adenomas in asymptomatic patients with a family history of colorectal cancer.

The results of screening individuals referred to the Family Cancer Clinic at St Mark's Hospital from 1986 are presented. Colonoscopy was performed in 644 asymptomatic individuals (from 436 families) with a family history of colorectal cancer. Sixty nine (15.8%) of the families fulfilled the Amsterdam criteria for the hereditary non-polyposis colorectal cancer syndromes (HNPCC). Seven cases of colorectal cancer were diagnosed at an average age of 49 years; six at Dukes's stage A and one at stage C, four in subjects from Amsterdam criteria families. One hundred and forty four (22.4%) subjects had one or more adenomas. The prevalence of adenomas in the subjects from Amsterdam criteria families was 34 of 127 (26.8%) compared with 110 of 517 (21.3%) in those from other families; the age and sex adjusted odds ratio (OR) was 1.76 (p = 0.02). Factors influencing the prevalence of adenomas in screened individuals were evaluated. Multivariate analysis showed that independent variables significantly related to the risk of adenomas were: age (p < 0.0001), sex (p = 0.0002), and the number of generations (> or = 2 v 1) of relatives affected by either colorectal cancer or adenomas (p = 0.0006). The latter variable was more highly predictive of the probability of finding an adenoma at colonoscopy than a family history of two generations with cancer only (p = 0.056). The OR of having colorectal adenomas increased with age, by about twofold for each decade, and was twice as high in men than women, and in subjects with two or more generations relative to those with one generation affected by colorectal cancer or adenomas. Six of seven patients with cancer and 46 of 144 (31.9%) with adenomas had lesions proximal to the splenic flexure only. The proportion of individuals with proximal adenomas only was 47.1% in Amsterdam criteria families and 27.3% in the others (p=0.03). These findings support the view that colonoscopy rather than sigmoidoscopy is the method of choice for screening high risk groups.

Death from unsuspected colorectal cancer.

An analysis of all subjects undergoing autopsy in the Plymouth Health District over a 10-year period revealed 61 cases of unsuspected colorectal cancer. The carcinoma was the primary cause of death in 57 cases and surgical treatment for cure might have been possible in over one-half. The 61 subjects accounted for 4.1% of all cases of fatal colorectal cancer in this area. Examination by means of rectal digital palpation, rigid sigmoidoscopy and flexible sigmoidoscopy might have diagnosed 10, 24 and 41 carcinomas respectively. This study has demonstrated that a significant number of colorectal cancers remain undetected until after death. These cases should be included in future studies of colorectal cancer.

Death from undiagnosed peptic ulcer complications: a continuing challenge.

A 10-year study of all 9653 autopsies performed in the Plymouth Health District, UK from 1977 to 1986 revealed 154 patients who died from undiagnosed peptic ulcer complications. In all, 118 of these patients died suddenly at home and 36 died in hospital. Most patients were elderly although 47 were under 70 years and 2 were under 50 years of age. Anti-inflammatory drugs were being used by 81 of these patients, an incidence of 60 per cent where full drug histories were available. Women who died were much more likely to be using these drugs than men. This study emphasizes the hitherto unrecognized importance of death from undiagnosed peptic ulcer disease and further highlights the potential risk of non-steroidal anti-inflammatory drug use.

Clean intermittent self-catheterisation in the elderly.

The results of teaching the technique of clean intermittent self-catheterisation (CISC) to 20 elderly patients (aged 65-81 years) are reported. The patients were followed up for a maximum of 4 years. The use of this technique in the management of selected elderly patients with lower urinary tract dysfunction is discussed.