Introducing the new Evidence-Based Dermatology section

BJD British Journal of Dermatology E DI TO R IA L Introducing the new Evidence-Based Dermatology section with clinical expertise and the needs and preferences of patients. Over the years, EBM has become an integral part of undergraduate and postgraduate training. There are now centres of evidence-based medicine for most specialties, including for dermatology, evidence-based practice journals, and most clinical guidelines are based on an evidence-based approach. The Cochrane Collaboration, including the Cochrane Skin Group, has achieved a tremendous amount since its inception, an impressive library of systematic reviews for a start. It is also heartening to see the exponential increase in dermatology RCTs over the years (Fig. 1), and the BJD has done its share and published more RCTs than any other dermatology journal.3 However, it is impossible for anyone to keep up with this vast number of published RCTs. Decision-making by clinicians, policy-makers and national bodies such as the National Institute for Health and Care Excellence require a systemic synthesis of original research findings to inform clinical practice and allocation of healthcare resources. The Evidence-Based Dermatology section of the BJD addresses this need for dermatology. Yes, it is true that the BJD has published systematic reviews and RCTs for a long time. For several years we have also welcomed Critically Appraised Topics (CATs) and Putting Papers into Practice (PPiP) contributions as well as the publication of clinical guidelines. However, we feel it is time to bring these different types of articles under one roof. Here we introduce the ‘four pillars’ of this new section: Systematic Reviews, Critically Appraised Topics (CATs), Critically Appraised Research Papers (formerly called ‘PPiP’) and Clinical Guidelines. DOI: 10.1111/bjd.15847 Linked Articles: Garcia-Doval et al. Br J Dermatol 2017; 177: 888–889. Callander et al. Br J Dermatol 2017; 177: 1007–1013. Evidence-Based Medicine (EBM) is not a new concept. David Sackett, one of the fathers of EBM, defined it as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’.1 In that sense, EBM had already started during the Enlightenment Period, when scepticism about ancient Hippocratic and modern authorities was cultivated. James Lind was the first to conduct intervention studies, experimenting with sailors to test methods to prevent scurvy back in the 18th century and discovered that those who ate lemons and oranges were protected. Lind’s treatise preceded the discovery of vitamin C by more than a century. In 1914, Joseph Goldberger, a U.S. public health physician, was tasked by the U.S. government to investigate the cause of pellagra, a disease that affected tens of thousands and had a mortality of 40%.2 One of his observations was that inmates at the Georgia State Sanatorium developed high rates of pellagra, whereas the nurses did not, and he concluded that the origin of pellagra was probably caused by a dietary deficiency rather than due to an unidentified germ. He then went on to conduct intervention studies among hospitalized women with pellagra-associated mental illness that provided proof of concept. More EBM milestones include the first randomized controlled trial (RCT) undertaken in the late 1940s as well as Archie Cochrane’s work that culminated in the foundation of the Cochrane Collaboration in 1992 with a focus on systematic reviews and meta-analyses. This marked a new paradigm for teaching and practising clinical medicine. Tradition, anecdote and theoretical reasoning from basic sciences would be replaced by evidence from high-quality RCTs and observational studies, in combination Systematic Reviews Systematic reviews are original research and need to meet certain criteria to ensure they are of high quality. This is partly ensured through adherence to the PRISMA statement when Number of dermatology RCTs 1959–2016 600 500 400 300 200 100 © 2017 British Association of Dermatologists British Journal of Dermatology (2017) 177, pp885–887 2016 2013 2010 2007 2004 2001 1998 1995 1992 1989 1986 1983 1980 1976 1973 1969 1966 1963 0 1959 Fig 1. Number of dermatology randomized controlled trials published since 1959 (based on a PubMed search conducted on 1 June 2017). 885 886 Editorial RCTs are included and the MOOSE statement in the case of observational studies. Qualitative systematic reviews should follow the ENTREQ guidance. Compliance with these criteria will enhance the quality of conduct and ultimately the reporting of the review.4–6 Another key requirement will be prior publication of the systematic review protocol in PROSPERO (the international prospective register of systematic reviews; https://www.crd.york.ac.uk/PROSPERO/). The published protocol provides details of the methodology of the systematic review, which can be checked against the final completed review to evaluate potential reporting bias and confirm that all predefined outcomes are addressed in the way they were planned. In this issue of the BJD, Garcia-Doval et al. publish an editorial about ‘How to keep systematic reviews trustworthy’, which we recommend to review authors as well as peer reviewers.5 For the latter, there will be new challenges as peer reviewing systematic reviews involves not only content knowledge and clinical expertise, but also knowledge regarding methodology, GRADE (Grading of Recommendations, Assessment, Development and Evaluation) to assess quality of the evidence, and potentially more complex statistics, for instance in the case of network analyses. We will extend our scope of search for peer reviewers to not only experts in the clinical field, but also methodologists and statisticians to ensure all aspects of peer reviewing of Systematic Reviews are adequately covered. Peer reviewers will be encouraged to use a specific tool for their evaluations of which AMSTAR (A Measurement Tool to Assess Systematic Reviews) is the most widely used.7 This validated tool has been specifically developed to assess the methodological quality and robustness of systematic reviews. Critically Appraised Topics Critical Appraised Topics (CATs) are brief publications that are interesting to read and address precise, relevant questions that arise from a management question encountered in clinical practice, typically following the PICO format (Problem/ Patient/Population, Intervention, Comparison and Outcome). They start by describing the specific case scenario, present the results of a systematic assessment of the published evidence in the light of the PICO question and lead to an evidence-based decision that readers can easily transfer to their own clinical practice. Although they share the same methods as those used for systematic reviews, CATs differ in that they focus on a narrow question and their direct, practical application of the systematic assessment of the evidence to a specific case. Importantly, the assessment of the available evidence should adhere to the same standards as those of a systematic review wherever possible, including the use of a risk-of-bias assessment and other formal tools for assessing methodological quality (see above under Systematic Reviews). An excellent example of a CAT and a highly recommended read for everyday practice was written by Wootton et al. on the question: ‘Should isotretinoin be stopped prior to surgery? A critically appraised topic’.8 For further guidance on how to write a CAT see the paper by Callander et al. in this issue of the BJD.9 British Journal of Dermatology (2017) 177, pp885–887 Critically Appraised Research Papers The Critically Appraised Research Papers (CARPs) section provides a summary and critical appraisal of a paper published outside the BJD that is relevant to clinical practice or research in the field of dermatology. The aims of this section are on two levels: (1) to alert readers to important papers from the wider dermatological and general medical literature, and (2) to provide examples of critical appraisal of the epidemiological literature. CARPs will include a summary and assessment of the research, in addition to an invited response from the authors of the original paper. The main points to be covered in a CARP are: (i) a summary of the article in structured abstract form; (ii) a summary of what is already known on the topic and how the research paper advances the field; (iii) an assessment of the validity (both internal and external); (iv) an assessment of the papers’ conclusions; and (v) the implications for clinical practice. Authors are encouraged to consult guidance for critical appraisal of the medical literature including the Centre for Evidence Based-Medicine’s Critical Appraisal tools (http://www.cebm.net/critical-appraisal/) and JAMA’s Users’ Guides to the Medical Literature (http://jamaevidence. mhmedical.com/book.aspx?bookid=847). Clinical Guidelines Last but not least, we continue to welcome the submission of clinical guidelines. Traditionally, the BJD has published national clinical guidelines produced by the British Association of Dermatologists Guidelines Group but we welcome any clinical guideline, be it from national or international bodies and expert groups.10 We are also keen to publish the systematic reviews that clinical guidelines are based on. Summary Please refer to the Author Guidance section on the BJD website for more detailed instructions on these different paper types. We look forward to working with you, and do keep the submissions coming to make the BJD the no. 1 journal for Evidence-Based Dermatology, weaving EBM even more into the very fabric of the BJD. Conflicts of interest None declared. 1 Unit for Population-Based Dermatology Research, St John’s Institute of Dermatology, King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London, U.K. 2 Program for Clinical Research, Department of Dermatology, University of California San Francisco (UCSF), CA, U.S.A. 3 Centre for Evidence Based Healthcare, C. FLOHR1 K. ABUABARA2 F. BATH-HEXTALL3 A. NAST4 E. van ZUUREN5 © 2017 British Association of Dermatologists Editorial School of Health Sciences, University of Nottingham, Nottingham, U.K. 4 Division of Evidence based Medicine (dEBM), Department of Dermatology, Venerology und Allergy, Charit
e Universit€atsmedizin Berlin, Berlin, Germany 5 Dermatology Department, Leiden University Medical Centre, Leiden, the Netherlands E-mail: [email protected] References 1 Sackett D. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312:71–2. 2 Morabia A. Joseph Goldberger’s research on the prevention of pellagra. J R Soc Med 2008; 101:566–8. 3 Anstey A, Reynolds NR. What does the BJD now stand for? A position statement Br J Dermatol 2015; 172:1463–5. © 2017 British Association of Dermatologists 887 4 van Zuuren EJ, Fedorowicz Z. Moose on the loose: checklist for meta-analyses of observational studies. Br J Dermatol 2016; 175:853–4. 5 Garcia-Doval I, van Zuuren EJ, Bath-Hextall F, Ingram JR. Systematic reviews: let’s keep them trustworthy. Br J Dermatol 2017; 177:888–9. 6 Tong A, Flemming K, McInnes E et al. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol 2012; 12:181. 7 Shea BJ, Grimshaw JM, Wells GA et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007; 7:10. 8 Wootton CI, Cartwright RP, Manning P, Williams HC. Should isotretinoin be stopped prior to surgery? A critically appraised topic. Br J Dermatol 2014; 170:239–44. 9 Callander J, Anstey AV, Ingram JR et al. How to write a Critically Appraised Topic: evidence to underpin routine clinical practice. Br J Dermatol 2017; 177:1007–13. 10 Ingram JR, Anstey A. The evolution of clinical guidelines for dermatologists: GRADE, AGREE and occasionally consensus of experts. Br J Dermatol 2017; 176:3–4. British Journal of Dermatology (2017) 177, pp885–887