Alessandro Liberati

Bio: Alessandro Liberati is an academic researcher from University of Modena and Reggio Emilia. The author has contributed to research in topics: Breast cancer & Systematic review. The author has an hindex of 46, co-authored 144 publications receiving 167184 citations. Previous affiliations of Alessandro Liberati include Mario Negri Institute for Pharmacological Research & Cochrane Collaboration.

Truth Telling: A Cultural or Individual Choice?

Abstract: To the Editor. —Dr Surbone 1 discusses cross-cultural differences in oncologists' "truth telling" when communicating with patients. While the patients described in her article were terminally ill, for the majority of cancer patients the issue of open communication should be addressed well before the terminal stage. In earlier stages full disclosure allows not only for discussion of diagnosis and prognosis but, often, for patient involvement in important decision making. For example, as Surbone points out, patients with early-stage breast cancer are obvious candidates for involvement in decision making since breast-conserving and radical surgeries appear to have equivalent outcomes. Indeed, when given a choice between surgeries, women are willing and able to decide and are almost always satisfied with the outcomes of their choice. 2 Evidence does not support fears that being given a choice is detrimental to patients. 3 In countries such as Italy, where these fears are strong, the

Selecting references that match constructs: the difficult job of citing the parachute hyperbole.

Abstract: The large scale availability of clotting factor concentrates and the organization of comprehensive care centres prompted a progressive increase in the life expectancy and quality of life of western world haemophilia patients [1, 2]. The best treatment regimen for haemophilia, across the world being considered, is regular prophylactic replacement with clotting factor concentrates. Strong observational evidence has been available since long time in support of this widely established pattern of practice; 26 unique observational studies of varying quality for a total of 1,612 patients on prophylaxis compared to 1,191 patients treated ondemand were reported through 2005 [3]. Notwithstanding this evidence and in front of several open questions about optimization of prophylactic regimen (i.e., onset, frequency, intensity, duration, patient selection), the directors of the Canadian Association of Haemophilia Centres prompted and sponsored a Cochrane Review on the topic. The systematic review found very little randomized controlled trial (RCT)-based evidence in this field; there were only four trials with a total of 37 patients [3]. All trials enrolled adult patients already affected by various degree of arthropathy, so that virtually no direct RCT-based information was available about primary prophylaxis in young children devoid of any joint damage [4]. The authors concluded that ‘‘There is insufficient evidence from randomised controlled trials to determine whether prophylactic clotting factor concentrates decrease bleeding and bleeding-related complications in hemophilia A or B, compared to placebo, ondemand treatment, or prophylaxis based on pharmacokinetic data from individuals. Well-designed RCTs are needed to assess the effectiveness of prophylactic clotting factor concentrates. Two clinical trials are ongoing.’’ The aforementioned Cochrane Review prompted a sustained debate about the need and ethicality of RCTs in the haemophilia field. A popular BMJ paper by Smith and Pell about the lack of evidence that parachutes are worth wearing if jumping from airplanes [5] was cited in support by those claiming against the need of RCTs [6]. The clever and humorous BMJ paper is widely cited, but it was miscited in the specific case of the haemophilia review as in many others. This commentary will try to put ‘‘the parachute hyperbole’’ in the right perspective, offering a brief discussion about how to go from particular instance (i.e., RCTs to experimentally test parachute) to the high order A. Iorio Stroke Unit and Division of Cardiovascular Medicine, Department of Internal Medicine, University of Perugia, Perugia, Italy

Sudden infant death syndrome and sleeping position.

Abstract: To the Editor. Several published articles1–3 have assessed the association between sudden infant death syndrome (SIDS) and “sleeping positions” of infants. All these articles point to the prone or lateral position during sleep as a risk factor. The aim of this letter is to present some remarks about the definition of “last sleeping position” used in most of those studies. We consider a paper1 describing a 3-year (1987–1990) case-control study conducted in New Zealand. For the definition of “sleeping position,” the authors considered: 1. the position in which the infant was usually put down to sleep 2. the position in which the infant was usually found after sleep 3. the position in which the infant was put to sleep the last time 4. the position in which …

The efficacy of mammography and screening for breast cancer. author's reply

Abstract: To the Editor. —The article by Dr Kattlove and colleagues 1 presents a basic benefit package for detection and treatment of early breast cancer. I believe this concept has many flaws. Implementation of this package takes the diagnosis and treatment of breast cancer out of the hands of the patient and her physician and transfers it into the hands of third-party payers. I cannot agree with the authors' denying screening mammography for women younger than 49 years. Early-age screening mammography detects breast tumors that are small. This leads to a more favorable prognosis for the breast cancer patient. Breast-conserving surgery for early cancer of the breast requires adjunct radiotherapy. Friedman 2 concluded from studying pathological tissues from 100 women who received radiation therapy that carcinoma of the breast cannot be considered a radiosensitive tumor. Radiation therapy produces initial fibrosis, loss of elasticity, fat necrosis, telangiectasia, lymphopenia, and obliterative arteritis. Tissue

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Abstract: David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.

Abstract: Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7 In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1 Conceptual issues in the evolution from QUOROM to PRISMA

Measuring inconsistency in meta-analyses

Abstract: Cochrane Reviews have recently started including the quantity I 2 to help readers assess the consistency of the results of studies in meta-analyses. What does this new quantity mean, and why is assessment of heterogeneity so important to clinical practice? Systematic reviews and meta-analyses can provide convincing and reliable evidence relevant to many aspects of medicine and health care.1 Their value is especially clear when the results of the studies they include show clinically important effects of similar magnitude. However, the conclusions are less clear when the included studies have differing results. In an attempt to establish whether studies are consistent, reports of meta-analyses commonly present a statistical test of heterogeneity. The test seeks to determine whether there are genuine differences underlying the results of the studies (heterogeneity), or whether the variation in findings is compatible with chance alone (homogeneity). However, the test is susceptible to the number of trials included in the meta-analysis. We have developed a new quantity, I 2, which we believe gives a better measure of the consistency between trials in a meta-analysis. Assessment of the consistency of effects across studies is an essential part of meta-analysis. Unless we know how consistent the results of studies are, we cannot determine the generalisability of the findings of the meta-analysis. Indeed, several hierarchical systems for grading evidence state that the results of studies must be consistent or homogeneous to obtain the highest grading.2–4 Tests for heterogeneity are commonly used to decide on methods for combining studies and for concluding consistency or inconsistency of findings.5 6 But what does the test achieve in practice, and how should the resulting P values be interpreted? A test for heterogeneity examines the null hypothesis that all studies are evaluating the same effect. The usual test statistic …