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In order to give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence based” answers to common questions which are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format which has been successfully developed by Kevin Macaway-Jones and the group at the Emergency Medicine Journal—“BestBets”.
A word of warning. The topic summaries are not systematic reviews, through they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor search the grey, unpublished literature. What Archimedes offers are practical, best evidence based answers to practical, clinical questions.
The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focussing the mind, assisting searching,2 and gaining answers3.) A brief report of the search used follows—this has been performed in a hierarchical way, to search for the best quality evidence to answer the question.4 A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as number needed to treat, NNT) books by Sackett5 and Moyer6 may help. To pull the information together, a commentary is provided. But to make it all much more accessible, a box provides the clinical bottom lines.
The electronic edition of this journal contains extra information to each of the published Archimedes topics. The papers summarised in tables are linked, by an interactive table, to more detailed appraisals of the studies. Updates to previously published topics will be available soon from the same site, with links to the original article.
Readers wishing to submit their own questions—with best evidence answers—are encouraged to review those already proposed at www.bestbets.org. If your question still hasn’t been answered, feel free to submit your summary according to the Instructions for Authors at www.archdischild.com. Three topics are covered in this issue of the journal:
Are topical corticosteroids superior to systemic histamine antagonists in treatment of allergic seasonal rhinitis?
Do behavioural treatments for sleep disorders in children with Down’s syndrome work?
Inhaled steroids in the treatment of mild to moderate persistent asthma in children: once or twice daily administration?
N of 1 trials
Some therapies seem to have a general effect on most patients with a condition—paracetamol for fevers, as an example. Other drugs certainly improve the life of some children, but have no effect on others (DNase in cystic fibrosis seems to be like this). These medicines, especially for chronic conditions, are often given for a limited time in order to see if they have an effect. The “N of 1” trial seeks to advance the basic idea of a “therapeutic trial”, by putting it onto a more scientific footing. The format is to randomise between receiving active therapy and placebo, then receive the other. This should be repeated. Practically, this needs consent and understanding of the parents and child, appropriate and agreed outcome measures, and a friendly pharmacy to make up the medicines for you. These trials have been used in many areas in adult medicine, and have been reported in paediatrics.1 2 They are difficult to perform, needing to acquire placebos, capture outcomes accurately, and have a degree of statistical analysis. They have a great strength: they may prevent a child taking a treatment which is doing no good, or allow a child to gain benefit from a drug which has great interpersonal variation.