A non technical overview of sample size calculation and why it is necessary with some brief examples of how to approach the problem and why it is useful to actually think of these calculations.
These annotated slides will help you interpret an OR or RR in clinical terms. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
Critical Appraisal of systematic review and meta analysis articlesDr. Majdi Al Jasim
Critique of systematic review and meta analysis articles
This presentation is made to educate health care provide rs on how to do critical appraisal of systematic review and meta analysis articles
This module has prepared for the postgraduate medical students in any specialty. Last 10 questions are MCQ which is very important for FCPS part 1 (all subjects)
A non technical overview of sample size calculation and why it is necessary with some brief examples of how to approach the problem and why it is useful to actually think of these calculations.
These annotated slides will help you interpret an OR or RR in clinical terms. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
Critical Appraisal of systematic review and meta analysis articlesDr. Majdi Al Jasim
Critique of systematic review and meta analysis articles
This presentation is made to educate health care provide rs on how to do critical appraisal of systematic review and meta analysis articles
This module has prepared for the postgraduate medical students in any specialty. Last 10 questions are MCQ which is very important for FCPS part 1 (all subjects)
Study designs, Epidemiological study design, Types of studiesDr Lipilekha Patnaik
Study design, Epidemiological study designA study design is a specific plan or protocol
for conducting the study, which allows the investigator to translate the conceptual hypothesis into an operational one.
Summary slides for "Systematic Review and Meta-Analysis Course for Healthcare Professionals", January 8-9, 2013, King Abdullah Medical City, Makkah, Saudi Arabia
http://KAMCResearch.org
Critical appraisal is the process of carefully and systematically analyze the research paper to judge its trustworthiness, its value and relevance in a particular context. (Amanda Burls 2009)
A critical review must identify the strengths and limitations in a research paper and this should be carried out in a systematic manner.
The Critical Appraisal helps in developing the necessary skills to make sense of scientific evidence, based on validity, results and relevance.
Study designs, Epidemiological study design, Types of studiesDr Lipilekha Patnaik
Study design, Epidemiological study designA study design is a specific plan or protocol
for conducting the study, which allows the investigator to translate the conceptual hypothesis into an operational one.
Summary slides for "Systematic Review and Meta-Analysis Course for Healthcare Professionals", January 8-9, 2013, King Abdullah Medical City, Makkah, Saudi Arabia
http://KAMCResearch.org
Critical appraisal is the process of carefully and systematically analyze the research paper to judge its trustworthiness, its value and relevance in a particular context. (Amanda Burls 2009)
A critical review must identify the strengths and limitations in a research paper and this should be carried out in a systematic manner.
The Critical Appraisal helps in developing the necessary skills to make sense of scientific evidence, based on validity, results and relevance.
Largest laboratory conference in the Middle EastCheryl Prior
The MEDLAB Congress will host 6 multi-disciplinary conference tracks that will provide CME Credits, unparalleled education and management solutions to help labs excel in today's competitive market.
5,000 delegates will gather to find out about the latest diagnostics developments at the six conference tracks: laboratory management, microbiology, immunology, haematology, clinical chemistry and molecular diagnosis.
NHSScotland is constantly striving to increase efficiency and productivity whilst improving quality and effectiveness. In this session, delegates heard directly from colleagues who have changed their systems to deliver more effective care and how they value difference and variation within the NHS, using evidence to affect change. Delegates also had the opportunity to see some real examples from various settings across NHSScotland where evidence-based practice has been used to change systems and processes and how this has made a difference to patient outcomes, experience and value.
See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources
8th Middle East Update in Urology ConferenceCheryl Prior
The 8th Middle East Update in Urology Conference will provide delegates with an update in the latest urological treatments, diagnoses and management practices pertaining to those disorders most pertinent to the region; in particular, kidney and infertility, oncology, prostate biopsy and paediatric urology.
Key topics:
Updates in paediatric urology
The prostate and prostate biopsy
Uro-oncology
Reconstruction
Immune therapy for kidney cancer
Male infertility
Who should attend?
Urologists
Andrologists
Nephrologists
Paediatricians
General Practitioners
Uro-oncologists
Urogynaecologists
Benefits of attendance
Analyse the latest techniques for prostate biopsy
Apply best practice for the transition of care of patients with complex congenital conditions
Evaluate current management practices for adolescent varicoceles
Appraise the latest therapies for the treatment of male infertility
Assess the development of augmentation cytoplasty
8th Middle East Paediatrics ConferenceCheryl Prior
The 8th Middle East Paediatrics Conference is the must attend paediatrics conference of the year, featuring 12 different sessions over the course of three days. Expert doctors coming from the USA, UK and the Middle East come together to discuss the latest topics, as well as to distribute the most up-to-date information on the management of different paediatric diseases and conditions.
Activity directors:
Dr Jaishen Rajah, Sheikh Khalifa Medical City
Dr Giovanni Piedimonte, Cleveland Clinic
Who should attend:
Paediatricians
Paediatric Consultants/Specialists
Family Medicine Physicians
General Practitioners
Neonatologists
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Biases in meta-analysis
1. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Biases in meta-analysis
Dr. S. A. Rizwan M.D.,
Public Health Specialist & Lecturer,
Saudi Board of Community Medicine – Riyadh,
Ministry of Health, KSA
26.11.2019 1
With thanks to Martin Bland
2. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Outline
• Type of biases in SRMA
• Definition of publication bias
• Identifying publication bias
• Dealing with publication bias
226.11.2019
3. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Types of biases
• Biases in meta-analysis are
generally reporting biases
• Most important of these is the
publication bias
326.11.2019
4. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Publication bias
• Research with statistically significant results is more likely to be submitted and
published than work with null or non-significant results.
• Research with statistically significant results is likely to be published more
prominently than work with null or non-significant results — in English, in higher
impact journals.
• Well designed and conducted research is less likely to produce statistically significant
results than badly designed and conducted research.
• Combining only published studies may lead to an over optimistic conclusion.
426.11.2019
5. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
FUNNEL PLOTS
526.11.2019
6. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Funnel plot –
explanation
26.11.2019 6
7. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Identifying publication bias
• A plot of effect size against sample size.
• No bias is present -> shaped like a funnel.
• 50 simulated trials with true effect = 0.5.
• Funnel plot: effect against sample size.
• 95% of trials should lie within the lines.
• Usually do not show these because they
depend on population.
-.50.511.5
Difference
0 500 1000 1500
Total sample size
726.11.2019
8. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Identifying publication bias
• A plot of effect size against sample size.
• No bias is present -> shaped like a funnel.
• 50 simulated trials with true effect = 0.5.
• Funnel plot: effect against standard error.
• Boundaries are now straight lines.
-.50.511.5
Difference
0 .2 .4 .6
Standard error
826.11.2019
9. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Identifying publication bias
• A plot of effect size against sample size.
• No bias is present -> shaped like a funnel.
• 50 simulated trials with true effect = 0.5.
• Funnel plot: effect against 1/standard
error.
-.50.511.5
Difference
0 5 10 15 20
1/standard error
926.11.2019
10. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Identifying publication bias
• A plot of effect size against sample size.
• No bias is present -> shaped like a funnel.
• 50 simulated trials with true effect = 0.5.
• Funnel plot: effect against meta-analysis
weight.
-.50.511.5
Difference
0 100 200 300 400
Meta-analysis weight
1026.11.2019
11. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Identifying publication bias
• Sometimes plot of sample size (etc.)
against effect size.
• Turned round through 90 degrees.
• 50 simulated trials with true effect = 0.5.
• Funnel plot: meta-analysis weight against
effect size.
0100200300400
Meta-analysisweight
-.5 0 .5 1 1.5
Difference
1126.11.2019
12. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Identifying publication bias
• If only significant trials are published, part
of the funnel will be sparse or empty.
• 50 simulated trials with true effect = 0.5.
• Funnel plot: effect against standard error.
• Open diamonds are trials where the
difference is not significant.
-.50.511.5
Difference
0 .2 .4 .6
Standard error
1226.11.2019
13. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Identifying publication bias
• If only significant trials are published, part
of the funnel will be sparse or empty.
• If trials where the difference is not
significant are not published, we won’t see
them.
• We won’t have the guide lines, either.
-.50.511.5
Difference
0 .2 .4 .6
Standard error
1326.11.2019
14. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Publication bias – example
• Hormone replacement therapy and
prevention of nonvertebral fractures
• The dotted line represents the point of no
effect
Torgerson DJ, Bell-Syer SEM. (2001) Hormone replacement therapy
and prevention of nonvertebral fractures. A meta-analysis of
randomized trials. JAMA 285, 2891-2897
1426.11.2019
15. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Publication bias –
example
26.11.2019 15
16. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Publication bias – example
1626.11.2019
17. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
SIGNIFICANCE TESTS
1726.11.2019
18. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Publication bias by Significance tests
• ‘Begg’s test’ (Begg and Mazumdar 1994)
• ‘Eggar’s test’ (Egger et al., 1997)
• Both ask: ‘Is the trial estimate related to the size of the trial?’
1826.11.2019
19. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Begg’s test
• Starts with the funnel plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials.
• Is the trial estimate (log odds ratio in this
example) related to the size of the trial?
• Correlation between log odds ratio and
weight?
• Problem: variance is not the same for all
points.
-1.5
-1
-.5
0
.5
Logoddsratio
0 2 4 6 8 10 12 14 16 18 20
Meta-analysis weight
1926.11.2019
20. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Begg’s test
• Starts with the funnel plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials.
• Problem: variance is not the same for all
points.
• Solution: divide each estimate by standard
error.
• Begg subtracts pooled estimate first then
divides by SE of the deviation.
-4
-2
0
2
4
Deviation/SE
0 2 4 6 8 10 12 14 16 18 20
Meta-analysis weight
2026.11.2019
21. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Begg’s test
• Starts with the funnel plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials.
• Now find Kendall’s rank correlation
between deviation/SE and weight.
• Could use any suitable variable on x axis
(SE. 1/SE, etc.)
• Tau b = 0.09, P = 0.7. -4
-2
0
2
4
Deviation/SE
0 2 4 6 8 10 12 14 16 18 20
Meta-analysis weight
2126.11.2019
22. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Begg’s test
• Starts with the funnel plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials.
• Problem:
• Power very low at small numbers of trials.
• ‘Fairly powerful with 75 studies, moderate
power with 25 studies’. (Begg and
Mazumdar 1994). -4
-2
0
2
4
Deviation/SE
0 2 4 6 8 10 12 14 16 18 20
Meta-analysis weight
2226.11.2019
23. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Eggar’s test
• Based on the Galbraith plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials, log odds ratio
• Regress trial difference (log odds ratio)
over standard error on 1/standard error.
-4
-2
0
2
Difference/standarderror
0 2 4 6
1/standard error
Pooled effect 95% limits
2326.11.2019
24. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Eggar’s test
• Based on the Galbraith plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials, log odds ratio
• Regress trial difference (log odds ratio)
over standard error on 1/standard error.
• Does the line go through the origin?
• Test intercept against zero.
-4
-2
0
2
Difference/standarderror
0 2 4 6
1/standard error
Regression Pooled
2426.11.2019
25. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Eggar’s test
• Should we weight the observations?
• ‘In some situations (for example, if there are several small trials but only one larger study)
power is gained by weighting the analysis by the inverse of the variance of the effect
estimate.
• ‘We performed both weighted and unweighted analyses and used the output from the
analysis yielding the intercept with the larger deviation from zero.’ (Egger et al., 1997).
2526.11.2019
26. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Eggar’s test
• Based on the Galbraith plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials, log odds ratio
• Unweighted:
• D/SE = –1.14 + 0.39×1/SE
• Intercept = –1.14, se = 0.88, P = 0.22, 95%
CI = –3.05 to 0.77.
-4
-2
0
2
Difference/standarderror
0 2 4 6
1/standard error
Regression Pooled
2626.11.2019
27. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Eggar’s test
• Based on the Galbraith plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials, log odds ratio
• Unweighted:
– D/SE = –1.14 + 0.39×1/SE
– Intercept P = 0.22.
• Weighted:
– D/SE = –2.01 + 0.67×1/SE
– Intercept P = 0.17.
-4
-2
0
2
Difference/standarderror
0 2 4 6
1/standard error
Regression Pooled
2726.11.2019
28. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Eggar’s test
• Based on the Galbraith plot.
• Corticosteroids for severe sepsis and
septic shock (Annane et al., 2004), all
trials, log odds ratio
• Is this test biased?
– Doing both regressions and choosing the more
significant is multiple testing.
– The regression intercept is a biased estimate. -4
-2
0
2
Difference/standarderror
0 2 4 6
1/standard error
Weighted Unweighted
2826.11.2019
29. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Publication bias by significance tests - example
• Example: Effect of breast feeding in
infancy on blood pressure in later life
(Owen et al., 2003)
• Begg's funnel plot (pseudo 95%
confidence limits) showing mean
difference in systolic blood pressure by
standard error of mean difference.
• ‘The Egger test was significant (P = 0.033)
for publication bias but not the Begg test
(P = 0.186).’
2926.11.2019
30. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
DEALING WITH PUBLICATION BIAS
3026.11.2019
31. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Dealing with publication bias
• Trim and fill
• Selection models
• Meta-regression
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32. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Trim and fill
• Trim: we eliminate trials,
starting with the least powerful,
until we have symmetry. Get a
new pooled estimate.
• Fill: for the trials eliminated, we
reflect them in the pooled
estimate line and put in new
trials.
3226.11.2019
33. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Trim and fill
• Example: 89 trials comparing
homeopathic medicine with
placebo.
• Dotted line: no effect.
• Solid line: pre trim and fill
estimate.
• Open triangles are filled trials.
• Broken line: post trim and fill
estimate.
Sterne JAC, Egger M, Smith GD. (2001) Systematic reviews in health care -
Investigating and dealing with publication and other biases in meta-analysis. British
Medical Journal 323, 101-105.
3326.11.2019
34. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Trim and fill
• Simulation studies have found that the trim and fill method detects ‘missing’ studies in a
substantial proportion of meta-analyses in the absence of bias.
• Application of trim and fill could mean adding and adjusting for non-existent studies in
response to funnel plot asymmetry arising from nothing more than random variation
(Sterne et al., 2001)
3426.11.2019
35. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Selection models
• Model the selection process that determines which results are published.
• Based on the assumption that the study's P value affects its probability of publication.
• Many factors may affect the probability of publication of a given set of results, and it is
difficult, if not impossible, to model these adequately.
• Not widely used.
3526.11.2019
36. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Meta-regression
• Use study characteristics, e.g. Jadad score, sample size, to predict outcome.
• Example, breast feeding and blood pressure: (Owen et al., 2003)
• ‘The estimate of effect size decreased with increasing study size: –2.05 mm Hg in the 13
studies with fewer than 300 participants, –1.13 mm Hg in the seven studies (nine
observations) with 300 to 1000 participants, and –0.16 mm Hg in the four studies with more
than 1000 participants (test for trend between groups P = 0.046). However, a test for trend
with study size treated as a continuous variable, was not significant (P = 0.209).’
3626.11.2019
37. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Caution in dealing with publication bias
• These methods require large numbers of studies. They are not powerful in most meta-
analyses.
• Relationship between trial outcome and sample size may not result from publication bias.
Small trials may differ in nature, e.g. have more intensive treatment or treatment by more
committed clinicians (i.e. more committed to the technique, not to their work!)
• Publication bias may not result from significance or sample size.
• Researchers or sponsors may not like the result.
• Most healthcare researchers are amateurs with other demands on their attention (e.g. their
patients).
3726.11.2019
38. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Caution in dealing with publication bias
• Better to think of these methods as a way of exploring possibilities than to produce
definitive answers.
• Example: homeopathy versus placebo (Sterne et al., 2001)
• Regression of trial effect on asymmetry coefficient, language English/other, allocation
concealment, blinding, handling of withdrawals, indexed by Medline (bold were significant).
• ‘The largest trials of homoeopathy (those with the smallest standard error) that were also
double blind and had adequate concealment of randomisation show no effect.’
• ‘The evidence is thus compatible with the hypothesis that the clinical effects of
homoeopathy are completely due to placebo and that the effects observed . . . are
explained by a combination of publication bias and inadequate methodological quality of
trials.’
• ‘We emphasise, however, that these results cannot prove that the apparent benefits of
homoeopathy are due to bias.’
3826.11.2019
39. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
Take home messages
• Meta-analysis are not free from biases
• They are riddled with biases called reporting biases
• Most important among these is called publication bias
• Funnel plots and significance tests are commonly used to test for it
• A number of statistical techniques are available for dealing with it
3926.11.2019
40. Saudi Board of Preventive Medicine, Riyadh Ministry of Health, KSA Lecture 10/10
Dr. S. A. Rizwan, M.D.Demystifying statistics series: Meta-analysis course
THANK YOU
Kindly email your queries to sarizwan1986@outlook.com
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