Over 200,000 physicians belong to the American Medical Association. The Journal, therefore, of this Association has a significant audience and a long tradition. Continuing Medical Education inserts in JAMA may represent the basic education of many new developments for general practitioners.
Unfortunately, the authors of this most recent CME portion seem to require their own education on the conduct of a “systematic review”.
A properly performed systematic review utilizes a precise, replicable, well-described search strategy with which to canvass the evidence for synthesis. The assembled evidence is then evaluated based on pre-specified criteria for inclusion or exclusion. The end-result, hopefully, is a knowledge translation document based on the entire scope of published literature, accounting for controversy and irregularity in the context of a larger summary.
These authors perform a systematic review on “acute stroke intervention”. They identify and review 145 abstracts utilizing multiple combinations of MeSH terms and synonyms for “brain ischemia/drug therapy, stroke drug/therapy, tissue plasminogen activator, fibrinolytic agents, endovascular procedures, thrombectomy, time factors, emergency service, treatment outcome, multicenter study, and randomized controlled trial”. A massive undertaking, to be sure – considering these authors are also including intra-arterial and mechanical therapy in their review.
Yet, as indicated in their evidence review chart in the supplement, this strategy managed to identify only 17 RCTs – in the whole of systemic and endovascular therapy. As an example for comparison, the latest Cochrane Review of thrombolytics for acute ischemic stroke included 27 trials of fibrinolytic agents alone. And, as covered in their text and cited in their References, the RCT evidence regarding systemic therapy for acute stroke consists of: NINDS and ECASS III.
That’s it.
No MAST-E, MAST-I, or ASK. No mention of the smaller imaging-guided trials, EPITHET, DEDAS, DIAS, or DIAS II. Or, even excluding non-tPA trials, no ECASS, ECASS II, ATLANTIS, or, even the largest of flawed acute stroke trials, IST-3. And, even with such limited coverage, certainly no mention of any of the controversy over imbalances in NINDS, nor flaws in ECASS III pertaining to tPA’s persistent non-approval by the FDA for the 3-4.5 hour time window.
If this were simply a commentary for the lay press regarding the bare minimum highlights of the last 20 years of stroke treatment, perhaps this would suffice. And, frankly, these authors do much better regarding their reporting on the recent endovascular trials. But, a CME publication in a prominent medical journal failing to address 90% of the evidence on a particular topic – yet calling itself a “systematic review” – is retraction-worthy.
“Acute Stroke Intervention – A Systematic Review”
http://jama.jamanetwork.com/article.aspx?articleid=2247149
Ryan,
Thanks for highlighting this paper. I find this extraordinarily disappointing when I thought that we are finally getting the pendulum to swing back to a balanced interpretation of the stroke literature.
The conclusion of the abstract is absurd on so many levels; " Intravenous rtPA remains the standard of care for patients with moderate to severe neurological deficits who present within 4.5 hours of symptom onset"
Have you thought of submitting a letter to JAMA? Or has your head gone to numb from banging it against the wall? I guess there is a time and place to pick your battles… but this one does seem to go way over the top.
I'm not so much beating my head against the wall anymore for such issues. Any letter I submit will probably be: 1) rejected, or 2) accepted, and live behind a paywall. Like my critique of the Cochrane review a few months back, I guarantee my thoughts are exposed to far greater an audience via the blog than journal correspondence.