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Cochrane News
Cochrane's 30 under 30: Audrey Tan and Eve Tomlinson
Cochrane is made up of 11,000 members and over 67,000 supporters come from more than 130 countries, worldwide. Our volunteers and contributors are researchers, health professionals, patients, carers, people passionate about improving health outcomes for everyone, everywhere.
Cochrane is an incredible community of people who all play their part in improving health and healthcare globally. We believe that by putting trusted evidence at the heart of health decisions we can achieve a world of improved health for all.
Many of our contributors are young people working with Cochrane as researchers, citizen scientists, medical students, and volunteer language translators and we want to recognize the work of this generation of contributors as part of this series called, Cochrane's "30 under 30."
In this series, we will interview 30 young people, 30 years old or younger who are contributing to Cochrane activities in a range of ways, all promoting evidence-informed health decision making across the world.
We will be hearing from them in a series of interviewees published over the coming months.
The Cochrane 30 Under 30 series is now closed. However, we are keen to hear from early career professionals about their work with Cochrane for future series. If you would like to be added to our waitlist, please conact firstname.lastname@example.com. Or if you want to know more about Cochrane's work contact email@example.com where our community support team will be happy to answer your questions.
Name: Eve Tomlinson and Audrey Tan
Age: 26 and 24
Occupation: NIHR Network Support Fellows for the Cancer Network and Circulation and Breathing Network
How did you first hear about Cochrane?
Eve: I first found out about Cochrane during my BSc in Psychology. I came across a Cochrane review whilst searching for literature for one of my research projects and found it to be such a useful resource giving a thorough overview of the studies in the topic area I was exploring. I was struck by how robust the methods for the review were and found it a great base to work from to then delve into the individual studies further.
Audrey: I first heard about Cochrane during my MSc in Evidence-Based Social Intervention and Policy Evaluation. Cochrane was introduced to us as the gold-standard for evidence synthesis and the pre-eminent organisation for synthesis methodology.
How did you become involved with Cochrane? What is your background?
Eve: Prior to becoming involved with Cochrane I worked as a Clinical Trial Coordinator at the Royal United Hospital, Bath, in the Oncology and Haematology Department. I think it is the combination of my experience in Cancer clinical trials and in health research from my degrees that means I'm well placed in the role of Network Support Fellow for the Cancer Network.
Audrey: While my undergraduate background is in qualitative research methods, after my MSc I started working for the Royal College of Obstetricians and Gynaecologists as a Systematic Reviewer writing systematic reviews for NICE clinical guidelines. I jumped at the opportunity to work for Cochrane as a Network Support Fellow; having the chance to work for this pre-eminent organization in the field of evidence-based medicine at an early stage in my career seemed too good to pass up.
What do you do in Cochrane?
Eve: I am the Network Support Fellow for the Cancer Network. I am working alongside the Network Senior Editor and Associate Editor to aid the delivery of our Network Strategic Plan. One of my main focuses is to support the six Cancer Cochrane Review Groups with review prioritisation activities, in order to ensure that Groups are producing reviews relevant to end users such as patients, carers, health care professionals and decision makers. I am also working to improve collaboration and shared learning in the Cancer Network, recently setting up the Cancer Network Newsletter to facilitate this.
Audrey: Similar to Eve, I've been helping my Groups develop prioritisation plans. I've also undertaken a stakeholder mapping exercise to identify groups and organisations that can facilitate research dissemination, conducted a member profile survey of people within the Network to identify opportunities for collaboration, and joined the author team on several reviews. Another main component that's unique to my role is increasing Groups' capacities to perform network meta-analyses.
What specifically do you enjoy about working for Cochrane and what have you learnt?
Cochrane is a global organisation and between our Networks (Cancer and Circulation and Breathing) there are Review Groups based in the UK, France, The Netherlands, Germany, Australia, Canada, and America. We enjoy being able to work with people from all over the world that care about making a difference to health care. We've learnt early on that although the Review Groups are different geographically, with differing personnel structure, funders and resources, they are all exerting enormous effort to achieve the same overarching goal: to produce high-quality, accessible reviews of evidence to allow people to make accurate and informed decisions about their health and health care generally.
What are your future plans?
Eve: I look forward to working more with the Review Groups in the Cancer Network on review prioritization, dissemination and the identification and development of stakeholder partnerships. I plan to learn more about the process of conducting a Cochrane review by joining a priority review author team.
Audrey: My long-term goal is to transition my career into working in health policy so gaining the experience now "on the ground" in evidence-based research is an ideal starting place.
In your personal experience, what one thing could Cochrane do better to improve its global profile?
Cochrane should improve the ways it disseminates research in order to make sure it is being accessed and understood by those who need it most. Cochrane reviews are a robust and comprehensive source of knowledge, but a lot of people just don't know about them. The increase in the creation of working links with sites such as Wikipedia will hopefully help with this, as will the use of alternative methods of dissemination such as using BlogShots and social media. Cochrane should work with medical students and registrar doctors to engage them with Cochrane work and translate findings into best practice, to get involved with reviews and recommend Cochrane reviews to patient groups.
What do you hope for Cochrane for the future?
We hope that Cochrane will focus efforts to expand further into lower and middle-income countries, opening up more Centres and Review Groups in these countries to ensure that Cochrane evidence is applicable worldwide.
How important is it that young people get involved in Cochrane? Why is this, do you think?
It is important for Cochrane to have a diverse workforce, including younger voices that bring enthusiasm, new ideas and challenge current practice.
Involving young people in Cochrane's work has numerous benefits, including improving research and development by introducing young people's perspectives, facilitating research dissemination and achieving a wider impact, and enabling young people to improve their own research skills.
What would your message be to other young people who want to get involved with Cochrane's work but not sure where to start….?
There is so much you can be part of in Cochrane at the click of a mouse e.g. through accessing Cochrane TaskExchange and Cochrane Crowd. As there are so many different topics covered by Cochrane and departments within the organisation, it would be a good idea to check out the Cochrane Website to learn more and determine which part you want to get involved with, then contact your local Cochrane Centre for further information.
Maternity Matters: A new special series of blogs and other resources from Cochrane UK
Throughout August, the Cochrane UK team are running a new special series; 'Maternity Matters'.
Maternity Matters is series of blogs and other resources, including graphics and podcasts, sharing some of the latest evidence on women's and babies' health, from pregnancy through to the early days after birth.
The series focuses on NHS priorities on maternity and highlights new Cochrane Reviews or research. The blogs look at risk reduction in pregnancy with new Cochrane Reviews on smoking cessation and vitamin D; on women's experiences and particular needs in pregnancy after recurrent miscarriage and after stillbirth; on continuity of care; and on managing the third stage of labour.
Professor Catherine Swann (@cjswannPHE), Deputy Director of Maternity and Community at Public Health England, welcomes the series:
See below for a round-up of materials and join in the discussions on Twitter, by following @CochraneUK and using the hashtag #MaternityMatters
- Maternity Matters: a special series from Cochrane UK This blog introduces Maternity Matters, a special series of blogs and other resources on women's and babies' health, during and after pregnancy and childbirth.
Learn more about Cochrane UK, the Cochrane Pregnancy and Childbirth Group, the Cochrane Neonatal Group, the Cochrane Children and Families Network and the Cochrane Child Health Field.Friday, August 2, 2019
Podcast: Support during pregnancy for women at increased risk of low birthweight babies
The Cochrane Pregnancy and Childbirth Group has produced more than 600 reviews and one of its first from 1995 looked at the effects of providing support during pregnancy for women at increased risk of having a low birthweight baby. The review underwent another update in April 2019 and we asked a new member of the research team, Christine East from Monash University and La Trobe University in Melbourne, Australia to tell us about the importance of the review and its latest findings.
Some newborn babies are smaller than expected and this can be for a number of reasons. Sometimes they are simply born early. Others may be born at full term but may not have grown well enough in the womb. Whatever the reason, low birthweight babies face more challenges than babies born at a normal weight.
One of the ideas for how to prevent babies being born small is to provide social support to women during their pregnancy. This might be in the form of emotional support, helping women get to appointments, or helping them understand when to let their midwife or doctor know about any concerns they are having.
Our review examines the evidence on these and other such strategies. We looked at the randomised trials that had tested the effects of programmes offering additional social support to women who were at risk of having a low birthweight baby. Some trials involved support from healthcare professionals, while, in others, lay persons provided the support. The main outcomes were babies born preterm, that is, three or more weeks earlier than the usual 40 weeks, or weighing less than 2500 grams at birth.
We included 25 reports, which had data for more than 11,000 mothers and their babies, across 21 different studies. We found that when compared with routine care, programmes that offered additional social support for these at-risk women may slightly reduce the number of babies born weighing under 2500 grams. There was also evidence that social support might decrease the number of babies born preterm, although the potential effect was not large. We also found that additional social support might reduce the number of births by caesarean section and the number of hospital admissions during pregnancy. And the results were consistent whether the support came from healthcare professionals or specially trained lay persons.
In summary, pregnant women need the support of caring family members, friends and health professionals. Programmes that offer additional social support during pregnancy are unlikely to have a large impact on babies being born small or before term. However, these support services may help in reducing the likelihood of caesarean birth and the need for the woman to have to stay in hospital at some point during her pregnancy.
Keeping Cochrane evidence up-to-date
A recent article in Nature, 'Out of date before it's published', looked at how we are keeping pace with fast-moving research fields. It featured the work of Cochrane to increase the speed and efficiency of Cochrane systematic review production.
Julian Elliott co-leader of Project Transform, discussed the need for the latest health evidence to be available and the idea of living systematic reviews. You can learn more about Project Transform and the work in this short video:
Chris Mavergames, Cochrane's Head of Informatics & Knowledge Management, touched upon our 'evidence pipeline', Cochrane Crowd, and what's next for technology to make the process faster. You can learn more about our Citizen Scientist platform, Cochrane Crowd, in this short video:
Cochrane's 30 under 30: Selena Ryan-Vig
Cochrane is made up of 11,000 members and over 67,000 supporters come from more than 130 countries, worldwide. Our volunteers and contributors are researchers, health professionals, patients, carers, people passionate about improving health outcomes for everyone, everywhere.
Cochrane is an incredible community of people who all play their part in improving health and healthcare globally. We believe that by putting trusted evidence at the heart of health decisions we can achieve a world of improved health for all.
Many of our contributors are young people working with Cochrane as researchers, citizen scientists, medical students, and volunteer language translators and we want to recognize the work of this generation of contributors as part of this series called, Cochrane's "30 under 30."
In this series, we will interview 30 young people, 30 years old or younger who are contributing to Cochrane activities in a range of ways, all promoting evidence-informed health decision making across the world.
We will be hearing from them in a series of interviewees published over the coming months.
The Cochrane 30 Under 30 series is now closed. However, we are keen to hear from early career professionals about their work with Cochrane for future series. If you would like to be added to our waitlist, please conact email@example.com. Or if you want to know more about Cochrane's work contact email@example.com where our community support team will be happy to answer your questions.
Name: Selena Ryan-Vig (on Twitter: @CochraneUK)
Age: 26
Occupation: Communications & Engagement Officer, Cochrane UK
How did you first hear about Cochrane?
I have to admit that it was only in my final year at university that I became familiar with Cochrane. I was studying a module about 'the psychology of pain' and my lecturer was an author on Cochrane Reviews assessing interventions for the treatment and prevention of pain. He asked the class whether we'd heard of Cochrane Reviews and, if not, why not. I made sure to brush up at that point.
It didn't take much reading to realise the importance of Cochrane's work. So, when the opportunity presented itself, I was keen to work for an organization whose mission – of generating reliable health information which is free from commercial sponsorship – I respect.
How did you become involved with Cochrane? What is your background?
I studied psychology at the University of Bath, with a placement year spent working in a national mental health charity for women. After graduating, I wasn't entirely sure what kind of job I was looking for, but I was interested in research and I knew I'd like to work within the charity or public sector. When I saw an opening at Cochrane UK on the NHS jobs website, it felt like a good fit. I began working at Cochrane UK as an information and administration assistant and moved into my current role about a year and a half later.
What do you do in Cochrane?
My role primarily involves sharing information about Cochrane and Cochrane Reviews with different audiences, such as researchers, healthcare professionals and the public. For example, I make video summaries and 'blogshots' (a kind of infographic) to share the key messages from Cochrane Reviews in ways which can be easily and quickly accessed and understood. I also produce our newsletters, curate Cochrane UK's website and social media accounts and monitor the analytics on these.
Additionally, with a colleague, I run interactive sessions in schools with students aged 15-18. We give an overview of evidence-based health care and why it's important, and encourage students to think critically, particularly around health claims they may see in the media (such as 'bacon causes cancer'). I also give occasional talks in universities or at conferences to raise awareness of Cochrane's work.
What specifically do you enjoy about working for Cochrane and what have you learnt?
The global nature of Cochrane is amazing and something which I only really appreciated when I was fortunate to attend my first Cochrane Colloquium in Seoul in 2016. Everyone has to make decisions about health, and when we do it's important that those decisions are informed by the best available research evidence. It's inspiring to be part of an organization made up of so many people from around the world who are driven by that ethos. I enjoy the variety of my role at Cochrane UK. I've been given many different opportunities and feel lucky to be part of a team so generous with their support and time.
What are your future plans?
To be decided! I'm interested in science communication; particularly how nuanced and complex research findings can be conveyed accurately but accessibly to different audiences. Equally, it's been really rewarding working with young people to hone their critical thinking skills about some of the (mis)information about health we're bombarded with every day. Both are potential avenues I'd be keen to gain more training in and explore further.
In your personal experience, what one thing could Cochrane do better to improve its global profile?
I'm bound to be biased given my role in communications, but I would love to see even more resources in Cochrane being allocated towards the dissemination of Cochrane Reviews. So much work goes into conducting a Cochrane Review, but if the target audiences of that review don't know it exists – or are unsure how to access it – a lot of that effort is undermined. We're fortunate at Cochrane UK to have two full time members whose primary focus is on disseminating Cochrane evidence, but not every centre or group has this luxury.
What do you hope for Cochrane for the future?
Making decisions about health that are informed by the best available evidence seems like such a no-brainer, that it's scary to think that – globally - this is often far from the current reality. With so much misleading and sensationalised health information in circulation, I hope that Cochrane – and other organizations like it – can be 'louder'. It would be great to see Cochrane doing more outreach work to help better equip individuals to distinguish between reliable, and less reliable, sources of evidence.
How important is it that young people get involved in Cochrane? Why is this, do you think?
It's really important that young people get involved with, and become more aware of, the importance of evidence-based decision-making and Cochrane's role in that. This is particularly true of early career researchers or health professionals but more broadly than that too. That's because everyone needs to make decisions about health at some stage in their lives and being aware of reliable, trust-worthy sources of information is a key part of that.
What would your message be to other young people who want to get involved with Cochrane's work but not sure where to start….?
Students could look up Students 4 Best Evidence; a blogging website for, and by, students interested in evidence-based practice for introductions to some of the fundamentals of evidence-based practice. TaskExchange is also good if you'd like to get stuck in contributing to some of the tasks involved in producing a systematic review; from data extraction to translation. There's lots more information about getting involved here too.
Cochrane Infectious Diseases Group seeks Research Assistant in Evidence Synthesis - Liverpool, UK
Founded in 1898 and the oldest of its kind in the world, the Liverpool School of Tropical Medicine (LSTM) is an internationally recognised centre of excellence for teaching and research in tropical diseases.
LSTM'S Centre for Evidence Synthesis in Global Health leads developments in evidence synthesis for tropical medicine and global health. In the 1990s, we helped establish Cochrane. We now run the Cochrane Infectious Diseases Group (CIDG), with over 150 Cochrane reviews and 600 authors throughout the world; we work closely with the World Health Organization and we co-ordinate a global evidence ecosystem, with active partner programmes in South Africa, India and Sri Lanka. As part of this, we are recruiting staff as part of a six year "Research, Evidence and Development Initiative" (READ-It) programme. The successful applicant will be part of this process and be part of review teams in the existing and new review portfolio. Our priorities are developing rapidly, and we are seeking to engage the successful applicant in a high-priority area commensurate with their areas of interest. For example, some topics we have include:
rapid diagnostic tests in malaria
triple therapy in filariasis
Public health aspects of tampon use
Short course management of latent TB
Qualitative synthesis
There are also a variety of methodological projects related to Cochrane (review updating, conflicts of interest, statistical reporting); and methods for moving from evidence to policy, including how WHO use aspects of human rights in guideline development. We aim for a mixed portfolio to provide a broad exposure to evidence informed science.
The ideal candidate will have a Masters in epidemiology, public health, or clinical tropical medicine, and have good quantitative skills. You will have experience in evidence synthesis in topics related to biomedical or social science research in low- and middle-income countries and have confidence in critically appraising medical literature at postgraduate level.
You need to have completed a systematic review or an applied research project. You need clear evidence of critical insight into priority policy questions in international health relevant to infectious diseases.
Demonstrating initiative, commitment, organisational skills, and the ability to meet deadlines is essential; as is a flexible approach to work with the ability to work independently or as part of a diverse team.
If you have authored a Cochrane review, have experience of using GRADE, or have a track record in published research, it will be an added advantage to your application.
Tuesday, July 30, 2019 Category: Jobs
Video: Cochrane Abdomen and Endocrine Network
Cochrane has created eight new Networks of Cochrane Review Groups responsible for the efficient and timely production of high-quality systematic reviews that address the research questions that are most important to decision makers.
In this short film we focus on the Cochrane Abdomen and Endocrine Network. This film introduces the team, what has happened so far, and the ambition for what is to come.
Podcast: Psychosocial support for informal caregivers of people living with cancer
The rising incidence of cancer and successes in its treatment mean that an ever increasing number of people are living with cancer. This is leading to the involvement of more and more informal caregivers in their care. In a new Cochrane Review from June 2019, Charlene Treanor from the Centre for Public Health in Queen's University Belfast in Northern Ireland and colleagues looked at the evidence on the effects of psychosocial interventions for these people. We asked her to tell us about their findings in this podcast.
"Informal caregivers, meaning those people who are not paid or trained healthcare professionals, play an important role in supporting individuals affected by cancer. They include family members, friends and neighbours and the type of support they provide is wide ranging. Among other things, it includes going to hospital appointments, taking on additional household roles such as shopping and cooking, and providing emotional support.
Informal caregivers can spend up to 30 hours a week providing care, often in addition to their job and any other family caring roles they have. This additional role, coupled with having to come to terms with the cancer diagnosis of their loved one, can impact on all aspects of their health including increased fatigue, disturbed sleep and impaired quality of life.
Formal support for informal caregivers is often limited or absent, but it's important to know whether there are things that might be done to help them. We've looked at this for psychosocial interventions designed to inform, educate and increase the coping capacity of informal caregivers through an interaction with a healthcare professional. We wanted to see if this might improve outcomes for informal caregivers and, perhaps, for the individuals living with cancer.
We identified 19 trials covering a range of psychosocial interventions including psychoeducation and psychotherapy delivered face-to-face or by telephone to groups of caregivers, pairs of caregivers and patients (usually spouses), or individual caregivers. Almost 2000 caregivers and just over 1700 patients took part in the studies. All were from high income countries and, given the differences in resources which mean that informal caregivers in lower resource settings might take on caring tasks more akin to those of a healthcare professional, their experiences and need for support are unlikely to be represented by this review.
Disappointingly, we found that psychosocial interventions did not help with the health or wellbeing of informal caregivers or patients. And although there did seem to be a small benefit for caregiver global quality of life immediately after the intervention, this did not last. Indeed, some interventions even had a negative effect, including discomfort related to the intervention's content, distress for caregivers who had previously low distress, and negative changes in relationship satisfaction.
There may be several reasons for the lack of benefits. For instance, it wasn't clear if caregivers were included in the design of the interventions, so those being tested might not have addressed their needs appropriately. Moreover, caregivers with a history of, or current psychological illness were excluded from the research, and these might be those in most need of the help.
We identified 13 ongoing studies and it will be interesting to see how these add to the current evidence, although the interventions being tested appear similar to those already included in the review. However, it may be that the interventions are effective for other important caregiver outcomes such as relationship quality and these outcomes should be captured in future updates of our review. Looking further into the future, research needs to be done for caregivers in low and middle income countries and for caregivers most in need. The researchers doing these trials should also involve caregivers in intervention design and development."
Professor Julian Higgins receives award from the Society of Research Synthesis Methodology
Here at Cochrane we are delighted to hear that Professor Julian Higgins has received the 2019 Extraordinary Service Award at the Society of Research Synthesis Methodology 2019 Annual Meeting.
The Extraordinary Service Award (also called the Shadish Award) is named for Professor William Shadish and recognizes an individual who has made extraordinary service contribution to the Society of Research Synthesis Methodology. Julian was a founding trustee and is a past President of the Society for Research Synthesis Methodology (2005-2006).
The impact of Julian's work in the field is massive. He is involved in a wide range of systematic review methods research, including assessing and adjusting for bias in primary studies, meta-epidemiological studies, meta-analysis methods including Bayesian approaches, network meta-analysis and analysing individual participant data.
In Cochrane, Julian also has a long-standing history, contributing to the development of methods that are integral to the Reviews Cochrane produces. A Co-Convenor of the Cochrane Bias Methods Group, he has made major contributions to bias assessment in Cochrane Reviews, developing Risk of Bias (RoB) 1 and RoB 2 tool. He is currently a member of the MERCIR coordinating group, Senior Methods Advisor at Cochrane and sits on its Editorial Board, Scientific Committee, and Methods Executive. He has also co-edited the Cochrane Handbook for Systematic Reviews of Interventions since 2003 (Version 6 of the Handbook launches in October 2019).
Congratulations to Julian on this well deserved award!Thursday, July 25, 2019
PhD Scholarship Opportunity: Implementation Science in Primary Care
Location: Notting Hill, UK
Employment Type: Full-time
Duration: 3 year fixed-term appointment
Remuneration: $27,872 AUD per annum full-time rate (tax-free stipend for 3 years)
Closing Date: 13 Aug 2019
An exciting opportunity exists for an exceptional candidate who is interested in undertaking a PhD project in the field of implementation science, within the Implementing work-related Mental health guidelines in general PRacticE (IMPRovE) NHMRC Partnership Trial.
Located within the Department of General Practice at Monash University, IMPRovE will implement the recently published Clinical practice guidelines for the diagnosis and management of work-related mental health conditions through a pragmatic cluster randomised controlled trial. Our key objectives are to increase the delivery of evidence-based general practice care for patients, assess the cost-effectiveness of our intervention and plan for national scale up. Components of the intervention will include academic detailing, peer-to-peer support and learning through a digital Community of Practice and the provision of resources.
The PhD project attached to this scholarship will focus on using implementation science theory and methods to contribute to a process evaluation of the IMPRovE trial. Supported by a large interdisciplinary team of investigators, and policy and practice partners, the PhD candidate will characterise the aspects of the intervention and our partnership approach that are likely to lead to successful change in GP practice, and to characterise aspects that may hinder success. This will involve initially undertaking a systematic review to identify the elements of a successful digital Community of Practice. Then, the focus will move towards evaluating the successful and unsuccessful components of the intervention as part of the process evaluation of the trial.
Catherine Marshall appointed Co-Chair of the Governing Board
At its teleconference on 10 July, the Governing Board voted unanimously to appoint Catherine Marshall as its new Co-Chair from 1 September 2019. Catherine will work alongside fellow Co-Chair Martin Burton, and replace Marguerite Koster, who is stepping down from the role after one year due to increased commitments in her job at Kaiser Permanente, in Southern California, but will remain on the Board as a member.
Catherine was one of the first two appointed members of the Cochrane Governing Board in 2016. She is also a member of the Board's Governance Committee, and Finance Audit and Investment Committee, and was elected as Treasurer in September 2018.
Outside Cochrane, Catherine is an Independent Guideline Adviser and Health Sector consultant based in New Zealand. She is currently Co-Chair of the Partnership Advisory Group with the Guidelines International Network (G-I-N) and was previously Vice Chair of its board of trustees. She was also the inaugural Chief Executive of the New Zealand Guidelines Group, where one of her key responsibilities was the development and implementation of evidence-based guidelines and advice – which often relied on evidence from the Cochrane Library. Catherine is also a prominent health consumer advocate, working on the development of health consumer legislation in New Zealand and as a former member of the NZ Stronger Consumer Voices Alliance. In 2018, she helped organize and participate in the consumer programs for the Cochrane Colloquium in Edinburgh.
"Catherine is a recognized leader in the global evidence-based medicine community" says outgoing Co-Chair Marguerite Koster. "Her experience leading non-governmental and charitable organizations will be a significant asset to Cochrane as she assumes the position of Co-Chair of the Governing Board."
Martin Burton adds, "I am delighted that Catherine has been elected to the Co-Chair position. She is passionate about Cochrane and brings a unique set of skills to the role. At the same time, I am sorry to say "goodbye" to Marguerite. She has been a truly outstanding Co-chair and a wonderful colleague to work with. I am very pleased that she is prepared to continue to serve on the Governing Board."
And of her appointment, Catherine says, "In the last three years as a Governing Board member of Cochrane, I have been deeply impressed by the strength of Cochrane and the talent of the people who contribute to the collaboration. I am strongly committed to expanding our reach around the globe and finding ways Cochrane advice can assist health consumers."
Members of the Governing Board can be contacted at email@example.com
Financial conflicts of interest in systematic reviews
The Cochrane Review 'Financial conflicts of interest in systematic reviews: associations with results, conclusions, and methodological quality' has recently published. We talked to author Camilla Hansen to learn what the latest evidence says and why it is important.
Can you please tell us about this Cochrane Review?
"Systematic reviews summarise existing evidence on a specific research question. These summaries sometimes provide a basis for developing clinical guidelines and can have a major impact on how patients are treated. It is therefore essential that findings from systematic reviews are trustworthy. If not, we may end up wasting resources on interventions that don't actually work, or even harming patients by using interventions that are dangerous, rather than helpful.
There is a lot of debate about the impact of financial conflicts of interest on research findings and their interpretation. This exact issue has been investigated in many methodology studies of financial conflicts of interest in primary research studies, mainly clinical trials; and these studies have shown that financial conflicts of interest do impact on the conclusions drawn from the randomised trials.
In contrast, fewer methodological studies have investigated the impact of financial conflicts of interest in systematic reviews, and we are not aware of any previous attempt to bring these studies together into a methodological systematic review. We decided to fill this gap.
We included ten studies that investigated a total of 1010 systematic reviews. We primarily investigated the potential impact on results (divided into estimated treatment effects and statistically favourable results) and conclusions. We found no clear difference in results between systematic reviews with and without financial conflicts of interest, but our findings are based on very limited data with a high degree of uncertainty. However, the evidence is stronger in relation to the conclusions of systematic reviews and we found that those with financial conflicts of interest more often had favourable conclusions than systematic reviews without financial conflicts of interest. This is based on seven methodology studies that looked at a total of 411 systematic reviews.
We also investigated the potential impact on the quality of the systematic reviews and found a tendency that systematic reviews with financial conflicts of interest had lower methodological quality than those without financial conflicts of interest.
What are financial conflicts of interest in this context and why are they important?
Financial conflicts of interest can occur when either a company or individuals may benefit financially from how the evidence in a systematic review is interpreted and used, and our focus was on those that relate to connections with drug and device companies. The issue can arise when a systematic review is directly funded by such a company or done by authors employed by such companies. It can also happen when a systematic review is conducted by authors who have financial relationships with drug or device companies, for example when authors have received fees or research grants, or are on advisory boards of drug and device companies. The Cochrane review did not investigate systematic reviews done by authors with a personal financial and professional interest related to certain interventions. For example, surgeons doing specific fee-based procedures in private practice. Similarly, the Cochrane review did not investigate academic conflicts of interest where researchers' grant applications and academic careers may be influenced by positive studies published in high impact journals.
How did this review come about?
I am doing a PhD on conflicts of interest in clinical research. I realised, together with my supervisors, that no methodological systematic review had been published on this important topic. We therefore decided to do a Cochrane Methodology Review.
What sort of funding can present a conflict of interest? And why?
In medical research, funding can present conflicts of interest in a variety of ways. Sometimes, systematic reviews are primarily funded by non-profit sources (e.g. when reviews are conducted by academic researchers employed at public universities and financed through their salaries), but occasionally industry provides additional indirect funding by contributing with assistance from medical writer or company statisticians. In some cases, systematic reviews are funded by non-profit sources, but conducted by authors with financial ties to the manufacturer of the drug or device they are reviewing. At other times, systematic reviews are solely financed through industry funding (e.g. when drug or device companies provide funding and salary for academic researchers at public institutions to conduct a specific review).
Common for all types of funding is that it can create ties between the researchers and industry. In some cases, the funding company may influence the design, analysis, or reporting of the study. Since the company has an interest in reaching a specific conclusion, this can impact on decisions made in the way that a study is carried out. In other cases, the conflicts of interest may result in the academic researchers being unduly influenced by the interests of the funder, when interpreting the evidence.
For this review, we focused on funding from drug and device companies only. However, previous studies have also demonstrated that funding from other industries, e.g. tobacco and nutrition companies, impact on research findings and interpretation. Recently, it has been debated whether funding from non-profit organisations or governmental institutions may also create conflicts of interest since they may have an interest in a particular direction of the findings of a study. However, currently little research has been done on the topic.
How does your review build on the work of the previously published review update in 2017 that concluded "sponsorship of drug and device studies by manufacturing company leads to more favourable efficacy results and conclusions than sponsorship by other sources?"
The review from 2017 was led by my colleague Andreas Lundh and focused on funding in primary research studies, mainly clinical trials. Although we deployed similar methods in our review, our focus was on financial conflicts of interest in systematic reviews, rather than the trials in those reviews.
We are also working on a third Cochrane Methodology Review focusing on conflicts of interest in a group of non-research publications, namely clinical guidelines, transcripts from drug and device advisory committee meetings, opinion pieces such as editorials, and narrative reviews.
Therefore, there will soon be three Cochrane Methodology Reviews investigating how conflicts of interest impact on three core types of publications that all influence patient care.
I was interested to read that in contrast to the 2017 review on primary studies, you did not find an association between financial interests and statistically favourable results in systematic reviews. Were you surprised?
You are right that we did not find such an association, but we only found two studies investigating the results sections of systematic reviews, which means that there is not enough data at the moment to determine whether or not there is an association.
You mentioned that you are working on another review: "Conflicts of interest in clinical guidelines, opinion pieces, and narrative reviews". When is it due? Any preliminary findings you can share?
We are finalising that review right now, and it looks as though the findings from the 2017 review on clinical trials, the new one on systematic reviews, and that third Cochrane Review are quite similar.
What can people who read and use systematic review evidence learn from your review?
Our findings suggest that systematic reviews with financial conflicts of interest should be interpreted carefully. People who read and use systematic review evidence should primarily look for systematic reviews without financial conflicts of interest, for example a Cochrane Review. If that is not available, we suggest that users read the review conclusions with scepticism, are aware of the declarations of interest for the review authors and funding sources, and pay particular attention to their critical appraisal of the review's methods."
Fighting bad Science in Austria - BMJ Podcast on Medizin-Transparent
The British Medical Journal 'Talk Medicine' podcast recently featured the work of Medizin-Transparent in the Podcast "Fighting bad science in Austria". Gerald Gartlehner, Director of Cochrane Austria, explains how Medizin-Transparent works.
Medizin-Transparent.at tests the truth of medical statements made in the media in order to support readers, patients, doctors, and decision-makers to critically analyze the information they encounter. This online service is a project of Cochrane Austria and the Department for Evidence-based Medicine and Evaluation.
Tuesday, July 23, 2019
Teaching school children about evidence-based medicine: Cochrane UK's outreach programme
Since 2016 Cochrane UK has been visiting secondary schools in and around Oxford to talk about Evidence-Based Medicine (EBM) and its relevance in our everyday lives. They started with visiting an after-school Science Club and now boost a growing portfolio of schools who welcome them into their classrooms.
Cochrane UK have taught pupils from Years 9 -13 in formal lessons and in extracurricular science and medical clubs. Their talks and workshops aim to bring an awareness of why it is important to question the evidence behind medical claims. They use topical newspaper headlines to illustrate how medical evidence can be misrepresented in the media - how it can sometimes be inaccurate and sometimes just plain wrong. They also illustrate the relevance of EBM on a personal, everyday level by looking at how we choose cold remedies to how we consider medical interventions at national and global levels, using the HPV vaccination programme as an example. They also cover what constitutes a randomised controlled trial and how a systematic review is produced.
Recently Cochrane UK organised their second half day workshop on EBM. Twenty-five Year 12 students from local schools took part. Students were introduced to our Citizen Scientist platform Cochrane Crowd, a collaborative volunteer effort to help categorise and summarise healthcare evidence. With the students logged into Cochrane Crowd, they were challenged to screen as many abstracts as they could within 10 minutes, and they managed an impressive 300+!. You can read more about the first workshop Cochrane UK ran, in October 2018, here.
The schools outreach project now has a momentum and we are getting known in and around Oxfordshire. We are very keen to extend the programme across the UK and would love to hear from others who might be interested in getting involved. We would be happy to give support and training, and would also share our various slide-sets and resources. Equally, we would be delighted to hear from anyone who has undertaken similar teaching to learn about your experiences.
We can be contacted via Cochrane UK.
Lynda Ware
Senior Fellow in General Practice
Cochrane UK
Selena Ryan-Vig
Communications and Engagement Officer
Cochrane UK
Early Bird Colloquium Registration Deadline: July 25
The Cochrane Colloquium is Cochrane's flagship annual event that is a great opportunity to meet and network with Cochrane contributors and users globally and to learn more about the wide usage of Cochrane evidence in health decision-making at all levels. This year, the 26th Cochrane Colloquium will take place in the vibrant city of Santiago, Chile, 22-25 October 2019.
The deadline for Early Bird registration for this year's Colloquium is Thursday, July 25 at midnight Chile time (GMT-4). Registering at the Early Bird rate provides an 18% discount on the standard registration rate. Register now!
Video: Cochrane Cancer
Cochrane has created eight new Networks of Cochrane Review Groups responsible for the efficient and timely production of high-quality systematic reviews that address the research questions that are most important to decision makers.
In this short film we focus on the Cochrane Cancer Network. This film introduces the team, what has happened so far, and the ambition for what is to come.
Cochrane's 30 under 30: Imen Farhat
Cochrane is made up of 11,000 members and over 67,000 supporters come from more than 130 countries, worldwide. Our volunteers and contributors are researchers, health professionals, patients, carers, people passionate about improving health outcomes for everyone, everywhere.
Cochrane is an incredible community of people who all play their part in improving health and healthcare globally. We believe that by putting trusted evidence at the heart of health decisions we can achieve a world of improved health for all.
Many of our contributors are young people working with Cochrane as researchers, citizen scientists, medical students, and volunteer language translators and we want to recognize the work of this generation of contributors as part of this series called, Cochrane's "30 under 30."
In this series, we will interview 30 young people, 30 years old or younger who are contributing to Cochrane activities in a range of ways, all promoting evidence-informed health decision making across the world.
We will be hearing from them in a series of interviewees published over the coming months.
The Cochrane 30 Under 30 series is now closed. However, we are keen to hear from early career professionals about their work with Cochrane for future series. If you would like to be added to our waitlist, please conact firstname.lastname@example.com. Or if you want to know more about Cochrane's work contact firstname.lastname@example.com where our community support team will be happy to answer your questions.
Name: Imen Farhat (on Twitter: @ImenFarhat2)
Age: 27
Occupation: Research Associate
Program: Masters in Epidemiology at Université Laval, systematic review methodologist at Cochrane Canada Francophone
How did you first hear about Cochrane?
When I was a graduate student, I attended a presentation by Dr Alexis Turgeon, a clinical researcher at Université Laval and the director of Cochrane Canada Francophone. The presentation was on systematic reviews and meta-analyses and the Cochrane methodology. It piqued my curiosity: Why would researchers choose to base a study on already published studies instead of developing an original one? I decided to explore the Cochrane website and was impressed by the methodology and the scientific rigor for published Cochrane studies.
How did you become involved with Cochrane? What is your background?
I have a strong interest in epidemiology, biostatistics, public health and evidence synthesis with the purpose of improving patients' clinical outcomes and quality of life with evidence-based clinical practice. I have a Bachelor of Science in Mathematics and Biology from McGill University (QC, Canada) and a Master's of Science in Epidemiology from Université Laval (QC, Canada). During my graduate studies, I joined the Cochrane Crowd and occasionally helped in the Cochrane Canada Francophone team perform meta-analysis. When I graduated with my master's, I was lucky to get a job working alongside Cochrane Canada Francophone.
What do you do in Cochrane?
I am a systematic review methodologist with Cochrane Canada Francophone. My main role is to train students and researchers interested in performing knowledge synthesis work. I also answer service requests made by systematic reviewers to Cochrane Canada Francophone. Since I am bilingual (French/English), I also help systematic review authors from the French community outside Cochrane Canada Francophone.
What specifically do you enjoy about working for Cochrane and what have you learnt?
I am delighted to be working with multidisciplinary teams that are part of a global network whose focus is to improve patients' outcomes and evidence-based medicine. I also enjoy the rigour and methodology developed by Cochrane to synthesize evidence. My experience with Cochrane has been very fulfilling as I improved my critical thinking, developed my expertise, and learned how to improve the quality of the systematic reviews. Every day, I have the opportunity to learn new things, improve my medical literacy and share my expertise with others.
What are your future plans?
My future plans are to continue working in clinical research that aims to improve population health and to get more involved with knowledge transfer tools and shared decision making. I look forward to applying to doctoral programs to receive advanced training in epidemiology and health research methodology.
In your personal experience, what one thing could Cochrane do better to improve its global profile?
To improve its global profile, I think Cochrane should embrace technology and social media to disseminate results of systematic reviews to the global population. Although Cochrane is widely known in research and academia, its reach to the public is still far from its potential. I think that working with clinicians to improve evidence-based medicine is crucial in changing practice. However, many individuals outside of academia look for health related answers, either to improve their lifestyle or due to some medical conditions, without ever finding a reliable answer.
I also think that making weekly podcast in widely spoken languages available on popular streaming platforms might allow knowledge seeking individuals to easily access high-quality research that can be understood without prior medical or epidemiological knowledge.
What do you hope for Cochrane for the future?
I hope that Cochrane continues its growth and reaches groups of people that were not reached yet. I think that making the process easier for authors to perform Cochrane reviews will also benefit for the whole community.
How important is it that young people get involved in Cochrane?
I think young people are an important part of the continuous success of any organization. They bring a new dynamic, new ideas and innovation which allows the organization to grow and evolve. They also come with questions and a great appetite for learning and thus, might reflect what other groups, such as the public and non-specialists, think and question.
Why is this, do you think?
I think that young people are as much important as experienced ones for Cochrane. Often, young people are not set in their ways which allows them to be more flexible and pursue new ideas. They can adapt rapidly to new technologies, represent the next generation thinking, and are representative of one part (20-30 age category) of the population. Experimenting and incorporating technology is crucial for Cochrane to stay up to date.
As for young people, getting involved in Cochrane can bring them a sense of belonging to a community working together to improve research and evidence-based medicine. This can be very rewarding both at the spiritual level, but also at the intellectual level. Cochrane is one way for young people to develop their critical thinking and sharpen their skills.
What would your message be to other young people who want to get involved with Cochrane's work but not sure where to start….?
I would suggest they visit the Cochrane website where they can learn more about evidence-based medicine and knowledge synthesis. They can also join the Cochrane Crowd and help summarize and categorize healthcare evidence and get involved by participating in the Cochrane TaskExchange where they can share their skills with others. Students 4 Best Evidence is an interesting initiative from Cochrane where students can learn about evidence-based medicine but also blog about some topics related to research methods and evidence-based knowledge synthesis.
Cochrane launches Cochrane's Evidence Essentials: An introduction to evidence-based medicine and systematic reviews
New online learning is now freely available to anyone who is interested in an introduction to Evidence Based Medicine, Cochrane evidence and how to use it.
Cochrane is delighted to announce the launch of four, free, online learning modules, Cochrane Evidence Essentials. Written from the perspective of a healthcare consumer and co-created with patients and carers, this learning resource is perfectly pitched to give anyone an introduction to Evidence Based Medicine and Systematic Reviews. It will be especially valuable to the growing community of patients, carers and family members who work alongside researchers to co-create Cochrane evidence.
The journey through the learning is guided by "Eleni" a fictional character, who is looking for reliable evidence to help her make informed choices. By following Eleni's story, users can explore topics that include Evidence Based Medicine, clinical trials, systematic reviews, and how to find, understand and use Cochrane evidence. The learning is engaging and includes contributions from a wide range of subject matter experts, quizzes, short films, audio, interviews, interactive graphics, and links to further information for people who wish to learn more.
Richard Morley, Cochrane's Consumer Engagement Officer, said "In my role, I support healthcare consumers every day. I know how hard it can be to find good resources that introduce people to the unfamiliar concepts around Evidence Based Medicine and Systematic Reviews. It was this that led to us providing this highly accessible, new learning that will allow non-experts to learn all about our work and importantly will help more healthcare consumers make informed decisions about their health.
I am especially pleased that we co-produced this learning with healthcare consumers. The result is a learning resource that covers the topics that people need, and in a way that is accessible to all."
Karen Morley, Cochrane Consumer and co-author of the resources, said "As a consumer, there was so much I wanted to know and understand about Evidence Based Medicine and Cochrane systematic reviews. The information I was seeking was scattered, complex and often challenging. I'm thrilled to see our raw content extensively refined, tested and brought together in this beautiful interactive package. How exciting!"
Chris Champion, Head of Membership, Learning and Support Services added "For Cochrane to achieve its vision, producing high quality reviews isn't enough, we aspire to a world where all health decisions are informed by that high-quality evidence, and so we need to help people understand evidence and how to use it. This approachable new suite of learning does exactly that by providing high quality, introductory learning about Evidence Based Medicine and systematic reviews, to allow more people to understand the role evidence has in health decisions and to provide them with the understanding to use that evidence. I hope that anyone new to the world of Evidence Based Medicine will find these indispensable."
The online modules can be accessed with a free Cochrane account at https://training.cochrane.org/essentialsTuesday, July 23, 2019
Featured Review: Evidence for the benefits and harms of screening for malignant melanoma
The Cochrane Review 'Screening for reducing morbidity and mortality in malignant melanoma' has been recently updated. We talked to Cochrane author Karsten Juhl Jørgensen to learn what the latest evidence says and why it is important.
Can you tell us about this Cochrane Review?
We reviewed the evidence for the benefits and harms of screening for malignant melanoma (a type of skin cancer) compared with no screening. We included all types of screening (e.g. skin self‐examination, or examination by a health professional) of any person not suspected of having malignant melanoma, i.e. people with no known suspicious mole or lesion, irrespective of age or gender. Studies in people thought to have a high risk of developing malignant melanoma were included, but not those known to previously have had melanoma.
What does the evidence tell us about the current available evidence for screening?
We found two randomised trials that met our inclusion criteria, but no data on any important outcomes where reported. This means that we do not have sufficient evidence to determine the benefits and harms of screening for malignant melanoma. Both international and national health organisations such as WHO and the UK National Screening Committee have outlined specific criteria to implement screening programmes on a population level (UKNSC 2015; WHO 2008), underlining the importance of solid evidence for both benefits and harms. Current screening practices for melanoma do not live up to these required evidence standards.
Why is this such an important topic?
Malignant melanoma is a skin tumour, which can cause death by spreading to other parts of the body; the number of malignant melanomas is rising sharply, while the risk of dying from the disease has been virtually stable. Currently, Germany has a national skin cancer screening programme and many interest groups campaign for melanoma screening.
Screening has the potential to reduce deaths from melanoma through earlier detection. However, there are also potential harms from screening people without symptoms of melanoma, such as finding melanomas and other skin lesions that would not have caused symptoms if they had remained undetected (i.e. overdiagnosis), unnecessary surgery, and possible psychological stress. There is also the risk that healthcare resources and finances are not being utilised optimally and could provide greater benefits if allocated to other interventions with a stronger evidence base... It is therefore important to establish the evidence base for both benefits and harms of screening for melanoma.
What does this tell us about screening programmes in current use?
We do not know whether current screening initiatives for malignant melanoma results in any benefits, or whether such potential benefits are outweighed by the potential harms, or if it is reasonable in relation to the resources used. We do know that current screening programmes and campaigns do not fulfil established general criteria for screening.
What is needed to determine the benefits and harms of screening?
To determine the benefits and harms of screening for malignant melanoma, a rigorously conducted randomised trial is needed. As malignant melanoma is a comparatively uncommon cause of death, such a trial would need to be quite large to provide useful answers.
Since opportunistic screening is already widespread in many countries, a challenge to any trial would be to make sure that the control group is not subject to such screening (i.e. to avoid contamination of the control group), since this may dilute both potential benefits and potential harms of screening estimated from the trial. Apart from a potential effect on mortality from melanoma, other important outcomes to consider in future trials include less aggressive treatment, overdiagnosis, psychosocial consequences, and resource use.
Why is this important?
This review shows that adult general population screening for malignant melanoma is not supported or refuted by current evidence from randomised controlled trials and therefore does not fulfil well-established screening criteria. Yet screening for malignant melanoma is currently practised in many countries in a more or less organised form. This is problematic since data from randomised trials demonstrating that benefits outweigh harms is considered mandatory before the introduction of screening programmes for cancer (UKNSC 2015; WHO 2008). The case of screening for malignant melanoma reinforces the importance of this requirement. First, non‐randomised studies of the effects of screening may lead to seriously misleading results. Second, screening has important harms, such as overdiagnosis and overtreatment of malignant melanomas, and robust trials would need to be performed to quantify them and enable us to weigh them against the benefit. Third, the majority of people who take part in the screening programmes cannot benefit from screening as they will never develop the disease. Fourth, screening programmes have a high potential for opportunity costs (Harris 2014). Fifth, when offering screening, healthcare systems invite asymptomatic people to an intervention that they have not asked for, which leads to ethical considerations that differ from those in regular health care (Sackett 2002).
Featured Review: Electric fans during heatwaves
The Cochrane Review 'Electric fans for reducing adverse health impacts in heatwaves' is being turned to for advice on dealing with recent heatwaves. We talked to lead author, Mike Clarke, to learn if the evidence says that the use of electric fans contribute to or impede heat loss during a heatwave.
Why is this Cochrane Review so important? Isn't it obvious that electric fans are useful when the weather gets hot?
Although it's clear that fans make us feel cooler when the temperature is in the high 20s and 30s °C, and the speed with which they leave the shop shelves as temperatures rise shows this; what's much less clear is what they do to health generally and, at the extreme, whether they increase or reduce the chances of people surviving a heatwave. We did the review to look into this and the studies we identified suggest a need for caution, especially as the temperature rises beyond 35°C.
What did you find?
After searching through thousands of articles in multiple languages, we were disappointed that there were no high quality comparative trials that would allow us to reliably determine the effects of fans on major health outcomes or survival. However, we did find several other studies that had looked at this during heatwaves, such as the one that led to an additional 30,000 deaths in Europe in the summer of 2003. These studies had mixed results, and the important message is that some of them suggested that using an electric fan might increase the chances of dying during the heatwave.
How could that be?
One of the main ways that fans make us feel better is that they cool us by speeding up the evaporation of our sweat. The downside of this is that our bodies are losing water more quickly. If we don't replace this by drinking more, we will dehydrate, which is dangerous. Another issue is that a fan might actually heat us up. This is because it's blowing hot air on to us, especially when the temperatures gets above 35°C, and that's like what happens when switching an electric oven from its regular setting to the fan setting in order to cook our food faster.
Who might this be most relevant to and what should people do?
If fans are harmful, it's going to be a particular problem when they are used for people who aren't able to let us know if they're feeling particularly unwell or becoming dehydrated, such as the very young or old, and those who have difficulty communicating, such as people with dementia or other types of cognitive impairment. Everyone needs to be aware of the potential harms from using fans, especially those who are looking after these vulnerable groups.
People should heed the advice from Public Health England, which was released with their national heatwave plan for England. They recommend that electric fans be used if the temperature is below 35°C, but not aimed directly at the body and that those using them should stay hydrated with regular drinks.
How did this review come about?
The review was done in the run up to the London Olympics in 2012, when it was important to gather evidence that might be needed if a heatwave struck when thousands of athletes and tens of thousands of extra visitors arrived for the Games. We assembled an international team, with researchers from Canada, Hong Kong, India and the UK looking for and checking the existing research. We were from a variety of organisations, including the Climate Change and Health Office of Health Canada; Queen's University Belfast in the UK; the Chinese University of Hong Kong-Oxford University Centre in Hong Kong; what is now Public Health England; and Evidence Aid, which is an international organisation dedicated to improving access to evidence relevant to disasters and humanitarian emergencies, such as heatwaves. The Centre for Public Health in Queen's University Belfast provided methodological support for the team, and working with the Cochrane Gynaecological Cancer Group in Bath (UK), we were able to get the review done in about nine months.
If the review was done in 2012, are the findings still valid?
Yes. We're not aware of any studies that would change our conclusions that the benefits and harms on major health outcomes of using electric fans during heatwaves are uncertain, and that there is a risk that using fans might increase the number of deaths.
What type of study would provide the information to clear this up?
What I'd really like to see is a large trial in which one group of people go without fans and another group use them during a heatwave. Given the uncertainty about benefits and harms, it would be reasonable to decide these groups using a random process and it might be particularly relevant for, for example, older people living in care homes whose health should be closely monitored during the heatwave. Ideally, a national or international funder of health research should arrange for such a study to be in place, ready to take "off the shelf" and activate the next time a heatwave strikes.
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Contact Us: firstname.lastname@example.com
This minimalistic modern arrangement features mini calla lilies gracefully resting in a glass vase. Classic version of this arrangement comes in a 5 by 10 inch cylinder vase. Premium option conveys more industrial feel and comes in a rectangular vessel.
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subset: commoncrawl


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Herzberg is an Irvine resident with shared ownership of two dispensaries in Santa Ana and he owns the cannabis real estate company CalCann Holdings. Like many Americans, Herzberg is a frequent flier and several years ago joined the Department of Homeland Security's Global Entry Program, which allows "low risk" passengers to circumvent traditional airport security screenings.
Despite being legal in more than half of US states, in one form or another, most people are surprised to learn that cannabis use or being associated with cannabis in general can preclude individuals from many of the rights and privileges that most of us take for granted.
For example, in states where medical cannabis is legal, many are often at risk of losing their jobs because of their status as medical cannabis patients. The most notable example of this in the case Coates v. Dish Network, LLC., in which a quadriplegic employee of Dish Network was fired for his off-hours use of medical cannabis.
The case ended up going all the way to the Colorado Supreme Court, but ultimately Coates lost his case. This is primarily because Colorado did not write into its medical cannabis laws patient protections for employees and, most importantly, because cannabis is still illegal under federal law.
Using similar arguments, U.S. Customs and Border Protection officials defended the revocation of Herzberg's security clearance by saying that they are simply abiding by their zero tolerance policy on drugs. But Herzberg is less than convinced.
"I really don't think they have a basis for their decision," Herzberg told the Orange County Register. "I have absolutely no risk factors other than owning a marijuana business."
Although Herzberg is the only cannabis business owner known to have lost his flight security clearance based, which is at best a minor inconvenience, this just the latest incident in a long line of disturbing event that may hint at a looming crackdown of California cannabis.
At the beginning of this year, on January 4th, United States Attorney General Jeff Sessions rescinded the Obama-era Cole Memo, which stated that the Justice Department would not interfere with states that have legalized cannabis, provided that business owners act in accordance with state cannabis laws.
Fast forward three months later, and Sessions attacks California for its sanctuary policies and immigration laws. Soon thereafter, Herzberg's security clearance is revoked. Does this mean that Sessions is gearing up for a cannabis crackdown in California? It's difficult to say.
Given his precarious placement in the Trump Administration, it is unlikely that Sessions will risk making politically damaging moves, such as a nationwide crackdown on cannabis. However that does not mean he would be unwilling to punish California in an attempt to please the president and his base, and that opportunity may present itself in the form of the cannabis industry.
A federal cannabis crackdown may not be imminent, but the risk of operating a legal cannabis has not been this high since Colorado first legalized cannabis in 2014, underscoring the need for cannabis business owners to remain vigilant, cautious, and most importantly compliant with state cannabis laws.


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(This article is part of a series network-basics)
A nice way to illustrate the workings of an IP-network is to compare it's addressing and routing to a traditional postal service.
In a computer network the material that needs to be transported is chopped into "packets". Each packet has address information, the actual payload (the stuff that the user wants to transport) and then some. A packet could be compared to a single postcard or a letter send via post.
Here is an address on a letter:
John Smith
Long Street 1001
00500 Example City
It is hierarchical. The postal service would use the address starting from the bottom, from most generic information. They would first deliver this letter to the right city by their scanners reading the postal code's first few digits. Knowing which direction the letter is going, they would put it to a delivery car that takes it one node closer to the destination city or area. When it reaches the right city's main office, they will then deliver the letter to the right Post Office by reading the rest of the postal code. Finally the mail man operating at this area would deliver the letter to the correct mail box.
At this point the Postal Service (the Network) has done its job.
Quite similarly the IP network will read portions of the destination address and route the packet closer to the recipient. When the sending host has given the packet to the network to be carried, each node (router) will look at its internal instructions (routing table) to know to which direction (next-hop-address) the packet should be forwarded.
As a result of many routers doing this, the packet will be forwarded, one hop at the time, to the router that is "closest" to the recipient. This router then will pass the packet to the destination host, just like the mail man carried the letter from the closest Post Office to the customer's mail box.


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No rods, no lures? Oh well, no worries!
MATES Wayne Greenstreet and Tim O'Dea only visit Gladstone once a year for the barramundi fishing competition, but their trip was soured this year when they found their boat had been robbed.
The pair travelled from their homes in Brisbane to compete in the fishing competition held at Lake Awoonga, and arrived early enough Friday at their accommodation in Benaraby to go out for a fish around 5pm the same day.
They came back around midnight, went for a quick nap and woke up a few hours later keen to get back into the boat.
"We kept everything in the boat because we were only planning to have a quick nap before going back out," Tim said.
"Four of my rods were missing, and one of Wayne's. But all of Wayne's lures were stolen ... about $2500 worth."
All up about $5000 worth of fishing gear and equipment was stolen, including $400 from Tim's wallet and a mobile phone.
Most of the equipment was stored in lockers, although not locked, it would have taken a bit of effort to get the items out, Tim said.
"We went out looking for whoever stole our gear, around the site and down by the dam," he said.
"We were beyond angry by that stage. We called the police but there's not much they can do if there's no trace of the people who stole."
Despite the setback, the pair went for one last fish before heading home yesterday and even had a laugh about the whole ordeal.
"We tried not to let it ruin the trip," Tim said.
"You just have to laugh about these sorts of things."


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Detailed plot synopsis reviews of Unless
Chapter Analysis of Unless
Click on a plot link to find similar books!
Plot & ThemesTone of book? - thoughtful Time/era of story - 2000+ (Present Day) Life of a profession: - writer Family, loving relations - Yes Special relationship with - daughter Internal struggle/realization? - Yes Struggle over - vague finding self/purpose in life (i.e. no plot to book) Job/Profession/Status story - Yes
Main CharacterGender - Female Profession/status: - writer Age: - 40's-50's
SettingHow much descriptions of surroundings? - 4 () City? - Yes City: - dangerous Small town? - Yes
Writing StyleAmount of dialog - roughly even amounts of descript and dialog
Books with storylines, themes & endings like Unless
|Nights in Rodanthe by Nicholas Sparks
|Accidental Happiness by Jean Reynolds Page
|Postcards from Berlin by Margaret Leroy
|The Job by Eric T. Whitfield
|Naive Super by Erlend Loe


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There is a lightness in your step and a broad smile on your face as your eyes gaze upon the glorious equine being who is moving in harmony with you. A flush of heat moves from the core of your heart and the expansion takes your breath away. Finally, after all of your seeking, you have found the experience with Horse that you have been longing for… the sacred dance of intimacy and connection. You continue to flow with grace and ease, your equine companion astutely in-tune to your every move.
At the end of this dance you are filled with reverence, you are humbled; you are filled with an energy that could light up the world a thousand times over. In this Dance with Horse you have found liberty, a freedom to move, to be, to connect, to follow the flow as it divinely transpires between you and your partner. Through your strength to be vulnerable, to explore and to take risks, you find an inner freedom and courage you had not resourced before in your life. You will never see life the same again.
The Dance with Horse program is beyond horsemanship, it is beyond asking horse to heal you. Instead, it is a joyous celebration of interspecies communication and connection. The Dance with Horse program is designed for the individual who is ready to experience a sacred level of engagement and flow with Horse. You will be taken through several creative explorations that will help you ignite confidence, clarity and pure joy at liberty with horses.
Just as animals in the wild find ways to court, mingle, touch, jostle and commune, you too will learn the art of an intuitive relational dance. The Dance with Horse program takes you beyond your currently interactions with Horse to an entire new area of play, exploration and joy. Horse is a river of energy and you learn what it means to truly flow.
Be part of this extraordinary experience with Kathy's masterful herd of horses that have been dancing with her for years. Learn not only the easy steps, but also how to let your energy flow and open up your entire body to the gift of mutual admiration. Each day will be filled with hands on experiences to open up your energy field to the dance. You will receive ample opportunities to work directly with a horse to develop your ability to attune to the nature of horse and instinctively find mutual partnership. By the end of the week you and horse, with music, will find what is perfect and divine in your partnership.
Dance with Horse covers energy management, reading the horses' communications, timing, intention and flow, and a non-dominant approach to communications. You learn to be open and receptive to create deeper levels of connection. Horses are provided for this program and are safe and confident in their interaction with humans. You may also bring your own horse.
Horses are provided. Program has limited space to ensure quality experiences. Register early to reserve your spot.
VIP Private Dance with Horse Retreat
Experience private instruction with Kathy during a VIP day/retreat. Kathy's masterful herd of horses will guide you to places you have yet to experience during this one-on-one experience.
You may also book to stay at the ranch in a private cottage with a full kitchen and all amenities.
One-day VIP session is $850 (no lodging).
One-day VIP session is $1,150 and includes a two-night stay at ranch.
Two-day VIP session is $1,800 and includes a two-night stay at ranch.
Three-day VIP session is $2,600 and includes a three-night stay at ranch.
Three Day Dance with Horse Workshop Tuition
(Limited to four participants)
Location: Moon Shadow Ranch, Berthoud, Colorado
Dates: Click Here to view our Calendar and Dance with Horse Workshop Dates
Tuition: $1,600


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If you do have a complete set are you willing to sell it? I'd be more than happy to pay a reasonable price.]]>
If you wanted to buy some :)
Since writing this post on my blog 4 years ago I don't have my spares anymore as I gave them away/sold them :)]]>


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If you have a thin, weak explosion but need a big, heavy, earth-shattering one, here's a quick method. For now, let's assume that you have access to other high quality library, don't have the time and means to arrange a field recording session. Just sitting in the edit or mix room with limited material at your disposal and the director want a huge blast instead of the weak, thin one you have there.
You can create it within a minute, here's how. This is only one fast and dirty approach, these techniques can be mixed or you can change the order of them, even leave out what you feel inappropriate. I used tools which are either part of the Pro Tools package or you can freely download them. The only exception is Lowender by Refuse, which is a great and cheap plugin.
Let's see what we have now
This is a stock explosion which is not so bad, but not good either and the director wants something much more powerful. The first thing to do is to duplicate the track (alt+shift+d) and filter out even more low-end from the sound. Then put a "analogue" distorsion plugin onto the duplicated track. I used the Softube Saturation knob.
You can experiment with the amount and type of the distorsion, but do not stuck here, remember, we are in a hurry. You can quickly blend the original and the distorted one together. The enhanced distorsion will help to elevate the percieved power of the explosion without using too much volume.
So far, we have this:
Great, but where's my low-end?
It's missing. But now our next step is to enhance that part. We are not far from the finished, beefed up explosion. Now I used the Lowender plugin to give more low-end to the original explosion.
If you happen to use the same, I recommend to audition the three different ranges (classic, guitar, bass) because they can give you very different results. Choose what you consider the best.
After this, we have and almost finished big explosion:
The last ingredient
Obviously, as all the steps, this is optional too. Sometimes this step is a miracle, a really powerful addition. Other times simply mute it, if it happen to be the opposite.
Make a new mono track, and select and area, about 1–4 seconds. Initiate the signal generator from the Audiosuite plugins and make some low freq sine wave tone. I chose 80Hz, but it can be almost anything. The only thing you have to avoid is to choose a tone which is too high because we want more low end. This is a very old trick, which is basically a downward sweep.
When we have our tone, use the Vari-fi plugin to make our downward sweep. We need Vari-fi to slow down, fades on (at least I prefer it on) and now you can choose to options: Fit to or Extend. Personally I love the extend mode, but it is so situation dependent that you have to try which fits better. Just render it, try it and if you don't like the result, make an undo and re-render it with the other method.
The last step is to mix it all together with downward sweep, the original one and the distorted one. For the sake of this example I mixed the sweep a little high into this last audio clip, but I think you already grabbed the point here, it should only enhance the explosion.
If you have more than a minute
As I told you this is a really fast and easy method. If you have just a few minutes more, you can try different things like duplicating the original and use pitch shifting, use some other effect which has ample low-end and mix that with your explosion, play with some modulation plugins, etc.
The possibilities are endless, but remember, the patience of the director might run out sooner than you would like, so if you're in trouble, use this really fast method. Enjoy!


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Police say it is almost a miracle two children survived the fatal Thunder River Rapids tragedy at Dreamworld that left four people dead, as a union says it raised concerns about the operation and maintenance of some equipment at the park more than a year ago.
Queensland police have confirmed two flumes -- large, circular flotation devices -- collided at the conclusion of the Thunder River Rapids Ride, causing one to flip and tossing some of the occupants backwards onto the conveyer belt.
ACT woman Kate Goodchild, her brother Luke Dorsett, his partner Roozbeh Araghi, and Sydney mother Cindy Low were killed.
Two children, a 10-year-old boy and 12-year-old girl, were tossed from the ride.
"In terms of how they escaped, maybe through the providence of God or somebody, but it seems from what I've seen almost a miracle that anybody came out of that," Queensland Police Assistant Commissioner Brian Codd told media on Wednesday.
"If we're going to be thankful for anything, I'm thankful for that."
Police initially said two young girls escaped.
Earlier, Kim Dorsett, mother of Goodchild and Dorsett, told The Sydney Morning Herald she was "absolutely devastated".
"My whole family has been wiped out," she said.
Families have been leaving flowers outside the theme park, which remains closed on Wednesday.
Queensland Premier Annastacia Palaszczuk has said the children were being treated at Gold Coast University Hospital.
"They are being cared for at the moment and we are making sure that family members are contacted as we speak," she said.
A team of 30 detectives and specialist engineers are scouring the site of the 30-year-old ride, while police will probe Dreamworld's policies, procedures, maintenance schedules and the make-up of the ride to determine its compliance with contemporary engineering standards.
On Wednesday the Australian Worker's Union said it had raised concerns about ride operation issues at the park for more than a year before the accident.
"We did hold some very grave concerns about safety of equipment and the operation of equipment," AWU Queensland secretary Ben Swan told The ABC.
He said the union had lodged its first complaint about safety 18 months ago with park owner Ardent Leisure after a separate industrial incident.
Amusement park ride engineer David Eager, who sits on the Standards Australia Amusement Rides and Devices Committee, told the ABC on Wednesday that Dreamworld performs maintenance on its rides on a daily basis.
"As a general rule, you can keep them going forever by diligent and appropriate maintenance," he said in response to a question about ageing rides.
"And you might change the whole ride completely over that period. Like, an annual maintenance might be a total strip-down, you look at all the pins, the bolts, make sure there's no wear and tear, no crack, you do non-destructive testing on them."
He said a rides were generally only gotten rid of when something better came along
"But this is one of those rides that's a family ride. It's not a roller-coaster -- that's the biggest, it's the fastest. (This is) a river ride where people splash around on a hot summer's day in Queensland and just enjoy it," he said.
The Thunder River Rapids Ride reportedly broke down twice before the accident. In April this year, a man received cuts to his head and was hospitalised after being thrown from a 30-year old Log ride.
Past visitors have written on park's Facebook page to complain about their experiences at the park, while others have defended it.
"RIP and thoughts with the families, park staff, emergency workers and witnesses, devastated," wrote one user.
"This tragedy has hit us hard, myself and my 5 children have all been on this ride many times over the 30 years that it has been operating, the first time back when it first opened.
Another wrote: "seriously how many more years are you going to operate these extremely outdated rides for?? With so many complaints about safety and rides always closed for maintenance or because they are 'broken' you would think it's time for it to be demolished."


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100 Days (1991)
Considering our love of the occult, it's strange that we haven't made more movies starring characters like Devi, played by Madhuri Dixit, who can see into the future. In this case, Devi tries to piece together her sister's murder after finding her corpse in the walls of her husband's house. Before long, she has another premonition that a woman is about to be murdered. Jackie Shroff in a black costume and a tightly-woven plot make this a rare movie that keeps up its thriller element right until the end.
Darr (1993)
Shah Rukh Khan first achieved stardom because of his negative roles, none more famous than Yash Chopra's Darrwith the (in)famous K-k-k-k-Kiran stammer. The sheer violence of Rahul Mehra's (SRK) obsessive love for Kiran (Juhi Chawla) makes this a classic movie.
Baazi (1995)
An underrated movie at the box-office, this Aamir Khan movie is a thriller of many shades. To anyone who has seenSarfarosh, it will seem like a prelude. The film starts with a failed assassination attempt which glorifies the hero Amar, played by Aamir Khan. However, he is sent to prison for killing a terrorist who also happens to be a politician's brother. Eventually, he gets a chance to track down those who have maligned his name when the group once again takes government officials hostage and he goes on to save the day. Forget all the Hollywood movies it is seemingly inspired by, and enjoy this thriller on its own merits.
Vaastav (1999)
Marking Mahesh Manjrekar's debut as a director, this movie has distinct shades of Mother India and is notable for one reason – Sanjay Dutt. From being a nobody to a dreaded gangster, Sanjay leads by example in this often violent movie. He gets into the skin of his character Raghu who, tired of the mindless violence around him, finally begs his mother to shoot him. The movie unmasks the corrupt politician-gangster nexus through a powerhouse performance by Dutt.
Agneepath (1990)
No, no, not the Chikni Chameli one! We're talking about the original which released in 1990 and starred Amitabh Bachchan as the wronged son who single-handedly sets out to avenge the injustice faced by his father and family. It is also one of the last movies where Amitabh played Vijay and enacts the 'angry young man' persona for his fans before his eventual move to character roles. If you loved the Hrithik Roshan version of the film, then you owe it to yourself to catch the original and learn why, when it comes to Bachchan's performance, the line, "Baap baap hota hai" rings true.
Godmother (1999)
This mafia godmother story, starring the ever-bankable Shabana Azmi, is an allegory to feminism much before the word came into popular culture. The film is all about a powerless widow who turns into the most influential villager by unflinchingly and mercilessly eliminating anyone who opposes her. The movie has a very idealistic ending that Santokben Jadeja, who reportedly inspired the movie, would approve of. Nevertheless, this is a movie from the late 90s that deserves to be seen by more people.
Anjaam (1994)
Another movie starring Shah Rukh Khan as an obsessive lover, here things take a reverse turn when as his muse (Madhuri Dixit) turns into his enemy after she rejects his advances. Khan's character first destroys her family life and then has her sent to prison where she is mistreated by the female warden. This sets the stage for her violent revenge in the second half where she literally bites off her victims' hands and executes the perfect revenge plot.
Bandit Queen (1994)
No list of gory movies from the '90s can be complete without mentioning Bandit Queen. This controversial movie on the life of Phoolan Devi, directed by Shekhar Kapur, has some disturbing scenes involving rape and violence. From marital rape to beating her ex-husband senseless with the butt of a rifle, Bandit Queen's goriness requires a tough stomach.
Satya (1998)
With Satya, Ram Gopal Varma established a new type of language when it came to making gangster movies. Co-writers Saurabh Shukla – who also plays the unforgettable Kallu Mama – and Anurag Kashyap teach us the lesson that crime never pays with a degree of violence and insanity that shocks you at times. Aided ably by Manoj Bajpayee's brilliant turn as Bhiku Mhatre, the depth to which the protagonist spirals into the underworld and the havoc it wreaks on everyone's lives has been hard for Varma to recreate since.
Sadak (1991)
This Sanjay Dutt – Mahesh Bhatt pairing was one of the big hits of the '90s. The director-actor duo came together for Sadak alongside the performance of a lifetime by Sadashiv Amrapurkar, who plays an evil eunuch and the main trouble-maker, in this otherwise forgotten movie that is still best remembered for its soulful songs.
-Like this article? Also read: 10 of Om Puri's Best Dialogues Cover Image Courtesy: Darr


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The Family Men
Black Inc., $29.99
In her debut novel, The Family Men, Catherine Harris joins the ranks of Anna Krien, Nicole Hayes and Miriam Sved, tackling the culture of football with a critical look at the legacy of AFL: how the game binds and alienates players and families – and how casual misogyny radiates out, spinning into pressure to conform, assaults on women, and lingering distrust and resentment towards anyone who fails to toe the boundary line.
The 2009 Josephine Ulrick Literature Prize winner, Harris' first published book was a collection of short stories, Like Being a Wife, and here her coverage remains slick, brutal and evasive where it needs to be. The novel builds like a slow striptease towards Sportsman's Night, where Harry and his brother Matt, rising star players, are seduced into the decadence of an all-you-can-drink bar, gold statuettes, and a club where the only women are up on stage gyrating in team colours.
Harris skilfully handles a narrative that shifts in pace, passing the ball from Harry to his old man Alan (an ex-footballer shrugging off his dirty past with the cleansing of the Lord) to an almost-girlfriend Rosie (fighting for more than groupie status) to officials such as Laurie (ripe with hypocrisy); a world where any misdemeanour can be forgiven if you keep winning for the team. Like Malcolm Knox's A Private Man, Harris surveys the ground where normal rules no longer apply; responsibility is reshaped so that players can act without moral conscience: what goes on tour stays on tour.
The media has become saturated with tales of footballers in court for physical and sexual assault, rewarded later with panels on TV shows and sponsorship deals. In 2008, Channel 7's Sunrise asked its viewers: "Are women to blame for footballers behaving badly?" Harris doesn't shy away from these issues. The footy club clearly marks women as "saints" or "sluts": some too good to touch while others come free for all, "a f---ability draft, pure and simple".
As we follow a young girl's journey on the train, preparing to dance for the first time in front of the footballers, Harris ramps up the tension, putting the reader in the same position as the men waiting in the bar: desperately wanting that reveal, the pay off at the end. It's an uncomfortable role to be cast in, as Harry understands all too well. We become implicated too, in the voyeuristic desire to see the girl exposed, to see how far Harry (and Harris) will go.
One of the few trustworthy relationships Harry has may be with a footy journalist, Margot, but in general his self-loathing is firmly misfired at the women around him: his mother, the groupies who accost him whenever he leaves the house, and Rosie, "the way she collapses everything, reducing it to its most basic component parts. Sex. Procreation. Death".
Harry may be arrogant and occasionally cruel but he keeps searching, trying to find – as his father's condition deteriorates – what it means to be a family man, when all he has inherited is a legacy of addiction, evasion and disintegration. Harris' incisive first novel looks past the days of glory to a bloody aftermath, to what happens to footy legends when taking one for the team is no longer seductive, to the lingering shadows left when the MCG lights are switched off at the end of the season.
Kirsten Krauth's debut novel is just_a_girl and she blogs at Wild Colonial Girl.