BackgroundSystematic reviews are used widely to guide health care decisions. Several tools have been created to assess systematic review quality. The measurement tool for assessing the methodological quality of systematic reviews known as the AMSTAR tool applies a yes/no score to eleven relevant domains of review methodology. This tool has been reworked so that each domain is scored based on a four point scale, producing R-AMSTAR.Methods and FindingsWe aimed to compare the AMSTAR and R-AMSTAR tools in assessing systematic reviews in the field of assisted reproduction for subfertility. All published systematic reviews on assisted reproductive technology, with the latest search for studies taking place from 2007–2011, were considered. Reviews that contained no included studies or considered diagnostic outcomes were excluded. Thirty each of Cochrane and non-Cochrane reviews were randomly selected from a search of relevant databases. Both tools were then applied to all sixty reviews. The results were converted to percentage scores and all reviews graded and ranked based on this. AMSTAR produced a much wider variation in percentage scores and achieved higher inter-rater reliability than R-AMSTAR according to kappa statistics. The average rating for Cochrane reviews was consistent between the two tools (88.3% for R-AMSTAR versus 83.6% for AMSTAR) but inconsistent for non-Cochrane reviews (63.9% R-AMSTAR vs. 38.5% AMSTAR). In comparing the rankings generated between the two tools Cochrane reviews changed an average of 4.2 places, compared to 2.9 for non-Cochrane.ConclusionR-AMSTAR provided greater guidance in the assessment of domains and produced quantitative results. However, there were many problems with the construction of its criteria and AMSTAR was much easier to apply consistently. We recommend that AMSTAR incorporates the findings of this study and produces additional guidance for its application in order to improve its reliability and usefulness.

Magnetic resonance imaging can be used to investigate cartilage in gout. Cartilage damage was relatively uncommon, focal, and associated with bone erosions, tophi and synovitis, but not bone oedema. This emphasises the unique pathophysiology of gout.

There are no conflicts with any commercial organization. Funding was provided for the students by the summer studentship programme of the Faculty of Medical and Health Sciences of the University of Auckland.

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BackgroundFraming bias occurs when people make a decision based on the way the information is presented, as opposed to just on the facts themselves. How the diagnostician sees a problem may be strongly influenced by the way it is framed. Does framing bias result in clinically meaningful diagnostic error?MethodsWe created three hypothetical cases and asked consultants and registrars in Emergency Medicine and Internal Medicine to provide their differential diagnoses and investigations list. Two of the presentations were written two ways to frame the case towards or away from a particular diagnosis (Presentation 2 – pulmonary embolus (PE) and Presentation 3 – interstitial lung disease (ILD)) and these were randomly assigned to the participants. Both versions were however entirely identical in terms of the objective facts. Physician impressions and diagnostic plan were compared. A third presentation was identical for all and served as a control for clinician baseline ‘risk-averseness’.ResultsThere were significant differences in the differential diagnoses generated depending on the presentation’s framing. PE and ILD were considered and investigated for the majority of the time when the presentation was framed towards these diagnoses, and the minority of the time when it was not. This finding was most striking in Presentation 2, where 100%versus50% of clinicians considered PE in their diagnosis when the presentation was framed towards PE. This result remained robust when undertaking stratified analysis and logistic regression to account for differences in seniority and baseline risk-averseness— neither of the latter variables had any effect on the result.ConclusionWe demonstrate a clinically meaningful effect of framing bias on diagnostic error. The strength of our study is focus on clinically meaningful outcomes: investigations ordered. This finding has implications for the way we conduct handovers and teach juniors to communicate clinical information.