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The Cochrane Content: A Decade of Data To Stiff Or Not Too Stiff? L. Cochrane, a physician and epidemiologist, wrote, in fter blunt poly trauma, the cervical spine may A.1972, an essay on “Effectiveness and Efficiency.” It was Abe injured in up to 12% of patients. The a seminal statement on the good practice of medicine based on relative risk of 8.5% is a factor in associated head the best obtainable, reliable evidence. It provided inspiration, in injuries. It has been believed, prior to ATLS 1987, to the researchers who later founded the “Cochrane guidelines, that a delayed or missed diagnosis of Collaboration.” cervical injury is associated with 10 times the Iain Chalmers et al compiled all randomized clinical trials rate of permanent neurological sequelae. in the perinatal field (Effective Care in Pregnancy and Child Modern trauma care assumes that cervical Birth. New York, NY: Oxford University Press; 1989). injury is present, until it is excluded, something Recognizing the immense value of listing, for access and com- more easily done with conscious patients. The bination, published RCTs, they created the ‘Collaboration’ and risk is such that the cervical spine and the named it after Cochrane. It was made international with the traumatized patient may be kept stiff and hope that other collections of RCT data would be developed in immobile for prolonged periods with resulting all areas of clinical care. There are now to be added Ͼ2000 serious morbidity. This can happen even when systematic reviews in the latest quarterly edition of the the cervical spine has not been injured. Cochrane Library. C.G. Morris et al (BMJ. 2004; 329: J. Grimshaw in an editorial (CMAJ. 2004; 171:747-749), 495-499) have found that immobilization describes the value of the Cochrane Collaboration 10 years and the use of a cervical collar can cause after its formal start. The Cochrane Collaboration is now a vast major problems, mainly related to skin collection of data on clinical trials. The Cochrane Library pub- necrosis. The most vulnerable areas are the lishes quarterly reviews; issue 3, 2004 contained 2074 system- occiput, upper and lower back, and the heels. atic reviews. The reviews are continously updated; The Plain radiographs and directed computed Cochrane Methodology Register has Ͼ5000 references to tomography can exclude neck fractures with methodological papers. Ͼ99% sensitivity, in unconscious patients. The Cochrane Collaboration is an essential reference tool Spinal precautions include cervical collars, spinal for all health professionals who are engaged in clinical boards for transfer, prolonged nursing in the supine research. It is important for health administrators, agencies, position on a firm mattress, lateral restraints, head and planners. The financial support comes from Australia, tapes, and the apparatus associated with surgical stabiliza- Denmark, England, Finland, Ireland, Norway, Northern tion. Ireland, South Africa, Spain, and Wales. The authors cite the case of an elderly man with multiple Archie Cochrane recognized, as have other epidemiolo- broken ribs, pulmonary contusions, and a closed head injury. gists, the many areas of complaint that are not easily measur- able–clinical outcomes that can only be described in subjec- tive terms. Depression, quality of life, fatigue, undiagnosible Blue Notes Editor: odd spells, and vague fleeting pains are examples. He also acknowledged circumstances where treatments for some dis- Charles Sorbie, MB, ChB, FRCS(E), FRCS(C) eases can be effective but the same diseases can remit without Dr Charles Sorbie is Professor of Surgery at treatment. He would have known that today we have new tech- Queen’s University and a member of the Attending Staff at the General and Hotel Dieu Hospitals in nologies that develop faster than they can be assessed. Kingston, Ontario. Cochrane regretted that he had neglected the quality of care A former chairman of the Department of Surgery at in his essay on effectiveness and efficiency. This he sensed as Queen’s University, Dr Sorbie has been President of he recalled sad and revealing episodes in his life, which the Canadian Orthopaedic Research Society, the Canadian Orthopaedic Association, and the Societé included his experience while a prisoner of war. Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT).

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He had been weaned from mechanical ventilation. He had “normal” spinal imaging. Spinal precautions were continued Arnold T. Berman, MD, Philadelphia, PA for 10 days by which time, he had a large sacral ulcer extend- (16 years) ing to bone. After repeated episodes of sepsis, a depressed Randal R. Betz, MD, Philadephia, PA level of consciousness, and pneumonia, the patient died, 73 (12 years) days after admission. No spinal or neurological injury was ever detected. Edward A. Nalebuff, MD, Boston, MA (27 years) Erik B. Riska, MD, Helsinki, Finland Comings and Goings (15 years) rthopedics is pleased to welcome the following new members to the Board of Editors: Dempsey Springfield, New York, NY O (13 years) Albert Aboulafia, MD, Baltimore, MD; Shinichi Yoshino, MD, Tokyo, Japan Ronald A. Navarro, MD, Harbor City, CA; (11 years) Robert J. Ziets, MD, New York, NY. We also bid farewell to the Board of Editors members recently Finally, we regret the passing of James F. Wenz, MD, retired, and thank them for their generosity and dedication. from Baltimore, MD, a member of the Board of Editors for (Length of tenure on the Board is noted in parentheses). 3 years.

Archibald Leman Cochrane (1909-1988) he person for whom the Cochrane Collaboration is named, was a Scot, born in a small town, famous for the manufacture Tof tweed cloth. Galasheils is on the Gala Water in the Uplands of southern Scotland. Young Archie went to a famous boarding school, Uppingham, in England, a school of great merit, founded in 1584. After gaining first class honors in Natural Sciences in Cambridge, Cochrane worked in 1931 at Strangeways Laboratory–well known to orthopedic surgeons–performing research on tissue culture. He spent three years studying psychoanalysis in Berlin, Vienna, and The Hague. After graduating in medicine, he joined, in 1936, the International Brigade to take part in the Spanish Civil War. In 1941, as a Captain in the Royal Army Medical Corps, he was captured in Crete by the Germans and spent the rest of the war as a prisoner. He had to withstand very harsh conditions while surrounded by prisoners with lethal diseases for which he had no useful treatments. This experience taught him much about effectiveness and efficiencies. It opened his mind to making the most out of the available least. He studied epidemiology in Philadelphia, became a Professor in the Welsh National School of Medicine, and later the Director of the Medical Research Council Epidemiology Research Unit in Wales. His publication Effectiveness and Efficiency: Random Reflections on Health Services has inspired countless individuals who have an interest in health and disease. Archie Cochrane had a profound experience in the value of “comforting” when medical remedies could not succeed. In a prison camp at Elsterhorst, Germany, a young Russian prisoner was admitted, moribund and screaming in pain. He had gross bilateral, cavitary tuberculosis with pleurisy... I had no morphia, just Aspirin, which had no effect. I felt desperate. I knew very little Russian then and there was no one in the ward who did. I finally, instinctively, sat down on the bed and took him in my arms and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not pleurisy that caused the screaming, but loneliness.

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