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PUBH6005 Critical Appraisal Essay Assessment 3 Answer

ASSESSMENT BRIEF
Subject Code and Title
PUBH6005: Epidemiology
Assessment
Assessment 3: Critical Appraisal Essay
Individual/Group
Individual
Length
2,500 words

Learning Outcomes
This assessment addresses the following learning outcomes:
  1. Assess levels of evidence and make recommendations
  2. Interpret data arising from surveillance and research studies, including rates and ratios
  3. Understand the difference between association and causation, statistical and public health significance
  4. Critically evaluate epidemiological studies, including potential for bias, confounding and chance errors


Context:

This assessment requires you to apply the knowledge and skills gained in all the modules to undertake a critical appraisal. You will need to appraise 3 articles of a topic and research question given to you by your facilitator.

Part A

  1. Search the library database to find three studies that answer your research question. All three studies must be of different study designs. For instance, you could include case control, cohort and RCTs. These studies do not have to prove their hypothesis or agree with each other. Please note that marks will be deducted if all identified papers are of similar study.
  2. Critically appraise all three articles you found using the CASP checklist. Make sure you use the relevant CASP checklist corresponding with your study design. Please note that you will need to make 3 different tables for the critical appraisal of the three different study design papers.
  3. Submit the Part A of the three tables for feedback before writing up Part B (essay).

Part B

Base on the feedback in Part A, you should write an essay on the three articles using the following headings:

Introduction: introduces the topic, outlines background information to your research question and finishes with the research question. This sets the context for the rest of the assignment. You may refer to any published articles as they would have the same style of scientific writing. Citation for all sources used (in-text and in the reference list).

Methodology: explain how you found the three articles that you critically reviewed, including the databases you used and the search strategy/keywords used. You may use a systematic review as an example to write this part. Also mention which critical appraisal tools you used.

Results: answer directly to all the relevant CASP checklist questions. You MUST present a table. Additionally, create a column to include ‘justification’ to your decision of each question, i.e. Yes, No, Unclear.

Discussion: discuss all three papers of different study designs in regards to bias, chance and confounding factors. All answers of ‘YES, NO and UNCLEAR’ in your result MUST be accompanied by an explanation on how you can avoid pitfalls (bias, confounding factor), improve on the current methodology, or to further support by comparing and contrasting other approaches to an issue. Provide suggestions or solutions for future research of your research question/topic.

Conclusion: provide one concluding paragraph based on what you have discussed.

References: include all the sources you have used within your text and organize them in alphabetical order according to APA 6th edition style.

Answer

Table 1 Cross-sectional study:( To find an association between the use of tobacco and alcohol and head and neck/oral cancer in South East-Asia?)
Critical appraisal questionsUnderline your answer
Were the criteria for inclusion in the sample clearly defined?Yes/No/Unclear
Yes 
Evidence: justification, compare and contrasting or/and providing solution
This Cross-sectional study table has discussed the review of this study. The table has described the bias risks as average level. The process of “Randomized Control trial” has been used.  

Critical appraisal questionsUnderline your answer
Were the study subjects and the setting described in detail?Yes/No/Unclear
Yes 
Evidence: justification, compare and contrasting or/and providing solution
This Cross-sectional study table has discussed the review of this study. The table has described the bias risks as average level. The process of “Randomized Control trial” has been used.  

Critical appraisal questionsUnderline your answer
Was the exposure measured in a valid and reliable way?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
This Cross-sectional study table has discussed the review of this study. The table has described the bias risks as average level. The process of “Randomized Control trial” has been used.  

Critical appraisal questionsUnderline your answer
Were objective, standard criteria used for measurement of the condition?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
This Cross-sectional study table has discussed the review of this study. The table has described the bias risks as average level. The process of “Randomized Control trial” has been used.  

Critical appraisal questionsUnderline your answer
Were confounding factors identified?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
The chances of “5 year survival” have been lengthened for the cases of some patients were estimated with low “5 year survival” chances.
Critical appraisal questionsUnderline your answer
Were strategies to deal with confounding factors stated?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
However, the condition of the mental state of a patient also plays a role in surviving oral cancer. There are many instances where a chance of “5 year survival” was low still patients managed to survive more than the time.
Critical appraisal questionsUnderline your answer
Were the outcomes measured in a valid and reliable way?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
Usage of article, Gupta, Bhawna, and Newell W. Johnson. "Systematic review and meta-analysis of association of smokeless tobacco and of betel quid without tobacco with incidence of oral cancer in South Asia and the Pacific." PloS one 9.11 (2014): e113385. To prepare the table.
Critical appraisal questionsUnderline your answer
Was appropriate statistical analysis used?Yes/No/Unclear
No 
Evidence: justification, compare and contrasting or/and providing solution
Literary works and journals of writers have been used to answer the research question. No primary collection of data has been made. 


Table 2 Case-control study:( To find an association between the use of tobacco and alcohol and head and neck/oral cancer in South East-Asia?)
Critical appraisal questionsUnderline your answer
  1. Did the study address a clearly focused issue?
Yes/No/Unclear
Yes 
Evidence: justification, compare and contrasting or/and providing solution
The study has been conducted around investigating the impact of tobacco, betel quid, and alcohol on head and neck cancer risk in East Asia. The implication from this study is that betel quid chewing is the strongest risk factor for oral cancer while alcohol plays a major role for head and neck cancer among people from East Asian population. 
Critical appraisal questionsUnderline your answer
2.Did the authors use an appropriate method to answer their question?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
A multicentre case-control study in East Asia including 8 centres helped in collecting data from a variety of participants. Further the inclusion criteria included patients with head and neck cancer in different tumour categories making it possible to compare and contrast the reasons of cancer. Controls were selected from a strictly defined list of diseases unrelated to tobacco, or dietary practice making it possible to present a justified comparison between patients and controls and reach the results or answers to research questions. 

Critical appraisal questionsUnderline your answer
3.Were the cases recruited in an acceptable way?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
Between December 2010 and February 2015, 921 incident patients with head and neck cancer, including oral cavity, oropharynx, hypopharynx, and larynx, and 806 controls were recruited. The cases were recruited (patients and controls) in a manner to gain information on current as well as previous alcohol consumption and dietary habits.
Critical appraisal questionsUnderline your answer
4. Were the controls selected in an acceptable way?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
Controls were selected from a strictly defined list of diseases unrelated to alcohol, tobacco, or dietary practices. The controls were selected to obtain information on previous alcohol consumption, tobacco consumption and various lifestyle factors making the selection proper and acceptable.
Critical appraisal questionsUnderline your answer
5. Was the exposure accurately measured to minimise bias?No
Evidence: justification, compare and contrasting or/and providing solution
Bias away from null was not a major issue in the study and care was taken to keep risk estimated under control in comparison to a recent U.S cohort study

However, there was some possibility of bias due to betel chewing population being from Taiwan only and a limited sample size for specific subsites like hypopharyngeal and laryngeal cancers. 


Critical appraisal questions


Underline your answer
6.Aside from the experimental intervention, were the groups treated equally?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
Spread of the case control table shows that the groups were treated equally. 
Critical appraisal questionsUnderline your answer
7.Have the authors taken account of the potential confounding factors in the design and/or in their analysis?Yes/No/Unclear
Unclear
Evidence: justification, compare and contrasting or/and providing solution
It is not very clear whether authors focused on the issue of confounding factors or variables affecting the study design and analysis. 
Critical appraisal questionsUnderline your answer
8.How large was the treatment effect?Yes/No/Unclear
Unclear

Evidence: justification, compare and contrasting or/and providing solution
The effect of treatment is not clear in the study as it focused on impact of tobacco smoking and alcohol drinking on proportion of head and neck cancer. 
Critical appraisal questionsUnderline your answer
9. How precise was the estimate of the treatment effect?Yes/No/Unclear
Unclear
Evidence: justification, compare and contrasting or/and providing solution
The treatment effect is not discussed in the study.
Critical appraisal questionsUnderline your answer
10.Do you believe the results?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
The large-scale nature of the study in a population with Chinese ethnicity makes the results justified and the selection of participants and controls allows a well-compared study. 
Critical appraisal questionsUnderline your answer
11.Can the results be applied to the local population?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
The study results can be applied to local population in South East Asia as it represents head and neck cancer patients from East Asia and established tobacco and alcohol consumption as a major risk factor in people from different ethic backgrounds and regions within East Asia. 
Critical appraisal questionsUnderline your answer
12.Do the results of this study fit with other available evidence?Yes/No/Unclear
Unclear
Evidence: justification, compare and contrasting or/and providing solution
The research is conducted with limited number of sources and the results cannot be stated as decisive.

Study 2: case-control

According to Gupta, Bhawna, & Newell Johnson, 2014 helps to explain in their research which is interpreted through a model of case control analysis that smokeless and tobacco less substances cannot improve lives for people in South East Asia. The general issue concerning the folk is to somehow get through beyond the trial period that identifies new developments for medically sustaining a person in his ailments. The reason for the case control signifies that changing habits and latest technologies can go hand in hand for vitalizing life in the continent.

Table 3 Cohort study:( To find an association between the use of tobacco and alcohol and head and neck/oral cancer in South East-Asia?)
Critical appraisal questionsUnderline your answer
Did the study address a clearly focused issue?Yes/No/Unclear
yes
Evidence: justification, compare and contrasting or/and providing solution
From Cohort table of “Life expectancy”, the evidence suggests the results presented here. From this table, the scenario is clear that the “survival rate” is higher for the patients aged between 20 and 30. “Number of deaths” is also lower in the case of the patients between the ages 20 to 30.
Critical appraisal questionsUnderline your answer
Was the cohort recruited inan acceptable way?Yes/No/Unclear
yes
Evidence: justification, compare and contrasting or/and providing solution
The usage of “Cohort table” has been done to understand the metrics and behavior of different cohorts.
Critical appraisal questionsUnderline your answer
Was the exposure accuratelymeasured to minimise bias?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
From Cohort table of “Life expectancy”, the evidence suggests the results presented here. From this table, the scenario is clear that the “survival rate” is higher for the patients aged between 20 and 30. “Number of deaths” is also lower in the case of the patients between the ages 20 to 30.
Critical appraisal questionsUnderline your answer
Was the outcome accuratelymeasured to minimise bias?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
Random figures were chosen from the statistics presented in articles
Critical appraisal questionsUnderline your answer
Have the authors identifiedall important confoundingfactors?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
The ratio between case and controls are 1575:1375 and 1193:867 in the case of the Exposed and non-exposed respectively. Both these ratios suggest that “odds of exposure among patients” is higher than “odds of exposure among control.” 

Critical appraisal questionsUnderline your answer
Have they taken account ofthe confounding factors in thedesign and/or analysis?Yes/No/Unclear
No
Evidence: justification, compare and contrasting or/and providing solution
As the collection of data was never directly from patients, proper treatment and relationship between the mental strength of a survivor can never be assessed. More organized and large scale research is needed to make any firm conclusion.
Critical appraisal questionsUnderline your answer
Was the follow up of subjects complete enough?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
 More organized and large scale research is needed to make any firm conclusion.
Critical appraisal questionsUnderline your answer
Was the follow up of subjects long enough?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
 More organized and large scale research is needed to make any firm conclusion.
Critical appraisal questionsUnderline your answer
What are the results of this study?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
The statement can be made that the chances of oral or heck/head cancer is high for those who have been using tobacco and alcohol products from years (Lucas et al. 2016).
Critical appraisal questionsUnderline your answer
How precise are the results?Yes/No/Unclear
Unclear
Evidence: justification, compare and contrasting or/and providing solution
The implication from this study can be done that the chances are higher to be affected by cancer though there are many patients who are not exposed to these products. (onlinelibrary.wiley.com, 2019) 

Critical appraisal questionsUnderline your answer
Do you believe the results?Yes/No/Unclear
No
Evidence: justification, compare and contrasting or/and providing solution
A detailed analysis along with treatment plan and other supportive therapies is needed.
Critical appraisal questionsUnderline your answer
Can the results be applied to the local population?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
From this table, the scenario is clear that the “survival rate” is higher for the patients aged between 20 and 30. “Number of deaths” is also lower in the case of the patients between the ages 20 to 30. The “probability of death” from spread of oral or neck/head cancer is lower in these cases and chances of survival are also high. After this age group, people aged between the group of 30 to 40 (Bo et al. 2016). (In South-East Asia)
Critical appraisal questionsUnderline your answer
Do the results of this study fit with other available evidence?Yes/No/Unclear
Unclear
Evidence: justification, compare and contrasting or/and providing solution
A detailed analysis along with treatment plan and other supportive therapies is needed.
Critical appraisal questionsUnderline your answer
What are the implications of this study for practice?Yes/No/Unclear
Yes
Evidence: justification, compare and contrasting or/and providing solution
If the concern is implication from this study, the statement can be made that the chances of oral or heck/head cancer is high for those who have been using tobacco and alcohol products from years (Lucas et al. 2016). The implication from this study can be done that the chances are higher to be affected by cancer though there are many patients who are not exposed to these products. (onlinelibrary.wiley.com, 2019)


Study 3: Cohort

According to Loree, Lundahl, & Ledgerwood, 2015 in their study broaches on the concept of turning perspective diseases for specifically identifying treatments for the people with varied ages around the parts of South East Asia. They address the problem of increased deaths in their countries and consolidate the data through a form of cohort study that better explains the core nature of the matter. The cohort table provides ample scales indicating the rate of deaths caused due to overexposure of substances that can be limited if the society and the government both get involved. The expectancy for those people in South Asia is at a bad shape which was framed through the cohort model inserted into the research. 

DISCUSSION

level of Evidence: this Cross-sectional study table has discussed the review of this study. the table has described the bias risks as average level. the process of “Randomized Control trial” has been used.  

Consistency: The above tables took together the relevant literary authors under consideration for evaluating the intercessed adequacy requirements. The research question put under close discussion the related findings that could somehow provide the study a good meaning. This was possible due to identifying the costs involved in curing tobacco abusers from the respective impacts they cause to each other (Beach et al. 2015). The same applies when there is a lack of resources existing and the awareness programs fail to limit the outbreak of such ailments. This study provided us with an expression that vitalized the scope of understanding for emphasizing on the rise of cases that sheds light into how behavior patterns could define the overall epidemiology of individuals residing in countries from Southeast Asia. (ncbi.nlm.nih, 2019)

Question:

To find an association between the use of tobacco and alcohol and head and neck/oral cancer in South East-Asia.

Clinical impact: There were many problems that associated itself with the question concerning the research by limiting the levels of reaching to the target audience in question. This can be seen as some of the results which came back at the end of the examination failed to consider all the people who might be impacted. (uptodate.com, 2019)

From the 2 x 2 case control tables, the scenario is clear that the number of the “head/ neck or oral cancer” patient number is higher for the patients who are exposed. Therefore, it can be clearly understood that the people who consume alcohol or oral tobacco. From the table, the results can expose that the number of patients and controls are higher for the consumers of these products. The number of the patients is 2910 from which 1535 are cases and from them the control is made 1335. The non-consumers are also numbered as 1193 and 867 and the total number is 2060. Therefore, the conclusion cannot be made that the alcohol and oral tobacco consumption is the only reason behind the cancer of the oral cavity or head/neck (Bibbey et al. 2015). Only, the remarks can be made that the chances of exposure to this disease is higher for themselves who consume alcohol or tobacco regularly. The control of these cases was done with medication like Methotrexate, Docetaxel and Bleomycin. The control was possible for the most number of cases. Some cases need operation which involves dissection of some of the organ. The treatment success rate is measured in “5 year Survival Rate.” the rate for the oral cancer patients presented here is about 60%. 

Clinical impact: Therefore, it is clear that the chances of 5 year survival are high depending on the stage where it has been discovered.  The rate is variable for the different aged persons. The person with higher age has lower immunity than the people who are young (Loree, Lundahl & Ledgerwood, 2015). The survival rate is therefore lower in the case of the elder people and higher in young people. Generally the dependence of survival rate is also on the factor like cancer stage. Research shows that the rate of survival is between 70 to 90% for the oral cancers staged between 1 and 2 (Rumalla, Reddy & Mittal, 2016). The ratio between case and controls are 1575:1375 and 1193:867 in the case of the Exposed and non-exposed respectively. Both these ratios suggest that “odds of exposure among patients” is higher than “odds of exposure among control.” 

Generalizability: means success rate is lower than the rate of affecting persons. Therefore, it might be said that “exposure might be a risk factor for the disease.” the grade of this study is average. the evidence which were selected to complete the job, are exact and are proven. 

Applicability: The factors which drive the performance of the cohorts can be analyzed from the factors. Here, the factor is age group which determines the rate of “5 year survival.” also; the section describes the mortality and death rate of the people. the results are applicable only for the South-East Asian countries. 

Summary of relevance: From Cohort table of “Life expectancy”, the evidence suggests the results presented here. From this table, the scenario is clear that the “survival rate” is higher for the patients aged between 20 and 30. “Number of deaths” is also lower in the case of the patients between the ages 20 to 30. The “probability of death” from spread of oral or neck/head cancer is lower in these cases and chances of survival are also high. After this age group, people aged between the group of 30 to 40 (Bo et al. 2016). The usage of “Cohort table” has been done to understand the metrics and behavior of different cohorts. 

Relevance: the study is completely relevant when considering the impact of “alcohol and tobacco consumption” and “oral/neck/head cancer.”

CONCLUSION

Drawing a straight conclusion like “Tobacco and Alcohol consumption is the case of oral cancer” is not right as there are many instances where the patients are non-exposed to these products. Again, the current literary work has been finished with the data from historical times. As the collection of data was never directly from patients, proper treatment and relationship between the mental strength of a survivor can never be assessed. More organized and large scale research is needed to make any firm conclusion. The implication is the conclusion here that the consumption of alcohol and tobacco are the main reason behind cancer affection.  

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