Systematic Review and Evidence-Based Medicine
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- čas přidán 31. 08. 2014
- You've probably heard of "evidence-based medicine". It's the idea that we practice based on research and data. There's another way of practicing called "eminence-based medicine". It's the idea that we listen to the person who's been around the longest or who has somehow managed to be labelled the expert.
It used to be that such a person would periodically get to write a review article in some journal, and that would be how everyone learned what to do in medicine. That's a problem. We've got a solution. Systematic reviews!
For those of you who want to read more or see references, look here: theincidentaleconomist.com/wor...
John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics
/ aaronecarroll
/ crashcoursestan
/ realjohngreen
/ olsenvideo
A three hour grad school lecture minus 2:55:00 of fluff, for free! Thanks Dr. Carrol!
Lol, you can't have gone to much of a grad school :P
Ryan Hutton actually I have lectures are mostly worthless, all the info you need is usually in the reading or notes or whatever the prof gives you. And let me be clear, I'm NOT saying that there isn't 16+hours of work attached to that meaningless 3 hour lecture
So, Ryan, where did you do your graduate studies, and how did you find the lectures?
***** you can skip one lecture of one class, you will still be responsible for knowing all material on the final exam
swill128 So because you don't need to get 100% to pass an exam, suddenly all lecture content is useless?
Maybe it's different because you did/do natural science and I do philosophy/economics. I know my economics lectures are far less useful than my maths/philosophy lectures where further analysis beyond that possible in the course notes helps my understanding of a particular topic greatly.
Thanks for the insight, Doc. This is one of my favorite segments of yours so far, descriptive of the process, concise and illuminating.
Thanks again.
I love Healthcare Triage! amazing way to educate the general population! Thank you Aaron!!
Aaron, I have a list of ideas for topics you can discuss.
-Circumcision
-Vegetarianism/Veganism
-What to feed your dogs in terms of people food
Also, 60 seconds? I've never been this early.
I like the second topic idea a lot, consider this an upvote! :3
1234kalmar
Where do you get your protein? :P
So sick of that question.
Joseph Harrietha
Why not? My dog eats eggs, rice, oranges, and other stuff. Do some research. Dogs can eat people food. He loves peanut butter. :D
Joseph Harrietha
He never had to go to the vet, he's a big, 130-lb dog, and he's got that healthy mutt glow, unlike those inbred pure-breeds. He loves peanut butter. It's got protein, vitamin-B, and lots of other great stuff.
Joseph Harrietha
Dogs all over the world are fed people food. In south America for instance, they don't always have the luxury of kibble, and see the entire concept as stupid. Dogs can eat lots of people food without harm.
One of my favorite HCT segments to date. Loved hearing about your research!
I think it is great that these videos also teach how to understand science and distinguish between good or bad studies. The concepts are applicable to some many other fields, and I find them quite helpful :)
Thank you! I am about to start a systematic review for university, this has been a really helpful overview.
Your structure of a paper is really helpful for me writing my thesis.
This video is very helpful . I enjoy listening to you speaks . I hope you have more videos.
Can you do an episode on self-diagnosis?
Dr. Carroll, I'm very curious what you think about the AllTrials campaign. Granted, they seem to be focusing most of their efforts in Europe, but I'm glad the issue is getting attention.
Hi Dr Carrol :) In biology last term we wrote a response to a socio-scientific issue, which happened to be artificial water fluoridation. My end position was, unsurprisingly, that fluoride should be kept in my city's waterways. I read several systematic reviews which followed a structure just like the one you described, and it's pleasing to see my research was scientifically legitimate.
In saying that, I would really appreciate a video about your opinion on water fluoridation, especially in the United States (as Americans tend to get more upset about these things than the good ol' Kiwis!)
Thanks for a very informative video!
Ypu really must have been a painfully brilliant Student. Love it.
Underestimating the "I need to calm down this obnoxious stressed-out Parent"
Incredible video, I would thumbs it more if I could!!
Are there any evidence-based studies on the actual effects on the human body of second hand smoke?
You may be interested in this: Before leaving the hospital after giving birth 3 different Dr's came to my room to emphasize new studies on colic showed that babies are not born with the enzymes to break dairy down and do not develop them until after 6 weeks but the babies gut changes every 3 months and I was to cut all dairy out and test every 3 months to see if changes occurred. I also spoke with Dr. Jay Gordon (pediatrician and author) who emphasized only circular and pushing palm of my hand up in the upper left hand corner of my babies back instead of patting to burp. I followed all directions and my baby NEVER cried, NEVER spit up, NEVER had diaper rash. I was able to introduce dairy by 9 months without any reactions (previously he cried, a lot, when I tried). Very interesting. There should be a systematic review done using this model as a search.
How about an episode on the safety of bottled water versus tap water (including tap water in a variety of countries)?
Aaron, I have a suggestion for a topic!
Dietary vitamin supplements! There is a huge market for all kinds of vitamins, claiming all kinds of toff from increased energy to better sleep.
So the answer to your baby throwing up about twice a day is to clean it up and not worry about it too much? But to always keep an eye one him/her in case it gets worse?
Keep an eye on the weight and general well being of the baby, which should be done anyway. But yes, this is very frequent and most times it does not need to be treated.
Good to know, thanks. :)
LetumComplexo I can't remember who it was, but I've heard that "if your child has GER, you don't have a health problem, you have a laundry problem". It must be nerve-wrecking at times though!
But in the 5% of cases that don't get better on their own, are there any actually effective treatments? All the ones listed were debunked. What are you supposed to do?
aaa303 I'm guessing you treat the symptoms of GER rather then the GER itself in those cases.
So....how about antacids like ranitidine?
+Cloud Seeker
I seem unable to reply in the other thread anymore, just got back from work so I can show you what you wanted regarding placebo and allergy treatment. There's a scientific journal called Current Allergy and Asthma Reports, here's one article from it way back in 2007: link.springer.com/article/10.1007/s11882-007-0006-2
idk if there's anything more recent, there probably is, I'm too lazy to look :p
I admit that we used a bouncer seat for the first three months of my daughter's life thanks to GER. But to be fair she had colic on top of that, plus there was some convenience of having her sleep(?) in the same room as me for feeding purposes. Magically all the colic, sleeping problems, and GER disappeared around three months, just about the time an infant's digestive tract matures. Who knew?
I think it would be really cool if you could do a video on the difference between western medicine and other types of medicine, especially in Asia. Thanks :)
I have reflux, my mom said I cried all night long due to pain caused by it, after a while doctors prescribed a (at the time) new drug. I think it was called losec or something like that. and the nighttime crying stopped. I still take drugs for reflux every day (although the brand and dosage have changed). I do not know if losec was of the type of drugs that you where talking about but for my case it worked (and still does)
There is a typo in your "Methods" slide.
I had GER as an infant, but I didn't vomit and it went up my nose, which is why I am now anosmic.
I have GERD. I self-diagnosed myself with it. I'm about 98% sure I have it. I get persistent heartburn, even as a child. It's gotten worse as an adult. I live a fairly normal life as long as I have my PPI.
I take Nexium which is an OTC PPI. I was taking Lansoprazole but my body became resistant to it's effects after 3 years of taking it everyday, so now I'm on Nexium or Eomeprazole or something. Strangely enough Omeprazole doesn't work on me or it doesn't seem to.
I slightly avoid my triggers, which are typically too much chocolate or tomato. Things that are very acidic will act up my heartburn if I over consume. I can probably get away with 1-2 times a week, more than that and even with the PPI, I get bad hearburn.
There isn't much in the way of treatment for GERD, even surgical solutions are not guaranteed to work or solve the issue completely. A doctor visit is just going to result in a RX for a Acid Reducter or PPI as surgical solutions are very invasive and they are unwilling to do them most of the time.
I can't imagine what it is like for an infant that can't take a PPI.
Still want a episode on homeopathy. Sure its a easy subject to say "it doesn't work" but many people still think it does work.
Subject idea: thalidomide (softenon) and the emergence of preclinical trials
Are Americans really so terrified when infants regurgitate small amounts of milk? Here in Norway, it's considered normal, as long as the amount and/or frequency isn't extreme.
My daughter had GERD and it's not a small amount of milk. After every feeding, whether breast of formula, it was like The Exorcist, projectile vomit. My daughter started loosing weight, eventually we got her on Zantac (ranitidine) and things got better.
Amanda Dobson In your daughter's case, it was the kind of exception I mentioned at the end of my comment, and it's clear that you noticed that it was too much to be healthy.
Small amounts of spitup have nothing to do with GER. That's like saying brain tumours are normal because everyone gets headaches from time to time.
can you cite a scholarly article to support that?
Could you please do a video on the effects of either intermittent fasting VS Going Vegan in making us live longer.
Cheers
I think the many drugs that are advertised should also have to have a systematic review along with the long list of side effects.
What about other drugs, like ranitidine, for treating GER in infants?
I was wondering that too. I work in a pharmacy, and we see a lot of prescriptions for ranitidine for infants. Fewer for lansoprazole or omeprazole, but we do see them occasionally.
All of my kids were on ranitidine or lansoprazole as infants. They had bad cases of GER. My youngest had three apparent life threatening events (cyanotic, limp, and unresponsive) that were attributed to GER after extensive testing in the NICU. Before the medicines, they were really "urpy" and spit up a lot. When we started the medicines, they got better. When we took them off, symptoms returned. When we put them on again, they got better again. We were finally able to wean them off when they were 6-12 months old.
I know anecdotes don't prove anything scientifically, but it suggests to me the need for further research, especially in populations that are unusually affected by GER.
Mark Rogers
Dr. Carroll doesn't talk about it in this video, but another real problem is the severity of the condition. There's no question that PPIs have a very real impact on how acids work in the stomach. There's tons of research and base level molecular science to prove it. The better question is whether or not they will work on YOUR kid.
Anecdotes like yours help to show that there probably are real cases where PPIs would make sense for an infant with GER. Research as described in the video helps show that a blanket approach to giving every spitting kid PPIs is a bad idea. We have to trust a doctor to help be able to diagnose the severity correctly, and weigh that against the potential side effects.
If your child might die from GER, than you might risk the respiratory infections, cause death is bad and all that.
avoisin Your explanation makes sense. I wish Dr. Carroll would talk about possible exceptions instead of just hammering out the message that these drugs are useless for babies.
So all of these doctors were prescribing medication that didn't work? Based on what? If the system works as well as you say, why was a systematic review necessary to disprove something that had never been proved in the first place? Surely if there was no evidence to support this medication's use, it shouldn't have been used. Was it used simply because there was no evidence against it either?
Eminence based medicine. Who makes the medicine? Who pays for special holidays for the doctors who push for particular medicines?
Doctors are humans too. If the parents are nervous, they will try something, rather than do nothing.
Magnus Nygaard But surely that is dangerous? They had no idea what could have happened. Surely research into that should be necessary rather than just start guessing as to what will work.
oddzag Sure - but they still have basic medical knowledge, so it's not a completely wild guess. I agree they shouldn't do it, but I understand why they DO do it, sometimes.
Magnus Nygaard How can they have basic medical knowledge when there is no knowledge to support a particular hypothesis a doctor makes up? Science doesn't work like maths. You aren't taught a few formulas and then you can figure out everything about the entire universe. Rather you're taught a particular way of thinking and researching and given some of the information as known at that point in time. It's not up to the doctors to be making decisions about their patients lives. It's up to the doctors to inform their patients about what science says they ought to be doing with their lives.
The only real explanation I can think of here is coercion by firms...
Thumbs up for Dr. Aaron Nothingworks. :D just kidding, he is awesome. In all seriousness tho. How about a video on stuff that do work? :)
It's interesting that so many people are able to immediately notice the issues with eminence-based *medicine,* but not able to apply the same critical thinking to 'fields' entirely based on eminence (of people, or of books - yes, this is a jab at religion).
For my daughter's first two months, she threw up and screamed constantly. We added the rice cereal and the problem went away.
you should do a episode on how much sleep people need.
When you say placebo controlled test on infants, it makes me thinking: Do infants shows placebo effects too?
I'd guess their parents do, and their behavior effects the infants. For sure it could effect how the infants' responses are reported.
Wouldn't the fact that you set out with a specific result in mind bias you towards finding the result you're looking for?
You wanted to disprove that tilting babies and thickening feed prevent whatever-it-was, so you found exactly that.
Although I suppose skeptics can check your work and try to replicate it since you show your methods in the paper.
Well, the objective wasn't to disprove the hypothesis, it was to TEST it. Yes, he had his own opinion, and yes, potentially that could lead to confirmation bias if he excluded relevant results that disagreed with his opinion. But, as you noted, the method is the way we minimize that. That his opinion happened to be right doesn't count against the systematic review's reliability.
Well that's pretty much how all scientific studies work. You have a hypothesis. That doesn't necessarily mean that the end result will be biased
It is interesting to consider systematic reviews when people use google scholar, which still alters your search results personally.
So.. What you're saying is that throwing up two times a day is normal for infants and you can't do anything about it?
see I have issues with a lot of evidence based stuff because its all lumped together, just like steroid use in septic shock; thought to not be effective, then they stratified the result and found that those failing IV fluids responded very well to steroids.
They also say that mucinex may not work (only 1 RTC supports) but that goes directly against my personal experience when I could tell when my 8 hours of effect of the drug were up even if I was sleeping or not looking at the time. I could literally feel the difference. placebo? doubt it. maybe it doesn't work for everyone, but it worked for me at that time.
research is a hammer not a scalpel.
HCT42 systematic Review FINAL
I wish people understood better how to interpret study results, never mind systematic review. This is especially frustrating when it comes to the reporting of studies. It leads to a general mistrust because, from a public perspective, they will often hear this artificial back-and-forth about the potential merits or harms regarding a substance or treatment. When this happens often enough, a person is likely to just shrug their shoulders to the whole thing, which reinforces a general attitude of disdain for science and scientists.
Nothing is ever "proven". You simply eliminate all other possibilities until you're left with an explanation that fits the evidence.
Aaron has Stalone's mouth
ah but tell the mother at 3 am that is a Physiological reflux
Sounds reasonable, as long as you don't miss studies like in your video claiming that smoking marijuana is not harmful to your lungs. Since it was by the same people who did a study that you did cite, I have my doubts that you saw the study and then rejected it. (and I haven't seen you correct your mistake yet)
As a pregnant person I am super tired of 'eminence based medicine.' I guess that won't change after I become a parent...
I thought the opposite of evidence-based medicine was crap-based medicine.
Actually, I've heard arguments in favor of "science-based medicine" over evidence based medicine, where there is a greater focus on basic science rather than just looking at how clinical studies turn out. The idea, I guess, being to require more evidence to support treatments that are unsupported by basic science than those that are. I've only heard this discussed from the science-based side of things. Is there a counterpoint?
When most people say "evidence-based medicine" they mean what science-based medicine is. As I'm sure you're at least sort of aware, "science-based medicine" isn't supposed to be something different than or competing with EBM at all; it's a movement made to address a few of the natural pitfalls and excesses of EBM as currently practiced, and its goals basically comes down to critical thinking, skepticism, and being careful about evidence.
Ideally, EBM and SBM are the same thing, so it isn't about SBM "over" EBM. They don't really need to be distinguished until you find examples where EBM is lacking. This happens perhaps most often in the "field" of alternative medicine, where established scientific principles are often tossed aside in favor of e.g. performing needless studies on something with no plausible mechanism of action. "EBM" in this case can still, and does, just go "welp there's not enough evidence; need more randomized trials". There have been many "counterpoints" to SBM, but these often, if not always(?), don't quite understand what the intention of SBM actually is.
Vulcapyo makes a good explanation. One "counterpoint" can be explained by the example of the disgusted responses of North American clinicians when we heard that people in the USSR were treating peptic ulcer disease (PUD) with antibiotics. The SBM of the time showed this to be crazy. Yet the evidence eventually supported it, and science discovered helicobacter.
And the lesson of the day is "babies gonna throw up. deal with it"
So while your at it why not explain the money structure that underlies every study and where the money for research in Universities comes from and how its taken up by private industry and how the prices charged to citizens of the US pay the highest fees in the planet and are 32th in the world for life expectancy and 1 is drug related deaths.
It's an Eminence Front.
Ii
view 273. A first.
Neo-cons have told me for decades that this type of research is poppycock! Better to just listen to those conservative think-tanks.