Dear All,
Many thanks for your suggestions about what treatments don't need
randomised trials. The most suggested was insulin for juvenile diabetes,
but a number were suggested twice and many were already on Ben
Djulbegovic's list (see below). There were only two (but very helpful)
suggestions on criteria. So here is the full list - I don't guarantee all
these are dramatic enough to qualify. In the next stage we plan to look at
which treatments fit which of several possible criteria. In the meantime,
if you have other suggestions, please let me know.
Thanks to all for the excellent contributions,
Paul Glasziou
Department of Primary Health Care &
Director, Centre for Evidence-Based Practice, Oxford
ph: 44-1865-227055 www.cebm.net
---------------------
1. Dramatic therapies
Endocrine
* insulin in diabetic coma (2 people) insulin in diabetic
keto-acidosis - survival
* thyroid extract for myoedema - cure
thyrostatics for thyrotoxicosis - cure
* steroids in the treatment of adrenal cortical hypofunction?
Hematological
Hemotherapy to treat Hemophilia.
* Blood transfusion in acute severe blood loss
Nutritional
* vitamin B12 in pernicious anemia; liver extract for PA and
subacute combined - cure of PA
citrus fruits to treat scurvy
Infectious
streptomycin for TB meningitis - return of consciousness and survival
* penicillin in pneumonia (in bacterial endocarditis)
gancyclovir for CMV retinitis in AIDs - complete arrest of the
disease.
Cardiovascular
Defibrillation for ventricular fibrillation. People lived!
automatic external defibrillators in cardiac arrest
Musculoskeletal
total hip and knee replacements
Closed reduction of fracture of long bones with deformity?
Neurological
cholinesterase inhibitors for myastheia gravis - immediate return
of muscle power
Surgical
appendicectomy in perforated appendicitis
sewing up wounds,
ether anesthetic
maintaining sterile conditions for surgery
Cancer
* Imatinib in treatment of CML (chronic myeloid leukemia)
* Combination chemotherapy with cisdiamminedichlorplatinum,
vinblastine and bleomycine in disseminated testicular cancer.
Other
some organ transplantation (e..g liver transplantation in
fulminant acute hepatitis)
some antidotes in poisoning
recompression for decompression illness.
* From Ben Djulbegovic's list at:
http://www.hsc.usf.edu/~bdjulbeg/oncology/practice-change.htm
2. suggest WHY they are so convincing that a trial is unnecessary
Nino Cartabellotta suggested:
We compiled a list of criteria for accepting in clinical practice health
interventions without RCTs evidence (the criteria should be all satisfied):
1. bad outcome of disease if untreated (high/very high control event
rate)
2. drammatic benefit of treatment (high relative risk reduction)
3. accettable side effects of treatment (high/very high number need
to harm)
4. no alternative treatment
5. convincing physiopatological basis
And Douglas Badenoch pointed out:
The CEBM's Levels of evidence (www.cebm.net/levels_of_evidence.asp)
includes a Level 1c for "All or none" case series in Therapy, Prognosis,
Differential Diagnosis and Economic Analysis.
This has been defined as
"Met when all patients died before the [intervention] became available, but
some now survive on it; or when some patients died before the
[intervention] became available, but none now die on it."
The questions would be, to my mind
1 How many is enough for such a case-series?
2 How well are the PICO elements of the research defined, measured
and implemented in the study?
3 Do the PICO elements of the study relate to the PICO elements of
your clinical question?
|