At the request of Ben, and agreeing with John, rationality ain't got
nothing to do with it.....
Enjoy the read.
Goodnight from Rome
On 25/09/2009, Jon Brassey <[log in to unmask]> wrote:
> It appears to me that there is assumption that humans are rational! Policy
> makers/politicians/clinicians are not rational (as judged in the context of
> the 'evidence based' world). This assumption of rationality is perhaps a
> fundamental flaw in the 'evidence based' world. Human nature appears to
> prefer 'trusted colleagues' to 'academic evidence'. In decision making
> 'academic evidence' frequently comes a long way down the list of influences.
>
> Policy makers appear irrational when 'judged' by the standards of the
> application of research evidence. However, policy makers/politicians need to
> be seen to be doing something, so from that perspective they're behaving
> rationall!.
>
> Martin finished his last post with "*Evidence based is not even part of
> medicine today and unlikely to be so in the face of such overwhelming
> ignorance.*" After 20+ years of promotion and not massive uptake perhaps
> the 'evidence based' world needs to ask some questions. If Ford designed a
> car and it didn't sell, would Ford blame the consumers or their own
> process? If 'we' design EBM and the doctors don't accept it, it's really
> easy to blame their ignorance.
>
> Apologies for appearing downbeat!
>
> Best wishes
>
> jon
>
>
>
>
> On Fri, Sep 25, 2009 at 7:52 PM, Djulbegovic, Benjamin <
> [log in to unmask]> wrote:
>
>> Martin, this and paralell thread related to some unpublished data about
>> interactions between seasonal and swine flu vaccine, is why the discussion
>> groups like ours should exist. We have everything here:
>>
>> - experts vs. evidence (it looks like that content i.e. "experts" always
>> win)
>> - politics vs. EBM ( Tom: please send the article, which you forward to
>> me,
>> to the entire group. A fascinating piece!)
>> - (lack of evidence) vs. decision-making (it looks like that not acting is
>> regretted more than acting even when uncertainty looms large?)
>>
>> - if EBM is ignored in face of such multi-billion dollar decisions (which
>> is what flu vaccine and antiviral will end-up costing) , the discussion
>> about expensive but still benefical cancer drugs is too much about
>> nothing,
>> I am afraid (think about the opportunity costs here!)
>>
>> These two threads deserve a full intellectual might of this wonderful
>> discussion group. Perhaps, someone will notice?
>>
>> thanks
>>
>> ben
>>
>>
>> ________________________________________
>> From: Evidence based health (EBH) [[log in to unmask]]
>> On Behalf Of Martin Dawes, Dr. [[log in to unmask]]
>> Sent: Friday, September 25, 2009 10:31 AM
>> To: [log in to unmask]
>> Subject: Do the antivirals reduce mortality in flu? Roche thinks so on the
>> basis of two retrospective studies
>>
>> Last night I was at a pandemic planning meeting for GP's in Montreal where
>> we were told by a local infectious disease expert that Tamiflu reduced
>> mortality and we should give it to all at risk people with ILI and give it
>> early.
>>
>> When I asked for the data I was told that it was a new study from Dr
>> Iacuzio (medical director of Roche: conflict of interest? - it only caused
>> a
>> small rise in share price - from 165 to 170 14th sept to 21st and it has
>> slipped down again to 166)
>>
>> The announcement was at 49th ICAAC
>>
>> So 30 family doctors now think Tamiflu reduces mortality because of this
>> non randomised data. The fact that one of the studies was in hospitalized
>> patients and the advice was being given to community doctors makes this
>> even
>> more deceitful
>>
>> Evidence based is not even part of medicine today and unlikely to be so in
>> the face of such overwhelming ignorance.
>>
>> Martin
>>
>>
>> Studies report higher survival rates in Tamiflu-treated patients
>>
>>
>>
>> Singapore, Sep 14, 2009: Roche announced that two new observational
>> studies
>> concluded that influenza patients treated with Tamiflu (oseltamivir
>> phosphate) had significantly higher survival rates than untreated
>> patients.
>> The studies, examining nearly 1,000 people, analyzed outcomes for two
>> different groups -adults and children diagnosed with the highly pathogenic
>> A
>> (H5N1) avian influenza and adults hospitalized with seasonal influenza.
>> Results, which build on similar findings, were presented at the 49th ICAAC
>> annual meeting in San Francisco.
>>
>> "These retrospective studies support the potential benefits of antiviral
>> treatment in severe cases of influenza," said Dr Dominick Iacuzio, medical
>> director at Roche, which manufactures Tamiflu. "While Tamiflu is approved
>> and used in many countries to treat and prevent all types of A and B
>> influenza, these 'real-world' studies contribute to the body of clinical
>> evidence."
>>
>> The first study examined outcomes data for 215 patients from 10 countries
>> who were diagnosed with the virulent A (H5N1) avian influenza. The
>> retrospective observational study found that untreated patients had a
>> mortality rate of 88%, with 11 out of 89 (12%) untreated patients
>> surviving,
>> in contrast to survival of 45 out of 85 (53%) patients who received at
>> least
>> one dose of Tamiflu up to eight days after symptom onset. Among a subset
>> of
>> patients who received Tamiflu within two days of symptom onset, 5 out of 7
>> patients (71%) survived.
>>
>> The study was conducted by researchers from Avex Avian Influenza Expert
>> Group and the London School of Hygiene and Tropical Medicine, in
>> collaboration with Roche. It is the first to systematically assess human A
>> (H5N1) infection in multinational cases. Data were collected in-country
>> and
>> supplemented with data abstracted from published cases. Data were
>> anonymized
>> and reviewed for accuracy. Nearly all cases were confirmed at laboratories
>> accredited by the World Health Organization (WHO).
>>
>> "These data confirm the importance of prompt diagnosis and treatment with
>> Tamiflu. They also support previous studies indicating that treatment may
>> still beneficial even after 48 hours," explained Dr. Iacuzio.
>>
>> The A (H5N1) avian influenza virus continues to spread throughout parts of
>> Southeast Asia, Africa and the Middle East. Since 2003, the WHO has
>> reported
>> 440 human cases of A (H5N1), 262 of them fatal.
>>
>> The second study analyzed 760 patients hospitalized with severe seasonal
>> influenza, half of whom received Tamiflu (n=395). The data showed that the
>> rate of mortality was reduced by 37% in patients treated with Tamiflu
>> compared to patients who were not treated [3.8% in patients treated with
>> Tamiflu compared to 6.0% in patients who did not receive treatment,
>> adjusted
>> Hazard Ratio 0.38(0.19,0.78)].
>>
>> The retrospective, observational study was conducted in two general
>> hospitals in Hong Kong during a 24-month period, studying patients over
>> the
>> age of 18 who were hospitalized with confirmed influenza. Most patients
>> were
>> older (average age 70), 60% had underlying chronic illness, and 78% were
>> hospitalized with influenza complications.
>>
>>
>> http://www.biospectrumasia.com/content/140909OTH10638.asp
>>
>> On 2009-09-25, at 9:50 AM, Dr. Carlos Cuello wrote:
>>
>>
>>
>> http://link.reuters.com/cad68d
>>
>> WHO is making recommendations based on experience from observational data
>> and indirect from seasonal flu and in vitro tests (virus resistance)
>>
>> Somehow, the recommendations still aré strong. I guess, for physicians
>> wanting to based their clinical decisions on evidence, these aré the most
>> difficult topics, when the evidence is low quality but recommendations are
>> strong.
>>
>> BTW is someone running a RCT about Tamiflu on H1N1?
>>
>> It ' d be interesting to check clinicaltrials.gov<
>> http://clinicaltrials.gov/> & others
>>
>> Enviado desde mi iPhone
>>
>> El 25/09/2009, a las 03:47, Richard Nicholl <[log in to unmask]
>> <mailto:[log in to unmask]>> escribió:
>>
>>
>> “People take Tamiflu, Doctors prescribe Tamiflu (not because they expect
>> any noticeable benefit but because they fear what might happen if they
>> don’t) and they get better, and the epidemic subsides; and everybody has
>> been a good citizen and so thus proves that the Tamiflu and public health
>> policy must have worked.”
>>
>>
>>
>> Isn’t this was happened with the Millenium Bug….did it really exist???
>>
>>
>>
>> Richard Nicholl
>>
>> Consultant Neonatologist, Northwick Park Hospital, NorthWest London
>> Hospitals NHS Trust, Harrow HA1 3UJ
>>
>> RCPCH Tutor ,
>>
>> FY2 Programme Director
>>
>> secretary 8am-4:30pm: 0208 8693941
>>
>> NNU: 0208 869 2900
>>
>> bleep 325
>>
>> email: <mailto:[log in to unmask]> [log in to unmask]
>> <mailto:[log in to unmask]>
>>
>>
>>
>> -----Original Message-----
>> From: Evidence based health (EBH) [mailto:
>> [log in to unmask]<mailto:
>> [log in to unmask]>] On Behalf Of Owen Dempsey
>> Sent: 24 September 2009 18:08
>> To: <mailto:[log in to unmask]>
>> [log in to unmask]<mailto:
>> [log in to unmask]>
>> Subject: Re: Do the antivirals reduce mortality in flu?
>>
>>
>>
>> Agree with Bens comment: EBM important and should guide policy, however
>> It’s a shame that EBM continues to be hijacked and used to justify top
>> down
>> public health policy. I think Neal’s almost throw away comment:
>>
>> “Both the population and the individual perspectives (and nota bene the
>> plural) seem to me to be entirely legitimate.”
>>
>>
>>
>> carries dangers based as it is on a false premise. Thus: The idea that all
>> views on e.g. use of Tamiflu; [i.e. the competing views that either
>> ‘everybody’ should have Tamiflu (as under the criteria of the guidelines)
>> versus the decision/choice that Tamiflu is too risky for a given healthy
>> individual and shouldn’t be prescribed or taken] are of equal moral
>> status,
>> is flawed. This liberal ‘all views are fine by me’ stance assumes that
>> everybody has equal access to and understanding of the ‘real’ state of
>> affairs when it comes to the risk benefit ratio of this intervention.
>> This
>> is akin to pretending that we live in a ‘real’ democracy (which is of
>> course
>> an impossible fiction to attain) instead of an ‘organised democracy where
>> the outcomes e.g. of elections are preordained and the ‘people’
>> misinformed.
>>
>>
>>
>> With Tamiflu, the government, health spokesmen and the drug industry –
>> with
>> the help of the corporate media conspire to mislead the public by
>> over-egging the dangers of e.g. Mexican/Swine Flu and overstating (even if
>> it is by implication i.e. simply by recommending its use) the benefits of
>> Tamiflu. We actually know that the evidence of benefit is weak and
>> benefit
>> is small; and there are continuing anxieties about harms especially in the
>> young, but we choose to ignore this knowledge. (ref. Carl Heneghan et als
>> excellent journal club report in the BMJ rapid responses in the last 2
>> years or so). The knowledge for EBM is there but we are manipulated with
>> falsehoods, therefore the choices/decisions people are making, including
>> professionals, are ‘forced by public policy’ and are based on a deceit, so
>> it is ridiculous to say all choices have equal value. What can be said is
>> that most people are making choices that in part maintain the status quo
>> of
>> a society that is still exploitative, and in part simply makes profits of
>> one sort or another for politicians, drug companies and the self esteem of
>> the medical profession. A bit more honesty about the evidence from public
>> health and our esteemed spokesmen would be welcome.
>>
>>
>>
>> By the By:
>>
>>
>>
>> Zizek talks about the Theories of Fiction of Bentham and Lacan’s notions
>> on
>> democracy in his book Sublime Object of Ideology. Is it a necessary that
>> society believes in the fiction of public health policy? Is it true to
>> say
>> that here is no such thing a society, or, that a fully paid up member of
>> society that believes unquestioningly in public health policy is like a
>> good
>> Stalinist, ‘made of special stuff’ that special stuff being Lacan’s
>> ‘petit
>> objet a’, a surplus left over as desire tries to fulfil fantasy, it
>> doesn’t
>> actually exist. It’s a lack. People try to make up for this lack by
>> conforming AS IF the fantasy were true. If you don’t believe in public
>> health policy then you are no longer a bona fide member of society (but a
>> dissident to be outcast or ignored). People take Tamiflu, Doctors
>> prescribe
>> Tamiflu (not because they expect any noticeable benefit but because they
>> fear what might happen if they don’t) and they get better, and the
>> epidemic
>> subsides; and everybody has been a good citizen and so thus proves that
>> the
>> Tamiflu and public health policy must have worked.
>>
>>
>>
>> Best wishes
>>
>>
>>
>> Owen
>>
>>
>>
>>
>>
>> -----Original Message-----
>> From: Evidence based health (EBH) [mailto:
>> [log in to unmask]<mailto:
>> [log in to unmask]>] On Behalf Of Djulbegovic, Benjamin
>> Sent: 24 September 2009 14:38
>> To: <mailto:[log in to unmask]>
>> [log in to unmask]<mailto:
>> [log in to unmask]>
>> Subject: Re: Do the antivirals reduce mortality in flu?
>>
>>
>>
>> Niel, no doubt the efforts like these should be commended and appreciated…
>>
>> Just quick comment on your remark “The caveat is that this topic is, in
>> some circles, controversial.”
>>
>> This is in fact even more important reason to develop evidence
>> profiles/decision aids. Knowing what we know and what we don’t know (and
>> how
>> good is the quality of our knowledge) is what EBM is all about, as you
>> well
>> know it.
>>
>>
>>
>> Tom Jefferson has done a lot of work synthesizing the evidence on the
>> effects of flu vaccine. Tom: have you created evidence profile (or, even
>> decision aid) that it can be shared with the public? (BTW, one of the
>> reasons that Cochrane reviews are not being used as they should is because
>> until recently they have not included Summary of Evidence/Evidence Profile
>> tables.)
>>
>> Thanks to both of you on working on such an important topic
>>
>> best
>>
>> ben
>>
>>
>>
>>
>>
>> From: Maskrey Neal [mailto:[log in to unmask]<mailto:
>> [log in to unmask]>]
>> Sent: Thursday, September 24, 2009 8:56 AM
>> To: Djulbegovic, Benjamin; <mailto:[log in to unmask]>
>> [log in to unmask]<mailto:
>> [log in to unmask]>
>> Subject: RE: Do the antivirals reduce mortality in flu?
>>
>>
>>
>> Thanks Ben, I’ll file that appraisal in my revalidation folder :)
>>
>> The response has been very positive and we’re grateful to this group for
>> all the inspiration.
>>
>>
>>
>> I strongly suspect we won’t get lots of clinical outcomes-based
>> effectiveness data on swine flu vaccination in time for the early
>> programmes, but it would perhaps be worth us taking a look again at the
>> existing data (such as it is) on vaccination for seasonal influenza. The
>> caveat is that this topic is, in some circles, controversial.
>>
>>
>>
>> Bw
>>
>>
>>
>> Neal
>>
>> ________________________________
>>
>> From: Djulbegovic, Benjamin [mailto:[log in to unmask]<mailto:
>> [log in to unmask]>]
>> Sent: 24 September 2009 13:14
>> To: Maskrey Neal; <mailto:[log in to unmask]>
>> [log in to unmask]<mailto:
>> [log in to unmask]>
>> Subject: RE: Do the antivirals reduce mortality in flu?
>>
>>
>>
>>
>>
>> Neil, this is great! Have you (or anyone else) developed a decision aid
>> for
>> flu vaccine? With this panic about getting any possible vaccine one can
>> get,
>> it would be nice to have similar aid (of reason).
>>
>> Thanks
>>
>> ben
>>
>>
>>
>> From: Evidence based health (EBH) [mailto:
>> [log in to unmask]<mailto:
>> [log in to unmask]>] On Behalf Of Maskrey Neal
>> Sent: Monday, September 21, 2009 10:32 AM
>> To: <mailto:[log in to unmask]>
>> [log in to unmask]<mailto:
>> [log in to unmask]>
>> Subject: Re: Do the antivirals reduce mortality in flu?
>>
>>
>>
>> Sorry list, two postings in the same day is too much I know. Do these
>> help,
>> Martin?
>>
>>
>>
>> We’ve trawled the literature for oseltamivir to produce the best patient
>> decision aids we can. You can access them via the link from our home page
>> here <http://www.npc.co.uk/> http://www.npc.co.uk/
>>
>> …..or directly on our NPCi e-Learning site here <
>> http://www.npci.org.uk/therapeutics/infect/commonintro/patient_decision_aids/patient_decision_aid1.php>
>>
>> http://www.npci.org.uk/therapeutics/infect/commonintro/patient_decision_aids/patient_decision_aid1.php
>>
>>
>>
>> It’s not great data but the best we can find. If you can find better
>> please
>> tell us, but the UK national committee haven’t.
>>
>>
>>
>> In terms of decision making, values matter. National or regional public
>> health values (driven by onerous responsibilities to see the health system
>> optimally prepared, no avoidable catastrophes, disruption to essential
>> services avoided / minimised, and an excess of flu related deaths at least
>> as low as other developed countries) would indicate wide use of
>> oseltamivir
>> as being entirely reasonable despite the data being limited, at least in
>> some patient groups. The trade off is the remoter risk of future
>> resistance
>> and the cost - but the swine flu is now and the resistance is a future
>> possibility. Cf clopidogrel in ACS, any antibiotic prescribing for RTIs
>> and
>> many more examples.
>>
>> Individuals (patients and clinicians) might make different choices based
>> on
>> their perspective and values, none of which are likely to be exactly the
>> same as each others. And we might all make a different choice when we
>> actually have the flu, or someone we know has had flu-related pneumonia or
>> worse, as opposed to dispassionate discussions when we don't.
>>
>> Australian hospital docs on a recent UK documentary were apparently also
>> all for taking an antiviral too, based on the unavoidable problem that
>> looms
>> large in their values. They were most worried because no one can say at
>> presentation whether an individual will be one of the many who will have a
>> mild uncomplicated illness or be one of the few who gets very very very
>> sick. We seem to be hard wired as humans to be prepared to treat lots
>> unnecessarily to reduce the risk of an error of omission. That's one of
>> our
>> ways of dealing with stochastic uncertainty.
>>
>> Both the population and the individual perspectives (and nota bene the
>> plural) seem to me to be entirely legitimate.
>>
>>
>>
>> Bw
>>
>>
>>
>> Neal
>>
>> Neal Maskrey, National Prescribing Centre, Liverpool UK
>>
>> ________________________________
>>
>> From: Evidence based health (EBH) [mailto:
>> [log in to unmask]<mailto:
>> [log in to unmask]>] On Behalf Of Brian Alper MD
>> Sent: 21 September 2009 14:06
>> To: <mailto:[log in to unmask]>
>> [log in to unmask]<mailto:
>> [log in to unmask]>
>> Subject: Re: Do the antivirals reduce mortality in flu?
>>
>>
>>
>> It depends on what outcome you are promoting the antivirals for:
>>
>>
>>
>> If for mortality – there is observational evidence for seasonal influenza
>> for hospitalized adults
>>
>> If for duration of illness – there are randomized trials (seasonal
>> influenza)
>>
>> If for other complications – there some randomized trials (seasonal
>> influenza)
>>
>> If for reducing transmission to others – I’m not sure of evidence for
>> “treatment” but there is evidence for prophylaxis
>>
>>
>>
>>
>> Brian S. Alper, MD, MSPH
>>
>> Editor-in-Chief, DynaMed (www.ebscohost.com/dynamed<
>> http://www.ebscohost.com/dynamed>)
>>
>>
>>
>> -----Original Message-----
>> From: Evidence based health (EBH) [mailto:
>> [log in to unmask]<mailto:
>> [log in to unmask]>] On Behalf Of Martin Dawes, Dr.
>> Sent: Monday, September 21, 2009 8:59 AM
>> To: <mailto:[log in to unmask]>
>> [log in to unmask]<mailto:
>> [log in to unmask]>
>> Subject: Do the antivirals reduce mortality in flu?
>>
>>
>>
>> Sorry
>>
>> Naïve question but I could not find any RCT's - am I missing something
>> here
>> or are we promoting unproven therapy?
>>
>>
>>
>> Thanks
>>
>> Martin
>>
>>
>>
>> (neuraminidase and influenza and mortality) AND (randomized controlled
>> trial[Publication Type] OR (randomized[Title/Abstract] AND
>> controlled[Title/Abstract] AND trial[Title/Abstract]))
>>
>> No virus found in this incoming message.
>> Checked by AVG - <http://www.avg.com/> www.avg.com<http://www.avg.com/>
>> Version: 8.5.409 / Virus Database: 270.13.112/2392 - Release Date:
>> 09/24/09
>> 05:52:00
>>
>>
>>
>> --
>> Carlos A. Cuello-García, MD
>> Director, Centre for Evidence-Based Practice-Tecnologico de Monterrey
>> Cochrane-ITESM coordinator. Professor of Paediatrics and Clinical Research
>> Avda. Morones Prieto 3000 pte. Col. Doctores. CITES 3er. piso,Monterrey
>> NL,
>> México. CP64710
>> Phone. +52(81)88882154 & 2141. Fax: +52(81)88882019
>> www.cmbe.net<http://www.cmbe.net/>
>> http://twitter.com/CharlieNeck
>>
>> The content of this data transmission must not be considered an offer,
>> proposal, understanding or agreement unless it is confirmed in a document
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>> transmission is confidential and is intended to be delivered only to the
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>> for any purpose
>>
>
--
Dr Tom Jefferson
Via Adige 28
00061 Anguillara Sabazia
(Roma)
Italy
tel 0039 3292025051
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