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Molecular predictors will be marketed soon that will seamlessly expand the diagnostic category to include 'future' risk, for something for which EBHC has no gold standard:Biomes Res Int. 2015; 2015: 910267.Published online 2015 Jul 1. doi: 10.1155/2015/910267Howlett P et al"There is however promising research suggesting that microRNAs, stable noncoding RNAs (ribonucleic acid) found in serum and plasma which modulate RNA transcription, may play such a role. There is a relative paucity of research in this area to date and studies investigating a link to PAF are even scarcer. However promisingly, several preliminary studies have shown that plasma miRNA-150 expression, already implicated in the regulation of genes associated with atrial remodeling, is significantly reduced in individuals with PAF [59, 60]."OwenThe paper also mentions the aspect of diagnosis that escapes calculation.' .... Paroxysmal AF is challenging to diagnose because of its intermittent nature, and there is no accepted gold standard method for its diagnosis.'This means that the diagnosing of PAF is at the discretion of experts, and virtually limitlessly expandable. The next stage in the cascade for venture capitalists is to find some geneticists floating a company selling a molecular genetic signature that predicts risk of developing AF or even PF.Owen-we need a new EBM-there are no comments about how the screening diagnosis strategies compares with optimising treatment of the patients we previously know having the risk, a critical clinical question; see the example of Manchester http://www.issuesandanswers.-there is not a section about patients/relatives' point of view only a mention about increasing awareness-RCTs are about "diagnosis" so the translation to "final outcomes" is generally an academic exercise-there is not a section about "harms" of the screening-the paper has a "caveat emptor" sentence but not a section: "Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice".-first, the title of the paper should emphasize "diagnosis", so "Screening strategies for DIAGNOSIS of atrial fibrillation"-thanks, Luiza for your kind words-for the debate we can use an example, if i have read and understood well (criticism wellcome):Screening strategies for atrial fibrillation
Pulso, cribado, fibrilación auricular. Efectivo, oportunístico en atención primaria. Mejor diagnóstico. ¿Y salud?
Atrial fibrillation screening: syst review, cost-effectiveness analysis. Better diagnosis YES. Better final outcomes?
https://www.journalslibrary.nihr.ac.uk/hta/hta21290#/ abstract org/wp-content/uploads/11.00- Ivan-Benett-Case-against-v2. -un saludo juan gérvas @JuanGrvas2017-06-20 19:59 GMT+02:00 Juan Gérvas <[log in to unmask]>:-un saludo juan gérvas @JuanGrvas-by the way, David Sackett advise us about "experts" and its arrogance http://www.cmaj.ca/content/-but we become lost in translation with the "expert" and its financial conflicts of interest when "producing clinical guidelines"-we need to be careful with RCTs because the manipulation of data, the bias of publication itself and more and more-of course, we can trust a fine selection of authors as Guyatt, Ioannidis, Horwitz & Singer, and Richardson167/4/363.full -so we need to be very carefully, from the RCTs to the clinical desk, not only because the patient/situacion complexety but also because EBM itself-in summary, i insist, we need a new EBM without arrogance, with a mandatory "caveat emptor" and "harms" sections in all publications directed to clinicians (plus "EBM usually do not care to much about translating the new knowledge and evaluating its impact in clinical care in patients' health outcomes (final health outcomes) -we need less and best EBM, a new one with focus in outcomes from the point of view of patients/relatives and the society")2017-06-20 12:48 GMT+02:00 Owen Dempsey <[log in to unmask]>:Who could not agree with that Huw.
Advice : 'ad vire' - to make see, is the language of experts. And whilst expertise is important and has a role, maybe our job is also to make visible what is not so easily seen: to de-mystify, to de-expertise the consultation, to de-mathematise life, and to challenge advice based on unproven interventions and to challenge, even attempt to reverse, the dogma that more is necessarily better.
We won't be able to do this unless we understand how capitalism shapes our values and mindsets.
Owen
Politicians generally listen and react to the views of people. Unfortunately it often requires many disasters to make this happen as we have discovered recently in London.
They are also influenced by experts who may misguide politicians and the public, often because of fixed ideas that are not supported by evidence. Surely it is our job to strive to improve the advice given to our patients, the wider public and politicians and to warn about the disasters that may happen if sensible advice is ignored.
Huw
Yes, EBHC methodology may help us guard against quackery but it isn’t succeeding very well. And it won’t succeed if it is viewed (theorised, taught and practiced) in isolation from the political world.
As Huw said earlier, EBHC methodology is inadequate when applied to diagnosis and the asymptomatic, as in predictive diagnostic processes that include screening . And it’s methodology is used (hijacked if you like) and ‘shapes’ public opinion through the elitist models promoted by The Chicago School of neoliberalism (Nik-Kah, 2016).
‘Public opinion … is the work of men like ourselves, the economists and political philosophers of the past few generations, who have created the political climate in which the politicians of our time must move …’(Hayek, F. 1948. ‘Free’ Enterprise and Competitive Order, in Hayek F.A. ed., Individualism and Economic Order. Chicago: University of Chicago Press: 107–18cited in Nik-Kah, 2016)
This shapes the mindsets of patients (and experts), that are increasingly anxious so that they are increasingly likely to present with symptoms. This creates a vicious circle that intensifies harms (as in Esposito 's immunisation paradigm(Esposito, 2008)).
The mathematics of EBHC is unassailable as logic. But the mathematical model is inadequate to life itself, as Husserl pointed out in the 1930s:
‘But now we must notice something of the highest importance that occurred even as early as Galileo: the surreptitious substitution of the mathematically substructed world of idealities for … our everyday life-world.’(Husserl, 1970, pp 48-49)
The domination of EBHC by its mathematical basis makes it the perfect tool for making life calculable for the market. But it is, after all, only a model for life and life cannot be moulded to fit the model. I think the crucial flaw of EBHC methodology is that it doesn't have a definition of its object, diagnosis. And, as a result, diagnosis and EBHC becomes vulnerable to 'the social', capitalism, and its maximalist expert mindset.
Esposito, R. (2008) The Immunization Paradigm. diacritics, 36(2): 23-48.
Husserl, E. (1970) The Crisis of the European Sciences - an introduction to phenomenological philosophy. Evanston: Northwestern University Press.
Nik-Kah, E.V.-H., R (2016) The Ascendancy of Chicago Neoliberalism. In: S. Springer (ed.) The Handbook of Neoliberalism: New York: Routledge.
On Tue, Jun 20, 2017 at 8:01 AM, Huw Llewelyn [hul2] <[log in to unmask]> wrote:
Andre Knottnerus & Peter Tugwell wrote recently that "It is much more productive to recognize that EBM-workers themselves have always been among the first to say that EBM should continuously improve, to figure out how this can be done, and to act upon this, in collaboration with others who want and are able to contribute.
Current EBM does not provide evidence for the best findings for use in differential diagnosis (including for screening test results), evidence for the best findings for use in diagnostic criteria or evidence for the best findings for use in predicting which patients will benefit from a treatment. These issues are central to medical science and practice (see https://blog.oup.com/2013/09/
medical-diagnosis-reasoning- ).probable-elimination/
I am trying to improve matters by education (see http://oxfordmedicine.com/
view/10.1093/med/ ). Is there anyone in the EBM community who wishes to join me? Are Andre Knottnerus & Peter Tugwell wrong?9780199679867.001.0001/med- 9780199679867-chapter-1
Huw Llewelyn
Thank you, Craig, well said!
Best
Amy
From: "EVIDENCE-BASED-HEALTH@
JISCMAIL.AC.UK " <EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK > on behalf of Craig Lockwood <[log in to unmask]AU>
Reply-To: Craig Lockwood <[log in to unmask]AU>
Date: Tuesday, June 20, 2017 at 12:08 AM
To: "EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK " <EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK >
Subject: Re: Hijacked evidence-based medicine
My take on this:
Its not EBM that has been hijacked, it was medicine itself, and that happened a long time ago. If anything, I’m of the view that EBM actually has the framework that can assist to remove medicine from the tentacles of vested interests; but that will always be difficult in a field where care provision is based on a quasi-business model. EBM does promote transparency, and has increased the pressure on big pharma to give open access to trial data, these are gains that can be reasonably credited to EBM (or EBHC as I like to call it).
My $0.02
Craig
Assoc/Prof Craig Lockwood, PhD
Director: Implementation Science
The Joanna Briggs Institute,
Chair: Implementation Working Group G-I-N
Postgraduate Coordinator: Faculty of Health Sciences,
The University of Adelaide,
SA 5005 Adelaide
T : +61 8 831 36157
e-mail: craig.lockwood@
adelaide.edu.au
CRICOS Provider Number 00123M
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From: "Evidence based health (EBH)" <EVIDENCE-BASED-HEALTH@
JISCMAIL.AC.UK > on behalf of Anoop B <[log in to unmask]>
Reply-To: Anoop B <[log in to unmask]>
Date: Tuesday, 20 June 2017 at 2:11 am
To: "EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK " <EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK >
Subject: Re: Hijacked evidence-based medicine
Thank you Carlos!
The conclusion of the article you posted sums it up well" What does not help - as also Ioannidis emphasizes - is making a caricature of EBM and then attacking this on inappropriate grounds. It is much more productive to recognize that EBM-workers themselves have always been among the first to say that EBM should continuously improve, to figure out how this can be done, and to act upon this, in collaboration with others who want and are able to contribute. That is how progress and innovation work. If there is one really big concern, it is that non-evidence-based or even contra-evidence-based approaches are still widely present in ‘fact-’ or ‘evidence-free’ practices, that are not only far from risk- and harmless, but sometimes even advocated, in medicine, society and policy.
On Mon, Jun 19, 2017 at 12:07 PM, Carlos A. Cuello Garcia <[log in to unmask]> wrote:
There are good comments and an editorial from recognized EBM leaders (Guyatt, Ioannidis, and others) since April 2017 in the JCE:
"
Evidence-based medicine: achievements and prospects
"
http://www.jclinepi.com/
article/S0895-4356(17)30163-4/ fulltext
"EBM has not only called out the problems but offered solutions" ....‘Individualized care is in the heart of EBM.'
--
Carlos A. Cuello, MD, Ph.D.(c)
Health Research Methodology Program
Department of Health Research Methods, Evidence, and Impact
McMaster University. Faculty of Health Sciences
HSC-2C, 1280 Main Street West. Hamilton ON Canada L8S 4K1
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Un o’r 4 prifysgol uchaf yn y DU a’r orau yng Nghymru am fodlonrwydd myfyrwyr.
(Arolwg Cenedlaethol y Myfyrwyr 2016)
www.aber.ac.uk
Top 4 UK university and best in Wales for student satisfaction
(National Student Survey 2016)
www.aber.ac.uk------