Has Evidence-Based Medicine Gone Too Far?

Although there is no question that evidence-based medicine is a very important development in the evolution towards higher quality healthcare, the demand for evidence for a given treatment can go too far.
The following abstract is an ACTUAL published article in the British Medical Journal describing the lack of evidence that parachutes are effective when falling out of a plane.

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.Smith GC, Pell JP (2003) BMJ. 327 (7429), 1459-61.

Objectives To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.
Design Systematic review of randomised controlled trials.
Data sources: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists.
Study selection:  Studies showing the effects of using a parachute during free fall.
Main outcome measure: Death or major trauma, defined as an injury severity score > 15.
Results We were unable to identify any randomised controlled trials of parachute intervention.
Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

Read the full text article here.

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Making Twitter Work for a Specialty Medical Practice (Like ENT)

I've been asked by a few ENT colleagues how I got Twitter to work for my practice and how in the world I managed to get more than a few dozen followers.

I've been at it for about 1 year now (up to 355 followers @FauquierENT) and here are a few tips to making it work for a medical practice... Just an opinion... And it may not apply to everyone...

• When you tweet something, always back it up with a useful link to a webpage using a link shortner like bit.ly or goo.gl.
• Tweet about topics that the LAY-PERSON would find interesting. Twittering about "Outcomes of Vascularized Bone Graft Reconstruction of the Mandible in Bisphosphonate-Related Osteonecrosis of the Jaws" is NOT going to garner you fans even if you personally as an ENT find it riveting reading. An example of a good tweet I recently posted is "Do Cell Phone Makers Secretly Know Cell Phones May Cause Health Problems? http://ht.ly/3bBUZ"
• Follow people you find interesting. They will follow you back typically and their followers will slowly start to follow you. Given I twitter about ENT topics, I make it a point to follow ALL otolaryngologists, respected medical journalists, and health related newspapers.
• Write a blog and use twitter to "advertise" your blog article.
• ADVERTISE on your website that you have a twitter account.
• Be active with tweets. Potential followers will not be that excited to follow you if you have something interesting to say only once every few weeks.
• IF you come across something interesting in a medical journal, tweet it, and support it with a link.

So there you have it... Now go sign up with twitter and don't forget to follow my tweets!

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New Non-Addictive Sleep Drug to Help People Sleep!!!

It was with great interest that I read a recent report that a new drug, Silenor, was approved by the FDA this month (March 18, 2010) to help people who have trouble sleeping. Although there are already prescription medications to help with sleep (Ambien and Lunesta being the most common ones), Silenor is very interesting in that there was no suggestion of any addictive properties or withdrawal with this medication in over 1000 patients during clinical trials.

In fact, Silenor has not been designated as a controlled substance by the U.S. Drug Enforcement Administration (DEA) because of its demonstrated lack of abuse potential. Ambien and Lunesta are both considered as controlled substances.

Silenor binds with high affinity to the histamine H1 receptor... the same receptor that over-the-counter benadryl attaches to resulting in a side-effect of drowsiness. BUT, Silenor attaches to this receptor 14X more strongly compared to benadryl.

Silenor is made by Somaxon Pharmaceuticals (SOMX).

Read more here.

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RANDOM: Benford's Law Applied to Health?

Today, I listened to an amazing NPR RadioLab episode titled "Numbers."

In one of the stories in this episode, Jad and Robert Krulwich educated me on an interesting mathematical phenomenon called Benford's Law. Simply stated, Benford's Law states that in lists of numbers from many (but not all) real-life sources of data, the leading digit is distributed in a specific, non-uniform way. According to this law, the first digit of a number is "1" almost one third of the time, and larger digits occur as the leading digit with lower and lower frequencies, to the point where 9 as a first digit occurs less than one time in twenty. This is completely contrary to the expectation that the number 9 or 8 should occur equally as frequently as 1 or 2.


(From "The First-Digit Phenomenon" by T. P. Hill, American Scientist, July-August 1998)

But get this... This law holds true whether talking about random samples from a day's stock quotations, a tournament's tennis scores, the numbers on the front page of The New York Times, the populations of towns, electricity bills in the Solomon Islands, the molecular weights of compounds, the half-lives of radioactive atoms, and much more.

It seems to me that if the universal natural state of order follows Benford's Law... I wonder whether it also holds true for the human body...

I did a pubmed search and it seems that there have been a few researchers who had the same idea, most applied only to basic biological processes:

- Biologic kinetic rate parameters follow Benford's Law (abstract)
- mRNA transcription data from a wide range of organisms and measured with a range of experimental platforms show close agreement with Benford's law (abstract)
- Different states of anesthesia can be detected by Benford's Law (link)

Just for giggles and kicks, I looked up normal bloodwork values for a human being. This website nicely listed the most common normal values. I than jotted down the frequencies of the first integer of all the lab values listed and here's what I came up with:

#1 (30.5%)
#2 (17.1%)
#3 (10.2%)
#4 (10.2%)
#5 (7.3%)
#6 (7.3%)
#7 (6.5%)
#8 (5.8%)
#9 (5.1%)

Amazingly... though the frequencies don't match up perfectly, they do come eerily close to Benford's Law.

With larger lists of numbers, the approximations may come even closer. Potential neat project for a student, eh?

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