On the need for evidence-based medicine

We tested the hypothesis that the fludrocortisone in doses sufficient to elevate blood pressure (BP) in normal subjects would increase platelet cytosolic calcium. Eight normal volunteers were given 0.8 mg fludrocortisone daily for 7 days (short protocol). Eight other normal volunteers ingested the drug for 6 weeks (long protocol). In the short protocol, fludrocortisone increased platelet cytosolic calcium and body weight by day 3, while BP was increased by day 7. In the long protocol, platelet cytosolic calcium was increased after 1 week, returned to basal values by 3 weeks and remained at that level for the rest of the study. Stimulation of the subjects' platelets ex vivo with thrombin and vasopressin led to a significant increase in intracellular free calcium concentration; however, fludrocortisone treatment did not alter the calcium response to either agonist. Fludrocortisone decreased serum potassium, plasma renin activity, plasma noradrenaline concentration and serum ionised calcium. These changes, as well as the BP increase, reverted to basal values when the drug was discontinued. We next incubated human platelets with fludrocortisone (1.4 nmol/l) and found a significant increase in cytosolic calcium by 30 min. The data suggest that a blood pressure-raising dose of mineralocorticoid leads to a transient (days to weeks) increase in platelet cytosolic calcium. Platelet cytosolic calcium and blood pressure are dissociated in that cytosolic calcium increases before the BP increase and later decreases to lower values, while the BP increase is sustained. Mineralocorticoid also has a direct effect on platelet cytosolic calcium in vitro.(ABSTRACT TRUNCATED AT 250 WORDS)     

Introducing evidence-based medicine into a community family medicine residency

In this article we discuss how we are introducing the concept of evidence-based medicine (EBM) into our Family Practice Residency Program. We review the basic concepts of EBM., show how these have been incorporated in the curriculum, and how they are applied to patient care. We identify the need for further work to evaluate our efforts and improve them.     

The evidence missing from evidence-based practice.

Comments on the report by the APA Presidential Task Force on Evidence-Based Practice (see record 2006-05893-001) entitled Evidence-based practice in psychology. Regrettably, the task force report was largely silent on three critical issues. As a consequence, it omitted much of the evidence necessary for a complete picture of evidence-based practice. First, the task force report did not operationalize "evidence." Second, the task force report did not address the crucial problem of iatrogenic treatments. Third, the task force report said little about the necessity for ongoing objective evaluation of clinical cases, which is critical to ethically responsible services. Current debate centers on how research findings should be factored into interventions, not on whether it is necessary to do so. Rather than waiting for the resolution of competing views on the matter, psychologists bear an ethical obligation to offer evidence-informed services. Three critical steps that were largely neglected by the task force report can go far toward helping psychologists honor that commitment: (a) providing a clearer operationalization of scientific evidence, (b) using current research to rule out the use of potentially harmful methods, and (c) using objective criteria to evaluate all of their cases on an ongoing basis. These steps, in turn, clarify the menu of options available to therapists, help protect clients from harm, and offer the advantage of allowing clinicians to contribute to the growing body of knowledge about what does and does not work in psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alternative medicine: where''s the evidence?

Third ventriculocisternostomy was performed in 23 patients for management of hydrocephalus. The procedure was offered as the first treatment in 18 cases and in lieu of a shunt revision in 4 cases. Median follow-up was 17 months (range 7-44 months). In 16 patients the operation was successful in treating their symptoms (73%). Cine MRI was helpful in evaluating patients with persistent ventriculomegaly. Resolution of symptoms in association with decreased ventricular size correlated best with outcome following this procedure. Third ventriculocisternostomy is technically safe and minimally invasive and should be offered as the first procedure in the management of noncommunicating hydrocephalus.     

Treatment of lichen planus. An evidence-based medicine analysis of efficacy

OBJECTIVE: To critically appraise the body of literature concerning treatment of lichen planus (LP). DESIGN: Review of MEDLINE and BIOSIS databases to identify articles published with at least an English abstract before March 1998 that examined treatment of LP. MAIN OUTCOME MEASURES: Forming a primary database on which most recommendations are based. We thus selected 83 clinical trials or small series of patients in the medical literature that referenced clinical data on patients treated for LP. RESULTS: There are no large randomized trials with definitive results in the medical literature examining the efficacy of the various drugs or physical treatments of LP. There are only 3 level B trials (small randomized trials with uncertain results because of moderate to high alpha or beta error) that address efficacy of treatment in LP, i.e., 1 with acitretin in cutaneous LP and 2 with topical corticosteroids in mucosal LP. The remainder of the published trials are observational and are not always prospective. Many of the recommendations of the experts are based on their personal experience. CONCLUSIONS: Although LP may be associated with substantial morbidity and altered quality of life, especially the erosive mucosal LP, definitive clinical trials have not been performed. Acitretin is the first-line therapy in cutaneous LP. The efficacy of systemic corticosteroids and psoralen plus UV-A therapy has not been established with a high level of proof. Topical corticosteroids are the first-line therapy in mucosal erosive LP. Other treatments, such as topical cyclosporine or extracorporeal photochemotherapy, remain to be evaluated. European-US cooperation is warranted to perform large randomized controlled trials in cutaneous and mucosal LP.     

Evidence-based medicine: what is the evidence?

The cytology of nasal secretions in 20 patients with allergic rhinitis and 15 patients with chronic maxillary sinusitis was investigated with transmission electron microscope to study the ultrastructure of the cluster epithelial cells in nasal secretions of allergic rhinitis. The results showed that the cluster epithelial cells were predominant cellular element in allergic nasal secretions. The number of cluster cells correlated positively with the number of eosinophils and the levels of eosinophilic cationic protein. It is suggested that the exfoliation of cluster nasal epithelial cellular elements may be caused by eosinophic cationic protein with resultant hyperreactivity of nasal mucosa.