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Adapt or die: how the pandemic made the shift from EBM to EBM+ more urgent
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  • Published on:
    Equipoise, or not, when comparing filtering face piece respirators to surgical (medical) masks, and the futility of using a randomized control trial (RCT) for comparison. The need for evidence-based medicine+ - a paradigm shift.
    • Kevin Hedges, Occupational Hygienist Workplace Health Without Borders (International) and Canadian Aerosol Transmission Coalition

    Airborne transmission and inhalation, of SARS-CoV-2 is recognized by international public health agencies (Addleman et al. 2021) from both short- and long-range aerosol transmission (Tang et al. 2021).
    When comparing filtering face piece (FFP) respirators, with a surgical (medical) masks, for protection against an inhalable (ISO 7708) airborne virus such as SARS-CoV-2, “EQUIPOISE” a central tenet for conducting a randomised control trial (RCT), does not exist. The futility of using a RCT is analogous to carrying out a study in a construction site for hard hats or seat belts in a passenger vehicle. FFP respirators used in Canada are selected and used in accordance with CAN/CSA-Z94.4-18 (Selection, use, and care of respirators). Specifications are provided in CSA Z94.4.1:21 (Performance of filtering respirators).
    At least two international studies using RCT have been initiated since the start of the COVID-19 pandemic.
    a) United Kingdom: The impact of different grades of respiratory protective equipment on sickness absence due to respiratory infections including SARS-CoV-2 for healthcare workers (The funding committee did not recommend funding).
    b) Canada, multi-centre: where nurses are randomized to either use of a medical mask or to a fit-tested N95 respirator when providing care for patients with febrile respiratory illness.
    The findings from a poorly designed RCT may also be used as improper and biased rationale to downgrade respirator (masks...

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    Conflict of Interest:
    None declared.
  • Published on:
    EBM+ or a Trojan horse of 'science-experts'
    • Mark Murphy, GP Eldon Family Practice, Dublin 8, Ireland

    The clinical evidence we produce which impacts the care we deliver to patients must have the highest standards. Unlike biomedical evidence, the evidence behind our treatments, risk factors and diagnostic tests should be relevant to the patients and clinicians who practice at the coal-face and real-world of General Practice and our hospitals.
    We may have had 250,000 'peer-reviewed' articles relating to COVID-19 (whatever credibility that affords), but allowing biomedical assumptions to creep into guidelines and direct patient care, is taking a step backwards in evidence-based practice. COVID saw a multitude of 'experts' give their opinion freely in the media and on social media platforms, based on biomedical ‘evidence’, on opinion, through the platforming of academic-status and on dubious case-studies. This was self-evidently un-scientific, and arguably has set science back. Yet this article seems to advance the notion that this evidence should impact patient care.
    So much has to be done to enable EBM to flourish- yet this article will likely set EBM back. The evidence underpinning our treatments should be quantifiable in absolute terms, and the uncertainties and conflicts of interests (COIs) acknowledged. The evidence behind our risk factors characterised in absolute terms, within the context of confounders and biases from observational studies. Our diagnostic tests should be understood within the context of odds and post-test probability. O...

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    Conflict of Interest:
    None declared.
  • Published on:
    EBM orthodoxy has had a quasi-religious feel to it.
    • Jan K Melichar, Addiction Psychiatrist & Pragmatic Academic Clinician University Hospital Wales, Cardiff

    This refreshing article does much to help move forward from the self-imposed strictures of the EBM orthodoxy. I hope EBM+ grows as an idea as, currently, EBM feels, sometimes, quasi-religious in the fervour to reject “the wrong sort” of evidence. It leaves clinicians in fields like addiction - where RCTs are very difficult to do unless so simple in their structure that the results are clinically difficult to use or, worse, irrelevant - stuck. Meta-analyses of clinically irrelevant studies are still clinically irrelevant. Data is hard to come by that is not EBM-perfect, so why bother doing the clinical research? Hopefully this suggestion will improve that disconnect.

    Conflict of Interest:
    None declared.