As a practicing clinician, who reads Evidence Based Medicine to keep
up to date with significant progress in medicine, I cannot help feeling
perplexed about the review of Ambrosy and Gheorghiade on the article by
Zannad et al (Eplerenone in patients withsystolic heart failure and mild
symptoms, NEJM 2011; 364 : 11-21). Throughout their commentary, the
reviewers fail to mention that the main conclusion...
As a practicing clinician, who reads Evidence Based Medicine to keep
up to date with significant progress in medicine, I cannot help feeling
perplexed about the review of Ambrosy and Gheorghiade on the article by
Zannad et al (Eplerenone in patients withsystolic heart failure and mild
symptoms, NEJM 2011; 364 : 11-21). Throughout their commentary, the
reviewers fail to mention that the main conclusion of the study,namely
that a potassium sparing diuretic is beneficial in systolic heart failure
while increasing the risk of hyperkalaemia, is hardly innovative, since
aldosterone-receptor blockade has been part of recommended therapy for a
number of years (1,2). This being the case, it is also perplexing why
Ambrosy and Gheorghiade fail to mention that the choice of a placebo in
the control group, and the excess mortality hence recorded,is particularly
difficult to justify under the Helsinki Declaration of Human Rights,
according to which a new method should be tested against the best
available alternative. Ethical considerations aside, such an unbalanced
comparison artificially expands any measure of relative risk reduction in
mortality achieved by Eplerenone. It also deprives the prescriber,
perphaps not unintentionally in an industry-funded trial, of an answer to
the question of whether the significant extra cost of this drug buys any
substantial benefit over that achieved by Spironolactone. If the journal
really prides itself in providing a fair and comprehensive review of
recent medical developments, these omissions should be urgently rectified.
References
1) Hunt SA, Abraham WT, Chin MH et al. 2009 focused update incorporated
into the ACC/AHA 2005 Guidelines for the diagnosis and management of heart
failure in adults : A report from the American College of cardiology
Foundation/American Heart Association Task Force on Practice Guidelines;
developed in collaboration with the International Sociaty for Heart and
Lung Transplantation. Circulation 2010;121 (12):e258.
2) Dickstein K, Cohen-Solal A, Filippatos G et al. ESC Guidelines for the
diagnosis and treatment of acute and chronic heart failure 2008 - The Task
Force for the diagnosis and treatment of acute and chronic heart failure
2008 of teh European Society of Cardiology; developed in collaboration
with the Heart Failure Association ot the ESC (HFA) and endorsed by the
European Society of Intensive Care Medicine (ESICM). Eur J Heart Failure 2008;10:933-989.
We welcome the publication of Medow and Lucey in the December issue, describing a qualitative approach to Bayes' theorem [1]. Especially because the authors provide a new impulse to the development of clinician-friendly strategies for teaching clinical decision making skills.
However, the approach proposed by the authors is not new. We reported a didactic model based on a visual representation of B...
We welcome the publication of Medow and Lucey in the December issue, describing a qualitative approach to Bayes' theorem [1]. Especially because the authors provide a new impulse to the development of clinician-friendly strategies for teaching clinical decision making skills.
However, the approach proposed by the authors is not new. We reported a didactic model based on a visual representation of Bayesian logic on a logarithmic scale eight years ago in peer-reviewed journals [ 2-4]. Our logical frame is also categorical and similar to the one proposed here, but it is more elaborate: it allows for the extremes of the probability scale, it provides more test power categories, and it covers asymmetry of test results.
The authors report a major limitation of their model: it applies to the intermediate range of probabilities (10-90), leaving the very high post test probabilities often at stake in specialist care and the very low concerned in general practice to the discretion of the clinician. In our model, using a log odds scale, findings with a "weak" power allow to advance or regress half step towards or away from diagnosis, "good" arguments one step, "strong" arguments one and a half and "very strong" two steps. In the author's model only two categories of test values are considered, good and very good. In case of weaker tests, the authors propose to change the probability category scale. Our model offers four categories of power of tests, reportedly also used by Alan Turing 50 years ago, corresponding to the log10 of the likelihood ratio rounded to half the unit [5].
Finally, their model somehow suggests symmetry of test results, a major misconception of junior clinicians. This symmetry applies to their example of a nuclear stress test, but not e.g., to D-dimers which are useful to exclude a pulmonary embolism, but add almost nothing for confirmation of the diagnosis.
We apply this approach for more than a decade in under and post graduate teaching and in clinical decision making workshops in different countries of Europe, Asia, Africa and South America with enthusiastic acceptance by trainees, but the effect of training with this approach still needs thorough assessment [6].
References
[1] Medow MA, Lucey CR. A qualitative approach to Bayes' theorem. Evid Based Med 2011;16(6):163-167.
[2] Van Puymbroeck H, Remmen R, Denekens J, et al. Teaching problem solving and decision making in undergraduate medical education: an instructional strategy. Med Teach 2003;25(5):547-550.
[3] Van Den Ende J, Bisoffi Z, Van Puymbroek H, et al. Bridging the gap between clinical practice and diagnostic clinical epidemiology: pilot experiences with a didactic model based on a logarithmic scale. J Eval Clin Pract 2007;13(3):374-380.
[4] Van Den Ende J, Moreira J, Basinga P, et al. The trouble with likelihood ratios. Lancet 2005;366(9485):548.
[5] Good I. AM Turing's statistical work in world war II. (Studies in the history of probability and statistics XXXVII). Biometrika 1979;66(2):393-396.
[6] Moreira J, Bisoffi Z, Narvaez A, et al. Bayesian clinical reasoning: does intuitive estimation of likelihood ratios on an ordinal scale outperform estimation of sensitivities and specificities? J Eval Clin Pract 2008;14(5):934-940.
The dorsal horns are not merely passive transmission stations but
sites at which dynamic activities (inhibition, excitation and modulation)
occur. [18]
Via a series of filters and amplifiers, the nociceptive message is
integrated and analysed in the cerebral cortex, with interconnections with
various areas. [1]
The processing of pain takes place in an integrated matrix throughout...
The dorsal horns are not merely passive transmission stations but
sites at which dynamic activities (inhibition, excitation and modulation)
occur. [18]
Via a series of filters and amplifiers, the nociceptive message is
integrated and analysed in the cerebral cortex, with interconnections with
various areas. [1]
The processing of pain takes place in an integrated matrix throughout
the neuroaxis and occurs on at least three levels, at peripheral, spinal,
and supraspinal sites. [9]
Knowledge of the modalities of pain control is essential to correctly
adapt treatment strategies (drugs, neurostimulation, psycho-behavioural
therapy, etc.).
Dysfunction of pain control systems causes neuropathic pain. [1]
Spinal Cord Stimulation modalities evolved from the gate-control
theory postulating a spinal modulation of noxious inflow. [16] [2] [7]
[11] [12] [15] [17] [20] [22] [23] [24] [25] [26]
It has been demonstrated in multiple studies that dorsal horn
neuronal activity caused by peripheral noxious stimuli could be inhibited
by concomitant stimulation of the dorsal columns. [8]
Pain relief was more prominent at pain ascending through C fibers
than pain ascending through Adelta fibers [21]
Many theories on the mechanism of action of Spinal Cord Stimulation
have been suggested, including activation of gate control mechanisms,
conductance blockade of the spinothalamic tracts, activation of
supraspinal mechanisms, blockade of supraspinal sympathetic mechanisms,
and activation or release of putative neuromodulators. [14]
At present, Spinal Cord Stimulation is a well established form of
treatment for failed back surgery syndrome, complex regional pain
syndromes (CRPS), low back pain with radiculopathy and refractory pain due
to ischemia. [4] [3] [8] [13]
Stimulation produced analgesia can provide a level of analgesia and
efficacy that is unattainable by other treatment modalities. [19]
Spinal Cord Stimulation for the treatment of chronic pain is cost-
effective when used in the context of a pain treatment continuum. [14]
Precise subcutaneous field stimulation is targeted to specific areas
of neuropathic pain. [6]
We aim at attenuation or blockade of pain through intervention at the
periphery, by activation of inhibitory processes that gate pain at the
spinal cord and brain. [9]
Segmental noxious stimulation produces a stronger analgesic effect
than segmental innocuous stimulation. [10]
That is exactly what intradermal sterile water or subcutaneous saline
injections do!
Chloride, used in subcutaneous "sham" injections, independently
regulates the pain pathway. [5]
In these studies there was no valid control group receiving sham
injections.
In the past, other researchers, in similar studies, have also had
difficulties in blinding and comparing with control groups. [4]
These RCTs simply compared an established therapeutic intervention to
another established therapeutic intervention.
References
[1] Labat JJ, Robert R, Delavierre D, et al. Anatomy and physiology of chronic pelvic and perineal pain. Prog Urol 2010;20(12):843-52. Epub 2010 Oct 20.
[2] Moharic M, Burger H. Effect of transcutaneous electrical nerve stimulation on sensation
thresholds in patients with painful diabetic neuropathy: an observational
study. Int J Rehabil Res 2010;33(3):211-7.
[3] Shrivastav M, Musley S. Spinal cord stimulation for complex regional pain syndrome.
Conf Proc IEEE Eng Med Biol Soc 2009;2009:2033-6.
[4] Kunnumpurath S, Srinivasagopalan R, Vadivelu N. Spinal cord stimulation: principles of past, present and future practice:
a review. J Clin Monit Comput 2009;23(5):333-9.
[5] Price TJ, Cervero F, Gold MS, et al. Chloride regulation in the pain pathway. Brain Res Rev 2009;60(1):149-70. Epub 2008 Dec 31.
[6] Henderson JM. Peripheral nerve stimulation for chronic pain. Curr Pain Headache Rep 2008;12(1):28-31.
[7] Handwerker HO. From Descartes to fMRI. Pain theories and pain concepts. Schmerz 2007;21(4):307-10, 312-7.
[9] DeLeo JA. Basic science of pain. J Bone Joint Surg Am 2006;88 Suppl 2:58-62.
[10] Defrin R, Ariel E, Peretz C. Segmental noxious versus innocuous electrical stimulation for chronic pain
relief and the effect of fading sensation during treatment. Pain 2005;115(1-2):152-60.
[11] Craig AD. Pain mechanisms: labeled lines versus convergence in central processing. Annu Rev Neurosci 2003;26:1-30. Epub 2003 Mar 6.
[12] Staal JB, Hlobil H, van Tulder MW, et al. Return-to-work interventions for low back pain: a descriptive review of
contents and concepts of working mechanisms. Sports Med 2002;32(4):251-67.
[14] Krames E. Spinal Cord Stimulation: Indications, Mechanism of Action, and Efficacy. Curr Rev Pain 1999;3(6):419-426.
[15] Costentin J. Pain and its main transmitters. Ann Pharm Fr 2000;58(2):77-83.
[16] Meyerson BA, Linderoth B. Mechanisms of spinal cord stimulation in neuropathic pain. Neurol Res 2000;22(3):285-92.
[17] Yaksh TL. Regulation of spinal nociceptive processing: where we went when we
wandered onto the path marked by the gate. Pain 1999;Suppl 6:S149-52.
[18] Melzack R. From the gate to the neuromatrix. Pain 1999;Suppl 6:S121-6.
[19] Stanton-Hicks M, Salamon J. Stimulation of the central and peripheral nervous system for the control
of pain. J Clin Neurophysiol. 1997;14(1):46-62.
[20] Humphries SA, Johnson MH, Long NR. An investigation of the gate control theory of pain using the experimental
pain stimulus of potassium iontophoresis. Percept Psychophys 1996 ;58(5):693-703.
[21] Kakigi R, Watanabe S. Pain relief by various kinds of interference stimulation applied to the
peripheral skin in humans: pain-related brain potentials following CO2
laser stimulation. J Peripher Nerv Syst. 1996;1(3):189-98.
[22] Davis P. Pain: opening up the gate control theory. Nurs Stand. 1993;7(45):25-7.
[23] Cambier J. Gate control of the nociceptive message: applications to the treatment of pain. Bull Acad Natl Med 1989;173(7):855-60; discussion 860-1.
[24] Benabid AL, Henriksen SJ, McGinty JF, et al. Thalamic nucleus ventro-postero-lateralis inhibits nucleus
parafascicularis response to noxious stimuli through a non-opioid pathway. Brain Res 1983;280(2):217-31.
[25] Malow RM, Dougher MJ. A signal detection analysis of the effects of transcutaneous stimulation
on pain. Psychosom Med. 1979 Mar;41(2):101-8.
[26] Goldman DE. Gate control of ion flux in axons. J Gen Physiol 1965;48:SUPPL:75-7.
Although the accuracy of a mercury sphygmomanometer can be debated,
automatic and semi-automatic devices which inflate the cuff often do so to
well above the systolic pressure and can cause patients considerable
discomfort even when an appropriate cuff size has been used. These devices
frequently re-inflate for a variety of reasons, but out of control of the
operator who is waiting for a reading.
Although the accuracy of a mercury sphygmomanometer can be debated,
automatic and semi-automatic devices which inflate the cuff often do so to
well above the systolic pressure and can cause patients considerable
discomfort even when an appropriate cuff size has been used. These devices
frequently re-inflate for a variety of reasons, but out of control of the
operator who is waiting for a reading.
Anecdotally, I have had several patients request I use what they call
the "old fashioned" mercury sphygmomanometer at future consultations.
It would not be surprising to find that the "error" rate in blood
pressure determinations with the "old fashioned" sphygmomanometer was due,
in part, to a faulty technique by the individuals taking the blood
pressures. Remarkably, little or no time is spent in teaching medical
students the proper technique for blood pressure determination including
the appropriate cuff size to use, the various audible phases, etc. One
ca...
It would not be surprising to find that the "error" rate in blood
pressure determinations with the "old fashioned" sphygmomanometer was due,
in part, to a faulty technique by the individuals taking the blood
pressures. Remarkably, little or no time is spent in teaching medical
students the proper technique for blood pressure determination including
the appropriate cuff size to use, the various audible phases, etc. One
cannot determine if there is an exaggerated second phase of Karotkoff
sounds, which is an indicator of the presence of atherosclerotic disease,
with an electronic blood pressure apparatus. Neither can one determine the
presence of a pulsus paradoxicus with an electronic device. The relegation
of the stethoscope to the rubbish bin or museum was predicted decades ago
and has not yet taken place. I, for one, will continue to use my
stethoscope and take my patients' blood pressures with a manual
sphygmomanometer, thank you.
Bayes theorem can only be applied properly when considering a single
diagnosis or its absence e.g. the presence or absence of asymptomatic
diabetes mellitus, hypothyroidism, hyperlipidaemia, cervical cancer,
breast cancer, etc. These asymptomatic situations are very important in
the clinical setting and also in the community. It is in these situations
that the reasoning described in this paper can be...
Bayes theorem can only be applied properly when considering a single
diagnosis or its absence e.g. the presence or absence of asymptomatic
diabetes mellitus, hypothyroidism, hyperlipidaemia, cervical cancer,
breast cancer, etc. These asymptomatic situations are very important in
the clinical setting and also in the community. It is in these situations
that the reasoning described in this paper can be used. However, much of
our time is taken up with differential diagnosis, which cannot be modeled
by Bayes theorem (which explains why it is not often used as pointed out
by the authors).
When dealing with differential diagnoses, we must first choose a good
diagnostic lead [1, 2, 3] (or pivot [4]) e.g. acute abdominal pain, which
has a limited differential diagnosis. Tim de Dombal and his colleagues
did something similar [5]. We then choose a diagnosis from the list (e.g.
appendicitis) and look for findings (e.g. guarding) that occur commonly in
that chosen diagnosis and rarely (or never) in at least one other
diagnosis in the list (e.g. non-specific abdominal pain). This 'other'
diagnosis thus becomes less probable (or is ruled out if the finding
cannot by definition occur in people with that diagnosis). The chosen
diagnosis (e.g. appendicitis) correspondingly becomes more probable. A
'definitive' or 'sufficient' criterion (e.g. a red swollen appendix at
surgery would confirm a diagnosis.
A different 'reasoning by elimination theorem' is thus required to
model this reasoning process, which uses Bayes theorem as the starting
point of its proof [1, 2]. The author's qualitative approach in this
paper could also be applied to this 'reasoning by elimination theorem'
that models differential diagnostic reasoning.
References
1. Llewelyn DEH. Mathematical analysis of the diagnostic relevance of
clinical findings. Clin Sci 1979;57(5):477-479.
2. Llewelyn H, Ang HA, Lewis K, et al. The Oxford Handbook of
Clinical Diagnosis, 2nd ed. Oxford University Press, Oxford 2009;754-
772.
3. Lipschick GY, Von Feldt JM, Frame L, et al. The Oxford American Handbook of Clinical Diagnosis. Oxford University
Press, New York 2009;18-27.
4. Eddy DM, Clanton CH. The art of diagnosis: solving the clinico-
pathological conference. N Eng J Med. 1982;306:1263-1268.
5. Horrocks JC, de Dombal T. Computer-aided diagnosis:
description of an adaptable system, and operational experience with 2,034
cases. Br Med J 1972; 2: 5-9.
Different individuals have adapted and adopted the principles of EBM
to different degrees and in vastly different ways [1]. There is yet
another approach to EBM, which goes back a long way in terms of verbal
justification on ward rounds but which has not been put in writing and
taught in that way until recently [2]. It involves specifying the
'evidence' obtained from the patient that was used for ea...
Different individuals have adapted and adopted the principles of EBM
to different degrees and in vastly different ways [1]. There is yet
another approach to EBM, which goes back a long way in terms of verbal
justification on ward rounds but which has not been put in writing and
taught in that way until recently [2]. It involves specifying the
'evidence' obtained from the patient that was used for each diagnosis and
decision.
Instead of simply listing diagnoses and actions after the history and
examination, the 'patient's evidence' for each diagnosis can be placed in
parentheses after each diagnosis (e.g. "Diagnosis 1: Acute bronchitis
[Cough with yellow sputum for 5 days, sweats, no wheeze, no crackles on
20/11/11, all findings resolved by 25/11/11]". After each treatment or
test, the diagnostic indication is placed in parentheses (e.g.
"Amoxicillin 250mg tds for 5 days for diagnosis 1". The Oxford Handbook
of Clinical Diagnosis [2] provides thousands of such examples for students
and young doctors and suggests different formats for presenting the
'patient's evidence'.
Many 'problem oriented' computer systems allow these links to be made
automatically for each episode of care. If the patient has many diagnoses
then they can all be listed with their 'diagnostic evidence' and
management [2]. These can be updated (ideally automatically by computer)
after each clinical episode in hospital and general practice.
When 'transparent evidence-based summaries' of this kind were written
on a cohort of 76 patients admitted to a hospital under my care, an audit
showed that 45 (59.2%) of patients went home within 3 days compared with
161 out of 376 (42.8%) patients going home within 3 days when such
summaries were not written on admission (a difference of 16.4%, P= 0.008).
This appeared to happen because the nurses and doctors taking over care
could understand what had been done quickly and easily and continue the
care or change it if necessary without delay.
This approach of linking in writing individual patients' findings to
diagnoses and management for patients and others to read can be termed
'transparent medicine'. When the patient's findings match those in
evidence-based guidelines (or a supporting publication discovered during
or after a ward round) then the process can be described as 'transparent
EBM'. I doubt whether anyone would argue with this way of practising
medicine, which combines written transparency with EBM.
If the public become widely aware of this approach, it might become
ethically unjustifiable to practice 'non-transparent EBM' unless some RCT
showed that non-transparent EBM was as safe, efficient and effective as
'transparent EBM'!
References
1. Glasziou P. Editorial: What is EBM? Evid. Based Med. 2011 16:129-
130; doi:10.1136/ebm-2011-100099
2. Llewelyn H, Ang HA, Lewis K, et al. The Oxford Handbook of
Clinical Diagnosis, 2nd ed. Oxford University Press, Oxford 2009.
I agree with Dr. Tomedi's assertion that one might question the
credibility of a commentary written by someone who has received
pharmaceutical industry
support, or for a number of other reasons. It is for this reason that BMJ
Group policies ask authors to acknowledge and openly state any competing
interests (1), and as a result of this policy, Dr. Tomedi could become
aware
of them and consider them in reading the commenta...
I agree with Dr. Tomedi's assertion that one might question the
credibility of a commentary written by someone who has received
pharmaceutical industry
support, or for a number of other reasons. It is for this reason that BMJ
Group policies ask authors to acknowledge and openly state any competing
interests (1), and as a result of this policy, Dr. Tomedi could become
aware
of them and consider them in reading the commentary. An alternative
policy
could be to prohibit any person who has received pharmaceutical company
funding from writing a commentary. However, in some fields, many experts
have received some such funding. In the specific case of this commentary
(2), the commentator has raised a number of cautions about the results of
the study he critically appraised. And the competing interests appear to
span a number of sources (companies). It is certainly appropriate to
question bias, and then use one's judgment based on the available
information. I hope readers will continue to do this as they evaluate not
only the methodology of articles in the medical literature, but also the
context and other factors such as the qualifications of the authors, to
the
extent they can be evaluated.
2. Thomas, Mike. Cross-over randomised controlled trial: Long-
acting ?-agonist step-up therapy is more likely to provide best response,
compared to inhaled corticosteroid or leukotriene-receptor antagonist step
-up in children with uncontrolled asthma receiving inhaled
corticosteroids. Evid Based Med 2010;15:167-168 Published Online First: 16
August 2010
doi:10.1136/ebm1117
The important influence of pharmaceutical manufacturers on the medical literature, and the positive "spin" placed on results and conclusions, has been well documented. Given this pervasive problem, readers may question the credibility of the commentary of an EBM reviewer who has "received consulting fees from MSD, Schering, Novartis and GSK and received honoraria from Altana, Astra Zeneca, Boehringer Inglehi...
The important influence of pharmaceutical manufacturers on the medical literature, and the positive "spin" placed on results and conclusions, has been well documented. Given this pervasive problem, readers may question the credibility of the commentary of an EBM reviewer who has "received consulting fees from MSD, Schering, Novartis and GSK and received honoraria from Altana, Astra Zeneca, Boehringer Inglehiem, GSK, MSD, Merck Respiratory, Schering-Plough and Teva."
I was surprised to see the assertion by Philip Home that
rosiglitazone is a "particularly safe drug." Given its withdrawal from public use (the current prescribing ban recommended by MHRA in the UK, the European Medicines Agency and the FDA in the United States) due to concerns over increased cardiovascular risks, it would seem that our
health authorities see it as anything but a safe drug.
Dear Editor,
As a practicing clinician, who reads Evidence Based Medicine to keep up to date with significant progress in medicine, I cannot help feeling perplexed about the review of Ambrosy and Gheorghiade on the article by Zannad et al (Eplerenone in patients withsystolic heart failure and mild symptoms, NEJM 2011; 364 : 11-21). Throughout their commentary, the reviewers fail to mention that the main conclusion...
Dear editor,
We welcome the publication of Medow and Lucey in the December issue, describing a qualitative approach to Bayes' theorem [1]. Especially because the authors provide a new impulse to the development of clinician-friendly strategies for teaching clinical decision making skills.
However, the approach proposed by the authors is not new. We reported a didactic model based on a visual representation of B...
Dear Editors,
The dorsal horns are not merely passive transmission stations but sites at which dynamic activities (inhibition, excitation and modulation) occur. [18]
Via a series of filters and amplifiers, the nociceptive message is integrated and analysed in the cerebral cortex, with interconnections with various areas. [1]
The processing of pain takes place in an integrated matrix throughout...
Although the accuracy of a mercury sphygmomanometer can be debated, automatic and semi-automatic devices which inflate the cuff often do so to well above the systolic pressure and can cause patients considerable discomfort even when an appropriate cuff size has been used. These devices frequently re-inflate for a variety of reasons, but out of control of the operator who is waiting for a reading.
Anecdotally, I...
It would not be surprising to find that the "error" rate in blood pressure determinations with the "old fashioned" sphygmomanometer was due, in part, to a faulty technique by the individuals taking the blood pressures. Remarkably, little or no time is spent in teaching medical students the proper technique for blood pressure determination including the appropriate cuff size to use, the various audible phases, etc. One ca...
Dear Editor,
Bayes theorem can only be applied properly when considering a single diagnosis or its absence e.g. the presence or absence of asymptomatic diabetes mellitus, hypothyroidism, hyperlipidaemia, cervical cancer, breast cancer, etc. These asymptomatic situations are very important in the clinical setting and also in the community. It is in these situations that the reasoning described in this paper can be...
Dear Editor,
Different individuals have adapted and adopted the principles of EBM to different degrees and in vastly different ways [1]. There is yet another approach to EBM, which goes back a long way in terms of verbal justification on ward rounds but which has not been put in writing and taught in that way until recently [2]. It involves specifying the 'evidence' obtained from the patient that was used for ea...
I agree with Dr. Tomedi's assertion that one might question the credibility of a commentary written by someone who has received pharmaceutical industry support, or for a number of other reasons. It is for this reason that BMJ Group policies ask authors to acknowledge and openly state any competing interests (1), and as a result of this policy, Dr. Tomedi could become aware of them and consider them in reading the commenta...
Dear editor,
The important influence of pharmaceutical manufacturers on the medical literature, and the positive "spin" placed on results and conclusions, has been well documented. Given this pervasive problem, readers may question the credibility of the commentary of an EBM reviewer who has "received consulting fees from MSD, Schering, Novartis and GSK and received honoraria from Altana, Astra Zeneca, Boehringer Inglehi...
Dear Editor,
I was surprised to see the assertion by Philip Home that rosiglitazone is a "particularly safe drug." Given its withdrawal from public use (the current prescribing ban recommended by MHRA in the UK, the European Medicines Agency and the FDA in the United States) due to concerns over increased cardiovascular risks, it would seem that our health authorities see it as anything but a safe drug.
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