Evidence Based Decisions

Re: Evidence Based Decisions

Phil Elkins — Fri, 24 Jul 2009 09:11:32 GMT

Perfect answer!!

Re: Evidence Based Decisions

Skeptvet — Thu, 23 Jul 2009 22:59:38 GMT

It sees like this thread has wandered quite a bit and spawned its share of offspring! On the topic of the original post, I think it is critical that vets make use of the best quality evidence available. For lots of reasons clinical experience is not nearly as trustworthy as most of us believe. If it's all we have, then it's what we use to guide our decisions, But if we have clinical trials, that's better, and the higher quality the trial the more weight the conlcusions should have and the more willing we should be to accept the answer instead of our own intuition or experiences. Evidence comes on a sliding scale of reliability, and while vet med sadly doesn't have nearly as much high quality evidence as we need, we do have some. It is easier than most vets seem to realize for those of us in practice to find and interpret the clinical evidence that exists and use it to bettter our practices. After all, the alternative seems to be making stuff up or following uncritically the advice of someone else or of tradition, and history doesn't suggest those are very reliable ways to determine best practices.

Re: Evidence Based Decisions

sophia guymer — Wed, 10 Jun 2009 20:15:31 GMT

[quote user="Evelyn Barbour-Hill"]Just go to the Forums page, click on 'Write a new post[/quote]

Thank you, , sometimes I use the approach my husband uses regularly, either pretend to be ignorant and let someone else solve it, or do a bad job so you won't have to do it again!

Re: Evidence Based Decisions

Mark Frost — Tue, 09 Jun 2009 16:49:06 GMT

[quote user="sophia guymer"]

[quote user="Arlo Guthrie"]Might it be worth starting a new thread concerning pimobendan / benazepril / QUEST? [/quote]

I haven't checked if it is already done but if not, then yes please Arlo, I don't know how to go about it, but would like to know bit more about this subject so if there was another thread to follow or participate in, that would be great!

sophia

[/quote]

Has been done now.. normal service can resume here!

Re: Evidence Based Decisions

Evelyn Barbour-Hill — Tue, 09 Jun 2009 15:18:14 GMT

Just go to the Forums page, click on 'Write a new post"

Re: Evidence Based Decisions

sophia guymer — Tue, 09 Jun 2009 14:29:03 GMT

[quote user="Arlo Guthrie"]Might it be worth starting a new thread concerning pimobendan / benazepril / QUEST? [/quote]

sophia

Re: Evidence Based Decisions

Peter Ding — Tue, 09 Jun 2009 13:03:51 GMT

I am always reminded of the fact that osteoarthritis is manifestly extremely variable in the severity of clinical symptoms from day to day, month to month or season to season in so many patients that it is almost impossible to come up with statistically significant data that supports the use of any product or treatment where the effect isn't immediate and long lasting.

How do you obtain data for evidence-based medicine with such conditions?

Most studies i have seen with GAGS, magnetic collars etc are not only often poorly designed but seldom involve statistically significant numbers.

Re: Evidence Based Decisions

Arlo Guthrie — Tue, 09 Jun 2009 07:48:07 GMT

Errr, going a bit off-topic again here. Might it be worth starting a new thread concerning pimobendan / benazepril / QUEST?

Just that it makes it easier for others to find discussions if the thread title is relevant to the subject under discussion.

Re: Evidence Based Decisions

Alex Avery — Mon, 08 Jun 2009 21:25:00 GMT

Is there not an ongoing trial at the moment looking into the use of pimobendan in dobermans as a preventative?

Re: Evidence Based Decisions

Alex Gough — Mon, 08 Jun 2009 18:15:38 GMT

Both have a great evidence for efficacy alone, with pimo more efficacious than ACEi. I doubt the trial will ever be done to compare both together vs either alone. However, I think as they work in different ways, and good evidence they both work, the consensus is that you use both if finances allow. Of course the other big question is when to use pimobendan. Most, (but not all) evidence suggests no point in starting ACEi prior to onset of heart failure. Im not sure if anyone knows if starting pimo prior to onset of heart failure might increase survival times.

Alex

Re: Evidence Based Decisions

Mark Frost — Mon, 08 Jun 2009 15:24:03 GMT

[quote user="alex gough"]

A case in point would be the great QUEST trial, which has altered the way I prescribe in heart failure.

Alex

[/quote]

Good example.. there was a variety of opinion on the subject prior and it was difficult to know as a relatively inexperienced 1st opinion vet if someone could only afford frusemide + 1 medication which to go for. The QUEST trial gives us an evidence based way of deciding (in MVD anyway). However, without a trial showing evidence of greater success using both pimobendan and benazepril plus frusemide, does that mean its not right to use them both?

Re: Evidence Based Decisions

Alex Gough — Mon, 08 Jun 2009 14:30:57 GMT

I agree, and I think there is a big difference between no evidence for an intervention, and evidence against an intervention. It should also be borne in mind that because an intervention was found not to make a statistically significant difference in a treatment, it is a different calculation to decide whether this proves the medication ineffective. On a course on study design I went on at Cambridge Mark Holmes and Peter Cockcroft criticised their own study on homeopathy in cattle. Although there was no statistical difference between homeopathy and placebo, so no evidence for effect, their study was insufficiently powered to prove for sure that the homeopathy didn't work.

Sadly a large proportion of what we do is not evidence based, and that is something we will have to live with in veterinary medicine because of small numbers of cases and lower funding for research compared with human medicine. However, where the evidence exists, we should use it. A case in point would be the great QUEST trial, which has altered the way I prescribe in heart failure.

Alex

Re: Evidence Based Decisions

Alex Avery — Sun, 07 Jun 2009 20:40:26 GMT

[quote user="beldather"]oh to have unlimited time and journal access [/quote]

I completely agree! That is the benefit of using the forums to discuss everything from drug usage to surgical techniques, different people will have read different journals and so can point people towards evidence supporting their experience or contradicting it. I barely have the time to flick throught the vet times let alone anything more substantial and also apreciate the input of people more knowledgable and experienced than myself (the vast majority )!

Re: Evidence Based Decisions

beldather — Sun, 07 Jun 2009 14:59:59 GMT

[quote user="alex gough"]On the subject of cartrophen, a very recent systematic review of the management of canine osteoarthritis (Sanderson et al 2009, Vet Rec) showed that "There was weak or no evidence in support of the use of doxycycline, electrostimulated acupuncture, extracorporeal shockwave therapy, gold wire acupuncture, hyaluronan, pentosan polysulphate, P54FP (extract of turmeric), tiaprofenic acid or tibial plateau levelling osteotomy."[/quote]

Yet, this is where I get somewhat confused.
Of the papers covered by that review (wasn't able to read all of them so may have missed a few) the first paper showed an increased rate of improvement using pentosan over placebo. Was the study poorly managed, quite possibly (abstract only unfort) so that means the results 'may' be wrong.
The second paper was regarding the use of oral pentosan which is a) kinda irrelevant as we don't use that, but when coupled with the fact that there is a few human studies floating around showing that oral bioavalability of pentosan is absolutely minimal, further questions the relevance of it in the review.

I do think we have to be careful not to be too caught up in EBM that we ignore its failings. EBM works well if we have the studies and data to support the conclusions drawn, but it falls down if those studies just arn't there, or if the studies are poorly done. That's where anecdotal will have to be used, with hopefully us lowly humans doing our best to be as objective about it as possible.
Am I trying to defend my use of cartrophen.. probably, but then its difficult not to question 'evidence' when it clashes with your perceptions as well as other evidence, especially when systematic reviews and metanalysis is rated so highly, we might have to be a bit careful about garbage in garbage out type results.
The answer of course is to get the data that's required by pushing for as many well designed and implemented studies as possible so as to finally be able to leave anecdotes behind.

Just another interesting tangent, is that glycosaminoglycan polysulphate had higher evidence then pentosan, and yet they are effectively within the same family. Both are GAG's. So where lies the difference, oh to have unlimited time and journal access

Regards

Blair

Re: Evidence Based Decisions

Niall Taylor — Fri, 05 Jun 2009 19:02:41 GMT

[quote user="Niall Taylor"]

There is always a serious nagging doubt in my mind when participating in discussions like the cartrophen one and I am very aware that such opinion based views are no substitute for proper evidence. I hope and trust that no one takes my opinions as gospel and makes serious decisions based solely on them.

[/quote]

I should add of course that it's not usually too long before one or two of the contributors bring everyone down to earth by pointing out the limits of such discussions (Sophia Guymer used a humorous comment about homeopathy to do just that) and/or offering more concrete evidence to support their views (as Blair did in the following post).

Cheers,

Niall

Re: Evidence Based Decisions

Niall Taylor — Fri, 05 Jun 2009 18:52:24 GMT

[quote user="pete coleshaw"]I notice a colleague elsewhere on this site happily discussing the merits of otherwise of Cartrophen...[/quote]

Maybe we shouldn't be having discussions of this type at all but there are benefits I feel, it's always interesting to hear other people's opinions and maybe if enough people shared the same opinion it would motivate me to get off my behind and look for the evidence that is no doubt out there somewhere! But, yes, it does depend on the hope/assumption that no body takes the views expressed too seriously.

I certainly wouldn't stop anyone else in the practice from using Cartrophen just because of my (subjective) feeling that it was less than effective. I would also hope that someone with a more positive (but equally subjective) opinion of its efficacy wouldn't insist it be used to the exclusion of all other analgesics.

Interesting point Pete, thanks for flagging it up.

Cheers,

Niall

Re: Evidence Based Decisions

Alex Gough — Fri, 05 Jun 2009 17:03:55 GMT

Aargh, just started to reply to this and realised I was going into forbidden territory! Suffice to say I agree that not everything is evidence based, we should be striving to improve our evidence base, not just accept that situation. And if we had started with initial anecdotal observations that a particular intervention were encouraging, then the next step is to produce a study, not spend 20 years accusing all and sundry of corruption and ignorance for not agreeing this intervention is essential.

On the subject of cartrophen, a very recent systematic review of the management of canine osteoarthritis (Sanderson et al 2009, Vet Rec) showed that "There was weak or no evidence in support of the use of doxycycline, electrostimulated acupuncture, extracorporeal shockwave therapy, gold wire acupuncture, hyaluronan, pentosan polysulphate, P54FP (extract of turmeric), tiaprofenic acid or tibial plateau levelling osteotomy." Treating canine osteoarthritis is a great example of how easy it is to fool yourself that a treatment is working, because how well a dog is doing on a day to day basis depends on so many factors, such as recent exercise, weight gain or loss, concurrent illness, mental distractions etc, as well as the confounders that make ineffective treatments appear to work such as owner and vet expectation, regression to the mean etc. In fact it is almost impossible to form an opinion on whether something that has a slow onset action such as cartrophen has a good effect on the treatment and progression of osteoarthritis from personal experience, unless you are treating a lot of cases with the drug, and a lot without. Hence the need for trials. Personal opinions on the merits of a drug or intervention are only useful if there is nothing better to go on.

Alex

Re: Evidence Based Decisions

pete coleshaw — Fri, 05 Jun 2009 16:48:00 GMT

I notice a colleague elsewhere on this site happily discussing the merits of otherwise of Cartrophen. I applaud this - this is just what the site should be used for - good to chat with colleagues, share experiences, good and bad, move forwards one's ideas, change one's ideas - exchange of anecdotes is great - a few people sharing the same experience tends to reinforce one's ideas - it's how progress in vet medecine happens. Ultimately, others may test the hypotheses through double blinded peer reviewed trials - but this is the sequel. Whenever the hard evidence is not 'proven', we as practitioners use the best information we have. A round earth started off as someone's thoughts.

Why do we do this for all aspects of our veterinary life, but not for diets?

Re: Evidence Based Decisions

Alex Gough — Wed, 03 Jun 2009 14:38:31 GMT

Im going to reply to this in a new thread, because just as RMB has taken over other threads, i dont want a discussion on homeopathy to annoy people.

Alex

Re: Evidence Based Decisions

John Hoare — Tue, 02 Jun 2009 22:07:48 GMT

[quote user="alex gough"]

[quote user="Tom Lonsdale"]

Actually, if you will allow me, I believe that the ability to unlearn existing dogma, or at the very least hold it in suspense, whilst we explore new realms is a vital first step.

[/quote]

I totally agree Tom. The essence of a true scientist is that they constantly examine their beliefs, and are prepared to change their mind. The true scientist should be open-minded in that if their current thinking is proved wrong, or no evidence to support it can be provided, then they either produce evidence in support of their belief, or change their mind.

In order to look at this without offending you or your beliefs in RMB, lets look at homeopathy. I have no idea whether you are a proponent of homeopathy or not. But I do find the psychology of homeopaths interesting, in which despite a totally implausible basic scientific theory as a foundation, and an overwhelming body of research to suggest it is no better than placebo, homeopaths generally do not re-examine their beliefs. Then people who dont take their word that homeopathy works are called "close-minded."

Arlo, are you going to reinstate Tom's post with the comments from Professor

[/quote]

Alex,

I would disagree that there is an overwhelmingbody of research to suggest that it is no better than placebo. I would also suggest that those vets who are now practicing homeopathy have already re-examined their beliefs. Thery all began their veterinary career as 'conventional vets' and took on board the conventional view that homeopathy could not and did not work. Then some event occured which led them to re-evaluate their beliefs, look into the subject , tentatively try it out, and as they found that it worked they began to use it more and more.

Certainly in my case I used to think that homeopathy was nonsense. It was not until I had been successfully treated homeopathically twice that I began to study it. All I can say from 13 years experience of homeopathy is that if it doesn't work then 80% of cases that are treated conventionally do not require any treatment at all.

As John Audubon saidin the introduction to his masterpiece The Birds of North America " If the bird and the book disagree, always assume that the bird is correct"

Jackj

Re: Evidence Based Decisions

Alex Gough — Fri, 29 May 2009 18:07:11 GMT

There is an interesting article here on why people cling to incorrect and outdated beliefs:

http://www.newsweek.com/id/199679

"Once we believe something, whether it's truth or myth, we begin to see confirmation in the world around us. In psychology, Alcock explains, this is known as an illusory correlation: making connections between particular events that line up with our beliefs about the world. "We can become attached to beliefs that seem to serve a function for us," Alcock explains, "and we don't like to give them up even if they're false because they seem too true to be false.""

Re: Evidence Based Decisions

sophia guymer — Thu, 28 May 2009 17:15:30 GMT

[quote user="pete coleshaw"]

not trying to be difficult but I thibnk I could tick all boxes, and dont know that I would like to be without any of your parameters

[/quote]

Thanks Pete,

I thought it was just me?!

I did end up picking one though.

Re: Evidence Based Decisions

pete coleshaw — Thu, 28 May 2009 12:22:06 GMT

not trying to be difficult but I thibnk I could tick all boxes, and dont know that I would like to be without any of your parameters

Re: Evidence Based Decisions

Arlo Guthrie — Thu, 28 May 2009 09:45:24 GMT

[quote user="alex gough"] Yes, I've started to read it, but it wouldnt be fair to hijack this thread to discuss it, and i have stopped debating it in the raw foods thread. Shame in a way, would be interesting to discuss some of the points you make which seem to be in contradiction to what other RMB advocates have said in the RMB thread. [/quote]

Hi Alex,

I appreciate the sentiment - i.e. staying on topic. But feel free to discuss these points in another thread. I sort of think that Tom didn't get too involved with the RMB for health thread, and that either it should now be continued with his input, or mabe use the thread Phil started: 'Tom wants a response' for continuing discussions about anything with Tom.

Arlo

Re: Evidence Based Decisions

Alex Gough — Thu, 28 May 2009 09:32:46 GMT

[quote user="Tom Lonsdale"]So have you started to read Raw Meaty Bones? It’s sound advice to read it five times, in conjunction with the supporting texts. I read it at least 30 times getting the nuances and cadences right.[/quote]

Yes, I've started to read it, but it wouldnt be fair to hijack this thread to discuss it, and i have stopped debating it in the raw foods thread. Shame in a way, would be interesting to discuss some of the points you make which seem to be in contradiction to what other RMB advocates have said in the RMB thread.

Alex