Reader Comments

Post a new comment on this article

The EBM attitude. Cute but no more than an attitude.

Posted by Braillon on 19 Nov 2009 at 14:13 GMT

Ulvenes et al stated that Norwegian physicians have a positive attitude towards the concept of EBM.(1) This attitude may be specific to Norway: all over the world, either for clinical practice or scientific publication, denial is a sad fact.
For practice, since the 80’s the dilatation and stenting of various arteries spread like an epidemic (eg. per year in the United States: more than 1 million for the coronary and 45.000 for the renal arteries) despite lack of evidence. In 2007, COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial showed that percutaneous coronary intervention, as an initial management strategy in patients with stable coronary artery disease (85% of the procedure’s indications), did not offer benefit from medical therapy alone in reducing the risk of cardiovascular events.(2) Recently, ASTRAL (Angioplasty and STent for Renal Artery Lesions) trial again showed no benefit but only burden: 23 serious complications per 400 patients (including 2 deaths and 3 amputations).(3)
For publications here is a very recent example. A major journal with prestigious editorial staff and reviewers published a study which concluded that “intimal dissection of the hepatic artery after transarterial chemoembolization (TACE) is a problem in liver transplantation (LT) for hepatocellular carcinoma”.(4) TACE was performed as a bridging therapy prior to LT, the introduction stating “ the bridging effect of TACE before LT results in 5-year survival rates ranging from 59% to 93%” with 2 references, a specific review in German and a more general one (a single-center experience about transplantation). PubMed shows two evidence-based reviews specifically devoted to the topic, published in English. One concluded that “transarterial chemoembolization as a bridge to LT does not improve long-term survival nor decreases dropout rates on the waiting list.(5) The other reported “less favorable outcome in the intent-to-treat analysis.”(6) The problem is clearly not the one reported by the authors and validated by the reviewers. Don’t forget the editors too, they were two to refuse publishing a 113 words correspondence questioning the use of TACE.
Evidently, everyone knows that he has irrelevant hopes and from time to time forgets the EBM gospel for the “I can do it … I do it”. From time to time? May be we are schizophrenics!

Potential conflict of interest: Nothing to report.

1 Ulvenes LV, Aasland O, Nylenna M, Kristiansen IS. Norwegian Physicians' knowledge of and opinions about Evidence-Based Medicine: Cross-Sectional Study. PLoS One. 2009; 4(11): e7828.
2 Boden WE, Teo KK, Weintraub WS, the COURAGE Trial Investigators. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007;356(15):1503-16.
3 The ASTRAL Investigators. Revascularization versus medical therapy for renal-artery Stenosis. N Engl J Med. 2009;361(20):1953-1962
4 Lin TS, Chiang YC , Chen CL et al. Intimal dissection of the hepatic artery following transarterial embolization for hepatocellular carcinoma: An intraoperative problem in adult living donor liver transplantation. Liver Transplant 2009; 15: 1553–56
5 Lesurtel M, Müllhaupt B, Pestalozzi BC et al. Transarterial chemoembolization as a bridge to liver transplantation forhepatocellular carcinoma: an evidence-based analysis. Am J Transplant 2006;6:2644–2650.
6 Vogl TJ, Naguib NN, Nour-Eldin NE et al. Review on transarterial chemoembolization in hepatocellular carcinoma: Palliative, combined, neoadjuvant, bridging, and symptomatic indications. Eur J Radiol. 2008 Oct 1. Available online

No competing interests declared.