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Proof of equipoise

12 Nov, 12 | by Bob Phillips

In order to test a new treatment, in a standard randomised controlled trial, we are ethically assumed to have ‘equipoise’: an honest uncertainty at the same chance of a patient being allocated to the new or old treatment. But, I hear you scoff, how can any investigator put themselves through the hell of ethical administration forms, R&D offices and the potential of an infestation of drug safety investigators without being pretty convinced that the new way is better?

Well, in true evidence-based self-analytical fashion, a highly respected gang of investigators determined to see if equipoise had been met [1]. They undertook a systematic review of cohorts of publicly funded studies (not pharma ones) and assessed if the new treatment was better than the old one or placebo, whichever was the comparator. They found that only slightly less than half the time the new treatment was no better than the comparator, and the new therapy was only very rarely an major advantage.

How can we use this information? Well, I think we can use it every time we face a patient and family with the option to enter a large, non-pharma, RCT. We can honestly say that, looking back, we’re right with the new treatment only half the time and that trials are truly the only accurate way of testing treatments fairly.


New treatments compared to established treatments in randomized trials. Benjamin Djulbegovic et al. Cochrane Library, DOI: 10.1002/14651858.MR000024.pub3


I can’t intubate .. can I have a mask?

23 Feb, 11 | by Bob Phillips

Not to obscure your deeply shamed face (I know, I’ve had it happen …) but a laryngeal mask, one of those disturbing bits of equipment anesthetists use when the operations’s not long enough to enjoy a nice cup of tea during an operation.

Can an LMA be a reasonable choice in neonatal resuscitation?

Clean your hands! And wash your stethoscope while you’re at it.

7 Feb, 11 | by Bob Phillips

It’s now been some years since I’ve felt comfortable working with the feel of soft cotton on my elbows. Even when not in a designated clinical zone, its sort of wrong. Anyway, after the success of ‘wash your hands’ decade in making millions of people have cracked, sore skin, there’s a thrust to the obsessive wiping of stethoscopes too.

But how ‘evidence based’ is this new hygienic puritanism?

Why the obsession with Vitamin D?

7 Feb, 11 | by Bob Phillips

So, in the dark and cold climes of an early Northern Spring, Archi has been assailed by questions of vitamin D. There are, it is claimed, near-miraculous things from Vitamin D sufficiency – less cancer, less heart disease, less rickets. Well, I’ll buy the last one, but the others? And does any child really need supplements, or just those in poverty or the middle classes? (For two reasons; the first for nutritional health, the second for social acceptability.)


Many outcomes give no answer?

14 Jul, 10 | by Bob Phillips

Some systematic reviews are confusing. Sometimes this is just poor writing style. Sometimes it’s because the techniques are difficult to grasp (meta-analytic item-response analysis, anyone?) And occasionally it’s because the data don’t seem to add up ‘right’. more…

Q: Who’s still prescribing 0.45% saline for rehydration?

18 Apr, 10 | by Bob Phillips

Me … well, actually I don’t anymore, but that’s mainly because I don’t do rehydration. I tend to do hyperhydration to stop the methotrexate causing any more damage than I know it’s going to.

BUT if I did prescribe any fluids for a dried up sprogling, I’d reach for 0.45% saline with a sniff of K+. Am I doing it all wrong? more…

Q: Should you test Asian patients for HLA-B*1502 before presecribing AEDs?

12 Apr, 10 | by Bob Phillips

I think this is a fascinating question. In paediatric oncology, we’re been doing a tiny bit of genetically personalised medicine for a while now, testing the allelic variations of thiopurine metabolisers so we don’t (over~) poison a small proportion of children with ALL. There are suggestions more…

Motherhood, apple pie, psychosis and anaphylaxis

28 Mar, 10 | by Bob Phillips

I’ve been worrying about this for some time now.

How should we, as health professionals, address the deeply held beliefs of our patients when they aren’t true? Especially when they may harm others, although in a fairly obscure or indirect way? more…

Novelty or reality?

21 Mar, 10 | by Bob Phillips

There’s a rather old study of playground renovation that’s been re-circulating recently (via Twitter, via @drbengoldacre and @cebmblog) which claims to demonstrate that really fancy multicoloured markings in primary school playgrounds get kids moving much more. more…

Q: Carbamazapine calms you down?

28 Feb, 10 | by Bob Phillips

Gormley's 'Another Place'Despite being a paediatric oncologist in my spare time, I am aware that brain tumours and neurosurgeons aren’t the only cause of acquired brain injury in childhood. And I know that the problems of ABI can be tremendous, from the horror of the initial injury and ICU, facing mortality and physical changes, through the unpredictable time of fully active rehab into a strange period where the gap between what could of been and what is can seem to grow wider. Aggression and agitation may be perceived as an entirely understandable reaction to living through ABI, but can cause real difficulties in family, school and social lives. more…

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