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Archive for April, 2011

First blog: The top 3, from the Editor of EBM

3 Apr, 11 | by EBM

Welcome to the start of an occasional blog from the journal Evidence-based Medicine (http://ebm.bmj.com/). In this blog, you’ll find issues of interest to those practicing and teaching evidence-based medicine (EBM).

At the journal each week, the associate editors and I review a long list of articles (click on “EBM Long List” on the home page).  The list is generated by systematic searching of peer-reviewed journals most likely to contain articles of relevance to primary care and general medicine practice that meet basic validity criteria (http://ebm.bmj.com/content/16/2/e1.extract).  We then choose the top three selections based on validity and relevance/impact.
Look for critical appraisal and commentary on the top 3 in an upcoming issue of the journal. This week the top 3 are:

Wells G et al. Cardiac resynchronization therapy: a meta-analysis of randomized controlled trials. CMAJ 2011; 183: 421-429.  This systematic review suggests the evidence for cardiac resynchronization and implantable defibrillator therapy for patients with heart failure is robust. One might raise questions regarding benefits about subgroups (e.g. older patients or those with comorbidity).

Gerstein HC et al. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med 2011; 364: 818-828.  Long-term results from this trial find increased mortality from intensive glucose control among those with type 2 diabetes.  One wonders how many such trials will be needed to temper the zeal with which glucose control is sought among all patients.

Connolly SJ et al. Apixaban in patients with atrial fibrillation. N Engl J Med 2011; 364: 806-817.  A randomized trial adds another alternative to vitamin K antagonists for a-fib, for patients unsuitable for or unwilling to take warfarin. It will be of interest to see how this alternative fits in with other non-warfarin options now available in terms of costs, risks, and efficacy.

Some articles didn’t make the cut, mainly due to less direct, immediate or widespread relevance to practice.

**A systematic review in JAMA (2011; 305: 913-922) suggests that antihypertensive treatment can decrease cardiovascular disease and death for people without hypertension but with heart disease. The review raises the question of efficacy for those without hypertension or heart disease.
**A randomized trial (Lancet 2011; 377: 823-836) suggest that among those receiving specialist care for chronic fatigue syndrome, that cognitive behavioral therapy and graded exercise therapy have modest efficacy.
**A double-blind randomized trial in the hospital found that high and low dose, and bolus and infusion of diuretics led to similar symptom and renal function outcomes of acute heart failure (N Engl J Med 2011; 364: 797-805).
**In a trial of olmesartan, the medication appeared to delay microalbuminuria but increased fatal cardiovascular events for those with heart disease (N Engl J Med 2011; 364: 907-917).
**Finally, ultrasound had surprisingly poor sensitivity (and specificity) for nonpalpable cryptorchidism in a study that compared it to surgical exploration results (Pediatrics 2011; 127: 119-128).

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