List Archives

Tue Apr 19 22:46:31 BST 2005

I wish I knew what really drives practice change. It is easy to change 
your own practice, but much harder to change the practice of others. Not 
too long ago, and even today with some topics, the practice of others 
could be changed by the forceful opinion of a 'recognized expert'. 
Today, to change most of our practices,  we require the support of some 
form of objective evidence.

Current evidence suggests that compelling arguments can be developed FOR 
and AGAINST the use of steroids...... but the practice is embedded in 
our current system of care.  We all use steroids... or not... and a few 
of us use them sometimes. What is required to change a believer into a 
non-believer? Very well conducted research suggests that practice change 
is best achieved by dedicated individuals, who are respected by others, 
armed with COMPELLING evidence.

There are any number of practices that are supported by COMPELLING 
evidence that are under utilized. Why not take a page from Sun Tzu and 
spend our time fighting for change that we are certain will benefit our 
patients and that we are more likely to achieve.

Gordon

Thomas Anthony Horan wrote:

>Dear Gordon,
>
>Thus after all the heat of the recent discusion and the almost complete absence of light, (except for you and Karim of course) and the presentation of no new evidence, is it fair to say that there is little reason and little chance to change current practise? 
>
>Does this consellation of factors make the petition moot? Unnecessary? Unwise?
>
>yours truly,
>
>Tom Horan
>
>  
>
>>----------
>>From: 	Gordon S. Doig[SMTP:gdoig at med.usyd.edu.au]
>>Reply To: 	Trauma & Critical Care mailing list
>>Sent: 	segunda-feira, 18 de abril de 2005 19:11
>>To: 	Trauma & Critical Care mailing list
>>Subject: 	Re: SCI - The Evidence
>>
>>
>>Not one person has provided one reference in response to my requests. 
>>I've posted these requests at least twice now.
>>
>>With regards to the evidence that I can find:
>>
>>Using PubMed to find systematic reviews of the primary evidence 
>>[Clinical Query with the search term : ((("spinal cord injuries"[TIAB] 
>>NOT Medline[SB]) OR "spinal cord injuries"[MeSH Terms] OR spinal cord 
>>trauma[Text Word]) AND ("steroids"[MeSH Terms] OR steroids[Text Word])) 
>>AND systematic[sb]MeSH terms ] the most recent systematic review I  find is:
>>
>>Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 
>>2002;(3):CD001046. 
>><www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12137616>
>>
>>
>>Conducting a highly  specific (focused or narrow) search for recent 
>>Level I RCTs on the topic, [PubMed Clinical Query with search term: 
>>((("spinal cord injuries"[TIAB] NOT Medline[SB]) OR "spinal cord 
>>injuries"[MeSH Terms] OR spinal cord trauma[Text Word]) AND 
>>("steroids"[MeSH Terms] OR steroids[Text Word])) AND (randomized 
>>controlled trial[Publication Type] OR (randomized[Title/Abstract] AND 
>>controlled[Title/Abstract] AND trial[Title/Abstract])) ]
>>
>>36 Abstracts are retrieved. I find NOTHING that wasn't included in the 
>>2002 systematic review above.
>>
>>
>>Conducting a high sensitivity search for recent Level I RCTs on the 
>>topic [((("spinal cord injuries"[TIAB] NOT Medline[SB]) OR "spinal cord 
>>injuries"[MeSH Terms] OR spinal cord trauma[Text Word]) AND 
>>("steroids"[MeSH Terms] OR steroids[Text Word])) AND 
>>((clinical[Title/Abstract] AND trial[Title/Abstract]) OR "clinical 
>>trials"[MeSH Terms] OR clinical trial[Publication Type] OR 
>>(random[Title/Abstract] OR random/aleatory[Title/Abstract] OR 
>>random/and[Title/Abstract] OR random/arm[Title/Abstract] OR 
>>random/basal[Title/Abstract] OR random/blocked[Title/Abstract] OR 
>>random/cdp[Title/Abstract] OR random/ethanol[Title/Abstract] OR 
>>random/nonrandom[Title/Abstract] OR random'[Title/Abstract] OR 
>>randomaly[Title/Abstract] OR randoman[Title/Abstract] OR 
>>randomand[Title/Abstract] OR randombred[Title/Abstract] OR 
>>randombreds[Title/Abstract] OR randomdigit[Title/Abstract] OR 
>>randomdot[Title/Abstract] OR randome[Title/Abstract] OR 
>>randomed[Title/Abstract] OR randomely[Title/Abstract] OR 
>>randomer[Title/Abstract] OR randomezed[Title/Abstract] OR 
>>randomi[Title/Abstract] OR randomic[Title/Abstract] OR 
>>randomicaly[Title/Abstract] OR randomicity[Title/Abstract] OR 
>>randomied[Title/Abstract] OR randomil[Title/Abstract] OR 
>>randomily[Title/Abstract] OR randomingly[Title/Abstract] OR 
>>randominzed[Title/Abstract] OR randomis[Title/Abstract] OR 
>>randomisation[Title/Abstract] OR randomisation'[Title/Abstract] OR 
>>randomisations[Title/Abstract] OR randomise[Title/Abstract] OR 
>>randomised[Title/Abstract] OR randomised'[Title/Abstract] OR 
>>randomisee[Title/Abstract] OR randomisely[Title/Abstract] OR 
>>randomises[Title/Abstract] OR randomisierte[Title/Abstract] OR 
>>randomisierten[Title/Abstract] OR randomisierter[Title/Abstract] OR 
>>randomising[Title/Abstract] OR randomisly[Title/Abstract] OR 
>>randomiz[Title/Abstract] OR randomizable[Title/Abstract] OR 
>>randomizadely[Title/Abstract] OR randomizado[Title/Abstract] OR > 
>>randomizaion[Title/Abstract] OR randomization[Title/Abstract] OR 
>>randomization/matching[Title/Abstract] OR randomization'[Title/Abstract] 
>>OR randomizations[Title/Abstract] OR randomize[Title/Abstract] OR 
>>randomized[Title/Abstract] OR randomized/455[Title/Abstract] OR 
>>randomized/58[Title/Abstract] OR 
>>randomized/quasirandomized[Title/Abstract] OR 
>>randomized/registry[Title/Abstract] OR 
>>randomized/screened[Title/Abstract] OR randomized'[Title/Abstract] OR 
>>randomizedduring[Title/Abstract] OR randomizedly[Title/Abstract] OR 
>>randomizedphase[Title/Abstract] OR randomizedtrial[Title/Abstract] OR 
>>randomizely[Title/Abstract] OR randomizer[Title/Abstract] OR 
>>randomizes[Title/Abstract] OR randomizing[Title/Abstract] OR 
>>randomizing'[Title/Abstract] OR randoml[Title/Abstract] OR 
>>randomlike[Title/Abstract] OR randomly[Title/Abstract] OR 
>>randomly'[Title/Abstract] OR randomlyassigned[Title/Abstract] OR 
>>randomlyselected[Title/Abstract] OR randommess[Title/Abstract] OR 
>>randommized[Title/Abstract] OR randommobility[Title/Abstract] OR 
>>randomnes[Title/Abstract] OR randomness[Title/Abstract] OR 
>>randomnly[Title/Abstract] OR randomomized[Title/Abstract] OR 
>>randoms[Title/Abstract] OR randomsed[Title/Abstract] OR 
>>randomsource[Title/Abstract] OR randomyl[Title/Abstract] OR 
>>randomyly[Title/Abstract] OR randomzied[Title/Abstract]) OR "random 
>>allocation"[MeSH Terms] OR "therapeutic use"[Subheading])]
>>
>>
>>524 Abstracts are retrieved. Again, I find no major RCTs that weren't 
>>considered in the above meta-analysis.
>>
>>The only additional trial that is even close to this topic is the CRASH 
>>trial:  Link to CRASH trial 
>><www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15474134>
>>
>>Because the CRASH trial only reports 14 day outcomes, it does not 
>>definitively counter the previous meta-analysis.
>>
>>Based on the available evidence, there is a suggestion that steroids 
>>improve outcome from SCI..... however, there is reasonable uncertainty 
>>in patients with Clinically Significant Head Injury. This uncertainty 
>>will be resolved by the release of the 6th month outcomes from CRASH.
>>
>>I now have two questions: 1)  Have I missed any evidence? If so, please 
>>provide the refs and 2) If nobody could provide references to counter 
>>the previous systematic review, why on earth was everyone arguing???
>>
>>Gordon
>>
>>
>>
>>
>>
>>
>>
>>Gordon S. Doig wrote:
>>
>>    
>>
>>>Hi Karim
>>>
>>>Welcome back....
>>>
>>>With regards to the evidence driving this discussion, I have conducted 
>>>a quick Medline search and can find no new landmark trials of steroids 
>>>in SCI (Pubmed Clinical Queries using the terms steroids and spinal 
>>>cord trauma).
>>>
>>>Although the CRASH study has provided some interesting information on 
>>>this topic (See www.EvidenceBased.net 
>>><http://icu-10.med.usyd.edu.au/ebdm/journalnew5.shtml>,  for a review 
>>>of the trial) I am not aware of the release of the 6 month outcomes. 
>>>Has anyone seen the 6mth outcomes? Are there any other new Level 1 
>>>trials that I am missing? If there are no additional outcomes, or 
>>>other trials on this topic, you need to be VERY cautious driving major 
>>>decisions based on 14 day follow-up.
>>>
>>>Gordon
>>>
>>>
>>>
>>>Karim Brohi wrote:
>>>
>>>      
>>>
>>>>Mohammed and others
>>>>
>>>>Apologies for coming back to this late - more aeroplanes.
>>>>
>>>>There are two issues here which should be kept very separate.
>>>>
>>>>1. Should I go against a current hospital protocol and (for example) 
>>>>refuse to prescribe steroids to patients with SCI.
>>>>
>>>>The answer to this is absolutely not.  If there is a protocol in 
>>>>place then, as Errington and others have suggested, the protocol
>>>>must be revisited by your hospital's trauma committee with the 
>>>>evidence in front of them. If the decision of the committee is that> 
>>>>steroids should stay, then you should continue to prescribe them - 
>>>>and revisit the issue again in the future.
>>>>
>>>>2. Am I allowed to express my opinions about medical practice in open 
>>>>debate? 
>>>>The answer to this is absolutely - YES. Whether you are in the US, 
>>>>the UK, or anywhere else with some sign-up to free speech
>>>>regulations.
>>>>
>>>>However - You must be debating the literature, available medical 
>>>>evidence, expert opinion - whatever - and coming to a conclusion
>>>>based on this.
>>>>
>>>>What you cannot and should not do is say 'In my hospital everything 
>>>>is terrible and people are dying every day because X is not
>>>>happening or Dr Y won't do this or Department Z has this policy which 
>>>>is unacceptable.'  This is exposing internal deficiencies in a
>>>>system to outside scrutiny without first discussing this within your 
>>>>institution.  This is really rather naïve, irresponsible, and
>>>>almost certainly counter-productive.  I would hazard Mohammed that 
>>>>this is what your hospital is upset about, and not about you
>>>>putting your name to the letter.  There has been a lot of this sort 
>>>>of conversation on the list recently - even with specific people
>>>>or departments mentioned.
>>>>
>>>>I have a couple of other points to make about the steroid issue and 
>>>>the letter.  I've received a couple of private emails with
>>>>points I'll address openly:
>>>>
>>>>* I want to reinforce that the decision whether or not to use 
>>>>steroids in your hospital is an institution-specific one that should
>>>>be agreed upon by all parties involved in care.
>>>>
>>>>* "There's no evidence for anything we do - why pick on steroids?"
>>>>
>>>>    1. There is no evidence that steroids do any good - and there is 
>>>>similar level evidence to sugest that they may do harm.
>>>>Most people who have prescribed these high dose steroids to multiply 
>>>>injured patients will have one story where this is the case.
>>>>
>>>>    2. Because many organisations have removed steroids from their 
>>>>list of recommendations and, at minimum, downgraded them to
>>>>an option to be used with caution.  However the new ATLS will last us 
>>>>at least 4 years (and possibly 7!).  We are urging the
>>>>committee to revisit the issue and at least downgrade the 
>>>>recommendation.  This is our recommendation - the committee may or 
>>>>may not
>>>>follow it - that will be their decision.
>>>>
>>>>* Is this the way to change practice?
>>>>
>>>>Well, no doubt that after this exchange of emails many of you will be 
>>>>extremely wary of putting your name to anything - and
>>>>certainly not to this letter.  However I would urge you to consider 
>>>>the alternative.  That at no insitutional, local, regional,
>>>>national or international meeting will you ever raise your hand and 
>>>>say 'I disagree'.  That you will never question or discuss
>>>>protocols and guidelines handed down to you by others.  That you 
>>>>essentially will give over responsibility for the practice of
>>>>medicine to others.
>>>>
>>>>Should we do this by petition?  Why not just get everyone to send 
>>>>their own letters? - Well because for most people it's too much
>>>>effort - it's much easier to add you rname to a letter than to write 
>>>>one.  And their is weight in numbers, as has been discussed.
>>>>By all means if you would like to write a letter or email yourself 
>>>>please do so.
>>>>
>>>>Remember that the letter is expressing the signatories views on the 
>>>>literature and urging a revisit of the situation by the ACS
>>>>committee on trauma & ATLS subcommittee.  There is no claim of 
>>>>wrongdoing, malpractice or of any legal intervention.  This is an
>>>>appraisal of scientific evidence and a recommendation - no more and 
>>>>no less.
>>>>
>>>>It is interesting that there are 2100 people reading this emails and > 
>>>>only about 30 signatories so far - and these are primarily the
>>>>people that have been involved in the discussion.  So what does this 
>>>>mean?  Voter apathy? Fear of reprisals?  Or people out there
>>>>are comfortable prescribing steroids for SCI and it is only this 
>>>>vocal minority which is creating a stir?  Who knows?  This has been
>>>>a very one-sided discussion - I do wonder where the steroid believers 
>>>>are.
>>>>
>>>>Karim
>>>>
>>>>-- 
>>>>trauma-list : TRAUMA.ORG
>>>>To change your settings or unsubscribe visit:
>>>>http://www.trauma.org/traumalist.html
>>>>
>>>> 
>>>>
>>>>        
>>>>
>>-- 
>>-------------
>>Evidence-based Decision Making http://www.EvidenceBased.net
>>Patient-based Teaching Cases http://www.AcademicHealthScience.net/ce
>>Outcomes Research http://www.AcademicHealthScience.net/UM
>>RNSH ICU Home Page http://icu-web.org
>>
>>--
>>trauma-list : TRAUMA.ORG
>>To change your settings or unsubscribe visit:
>>http://www.trauma.org/traumalist.html
>>
>>    
>>
>--
>trauma-list : TRAUMA.ORG
>To change your settings or unsubscribe visit:
>http://www.trauma.org/traumalist.html
>
>  
>

-- 
-------------
Evidence-based Decision Making http://www.EvidenceBased.net
Patient-based Teaching Cases http://www.AcademicHealthScience.net/ce
Outcomes Research http://www.AcademicHealthScience.net/UM
RNSH ICU Home Page http://icu-web.org

List Archives

For your convenience, find the Trauma List Archive Below

SCI - The Evidence