Friday Fun: Scientists’ Luxuriant Flowing Hair and California Sound Walk

  Did you know that “the public loves to see and applaud scientists who have luxuriant flowing hair”? Well, according to the Luxuriant Flowing Hair Club for Scientists (LFHCfS), this is true.  (This contribution to the world’s knowledge base comes to us from the Annals of Improbable Research. Have a look at the Special Anatomy Issue.)

From the site:

The project was first announced in mini-AIR 2002-02-04 (LFH Survey). The initial list, assembled by a subcommittee comprised of seven members of the American Association for the Advancement of Science,  was meant as a nucleating seed, from which a larger list could grow. The first member, chosen by acclamation, was psychologist Steven Pinker, whose hair has long been the object of admiration, and envy, and intense study. From that lone, Pinkerian seed, there has grown a spreading chestnut, black, blond, and red-haired membership tree, which you can see below and on the other LFHCfS web pages.

On this Web site you can nominate yourself and your hair, and submit photographs and bios of scientists with luxuriant flowing hair. (I tried to find a photo of Paul M. with his pony tail untied, but couldn’t locate one.)

Listening to Nature: A Sound Walk Across California

I love this site. You can choose a section of California and listen to the sounds of the birds, or sea lions, or toads … lovely.  From the California Library of Natural Sounds.

Achieving Excellence in Medical Education: book review

  This book by Richard Gunderman was just reviewed in the November 30 issue of the New England Journal of Medicine. I looked around and found some more reviews of the book:

Gunderman, Richard B. Achieving Excellence in Medical Education, New York: Springer, 2006. ISBN-13 978-1-84628-296-6, ISBN-10 1-84628-296-9

From the publisher:  A goldmine of theoretical insights and practical suggestions, “Achieving Excellence in Medical Education” explores the essential question facing medical educators and learners today: What is our vision of educational excellence, and what can we do to enhance our performance? Among the topics explored within this engaging, informative, and thought-provoking text are: Education’s position as a priority of medical schools, seminal educational insights from non-medical educators, best practices of outstanding educators and learners, promises and pitfalls of new educational technologies, key resources for promoting excellence in medical education, medical education’s role in preparing future leaders, leadership roles for medical schools in universities and society.

From NEJM: In this unusual book, there are discussions of a very broad range of issues in medical education — from learning theory to educational technology, and from diversity in medicine to the economic challenges of academic practice and the relationships between medical schools and teaching hospitals. Such an attempt by a single author to be comprehensive often veers off into personal, sometimes idiosyncratic perspectives, but in this case I was pleasantly surprised. This book not only succeeds in what I doubted a single author could accomplish — the book is, in fact, a useful and balanced overview of the state of . . . 

From JAMA:  “Academic medicine is like a tripod, standing on three legs. One leg is patient care, one is research, and one is education. Over the course of the twentieth century, the emphasis placed on each of these missions has changed. In recent years, education has become the short leg of the tripod.” So begins Richard B. Gunderman, MD, PhD, in his plea to understand, preserve, and expand medical education. His work is well-grounded in educational theory and colored by historical review. His passionate dedication to medical education is evident in the tone of his writing, which uses such phrases as “we must” and “we should.” Throughout the text, the author draws from educational theory, but his second chapter is devoted exclusively to it. He discusses learning theory, reviewing the four most important theories influencing modern educational practice. He explores what it means to exhibit expertise and how to train to expertise . .

Look inside this book, courtesy of Amazon.com

Chiropractic Subject Headings (ChiroSH): 2006 edition

 Here is an important reference work that has just been released by the Chiropractic Library Consortium (CLIBCON), creators of the Index to Chiropractic Literature.

The fifth edition of ChiroSH (Chiropractic Subject Headings) is largely the work of two librarians, Ann Kempke of Northwestern Health Sciences University, and Bethyn Boni of New York Chiropractic College. ChiroSH is meticulously researched and edited and, in my opinion, will be a valuable resource for both the chiropractic profession and the public. Currently no reliable dictionary or glossary exists for chiropractic, and ChiroSH helps fill this gap by providing scope notes for a large number of the terms used by chiropractors.

Chiropractic Library Consortium. Chiropractic Subject Headings (ChiroSH). 5th edition. Editors: Ann Kempke, Bethyn Boni. CLIBCON, 2006.

Link to ChiroSH from the Index to Chiropractic Literature Web site.  The CLIBCON librarians welcome feedback on ChiroSH and the Index to Chiropractic Literature.  

From the introduction:
Chiropractic Subject Headings (ChiroSH) is a thesaurus developed by librarians at chiropractic college libraries, intended for use by indexers for the Index to Chiropractic Literature (ICL) and by catalogers at chiropractic and natural health sciences libraries.  The first draft of the thesaurus was developed from the subject authority files of the Texas Chiropractic College and Northwestern College of Chiropractic libraries, the subject thesaurus included in the first volume of CRAC: Chiropractic Research Abstracts Collection, and the subject lists included in ICL. ChiroSH is intended to be used in conjunction with the Medical Subject Headings (MeSH), published by the National Library of Medicine. 

Several ChiroSH headings are based upon MeSH headings, but most ChiroSH headings are unique to this thesaurus.  Chiropractic terms with established medical headings are provided with “See” references to direct users to MeSH, where they will find scope notes, accepted subheadings (qualifiers), and cross references. 

See also Glossaries for Medical Education & Health [SACME] 

Gift Horse or Trojan Horse? The EBM debate continues

 A colleague just brought the June 2006 issue of Social Science and Medicine to my attention. This issue contains a special section on evidence-based medicine. Here are the PubMed records for the entire issue, but I am including the nine EBM abstracts below. A subscription is required for full text.

Lambert H, Gordon EJ, Bogdan-Lovis EA. Introduction: Gift horse or Trojan horse? Social science perspectives on evidence-based health care. Social Science & Medicine 2006; 62(11):2613-2620.

Excerpt: In this introduction, we provide some background to the contents of this Special Issue by outlining briefly the key components and attendant assumptions of evidence-based approaches to health care, and summarise the main advantages and limitations of this approach according to its champions and detractors. We then offer a synopsis of each paper before reflecting on the intersecting themes, topics and implications for social science understandings of EBM that emerge from the collection as a whole. The Special Issue originated in two conference panels convened independently by the present authors. In 2003, Elizabeth (Libby) Bogdan-Lovis and Elisa Gordon, together with Kate Bent, convened a panel on, Gift horse or Trojan horse?: Evidence-based Practice Transforming Medicine at the American Anthropological Association annual meetings, while Helen Lambert organised a panel entitled, Anthropology and Medical Science: Notions of Evidence for the 2003 UK Association of Social Anthropologists’ Decennial conference. This Special Issue includes a selection of the papers originally presented on those occasions.

Goldenberg MJ. On evidence and evidence-based medicine: Lessons from the philosophy of science. Social Science & Medicine 2006; 62(11):2621-2632.

Abstract: The evidence-based medicine (EBM) movement is touted as a new paradigm in medical education and practice, a description that carries with it an enthusiasm for science that has not been seen since logical positivism flourished (circa 1920-1950). At the same time, the term “evidence-based medicine” has a ring of obviousness to it, as few physicians, one suspects, would claim that they do not attempt to base their clinical decision-making on available evidence. However, the apparent obviousness of EBM can and should be challenged on the grounds of how `evidence’ has been problematised in the philosophy of science. EBM enthusiasm, it follows, ought to be tempered.The post-positivist, feminist, and phenomenological philosophies of science that are examined in this paper contest the seemingly unproblematic nature of evidence that underlies EBM by emphasizing different features of the social nature of science. The appeal to the authority of evidence that characterizes evidence-based practices does not increase objectivity but rather obscures the subjective elements that inescapably enter all forms of human inquiry. The seeming common sense of EBM only occurs because of its assumed removal from the social context of medical practice. In the current age where the institutional power of medicine is suspect, a model that represents biomedicine as politically disinterested or merely scientific should give pause.  

Lambert H. Accounting for EBM: Notions of evidence in medicine. Social Science & Medicine 2006; 62(11):2633-2645.

Abstract: This paper takes as a focus of anthropological enquiry the set of techniques and practices for the appraisal and clinical application of research evidence that has become known as evidence-based medicine (EBM) (or, more recently, evidence-based health care). It first delineates and classifies the criticisms of EBM emerging from within the health professions. It then charts the evolution of EBM in responding to these criticisms and uncovers its character as a pedagogical innovation aimed at transforming clinical practice. It identifies EBM as an indeterminate and malleable range of techniques and practices characterised not by particular kinds of methodological rigour, but by the pursuit of a new approach to medical knowledge and authority. It situates this characterisation within a contemporaneous political and economic climate of declining trust and growing accountability. This analysis provides a basis from which to consider the notions of evidence implicit in EBM itself and also in the qualitative social sciences, including anthropology, which not only critique but also contribute to these notions themselves. Finally, the paper considers possible future trajectories for EBM with regard to the incorporation of cultural and structural dimensions of health and the inclusion of qualitative material in the evidence base. 

Barry CA. The role of evidence in alternative medicine: Contrasting biomedical and anthropological approaches. Social Science & Medicine 2006; 62(11):2646-2657.  Full Text

Abstract: The growth of alternative medicine and its insurgence into the realms of the biomedical system raises a number of questions about the nature of evidence. Calls for `gold standard’ randomised controlled trial evidence, by both biomedical and political establishments, to legitimise the integration of alternative medicine into healthcare systems, can be interpreted as deeply political. In this paper, the supposed objectivity of scientific, biomedical forms of evidence is questioned through an illumination of the multiple rhetorics embedded in the evidence-based medicine phenomenon, both within biomedicine itself and in calls for its use to evaluate alternative therapeutic systems. Anthropological notions of evidence are constructed very differently from those of biomedical science, and offer a closer resonance with the philosophy of alternative medicine. Examples are given of the kinds of evidence produced by anthropologists researching alternative medicine. Ethnographic evidence of `what works’ in alternative medicine includes concepts such as transcendent, transformational experiences; changing lived-body experience; and the gaining of meaning. It is proposed that the promotion of differently constructed modes of evidence can be used to legitimise alternative medicine by widening the definition of what works in therapy, and offering a critique of what people feel is lacking from much of orthodox medical care.  

Naraindas H. Of spineless babies and folic acid: Evidence and efficacy in biomedicine and ayurvedic medicine. Social Science & Medicine 2006; 62(11):2658-2669.

Abstract: The basic premise of the paper is that Western medicine’s co-opting of specific technologies and materials from other (indigenous) medical traditions, stripped of the original theories underlying their use, has problematic consequences for the practitioners and patients of both source and recipient traditions. The paper begins by illustrating the historical continuity of this process by way of an example from India‘s colonial era. The fact that specific practices or materials are regarded as biomedically useful because they `work’ (are efficacious) does not mean that the `traditional’ theories underlying them are seen as correct. The knowledge contained in these traditions is not counted as legitimate, as the emphasis in biomedicine (the legitimate canon) on an identifiable concrete location in the body for the source of health problems creates difficulties–both for patients when their problems are not provided with a cause that matches their subjective awareness, and for the practitioners of other traditions whose patients have been exposed to biomedicine. The paper goes on to demonstrate, using case examples from extended ethnographic fieldwork in southern India, how this is played out in a setting in which an educated Indian patient population accepts this form of knowledge as legitimate but espouses ayurvedic therapy. Notions of `evidence’ are shown to be central to the interplay between biomedical and other medical traditions, since objective tests and measures in biomedicine are accepted as the only legitimate `evidence’ of cure, but these do not necessarily accord either with the premises of these other traditions or with patients’ subjective perceptions of well-being. Returning to an acceptance and practice of other traditions, consequently, requires nothing less than a fundamental cognitive shift in the grounds for what constitutes `evidence.’ 

Landsman GH. What evidence, whose evidence?: Physical therapy in New York State‘s clinical practice guideline and in the lives of mothers of disabled children. Social Science & Medicine 2006; 62(11):2670-2680.

Abstract: To provide recommendations based on the best scientific evidence available about “best practices,” the New York State Department of Health Early Intervention Program sponsored the development of an evidence-based clinical practice guideline for assessment and intervention for young children with motor disabilities. The author served on the multidisciplinary consensus panel convened to develop the guideline, holding a position as a parent of a child with motor disabilities, and in addition utilizing data from her qualitative anthropological research on mothers of young children newly diagnosed with disabilities. This article describes the state panel’s process for developing the guideline, focusing on recommendations about physical therapy interventions for cerebral palsy. Although evidence-based practice privileges randomized clinical trials, few studies of physical therapy techniques for young children with motor disabilities meet such criteria for evidence. The panel’s recommendations, in the absence of such scientific evidence, are analyzed in comparison with competing theories of motor development in physical therapy research and practice, and with interpretations of physical therapy held by mothers of young children with disabilities who were interviewed in the study. The article explores questions of what constitutes evidence in three arenas: (1) clinical practice guidelines, (2) physical therapy research, and (3) the lives of families of young children with motor disabilities. It has broader implications for understanding how information, variously derived, is transformed into evidence. While to some extent authority and power affect the range of knowledge that can be transformed into evidence, the more significant constraints may be the rules of evidence we value and the particular paradigm of our science.  

Bogdan-Lovis EA, Sousa A. The contextual influence of professional culture: Certified nurse-midwives’ knowledge of and reliance on evidence-based practice. Social Science & Medicine 2006; 62(11):2681-2693.

Abstract: This paper reports research undertaken to assess US certified nurse-midwives’ (CNMs) knowledge of, access to, and use of evidence-based medicine (EBM). Findings are presented in the context of interprofessional, institutional, and popular culture. The descriptive study follows concepts of diffusion of innovation, evidence-based patient choice, and authoritative knowledge to analyse incentives and barriers to the implementation of evidence-based midwifery care.Structured interviews were conducted with practicing CNMs in an urban practice site and a regional teaching centre. The analysis of responses explored congruence between practitioner knowledge, professed practice, and published professional as well as hospital-based internal practice guidelines, for two specific interventions for which there is ample systematic review, epidural and episiotomy. The CNMs demonstrated enthusiasm for their own individual understanding of EBM, but responses to specific questions about EBM-supported practice indicate that many had an incomplete understanding of the concept. Furthermore, in those cases where CNMs demonstrated accurate knowledge of EBM, practice protocols followed subspecialty dictates, thereby preventing their knowledge from translating into adherence to EBM-guided clinical practice guidelines. Finally, patient expectations for technological intervention appeared to influence CNMs’ care decisions, even when those expectations lacked sound supporting evidence.If, as conceived by its originators and champions, EBM is to be widely adopted, then practitioners such as CNMs need to accurately understand its concepts and also to be afforded the opportunity to exercise professional control over its implementation. Central to an epistemically balanced EBM is the need to ensure that midwifery knowledge contributes in a robust and ongoing fashion to EBM’s scientific research base. Lastly, EBM advocates must identify balanced strategies to both rationally and fairly address consumerist pressures for aggressive health care consumption. 

De Vries R, Lemmens T. The social and cultural shaping of medical evidence: Case studies from pharmaceutical research and obstetric science. Social Science & Medicine 2006; 62(11):2694-2706.

 Abstract: Most critiques of evidence-based medicine (EBM) focus on the scientific shortcomings of the technique. Social scientists are more likely to criticize EBM for it ideological biases, a criticism that makes sociological sense but is difficult to substantiate. Using data from our studies of (1) the influence of pharmaceutical companies on the conduct and reporting of clinical trials, and (2) obstetric science in the
Netherlands (where nearly one-third of births occur at home) we show how the evidence of evidence-based medicine is shaped by forces both structural and cultural. The threats to objective evidence are many, and, if EBM is to be true to its own principles, it must take these threats into account. 

Gordon EJ. The political contexts of evidence-based medicine: Policymaking for daily hemodialysis. Social Science & Medicine 2006; 62(11):2707-2719. Abstract: Policymakers and clinicians increasingly rely on evidence-based medicine (EBM) to make decisions about insurance coverage and clinical treatment. Conflicting value judgments about evidence and pressures exerted by stakeholders render health policymaking a political process. This paper examines how value judgments become embedded in the process of improving medical outcomes by focusing on health policymaking. Specifically, this paper highlights how EBM is variably used as a standard for decision-making depending on perceived risks by policymakers and what is on the competing agenda. I draw upon the case study of the policymaking process for the recent US bill, H.R. 1004: Kidney Patient Daily Dialysis Act, which would legislate daily hemodialysis (DHD) as a new renal replacement therapy modality, and provide federal medicare funding of hemodialysis from 3 to 6 times per week. DHD constitutes an ideal case study with which to explore the political underpinnings of EBM. The interpretations of substantial outcome data showing medical, quality of life, and hypothetical economic improvements of DHD over conventional dialysis are currently being contested in the medical and political spheres. Accordingly, the drive for what some stakeholders view as better evidence through randomized clinical trials is central to the debate and policymaking process. This paper underscores how the demand for, the interpretations, the funding for, and the use of evidence render EBM a political endeavor with vital ethical implications for clinical care.

Free literature databases: a selection

  Here is a selection of databases or search engines that are free on the Web, listed by broad category.

Biomedicine/Evidence-Based Medicine:
PubMed [U.S. National Library of Medicine]
NLM Gateway [U.S. National Library of Medicine]
The Cochrane Collaboration [citations only, without subscription]
Cochrane Reviews abstracts & summaries
Centre for Reviews and Dissemination Databases
  [including Database of Abstracts of Reviews of Effects (DARE)]
TRIP Database: Turning Research into Practice 
Scirus for scientific information only

Education/Medical Education:
ERIC [Education Resources Information Center, U.S. Dept. of Education]
TIMELit: Topics in Medical Education  [Centre for Medical Education, Dundee]
RDRB: Research & Development Resource Base (in CME) [University of Toronto]

Complementary & Alternative Medicine:
PEDro (Physiotherapy Evidence Database) [Centre for Evidence-Based Physiotherapy (CEBP)]
OSTMED (The Osteopathic Literature Database) [to 2003]
Index to Chiropractic Literature [CLIBCON]

General:
Google Scholar [Advanced Scholar Search]
Google Book Search [Advanced Book Search]                             *

Why is evidence-based medicine important?

  Here is an interesting little piece from the October 2006 issue of Evidence-Based Medicine.  The writer has summarized a discussion that took place earlier this year on a listserv entitled EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK.

Glasziou P. Why is evidence-based medicine important? Evid Based Med 2006; 11(5):133-135.

Excerpt: I’m sure readers of the  Evidence-Based Medicine journal have a variety of reasons for subscribing. But most of you would assume evidence-based medicine (EBM) is important to clinicians. Recently Olive Goddard (the manager at the Centre for Evidence-Based Medicine in Oxford) forwarded this question to the Evidence-Based Health Care list: “Could you please tell me why EBM is important? Can a physician practice medicine without knowing EBM?” The email list has over a thousand subscribers and many had an opinion about this question. I will abbreviate these to highlight some of the threads, but you can read the full text on the list.

To retrieve the original posts on this question, go to the search screen and type Why is EBM Important? in the subject search box.   Listserv Archives

Friday Fun: Scary Ads from the Past

Here’s a festive suggestion for that “difficult to buy for” person  … 
Have a look at some more vintage ads …

RateMDs.com and Regret the Error

  Here are two sites that provide some fascinating reading. One accepts postings on individual doctors and the other tracks mistakes made in print and online news sources.

RateMDs.com: Changing the way the world looks at medicine

RateMDs.com nets ire of Canadian physicians is a news item in the March 13, 2007 issue of CMAJ:
An American Web site that lets patients post anonymous comments about their physicians online appears to have become wildly popular in Canada in recent months. But it’s provoking both fear and threats of legal action from the medical community north of the border.

RateMDs.com allows patients to rate and read about their doctors. And it’s addictive reading. You can track doctors (all kinds of doctors) in the United States and Canada. Some of the comments are quite scandalous. According to this article in the Vancouver Sun, the Canadian Medical Association and the Canadian Medical Protective Association are not much impressed with some of the comments posted about Canadian doctors:
The Silicon Valley, Calif., operators of RateMDs.com have removed two out of the seven most scathing comments about unnamed doctors cited by the Canadian Medical Protective Association (CMPA). But they ignored all other requests made of them by that organization and the Canadian Medical Association, the latter whose chief executive officer, William Tholl, also sent a recent letter saying he echoed the concerns of CMPA. John Swapceinski, co-founder of the website, said the letters sent to him and co-founder Joanne Wong, were meant to be intimidating but, ”I’ve developed a very thick skin since we first started this business.”

    Regret the Error: Mistakes happen

Regret The Error reports on corrections, retractions, clarifications and trends regarding accuracy and honesty in the media.

Imagine someone spending hours every day tracking mistakes in the media (newspapers, print and online) and providing links to those that have corrections pages, and those that don’t. It makes for some interesting reading. There are all kinds of special features, such as the 2005 Plagiarism Round-Up.

Dangerous deception: Hiding the evidence of adverse drug effects

  The following two articles appear in the November 23 issue of the New England Journal of Medicine. Free full text is available.

Avorn J. Dangerous deception — Hiding the evidence of adverse drug effects. N Engl J Med 2006; 355(21):2169-2171.

Excerpt: September 30 is becoming a day of infamy for drug safety. On that date in 2004, Merck announced that rofecoxib (Vioxx) doubled the risk of myocardial infarction and stroke, and the company withdrew the drug from the market after 5 years of use in more than 20 million patients. On September 30, 2006, a front-page article in the New York Times reported that the Food and Drug Administration (FDA) had issued a warning that the antifibrinolytic drug aprotinin, widely used to reduce perioperative bleeding in patients undergoing cardiac surgery, could cause renal failure, congestive heart failure, stroke, and death.  Free Full Text        Interview with Jerry Avorn   

Hiatt WR. Observational studies of drug safety — Aprotinin and the absence of transparency. N Engl J Med 2006; 355(21):2171-2173.

Excerpt: The full safety profile of a new drug is rarely known at the time of approval by the Food and Drug Administration (FDA). Most drug-development programs designed for treatments of symptomatic indications are underpowered to detect any increased risk of rare drug reactions or change in background event rates attributable to the drug. Large, post-marketing, randomized, controlled trials provide robust data on drug safety but may be subject to multiple sources of bias. Observational studies of a drug’s effects in clinical practice can offer additional information on risks. The recent discussions of aprotinin (Trasylol, Bayer) by the Cardiovascular and Renal Drugs Advisory Committee of the FDA, which I chair, provide insight into the strengths and weaknesses of using observational data to assess drug safety and highlight the importance of using a transparent and open process when reviewing such data.  Free Full Text  

Spine Patient Outcomes Research Trial (SPORT): JAMA articles

   A lead article in  the November 22/06 issue of the New York Times entitled Study Questions Need to Operate on Disk Injuries comments on the following SPORT articles published today in JAMA:

Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Hanscom B, Skinner JS et al. Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA 2006; 296(20):2441-2450.

Context: Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.

Objective: To assess the efficacy of surgery for lumbar intervertebral disk herniation.

Design, Setting, and Patients: The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks.

Interventions: Standard open diskectomy vs nonoperative treatment individualized to the patient.

Main Outcome Measures: Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.

Results: Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.

Conclusions: Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.
Trial Registration clinicaltrials.gov Identifier: NCT00000410  DOI Link    Journal Record  

Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson ANA et al. Surgical vs nonoperative treatment for lumbar disk herniatioo: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006; 296(20):2451-2459.

Context: For patients with lumbar disk herniation, the Spine Patient Outcomes Research Trial (SPORT) randomized trial intent-to-treat analysis showed small but not statistically significant differences in favor of diskectomy compared with usual care. However, the large numbers of patients who crossed over between assigned groups precluded any conclusions about the comparative effectiveness of operative therapy vs usual care.

Objective: To compare the treatment effects of diskectomy and usual care.

Design, Setting, and Patients Prospective: Observational cohort of surgical candidates with imaging-confirmed lumbar intervertebral disk herniation who were treated at 13 spine clinics in 11 US states and who met the SPORT eligibility criteria but declined randomization between March 2000 and March 2003.

 Interventions: Standard open diskectomy vs usual nonoperative care. Main Outcome Measures: Changes from baseline in the Medical Outcomes Study Short-Form Health Survey (SF-36) bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons/MODEMS version).

Results: Of the 743 patients enrolled in the observational cohort, 528 patients received surgery and 191 received usual nonoperative care. At 3 months, patients who chose surgery had greater improvement in the primary outcome measures of bodily pain (mean change: surgery, 40.9 vs nonoperative care, 26.0; treatment effect, 14.8; 95% confidence interval, 10.8-18.9), physical function (mean change: surgery, 40.7 vs nonoperative care, 25.3; treatment effect, 15.4; 95% CI, 11.6-19.2), and Oswestry Disability Index (mean change: surgery, -36.1 vs nonoperative care, -20.9; treatment effect, -15.2; 95% CI, -18.5. to -11.8). These differences narrowed somewhat at 2 years: bodily pain (mean change: surgery, 42.6 vs nonoperative care, 32.4; treatment effect, 10.2; 95% CI, 5.9-14.5), physical function (mean change: surgery, 43.9 vs nonoperavtive care 31.9; treatment effect, 12.0; 95% CI; 7.9-16.1), and Oswestry Disability Index (mean change: surgery -37.6 vs nonoperative care -24.2; treatment effect, -13.4; 95% CI, -17.0 to -9.7).

Conclusions: Patients with persistent sciatica from lumbar disk herniation improved in both operated and usual care groups. Those who chose operative intervention reported greater improvements than patients who elected nonoperative care. However, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously.
Trial Registration clinicaltrials.gov Identifier: NCT00000410  DOI Link    Journal Record