this house believes that in 2014 antibiotics should be used to treat certain specific types of...
TRANSCRIPT
This house believes that in 2014 antibiotics should be used to treat
certain specific types of chronic back pain
Philip Sell
What we have
CONFOUNDING FACTORS
The Evidence
• Level one Single study
• Quality of evidence– Consort– Grade
Systematic Review
Meta-analysis
Why the unease ?
• Why is it some have no doubts
• Why is it some have massive doubts?
Medically unexplained symptoms
Propioibacterium freudenreichii in Emmental cheese
The reason we are uncomfortable
Miracle cure for back pain: Agony ended by everyday antibioticsCHEAP antibiotics could end the agony of back pain for millions of Britons for ever.
DAILY EXPRESS
Press reports before peer acceptance
• MMR studies
• Steroids in cord injury
• Hence our doubts
Magical thinking in improvement
Need for a science-based approach• Rigorous theory and methods
• Fully specify interventions and mechanisms
• How much evidence is needed
Problem: childbed fever
Vienna Maternity Institution: rates of puerperal fever 1841-1849
Intervention was right; theory was wrong
• The logic of hand-washing with chlorine was right (the technical intervention worked)
• But the big theory of resorption of cadaveric particles was wrong
• And the adaptive work was disaster
Why we should wait for further evidence
Original Article Magnetic Resonance Imaging in Follow-up Assessment
of Sciatica
Abdelilah el Barzouhi, M.D., Carmen L.A.M. Vleggeert-Lankamp, M.D., Ph.D., Geert J. Lycklama à Nijeholt, M.D., Ph.D., Bas F. Van der Kallen, M.D., Wilbert B. van den Hout, Ph.D., Wilco C.H. Jacobs, Ph.D., Bart W. Koes, Ph.D., Wilco C. Peul,
M.D., Ph.D., for the Leiden–The Hague Spine Intervention Prognostic Study Group
N Engl J MedVolume 368
March 14, 2013
N Engl J MedVolume 368
March 14, 2013
How it all began.....
-4 0 4 8 12 16 20 24 28 32 36 40 44 48 52
4
8
12
16
AUC surgery=273.9 ± 20.7
AUC conservative 316.3 ± 18.8
Mean difference of Roland AUC’s (CI) 42.5 (-12.4—97.4) *
weeks
Conclusion
• MRI performed at 1-year follow-up in patients who had been diagnosed with sciatica and a herniated disc on MRI …… did not distinguish between those with a favorable outcome and those with an unfavorable outcome
Back pain’s association with vertebral endplate signal changes in sciatica
Abdelilah el Barzouhi, M.D., Carmen L.A.M. Vleggeert-Lankamp, M.D., Ph.D., Bas F. Van der Kallen, M.D., Geert J. Lycklama à Nijeholt, M.D., Ph.D., Wilbert B. van
den Hout, Ph.D., Wilco C.H. Jacobs, Ph.D., Bart W. Koes, Ph.D., Wilco C. Peul, M.D., Ph.D., for the Leiden–The Hague Spine Intervention Prognostic Study
Group
Eurospine 2013
Evolution of back pain in surgically treatedpatients according to VESC
Evolution of back pain in conservatively treated patients according to VESC
Backpain diminishes over time
The Trial
• Unusual Control group show no change
• Trial recruitment
• Not spontaneous presentation
• Trial entry Invite to attend to 347 patients known to the organisation. 162 recruited
Harmless?
Harmless?• MMR
• Poor uptake of vaccines
• Measles epidemic in Wales
This house believes that in 2014 antibiotics should be used to treat
certain specific types of chronic back pain
MORE STUDY REQUIREDBE OPEN MINDED
REJECT THE MOTION