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The Rise and Fall of Evidence Based Medicine (1998) [pdf]

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Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#121

Post by kspacewalk2 »

pella wrote: post #110
kspacewalk2 wrote: post #37

Earlier quoted context omitted.

Sounds extremely susceptible to quackery and hand-waving appeals to authority.

The author of the article was in favor of face masks even in the early stages of the COVID pandemic. Meanwhile, the mask opponents concluded from the principles of evidence-based medicine that masks are not effective. During a pandemic, there is no time to wait for 10 years until sufficient evidence accumulates. If evidence-based medicine cannot be used in the case of pandemics, an improved methodology is needed.

Whether or not "guesswork that's probably scientifically informed" is in fact "improved methodology" is the question. As is using the fact that heads came up when you flipped a coin hoping for heads is sufficient grounds for applying the same method to much more consequential tasks. I for one am very glad we didn't abandon the supposedly far too cautious approach of evidence-based medicine when we properly tested the COVID vaccines, for example, before administering them to billions. That of course is far more consequential to ending the pandemic than masks ever were. But sure, for low-effort low-risk policies like "wear masks made out of whatever, it might do something", we can go with scientifically informed guesswork.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#122

Post by LorenPechtel »

haldujai wrote: post #59
LorenPechtel wrote: post #44

Earlier quoted context omitted.

I do agree things should be studied but you have to be careful with it. Studies are big and expensive and things can be missed. Remember the big flap over hormone replacement therapy being shown harmful? Oops--all it really showed is what we knew all along, estrogen is risky for fat women.

> estrogen is risky for fat women I think what you meant to say is unopposed estrogen is risky for all women.

No, I specifically was referring to fat women. Check the recommendations on birth control pills--same thing, older + fat makes them risky. The problem with the big study is that their sample was disproportionately overweight.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#123

Post by LorenPechtel »

rgbgraph wrote: post #69
haldujai wrote: post #59

Earlier quoted context omitted.

> estrogen is risky for fat women I think what you meant to say is unopposed estrogen is risky for all women.

It's a shame I have yet to see a microdose of testosterone included in HRT.

How can you imply a woman past menopause might possibly want sex?? And who would be willing to satisfy that desire, anyway??

Actually, it's probably a bad idea to combine them because the body's response to hormones is so variable. Keep them as separate pills so you can tweak the balance easier.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#124

Post by stubybubs »

haldujai wrote: post #104
stubybubs wrote: post #102

Earlier quoted context omitted.

Estrogen/progesterone and testosterone are not exclusively female/male hormones. Testosterone may boost sex drive and increase muscle mass, as well as provide some psychological benefit in women. Estrogen is the most important regulator of bone health in both men and women. There are people with estrogen insensitivity syndrome, both men and women, and from all reports they are having an extremely uncool time: https:/…

Yes but why on earth would testosterone be part of HRT for menopause? The point is to replace what’s missing and causing symptoms. Menopause =/= estrogen insensitivity.

It would be part of HRT for menopause for the reasons I gave: mental health, sexual desire, muscle maintenance.

The discussion about estrogen in men is just for context. It's not unusual to talk about levels of any hormone in men or women. There's nothing "shocking" about testosterone in women, or estrogen in men.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#125

Post by dekhn »

bedobi wrote: post #78
dekhn wrote: post #68

Earlier quoted context omitted.

To add to that studies findings: in general, many people who have back surgery end up worse-off than before, because back surgery is risky.

Uh, no. That study is literally the source of truth on that topic. There's no "to add to". I hope you never have to experience what me and others who have the same problem have experienced, but I guarantee you you'd want to do the surgery too if you ever did. In any case, I was happy to share my story but I have zero interest in debating it, so I'll check out here.

I've had constant back pain since my teens (and I'm 50) likely due to a damaged disk. I've already gone through this (I work in the medical field and can consult with doctors and medical researchers). I concluded that the risks of back surgery making a problem worse are high enough that I am going to live with the pain for the foreseeable future.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#126

Post by haldujai »

stubybubs wrote: post #124
haldujai wrote: post #104

Earlier quoted context omitted.

Yes but why on earth would testosterone be part of HRT for menopause? The point is to replace what’s missing and causing symptoms. Menopause =/= estrogen insensitivity.

It would be part of HRT for menopause for the reasons I gave: mental health, sexual desire, muscle maintenance. The discussion about estrogen in men is just for context. It's not unusual to talk about levels of any hormone in men or women. There's nothing "shocking" about testosterone in women, or estrogen in men.

> It would be part of HRT for menopause

I was fixating on semantics but it's not the point.

Not my area but for what it's worth UpToDate (KA Martin, RL Barbieri, JL Shifren @ MassGen Brigham) address it in expert opinion form:

> We do not suggest the routine use of androgen [testosterone] therapy for postmenopausal women. Levels of endogenous androgens do not predict sexual function for women; however, androgen therapy that increases serum concentrations to the upper limit or above the limit of normal for postmenopausal women has been shown to improve female sexual function in selected populations.

The linked out sexual dysfunction article (JL Shifren):

> In our practice, we rarely use testosterone, but will prescribe it when greatly desired by a peri- or postmenopausal patient with low libido associated with distress who has no contraindications to testosterone therapy or identifiable etiology for sexual dysfunction and is otherwise physically and psychologically healthy. Typically, the patient has already tried other safer interventions prior to the testosterone prescription, including low-dose vaginal estrogen, relationship interventions (eg, sex therapy, date nights, use of sexual aids such as vibrators, books), and adjustment of antidepressant medication (when indicated) [12]. At least one visit with a sex therapist is strongly advised prior to pharmacologic treatment, as this safe and effective intervention may make pharmacologic therapy unnecessary or enhance the response to treatment. Testosterone levels should not be used in determining the etiology of a sexual problem or in assessing efficacy of treatment, as no clear association between androgen levels and sexual function has been found in several large, well-designed studies.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#127

Post by haldujai »

rgbgraph wrote: post #120
haldujai wrote: post #119

Earlier quoted context omitted.

You seem to be misunderstanding how evidence works, it is not about “what you consider” and is entirely based on fact. We also don’t talk ARR in isolation when we decide on interventions, it’s NNT vs NNH and considering the specific risk being reduced and the specific harm. I’ll use your 2% ARR for death although there are better numbers in different patient populations. In other words: Statins will save 1 life for e…

This conversation is going in circles. Linked study equivocating on the overstatement of statin side-effects has the first author as a pharmaceutical consultant (you do not see this as a problem, I do). 2% ARR is meager in relation to lifestyle changes that can account for 3x-15x the in ARR compared to statins (you do not see this as a problem, I do). Those are the facts. How you interpret them is subjective. All of…

> at the cost of untold resources

Not going to argue the methodology but it seems like a starting point is $22,000-37000/QALY[0-1].

> instead of

This is a false dichotomy, guidelines all start with lifestyle modifications.

[0]https://jamanetwork.com/journals/jamacardiology/fullarticle/...

[1]https://jamanetwork.com/journals/jama/article-abstract/23964...

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#128

Post by deltaninenine »

haldujai wrote: post #100
deltaninenine wrote: post #87

Earlier quoted context omitted.

Long term damage to liver. You use it long enough your liver will die. But it's too hard to do a causal analysis on this as the timelines are measured in decades.

I have never heard of or seen statin-induced cirrhosis practicing in a liver transplant center so if this is real it’s a case report.

Google it. Its well known.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#129

Post by haldujai »

LorenPechtel wrote: post #122
haldujai wrote: post #59

Earlier quoted context omitted.

> estrogen is risky for fat women I think what you meant to say is unopposed estrogen is risky for all women.

No, I specifically was referring to fat women. Check the recommendations on birth control pills--same thing, older + fat makes them risky. The problem with the big study is that their sample was disproportionately overweight.

Unopposed estrogen (i.e. the old estrogen only HRT) is bad for women of all sizes, endometrial cancer sucks.

Separately, obesity causes higher system estrogen levels and carries the same risks.

What you may be referring to is the more recent WHI study which does have methodological flaws, but unopposed estrogen is a no-no for patients with a uterus.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#130

Post by haldujai »

LorenPechtel wrote: post #123
rgbgraph wrote: post #69

Earlier quoted context omitted.

It's a shame I have yet to see a microdose of testosterone included in HRT.

How can you imply a woman past menopause might possibly want sex?? And who would be willing to satisfy that desire, anyway?? Actually, it's probably a bad idea to combine them because the body's response to hormones is so variable. Keep them as separate pills so you can tweak the balance easier.

Not every post-menopausal patient will have sexual dysfunction.

Testosterone is not the only (or first line) treatment for sexual dysfunction and is off-label/not FDA approved.

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