What is a fair assessment of the medical literature?

[Pooka1]

I have been thinking more about the general comments by hdugger about medical research.

There is obviously a different standard for publishing these medical papers than in other scientific fields. I don't think even now I fully grasp or accept that or something. I like to think science is science. But maybe not when it comes to medicine.

I mean it may be that the 2003 Mooney paper is some paragon of medical study design and interpretation for all I know.

I mean just because I might find that at extreme odds with what gets published in other scientific fields doesn't mean it isn't some award winning paper within that field. But this point, I can't imagine what might be rejected and why given what is published. I'm guessing if it has medical case data, it will likely be published just to get the data out there for further consideration as the comment hdugger posted said.

I think I need to consider that.

On the other hand, we do have review papers that point out the shortcomings of the literature and the disconnect between the standard of care and the lack of data supporting that standard (see Dolan et al., 2007... the equipoise paper for those following along).

And we have that study showing that most published research results are false. It is not hard to see why that is the case when it is so hard to do a controlled study.

Anyway, I think until I get a grip on this situation, I'm going to back off a bit on criticizing these studies. A bit. Science hopefully is science at the end of the day, though.

[bcputnam]

I too have quite a bit of experience in the medical field and the use of peer reviewed literature in another medical discipline. Prospective, randomized studies are routinely found in the pharmacological area but in medical device or other arenas are few and far between. This is especially true in pediatrics where the idea of playing Russian roulette with our children would be appalling. I have seen a definite bias in the way we practice medicine here in the US vs. rest of world...we have such an emphasis on the "fixes" vs. the "preventions". It seems crazy to me to have scoliosis screening in our schools for early detection and then with an early diagnosis be told to sit and wait. Intuitively that makes no sense to me. I can only continue to use my own best judgment in seeking out the data and smaller investigator initiated studies that are available and continue to challenge and find that practitioner who can partner with us in management and treatment of my son's condition.

[Pooka1]

I am surprised, though, at the shoot-now-ask-questions-later approach to new surgical techniques. I was reading something the other night from a Dr. at Oakland's children hospital, describing scoliosis and some of its treatments. At the top in big letters he said that he was no longer recommending the surgery method he'd invented and elaborated in the report. Are new surgical techniques really just invented in the midst of surgery and then examined later for their effectiveness? Or are there some hurdles you have to leap before you start operating in a novel way? I'm familiar with the path to approving drugs, and I guess I had some kind of idea that surgical techniques had to follow a similar kind of path.

That's a good question. I'd like to know the answer.

Anyway, after reading things like that, poorly controlled torso rotation exercises seem pretty benign

Perspective always!

I wish I could go out and do a study on whether eating ice cream stops the progression of curves.

My hypotheses are w.r.t ice cream therapy:

1. the smaller curves will respond better than larger
2. the lumbar curves will respond better than thoracic
3. the older, post-menarchal girls with higher Risser signs will respond better
etc.
etc.

See a pattern?

When your study results don't differ much from what is know of the natural history then maybe you're not changing the natural history. The natural history is pretty good for AIS at least in terms of most cases not reaching surgical range. The case may be quite different for IIS and JIS though as it seems to be for connective tissue scoliosis. I think that's where more research should be... changing a more challenging natural history.

This same point about research results that are similar to the natural history was made recently with respect to VBS in a presentation from that conference that balletmom posted. That is, the stapling seems to work best in the cases where you would predict less progression. I would say the same about many of these alternate treatments. Because some things are known about the propensity of given curves to progress (albeit with huge error bars), I think a standard for publication should be that the data are compared against what is know about the natural history both short and long term. And some things are known or at least there is some evidence for some claims.

[Pooka1]

I have seen a definite bias in the way we practice medicine here in the US vs. rest of world...we have such an emphasis on the "fixes" vs. the "preventions".

Well, maybe there is that bias because preventions have not panned out.

Or maybe they simply don't get studied.

It seems crazy to me to have scoliosis screening in our schools for early detection and then with an early diagnosis be told to sit and wait. Intuitively that makes no sense to me.

Well, I can see screening and then watching/waiting in order to fuse curves earlier when you can fuse less levels if it comes to that.

It seems that both my daughters could have much shorter fusions if they were fused at 35* let's say rather than high 50's*. But of course that isn't ethical because you don't know if they will progress. That said, I predict there will come a day when kids who have, or a highly suspected to have, certain connective tissue disorders will be fused much earlier if/when it is rigorously shown that they almost always progress to surgical range and that bracing fails for them. This is not the case with AIS.

[LindaRacine]

I too have quite a bit of experience in the medical field and the use of peer reviewed literature in another medical discipline. Prospective, randomized studies are routinely found in the pharmacological area but in medical device or other arenas are few and far between. This is especially true in pediatrics where the idea of playing Russian roulette with our children would be appalling. I have seen a definite bias in the way we practice medicine here in the US vs. rest of world...we have such an emphasis on the "fixes" vs. the "preventions". It seems crazy to me to have scoliosis screening in our schools for early detection and then with an early diagnosis be told to sit and wait. Intuitively that makes no sense to me. I can only continue to use my own best judgment in seeking out the data and smaller investigator initiated studies that are available and continue to challenge and find that practitioner who can partner with us in management and treatment of my son's condition.

Not that it's terribly relevant to this discussion, but the Oakland surgeon (Ron Blackman) stopped doing the surgeries (he was the first thorascopic pioneer) because he was seeing a very high percentage of broken rods. Other surgeons, who kept doing the surgery, discovered that in the early surgeries, they were not completely cleaning out the discs, which led to non-fusion. The surgeons who do a lot of thorascopic scoliosis surgery are getting very good results.

--Linda

[Pooka1]

The surgeons who do a lot of thorascopic scoliosis surgery are getting very good results.

That's my impression in selected cohorts.

Correct me if I'm wrong but even with outdated instrumentation like Harrington rods, isn't even the long-term on thoracic fusions pretty good? That is, aren't the vast majority of issues down the road associated with lumbar fusions with outdated instrumentation? When you add in the new instrumentation, it paints an even better picture.

I have the impression that thoracic fusion has largely been "solved" though of course not completely since we don't have a lot of long term data. And hopefully the new instrumentation that restores correct balance in 3 dimensions will put lumbar fusion in the "solved" category also.

[Pooka1]

That's my impression in selected cohorts.

Correct me if I'm wrong but even with outdated instrumentation like Harrington rods, is isn't even the long-term on thoracic fusions pretty good? That is, aren't the vast majority of issues down the road associated with lumbar fusions with outdated instrumentation? When you add in the new instrumentation, it paints an even better picture.

I have the impression that thoracic fusion has largely been "solved" though of course not completely since we don't have a lot of long term data. And hopefully the new instrumentation that restores correct balance in 3 dimensions will put lumbar fusion in the "solved" category also.

OOOPS!

I thought Linda said "thoracic."

Nevermind.