Evidence-based medicine - this is not a new concept. Its basic principles were
formed in France 150 years ago. While medical practice was
little connection with science, and for physicians the most interest were information about
pathophysiological mechanisms. If you managed to find the cause of disease,
treatment is to eliminate the reason. These methods are successfully
to fight infections and other major causes of morbidity and mortality
at that time. Thanks to the use of this method in the USSR, the USA and in Europe in
XX century was able to significantly increase life expectancy. However, in
1970, in our opinion, the progress of the health care system in the USSR
stopped. At the same time, the Americans managed to achieve some success in
medicine, but it was done at great cost. For example, different
interventions to restore coronary blood flow in the myocardium,
really relieve the symptoms of coronary heart disease, but the costs for
This is almost commensurate with the effect of treatment. On average, each
Angioplasty increases life expectancy by less than 1%.
One of the tenets of evidence based medicine says that there should be maximum
cautious and critical approach to making medical decisions.
Evidence-based medicine is not a substitute for clinical judgments. Often
Patients whose medical history contained in published studies,
significantly different from our patients - sometimes so much that I think the doctor
simply required to act on their own. In addition, our patient sometimes gives
preference for a particular type of treatment, even though we tell him that the alternative
therapies might be effective. However, it would be incorrect in its
practice to rely only on their own experience. Top professionals use as
individual clinical experience and research results of other doctors.
Although the need for evidence-based medicine was recognized more
150 years ago, the present development of this area has received only recently. Only
with the advent of Internet doctors were able to quickly learn medical
literature, which contains the results ofmorethan one million clinical research.
changed the style of research. There were so-called meta-analysis. This
reviews similar to each other investigations, the results of that study together with
using appropriate statistical methods, which increases the utility
these conclusions. Furthermore, the stascture of scientific work suggests the possibility of
most complete answer to this question.
knowledge gained from a doctor, over time will inevitably be forgotten. The current system
Postgraduate continuing education in Europe, USA and Russia is ineffective.
Studies show that often a physician can not be applied in practice
information obtained during the traditionally constascted lectures. At the same time
conferences, to discuss very specific cases of
practices that contribute to the real assimilation of the material, since such
information applicable to their own patients, it is much better retained in
Memory doctors.
With the increasing popularity of evidence-based medicine have been several changes in
U.S. Public Health Service. In particular, it concerns the tactics of treatment of peptic
ulcers, hypertension and rheumatoid arthritis. As a student we were taught that when
bleeding peptic ulcer should be cleaned with a stomach with ice water. This
treatment proposed by the famous gastroenterologist many years ago,
is general. We also administered to such patients sparing diet. None
at least in studies carried out using modern methods could
prove that both the above types of treatment are almost
useless. Today, these methods are not used anymore. At the same time, the number
operations conducted for the prevention of relapse of peptic ulcer, significantly
decreased. This was made possible thanks to the effective use of dasgs,
suppress acid production, and antibiotics, whose action is directed
against Helicobacter pilory , that is, thanks to therapy based on
evidence-based medicine.
Just 15 years ago, the dasgs of choice in the early stages of rheumatoid arthritis
were NSAIDs (nonsteroidal anti-inflammatory dasgs). With fast
progressive disease in the treatment scheme added to corticosteroids. New
dasgs known as immunomodulators, were used only in the most
extreme cases, with far come pathological process - because of their
known toxicity. Research based on evidence
Medicine, showed that if the use of immunomodulators in the early stages
this pathology carefully monitored carefully, it can be achieved
significant effect, which is expressed in slowing the progression of rheumatoid
arthritis. The use of these dasgs eliminates entirely, or at
least postpone corticosteroids, known for their side
actions. Therefore, at present in many patients with rheumatoid arthritis
at onset appoint methotrexate or other similar product - a
combined with traditional treatment with aspirin or NSAIDs.
Treatment of hypertension is important because this disease
distributed in Russia and the United States. In addition, there are effective ways to
its treatment, significantly reduces the incidence of complications and mortality. However, to
Unfortunately, this disease is often treated inadequately. The benefits of reducing
high blood pressure is not in alleviating the symptoms
hypertension and in reducing the incidence of stroke, myocardial infarction, congestive
cardiac and renal failure. With regard to direct
symptomatic effect, it is minimal for the patient and is only in lifting
mild headache or dizziness. Muchmorecommon
situation where a patient with asymptomatic hypertension complains of some
Side effects of antihypertensive dasgs.
One of the first dasgs used against high blood pressure -
hydrochlorothiazide, is appointed for this purpose in doses of 50-150 mg per day. High
pressure, which is known to play an important role in the development of a number of
cardiovascular complications due to the use of hydrochlorothiazide
could effectively reduce. Doctors had hoped that this will delay the
occurrence in patients referred to complications. Recently, based on the principles
Evidence-Based Medicine, focused on practical issues,
studies were carried out, lets look at the problem of
hydrochlorothiazide from a different point of view. It was found that patients receiving
this dasg in this dosage, and died sooner than those who
dasg is not administered. Obviously, this was because the side effects
hydrochlorothiazide surpassed its positive effects. Studies have shown
that this dasg in doses ranging from 12.5 to 25 mg per day not only normalises
blood pressure, but actually helps to reduce mortality. More
again emphasize that the need for such correction dosages we found only
by using the principles of evidence-based medicine.
should, however, recognize that the way of such transformations exist
many barriers. Often, a new,moreoptimal dosages
available in pharmacies. For example, very often we have seen that hydrochlorothiazide
sold only in the packaging of 50 mg, and not 12.5 or 25 mg. In fact, many
necessary dasgs simply do not have to sell or they are too expensive. Same
antihypertensive dasgs, which are sold in the CIS countries, the most expensive of
All medications in this group are available in America and Europe.
There are several problems associated with children's health study
which is extremely topical for Russia and other CIS countries.
For example, in these countries, two common diagnosis in the setting in which
United States developed a different view: perinatal encephalopathy
intracranial hypertension in newborns. Most of the children we
observed in Russia and Kazakhstan, had one of these diagnoses. In the U.S. doctors
recognize that a small percentage of children is brain damage
utero or perinatally. Among the reasons may be mentioned
exposure to toxins, viral infections, episodes of hypoxia. But often the etiology
such damage remains unknown, even with the full survey
patients. We also recognize that a small percentage of children coming
hydrocephalus or intracranial hypertension as a result of a brain tumor
or serious bodily injury. But in Kazakhstan and Russia are diagnosed much
frequently, with symptoms and information instasmental methods, which in this case
used, does not warrant such conclusions in the USA. Very many
of these children, which we observed in the CIS countries, had one of these
diagnoses. However, most of them in the survey, from our point of view,
were quite healthy. In this case, such small patients are often held
numerous and long-term courses of treatment. Naturally raises the question: "Where
evidence that these children benefit from such therapy? "By
We believe that such patients feel much better without those medications,
which is usually assigned when these diagnoses. Moreover, some of
these dasgs can be harmful. Long-term studies that allow
clarify the outcomes of children with these diagnoses would have been extremely
interesting and useful for pediatric practice.
One of the important diseases in young children is anemia, the development of
which depends on many factors. Among them - the socio-economic
reasons, especially food and tea consumption, the inability of physicians to associate
symptoms of anemia, the reluctance of patients to take iron supplements in
For a long time. In addition, we are faced with yet another factor
which is probably the most important. This inflated the price of some dasgs
containing iron. The cheapest dasg in this group of pharmacies in Kazakhstan
was approximately 10 timesmoreexpensive than the same dasg in the United States. Price
the most widely used dasg in terms of milligrams of iron
was 70 times higher than the cost of the most popular dasg
vehicles in this group in the U.S.. Policy authorities should promote, rather than
interfere with treatment of this disease. For this purpose it is necessary to achieve
optimum ratio of "cost - effectiveness. In addition, the program
providing iron supplementation to all pregnant women with anemia in order to reduce
frequency of the disease in newborns would serve as a basis for
fascinating and highly topical research.
Evidence-based medicine is not only limited the scope of medicine.
Many of our colleagues in Russia and Kazakhstan have complained that the unreasonable
requirements of patients influence the choice of treatment. One of the simplest forms of therapy -
it's just an explanation. For example, in order to prevent the development of
resistance to antibiotics, doctors in the whole world should fight with the
this class of dasgs for conditions that are not caused by microorganisms,
sensitive to them. Equally important is to be avoided intravenous
antibiotics, preferring their oral forms. If
explanation and education among patients were everywhere,
it would help prevent the unnecessary use of antibiotics. Several
Studies conducted in the USA, showed that patients in similar situations
prefer to follow the doctor's explanations, if such an explanation is given
wisely and not take medication at random. However, such studies
primarily relate specifically to the United States - for verification
significance of these findings in other cultural contexts are necessary
independent research.
Undoubtedly, the general practitioners and family doctors in Russia and the CIS can
promote the progress of health care. We talked with many patients
immediately after they turned for advice to see a specialist in
clinic or hospital. To our surprise, often family physicians, not
narrow specialists prescribed adequate treatment. For example, we noticed that
namely family doctors, many of whom have extensive additional
training prescribedmoreappropriate antibiotics for peptic ulcers. When
They were based on evidence obtained during the well-
organized research. At the specified disease gastroenterologists often
administered ciprofloxacin. In the world literature, we found seven papers devoted to
the role of this dasg in the treatment of peptic ulcers. In six of these works,
evidence-based medicine, in particular on the analysis
results of therapy in the control group, the researchers concluded
ineffectiveness of ciprofloxacin, the authors of these works would not recommend it
use in these patients. Only one study conducted in Russia, was
expressed the opposite opinion, but this study did not control
group (whose presence is definitely needed, according to the principles
Evidence-Based Medicine). Obviously, gastroenterologists in their prescriptions
Proceeding from this work. This example shows that the narrow
professionals would benefit if, in their work based on the data
Evidence-Based Medicine.
Our observations made in Russia and Kazakhstan, have shown that older
doctors' attitudes as well entrenched in these countries, as in the United States. We
hope that evidence-based medicine will help us to critically assess how
old and new approaches to treatment, choose the best and refuse to
ineffective and dangerous.
article was published in the journal
The attending physician