ABSTRACT
In a new and interesting book entitled Medical Nihilism (2018), Jacob Stegenga attempts to convince us that modern medical therapies are less effective than we think. Given the heterogeneity of hypotheses in medicine and the evidence for or against them, I argue that such a decontextualised critique cannot be made unless substantially weakened. Instead, I put forward an alternative, more nuanced and defensible epistemic view of medicine. According to this view, evaluating medical evidence requires analysis of both the methods of research e.g. randomised controlled trial (RCT), and context-specific information. This is because the way a trial (even an RCT) is conducted e.g. the population recruited and how it is intervened on, will vary and will have significant effects on the likelihood of a positive outcome. Moreover, the relationship between the positive outcome of a trial and the actual effectiveness of an intervention (the trial validity) will depend on these context specific factors. I argue for this position against nihilism by showing how each of Stegenga's individual claims about medical trials (trials are biased in favour of positive outcomes etc) can be questioned by taking the context into consideration.
Subject(s)
Evidence-Based Medicine/standards , Randomized Controlled Trials as TopicABSTRACT
INTRODUCTION: Glycaemic control is an important predictor of mortality in sepsis. Various international organizations including the Surviving Sepsis campaign recommend glycaemic control in critical illness with a glucose target between 6.1-10 mmol/L. The NICE-SUGAR Trial in 2009 was a landmark in the debate over tight versus liberal glycaemic control in the critically ill and subsequent guidelines have been adjusted to reflect a move towards moderate glycaemic control. METHODS: We conducted a nation-wide study comparing glucose targets used in intensive care units in the United Kingdom in 2007 with those used in 2014 to 2015 to see the impact of the NICE-SUGAR study and subsequent guideline changes. RESULTS: We received a combined response from 81% of intensive care units in the UK. There was an increase in the average median glucose target in 2014/2015 compared with 2007 (7.8 versus 7.2; p < 0.01). However, there is still much variability in glucose targets used in critical care in the UK. CONCLUSIONS: There is an overall trend towards using a more moderate glucose target in critical care in the UK reflecting changes in international guidelines. However, it is likely that controversies, which still exist in the literature, are reflected in the variability of glycaemic control targets. It is possible that the advent of closed-loop or continuous glucose monitoring may have a further impact on this.
ABSTRACT
INTRODUCTION: Traumatic abdominal wall hernias (TAWHs) are uncommon and to date less than 50 cases have been reported in the literature. Furthermore mesenteric avulsion is a rare complication of TAWHs and occurs in less than 5% of all cases. PRESENTATION OF CASE: A 47-year-old lady presented to the emergency department after a road traffic accident. In spite of seat belt use and airbag deployment, the patient presented with a visible left paramedian abdominal mass, which was tender and irreducible on examination. Subsequent computed tomography (CT) of the abdomen confirmed herniation of the small bowel with no free air or fluid in an otherwise stable patient. Intra-operative findings confirmed mesenteric avulsion and bowel necrosis. DISCUSSION: The role of emergency or elective repair of TAWHs remains unclear. As 58% of blunt mesenteric and bowel injuries due to avulsion are missed on initial work-up, it is advisable for clinicians to balance the risk of unnecessary and non-therapeutic emergency laparotomy with the morbidity and mortality associated with delay in diagnosis. CONCLUSION: Mesenteric avulsion in TAWH is rare and difficult to diagnose and a high index of suspicion is warranted despite normal findings on initial assessments.
