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Feature Evidence Based Medicine

Why we can’t trust clinical guidelines

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3830 (Published 14 June 2013) Cite this as: BMJ 2013;346:f3830

Rapid Response:

Re: Why we can’t trust clinical guidelines

Instead of commenting on the merits or faults of Ms. Lenzer’s article, Dr. Radecki chose to rebut the Stroke neurologists’ replies to the article from an arbiter position. Well, Dr. Radecki, allow me to retort.

First, I give rt-PA to a minority of patients with stroke, only within the guidelines. The recommendations of these guidelines are supported by the very meta-analysis that you cite as proof against rt-PA. As is well known, no guideline proposes use of rt-PA beyond 3 hours.

Second, I do not lament the patients who did not receive rt-PA and were victims of what you call “conservative counter-reaction”. It is reasonable to have doubts and question any kind of evidence coming from any kind of source. I’ve been there. I’ve held rt-PA administration in patients when I was in doubt. However, as the evidence for the benefit of early rt-PA administration mounts, the passive aggressive opposition to its use by cherry-picking the evidence that you like may harm future patients.

Third, I do not denigrate the valid scientific enquiry of the skeptics. From the replies we read here, there is no such valid scientific enquiry, only opinions. It’s easy to say that the results are not perfect. We are far from a perfect solution. We shouldn't throw out the baby with the bath water.

Finally, I as well as all of the Stroke neurologists that you rebut here are against corruption of science by the pharmaceutical industry. However, we are equally opposed to the kind of yellow journalism that has sparkled this discussion.

Competing interests: Publication honorarium from MedLink.

22 August 2013
Adrian Marchidann
Stroke Neurologist
SUNY Downstate Medical Center
450 Clarkson Ave, Brooklyn, NY 11203