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Giving talks in which you don't have a slide deck already made is illuminating. Look what I found out about publication bias>
It was "discovered" in 1979 by Rosenthal content.apa.org/record/1979-27…
How did he do this?
Thread ...
He used a variant of ...sit down for this...the Fragility Index, which we reported on in cardiology
ahajournals.org/doi/10.1161/CI…
The criticism was fierce. But I liked it. @ShahzebKhanMD
Here's Rosenthal's explanation

I am no stats person but this looks a lot like a fragility concept applied to all studies.
Rosenthal's conclusion -- prescient.
Here is Steve Nissen in 2013 in @JAMAInternalMed jamanetwork.com/journals/jamai…
Clinical trial registration has probably got us to a better place now. But still, I think this supports a #medicalconservative approach to evidence translation.
Happy to hear thoughts on this from anyone. cc @kaulcsmc @gcfmd @AndrewFoy82 @califf001
@LuisCLCorreia
I know @eturnermd1 has a wonderful paper in NEJM on this issue with anti-depressant drugs
(I wonder if most patients know about this? These drugs are super common) nejm.org/doi/full/10.10…
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John Mandrola, MD
@drjohnm
Thread: To me, the most stunning report from #ESCCongress thus far: RATE-AF trial
Older pts w/ permanent AF + shortness of breath. (there are lots of these pts).
Rate control is crucial
In 2020, most receive beta-blockers.
But BB can cause dyspnea.
What about dig?
Gulp! 1/
Rate-AF randomized these pts to bb vs digoxin. Here is the protocol paper: bmjopen.bmj.com/content/bmjope…
Crucially they looked at quality of life. That's a really important outcome.
The results shocked me. Look at heart rates. Dig isn't supposed to be this good.
Read 10 tweets
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John Mandrola, MD
@drjohnm
Need help from trial methods people. I ran across this amazing paper by @phlegmfighter et al looking at consequences of recommendations in the design and interpretation of Non-inferiority trials. pubmed.ncbi.nlm.nih.gov/28875400/
THEY SUGGEST SYSTEMIC BIASES.
Thread Image
If you put the new treatment on the left side of the interpretative diagram, there are four ways to make Non-inferiority. Scenarios 1-4. but.... Image
They show that if the convention were to put the active control on the left side of the diagram, make the new treatment the control, you would bias strongly toward the control (thus making NI more difficult to reach). No change in data, just the mirror image here: Image
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John Mandrola, MD
@drjohnm
Thread coming on one way docs might add value to the #COVID19 crisis: critical appraisal.
I wrote a critique of a flawed study published in a major journal. The study reported on the assoc of anticoagulant use and death in COVID pts.
medscape.com/viewarticle/93…
It is an important topic b/c numerous studies have suggested a high rate of clot-related complications in acute #COVID19 illness. it makes sense to consider anti-coagulants...
But anticoagulants come with harms--bleeding. What's more, in non-COVID pts we know that there are actual clots that we are treating. Infection control issues sometimes prevents knowing whether a person w/ #COVID19 actually has clots.
Read 13 tweets

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