On the origins and development of evidence-based medicine and medical decision making

The aims of this paper are to identify the issues and forces that were the impetus for two recent developments in academic medicine, evidence-based medicine (EBM) and medical decision making (MDM); to make explicit their underlying similarities and differences; and to relate them to the fates of these innovations. Both developments respond to concerns about practice variation; the rapid growth of medical technology, leading to a proliferation of diagnostic and treatment options; the patient empowerment movement; and psychological research that raised questions about the quality of human judgment and decision making. Their commonalities include: use of Bayesian principles in diagnostic reasoning, and the common structure embedded in an answerable clinical question and a decision tree. Major differences include: emphasis on knowledge or judgment as the fundamental problem; the status of formal models and utility assessment; and the spirit and tone of the innovation. These differences have led to broader acceptance of EBM within academic medicine, while decision analysis, the fundamental tool of MDM, has been less welcomed in clinical circles and has found its place in guideline development, cost-effectiveness analysis, and health policy.     

Dorsal nasal reconstruction using bone harvested from the mandible.

PURPOSE: This article describes a technique for reconstructing nasal deformities resulting from trauma. Bone harvested from the lateral ramus/body of the mandible is used to provide nasal support for major nasal deformities. PATIENTS AND METHODS: Ten patients underwent repair of their nasal deformities with an autogenous bone graft harvested from the mandible. Primary bone grafting was used to repair a nasal deformity associated with a naso-orbito-ethmoidal fracture in 8 patients. Secondarily, 2 patients underwent placement of a graft for correction of a saddle nose deformity. RESULTS: All patients achieved aesthetic results. There was maintenance of nasal projection and symmetry without displacement of the graft. None of the patients complained of an unnatural hardness of the nasal tip or dorsum. All grafts healed without evidence of infection, dehiscence, or necrosis. CONCLUSION: The lateral ramus/body of the mandible provide an excellent donor site alternative for nasal reconstruction.